international journal of human and health sciences. supplementary issue: 2019 doi: http://dx.doi.org/10.31344/ijhhs.v0i0.130 s12 tech-based social enterprises in healthcare nurfarini daing abdul rahman myharapan damansara intan, petaling jaya, selangor abstract disruptive technologies continue to redefine how we live, far faster than we could have ever imagined. technologies from artificial intelligence to iot, are powering solutions in the healthcare sector and paving the way to incredible new medical “miracles”. the question now is, how can we ensure that these technologies deliver quality care that is accessible to the people who need it the most, effectively and sustainablythe poor in urban or remote areas, the marginalized and underserved who are not able to benefit from it? this issue is compounded by the complexities of the social determinants of health, which cuts across the layers of our existence in this increasingly fast-paced, volatile and uncertain world. new models to delivering healthcare products and services have been embraced by a relatively new breed of entrepreneurs, the kind driven by a social mission. together with healthcare practitione rs, experts and institutions, and most importantly, patients (or preferably consumers), social business entrepreneurs are challenging the norm through technological applications and savvy business models and reimagining how our world could be. will we, in the future, no longer have a need for human doctors? how can wellness be afforded to even the very poor? referencing several notable healthcare social businesses in the industry, the presentation hopes to provide a starting point to deeper discussio ns – a call to action for all participantsinto a sector that requires multi-stakeholder participation and support in order to move the needle even further. microsoft word ijhhs imam 23rd asc 2022 s4 az-zahrawi memorial lecture islamic input in medical education and healthcare practice: challenges and the way forward md. tahir md. azhar1 a short history of medical curriculum evolution and the efforts to give it the spiritual and humanistic dimensions will be presented. the experience of the iium medical school curriculum and the obstacles and challenges would be mentioned. the whole exercise is ‘dakwah’. keywords: 1. international islamic university malaysia (iium) gombak campus, selangor. ___________________________________________________________________________ correspondence to: prof. emeritus dato' dr. md. tahir md. azhar, special appointee in the office of ombudsman and integrity at iium gombak campus, selangor. mdtahir@iium.edu.my __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v7i70.507 microsoft word ijhhs imam 23rd asc 2022 s12 forum 2 reform in healthcare professions adeeba binti kamarulzaman1, tuti ningseh mohd dom2, zahrah saad3, muhamad yusri musa4 healthcare professionals has been at the main frontline in the recent covid-19 pandemic, battling through enormous difficulties including getting infected, burn-out, mental health issues, poor resource management and we lost a significant number of colleagues worldwide. various challenges faced by health fraternity has led to calls for reform and significant steps taken by stakeholders including the ministry of health, malaysia to improve working condition of healthcare workers (hcw) with formation of multiple committees, advisory board and most importantly the health white paper to ensure the word class standard of our health services remains relevant, sustainable and outstanding quality. healthcare professionals such as doctors, dentists, nurses, paramedics and allied health professionals need to keep up with the changes and foresee upcoming challenges to ensure the integrity and quality of practices for each professions is kept at highest quality. keywords: reform, healthcare professionals, sustainable 1. faculty of medicine, university malaya, kuala lumpur 2. faculty of dentistry, universiti kebangsaan malaysia (ukm), kuala lumpur 3. malaysian allied health science academy university (mahsa university), bandar saujana putera, selangor 4. usm bertam medical centre (usmbmc), kepala batas, pulau pinang ___________________________________________________________________________ correspondence to: muhamad yusri musa, lecturer and consultant otorhinolaryngologist, usm bertam medical centre, advanced medical and dental institute, usm, kepala batas, penang, malaysia. myusrim@usm.my __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v7i70.514 microsoft word ijhhs imam 23rd asc 2022 s6 plenary 2 financing of healthcare in malaysia: change or business as usual? azrul mohd khalib1 internationally, malaysia's healthcare system has been considered a major success with universal health coverage considered to have been achieved since the late 1980s. most of the population is within 10 kilometres of a healthcare facility or services which provide degrees of treatment and care, comparable to many economies of similar level. however, as the country begins making its transition to a high income country, the question is whether the financing for such a system is still fit for purpose, able to meet current challenges and needs (e.g. an ongoing non-communicable disease crisis and mental health), and most importantly, respond to the emerging threats such as another pandemic on the scale of covid-19 and a growing aging population. what are the possibilities for financing malaysia's healthcare system to ensure its resilience and sustainability? what could we consider to replace what we have today and not leave vulnerable populations behind? should we disrupt what we have for the promise of better coverage, quality, and innovation in preventative health, treatment and care? this discussion will present an alternative model for consideration. keywords: 1. healthcare, financing, challenges, pandemic, aging-population ___________________________________________________________________________ correspondence to: azrul mohd khalib, chief executive officer (ceo), galen centre for health and social policy, kuala lumpur. azrul@galencentre.org __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v7i70.509 s17 pulmonary phaehyphomycosis in retroviral disease patient ummu afeera binti zainulabid1, muhammad naimmuddin bin abdul azih1, sasi kumar a/l maniyam1, azliana binti abd. fuaa2, mohd radhwan bin abidin3, hajar fauzan bin ahmad4 abstract pulmonary phaeohyphomycosis is a rare infection in the lung caused by black fungi containing a cytoplasmic melanin-like pigment. a 42-year-old man with underlying retroviral disease on haart was investigated for having constitutional symptoms. despite undetectable viral load and a high cd4 count, he was found to have unexplained significant loss of weight and appetite over a period of 6 months. clinical examination revealed a cachexic man with multiple inguinal lymphadenopathies. excisional biopsy of the inguinal lymph node revealed reactive follicular hyperplasia. ct thorax, abdomen and pelvis was arranged to look for occult malignancy or infection and he was found to have multiple non-enhancing subcentimeter lung nodules mainly at the lateral segment of the right middle lobe of his lung. the largest nodule measured about 0.8 x 1.5 x 0.5 (ap x w x cc), with some nodules having an irregular margin with no extension into the adjacent bronchi. bronchoscopy was done and demonstrated a black patch at the right intermedius, lateral segment of the middle lobe which did not disappear upon bronchial flush or wash. histopathological examination found focal areas of blackish pigment and the bronchial alveolar lavage sent for fungal culture grew cladosporium species. the patient was treated with oral itraconazole with marked clinical improvement. this case highlights an unusual black fungi infection in the lung that stands out not only for its rarity and it's responsiveness to treatment, but also the susceptibility of an rvd positive patient to this infection despite having suppressed viral load and normal cd4 count. keywords: kounis syndrome, acute coronary syndrome, anaphylactoid reaction, mast cell activation 1. internal medicine, hospital tuanku ampuan najihah, malaysia 2. department of pathology and laboratory medicine, kulliyyah of medicine, international islamic university of malaysia 3. department of radiology, kulliyyah of medicine, international islamic university of malaysia 4. faculty of industrial sciences and technology, universiti malaysia pahang doi: http://dx.doi.org/10.31344/ijhhs.v5i0-2.335 http://dx.doi.org/10.31344/ijhhs.v5i0-2.335 s6 big data analysis during pandemic: malaysia health data warehouse experience mohamad fadli khairie malaysia has reported more than 1.5 million covid-19 cases since the beginning of the pandemic. planning and executing an effective public health intervention and policy require a large amount of data from various sources to be analysed on a daily basis. in response to the data request, malaysia health data warehouse (myhdw) utilizes its ability to collect, aggregate, analyse and visualize big data. this presentation explores the experience of malaysia health data warehouse leveraging big data analysis during the pandemic. various health data has been collected by healthcare personnel at healthcare facilities. this data will be uploaded to myhdw through several data source systems where afterward, all this data underwent etl (extract, transform, loading) process prior to loading onto the data warehouse. most data requests concern healthcare utilisation or specific disease trends. using data interoperability, intended data were extracted from the database. afterward, data will be cleaned, analysed, and visualised either in the form of table, operational dashboard, interactive maps or incorporated in press statements or policy documentation. several outputs have been produced by myhdw during the pandemic, such as spatial analysis of covid-19 data, cardiovascular mortality trends during the pandemic, impact analysis of hospital utilisation during the pandemic, and excess mortality. big data analysis through malaysia health data warehouse is an asset to the country in coordinating effective responses during the pandemic. keywords: big data, gis, data warehouse ___________________________________________________________________________ correspondence to: senior deputy director, operation unit malaysia health data warehouse, health informatics centre, ministry of health, kompleks e, pusat pentadbiran kerajaan persekutuan, putrajaya, malaysia. email: m_fadli@moh.gov.my __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v6i0.396 mailto:m_fadli@moh.gov.my s5 covid-19 in pregnancy: a maternal compromise jason ng kit fai1, amalina che din1, celine mien er fong1 abstract few studies have reported the effects of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) on pregnancy albeit the exact mechanism of maternal compromise requiring escalated management is not known. this case demonstrated how a pregnant woman deteriorated and recovered from covid-19 after delivery. a 37-year-old lady, g4p3, at 29 weeks gestation presented with reduced fetal movement, fever, chest pain and cough, with a background of gestational diabetes. she was proven positive for covid-19 and was started on treatment promptly. initially, she was maintaining her oxygen saturations but later deteriorated despite maximum oxygen therapy. she was escalated to the intensive care unit (icu) and treated with non-invasive mechanical ventilation requiring up to a fio2 – 0.7. in view of the patient's best interest, multiple multidisciplinary team discussions took place and unanimously decided to proceed with emergency lower segment caesarean section under spinal anaesthesia which was uneventful. she made gradual recovery and was discharged from icu after 2 weeks. during her admission, she was found to be mrsa positive from her caesarean section wound and was treated accordingly. both mother and baby were fit for discharge after 1 month of admission. there is a lack of evidence regarding implications of covid-19 on pregnancy. gestational diabetes on top of the physiological immunosuppressed status may put pregnant women in a vulnerable group. further studies are required to identify factors generating increased rate of surgical intervention, preterm deliveries, and icu admission in covid-19 positive pregnancies. keywords: covid-19, acute respiratory distress syndrome, gestational diabetes 1. scunthorpe general hospital, united kingdom doi: http://dx.doi.org/10.31344/ijhhs.v5i0-2.322 http://dx.doi.org/10.31344/ijhhs.v5i0-2.322 s21 case of nait causing severe thrombocytopenia due to anti-hla class i noor aqilah binti ashamuddin1, dr sabariah binti mohd noor1, dr irni binti mohd yasin1 abstract neonatal alloimmune thrombocytopenia (nait) is the leading cause of thrombocytopenia in otherwise healthy new-born. (1,2) maternal antibodies raised against paternally inherited alloantigen carried on fetal platelet causing nait. maternal igg antibodies passed through to the fetal via the placenta, attack and cause the destruction of the fetal platelet. (3) we present a case of nait without any complications in a premature baby (35 weeks) with vacrel association, g6pd deficiency, left calcified cephalohaematoma, cardiomegaly and hypospadias with severe thrombocytopenia (platelet counts is 23 109/l) at day two of life and received twice platelet transfusion. platelet count initially 123 109/l at birth but significantly drop and persistently less than 50 109/l until day 10 of life before it normalized. maternal serum antibody screening was negative, but platelet immunology test detected maternal platelet-reactive antibody anti-hla class i and correlates with incompatible parental crossmatch indicating that parent had “platelet-antigen incompatibility”. the goal of obstetric management is to identify pregnancies at risk and prevent intracranial haemorrhage. (4) there is no evidence to support routine screening for pregnancies as per current practice. (2, 5) the latest treatments include maternal administration of intravenous immunoglobulin to suppress maternal antibody production and or to reduce placental transfer of antibodies; with or without steroids during antepartum period besides planning of mode, timing and method of delivery. (2, 5, 6, 7) this is a rare and unique case of nait secondary to anti-hla class i antibody and hence clinician should be au fait with the diagnosis and management as it is infrequent among malaysian. keywords: neonatal alloimmune thrombocytopenia (nait), anti-hla class i, platelet antibody 1. hospital raja permaisuri bainun, ipoh, perak, malaysia doi: http://dx.doi.org/10.31344/ijhhs.v5i0-2.339 http://dx.doi.org/10.31344/ijhhs.v5i0-2.339 international journal of human and health sciences. supplementary issue: 2019 doi: http://dx.doi.org/10.31344/ijhhs.v0i0.136 s18 interactive patients’ digital interface: a shari’ah compliant model: patient care system pacsystm tn hj. shaharom md shariff an nur specialist hospital, bandar baru bangi, selangor abstract a fully integrated bedside solution helps to engage and entertain patients, making their stay in hospital more comfortable and supporting smoother day-to-day hospital running, enhancing efficiency, enabling faster recovery and supporting optimal clinical workflow for healthcare providers. pacsys™ designed by medic ig infotech sdn bhd, a subsidiary of medic ig holdings sdn bhd, is an interactive bedside solution that delivers a wide range of tv channels, an extensive on-demand video library, internet connectivity and a reliable shari’ah complia nt solution. it is the most comprehensive and interactive hospital media system available on the market today. our partnership with telekom malaysia makes our hospital interactive shari’ah compliant solution second to none. designed for the healthcare environment, pacsys™ not only meets patients’ entertainment and communication needs, but also provides extensive opportunities for hospitals to engage further through our range of powerful patient engageme nt and clinical solutions. providing patients with access to entertainment can be extremely useful in keeping patients distracted, calm, and rested, and in the best possible condition to respond to treatment. due to the shari’ah compliant hospital requirement, the access to entertainment is being filtered through salam web technologies™ which provides the filtering process in denying access to view non halal websites. pacsys™ was designed with the hospital environment in mind, providing patients with a wide range of multimedia services to keep them entertained and in touch with the outside world and delivers a selection of popular tv channels. pacsys™ gives clinicians secure, direct access to the hospital information system at the point of care, poc. clinicians use poc to view medical records, order and verify medication, and share patient scans and test results—right at the bedside. patients have access to educational materials, satisfaction surveys and other helpful tools through pacsys™. medical staff can access videos, audio files, and documents to educate patients on shari’ah related matters example prayer (solat), fasting and other islamic knowledge and practices. hospitals can prompt participation in patient surveys to collect real-time, actionable information on satisfaction scores. international journal of human and health sciences. supplementary issue: 2021 s24 home medication review by hospital tuanku fauziah: carers’ perspectives wei chern ang1,2, jurisma che lah2, nursyafiqah zulkepli2, nursyamimi sukri2, amalina rosedi2 1clinical research centre, hospital tuanku fauziah, ministry of health malaysia, perlis; 2department of pharmacy, hospital tuanku fauziah, ministry of health malaysia, perlis doi: http://dx.doi.org/10.31344/ijhhs.v5i0.315 introduction: home medications review (hmr) is a continuation of patient care from health facilities to their home to assess patients’ pharmacotherapy by a multidisciplinary team. bedridden patients were the main group who received this service. to improve the provision of hmr, we need to understand carers’ viewpoints of the current service. objectives: to explore the carers’ perspectives of hmr conducted by the medical outreach team (mot) of hospital tuanku fauziah. methods: this is a qualitative study conducted among carers who were involved in the hmr programme for more than six months. subjects were recruited by purposive sampling from august 2019 to december 2019. in-depth interviews were audio-recorded at patients’ homes until data saturation and transcribed verbatim. the transcripts then underwent thematic data analysis. results: nine carers were interviewed. all participants had a limited understanding of hmr since they were not properly counselled prior to admission to the programme. the convenience of not having to go to the hospital was perceived as the major benefit of the programme. healthcare providers were welcomed during each visit. recognising allied health professionals in the mot possesses a problem for some carers. there was a concern about having to collect newly add-on medications from the hospital. some participants suggested increasing the frequency of visits and hope for more financial aids. conclusion: this study proved that carers’ understanding of hmr was generally poor. all carers were satisfied with the current hmr programme provided by the mot. however, several aspects of our hmr need to be improved. despite the covid-19 situation that puts hmr onhold and telemedicine have been adapted, hmr is here to stay in the post-covid-19 era. this is supported by studies conducted in the pre-covid-19 era that hmr is more beneficial than telemedicine due to the personal touch of face-to-face encounters. keywords: home care services, allied health personnel, caregivers, qualitative research, covid-19 http://dx.doi.org/10.31344/ijhhs.v5i0.315 international journal of human and health sciences. supplementary issue: 2019 doi: http://dx.doi.org/10.31344/ijhhs.v0i0.149 s31 trio-preparation of health care students for digital era in universiti malaysia sabah – case study maher safien, deena c. thomas, richard avoi, mohamed firdaus, fairrul bin masnah@kadir, mohammad safree bin jaffree university malaysia sabah, kota kinabalu, sabah, 88400, malaysia abstract introduction: creating an educational climate that engages the students in the digital era is crucial as it prepares them for the future. objectives: the aim of this multiple case study is to highlight the impact of creative educational environment on the students’ awareness of digital era tools. methods: in this study three activities were organized. firstly, a brain storming seminar titled “medical practice in artificial intelligence era” was held. the second event was e-poster competitions which challenged the students’ curiosity to address the health problems and to introduce innovative solutions to solve it. medical and nursing students presented 32 posters. third activity was meduino, a hands-on workshop to familiarize the students with arduino technology in medical practice. results: around 260 participants attended the seminar. in their feedback, 72% of students found the topics attractive and more than 60% found its theme relevant and beneficial. e-poster competition was evaluated using a modified rubric scale. the data was analysed by spss showed that only “creativity” and “practicality” merits scored little above the mean range. there was no statistically significant difference in the mean score of ‘creativity’ and ‘practicality’ between medical students and nursing students. however, in general medical students’ scores were higher compared to nursing students. 90% of students said that they improved cognitively and 85% found it fascinating. in meduino workshop (robotics), the 30 participants practiced mini projects. 86 % found it attractive, 81% expressed that it improve d their cognitive about technology as noted in comparing the pre and postevent questionnaires. the students’ concerns included the time constraints short time and lack of lecturers’ guidance during posters’ preparation. conclusion(s): transforming educational environment physically, emotionally and socially managed to address few aspects digital era. allocating more time, facilities and training in the informal curriculum could enhance health-care students mastering of future tools. keywords: e-poster, creativity, robotics, educational environment. microsoft word ijhhs imam 23rd asc 2022 s9 sponsored plenary influenza – beyond respiratory illness musa mohd nordin1 annual epidemics of seasonal influenza cause hundreds of thousands of deaths, high levels of morbidity, and substantial economic loss. global influenza circulation has been heavily suppressed by public health measures and travel restrictions during covid-19 pandemic. as many countries are now transitioning to covid-19 endemic state, restrictions have been loosened or been lifted entirely, creating an opening for influenza and other respiratory viruses. as such, many more people might catch the flu and potentially be at risk of serious illness. although influenza is primarily considered a respiratory infection and causes significant respiratory mortality, evidence suggests that influenza has an additional burden due to broader consequences of the illness. some of these broader consequences include cardiovascular events, exacerbations of chronic underlying conditions, increased susceptibility to secondary bacterial infections, functional decline, and poor pregnancy outcomes, all of which may lead to an increased risk for hospitalization and death. flu vaccination could be more important than ever now, both to protect those most at risk, as well as to protect health systems that are already under pressure due to covid-19. the world health organization (who) and the centers for disease control (cdc) recommends that almost everyone aged 6 months and older get a seasonal flu vaccine each year. flu vaccines are updated each season to keep up with changing viruses. also, immunity wanes over a year so annual vaccination is needed to ensure the best possible protection against the flu. despite health authorities’ recommendation, many at-risk adults are not aware of the impact of influenza and the importance of prevention. healthcare provider’s recommendation can make a difference. clinicians are the most valued and trusted source of health information for adults. cdc recommended a systematic communication to help patients make an informed decision about vaccinations. keywords: vaccine; flu, covid-19; immunity 1. kpj damansara hospital, petaling jaya, selangor. ___________________________________________________________________________ correspondence to: dato’ dr musa mohd nordin, consultant pediatric neonatologist, kpj damansara hospital, petaling jaya, selangor. musamn@gmail.com __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v7i70.512 s4 az-zahrawi memorial lecture psychospirituality in medicine mohamed hatta shaharom “o allah, most benevolent, most merciful. we seek your guidance and blessings in our efforts to gain knowledge; and to be instruments of your mercy as we serve humankind regardless of race or creed.” the psychospiritual domain of the four-domain holistic approach to health has been a reality without a name during the ascent of western modern or conventional medicine of the 19th and the greater part of the 20th centuries common era (ce). the focus then was on the biomedical model of medicine. alongside this, the 1900 interpretation of dreams of sigmund freud (pronounced: froid) ushered in a new era of psychoanalysis and sexual liberalism that influenced the whole of western life, including medicine. freud considered religion as a neurosis, a manifestation of ill health. just as freud was about to be dethroned from the altar of western secular psychology, george engel conceptualised the biopsychosocial model in health and medicine in 1977 ce. by the late 1980s, research on the role and effects of spirituality on health and illness appeared on the horizon of scientific research. spirituality may include or exclude the role of religions in a person's life. since time immemorial, spirituality has always existed in the paradigm of those who espoused religiosity in their lives. now as we approach the year 2022 ce, the psychospiritual role in health and illness is considered part and parcel of holistic health. any discussion and training in medicine that is without the inclusion of the psychospiritual sciences must be considered incomplete. it is trendy and a necessity now to discuss mental health during this sars-cov-2 onslaught, along with the disease that it brings. every medical student understands and appreciates the universality of psychological or mental health. however not all medical practitioners appreciate the necessity of the spiritual domain to complete the four-domain holistic paradigm in life and medicine. fortunately, a growing number of therapists and clinicians are able to see the potential of spirituality in the management of patients of various beliefs including the whole range of believers and non-believers; among them are atheists, agnostics, narcissists, the religious and the secular. the uninitiated and the cynic may argue that spirituality is not a panacea, i.e. a cure for all ills. however, for the discerning therapist and the insightful clinician, spirituality is functional in treatment or ‘ilāj ( ,)عالج as the client and patient inch along in the process of healing or shifā’( .)شفاء even in the prevention or al-wiqāyah ( الوقاية) of illnesses, the spiritual domain must never be ignored. since the spiritual domain is a reality in life, it has a significant part to play in preserving health and the treatment of illness. “enlightened medicine is a practice humbled in the presence of the divine, and evidenced by the signs of the divine.” keywords: psychospiritual, spirituality, holistic, mental health ___________________________________________________________________________ correspondence to: mohamed hatta shaharom, president, malaysian society of psychospiritual therapy, malaysia. email: hattashaharom@yahoo.com __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v6i0.394 mailto:hattashaharom@yahoo.com international journal of human and health sciences vol. 05 no. 03 july’21 372 case report spontaneous regression of osteochondroma – a rare phenomenon chia kok king1, juhara haron2, nik fatimah salwati nik malek3 abstract background: osteochondroma is a common benign bone tumour, but its spontaneous regression is a rare occurrence. the first case was reported by hunter in 1786. and only 30 cases were found in literature to date. spontaneous regression of osteochondroma usually occurs in paediatric age group prior to skeletal maturation without any sequelae. the exact pathophysiology of its spontaneous regression is still not fully understood. we report a case of spontaneous regression of osteochondroma in a child after a 6-year period of follow up without needing any surgical intervention. keywords: osteochondroma, bone, tumour, spontaneous regression, paediatric correspondence to: juhara haron, associate professor and consultant radiologist, dept. of radiology, school of medical sciences and hospital universiti sains malaysia, universiti sains malaysia, kelantan, malaysia. e-mail: drjuhara@usm.my 1. chia kok king, radiology trainee, dept. of radiology, hospital universiti sains malaysia, kelantan, malaysia 2. juhara haron, associate professor and consultant radiologist, dept. of radiology, school of medical sciences and hospital universiti sains malaysia, universiti sains malaysia, kelantan, malaysia 3. nik fatimah salwati nik malek, head of department and consultant radiologist, dept. of radiology, hospital sultanah bahiyah, kedah, malaysia international journal of human and health sciences vol. 05 no. 02 april’21 page : 372-374 doi: http://dx.doi.org/10.31344/ijhhs.v5i3.291 introduction osteochondroma is a common benign bone tumour that typically develops during childhood with very low malignant potential. it is characterised by a bony protuberance with a cartilage cap.1 the bone lesion can be pedunculated or wide-based sessile in appearance, and the lesion must be in trabecular continuity with the host osseous medullary canal.2 it most commonly arises from appendicular bone, with distal femur being the most common location.3 most patients with osteochondroma are asymptomatic. however, some patients may experience uncomfortable sensation due to the impingement to nearby soft tissues causing neural compression, vascular compression, bursitis, and fracture in case of trauma. about 1% of the solitary osteochondroma may have the potential of malignant transformation, leading to the decision of surgical resection. 1 the symptomatic lesion is another frequent indication for surgery.3 however, spontaneous regression of osteochondroma had been reported as the child grows, where surgical resection is unnecessary. the current treatment of osteochondroma is mainly conservative. however, surgical resection is frequently offered in complicated cases, malignant transformation and for a cosmetic purpose.3 the regression potential of osteochondroma is highlighted in this article. case report a 12-year-old girl presented with initial progressive focal left thigh swelling with intermittent pain for two months. physical examination revealed a focal swelling which was firm in consistency, measuring 5.0 x 4.0 cm at the medial aspect of the left thigh. no overlying skin dystrophic 373 international journal of human and health sciences vol. 05 no. 03 july’21 change. the swelling did not cause a restriction in daily activities. a pedunculated cauliflower-like osteochondroma at the medial part of the distal femur was confirmed on plain radiograph and mri with a thin fibrous cartilage cap. she was managed conservatively with yearly follow up with radiograph for over six years, which she only complained of minimal discomfort on pressure without any significant pain. figure 1: ap view of left knee plain radiograph on (a) initial visit and (b) after six years, showing the 30% reduction in the size of the osteochondroma. figure 2: mri of the left knee in coronal reconstruction. thin fibrous cartilage cap (arrow) which appears hypointense on (a) t1-weighted image and hyperintense on (b) t2-weighted image. the radiograph at six years follow up showed loss of cauliflower-like appearance, as well as a 30% of size reduction. a repeat mri revealed the disappearance of the fibrous cartilage cap. the finding is consistent with spontaneous regression of osteochondroma. no feature of malignant transformation was observed on mri. she was treated conservatively with surveillance mri. figure 3: mri fat-saturated t2-weighted images of the left knee in coronal and axial reconstructions on (a, c) initial visit and (b, d) after six years, showing the disappearance of hyperintense fibrous cartilage cap (arrow). discussion hunter reported the first case in 1786, which then published in 1835.4 currently, only 30 case reports of spontaneous regression were reported ever since.5 spontaneous regression of osteochondroma usually occurs in the paediatric age group before skeletal maturation without any sequela. the exact pathophysiology of its spontaneous regression is still not fully understood. however, three theories were proposed to explain the mode of regression: 1. incorporation theory: osteochondromas maturing before growth plate closure are incorporated into bone growing in the vertical axis.6 2. absorption theory: after growth plate closure, some osteochondromas will be repaired via the remodelling process, resulting in regression of the tumour.7 3. fracture theory: fracture of an osteochondroma activates the physiological process of tumour resorption.8 vanishing osteochondroma was also reported in the literature when more than 70% decreased in tumour dimension was observed.5 in our patient, the osteochondroma is regressing before growth plate closure supporting the incorporation theory. no trauma was reported international journal of human and health sciences vol. 05 no. 03 july’21 374 in our patient. no sign of fracture of the osteochondroma was found on plain radiographs and mri. the limitation of our case report is due to the lack of histopathological diagnosis. however, osteochondroma is radiologically pathognomonic when there is a bony protuberance with trabecular continuity with the host bone on plain radiograph and cartilage cap on mri. conclusion spontaneous regression of osteochondroma is a rare phenomenon, but regression can be anticipated in a growing child. regular clinical and short-term imaging follow-up of the osteochondroma before skeletal maturation can be helpful in the treatment decision, as well as early detection of malignant transformation. conflict of interests the authors declare that they have no conflict of interests. funds nil authors’ contributions conception and design: ckk. collection and assembly of data: ckk, nfsnm. critical revision of the article for important intellectual content: jh. references: 1. czerniak b. dorfman and czerniak’s bone tumors. in: dorfman and czerniak’s bone tumors. 2015. p. 331–3. 2. hill ce, boyce l, van der ploeg id. spontaneous resolution of a solitary osteochondroma of the distal femur: a case report and review of the literature. j pediatr orthop part b. 2014; 3. murphey md, choi jj, kransdorf mj, flemming dj, gannon fh. imaging of osteochondroma: variants and complications with radiologic-pathologic correlation. radiographics. 2000;20(5):1407–34. 4. palmer jf. the works of john hunter with notes. longman; 1835. 5. h. a, s. y, n. y, k. h, s. m, h. t, et al. spontaneous shrinkage of solitary osteochondromas. skeletal radiol. 2018; 6. paling mr. the “disappearing” osteochondroma. skeletal radiol. 1983;10(1):40–2. 7. copeland rl, meehan pl, morrissy rt. spontaneous regression of osteochondromas. two case reports. jbjs. 1985;67(6):971–3. 8. castriota-scanderbeg a, bonetti mg, cammisa m, dallapiccola b. spontaneous regression of exostoses: two case reports. pediatr radiol. 1995;25(7):544–8. 95 international journal of human and health sciences vol. 07 no. 01 january’23 case report lethal complicationin a newly diagnosed patient with hypertension najwan mustafa alsulaimi abstract polyarteritis nodosa (pan) is a rare but lethal systemic vasculitis that affects the mediumsized arteries. although it is mostly idiopathic, few underlying etiologic agents have been identified and cause secondary pan. hepatitis b virus (hbv) is one of them. early recognition of hbv-associated pan is critical to improve the patient’s outcomes. we describe a case of 59-year-old gentleman who presented to multiple medical facilities over a few months with non-specific symptoms of unexplained abdominal pain and weight loss in addition to a new onset of hypertension. his clinical course deteriorated, and he was admitted to the intensive care unit with a hemorrhagic shock before he was diagnosed and treated for hbv-associated pan resulted in renal arterial microaneurysms rupture. this case highlighted the importance of early management of pan to prevent its fatal consequences. therefore, we recommend screening for hbv or considering pan – especially where hbv is endemic – in patients presenting with non-specific symptoms and unexplained weight loss with a new-onset diastolic hypertension. keywords:hepatitis b virus, polyarteritis nodosa, diastolic hypertension correspondence to: dr. najwan mustafa alsulaimi, department of internal medicine, faculty of medicine, king abdulaziz university, jeddah, saudi arabia. email: nalsalaimi@kau.edu.sa introduction hepatitis b virus (hbv) is one of few infectious agents which causes secondary polyarteritis nodosa (pan). pan is a rare multi-organ necrotizing vasculitis and has a high mortality rate of 34 percent1. pan can be categorized as primary or secondary. secondary pan needs prompt treatment of the underlying etiology for survival. we present a middle-aged man with a newly diagnosed hbv infection manifesting as lifethreatening pan. we also discuss hbv-associated pan with an emphasis of reviewing its clinical presentations for the purpose of improving early detection in the primary care settings. case description a 59-year-old man presented to multiple clinics and emergency departments over a three-month period reporting intermittent abdominal pain, anorexia, and approximately sixteen kilograms of unintentional weight loss. initial computed tomography (ct) of the abdomen, esophagogastroduodenoscopy (egd), and colonoscopy were grossly unremarkable. he was sent home from the emergency department (ed) with a new diagnosis of hypertension. he later returned to the ed with ongoing symptoms in addition to severe fatigue. on further assessment, he had a fever of 38.5 degrees celsius, tachycardia, and leukocytosis. he was started on broad-spectrum antibiotics and admitted with a presumed sepsis diagnosis with unknown source. despite antibiotic therapy, he had persistent abdominal pain, leukocytosis and rising levels of inflammatory markers which led to consideration of connective tissue diseases and repeat ct of the abdomen. the new ct showed innumerable renal arterial aneurysms and wedgeshaped infarcts in the kidneys bilaterally. high dose corticosteroids were initiated for the diagnosis of idiopathic pan. the next day, he developed acute worsening of abdominal pain and was transferred to the intensive care unit for hemorrhagic shock. an emergent ct angiogram (cta) showed left perinephric hemorrhage with an area of active arterial contrast extravasation suggestive of renal aneurysmal hemorrhage (figure 1). the hemorrhage was successfully controlled with endovascular embolization (figure 2). additional international journal of human and health sciences vol. 07 no. 01 january’23 page : 95-98 doi: http://dx.doi.org/10.31344/ijhhs.v7i1.505 international journal of human and health sciences vol. 07 no. 01 january’23 96 work-up revealed an active hbv infection with hbv dna pcr of 28 million international unit/ ml. a multi-disciplinary team of rheumatologists, nephrologists and infectious disease physicians were involved, and a combination treatment of corticosteroids, anti-viral regimen and plasmapheresis was initiated. a positive response in clinical symptoms, a decreased level of viremia, a stability of aneurysms on imaging and decreased level of inflammatory markers were achieved and maintained over a two-month outpatient follow-up. figure 1: left perinephric hemorrhage with an area of active arterial contrast extravasation best visualized on cta coronal image and likely from renal aneurysm rupture figure 2a: left renal arteriogram image demonstrates small extravasation emanating from a microaneurysm within the left upper renal pole figure 2b: left renal arteriogram post embolization image demonstrates no further signs of bleeding with coils in place discussion hbv has been identified as the underlying etiology in 7 to 36 percent of pan cases 2. based on the prevalence of hbv infection in a population, the annual incidence of pan has been reported to be between 2 and 77 per million2. the lower prevalence has been seen in the countries with effective hbv immunization and blood products screening programs2. hbv-associated pan commonly complicates the picture early in the course of hbv infection and is infrequently co-occurred with jaundice or the typical hepatitis manifestations and laboratory findings2. since pan is a systemic disease, it may affect almost any organ with the exception of the lungs3. early presenting symptoms are usually non-specific such as polyarthralgia, fatigue, fever, and abdominal pain which have broad differential diagnoses. in this phase, the findings of elevated blood pressure specifically new diastolic hypertension, and unintentional weight loss can be important clues. eventually, the focal symptoms developed due to involvement of the vasculatures of specific organ systems such as the kidneys, the skin and the nervous system4. the american college of rheumatology (acr) has established ten criteria to help the clinical diagnosis in a suspected pan case. the presence of three criteria or more, has been associated with the sensitivity and specificity of 82.2 precent and 86.6 precent respectively in a cohort of patients with vasculitis5. in our patient, 97 international journal of human and health sciences vol. 07 no. 01 january’23 four of these criteria were met; unexplained weight loss of four or more kilograms, new onset elevated diastolic blood pressure of greater than 90 mmhg, evidence of hbv infection, and the characteristic arteriographic abnormalities of microaneurysms in the renal arteries. conclusion hbv immunization has made secondary pan rare, making it lower on the differential of diagnosis for the frontline healthcare providers such as internal medicine, emergency medicine and family medicine physicians. the early diagnosis and treatment of pan is crucial given the high morbidity and mortality associated with delayed management. a new diagnosis of hypertension in a patient with weight loss, fatigue, or unexplained abdominal pain may warrant screening for hbv or consideration of pan. references 1. pagnoux c, seror r, henegar c, mahr a, cohen p, le guern v, et al. clinical features and outcomes in 348 patients with polyarteritis nodosa: a systematic retrospective study of patients diagnosed between 1963 and 2005 and entered into the french vasculitis study group database. arthritis & rheumatism. 2010;62(2):616–26. 2. sharma a, sharma k. hepatotropic viral infection associated systemic vasculitides—hepatitis b virus associated polyarteritis nodosa and hepatitis c virus associated cryoglobulinemic vasculitis. journal of clinical and experimental hepatology. 2013;3(3): 204-12. 3. guillevin l, mahr a, callard p, godmerp, pagnoux c, leray e, et al. hepatitis b virus-associated polyarteritis nodosa: clinical characteristics, outcome, and impact of treatment in 115 patients. medicine. 2005;84(5):313-22. 4. han sh. extrahepatic manifestations of chronic hepatitis b. clinics in liver disease. 2004;8(2):403-18. 5. lightfoot rw jr, michel ba, bloch da, hunder gg, zvaifler nj, mcshane dj, et al. the american college of rheumatology 1990 criteria for the classification of polyarteritis nodosa. arthritis and rheumatism. 1990;33(8):1088-93. international journal of human and health sciences vol. 07 no. 01 january’23 98 47 international journal of human and health sciences vol. 05 no. 01 january’21 original article : forecasting of content ca 125 endometriosis using logistic regression model sardjana atmadja1, gulam gumilar2 abstract objective : this study is to prove that there is a significant relationship between the absence of students participating in activities at school / on campus and the symptoms of primary dysmenorrhoea experienced during menstruation. endometriosis is characterized as pain under the abdomen during menstruation. in addition, this study is also to obtain a profile of students and factors that influence primary dysmenorrhoea. a logistic regression model has been used to assess the main factors of dysmenorrhoea among these students. methods : the study was conducted at the rsk permata hati malang. a total of 123 students were randomly selected in this study. the factors observed were menarche, menstruation, menstruation period and blood loss volume and ca 125 level. from the logistic regression model, it was found that there were three factors that influence the occurrence of dysmenorrhoea among students, namely menarche, menstruation period and menstrual blood volume. results: the hosmer and lemeshow test showed that the measurement model of ca 125 levels in endometriosis was appropriate (chi squar test value was 2.847 with p-value = 0.416). instead of press. (3) and eq. (4), it was found that the contributors to dismenortea were menstrual length, menstrual discharge and the beginning of menarche. by looking at the odds ratio it is found that the risk of students experiencing dysmenorrhoea is (i) 2.5 times higher for those with longer menstrual periods (ii) 3.7 times higher for those who have menstrual expenditure which is a little and (iii) three times higher for those who have mined it for more than 13 years. conclusion: significant ca 125 levels were obtained for students and students suffering from dysmenorrhoea. the study also found that the risk of getting dysmenorrhoea increased if students and students had menstrual periods longer than 35 days, menstrual expenditure levels were small and menarche was more than 13 years old. keywords: ca 125 level, logistic regression model; dysmenorrhoea and menarche. correspondence to: sardjana atmadja, professor, department of obstetrics and gynecology syarif hidayatullah state islamic university jakarta. email : sardjana_spog@yahoo.com 1. sardjana atmadja, professor, department of obstetrics and gynecology syarif hidayatullah state islamic university jakarta 2. gulam gumilar, assistant professor, department of obstetrics and gynecology gajahmada university yogyakarta. international journal of human and health sciences vol. 05 no. 01 january’21 page : 47-49 doi: http://dx.doi.org/10.31344/ijhhs.v5i1.232 background the use of logistic regression models has grown rapidly along with advances in medical science and technology (iptekdok). the use of logistic regression in the field of clinical epidemiological inquiry has been used extensively in fields such as biomolkuler, ecology, clinical pharmacological investigations. logistic regression analysis was first reserved by cox (2010). the logistic regression model is a test of a linear linear model as introduced by nelder and wedderburn (2012). hosmer and lemeshow (2000) have discussed logistic regression models. this paper discusses the use of logistic regression models to predict endometriosis among malang students. dysmenorrhoea is pain that is felt under the abdomen during menstruation. dysmenorrhoea is a pain often faced by women. endometriosis can cause students to not attend school / college. sardjana (2018) has found that 20% of malang students experience endometriosis and cannot go to school. syamsul and colleagues (2017) report that 10% of career women experience serious pain caused by dysmenorrhoea and are not allowed to work. alkaff (2016) reported that 52% of students in yogyakarta were unable to do their daily international journal of human and health sciences vol. 05 no. 01 january’21 48 activities well during menstruation. data the study was conducted among students. a total of 123 students were randomly selected to answer the research questionnaire. five non-leaning scales were selected for analysis. schedule 1. change of study changes to coded letters kod dys experincing dismenorea or no dura 1 menstrual period leng 1 long time around menstruation menarke the beginning of the menarche mens 1 level of expenditure reg menstruation is normal logistic regression model if π (x) = e (y / x) is a conditional min if the distribution of logistics is used, then the logistic regression model is defined as follows: π(x) =             −+ ∑ = n i i i 1 0exp1 1 χββ (1) where β0, β1, ..., βn are for non-leaning allowances and x1, x2, ..., x¬n are non-leaning change makers. logit incarnation of terhadap (x), provides logit for logit regression models for logistic regression models such as the following: g(x) = in ( ) ( )       − x x λ λ 1 = β0 + β1x1 + … + βnxn (2) results and analysis step 2 provides pertinaian statistics as well as two chi-square tests conducted to determine whether there are differences between herds with dysmenorrhoea and non-dysminorrhea. from the steps it was found that the level of menstrual discharge and menstrual length gave a significant difference to dysmenorrhoea. although menarche, the prevalence of menstruation and menstrual period is not meaningful. using the backward logistic regression method using the exclusion criteria through the probability ratio test, the linear logistic regression model is given as follows: π(x) = ( ){ }321 077,1132,1916,0099,0exp1 1 xxx −+−−+ (3) where x1 is the menstrual period, x2 is the rate of menstrual expenditure and x3 is the beginning of menarche. schedule 2. menstrual cycle patterns for students characteristic dismenorea n = 71 not dismenorea n = 52 p-value for the khikuasadua test menarke min sisihan piawai 11-12 year 13 year 14-16 year 12,86 1,23 32 24 15 12,98 1,20 23 11 18 0,770 normal menstruation 58 44 0,400 not normal 13 7 tempoh kitaran <= 30 hari > 30 hari 57 9 35 14 0,048 periode menstruaation <= 6 day > 6 day 42 28 26 24 0,383 menstrual discharge levels lots a little 48 22 46 6 0,010 then, the logit for the logistic regression model is given by: g(x) = in ( ) ( )       − x x λ λ 1 = 0,099 – 0,916x1 + 1,312x2 1,077x3 (4) the hosmer and lemeshow tests show that the model fits well (the value of the second chi-power test is 2.847 with a p-value = 0.416). instead of press. (3) and eq. (4), it was found that the contributors to dismenortea were menstrual length, menstrual discharge and the start of menarche. by looking at the odds ratio it is found that the risk of students experiencing dysmenorrhoea is (i) 2.5 times higher for those who have high menstrual cycle periods, (ii) 3.7 times higher for those who has a small amount of menstrual expenditure and (iii) is three times higher for those who have menarcheenya more than 13 years. conclusion from the research it was found that the prevalence of dysmenorrhoea among malang students was 58% and 20% reported being unable to attend college due to dysmenorrhoea. press (4) provides 49 international journal of human and health sciences vol. 05 no. 01 january’21 the logit for a logistic linear regression model. from this model, it can be concluded that the three factors that influence dysmenorrhoea are the length of the menstrual period, the level of menstrual discharge and the start of menarche while the menstrual period and the prevalence of menstruation are not significant. this decision is the same as the research conducted by andersch and milsorm (in ng and colleagues (2012)). other studies such as harlow and park (in ng and colleagues (2012)) and sundell and colleagues are ng and colleagues (2012)] found dysmenorrhoea is influenced by several alterations including menarche and increased menstrual tempo. the study also found that the risk of experiencing dysmenorrhoea increases if students have a high menstrual cycle tempo, levels of menstrual expenditure are low and menarche is more than 13 years old. reference: 1. alkaf f ( 2016 ).terapi pilihan endometriosis. yogyakarta bp 19 : 911 2. cox, d.r. (2010). the analysis of binary data. london: methuen and co. 3. hosmer, d.w. dan lemeshow, s. (2010). applied logistic regression, second edition. john wiley & sons. 4. htut, y., amran, a. dan shukri, y.a (2017). a prevalence study of dysmenorrhoea in students from universiti sains malaysia, perak branch campus, tronoh. medical journal of malaysia, 51: 264-269. 5. nelder, j.a. dan weddeburn, r.w.m. 2012. generalized linear models, jour. rpyal statistical soc. a, 135: 370-384. 6. ng, t.r., tan, t.c. dan wansaicheong, g.k., (2012). a prevalence study of dysmenorrhoea in female residents aged 15-54 years in clementi town, singapore, annals acad. med. singapore, 21(3): 323327. 7. samsul h ( 2017 ). terapi alternative endometriosis. sby,13 : 45 8. sardjana ( 2018 ) . prevalensi endometriosis pelajar dan mahasiswi di malang.pit 2000,22: 2327 251 international journal of human and health sciences vol. 05 no. 02 april’21 case report: pleuropulmonary solitary fibrous tumour with paraneoplastic syndrome ummu afeera zainulabid1, megat razeem abdul razak2, nor hafliza md salleh3, noriah othman4, dahlia mohamed5 abstract: the pleuropulmonary solitary fibrous tumour (sft) is a rare type of tumour. this paper outlined a 63-year-old female who came to the hospital with two weeks history of chronic cough, shortness of breath, and hypoglycemia. contrast-enhanced ct thorax showed a huge heterogeneously-enhancing mass occupying the right hemithorax. us-guided biopsy followed by histological examination showed the features of an sft. in view of the association between pleuropulmonary sft and hypoglycaemia, the patient was highly likely to be suffering from a paraneoplastic syndrome known as doege-potter syndrome. keywords: solitary fibrous tumour, doege potter syndrome, superior vena cava obstruction. correspondence to: dr. ummu afeera zainulabid, internal medicine specialist & medical lecturer, department of internal medicine, kulliyyah of medicine, international islamic university of malaysia, kuantan, malaysia. e-mail: ummuafeera@iium.edu.my 1. internal medicine specialist & medical lecturer, department of internal medicine, kulliyyah of medicine, international islamic university of malaysia, kuantan, malaysia. 2. pulmonologist, tengku ampuan afzan hospital, kuantan, malaysia. 3. pathologist, tengku ampuan afzan hospital, kuantan, malaysia. 4. pathologist, serdang hospital, kajang, selangor, malaysia. 5. radiologist, sultan haji ahmad shah hospital, temerloh, pahang, malaysia. international journal of human and health sciences vol. 05 no. 02 april’21 page : 251-253 doi: http://dx.doi.org/10.31344/ijhhs.v5i2.269 introduction the pleuropulmonary solitary fibrous tumour (sft) often follows a silent clinical course until the tumour size is large enough to produce compressive symptoms. in certain cases, sft presents with paraneoplastic syndromes one of the most commonly encountered being the doege-potter syndrome. doege-potter syndrome is a paraneoplastic syndrome that presented with hypoglycaemia as a result of non-islet cell tumours like sft. case report a 63-year-old female, non-smoker, non-diabetic initially presented to a district hospital with a twoweek history of cough associated with difficulty in breathing and constitutional symptoms. clinical examination revealed an elderly cachexic lady with a tracheal shift to the left side, reduced breath sound and dullness to percussion in the right lung. other examinations were unremarkable. the chest radiograph showed a homogenous opacity obscuring the right hemothorax. there was also a mediastinal shift with tracheal deviation to the left. contrast-enhanced ct thorax showed a huge heterogeneously-enhancing mass occupying the right hemithorax. it measured approximately 16.4 cm x 16.5 cm x 21.1 cm. minimal residual collapsed lung was noted in the right apical region. pleural tapping was done at the district hospital. the pleural fluid was exudative in nature. the patient was also found to have unexplained hypoglycemia. she was initially thought to have adrenal metastasis from the lung and started on iv hydrocortisone 100mg tds. however, the hypoglycemia persisted. her condition worsened and she was transferred to our care in the tertiary hospital. she was then put on non-invasive ventilation. she was found to have superior vena cava syndrome (svcs) as evidenced by the venous distention in the neck, upper chest, and arms as well as facial swelling. in view of that, she was immediately started on high dose iv dexamethasone. following that, the svcs and refractory hypoglycemia improved remarkably. once her condition improved, a trucut biopsy of right lung mass was done under ultrasound guidance. microscopically, the section showed spindle to oval-shaped tumour cells. the international journal of human and health sciences vol. 05 no. 02 april’21 252 figure 1: contrast-enhanced ct thorax in axial, coronal, and sagittal images show a huge heterogeneously-enhancing mass occupying the right hemithorax with massive right pleural effusion. hypocellular and hypercellular areas were seen within a ropey collagenous stroma. pericytic vascular patterns were also visible. the tumour cells displayed round to oval nuclei, mild to moderate nuclear atypia, and pale indistinct cytoplasm. occasional multinucleated or large atypical tumour cells were present. mitotic figures were present and seen ( seven mitoses per 2mm). no marked nuclear pleomorphism or bizarre tumour cells were noted. there was no necrosis or haemorrhage. figure 2: a) the biopsy shows spindle to oval-shaped tumour-h&e 100x magnification. b) pericytic vascular pattern (yellow arrow)-h&e 100x magnification. c) multinucleated tumour cells (red arrow)-h&e 200x magnification. d) multinucleated tumour cells (star)h&e 400x magnification. the tumour cells were positive for cd34, bcl2, cd99, and stat 6 with patchy ck ae1/ae3 positivity. based on the histological findings, a diagnosis of a solitary fibrous tumour (sft) was reached. they were negative for ck7, ema, and ttf1. the patient was referred to the national oncology centre in hospital kuala lumpur for the continuation of care. figure 3: immunohistochemistry for cd34, bcl2, and cd99 are positive – 200x magnification. discussion sft was first described in 1931. it has been described with various nomenclatures, including solitary fibrous mesothelioma, pleural fibroma, and others. sft may present in patients of all age groups but it is most commonly encountered among those aged 50-70 years.1 in this case report, the patient was found to have a very large sft in the right lung. the lesion occupied the right hemithorax, leading to massive right pleural effusion. intrathoracic sft may arise in the pleura, mediastinum, or lung parenchyma. aside from the pleura, sft has also been found in the serosal membranes, the dura of the meninges, and deep soft tissues.2 it was reported in the literature that pleuropulmonary sft often presents with nonspecific pulmonary symptoms such as cough, shortness of breath, or chest pain. the patient in this case report presented with similar symptoms.1 macroscopically, pleuropulmonary sft usually appears as a well-delineated and occasionally lobulated mass of soft tissue attenuation arising from the pleura.3 histologically, sft is usually described as a low-grade neoplasm with variable cellularity. the cancer cells may present in oval or fusiform shape with oval nuclei and well-distributed chromatin. recently, immunohistochemistry has gained importance as an extremely useful tool for the diagnosis of sft. perrot et al. summarised the most essential immunohistochemical characteristics in sft as positive for vimentin and negative for keratin. furthermore, cd34 is positive in the majority of the benign sfts as well as some malignant ones. 253 international journal of human and health sciences vol. 05 no. 02 april’21 however, cd34 remains negative for most of the other tumours of the lung.4 there are a few criteria that suggested malignancy based on this patient’s biopsy, namely increased mitotic activity (> 4/2 mm), hypercellularity, and moderate nuclear atypia. however, other features for malignancy i.e. tumour necrosis or haemorrhage were not seen. the infiltrative nature of the tumour could not be ascertained histologically. differentiating between benign and malignant tumors is challenging. however, there are a few radiological characteristics that are highly suggestive of malignancy, including lesions that are larger than 10 cm with central necrosis and large pleural effusions. all these features were seen in this case.4 furthermore, this patient had a unique presentation of non-insulin mediated hypoglycemia. sft is a known tumour that causes non-insulin mediated hypoglycaemia. this is a type of paraneoplastic syndrome known as doege-potter syndrome. it occurs in less than 5 percent of sft. it is primarily seen in large peritoneal/pleural tumours such as this case. it happens as a result of tumour secretion of large insulin-like growth factor ii (igf2). fortunately, it responded well to high dose glucocorticoid.4,5 conclusion pleuropulmonary sft is a rare condition. highlyspecific physical, imaging, and histopathological examination are needed to diagnose the condition. however, the treatment of pleuropulmonary sft is not well-established at this point in time, thus long-term follow up is mandatory. this case report emphasised the importance of recognising doege-potter syndrome in a patient with sft and hypoglycemia. acknowledgements: we thank the patient and her family for the approval to publish this case report. verbal informed consent was obtained. we also thank all clinicians that provided clinical information. conflict of interest: the authors declared no conflict of interest. funding statement: this case report did not receive any special funding. ethical approval issue: not applicable. author’s contribution: conception: uaz, mrar. collection and assembly of data: uaz, mraz, nhms, no. writing manuscript: uaz, mrar. editing and approval of final draft: uaz. references: 1. lococo f, cesario a, cardillo g, et al. malignant solitary fibrous tumors of the pleura: retrospective review of a multicenter series. j thorac oncol. 2012;7(11):1698-1706. 2. sung sh, chang j, kim j, lee ks, han j, park s il. solitary fibrous tumors of the pleura : surgical. ann thorac surg. 2005;79:303-307. 3. bora g, colaut f, segato g, delsedime l, oliaro a. solitary fibrous tumor of the pleura : histology, ct scan images and review of literature over the last twenty years. biomed j sci & tech res. 2017;1(1):188-192. 4. ghanim b, hess s, bertoglio p, et al. intrathoracic solitary fibrous tumoran international multicenter study on clinical outcome and novel circulating biomarkers. sci rep. 2017;7(1):1-10. 5. lee ce, zanariah h, masni m, pau kk. solitary fibrous tumour of the pleura presenting with refractory non-insulin mediated hypoglycaemia (the doegepotter syndrome). med j malaysia. 2010;65(1):7274. 81 international journal of human and health sciences vol. 05 no. 01 january’21 original article: the relationship between income and nutritional status with the incidence of hypertension in elderly emi nur sariyanti1,diffah hanim2, sapja anantanyu3 abstract: background:blood pressure is a disease that is often found in the elderly. many studies show that socioeconomic status is closely related to the incidence of hypertension especially in the elderly. in addition, since hypertension is generally associated with being overweight and obese, nutritional status can also be a factor for experiencing hypertension in the elderly. objective:to analyze the relationship between income and nutritional status with the incidence of hypertension in the elderly. method: this study used a cross-sectional study design involving 133 elderly respondents in the area of the klaten community health center. income data were obtained using the respondents’ basic characteristic questionnaire. nutritional status was obtained based on anthropometric measurements of body weight and height which were calculated using the body mass index (bmi). while blood pressure data were obtained from sphygmomanometer measurements. the data obtained were analyzed using the spearman test with a p-value <0.05. this study was approved by ethics commission universitassebelasmaret. results: the results of this study indicate there is a relationship between income and the incidence of hypertension in the elderly (p=0.046) while the nutritional status has no relationship with the incidence of hypertension (p=0.640). conclusion: high income has a low risk of the elderly experiencing hypertension, while nutritional status good or not they do not have a risk of hypertension. keywords: nutritional status, hypertension, income, elderly. correspondence to: emi nur sariyanti, human nutrition, nutrition science, postgraduate school, universitas sebelas maret, surakarta, indonesia e-mail: eminursariyanti82@gmail.com 1. human nutrition, nutrition science, postgraduate school, universitas sebelas maret, surakarta, indonesia. 2. public health department, faculty of medicine, universitas sebelas maret, surakarta, indonesia. 3. development counseling/community empowerment department, faculty of agriculture, universitas sebelas maret, surakarta, indonesia. international journal of human and health sciences vol. 05 no. 01 january’21 page : 81-84 doi: http://dx.doi.org/10.31344/ijhhs.v5i1.238 introduction hypertension or high blood pressure is defined as abnormally high arterial blood pressure. according to the joint national committee 7 (jnc7), normal blood pressure is systolic blood pressure <120 mmhg and diastolic blood pressure <80 mm hg. hypertension is defined as a systolic blood pressure level of ≥140 mmhg and/or a diastolic blood pressure level ≥ 90 mmhg. vulnerable blood pressure between 120-139 mmhg systolic blood pressure and 80-89 mmhg diastolic blood pressure is defined as “prehypertension”1. aging is an independent risk factor for non-communicable diseases, including systemic arterial hypertension, the leading cause of preventable death in the world2. about 7.5 million deaths or 12.8% of all annual deaths worldwide occur due to high blood pressure3. increased blood pressure is a major risk factor for chronic heart disease, stroke, and coronary heart disease. increased blood pressure is positively correlated with the risk of stroke and coronary heart disease4. treatment and prevention are key to reducing the incidence of cardiovascular complications, such as acute myocardial infarction and stroke5. the incidence and severity of hypertension is influenced by nutritional status and nutritional intake. excessive energy intake such as sodium consumption and increased alcohol consumption acutely can increase blood pressure6. lots of evidence that directly links obesity with high blood pressure. obesity increases blood international journal of human and health sciences vol. 05 no. 01 january’21 82 pressure and obese individuals are more likely to experience an increase in blood pressure than non-obese people. even in older adults, a higher bmi is associated with an increased risk of hypertension7,8. in addition, it has been studied in many studies on socioeconomic status closely related to hypertension9. however, various studies present some of the results supported mostly by seniors10,11. therefore the authors are interested in knowing the relationship between income and nutritional status with the incidence of hypertension in the elderly. material and method this study uses a cross-sectional research design. the population in this study was the elderly > 60 years old who lived in the health center area of klaten regency, central java. the sample in this study amounted to 133 respondents. the inclusion criteria in this study are the elderly who are ≥ 60 years old, who can still stand upright, who can still do their daily activities,are not illiterate. whereas the exclusion criteria in this study are the elderly who are sick. this research was conducted from december 2019 to january 2020. the subjects agreed to participate as respondents until the study ended and signed informed consent. income data were obtained using the respondents’ basic characteristics questionnaire and nutritional status data were obtained from anthropometric measurements of height and weight and were calculated using the body mass index (bmi). as for the blood pressure data obtained from the sphygmomanometer measurement results, the criteria and classification of variables used can be seen in table 1. the data obtained were analyzed bivariate using the spearman rank test (α = 0.05). table 1. classification of variables. variables criteria classification income idr > 2.500.000 • high idr 1.500.000 – 2.500.000 • medium idr < 1.500.000 • low nutritional status > 27 • obesity 25 – 27 • overweight 18,5 – 25 • normal <18,5 • low blood pressure <120 mmhg a. normal 120-139 mmhg b. prehypertension >140 mmhg c. hypertension results based on the characteristics of respondents (table 2), the sex of the respondents was dominated by elderly women with a percentage of 84.2% and men as much as 15.8%.education level of most of the respondents are primary schools with a percentage of 50.4%, while 63.9% of respondents work as housewives / unemployed. observations in this study also showed that 90.4% of respondents’ income was very low. in addition, most of the respondents’ nutritional status had a normal category with a percentage of 37.6%, but most of the respondents’ blood pressure showed 53.4% included in the hypertension criteria. table 2.characteristics of respondents. variables jumlah (%) sex 3. male 15.8 4. female 84.2 education • college 1.5 • senior high school 2.3 • junior high school 8.3 • primary school 50.4 • no school 37.6 work • housewife / unemployment 63.9 • farmer 5.3 • entrepreneur 12.8 • enterpriser 18 income • high 2.3 • medium 2.3 • low 95.4 nutritional status • obesity 22.6 • overweight 18.8 • normal 37.6 • low 21.1 blood pressure d. normal 32.2 e. prehypertension 14.3 f. hypertension 53.4 table 3 shows that respondents in this study tended to have low incomes with normal nutritional status and were prone to hypertension. based on bivariate analysis using spearman rank, it is known that there is a relationship between income and blood pressure in the elderly with a value< 0.05 (p = 0.046), this shows that the elderly who have higher income tend to have normal blood pressure compared to the low-income elderly. in addition, bivariate analysis of nutritional status showed no relationship with blood pressure with values> 0.05 (p = 0.641).this shows elderly people have a tendency to experience hypertension. 83 international journal of human and health sciences vol. 05 no. 01 january’21 table 3. the relationship between income and nutritional status with the incidence of hypertension. tekanandarah p* normal prehypertension hypertension income • high 3 0 0 0.046• medium 1 1 1 • low 39 18 70 nutritional status • obesity 10 5 15 0.641 • overweight 8 3 14 • normal 14 5 31 • low 11 6 11 *p value rank spearman discussion statistical analysis showed that there was a relationship between income and the incidence of hypertension (p = 0.046). this can be interpreted that the elderly who have a high income have a lower risk of experiencing hypertension. the data in table 3 also shows that older people who have a higher income tend to have a lower risk of hypertension than those who have a lower income. income is also associated with work which is one of the factors causing hypertension. people who do not work tend to have lower incomes and are generally more prone to hypertension9. this is associated with physical activity carried out by people who work, will have higher physical activity.so that it can reduce body fat and reduce the risk of hypertension12,13. the results of the analysis at riskesdas also showed that low socioeconomic factors could be a risk factor for hypertension. in addition, respondents who are not in school and do not work also have a higher risk of experiencing hypertension14.in general, the risk of hypertension in the elderly tends to increase15. this is associated with decreased organ function due to the aging process, especially the decrease in heart’s ability to pump blood results hypertension4,16,17. statistical analysis between nutritional status and the incidence of hypertension also showed no relationship (p = 0.460). this shows thatwhether the elderly have good nutritional status ornot have the same risk of experiencing hypertension.one of the factors of a person suffering from hypertension is an unbalanced nutritional status18,19. the greater the body mass, the more blood is needed to supply oxygen and food. increased blood volume can be at risk of putting more pressure on the arterial wall, so that there is a risk of developing hypertension20. in some countries, hypertension is a disease associated with being overweight and obese.21 other research also suggests that elderly people who are overweight or obese increase hypertension22. hypertension in the elderly is difficult to cure but can be controlled by changing lifestyles. medication for hypertension itself is already present, but some studies discuss a simple lifestyle and changing diet to prevent or restore high blood pressure23. the who also determined that good intake and consistency of physical activity affect health, and reduce the incidence of morbidity in chronic diseases such as cardiovascular disease, diabetes, obesity, and hypertension 24. conclusion our study suggests that, there is a relationship between income and the occurrence of hypertension. older people who have a higher income have a lower risk of hypertension. while nutritional status has no relationship with the incidence of hypertension, this study shows that elderly people tend to experience hypertension more. acknowledgment we acknowledge and thank for all people who dedicated their time and participated in this research. the author would like thank parents and friends who have helped in this research. the author also thanks all the participants involved in this study. we are also grateful to sebelasmaret university for supporting this research. ethical approval issue:this research was approved by the ethics committee of faculty of medicine, sebelasmaret university, surakarta, indonesia no.002 / un27.06 / kepk / ec / 2020. conflict of interest: none declared author’s contribution: emi nur sariyanti principal investigor, conceptualized and designed the study, prepared the draft of the manuscript and reviewed the manuscript.diffahhanim conducted the study, data analysis and interpretation, assisted in drafting of the manuscript, reviewed the manuscript. sapjaanantanyu assisted in drafting of the manuscript, reviewed the manuscript. international journal of human and health sciences vol. 05 no. 01 january’21 84 references: 1. chobanian av, bakris gl, black hr, et al. seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure. hypertension. 2003;42(6):1206-52. 2. logan ag. hypertension in aging patients. expert review of cardiovascular therapy. 2011;9(1):11320. 3. world health organization. global status report on noncommunicable diseases 2010. https://www.who. int/nmh/publications/ncd_report2010/en/ 4. singh s, shankar r, singh gp. prevalence and associated risk factors of hypertension: a crosssectional study in urban varanasi. international journal of hypertension. 2017. 5. yusuf s, hawken s, ôunpuu s, et al. effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the interheart study): case-control study. the lancet. 2004;364(9438):937-52. 6. savica v, bellinghieri g, kopple jd. the effect of nutrition on blood pressure. annual review of nutrition. 2010;30:365-401. 7. pikilidou mi, scuteri a, morrell c, et al. the burden of obesity on blood pressure is reduced in older persons: the sardinia study. obesity. 2013;21(1):e10-e13. 8. lin ya, chen yj, tsao yc, et al. relationship between obesity indices and hypertension among middle-aged and elderly populations in taiwan: a community-based, cross-sectional study. bmj open. 2019;9(10). 9. wu x, wang z. role of socioeconomic status in hypertension among chinesemiddle-aged and elderly individuals. int j hypertens. 2019;13:6956023. 10. leng b, jin y, li g, et al. socioeconomic status and hypertension: a meta-analysis. journal of hypertension. 2015;33(2):221-9. 11. liu j, rozelle s, xu q, et al. social engagement and elderly health in china: evidence from the china health and retirement longitudinal survey (charls). international journal of environmental research and public health. 2019;16(2): 278. 12. purnama ds, prihartono na. prevalensihipertensi dan faktor-faktor yang berhubungandengankejadianhipertensi pada lansia di posyandulansia wilayah kecamatanjoharbaru jakarta pusat tahun 2013. jakarta: universitas indonesia. 2013. 13. araújo sp, jardim tsv, sousa all. blood pressure, nutritional status and physical activity level affect the healthrelated quality of life of oldest old. j geriatr med gerontol. 2016;2:018. 14. rahajeng e, tuminah s. prevalensihipertensi dan determinannya di indonesia. majalahkedokteran indonesia. 2009;59(12):580-587. 15. kellicker pg, schub t. stroke in older adult. glendale, california: cinahlinformation systems. 2010. 16. lionakis n, mendrinos d, sanidas e, et al. hypertension in the elderly. world journal of cardiology. 2012;4(5):135. 17. herlinah l, wiarsih w, rekawati e. hubung and ukungankeluargadenganperilakulansiadalampengendalianhipertensi. jurnal keperawatan komunitas. 2013;1(2):108-15. 18. krumel da. medical nutition therapy in hypertension. didalam mahan lk dan escott stump s, editor 2004, food, nutrition and diet therapy. usa: saunders co. 2004. 19. paruntu ol, rumagit fa, kures gs. hubungan aktivitas fisik, status gizi dan hipertensi pada pegawai di wilayah kecamatantomohon utara. jurnal gizido. 2015;7(1). 20. darmawan h, tamrin a, nadimin n. hubungan asupan natrium dan status gizi terhadap tingkat hipertensi pada pasien rawat jalan di rsud kota makassar. media gizipangan. 2018;25(1):11-17. 21. flegal km, carroll md, ogden cl, curtin lr. prevalence and trends in obesity among us adults, 1999-2008. jama. 2010;303(3):235-41. 22. deji sa, olayiwola io, fadupin gt. assessment of nutritional status of a group of hypertensive patients attending tertiary healthcare facilities in nigeria. east african medical journal. 2014;91(3):99-104. 23. dahlöf b, devereux rb, kjeldsen se, et al. cardiovascular morbidity and mortality in the losartan intervention for endpoint reduction in hypertension study (life): a randomised trial against atenolol. the lancet. 2002;359(9311):995-1003. 24. pongkiatchai r, wongwiseskul s. nutrition literacy and the elderly with hypertension. journal of food health and bioenvironmental science. 2018;11(3):49-55. international journal of human and health sciences vol. 05 no. 02 april’21 254 case report: a case of non-syndromic craniosynostosis devananthan ilenghoven,1,2,3 hamidah mohd zainal,1,2 normala haji basiron,1,2 mohd ali mat zain1,2 abstract: craniosynostosis refers to skull deformities secondary to the premature closure of cranial suture. isolated or multiple sutures craniosynostosis is more common than syndromic craniosynostosis. deformities with synostosis are stigmatizing, and this provides a strong aesthetic indication for surgical correction in the non-syndromic group of patients. we present a case of non-syndromic sagittal synostosis in a ten months old patient underwent open surgical repair for skull deformity. keywords: non-syndromic craniosynostosis, sagittal synostosis. correspondence to: dr. devananthan ilenghoven, mbbs, mrcsi. plastic, reconstructive and aesthetic surgery unit,faculty of medicine, universiti teknologi mara,cawangan selangor, kampus sungai buloh, jalan hospital,47000 sungai buloh, selangor, malaysia. e-mail: i.devananthan@gmail.com 1. department of plastic and reconstructive surgery, hospital kuala lumpur, ministry of health, malaysia. 2. reconstructive sciences unit, school of medical sciences, universiti sains malaysia, health campus, 16150 kubang kerian, kelantan, malaysia. 3. plastic, reconstructive and aesthetic surgery unit, faculty of medicine, universiti teknologi mara, cawangan selangor, kampus sungai buloh, jalan hospital, 47000 sungai buloh, selangor, malaysia. international journal of human and health sciences vol. 05 no. 02 april’21 page : 254-257 doi: http://dx.doi.org/10.31344/ijhhs.v5i2.270 introduction: craniosynostosis was described as the premature closure of cranial suture leading to skull deformities by sommerring in 1791.1 virchow observed in 1851 that skull growth perpendicular to the fused suture is inhibited by premature fusion.2 compensatory growth of adjacent sutures with premature fusion affects the entire skull.3 craniosynostosis requires correction surgery that performed addressing the whole skull and not just the fused suture. sagittal suture fusion has an estimated incidence of 1 in 2000, making it the commonest suture involved.4 non-syndromic craniosynostosis is more common than syndromic craniosynostosis; up to 85%.5 approximately 40-60% of all craniosynostosis cases are nonsyndromic sagittal craniosynostosis; making it the most frequent variant leading to scaphocephaly.6 clinical diagnosis is adequate in most cases; however, confirmation with imaging such as x-rays, computed tomography (ct), and threedimensional ct reconstruction is effective in delineating skull base deformity. imaging offers added benefit during surgical planning. common indications for craniosynostosis surgery are increased intracranial pressure and cosmetic deformity. deformities with synostosis are stigmatizing, and this provides a robust aesthetic indication for surgical correction. we present a case of a non-syndromic sagittal craniosynostosis patient underwent open surgical repair for skull deformity. case report: a ten months old boy was referred to the craniofacial plastic team due to the elongated shape of his skull. he was born full-term via normal vaginal delivery with an uneventful pregnancy. the child was non-syndromic and did not have any medical or surgical problems. he has an eight-year-old elder brother who is well. there was no similar history among other relatives. according to parents, the child had typical developmental milestones. on clinical examination, sagittal suture ridging was palpable. the head was shortened in the biparietal diameter and elongated in the anteriorposterior diameter. the child was diagnosed 255 international journal of human and health sciences vol. 05 no. 02 april’21 clinically with scaphocephaly. computerized tomography was performed, which showed sagittal suture fusion. magnetic resonance imaging revealed impediment of lateral growth of the skull with continuous growing anteroposterior part of the skull (figure:1). no dilated ventricles or other abnormality of the brain observed. figure 1: 3d – reconstructed computerized tomography performed showing sagittal suture fusion and elongated ap diameter. the child underwent modified pi procedure and cranial vault reshaping, a combined surgery with the pediatric neurosurgical team. a bi-coronal incision was performed. hemostatic clips were placed to reduce blood loss. subperiosteal plane dissection performed and extended laterally detaching the temporalis from the temporal bone. anterior flap elevated down to the level nasofrontal and supraorbital rims. the supraorbital and supratrochlear nerves were identified and preserved. the posterior flap elevated subgaleal beyond the lambdoid sutures. a pi (π) shaped, bifrontal and bilateral parasagittal craniectomy of 1cm strip was performed with a cranial oscillating saw with removal up to lambdoid and coronal sutures (figure 2). the frontal bone flap was bisected into half, reshaped and applied back as two bone grafts and attached to the frontal orbital bar with ethilon® 1/0 sutures. bilateral temporal bone was out-fractured to increase the skull width (figure 3). both frontal and occipital bones were brought towards the central axis, correcting the anterior-posterior dimensions. the total intracranial volume was maintained by increasing the width of the skull initially and shortening the length later. drains left in place, and the skin was closed in layers. the child’s recovery was uneventful and discharged well on the postoperative day-10. the patient is currently on regular follow up. figure 2: bi-coronal skin incision (right). pi (π) shaped bi-frontal and bilateral parasagittal 1cm strip markings up to lambdoid and coronal sutures (left). figure 3: frontal bone flap bisected into half, reshaped and applied back as two bone grafts and attached to the frontal orbital bar with nonabsorbable sutures. figure 4: postoperative 1-week image shows correction of frontal bossing and improvement of ap diameter. discussion: relevant discussion points about nonsyndromic craniosynostosis (nscs) includes development and pathogenesis of the disease, clinical evaluation, imaging modalities, preoperative patient optimization, the surgical technique employed, post-surgical follow-up, and psychosocial issue of untreated cases. skull in the newborns consist of flat bones separated by six major cranial sutures and four fontanelles.7 dense fibrous tissue composition of sutures permits limited physiological movement such as expansion and compression that occurs international journal of human and health sciences vol. 05 no. 02 april’21 256 during birth.8 size of the cranium at birth is approximately 80% of adult size, and definitive size is achieved at three years of age. however, sutures and fontanelles close according to the various timeline from three months to mid-thirty years.7 the pathological process seen here is skull growth restriction parallel to the affected prematurely fused sutures. the fusion of sutures leads to the limitation of underlying brain growth due to loss of suture accommodation and compensatory overgrowth at non-fused suture areas leading to distortion.9 nscs has various types of head shape dysmorphic characteristic. involvement of different regions and numbers of sutures leads to a variety of clinical findings.10 in descending order, sagittal suture is the commonest affected, followed by coronal, metopic and lambdoid sutures for single suture synostosis.7 the pathogenesis of craniosynostosis is complex and unclear. multifactorial theories proposed include genetic mutations, intrinsic bone abnormalities and environmental factors.8 craniosynostosis has been as sociated with metabolic conditions such as hypophosphatemia and rickets. the main factor that leads to craniosynostosis is the constraint in fetal growth which are seen in nulliparous mothers and multiple pregnancies. multiple prenatal factors that are taken into consideration include maternal smoking, teratogen exposure, maternal consumption of antiepileptics or excessive antacids, low birth weight and pre-term delivery.11 there is no single genetic cause identified; however, the gene encoding for fibroblast growth-factor is frequently mutated in syndromic craniosynostosis. abnormal maturation of suture and cranial malformation are evident due to defective signaling and tissue interaction.9,12 the most typical clinical presentation of nscs during the first year of life is an unusual shape of the head. head anomaly includes being flattened and broad (brachycephaly), triangular front (trigonocephaly), skewed (plagiocepha ly), or long and narrow (scaphocephaly or dolichocepha ly). skull should be palpated for ridging, mobility and the presence of fontanelles. quantitative cranial anthropometric measurements are taken, and special attention is given to look for congenital anomalies. major functional complications associated with this disorder are often irreversible. they comprise of limited brain growth, visual impairment, intracranial hypertension and neuropsychiatric disorder.8,11 therefore, the examination must be performed thoroughly, and other craniofacial disorders should be ruled out. patients must be managed in a specialized pediatric craniofacial centre wherever possible. surgery is planned soon after diagnosis. timing for surgery advocated from the first few weeks of birth till nine months of age.8 staged or secondary surgeries are performed in severely affected patients that need correction of residual deformities. management of nscs focuses on prevention and correction of skull deformity and stabilizing intracranial pressure if elevated. attention is also given towards eye protection, airway, infant feeding and optimal oral health. unlocking and reshaping of bone optimize correction and reduces intracranial pressure. functional and aesthetic reasons are also taken into consideration.11 some authors proposed a minimally invasive technique which reduces operative morbidity and shorter hospital stay; however, there are diverse techniques available.7 recent advances in pediatric anesthesia and biomaterial developments allows bone substitution with hydroxyapatite cement and usage of resorbable fixation systems.8 recommended operative technique for nscs includes (1) open calvarial reconstruction, (2) cranial distraction osteogenesis, (3) endoscopic suture release, (4) strip craniectomy with spring implantation, and (5) strip craniec tomy with the use of a postoperative moulding helmet.11 surgery of choice performed for sagittal craniosynostosis is the pi procedure, an open calvarial reconstruction method named after the shape of the bone removed. in this technique, the bilateral coronal, lambdoid and the sagittal sutures are removed initially. the sagittal suture is used as a strut to maintain the expanded parietal bone, which was out-fractured to increase the skull width. frontal bossing and anterior-posterior dimension adjustment addressed before securing the frontal and occipital bones to the parietal bones. patient follow-up after reparative surgery should continue until skeletal maturity.10 follow up period varies according to the severity of deformity; however, they are reviewed at least annually up to adolescence. signs and symptoms of increased intracranial pressure (e.g., nausea and vomiting, irritability, headache, visual disturbances, sei zures, developmental delay, and declining academic performance) and aesthetic results are reviewed during follow-ups.8 untreated nscs results in aggravated craniofacial deformities. visible facial differences with 257 international journal of human and health sciences vol. 05 no. 02 april’21 cognitive difficulties, impairment of vision, language or behavior leads to difficult peer interaction and psychosocial issues.11 this resulted in poor health-related quality of life. caregiver, including parents, undergoes stress and are psychologically affected by their children’s condition. they have to endure having a child with a congenital anomaly, frequent hospital visits, surgeries, financial support and providing specialized care. these factors will affect the caregiver’s behavior and the child’s psychosocial adaptation. conclusion: non-syndromic sagittal craniosynostosis is a common condition managed by craniofacial plastic surgeons; however, there are wide discrepancies in the management options for it in terms of pre-operative evaluation, operative techniques, and peri-operative management. a competent multidisciplinary team should perform early diagnosis and comprehensive treatment. management aimed at improving the patient’s daily functionality and psychosocial well-being are imperative. the modified pi technique is an effective method for immediate correction of sagittal synostosis. it addresses all aspect of deformity, avoids further manipulations such as moulding helmets and produces a rounder cranial vault. acknowledgements: we would like to thank the director-general of health, ministry of health, malaysia, for his permission to publish this article. conflict of interest: the author(s) declare no potential conflicts of interest concerning the research, authorship, and publication of this article funds: the authors declare that no funding exists. ethical approval issue: informed consent has been obtained. author contributions: d ilenghoven: conceptualization of study and writing the manuscript. h mohd zainal: critical revision and intellectual content.nh basiron, ma mat zain: editing and approval of the final draft. references: 1. sommering st. about the construction of the human body. 2nd ed. varrentrapp and wenner, 1839. 2. virchow r. about cretinism, especially in franconia, and pathological skull forms. verh phys 1851;2:23171. 3. delashaw jb, persing ja, broaddus wc, jane ja. cranial vault growth in craniosynostosis. j neurosurg. 1989;70:159–65. 4. di rocco f, arnaud e, renier d. evolution in the frequency of nonsyndromic craniosynostosis. j neurosurgpediatr. 2009;4:21-5. 5. warren sm, proctor mr, bartlett sp, et al. parameters of care for craniosynostosis: craniofacial and neurologic surgery perspectives. plastreconstr surg.2012;129:731–7. 6 lajeunie e, le merrer m, bonaiti-pellie c, et al. genetic study of scaphocephaly. am j med genet.1996;62:282–5. 7. kabbani h, raghuveer ts. craniosynostosis. am fam physician. 2004;69:2863-70. 8. ghali ge, sinn dp, tantipasawasin s. management of nonsyn dromic craniosynostosis. atlas oral maxillofac surg clin north am. 2002;10:1-41. 9. buchanan ep, xue y, xue as, olshinka a, lam s. multidisci plinary care of craniosynostosis. j multidisciphealthc. 2017;10:26370. 10. puente-espel j, rios-lara y lópez rl, morenoálvarez mc, morel-fuentes ejj. craniosynostosis: a multidisciplinary approach based on medical, social and demographic factors in a developing country. rev med hosp gen mex. 2016;79:230-9. 11. governale ls. craniosynostosis. pediatr neurol. 2015;53:394-401. 12. zakhary gm, montes dm, woerner je, notarianni c, ghali ge. surgical correction of craniosynostosis. a review of 100 cases. j craniofac surg. 2014;42:168491. 239 international journal of human and health sciences vol. 07 no. 03 july’23 original article enhancing hand cleaning during dental visit through nudging normaliza ab malik1, nor ba’yah abdul kadir2 abstract background: hand washing or hand-cleaning is a behaviour that has not been performed routinely as a habit for everyone, but its importance has been greatly emphasised during the covid-19 outbreak. nudges in the form of prompts, cues and reminders have been used to encourage hand cleaning. objective: to improve hand-cleaning to prevent transmission of the disease during dental visits through nudge. methods: this experimental, observational pilot study was conducted at private dental practices. hand sanitisers were placed at a few places in the clinic to encourage hand cleaning. hand sanitiser was not placed outside the treatment room during the baseline data collection. the patients’ behaviour in using the hand sanitisers was observed and analysed. results: a total of 130 participants were involved in the study, with more than half being female (59.2%) and above 35 years old (60.8%). more than half of the participants performed hand cleaning behaviour immediately after treatment (68.2%). however, there was no significant difference between those who performed the hand cleaning when the hand sanitiser was placed in the waiting room and front of the treatment room (p>0.05). placing the hand sanitiser in front of the dental treatment room increased the likelihood of hand cleaning. however, there was no significant difference (or: 3.4, 95%ci: 1.09-10.7, p<0.05). conclusion: this study has shown the potential effect of using a nudge to encourage hand cleaning after dental treatment by placing an additional hand sanitiser in front of the dental treatment room. despite the increase in the number of people using the hand sanitiser immediately after treatment, there is limited evidence on the long-term effect of this measure, and therefore, long-term research is warranted. keywords: hand cleaning, dental practices, nudge, covid-19 correspondence to: normaliza ab malik, faculty of dentistry, universiti sains islam malaysia, 55100 kuala lumpur, malaysia. email: liza_amalik@usim.edu.my 1. faculty of dentistry, universiti sains islam malaysia, 55100 kuala lumpur, malaysia. 2. faculty of social sciences and humanities, universiti kebangsaan malaysia, 43600 bangi, selangor, malaysia. introduction covid-19 virus has hit the world tremendously. the virus, transmitted mainly through respiratory droplets,1 and the infection can occur from the asymptomatic person,2 pose a significant risk to those who neglect the preventive health measures. preventive health behaviour has been one of the main ways to contain the spread of the virus. governments worldwide have taken many measures to prevent disease transmission, such as emphasising self-protection, minimising social activities and advising quarantine for those with symptoms. to improve self-protection, behaviour has been the primary target. thus, governments and policymakers have focused on the way people behave. one approach that has been used to tackle a person’s behaviour is behavioural insight.3 behavioural insight has been used in many sectors to improve policies, including health and healthcare outcomes.4 nudge which thaler and sustein introduced in 2008 has been considered an expression of behavioural insight.5 a systematic scoping review has shown that nudge can change people’s international journal of human and health sciences vol. 07 no. 03 july’23 page :239-243 doi: http://dx.doi.org/10.31344/ijhhs.v7i3.580 international journal of human and health sciences vol. 07 no. 03 july’23 240 behaviour effectively and improve outcomes of particular conditions.6 nudge-type interventions may have been used in a certain way with the potential to change the decision-making and behaviour of people throughout the covid-19 outbreak, in particular, health precaution and selfprotection. studies have shown that dentistry is one of the crucial areas as it may pose an individual with a significant risk of infection due to the nature of the treatment. during the early stage of the pandemic, the dentist was instructed by the health authority or regulatory authorities to stop providing treatment except to those who required emergency treatment. this is because dental treatments produce splatters and aerosols, which can remain airborne for many hours and contaminate inanimate surfaces when they fall.7 furthermore, the droplets can be transmitted over a long distance, thus capable of contaminating surfaces beyond the dental chair. thus, post significant risk if proper preventive measures are not taken. in order to prevent or decrease contact transmission, reinforcement on hand hygiene is one of the utmost necessary preventive measures. studies have shown that handwashing or hand-cleaning is a self-hygiene method that removes bacteria and viruses from hand and reduces person-to-person transmission.8 the same goes for alcohol-based hand sanitiser. generally, handwashing or handcleaning compliance is very low regardless of the presence of diseases.9 the u.s centers for disease control and prevention (cdc) recommended handwashing and hand sanitisers at home, school, workplace and other risk areas.10 handwashing is essential to preventing oneself from getting sick and spreading the germs around them. initiative has been made by placing hand sanitisers at apparent locations such as in front of the elevators, counters and door entrances. more reminders have been put up to encourage hand cleaning, but the evidence of its effectiveness is limited. therefore, this study explores how nudge was implemented in dental practices to improve hand-cleaning to prevent disease transmission during dental visits. methods this was an experimental, observational pilot study. patients attending two private dental practices were invited to participate in the study. informed consents were obtained from all the participants who agreed to participate in the study. hand sanitisers were placed at a few places in the clinic to encourage hand cleaning; at the counter, waiting area and outside the treatment room (figure 1&2). however, the hand sanitiser was not placed outside the treatment room for baseline data. a research assistant observed the patients’ behaviour in using the hand sanitisers. descriptive data analysis was conducted for the socio-demographic information. logistic regression was conducted to determine factors associated with the hand cleaning behaviour immediately after treatment. figure 1 & 2: hand sanitizer was placed in front of treatment room. results a total of 130 participants involved in the study. more than half of the participants were female (59.2%) and above 35 years old (60.8%). most of the participants visited the dental practices had a degree or higher qualifications. two third claimed they did not have any chronic illness and almost half (43%) were working in the private sectors (table 1). table 2 presents the percentage of participants who performed the hand cleaning behaviour after the dental treatment. more than half of the participants performed hand cleaning immediately after treatment (68.2%) when the hand sanitiser was provided in front of the dental treatment room. however, there was no significant difference between those who performed the hand cleaning when the hand sanitiser was placed in front of the treatment room and waiting room (p>0.05). table 3 presents the factor associated 241 international journal of human and health sciences vol. 07 no. 03 july’23 with immediate hand cleaning after treatment. placing the hand sanitiser in front of the dental treatment room increased the likelihood of hand cleaning; however, it was not significantly different if there were no hand sanitiser. the participants were more likely to perform hand cleaning immediately after treatment when the hand sanitiser was placed outside the dental treatment room than when there was no hand sanitiser (or: 3.4, 95%ci: 1.09-10.7, p<0.05). it is also shown that those having a certificate and diploma were more likely to perform the hand cleaning compared to other levels of education. those with certificate and diploma qualifications were 4.7 times as likely to perform hand cleaning immediately after treatment compared to those with other qualifications. table 1: demographic profile of the participants variable category frequency percentage age 18 25 years old 29 22.3 26 35 years old 22 16.9 36 45 years old 27 20.8 46 55 years old 32 24.6 > 55 years old 20 15.4 total 130 100.0 gender male 53 40.8 female 77 59.2 total 130 100.0 education up to secondary school 33 25.4 certificate / diploma 23 17.7 bachelor’s degree & higher 74 56.9 total 130 100.0 having a chronic illness yes 16 12.3 no 114 87.7 total 130 100.0 work sectors government 27 20.8 private 57 43.8 education centre 6 4.6 unemployed 40 30.8 total 130 100.0 discussion hand washing or hand-cleaning is a behaviour that has not been performed routinely as a habit for everyone.11 habits are “automatic behaviour” or specific behavioural actions that occur with environmental cues or without a conscious decision of a particular condition.12 not everyone washes their hand before eating, holding food or even before touching their nose, mouth or rubbing their eyes. besides, many people find it is hard to wash their hands effectively. therefore, it has imposed a significant challenge during the covid-19 outbreak. during the covid-19 outbreak, nudges in the form of prompts, cues, and reminders have been used in malaysia. an analysis of 22 studies reported that the covid-19 virus could persist on inanimate surfaces (i.e. glass, metal and plastic) for up to nine days.13 thus, hand cleaning and surface disinfection is crucial to prevent further spreading of this virus during a dental visit. consequently, an additional hand sanitiser was placed in the dental clinic at a location that seems to be highly visible to encourage hand cleaning. studies also showed that interventions increase handwashing, often overwhelming, but most of it is not sustainable.14,15 a one-year follow-up experimental study showed that handwashing could be sustained or become habitual behaviour when anticipating monitoring and incentive interventions.16 however, the group that received incentive intervention showed lower handwashing persistency compared to the monitor intervention group after removing the interventions. besides, social norms have also been used to improve handwashing behaviour by engaging other people around them, such as family members, administrators or colleagues.17 despite that, selfhygiene concerning persistence in handwashing might be expected to be consistent when under high-responsibility conditions, such as at a hospital or other high-risk areas.18 the goal is to help people perform their hand cleaning, thus making hand cleaning possible, easy and convenient to improve hand hygiene. more reminders have been put up to encourage handwashing or hand cleaning, but the evidence of its effectiveness is still limited. this study found that placing hand sanitisers at highly visible locations is essential, as the location is another crucial factor in increasing the nudging effect. more patients tended to clean their hands international journal of human and health sciences vol. 07 no. 03 july’23 242 table 2: percentage of participants of those who performed the hand cleaning behaviour after treatment (n=130) after treatment at the counter after treatment yes n (%) no n (%) p value yes n (%) no n (%) p value baseline 7 (31.8) 58 (53.7) 0.100 23 (57.5) 42 (46.7) 0.342 nudge 15 (68.2) 50 (46.3) 17 (42.5) 48 (53.3) table 3: factor associated with hand cleaning immediately after treatment: finding from logistic regression variables or 95% ci p value nudge 3.418 1.090, 10.72 *0.035 baseline gender 0.200 male 2.037 0.687, 6.040 female age 0.858 18-25 yrs old 1.967 0.273, 14.17 26-35 yrs old 0.891 0.113, 7.051 36-45 yrs old 0.990 0.142, 6.893 46-55yrs old 0.589 0.268, 10.15 >55 yrs old education level *0.020 up to secondary school 0.671 0.154, 2.911 certificate / diploma *4.764 1.391, 16.32 bachelor’s degree & higher work sector 0.454 government 1.953 0.332, 11.49 private 2.864 0.609, 13.48 education center 4.429 0.488, 40.21 unemployed chronic disease no 1.909 0.188, 19.41 0.585 yes healthcare worker no 1.306 3.418, 1.090 0.152 yes 243 international journal of human and health sciences vol. 07 no. 03 july’23 when the hand sanitiser was placed in front of the treatment room. the implementation of a nudge was encouraging and able to steer people to the desired behaviour. conclusion nudge-type interventions have been implemented during the covid-19 outbreak at national and local communities’ levels, and at the individual organisations and workplaces. this study has shown the potential effect of using a nudge to encourage hand cleaning after dental treatment by placing an additional hand sanitiser in front of the dental treatment room. despite the increase in the number of people using the hand sanitiser immediately after treatment, there is limited evidence on the long-term effect of these measures. therefore, long-term research to explore the effectiveness of the nudge to improve self-protection is necessary. conflict of interest: none declared. ethical clearance: the study was approved by the ethical review committee of universiti sains islam malaysia, kuala lumpur, malaysia (jkep/2020-107). source of fund: nil. authors’ contribution: both the authors were equally involved in concept and design of the study, data collection, analysis, manuscript preparation, revision and finalization. references 1. lu cw, liu xf, jia zf. 2019-ncov transmission through the ocular surface must not be ignored. lancet. 2020;395(10224):e39. 2. rothe c, schunk m, sothmann p, bretzel g, froeschl g, wallrauch c, et al. transmission of 2019-ncov infection from an asymptomatic contact in germany. n engl j med. 2020;382(10):970-1. 3. oullier o. behavioural insights are vital to policymaking. nature. 2013;501(7468):463. 4. hallsworth m, snijders v, burd h, prestt j, judah g, huf s, et al. applying behavioral insights: simple ways to improve health outcomes. doha, qatar: world innovation summit for health, 2016. 5. hausman dm, welch b. debate: to nudge or not to nudge. j polit phil. 2010;18(1):123-36. 6. szaszi b, palinkas a, palfi b, szollosi a, aczel b. a systematic scoping review of the choice architecture movement: toward understanding when and why nudges work. j behav decision making. 2018;31(3):355-66. 7. ashtiani re, tehrani s, revilla-león m, zandinejad a. reducing the risk of covid-19 transmission in dental offices: a review. j prosthodont. 2020;29(9):739-45. 8. hadaway a. handwashing: clean hands save lives. j consum health internet. 2020;24(1):43-9. 9. wilson s, jacob cj, powell d. behavior-change interventions to improve hand-hygiene practice: a review of alternatives to education. crit public health. 2011;21(1):119-27. 10. centers for disease control and prevention (cdc). coronavirus disease 2019 (covid-19) – protect yourself. u.s. department of health & human services, 2020. 11. kandel n, lamichane j. strategy of making hand washing a routine habit: principles of 5es and 3rs. j nepal med assoc. 2016;55(203):40-4. 12. hagger ms. habit and physical activity: theoretical advances, practical implications, and agenda for future research. psychol sport exercise. 2019;42:118-29. 13. kampf g, todt d, pfaender s, steinmann e. persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents. j hosp infect. 2020;104(3):246-51. 14. holmen ic, niyokwizerwa d, nyiranzayisaba b, singer t, safdar n. challenges to sustainability of hand hygiene at a rural hospital in rwanda. am j infect control. 2017;45(8):855-9. 15. jiménez a, jawara d, ledeunff h, naylor ka, scharp c. sustainability in practice: experiences from rural water and sanitation services in west africa. sustainability, 2017;9(3):403. 16. hussam r, rabbani a, reggiani g, rigol n. handwashing and habit formation. university of california, berkeley. 2016. retrieved from: http:// cega.berkeley.edu/assets/cega_events/114/reshma_ hussam_beingh_2016.pdf 17. parveen s, nasreen s, allen jv, kamm kb, khan s, akter s, et al. barriers to and motivators of handwashing behavior among mothers of neonates in rural bangladesh. bmc public health. 2018;18(1):483. 18. taylor j, purdon c. responsibility and hand washing behaviour. j behav ther exp psychiatry. 2016;51:43-50. international journal of human and health sciences vol. 05 no. 02 april’21 226 original article palliative care services in childhood cancer in bangladesh: current situation and challenges abu sadat mohammad nurunnabi abstract background: palliative care is a major priority in childhood cancer care strategy as it provides compassionate support both for the children and their families. objective: the aim of the present study was to observe the current situation of palliative care services in childhood cancer in bangladesh and its challenges. methods: an anonymous survey was done between july and december of 2013 in some specialized pediatric oncology units of different public and private hospitals in dhaka city of bangladesh, based on a semi‐structured questionnaire. a total of 300 respondents including physicians, nurses, caregivers, hospital managers who deal with childhood cancer, and parents of children suffering from cancer took part in this survey. queries addressed are access to treatment, availability of drugs, palliative care, pain management, cost of treatment, quality of care and perceived challenges. results: difficulty in access to treatment (86%), out‐of‐pocket payment for oncology therapies (88%), palliative care (91%) were evident. 93% reported that availability of specialized palliative care services, pain management and psychological plus decision‐making support were directly related to income level. overall, 96% of respondents indicated that palliative care is important for their patients and 79% indicated that they were competent to provide this care; however, only 64% indicated that they had enough time to deliver quality palliative care. challenges include lack of awareness, less availability of facility, high cost, limited and inefficient manpower, low quality of care, less communication between health professionals and parents/family members of the patient. conclusion: in bangladesh, pediatric oncology is usually practiced in resource‐ strained oncology units of pediatric divisions in different public hospitals along with few private hospitals. however, this survey confirmed that many of the children lack access to quality palliative care. effective palliative care requires establishment of more facilities with cancer registry, availability of drugs for therapies and pain management, manpower development, communication with patients and families in decision‐making. keywords: palliative care, childhood cancer, pediatric oncology, bangladesh. correspondence to: dr. abu sadat mohammad nurunnabi, bangladesh medical research council (bmrc), mohakhali, dhaka-1212, bangladesh. e-mail: shekhor19@yahoo.com international journal of human and health sciences vol. 05 no. 02 april’21 page : 226-229 doi: http://dx.doi.org/10.31344/ijhhs.v5i2.264 introduction: palliative care is an approach that focuses on reducing severity of symptoms of diseases rather than delaying the progression of the disease or provide curative measures and improves the quality of life of patients (both adults and children) and their families who are facing problems associated with life-threatening illness such as cancer1. it prevents and relieves suffering through the early identification, correct assessment and proper treatment of pain or any other physical/ psychosocial problems1,2. the world health organization (who) declares palliative care a human right and has proposed a comprehensive agenda for national policy, education, public awareness, morphine availability, and palliation standards1. pediatric palliative care programs are increasingly common in resource-rich countries; however, there is little or no information about their availability and quality in middleand lowincome countries3. bangladesh is a low-income country of south asia, with a population over 160 million and more thanone-third of its population are children4. in 2016, healthcare expenditures in bangladesh remain low at 34us dollars per capita, with near about 72% of this spending being out-of-pocket4. within this health economics, bangladesh is estimated to have 6-9 thousand new cases of childhood cancer annually, although there is no available national population-based cancer 227 international journal of human and health sciences vol. 05 no. 02 april’21 registry5,6. moreover, statistics showed that afewer than 25% of these children are actuallydiagnosed6. barriers to optimal pediatric cancer care include lack of screening programme, delayed diagnosis, limited access to standard therapies, inadequate manpower and health care infrastructure, limited understanding of specific needs, unavailability of rural services, mismanagement of resources, limited clinical education, and misplaced priorities2,3,7,8. for the limited number of children who begin treatment, cure rates are reported to be only 50-60%, even in specialized tertiary treatment facilities8. due to financial difficulties and misperceptions about the incurability of cancer, 43% of children diagnosed with cancer do not start treatment or stop treatment prematurely7. additionally, due to late diagnosis and advanced disease at presentation, more than 20% of children are incurable at the time of diagnosis and 10% die in early treatment phases7,8. palliative care is a major priority in childhood cancer care strategy as it provides compassionate support both for the children and their families1,2,7,8. there are an estimated 2 million children in bangladesh in need of palliative care and 29 thousands children needing specialized end-of-life care annually in bangladesh, including children with cancer and other life-threatening or life-limiting conditions; however, less than 1% of children requiring palliative care in bangladesh have access to it7. there are very few palliative care services operating and most are focused on adult patients; however, only few pediatric palliative care services exist in government and private hospitals6,7. under the circumstances, i proposed this study to collect data on the currentsituation of palliative care services in childhood cancer in bangladesh and find out the challengesidentified by different stakeholders. methods: an anonymous survey was done based on a self-administered, semi‐structured questionnaire between july and december of 2013 in some specialized pediatric oncology units of different public and private hospitals in dhaka city of bangladesh. a total of 300 respondents including physicians, nurses, caregivers (both professionals who deal with childhood cancer and parents of the children suffering from cancer), and hospital/ program managers who deal with childhood cancer patients took part in this survey. queries addressed were access to treatment, availability of drugs, palliative care, pain management, cost of treatment, quality of care and perceived challenges.all the participants were given detailed explanation of the study and informed written consent was taken from them. data were collected and coded to ensure anonymity, then assembled, and compiled. all data were presented systematically in tables. qualitative data were expressed as frequency and percentage. results: among 300 respondents, most of them are from 31-40 age group (49%), followed by 21-30 years group (24.67%), 41-50 years group (17%) and 5160 years group (9.33%). 108 were males (36%), while 192 were females (64%).28 physicians, 47 nurses, 8 hospital/program managers, 6 counsellors and 211 caregivers (both professionals and parents of the children) participated in the study (table 1). difficulty in access to treatment (86%), out‐of‐pocket payment for oncology therapies (88%), palliative care (91%) were evident (table 2). 93% reported that availability of specialized palliative care services, pain management and psychological plus decision‐ making support were directly related to income level. overall, 96% of respondents indicated that palliative care is important for their patients and 79% indicated that they were competent to provide this care; however, only 64% indicated that they had enough time to deliver quality palliative care (table 3). challenges include lack of awareness, less availability of facility, high cost, limited and inefficient manpower, low quality of care, less communication between health professionals and parents/family members of the patient (table 4). table 1. demographics of the participants (n=300) demographiccharacteristics number percentage (%) age (in years) 21-30 74 24.67 31-40 147 49 41-50 51 17 51-60 28 9.33 sex male 108 36 female 192 64 role in oncology/palliative care physician 28 9.33 nurse 47 15.67 hospital/program manager 8 2.67 counsellor 6 2 caregiver 211 70.33 international journal of human and health sciences vol. 05 no. 02 april’21 228 table 2. perceived difficulty in access to cancer care (n=300) barriers number percentage (%) access to diagnosis and treatment 259 86.33 treatment cost 264 88 access to palliative care 272 90.67 table 3. perceived scopes and provision of palliative care (n=300) barriers number percentage (%) i think palliative care is important. 289 96.33 i think palliative care services, pain management and psychological plus decision‐making support is available for money. 278 92.67 i think quality palliative care is available. 85 28.33 i think my facility is costeffective. 93 31 i think in my role i have desired competence. 237 79 i think i have enough time to deliver my service. 191 63.67 table 4. perceived challenges in palliative care (n=300) challenges number percentage (%) lack of awareness. 105 35 less availability of palliative care facility. 178 59.33 high treatment cost. 242 80.67 low quality of care. 103 34.33 limited manpower. 234 78 lack of communication between health professionals and parents/family members. 209 69.67 lack of national policy and regulations. 218 72.67 discussion: palliative care is a multidisciplinary approach to patients’ care to accomplish the possible highest quality of life (qol) and promote dignity for patients who are suffering with incurable and life limiting disease such as cancer1. the aspects of the palliative care in bangladesh concern the matters of concentrating on the rights of the patients in getting release from sufferings of all kinds (physical, psychological, social and spiritual). there is increased awareness of the need for palliative care for chronic diseases especially for children, who remain more vulnerable to suffering. however, there remains a huge unmet need for palliative care for chronic life-limiting health problems in most parts of the world1. palliative care is an essential part of cancer control, both for adults and children. world health assembly declared palliative care as part of human rights and called upon who and its member states to improve access to palliative care as a core component of health systems, with an emphasis on with an emphasis on primary health care and community/home-based care1-3,9,10. in bangladesh, ashic foundation started registering childhood cancer cases since 2001, as the first pediatric cancer focused institution. the pediatric oncology department of national institute of cancer research & hospital (nicrh) was introduced in 2008. before that, childhood cancer patients were treated under medical oncology department at nicrh as well as other public and private hospitals. the ashic foundation is a non-governmental organization whose purpose is to support childhood cancer patients and their families in bangladesh. they provide housing during treatment, followups in dhaka city, palliative care service and psychological counselling support5. however, poverty is a major issue in bangladesh; however, the national economy is showing positive growth in recent years4. children present late with cancer as a result of poor public and local health worker awareness of the meaning of signs and symptoms of cancer. consequently, only about 80% of children reaching secondary/tertiary hospitals can be offered potentially curative therapy, and of those many families cannot afford to pay for full treatment which is also true for access to palliative care7. the social welfare department of the government hospitals provide some support and help to patients/families. nevertheless, at present the cost of cytotoxic chemotherapy falls to parents3. children with incurable cancer require palliative care, particularly at the end of life,3,4 and all clinicians must recognize the moral and ethical obligations to address and attend the needs of the patients10. a maximum of 200 in-patient beds are available for palliative patients, which are government and private resources combined, such as bangabandhu sheikh mujib medical university (bsmmu), dhaka shishu hospital, nicrh, other government medical college/institutions, ashic foundation hospital, ahsania mission cancer hospital, ahmed medical centre, delta medical centre, bangladesh medical college hospital, etc.6,11.this survey confirmed that many of the 229 international journal of human and health sciences vol. 05 no. 02 april’21 children in bangladesh lack access to all or most of elements of palliative care.islam & eden6 also identified similar challenges as found in the present study; professional and public awareness, late diagnosis, perceptions of incurability, treatment refusal and abandonment, toxic deaths and drug costs/inconsistent availability. the perspectives and challenges are also supported by the evidence produced by cruz-oliver et al.3, elsayem et al.12, caruso brown et al.13, sasaki et al.14 and lorenz et al.15.research has also identified the lack of knowledge about the philosophy of palliative care and misperceptions about palliative care as major barriers which could limit the access of patients to palliative care services and had the potential to restrict our abilities to develop the service13-15. this lack of awareness was a problem both for health administrators within the hospital and for healthcare practitioners12-15. however, efforts to engage the public and policy makers on the need for palliative care have met with limited success7,15. concerted efforts should be taken to raise public and professional awareness, develop more pediatric cancer hospitals in the country, reduce diagnostic delays and subsidize drug and travel costs, through public-private partnership1,6,12-15. conclusion: in bangladesh, pediatric oncology is usually practiced in resource‐strained oncology units of pediatric divisions in different public hospitals along with few private hospitals. however, this survey confirmed that many of the children lack access to quality palliative care. effective palliative care requires establishment of more facilities with cancer registry, availability of drugs for therapies and pain management, manpower development, communication with patients and families in decision‐making. acknowledgement: i am grateful to the authorities of the corresponding hospitals for their permission and support to carry out this research. conflict of interest: the author declares no conflict of interest. ethical approval issue: the study was approved by the ethical review committee of dhaka medical college, dhaka, bangladesh. funding statement: no funding. references: 1. world health organization (who). strengthening of palliative care as a component of integrated treatment throughout the life course. j pain palliat care pharmacother. 2014;28(2):130-4. 2. casarett d, teno j. why population health and palliative care need each other. jama. 2016;316(1):27-8. 3. cruz-oliver dm, little mo, woo j, morley je. endof-life care in lowand middle-income countries. bull world health organ. 2017;95(11):731. 4. the world bank. country specific data: bangladesh. accessed december 16, 2019. https://data.worldbank. org/country/bangladesh 5. ferlay j, bray f, pisani p, parkin dm. iarc cancer base no. 5 version 2.0. lyon: iarc pr. 2004. 6. islam a, eden t. brief report on pediatric oncology in bangladesh. south asian j cancer. 2013;2(2):105-6. 7. world child cancer. facts and stats: bangladesh. accessed december 17, 2019. https://www. worldchildcancer.org/what-we-do/where-we-work/ bangladesh. 8. connor sr, sepulveda bermedo mc. eds. global atlas of palliative care at the end of life. london: worldwide palliative care alliance. 2014. 9. dehghan r, ramakrishnan j, ahmed n, harding r. “they patiently heard what we had to say... this felt different to me”: the palliative care needs and care experiences of advanced cancer patients and their families in bangladesh. bmj support palliat care. 2012;2:145-9. 10. de lima l, pastrana t. opportunities for palliative care in public health. ann rev pub health. 2016;37(1):35774. 11. khan f, ahmad n, anwar m. palliative care is a human right. j bang soc anaesthsiol. 2008;21:76-9. 12. elsayem af, elzubeir he, brock pa, todd kh. integrating palliative care in oncologic emergency departments: challenges and opportunities. world j clin oncol. 2016;7(2):227-33. 13. caruso brown ae, howard sc, baker jn, ribeiro rc, lam cg. reported availability and gaps of pediatric palliative care in lowand middle-income countries: a systematic review of published data. j palliat med. 2014;17(12):1369-83. 14. sasaki h, bouesseau mc, marston j, mori r. a scoping review of palliative care for children in low and middle-income countries. bmc palliat care. 2017;16(1):60. 15. lorenz ka, lynn j, dy sm, shugarman lr, wilkinson a, mularski ra, et al. evidence for improving palliative care at the end of life: a systematic review. ann intern med. 2008;148(2):147-59. international journal of human and health sciences vol. 05 no. 03 july’21 286 review article: situation analysis of episiotomy in the gulf: a scoping review faisal zain mohammed al-zabidi1, maged said elsirafi1, mohamad ayham muqresh1, mohamed abdelghafour ali1, syed muhammad baqui billah1 abstract: objective: to assess episiotomy rates and indications in gulf council countries (gcc). materials and methods: two databases (pubmed, google scholar) were searched for relevant papers published from january 2014 to december 2019. only 9 articles (3 in saudi arabia, 2 in iraq and 1 in oman, 1 in qatar, 2 in uae) were eligible. all articles reported episiotomy rates and indications as a primary or secondary outcome. results: the cumulative rate of episiotomy in gcc was 52%, while this was 45% in saudi arabia. the perineal tear reported rate in gcc was 29%, however, the cases accompanied with episiotomy was 65%. the most frequent indication was rigid perineum in both 16.9% in saudi arabia and 65.5% in iraq. conclusion: episiotomy rates were reported to be high in gcc and saudi arabia. only few articles reported episiotomy from the gcc. the commonly reported indications were both subjective for the doctor or the patient. we recommend that episiotomy rates with clear indications should be investigated in future research. keywords: episiotomy rates, episiotomy indications, episiotomy outcomes, episiotomy in gulf council countries, episiotomy in saudi arabia. correspondence to: syed muhammad baqui billah, assistant professor of epidemiology, sulaiman al rajhi university, al-qassim, saudi arabia. e-mail: sbbillah@gmail.com 1. college of medicine, sulaiman al rajhi university, al-qassim, saudi arabia. international journal of human and health sciences vol. 05 no. 02 april’21 page : 286-291 doi: http://dx.doi.org/10.31344/ijhhs.v5i3.277 introduction: episiotomy is an obstetric surgical procedure that is performed in the perineal area with a small incision in order to enlarge the vaginal orifice, hence facilitate delivery. the most common type of episiotomy is medio-lateral; however, a midline approach is also common.1,2 early episiotomy procedures can be traced to the 1740s scottish midwives, but it is not until the 1960’s when episiotomy was routinely implemented. in spite of the claim to decrease labor duration and to prevent perineal injury, evidence in 2017 suggested that routine episiotomy had no benefits rather was associated with variant risks such as perineal laceration, excessive bleeding, wound infection, pain during sitting and decreased sexual pleasure.3 the most common indications in the gulf cooperation council (gcc) countries for episiotomy were perineal rigidity, maternal exhaustion, high fetal weight, vaginal breech, and concern of fetal heart rate.4,5 the short-term complications were perineal laceration, excessive bleeding, wound infection, wound edema, pain, anal sphincter or bladder injury, and episiotomy dehiscence. where long-term complications include chronic infection, pelvic organ prolapse (pol), fecal or urinary incontinence, sexual dysfunction, and chronic pain.6 anxiety and depression were the most common psychological effects of episiotomy.7 the new recommendation by the american college of obstetricians and gynecologists, 2013 recommended that episiotomy should be restricted in clinical practice.8 this study aims to estimate the episiotomy rates, indications, and complications of episiotomy in gcc. 287 international journal of human and health sciences vol. 05 no. 03 july’21 materials and methods we based our scoping review on the framework described by arksey and o’malley (2005) and adhered to enhancement proposed by levac, colquhoun, and o’brien (2010). a search plan was formulated and proceeded with a broad research question, search terms identification and database selection. our review included the following six key stages: first, identifying the research question; second, identifying relevant studies; third, study selection; fourth, charting the data; fifth, collating, summarizing, and reporting the results; and finally, sixth, consultation of the framework. research question we wanted to find answer to the question on the rates, indications and complications of episiotomy in gcc countries. we developed the review question using the cochrane picos (population, intervention/exposure, comparison, outcomes, and study design) framework. the populations of interest were nulliparous and multiparous pregnant women. the interventions/exposures were any women who went for an episiotomy procedure. the comparison was the different rates of episiotomy between the gcc countries. the outcomes were the benefits, risks, complications, and doctors’ current belief on the indications of the episiotomy procedure. data sources and search strategy two reviewers started an initial and comprehensive search on october 24, 2019, in two electronic databases: pubmed and google scholar. a further search was conducted on november 13, 2019, to add researchgate. we selected the databases to be universal and to cover a wide range of disciplines. the search consisted of the following terms: “episiotomy and rates”, “episiotomy and indications”, “episiotomy and outcomes”, “episiotomy and gulf council countries” “episiotomy and complication”, “episiotomy and saudi”, “episiotomy and oman”, “episiotomy and yemen”, “episiotomy and iraq”, “episiotomy and qatar”, “episiotomy and uae”, “episiotomy and bahrain”, “episiotomy and kuwait”. we didn’t limit our search on any language, date, subject or type. eligibility criteria the screening process was done on two-screening stages to assess the relevance of studies identified in the search. studies were eligible for inclusion if they broadly described any of the following: episiotomy indications, rates, and complications in any of the gcc. the primary screening began with reviewing the title and abstract of citations based on a pre-formed designed agreement consisting of two questions: whether the citation described primary research on episiotomy and whether it had relevance to one or more aspects of the research question. the primary screening of each citation was independently screened by two reviewers. none of the reviewers were blinded to the author or journal name. in case of conflicts, reviewers met together to discuss and resolve any uncertainties related to article selection. data characterization all potentially relevant citations were obtained for secondary screening and subsequent review of the full-text articles. a form was developed and implemented by the authors to confirm the relevance and to extract study characteristics such as publication year, publication design, country, sample size, sample age, sample source, outcome, measuring tools. any citation that didn’t meet the eligibility criteria were eliminated at this phase. data summary and synthesis two reviewers independently completed all steps of the scoping review and compiled the data in a single spreadsheet (microsoft excel) for validation and coding. descriptive statistics were calculated to summarize the data. frequencies and rates were used to describe nominal data and to facilitate categorization and charting. the flow chart of the literature search is given in figure 1. results the pubmed search yielded a total of 22 full articles, through reading the abstract of the articles, they were narrowed down to 14 that had relevant information and after further reading of full text only 5 papers had matched the inclusion criteria, an additional search through google scholar yielded an additional 4 articles. in the end, 9 articles were selected in total, the data were extracted in a separate excel sheet to be identified and further subdivided following a template containing the following: (gravidity, age, history of episiotomy, history of perineal tear, history of caesarean section, instrumental delivery, comorbid illnesses, term, type of labour, birth weight, number of babies, indications of the procedure). the cumulative rate of total episiotomy in gcc was 52%, of which around 54% occurred in international journal of human and health sciences vol. 05 no. 03 july’21 288 nulliparous women as depicted in table 1. the overall episiotomy rate was 45% in saudi arabia, with nearly 72% of them being nulliparous. the rate of nulliparous who had an episiotomy in saudi arabia was 92%; that of multiparous who had an episiotomy in saudi arabia was 19%. the overall perineal tear reported rate in gcc was 26.3%, however, the cases who have had episiotomy had more tear rates (65%). the most frequent indication was rigid perineum in both saudi arabia (16.9%) and iraq (65.5%). the country wise description is given below. saudi arabia only 3 research works met the eligibility criteria from saudi arabia studies. zaheera saadia from the qassim region worked with 291 patients in 2014 and found 149 (51.2%) underwent episiotomy.5 the paper showed two classifications according to the gravidity and the use of instruments during the delivery. 5 in 2016, ayman oraif from jeddah assessed 1000 patients, where 357 (36%) underwent episiotomy. the patients were classified according to gravidity and nothing further.9 in 2017, an article was written by rola turki and her colleagues, jeddah, a sample figure 1: flowchart of the data collection 289 international journal of human and health sciences vol. 05 no. 03 july’21 consisted of 705 patients; 54.6% (384) underwent episiotomy. the data were classified according to different variables (gravidity, instrumental usage, term, spontaneous vs. induced). also, the paper discussed the correlation with perineal laceration as its intended primary goal for the paper.10 iraq two articles were qualified after filtering according to eligibility criteria, both of them were conducted in erbil, kurdistan iraq. in 2016, huda juma’a ali studied 500 patients, and found 44.2% (221) underwent episiotomy. the data are subdivided table 1. frequency distribution of all included studies on episiotomy (n=9) international journal of human and health sciences vol. 05 no. 03 july’21 290 by (gravidity, age, past history of episiotomy or perineal tear, history of cs, instrumental usage, comorbidity). the paper highlighted the presence of perineal laceration as well.4 the other article was published in 2019 by hamdia mirkhan ahmed, she studied 1500 patients; 73.9% (1109) of them underwent episiotomy. the data further classified according to gravidity and other variables. perineal laceration and its association also had been mentioned.11 qatar a paper by amila husic in 2008, discussed briefly the rates and indication of episiotomy. they reported an overall rate of 60% and a nulliparous rate of up to 95%. the author reported that the results waren't statistically significant as the sample size was small (n= 263).12 united arab emirates two articles were conducted by the same doctors e. rizk and l. thomas, al-ain hospital, published in 2000 and 2005 respectively. both of them reported rates of episiotomy and perineal lacerations. the overall rate of episiotomy in 2000 was 76.3% while the rate of laceration was 15.3%.13 in 2005, the overall rate dropped to 34.6% and the laceration rate was 35.1%. in the same paper further subdivisions mentioned, the nulliparous’ episiotomy rate was 73% while the multiparous’ 28.6%.14 oman one article was included from oman in 2015, by khadija al-ghammari and her colleagues. the sample size was 1,068 patients; 39.9% (426) underwent episiotomy.15 no further classification or subdividing were mentioned. discussion the world health organization (who) stated in 2018 that there was no supporting evidence of liberal use of episiotomy. specification of each indication should be addressed and evaluated, so being a nullipara is not an indication. reduced chances of having laceration used to be one of the anticipated gains of episiotomy, despite that no change in overall rates of perineal laceration was reported with or without episiotomy; but severe laceration was correlated to episiotomy and such finding was reported by rola turki.10,16 although who preferred mediolateral technique for use, we didn’t find the technique was used by any clinicians from our review papers.16 the one single burden we encountered during the data collection was the scarcity of the publication on this topic. there are few publications regarding episiotomy in saudi arabia, iraq, uae, qatar and oman and no publication at all in kuwait, bahrain or yemen. only 2 out of the 9 papers mentioned the exact indication, leaving a blank space for lack of indications.4,5 also, the technique of episiotomy was not reported as we can’t really tell whether the complication (i.e. lacerations) was due to episiotomy in general or one type of the procedures. conclusion: episiotomy rates were reported to be high in gcc and saudi arabia. a few articles reported episiotomy from across the gcc, which necessitates more research to be conducted in this topic. the commonly reported indications were both subjective for the doctor or the patient. episiotomy rates, it’s clear indications, type of incision and outcomes to be investigated in future research. a clear list of indications should be determined beforehand by each institution and go under periodic auditing for efficacy assessment. we can also follow the records whether the frequency and rates of episiotomy followed any declining pattern over time or not. ethical approval: this is a scoping review assessing published articles, hence there is no need for ethical approval. conflict of interest: the authors declare no conflict of interest among themselves. funding statement: there was no funding source for the study. individual authors contribution: ma designed the study, fz and me collected data, fz, me and mm entered data, fz analyzed data, ma, sb, fz, me and mm all contributed to the manuscript, reviewed and finalized the draft. 291 international journal of human and health sciences vol. 05 no. 03 july’21 references: 1. who recommendation on episiotomy policy. accessed 09.07.2020 https://extranet.who.int/rhl/ topics/preconception-pregnancy-childbirth-andpostpartum-care/care-during-childbirth/care-duringlabour-2nd-stage/who-recommendation-episiotomypolicy-0 2. kalis v, laine k, de leeuw jw, ismail km, tincello dg. classification of episiotomy: towards a standardisation of terminology. bjog int j obstet gynaecol. 2012;119(5):522–6. 3. ould f. a treatise of midwifry, in three parts. am j obstet gynecol. 1995;172(4):1317–9. 4. ali hj, zangana jms. rate of perineal injuries and episiotomy in a sample of women at maternity teaching hospital in erbil city. j educ pract. 2016;7(20):12–7. 5. saadia z. rates and indicators for episiotomy in modern obstetrics – a study from saudi arabia. mater socio-medica. 2014;26(3):188–90. 6. gün i̇, doğan b, özdamar ö. longand short-term complications of episiotomy. turk j obstet gynecol. 2016;13(3):144–8. 7. edessy m, nasr aa, el-aty mga, ahmed w. post episiotomy physical and physiological morbidities in al azhar university hospital of assiut -upper egypt. soj gynecol obstet womens health [internet]. 2015 jul 22. accessed 09.06.2020 https:// s y m b i o s i s o n l i n e p u b l i s h i n g . c o m / g y n e c o l o g y obstetrics-womenshealth/gynecology-obstetricswomenshealth02.php 8. acog practice bulletin no. 198: prevention and management of obstetric lacerations at vaginal delivery. obstet gynecol. 2018;132(3):e87. 9. oraif a. routine episiotomy practice at a tertiary care center in saudi arabia. open j obstet gynecol. 2016;06:794–7. 10. turki r, abduljabbar hs, manik j, an, thiagarajan j, bajou o, et al. severe perineal lacerations during childbirth in saudi women-a retrospective report from king abdulaziz university hospital. biomed res. 2017;28(8):3350–4. 11. ahmed hm. midwives’ clinical reasons for performing episiotomies in the kurdistan region. sultan qaboos univ med j. 2014;14(3):e369–74. 12. husic a, hammoud mm. indications for the use of episiotomy in qatar. int j gynecol obstet. 2009;104(3):240–1. 13. rizk de, thomas l. relationship between the length of the perineum and position of the anus and vaginal delivery in primigravidae. int urogynecol j pelvic floor dysfunct. 2000;11(2):79–83. 14. rizk dee, abadir mn, thomas lb, abu-zidan f. determinants of the length of episiotomy or spontaneous posterior perineal lacerations during vaginal birth. int urogynecol j pelvic floor dysfunct. 2005;16(5):395–400. 15. al-ghammari k, al-riyami z, al-moqbali m, almarjabi f, al-mahrouqi b, al-khatri a, et al. predictors of routine episiotomy in primigravida women in oman. appl nurs res anr. 2016;29:131–5. 16. world health organization. who recommendations on intrapartum care for a positive childbirth experience, 2018. accessed 09.06.2020 https:// www.who.int/reproductivehealth/publications/ intrapartum-care-guidelines/en/ international journal of human and health sciences vol. 05 no. 03 july’21 336 original article prevalence and assessment of experience of dental caries among school going adolescents in a rural area of sylhet, bangladesh sadia akther sony1, fariha haseen1, syed shariful islam1, ishrat jahan2 abstract: background: socio-epidemiological data of dental caries helps to plan effective community interventions.objective: to estimate the prevalence and assess the experience of dental caries among school going adolescents in a rural area of bangladesh. methods: a cross-sectional study was donein sylhet district in bangladesh, between january and december of 2014. students of class viii, ix and x, aged 12-16 years were taken for the study. a total of 90 studentswere divided into 12-14 years and 15-16 years age groups using simple random sampling technique. a pre-designed, self-administered questionnaire was used for demographic survey. students were examined for dental caries. assessment of experience of dental caries was done by decayed, missing and filled teeth (dmft) index. results: the mean age of the respondents was 14.37±0.50 years. females were 68(75.6%) and males were 22(24.4%). 31(34.4%), 30 (33.3%) and 29(32.2%) were from viii, ix and x respectively. the older age group (15-16 years) had more decayed teeth than that of 12-14 years group (2.28 vs. 1.46; p=0.04). the mean dmft score was lower in male compared to female (1.43 vs. 2.30; p>0.05).there was significant difference in the total dmft score among the classes (p=0.009). mean dmft score was 1.88. caries prevalence was 42.2% in the maxillary arch and 58.9% in the mandibular arch. among males, the mandibular arch showed a higher caries level (63.64%) than the maxillary arch (40%), while in females, in maxillary and mandibular archeswere 42.64% and 42.65% respectively (p>0.05). conclusion: 64.4% of the study population had dental caries with male predominance; mandibular arch was more involved. keywords: dental caries, dmft index, school going adolescents, rural area, bangladesh. correspondence to: dr. sadia akther sony, program manager, department of public health and informatics, bangabandhu sheikh mujib medical university (bsmmu), dhaka-1000, bangladesh. email: sadiasony@gmail.com 1. department of public health and informatics, bangabandhu sheikh mujib medical university (bsmmu), dhaka-1000, bangladesh. 2. department of public health, north south university, bashundhara, dhaka-1229, bangladesh. international journal of human and health sciences vol. 05 no. 02 april’21 page : 336-340 doi: http://dx.doi.org/10.31344/ijhhs.v5i3.284 introduction: caries is one of the most important and common dental health problems around the world;dental caries is the most prevalent dental affliction of childhood1,2. the global burden of disease study 2017 estimated that more than 530 million children suffer from caries of primary teeth globally1. despite credible scientific advances and the fact that caries is preventable, the disease continues to be a major public health problem. in developing countries, changing lifestyles and dietary patterns are markedly increasing the caries incidence3.oral diseases are more intense among the children and oral diseases restrict activities in school, at work and at home causing several school and work hours to be lost each year.moreover, the psychosocial impact of these diseases often diminishes quality of life4. among children, adolescents are particularly at higher risk for dental caries. adolescence is a critical period as health practices during adolescence usually persist during adult years1,4. to achieve a sound oral health practice of good oral hygiene is a must. oral hygiene is the practice of keeping mouth and oral cavity clean to prevent dental problems,especially dental caries, gingivitis and bad breath4. the unique characteristic of oral and dental diseases is that they are universally prevalent and do not 337 international journal of human and health sciences vol. 05 no. 03 july’21 undergo remission or termination if untreated and require technically demanding expertise and time-consuming professional treatment4,5. the other fact is socio-epidemiological data of dental caries helps to plan effective community oriented oral health promotion interventions for school children which saves millions of morbidities and millions of dollars in health care5. ‘polarization’ of caries is occurring on a worldwide basis, where the prevalence of caries is declining in developed countries, increasing in less-developed countries, and is epidemic in countries with emerging economies6. bangladesh is developing country of south asia, with majority of its population living in the rural areas. the aim of the study is to estimate the prevalence of dental caries among school going adolescents in a rural area of sylhet, bangladesh, to provide basic socioepidemiological data for planning and eventuation of oral health services in the rural areas focusing particularly in the preventive aspects.the study population was chosen adolescents aged from 12 to 16 years. this age is especially important as it is generally the age at which children move to secondary school from primary level. moreover, this group is a reliable sample from the adolescent age which can be easily obtained through the school system4,7. last but not the least, it is the age that all the permanent teeth, except third molars will have erupted. the world health organization (who) has also chosen the age as the global monitoring age for caries for international comparisons and monitoring disease trends7. methods: a cross-sectionalstudy was done at sazzad majumdar bidya niketon, situated under voron sultanpur union of zakiganj upazilla of sylhet district in bangladesh, between january and december of 2014. the students of the three classes: class viii, ix and x, aged between 12 and 16 years were taken for the study. both the school and the study samples were collected by using simple random sampling technique. a total of 90 students were divided in two age groups: 12 to 14 years and 15 to 16 years7. a pre-designed, self-administered questionnaire was used for demographic survey, as per who protocol7. clinical examinations of teeth were carried out under field conditions in a classroomsetting by one dental surgeon using plane mouth mirrors, who periodontal probes andnatural light as a source of illumination. a data collector recorded the observations.students were examined whilst seated on a chair. assessment of experience of dental caries was done by decayed, missing and filled teeth (dmft) index7. the components of dmft index are dt = decayed teeth, mt = missing teeth and ft = filled teeth. presence of caries is measured by total dmft score (maximum 32, minimum 0). demographic characteristics are analyzed by using frequency table and percentage. mean age was seen; relationship between age category and sex and educational status are presented by cross tabulation.statistical data analysis was done using spss version 21.0. after data collectiondata entry was done. dataanalysis was summarized in form of proportion and frequency tables for categoricalvariables. continuous variables were summarized using means and standard deviation. probability (p)valueswere computed for categorical variables using student ‘t’ test and oneway anova test; p value <0.05 was considered to constitute a statistically significant difference. results: a total of 90 students who were aged between 12 to 16 participated in the study. 44(48.9%) were aged between 12 and 14 years, while 46(51.1%) were between 15 and 16 years. the mean age of the respondents was 14.37±0.50 years. most of the participants were females 78(75.6%);the number of male participants was 22(24.4%). they were almost equally distributed according to their educational status.31 (34.4%) were from class (grade)viii, 30(33.3%) from class (grade) ix and 29(32.2%) were from class (grade) x. (table 1).the older age group (15 to 16years) had more decayed teeth (mean dt score was 2.28), while than that of 12 to 14 years group (mean dt score was 1.46), which was statistically significant (p=0.04). the mt score was almost equal inboth age groups and did not show any statistical difference (p>0.05). the ft score was zero in the age group 12 to 14 years and there was statistical difference (p=0.04). the mean dmft score was lower in male (1.43), compared to female (2.30); however, no significant gender related difference was found. according to educational status, the mean dt scores were in class viii 1.35, in class ix 1.75, and in class x 2.59; the difference was statistically significant (p=0.01). however, there was no statistically significant difference in the mt and ft scores among them according to their educational status. there was significant difference in the total dmft score among the classes (p=0.009). the total international journal of human and health sciences vol. 05 no. 03 july’21 338 with dental caries. this result ishigher than some studies in south asia; in a study in india, as conducted by suprabha et al.8, it was observed that the prevalence of caries was59.4%among the 11 to 13 years old children in urban community. in a similar study by dixit et al.9, done in nepal, caries prevalence amongthe 5 to 6years old was 52% and 12 to 13-years old was 41%. rahman etal.10 found in a study in bangladesh that the prevalence of dental caries among under 5children was 44.34%. however,our result is similar to the findings ofsarwar et al.11 and karunakaran et al.12. this may be an indication of anupward trend in dentalcaries in developing countries. dental caries can be explained as a multifactorial disease influenced by various intraoraland extraoral factors including age and sex13. in the present study, therewas significant relationship between gender and caries experience.several studies have reported variations in dental caries according toage and gender. rehman at al.10, karunakaran et al.12 and dummer et al.14found caries prevalence higher among the boys compared tothe girls. on the contrary, girls were found to havehigher caries prevalence by mishra & shee15 and saimbi et al.16. the variation could be attributed tothe different age groups and geographic locations studies in the surveys. inter arch comparison revealed that the caries prevalence was higher in the mandibulararch in both sexes. rehman et al.10 andjawadekar et al.17 found the same findings in their studies. however, higher caries prevalence in upper arch was reported by sathe & mali18.in this study, the older age group (15 to 16years) had more decayed teeth as the meandt score was 2.28, while in 12 to 14years groups mean dt scorewas 1.46, which means the score of decayed teeth is higher in older group of participants.our study revealed a dmft index of 1.88. this result was higherthan earlier findings mean dmft score among the respondents was 1.88 (table 2). caries prevalence was 42.2% in the maxillary arch and 58.9% in the mandibular arch. among male students, the mandibular arch showed a higher caries level (63.64%) than the maxillary arch (40%). among female students, caries in maxillary arch was 42.64% and in mandibular arch 42.65%. however, the difference was not statistically significant (p>0.05) (table 3). table 1. socio-demographic characteristics of the respondents (n=90) variables frequency percentage age 12 to 14 years 44 48.9 15 to 16 years 46 51.1 mean±sd 14.37±0.50 years gender male 22 24.4 female 68 75.6 educational status class viii 31 34.4 class ix 30 33.3 class x 29 32.2 table 2. distribution of the scores of the components of dmft index according to the socio-demographic characteristics variables dt mean±sd p value mt mean±sd p value ft mean±sd pvalue dmft mean±sd pvalue age in years 12to 14 1.46±1.44 0.04* 0.02±0.15 0.95 0 0.04* 1.43±1.48 0.07 15to 16 2.28±1.92 0.02±0.14 0.02±0.14 2.30±1.93 gender male 2.13±1.85 0.72 0.04±0.21 0.09 0 0.25 1.43±1.84 0.88 female 1.80±1.70 0.01±0.12 0.01±0.12 2.30±1.75 educational status class viii 1.35±1.50 0.01* 0 0.59 0 0.35 1.29±1.51 0.009* class ix 1.75±1.60 0.03±0.18 0 1.73±1.66 class x 2.59±1.94 0.03±0.19 0.03±0.16 2.66±1.91 dt=decayed teeth; mt=missing teeth; ft=filled teeth; sd=standard deviation; *=p<0.05 table 3.arch wise prevalence of dental caries gender maxillary arch caries p value mandibular arch caries p value male 40% 0.76 63.64% 0.24female 42.64% 42.65% total 42.20% 58.90% discussion: in the present study,the prevalence ofdental caries among the respondents of the study was 64.40% with a mean dmft score1.88. more than 60% of the respondents in that rural area was affected 339 international journal of human and health sciences vol. 05 no. 03 july’21 in bangladesh by fakir et al.19, as their study revealed that in the age group 8-12 yearsstudents dmft index was 1.05 for permanent teeth and 1.72 for deciduous teeth – an increase incaries with increasing age.dental treatment is not so difficult but proper treatmentfacilities is not available all over the country. hence, simple preventive measure should be taken tomaintaining good oral and dental health.the oral health teaching manual should be revised to include newer concepts of oral healthcare like tooth brushing using fluoridated toothpaste twice a day at an interval of twelve hours, avoiding sugar containingfood as far as possible and ringing of the mouth properlyafter taking sweet food etc.10,11,19. limitations of the study: due to the study design findings could not be generalized beyond the participants of the study. as this study was done in a rural school of sylhet, it cannot be generalized in the rest of the community who live in the other parts ofbangladesh.another limitation of this study was that it used a structured questionnaire to collect datafrom the survey population. this could provide limited responses from people and they did not have the capacity for in-depth answers. conclusion: 64.4% of the study population bears the burden of dental caries with a mean dmft score 1.88. male school children were found more affected than the females; mandibular arch was the predominantly affected arch. a high prevalence of unmet health care need still exists in the country as reflected through a high ‘decayed teeth’ score in dmft index.timely referral and restorative management of children suffering from dental caries would reduce the burden of dental caries. hence, essential dental treatments should be easily accessible and available in the rural areas. conflict of interest: none to disclose. ethical approval issue: the study was approved by the institutional review board (irb) of bangabandhu sheikh mujib medical university (bsmmu), dhaka, bangladesh. funding statement:we acknowledge the grant received frombangabandhu sheikh mujib medical university (bsmmu), bangladesh,to support this study partially. authors’ contribution: concept and study design: sas, fh, ssi; data collection and compilation: sas, fh, ij; data analysis: sas, fh, ssi; critical writing, revision and finalizing the manuscript: sas, fh, ssi, ij. international journal of human and health sciences vol. 05 no. 03 july’21 340 references: 1. gbd 2017 disease and injury incidence and prevalence collaborators. global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the global burden of disease study 2017. lancet. 2018;392(10159):1789-1858. 2. benjamin rm. oral health: the silent epidemic. public health rep. 2010;125(2):158-159. 3. kumar s, kulkarni s, jain s, meena y, tadakamdla j, tibdewal h, et al. oral health knowledge, attitudes and behavior of elementary schoolteachers in india. rev gaúcha odontol. 2012;60(1):19-25. 4. petersen pe. the world oral health report 2003: continuousimprovement of oral health in the 21st century the approach ofthe who global oral health programme. community dent oralepidemiol. 2003;31(1):3-24. 5. grewal n, kaur m. status of oral health awareness in indian children as compared to western children: a thought provoking situation (a pilot study). j indian soc pedod prev dent. 2007;25(1):15-19. 6. yee r, sheiham a. the burden of restorative dental treatment for children in third world countries. int dent j. 2002;52(1):1-9. 7. world health organization (who). oral health survey: basic methods. 4th ed. geneva: who. 1997. 8. suprabha bs, rao a, shenoy r, khanal s. utility of knowledge, attitude, and practice survey, and prevalence of dental caries among 11to 13-yearold children in an urban community in india. glob health action. 2013;6:20750. 9. dixit lp, shakya a, shrestha m, shrestha a. dental caries prevalence, oral health knowledge and practice among indigenous chepang school children of nepal. bmc oral health. 2013;13:20. 10. rahman s, rasul c, kashem m, biswas s. prevalence of dental caries in the primary dentition among under five children. bangladesh med j khulna. 2012;43(12):7-9. 11. sarwar afm, kabir mh, rahman afmm, haque a, kasem ma, ahmad sa, et al. oral hygiene practice among the primary school children in selected rural areas of bangladesh. j dhaka national med coll hosp. 2012;18(1):43-48. 12. karunakaran r, somasundaram s, gawthaman m, vinodh s, manikandan s, gokulnathan s. prevalence of dental caries among school-going children in namakkal district: a cross-sectional study. j pharm bioallied sci. 2014;6(suppl 1):160-161. 13. joshi n, rajesh r, sunitha m. prevalence of dental caries among school children in kulasekharam village: a correlated prevalence survey. j indian soc pedod prev dent. 2005;23(3):138-140. 14. dummer pm, addy m, hicks r, kingdon a, shaw wc. the effect of social class on the prevalence of caries, plaque, gingivitis and pocketing in 11-12-yearold children in south wales. j dent. 1987;15(5):185190. 15. misra fm, shee bk. prevalence of dental caries in school going children in an urban area of south orissa. j indian dent assoc. 1979;51(9):267-270. 16. saimbi cs, mehrotra ak, mehrotra kk, kharbanda op. incidence of dental caries in individual teeth. j indian dent assoc. 1983;55(1):23-26. 17. jawadekar sl, dandare mp, nato m, jawadekar ss. dental caries susceptibility pattern. j indian dent assoc. 1989;60:200-203. 18. sathe p, mali a. textbook of community dentistry. hyderabad: paras medical publisher; 1998. 19. fakir mm, alam kmu, mamun fa, sarker n. a survey on oral health condition in primary school children. med today. 2010;22(2):70-72. international journal of human and health sciences vol. 07 no. 02 april’23 188 case report ipsilateral femoral neck and shaft fracture; a case series of 5 patients. johan abdul kahar1, muhammad najmi ab ghani2 abstract femoral shaft fractures are very common following trauma in adults and sometimes the patient may have an ipsilateral neck of femur fractures too. unfortunately, the neck of femur fractures may be missed. the challenge lies in detecting and properly managing the neck of femur fracture in the presence of a femoral shaft fracture. we share our experience in treating 5 patients with ipsilateral neck and shaft of femur fractures and discuss the learning points in regards to diagnosis and treatment of this condition. keywords: ipsilateral neck and shaft of femur fractures, missed neck of femur fracture. correspondence to: johan abdul kahar, department of orthopaedic, faculty of medicine and health sciences, universiti putra malaysia, 43400 serdang, selangor, malaysia. e-mail: akjohan@upm.edu.my 1. department of orthopaedic, faculty of medicine and health sciences, universiti putra malaysia, 43400 serdang, selangor, malaysia. 2. department of orthopaedic, hospital pengajar universiti putra malaysia, persiaran mardi-upm, 43400 serdang, selangor darul ehsan, malaysia. international journal of human and health sciences vol. 07 no. 02 april’23 doi: http://dx.doi introduction femoral shaft fracture is a commonly seen injury in orthopaedic practice. it typically occurs following high energy trauma and is commonly associated with other injuries which may influence the initial and definitive managements of the femoral fracture. various options of treatment are available for managing isolated femoral shaft fractures but choosing the correct treatment may be difficult when the femoral neck is fractured as well. concomitant neck of femur fractures is not unusual and may be missed. we wish to share our experience in managing 5 cases of ipsilateral femoral neck and shaft fractures. case reports case report 1: a 30-year-old male construction worker fell from 10th floor into a pile of plywoods. he sustained open fracture of distal 1/3 shaft of his right femur (gustillo ii), closed comminuted fracture of the right patella and a scalp laceration. initially the femoral neck fracture was not apparent on the trauma radiographs. following suspicion by the treating surgeon, the femoral neck was examined with image intensifier during the same anaesthesia for the debridement of the open femoral shaft fracture. stress views under anaesthesia revealed a basal neck of femur fracture. patient was put on temporary skeletal traction and delayed fixation of the femur was performed 6 days later. the femoral neck and shaft were fixed with a reconstruction nail. case report 2: a 37-year-old female pedestrian was allegedly hit by a car and sustained open fracture of mid shaft of left femur (gustillo ii) with ipsilateral basal neck of femur fracture. she had no other injuries. the patient underwent wound debridement, broad dynamic compression plate (dcp) fixation of the shaft fracture and in-situ percutaneous screw fixation of the neck of femur fracture using two cannulated half-threaded 6.5mm screws. case report 3: a 23-year-old male was involved in alleged motor vehicle accident where his motorcycle collided 189 international journal of human and health sciences vol. 07 no. 02 april’23 figure 1-5: the initial plain radiographs of the patient on the day of trauma. fracture line at the neck of femur was not visible. figure 6-9: post-operative plain radiographs of the patient. the neck of femur fracture can be clearly seen. with another car. he sustained closed fracture of the mid shaft of his left femur with ipsilateral basal neck of femur fracture. he also sustained closed fracture of mid shaft of tibia and fibula and a posterior cruciate ligament avulsion on the same side. at 8 hours post trauma, he was diagnosed to have fat embolism syndrome and was brought to operating to undergo fracture fixation of his left femur and tibia. the tibia was fixed with a narrow dcp, followed by broad dcp fixation of the femoral shaft and percutaneous screw fixation of the neck of femur using two cannulated halfthreaded 6.5mm screws. figure 10-12: the initial plain radiographs of the patient on the day of trauma. basal neck of femur fracture can be seen on femur and pelvis films. international journal of human and health sciences vol. 07 no. 02 april’23 190 figure 13-16: post-operative plain radiographs of the patient. figure 21-23: the initial plain radiographs of the patient on the day of trauma. basal neck of femur fracture can be seen on femur radiographs. figure17-20: plain radiographs of the patient at two months post-operatively. no sclerosis of head of femur seen and the neck of femur fracture was not displaced. figure 24-27: post-operative plain radiographs of the patient. 191 international journal of human and health sciences vol. 07 no. 02 april’23 case report 4: a 33-year-old male sustained a closed fracture of the left femur following a motor vehicle accident where his motorcycle rear-ended a car. the patient had no other injuries. a careful examination by contrast adjustment of the pelvis and hip radiographs on the computer revealed a thin fine line which represents a basal neck of femur fracture. the fractures were fixed with a reconstruction nail on day 5 post-trauma. case report 5: a 53-year-old polytrauma patient was admitted figure 28-32: the initial plain radiographs of the patient on the day of trauma. basal neck of femur fracture can barely be seen even after enlarging the image and adjusting the contrast. figure 33-36: post-operative plain radiographs of the patient. no displacement of the neck of femur fracture. figure 37-39: the initial plain radiographs of the patient on the day of trauma. international journal of human and health sciences vol. 07 no. 02 april’23 192 into intensive care unit following his involvement in an alleged motor vehicle accident. he sustained multiple rib fractures with chest contusion, mandible fractures, closed fracture mid shaft of left femur with an ipsilateral neck of femur fracture, bilateral distal radius fracture as well as an open pilon fracture of the left tibia. the subcapital neck of femur fracture was undisplaced and vertical. he was put on traction and admitted into intensive care unit (icu). for the femoral fractures, he was planned for screw fixation of the neck of femur and retrograde nailing. however due to his unstable general condition, definitive fracture fixations were unable to be done. he remained hypoxic despite being on high ventilator settings and was ventilator dependent throughout his icu stay, until day 19 of admission when he passed away due to multi organ failure and acute respiratory distress syndrome (ards). discussion while femoral shaft fractures are very common, to have an ipsilateral femoral neck fracture at the same setting is unusual. emphasis should be on detection of its occurrence and proper management of the neck of femur fracture while treating the concomitant shaft fracture. the incidence of ipsilateral femoral neck and shaft fractures is estimated to be up to 6%1,2; which is quite high considering an orthopaedic surgeon will encounter one such case in about every 20 femoral fractures. the ipsilateral neck of femur fractures typically exhibit a common trait. usually, they are vertical and minimally displaced1,3. this fracture pattern consistency was clearly demonstrated in our case series. unfortunately, concomitant neck of femur fractures are commonly missed; it can be undetected in up to 30% of the patients. other than the fact that the fracture is often undisplaced, suboptimal views of post-traumatic plain radiograph may mask the injury. the hips are often in external rotation causing the neck of femur to be obscured by the greater trochanter. occasionally, artefacts such as traction splint bar may obstruct the view of the neck of femur too. it is also possible that the trauma series radiographs failed to include the hip especially in emergency situations in an unstable patient. these factors are recognised to contribute to missed ipsilateral neck of femur fracture in the presence of femoral shaft fracture1-3. late detection or missing a neck of femur fracture may lead to devastating complications such as avascular necrosis of the femoral head and non-union of the neck of femur fracture1,3-5. early detection of the fracture is of paramount importance as early management of neck of femur fractures results in better outcome. within the limits of the plain radiographs in the trauma settings, the attending doctor should scrutinize every hip and pelvis films of a patient with femoral fractures. this is because it is almost impossible to suspect neck of femur fracture by physical examination as hip range of motion is not testable in the presence of femoral shaft fracture. suspicious radiographs should be repeated too. using computerised system to view these imaging studies may make detection of occult neck of femur fracture easier as the surgeon can adjust the contrast and enlarge the area of interest to further enhance the fracture line appearance. another way is making use of computed tomography (ct) scan of the abdomen that may have been done for assessment of concomitant intraabdominal or pelvic injuries in a patient with a femoral shaft fracture. most of the time the ct images will include the upper part of femur which can be further examined carefully1,2,4. however, despite its presumable accuracy in detecting occult femoral neck fractures, ct scan may lack sensitivity as demonstrated by a blinded study by o’toole et al5. therefore, a surgeon needs to be vigilant when interpreting the ct scan images of the proximal femur. sometimes, the ipsilateral neck of femur fracture is not detected until intramedullary nailing were done for the shaft fractures. these fractures are usually presumed to be iatrogenic due to inappropriate entry point and improper technique of introducing the nail; but they may actually be missed fractures that only became apparent following manipulation during the nailing procedure2. a few studies have demonstrated this; for example, yang et al found that most of their ipsilateral neck n shaft femur that was nailed actually sustained it preoperatively based on the ct scan that was done for concomitant suspected intraabdominal injuries2. riemer et al also found occurrence of ipsilateral neck of femur fractures in shaft fractures that are treated with plates6. this goes to show that the intramedullary nailing does not necessarily cause the neck of femur fractures. considering the importance and challenges in detecting concomitant ipsilateral femoral neck fractures, it is a good practice for the surgeon to carefully examine the neck of femur under image intensifier during positioning and preparation 193 international journal of human and health sciences vol. 07 no. 02 april’23 prior to starting intramedullary nailing of the femur. it is also advisable to perform a stress test for the neck of femur under image intensification once the femoral shaft is stabilised following fixation, so that any fracture can be managed under the same anaesthesia1,3,5. a study by avilucea et al demonstrated superior sensitivity of intraoperative dynamic stress fluoroscopy in detecting femoral neck fractures when compared to pre-operative ct scan and intra-operative static plain hip radiographs. they proposed a maneuvre that consist of axial loading, valgus stress, internal rotation and external rotation3. another aspect of managing ipsilateral neck and shaft of femur fracture is deciding the method of fixation of the fractures. it is not unusual that the neck of femur fracture is incidentally discovered during intramedullary nailing procedure. if it is found during patient positioning, the fractured neck of femur should be reduced and held temporarily with threaded guidewires to maintain reduction. with the wires in-situ, reaming of canal and insertion of nail can be completed before finally locking it proximally with a reconstruction screw into the femoral neck1,7. if the fracture is detected after completion of nailing or reconstruction screws are not readily available, two or three half-threaded cannulated screws can be used to fix the neck of femur fracture using the “miss-a-nail” technique7-9. in the situation where the neck of femur fracture was detected upon patient’s presentation, the surgeon has the liberty to choose the appropriate method of fixation. options available include plating of the shaft and screw fixation of the neck of femur6, retrograde nailing of the shaft and screw fixation of the neck of femur1 and reconstruction nail fixation7,10-12. most if not all authors would agree that there is no single best solution to this type of injury and treatment need to be individualised to each patient8. regardless the method chosen, loss of reduction of the neck of femur fracture should be avoided especially considering they are usually undisplaced initially in these situations2,6. this can be avoided by temporarily placing guidewires across the neck of femur fracture first. then reaming and nail insertion can proceed without conflicting hardwares, before finally inserting the reconstruction screw. for plating and retrograde nailing, the neck of femur can be fixed first, but excessive manipulation of the proximal femur must be avoided during the shaft fixation to avoid implant failure. in our series, we plated the shafts of femur of patient 2 and patient 3 before proceeding with closed reduction and screw fixation of the neck of femur. we feel that the neck of femur fracture could have been compressed further. perhaps better reduction can be obtained had we fixed the neck of femur first. similarly, in patient 1, the neck of femur fracture site appeared more opened up compared to pre-operative radiographs. the reconstruction nailing for patient 1 and patient 4 were done following the usual steps. perhaps if we have temporarily held the neck of femur fracture with a few threaded guidewires before reduction, reaming and nail insertion, the neck of femur fracture would not have displaced. we were fortunate that in patient 4, no displacement of neck of femur fracture occurred. conclusion ipsilateral neck and shaft of femur fractures may occur in high energy trauma. unfortunately, the neck of femur fracture may be undetected in the presence of shaft fractures and may even be presumed iatrogenic following intramedullary nailing procedures. emphasis should be on early detection and proper treatment of both fractures. to avoid missing a concomitant neck of femur fracture in a case of femoral shaft fracture, the treating doctor need to carefully examine the hip/ pelvis radiographs and available ct scans that include the proximal femur. subsequently, once the femoral shaft is fixed, intra-operative fluoroscopic stress views of the femoral neck will help to minimise the likelihood of overlooking femoral neck fractures. options of treatment should be individualised to each patient. regardless the method of fixation, displacement of the neck of femur fracture site should be avoided. conflict of interest both authors declare that they have no conflicts of interest. ethical clearance both authors declare that they have no conflicts of interest. authors’ contribution both authors were involved equally in patient management, data collection, literature review and manuscript preparation. international journal of human and health sciences vol. 07 no. 02 april’23 194 references 1. wolinsky pr, johnson kd. ipsilateral femoral neck and shaft fractures. clinical orthopaedics and related research®. 1995; 318:81-90. 2. yang kh, han dy, park hw, et al: fracture of the ipsilateral neck of the femur in shaft nailing: the role of ct in diagnosis. j bone joint surg. 1998; 80:673. 3. avilucea fr, joyce d, mir hr. dynamic stress fluoroscopy for evaluation of the femoral neck after intramedullary nails: improved sensitivity for identifying occult fractures. journal of orthopaedic trauma. 2019; 33(2):88-91. 4. tornetta iii p, kain ms, creevy wr. diagnosis of femoral neck fractures in patients with a femoral shaft fracture: improvement with a standard protocol. jbjs. 2007; 89(1):39-43. 5. o’toole rv, dancy l, dietz ar, et al. diagnosis of femoral neck fracture associated with femoral shaft fracture: blinded comparison of computed tomography and plain radiography. journal of orthopaedic trauma. 2013; 27(6):325-30. 6. riemer bl, foglesong me, miranda ma: femoral plating. orthop clin north am. 1994; 25:625. 7. shetty ms, kumar ma, ireshanavar ss. ipsilateral hip and femoral shaft fractures treated with intramedullary nails. international orthopaedics. 2007; 31(1):77-81. 8. bucholz rw, rathjen k. concomitant ipsilateral fractures of the hip and femur treated with interlocking nails. orthopedics. 1985: 8(11):1402-6. 9. wiss da, sima w, brien ww. ipsilateral fractures of the femoral neck and shaft. journal of orthopaedic trauma. 1992;6(2):159-66. 10. hossam e, morsey a, eid e. ipsilateral fracture of the femoral neck and shaft, treated by reconstruction interlocking nail. arch orthop trauma surg. 2001; 121:71. 11. koldenhoven ga, burke js, pierron r. ipsilateral femoral neck and shaft fractures. south med j. 1997; 90:288. 12. randelli p, landi s, fanton f, et al. treatment of ipsilateral femoral neck and shaft fractures with the russell-taylor reconstructive nail, orthopedics. 1999; 22:673. international journal of human and health sciences vol. 05 no. 01 january’21 96 original article: clinical efficacy and safety of ‘oxy +’ in type 2 diabetes: a pilot study md. anzar alam1, mariyam ahad1, mohdaleemuddin quamri1, fasihur rehman ansari1, farooqui shazia parveen1 abstract: background and objectives: diabetes is a common metabolic disorder.type 2 diabetes accounts for the vast majority of around 92% of the population worldwide. long term hyperglycemia leads to macro and microvascular complications. oxy+ is a nutraceutical capsule which contains mainly arthrospira (spirulina). most of the diabetic people use it. hence a clinical trial was conducted to evaluate the clinical efficacy and safety of oxy + in type 2 diabetes.material methods: the study was designed as a single-blind pilot study; 10 eligible patients of type 2 diabetes were allocated. oxy+ was given in capsule form; 2 capsules twice daily orally for 45 days after the meal. test drug was evaluated on subjective parameters at 0th, 15th, 30th and 45th days whereas objective parameters were assessed before and after the treatment. the results of the intervention were analyzed using suitable statistical methods.results and observation:the study effects on subjective parameters like polyuria, tiredness, polyphagia, polydipsia, and tingling sensation were found significantly reduced. the objective parameters were assessed before and after as mean ± sd for fbs (164.4±36.019 vs 111.1±25.075), ppbs (248.5±51.70 vs 170.1±45.148) and hba1c (9.14±1.517 vs 6.95±1.224).the results were analyzed after using paired‘t’ test.interpretation and conclusion:the findings about both parameters (subjective and objective) that the ‘oxy+’ is effective in type 2 diabetes and the cure was considerable. safety parameters (sgot, sgpt, blood urea, and serum creatinine) were remained unchanged. therefore, it can be concluded that the ‘oxy+’ would be safe and effective in the management of type 2 diabetes. keywords: type 2 diabetes; oxy+; metabolic disorder; nutraceutical; arthrospira (spirulina). correspondence to: dr. md anzaralam. lecturer, dept. of moalajat, national institute of unani medicine, bangalore, india. e-mail:dranzarnium@gmail.com 1. department of moalajat, national institute of unani medicine, bangalore, india. international journal of human and health sciences vol. 05 no. 01 january’21 page : 96-100 doi: http://dx.doi.org/10.31344/ijhhs.v5i1.241 introduction: diabetes mellitus is a group of metabolic diseases characterized by chronic hyperglycemia resulting from defects in insulin secretion, insulin action, or both.1diabetes mellitus (dm) is probably one of the oldest diseases known to mankind and it was first reported in egyptian manuscript about 3000 years ago.2type 2 diabetes accounts for the vast majority around 92% of diabetes worldwide.3according to idf (international diabetes federation) atlas 9th edition 2019 worldwide prevalence of diabetes is 463 million and it is expected to be 700 million in the year of 2045.4the estimated global direct health expenditure on diabetes in 2019 is usd 760 billion and is expected to grow to a projected usd 825 billion by 2030 and usd 845 billion by 2045.5the main cause is poor glycaemic control which leads to microvascular(diabetic nephropathy, neuropathy, and retinopathy),6 and macrovascular (coronary artery disease, peripheral arterial disease, and stroke) complications.7diabetes can be controlled effectively by reducing overweight and by taking a balanced lifestyle (diet and physical activity) in combination with medication when needed.8,9biguanides,11 sulfonylureas,12 thiazolidinediones, α-glucosidase inhibitors, sodium-glucose co-transporter inhibitors,13meglitinides, incretins, dpp-4 inhibitors and hormone analoges are commonly used for the treatment of this debilitating disease.14,15long term use of the above-mentioned medications leads to a multitude of complications; hypoglycemia, renal issues, heart problems and git disorders.16,17 97 international journal of human and health sciences vol. 05 no. 01 january’21 oxy+ is a natural source of oxygen found in nature and used as a dietary supplement and manufactured in aruba for lifefactors.18it is a richest source of arthrospira (spirulina) (contain phycocyanin, sulfated polysaccharides, γ-linoleic acid, carotene, iron etc.)19,20 and which have been reported to be an antioxidant, immuno-modulator, hypoglycemic, anti-dyslipidemic, hepatoprotective, antiviral and anticancer activities.21,22previous pre-clinical,23 and clinical studies have shown that arthrospira (spirulina) and its active ingredients can reveal anti-diabetes properties.24–27 this interpretation led us to substantiate the hypoglycemic activity of research drug among diagnosed cases of type 2 diabetes. therefore, a study was contemplated to evaluate the clinical efficacy and safety of research drug (oxy+) in type 2 diabetes. 2. materials and methods: 2.1 participants: patients were identified and recruited from different clinics from bangalore and called to enroll opd of national institute of unani medicine (nium) bangalore. inclusion criteria included the diagnosed cases of type 2 dm with fasting blood sugar>126 mg/dl; postprandial blood sugar>200 mg/dl, hba1c>6.5%, and aged between 30-60 years of both gender, patients willing to participate in the study and ready to follow the instructions.24,28exclusion criteria included pregnant and lactating mother and other complications of diabetes. 2.2 study design: eligible patients with type 2 diabetes were enrolled to participate in this study. at first, all participants were informed about the study protocol by being given a complete description of the objectives, benefits and potential harm of the study. informed consent was received from each participant who chosen to participate in the study.total 30 subjects are screened, 18 are excluded, 2 are denied and finally10 subjects who met the inclusion criteria were enrolled for this study. this study was singleblind pilotstudy (figure 1). 2.3 administration of drug: research drug was given twice a day in the form of capsule after meal for the period of 45 days. 2.4 assessments: all the patients were assessed fortnightly for subjective parameters (0th, 15th, 30th, and 45thday) whereas objective parameters were assessed before and after the treatment. 2.5 adverse drug effect: throughout the course of trial, there wasno any adverse effect was reported. figure 1:flow diagram of the trial. 2.6 statistical analysis: statistical analysis was performed using spss 15.0, used to analyze the data and use microsoft word and excel to create graphs, tables etc.the findings were statistically calculated using student t test, combined proportion test and exact fischer test.significance is measured at the level of 5%. results were based on continuous measurements as mean ± sd (min-max). 3. results: baseline characteristics the demographic characteristics of subjects were in baseline characteristics including age, genders, and dietary habits (table 1). table 1: distribution of the patients according to demographic details. variables oxy+ group total (n=10) age in years 39-45 4 4(40%) 46-52 1 1(10%) 53-60 5 5(50%) total 10 10(100%) mean ± sd 50.4±7.42 50.4±7.42 gender female 7 7(70%) male 3 3(30%) dietary habits mixed diet 9 9 (90%) vegetarian 1 1(10%) total 10 10(100%) a student t test, bfisher exact test, cchi-square test, *significant international journal of human and health sciences vol. 05 no. 01 january’21 98 primary outcome the objective parameter was assessed before and after as mean ± sd for fbs (164.4±36.019 vs 111.1±25.075), ppbs (248.5±51.70 vs 170.1±45.148) and hba1c (9.14±1.517 vs 6.95±1.224) (table 2). table 2: evaluation of objective variables before and after treatment. variables before treatment after treatment difference p value fbs (mg/dl) 164.4±36.019 111.1±25.075 53.3 <0.0012** ppbs(mg/ dl) 248.5±51.70 170.1±45.148 78.40 <0.0001** hba1c (%) 9.14±1.517 6.95±1.224 2.19 <0.0008 student t test (two tailed, dependent) has been used secondary outcomes all safety profile was found safe from baseline to end of the trial without any adverse effect (table 3). table 3: evaluation of safety variables. safety variables before treatment after treatment difference p value sgot (mg/ dl) 26.5±7.82 29.9±11.43 -3.400 <0.265 sgpt (mg/ dl) 28.4±7.619 34.4±9.27 -6.0 <0.073 blood urea (mg/dl) 9.14±1.517 6.95±1.224 2.19 0.566 serum creatinine (mg/dl)) 9.14±1.517 6.95±1.224 2.19 <0.0008 student t test (two tailed, dependent) has been used discussion: diabetes mellitus has become an observably global public health problem.29 migration from rural areas to urbanization and a sedentary lifestyle; changes in food habits may increase the risk of obesity and diabetes.30 physical activity increases glycemic regulation and decreases the risk of cardiovascular disease (cvd) and death in type 2 diabetes patients.31according to the international diabetes foundation (idf) statistics, presently every seven seconds someone is estimated to die from diabetes or its complications, with 50% of those deaths.32 a combination of lifestyle changes and pharmacological therapy is required to maintain good metabolic control in diabetes and to keep the patient stable for the long term.33,34 hozayen wg et al, (2016) reported that, arthrospira (spirulina) exhibits insulin-mimetic and anti-diabetic activity.35 one other study documented that, spirulina is a rich source of fiber contents which may lead to reduced glucose absorption and possible action of peptides, and polypeptides generated by digestion of spirulina protein are responsible for it.36 layam a et al,23 alam et al,24 park hj et al,25 lee eh et al, 26anitha l et al,27 kumari p et al,37 and kaur k et al,38 reported that spirulina exhibits as an anti-hyperglycemic activity. parikh p et al,36 and anweret al,39 reported that spirulina provides a plentiful source of proteins and it is well recognized that ingestion of protein and amino acids stimulates the secretion of insulin. this effect may be responsible for the reduction in fasting, postprandial blood sugar, and hba1c.36,39 various hypotheses that, about spirulina, which is a rich iron source, led to high hemoglobin levels. the rise in hemoglobin levels may have been attributed to the dropin blood glucose levels, which would also lead to a drop in glycosylated hemoglobin.23,36,39,40 limitations of the study: the limitations of the present study include lack of a control group and blinding. moreover, it was a small sample size. conclusion: accordingly, it can be concluded that oxy+ has a beneficial effect on reducing fasting blood sugar (fbs), postprandial blood sugar (ppbs) and glycosylated hemoglobin (hba1c). consequently, it can be concluded that the ‘oxy+’ would be safe and effective in the management of type 2 diabetes. acknowledgement: we would like to extend our sincere gratitude and appreciation to participants of this study. funding : supported by alberto fridolphoproduzioneoranjestad, aruba. conflict of interest : the authors declare no conflict of interest. ethical approval issue:prior ethical approval was taken from institutional ethics committee. authors’ contribution: conception and design of the study: md anzaralam.data collection and compilation: mariyam andfasihur rehman ansari.data analysis: farooqui shazia parveen. critical writing, revision and finalizing the manuscript: mohdaleemuddinquamri. 99 international journal of human and health sciences vol. 05 no. 01 january’21 references: 1. kharroubi at, darwish hm. diabetes mellitus: the epidemic of the century. world journal of diabetes. 2015;6(6):850-867. 2. olokoba ab, obateru oa, olokoba lb. type 2 diabetes mellitus: a review of current trends. oman medical journal. 2012;27(4):269-273. 3. xu g, liu b, sun y, du y, snetselaar lg, hu fb, bao w. prevalence of diagnosed type 1 and type 2 diabetes among us adults in 2016 and 2017: population based study. bmj. 2018;362:k1497. 4. yuen l, saeedi p, riaz m, karuranga s, divakar h, levitt n, yang x, simmons d. idf diabetes atlas: projections of the prevalence of hyperglycaemia in pregnancy in 2019 and beyond: results from the international diabetes federation diabetes atlas. diabetes res clin pract. 2019;157:107841. 5. williams r, karuranga s, malanda b, saeedi p, basit a, besançon s, bommer c, esteghamati a, ogurtsova k, zhang p, colagiuri s. global and regional estimates and projections of diabetes-related health expenditure: results from the international diabetes federation diabetes atlas. diabetes research and clinical practice. 2020;108072. 6. chawla a, chawla r, jaggi s. microvasular and macrovascular complications in diabetes mellitus: distinct or continuum?. indian journal of endocrinology and metabolism. 2016;20(4):546-551. 7. shan pf, li q, khamaisi m, qiang gf. type 2 diabetes mellitus and macrovascular complications. international journal of endocrinology. 2017;2017. 8. asif m. the prevention and control the type-2 diabetes by changing lifestyle and dietary pattern. journal of education and health promotion. 2014;3. 9. wilding j. managing patients with type 2 diabetes and obesity. the practitioner. 2015;259(1778):25-8. 10. yanai h, adachi h, masui y, katsuyama h, kawaguchi a, hakoshima m, waragai y, harigae t, hamasaki h, sako a. exercise therapy for patients with type 2 diabetes: a narrative review. journal of clinical medicine research. 2018;10(5):365-369. 11. hotta n. a new perspective on the biguanide, metformin therapy in type 2 diabetes and lactic acidosis. journal of diabetes investigation. 2019;10(4):906-8. 12. mifsud s, schembri el, fava s. a case of severe relapsing sulphonylurea-induced hypoglycaemia. bmj case reports cp. 2019;12(12):e231368. 13. chaudhury a, duvoor c, dendi r, sena v, kraleti s, chada a, ravilla r, marco a, shekhawat ns, montales mt, kuriakose k. clinical review of antidiabetic drugs: implications for type 2 diabetes mellitus management. frontiers in endocrinology. 2017;24:8-6. 14. eqbal k, alam ma, quamri ma, sofi g, bhat mda. efficacy of qurs-egulnar in ziabetus (type 2 diabetes mellitus): a single blind randomized controlled trial. jcomplement integr med.2020;18(2):0072. 15. green bd, flatt pr. incretin hormone mimetics and analogues in diabetes therapeutics. best practice & research clinical endocrinology & metabolism. 2007;21(4):497-516. 16. betônico cc, titan sm, correa-giannella ml, nery m, queiroz m. management of diabetes mellitus in individuals with chronic kidney disease: therapeutic perspectives and glycemic control. clinics. 2016;71(1):47-53. 17. yarovoi sk, kareva en, dzhalilov ov. effects of oral hypoglycemic drugs on lithogenic properties of urine in nephrolithiasis patients with concurrent type 2 diabetes. urologiia (moscow, russia: 1999). 2018;(3):63-9. 18. alam ma, siddiqui ma, quamri ma, sofi g.efficacy and safety of spirulina in type 2 diabetes-a randomized standard control trial. journal of research in unani medicine 2018;7(1):24-29. 19. mathur m. bioactive molecules of spirulina: a food supplement. bioactive molecules in food. reference series in phytochemistry. springer, cham, 2018. 20. al-dhabi na, valanarasu m. quantification of phytochemicals from commercial spirulina products and their antioxidant activities. evidencebased complementary and alternative medicine. 2016;763:1864. 21. ravi m, de sl, azharuddin s, paul sf. the beneficial effects of spirulina focusing on its immunomodulatory and antioxidant properties. nutr diet suppl. 2010;2:73-83. 22. alam ma, haider n, ahmed s, alam mt, azeez a, perveen a. tahlab (spirulina) and few other medicinal plants having anti-oxidant& immunomodulatory properties described in unani medicine-a review. international journal of pharmaceutical sciences and research. 2013;4(11):4158-4164. 23. layam a, reddy cl. antidiabetic property of spirulina. diabetologiacroatica. 2006; 35(2):29-33. 24. alam a, siddiqui ma, quamri a, fatima s, roqaiya m, ahmad z. efficacy of spirulina (tahlab) in patients of type 2 diabetes mellitus (ziabetusshakri): a randomized controlled trial. journal of diabetes & metabolism. 2016;7(10):1-5. 25. park hj, lee yj, ryu hk, kim mh, chung hw, kim wy. a randomized double-blind, placebo-controlled study to establish the effects of spirulina in elderly koreans. annals of nutrition and metabolism. 2008;52(4):322-8. international journal of human and health sciences vol. 05 no. 01 january’21 100 26. lee eh, park je, choi yj, huh kb, kim wy. a randomized study to establish the effects of spirulina in type 2 diabetes mellitus patients. nutrition research and practice. 2008;2(4):295-300. 27. anitha l, chandralekha k. effect of supplementation of spirulina on blood glucose, glycosylated hemoglobin and lipid profile of male non-insulin dependent diabetics. asian journal of experimental biological sciences. 2010;1(1):36-46. 28. anonymous. international diabetes federation. diabetes atlas; 8th edition; 2017. 29. wu y, ding y, tanaka y, zhang w. risk factors contributing to type 2 diabetes and recent advances in the treatment and prevention. international journal of medical sciences. 2014;11(11):1185-1200. 30. cheema a, adeloye d, sidhu s, sridhar d, chan ky. urbanization and prevalence of type 2 diabetes in southern asia: a systematic analysis. j glob health. 2014;4(1):010404. 31. hamasaki h. daily physical activity and type 2 diabetes: a review. world journal of diabetes. 2016;7(12):243-251. 32. saeedi p, petersohn i, salpea p, malanda b, karuranga s, unwin n, colagiuri s, guariguata l, motala aa, ogurtsova k, shaw je. global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: results from the international diabetes federation diabetes atlas. diabetes research and clinical practice. 2019;157:107843. 33. kim mk, ko sh, kim by, kang es, noh j, kim sk, park so, hur ky, chon s, moon mk, kim nh. 2019 clinical practice guidelines for type 2 diabetes mellitus in korea. diabetes & metabolism journal. 2019;43(4):398-406. 34. alam ma, quamri ma, sofi g, tarique bm. understanding hypothyroidism in unani medicine, journal of integrative medicine.2019;17(6):387-391. 35. hozayen wg, mahmoud am, soliman ha, mostafa sr. spirulina versicolor improves insulin sensitivity and attenuates hyperglycemia-mediated oxidative stress in fructose-fed rats. journal of intercultural ethnopharmacology. 2016;5(1):57-64. 36. parikh p, mani u, iyer u. role of spirulina in the control of glycemia and lipidemia in type 2 diabetes mellitus. journal of medicinal food. 2001;4(4):193-199. 37. kumari p, khanam s, varma mc, kumar p, chouhan r, pandey ak. study the spirulina as a potential antidiabatic. journal of chemical, biological and physical sciences. 2013;3(3):1963-71. 38. kaur k, sachdeva r, grover k. effect of supplementation of spirulina on blood glucose and lipid profile of the non-insulin dependent diabetic male subjects. j. dairying, foods & h.s.2008;27(3/4):202-20 s8. 39. anwer r, alam a, khursheed s, kashif sm, kabir h, fatma t. spirulina; possible pharmacological evaluation of insulin like protein. journal of applied phycology.2013;25:883-9. 40. simon jp, baskaran ul, shallauddin kb, ramalingam g, prince se. evidence of antidiabetic activity of spirulina fusiformis against streptozotocin-induced diabetic wistar albino rats. 3 biotech. 2018;8(2):129. microsoft word ijhhs imam 23rd asc 2022 s13 symposium healthcare professionals’ wellbeing 1. is the job market really saturated? mustapha kamal1 surplus of doctors or highly unemployed doctors? malaysia faces the challenge of answering, balancing between the two. as per reported in 2019, we have 23077 contract doctors in ‘kementerian kesihatan malaysia’ (kkm) and just recently, only roughly about 4000 have been absorbed into permanent posts. since then, private practice has blossomed with more private clinics opening like mushrooms. diabetes, hyperlipidaemia and hypertension are on the rise. ischemic heart disease remains as the number one pathological contributor to death. mental health is currently crippling into our youth and our working class. since the start of the contract system, kkm has been unable to deliver specialists as they used to, due to the change of system. malaysia’s population is estimated to be at 32.7million according to the department of statistics malaysia. with a whopping total of almost 50000 doctors in kkm as per 2019 statistics, can they face the tide? are we overproducing doctors or underdeveloping new doctors? keywords: contract doctors; doctors malaysia; doctors’ training; doctors’ wellbeing 1. megaklinik zahran, bandar baru bangi, selangor.   ___________________________________________________________________________ correspondence to: dr. mustapha kamal, megaklinik zahran, bandar baru bangi, selangor.  dr.mustaphakamal93@gmail.com __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v7i70.515 international journal of human and health sciences. supplementary issue: 2019 doi: http://dx.doi.org/10.31344/ijhhs.v0i0.133 s15 digital diagnostics and therapeutics nazimi abd jabar centre for oral and maxillofacial surgery, faculty of dentistry, universiti kebangsaan malaysia, kuala lumpur abstract information technology (it) has much to offer for the healthcare. healthcare it covers a broad range of computer and technological advancement used in its environments and tools such as electronic health records (ehr), laboratory and medical imaging information systems, use of dedicated medical devices and facilitation of healthcare communication. it also supports the diagnostic ability for the healthcare members and enhance treatment deliveries reflecting patient-centered approach. however, despite vast challenges involve in the development and maintenance of these complex systems as a platform to hold enormous clinical and diagnostic information for huge number of patients, very little of these captured data are involved in the entire aspect of surgica l diagnostics and therapeutics. in most clinical situations, it merely serves for record keeping with minimal involvement in shaping the surgical workflow, perioperative clinical decision making or to enhance surgical deliveries. the aim of this presentation was to highlight our institutional experience with the utilization of various advance digital diagnostics and therapeutic software and tools for surgical management of jaw tumors and maxillofac ia l fracture reconstruction, with emphasis on orbital blowout fracture reconstruction. bridging and personalized diagnostic procedures for therapeutic or surgical use, pre-procedural or virtua l planning, image-guided surgery and perioperative surgical control and check with the use of computer technology will be highlighted in this presentation. it is hoped that this presentation could serve as sharing and learning platform for all conference delegates with regards to the revolutionary digital diagnostic and therapeutic trends in some aspect of oral and maxillofac ia l surgical procedures. international journal of human and health sciences vol. 07 no. 02 april’23 166 original article estimation of nicotine in tobacco extract using c8 column in high performance liquid chromatography ravi shekhar1, santosh kumar2, pritam prakash3 abstract background: nicotine is the most used toxic substance in spite of mass media awareness. column used in the estimation of nicotine is found to be the inhibiting factor for its estimation. objective: to develop a method for nicotine estimation on c8 column in hplc. methods: the method involved a model waters 1515 binary hplc pump system interfaced with a 2489 waters uv/vis detector, a 4.6 x 250 mm, 5μm beads symmetry c8 column at 37°c, and an isocratic mobile phase containing 60%: 40% v/ v mixture of 10mm sodium acetate (ph 5.5) and methanol at a flow rate of 1.0ml/min at 256 nm. the method was validated for specificity, linearity, precision, accuracy, the limit of detection (lod), the limit of quantitation (loq) and system suitability. results: the hplc nicotine peak with average retention time of 3.415 minutes was observed on chromatogram with rsd <0.5%; linearity was greater than 0.99 with acceptable precision (within usp limits of <2.0% rsd) and usp tailing less than 2. lod was found to be 0.200 μg/ml and limit of quantitation (loq) was found to be 0.609 μg/ml of nicotine. the average yield of the nicotine extracted by acid base extraction method from tobacco was 1.68% (range: 1.34–2.22%).conclusion: a hplc method based on c8 column for analysis of nicotine was developed and validated successfully. keywords: high performance liquid cheomatography, column c8, nicotine, tobacco correspondence to: dr ravi shekhar, additional professor, department of biochemistry, indira gandhi institute of medical sciences, patna, bihar-800014, india. email: ravishekhar1974@yahoo.com 1. additional professor, department of biochemistry, indira gandhi institute of medical sciences, patna, bihar-800014, india. 2. senior resident, department of biochemistry, indira gandhi institute of medical sciences, patna, bihar-800014, india. 3. associate professor, department of biochemistry, indira gandhi institute of medical sciences, patna, bihar-800014, india. introduction nicotine, poisonous nitrogen-containing compound, is a tobacco alkaloid.1 it is synthesised from numerous species of plants containing tobacco. nicotine, 3-(1-methyl-2-pyrrolidinyl) pyridine is a colorless, slightly pale yellow, hygroscopic oily liquid existing in nicotiana tabacum l (ntl) leaves.2 it contains a pyridine nucleus with a side chain at position-3.3 in small quantity, in smoking, it stimulates the nervous system. nicotine is known to improve the health conditions of patients of psychiatric disorders, like schizophrenia abnormalities4 and dementia patients, or those on therapy dopaminergic neurons and axons, levodopa induced dyskinesia, skin mild cognitive dysfunction.5 nicotine has antimicrobial and insecticidal functions6 and used as a natural pesticide with features of degradable, harmless and without environmental pollution challenges.7 tobacco addiction causes many diseases in developing countries that lead to high mortality.8 tobacco chewing is very common in india and causes cancer related mortality. this with tobacco smoking is a huge burden to indian health care and over all social wellbeing. nearly international journal of human and health sciences vol. 07 no. 02 april’23 doi: http://dx.doi.org/10.31344/ijhhs.v7i2.569 mailto:ravishekhar1974%40yahoo.com%20?subject= 167 international journal of human and health sciences vol. 07 no. 02 april’23 267 million adults (15 years and above) in india (29% of all adults) are users of tobacco, according to the global adult tobacco survey india, 2016-17. khaini, gutkha, betel quid with tobacco and zarda are the most prevalent form of smokeless tobacco use in india. smoking forms are bidi, cigarette and hookah.9 to measure health related effect of nicotine it is needed to be measured in source and plasma of the addicted individuals. there are several methods of nicotine estimation including gas chromatography with flame ionization detector (gc-fid),10 and gas chromatography-mass spectrometry (gc-ms).11,12 since, lc is a workhorse technique used for efficient and tedious analytical procedures,13-15 it has been employed successfully for nicotine quantification in e-liquids such as liquid chromatography-mass spectrometry (lc-ms),16,17 in addition to hplc with photodiode array detection (hplc-pda).18,19 hplc method is the rapid, simple and efficient of all. c8 column is packed with octylsilane bonded to silica, which is commonly used in reverse phase hplc methods. the retention time for such column is less in comparison to c18 (octadecylsilane) column with 18 carbon hydrophobic chains bonded to silica particles beads because of less hydrophobicity. the density of c8 column is less in comparison to c18 column. hence, the study aims to estimate nicotine in tobacco using c8 column in hplc. materials and methods materials and chemicals:nicotine standard liquid (density 1 g/ml) was from sigma aldrich, usa. hplc grade sodium acetate trihydrate and water was obtained from finar limited, ahmadabad, india, hplc grade methanol was obtained from thermo fisher scientific, mumbai, india. chloroform, glacial acetic acid, sodium hydroxide and sodium carbonate anhydrous were purchased from empura, merck life science private limited, mumbai, india. preparation of nicotine (nct) extract:acid-base extraction method was used to extract nicotine from commercially available chewable tobacco. this method is based on the alkaloid property of nicotine, which involves different solubility levels in water and an organic solvent. the 5g of tobacco leaves was boiled with 350ml of water at 80±5◦c for 20 min, then 5g of sodium carbonate was added and the mixture was continuously heated for 10 min. after filtration, the obtained filtrate was checked by ph strip paper and adjusted to ph 12 using 1n sodium hydroxide. the filtrate was then mixed with 50ml chloroform in a separatory funnel with stop cock closed. the separatory funnel was allowed to rest vertically on a stand to allow the organic and water phase to separate into layers. the bottom layer is drained carefully into a beaker. the process was repeated once more with 50ml chloroform. both of the drained filtrate was combined and poured on a wide petri-dish 150mm × 25 mm. the dish was placed on a dry block incubator at 50◦c for one hour to obtain crude extracts. the process of evaporation was carried out in a fume hood to avoid unwanted hazards. a yellow dried residue was obtained. the dried extract was then dissolved in 10ml hplc grade methanol. a brownish gummy insoluble substance formed which was mostly nucleic acid, whereas the soluble suspension was filtered into a clean test tube through a 0.2μm ptfe syringe filter. each extraction was performed in duplicate, the obtained extracts were protected from light and stored at 4◦c for analysis. determination of nicotine content in the extracts:the concentration of extracted nicotine was measured by injecting 10μl of the dissolved extract in hplc system (table 1). waters hplc system equipped with 1515 binary hplc pump, 2707 waters auto-sampler, waters column oven, and 2489 waters uv/vis detector was utilized. waters breeze 2 software was used for data acquisition and system suitability calculations.the samples were filtered through 0.2μm nylon filter into a 2ml autosampler vial and10μl injection of sample was injected on column in triplicate by the autosampler. chromatogram, retention time, response and other parameters were estimated by waters breeze 2 software (figure 1). table 1: chromatographic parameters for determination of nicotine parameter condition method reverse phase high performance liquid chromatography column x bridge c8 (waters, usa) 250mm × 4.6mm, and 5μm particle size flow rate 1 ml/minute detection uv detector, 259nm pda detector, 37oc column temperature 37oc injection volume 10μl mobile phase sodium acetate buffer (ph 5.5; 10mm): methanol (60% : 40% v/ v) international journal of human and health sciences vol. 07 no. 02 april’23 168 figure 1: chromatogram of nicotine sample 5μg/ ml; tr=3.405 min. with 10μl injection; mobile phase: sodium acetate buffer (ph 5.5;10mm) : methanol (60% : 40% v/v); flow rate 1ml/min; column c8 symmetry (4.6 × 250mm,5μm beads); detector:uv 256 nm. method validation:the developed method was validated for the parameters like linearity, precision, accuracy, recovery, and system suitability as described here.a stock solution of nicotine 100ppm was prepared by dissolving 1μl liquid nicotine standard in 10 ml of mobile phase. different concentrations of standard were prepared from the stock of 1, 2, 5, 10 and 25μg/ml in mobile phase. the standards were filtered through 0.2μm nylon filter into a 2ml auto-sampler vial and injected on column in triplicate by the auto-sampler. slope and intercept were estimated by waters breeze 2 software.the precision of an analytical method is the degree of agreement among the individual test results when the method is applied repeatedly to multiple sampling of homologous sample. it can be expressed as repeatability and intermediate precision.repeatability is to use of analytical procedure within a laboratory over a short period of time using the same analyte with the same equipment and is expressed as the percent relative standard deviation (rsd). the repeatability of the method was analyzed by measuring six replicates of nicotine at 100% assay concentration of 5µg/ml.intermediate precision of the method was checked by repeating the entire procedure for three consecutive days and calculating the rsd inthree consecutive days.accuracy was established by analyzing standard (5µg/ml) three times at 50%, 100% and 150% of the assay level. the average results were calculated against the true standard concentration and percent recovery was calculated. limit of detection (lod) and limit of quantification (loq):limit of detection (lod) and limit of quantification (loq). the calculation of both lod and loq were based on the standard deviation (sd) of the response (σ) and the slope of the calibration curve (s) for nicotine standards (n=5). the lod and loq were expressed according to the following equationsthe loq is lowest reliable concentration in the calibration curve that could be quantified by the analytical method. system suitability:data from six injections of 5µg/ml standard (at 100% assay concentration) was utilized for calculating system suitability parameters like retention time, usp tailing, number of theoretical plates and area calculated by waters breeze 2 software. results and discussion the standard curve of nicotine standards showed linearity in the range of 1-25µg/ml (figure 2) with a linear equation of y = 6675.7x – 1590.8 as obtained in linear regression analysis. the coefficient of correlation was r=0.9999855 and goodness of fit r2=0.9999711.this was in well agreement with usp recommendation of r2> 99%. the method passed the test for repeatability as determined by per cent rsd 1.01%of the area of the peaks of six replicates injection at 100% assay concentration. the method passed the test for intermediate precision as percent rsd obtained with intraday as well as for 3 different days were within the limits of 2% (table 2).the accuracy of the analyte in mentioned in table 3. the % recovery at 50%, 100% and 150% were found to be 98.3 to 101.5% with percent rsd well below 2%.limit of detection and limit of quantification (lod and loq)limit of detection (lod) was calculated based on the equation as described in section 2.3.3. lod was found to be 0.200μg/ ml and limit of quantitation (loq) was found to be 0.609μg/ml of nicotine.system suitability test was performed by running six injections of standard 5µg/ml at 100% assay level. % rsd of the response of six injections was found to be less than 2% and the theoretical plate count was above 2000 with usp tailing 1.12.the variation in retention time was less than 1%. suitability test of the current method passed all usp criteria (table 4).the concentration of the extract found by hplc analysis and total amount of nicotine in 10ml of extract was calculated, starting amount of tobacco taken 5g. the amount of nicotine per tobacco leaf extract ranged from 1.34 to 2.22% (table 5). https://www.cureus.com/publish/articles/113274-quantitative-estimation-of-nicotine-in-tobacco-extract-by-high-performance-liquid-chromatography-using-c8-column/preview#figure-anchor-440839 https://assets.cureus.com/uploads/figure/file/440839/lightbox_0183e720243d11eda4cf13207d8ad36c-doc3-1.pn https://www.cureus.com/publish/articles/113274-quantitative-estimation-of-nicotine-in-tobacco-extract-by-high-performance-liquid-chromatography-using-c8-column/preview#figure-anchor-440850 169 international journal of human and health sciences vol. 07 no. 02 april’23 figure 2: standard curve of nicotine (r=0.9999855; r2=0.9999711; y = 6675.7x – 1590.8) table 2: precision results for the hplc method at different assay concentrations concentration (µg/ml) intra-day variation inter-day variation mean (n=6) (%rsd) mean (n=12) (%rsd) 1 1.02 1.98 1.02 1.89 2 2.03 1.07 2.02 1.08 5 5.06 1.04 5.06 0.98 10 10.08 0.92 10.11 1.03 25 25.27 0.93 25.20 0.93 table 3: accuracy results for the method at different assay concentrations % spiked or assay sample replicate % recovery % mean recovery %rsd 50% ( 2.5 µg/ ml) 1 99.1 98.7 (2.47) 0.412 98.7 3 98.3 100% (5 µg/ml) 1 101.2 99.7 (4.99) 1.412 99.5 3 98.4 150% (7.5 µg/ ml) 1 99.8 101.2 (7.59) 1.222 101.5 3 102.2 table 4: system suitability test (no adjacent peaks were observed at the retention time of nicotine) replicate injection retention time tr area usp tailing usp plate count 1 3.405 31958 1.138 5607.119 2 3.412 32037 1.1416 5611.324 3 3.397 31694 1.1508 5656.237 4 3.426 31581 1.137 5597.425 5 3.414 31423 1.15 5486.142 replicate injection retention time tr area usp tailing usp plate count 6 3.436 31092 1.12 5404.258 mean 3.415 31630.83 1.140 5560.418 sd 0.014 349.862 0.011 63.173 % rsd 0.413 1.106 0.986 1.136 table 5: percentage content of nicotine in dried and crushed tobacco leaves tobacco leaves tobacco amount (g) concentrationof nicotine in the extract (μg/ ml) total amount of nicotine present in the extract (g) nicotine (%) saraisa, samastipur 5.00 7.5 0.075 1.5 saraisa, muzaffarpur 5.00 8.3 0.083 1.66 saraisa, vaishali 5.00 11.1 0.111 2.22 saraisa, darbhanga 5.00 6.7 0.067 1.34 althoughwe could quantify the nicotine present in the tobacco leaves extract directly, the procedure can be used for other sources of tobacco, such as e-cigarette and chewing gum etc., after proper extraction. c18 column is more hydrophobic in comparison to c8 column; hence the retention time is different.20 the elution time of nicotine under the proposed method is much less than other methods indicating suitability for rapid determination of nicotine. the theoretical plates for proposed method were adequate. also, the peak shape of nicotine was reasonably good and principal peak was well separated from the mobile phase interference. furthermore, the method uses a mobile phase without ion-pair reagent, so longer column equilibration time was avoided as mentioned in other methods. under the proposed method, chromatographic conditions stabilized in less than 45 minutes.there are many methods developed on c18 column almost none is done on c8 column. the present study tried to contribute in the direction of developing one of such methods. c8 has a lower degree of hydrophobicity, which may cause faster retention time for non-polar compounds. as the retention is short in c8 for the analyte, it can be run on a short length column. there is also less tailing in c8 column compared https://www.cureus.com/publish/articles/113274-quantitative-estimation-of-nicotine-in-tobacco-extract-by-high-performance-liquid-chromatography-using-c8-column/preview#table-anchor-440854 https://www.cureus.com/publish/articles/113274-quantitative-estimation-of-nicotine-in-tobacco-extract-by-high-performance-liquid-chromatography-using-c8-column/preview#table-anchor-440855 https://www.cureus.com/publish/articles/113274-quantitative-estimation-of-nicotine-in-tobacco-extract-by-high-performance-liquid-chromatography-using-c8-column/preview#table-anchor-440857 https://assets.cureus.com/uploads/figure/file/440850/lightbox_4776c1702eca11edbadcd5cbf81a4ff2-fig-2-1.pn international journal of human and health sciences vol. 07 no. 02 april’23 170 to c18 column. moreover, this procedure can bring down the cost of the analysis,as c8 is relatively cheaper to c18 column. conclusion a simple hplc method using a c8 type column is developed for the analysis of nicotine in tobacco extracts and other sources. the method is specific for nicotine and validated with respect to various analytical parameters. the method is faster and simple for the analysis of nicotine present in different substance of abuse containing tobacco formulations as well as plant nicotine extracts. conflict of interest: none declared. ethical approval: not applicable. source of fund: self-funded. authors’ contribution: all authors were equally involved in conception, research design, data collection, analysis, manuscript preparation, revision and finalization. references 1. devito ee, herman ai, waters aj, valentine gw, sofuoglu m. subjective, physiological, and cognitive responses to intravenous nicotine: effects of sex and menstrual cycle phase. neuropsychopharmacology. 2014;39:1431. 2. hossain am,salehuddin sm. analytical determination of nicotine in tobacco leaves by gas chromatographymass spectrometry. arabian j chemistry. 2013;6:275-8. 3. lin sx, curtis ma, sperry j: pyridine alkaloids with activity in the central nervous system. bioorg med chem. 2020;28:115820. 4. goniewicz ml, gawron m, smith dm, peng m, jacob p 3rd, benowitz nl. exposure to nicotine and selected toxicants in cigarette smokers who switched to electronic cigarettes: a longitudinal within-subjects observational study. nicotine tob res. 2017;19:160-7. 5. benowitz nl, pipe a, west r, hays jt, tonstad s, mcrae t, et al. cardiovascular safety of varenicline, bupropion, and nicotine patch in smokers: a randomized clinical trial. jama internal medicine. 2018;178:622-31. 6. casanova h, ortiz c,peláez c, vallejo a, moreno me, acevedo m. insecticide formulations based on nicotine oleate stabilized by sodium caseinate. j agri food chem. 2002;50:6389-94. 7. hu r-s, wang j, li h, ni h, chen yf, zhang y-w. simultaneous extraction of nicotine and solanesol from waste tobacco materials by the column chromatographic extraction method and their separation and purification. separ purif technol. 2015;146:1-7. 8. jarvik me. beneficial effects of nicotine. brj addiction. 1991;86:571-5. 9. world health organization (who). health topics – tobacco. (2022). retrieved from: https://www.who.int/ india/health-topics/tobacco.accessed: march 14, 2022. 10. peace mr, baird tr, smith n, wolf ce, poklis jl, poklis a. concentration of nicotine and glycols in 27 electronic cigarette formulations. j anal toxicol. 2016;40:403-7. 11. pagano t, difrancesco ag, smith sb, george j, wink g, rahman i, et al. determination of nicotine content and delivery in disposable electronic cigarettes available in the united states by gas chromatographymass spectrometry. nicotine tob res. 2016;18:700-7. 12. aszyk j, woźniak mk, kubica p, kot-wasik a, namieśnik j, wasik a. comprehensive determination of flavouring additives and nicotine in e-cigarette refill solutions. part ii: gas-chromatography-mass spectrometry analysis. j chromatogr a. 2017;1517:15664. 13. karvaly gb, tekes k, szimrók z, fűrész j, kuča k, kalász h. a fieldable, high-throughput, costefficient high performance liquid chromatographyultraviolet absorption detection (hplc-uv) method for the quantitation of bispyridinium quaternary aldoxime cholinesterase reactivators in blood. acta chromatographica. 2021;33:134-44. 14. alhusban aa, tarawneh oa, dawabsheh so, alhusban aa, abumhareb fw. liquid chromatography-tandem massspectrometry for rapid and selective simultaneous determination offluoroquinolones level in human aqueous humor. j pharmacol toxicol methods. 2019;97:36-43. 15. zinjad p, gondhale p, kulkarni s, musmade b, bhope s, padmanabhan s. development and validation of hplc-uvmethod for the quantitative analysis of carcinogenic organic impurities and its isomers in the sodium polystyrene sulfonate polymer. acta chromatogr. 2020;33:162-9. 16. liu x, joza p, rickert b. analysis of nicotine and nicotine-related compounds in electronic cigarette liquids and aerosols by liquid chromatography-tandem mass spectrometry. contrib tobacco nicotine res. 2017;27:154-67. 17. aszyk j, kubica p, kot-wasik a, namieśnik j, wasik a. comprehensive determination of flavouring additives and nicotine in e-cigarette refill solutions. part i: liquid chromatography-tandem mass spectrometry analysis. j chromatogr a. 2017;1519:45-54. 18. gholap vv, kosmider l, halquist ms. a standardized approach to quantitative analysis of nicotine in e-liquids based on peak purity criteria using highperformance liquid chromatography. j anal methods chem. 2018;2018:1720375. 19. palazzolo d, nelson jm, hudson z. the use of hplcpda in determining nicotine and nicotine-related alkaloids from e-liquids: a comparison of five e-liquid brands purchased locally. int j environ res public health. 2019;21:3015. 20. klimek-turek a, misiołek b, dzido th. comparison of the retention and separation selectivity of aromatic hydrocarbons with polar groups in rp-hplc systems with different stationary phases and eluents.molecules. 2020;25:5070. https://dx.doi.org/10.1038/npp.2013.339 https://dx.doi.org/10.1038/npp.2013.339 https://dx.doi.org/10.1038/npp.2013.339 https://dx.doi.org/10.1016/j.arabjc.2010.10.006 https://dx.doi.org/10.1016/j.arabjc.2010.10.006 https://dx.doi.org/10.1016/j.arabjc.2010.10.006 https://dx.doi.org/10.1016/j.bmc.2020.115820 https://dx.doi.org/10.1016/j.bmc.2020.115820 https://dx.doi.org/10.1093/ntr/ntw160 https://dx.doi.org/10.1093/ntr/ntw160 https://dx.doi.org/10.1093/ntr/ntw160 https://dx.doi.org/10.1093/ntr/ntw160 https://dx.doi.org/10.1001/jamainternmed.2018.0397 https://dx.doi.org/10.1001/jamainternmed.2018.0397 https://dx.doi.org/10.1001/jamainternmed.2018.0397 https://dx.doi.org/10.1021/jf0257244 https://dx.doi.org/10.1021/jf0257244 https://dx.doi.org/10.1016/j.seppur.2015.03.016 https://dx.doi.org/10.1016/j.seppur.2015.03.016 https://dx.doi.org/10.1016/j.seppur.2015.03.016 https://dx.doi.org/10.1111/j.1360-0443.1991.tb01810.x https://www.who.int/india/health-topics/tobacco https://www.who.int/india/health-topics/tobacco https://dx.doi.org/10.1093/jat/bkw037 https://dx.doi.org/10.1093/jat/bkw037 https://dx.doi.org/10.1093/ntr/ntv120 https://dx.doi.org/10.1093/ntr/ntv120 https://dx.doi.org/10.1093/ntr/ntv120 https://dx.doi.org/10.1093/ntr/ntv120 https://dx.doi.org/10.1556/1326.2020.00781 https://dx.doi.org/10.1556/1326.2020.00781 https://dx.doi.org/10.1556/1326.2020.00781 https://dx.doi.org/10.1556/1326.2020.00781 https://dx.doi.org/10.1556/1326.2020.00781 https://dx.doi.org/10.1016/j.vascn.2019.03.001 https://dx.doi.org/10.1016/j.vascn.2019.03.001 https://dx.doi.org/10.1016/j.vascn.2019.03.001 https://dx.doi.org/10.1016/j.vascn.2019.03.001 https://dx.doi.org/10.1556/1326.2020.00774 https://dx.doi.org/10.1556/1326.2020.00774 https://dx.doi.org/10.1556/1326.2020.00774 https://dx.doi.org/10.1556/1326.2020.00774 https://dx.doi.org/10.1515/cttr-2017-0016 https://dx.doi.org/10.1515/cttr-2017-0016 https://dx.doi.org/10.1515/cttr-2017-0016 https://dx.doi.org/10.1515/cttr-2017-0016 https://dx.doi.org/10.1016/j.arabjc.2010.10.006 https://dx.doi.org/10.1016/j.arabjc.2010.10.006 https://dx.doi.org/10.1016/j.arabjc.2010.10.006 https://dx.doi.org/10.1016/j.arabjc.2010.10.006 https://dx.doi.org/10.3390/molecules25215070 https://dx.doi.org/10.3390/molecules25215070 https://dx.doi.org/10.3390/molecules25215070 https://dx.doi.org/10.3390/molecules25215070 microsoft word ijhhs imam 23rd asc 2022 s7 plenary 3 generational endgame (geg) mohamad haniki nik mohamed1 tobacco use especially among malaysian adolescents remains as a significant threat to public health. a local survey in 2017 reported 13.8% of adolescents between 13 to 17 years old were smokers. while this problem is growing in the country, we estimate the underage initiation of tobacco use and present evidence supporting policy measures like banning the purchase and use from the current 17 years old individuals, the country backed with effective implementation of tobacco control efforts to significantly reduce future tobacco burden. disallowing access, sale, purchase, and use of tobacco from current 17 years old individuals onwards via the generational endgame (geg) should significantly reduce youth initiation and taper down the overall adult tobacco use prevalence over the long run in malaysia.    as the saying goes, prevention is better than cure. hence, effective tobacco control strategies need to be enforced to safeguard our children and adolescents from becoming life-long nicotine addicts from combustible cigarettes, e-cigs or other products. the geg along with other approaches outlined by the who framework convention on tobacco control (fctc) and the mpower strategies; including expanding smokefree areas, reducing tobacco advertising, promotion and sponsorship as well as increasing the price of cigarettes and all tobacco products through effective taxation measures. enforcement is key and all parties must work together in order to thwart tobacco industry’s interference in order to achieve the tobacco endgame 2040. keywords: generation end game; tobacco; adolescents 1. kulliyyah of pharmacy, international islamic university malaysia (iium) correspondence to: prof dr mohamad haniki nik mohamed, professor, kulliyyah of pharmacy, international islamic university malaysia (iium). haniki@iium.edu.my doi: http://dx.doi.org/10.31344/ijhhs.v7i70.510 microsoft word ijhhs imam 23rd asc 2022 s5 plenary 1 the pronoun conundrum: he or she or they or per or ve: to renounce or denounce? sharifah zubaidiah syed jaapar1 gender dysphoria (gd) is when a person has a strong desire to act differently than their assigned gender, which causes significant distress and dysfunction. western countries, especially those that legalise the third gender, employ affirmative therapy for people with gd. however, islam and malaysian law only recognise gender expression based on natal sex. this further put those with gender dysphoria in malaysia at risk of developing anxiety, depression, self-harm behavior, and suicide. apart from that, they are more likely to engage in risky behaviours such as unsafe sex, sex with same-sex, chemsex, substance misuse, drinking alcohol and smoking. this sexual behaviour, especially man sex with man (msm), contributes to hiv/aids, sexual transmitted diseases, and anal cancer. consequently, it increases the health burden. thus, this presentation will discuss approaches to dealing with people with this gender dysphoria. there are also ethical dilemmas or conflicts among psychiatrists in giving the diagnosis of gender dysphoria, especially in children and adolescents. once giving the diagnosis of gender dysphoria, what is the best approach that a muslim psychiatrist needs to consider? are we going to practise affirmative therapy or conversion therapy or what? do muslim healthcare providers have the right to enforce patients against their will? still, this would make it harder for people to get help and make them less likely to go to healthcare providers, especially muslims. in contrast, this will encourage people with gd to go to healthcare providers that can support or affirm their desire, which is against islamic and malaysian law. muslim healthcare providers should take the opportunity to help people with gd manage their conflicts according to the islamic way. keywords: gender dysphoria; mental health; natal sex; islam gender 1. psychiatry department, universiti sains malaysia kubang kerian, kelantan. ___________________________________________________________________________ correspondence to: dr. sharifah zubaidiah syed jaapar, psychiatrist and senior medical lecturer, psychiatry department, universiti sains malaysia kubang kerian, kelantan. zubaidiah@usm.my __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v7i70.508 international journal of human and health sciences. supplementary issue: 2019 doi: http://dx.doi.org/10.31344/ijhhs.v0i0.139 s21 digital technology adaptations in emergency response kamarul al haqq bin abdul ghani department of orthopedic and traumatology, hospital tengku ampuan rahimah htar klang, jalan langat, 41200 klang, selangor darul ehsan there are three important elements of medecins sans frontieres (msf) in the field emergency response: 1) medical innovations (i.e., mobile unit surgical trailer, must, point of care ultrasonography, pocus, anti-microbial resistance, amr or other apps et al), 2) innovations to ensure efficiency (geographic information system, gis/missing maps, telemedicine/remote operations), and 3) medical adaptations (where msf staff are forced to innovate because there are no x-rays, or even standard equipment in the hospitals or attacks on medical facilities). s7 symposium symposium 1: post covid-19 world post covid-19 world (health) mohammad farhan rusli the covid-19 pandemic that landed on malaysian shores in january of 2019, was an event that is unbelievable, unexpected, ill-prepared and extremely underestimated. the pandemic exposed cracks and fractures that exist in our healthcare system and showed how fragile and vulnerable our public health infrastructure is. as malaysians soldier on to what seems a knee-level muddy struggle in health, economy, and social well-being in a post-covid-19 world, one must note that we must adapt and prepare in order to be resilient and be on-standby for future pandemics should they hit us again. herewith lies the 5 pillars – digitalization of the healthcare system, integration of public health and clinical care, inter-agency collaboration, effective risk-communication, and most importantly, effective and strong governance. the first pillar focuses on the need to rapidly deploy and create a digital ecosystem that has a strong ui/ux base, both modifiable and adaptive in nature that is robust in facing any new developments in pandemic and public health challenges. the second pillar addresses the need to bridge the gap between public health services and clinical care for a seamless patient experience. the third pillar is the way forward on cutting through the bureaucracy that hinders effective implementation. the fourth pillar details the need of keeping order in chaos, enabling the people to understand and absorb trustable, reliable and accurate information. the fifth pillar is the cream of them all, where governance of the future will capture and effectively prepare the nation for a post-covid-19 world with key policies, regulations and readied workforce. keywords: public health, digitalisation, pandemic, covid-19 ___________________________________________________________________________ correspondence to: public health medicine specialist, department of community health, international islamic university malaysia, kuliyyah of medicine, iium kuantan campus, jalan sultan ahmad shah, bandar indera mahkota, kuantan, pahang, malaysia. email: farhan@iium.edu.my __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v6i0.397 mailto:farhan@iium.edu.my s5 plenary managing non-covid cases in times of covid farique rizal abdul hamid the global context towards sustainable development has essentially changed with the covid19 pandemic. the world faces the greatest social, economic and environmental challenges. this pandemic is characterized by its rapid spread, differential recovery rate and susceptibility to elderlies and people with weak immune systems. the impact of covid-19 lockdown can distract the management plan and exacerbate the prognosis of non-covid-19 patients. there are many lessons the world can learn from this disastrous pandemic outbreak for us to revise and strategize an efficient disaster management system which includes non-covid-19 cases. the survival of non-covid-19 cases is still a mystery as the pandemic waves are always uncertain. the key to unlocking the secret is the balancing-resilience strategy in the new normal disaster management framework. this pandemic offers an opportunity to make the world resilient to multiple hazards while sustaining the best care for non-covid-19 patients. keywords: non-covid-19 cases, efficient disaster management, balancing-resilience strategy ___________________________________________________________________________ correspondence to: kedah state deputy medical director, kedah state health department, simpang kuala, jalan kuala kedah, alor setar, kedah. email: drfarique@moh.gov.my __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v6i0.395 mailto:drfarique@moh.gov.my microsoft word ijhhs imam 23rd asc 2022 s8 plenary 4 syariah compliant milk bank: the need and issues syed abdul khaliq1 world health organisation (who) defines premature infants as those babies born before the completed 37th week of pregnancy (turner-maffei et al., 2014). malaysian national neonatal registry (mnnr), reported an increase in the rate of premature births. this is also the trend seen worldwide. premature babies, as they born prior to period of maturity, they are physically and physiologically still immature; their brain is immature, their eyes, their heart, their kidney, their gastrointestinal tract, their kidney and even their immune system are still very immature. many may need admission into intensive care wards and special care nurseries to support, close monitoring and help them grow stronger. they are prone for infection, as their skin are still fragile, and they are not able to surmount an adequate immune response to fight off infection. ensuring premature babies having access to breastmilk is of utter importance. breastmilk has the protective capabilities such as the iga, to prevent them from getting infections, breastmilk is more tolerable for premature babies and is proven to prevent serious diseases such as necrotising enterocolitis. some mothers, however, cannot breastfeed their child and cannot supply expressed breastmilk due to various reasons. therefore, there is a critical need for the development of milk bank. milk bank is not new, it is rather common in many countries. in fact, it is well established in the united states, united kingdom and many other developed countries. the establishment of these milk banks has saved and protected the lives of newborn babies, especially the those premature. however, for muslims, the issue arised in regards the issue of milk-kinship. the 97th conference of the fatwa committee national council for islamic religious affair of malaysia held on 15th – 17th december 2011 to forbid the establishment of milk bank in malaysia. thus, establishment of a syariah-compliant human milk bank is of a dire need. keywords: milk bank; breastmilk; religion; muslim 1. hospital pakar an-nur, jalan gerbang wawasan 1, bandar baru bangi, selangor. ___________________________________________________________________________ correspondence to: dr. syed abdul khaliq, consultant neonatologist & general pediatrician in hospital pakar an-nur, jalan gerbang wawasan 1, bandar baru bangi, selangor. drsyedkhaliq@gmail.com __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v7i70.511 international journal of human and health sciences. supplementary issue: 2021 s25 second wave of covid-19 pandemic in malaysia and the impact on nuclear cardiology services: an institutional experience ahmad zaid zanial1, syifaa’ aminudin2, fatinhayani mohamad najib3, siti zarina amir hassan1 1nuclear medicine department, hospital kuala lumpur,2pharmacy department, hospital kuala lumpur,3nuclear medicine department, hospital kuala lumpur doi: http://dx.doi.org/10.31344/ijhhs.v5i0.316 introduction: nuclear cardiology applying radioactive tracer and hybrid imaging techniques are able to provide information needed to detect and evaluate ischaemic heart diseases. in our centre, nuclear cardiology services involving stress and rest myocardial perfusion scans and viability studies contribute about 40% of overall scan workload. the second wave of covid19 pandemic in malaysia announced by the end of february 2020 has affected nuclear cardiology services. objectives: our aims were to determine the impact of covid-19 pandemic second wave on the nuclear cardiology imaging studies performed as well as to ascertain crucial institutional experience especially unavoidable problem and adjustment during the period. methods: a review of technetium-99m tetrofosmin radiopharmaceutical dispensing data and scan records for 1st february to 31st august 2019 and 2020 was conducted at nuclear medicine department, hospital kuala lumpur. figures were compiled and statistical analysis done. survey and focus discussion conducted involving nuclear medicine physicians, pharmacists and physic officers to identify the main difficulty faced and most important job-adapting measure taken. results: a total of 1109 cardiac radiopharmaceutical doses dispensed during the studied period but were less when compared to 1342 doses dispensed last year. significant reduction was noted in april and may 2020 with only 69 and 67 cases respectively in comparison with monthly average of 192 cases in 2019. although some scan appointments were postponed to avoid the usual waiting area congestions, the main difficulty faced was technetium-99m generator supply disruption with limited production in europe and international transportation restriction. implementing infection control standard operating procedure (sop) instructions as part of routine work practice with emphasis of time, distance and shielding concept was the most important job-adapting measure. conclusion: nuclear cardiology services were affected by the second wave of covid-19 pandemic locally. main problem ascertained was disruption of radioactive supply. most important adjustment was infection control sop implementation. keywords: covid-19, pandemic, nuclear cardiology, experience http://dx.doi.org/10.31344/ijhhs.v5i0.316 s19 a case of chronic relapsing inflammatory optic neuropathy steven toh1, chean chung shen2 abstract chronic relapsing inflammatory optic neuropathy (crion) is a recently described form of recurrent isolated subacute optic neuropathy, with accumulating evidence that it is a nosological distinct entity. the condition is highly responsive to systemic steroid treatment and prone to relapse on steroid withdrawal. diagnosis and management of this condition is often challenging. this 33-year-old lady with family history of multiple sclerosis (ms), with uniocular visual loss of her right eye since 2 years old without apparent cause, presented with reduction of vision and loss of colour vision in the left eye, associated with painful eye movement. there was internuclear ophthalmoplegia but slit lamp examination were unremarkable. she had no other related sensory or motor symptoms. magnetic resonance imaging (mri) did not reveal any features of ms. aquaporin-4 antibody, anti-mog and gene testing for leber’s hereditary optic neuropathy were all negative. metabolic, infective, and other autoimmune causes were also excluded. visual evoked potential studies of left eye showed a mild reduction in amplitude with no prolongation of latency. her multiple optic neuritis recurrences were treated with intravenous steroids followed by tapering regime of oral prednisolone with good effect. knowledge of this rare condition as part of the differential diagnoses of possible aetiologies of optic neuropathy is important among ophthalmologists, as prompt diagnosis and steroid treatment helped reduce the associated risk of blindness. multiple relapses after initial successful treatment of inflammatory optic neuropathy should raise the suspicion of crion. keywords: ophthalmology, optic neuropathy, chronic relapsing inflammatory optic neuropathy, vision loss, steroid-responsiveness 1. school of medicine, university of liverpool, liverpool, uk 2. department of ophthalmology, lincoln county hospital, lincoln, uk doi: http://dx.doi.org/10.31344/ijhhs.v5i0-2.337 http://dx.doi.org/10.31344/ijhhs.v5i0-2.337 international journal of human and health sciences vol. 07 no. 02 april’23 176 original article: the effectiveness of giving crystal guava juice (psidium guajava l. “crystal”) on haemoglobin levels in female adolescents with anaemia devi ratna mayasari1, yulia sari2, ratih puspita febrinasari3 abstract anaemia is one of the health problems in female adolescents with haemoglobin levels in the blood circulation is below normal, which is <12 g/dl at the adolescent threshold. crystal guava is a fruit that is rich in iron and vitamin c, which helps increase haemoglobin levels in the blood. this study aims to analyse the effectiveness of giving crystal guava juice (psidium guajava l.“crystal”) on haemoglobin levels in female adolescents with anaemia. the design of this study was a quasi-experiment with pre and post-test control group design with 36 subjects divided into 3 group. this study was tested using spss version 25 with a significant level of 0.05. the result showed that there was an effect of giving crystal guava juice on haemoglobin levels in female adolescents with anaemia by p=0.018 (p<0.05). giving crystal guava juice with iron tablets is effective to increase haemoglobin levels in female adolescents with anaemia. keywords: iron, vitamin c, crystal guava juice, haemoglobin levels, female adolescents with anaemia correspondence to: devi ratna mayasari, master’s degree program of nutrition science, faculty of postgraduate, universitas sebelas maret, surakarta, indonesia, e-mail : deviratna@student.uns.ac.id 1. devi ratna mayasari, master’s degree program of nutrition science, faculty of postgraduate, universitas sebelas maret, surakarta, indonesia. 2. yulia sari, department of parasitology, faculty of medicine, universitas sebelas maret, surakarta, indonesia. 3. ratih puspita febrinasari, department of pharmacology, faculty of medicine, universitas sebelas maret, surakarta, indonesia. introduction adolescence is a period of transition from childhood to adulthood when physical, mental and emotional growth and development proceed very rapidly. according to who, the age limit for adolescents is 10-19 years old.1 adolescents are a group at high risk of developing iron deficiency and anemia. periods of puberty and development to significant additional iron requirements. very rapid growth, psychological changes, and increased activity lead to increased nutritional requirements in adolescents. irregular eating patterns, skipping breakfast and skipping lunch adversely affect the health of adolescents.2 anemia is a condition in which circulating hemoglobin levels are below the adolescents threshold of <12 g/dl.36 anemia is a health problem worldwide. according to who (2015), 30% or more than 2 billion people worldwide suffer from anemia. indonesia is a country with a high incidence of anemia, over 20%.4 based on basic health research data for 2007, 2013, and 2018, there was an increasing trend in the prevalence of anemia among adolescents. in 2018, he 32% of young people in indonesia suffered from anemia.5 percentage of iron deficiency anemia among pre-school age children and women at reproductive age ranged from 25% and 37% respectively. several studies have shown that untreated iron deficiency anemia can have a serious impact on health.6 anemia, or low hemoglobin levels, impairs cognitive international journal of human and health sciences vol. 07 no. 02 april’23 doi: http://dx.doi.org/10.31344/ijhhs.v7i2.571 mailto:deviratna@student.uns.ac.id 177 international journal of human and health sciences vol. 07 no. 02 april’23 and motor development, leading to fatigue and decreased productivity.7 female adolescents with anemia who become pregnant are at increased risk of premature birth, low birth weight, and maternal and neonatal mortality.8 of the various determinants of anemia, iron deficiency is common in developing countries.9,10 iron deficiency is estimated to be responsible for approximately 50% of anemia.2 giving iron tablets along with other micronutrients is more effective in raising hemoglobin levels because it increases the body’s absorption of iron, so iron supplementation should be combined with other micronutrients such as vitamin c. vitamin c is known to affect iron metabolism and specifically does not promote heme iron uptake or increase iron mobilization from stores. iron is soluble. therefore, it is efficient and effective in its iron form (fe2+). vitamin c changes the acidic atmosphere of the stomach and helps convert iron (fe3+) to iron (fe2+) in the intestine.11 vitamin c deficiency may also contribute to hemolysis due to capillary hemorrhage leading to oxidative damage to red blood cells and blood loss. vitamin c supplementation has been shown to increase hemoglobin levels.2 witjaksono (2014) stated that the effectiveness of taking iron with natural vitamin c from fruit is superior to taking iron with high-dose vitamin c tablets. one is crystal guava. crystal guava has the highest content of vitamin c compared to citrus fruits, papaya and bananas.12 food processing needs to change to increase demand for fruit consumption. one of his processed fruits that is very popular in the community is juice. based on research in chemmix pratama’s laboratory in yogyakarta, the content of crystal guava juice per 200 ml is 6.9 mg iron and 423 mg vitamin c. iron (fe3+) is converted to iron (fe2+) in the small intestine, making it easier for the body to absorb. the reductive process is even greater when the stomach ph becomes more acidic, which can increase the iron absorption process by up to 30%.13 in previous studies, most of the interventions were red guava juice, but in this study we wanted to compare the effects with crystal guava juice. a previous study found a 2.44 g/dl increase in hemoglobin levels before and after administration of blood products and guava juice. another study conducted in adolescent females given red guava juice found a 0.6 g/dl increase in hemoglobin levels with p<0.05.14 based on the above explanation, this study aimed to analyze the effectiveness of giving crystal guava juice (psidium guajava l. “crystal”) on hemoglobin levels in female adolescents with anemia. materials and methods the design of this research is quasi-experiment with pre and post-test control group design conducted in june-july 2022. the research subjects were female adolescents of the nurul qur’an islamic boarding school and miftahul huda islamic boarding school in boyolali regency. the subject selection technique in this study used purposive sampling, the determination of the sample was carried out according to the inclusion and exclusion criteria. inclusion criteria include female adolescents aged 12-19 years, have hemoglobin levels <12 g/dl, are willing to follow the research procedure by agreeing and signing informed consent, and can communicate, read, and write while the exclusion criteria include female adolescents who are sick such as tuberculosis (tb), helminthiasis, hiv, and malaria are based on a doctor’s diagnosis and has a guava allergy. the total number of subjects is 36 subjects divided into 3 groups, 12 subjects in the k group, 12 subjects in the p1 group, and 12 subjects in the p2 group. the k group was given iron tablets, the p1 group was given iron tablets and red guava juice, while the p2 group was given iron tablets and crystal guava juice. this study was conducted for 30 days and the treatment group was given red guava juice (p1) and crystal guava juice (p2) every 200 ml per day before eating. the recommended daily supplement dose for non-pregnant women of child bearing potential living in countries where anemia is prevalent is 60 mg of elemental iron and 400 mcg of folic acid in an iron tablet.15 crystal guava obtained from crystal guava plantations. examination of the nutritional content of crystal guava juice was carried out at the chemmix pratama food laboratory, yogyakarta. the nutritional content of crystal guava juice per 200 ml is 6.9 mg of iron and 423 mg of vitamin c. crystal guava juice is made naturally using the cold pressed juice technique. this technique works with high pressure (pressed) and produces very minimal heat so that it can maintain the nutritional content in the fruit such as iron and vitamin c compared to using a regular blender and can be stored longer.16-17 international journal of human and health sciences vol. 07 no. 02 april’23 178 research subjects signed informed consent before screening and intervention. anemia screening questionnaire in female adolescents to examine the early symptoms of anemia experienced and has been tested for validity in previous studies.18 body weight was measured using a digital scale with an accuracy of 0.1 kg and height measurements using a microtoice with an accuracy of 0.1 cm to determine nutritional status. measurement of hemoglobin levels using easy touch gchb at preliminary studies and during the research using cyanmethemoglobin method with a spectrophotometer. measurement of food intake was carried out using the food record form and the calculation using nutrisurvey 2007 to obtain data on nutrient intake. data analysis in this study was carried out using the spss version 25 program. analysis of the characteristics of the subject using the chi square test. the normality test of the data used the shapiro wilk test because the subjects were less than 50 people, while the wilcoxon test and kruskal wallis test were conducted to determine whether or not there was an effect on the intervention given. result the description of the data regarding the characteristics of the respondents in this study includes the gender of the subjects in this study, 100% female adolescents with anemia, there is no difference in each group. in addition, the education level of female adolescents is at junior high school. characteristics of age and nutritional status (bmi/ age) are shown in table 1. table 1. characteristics of age and nutritional status (bmi/age) of subject characteristics k p1 p2 p n % n % n % age early adolescence (10-13 yrs) 1 8.33 1 8.33 5 41.67 0.233middle adolescence (14-17 yrs) 11 91.67 11 91.67 7 58.33 late adolescence (18-24 yrs) 0 0 0 0 0 0 amount 12 100.00 12 100.00 12 100.00 nutritional status (bmi/u) malnutrition 1 8.33 1 8.33 0 0 0.816 good nutrition 8 66.67 8 66.67 10 83.33 overweight 3 25 3 25 2 16.67 obesity 0 0 0 0 0 0 amount 12 100.00 12 100.00 12 100.00 in table 1, it is known that the total of all research subjects was 36 subjects with the distribution of early adolescence (10-13 years) as many as 1 subject (8.33%) in k group, 1 subject (8.33%) in p1 group, and 5 subjects (41.67%) in p2 group. middle adolescents (14-17 years) were 11 subjects (91.67%) in k group, 11 subjects (91.67%) in p1 group, 7 subjects (58.33%) in p2 group. while at the age of late adolescents (18-24 years) as much as 0% of both k, p1, and p2 groups. from the results of the chi square test, it was found that there was no difference between the subjects in groups k, p1, and p2 with p=0.233 (p>0.05), which means that the subject was homogeneous. in the characteristics of nutritional status (bmi/ age), it was found that in the k group there was 1 subject with undernutrition (8.33%), 8 subjects with good nutrition (66.67%), and 3 subjects with overweight (25%). in the p1 group, the 179 international journal of human and health sciences vol. 07 no. 02 april’23 distribution was the same as the control group, namely 1 subject with undernutrition (8.33%), 8 subjects with good nutrition (66.67%), and 3 subjects with overweight (25%). in p2 group there were 10 subjects with good nutrition (83.33%) and 2 subjects with overweight (16.67%). from the statistical test results of the chi square test, it was found that there was no difference between the subjects in each group with p=0.816 (p>0.05), which means the subjects were homogeneous. table 2. the average results of hemoglobin levels before and after being given crystal guava juice in female adolescents with anemia group n before after ∆ mean p mean ± sd mean ± sd k 12 10.33±1.88 10.85±1.18 0.52±1.03 0.052*) p1 12 11.23±1.08 11.88±0.99 0.65±0.62 0.008*) p2 12 11.12±0.74 12.31±0.75 1.19±0.51 0.002*) p 0.018**) ∆ : difference in haemoglobin levels before and after intervention *) : wilcoxon test **) : kruskal wallis test table 2. shows that the mean haemoglobin level of the k pre-test group was 10.33±1.88 and the post-test haemoglobin level was 10.85±1.18 with a mean difference before and after the intervention was 0.52±1.03. the mean haemoglobin level in the p1 pre-test group was 11.23±1.08 and the haemoglobin level in the p1 post-test group was 11.88±0.99 with a mean difference of 0.65±0.62. the mean haemoglobin level in the p2 pre-test group was 11.12±0.74 and the haemoglobin level in the p2 post-test group was 12.31±0.75 with a mean difference of 1.19±0.51. the results of the statistical test of 2 groups before and after the intervention with the wilcoxon test for each group before and after the intervention showed that k group with p=0.052 (p>0.05) means that there is no difference before and after the intervention in k group. in the p1 group before and after the intervention, the results obtained with p=0.008 (p<0.05) meaning that there was a difference before and after the intervention in the p1 group. in the p2 group before and after the intervention, the results were p=0.002 (p<0.05), meaning that there was a difference before and after the intervention in the p2 group. the results of the statistical test between the 3 groups from the average difference before and after the intervention with the kruskal wallis test showed that there was a difference in haemoglobin levels before and after the intervention with p=0.018 (p<0.05). discussion based on the results of the study found that the average haemoglobin level in the k pre-test group was 10.33 g/dl with a standard deviation of 1.88. in the p1 group, the mean pre-test haemoglobin level was 11.23 g/dl with a standard deviation of 1.08. meanwhile, in the p2 group the mean pre-test haemoglobin level was 11.12 g/dl with a standard deviation of 0.74. all samples that have been examined have an average haemoglobin level below the normal threshold <12 g/dl, classified as mild, moderate, and severe anaemia. when these female adolescents become anaemic, many of them look pale, get sleepy easily, can’t concentrate on their studies, get tired easily, and have no endurance.19 the average haemoglobin level in the k posttest group was 10.85 g/dl with a standard deviation of 1.18. the mean haemoglobin level of the p1 posttest group was 11.88 g/dl with a standard deviation of 0.99. meanwhile, the average haemoglobin level of the p2 post-test group was 12.31 with a standard deviation of 0.75. in k group there was an increase in the average haemoglobin level. however, the haemoglobin level is still classified as mild anaemia. the p1 group also experienced an increase but also included mild anaemia. meanwhile, in the p2 group there was also an increase in haemoglobin levels already above the normal threshold by >12 g/dl. international journal of human and health sciences vol. 07 no. 02 april’23 180 underweight is an anthropometrically assessed sign of malnutrition and has been associated with anaemia in some, but not all, studies is related to various factors such as inappropriate home and community environment, inappropriate complementary feeding practices leading to inadequate intake of micronutrients and animal products, contaminated water and poor sanitation, weight gain, environment and infectious diseases. furthermore, overweight and obesity are associated with iron deficiency, and data from several countries suggest that overweight and obese people are at increased risk of iron deficiency. it may be due to hepcidin, a peptide hormone involved in iron homeostasis and produced primarily in the liver. hepcidin levels are elevated in overweight and obese individuals compared to lean individuals, had elevated hepcidin levels and poorer iron status than normalweight adolescents. giving red guava juice (p1) and crystal guava juice (p2) each can increase hemoglobin levels in female adolescents with anemia. however, giving crystal guava juice was more effective in increasing hemoglobin levels than red guava juice given to female adolescents with anemia significantly with p=0.018 (p<0.05). anemia can be treated by consuming iron-rich foods. it can aid in the process of iron absorption. in addition, dietary components that may contribute to iron absorption, such fruits rich in vitamin c, iron is also absorbed in the small intestine, absorbed by the body. the highest iron and vitamin c content is found in crystal guava juice even when compared to red guava juice. crystal guava juice contains 6.9 mg of iron and 423 mg of vitamin c, while red guava juice contains 6.8 mg of iron and 321.3 mg of vitamin c. the effectiveness of crystal guava juice on hemoglobin levels in female adolescents with anemia based on the wilcoxon test showed that there was a significant difference between hemoglobin levels before and after giving crystal guava juice. so it can be concluded that giving crystal guava juice has an effect after the intervention. when compared to the three treatment groups, namely groups k, p1 and p2, p2 group with the addition of iron tablets and crystal guava juice was the most effective in increasing hemoglobin levels compared to the other groups with an increase in hemoglobin levels of 1.19 g/dl. this study is consistent with the results of damayanti (2020), who found differences in hemoglobin levels between groups who received iron tablets and those who consumed guava juice.20 additionally, this study is consistent with studies done on anemic pregnant women who were given vitamin c. there was a significant increase in hemoglobin levels.21 this study is supported by other studies, namely, the provision of iron supplements also affects the increase in iron in pregnant women who experience anemia with p<0.05.22 food sources rich in iron and vitamin c, such as guava juice, can help increase iron absorption and can be used as an alternative therapy for anemic patients, especially adolescent women with anemia. iron in these food sources is absorbed with the help of vitamin c by reducing iron (fe3+) to iron (fe2+) in the small intestine to heme. as the ph of the stomach becomes more acidic, the iron breakdown process becomes even more pronounced.23 each heme binds to globin made by polylinosomes. tetramers are composed of four globins, each with a heme group, and formed into hemoglobin molecules, increasing hemoglobin levels.24 absorption of non-heme iron increases four-fold in the presence of vitamin c to approximately 30%. most blood transferrins transport iron to the bone marrow and other parts of the body. bone marrow uses iron to make hemoglobin. since the bone marrow requires precursors such as iron and vitamin c for the formation of red blood cells and hemoglobin, increased levels of iron and vitamin c lead to increased red blood cell formation in response to increased hemoglobin levels.25 prevention and control strategies should also be implemented. improve food intake and increase food variety through increased iron bioavailability, targeted food fortification, and iron supplementation for at-risk groups such as the young. in order to prevent anemia, it is necessary to improve knowledge and education about anemia. since early life is a critical period for intellectual and psychomotor development, anemia prevention must continue to be supported, promoted and embraced.26 conclusion giving crystal guava juice with iron tablets is effective to increase hemoglobin levels in female adolescents with anemia. giving crystal guava 181 international journal of human and health sciences vol. 07 no. 02 april’23 juice together with the consumption of iron tablets was proven to be the most effective in increasing hemoglobin levels in female adolescents with anemia compared to other groups with p=0.018 (p<0.05). sources of fund this study was supported by ministry of health scholarship. conflicts of interests: the authors declared no conflict of interest. ethical clearance this study were approved by the health research ethics committee of the faculty of medicine, sebelas maret university, surakarta based on the ethics committee letter with letter number 36/ un27.06.6.1/kep/ec/2022. authors’ contribution all authors were equally involved in the preparation of this study and manuscript. reference 1. kemenkes ri. pedoman pencegahan dan penanggulangan anemia pada remaja putri dan wanita usia subur (wus).; 2018. 2. world health organization. nutritional anaemias: tools for effective prevention and control.; 2017. 3. who. haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. geneva, switz world heal organ. published online 2011:1-6. doi:2011 4. sandy yd, tamtomo dg, indarto d. hubungan berat badan dengan kejadian anemia pada remaja putri di kabupaten boyolali. j dunia gizi. 2020;3(2):94-98. 5. kemenkes ri. hasil utama riskesdas 2018.; 2018. 6. indrayani ud, sarosa h, hussaana a, widiyanto b. the effects comparisons of sauropus androgynous, moringa oleiefera alone and in combination on iron deficiency in anemia rats. bangladesh j med sci. international journal of human and health sciences vol. 07 no. 02 april’23 182 2019;18(01):136-140. 7. stevens ga, finucane mm, de-regil lm, et al. global, regional, and national trends in haemoglobin concentration and prevalence of total and severe anaemia in children and pregnant and non-pregnant women for 1995-2011: a systematic analysis of population-representative data. lancet glob heal. 2013;1(1):16-25. doi:10.1016/s2214109x(13)70001-9 8. juul se, derman rj, auerbach m. perinatal iron deficiency: implications for mothers and infants. neonatology. 2019;115(3):269-274. doi:10.1159/000495978 9. billah smb, naher fk. injectable iron and blood transfusion for correction of anemia in pregnancy in a peripheral tertiary hospital in bangladesh: a quasi-experimental study. int j hum heal sci. 2022;06(04):372-376. 10. gupta n, yadav r, jaiswal n. maternal iron stores and its association with newborn iron dynamics and outcomes. bangladesh j med sci. 2022;21(3):620-625. 11. andaruni r, qamariah n, nurbaety b. efektivitas pemberian tablet zat besi (fe), vitamin c dan jus buah jambu biji terhadap peningkatan kadar hemoglobin (hb) remaja putri di universitas muhammadiyah mataram. midwifery j j kebidanan um mataram. 2018;3(2):104. doi:10.31764/ mj.v3i2.509 12. saudia bep, putri wa. pengaruh kombinasi pemberian tablet fe dan jus jambu biji terhadap kenaikan kadar hemoglobin mahasiswi jurusan kebidanan. j keperawatan terpadu (integrated nurs journal). 2021;3(1):59. doi:10.32807/jkt.v3i1.100 13. rusdi phn. pengaruh pemberian jus jambu biji merah (psidium guajava.l) terhadap kadar hemoglobin penderita anemia remaja putri. hum care j. 2020;5(3):603-610. 14. handayani ty, tarigan ra, pramita sari d. pengaruh jus jambu biji merah (psidium guajava ) terhadap meningkatkan kadar hemoglobin pada remaja putri. wind heal j kesehat. 2021;04(02):177-185. http:// jurnal.fkmumi.ac.id/index.php/woh/article/view/643 15. mcloughlin g. intermittent iron supplementation for reducing anaemia and its associated impairments in adolescent and adult menstruating women. int j evid based healthc. 2020;18(2):274-275. doi:10.1097/ xeb.0000000000000212 16. khaksar g, assatarakul k, sirikantaramas s. effect of cold-pressed and normal centrifugal juicing on quality attributes of fresh juices: do cold-pressed juices harbor a superior nutritional quality and antioxidant capacity? heliyon. 2019;5(6):e01917. doi:10.1016/j.heliyon.2019.e01917 17. gouws ca, georgouopoulou e, mellor dd, naumovski n. the effect of juicing methods on the phytochemical and antioxidant characteristics of the purple prickly pear (opuntia ficus indica)— preliminary findings on juice and pomace. beverages. 2019;5(2):1-18. doi:10.3390/beverages5020028 18. hidayati iz. penilaian uji validitas instrumen skrining anemia pada siswa madrasah aliyah islamic center baiturahman banyuwangi. maj kesehat masy aceh. 2019;2(3):48-58. doi:10.32672/ makma.v2i3.1293 19. murat s, ali u, serdal k, et al. assessment of subjective sleep quality in iron deficiency anaemia. afr health sci. 2015;15(2):621-627. doi:10.4314/ahs.v15i2.40 20. damayanti df, novianti r, astuti w. efektifitas pemberian jus jambu biji terhadap perubahan kadar hemoglobin pada remaja putri di pondok pesantren nurul jadid kumpai kabupaten kubu raya. j kebidanan khatulistiwa. 2020;6(1):16. doi:10.30602/jkk.v6i1.503 21. marlina l. pengaruh pemberian tablet vitamin c terhadap peningkatan kadar hemoglobin ibu hamil yang mengkonsumsi tablet fe di desa cihaurbeuti kabupaten ciamis. j keperawatan kebidanan stikes mitra kencana tasikmalaya. 2015;3(april):49-58. 22. ratih rh. pengaruh pemberian zat besi (fe) terhadap peningkatan kadar hematokrit pada ibu hamil yang mengalami anemia di rsia x pekanbaru tahun 2015. j ners dan kebidanan (journal ners midwifery). 2018;5(1):034-038. doi:10.26699/jnk.v5i1.art.p034-038 23. rusdi phn, oenzil f, chundrayetti e. pengaruh pemberian jus jambu biji merah (psidium guajava.l) terhadap kadar hemoglobin dan ferritin serum penderita anemia remaja putri. j kesehat andalas. 2018;7(1):74. doi:10.25077/jka.v7i1.782 24. hoffbrand a. kapita selekta hematologi. 6th ed. penerbit buku kedokteran egc; 2014. 25. sambou cn, yamlean pvy, lolo a. uji efektivitas jus buah jambu biji merah (psidium guajava, linn.) terhadap kadar hemoglobin(hb) darah tikus putih jantan galur wistar (rattus norvergicus l.). pharmacon. 2014;3(3):220-224. 26. safiri s, kolahi aa, noori m, et al. burden of anemia and its underlying causes in 204 countries and territories, 1990–2019: results from the global burden of disease study 2019. j hematol oncol. 2021;14(1):1-16. doi:10.1186/s13045-021-01202-2 s12 complete androgen insensitivity syndrome: diagnosis and psychological impact in adolescence, a case report salma yasmin mohd yusuf1, mazapuspavina md yasin1, akmal zulayla mohd zahid1, akmal hisham arshad1, khariah mat nor1 abstract this case report illustrates the case of complete androgen insensitivity syndrome (cais) which is a rare form of sexual development disorders (dsd). complex critical thinking is needed for pathophysiology of primary amenorrhea causes and sex chromosomes differences of sexual development, such as primary ovarian failure, mullerian agenesis or disorders with abnormal androgen synthesis or response. this is a phenotypically female who presented with primary amenorrhea at the age of 19 years old. normal levels of thyroid function test, serum prolactin and follicle stimulating hormone ruled out hypothyroidism, hyperprolactinemia, and primary ovarian failure. magnetic resonance imaging showed absence of uterus, fallopian tubes, ovaries, but presence of proximal 1/3rd of the vagina. there is a single testis in the left inguinal region with unknown status of spermatogenesis. the chromosomal analysis revealed 46, xy karyotype conveying the patient is genotypically male. the testis-determining factor (tdf) test or sex-determining region y (sry) protein for male sex determination was not done. similar presentation of primary amenorrhea diagnosis of cais was made to her 18-year-old sister. women with cais are vulnerable to various psychological conditions caused by the appalling fact of being genotypically male when they have been raised female all their life. the gender confusion, reproductive issues and how others perceive them in the outside world require sensitive support. hence, accentuate the need to address the emotional, psychological, and psychiatric vulnerabilities in issues pertaining to relationships, infertility and conception. keywords: complete androgen insensitivity syndrome, psychological impact, adolescence 1. primary care medicine department, faculty of medicine, universiti teknologi mara doi: http://dx.doi.org/10.31344/ijhhs.v5i0-2.330 http://dx.doi.org/10.31344/ijhhs.v5i0-2.330 microsoft word ijhhs imam 23rd asc 2022 s3 editorial doi: http://dx.doi.org/10.31344/ijhhs.v7i70.506 bismillahirrahman rahim alhamdulillah, all praise to allah, who alone has enabled us to continue our life and efforts for good, salawat and salaam on the last prophet, muhammad (peace be upon him) whose footsteps we will follow till the end of time. alhamdulillah, we have managed to organise this years’ 23rd imam annual scientific conference (asc) 2022. praises to allah for helping us through one of the most challenging years in history of health and medicine, not only in malaysia but for the entire world. unlike the last 3 years, we are now relatively safe from covid-19 and hopefully insya allah, we might be able to keep it away forever. the last asc was held fully virtually due to the pandemic. ala kulli hal, it was still a success in its own way and we managed to do almost everything including scientific paper presentation and invited lectures from prominent speakers including from our brothers and sisters in federation of islamic medical association (fima). 2022 brought a new theme, ‘the challenges in healthcare landscape: reset, refine and reform’ aptly selected by the scientific committee led by the outstanding and tireless dr. elsa haniffah mejia mohamed (and her amazing committee members). may allah bless the efforts and sacrifice of all the personnel behind the organizing team in making this asc a success. alhamdulillah, this year we are able to organize a hybrid ‘full conference’ both physically and virtually according to imam’s tradition and concept. as always, we hope to meet old friends and welcome new ones in our efforts to make imam mainstream in society and also medical fraternities. assalamualaykum and keep safe. salawat and salam to our beloved prophet muhamad (peace be upon him), his families, companions and the people who follow them. may the celebration of maulidurrasul strengthen the love towards the messenger of allah. supplementary issue editorial: dr elsa haniffah mejia mohamed dr nur aizati athirah daud professor dr irfan mohamad associate professor dr wan ahmad hafiz bin wan md adnan associate professor dr aneesa abdul rashid dr muhamad yusri musa dr syed abdul khaliq syed abdul hamid dr siti fatimah badlishah dr mohamad fadli khairie associate professor dr asma alhusna binti abang abdullah dr muhammad munawar bin mohamed hatta sn zamri shahri microsoft word ijhhs imam 23rd asc 2022 s10 forum 1 “during my time…” (by imam past-presidents) mohamed hatta shaharom1, lokman saim2, ishak mas’ud3, jeffrey abu hassan4 al-isti‘ādhah ِ یم ِ ج َّ ِ الر َان َ الشَّیط ن ِ ِ م َّ ا ِ ُ ب َعُوذ ((االستعاذة) أ basmalah ِ یم ِ ح َّ ِ ٱلر ن ٰ َ م ْ ح َّ ِ ٱلر ٰ َّ ِ ٱ م ِسْ َة) ب ل َ َسْم ((ب al-istighfār اللھم اغفر لي ) ( ) ṣalawāt ٍد َّ َم ُح ِ م ٰ آل َى َل ع َ دٍ و َّ م َ ح ُ ٰ م َى َل ّ ع ِ َل َّ ص ُم ھ ٰ َّ ات (ٱلل َ َو ل َ ()ص may we be protected by allah the almighty from self-aggrandisement (ta‘ẓīmun al-dhāti تعظیم الذات), self-delusion (wahmun al-dhātiوھم الذات ) and vanity (ghurūr غرور). our resolve is to be always on the path of the divine instead of the path of shaitan. 1. ship: sacrifice (prioritising commitments), humility (humbling experiences), intention (solely for allah), passion (from the heart). 2. fima: immediate involvement in the international, professional, academic and humanitarian spheres. 3. islamic sciences (diploma, institut pengajian ilmu-ilmu islam, malaysia) and arabic (egypt and malaysia). 4. islamic movement: influence of ikhwān al-muslimīn and jamaat-e-islami. (abul a‘la maududi died in 1979, yūsuf al-qaradawi led the funeral prayer at the lahore stadium, pakistan. leaders, activists and supporters of the ikhwān were all released by president anwar sadat by 1971, only to be harrassed and arrested again by 1979-1981). 5. academic administration and boards of companies. the politics of academia and intricacies of entrepreneurship. 6. malay language and literature, and dbp: sastera tanpa sains tiada kemajuan. sains tanpa sastera tiada keanggunan (literature without science is devoid of advancement. science without literature is devoid of elegance). “in our time...” describes the struggle and the earnestness of those around us; i.e. family, companions, colleagues and the milieu of professionals and fellow humans who wanted and still want to improve the conditions of the nation and the world. sorrow behind the smiles: notes on a humanitarian journey in iraq, kosovo, afghanistan and iran. dewan bahasa dan pustaka, kuala lumpur 2006. one example of the five books describing international humanitarian missions in iraq, kosovo, afghanistan, iran, palestine (gaza) and indonesia (aceh) with imam, mercy malaysia, mycare. as we look to the future with this conference on how we will need to reset, refine, and reform the future of malaysian healthcare, we should also look back at how imam/ppim contributed to the current healthcare milieu. we are blessed that 3 of our previous predecessors and presidents of imam/ppim are here today with us to discuss their experiences and challenges in helming imam/ppim during their time in office. we will also eagerly listen to them as we hope they will suggest to us the way forward in the challenges facing our profession and imam in the seemingly difficult future facing us. please do join us in this discourse to better the future of medicine in malaysia. keywords: imam, challenges, future, reform 1. persatuan terapi psikospiritual malaysia, https://www.facebook.com/malaysianpsychospiritualtherapy/ 2. school of medicine, kpj university college, kota seriemas, 71800 nilai, negeri sembilan 3. hospital pakar al-islam, jalan raja abdullah, kampung baru, kuala lumpur 4. kpj seremban specialist hospital, seremban, negeri sembilan s11 ___________________________________________________________________________ correspondence to: dr. jeffrey abu hassan, kpj seremban specialist hospital, seremban, negeri sembilan. jeffreyazim@yahoo.co.uk __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v7i70.513 international journal of human and health sciences vol. 07 no. 03 july’23 220 original article: the effect of giving moringa leaf flour to burger tempeh on the content nutrition and organoleptic ningrum t.m..1, yulia lanti retno dewi2, ratih puspita febrinasari3 abstract background: moringa leaves have a high nutritional content and can be used as food that is rich in nutrients. in 100 grams of moringa leaves contain 7 mg of iron, and 28.2 mg of moringa leaf flour. the mineral content in moringa leaves includes (calcium 440 mg, magnesium 42 mg, phosphorus 70 mg, potassium 259 mg and iron 0.85 mg), vitamins (a: 6.78 mg, c: 220 mg, e: 448 mg, and b3 : 0.8 mg) and various other benefits. the addition of moringa leaf flour is expected to increase the nutritional content of the burger tempeh food product. organoleptic test is needed to determine the level of preference, taste and texture to get the most preferred burger tempeh moringa product. objective: this study aims to determine the effect of adding moringa leaf flour to the nutritional and organoleptic content of burger tempeh. method: organoleptic tests were carried out at the nutrition laboratory of the university of m.h. thamrin jakarta. after getting the most preferred burger tempeh product, nutritional content testing was carried out at the laboratory of balai besar industri agro (bbia) in bogor. results: burger tempeh moringa selected in the organoleptic test was the tempeh burger which was added with 3 g and 12 g of moringa leaf flour. the nutritional content of the tempeh burger without the addition of moringa leaf flour is iron 2.41 mg, folic acid 1.76 mg and vitamin c 0.70 mg. after adding 3 g of moringa flour, the iron value increased to 2.51 mg, folic acid 1.78 mg. meanwhile, the addition of 12 g of moringa leaf flour increased to 2.98 m iron and 1.90 mg folic acid. conclusion: the addition of moringa leaf flour affects the nutritional and organoleptic content of tempeh burgers. keywords: moringa, moringa leaf flour, tempeh, moringa tempeh burger, organoleptic correspondence to: tri martya ningrum l.w., postgraduate program of nutrition science, sebelas maret university, indonesia e-mail: trimartya@student.uns.ac.id 1. postgraduate program of nutrition science, sebelas maret university, indonesia 2. department of nutrition science, faculty of medicine, sebelas maret university, indonesia 3. department of pharmacology, faculty of medicine, sebelas maret university introduction moringa has the scientific name moringa oleifera, the moringa plant belongs to the moringaceae family. this plant has a tree height between 7 to 11 meters. moringa leaves are oval, small, and compound in one stalk. moringa leaves contain nutrients such as calcium, iron, vitamins, and essential amino acids that are also found in quinoa and animal meats. moringa leaves are very rich in antioxidants, which include vitamin c, beta carotene, quercetin, and chlorogenic acids.1,12 giving moringa leaf extract can also reduce disease activity in people with lupus.2 in 100 grams of moringa leaves contain 7 mg of iron, and 28.2 mg of moringa leaf flour.3 the high iron content of moringa leaves is able to overcome the problem of anaemia in adolescent girls. mineral content includes (protein 6.7 g, calcium 440 mg, magnesium 42 mg, phosphorus 70 mg, potassium 259 mg and iron 0.85 mg), vitamins international journal of human and health sciences vol. 07 no. 03 july’23 page : 220-232 doi: http://dx.doi.org/10.31344/ijhhs.v7i3.578 221 international journal of human and health sciences vol. 07 no. 03 july’23 (a: 6.78 mg, c: 220 mg, e: 448 mg, and b3: 0, 8mg) and various other benefits.4 consuming moringa leaf extract can increase haemoglobin levels in adolescent girls and can be used as an alternative to overcome the problem of anaemia in adolescent girls.5 according to research conducted by indrayani et.al., 2019, moringa leaves can increase haemoglobin levels to prevent anaemia.6 table 1. nutritional value of moringa leaves in 100 g nutritional components fresh leaves calcium 94.01 proteins (%) 22.7 carbohydrates (%) 51.66 fibre (%) 7.92 calcium (mg) 350-550 energy (kcal/100g) fat (%) 4.65 source: syarifah aminah et.al., litbang pertanian (2015).7 moringa leaves can be made into flour by several methods, including blending, pounding, or using other grinding machines. drying is a series of processes in the manufacture of moringa leaf flour, including drying, which can be in the form of traditional drying or modern drying using electronic devices. research conducted by irwan (2020) made moringa leaf flour through a traditional drying process in 3 ways, namely blanching, withering, and drying. of the 3 drying methods, the withering method is the recommended choice by researchers, because the highest ca and fe content is in the withering method. the following is the nutritional content of moringa leaf flour.8 table 2. nutritional value of moringa leaf flour in 100 g nutritional components nutrient value protein 27, 83 g calcium (ca) 1,014.81 mg phosphorus (p) 700.65 mg iron (fe) 11.41 mg vitamin a 59.2 ug vitamin c 716.47 mg iodine 703.3 ug source: irwan (2020)8 and kusumawardani. et. al (2018)9 burgers usually consist of a burger bun and its filling, the filling is filled with a patty which is usually made from meat such as beef, fish and chicken, there is also a burger stuffing made from tempeh. stuffing tempeh burgers is an alternative for vegetarians (who only want to eat from plantbased foods). tempeh is a food ingredient that is easily obtained and the price is affordable, besides that it has high nutritional content, such as protein, calcium, iron and vitamin b12.10 because of its high nutritional content, tempeh is an option for burgers, as a substitute for beef, chicken or fish. to make it easier for people to consume food that can help overcome anaemia, it is necessary to have delicious food that contains sufficient nutrients and can increase blood haemoglobin levels in the body. from some of the literature that has been described in this background discussion, the authors try to make processed foods rich in nutrients and can overcome anaemia in adolescent girls. the processed food made is the tempeh moringa burger (btk), where usually the burger is made from processed beef, chicken or fish. the author tries to replace processed meat using tempeh and moringa leaf flour as additional ingredients for making tempeh burgers. table 3. nutrient value of tempeh burger stuffing in 100 g nutrients nutritional value energy 268.56 kcal carbohydrate level 33.37% water content 42.86% protein level 6.77% ash level 5.00% fat level 12.00 % source: nurwahyu et al., (2013)11 matherial and methods this research is an experimental study, using a completely randomized design (ral) with five treatments, namely making tempeh burgers with 0%, 3%, 6%, 9%, and 12% moringa leaf flour substitutions. this research was conducted for 30 days (mei june 2022). the organoleptic test was carried out at the nutrition laboratory of the university of mh international journal of human and health sciences vol. 07 no. 03 july’23 222 thamrin, jakarta. after getting the most preferred tempeh burger product, nutritional content testing was carried out at the laboratory of balai besar industri agro (bbia) in bogor. manufacturing stage the making of moringa tempeh burger was carried out in four stages, namely: making burger buns, formulating burger fillings, organoleptic testing and nutritional value analysis. 1. burger bread making making burger buns using the main ingredient wheat flour and added yeast bread. the initial stage is fermentation, where the flour is sprinkled with bread yeast and sugar, the fermentation time is about 2 hours. the next stage is knead or folding, which is kneading so that the dough is mixed evenly. then the next stage is the formation of the dough, then after the desired bread dough is formed, the stage is the fermentation process or the final development of the dough. the final stage is the roasting or oven process, the baking process is the last and most important process in making bread. after that the bread is stored in the freezer, to be used in a few days. 2. burger stuffing formula the formulation of the burger stuffing formula was carried out through a preliminary study. the main ingredient of burger stuffing is tempeh, with the addition of moringa leaf flour. moringa leaf flour was added using several experimental formulas, as many as 18 additional formulas, consisting of: 1%, 2%, 3%, 4%, 5%, 6%, 7%, 8%, 9%, 10%, 11%, 12%, 15%, 20%, 25%, 30%, 50%, and 75% moringa leaf flour. in the preliminary study, there were 10 (ten) panelists who were asked to taste the most delicious taste, so 4 (four) formulas were produced, namely the addition of 3%, 6%, 9%, and 12% moringa leaf flour. 3. organoleptic test from the results of the burger stuffing formula obtained in the preliminary study, it was followed by an organoleptic test. the organoleptic test of the moringa tempeh burger was carried out on 30 panelists. the organoleptic test includes parameters of color, aroma, texture, taste, after taste and overall (general acceptance). the organoleptic test was carried out at the nutrition laboratory of the university of mh thamrin, jakarta. table 4.moringa leaf flour substitute tempeh burger formula composition group f0 (112) f1 (182) f2 (220) f3 (389) f4 (778) tempeh(g) 100 97 94 91 88 moringa leaf flour (gr) 0 3 6 9 12 salt and pepper powder (gr) 10 10 10 10 10 seasoned flour (gr) 10 10 10 10 10 burger bread (gr) 15 15 15 15 15 toppings(g) 10 10 10 10 10 source: utami et. al. (2013)11 with modification 4. data analysis data analysis used in this study used a computer program. the data from the preference test on acceptability were processed with microsoft excel 2019 and then statistically analyzed using spss 25.0 with data normality analysis, then if the data distribution showed that it was not normal (p <0.05) then it was continued with kruskall wallis analysis. if the results of the kruskall wallis analysis show a difference, then proceed with the mann whitney follow-up test for each treatment. 5. nutritional value analysis analysis of the nutrients of the moringa tempeh burger included proximate analysis, iron, folic acid and vitamin c. the nutrient analysis was carried out at the laboratory of balai besar industri agro 223 international journal of human and health sciences vol. 07 no. 03 july’23 procedure for making tempeh burger with moringa leaf flour substitution (bbia) in bogor. the product that was analyzed for its nutritional value was the moringa tempeh burger which was the most preferred and had the greatest overall acceptance. results 1. organoleptic test results the organoleptic test involved 30 semi-trained panelists, namely panelists who had previously been given training on the components of the acceptance of the moringa tempeh burger. accept in general). the control tempeh burger (without the addition of moringa leaf flour) for the parameters of color, aroma, texture, taste, after taste and overall has the highest score. as for the tempeh burger with the addition of 3g of moringa leaf flour, it ranks second with the level of preference on the parameters of color, aroma, texture, taste, after taste and overall. the next sequence is the addition of 12g of moringa leaf flour, which has the highest over all value compared to the addition of 6g and 9g of moringa leaf flour, and has a higher after-taste and taste. the tempeh burger with the addition of 9g became the most disliked tempeh burger because it had the lowest over all value compared to other tempeh burger products. this study is in line with other studies that the addition of moringa leaf flour to mocaf biscuit products produced good organoleptic characteristics.12 international journal of human and health sciences vol. 07 no. 03 july’23 224 0 1 2 3 4 5 6 7 8 0 gr 3 gr 6 gr 9 gr 12 gr o rg on le pt ic t es t r es ul t formula burger tempeh moringa color aroma texture flavor after taste over a ll figure 2. graph of organoleptic test results of moringa tempeh burger 225 international journal of human and health sciences vol. 07 no. 03 july’23 c h ar ac te ri st ic s n % n % n % n % n % n % n % n % n % n % k 0 0 0 0 0 0 0 0 4 1 3 3 1 0 1 4 4 7 7 2 3 2 7 3 0 1 0 0 p 1 0 0 0 0 3 1 0 3 1 0 5 1 7 4 1 3 9 3 0 6 2 0 0 0 3 0 1 0 0 p 2 0 0 0 0 4 1 3 3 1 0 5 1 7 1 0 3 3 8 2 7 0 0 0 0 3 0 1 0 0 p 3 0 0 0 0 7 2 3 6 2 0 4 1 3 8 2 7 4 1 3 0 0 1 3 3 0 1 0 0 p 4 0 0 1 3 4 1 3 3 1 0 6 2 0 9 3 0 6 2 0 1 3 0 0 3 0 1 0 0 k 0 0 0 0 0 0 1 3 4 1 3 1 3 1 3 4 3 6 2 0 5 1 7 3 0 1 0 0 p 1 0 0 0 0 3 1 0 6 2 0 3 1 0 5 1 7 9 3 0 2 7 2 7 3 0 1 0 0 p 2 0 0 0 0 5 1 7 4 1 3 3 1 0 9 3 0 7 2 3 2 7 0 0 3 0 1 0 0 p 3 1 3 0 0 4 1 3 8 2 7 6 2 0 5 1 7 4 1 3 2 7 0 0 3 0 1 0 0 p 4 0 0 1 3 5 1 7 5 1 7 7 2 3 4 1 3 6 2 0 2 7 0 0 3 0 1 0 0 k 0 0 0 0 1 3 6 2 0 2 7 9 3 0 8 2 7 3 1 0 1 3 3 0 1 0 0 p 1 0 0 0 0 3 1 0 4 1 3 4 1 3 8 2 7 6 2 0 5 1 7 0 0 3 0 1 0 0 p 2 1 3 0 0 2 7 4 1 3 6 2 0 1 0 3 3 4 1 3 2 7 1 3 3 0 1 0 0 p 3 0 0 0 0 5 1 7 4 1 3 6 2 0 1 0 3 3 2 7 3 1 0 0 0 3 0 1 0 0 p 4 0 0 1 3 1 3 6 2 0 7 2 3 8 2 7 6 2 0 1 3 0 0 3 0 1 0 0 k 0 0 0 0 0 0 1 3 5 1 7 1 2 4 0 6 2 0 6 2 0 0 0 3 0 1 0 0 p 1 0 0 1 3 4 1 3 6 2 0 4 1 3 5 1 7 6 2 0 4 1 3 0 0 3 0 1 0 0 p 2 1 3 1 3 4 1 3 9 3 0 4 1 3 7 2 3 4 1 3 0 0 0 0 3 0 1 0 0 p 3 1 3 1 3 6 2 0 8 2 7 4 1 3 5 1 7 4 1 3 1 3 0 0 3 0 1 0 0 p 4 1 3 0 0 7 2 3 2 7 4 1 3 1 0 3 3 6 2 0 0 0 0 0 3 0 1 0 0 k 0 0 0 0 0 0 0 0 2 7 4 1 3 2 2 7 3 2 7 0 0 3 0 1 0 0 p 1 0 0 0 0 2 7 9 3 0 4 1 3 9 3 0 5 1 7 1 3 0 0 3 0 1 0 0 p 2 1 3 0 0 5 1 7 9 3 0 4 1 3 7 2 3 4 1 3 0 0 0 0 3 0 1 0 0 p 3 1 3 1 3 5 1 7 8 2 7 6 2 0 6 2 0 2 7 1 3 0 0 3 0 1 0 0 p 4 1 3 0 0 9 3 0 1 3 4 1 3 7 2 3 8 2 7 0 0 0 0 3 0 1 0 0 k 0 0 0 0 0 0 0 0 2 7 1 3 1 6 5 3 7 2 3 4 1 3 3 0 1 0 0 p 1 0 0 1 3 2 3 6 2 0 6 2 0 5 1 7 8 2 7 1 3 1 3 3 0 1 0 0 p 2 0 0 0 0 5 4 7 2 3 7 2 3 5 1 7 5 1 7 1 3 0 0 3 0 1 0 0 p 3 0 0 1 3 6 7 7 2 3 5 1 7 6 2 0 4 1 3 1 3 0 0 3 0 1 0 0 p 4 1 3 0 0 7 4 2 7 5 1 7 6 2 0 8 2 7 0 0 1 3 3 0 1 0 0 fl a v o r a ft er t a st e o v er a ll to ta l c o lo r a r o m a te x tu r e 4 5 6 7 8 9 1 2 3 o r g a n o le p ti c ta bl e 5. o rg on le pt ic t es t r es ul t *o bt ai ne d fr om m ic ro so ft ex ce l t es t r es ul ts international journal of human and health sciences vol. 07 no. 03 july’23 226 227 international journal of human and health sciences vol. 07 no. 03 july’23 international journal of human and health sciences vol. 07 no. 03 july’23 228 229 international journal of human and health sciences vol. 07 no. 03 july’23 international journal of human and health sciences vol. 07 no. 03 july’23 230 1. nutritional value analysis results the results of the nutritional analysis carried out for the moringa tempeh burger product showed an increase in the nutritional value of the addition of moringa leaf flour. the nutritional content of the tempeh burger without the addition of moringa leaf flour is 11.7 g protein, 13.4 g fat, 28.0 g carbohydrate, 279 kcal energy, 2.41 mg iron, 1.76 mg folic acid and 0 vitamin c. ,70 mg. after adding 3 g of moringa flour, the protein value was 11.4 g, fat was 13.0 g, carbohydrates were 28.3 g, energy was 276 kcal, iron increased to 2.51 mg, folic acid was 1.78 mg. meanwhile, the addition of 12 g of moringa leaf flour contained 11.6 g of protein, 12.7 g of fat, 29.8 g of carbohydrates, 280 kcal of energy, iron increased to 2.98 m and folic acid was 1.90 mg. discussion the making of the moringa tempeh burger is carried out in several stages and the last stage is the presentation. the presentation is in the form of arranging the burger buns that have been baked, then placing the stuffing of the burgers between the buns that have been divided into two parts, and adding vegetables, chili sauce and mayonnaise. to determine the acceptability of the moringa tempeh burger product, organoleptic tests were carried out including the parameters of color, aroma, texture, taste, after taste and overall (general acceptance). in the organoleptic test, the most preferred moringa tempeh burger product in general which includes color, aroma, texture, taste, after taste and overall is the addition of 3g of moringa leaf flour. furthermore, the formula for adding moringa leaf flour was taken with a higher concentration, which was obtained by adding 12g which had more color, texture, taste and overall values than other formulas. after obtaining the correct moringa tempeh burger formula, then an analysis of the nutritional content of the control product (without the addition of moringa leaf flour), addition of 3g, and the addition of 12g of moringa leaf flour was carried out. the results of the nutritional analysis showed that the iron content (fe) in all additions of moringa leaf flour to tempeh burgers had a higher value than tempeh burgers that had not been added with moringa leaf flour. that is 2.51 mg with the addition of 3g of moringa leaf flour, and 2.98 mg on the addition of 12g of moringa leaf flour, where the iron (fe) value before adding moringa leaf flour is 2.41 mg. 231 international journal of human and health sciences vol. 07 no. 03 july’23 table 42. nutritional content of moringa tempeh burger no. parameter tempeh burger moringa tempeh burger (3g) moringa tempeh burger (12g) 1 water (g) 42.8 43.7 41.2 2 ash (g) 2.21 2.44 2.87 3 protein (g) 11.7 11.4 11.6 4 fat (g) 13.4 13.0 12.7 5 crude fiber (%) 1.85 1.14 1.83 6 carbohydrates (g) 28.0 28.3 29.8 7 energy (kcal) 279 276 280 8 iron (fe) (mg) 2.41 2.51 2.98 9 folic acid (mg) 1.76 1.78 1.90 10 vitamin c (mg) 0.70 0.70 0.70 source : data primer (2022) figure 3. graph of the increase in iron (fe) in the moringa tempeh burger this is in accordance with other studies. the addition of moringa leaf flour increased iron (fe) levels in biscuits substituted with moringa leaf flour.13 likewise, the folic acid content in tempeh burgers increases with each addition of moringa leaf flour. that is 1.78 mg with the addition of 3g of moringa leaf flour, and 1.90 mg on the addition of 12g of moringa leaf flour, where the value of folic acid before adding moringa leaf flour is 1.76 mg. this is in accordance with other studies that the addition of moringa leaf flour to fish nugget products can increase folic acid levels.14 2,41 2,51 2,98 2 2,2 2,4 2,6 2,8 3 3,2 control 3 gr 12 gr iron (fe) 1,76 1,78 1,9 1,65 1,7 1,75 1,8 1,85 1,9 1,95 control 3 gr 12 gr folic acid figure 4. the graph of the increase in folic acid in the moringa tempeh burger other nutritional value analysis showed an increase in carbohydrate content and ash content in the moringa tempeh burger with the respective increasing values: tempeh/control burger (carbohydrate 28.0g, ash 2.21g), tempeh burger with the addition of 3g moringa leaf flour ( 28.3g carbohydrates, 2.44g ash), tempeh burger with the addition of 12g moringa leaf flour (29.8g carbohydrates, 2.87g ash). other nutritional content such as protein, fat, crude fiber, energy and vitamin c did not show a significant increase in nutrients, and even tended to decrease after the addition of moringa leaf flour to the tempeh burger. for example, the fat content decreased with each addition of moringa leaf flour (tempeh burger/control: 13.4g, tempeh burger with the addition of 3g moringa leaves: 13.0g, and tempeh burger with the addition of 12g moringa leaves: 12.7g). conclusion the addition of moringa leaf flour affects the nutritional content of the moringa tempeh burger. namely the content of iron (fe), folic acid, carbohydrates and ash content. meanwhile, the nutritional content of other nutrients did not increase significantly and even tended to decrease after the addition of moringa leaf flour, namely the fat content. the organoleptic test results of the moringa tempeh burger showed that the addition of moringa leaf flour affected the level of preference which included color, aroma, texture, taste, after taste and overall. suggestion research can be continued with research on the effect of giving moringa tempeh burgers on increasing haemoglobin levels in anemic young international journal of human and health sciences vol. 07 no. 03 july’23 232 women or anemic pregnant women. further research is needed on the nutritional content of vitamin b12 in the moringa tempeh burger product. thank-you note thanks to prof. dr. yulia lanti retno dewi, dr., m.sc. as main advisor and dr. ratih puspita febrinasari, dr., m.sc. as a companion advisor who has educated and fostered the author so that he can complete this article and assist in this research. and thanks also to bppsdmk ministry of health of the republic of indonesia for providing funding in this research references 1. winarno f.g. (2018). tanaman kelor (moringa oleifera) : nilai gizi, manfaat dan potensi usaha. jakarta : gramedia pustaka utama. 2. nurudhin, a., prabowo, n. a., yulyani, -, adnan, z. a., & adil, -. (2020). effect of moringa oleifera leaf extract on high sensitivity c-reactive protein, esr and mex sledai score in lupus patients. international journal of human and health sciences (ijhhs), 4(4), 291. https://doi.org/10.31344/ijhhs. v4i4.216 . 3. sari, y. k., & adi, a. c. (2018). daya terima, kadar protein dan zat besi cookies substitusi tepung daun kelor dan tepung kecambah kedelai. media gizi indonesia. https://doi.org/10.20473/mgi.v12i1.27-33. 4. sakinah, n., prangdimurti, e., & palupi, n. s. (2019). kandungan gizi dan mutu protein tepung biji kelor terfermentasi. jurnal teknologi dan industri pangan, 30(2), 152–160. https://doi.org/10.6066/ jtip.2019.30.2.152 . 5. fauziandari, e. n. (2019). efektifitas ekstrak daun kelor terhadap peningkatan kadar hemoglobin pada remaja putri. jurnal kesehatan karya husada, 7(2), 24–29. https://doi.org/10.36577/jkkh.v7i2.230 . 6. indrayani, u. d., sarosa, h., hussaana, a., & widiyanto, b. (2018). the effects comparisons of sauropus androgynous, moringa oleiefera alone and in combination on iron deficiency in anemia rats. bangladesh journal of medical science, 18(1), 136– 140. https://doi.org/10.3329/bjms.v18i1.39564 . 7. syarifah aminah., ramdhan t., yanis m. (2015), kandungan nutrisi dan sifat fungsional kelor (moringa oleifera). bulteni pertanian perkotaan volume 5 no. 2, kementerian pertanian ri. 8. zaki irwan. (2020). kandungan zat gizi daun kelor (moringa oleifera) berdasarkan metode pengeringan. jurnal kesehatan manarang volume 6, nomor 1, juli 2022. kusumawardani h.d., riyanto s., setianingsih i., puspitasari c., juwantoro d., harfana c., ayuni p. d. (2018). nutrient content, organoleptic, and shelf life of biscuit with composit flour substitution (moringa leaf, seaweed, and banana). jurnal media gizi mikro indonesia vol. 9 no. 2. 9. salahudin, f. (2016). pembentukan vitamin b12 pada fermentasi kedelai dengan isolat rhizopus oryzae dan klebsiella pneumoniae. jurnal penelitian dan pengembangan borneo akcaya, 3(1), 56–60. 10. utami n., jumirah, siagian a. (2013). pengaruh pengunaan tempe sebagai bahan dasar pembuatan isian burger terhadap komposisi zat gizi dan daya terimanya. jurnal gizi, kesehatan reproduksi dan epidomologi vol. 2 no. 5. 11. augustyn, g. h., tuhumury, h. c. d., & dahoklory, m. (2017). pengaruh penambahan tepung daun kelor (moringa oleifera) terhadap karakteristik organoleptik dan kimia biskuit mocaf (modified cassava flour). agritekno, jurnal teknologi pertanian, 6(2), 52–58. https://doi.org/10.30598/ jagritekno.2017.6.2.52 . 12. puspaningrum, d. h. d., srikulini, i. a. i., & wiradnyani, n. k. (2019). penambahan tepung daun kelor (moringa oleifera) dan tepung kacang kedelai (glycine max. l) terhadap nilai gizi snack bar. pro food, 5(2), 544–548. https://doi.org/10.29303/ profood.v5i2.115 . 13. halim, r., lanita, u., syukri, m., & faisal, f. (2022). pengaruh penambahan tepung kelor terhadap nilai gizi dan tingkat kesukaan produk nugget ikan. gema wiralodra, 13(2), 739–751. https://doi. org/10.31943/gemawiralodra.v13i2.291. https://doi.org/10.31344/ijhhs.v4i4.216 https://doi.org/10.31344/ijhhs.v4i4.216 https://doi.org/10.20473/mgi.v12i1.27-33 https://doi.org/10.6066/jtip.2019.30.2.152 https://doi.org/10.6066/jtip.2019.30.2.152 https://doi.org/10.36577/jkkh.v7i2.230 https://doi.org/10.3329/bjms.v18i1.39564 https://doi.org/10.30598/jagritekno.2017.6.2.52 https://doi.org/10.30598/jagritekno.2017.6.2.52 https://doi.org/10.29303/profood.v5i2.115 https://doi.org/10.29303/profood.v5i2.115 https://doi.org/10.31943/gemawiralodra.v13i2.291 https://doi.org/10.31943/gemawiralodra.v13i2.291 international journal of human and health sciences vol. 07 no. 03 july’23 252 original article histopathological changes in placenta in cases of intrauterine growth restriction soma ghosh1, shantanu bhuniya2, dilip kumar biswas3 abstract background: intrauterine growth retardation (iugr) creates a significant worldwide public health burden being leading cause of perinatal mortality and morbidity. objective: to determine correlation between placental pathology and iugr, to assess pattern of placental histopathological changes in iugr compared to uncomplicated pregnancy and to determine significant early neonatal outcome of iugr baby in specific placental changes. methods: a cross-sectional observational, descriptive study done in a study population of 100 placentae including 50 from uncomplicated pregnancy and 50 from iugr cases. the histopathological, morphological changes of placentae in iugr observed and compared with placentae of uncomplicated delivery for a period of eighteen months. all iugr cases with time of delivery between 28 weeks and 40 weeks of gestation were included excluding multiple pregnancy and iufd. results: the mean gestational age in pre-term labor (ptl)was 30.4 weeks compared to 37.2 weeks in term population. placental weight and diameter were reduced in ptl with decreased intervillous space, syncytial knot, terminal villous vascularity and stem villous fibrosis. increased deposition of placental intervillous, perivillous fibrin; number of hofbauer cells and fetal obstructive vascular lesions in ptl associated with different perinatal outcomes and mortality. fetal inflammatory response was much higher in males. increased stage, grade of infectious and ischemic changes of placentae were associated with more adverse outcomes. conclusion: adverse perinatal outcomes were more prevalent in preterm babies whose placentae showed infectious and ischaemic changes. an assessment of placental pathology is thus useful for resolving issues arising from pregnancy complications. keywords: iugr, placenta, preterm birth, chorioamnionitis, obstructive vasculopathy correspondence to: dr. soma ghosh, associate professor, department of pathology, burdwan medical college, west bengal, india. email: drsomadattaghosh@gmail.com 1. associate professor, department of pathology, burdwan medical college, west bengal, india. 2. junior resident, department of pathology, burdwan medical college, west bengal, india. 3. associate professor, department of obstetrics & gynaecology, burdwan medical college & hospital, west bengal, india introduction fetal growth is a complicated physiological process with contribution from both maternal and placental aspects.1 restricted growth is found with compromised placenta mediated foetal circulation. the perinatal morbidity and mortality are mostly caused by fetal growth restriction (fgr) encountered in 5-10% of all pregnancies.2 despite the latest diagnosing tools, false positive results are still in high frequency. here, comes the importance of studying placental pathology that can be beneficial for early diagnosis and subsequent management of fgr. by definition, fgr is the failure of foetus to attain appropriate weight during a specific gestational age.2 among the placental causes, uteroplacental insufficiency has been established as a predominant factor.2 foetal growth is mostly regulated by placental angiogenesis and circulation that carry oxygen to the growing foetus. the nutritional international journal of human and health sciences vol. 07 no. 03 july’23 page :252-261 doi: http://dx.doi.org/10.31344/ijhhs.v7i3.582 253 international journal of human and health sciences vol. 07 no. 03 july’23 supply to fetus is greatly affected by retarded growth of the placental blood vessels resulting in retarded growth of fetus. this establishes the significance of angiogenesis in placenta both in normal condition and in growth restriction.1,2 chronic lung disease, hypothermia, chronic necrotizing enterocolitis, polycythemia, abnormal glucose metabolism and perinatal asphyxia are commonly observed in postnatal life of a foetus who experienced fgr.3 diseases appearing in adulthood are diabetes, hypertension, obesity .3 identification of fgr can be done with the help of integrated prenatal screening tests comprising of low level of pregnancy associated plasma protein a (papp-a) with beta human chorionic gonadotropin (β-hcg), high levels of alpha-fetoprotein (afp) and inhibin coupled with vascular doppler study .4 the pathophysiology of placenta is best assessed by histopathological examination amongst wide variety of investigations.3.4an elaborate examination of histopathological characteristics of the placenta is of help to evaluate pathogenesis of fgr , guiding to efficiently manage patient and eventually reducing the prevalence of fgr as well as unwanted future complications. hence, we proposed this study to determine correlation between placental pathology and iugr, assess pattern of placental histopathological changes in iugr compared to uncomplicated pregnancy and determine significant early neonatal outcome of iugr baby in specific placental changes. methods a cross-sectional, observational, descriptive study was done in a teaching institute in west bengal for a time period of eighteen months with written informed consent from the patient after completing case record and eventually collecting placentae from gynaecology labour room. all iugr cases with time of delivery between 28 and 40 weeks of gestation during the study period were included (n=50), while similar numbers of placenta from uncomplicated pregnancy taken as control (n=50). the exclusion criteria were multiple pregnancy, iufd, those born before 28 weeks and after 40 weeks of gestation . the dependant variables were histopathological and morphological placental changes in iugr. the independent variables were maternal factors associated with placental changes in iugr and body weight of baby post-delivery. the study tools included case record form, routine histopathological reagents, slides, cover slip, hematoxylene & eosin (h&e) stain, 10 % formalin and microscope for histopathological processing, staining and observation. formalin (10%) fixed placental specimens received from gynaecology department and grossing was done at pathology department. h&e staining of tissue done after preparing paraffin blocks and sectioning in leica microtome. histopathological examination of sections done under 4x,10x and 40x objectives. placental parenchyma was examined for calcification, infarction and intervillous thrombosis. microscopic study was performed on tissue sample taken from each placenta including at least six blocks of placental tissue which comprised of transverse section of umbilical cord, two tissue bits of parenchyma including villi and intervillous space from edge of placenta, free membrane bit , two sections of parenchyma from placental centre, one to two sections from abnormal gross pathological part. the parameters included were post-delivery body weight of the baby; maternal gravida, age, weight,blood pressure, tsh,glucose level ; previous history of pregnancy with iugr or infection or per vaginal bleed or eclampsia. history elicited of appropriate maternal intake of iron , folic acid supplements and socioeconomic status . the placental shape, size, weight, morphological and histopathological changes noted. the microscopical parameters included intervillous space (ivs), intravillous and perivillous fibrin (ivf, pvf), maternal inflammatory response (mir), fetal inflammatory response (fir), villitis, fetal obstructive vascular lesion (fovl), infarction, syncytial knots(sk), calcification, stem villous fibrosis(svf), hofbauer cells, vessel density(vd), villous maturity score (vms). the specimens following routine tissue processing were stained by h&e method. statistical method: all numerical data was compared by using 2-tailed t-test and all categorical data was compared by using chisquare for trend, mann-whitney u test and binary logistic regression analysis. for statistical significance, p-value of less than 0.05 was considered. statistical analysis was done by using statistical package for the social sciences (spss) software, version 24.0 international journal of human and health sciences vol. 07 no. 03 july’23 254 results in the present study, 50 preterm (case) and 50 term (control) placentae studied in a study population of 100 pregnant mothers. their respective perinatal outcome was studied for duration of eighteen months. the study comprised of 68% primipara and 32% multiparous mothers without previous history of preterm birth. the mean maternal age was 20.6 years in preterm group and 22.2 years in term group. the mean gestational age, body mass index (bmi) in pre-term labor (ptl) was 30.4 weeks and 19.2 kg/m2 compared to 37.2 weeks and 20.9kg/m2 in term population.(table-1).the mean birth weight, mean of 1 minute and 5 minute apgar score were low in cases compared to control (table 1). the mean diameter and weight of placenta was also lower in ptl compared to term group. (table 1). edematous umbilical cord was found in 50% of cases, battledore placenta in 6% and single umbilical artery in 2%. the differences between placental weight and diameter in cases and control were statistically significant; but not the difference between mean placental thickness .(table :1) among the preterm neonates, 54% were females and 46% males with higher perinatal mortality in males (37%). ivs was narrowed in 48% and widened in 24% of preterm placentae but normal in all term placentae. (table:2a) vms 22 (normal villous maturation pattern) was observed in 56% term and 20% preterm placenta.30% of preterm placenta showed vms10; but no term placenta showed the score; which indicates less villous maturity in preterm placenta. microscopy of preterm placentae showed sk count (grade1,2), hofbauer cells (grade1-3),svf (grade1,2), vd(grade1-3), calcification (grade0-2), infarction (grade 0-2), fovl (grade0-2) . the term placentae showed sk(grade2); hofbauer cell(grade1); svf,vd (grade2); calcification (grade0,1); infarction and fovl(grade0) (table:2a,b) association of mir , fir, villitis and fovl with ptl were statistically significant. the association of different stages and grades of mir , fir and villitis with ptl were statistically significant.(table :3) increased stages and grades of mir,fir, villitis and fovl were more frequently associated with gestational age<32 wks than 32.1-36 wks. they comprised of early neonatal sepsis (n=21), respiratory distress syndrome (rds ,15) , table 1: differences in maternal and gestational age, bmi, birth weight of babies, 1 and 5min apgar score, placental weight, diameter and thickness among case and control group variable studypopulation mean 2sd p-value maternal age (years.) case 50control 50 20.6 22.2 2.6 2.7 0.001* bmi (kg/m2) case 50control 50 19.2 20.9 0.2 0.4 0.004* gestational age (weeks.) case 50control 50 30.4 37.2 2.9 0.8 0.003* birth weight of baby (gm.) case 50control 50 1692.3 2645.1 308.5 249.3 0.002* 1min apgar score case 50control 50 5.5 6.8 1.4 0.9 0.006* 5min apgar score case 50control 50 7.1 8.7 1.6 0.4 0.003* placental weight (gm) case 50control 50 310.7 422.5 25.7 29.9 0.005* placental diameter (cm) case 50control 50 17.7 18.2 0.6 0.8 0.002* placental thickness (cm) case 50control 50 2.2 2.4 0.1 0.1 0.854 255 international journal of human and health sciences vol. 07 no. 03 july’23 hyperbilirubinemia (7) , bradycardia with apnoea (12), hypoglycemia (32), hypothermia (34), hypoxic ischemic encephalopathy (hie ,17) and perinatal death (10) in ptl.however, the outcomes were favourable in term neonates with neither perinatal death nor late complication ( 96%). all adverse outcomes were more common in preterm newborns who were delivered before thirty two weeks of gestation, with birth weight less than 1.5 kg and low 1minute, 5 minute apgar scores except rds. increased grade of pvf, ivf deposition was associated with poor perinatal outcomes. table 2(a): placental microscopic changes variable case (n=50) control (n=50) p-value intervillous space grade1 :24(48) grade2 : 16(32) grade3 : 12(24) 0(0) 50(100) 0(0) 0.004* intravillous fibrin grade 1: 7(14) grade2 : 20(40) grade3 : 25(50) 42(84) 10(20) 0(0) 0.009* perivillous fibrin grade1 : 19(38) grade2 : 22(44) grade3 : 9 (18) 41(82) 11(22) 0(0) 0.001* syncytial knot grade 1:34(68) grade2:18(36) grade3:0(0) 0(0) 50(100) 0(0) 0.006* hofbauer cell grade1 : 17(34) grade2 : 13(26) grade3 : 22(44) 48(96) 4(8) 0(0) 0.001* stemvillous fibrosis grade1 :36(72) grade2 :14(28) grade3: 0(0) 0(0) 50(100) 0(0) 0.001* vessel density grade1 :15(30) grade2:35(70) grade3: 2(4) 0(0) 48(96) 2(4) 0.001* table 2 (b): placental microscopic changes variables case (n=50) control (n=50) p-value calcification grade 0 : 4(8) grade 1: 44(88) grade 2: 2(4) 32(64) 18(36) 0(0) 0.031* infarction grade 0: 31(62) grade 1: 13(26) grade 2: 6(12) 50(100) 0(0) 0(0) 0.005* fvol grade 0: 28(56) grade 1:10(20) grade 2: 12(24) grade 3: 0(0) 48(96) 2(4) 0(0) 0(0) 0.001* international journal of human and health sciences vol. 07 no. 03 july’23 256 table 3: incidence of chorioamnionitis (mir, fir), villitis and fovl in case and control group variables case control p-value mir present 47(94) 1(2) 0.001* absent 3(6) 49(98) fir present 32(64) 0(0) 0.001* absent 18(36) 50(100) villitis present 27(54) 0(0) 0.048* absent 23(52) 50(100) fovl present 22(44) 2(4) 0.033* absent 28(56) 48(96) table 4(a): association of ca-mir with perinatal outcomes variable association with perinatal outcome unadjusted odd’s ratio 95%ci significance lower upper ca(mir) neonatal sepsis 16.000 1.773 35.228 0.002* rds 5.289 1.158 24.086 0.039* bradycardia,apnoea 4.492 1.149 13.671 0.035* hyperbilirubinemia 3.448 1.163 13.641 0.028* hypoglycemia 8.749 1.228 14.154 0.002* hypothermia 5.229 1.171 24.132 0.044* hie 22.465 1.528 26.126 0.002* perinatal death 25.165 1.192 27.132 0.001* table 4(b): association of ca-fir with perinatal outcomes variable association with perinatal outcome unadjusted odd’s ratio 95% ci significance lower upper fir sepsis 12.000 1.915 46.117 0.009* rds 0.775 0.282 3.392 0.693 bradycardia,apnoea 8.207 2.122 35.838 0.001* hyperbilirubinemia 0.506 0.745 6.836 0.099 hypoglycemia 13.533 3.418 46.228 0.001* hypothermia 0.619 0.259 2.731 0.682 hie 12.721 1.561 113.340 0.011* perinatal death 13.433 1.259 13.241 0.004* 257 international journal of human and health sciences vol. 07 no. 03 july’23 table 4(c): association of villitis with perinatal outcome variable association with perinatal outcome unadjusted odd’s ratio 95% ci significance lower upper villitis sepsis 4.771 1.206 11.401 0.015* rds 0.701 0.298 3.196 0.661 bradycardia, apnoea 0.759 0.707 4.182 0.551 hyperbilirubinemia 10.118 1.448 82.861 0.040* hypoglycemia 5.870 1.553 15.388 0.026* hypothermia 0.704 0.248 3.926 0.991 hie 5.114 1.83 18.461 0.033* perinatal death 5.896 1.227 4.376 0.046* table 4(d): association of fovl with perinatal outcomes variable association with perinatal outcome unadjusted odd’s ratio 95% ci significance lower upper fovl sepsis 0.692 0.153 1.826 0.388 rds 3.440 1.162 11.825 0.041* bradycardia 3.263 1.183 16.202 0.004* hyperbilirubinemia 0.829 0.274 4.791 0.773 hypoglycemia 5.393 1.715 19.496 0.019* hypothermia 3.338 1.161 13.214 0.016* hie 22.700 3.296 111.833 0.008* perinatal death 14.753 1.155 14.502 0.036* figure 1: photomicrograph showing maternal neutrophils migrating into connective tissue of chorion and amnion (ca-mir grade 2); (h&e ×400). figure 2: photomicrograph showing chorionic vessel thrombi (inset) (h&e, ×400) fovl (h&e, ×100). international journal of human and health sciences vol. 07 no. 03 july’23 258 discussion low maternal age and bmi representing low socioeconomic status was responsible for increased incidence of ptl. several studies found positive correlation between low maternal age and bmi with ptl.5-7 owen et al. found increased incidence of spontaneous preterm birth (sptb) in mothers having previous history of ptb. this indicates that there may be some unknown factors which induce ptl in those primi and multipara.7 ptl was associated with decreased placental weight and size; but increased edematous umbilical cord diameter which resemble findings of mongia et al.8 mongia et al found increased ivf in hypoxia induced preterm labor.8tang et al found large placenta (2.91%), short cord (4.85%) and velamentous cord insertion (3.88%) in preterm population (28-37 wks); whereas vinograd et al found placenta accreta as an independent risk factor for late ptb.9,10 but, these findings with respect to placental weight and diameter are obvious features of premature gestation but not significant with regards to perinatal outcome.9,10 maternal immune reaction to fetal tissue was more common in male foetus than female, concluded from higher perinatal mortality in male babies. waiker et al. noted preterm male neonate with increased risk of developing coronary artery disease.11 deborah et al. noted widened ivs in the preterm placenta;12 but the present study found narrowed ivs with close approximation of villi in majority of the preterm placentae which may be due to prematurity and/or infection related pathological changes. allaf et al. found increased ivf deposition in term placenta, whereas mehta et al noted increased pvf deposition in preterm placenta along with disturbed fetoplacental blood flow.13,14 increased deposition of ivf, pvf in preterm placentae in present study was possibly due to vasculopathy related changes, aggravated by associated infection, resulting in ptl and poor perinatal outcome. allaf et al. noticed decreased sk and increased hofbauer cells in preterm placenta, resembling present study but contrary to mongia et al., where they postulated increased sk count as a feature of hypoxia induced ptl.8,13 reduced villous fibrosis with density and vascularity in underperfused preterm placenta in present study resemble findings of mongia et al; but allaf et al noted increased villous fibrosis in only 11.9% preterm placentae.8,13 andres et al and salafia et al described the phenomena of infarction induced ptl which hampers fetal growth and even fetal death .15,16low vms being a normal feature of premature placenta is not directly related to poor perinatal outcome.the study indicated mir, fir and villitis as significant risk factors for sptb in asymptomatic patient with intact membrane as well as in early premature rupture of membrane.15,16 defranco et al. noted 51.9% mir , 35.4% fir in sptb despite absence of clinical evidence of ca. risk of extreme ptb (<28 wks) was increased in presence of any grade or stage of mir or fir compared to late ptb (32–35 wks).17 üstün et al. found mild inflammation in 38% and severe grade in 31% of ptl.18 goldenberg et al found acute inflammation in 73.9% placentae of sptb.19 perkins et al found increased inflammatory changes in placentae of sptb with intact membranes than indicated preterm birth (iptb); while kovo et al noted just the reverse.20,21 salafia et al. found significant association between chronic villitis and ptl; whereas kim et al noted concomitant ca with villitis in 38% of ptl.22,23 this study confirms that higher grades and stages of acute chorioamnionitis associated mir, fir and villitis were significantly associated with early sptb (28-32weeks) compared to late (>32 weeks). fovl was focally present in 20% preterm placentae and multifocal in 24%. ischaemic vasculopathy may aggravate the incidence of ptl with poor perinatal outcome either alone or in association with infectious etiology. evidence showed a strong association between fovl and increased incidence of ptl.24,25 germain et al found higher rate of ptb in infectious group (95.0%) compared to ischemic group (90.2%).26 fovl is thus, an obvious risk factor for ptl as well as poor perinatal outcome and must be considered in further management of subsequent pregnancy as well as in neonatal care unit(nicu).26 (14) no congenital abnormality was noted in newborns of both preterm and term deliveries in the present study. among the preterm babies 42% cried immediately after birth, 40% had delayed and 18 % had poor cry. germain et al had noticed high rate of low birth weight <1.5 kg (35%) and nicu admission (75%) in infection induced ptl, compared to ischemic group; while salafia http://www.ncbi.nlm.nih.gov/pubmed?term=salafia cm%5bauthor%5d&cauthor=true&cauthor_uid=1575840 http://www.ajog.org/article/s0002-9378(05)01672-8/fulltext http://www.ncbi.nlm.nih.gov/pubmed?term=salafia cm%5bauthor%5d&cauthor=true&cauthor_uid=1575840 259 international journal of human and health sciences vol. 07 no. 03 july’23 et al noted decreased fetal growth with chronic villitis.22,26 several researchers noticed strong association between ca and increased occurrence of early neonatal sepsis,27-30 as like present study; but strunk et al31 observed reduced risk of late onset sepsis in neonate having ca. therefore, it may be postulated that, though ca and fovl both induced ptl, they had different pathogenesis to produce early neonatal sepsis and fatality. this study matches with the findings of korraa et al. who observed strong association between ca and rds,32 but bersani et al, andrews et al, liu et al, dempsey et al, elimian et al. found reduced incidence and severity of rds which was due to increased use of antenatal steroid.27,28,29,33,34 preterm babies in the present study had higher rate of rds which may be due to increased incidence of obstructive vasculopathy with placental histologic ca. bronchopulmonary dysplasia ( bpd) was not found resembling study of rocha et al. and masmonteil who could neither confirm decreased rate of rds nor increased risk for bpd, in neonates with ca.35,36all perinatal adverse outcomes in the present study were due to prematurity, infection and ischemia leading to placental insufficiency. however, a large cohort study is necessary to establish the individual adverse effects of chorioamnionitis with mir, fir, villitis or placental vasculopathy on perinatal outcome. in this study, hie induced preterm death was possibly sequel to obstructive vasculopathy as well as infection related pathological changes. early neonatal sepsis progressing to multisystem failure who presented with low apgar score, delayed and poor cry could be due to endothelitis. rds along with toxaemia induced placental insufficiency is another possible etiology. kaukola et al. observed increased risk of intraventricular hemorrhage (ivh) and poor neurologic outcomes in preterm presenting with chorioamnionitis and placental perfusion defect.37 several research found strong association between ca and neonatal death;29,30,32,33 however, roescher et al. concluded neonatal mortality as combined result of placental underperfusion and ca.38 dempsey et al. found no increased incidence of nec or ivh in infection induced ptl similar to present study.28 the association of fir with increased perinatal mortality than mir was unique in this study and the finding was similar to studies of lau et al. and mestan et al.39,40 perrone et al. concluded that low gestational age, ca, rather than placental vasculopathy, had negative impacts on adverse perinatal outcomes.24,39,40 but, lepais et al. observed that obstructive vasculopathy increased risk of fetal cardiopathy and neurodevelopmental complications respectively, which may be the outcome of chronic hypoxic damage induced by fir.25 ellis et al. found 11.4% positive and 99.9% negative predictive values of 1 min apgar of ≤ 3 for neonatal encephalopathy;41 whereas brian et al. and henry et al. noticed high mortality in preterm babies with 5 minute apgar scores of 0-3.42,43 this study had shown poor perinatal outcome in 1 minute apgar score of 0-3 and 5 minute score of 4-6. the present study was limited by conducting study in a single institution not representing general population, non-blinding of pathologist to clinical history, low sample size and short duration of study. conclusion histopathological examination of placenta must be considered mandatory for identifying infectious or obstructive vasculopathy to tailor neonatal therapy and to modify early neonatal care to prevent neonatal morbidity and mortality. conflict of interest: none. source of fund: institutional funding was given to support this research. ethical clearance: permission granted by the ethical committee of burdwan medical college (bmc/ethics/070 dt. 28/01/2020). author’s contribution: all authors were equally involved in conception, study design, data collection, statistical analysis, writing, editing, and final approval of the manuscript. http://www.ncbi.nlm.nih.gov/pubmed?term=mestan k%5bauthor%5d&cauthor=true&cauthor_uid=20308216 http://www.researchgate.net/profile/serafina_perrone international journal of human and health sciences vol. 07 no. 03 july’23 260 references 1. sankaran s, kyle pm. aetiology and pathogenesis of iugr. best pract res clin obstet gynaecol. 2009;23(6):765-77. 2. vedmedovska n, rezeberga d, teibe u, melderis i, donders gg. placental pathology in fetal growth restriction. eur j obstet gynecol reprod biol. 2011;155(1):36-40. 3. michael g. ross, marie h. beall. adult sequelae of intrauterine growth restriction. semin perinatol. 2008;32(3):213-8. 4. lausman a, mccarthy fp, walker m, kingdom j. screening, diagnosis, and management of intrauterine growth restriction. j obstet gynaecol can. 2012;34(1):17-28. 5. veerapen m k, pelaez l, potter j n e, duthely l, birusingh r, rampersaud e, et al. bridging the gaps between the histopathological and demographic risk factors of preterm birth in a unique miami inner-city population. fetal pediatr pathol. 2014;33(4):226-33. 6. lynch am, hart je, agwu oc, fisher bm, west na, gibbs rs. association of extremes of prepregnancy bmi with the clinical presentations of preterm birth. am j obstet gynecol. 2014;210(5):428.e1-9. 7. owen j, goldenberg r l, davis r o, kirk k a, copper r l. evaluation of a risk scoring system as a predictor of preterm birth in an indigent population. am j obstet gynecol. 1990;163(3):873-9. 8. mongia s m, jain s k, yadav m. placenta: the wonder organ. indian acad forensic med. 2011; 33(2):971-3. 9. tang my. pathologic analysis of the placenta in preterm deliveries. zhonghua fu chan ke za zhi. 1989;24(6):334-7. 10. vinograd a, wainstock t, mazor m, weisel rb, klaitman v, dukler d, et al. placenta accreta is an independent risk factor for late pre-term birth and perinatal mortality. j matern fetal neonatal med. 2015;28(12):1381-7. 11. walker mg, fitzgerald b, keating s, ray jg, windrim r, kingdom jcp. sex-specific basis of severe placental dysfunction leading to extreme preterm delivery. placenta. 2012;33(7):568-71. 12. deborah i, gersell, frederick tk. diseases of placenta. blaustein’s pathology of the female genital tract. 6th edition. springer; 2011;19:999-1073. 13. al-allaf lik, jarjees mtt, al-nuaimy wmt. preterm birth: histological and some histochemical changes of placenta in relation to perinatal outcomes. j bahrain med soc. 2008;20(2):60-7. 14. mehta r, nanjundaswamy s, schwarz ss, petrova a. neonatal morbidity and placental pathology. indian j pediatr. 2006;73(1):25-8. 15. andres r l, kuyper w, resnik r, piacquadio k m, benirschke k. the association of maternal floor infarction of the placenta with adverse perinatal outcome. am j obstet gynecol. 1990;163(3):935-8. 16. salafia c m, vogel c a, bantham k f, vintzileos a m, pezzullo j, silberman l. preterm delivery: correlations of fetal growth and placental pathology. am j perinatol. 1992;9(3):190-3. 17. defranco e, shen t, wangler m, kistka z, palomar l, stormo a, et al. placental pathology findings in case of familial spontaneous preterm birth. am j obstet gynecol. 2009;(suppl 186):663-4. 18. üstün c, koçak i, bariş s, uzel a, saltik f. subclinical chorioamnionitis as an etiologic factor in preterm deliveries. int j obstet gynecol. 2001;72(2):109-15. 19. goldenberg rl, andrews ww, petersen of, cliver s, goepfert ar, hauth jc. the alabama preterm birth project: placental histology in recurrent spontaneous and indicated preterm birth. am j obstet gynecol. 2006;195(3):792-6. 20. perkins r p, zhou s m, butler c, skipper b j. histologic chorioamnionitis in pregnancies of various gestational ages: implications in preterm labor. am j perinatol. 1988;5(3):300-3. 21. kovo m, schreiber l, ben-haroush a, asalee l, seadia s, golan a, et al. the placental factor in spontaneous preterm labor with and without premature rupture of membranes. j perinat med. 2011; 39(4):423-9. 22. salafia cm, vogel ca, vintzileos am, bantham kf, pezzullo j, silberman l. placental pathologic findings in preterm birth. am j obstet gynecol. 1991;65(4) :934-8. 23. kim c j, romero r, kusanovic p j, yoo w, dong z, topping v, et al. the frequency, clinical significance, and pathological features of chronic chorioamnionitis: a lesion associated with spontaneous preterm birth. modern pathol. 2010;23:1000-11. 24. perrone s, toti p, toti m s, badii s, becucci e, gatti m g, et al. perinatal outcome and placental histological characteristics: a single-centre study. j matern fetal neonatal med. 2012;25(suppl1):110-3. 25. lepais l, durand l g, boutitie f, lebreton f, buffin f, huissoud c, et al. fetal thrombotic vasculopathy is associated with thromboembolic events and adverse perinatal outcome but not with neurologic complications: a retrospective cohort study of 54 cases with a 3-year follow-up of children. placenta. 261 international journal of human and health sciences vol. 07 no. 03 july’23 2014;35(8):611-7. 26. germain a m, carvajal j, sanchez m, valenzuela g j, tsunekawa h, chuaqui b. preterm labor: placental pathology and clinical correlation. obstet gynecol. 1999; 94(2):284-9. 27. bersani i, thomas w, speer c p. chorioamnionitis – the good or the evil for neonatal outcome? j matern fetal neonatal med. 2012;25(s1):12-6. 28. dempsey e, chen m f, kokottis t, vallerand d, usher r. outcome of neonates less than 30 weeks gestation with histologic chorioamnionitis. obstet gynecol survey. 2005;60(10):639-40. 29. elimion a, verma u, beneckm d, cipriano r, visintainer p, tejani n. histologic chorioamnionitis, antenatal steroids, and perinatal outcomes. obstet gynecol. 2000;96(3):333-6. 30. pappas a, kendrick de, shankarans, stoll bj, bell ef, laptook ar, et al. chorioamnionitis and early childhood outcomes among extremely low-gestational-age neonates. jama pediatr, 2014;168(2):137-47. 31. strunk t, doherty d, jacques a, simmer k, richmond p, kohan r, et al. histologic chorioamnionitis is associated with reduced risk of late-onset sepsis in preterm infants. pediatrics 2012;129:134-41. 32. korraa a, nabil z, samir n, el geriany e. the value of placental pathological and microbiological aspects on preterm delivery and outcome. arch dis child 2012;97(suppl 2):a381. 33. andrews ww, goldenberg rl, faye-petersen o, cliver s, goepfert ar, hauth jc. the alabama preterm birth study: polymorphonuclear and mononuclear cell placental infiltrations, other markers of inflammation, and outcomes in 23 to 32 week preterm newborn infants. am j obstet gynecol. 2006;195(3):803-8. 34. liu z, tang z, li j, yang y. effects of placental inflammation on neonatal outcome in preterm infants. pediatrics neonatol. 2014;55(1):35-40. 35. rocha g, proença e, quintas c, rodrigues t, guimarães h. histological chorioamnionitis and lung damage in preterm newborns. arq med. 2005;19(12):15-21. 36. masmonteil tl. chorioamnionitis is a risk factor for bronchopulmonary dysplasiathe case against. paediatric respiratory rev. 2014;15(1):53-5. 37. kaukola t, herva r, perhomaa m, paakko e, kingsmore s, vainionpaa l, et al. population cohort associating chorioamnionitis, cord inflammatory cytokines and neurologic outcome in very preterm, extremely low birth weight infants. pediatr res. 2006;59:478-83. 38. roescher am, timmer a, erwich jj, bos af. placental pathology, perinatal death, neonatal outcome, and neurological development: a systematic review. plos one. 2014;9(2):e89419. 39. lau j, magee f, qiu z, houbé j, dadelszen p v, lee s k. chorioamnionitis with a fetal inflammatory response is associated with higher neonatal mortality, morbidity, and resource use than chorioamnionitis displaying a maternal inflammatory response only. am j obstet gynecol. 2005;193(3):708-13. 40. mestan k, yu y, matoba n, cerda s, demmin b, pearson c, et al. placental inflammatory response is associated with poor neonatal growth: preterm birth cohort study. pediatrics. 2010;125(4):891-8. 41. ellis m, manandhar n, manandhar ds, costello amd. an apgar score of three or less atone minute is not diagnostic of birth asphyxia but is a useful screening test for neonatal encephalopathy. indian pediatrics.1998;35(5):415-22. 42. casey bm, donald d. mc intire, kenneth j. leveno. the continuing value of apgar score for assessment of newborn infants. n engl j med. 2001;344:467-71. 43. lee hc, subeh m, gould jb. low apgar score and mortality in extremely preterm neonates born in the united states. acta paediatr. 2010;99(12):1785-9. 191 international journal of human and health sciences vol. 05 no. 02 april’21 review article: the covid-19 pandemic and positive reflections on ramadhan ahmad faidhi mohd zaini1,2, aneesa abdul rashid1,3 abstract this year the ramadhan holy month of the muslim calendar fell amidst a pandemic. ramadhan is a month of worship, where many of the normal practices involve among other things; social gathering. due to the covid-19 pandemic, many practices could not be done. this article looks into the positive reflections of ramadhan during a pandemic. keywords: covid-19, pandemic, ramadhan correspondence to: aneesa abdul rashid, lecturer, dept. of family medicine, faculty of medicine and health sciences, universiti putra malaysia, e-mail: aneesa@upm.edu.my 1. islamic medical association of malaysia,b-g-39 sri penara apartment, jalan sri permaisuri 1, bandar sri permaisuri, 56000 cheras, kuala lumpur, malaysia 2. department of anaesthesiology, tuanku mizan military hospital, seksyen 2, wangsa maju, 53300 kuala lumpur, malaysia 3. department of family medicine, faculty of medicine and health sciences, universiti putra malaysia, 43400 upm serdang, malaysia international journal of human and health sciences vol. 05 no. 02 april’21 page : 191-193 doi: http://dx.doi.org/10.31344/ijhhs.v5i2.258 introduction ramadhan is the most anticipated season in the muslim calendar year. it is known as the holy month for worship (ibadah), and reflections. it is also a month of festive celebrations in the majority of muslim countries. muslims will congregate for breaking of fast (iftar), ramadhan bazaar and the sunna congressional prayer (taraawih). the covid-19 pandemic hit the world hard, and many were mostly unprepared.1 there were many restrictions the muslims had to abide to during the ramadan during the covid-19 pandemic. the congregational prayers that are highly encouraged during this holy month, could not be done.2 many missed breaking their fast together with family and friends, a common tradition in ramadhan. however, this new-norm can be said to have its positive outcomes. while many muslims could no longer congregate for the said activities due to the movement restrictions or lockdowns, it has provided a unique opportunity for ramadhan to be celebrated in a more humbling experience with much selfretrospection. fasting to attain taqwa “o you who have believed, decreed upon you is fasting as it was decreed upon those before you that you may become righteous” -al-baqarah 2:183. fasting is a way to attain taqwa, which means a sense of god consciousness and righteousnouss in one’s everyday life. 3,4 the covid-19 pandemic should play as a reminder (tazkirah) from allah that humans are fragile and can succumb to death at any time as a result from this pandemic. covid-19 serves as message for us remember our death (zikrul maut). hence, the pandemic and ramadhan should act as a medium to bring one closer to god. a healthy diet during ramadan due to the movement restriction order in many muslim countries, less are lured to buy food from the many ramadhan bazaars. the bazaars usually encourages the act of buying much more than required; causing much wastage of food, something that islam frowns upon. cooking simple, fresh and a balanced meals at home not only increases family bonding, but also may serves as a step towards a much healthier lifestyle. modest cooking and meal preparations at home without excessive additive or preservatives is also another benefit. the period of pandemic which limits access to outside food is helpful for patients that are diabetic, hypertensive and or international journal of human and health sciences vol. 05 no. 02 april’21 192 with dyslipidaemia. preparing food at home, will reduce the chances from indulging sugary desserts and drinks that is the common norm. studies have also shown that ramadhan brings many benefits in terms of health including weight reduction, better lipid levels and immune system. 3–5 the month of al-quran “verily, we have sent it (this qur’an) down in the night of al-qadr (decree).” [al-qadr 97:1] “the month of ramadan in which was revealed the qur’aan, a guidance for mankind and clear proofs for the guidance and the criterion (between right and wrong). so whoever of you sights (the crescent on the first night of) the month (of ramadan i.e. is present at his home), he must observe sawm (fasts) that month…” [al-baqarah 2:185] ramadhan is synonymous with al-quran (the holy book of the muslims) as it was sent down from god to the prophet during this holy month. the lockdown gives ample opportunity to recite and study the quran. this may not be possible during previous times, due to heavy workload and tight schedule. nights of prayer from abu hurayrah that the prophet (peace and blessings of allah be upon him) said: “whoever spends the nights of ramadhan in prayer out of faith and in the hope of reward, his previous sins will be forgiven.” -al-bukhaari (2008) and muslim (174) the seerah narrated that tarawih, which is the muslim congregational prayers done uniquely in ramadhan was initially performed at home by the prophet muhammad p.b.u.h. he did not make a big congregation of tarawih prayer in the mosque. this is so that the prayers will not to be perceived by the sahabah (close friends of the prophet) as compulsory (wajib). praying at home with the family, as most have experiences, brings more sense of togetherness and love. ramadhan is seen by muslims as a means bring one closer and rekindle family relationships. 6 front-liners in ramadhan those that are sick and affected with covid-19 has special provisions to break their fast as verily illustrated in the same ayat (verse) that commands fasting. “so whoever sights [the new moon of] the month, let him fast it; and whoever is ill or on a journey then an equal number of other days. allah intends for you ease and does not intend for you hardship and [wants] for you to complete the period and to glorify allah for that [to] which he has guided you; and perhaps you will be grateful.” [al-baqarah, 185] front liners (health and security personnel) work under challenging conditions wearing personal protective equipment (ppe) during this pandemic.7 hence, looking after their wellbeing is paramount.4,7 it is allowed for them to break their fast during ramadhan while replacing the fast at a later date. the duty to treat and manage patients is a fardhu kifayah (paramount obligation). this is due to the expertise of the front-liners that can only be fulfilled by those trained in the field. conclusion ramadhan is regarded as a month of selftraining to develop positive and healthy habits. it is the perfect opportunity to stop smoking.3 it is the perfect time to embrace healthy eating. it is the perfect time to nurture and rekindle family relationships. hence, the covid-19 ramadhan, with all its challenges has come this year with many of its hikmah (positive reflections). “the five daily prayers, from one jumu’ah to the next and from one ramadhan to the next are expiation for (sins committed) in between, so long as you avoid major sins.” -sahih muslim (233) acknowledgement the authors would like to thank fima for the suggestion of this topic financial support none. declaration of interest the authors declare no conflict of interest 193 international journal of human and health sciences vol. 05 no. 02 april’21 references: 1. akhter, m. w. coronavirus the ignored warning from history. int. j. hum. health sci. ijhhs 4, 322 (2020). 2. al-jazeera. tarawih amid coronavirus: scholars call for home ramadan prayers. https://www.aljazeera.com/news/2020/04/ tarawih-coronavirus-scholars-call-homeramadan-prayers-200422110654018.html (2020). 3. abolaban, h. & al-moujahed, a. muslim patients in ramadan: a review for primary care physicians. avicenna j. med. 7, 81–87 (2017). 4. mughal, f. ramadan: what it means for general practice. br. j. gen. pract. 64, 356– 356 (2014). 5. rouhani, m. h. & azadbakht, l. is ramadan fasting related to health outcomes? a review on the related evidence. j. res. med. sci. off. j. isfahan univ. med. sci. 19, 987–992 (2014). 6. alghafli, z. et al. a qualitative study of ramadan: a month of fasting, family, and faith. religions 10, 123 (2019). 7. moothadeth, a. et al. fasting during ramadan and the covid-19 pandemic. occup. med. doi:10.1093/occmed/kqaa103. 315 international journal of human and health sciences vol. 05 no. 03 july’21 original article: level of knowledge on sexual and reproductive health among youths in southern region of peninsular malaysia siti mariam ja’afar1, hafizuddin awang2, azriani ab rahman1 abstract: background: premarital sexual activity is associated with low level of knowledge of sexual and reproductive health which gives less control over decision making pertaining to sexuality. low understanding of sexual and reproductive health knowledge made adolescents unaware of the consequences of premarital sexual activity. this study aimed to describe the knowledge of sexual and reproductive health among youths in the state of johor, in southern region of peninsular malaysia. materials and methods: a crosssectional study was conducted in eleven health facilities in johor state, malaysia. the study samples were all youths who fulfilled study inclusion and exclusion criteria. the youths were assessed through a validated self-administered, anonymous questionnaire on sociodemographic background and 21 items of knowledge on sexual and reproductive health. descriptive statistics were employed to present the findings. results: there were 204 respondents involved in the study. the mean (±standard deviation) age of respondents was 21 years old (±1.9). majority of them were female (60.7%) and malay (89.1%). most of the respondents had high level of education (secondary and tertiary levels) (98.5%). a small percentage of the respondents were smokers (18.6%), alcohol drinkers (7.5%), drug users (3.5%), and a smaller portion reported of having history of sexually molested (4%). this study found sexual exposure among subjects ranged from reading (35.3%) and watching pornographic materials (44%), imagining sex (18.2%), as well as masturbating (21.1%). as for level of knowledge on sexual and reproductive health, majority of our respondents had low level of knowledge on the domain of sexual activity and pregnancy, complication of premarital sexual activity, and contraception. conclusion: as the involvement of youths in sexual activity is getting more prevalent, youth sexual and reproductive health should be prioritized in malaysia. public health campaigns need to focus on the positive aspects of healthy sexual relationships. the importance of ensuring easy access to sexual and reproductive health services for all youths needs to be acknowledged and addressed. keywords: knowledge, sexual and reproductive health, youths, malaysia. correspondence to: dr hafizuddin awang, public health medicine specialist, setiu district health office, bandar permaisuri, 22100 setiu, terengganu. e-mail: drhafizuddin@moh.gov.my 1. department of community medicine, school of medical sciences, universiti sains malaysia, 16150 kubang kerian, kelantan. 2. setiu district health office, bandar permaisuri 22100 setiu, terengganu. international journal of human and health sciences vol. 05 no. 02 april’21 page : 315-323 doi: http://dx.doi.org/10.31344/ijhhs.v5i3.281 introduction: adolescence is a transitional phase that involves dramatic physical, mental, sexual and social changes between childhood and adulthood1. there are notable physical and sexual changes in teenagers during this transition from childhood to adulthood. psychosocial development during adolescence is important in determining the adolescents’ identity, autonomy, sexuality and achievement2. if adolescents are not adequately educated and introduced to sex education and knowledge of sexual and reproductive health, they may engage in high-risk behaviour and sexual practices, including premarital sexual activity2,3. premarital sexual activity is linked with lower level of sexual and reproductive health knowledge, international journal of human and health sciences vol. 05 no. 03 july’21 316 which gives less autonomy over sexuality decisions4,5. low understanding of sexual and reproductive health knowledge made adolescents unaware of the consequences of premarital sexual activity. therefore, they might be easily persuaded into sexual intercourse that is usually unprotected. a research in taiwan found that active participation in school prevents a child from sexual premarital activity, which could coincide with the inclusion of a formal sex education curriculum taught in school6. a few studies in malaysia revealed that young people’s knowledge of sexual and reproductive health was significantly poor4,7,8. they were not acquainted with the functions of reproductive organs9, virginity-related questions4, complications of premarital sexual activity (pregnancy, abortion)4, contraception4,9,10, and sexually transmitted diseases4. sex education in malaysia has long been integrated in the school curricular. it was introduced in secondary school in 1989 and then was expanded into primary school in 1994. there is no specific topic devoted to sex education, but the modules are blended into various school subjects. the sex education module, for example, is integrated into islamic and moral, science, and physical health subjects4. sex education is not provided by the malaysian ministry of education alone, but also by other government agencies and non-governmental organizations (ngos), such as the national board for population and family development and the malaysian adolescent health association3. despite the initiative taken by the ministry of education malaysia, the trend of premarital sexual activity is on the rise. a previous local study had found that the module of sex education should be taught to adolescents in accordance to their developmental stages11. the module itself should have information on all aspect of sexuality, from physical changes to sexual behaviour and contraception11. to the best of our knowledge, there is no well-published study on the knowledge level of sexual and reproductive health among youths in the southern region of peninsular malaysia. hence, this study aimed to describe the knowledge of sexual and reproductive health among youths in the state of johor, in southern region of peninsular malaysia. materials and methods: from 1st february 2017 until 28th february 2017, we conducted a cross-sectional study in eleven primary healthcare facilities in the district of muar, johor, a southern state of peninsular malaysia. the reference populations were all youths in muar district, and the source populations were youths who attended the eleven recruited health facilities for any kind of health services. the study samples were all adolescents who fulfilled study inclusion and exclusion criteria. the inclusion criteria were malaysian citizen aged between 18 until 24 years old. adolescents who were illiterate and unable to understand malay language were excluded from the study. the sample size was determined using a single proportion formula12. using the proportion of low knowledge on sexual and reproductive health of 70%4, precision of 7%, 5% type 1 error, 80% power and additional of 10% non-response rate, the total sample size required is 190 youths. we employed proportionate sampling for subject recruitment based on the number of youth daily attendance in each of the eleven health clinics. written consent was obtained from the youths and their parents (for adolescents aged below 18 years old) prior to data collection. the students were assessed through an anonymous validated self-administered questionnaire, but they were guided to answer the questions. the questionnaire consists of socio-demographic information, including personal and family background, and knowledge on sexual and reproductive health (21 items). questions on human reproductive organs, pregnancy, contraceptives, human immunodeficiency virus (hiv), sexually transmitted diseases and abortions are included in srh knowledge sections. there were 21 items; ‘vagina is a place for sexual act’, ‘hymen could be injured by sexual intercourse’, ‘perineal area can be touch by parents/siblings’, ‘seminal fluids contain sperms’, ‘you must sleep separately with other family members of different gender’, ‘girl who has reached menarche could become pregnant if involved with sexual activity’, ‘girl could become pregnant if penis is inserted into the vagina’, ‘pregnancy could happen if there is fertilization of sperm and ovum’, ‘girl could not become pregnant if had sexual intercourse only 317 international journal of human and health sciences vol. 05 no. 03 july’21 once’, ‘girl could not become pregnant if had sexual intercourse with only one man’, ‘premarital sex could cause a girl to become pregnant’, ‘sexually transmitted disease is caused by sexual intercourse’, ‘hiv is transmitted through sexual intercourse’, ‘baby dumping is related to premarital pregnancy’, ‘abortion could cause massive bleeding’, ‘abortion could cause maternal sepsis’, ‘illegal abortion could lead to maternal death’, ‘pregnancy could be prevented by wearing condom’, ‘washing vagina after sexual intercourse could prevent pregnancy effectively’, ‘abstinence is the best way to prevent pregnancy’, and ‘girls could not get pregnant if taken hot water bath after sexual intercourse’. the items were categorized into “true”, “false” or “do not know” response. correct response was given a score of ‘2’, “do not know” as ‘1’, and incorrect response as ‘0’. item analysis in the previous pilot study for the knowledge domain was good: cronbach’s α was more than 0.713. every youth participated in the study voluntarily, after signing an informed consent form in accordance with the declaration of helsinki. the aims of the study were explained to the youths in the presence of their parents (for minor adolescents), and all participants were assured that their anonymity would be protected. ethics approval was obtained from the medical review and ethical committee from national institute of health, ministry of health malaysia [nmrr16-2719-31657]. no monetary incentives were offered. statistical analysis socio-demographic information of the respondents was tabulated for descriptive statistics. all of the items on knowledge were tabulated according to theme for descriptive analysis. they were described in frequency (n) and percentage (%) for each of answer’s category (correct, not sure, and wrong). data entry and statistical analysis were carried out using spss statistics (ibm corp. released 2013. ibm spss statistics for windows, version 22.0. armonk, ny: ibm corp). results: socio-demographic characteristics of the respondents this study employed a total of 204 respondents. the mean (±standard deviation) age of respondents was 21 years old (±1.9). majority of them were female (60.7%) and malay (89.1%). most of the respondents had high level of education (secondary and tertiary levels) (98.5%). the highest percentage of respondents came from households with a monthly income of less than rm2000 (65%), and living with both parents (82.6%). majority of the respondents reported their parents showed good concern (95%) towards them. many of them reported never feel lack of parental attention (81.6%). 97.5% of respondents reported they had good relationship with family, where most of their parents know their friends (96%), and always reminded about prayer (90%). a small percentage of the respondents were smokers (18.6%), alcohol drinkers (7.5%), drug users (3.5%), and a smaller portion reported of having history of sexually molested (4%). this study found sexual exposure among subjects ranged from reading (35.3%) and watching pornographic materials (44%), imagining sex (18.2%), as well as masturbating (21.1%). details regarding socio-demographic characteristics were shown in table 1. table 1. socio-demographic characteristics of respondents (n=204) variables n (%) age (years)* 21.0 (±1.9)* gender female 122 (60.7) male 79 (39.3) race malay 179 (89.2) chinese 10 (4.9) indian 11 (5.4) others 1 (0.5) religion muslim 180 (89.7) buddha 9 (4.4) hindu 11 (5.4) christian 1 (0.5) prayer practice (muslim) (n=181) always 88 (48.6) seldom 91 (50.3) never 2 (1.1) education level primary 3 (1.5) secondary 111 (55.8) tertiary 85 (42.7) academic achievement top 20 78 (41.1) average 106 (55.8) bottom 20 78 (3.1) family construct (living arrangement) both parents 156 (77.5) mother and stepfather 4 (2.0) grandparents 4 (2.0) mother only 10 (5.0) international journal of human and health sciences vol. 05 no. 03 july’21 318 father and stepmother 2 (1.0) alone 8 (4.0) father only 2 (1.0) relatives 4 (2.0) adopted parents 1 (0.5) others 10 (5.0) household income (malaysian ringgit) <500 11 (5.5) 501 – 1000 46 (23.0) 1001 – 2000 73 (36.5) >2000 70 (35.0) parents’ marital status living together 160(80.0) separated 6 (3.0) divorced 9 (4.5) mother passed away 20 (10.0) father passed away 3 (1.5) both passed away 2 (1.0) parental concern good 190 (95.0) lack 10 (5.0) lack of parental attention always 9 (4.5) seldom 27 (13.5) never 164 (82.0) good family relationship yes 196 (97.5) no 5 (2.5) parent knows friend yes 193 (96.0) no 8 (4.0) parent reminded about prayer always 181 (90.0) seldom 17 (8.5) never 3 (1.5) smoking no 162 (81.4) yes 37 (18.6) alcohol drinking no 186 (92.5) yes 15 (7.5) substance abuse no 193 (96.5) yes 7 (3.5) reading pornographic material no 130 (64.7) yes 71 (35.3) watching pornographic material no 112 (56.0) yes 88 (44.0) masturbation no 146 (78.9) yes 39 (21.1) history of sexually molested no 193 (96.0) yes 8 (4.0) * mean (±sd) for assessing the knowledge on sexual and reproductive health, the results were divided into knowledge on reproductive organ; sexual activity and pregnancy; complications of premarital sexual activity; and contraception. knowledge on reproductive organ table 2 shows results on knowledge on reproductive organs. most of the respondents gave correct answers to questions pertaining to reproductive organs and functions. among three of the items on reproductive organs, questions that have the most “not sure” answer was the question on “hymen could be injured by sexual intercourse” with 61 (30.3%) respondents. table 2. knowledge on reproductive organs and its function among youths in johor (n=204) variables correct not sure wrong n (%) n (%) n (%) vagina is a place for sexual act 173 (86.1) 24 (11.9) 4 (2.0) hymen could be injured by sexual intercourse 125 (62.2) 61 (30.3) 15 (7.5) seminal fluids contain sperms 17 (88.6) 15 (7.4) 8 (4.0) knowledge on sexual activity and pregnancy table 3 shows out of 204 respondents, 82.6% of them knew that they must sleep separately with other family members of different gender. majority of the respondents were aware that the perineal area cannot be touched by parents or siblings. on questions related to pregnancy, majority of them (68.7%) know that girls who has reached menarche could become pregnant if involved with sexual activity, and premarital sex could lead to pregnancy (76.6% of respondents). half of them answered correctly on question of “girl could become pregnant if penis is inserted into the vagina”. 88.6% of them knew that pregnancy could happen if there’s fertilization of sperm and ovum. but for questions of “girl could not become pregnant if had sexual intercourse only once”, almost half of the respondents were unsure (49.3%). 33.8% of the respondents were unsure on question pertaining to “girl could not become pregnant if had sexual intercourse with only one man”, while 63.2% answered correctly. 319 international journal of human and health sciences vol. 05 no. 03 july’21 table 3. knowledge on sexual activity and pregnancy among youths in johor (n=204) variables correct not sure wrong n (%) n (%) n (%) perineal area can be touched by parents/siblings 8 (4.0) 34 (16.9) 159 (79.1) you must sleep separately with other family members with different gender 166 (82.6) 14 (7.0) 21 (10.4) girl who has obtain menarche could become pregnant if involved with sexual act 138 (68.7) 37 (18.4) 26 (12.9) girl could become pregnant if penis is inserted into the vagina 111 (55.2) 67 (33.3) 23 (11.5) pregnancy could happen if there’s fertilization of sperm and ovum 178 (88.5) 20 (10.0) 3 (1.5) girl could not become pregnant if had sexual intercourse only once 9 (4.4) 99 (49.3) 93 (46.3) girl could not become pregnant if had sexual intercourse with only one man 6 (3.0) 68 (33.8) 127 (63.2) premarital sex could cause a girl to become pregnant 154 (76.6) 34 (16.9) 13 (6.5) knowledge on complication of premarital sexual activity table 4 shows knowledge on complication of premarital sexual activity. in regards to sexually transmitted diseases, 70.6% answered correctly which they can be caused by sexual intercourse. for hiv, vast majority (90.0%) know that it can be transmitted through sexual intercourse. pertaining to baby dumping phenomenon that is related to premarital pregnancy, 90.5% answered correctly. for the question on abortion, majority -150respondents answered correctly which is abortion could cause massive bleeding. half of the respondents (50.2%) answered correctly on questions relating to abortion and maternal sepsis. for the question on maternal death related to illegal abortion, 121 respondents answered correctly. table 4. knowledge on complication of premarital sexual activity among youths in johor (n=204) variables correct not sure wrong n (%) n (%) n (%) sexually transmitted disease is caused by sexual intercourse 143 (71.1) 55 (26.4) 5 (2.5) hiv is transmitted through sexual intercourse 181 (90.0) 17 (8.5) 3 (1.5) baby dumping is related to premarital pregnancy 182 (90.5) 14 (7.0) 5 (2.5) abortion could cause massive bleeding 150 (74.6) 48 (23.9) 3 (1.5) abortion could cause maternal sepsis 101 (50.2) 93 (46.3) 7 (3.5) illegal abortion could lead to maternal death 121 (60.2) 77 (38.3) 3 (1.5) international journal of human and health sciences vol. 05 no. 03 july’21 320 knowledge on contraception in table 5, which shows knowledge on contraception, majority of respondents (66.7%) answered correctly on the question of condom usage in preventing pregnancy. majority of respondents (87.6%) concurred that abstinence is the best way to prevent pregnancy. surprisingly, many of the respondents (65.7%) were unsure on question of ‘washing vagina after sexual intercourse could prevent pregnancy effectively’, and only 23.4% of respondents answered correctly. most respondents (63.7%) were unsure if taking hot water bath after sexual intercourse could prevent pregnancy. discussion: the mean (±sd) age of respondents in this study is 21 (±1.9) years old, with a higher percentage of female respondents. nearly half of our respondents earned a tertiary level of education, which included preparatory course, college or university level. a study in kathmandu, nepal, found that young people who obtained higher education were more accepting of premarital sexual activity because they lived by themselves and they received less parental supervision14. youth academic achievement was also considered in this research. it is a self-rated statement in which those who recall the results were regarded as having good academic achievement within the top 20. those who ranked themselves as average and below 20 were considered to have poor academic performance. slightly half of our respondents had poor academic achievement in this study. in a study conducted in turkey, it was reported that young people with poor academic performance were more likely to be involved with sexual activity15. majority of our respondents were of malay ethnicity (89.1%) but half of them were not good practicing moslems. a good practicing moslem was defined as one who rated him/herself as consistently prayed while one who seldom or never prayed would be regarded otherwise. parental supervision is crucial in shaping a child’s personality. 90% of respondents stated in this study that their parents often reminded them of daily prayer. every religion has its own code of conduct including the norm for sexual activity, especially in islam. studies also found that those with better insight and faith are better shielded from premarital sexual activity16-18. in this current study, we found that majority of our respondents lived in an intact family structure, where both parents stayed together. only 20% of our respondents had parents that were either divorced or passed away. a study in the united states of america showed that the quality of parenting is important in shaping the attitude of their children. children raised in an intact family are shielded from early exposure to premarital sexual activity19. the relationship between children and family members were explored as well in this current study. 97.5% of the respondents claimed that they have good relationship with their siblings, parents or guardians. majority of respondents reported of table 5. knowledge on contraception among youths in johor (n=204) variables correct not sure wrong n (%) n (%) n (%) pregnancy could be prevented by wearing condom 134 (66.6) 60 (29.9) 7 (3.5) washing vagina after sexual intercourse could prevent pregnancy effectively 22 (10.9) 132 (65.7) 47 (23.4) abstinence is the best way to prevent pregnancy 176 (87.5) 17 (8.5) 8 (4.0) girls could not get pregnant if taking hot water bath after sexual intercourse 7 (3.5) 128 (63.7) 66 (32.8) 321 international journal of human and health sciences vol. 05 no. 03 july’21 having parental concern shown by their parents. over 80% of respondents claimed they have good parental attention. family engagement is an important determinant of the attitude of children towards sexual activity. it has been shown to be a protective factor for children from premarital sexual activity and to be particularly effective among younger youths19. only small group of youths were reported to indulge themselves in smoking, alcohol drinking and substance abuse. this could be due to majority of them is malay and muslim which are bound to cultural and religious restrictions. an iranian study documented a significant association between consuming alcohol and premarital sexual activity as alcohol impaired the reasonable judgement of youth20. in a taiwanese study, at the age of 20, youth who smoked cigarettes and drank alcohol were more likely to be involved in premarital sexual activity. in addition, consideration of premarital sexual activity was often driven by social pressure6. internet and social media play crucial role in shaping youths’ perception towards sexual activity. they serve as media for searching and sharing knowledge. the internet and social media can, however, pollute the minds of these young people without adequate guidance and supervision. previous study has shown that most young people use the internet to browse for sex-related materials (pornography) because these pornographic materials are readily available and accessible21. exposure to these kinds of pornographic materials can make youths addicted and then consider pornography to be acceptable. watching pornography and masturbation are inter-related. masturbation among young people has become a natural act that will become more common as they grow older22. our local research has shown that masturbation is a predictor of young people’s early participation in premarital sexual activity23,24. as for the extent of sexual and reproductive health knowledge, the majority of our respondents had low levels of sexual activity and pregnancy knowledge, premarital sexual activity complications, and contraception. youths were not very educated about virginity in the realm of reproductive organs and their function. this finding is comparable to the results of the 2014 national population and family development board survey, which indicated that our youths had low levels of sexual and reproductive organ knowledge25. similar findings about the lack of knowledge about reproductive organs among youth were also evidenced by research from another countries26-28. in view of the fact that youth are actually at higher risk of engaging in premarital sexual activity, lack of sexual and reproductive health knowledge is considered unacceptable today. participating in premarital sexual activity without adequate knowledge of sexual and reproductive health will expose young people to numerous health and social issues, such as sexually transmitted infections and the possibility of unwanted pregnancy and postpartum complications. in addition, teenage pregnancy among unprepared youth will lead further to illegal abortion and baby dumping7, 29-32. conclusion and recommendations: as youth participation in sexual activity is becoming more common in malaysia, sexual and reproductive health should be prioritized. public health initiatives should be led by research-based evidence. the initiatives need to focus on the positive aspects of healthy sexual relationships. there is a need to recognize and address the value of ensuring easy access to sexual and reproductive health services for all youth. this should include the availability, as well as screening and testing for sexually transmitted infections and a variety of affordable contraceptive options. all of these components should be integrated into the adolescent-friendly health services currently empowered in primary healthcare facilities in malaysia. the provision of adolescent-friendly health services has indeed increased the utilization rate and satisfaction level among adolescents in malaysia33,34. apart from that, sex education needs to be provided with the involvement of families, schools and the wider community, whilst at the same time being attentive to their concerns. we have to acknowledge that sexual and reproductive health is a vital part of the general health and wellbeing of all individuals. as shown by the findings on their level of knowledge in this present study, malaysia youths are currently disempowered. we international journal of human and health sciences vol. 05 no. 03 july’21 322 have to act quickly to ensure the well-being of our youth as our future generation. acknowledgement: the authors would like to thank the director general of health malaysia for allowing us to do data collection at the primary healthcare facilities under the governance of the ministry of health malaysia. conflict of interest: none declared. the authors have no financial, consultative, institutional, and other relationships that might lead to bias or conflict of interest. funding statement: this research received bridging incentive grant from universiti sains malaysia (304/ppsp/6316474). ethical approval issue: this study was approved by the medical review and ethical committee from national institute of health, ministry of health malaysia nmrr-16-2719-31657. individual authors contribution: conception: h.a., s.m.j, a.a.r; writer: h.a., s.m.j.; data collection and/or processing: s.m.j.; supervision: a.a.r.; analysis and/or interpretation: h.a., s.m.j., a.a.r. references: 1. mcintyre p. adolescent friendly health services: an agenda for change. geneva, switzerland: world health organization; 2002. accessed 15 december 2020. https://apps. w h o . i n t / i r i s / b i t s t r e a m / h a n d l e / 1 0 6 6 5 / 6 7 9 2 3 / w h o _ f c h _ c a h _ 0 2 . 1 4 . p d f ; j s e s s i o n i d = d 2 b 3 1 6 9 c 4 f 3 0 4 a 11 7 f 3 6 f d 8 1 8 3 d 0 3 6 3 0 ? sequence=1. 2. ministry of health. engaging the adolescent module using headss framework: family health development division, ministry of health malaysia; 2009. accessed 15 december 2020. http://fh.moh.gov.my/v3/index.php/component/ jdownloads/send/21-sektor-kesihatan-remaja/252engaging-the-adolescents-module-using-headssframework?itemid=0. 3. awang h, ab rahman a, sukeri s, hashim n, nik abdul rashid nr. making health services adolescent-friendly in northeastern peninsular malaysia: a mixed-methods study. international journal of environmental research and public health. 2020;17(4):1341. 4. rahman aa, rahman r, ibrahim mi, salleh h, ismail sb, ali sh, et al. knowledge of sexual and reproductive health among adolescents attending school in kelantan, malaysia. southeast asian journal of tropical medicine and public health. 2011;42(3):717. 5. sridawruang c, crozier k, pfeil m. attitudes of adolescents and parents towards premarital sex in rural thailand: a qualitative exploration. sexual & reproductive healthcare. 2010;1(4):181-7. 6. chiao c, yi c-c. adolescent premarital sex and health outcomes among taiwanese youth: perception of best friends’ sexual behavior and the contextual effect. aids care. 2011;23(9):1083-92. 7. wong lp. an exploration of knowledge, attitudes and behaviours of young multiethnic muslim-majority society in malaysia in relation to reproductive and premarital sexual practices. bmc public health. 2012;12(1):865. 8. low w. malaysian youth sexuality: issues and challenges. journal of health and translational medicine. 2009;12(1):3-14. 9. shu c, fu a, lu j, yin m, chen y, qin t, et al. association between age at first sexual intercourse and knowledge, attitudes and practices regarding reproductive health and unplanned pregnancy: a cross-sectional study. public health. 2016;135:10413. 10. kumar a, tiwari v. knowledge, attitude and behaviour towards pre-marital sex: a study among youths from two city-slums in india. health popul perspect issues. 2003;26(4):126-34. 11. mutalip ssm, mohamed r. sexual education in malaysia: accepted or rejected? iranian journal of public health. 2012;41(7):34. 12. fleiss jl, levin b, paik mc. statistical methods for rates and proportions. 3rd ed. canada: john wiley & sons; 2013. 13. razlina ar, azriani ar, mohd ismail i. validation of questionnaire on premarital sexual activities 323 international journal of human and health sciences vol. 05 no. 03 july’21 among secondary school students. 9th iaah world congress; kuala lumpur, malaysia 2009. 14. adhikari r, tamang j. premarital sexual behavior among male college students of kathmandu, nepal. bmc public health. 2009;9(1):241. 15. aras s, semin s, gunay t, orcin e, ozan s. sexual attitudes and risk‐taking behaviors of high school students in turkey. journal of school health. 2007;77(7):359-66. 16. helm jr hw, mcbride dc, knox d, zusman m. the influence of a conservative religion on premarital sexual behavior of university students. north american journal of psychology. 2009;11(2). 17. jaafar j, wibowo i, afiatin t. the relationship between religiosity, youth culture, and premarital sex among malaysian and indonesian adolescents. asia pacific journal of social work and development. 2006;16(2):5-18. 18. zaleski eh, schiaffino km. religiosity and sexual risk-taking behavior during the transition to college. journal of adolescence. 2000;23(2):223-7. 19. lammers c, ireland m, resnick m, blum r. influences on adolescents’ decision to postpone onset of sexual intercourse: a survival analysis of virginity among youths aged 13 to 18 years. journal of adolescent health. 2000;26(1):42-8. 20. mohammad k, farahani fka, mohammadi mr, alikhani s, zare m, tehrani fr, et al. sexual risk-taking behaviors among boys aged 15–18 years in tehran. journal of adolescent health. 2007;41(4):407-14. 21. brown jd, l’engle kl. x-rated: sexual attitudes and behaviors associated with us early adolescents’ exposure to sexually explicit media. communication research. 2009;36(1):129-51. 22. robbins cl, schick v, reece m, herbenick d, sanders sa, dodge b, et al. prevalence, frequency, and associations of masturbation with partnered sexual behaviors among us adolescents. archives of pediatrics & adolescent medicine. 2011;165(12):1087-93. 23. awaluddin sm, ahmad na, saleh nm, aris t, kasim nm, sapri nam, et al. prevalence of sexual activity in older malaysian adolescents and associated factors. journal of public health aspects. 2015;2(1):1. 24. manaf mra, tahir mm, sidi h, midin m, jaafar nrn, das s, et al. pre-marital sex and its predicting factors among malaysian youths. comprehensive psychiatry. 2014;55:s82-s8. 25. mahmud a, wan jaffar wh, mohammad ah, ishak i, muhammad sapri na, mahpul in, et al. laporan penemuan utama kajian penduduk dan keluarga malaysia kelima (kpkm-5) 2014: national population and family development board, malaysia; 2016. 26. eaton l, flisher aj, aarø le. unsafe sexual behaviour in south african youth. social science & medicine. 2003;56(1):149-65. 27. regmi p, simkhada p, van teijlingen e. “boys remain prestigious, girls become prostitutes”: socio-cultural context of relationships and sex among young people in nepal. global journal of health science. 2010;2(1):60-72. 28. sydsjö g, selling ke, nyström k, oscarsson c, kjellberg s. knowledge of reproduction in teenagers and young adults in sweden. the european journal of contraception & reproductive health care. 2006;11(2):117-25. 29. razali s, kirkman m, ahmad sh, fisher j. infanticide and illegal infant abandonment in malaysia. child abuse & neglect. 2014;38(10):1715-24. 30. glasier a, gülmezoglu am, schmid gp, moreno cg, van look pf. sexual and reproductive health: a matter of life and death. the lancet. 2006;368(9547):1595607. 31. awang h, husain nrn, abdullah h. pediatric tuberculosis in a northeast state of peninsular malaysia: diagnostic classifications and determinants. oman medical journal. 2019;34(2):110-117. 32. awang h, husain nrn, abdullah h. chest radiographic findings and clinical determinants for severe pulmonary tuberculosis among children and adolescents in malaysia. russian open medical journal. 2019;8(2). 33. awang h, ab rahman a, sukeri s, hashim n, nik abdul rashid nr. a reliability study of the malay version of the malaysian ministry of health’s adolescent client satisfaction questionnaire among adolescents attending health clinics in northeastern malaysia. korean journal of family medicine. 2020;41(6):412-415. 34. awang h, ab rahman a, sukeri s, hashim n, nik abdul rashid nr. adolescent-friendly health services in primary healthcare facilities in malaysia and its correlation with adolescent satisfaction level. international journal of adolescence and youth. 2020;25(1):551-561. international journal of human and health sciences vol. 01 no. 02 july’17 70 originalarticle factors associated with intestinal obstructions among adultsinkeysaney hospital, mogadishusomalia moalim am1, fiqi ao2, dalmar aa3, eren t4, ankarali h5, karaman m.i6, alimoglu o7. abstract background: intestinal obstruction (io) is the failure of propagation of intestinal contents, and may be due to a mechanical or functional pathology. objective: the aim of this study was to find out the factors, causes, management, and complications associated with io among adults at keysaneyhospital. materials and methods: a three-year hospital based cross-sectional study was carried out between january 1st, 2014 and december 31st, 2016 with use of the data collected from 180 patients’ medical files including demographics, duration of the disease process, year of admission, hospital stay, causes of io, operative findings, management, outcomes and complications. results: in the study group, 148 (82.2%) patients were men, whereas 32 (17.8%) were women, and among all admitted patients, 88 (48.8%) patients lived in mogadishu. the peak age was between 21-40 years, with a second peak age among elderly patients between 51-70 years. a majority of the patients of 73% presented within more than a week of illness, while 67 (37.2%) patients were discharged within the first week, 47 (26.1%) were discharged within the second week, and 66 (36.6%) stayed in the hospital for more than two weeks. mechanical obstruction accounted for 142 (78.9%) of all cases. mechanical small bowel obstruction (sbo) was the most common type with a rate of 61.1%, followed by mechanical large bowel obstruction (lbo) with a rate of 15.6%, while mechanical sbo/lbo was found in 2.2% as compounds of volvulus. paralytic ileus was found in 9.4% of the cases. the type of obstruction could not be determined in 11.6% of the cases. overall, adhesions and bands (36.7%) were the most common cause of obstruction followed by strangulated hernias (16.7%) and volvulus (12.7%). tuberculosis peritonitis (7.8%) was the most common cause of paralytic ileus. nonoperative management was carried out in 94 (60%) patients while the remaining 64 (40%) cases underwent surgery. common post-operative complications were wound infection (3.3%) and peritonitis (2.8%). other rare post-operative complications included wound dehiscence and organ failure. conclusions: several factors contribute to either the cause, or the management of ios. some of these determinants may include the time since the onset of illness because of late presentation due to lack of health facilities, lack of health awareness, ignorance and poverty. poor clinical judgment and lack of management guidelines are also the negative factors leading to poor prognosis in these patients. keywords: intestinal obstruction; general surgery; complications; health facilities; prognosis correspondence to: orhan alimoglu, md, prof. istanbul medeniyet university, school of medicine, department of general surgery, e-mail: orhanalimoglu@gmail.com international journal of human and health sciences vol. 01 no. 02 july’17. page : 70-78 1. abdijabar mohamud moalim, keysaney hospital, mogadishu, somalia 2. abdurrahman osman fiqi, benadir university, school of medicine, department of general surgery, mogadishu, somalia 3. abdirizak ahmed dalmar, benadiruniversity, school of medicine, department of general surgery, mogadishu, somalia 4. tunceren, istanbul medeniyet university, school of medicine, department of general surgery, istanbul, turkey 5. handanankarali, istanbul medeniyetuniversity, school of medicine, department of biostatistics, istanbul, turkey 6. muhammet ihsan karaman, istanbul medeniyet university, school of medicine, department of urology, istanbul, turkey 7. orhan alimoglu, istanbul medeniyet university, school of medicine, department of general surgery, istanbul, turkey introduction intestinal obstruction (io) is a common medical problem and accounts for a large percentage of surgical admissions for acute abdominal pain.1 globally, io is the failure of propagation of intestinal contents, and may be due to a mechanical or functional pathology. acute mechanical io is one of the leading causes of surgical admissions 71 international journal of human and health sciences vol. 01 no. 02 july’17 in most emergency departments worldwide2 and is a significant cause of morbidity and mortality, especially when associated with bowel gangrene or perforation.3,4 the incidence of io varies in different countries where it is rare in the usa and western europe while it is the most common cause of acute abdomen in certain parts of latin america, asiaindia, iran and afghanistan. io been the leading cause of acute abdomen in subsaharan countries but still acute appendicitis is the most frequent cause of acute abdomen even in the developed world. there are several causes of io and their relative incidence varies in different populations, between countries and has also changed over the last decades. several factors are described to be responsible for these differences. socioeconomic factors and diet have mostly been incriminated to be responsible for the observed difference.5-7 in africa, the leading causes of io have mostly been hernia and volvulus whereas adhesions are the most frequent reason for io in the developed world. there are, however, some african studies which are pointing to the change in these established patterns.8-10the few studies that have evaluated the epidemiology of abdominal surgical emergencies in this area of the world found io to be the most common cause for acute surgical interventions. in the developed world, however, it has held true for some time that appendicitis is the major cause of abdominal surgical emergencies. some of these studies suggest socioeconomic factors and cultural diet accounting for the differences of causation for abdominal surgical emergencies (ase) between developed and less developed countries in the past. though evidences are showing pattern change in africa, little is known about the change in the causative pattern.8,11 according to the few reports available in northern and central ethiopia, sigmoid volvulus was the leading cause of io. in southern ethiopia, small intestinal volvulus (siv) was the most frequent cause of io as of the 235 patients with acute io, 98 (41.7%) had siv. on the other hand, sigmoid volvulus wasthe second most common cause of io with a rate of 13.2%.1,12 in somalia, little is known about the general pattern and the relative incidence of io. two reports from yirgalem and hosanna, southern ethiopia, showed that small intestinal volvulus (siv) was the most frequent cause of io.7,8,13 according to the few reports, the annual mortality rate per 100,000 people from io in somalia has increased by 2.8% since 1990, which accounts to an increase of an average of 0.1% per year. the three most deadly digestive diseases in somalia during 2013 were peptic ulcer disease, paralytic ileus and io, followed by other digestive diseases, respectively. keysaneyhospital is the main referral and teaching hospital in northern mogadishu. it receives emergencies from mogadishu and its surroundings as well as referrals from other health institutions all over the country. therefore, some patients are finally seen and examined at the hospital several days after the onset of io.the trends and patterns of io have been shown to vary over time, and because of this fact, it was worthwhile to undertake this study. the aim of this study was to find out the factors, causes, management strategies, complications and outcomes associated with io among adults in keysaneyhospital, mogadishu-somalia by using the data that was collected during the last three years. in addition, the secondary aims of this study were to assess the management of io and to explore the complications, morbidity and mortality among patients. materials and methods research design the study was carried out at keysaneyhospital. it was a hospital-based retrospective cross-sectional quantitative study covering the three-years-period between january1st, 2014 and december 31st, 2016. files were retrieved from the records department and necessary data was obtained and statistically analyzed. source population all adult patients diagnosed with io that whether got operated or not at keysaneyhospital during the reference period between january 1st, 2014 and december 31st, 2016. study population adult patients with io who fulfilled our inclusion criteria at keysaney hospital within the study period. inclusion criteria all adult patients (>13 yrs) recorded as having io during the period of the study. exclusion criteria case files with incomplete, inadequate or missed information. study variables & their indicators the complications after management of io such as wound infection, peritonitis, wound dehiscence and organ failure were taken as dependent variables. age, sex, residence, time since illness international journal of human and health sciences vol. 01 no. 02 july’17 72 or duration of illness before arrival, annual distribution,management of io as operative or non-operative, and main causes of io including mechanical small bowel obstruction (sbo), mechanical large bowel obstruction (lbo), mechanical sbo/lbo, and paralytic ileus were chosen as independent variables. study limitations io was not a direct diagnosis in some cases, and therefore, a number of files may have been missed. several other files had incomplete information while others could not be traced at the records department. there is possibility of omission or error during filling performa questionnaire. ethical considerations ethical approval to carry out the study was obtained from benadir university, research ethical review committee. additionally, permission was obtained from the ethical and research committee of keysaney hospital. confidentiality of the information obtained has been maintained. operational definitions management outcome: the condition of the patient after the procedure, whether he/she was discharged alive or died in the hospital. initial management: the initial management of patients with io with adequate iv access for resuscitation, placement of ngt or initiation of antibiotics. operative management: surgical exploration of the abdomen which was determined by the nature of the obstruction. surgical site infections(ssi): infection following surgical incisions. fascial dehiscence: fascial disruption due to abdominal wall tension overcoming tissue or suture strength, or knot security. postoperative pneumonia: suspected in patients with clinical findings of infection including fever, cough or purulent sputum in the post-operative period. procedure: main procedure done as laparotomy to relieve the obstruction. length of hospital stay: time from admission to discharge or death of the patient classified as prolonged if it is more than eight days. anastomosis: surgical procedure to reconnect section to section of intestine following the removal of diseased tissue. fistula: breakdown along anastomosis which causes fluid to leakage. datamanagementandstatisticalanalysis information was collected from the main files of the patients in the record room as per age, sex, residence, time since illness, duration of hospital stay, year of admission, main cause of illness or preoperative diagnosis, operative findings, management instituted, complications and outcomes. data was collected by the researcher via structured data collecting performa developed for this purpose. datawasenteredandanalyzedin the spss (version 20) program.according to type of variable, the meanandstandarddeviation or count and percent frequencieswerecalculated. the relationships between variables were determined by using the suitable chi-squared test (pearson’s chi-squared test or fisher’s exact test). if p value of the test statistics was less than 0.05, it was accepted as statistically significant. results the age ranged was between 13 to 94 years. majority of the patients were in the two age groups which were between 21-30 years and 51-60 years accounting for 35.5%, followed by 31-40 years age group accounting for 15%, while the least number of patients were in the group between 6170 years (11.1%). there were 148 (82.2%) male patients and 32 (17.8%) female patients giving a male to female ratio of approximately 4:1. the majority of cases accounting for 88 (48.8%) patients came from mogadishu while 47 (26.1%) came from regions outside mogadishu. the residence of the remaining 45 (25.0%) patients could not be determined. when the annual distribution was investigated, there was minimal trend of decrease of cases through the study period revealing 63 cases (35%) in 2014, 59 cases (32.8%) in 2015, and 58 cases (32.2%) in 2016, respectively. the duration of symptoms before being admitted to the hospital was shown as below. these were divided into intervals of three days for simplicity. majority of the patients had symptoms for 7-9 days (36%), and for >9 days (37%), followed by those seen in the first three days of illness. the duration of symptoms was not documented in 45 (25%) patients. 67 (37.2%) patients were discharged within the first week, and 47 (26.1%) were discharged within the second week, while 66 (36.6%) stayed in the hospital for more than two weeks. overall, mechanical sbo accounted for 61.1% while mechanical lbo accounted for 15.6%. 73 international journal of human and health sciences vol. 01 no. 02 july’17 other types of obstructions had lower rates as shown in the table 1 below except undetermined cases. table 1. the distribution of the various types of intestinal obstructions type of intestinal obstruction n % mechanical 142 78.9 sbo 110 61.1 lbo 28 15.6 sbo/lbo 4 2.2 paralytic ileus 17 9.4 undetermined 21 11.6 mechanical obstruction was recorded in 142 (78.9%) cases, paralytic ileus in 17(9.4%), while in 21 (11.6%) patients the obstruction type was not determined (table 2). overall, adhesions and bands (n=66, 36.7%) were the most common cause of obstruction followed by strangulated hernias (n=30, 16.7%) and volvulus (total=12.7%, large gut volvulus= 8.3%, and small gut volvulus=4.4%). tuberculosis (tb) peritonitis (7.8%) was the main cause of paralytic ileus (table 2). table 2. causes of intestinal obstructions type of intestinal obstruction n % mechanical sbo adhesions and bands 66 36.7 strangulated/ obstructed hernia 30 16.7 volvulus 8 4.4 worms (ascaris) 1 0.6 intussusception 3 1.7 mechanical lbo tumours 2 1.1 volvulus 15 8.3 fecal impaction 5 2.8 neoplasms 4 2.2 inflammatory strictures 3 1.7 intussusception 1 0.6 mechanical sbo/lbo compound volvulus 4 2.2 paralytic ileus tuberculosis peritonitis 14 7.8 ischemia 3 1.7 undetermined 21 11.6 total 180 100.0 overall, non-operative management was carried out in 94 (60%) patients while the remaining 64 (40%) underwent surgery. of the 64 patients managed operatively, 9.4% had hernioraphy with or without resection and anastomosis, 7.8% had adhesiolysis and band release while 6.7% underwent segmental bowel resection. post-operative complications were encountered in 16 (8.9%) patients, while the remaining 164 (91.1%) were free of complications. association between types of io, hospital stay and patient age were found statistically significant (p=0.001, p=0.001, and p=0.001, respectively). in addition, the relation between residence and time since illness was found statistically significant (p=0.001, table 3). table 3. the relation between residence and time since illness time since illness residence 0-3 days 4-6 days 7-9 days >9 days undetermined mogadishu 33 29 26 0 0 outside mogadishu 0 0 10 37 0 undetermined 0 0 0 0 45 in addition, the association between types of io and hospital stay were significant (p=0.001). volvulus, lbo, fecal impaction, neoplasms, inflammatory strictures, intussusception, compound volvulus, tb peritonitis, and mesenteric ischemia were found more frequent in cases with hospital stay durations of 15 days or longer. other types of ios such as adhesions and bands, strangulated or obstructed hernia, volvulus, worms (ascaris), intussusception and tumors were more frequent in patients with hospital stay durations of 14 days or shorter. the relationships between hospital stay and gender was found significant as well (p=0.001). according to the results, it was observed that, all female patients stayedin the hospital for more than 21 days. on the other hand, most of the male patients generally stayed in the hospital for less than 21 days. discussion io continues to be a frequent emergency, which surgeons have to face (1-4% of emergency operations). a total of 180 cases were included in this study for the three-years-period between january 2014 and december 2016. the study aimed to determine the factors associated with io among adults during the study period. residence of the patients the study showed that the majority of 88 (48.8%) patients were from mogadishu, while 47 (26.1%) international journal of human and health sciences vol. 01 no. 02 july’17 74 patients that represented a large proportion of the remaining cases were from regions outside mogadishu. this issue brings about the fact that most of these cases couldn’t be handled outside mogadishu at district and provincial levels, while the remaining 45 (25.0%) were undetermined. in the study, it appears that residence of the patients is also much related with time since illness as those come from outside mogadishu present late, already complicated, which in turn affects the type of nonoperative or operative management, post-operative complications, hospital stay and mortality rates. demographic factors in the present study, 148 (82.2%) cases were males while 32 (17.8%) were females showing a male predominance with a male to female ratio of approximately 4:1. this compares to a study done in cmh rawalpindi where the male to female ratio was found to be 5:1.14 gender also affects hospital stay, causes, complications and mortality. over half of the patients were aged between 2140 years. there was a second peak age among elderly patients between 51-70 years. this finding was consistent with a study over a period of ten years at wesley guild hospital, in nigeria.15 the peak age group was in the third decade accounting for 17.8%. this age group comprises the most productive work force of any country. additionally, age affects hospital stay, complications, causes and mortality as well. most of these patients had previous laparotomies for different pathologies ranging from appendicitis to trauma with subsequent development of adhesions and bands. this age group is vulnerable to abdominal trauma through violence, stab wounds, bullet injuries, sports and even road traffic accidents, especially in the male population which explains the male preponderance. also the incidence of strangulated hernias in the general population is more common in this age group, especially in the male gender.16 inflammatory diseases like pelvic inflammatory disease in females and appendicitis which are also common in this age group lead to increased number of laparotomies and therefore increased chances of adhesion formations.17 a prospective, observational, cross sectional study, conducted at bahri (northern khartoum) teaching hospital (knth), khartoum, sudan, showed that 42 out of 54 patients (77.8%) were males while 12 patients (22.2%) were females.18 the age range was from 10 to 80 years and above. the highest rates found among patients were in the fourth, fifth and sixth decades. in fact, 78% of the patients were above 40 years. the maximum number of patients were in the sixth decade (n=23, 25%). the male:female ratio was about 2:1, and this ratio was relatively constant for the entire age groups.18 in a study conducted in uganda, 144 patients were admitted with acute bowel obstruction. twelve cases were excluded from the study due to incomplete records and the results were based on the remaining 132 patients. there were 91 males and 41 females, giving a male:female ratio of 2.2:1. the ages of patients ranged from one week to 80 years with a mean of 31.5 years. the duration of symptoms ranged from one to 14 days with a mean of four days. only 35 patients presented within 24 hours after the onset of symptoms.19 causes of intestinal obstruction in this study, mechanical obstruction accounted for 142 (78.9%) of all cases. mechanical sbo was the most common type with a rate of 61.1%, followed by mechanical lbo with a rate of 15.6%, while mechanical sbo/lbo was found in 2.2% as compound volvulus. paralytic ileus was found in 9.4% of the cases. the type of obstruction could not be determined in 11.6% of the cases due to missing information in the patients’ files. mechanical sbo occurrence is more frequent since the main causes of mechanical obstruction (adhesive obstruction and hernia strangulation) mainly occur at the level of small bowel. the pattern of io in keysaney hospital may be compared to that in the western world as seen in our study. many studies recently done in this region showed an obvious change in the pattern of io. the common causes were postoperative adhesions and abdominal tb instead of obstructed inguinal hernias.10 similarly a number of recent studies have found adhesive obstruction to be replacing obstructive hernias as the most common cause in contrast to earlier studies where strangulated hernias were found to be the most common cause in the developing countries with a rate of 39.0%.12 adhesions were third in those patients with a rate of 17.1%. the main cause of io at keysaney hospital was due to adhesions and bands (36.7%), mainly associated with previous laparotomies. intra75 international journal of human and health sciences vol. 01 no. 02 july’17 abdominal adhesions following surgery occur after 50-100% of all surgical interventions in the abdomen. factors that limit adhesion formation in abdominal surgery include good surgical technique, minimization of contact with gauze, covering of the sites of anastomoses and peritoneal surfaces as well as irrigation of the peritoneal cavity with saline to remove clots.20 a small group of adhesions may occur due to peritoneal infections or inflammatory conditions for those laparotomy has not been done previously. finally, this pattern may differ from other developing countries where the most common cause of io was obstructed inguinal hernia followed by adhesions.21 somalia is a developing country that health delivery in urban tends to be nearly nonexistent. as hernias are not electively repaired, obstructive hernias are common, but still, adhesive obstruction is the leading cause of io. the second most frequent cause of mechanical small bowel obstruction according to this study was strangulated external hernias (16.7%). a hernia strangulates due to a narrow neck, and therefore, becomes a surgical emergency since the viability of the gut is threatened and any delay of treatment would only increase the risk of gangrene formation and related complications.22 the third frequent cause of io was sigmoid volvulus (8.3%), which was the main cause of large bowel mechanical obstruction. this pattern is comparable to a study by liaqat et al, but contrasts with other studies which state that volvulus was the most common causes of io followed by adhesions and small bowel volvulus.23 sigmoid volvulus is a common problem in africans where predisposing factors include high residue diet and chronic constipation, as well as bands of adhesions. the other causes of mechanical colonic obstruction were fecal impaction (2.8%), and neoplasms (2.2%). overall, adhesions and bands (36.7%) were the most common cause of mechanical ios followed by strangulated hernias (16.7%), colonic volvulus (8.3%), tb peritonitis (7.8%), ileal volvulus (4.4%), fecal impaction (2.8%), and large gut neoplasms (2.2%). with a rate of 7.8%, tb peritonitis was the main cause of paralytic ileus, while ileus due to ischemia from mesenteric thrombosis occurred in 1.7%, overall. therefore, tb appears to be an important cause of functional io resulting from ileus due to peritonitis, especially with the increasing incidence of tb cases the epidemiology of which varies considerably from region to region.24 adhesions are the cause in 80% of instances. they are usually from previous abdominal surgeries as well as the use of abdominal mopping gauze swabs or towels, but may also arise from previous intra-abdominal sepsis. they produce kinking of the bowel or obstruction from pressure of a band or volvulus. intestinal adhesions are the most common cause of mechanical small bowel obstructions in the western world due to the greater number of operations performed.3 intestinal adhesions to other vascular structures occur as the injured peritoneal cavity needs to gain some extra blood supply during the healing process. thus, minimizing the disruption of the peritoneal cavity may be achieved by minimally-invasive surgery. according to a study from eastern india on 3717 patients admitted for acute abdomen, 376 (9.87%) patients were diagnosed with io and the common causes were strangulated hernia (36%), malignancies (17%), adhesions (16%), intestinal tb (14%), volvulus (6%) and intussusceptions (2%).25 the results of a one-year-retrospective review on acute bowel obstruction in northern uganda also showed a male to female ratio of 2.2:1. the duration of symptoms ranged from one to 14 days with a mean of four days. the most common causes of obstruction were hernias, adhesions, volvulus and intussusceptions. of the 23 patients with volvulus, 17 involved the sigmoid colon, but other presentations of volvulus were also seen as ileosigmoid knotting, caecal volvulus, volvulus neonatorum, and small bowel volvulus.19 in a retrospective study of the pattern of adult io at tenwek hospital, in southwestern kenya between 2009 and 2013, 445 cases were evaluated and the major cause of io accounted for a rate of 78.5% for all cases as sv was 25.6%, adhesive bowel disease was 23.1%, sbv was 21.3%, ileo-sigmoid knotting was 8.5%, obstructing large bowel tumors was 2.5%, and incarcerated hernias was 1.1% among all causes.23 time since illness (presentation time) majority of the patients (73%), presented within more than a week of the onset of illness, as this is usually the case in keysaney hospital, which has great impact on the management, complications international journal of human and health sciences vol. 01 no. 02 july’17 76 and outcome. time since illness has significant effects on the complications, management and outcomes of the patients. management of intestinal obstruction the mode of treatment was determined by the underlying condition. overall, surgery was performed in 40% of all patients, the type of which depended on cause and intra-operative findings. the rest of the patients that accounted for 60%, were managed conservatively. of all the patients managed operatively, 9.4% had hernioraphy, 7.8% had adhesionolysis and band release, 6.7% had detortion, 4.4% had gut exteriorization, 4.4% had resection and anastomosis. thus, prophylactic use of antibiotics is recommended since the risk of contamination and sepsis is quite high in such patients. management has effects on complications and mortality because if the patients’ management isn’t adequate he or she may have complications and may die as a consequence. in a study from western kenya, a total of 361 patients underwent laparotomy. bowel gangrene was noted in 112 (31%) cases. sigmoid volvulus, small bowel volvulus and ileo-sigmoid knotting accounted for 84% of all cases of bowel gangrene. the main operative procedures performed included resection and anastomosis (n=170, 47.1%), detortion and decompression (n=73, 20.2%), and adhesiolysis. at discharge, a total of 49 (13.6%) morbidities were noted in patients who underwent laparotomy, including surgical site infections (n=16, 4.4%), enterocutaneous fistula (4,1%), wound dehiscence (n=3, 0.8%), and intra-abdominal abscess formation (n=2, 0.5%). nineteen deaths were noted during the admission period, leading to a postoperative mortality rate of 5.3%. patients with gangrenous bowel at laparotomy had a higher morbidity rate (22.3%), and a higher mortality rate (9.8% vs. 3.2%, p=0.02) and longer duration of hospital stay of 7.6-9 days.23 in a study in libya, among 108 patients who were diagnosed with io, 45 were treated surgically and 4 (8.8%) patients were subjected to laparotomy due to the post-operative adhesion with evidence of strangulation as no operative adhesive intestinal obstruction was found in 3 (6.6%) of them. they had undergone laparotomy soon after resuscitation, because the cause of obstruction was not clear. in the hernia group 15 (33.3) were treated surgically and three of them had bowel resection. fourteen (31.1%) cases of large bowel tumors were treated surgically with resection and primary anastomosis, 4 case of sigmoid volvulus (8.8) underwent laparotomy, 3 (6.6%) cases of crohn’s disease were treated surgically by right hemicolectomy, one (2.2%) case of gallstone ileus underwent laparotomy and enterotomy and one (2.2%) foreign body (intestinal bezoars) underwent laparotomy and enterotomy.26 post-operative complications in the present study, the common post-operative complications were wound infection (3.3%), and peritonitis (2.8%). rare post-operative complications included wound dehiscence and organ failure. complications were affected by time since illness, residence, sex, age, cause, management. in a study of 877 patients who underwent 1,007 operations for io, which was published in 2000, it was reported that age, comorbidity, nonviable strangulation, and a treatment delay of more than 24 hours were significantly associated with an increased death rate. the rate of nonviable strangulation increased markedly with patient age. major factors increasing the complication rate were old age, comorbidity, a treatment delay of more than 24 hours, and the need for repeat surgery.27 according another study published in 2017, among the total of 210 patients with features of acute io who underwent surgery, 43 cases (20.47%) developed complications. wound infection (10.47%) was the most common followed by respiratory infection (7.14%), enterocutaneous fistula (2.86%) and burst abdomen (4.29%). majority of the cases who developed wound infection (86.4%), respiratory infection (100%), burst abdomen (100%) and enterocutaneous fistula (83.3%) were above 40 years of age. males were more commonly having wound infection (77.3%), burst abdomen (60%) and respiratory infections (93.3%) when compared to females. enterocutaneous fistula was seen in males and females in equal proportion. the mortality rate was 8.09%. the main causes of mortality were colon carcinoma (23.5%), acute mesenteric ischaemia (17.6%), sigmoid volvulus (17.6%) and compound volvulus (17.6%). the causes having high mortality rates were acute mesenteric ischaemia and ileosigmoid knotting (75% in each pathology). the main cause of 77 international journal of human and health sciences vol. 01 no. 02 july’17 mortality in the majority of cases (52.3%) was septicaemia which leaded to multiorgan failure. most of the deaths (88.2%) occurred in the first postoperative week.28 hospital stay a majority of 67 (37.2%) patients were discharged within the first week, and 47 (26.1%) were discharged within the second week, while 66 patients (36.6%) stayed in the hospital for longer than two weeks. hospital stay was affected by age, gender, time since illness, type of disease or cause, and management. recommendatios proper history taking and physical examination with documentation should be emphasized as this would reduce the study limitations encountered during this study. careful evaluation of patients is important so as to avoid unnecessary laparotomies which would effectively reduce the number of laparotomies in the general population and therefore lower occurrence rate of adhesive ios. public awareness of the need for elective repair of hernias would reduce the occurrence of hernial obstruction in the general population. it is necessary to build and improve health facilities capable of handling patients with io within the reach of the community to promptly treat patients. international journal of human and health sciences vol. 01 no. 02 july’17 78 references 1. helton w, fisichella p. intestinal obstruction. in: souba w, ed. acs surgery principals and practice (6th ed). new york, ny: webmd; 2007. 2. arshad mm, madiha s, rafique p, krishan si. pattern of acute intestinal obstruction: is there a change in the underlying etiology? saudi j gastroenterol. 2010;16(4):272-274. 3. eren t, boluk s, bayraktar b, ozemir ia, yildirimboluk s, tombalak e, alimoglu o. surgical indicators for the operative treatment of acute mechanical intestinal obstruction due to adhesions. ann surg treat res. 2015;88(6):325-333. 4. ellis h. 1997. the clinical significance of adhesions: focus on intestinal obstruction. eur j surg suppl.1997;577:5-9. 5. demissie m. small intestinal volvulus in southern ethiopia. east afr med j. 2001;78(4):208-211. 6. tegegne a. small intestinal volvulus in adults of gonder region, northwestern ethiopia. ethiop med j. 1992;30(2):111-117. 7. kotiso b, abdurahman z. pattern of acute abdomen in adult patients in tikuranbessa teaching hospital, addis ababa, ethiopia. east and central african journal of surgery. 2007;12(1):47-52. 8. tsegaye s, osman m, bekele a. surgically treated acute abdomen at gondar university hospital, ethiopia. east and central african journal of surgery. 2007;12(1):53-57. 9. osuigwe an, anyanwu snc. acute intestinal obstruction in nnewi nigeria: a five-year review. nigerian journal of surgical research. 2002;4(3):107-111. 10. lawal oo, olayinka os, bankole jo. spectrum of causes of intestinal obstruction in adult nigerian patients. s afr j surg. 2005;43:34-36. 11. asefa z. pattern of acute abdomen in yirgalem hospital, southern ethiopia. ethiop med j. 2000;38(4):227-235. 12. ntakiyiruta g, mukarugwiro b. the pattern of intestinal obstruction at kibogola hospital, a rural hospital in rwanda. east and central african journal of surgery, 2009;14(2):103-108. 13. okello tr, ogwang dm, kisa p, komagum p. sigmoid volvulus and ileosigmoid knotting at st. mary’s hospital lacor in gulu, uganda. east cent afr j surg. 2009;14:58-64. 14. irfan m, hussain sf, mapara k, memon s, mogri m, bana m, malik a, khan s, khan na. community acquired pneumonia: risk factors associated with mortality in a tertiary care hospitalized patients. j pak med assoc. 2009;59(7):448-452. 15. adesunkanmi ar, agbakwuru ea. changing pattern of acute intestinal obstruction in a tropical african population. east african medical journal. 1996;73(11):727-731. 16. rai s, chandra ss, smile sr. a study of the risk of strangulation and obstruction in groin hernias. aust n z j surg. 1998;68(9):650-654. 17. stewart b, khanduri p, mccord c, ohene-yeboah m, uranues s, vega rivera f, mock c. global disease burden of conditions requiring emergency surgery. br j surg. 2014;101(1):e9-22. 18. terayo aa, hamza aa, el-kheir is, ibrahim om, abdel-wahab m, fatehella n. intestinal obstruction in the first year of age: pattern and outcome of management. sas j surg. 2015;1(4):165-171. 19. okeny pk, hwang tg, ogwang dm. acute bowel obstruction in a rural hospital in northern uganda. east and central african journal of surgery. 2011;16(1):65-70 20. brüggmann d, tchartchian g, wallwiener m, münstedt k, tinneberg hr, hackethal a. intraabdominal adhesions: definition, origin, significance in surgical practice, and treatment options. dtscharztebl int. 2010;107(44):769-775. 21. khan js, alam j, hassan h, iqbal m. pattern of intestinal obstruction: a hospital based study. pak armed forces med j 2007;57(4):295-299. 22. kingsnorth a, leblanc k. hernias: inguinal and incisional. lancet. 2003;362:1561-1571. 23. ooko pb, sirera b, saruni s, topazian hm, white r. pattern of adult intestinal obstruction at tenwek hospital, in south-western kenya. pan afr med j. 2015;20:31. 24. essig km, kienast k, ferlinz r.ileus caused by tuberculosis.pneumologie. 1997;51(8):828-831. 25. adhikari s, hossein mz, das a, mitra n, ray u. etiology and outcome of acute intestinal obstruction: a review of 367 patients in eastern india. saudi j gastroenterol. 2010;16(4):285-287. 26. fm mikael, m patro, o issa, ma bakr, hi fadeel. intestinal obstruction at el thowra teaching hospital, el beida, libya. east and central african journal of surgery. 2012;17(2):77. 27. fevang bt, fevang j, stangeland l, søreide o, svanes k, viste a.complications and death after surgical treatment of small bowel obstruction: a 35-year institutional experience. ann surg. 2000;231(4):529537. 28. mohamed a, sahoo n, das sk, das bb, pradhan sk, gouda pk. profile of operated acute intestinal obstruction patients at a tertiary health care institution. j evolution med dent sci. 2017;6(15):1215-1219. international journal of human and health sciences vol. 07 no. 02 april’23 162 original article bacterial isolateprofile in gram-negative urinary isolates: role ofnitrofurantoin meghna sharma1, sapna soneja2, loveena oberoi3, anuradha malhotra2, kamaldeep singh4, babica mahindroo4 abstract background: in current times epidemic drug resistance has renewed interest in drugs belonging to the yesteryears, most importantly nitrofurantoin for urinary tract infections. studies have reported that more than 90% of urinary tract infections are due to enteric gram-negative organisms, of which more than 80% are e.coli.objectives: to study bacterial profile in gram-negative urinary isolates and evaluate the role of nitrofurantoin. methods:we retrospectively evaluated 500 consecutive gram-negative bacterial isolates for bacteriological profile and nitrofurantoin sensitivity of patients of urinary tract infections at a tertiary care facility in indiabetween january and june of 2022. results:we had a total of 500 gramnegative urinary isolates. 383 (76.6%) of these were found to be susceptible to nitrofurantoin. e. coli alone constituted 343 (68.6%) of total 500 gramnegative isolates, 264 (76.96%) of which were sensitive to nitrofurantoin. 20 (4%) proteus and 05 (1%) citrobacter species were isolated and found to be resistant to nitrofurantoin. 12 (80%) out of the 15 acinetobacter isolates were resistant to nitrofurantoin. all 12 (100 %) pseudomonas isolates tested resistant to nitrofurantoin. conclusion:e. coli is the most common of uropathogens and despite rise in antibiotic resistance, it continues to be sensitive to nitrofurantoin. resistance to nitrofurantoin is also being reported and this calls for judicious further use of this drug based on culture reports and local prevalence data. keywords: nitrofurantoin, urinary tract infection, uropathogens, e. coli, drug resistance correspondence to: dr.sapna soneja, associate professor, department of microbiology, government medical college, amritsar, india. email: drsapnabatra@gmail.com 1. resident, department of microbiology, government medical college, amritsar, india. 2. associate professor, department of microbiology, government medical college, amritsar, india. 3. professor, department of microbiology, government medical college, amritsar, india. 4. assistant professor, department of microbiology, government medical college, amritsar, india. introduction in current times drug resistance has reached epidemic proportions and has thrown a new challenge before the medical and scientific fraternity.1 the menace of drug resistance has even rendered the reserve drugs ineffective.2presently, clinicians are struggling with urinary pathogens resistant to most of the oral drugs available like sulfonamides, flouro quinolones, cephalosporins and even the newer drugs like faropenem.3times have seen an increased incidence of extended spectrum beta lactamase (esbl) producing bacteria.4studies have reported that more than 90% of urinary tract infections are due to enteric gram-negative organisms, of which more than 80% are e.coli.5 in this age of multi drug resistance, there is a renewed interest in drugs belonging to the yesteryears, most importantly nitrofurantoin for lower urinary tract infections.6 nitrofurantoin hits bacteria at multiple levels blocking bacterial enzymes involved in carbohydrate and protein synthesis, and subsequently at higher concentrations inhibits rna and dna formation by its action on bacterial ribosomes.7 nitrofurantoin gets activated by the bacterial international journal of human and health sciences vol. 07 no. 02 april’23 doi: http://dx.doi.org/10.31344/ijhhs.v7i2.568 163 international journal of human and health sciences vol. 07 no. 02 april’23 reductases to form highly reactive electrophilic intermediates that damage bacterial ribosomal proteins.8 nitrofurantoin has an oral bioavailability of 50% and is excreted primarily through the kidneys. this results in a high concentration in the urinary pathways though the plasma levels may be much lower.9a landmark study in uppsala university sweden,2014,had demonstrated 100% efficacy of nitrofurantoin in terminating esbl and non esbl e. coli. same study also demonstrated 99% efficacy in killing of vancomycin resistant and non-vancomycin resistant enterococci.10 nitrofurantoin has thus emerged as a costeffective oral alternative in current era of antibiotic resistance.the susceptibility of uropathogens is known to vary in different geographical regions and even in same geographical region.11most urinary tract infections are being treated empirically. in this retrospective study we aim to observe the prevalence of nitrofurantoin resistance in the gram-negative uropathogen isolates.the aim of the present study was to observe bacterial profile in gram-negative urinary isolates and evaluate the role of nitrofurantoin against those isolates. methods in this study, we retrospectively evaluated 500 consecutive gram-negative bacterial isolatesfor bacteriological profile and nitrofurantoin sensitivity of patients of urinary tract infections at our tertiary care facility in amritsar, india,betweenjanuaryandjuneof 2022. antimicrobial susceptibility was performed using kirby-bauer disk diffusion method on mueller hinton agarand finding interpreted with clsi m100-s-31. normally distributed continuous variables were recorded as mean and categorical variables were expressed as percentage. results we had a total of 500 gram negative urinary isolates.383(76.6%) of these were found to be susceptible to nitrofurantoin. e. coli alone constituted343(68.6%) of total 500gram negative isolates, 264(76.96%) of which were sensitive to nitrofurantoin. 20 (4%) proteus and 05(1%) citrobacter species were isolated andfound to be resistant to nitrofurantoin. 12 (80%)out of the 15acinetobacter isolates were resistant to nitrofurantoin. all 12 (100%)pseudomonasisolates tested resistant to nitrofurantoin. table 1:sensitivity to nitrofurantoin of gramnegative uropathgens staining sensitive to nitrofurantoin resistant to nitrofurantoin total gram negative 383 117 500 percentage 76.6% 23.4% 100 table 2:gram negative isolate profile gram negative isolate frequency percentage e. coli 343 68.6% klebsiella sp. 105 21% proteus 20 4% citrobacter 5 1% acinetobacter 15 3% pseudomonas 12 2.4% total 500 100% discussion urinary tract infections are one of the commonest infective pathologies affecting communities at large and are commoner in females because of anatomical reasons. irrational antibiotic use has contributed to the emergence of multi drug resistant uropathogens, forcing clinicians to go back to old generation of drugs like nitrofurantoin. shaifali et al. in their study on antibiotic susceptibility pattern of urinary pathogens found nitrofurantoin to be most effective drug against e.coli was the commonest uropathogen.12 our table 3: isolate sensitivity pattern to nitrofurantoin isolate e. coli klebsiella proteus citrobacter acinetobacter pseudomonas sensitive 264 (76.96%) 77 (73.33%) 3 (20%) resistant 79 (23.04) 28 (26.66%) 20 (100%) 5 (100%) 12 (80%) 12 (100%) total 343 105 20 5 15 12 international journal of human and health sciences vol. 07 no. 02 april’23 164 study has shown similar patterns. kothari et al. too observed e. coli to be the commonest pathogen causing urinary infections and nitrofurantoin to be the most effective drug against it. they also highlighted poor activity of nitrofurantoin against proteus sp.our study revealedthat proteus isolateswasresistant to nitrofurantoin, whilethey found 24.4% of e.coli isolates to be resistant to nitrofurantoin, that is marginally higher than the 23.04% observed in our study.13kulkarni and associates studied the susceptibility pattern of e. coli to various antibiotics and founde.coli to be the commonest of uropathogens. they also showed 92.41% sensitivity of e.coli to nitrofurantoin.14 singh and fellows studied the resistance pattern of uropathogens to nitrofurantoin and found alarming levels of resistance amongst enterobacteriaceae. they found highest level of resistance (92.30%) to nitrofurantoin in klebsiella sp. that is much higher than the 26.6% observed our study. they found nitrofurantoin to be effective against 69.9% of e. coli isolates.15 sood et al. studied antibiotic resistance in various uropthogens and found e.coli to account for 61.84% isolates. they found nitrofurantoin resistance in only 5-6% e.coli isolates.16 biswas et al. studied choice of antibiotics for empirical therapy of acute cystitis and found 9.3% resistance of e. coli to nitrofurantoin against 23.04% e.coli resistance observed in our study. they also found that more than 80% isolates resistant to fluoroquinolones are sensitive to nitrofurantoin.17 tanweer et al. studied urinary infections in renal transplant patients and found e.coli in 51% isolates.they reported 76% of the organisms to be sensitive to antibiotics, 7% isolates were multi drug resistant while remaining were partially sensitive. they also found pseudomonas to be the commonest multi drug resistant organism in post-transplant urinary infections. in our study we have 2.4%pseudomonas isolates, all of which are resistant to nitrofurantoin.18 conclusion to conclude, e. coli is the most common of uropathogens and despite the recent rise in antibiotic resistance, it continues to be sensitive to nitrofurantoin. resistance to nitrofurantoin is also being reported and this calls for judicious use of this drug based on culture reports and local prevalence data. conflict of interest: none to declare. funding statement: none. ethical approval: the studywas approved by the reb of government medical college, amritsar, india. authors’ contribution:meghna sharma was involved in conception and design of the study.all authors were equally involved in data collection, analysis, manuscript preparation, revision and finalization. 165 international journal of human and health sciences vol. 07 no. 02 april’23 references 1. gautam g, gogoi s, saxena s,et al. nitrofurantoin susceptibility pattern in gram-negative urinary isolates: in need of increased vigilance. j lab physicians. 2021;13(3):252-6. 2. amladi au, abirami b, devi sm, et al. susceptibility profile, resistancemechanisms&efficacy ratios of fosfomycin, nitrofurantoin&colistin for carbapenemresistantenterobacteriaceae causing urinary tract infections. indian j med res. 2019;149(2):185-91. 3. kahlmeter g. eco.sens. an international survey of the antimicrobialsusceptibility of pathogens from uncomplicated urinary tract infections: the eco.sens project. j antimicrobchemother. 2003;51(1):69-76. 4. garau j. other antimicrobials of interest in the era of extended-spectrum beta-lactamases: fosfomycin, nitrofurantoin and tigecycline. clin microbiol infect. 2008;14(suppl. 1):198-202. 5. ali s, mandal s, georgalas a, et al.a pattern of antibiotic resistance in gram-negative rods causing urinary tract infection in adults. cureus.2021;13(1):e12977. 6. shakti l, veeraraghavan b. advantage and limitations of nitrofurantoin in multi-drug resistant indian scenario.indian j med microbiol. 2015;33:477-81. 7. guay dr. an update on the role of nitrofurans in the management of urinary tract infections. drugs. 2001;61:353-64. 8. mcosker cc, fitzpatrick pm. nitrofurantoin: mechanism of action and implications for resistance development in common uropathogens. j antimicrobchemother. 1994;33(suppla):23-30. 9. european committee on antimicrobial susceptibility testing. nitrofurantoin: rationale for the clinical breakpoints, version 1.0; 2010. available from: http://www.cast.org/antimicrobial_susceptibility_ testing/breakpoints/. [accessed february 11, 2022]. 10. komp lindgren p, klockars o, malmberg c, et al. pharmacodynamic studies of nitrofurantoin against commonuropathogens. j antimicrobchemother.2015;70:1076-82. 11. singhal a, sharma r, jain m, vyas l. hospital and community isolates of uropathogens and their antibiotic sensitivity pattern from a tertiary care hospital in north west india. ann med health sci res. 2014;4(1):51-6. 12. shaifali i, gupta u, mahmood se, et al. antibiotic susceptibility patterns of urinary pathogens in female outpatients. north am j med sci.2012;4:163-9. 13. kothari a, sagar v. antibiotic resistance in pathogens causingcommunity-acquired urinary tract infections in india: amulticenter study. j infect dev countries.2008;2:354-8. 14. kulkarni sr, peerapur bv, sailesh ks. isolation and antibiotic susceptibility pattern of escherichia coli from urinary tract infections in a tertiary care hospital of north eastern karnataka. j nat sc biol med.2017;8:176-80. 15. singh p, malik s, lal v. resistance pattern of nitrofurantoin of uropathogens in different age groups at dr. lal path labs, national reference laboratory, rohini, delhi. asian j medhealth. 2019;16(1):1-8. 16. sood s, gupta r. antibiotic resistance pattern of community acquired uropathogens at a tertiary care hospital in jaipur, rajasthan. indian j community med.2012;37:39-44. 17. biswas d, gupta p, prasad r, sinha v, et al. choice of antibiotic for empirical therapy of acute cystitis in setting of high antimicrobial resistance. indian j med sci.2006;60:53-8. 18. iqbal t, naqvi r, akhter sf. frequency of urinary tract infection in renal transplant recipients and effect on graft function. j pak med assoc.2010;60:826-9. http://www.cast.org/antimicrobial_susceptibility_testing/breakpoints/. %5baccessed http://www.cast.org/antimicrobial_susceptibility_testing/breakpoints/. %5baccessed 235 international journal of human and health sciences vol. 04 no. 04 october’20 editorial fatal mistake: dentistry the next epicenter of sars-cov-2 spread taseef farook1, nafij bin jamayet1, mohammad khursheed alam2 correspondence to: dr. mohammad khursheed alam address: associate professor, preventive dentistry department, college of dentistry, jouf university, sakaka, saudi arabia. e-mail: dralam@gmail.comtel: +966535602339 1. school of dental sciences, universiti sains malaysia, kota bharu, kelantan, malaysia. 2. associate professor, preventive dentistry department, college of dentistry, jouf university, sakaka, ksa. international journal of human and health sciences vol. 04 no. 04 october’20 page : 235-236 doi: http://dx.doi.org/10.31344/ijhhs.v4i4.207 fatal mistake: dentistry the next epicenter of sars-cov-2 spread travel ban and lockdowns may not be enough to prevent viral transmission as the who declares sars-cov-2 (corona virus) a pandemic.1 however efficient in preventing spread, it is imperative to re-evaluate the role of dentistry, which the new york times determined to be at the highest risk levels of viral contamination2. this segment is more aimed to focus on dental care in developing countries, particularly those of southeast asia. while iaadr3, bmj4, nature5, lancet6 and various other reputable dental organizations have rolled out screening guidelines on education and best patient practice, it is almost impossible now to ‘screen’ someone of positive history at the dental office, and nearly impossible to control the spread of the aerosol droplets generated while operating the dental motors in the patient’s mouth.7 the pandemic spread, ignorance and untruthfulness from the patient and negligence of practitioners in acknowledging that the patient may have been exposed irrespective of negative history can contribute to greater spreads. this in combination with the recent asymptomatic carrier development of the disease make newcases even harder to detect.8,9 in developing countries especially near rural areas, there are ‘overprofessional’ dental care givers and quacks (practitioners with no formal dental education but illegally administer dental care) who are treating patients even at this moment. furthermore, many such rural settings have their residents travel abroad on contract-based labour who may have returned unscreened long before the world went into a panic frenzy over covid-19 and started surveillance and lock down. while such countries are demonstrating zealous acts of preventing massive gatherings such as islamic prayers and religious congregations, they are also allowing such practices to run rampant. in countries where poor medical infrastructure and negligent isolation result in deaths of patients suspected of coronavirus infections (but were actually suffering from other medical emergencies), such a careless leniency from authorizing bodies may enable dentistry to become the next epicenter of the infectious disease spread. the government and relevant organizations should take sterner actions in seeing dental practices temporarily close with only hospitals administering emergency dental care until the spread is in containment to prevent an unmanageable full-scale catastrophe. international journal of human and health sciences vol. 04 no. 04 october’20 236 references: 1. who director-general’s opening remarks at the media briefing on covid-19 11 march 2020. https://www.who.int/dg/speeches/detail/whodirector-general-s-opening-remarks-at-the-mediabriefing-on-covid-19---11-march-2020. 2. the new york times. the workers who face the greatest coronavirus risk the new york times. https://www.nytimes.com/interactive/2020/03/15/ business/economy/coronavirus-worker-risk.html. 3. meng, l., hua, f. & bian, z. coronavirus disease 2019 (covid-19): emerging and future challenges for dental and oral medicine. j. dent. res. 0022034520914246 (2020). 4. bmj. coronavirus disease 2019 (covid-19) symptoms, diagnosis and treatment | bmj best practice. https://bestpractice.bmj.com/topics/engb/3000168. 5. peng, x. et al. transmission routes of 2019-ncov and controls in dental practice. int. j. oral sci.12, 1–6 (2020). 6. li, l., xv, q. & yan, j. covid-19: the need for continuous medical education and training. lancet respir. med. (2020) doi:https://doi.org/10.1016/ s2213-2600(20)30125-9. 7. van doremalen, n. et al. aerosol and surface stability of hcov-19 (sars-cov-2) compared to sarscov-1. n. engl. j. med. (2020) doi:doi: 10.1056/ nejmc2004973. 8. bai, y. et al. presumed asymptomatic carrier transmission of covid-19. jama (2020). 9. al-tawfiq, j. a. asymptomatic coronavirus infection: mers-cov and sars-cov-2 (covid-19). travel med. infect. dis. 101608 (2020). 69 international journal of human and health sciences vol. 05 no. 01 january’21 original article: in-hospital outcomes of acute inferior myocardial infarction associated with complete heart block: a coronary care unit experience ahmed imran kabir1, mohammad ashraful alam2, mohammed mirazur rahman1, manzurul ibrahim musa1 abstract background: complete heart block (chb) is a common complication in patients of acute inferior myocardial infarction (mi). their in-hospital outcomes depend on the time of onset of the sequelae,pattern of newer area of infarction and concomitant complications. objective: to see in-hospital outcomes of the patients with acute inferior myocardial infarction complicated by complete heart block. methods: this prospective observational study was conducted in the coronary care unit (ccu) under department of cardiology, sher-e-bangla medical college hospital, barisal, bangladesh, between november 2014 and may 2015.a total of 100 patients (77 males and 23 females) were selected based on specific inclusion and exclusion criteria by using convenient sampling technique. all studyparticipants were evaluated by detailed history, clinical examination and relevant investigations.response to different treatment modalities and their complications were recorded. recovery of chb was also monitored. results: mean age of the patients was 57.16±10.24 years.early presentation (within 24 hours) of chb had only 4.17% mortality. however, mortality increased in patients as chb developed after 24 hours (26%). overall, 10% mortality was evident despite advanced cardiac support.complications reported in optimum medical treatment included hypotension (17 patients), bleeding (1 patient) and arrythmia (1 patient). 11% of the patients received temporary pacemaker by femoral vein approach.however, only 1 patient had hematoma, 1 had a-v fistula and 1developed vesovagal shock during puncture of the femoral vein. duration of hospital stay was more forthe patients who were refractory to conservative medical treatment and received temporary pacemaker; however, the difference was not statistically significant (5.06±0.71vs.8.07±1.01; p>0.05).conclusion:complete heart block associated with acute inferior mi is very much responsive to optimum medical treatment and an early presentation of complete heart blockallows an early intervention, better prognosis and recovery. keywords: myocardial infarction, complete heart block, temporary pacemaker, inhospital outcomes. correspondence to: dr. ahmed imran kabir, resident, department of respiratory medicine, bangabandhu sheikh mujib medical university (bsmmu), dhaka-1000, bangladesh. e-mail: ahmedkabir4559@gmail.com 1. resident, department of respiratory medicine, bangabandhu sheikh mujib medical university (bsmmu), dhaka-1000, bangladesh. 2. assistant professor, department of cardiology, national institute of cardiovascular diseases (nicvd), dhaka-1207, bangladesh. international journal of human and health sciences vol. 05 no. 01 january’21 page : 69-73 doi: http://dx.doi.org/10.31344/ijhhs.v5i1.236 introduction: complete heart block (chb) is a common complication in patients hospitalized with acute inferior myocardial infarction (mi)1 and tends to develop in 3-13% of such patients2.even with optimum medical management, sometimes adverse prognosisisobservedin those patients in terms of higher in-hospital stay or mortality, and complications like hypotension, left ventricular failure (lvf), cardiogenic shock, recurrent angina and cardiac arrest2,3.the pathophysiology behind is either ischemia/infarction involving the conduction system of the heart or autonomic imbalance, which gives rise to those series of consequences4. hence, complete heart block complicating acute inferior myocardial infarction international journal of human and health sciences vol. 05 no. 01 january’21 70 is a focus of researchworldwide due to higher incidence of related complications and mortality. evidence suggests that south asian population including bangladesh has one of the highest rates of coronary artery disease (cad) in the world5. besides,with recent advancement in cardiac care, most of the patients of acute inferior mi with complete heart block are generally viewed as having a more favorableprognosis than anterior wall infarctions6, if they areintervened early and treated conservatively with atropine and isoprenaline/isoproterenol and only few need temporary pacemaker2,3,4,6. however,to our knowledge, no such studies have been carried out in recent years despite advancement of cardiac treatment facilities in our country in this regard. the outcomes of chb in acute inferior mi with conservative medical treatment and temporary pacemaker in hospitalized patient demands a comparison to produce evidence. therefore, the present study was designed to observe the management procedures and their outcomesin patients of acute inferior myocardial infarction complicated bycomplete heart block in a coronary care unit (ccu) of a tertiary level health facility in bangladesh. this study results will act as evidence in coronary care and management in a developing country setting. methods: this prospective observational study was conducted in the coronary care unit under department of cardiology, sher-e-bangla medical college hospital, barisal, bangladesh, between november 2014 and may 2015. the study population was all the patients of acute inferior myocardial infarction admitted into the hospital during thatstudy period, who had associated complete heart block or developed complete heart block after admission. however, convenient sampling technique was adopted. finally, a total of 100 patients (77 males and 23 females)were selected based on inclusion and exclusion criteria. inclusion criteria: 1. patients diagnosed as complete heart block in association with acute inferior myocardial infarction (according to the third universal definition of myocardial infarction)7; 2. patients of acute inferior myocardial infarction who developed complete heart blockafter hospital admission. exclusion criteria: 1.patients with first and second degree heart block not progressing tocomplete heart block; 2. patients with previous conduction blocks; 3. patients with cardiomyopathy; 4. patients with congenital or rheumatic heart disease; 5. patients with history of medication which may cause conduction blocks e.g. clonidine, methyldopa, verapamil, digoxin, etc. data collection was done after taking written informed consent.initial evaluation of all patients done by history taking and clinical examination was recorded in the preformed data collection sheet. demographic profile, pulse, blood pressure, body weight, height and ecg report at emergency room were recorded.baseline investigations like ecg and echocardiography, hematological (e.g. complete blood count), and biochemical (e.g. blood glucose, lipid profile, ck(mb), serum troponin-i, serum creatinine, serum electrolytes) tests were also done. ecg was done on daily basis and continuously observed. initially, patients were intended to be managed by the optimum medical treatment. however, based on clinical evaluation and ecg findings, some patients were intervened by placing temporary pacemaker. the management protocol, response to different treatment modalities and recovery of chb, either transient or persistentas well as the complications observed – all were recorded in a pre-designed proforma during hospital stay. data were recorded and entered in an excel sheet and analyzed using spss (statistical package for social science) version 16.0. the results were presented in tables. qualitative or categorical variables were described as frequencies and proportions. proportions were compared using chi-square (χ2) test. p value wasdetermined at a 2-sided probability with a significance threshold of <0.05. results: in the present study, most of the patients were between 50-70 years; mean age was 57.16±10.24 years (table1). among 100 patients, 79 patients were managed with optimum medical treatmentincluding atropine and isoprenaline, while 11 patients received temporary pacemaker by femoral vein approach (table 2). early presentation (within 24 hours) of chb had only 4.17% mortality. however, mortality increased in patients as chb developed after 24 hours (26%). overall, 10% mortality was observed even with advanced cardiac facility (table2). complications reported in optimum medical treatment category included hypotension (17 patients), bleeding 71 international journal of human and health sciences vol. 05 no. 01 january’21 (1 patient) and arrythmia (1 patient) (table 3). in contrast, among the patients who received temporary pacemaker, only 1% had hematoma and 1% developed vesovagal shock during puncture of the femoral vein (table4). the duration of hospital stay was more for the patients who were refractory to conservative medical treatment and received temporary pacemaker; however, the difference was not statistically significant (5.06±0.71 vs. 8.07±1.01; p>0.05) (table 5). table 1:distribution of the patient by age group with sex (n=100) age group (in years) male frequency (%) female frequency (%) 31-40 5 (6.49%) 0 41-50 14 (18.18%) 4 (17.39%) 51-60 27 (35.07%) 10 (43.48%) 61-70 21 (27.27%) 8 (34.78%) 71-80 8 (10.39%) 1 (4.35%) >80 2 (2.60%) 0 total 77 23 mean±sd 57.16±10.24 years range 38-84 years table 2: outcome with time of onset of complete heart block (n=100) outcome patients who had chb within 24 hours of onset of symptoms n=72 patients who hadchb after 24 hours n=28diagnosed on admission n=31 presented after admission n=41 recovery with medical management 28 (90%) 36 (87.8%) 15 (53%) recovery with temporary pacemaker 2 (6.5%) 3 (7.3%) 6 (21%) death 1 (3.5%) 2 (4.87%) 7 (26%) table 3:pattern of complications in patients who received optimum medical treatment (n=79) complication frequency (%) hypotension 17 (21.5%) bleeding 1 (1.26%) hypersensitivity reaction 0 arrythmia 1 (1.26%) table 4:pattern of complications in patients who received temporary pacemaker (n=11) complication frequency (%) hematoma 1 (9.09%) a-v fistula 1 (9.09%) fatal arrhythmia 0 vasovagal shock 1 (9.09%) infection 0 table 5:mean duration of hospital stay (n=100) mean duration of hospital stay (in days) p value patients received optimum medical treatment (n=79) patients received temporary pacemaker (n=11) 5.06±0.71 8.07±1.01 p>0.05ns ns = not significant; p value reached by chisquare test. discussion: in the present study, most of the patients were between 50-70 years; mean age was 57.16±10.24years. similarly, the previous studies done by abidov et al.8, newby et al.9 showed increasing age had increasing possibility of complete heart block.although majorityof the patients in this study were male(77%), it showed no significant difference in clinical outcome. this is also supported by the study done by ali, asghar & rehman10. in the present study, patients who developed chb within 24 hours of onset of symptoms had early response to optimum medical treatment including atropine and isoprenaline. our data are supported bythat of mcneill et al.11, as they reported recovery of chb within first one hour of thrombolysis in 52% patients and bates et al.12that showed chb to last a mean of 2.5 hours and under 12 hours in 75% of patients after effective thrombolysis. chb was associated with an approximately 2-fold increase in in-hospital mortality in patients with acute inferior mi, in comparison to patients without chb2. overall, our study showed 10% mortality despite advanced cardiac support. this is quite similarto the short-term mortality as reported in other studies–ali, asghar & rehman10(9.52%), christiansen, haghfelt& amtorp13(19%), and nicodet al.1(24%). however, gregory& grance14 (33%), paulk& hurst15 (41%) and kostuk& beanlands16 (45%)reported higher mortality, while gould et al.17 (6%) and bates et al.12(6.4%) observed a lower incidence in their studies.all those studies were done in the era of specialized coronary care unit (ccu). in our study,complications reported in optimum medical treatment category included hypotension (21.5%), bleeding (1.26%) and arrythmia (1.26%). this has similarity with mcneill et al.13 as they reported hypotension; however,no hemorrhagic complications occurred in their patients. besides, 11% of our patients received temporary pacemaker by femoral vein approach. however, only 9.09% patient had hematoma, 9.09% had international journal of human and health sciences vol. 05 no. 01 january’21 72 a-v fistula and 9.09% developed vesovagal shock during puncture of the femoral vein,but no lethal arrhythmia was observed. however, melgarejo morenoet al.18observed that 11.8% patient developed femoral hematoma and 3.6% patients had fatal arrhythmia. our results have similarities with mcneill et al.13 and melgarejo moreno et al.18. in our study,the duration of hospital stay was comparatively more in those patients who received temporary pacemaker than those who received thrombolytic therapy. however, the differencewas not statistically significant. similar report was found in the study done by harikrishnan et al.2, as reported longer length of stay in the hospital in pacemaker group (5.50±0.14 vs.6.59±0.04)2. limitations of the study: as the sample size was small and the study subjects were selected purposively, it is difficult to generalize the findings to the reference population. it was a single-center study done in the southern part of the country. variations of outcomes might be observed in other parts of the country, as cardiac care facilities are variable. moreover, it was an observational non-randomized study and might be subjected to selection bias. therefore, we recommend further studies in the same population with lager samples and longer duration, in multiple sites with randomized sampling and ensuring availability of better emergency treatment facility and high technical back-up. conclusion our study revealed that complete heart block associated with acute inferior myocardial infarction is very much responsive to optimum medical treatment and an early presentation of complete heart block allows an early intervention, better prognosis and recovery. conflict of interest:none declared. ethical approval issue:the study was approved by the institutional ethical committee of sher-ebangla medical college, barisal, bangladesh. funding statement: no funding. authors’ contribution: concept and design: aik, maa; data collection and compilation: aik, maa, mmr, mim; data analysis: aik; manuscript writing, revision and finalizing: aik, maa, mmr, mim. 73 international journal of human and health sciences vol. 05 no. 01 january’21 references: 1. nicod p, gilpin e, dittrich h, polikar r, henning h, ross j jr.long-term outcome in patients with inferior myocardial infarction and complete atrioventricular block.j am coll cardiol. 1988;12(3):589-94. 2. harikrishnan p, gupta t, palaniswamy c, kolte d, khera s, mujib m, et al. complete heart block complicating st-segment elevation myocardial infarction: temporal trends and association with in-hospital outcomes. jacc: clin electrophysiol. 2015;1(6):529-538. 3. aplin m, engstrøm t, vejlstrup ng, clemmensen p, torp-pedersen c, køber l; trace study group. prognostic importance of complete atrioventricular block complicating acute myocardial infarction. am j cardiol. 2003;92(7):853-6. 4. antman em, morrow da. st segment elevation myocardial infarction: management. in:bonow ro, mann dl, zipes dp, libby p. eds. braunwald’s heart disease: a textbook of cardiovascular medicine. 9th ed. philadelphia: elseviersaunders; 2012:1111–70. 5. zaman mj, patel kc. south asians and coronary heart disease: always bad news? br j gen pract. 2011;61(582):9‐11. 6. berger pb, ryan tj. inferior myocardial infarction: high-risk subgroups. circulation. 1990;81(2):401-11. 7. thygesen k, alpert js, jaffe as, simoons ml, chaitman br, white hd, et al. third universal definition of myocardial infarction. eur heart j. 2012;33(20):2551-67. 8. abidov a, kaluski e, hod h, leor j, vered z, gottlieb s, et al. influence of conduction disturbances on clinical outcome in patients with acute myocardial infarction receiving thrombolysis (results from the argami-2 study). am j cardiol. 2004;93(1):76-80. 9. newby kh, pisanó e, krucoff mw, green c, natale a. incidence and clinical relevance of the occurrence of bundle-branch block in patients treated with thrombolytic therapy. circulation. 1996;94(10):2424‐8. 10. ali l, asghar n, rehman a. in hospital outcome of acuteinferior with right ventricular orposterior wall myocardialinfarction.ann pak inst med sci. 2013;9(4):219-24. 11. mcneill aj, roberts mjd, purvis ja, mcclements bm, campbell nps, khan mm, et al. thrombolytic therapy administered to patients with complete heart block complicating acute myocardial infarction. coronary artery dis. 1992;3(3):223-30. 12. bates er, califf rm, stack rs, aronson l, george bs, candela rj, et al. thrombolysis and angioplasty in myocardial infarction (tami-1) trial: influence of infarct location on arterial patency, left ventricular function and mortality. j am coll cardiol. 1989;13(1):12-8. 13. christiansen i, haghfelt t, amtorp o. complete heart block in acute myocardial infarction: drug therapy. am heart j. 1973;85(2):162-6. 14. gregory jj, grance wj. the management of sinus bradycardia, nodal rhythm and heart block for the prevention of cardiac arrest in acute myocardial infarction. prog cardiovasc dis. 1968;10(6):505‐17. 15. paulk ea jr, hurst jw. complete heart block in acute myocardial infarction: a clinical evaluation of the intracardiac bipolar catheter pacemaker. am j cardiol. 1966;17(5):695-706. 16. kostuk wj, beanlands ds. complete heart block associated with acute myocardial infarction. am j cardiol. 1970;26(4):380‐384. 17. gould l, reddy cv, kim sg, oh kc. his bundle electrogram in patients with acute myocardial infarction. pacing clin electrophysiol. 1979;2(4):42834. 18. melgarejo moreno a, galcerá tomás j, garcía alberola a, gil sánchez j, martínez hernández j, rodríguez fernández s, et al. [prognostic significance of the implantation of a temporary pacemaker in patients with acute myocardial infarction]. [article in spanish]. [abstract]. rev espcardiol. 2001;54(8):949-57. 115 international journal of human and health sciences vol. 05 no. 01 january’21 case report: hypocalcaemia in a patient with chronic liver disease: a case report navin kumar devaraj1, fadzilah mohamad1, aneesa abdul rashid1, abdul hadi abdul manap1, nurin amalina sallahuddin2 abstract: acute hypocalcaemia is an uncommon presentation in clinical practice. however, severe acute hypocalcaemia may require immediate resuscitative measures. thus, the case presented is aimed to highlight the importance of thorough assessment and prompt management in replacing the calcium. this case looks at a 34-year-old woman with underlying chronic liver disease (primary biliary cirrhosis) and hypoalbuminemia presented with symptom of perioral and peripheral paraesthesia for three days and was then infused with slow intravenous calcium gluconate. in avoiding recurrence, she was prescribed daily oral supplementation of calcium carbonate. keywords: hypocalcaemia, chronic liver disease, case study, management. correspondence to: dr. navin kumar devaraj, family medicine specialist & medical lecturer, department of family medicine, faculty of medicine & health sciences, universiti putra malaysia, selangor, malaysia. e-mail: knavin@upm.edu.my 1. family medicine specialist and medical lecturer, department of family medicine, faculty of medicine & health sciences, universiti putra malaysia, selangor, malaysia. 2. house officer and research assistant, faculty of medicine & health sciences, universiti putra malaysia, selangor, malaysia international journal of human and health sciences vol. 05 no. 01 january’21 page : 115-117 doi: http://dx.doi.org/10.31344/ijhhs.v5i1.245 introduction hypocalcaemia is an uncommon finding in routine electrocardiogram (ecg). there are many causes including hypomagnesaemia, hypalbuminaemia, vitamin d deficiency, medication or surgical side effects, hypophosphatemia, or pth deficiency among others1. hypocalcaemia is a common biochemical abnormality that may present as a spectrum from asymptomatic laboratory findings to acute life-threatening crisis. the clinical manifestations of hypocalcaemiadepend on the level of ionized calcium2. most common symptoms of hypocalcaemia are neuromuscular manifestations that include muscle spasms, cramps, tetany, paraesthesia and circumoral numbness3. patients may also present with cardiac features such as electrocardiographic (ecg) changes and cardiac impairment2. the normal concentration of serum calcium ranges between 8.9-10.1 mg/dl, whereby the normal range of ionized calcium is 4.65 to 5.25 mg/dl4. calcium concentration level below this is considered as hypocalcaemia. interestingly, chronic hypocalcaemia can occur and may produce dermatologic manifestations such as coarse hair, brittle nails, xerosis and cataracts1. this case will look at a young woman with chronic liver disease with a history of acute hypocalcaemia with classical ecg changes. she was treated with intravenous calcium gluconate and responded well with it. case summary a 34-year-old woman with underlying chronic liver disease (primary biliary cirrhosis) and hypoalbuminemia presented to the emergency department, andcomplained of numbness and tingling sensations in the perioral area and peripheries for three days. this was associated with muscular ache, over the back and lower legs. this was her first presentation with these symptoms. there was an absence of other neurological symptoms. on theexamination, her blood pressure was 130/80 mmhg, pulse rate 86 beats per minute, temperature 37oc and oxygen saturation 98%. her physical examination was unremarkable with no presence of chvostek or trousseau’s sign. laboratory tests were sent; of most significant was the lowered serum albumin level of 3.5 g/dl and serum calcium level 7.5 mg/dl. the corrected international journal of human and health sciences vol. 05 no. 01 january’21 116 calcium level was 7.9 mg/ dl which is below the reference range of 8.9-10.1 mg/ dl. an electrocardiogram (ecg) was done to consolidate the diagnosis of hypocalcaemia. ecg (figure 1) showed the classical changes of qt interval prolongation. as a result, a diagnosis of acute hypocalcaemia was made and patient was treated with slow intravenous infusion of calcium gluconate over 1 hour. ecg repeated an hour later showed sinus rhythm (figure 2). meanwhile serum calcium repeated two hours later showed a normal reading of 9.1 mg/dl. to avoid recurrence of this problem, patient was prescribed oral supplementation of calcium carbonate 500mg daily. she was seenagain in two weeks which once again showed a normal ecg and serum calcium level of 9.3 mg/ dl. she was advised to come back urgently ifshe experienced any symptoms of hypocalcaemia. figure 1: iinitial ecg with qt prolongation figure 2:repeated ecg with sinus rhythm discussion& conclusion hypocalcaemia can occur in patients with chronic liver disease due to vitamin d dependent metabolism. in both parenchymal and cholestatic liver disease, the intestinal fat malabsorption may cause vitamin d deficiency which may result to hypocalcaemia5. the clinical manifestations of hypocalcaemia are vast and cover across many domains. presentation of paraesthesias especially around the peri-oral region and the peripheries indicates neuromuscular irritability secondary to hypocalcaemia. patients can even present with a state of confusion or irritability suggesting neurological or mental effect due to hypocalcaemia. dermatologic clinical features of hypocalcaemia are dry coarse skin and brittle nails. it can also present as dysphagia and abdominal pain due to the smooth muscle involvement5. the classical ecg changes in hypocalcaemia is qt interval prolongation secondary to prolongation of st segment6. qt interval prolongation is directly related to the severity of hypocalcaemia7. as the qt interval can be longer or shorter depending on the heart rate (i.e. longer qt interval in slower heart rate and vice versa), bazett’s formula (qt interval divided by the square root of the r-r interval) is used to calculate the corrected qt interval (qtc)7. the normal duration of qt interval is 350 440ms and a qtc duration of more than 500 milliseconds is associated with increased risk of developing lifethreatening cardiac dysrhythmias8,9. other ecg abnormalities reported include t wave changes, arrhythmias and other changes mimicking acute myocardial infarction8. diagnosis of hypocalcaemia will require measurement of both serum calcium and albumin. in order to correct for hypoalbuminemia, 0.8 mg/ dl is added to the total serum calcium for each 1.0 g/dl decrease in albumin level below 4.0 g/dl1. it is important to distinguish whether the presentation is acute or chronic as the management will depend on the severity and chronicity of the presentation. in an acute hypocalcaemia case, prompt and rapid correction is needed as it predisposes to life-threatening cardiac arrhythmia10. a more aggressive treatment will be needed if severe hypocalcaemia results in tetany, refractory hypotension, seizures or arrhythmias. calcium gluconate is the preferred replacement compared to calcium chloride as the latter often causes local irritation5. the aim of the treatment is to raise the serum ionized calcium concentration 117 international journal of human and health sciences vol. 05 no. 01 january’21 and control of the symptoms. the calcium gluconate should not be given rapidly as it may cause cardiac dysfunction11. one to two ampules of calcium gluconate (90 to 180mg of elemental calcium) diluted in 50ml of 5% dextrose or normal saline should be infused intravenously over 10 to 20 minutes and may be repeated until the symptoms resolve5,11. in conclusion, acute hypocalcaemia is an uncommon presentation in clinical practice. this case report is aimed to highlight the importance of thorough assessment and prompt management in replacing the calcium. acknowledgement the author would like to thank the patient for her kind permission in the publishing of this case report. there was no ethical approval sought other than getting consent from the patient. conflict of interest no conflict of interest has been disclosed by the authors. funds this study did not receive any funding. individual authors contribution conception and design: nkd, aar. critical revision of the article for important intellectual content: fm, nkd, aham, aar, nas. final approval of the article: fm, nkd, aar, aham, nas. references: 1. suneja m, muster ah. hypocalcemia clinical presentation: history, physical examination, 2019. accessed 04.01.2020 https://emedicine. medscape.com/article/241893-clinical 2. carroll r, matfin g. endocrine and metabolic emergencies: hypocalcaemia. ther adv endocrinol metab. 2010;1(1):29–33. 3. fong j, khan a. hypocalcemia. can fam physician. 2012;58(2):158–62. 4. etiology of hypocalcemia in adults uptodate. accessed 18.01.2020 https://www.uptodate. com/contents/etiology-of-hypocalcemia-inadults?search=hypocalcaemia&source=se arch_result&selectedtitle=1~150&usage_ type=default&display_rank=1 5. schafer al, shoback dm. hypocalcemia: diagnosis and treatment. in: feingold kr, anawalt b, boyce a, chrousos g, dungan k, grossman a, et al., editors. endotext [internet]. south dartmouth (ma): mdtext. com, inc.; 2016.http://www.ncbi.nlm.nih.gov/ books/nbk279022/ 6. cooper ms, gittoes njl. diagnosis and management of hypocalcaemia. bmj. 2008;336(7656):1298–302. 7. cox nk. the qt interval: how long is too long? nurs made incred easy. 2011;9(2):17. 8. johnson jn, ackerman mj. qtc: how long is too long? br j sports med. 2009;43(9):657– 62. 9. gardner jd, calkins jb, garrison ge. ecg diagnosis: the effect of ionized serum calcium levels on electrocardiogram. perm j. 2014;18(1):e119–20. \ 10. cecchi e, grossi f, rossi m, giglioli c, de feo ml. severe hypocalcemia and lifethreatening ventricular arrhytmias: case report and proposal of a diagnostic and therapeutic algorithm. clin cases miner bone metab. 2015;12(3):265–8. 11. treatment of hypocalcemia uptodate. accessed 18.01.2020 https://www. uptodate.com/contents/treatment-of-hypoc alcemia?search=hypocalcaemia&source=s earch_result&selectedtitle=2~150&usage_ type=default&display_rank=2#h596754 207 international journal of human and health sciences vol. 03 no. 04 october’19 original article biological factors related to distress of patients with diabetes type-2 diyah candra anita1, dwi prihatiningsih2 abstract: objective: the purpose of this study was to analyze the relationship between biological factors with distress of diabetes type 2. material and methods: the research method is quantitative correlation. samples were taken by accidental sampling method for 3 months (november 2017-january 2018) in 44 patients who were treated at pku muhammadiyah yogyakarta hospital and pku muhammadiyah bantul hospital in yogyakarta, indonesia. the instruments of the study were medical records, diabetes distress scale (dds17) questionnaire, sphygmomanometer, scales, and microtoise. data analysis used was ordinal logistic regression. result and discussion: the results of the study showed 70.5% respondents were hyperglycemic; 79.5% respondents had normal total cholesterol; 45.5% respondents had normal hdl cholesterol; 52.3% respondents had normal ldl cholesterol; 63.6% respondents had normal triglycerides; 68.2% respondents had a normal bmi; 63.6% respondents had comorbidities; 50.0% respondents had complications; 72.7% respondents suffer from hypertension; and 68.2% respondents suffer from dm> 5 years. the result also showed 50.0% respondents had mild distress; 43.2% respondents had moderate distress; and 6.8% had severe distress. conclusion: it was concluded that biological factors related to distress were comorbidities, complications, bmi and total cholesterol. keywords: diabetes, distress, biological factors, cholesterol, bmi, hypertension correspondence to: diyah candra anita, nursing study program faculty of health sciences, ‘aisyiyah university of yogyakarta, indonesia, e-mail: diyah.candra@gmail.com 1. diyah candra anita, nursing study program –facultyof health sciences, ‘aisyiyah university of yogyakarta, indonesia 2. dwiprihatiningsih, nursing study program– faculty of health sciences, ‘aisyiyah university of yogyakarta, indonesia international journal of human and health sciences vol. 03 no. 04 october’19 page : 207-217 doi: http://dx.doi.org/10.31344/ijhhs.v3i4.104 introduction the prevalence of diabetes in the world is increasing. the international diabetes foundation (idf) estimates that the number of people with dm in 2040 will increase around 54.7% compared to 2015. diabetes type-2 is the most common form of diabetes. the prevalence of patients with dm type 2 is about 91% of the total number of people with diabetes. indonesia is the seventh ranked country with the highest prevalence of dm in the world1. dm is often associated as a cause of psychological stress for its patients2. this is due to changes in lifestyle, physical weakness, vision problems, and potentially death. about 69.2% of type-2 diabetics experienced stress3. unhealthy, negative and destructive response to stress is called distress. emotional pressure that triggers distress in diabetes is caused by anxiety feelings related to the disease and management of the disease4. the chance of diabetes distress (dd) is higher in patients with dm who have experienced complications both micro and macrovascular. this is due to their concerns on higher medical costs after complications, and negative views about theirselvesin the future5. the facts showed that around two-thirds of the mental health problems of diabetic patients were not diagnosed and not treated. this is due to the failure of medical staff to recognize the psychological condition of dm patients since they focus more on their poor health condition. one factor that complicates this problem is that the symptoms of mental disorders often overlap with physical signs of diabetes, for example anxiety symptoms are similar to hypoglycemic disorders in dm patients6. international journal of human and health sciences vol. 03 no. 04 october’19 208 excessive diabetes distress can decrease consciousness and increase the risk of death. the increased of cortisol hormone due to stress will inhibit the work of the insulin hormone, so that blood sugar becomes increasingly high. another negative consequences of stress conditions is the presence of sympathetic nerve stimulation which results in vascular vasoconstriction. thus, it will increase the resistance of peripheral resistance. this condition will increase of blood pressure, make the heart work heavier, and reduce of peripheral tissue perfusion7. diabetes distress is influenced by biological factors such as glucose levels, lipid profile, body mass index (bmi), duration of illness, number of comorbidities suffered, and the number of complications that exist4. if biological factors that contribute to distress can be controlled, the life expectancy of diabetic patients can be increased. the purpose of this study was to analyze the biological factors that contribute to the distress of patient with dm type-2. materials and methods this was a quantitative correlation research study with a cross-sectional design using blood sugar levels during fasting, lipid profiles, and body mass index as primary data; and medical records to determine the duration of diabetes, the number of comorbidities, and the number of complications as secondary data. the population in this study was all dm type 2 inpatients who were treated at pku muhammadiyah yogyakarta hospital and pku muhammadiyah bantul hospital in yogyakarta, indonesia. the inclusion criteria were patients’ age range was ≥20 years old; patients can communicate well; and patients did not experience amputation on both legs. the sampling method was accidental sampling during the study (three months), started in november 2017 until january 2018. the samples of the study were 44 respondents. the instruments used in this study were the results of medical records of laboratory tests during hospitalization, scales, microtoise, and diabetes distress scale 17 questionnaire in indonesian version. this research has received permission from the ethics commission of universitas‘aisyiyah yogyakarta, indonesia. the statistical analysis of correlation used was chi square test and spearman rank, while multivariate analysis test used was ordinal logistic regression test. results table 1. frequency distribution of respondents’ sociodemographic characteristics table 2. frequency distribution of assessment related to diabetes type-2 table 3. frequency distribution of respondents’ physical and laboratory assessments 209 international journal of human and health sciences vol. 03 no. 04 october’19 table 4. the mean value of respondents’ laboratory examination table 5. distress diabetes scale in respondents table 6. cross tabulation of sociodemographic characteristics with distress occurrence in respondents table 7. cross tabulation assessment of disease history with respondent distress incidence table 8. cross tabulation of laboratory assessment with distress incidence in respondents table 9. test of chi square analysis and spearman rank between lab check and type 2 diabetes patient distress table 10. ordinal logistic regression biological factors with type-2 diabetes distress discussion and conclusion table 1 shows that 43.2% of type 2 diabetes respondents were elderly. along with the aging process, more elderly people are at risk for dm disease. the emergence of insulin resistance in the elderly can be caused by four factors, namely: (1) less muscle mass and more fat tissue; (2) decreased physical activity resulting in a decrease international journal of human and health sciences vol. 03 no. 04 october’19 210 in the number of insulin receptors that were ready to bind to insulin; (3) dietary changes, namely eating more carbohydrates due to reduced number of teeth; (4) neurohormonal changes especially plasma insulin-like growth factor-1 (igf-1) and dehidroepiandosterone (dheas), which result in a decrease in glucose uptake due to decreased insulin receptor sensitivity and insulin action8. table 1 shows that 61.4% of diabetes respondents were women. several studies has been conducted to analyze the risk of type-2 diabetes based on sex. young women are more dominant in type2 diabetes because of the effects of gestational diabetes on mothers and infants. this condition will increase the risk of type-2 diabetes later in life9. during pregnancy, insulin sensitivity decreases. increased estrogen, lactogen, and progesterone hormones during pregnancy and lactation increase appetite, thereby it will increase the fat tissue in the elderly10. the increased prevalence of diabetes in elderly women is precisely due to a greater life expectancy, so that the risk of diabetes complications such as blindness, ischemic heart disease is higher9. the risk of women getting diabetes is 2.777 times greater than in men11. a study conducted in germany states that the quality of control of diabetes in middle-aged women is worse than that of men. this is because women have complex obligations in family care compared to men, which results in often being negligent in dealing with diabetes. in addition, the male masculine attitude as the head of the family influences the taking of an active attitude to resolve the problem, so that it will encourage men to recover quickly from their illness12. most of the respondents in this study (56.8%) had high school education level. some studies show that low education status is associated with negative effects on glycemic control, although the closeness of the correlation between the two variables is very small. education level is not a good predictor of type2 diabetes. education levels place more emphasis on adherence to the overall therapeutic regimen, namely: diet and exercise that are beneficial in glycemic control rather than drug adherence itself13. based on marital status (table 1), the majority of respondents were married (84.1%). poor quality of marriage is often associated with various indicators of poor health, including immunological and metabolic responses associated with the occurrence of type-2 diabetes. some studies show that there is no significant difference in the prevalence of type-2 diabetes based on marital status, but several findings indicate that single status, divorce, widows/widowers are significantly associated with dm14. married people can share environments that support better physical and mental health than those who are not married15. widows or widowers have higher risks of diabetes due to relatively higher stress levels. the level of stress experienced will change lifestyle behavior and fat storage in the body (central obesity)16. table 2.shows that the majority of respondents (68.2%) had diabetes for more than 5 years. the duration of diabetes indicates how long the patient has suffered from diabetes since the diagnosis was made. the long duration of suffering from diabetes is often associated with the risk of complications that arise afterwards17. 56.8% of respondents had a family history of diabetes mellitus (table 2). a person will be more quickly affected by dm if they have a lineage from the mother, and tend to suffer from diabetes more easily if he or she had a history of diabetes lineage from the father + mother. this is possible because of the combination of dm-carrying genes from the father and mother so that the age diagnosed with dm becomes faster. the study found that if one parent has diabetes, the risk of developing dm was 15%, if both parents had diabetes, the risk of developing dm increased to 75%. other studies also found that someone who has one or more family members, whether parents, siblings, or children with diabetes, was 2-6 times more likely to suffer from diabetes than people who do not have a family member who have diabetes18. the risk of getting dm from a mother is 10-30% greater than a father with dm. this is due to a decrease in genes when in the womb the mother is greater than the father. in female, the composition of estradiol will activate the expression of the β (erβ) estrogen receptor gene. this gene will be responsible for insulin sensitivity and increased glucose uptake. along with age, estrogen levels in the female body will decrease. decreasing estrogen will reduce activation of er gene expression so that insulin sensitivity and glucose uptake will also decrease19. in addition to erβ genes associated with type-2 diabetes, including tcf7l2 which plays a role in insulin secretion, abcc8 plays a role in helping insulin regulation, capn10 which is associated 211 international journal of human and health sciences vol. 03 no. 04 october’19 with the incidence of type-2 diabetes in america and mexico, glut2 which assists glucose uptake in the pancreas, gcgr along with glucagon hormone play their roles in glucose regulation. these genes can experience genetic mutations caused by environmental factors that cause type-2 diabetes20. 63.6% of respondents had comorbidities other than diabetes. chronic conditions in diabetes provided a risk of other diseases that occurred (comorbidity). based on the research, it was found that diabetes patients had at least one comorbid chronic disease, such as hypertension; and as many as 40% of patients had at least 3 comorbidities. the increasing prevalence of multimorbidity in elderly diabetes patients is a result of the poor quality of diabetes care. it is necessary to conduct more regular testing of hba1c and administration of drug regimens such as ace inhibitors and aspirin. comorbidity also has a profound effect on the patient’s ability to manage their self-care. comorbidity can weaken the financial resources of diabetics by increasing additional costs for medical care21. most of the respondents had hypertension (72.7%). diabetes and hypertension often occur simultaneously. this is because both of these diseases have the same main risk factors, namely: poor diet, lack of physical activity, smoking and drinking alcohol. the bad lifestyle causes the blood vessels to narrow and the heart to work extra hard to pump blood. the other result is the chaos of the production of body hormones and enzymes, including insulin production. in fact, insulin has an important role to regulate blood pressure22. figure 1. mechanism of development of hypertension in diabetes mellitus23 diabetes and hypertension have the same pathway. these pathways react between each other and can even cause a vicious circle. hypertension and diabetes, both of which are the end result of metabolic syndrome. central obesity is the cause of the metabolic syndrome. lifestyle optimization remains the foundation in the prevention and treatment of diabetes and hypertension24. some of the respondents (50.0%) had complications with the biggest type of complication was nephropathy (20.5%). diabetes is very closely related to complications both micro and macrovascular. diabetes will induce changes in microvasculature, cause extracellular matrix protein synthesis and capillary basal thickening which is a pathogenic feature of diabetic microangiopathy. these changes are closely related to advanced glycation endproducts (age), oxidative stress, inflammation and neovascularization. the most common microvascular complications are nephropathy, retinopathy, and diabetic neuropathy24. table 3 shows that the majority of respondents (68.2%) had a normal body mass index, which was in the range of 18.5-24.9. people who have a normal bmi have a two times greater risk of developing dm compared to people with a thin bmi. research found that people who have a fat bmi are about three times more likely to develop dm than those with a thin bmi25. this is in line with the theory of guyton that obesity is a predisposing factor for the rise of blood sugar levels. this is due to several things, including: (1) the beta cells of thelangerhans become less sensitive to stimuli or due to rising sugar levels; and (2) obesity will also reduce the number of insulin receptors in cells throughout the body one of the negative effects of excess weight is insulin resistance, namely the inability of insulin to produce normal biological functions (decreased insulin sensitivity), characterized by an increase in the amount of fasting insulin then it will cause an increase in blood glucose levels26. most respondents (70.5%) had high fasting blood glucose levels (hyperglycemia), which was> 125 mg/dl. the results of this study are in accordance with perkeni (2011), which states that 66,6% diabetics are on treatment, only 33,3% of which are in their glucose levels27. if blood glucose levels increase, it will cause an increase in age products that trigger the appearance of malondialdehyde which is a biomarker of oxidative stress. if the level of malondialdehyde is high it will increase international journal of human and health sciences vol. 03 no. 04 october’19 212 the risk of complications in type 2 diabetes28. total cholesterol levels in most respondents (79.5%) were normal, in the range of <200 mg / dl. as many as 45.5% of respondents had normal hdl levels, which were in the range 40 60 mg/ dl. ldl levels in most respondents (52.3%) were ideal, which was less than 100 mg/dl. most of the respondents (63.6%) had normal triglyceride levels of <150 mg/dl. the data obtained in table 3 shows that the lipid profile of most respondents was in good or controlled condition. diabetics do not always have a bad lipid profile, this is because fasting blood glucose levels do not have a direct relationship with total cholesterol levels, hdl levels, ldl, and triglycerides27. the mean ldl level of respondents in this study was 103.63 mg/dl which was borderline or cautious, while the mean cholesterol, hdl, and triglyceride levels were still in the normal range (table 4). in general, ldl cholesterol levels in diabetics are no higher than individuals without diabetes. low ldl cholesterol levels can reduce cardiovascular risk in diabetes. if higher ldl levels than normal can trigger atherosclerosis or cause increased vascular smooth muscle cell apoptosis29. increased cholesterol levels in the blood will be closely related to oxidative stress in the body. oxidative stress is harmful to the health of the body because it induces damage to dna, cells, and enzymes. in addition, the presence of free radicals can also oxidize ldl which triggers plaque buildup and atherosclerosis28,48. table 5 shows that some respondents (50.0%) had mild distress. diabetic distress is difficult to distinguish because it often overlaps with several conditions related to depression, anxiety, and stress. diabetic distress is a condition in which a person experiences a unique emotional problem that is directly related to the burden and worries of life due to diabetes that he suffered. according to fonda, a researcher at the diabetes institute, distress conditions are characterized by worries, frustration, and a little fatigue30. diabetes distress is a rational emotional response to the threat of disease that can change one’s life. distress is different from depression. distress comes from the demands of diabetes management and is a product of emotional adjustment31. patients tend to worry when there are many demands for lifestyle changes; they feel failed to manage diabetes when their fasting blood glucose is high; worry about the risk of complications; and frustrated because patients cannot control diabetes every day32. diabetic distress can be measured by a patent questionnaire, namely the diabetic distress scale which consists of four domains: (1) emotional disturbances; (2) interpersonal disturbances; (3) distress of health personnel; and (4) therapeutic distress regimen. the first domain of diabetic scale distress (dss) is the domain of emotional burden. the results of the research presented in table 5 show that the majority of respondents experienced moderate distress (52.3%) in the domain of emotional distress. emotional burden describes the distress associated with personal emotions in patients suffering from dm, including fear of possible complications caused by dm. personal reactions such as feeling afraid, angry or feeling that diabetes changes the pattern of life4, and feelings of anger because diabetes makes the activity limited. emotional burden is considered the most important domain in steaming diabetic distress14. the second domain in dss is distress caused by health workers, most respondents (45.5%) experienced mild distress or no distress (table 5). distress caused by health workers is a feeling of worry that the treating doctor does not understand enough about diabetes care and does not understand the patient’s concerns about the disease. another concern is the feeling of not having the right doctor for counseling for diabetes that he suffered15. most respondents (45.5%) experienced moderate distress in the problem of therapeutic regimens in diabetes (table 5). the third domain in dss describes the distress felt by patients caused by the need for adherence to therapeutic management plans, namely distress caused by too many drugs and needles and distrust of one’s ability to treat diabetes. the results of this study are in accordance with previous studies which found distress in this domain included in the medium category with an average score of 2.23. based on the interpersonal distress domain, respondents who experienced mild distress and moderate distress were as much as 47.7% (table 5). the results of this study are in line with previous studies which found an average score in this domain of 2.06 or included in the medium level distress category33. interpersonal distress domain is a feeling of worry that arises because the family does not support the self-care effort 213 international journal of human and health sciences vol. 03 no. 04 october’19 that is done, the feeling of being ignored for their efforts to survive with the diabetes they suffer, and the feeling of not being given the emotional support they desire15. diabetic distress does not always require doctor care. occasionally experiencing distress is normal. steps needed to overcome distress include: (1) making lifestyle changes that are slow but continuous, such as increasing physical activity, paying attention to diet, and diligently monitoring blood glucose. (2) improve coping strategies by accepting the fact that humans cannot control everything. the reception process will create a feeling of being more relaxed and able to reduce stress levels. (3) increasing faith and family support30.furthermore, recognizing the factors of cost-of-illness will help both patients and health care providers to improve the management plan and cost control and hence, to have better quality of life47. table 9 shows that the comorbidity variables (p = 0.031), complications (p = 0.010) and bmi (p = 0.013) were associated with the incidence of distress in type-2 diabetes patients due to the value of p <0.05. the closeness of the correlation of biological variables was moderate because the correlation coefficient was in the range of 0.300.49. the bio-psychosocial determinant of type-2 diabetes patients consists of three factors, namely: (1) biological determinants consisting of bmi, age, genetic history, and comorbidity; (2) social determinants, namely income, education and employment; and (3) psychological determinants, namely depression. comorbidity is a diabetes disease that is measured by analyzing the medical record. some studies show that disease that is closely related to the incidence of type-2 diabetes is hypertension34. the prevalence of hypertension relates to type-2 diabetes is 59.6%. the presence of comorbidity can also affect the life quality of patients with type-2 diabetes. one dimension of life quality is the physical health dimension, which includes activities carried out by daily patients, patient dependence on drug use, patient mobility, pain and feeling of comfort. all of these are related to the life quality of the patient, therefore if there is a concomitant disease other than diabetes, it will certainly affect the quality of life of the patient itself35. patients without comorbidities have a better quality of life 4.7 times compared to patients who have comorbid hypertension. the number of comorbidities that the patient has affects the quality of life of the patient. patients with one comorbidity have a quality of life 3.8 times better than patients who have more than one number of comorbidities36. complications in diabetes consist of micro and macrovascular. if the condition of diabetes is not handled properly, it will cause several complications such as heart disease, kidney disease, blindness, limb amputation, erectile dysfunction, and persistent infection. if an individual is able to make appropriate lifestyle changes and pay attention to blood glucose control, then this can substantially reduce the risk of complications28. the result of the study in table 9 shows that the p-value for diabetes distress and complications was 0.010 (p0.05). the wald parameter test result which was a multivariate test with ordinal logistic regression (table 10) shows that the variable complication was (p = 0.014). someone who had complications has the opportunity to experience distress 6,094 times. complications due to diabetes caused psychological changes, such as distress or depression. research shows that the number of complications was also related to psychological changes. diabetic patients with one complication had depression symptoms of 6.9%, two complications 42.4%, three complications 88.8%, and four complications 60.0%37. complications and distress in diabetes are interrelated. research suggested that distress can activate the hypothalamic pituitary axis, stimulate the sympathetic nervous system, increase platelet aggregation and inflammatory responses, and contribute to poor glycemic control, increasing the risk of diabetes complications38. distress can also interfere with glycemic control through negative effects on behavior such as adherence to diet, exercise, checking blood sugar and taking prescription drugs. type 2 diabetes patients are also at high risk of experiencing depressive symptoms, for example patients with diabetes complications such as nephropathy need hemodialysis, or patients with retinopathy experience visual impairments that can end up being blind, causing significant changes in their daily lives. stresses that are faced every day can be extraordinary which in turn can trigger distress that increases to depression37. table 9 shows that the bmi variable (p = 0.013) was associated with the incidence of distress in type 2 diabetes patients due to the value of p <0.05. the international journal of human and health sciences vol. 03 no. 04 october’19 214 closeness of the correlation of biological variables was moderate because the correlation coefficient was in the range of 0.30-0.49. the result of this study supports the research which states that bmi is associated with serious psychological pressure in dm patients. in general, there is a trade-off between depression and weight. younger people are at risk of depression if they experience weight loss, while older people are at risk of depression if they are obese39. diabetes is a chronic disease associated with suffering and early death. the emergence of diabetic distress is often associated with poor quality of life, low levels of knowledge of diabetes which allows for adverse effects on self-management and glycemic control. poor self-management will increase the risk of complications. one indicator of poor self-care management is excessive or even obese bmi40. the correlation between distress and bmi incidence is a relationship that affects each other. increased bmi can affect distress events, and vice versa, the incidence of distress can affect bmi. the research suggested that psychological distress can affect bmi and central obesity. psychological factors such as depression, anxiety, fatigue, and psychological trauma are risk factors for obsession. the results revealed that psychological stress was positively associated with bmi in women. stress in individuals with bmi <22 kg/m2 at the beginning would result in weight loss, however the stress suffered by individuals with bmi> 27 kg/m2 at the beginning would actually increase body weight41. women have a higher level of anxiety than men. stressors complained by women include: lack of environmental and family support, work problems, and anxiety about diabetes41. according to the american psychological association, sedentary life behaviors such as watching television, drinking alcohol, smoking, playing games, and surfing the internet, have serious implications for increasing body weight. the lack of physical activity results in slow metabolism of the body, so much fat is stored in adipocyte cells42. some people might use food as a means of overcoming their difficulties. those who have high stress levels can change their food choices from healthy eating low fat, to unhealthy foods (eg high hydrogenated fats) and can also increase their food consumption43. the biological mechanism that explains why stress can affect bmi is an increase in cortisol products. cortisol is a hormone secreted by the adrenal gland and is responsible for maintaining homoeostasis. chronic psychological stress will increase cortisol levels, which result in hyperglycemia, hypertension, reduced heart rate variability, increased central obesity, and metabolic syndrome44. gu, et al. reported that someone who experiences stress usually chooses foods with high fat and sugar content41. hence, they eat when they are not even hungry. it can be concluded that brain tissue during stress will stimulate a person’s eating behavior so that it can cause obesity. in a study it was reported that a person who has post-traumatic stress has a high level of salivary cortisol. cortisol dysregulation is also seen in men who have metabolic syndrome46. table 9 shows that total cholesterol levels were not related to distress events, because p = 0.274 (p> 0.05). on the other hand in the multivariate statistical test (table 10) the value of the total cholesterol was significant, p = 0.013 (p≤0.05) meaning that cholesterol levels had a significant influence on the incidence of distress of type-2 diabetes patients with an incidence of 6,104 times. the combination of stress and high cholesterol in individuals will increase the risk of heart disease. during stressful situations, the hypothalamus triggers the release of two hormones, namely adrenaline and cortisol, which have the effect of accelerating the heart rate, stimulating the release of energy, and increasing blood flow to the brain. this response is called fight and flight response45. adrenaline and cortisol hormone can trigger cholesterol production. this cholesterol will be used as energy and repair damaged cells. however, if the energy is not used, it will accumulate slowly in the body as fat tissue. cortisol has the additional effect of producing more sugar – whichis a shortterm source of energy for the body. during repeated stressful situations, sugar is repeatedly not used and will eventually be converted into triglycerides or other fatty acids. research shows that these fat deposits tend to end up in the stomach, which causes a higher risk of macrovascular complications in diabetic patients45. cholesterol levels of diabetics that are more than normal can indicate failure of diabetic management self-care. diabetics will be more anxious when they know their lipid profile is in the borderline or even very high. the most feared threat is a complication due to diabetes, especially 215 international journal of human and health sciences vol. 03 no. 04 october’19 heart disease, because it will further increase mortality opportunities. table 9 shows that the duration of suffering from diabetes (p = 0.395) was not related to the incidence of distress in diabetes. the result of this study is different from the research conducted by permana (2017) which states that the duration of diabetes is closely related to the incidence of distress. the longer the patient has diabetes, the lighter the distress he suffers33. the length of illness experienced by patients will result in patients being able to understand conditions both in terms of physical, psychological, social, and environmental relationships. the patient’s understanding of his illness will encourage patients to be better able to anticipate emergence of a situation or something that might happen to the patient. the duration of a person’s illness has an impact on the ability of people to understand their condition and control themselves about their state of health33. the absence of a relationship between the duration of illness and the incidence of distress was due to the patient’s anxiety remains high due to fear of complications, or the biological condition of him even though the patient has long suffered from diabetes. another theory reveals that the more patients understand the disease, then it will lead to higher anxiety about the disease4. table 9 shows that fasting blood glucose (fbg) levels (p=0.073), hdl cholesterol levels (p=0.727), ldl cholesterol levels (p=0.865), and triglyceride levels (p=0.748) were not associated with diabetic distress. the result of the study in table 4 shows that the average fbg level was 155.96 gr/dl (hyperglycemia), the mean total cholesterol was 176.77 mg/dl, the mean hdl was 44.63 mg/dl, the mean ldl was 103.63 mg/ dl, and average triglyceride level of 144.14 mg/ dl. the mean lipid profile in this study shows in the normal range, so it can be concluded that the average respondent did not experience dyslipidemia. when an individual is diagnosed with diabetes, patients will be informed to change their lifestyle significantly so that diabetes can be controlled. patients will be informed that the prognosis of the disease will be very dependent on perseverance and compliance in carrying out a therapeutic regimen, such as modification of diet, taking medication, diligently controlling blood glucose levels and even learning to inject insulin if needed. patients are also asked to increase physical activity regularly. if the patient has carried out diabetes self-care well, but it turns out that the lab results are not in line with their expectations, it will give rise to feelings of despair which then results in treatment non-compliance. breach of diet begins to be made which will further worsen the blood sugar level and the lipid profile of the patient46. conclusion biological factors related to distress were comorbidity, complications, and bmi; while the biological factors that were not related to distress are hypertension, duration of diabetes, fbg, total cholesterol, hdl, ldl, and triglycerides. the most influential biological factors in diabetes distress were complications and total cholesterol. recommendations the health care providers must be handling distress diabetic problems as an effort to anticipate before the stress occurs in diabetic patients. ethical approval issue: equitable distribution of benefits and burdens in the selection of individuals of participants in research. conflict of interest : none. author’s contribution : data gathering and idea owner of this study: diyah candra anita. study design: diyah candra anita. data gathering: dwi prihatiningsih writing and submitting manuscript: diyah candra anita. editing and approval of final draft: diyah candra anita. international journal of human and health sciences vol. 03 no. 04 october’19 216 references 1. z international diabetes foundation. diabetes atlas. [online].; 2015. cited 2017 may 12. available from: http://www.idf.org/idf-diabetes-atlas-seventh edition. 1. pranata a. hubungan diabetes distress dengan perilaku perawatan diri pada penyandang diabetes mellitus type-2 di wilayah kerja puskesmas rambupuji kabupaten jember. skripsi. jember: universitas jember; 2016. 2. rehman ua, kazmi s. prevalence and level of depression, anxiety stress among patiens type-2 diabetes mellitus. thesis. ; 2015. 3. fisher l, mullan j, skaff m, glasgowt r, arean p, hessler d. original article: treatment predicting diabetes distress in patients with type 2 diabetes: a longitudinal study. diabeticmedicine. 2009; 26: 622–627. 4. novitasari r. diabetes mellitus medical book yogyakarta: nuha medika; 2012. 5. habtewold t, islam m, radie y, tegegne b. comorbidity of depression and diabetes: an application of biopsychosocial model. int j ment health syst. 2016; 10(74): 1-9. 6. prasetyorini h, prawesti d. stres pada penyakit terhadap kejadian komplikasi hipertensi pada pasien hipertensi. jurnal stikes. 2012; 5(1): 61-70. 7. kurniawan i. diabetes melitus tipe 2 pada usia lanjut. maj kedokt indon. 2010; 60(12): 576-584. 8. grant j, hicks n, taylor a, chittleborough c, phillips p. gender-specific epidemiology of diabetes: a representative cross-sectional study. international journal for equity in health. 2009; 8(6): 1-12. 9. nuryanti i, bantas k. prevalensi dan faktor risiko kejadian diabetes mellitus pada wanita dewasa di indonesia. naskah publikasi. jakarta: universitas indonesia, fakultas kesehatan masyarakat; 2014. 10. allorerung d, sekeon s, joseph w. hubungan antara umur, jenis kelamin & tingkat pendidikan dengan kejadian diabetes mellitus tipe-2 di puskesmas renotana weru kota manado. naskah publikasi. manado: universitas sam ratulangi, fakultas kesehatan masyarakat; 2016. 11. siddiqui m, khan m, carline t. gender differences in living with diabetes mellitus. mater sociomed. 2013; 25(2): 140-142. 12. al-rasheedi a. the role of educational level in glycemic control among patients with type ii diabetes mellitus. int j health sci (qassim). 2014; 8(2): 177-187. 13. rahmanian k, shojaei m, jahromi a. relation of type 2 diabetes mellitus with gender, education, and marital status in an iranian urban population. rep biochem mol biol. 2013; 1(2): 64-68. 14. cornelis m, chiuve s, glymour m, chang s, tchetgen e, liang l, et al. bachelors, divorcees, and widowers: does marriage protect men from type 2 diabetes? plos one. 2014; 9(9): e106720. 15. whisman m, sbarra d, raison c. marital quality and diabetes: results from the health and retirement study. health psychology. 2014; 33(8): 832-840. 16. restada e. hubungan lama menderita dan komplikasi diabetes mellitus dengan kualitas hidup pada penderita diabetes mellitus di wilayah puskesmas gatak sukoharjo. naskah publikasi. surakarta: universitas muhammadiyah surakarta, prodi ilmu keperawatan; 2016. 17. santosa a, trijayanto p, endiyono. hubungan riwayat garis keturunan dengan usia terdiagnosis diabetes melitus tipe ii. in the 6th university research colloquium 2017; magelang: universitas muhammadiyah magelang. 1-6. 18. alonso-magdalena p, ropero b, garcía-arévalo m. antidiabetic actions of an estrogen receptor β selective agonist. diabetes. 2013; 62(6): 2015-2025. 19. winter s, pletcher p. is type 2 diabetes?[online] 2016.cited 2017 may 12.available from: http:// w w w. h e a l t h l i n e . c o m / h e a l t h / t y p e 2 d i a b e t e s / genetics#overview1. 20. piette j, kerr e. the impact of comorbid chronic conditions on diabetes care. diabetes care 2006. 2006; 29(3): 725-731. 21. barhum l. medical newstoday. [online].; 2017. cited 2018 november 27. available from: https:// www.medicalnewstoday.com/articles/317220.php 22. cheung b, li c. diabetes and hypertension: is there a common metabolic pathway? curr atheroscler rep. 2012; 14(2): 160–166. 23. chawla a, chawla r, jagg s. microvasular and macrovascular complications in diabetes mellitus: distinct or continuum? indian j endocrinol metab. 2016; 20(4): 546-551. 24. luthansa n, pramono d. indeks massa tubuh dan kejadian diabetes mellitus pada penduduk deasa di indonesia: analisis data. berita kedokteran masyarakat. 2017; 33(4): 167-172. 25. zhao q, laukkanen j, li q, zhao q. body mass index is associated with type 2 diabetes mellitus in chinese elderly. clin interv aging. 2017; 12: 745–752. 26. hanum n. hubungan kadar glukosa darah puasa dengan profil lipid pada pasien diabetes mellitus tipe2 di rsud kota cilegon. skripsi. jakarta:; 2013. 27. anita d. kadar glukosa darah dan malondialdehid ginjal tikus diabetes yang diberi latihan fisik. indonesian jurnal of nursing practices. 2015; 1(2): 109-116. 28. nesto r. ldl cholesterol lowering in type 2 diabetes: what is the optimum approach? clinical diabetes. 2008; 26(1): 8-13. 29. gebel e. diabetes distress. diabetes forecast. [online].; 2013 [cited 2018 june 14. available from: http://www.diabetes.org/living-with-diabetes/ complications/mental-health/diabetes-distress.html. 30. berry e, lockhart s, davies m, lindsay j, dempster r. diabetes distress: understanding the hidden struggles of living with diabetes and exploring intervention strategies. review. bmj jounal. 2014; 91(1075). 31. ndss. diabetes distress. [online].; 2016 [cited 2018 june 4. available from: https://static.diabetesaustralia. com.au/s/fileassets/diabetes-australia/4496ad69a10c-4c91-8db4-0e030f8df185.pdf 32. permana y. hubungan antara lama sakit dengan tingkat distress pada pasien diabetes melitus di 217 international journal of human and health sciences vol. 03 no. 04 october’19 rumah sakit islam surakarta. skripsi. surakarta: universitas muhammadiyah surakarta, prodi keperawatan; 2017. 33. kausar r, awan b, khan n. gender differences in risk perception and emosional distress in patients with type-2 diabetes. journal of the indian academy of applied physiology. 2013; 39(2): 222-227. 34. wielgosz a, dai s, walsh , mccrea l, celebican e. comorbid conditions in canadians hospitalized because of diabetes. can j diabetes. 2018;42: 106101. 35. faridah i, dewintasari v. hubungan usia dan penyakit penyerta terhadap kualitas hidup pasien diabetes mellitus tipe-2 di puskesmas kotagede 1 yogyakarta. in prosiding rakernas dan pertemuan ilmiah tahunan ikatan apoteker indonesia; 2016; yogyakarta. 123126. 36. utami m. komorbiditas dan kualitas hidup pasien hemodialisa. thesis. yogyakarta; 2016. 37. lin e, wayne k, von korff m, rutter c, simon. relationship of depression and diabetes self-care, medication adherence, and preventive care. diabetes care. 2004; 27: 2154-60. 38. huyser k, manson s, nelson l, noonan c, roubideaux y. serious psychological distress and diabetes management among american indians and alaska natives. ethn dis. 2015; 25(2): 145-151. 39. delaney g, newlyn n, pamplona e, hocking s, glastras g, mcgrath r, et al. identification of patients with diabetes who benefit most from a health coaching program in chronic disease management, sydney, australia, 2013. cdc. 2017; 14. 40. gu j, charles l, burchfiel c, andrew m, ma c, bang k, et al. associations between psychological distress and body mass index among law enforcement officers: the national health interview survey 20042010. saf health work. 2013; 4(1): 52-62. 41. apa. stress in american findings. [online].; 2010 [cited 2018 december 1. available from: http://www. apa.org/news/press/releases/stress/national-report.pdf. 42. zellner d, loaiza s, gonzalez z, pita j, morales j, pecora d, et al. food selection changes under stress. physiol behav. 2006; 87: 789-793. 43. branth s, ronquist g, stridsberg m, hambraeus l, kindgren e, olsson r, et al. development of abdominal fat and incipient metabolic syndrome in young healthy men exposed to longterm stress. nutr metab cardiovasc dis. 2007; 17: 427–435. 44. frye b. chronic stress and cholesterol. high cholesterol. 2018 july 28. 45. tareen r, tareen k. psychosocial aspects of diabetes management: dilemma of diabetes distress. transl pediatr. 2017; 6(4): 383-396. 46. afroz a., alam k., alramadan mj., hossain mdn., chowdhury, ha., ali, l., billah, b. cost-of-ilness and its determinants for type-2 diabetes mellitus in bangladesh. bjms. 2019; 18(3): 501-507. 47. billah, smb., jahan, ms. metabolic syndrome in urban and rural communities of bangladesh. ijhhs. 2018; 2(2): 71-77. international journal of human and health sciences vol. 05 no. 01 january’21 44 editorial: lifestyle changes in the management of non-communicable diseases in low and middleincome countries mainul haque1 keywords : way of life, alteration, management, avert, handle, deal with, ncds, non-communicable diseases, resource-constraint, developing, countries. correspondence to: mainul haque, professor of the unit of pharmacology, faculty of medicine and defence health, universiti pertahanan nasional malaysia (national defence university of malaysia), kem sungai besi, 57000 kuala lumpur, malaysia. land line: +60 3 9051 3400 ext 2257 (office). +60 3 6179 5871 (home). cell phone: + 60 10 926 5543. email: runurono@gmail.com orcid id: https://orcid.org/0000-0002-6124-7993 international journal of human and health sciences vol. 05 no. 01 january’21 page : 4-6 doi: http://dx.doi.org/10.31344/ijhhs.v5i1.223 non-communicable diseases (ncds) embracing cardiovascular disease, stroke, diabetes, and chronic obstructive pulmonary disease, are increasing all over the globe, but disproportionately in high frequency in lowand middle-income countries (lmics). 1-4 although our planet has achieved a lot in reducing deaths from infectious and contagious diseases. 5 a significant portion of patients suffering from ncds did not get enough healthcare support in lmics, although treatment options are available and access in high-income countries (hics). 2, 6 the globe is observing high death rates due to ncds, but the situation turns into a grave public health risk in lmics. 6-8 the chronic ncds on most occasions to date do not have much curative treatment. the current pharmacological invention possibilities clinically available are controlling and prevention strategies. furthermore, lmics because of resource constraint management of ncds is quite limited to address the whole population. additionally, research regarding ncds management principally conducted in hics. 2 usually lmics follows management strategies for ncds developed in hics. the need for research regarding ncds management has been recognized to improve prevention and control strategies for specific country context; again, resource constraints remain a major issue for research. 2, 6, 9 lifestyle is an essential component that has been identified as the primary cause of ncds around the globe. 10 tobacco, and alcohol consumption, unhealthy dietary practice, overweight and obesity, hypercholesterolemia, with sedentary life has been recognized as a significant cause of ncds. 6, 11, 12 these causative factors are the part of lifestyle disorders correlated to ncds and considered as the modifiable risk factors. 13 all these risk issues act as a leading role in producing ncds, a group of them called as metabolic syndrome had been extreme apprehension for the last few decades. 13 ncds appears as a significant cause of morbidity and mortality. the situation much worse in lmics because of resource constraints. it is additionally speculated that ncds will cause around seventy percent mortality in lmics by 2020. 12 metabolic syndromes are the most common metabolic disorder, which ultimately causes cardiovascular diseases and diabetes.13 additionally, these risk factors of ncds are correlated with cancer and chronic pulmonary disease.12 the principal preventive measures regarding ncds are focused on the road in modifying lifestyle-related risk factors. 14, 15 one indian study conducted in barwala village, delhi, india, reported that the study participants were contacted on their cell phone once a month for about 20 minutes. researchers during discussion emphasis repeatedly the necessity of adaptation of a healthful lifestyle in promoting their overall health. investigators additionally meet the study participant’s health-related questions and on condition that optimistic support. this research package also included weekly short message service (sms). the sms contained 25–30 words mentioning within brief but attractive sayings and running title: lifestyle changes in the management of non-communicable diseases 5 international journal of human and health sciences vol. 05 no. 01 january’21 limericks on the significance of amendment of risk factors. this finally reported that this cost-effective strategy of counseling had a positive outcome in turning-down lifestyle-related risk factors and promoting health.14 another multicentre study from south asia conducted among fourteen to seventeen years old population of six different schools found that more than 80% of the studyparticipants consume unwholesome foods, and 54% were physically inactive especially girls (or, 4.07; 95% ci, 2.69 to 6.17). much of the study-participants often exposed to passive smoking (or, 2.57; 95% ci, 1.72 to 3.83), and 14% were regular smokers more observed among males (or, 2.17; 95% ci, 1.19 to 3.91). more than 33% of study-participants chewed betel nut (or, 2.03; 95% ci, 1.34 to 3.06), and 25% used oral tobacco. this finally concluded that these lifestyle-related risk factors are preventable with the comprehensive and integrated intervention program. 15 another research similarly reported that educational intercessions targeting to alter dietary habits, and lifestyle features, varying the environment, changing the food supply, commissioning community involvements, and instigating economic policy strategies. 16 multiple countries around the globe implemented highlevel tax for tobacco, sugar-sweetened beverages, and many other unhealthy foods and improved in maintaining a healthy lifestyle.17-19 bangladesh and other lmics should stringent policy measures to modify lifestyle-related risk factors of ncds to safeguard their ordinary people. furthermore, lmics need to amend their health policy planning based on primary health care strategies to improve the the overall health care system.20-24 funding this research did not obtain any financial support. conflict of interest the authors do not possess any conflict of interest. references: 1. world health organization. noncommunicable diseases. key facts. 2018. available at https:// w w w. w h o . i n t / n e w s r o o m / f a c t s h e e t s / d e t a i l / noncommunicable-diseases [accessed february 13, 2020] 2. checkley w, ghannem h, irazola v, et al. management of ncd in lowand middle-income countries. glob heart. 2014;9(4):431–443. https:// doi.org/10.1016/j.gheart.2014.11.003 3. lee es, vedanthan r, jeemon p, et al. quality improvement for cardiovascular disease care in lowand middle-income countries: a systematic review. plos one. 2016;11(6): e0157036. https:// doi.org/10.1371/journal.pone.0157036 4. gowshall m, taylor-robinson sd. the increasing prevalence of non-communicable diseases in lowmiddle income countries: the view from malawi. int j gen med. 2018; 11:255–264. https://doi. org/10.2147/ijgm.s157987 5. holmes kk, bertozzi s, bloom br, et al. major infectious diseases: key messages from disease control priorities, third edition. in: holmes kk, bertozzi s, bloom br, et al., editors. major infectious diseases. 3rd edition. washington (dc): the international bank for reconstruction and development / the world bank; 2017 nov 3. chapter 1. available at: https://www.ncbi.nlm.nih. international journal of human and health sciences vol. 05 no. 01 january’21 6 gov/books/nbk525197/ https://doi.org/10.1596/9781-4648-0524-0/ch1 [accessed february 13, 2020] 6. islam sm, purnat td, phuong nt, mwingira u, schacht k, fröschl g. non-communicable diseases (ncds) in developing countries: a symposium report. global health. 2014; 10:81. https://doi.org/10.1186/ s12992-014-0081-9 7. oni t, unwin n. why the communicable/noncommunicable disease dichotomy is problematic for public health control strategies: implications of multimorbidity for health systems in an era of health transition. int health. 2015;7(6):390–399. https://doi. org/10.1093/inthealth/ihv040 8. boutayeb a, boutayeb s. the burden of noncommunicable diseases in developing countries. int j equity health. 2005;4(1):2. https://doi. org/10.1186/1475-9276-4-2 9. sharma a. global research priorities for noncommunicable disease prevention, management, and control. int j non-commun dis 2017;2 (4):107112. https://doi.org/10.4103/jncd.jncd_57_17 10. habib sh, saha s. burden of non-communicable disease: global overview. diabetes metab syndr clin res rev. 2010; 4 (1): 41-47. https://doi.org/10.1016/j. dsx.2008.04.005 11. al-mawali a. non-communicable diseases: shining a light on cardiovascular disease, oman’s biggest killer. oman med j. 2015;30(4):227–228. https://doi. org/10.5001/omj.2015.47 12. boutayeb a the double burden of communicable and non-communicable diseases in developing countries. trans r soc trop med hyg. 2006;100(3):191-9. https://doi.org/10.1016/j.trstmh.2005.07.021 13. esmailnasab n, moradi g, delaveri a. risk factors of non-communicable diseases and metabolic syndrome. iran j public health. 2012;41(7):77–85. 14. sharma m, banerjee b, ingle gk, garg s. effect of mhealth on modifying behavioral risk-factors of noncommunicable diseases in an adult, rural population in delhi, india. mhealth. 2017; 3:42. https://doi. org/10.21037/mhealth.2017.08.03 15. jamison dt, breman jg, measham ar, et al., editors. priorities in health. washington (dc): the international bank for reconstruction and development / the world bank; 2006. chapter 5, cost-effective strategies for noncommunicable diseases, risk factors, and behaviors. available at https://www.ncbi.nlm.nih.gov/books/nbk10246/ [accessed february 15, 2020] 16. willett wc, koplan jp, nugent r, et al. prevention of chronic disease by means of diet and lifestyle changes. in: jamison dt, breman jg, measham ar, et al., editors. disease control priorities in developing countries. 2nd edition. washington (dc): the international bank for reconstruction and development / the world bank; 2006. chapter 44. available at https://www.ncbi.nlm.nih.gov/books/ nbk11795/ co-published by oxford university press, new york. [accessed february 15, 2020] 17. haque m, mckimm j, sartelli m, samad n, haque sz, bakar ma. a narrative review of the effects of sugar-sweetened beverages on human health: a key global health issue. j popul ther clin pharmacol. 2020;27(1): e76-e103. https://doi.org/10.15586/jptcp. v27i1.666 18. nahar q, rokeya b, al mahmood ak, rahman m. effect of a modified chapati on blood glucose and lipid levels in diabetic patients. diab endocr j 2007; 35 (1): 25-28. 19. al-mahmood ak, ismail aa, rashid fa, azwany yn, singh r, gill g. effect of therapeutic lifestyle changes on insulin sensitivity of non-obese hyperlipidemic subjects: preliminary report. j atheroscler thromb, 2007; 14:122-127. 20. haque m, islam t, rahman naa, mckimm j, abdullah a, dhingra s. strengthening primary health-care services to help prevent and control long-term (chronic) non-communicable diseases in lowand middle-income countries. risk manag healthc policy. 2020; 13:409-426. https://doi. org/10.2147/rmhp.s239074 21. bitton a, fifield j, ratcliffe h, et al. primary healthcare system performance in low-income and middle-income countries: a scoping review of the evidence from 2010 to 2017. bmj glob health. 2019;4(suppl 8): e001551. https://doi.org/10.1136/ bmjgh-2019-001551 22. fadlallah r, bou-karroum l, el-jardali f, et al. quality, safety, and performance management in primary health care: from scoping review to research priority setting and implementation plan in the eastern mediterranean region. bmj glob health. 2019; 4(suppl 8): e001477. https://doi.org/10.1136/ bmjgh-2019-001477 23. murshid me, haque m. hits and misses of bangladesh national health policy 2011. j pharm bioall sci 2020; 12 (2):83-93. https://doi.org/10.4103/jpbs. jpbs_236_19 24. 24.murshid me, haque m. bangladesh national drug policy 1982-2016 and recommendations in policy aspects. eurasian j emerg med. 2019;18(2):104-109. https://doi.org/10.4274/eajem.galenos.2019.43765 5 international journal of human and health sciences vol. 01 no. 01 january’17 editorial: the birth of the international journal of human and health sciences (ijhhs ) rahman ara1, al-mahmood ak2 thirty six years ago, a group of doctors from 10 countries met in orlando usa to set up the federation of islamic medical associations (fima). from a humble origin, this federation now has 50 full and associate members from 46 countries stretching from north america in the west to australasia in the east. membership comprises of national islamic medical associations (imas), humanitarian and charitable non-governmental associations, expert societies and health care providers across the globe. one of the earliest international projects of fima was humanitarian and relief work (fima relief) launched in 1994, which received international recognition from among others, the american college of physician’s richard hinda rosenthal award. fima has since been acknowledged as a network partner with special consultative status to major international bodies including the united nation (ecosoc, newyork), the organisation of islamic conference (oic jeddah), islamic council on daawa and relief (iicdr, cairo), world health organisation (who-east mediterranean regional office, cairo) and the islamic organisation of medical sciences (ioms, kuwait). knowledge acquisition and generation has always been central to fima’s raison d’etreconsidering the plethora of academics within fima’s fraternity. the commitment towards academic excellence was highlighted when fima launched its consortium of islamic medical colleges (cimco) in the year 2000. the main objectives of cimco includes the promotion of health related research to serve humanity and the fostering of collaboration in the field of medical education, training, research and services in the light of the islamic teachings. even prior to the establishment of cimco, the academic culture of knowledge generation was evident within the membership of fima with the establishment of english language medical journals by several imas. these included the journal of islamic medical association of north america (jima) launched in 1976. this was followed by the journal of islamic medical association of south africa (jimasa) launched in 1998, the bangladesh journal of medical sciences (bjms) launched in 2009, the journal of the islamic medical association of nigeria (iman medical journal) launched in 2015, two journals from hayat foundation turkey both launched in 2016 (anatolian clinic and journal of health and culture) and from the indonesia islamic university (a cimco member) called indonesian journal of medicine and health launched in 2009 in the indonesian language and subsequently indexed by index copernicus international this year (2017). another milestone in fima’s contribution to knowledge generation was the establishment ofapublication called the fima yearbook in 1996. the fima yearbook has over the years been an important reference and resource material for knowledge on the application of islamic principles in the health sciences. thus fima through its member associations and affiliates has a wealth of experience in running academic publications. the experience of bjms is particularly encouraging. hosted by the ibn sina trust and the ibn sina medical college (a cimco member) it started modestly in 2009 with three issues and a total number of 21 articles. with support from fimacimco, by the year 2012 it was able to publish 189 articles of which 125 were from outside the host country. the number of submission now is three to four times more than number the journal can publish. the bjms now frequently receives around 1000 articles per year but can accommodate only around 140 articles after the peer review process. this reflectsthe attraction and attention it has garnered from medical scientists throughout the globe. the involvement of fimacimco was particularly significant in this respect. from the outset, contributions were received from the then fima president1 and other office bearers international journal of human and health sciences vol. 01 no. 01 january’17. page : 5-6 1. abdul rashid abdul rahman, medical director, an nur specialist hospital, medan pusat, bandar baru bangi, selangor, malaysia, secretary fima and immediate past chairman, cimco 2. abu kholdun al-mahmood, professor & head, dept. of biochemistry, ibn sina medical college, dhaka, bangladesh, editor in chief, ijhhs correspondence to: abdul rashid abdul rahman, medical director, an nur specialist hospital, medan pusat, bandar baru bangi, selangor, malaysia. email: abdulrashid43000@gmail.com the birth of the international journal of human and health sciences (ijhhs) 6 covering various topics on medical sciences. fima’s involvement heralded the beginning of international submissionsto the bjms. in 2009 a fima-cimco meeting hosted in malaysia by a cimco member; cyberjaya university college of medical sciences (cucms) acted as a catalyst for bjms to receive many manuscripts from medical educationists, researchers, scientist and scholars from within fima-cimco. a special edition of the 2009 fima yearbook captured the salient messages which emanated from that meeting2. another important output from the meeting were interesting articles on future challenges in medical education, towards preparation of highest quality medical professionals, revival of medical research in the muslim world, experiences of embracing islamic values in the medical curriculum, professional development and pharmaceutical industry were published in the bjms3-8. these articles attracted readers from different parts of the globe, which ultimately lead the journal to achieve a global standard. it also received articles based on clinical research and interesting case reports from practitioners9. fima-cimco scholars were also deeply involved in reviewing articles for the bjms ensuring articles published are of global standards. as a result of such relentless, voluntary and benevolent service from scholars of different parts of muslim world, bjms was indexed by scopus in late 2012 at the 34th fima council meeting of july 2017 in istanbul, the council endorsed the establishment of an international journal under the direct leadership of fima through cimco. with a wealth of experiences, fima-cimco will now navigate the sea of knowledge and publication through this initiative under the name ‘international journal of human and health sciences’. we are convinced that researchers from around the globe will be attracted by this novel approach of crossfertilisation between the hard and soft sciences and the holistic and integrative approach which forms the theme of this journal. this is well in keeping with the ethos of the great scientists and philosophers of the muslim world in the glorious golden era of discovery and innovation of the past. we have the experience to make it a success through our coordinated, collaborative and cooperative efforts. we look forward to an exciting and positive future by providing a platform for knowledge to thrive through dissemination of medical opinions and research findings via quality publications. this will serve as a gift to humanity, in keeping with the islamic mission and vision to spread knowledge, wisdom and blessing to mankind. references: 1. nordin, musa bin mohd. rumahsolehah malaysia: half way home for women and children with hiv/aids. bangladesh journal of medical science, 2009;08(4):29-32. 2. fima yearbook 2009 . medical education and professional ethics : islamic insights. jordan society for islamic medical sciencesamman: jsims,2010. isbn 969-8695-01-x. 3. mohamed, abdul latiff. future challenges in medical education. bangladesh journal of medical science. 2010; 09(3):4-13. doi:http://dx.doi. org/10.3329/bjms.v9i1.5226. 4. rashid, ara. increasing muslim contribution to medical research; reviving a lost legacy. bangladesh journal of medical science. 2010;09(02):64-67.. doi:http://dx.doi.org/10.3329/bjms.v9i2.5653. 5. khan, mohammad iqbal. towards the preparation of highest quality medical professionals.bangladesh journal of medical science. 2010;09(03):116-123. doi:http://dx.doi.org/10.3329/bjms.v9i3.6465. 6. khan, mohammad iqbal. sophistication of medical writings. bangladesh journal of medical science. 2009;08(03):44-45. doi:http://dx.doi.org/10.3329/ bjms.v8i3.3981. 7. osman, ariff. integrating islamic value in medical teaching curriculum: iium experience. bangladesh journal of medical science. 2013;12(02):117-120. doi:http://dx.doi.org/10.3329/bjms.v12i2.14937. 8. rahman, abdul rashid abdul. continuous professional development and the pharmaceutical industryeducation or marketing?.bangladesh journal of medical science. 2013;12(01):5-9. doi:http://dx.doi.org/10.3329/bjms.v12i1.13347. 9. fariza, nh nik; irfan, m; ramiza, rr. fish bone piercing epiglottis: a case report. bangladesh journal of medical science, 2010;09(01):53-55. doi:http://dx.doi.org/10.3329/bjms.v9i1.5232. 267 international journal of human and health sciences vol. 05 no. 02 april’21 letter to the editor community use of masks as a preventive measure for covid-19 in kabale district of uganda mustafa ssaka1, charles lwanga2, tunc eren3, orhan alimoglu3,4 abstract coronavirus disease 2019 (covid-19) caused a global pandemic and by june 1st, 2020, the global numbers of covid-19 cases reached six million with more than 370,000 deaths. community-wide mask wearing may contribute to the control of covid-19 by reducing the amount of emission of infected saliva and respiratory droplets from persons with subclinical or mild covid-19. however, use of masks in public and in health care facilities has been controversial as different organizations and agencies established different guidelines. in uganda, not any reports on mask utilization practices have been published yet. therefore, this report aims at documenting mask use practices, as observed in our interactions with non-covid-19 patients and their relatives at kabale regional referral hospital as well as kabale town residents. it was observed that many non-covid-19 patients and the relatives of hospitalized patients only wear their masks on reaching the hospital premises while community members of kabale town wear their masks only in the presence of security agencies and individuals in the public only wear masks in places where they would be refused from services without masks. wearing of masks in public places and health care facilities together with other preventive measures including hand hygiene, social distancing and wearing of full personal protective equipment for health care providers working on covid-19 patients are key measures in preventing the spread of infection. there is an increased need for intensified community educational activities on public awareness of the importance of appropriate use of masks. keywords: covid-19; pandemics; prevention and control. correspondence to: prof. dr. orhan alimoglu, department of general surgery, faculty of medicine, istanbul medeniyet university, goztepe training & research hospital, 34722, kadikoy, istanbul, turkey. e-mail: orhan.alimoglu@medeniyet.edu.tr 1. intern doctor, habib medical school, islamic university in uganda (hmsiuiu), kabale regional referral hospital, southwestern uganda. 2. intern nurse, habib medical school, islamic university in uganda (hmsiuiu), kabale regional referral hospital, southwestern uganda. 3. department of general surgery, faculty of medicine, istanbul medeniyet university, göztepe training and research hospital, istanbul, turkey. 4. africa health training and research center (masam), istanbul medeniyet university, istanbul, turkey. international journal of human and health sciences vol. 05 no. 02 april’21 page : 267-270 doi: http://dx.doi.org/10.31344/ijhhs.v5i2.274 community use of masks as a preventive measure for covid-19 in kabale district of uganda in december 2019, a novel coronavirus (sarscov-2) emerged in wuhan, china, sparking an epidemic of acute respiratory syndrome termed as coronavirus disease 2019 (covid-19) in humans.1 it was closely associated to bat borne sars related coronaviruses and was the second pandemic to be recorded in the 21st century following the influenza a h1n1 pandemic of 2009.2,3 in a period of three months, the virus spread to more than 118,000 individuals and caused 4,291 deaths in 114 countries, hence was declared to be a global pandemic.4 by june 1st, 2020, the global numbers of covid-19 cases reached six million with more than 370,000 deaths while uganda reported 417 cases.5,6 the pandemic led to the implementation of proactive infection control measures in hospital settings to prevent rapid spread of the virus.7 in addition, public health interventions including border control, quarantine and testing of all incoming travelers or returnees, wearing of face masks, frequent hand hygiene, and social distancing measures were taken by different countries to international journal of human and health sciences vol. 05 no. 02 april’21 268 reduce the risk of community transmission.8 on march 21st, 2020, the first case of covid-19 was confirmed in uganda, that was a 36-year-old man who had travelled to dubai on march 17th, 2020.9 ever since the index case was identified, there has been a gradual increase in the number of covid-19 cases in the country most of which are imported cases mainly through travelers and truck drivers.10,11 following the increase in numbers of covid-19 in the country, the head of the state put forward various strategies in order to curb community transmission of the virus.6 these included closure of schools, country lockdown, social distancing rules, hand washing and the use of face masks for the essential workers such as health workers.12 however, as the lockdown is being eased amidst raising number of cases within the population, the president of uganda, with guidance of the ministry of health, made it mandatory to wear masks while in public and punishable by law if not used.13 in many countries, public wearing of masks has been considered as one of the key preventative measures of covid-19 transmission.14,15 community-wide mask wearing may contribute to the control of covid-19 by reducing the amount of emission of infected saliva and respiratory droplets from persons with subclinical or mild covid-19.16,17 however, use of masks in public and in health care facilities has been controversial as different organizations and agencies established different guidelines.18 the world health organization recommends surgical masks for health workers providing routine care to coronavirus disease patients, whereas the us centers for disease control and prevention recommend n95 respirators.19,20 in their review of 172 observational studies, chu et al. analyzed 44 comparative studies on evidence obtained from sars, mers, covid-19 and on beta coronaviruses causing these diseases and reported that the use of masks prevented infection.15 the respiratory mask has been found to reduce the risk of transmission by 67%, and the n95 mask by 96% in healthcare professionals. in total, the use of masks reduced the risk of infection by 85%. in addition, eye protection was found to reduce the risk of infection by 78%. infections in healthcare workers can result in not only deaths, but also the quarantine of many healthcare professionals which can lead to outbreaks in hospitals and to disruption in the health system. most authorities recommend that there’s no need for the community members to wear a mask, and that masks should only be worn by sick patients.15 on the other hand, evidence suggest that, if wearers are compliant to the standard precautions of wearing masks, the use of masks provide protection in high transmission settings such as the public and health care settings, and are more effective if used early when combined with hand hygiene.17,21-24 hence, it is necessary to wear masks in high transmission settings; such as workplaces, busses, trains, planes and other closed settings.18,15 in uganda, not any reports on mask utilization practices have been published yet. therefore, this report aims at documenting mask use practices, as observed in our interactions with non-covid-19 patients and their relatives at kabale regional referral hospital as well as kabale town residents. it was observed that many non-covid-19 patients and the relatives of hospitalized patients only wear their masks on reaching the hospital premises and wearing them off as soon as they leave the hospital gates. this behavior has been considered as a result of implementing guidelines of hospital covid-19 task force which only allows individuals with face masks to enter the hospital gates to access health services. furthermore, it was observed that community members of kabale town wear their masks in the presence of security agencies who may intercept their movements as security officers follow the directives of the president.13 additionally, individuals in the public only wear masks in places where they would be refused from services without masks and remove them as soon as they leave such facilities such as banks, supermarkets, markets and public offices. in conclusion, wearing of masks in public places and health care facilities together with other preventive measures including hand hygiene, social distancing and wearing of full personal protective equipment for health care providers working on covid-19 patients are key measures in preventing the spread of infection.17,19,22,25 despite the known benefits of wearing face masks, individuals in kabale town, kabale district of uganda seem to wear masks to please health workers at kabale regional referral hospital and security officers at different points where they encounter with them. more comprehensives studies are necessary to explore the utilization practices regarding the use of face masks, perceptions and contributory factors in kabale community. this report also highlights the increased need for the ugandan ministry of health 269 international journal of human and health sciences vol. 05 no. 02 april’21 and partner organizations to intensify community educational activities on public awareness of the importance of appropriate use of masks. these include both urban and rural communities who may not have access to radio and televisions since most of the current preventive measures on covid-19 are aired or televised. this may help communities embrace behavioral changes having arised due to the covid-19 pandemic. conflict of interest: the corresponding author and other co-authors declare that no conflict of interest exists. funds: the authors declare that no funding exists. ethical approval issue: not applicable. author contributions: mustafa ssaka: literature search, data collection, data analysis, manuscript writing, final approval of the version to be published, agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. charles lwanga: literature search, data collection, data analysis, manuscript writing, final approval of the version to be published, agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. tunc eren: literature search, data collection, data analysis, manuscript writing, manuscript editing, critical revision, final approval of the version to be published, agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved designation of the study and performed the research. orhan alimoglu: project development, data collection and management, data analysis, manuscript editing, critical revision, final approval of the version to be published, agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. references: 1. zhou f, yu t, du r, fan g, liu y, liu z, xiang j, wang y, song b, gu x, guan l, wei y, li h, wu x, xu j, tu s, zhang y, chen h, cao b. clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study. lancet 2020;395(10229):1054-62. doi: 10.1016/s0140-6736(20)30566-3 2. chan jfw, kok kh, zhu z, chu h, to kkw, yuan s, yuen ky. genomic characterization of the 2019 novel human-pathogenic coronavirus isolated from a patient with atypical pneumonia after visiting wuhan. emerg microbes infect 2020;9(1):221-36. doi: 10.1080/22221751.2020.1719902 3. world health organization. who director-general’s opening remarks at the media briefing on covid-19 11 may 2020. accessed: 3 june 2020. https://www. who.int/dg/speeches/detail/who-director-general-sopening-remarks-at-the-media-briefing-on-covid-19--11-may-2020 4. lunn p, belton c, lavin c, mcgowan f, timmons s, robertson d. using behavioural science to help fight the coronavirus. esri working paper 2020;656. accessed: 15 june 2020. http://aei.pitt.edu/102644/ 5. world health organization. coronavirus disease (covid-19) situation report – 133. accessed: 5 june 2020. https://www.who.int/docs/default-source/ coronaviruse/situation-reports/20200601-covid-19sitrep-133.pdf?sfvrsn=9a56f2ac_4 6. ministry of health, republic of uganda. update on the covid-19 outbreak in uganda. accessed: 15 june 2020. https://www.health.go.ug/document/updateon-the-covid-19-outbreak-in-uganda/ 7. cheng vcc, wong sc, to kkw, ho pl, yuen ky. preparedness and proactive infection control measures against the emerging novel coronavirus in china. j hosp infect 2020;104(3):254-5. doi:10.1016/j. jhin.2020.01.010 8. cheng vcc, wong sc, chen jhk, yip ccy, chuang vwm, tsang oty, sridhar s, chan jfw, ho pl, international journal of human and health sciences vol. 05 no. 02 april’21 270 yuen ky. escalating infection control response to the rapidly evolving epidemiology of the coronavirus disease 2019 (covid-19) due to sars-cov-2 in hong kong. infect control hosp epidemiol 2020;41(5):493-8. doi:10.1017/ice.2020.58 9. makerere university. characteristics and outcomes of initial patients diagnosed and treated with covid 19 in uganda. accessed: 22 may 2020. https:// covid19.munilabs.org/wp-content/uploads/2020/06/ covidepi-makerere-university-report.pdf 10. uganda virus research institute. 8 new covid-19 cases confirmed on 4th may 2020. accesssed: 5 may 2020. https://www.uvri.go.ug/news/8-new-covid-19cases-confirmed-4th-may-2020 11. the independent. uganda: 30 new covid cases. accessed: 8 june 2020. https://www.independent. co.ug/uganda-30-new-covid-cases/ 12. uganda media centre ministry of ict and national guidance, republic of uganda. president museveni address to the nation on matters regarding corona virus. accessed: 8 may 2020. https://www. mediacentre.go.ug/media/president-museveniaddress-nation-matters-regarding-corona-virus 13. eastern africa consortium for clinical research (eaccr2). covid-19 updates: 13th presidential address. accessed: 4 may 2020. https://www.eaccr. org/covid-19-updates-13th-presidential-address 14. ministry of health, republic of uganda. national guidelines for management of covid-19. accessed: 15 june 2020. https://www.health.go.ug/covid/ document/national-guidelines-for-management-ofcovid-19/ 15. chu dk, akl ea, duda s, solo k, yaacoub s, schünemann hj, covid-19 systematic urgent review group effort (surge) study authors. physical distancing, face masks, and eye protection to prevent person-to-person transmission of sarscov-2 and covid-19: a systematic review and meta-analysis. lancet 2020;s0140-6736(20)311429. doi:10.1016/s0140-6736(20)31142-9 16. cheng vc, wong sc, chuang vw, so syc, chen jhk, sridhar s, to kkw, chan jfw, hung ifn, ho pl, yuen ky. the role of community-wide wearing of face mask for control of coronavirus disease 2019 (covid-19) epidemic due to sars-cov-2. j infect 2020;81(1):107-14. doi:10.1016/j.jinf.2020.04.024 17. world health organization. advice on the use of masks in the context of covid-19. accessed: 8 june 2020. https://www.who.int/publications/i/item/ advice-on-the-use-of-masks-in-the-communityduring-home-care-and-in-healthcare-settings-in-thecontext-of-the-novel-coronavirus-(2019-ncov)-outbreak 18. chen n, zhou m, dong x, qu j, gong f, han y, qiu y, wang j, liu y, wei y, xia j, yu t, zhang x, zhang l. epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study. lancet 2020;395(10223):507-13. doi:10.1016/s01406736(20)30211-7 19. world health organization. infection prevention and control during health care when novel coronavirus (ncov) infection is suspected. accessed: 8 june 2020. https://www.who.int/publications/i/item/10665331495 20. centers for disease control and prevention (cdc). infection control guidance for healthcare professionals about coronavirus (covid-19). accessed: 15 june 2020. https://www.cdc.gov/ coronavirus/2019-ncov/hcp/infection-control.html 21. chughtai aa, seale h, islam ms, owais m, macintyre cr. policies on the use of respiratory protection for hospital health workers to protect from coronavirus disease (covid-19). int j nurs stud 2020;105:103567. doi:10.1016/j. ijnurstu.2020.103567 22. macintyre cr, chughtai aa. a rapid systematic review of the efficacy of face masks and respirators against coronaviruses and other respiratory transmissible viruses for the community, healthcare workers and sick patients. int j nurs stud 2020;108:103629. doi:10.1016/j.ijnurstu.2020.103629 23. cowling bj, chan kh, fang vj, cheng cky, fung rop, wai w, sin j, seto wh, yung r, chu dws, chiu bcf, lee pwy, chiu mc, lee hc, uyeki tm, houck pm, peiris jsm, leung gm. facemasks and hand hygiene to prevent influenza transmission in households: a cluster randomized trial. ann intern med 2009;151(7):437-46. doi:10.7326/0003-4819151-7-200910060-00142. 24. macintyre cr, cauchemez s, dwyer de, seale h, cheung p, browne g, fasher m, wood j, gao z, booy r, ferguson n. face mask use and control of respiratory virus transmission in households. emerg infect dis 2009;15(2):233-41. doi:10.3201/ eid1502.081167. 25. howard j, huang a, li z, tufekci z, zdimal v, van der westhuizen h, von delft a, price a, fridman l, tang l, tang v, watson gl, bax ce, shaikh r, questier f, hernandez d, chu lf, ramirez cm, rimoin aw. face masks against covid-19: an evidence review. preprints 2020;2020040203. doi:10.20944/preprints202004.0203.v2. 305 international journal of human and health sciences vol. 04 no. 04 october’20 case report: inflammatory myofibroblastic tumor of the breast: a case report ahmet salih karaoglu1, mahmut hudai demir1, abdullah ayaz1, hamza uysal1, tuce soylemez2, tunc eren3, abdullah aydin2, orhan alimoglu3 abstract: inflammatory myofibroblastic tumors (imts) of the breast are extremely uncommon lesions, usually labelled as a subgroup of inflammatory pseudotumors. they are composed of inflammatory cells and bland spindle cells without nuclear atypia. nearly half of all imts of the breast include clonal translocation of the anaplastic lymphoma kinase (alk) gene, located at the chromosome band 2p23, and generally present with a palpable lump, swelling, and pain. herein, we present a 66-year-old female patient with pain, swelling and a palpable lump in her right breast. a 40×26 mm sized t1a hypointense and t2a hyperintense mass with slightly lobulated margins was detected at breast magnetic resonance imaging. a mass associated with an intramammary lymph node was evaluated in the upper inner quadrant of the right breast via mammography. the results were considered as bi-rads 3. breast-conserving surgery with sentinel lymph node biopsy was performed. during pathological evaluation, cytoplasm with poorly-defined margins, and large-nucleoli tumor cells with benign ducts between these tumor cells, were observed. intensive inflammatory cell infiltration and sclerotic changes in different areas were also noted. the lesion stained positive for caldesmon, smooth muscle actin, vimentin, cd10, and s100; however, it was negative for alk on immunohistochemistry. the patient remained disease-free after the surgical procedure. keywords: inflammatory pseudotumor, inflammatory myofibroblastic tumor, breast, anaplastic lymphoma kinase. correspondence to: prof. dr. orhan alimoglu, department of general surgery, faculty of medicine, istanbul medeniyet university goztepe training & research hospital, dr. erkin street, goztepe, 34722, kadıkoy, istanbul, turkey. e-mail: orhan.alimoglu@medeniyet.edu.tr 1. faculty of medicine, istanbul medeniyet university, istanbul, turkey. 2. department of pathology, faculty of medicine, istanbul medeniyet university, istanbul, turkey. 3. department of general surgery, faculty of medicine, istanbul medeniyet university, istanbul, turkey. international journal of human and health sciences vol. 04 no. 04 october’20 page : 305-308 doi: http://dx.doi.org/10.31344/ijhhs.v4i4.218 introduction inflammatory myofibroblastic tumors (imts) are usually labelled as a subgroup of inflammatory pseudotumors.1 imts are comprised of bland spindle cells without nuclear atypia and inflammatory cells such as plasma cells, lymphocytes and eosinophils.2 they can be found in various anatomic locations such as the lungs, kidneys and breasts.3-10 inflammatory myofibroblastic tumors are extremely rare lesions, even rarer in the breast compared to the other parts of body.3,4,7,10 imts are mostly presented with a palpable lump, swelling, and pain. nearly half of all imts of the breast include clonal translocation of the anaplastic lymphoma kinase (alk) gene located at the chromosome band 2p23.5 in this article, we aimed emphasize this rare tumor type and provide a substantial addition to the literature. case report a 66-year-old female patient who had a family history of breast cancer presented with pain, swelling, and a palpable lump in the upper inner quadrant of her right breast. in her past medical history, she had previously undergone appendectomy, tonsillectomy, and thyroidectomy. moreover, she had been diagnosed with hypertension, diabetes mellitus type 2, and asthma. upon physical examination, a mass with a size of approximately 4×4 cm was palpated in the upper inner quadrant of her right breast. the examination of her bilateral axillae was unremarkable. breast ultrasonography (us) revealed a 39×31 mm lesion including microcalcification with rough and lobulated margins. furthermore, a breast magnetic international journal of human and health sciences vol. 04 no. 04 october’20 306 resonance imaging (mri) showed a 40×26 mm, t1a hypointense and t2a hyperintense mass with slightly lobulated margins in the upper inner quadrant of her right breast (figure 1 and 2). a mass associated with an intramammary lymph node was evaluated in the upper inner quadrant of her right breast. the results were considered birads 3. breast-conserving surgery with sentinel lymph node biopsy was performed as follows. periareolar methylene blue was injected under general anesthesia. two lymph nodes were excised and sent to frozen examination. a batwing incision was created in the upper inner quadrant of the right breast and a wide excision was performed, including the tumor, to the boundary of the major pectoral muscle. the specimen was sent for frozen section examination. no metastasis was detected via sentinel lymph node biopsy, the surgical margins of the specimen were intact, and the operation was terminated. figure 1: breast mri (t1a and t2a). figure 2: breast mri (t1a and t2a). discussion in 1939, the imt was described in the lungs for the first time in medical literature.6 imts are infrequent tumors that can be found in different anatomic locations including the lungs, omentum, retroperitoneum, mesentery, extremities, liver, spleen, head, thyroid, and urinary bladder.3,4,7,10 imts present with a firm palpable mass. in our case, the patient presented with a palpable breast lump, and pain. imts are microscopically characterized by the proliferation of spindle cells and inflammatory cells such as the lymphocytes, plasma cells, and histiocytes.8,9 in our case, largenucleoli tumor cells with benign ducts between these tumor cells were observed. intensive inflammatory cell infiltration and sclerotic changes in different areas were also noted (figure 3). despite numerous hypotheses, the pathogenesis of imts has not truly been understood. however, the most appropriate hypothesis is that the inflammatory process is due to either infectious or non-infectious stimuli. aberration of the long arm of chromosome 2 and the short arm of chromosome 9 has been reported in recent studies.10 in approximately half of imt cases, alk gene mutation at 2p23 has been noted.1,2,11 the lesion stained positive for caldesmon, smooth muscle actin, vimentin, cd10, and s100; however, it was negative for alk on immunohistochemistry in our case. from our observations of what has been reported in literature, the mediterranean climate region and asian populations have shown a higher frequency of imts of the breast when compared to other populations. we investigated 32 imts of the breast in pubmed, and 13 such cases were associated with asian populations, 13 were associated with the mediterranean climate region while the remaining six were associated with other regions. our patient was from a region with a mediterranean climate. according to this data, we consider that imts of the breast may be correlated with specific geographical regions. our patient remained disease-free after the surgical procedure. we would like to emphasize the importance of keeping this rare condition in mind as a differential diagnosis during the clinical evaluation of a palpable breast mass. conflict of interest: no conflict of interest has been disclosed by the authors. funds: the authors declare that no funding exists. author contributions: 307 international journal of human and health sciences vol. 04 no. 04 october’20 a b figure 3 (a, b, c): tumor consisting of spindle shaped neoplastic cells with accompanying inflammatory cells [hematoxylin and eosin stain, 40× (a), 200× (b), and 400× (c)]. b a.s. karaoglu designed the research study and wrote the manuscript. m. h. demir, a. ayaz, and h. uysal contributed to the designation of the study and performed the research. t. söylemez and a. aydın performed the research and contributed to the collection and assembly of the data. o. alimoğlu and t. eren performed the research, contributed to the collection and interpretation of the data, and performed the critical revision of the article for important intellectual content. ethical approval issue: n/a. international journal of human and health sciences vol. 04 no. 04 october’20 308 references: 1. bosse k, ott c, biegner t, fend f, siegmann-luz k, wallwiener d, et al. 23-year-old female with an inflammatory myofibroblastic tumor of the breast: a case report and a review of the literature. geburtshilfe und frauenheilkunde. 2014;74(2):167–170. 2. gleason bc, hornick jl. inflammatory myofibroblastic tumors: where are we now? journal of clinical pathology. 2008;61(4):428–437. 3. kim ey, lee ik, lee ys, yang n, chung dj, yim ki, et al. inflammatory myofibroblastic tumor in colon. j korean surg soc. 2012;82:45-49. 4. gilani sm, kowalski pj. inflammatory myofibroblastic tumor: a rare entity with wide differential diagnosis. pathologica. 2014;106(1):1–6. 5. griffin ca, hawkins al, dvorak c, henkle c, ellingham t, perlman ej. recurrent involvement of 2p23 in inflammatory myofibroblastic tumors. cancer res. 1999;59:2776–2780. 6. brunn h. two interesting benign lung tumors of contradictory histopathology: remarks on the necessity for maintaining chest tumor registry. j thorac surg. 1939;9:119-131. 7. zhao hd, wu t, wang jq, zhang wd, he xl, bao gq, et al. primary inflammatory myofibroblastic tumor of the breast with rapid recurrence and metastasis: a case report. oncology letters. 2013;5(1):97–100. 8. zhou y, zhu j, zhang y, jiang j, jia m. an inflammatory myofibroblastic tumor of the breast with alk overexpression. bmj case reports. 2013; 2013. article id bcr0720114474 9. gobbi h, atkinson jb, kardos tf, simpson jf, page dl. inflammatory myofibroblastic tumor of the breast: report of a case with giant vacuolated cells. breast. 1999; 8(3):135–138. 10. lecuona at, van wyk ac, smit sg, zarrabi ad, heyns cf. inflammatory myofibroblastic tumor of the bladder in a 3-year-old boy. urology. 2012;79:215– 218. 11. downing jr, shurtleff sa, zielenska m, curciobrint am, behm fg, head dr, et al. molecular detection of the (2;5) translocation of non-hodgkin’s lymphoma by reverse transcriptase-polymerase chain reaction. blood. 1995;85(12):3416–3422. 49 international journal of human and health sciences vol. 02 no. 02 april’18 review article: keeping communities healthy: the islamic paradigm nordin mm abstract one of the five matters before being overtaken by its opposite as advocated by the prophet (saw) was “your health, before you fall sick” (muslim). this concept of the prophet’s medicine (tibb nabawi) has been much discussed and unfortunately misunderstood, even abused in recent times. this paper attempts to examine the quranic exhortations on health and healing and its practices as exemplified by authentic traditions of the prophet (saw). this would enable us to extract guiding principles about various healthcare issues including holistic care, preventative strategies, training, bioethics, hospital services, clinical research and global health. correspondence to: dato’ dr musa mohd nordin frcp (edin), frcpch (uk), famm chairman, advisory board federation of islamic medical associations (fima) international journal of human and health sciences vol. 02 no. 02 april’18 page : 49-54 health: a blessing from allah health is a precious gift, a blessing from allah (swt) which should be protected and enhanced. without good health, we would not be able to live up to our physical potential as his khalifah (vicegerent) on earth to undertake amar maaruf nahi mungkar, to enjoin good and to forbid evil and to pursue the communal quest for adlwaihsan(justice with fairness and mercy), the preservation of public interest (maslahah amah), mutual benefit (masalih mushtarakah) and protection from harm (dar’ al mafasid). unfortunately, this blessing is often forgotten or not prioritized by many amongst us. this was alluded to by the prophet muhammad (saw) when he said; “there are two blessings which many people do not appreciate, health and leisure time” (muslim &bukhari) quranic verses of healing and although the quran is primarily a book of hidayah (guidance), it nonetheless makes reference to health and healing. six verses in the quran have been described as verses of shifaa’ (healing). one of these verses, in surah as-shu’ara, 26:80, describes prophet ibrahim’s (as) recognition of his ultimate healer; “and when i fall sick, he heals me” and to the jewish community during the time of prophet isa (as), where the healers were held in high esteem, prophet isa (as) was sent with medical miracles (mu’jizat), emphasizing the need to be at the cutting edge of medical sciences: “… and i cure the blind and the leper, and i give life to the dead by permission of allah …” (aliimran, 3:49) health within the context of the maqasidshari’ah the cardinal purposes of the muslim’s individual, community, national and global life experiences have been comprehensively defined by the maqasidshari’ah, the higher objectives of islamic jurisprudence1. the well being of the community is protected by the preservation of the fiveessentials(daruriyyat) in human life, namely faith and morality (deen), life (nafs), intellect (‘aql), progeny (nasl) and wealth (maal). allah says in surah al-maidah, 5:32; “and if anyone saved one life, it would be as if he had saved mankind entirely” three of the priorities of the maqasidshari’ah are directly related to health whilst the first (deen) and the fifth (maal) essentials in the hierarchy, though indirect are intimately associated. thus, the objectives of the healthcare system are to nurture a community which is healthy and morally upright, prevent premature and inappropriate international journal of human and health sciences vol. 02 no. 02 april’18 50 deaths, protect against intellectual and physical disabilities, promote safe reproduction and proliferation of the human seed through the utilization of health intervention programs which are cost-effective. a bias for preventative health strategies a pervasive thread in the islamic paradigm, whether in economic, social or health matters is the emphasis on preventative strategies. the prevention of diseases and the preservation of wellness are pillars of best practices in medicine. apart from the injunctions in the quran and authentic hadiths, it is based on a principle of jurisprudence, ةعیرذلادس, closing all avenues of destruction. several principles of health care practises and interventions can be summarized as follows2: • the prophet muhammad (saw) said, “cleanliness is half of faith (iman) (muslim)”. this hadith which connects cleanliness with belief is a cornerstone in islam’s advocacy for optimal health. • the quran advocates healthy eating and encourages the believers to eat only permissible and good food “o mankind, eat from whatever is on earth [that is] lawful and good and do not follow the footsteps of satan. indeed, he is to you a clear enemy.” (albaqarah 2:168). there are numerous statements that have been recorded in both the qur’an and the hadith of the prophet (saw) encouraging muslims to be moderate in eating and drinking. and eat and drink and be not extravagant; surely he does not love the extravagant. (al-a`raf 7: 31) “no human ever filled a container more evil than his belly. the few morsels needed to support his being shall suffice the son of adam. but if there is no recourse then one third for his food, one third for his drink and one third for his breath.” (ahmad and at-tirmidhi) • the prophet (saw) in various hadiths enjoined his companions to exercise. he said, “a strong believer is better than a weak believer” (muslim). thus, a muslim is enjoined to be not only strong in faith and character but also in physical strength and fitness through regular exercises. • islam recognises the existence of contagious diseases and the prophet (saw) commanded us to avoid such diseases. he said: “run away from the leper same as you would from a lion.” [bukhari and muslim]. • islam also introduced the concept of quarantine in the event of an infectious outbreak. the prophet (peace be upon him) said: “if you hear that a land has been stricken by plague, do not approach it, and if your land is stricken by plague, do not leave it”. [sahîh al-bukhari] health professional training versus quackery the believers are urged to seek medical treatment when they are ill. and when a cure is available some scholars would even suggest it as being mandatory. the prophet (saw) said: “seek medical treatment, for truly allah does not send down a disease without sending down a cure for it. those who have knowledge of the cure know it, and those who are ignorant of it do not.” [musnad ahmad] the prophet (saw) is also reported to have said: “he is not one of us who is not kind to children or does not respect our elders, or denies our learned people the esteem they deserve” (abu dawud, altirmidhi) the two earlier hadiths also illustrates islam’s high regard for people who are experts and highly trained in their specialty and muslims are enjoined to seek treatment from these health professionals. this hadith is especially instructive and relevant in this modern world of information and communication technology where individuals and groups claim to be overnight experts in medicine by simply accessing information from the internet. an incident which happened during the time of the prophet muhammad (saw), further emphasizes the importance of authentic knowledge and specialty training. when a man fell ill, the prophet (saw) said, “summon the physician of the tribe so and so for him.” (ahmad). it also shows the prophet’s (saw) criticism of the ignorant who blindly practise the art of healing without the pre-requisite medical knowledge and skills. code of medical ethics the early physicians who worked in the medieval muslim hospitals were required to follow a strict code of ethical practices. ishaq bin ali al-rahawi’s (854-931 ad) adab al-tabib (the conduct of a physician), is the earliest known arabic treatise dedicated to medical ethics. rahawi considered physicians as “guardians of souls and bodies” and in this treatise he spells out all the deeds and acts a muslim physician must observe. he also described the process of licensing physicians, when he wrote: “...the physician was not allowed to sit for treating patients until after 51 international journal of human and health sciences vol. 02 no. 02 april’18 he passes the generally aforementioned tests and examinations…” this was later enforced into law during the abbasid caliphate whereby all doctors were required to pass an examination before being allowed to practice medicine. this physician licensure became mandatory after the caliph al-muqtadir, in 931 ad, was informed of the death of one of his subjects due to a physician’s error. individual autonomy versus community interest the ethical principle of autonomy highly respects and values the individual (or parents or legal guardians) as the one who makes the self-defining choices upon which he then acts and for which he is accountable. this however needs to be considered within the context of the wider public interest and benefits (maslahah ammah). this is defined by the islamic legal maxim (al-qawa’id al-fiqhiyyah) which stipulates: “individual rights may have to be sacrificed in order to protect the public interest.” in the domain of healthcare, medical interventions such as global immunization programs, which have been proven to promote and protect the general health and well being of the community, have priority over the considerations of the individual interest. the early muslim hospitals the prophet’s mosque in the city of madinah held the first muslim hospital service in its courtyard. during the ghazwahkhandaq (battle of the trench), muhammad ordered a tent to be assembled to provide medical care to the wounded soldiers. among those who attended to the injured soldiers was the first muslim nurse, rufaida al-aslamia. the prophet muhammad (saw) used to order all casualties to be carried to her tent so that she might treat them with her nursing and medical expertise. this later evolved into the many bimaristans, a persian word meaning “house of the sick”, during the early islamic rule. the umayyad caliph alwalidibnabd al-malik is often credited with building the first bimaristan, in damascus in 707 ad. many of these early hospitals were built with charitable endowments, waqf3. they were staffed by salaried physicians who did regular ward rounds. pharmacists dispensed medicines from the well equipped dispensaries. there were separate wards for men and women and wards were segregated according to the type of illnesses. patients were nursed until they have fully recovered and upon discharge were given a sum of money for their immediate personal needs. there is good reason to believe that the christians were impressed by the hospitals they overran during the crusades. a network of hospitals later spread across europe which were influenced and modeled on the famous islamic hospitals in cairo and damascus. search for cures and the first clinical trials abu hurairah (ra) narrated that the prophet (saw) said: “there is no disease that allah has created, except that he also has created its remedy.” (bukhari) in this and several other hadiths, the prophet (saw) advocated research into the finding of cures for ailments, thus urging the believers to be at the frontiers of medical research. this inspired the likes of physician, al-razi (854 – 925 ad) who carried out the earliest known example of a clinical research trial on the effectiveness of bloodletting in the treatment of patients with meningitis by employing a control group. this demonstrates al-razi’s commitment to evidence based medical science4. ibnsina (980 – 1037 ad) in his magnum opus, al qanun fi tibb (the canons of medicine) outlined 7 principles before a medicine can be considered to be effective5. among others he emphasized that trials which were successful in animal models must be replicated in human subjects. and that the results of the trials should be reproducible in other similar research. in this respect, the wakefield claim of the link between the mmr vaccine and autism has never been reproduced in other studies. on the contrary, this claim has been debunked in at least 67 different studies.6 health status in muslim countries there are over 1.8 billion muslims living in 57 muslim majority countries. the health of the muslims communities can be benchmarked against a set of 8 millennium development goals (mdg), from the baseline statistics in 1990 up to 2015.7 mdg 4, 5 and 6 are directly related to the health of the communities whilst the health sector is an important stakeholder in the other five mdgs. mdg 4 calls for a 2/3 reduction in the mortality of children under 5 years old by 2015. 1 in 12 children die in muslim countries compared to 1 in 18 in world. many of these under five deaths are preventable with the introduction of basic public health interventions which include, access to safe international journal of human and health sciences vol. 02 no. 02 april’18 52 drinking water, good nutrition, breastfeeding, hygienic sanitation and immunization.8 mdg 1 calls for the eradication of extreme poverty and hunger and among others targets to halve the proportion of people who suffer from hunger. nearly half of the under-5 children in some muslim countries are underweight and stunted. and one of the major risk factor for under-5 deaths is malnutrition. thus the close relationship between the economic status of communities, rates of malnutrition of its mothers and children and a health indicator as in mdg 4. mdg 5 calls for improvement of maternal health, through ¾ reduction of maternal deaths. many muslim countries are not on track to achieve mdg 5. in afghanistan 1 in 6 pregnancies results in death, in africa 1 in 15 as against the global average of 1 in 74 pregnancies. this is due to the high fertility rates, low average age of pregnancies, illiteracy, lack of antenatal care, lack of access to skilled obstetric care and complicated by the compromised social and economic status of women in these communities. some muslim countries have however made considerable progress in their health programs. maldives and iran have reduced their maternal mortality ratios by more than 80% and are on target for mdg 5. the under-5 mortality in malaysia has been significantly reduced from 16.8 to 7.7 per 1,000 live births from 1990 to 2012. the maternal mortality ratio declined from 44 to 25.6 per 100,000 live births from 1991 to 2012. the challenges for malaysia to be on track for mdg 4 and 5 is to enhance health care providers’ knowledge and skills, provision of family planning services for high risk mothers, expansion of the integrated management for childhood illness program and prevention of childhood injuries.9 progress in the health status of other muslim communities have been hampered by natural disasters, economic crises, political instability, armed conflicts, rural urban migration, breakdown of basic social structures and ultra-conservatism of some of its religious scholars. reclaiming the lost heritage and moving forward history will testify that the early muslim scientists dominated virtually most aspects of knowledge and research from 600 – 1700 ad. az-zahrawi (930-1013 ad), the father of modern surgery, was pioneering new surgical instrumentations when europe was restricted by a religious edict in 1163 ad which ruled: “all forms of surgery must be stopped in all medical school by all surgeons” is it any wonder that martin kramer, an american historian wrote10: “had there been nobel prizes in 1000, they would have gone almost exclusively to muslims.” somehow, muslim communities have lost it along the way and have lagged behind in developing their health systems which they once led and inspired the world during the glorious days of islamic civilization. religious conservatism, has undoubtedly been one of the contributory factors to the decline and stagnation of the pursuit of science and the spirit of enquiry and research in the muslim world today. in the eradication of smallpox, the last few cases were from bangladesh and somalia. and the global polio eradication initiative (gpei) targets 2018 to end polio and three muslim countries are still polio endemic, namely, afghanistan, nigeria and pakistan.11 we should never loose sight of the compassionate and humane nature of islam as exemplified in surah al-hajj, 22:78: “and strive for allah with the striving due to him. he has chosen you and has not placed upon you in the religion any difficulty.” and an authentic tradition further fortified this concept as narrated by aisha (ra) “if given an option between 2 actions, the prophet (saw) would surely choose the easier one, as long as it is not sinful.” (bukhari) when deliberating the permissibility of the oral polio vaccine (opv) which is manufactured using porcine-based trypsin, at the 11th session of the european council of fatwa & research (ecfr) from 1-7 july 2003, in stockholm, the ecfr concluded;12 “the council urges muslim leaders and officials at islamic centers not to be too strict in such matters that are open to considered opinion and that bring considerable benefits to muslim children, as long as these matters involve no conflict with any definite text.” and we firmly believe this spirit and approach pervades the corpus of the jurisprudence of facilitation (fiqh taysir). at no point in time does it blemish the belief nor practice of the faithful because scholars have anticipated the challenges of modernity and have reiterated; “allah will bless the believer who recognises and engages with the new world, yet remains true to 53 international journal of human and health sciences vol. 02 no. 02 april’18 his religious values.” investments in the health and education of muslim communities should be among the major priorities of our political and economic leaders. the caliphs of the early islamic era took a very keen interest in the building of health infrastructure. in the early tenth century, caliph al-muktafi (died 907), called upon al-razi to decide on the selection of a site for the new hospital. al-razi hung up pieces of meat in various districts of baghdad and advised the site where the meat decayed the least to be selected. this is the first scientific observation of unknown particles (germs) in air which led to air borne diseases! caliph al-muqtadir (ruled from 908-932 ad), his successor, built several more hospitals and staffed them with the best physicians, many of them christians and jews; and filled the libraries with the latest books and writings. hospitals were also found in the other large cities in the islamic empire, notably cairo and cordoba, whilst europe was still trapped in the “dark ages”. we hope and pray to allah (swt) that our muslim communities would be governed by similarly enlightened political and socio-economic leadership. in this context, it is worthwhile considering the wise words of pervez hoodbhoy, a pakistani physicist, who wrote;13 “with well over a billion muslims and extensive material resources, why is the islamic world disengaged from science and the process of creating new knowledge? common sense and the principles of logic and reason (are) our only reasonable choice for governance and progress. being scientists, we understand this easily. the task is to persuade those who do not.” we also hope and pray to allah (swt) that our countries would be similarly blessed with peace, security and protected from major natural disasters. and that as a community we would be inspired by the following hadith, to catch up on lost ground and rejuvenate our quest for leadership in the medical sciences and other aspects of scientific scholarship in the continuous process of islah(transformation) towards the community’s health and well-being. “a word of wisdom is the lost property of a muslim. he should seize it wherever he finds it.”(at-tirmidhi) international journal of human and health sciences vol. 02 no. 02 april’18 54 references 1. shari’ah intelligence. the basic principles and objectives of islamic jurisprudence. islamic education trust nigeria. august 2015: 161 2. musa mn et al. immunisation controversies. what you really need to know. august 2015:90-93 3. pe pormann et al. medieval islamic medicine.. american university in cairo press, 2007. page 9 4. jim al-khalili.the golden age of arabic science. 2012:138-51 5. abdul rashid ar. medicines, supplements and herbs for women. fiqh medicine convention 2.0. 19 april 2015 6. margaret a. maglione et al. safety of vaccines used for routine immunization of us children: a systematic review. pediatrics. june 2014 7. http://www.un.org/millenniumgoals/ accessed 13 dec 2015 8. health in the muslim world: meeting the mdgs. fima year book 2012. pages 13-18 9. h t t p : / / w w w. m o h . g o v. m y / i m a g e s / g a l l e r y / publications/health%20facts%202014.pdf accessed 13 dec 2015 10. martin kramer.islam’s sober millennium. jerusalem post. december 31, 1999. 11. gpei scientific declaration on polio eradication 2013. immunisation controversies-what you really need to know. august 2015: 208-209 12. fatwa 11/11.the 11th regular session of the european council of fatwa & research. 1-7 july 2003. stockholm, sweden. 13. pervez amiralihoodbhoy.science and the islamic world-the quest for rapprochement. physics today; 2007;49:49-55 international journal of human and health sciences vol. 05 no. 01 january’21 118 case report: challenges in diagnosis of chronic osteomyelitis : a case report from sri lanka v. thadchanamoorthy1, kavinda dayasiri2 abstract: the prevalence of osteomyelitis has been continuously decreasing in children with improvement of health care services and introduction of hemophilus and pneumococcal vaccines. despite this, diagnosis and management of osteomyelitis are often a challenge to pediatricians as well as orthopedic surgeons. we report a 13-year old boy who had been treated as for rheumatic fever over 2 years with benzathene penicillin, but ultimately turned out to have chronic osteomyelitis of right tibia. evidence of chronic osteomyelitis was radiologically confirmed by x-ray and computerized tomogram (ct) of right tibia and pus cultures grew staphylococcus aureus. clinical features and biochemical markers completely resolved upon debridement of pus and intravenous antibiotics. he is currently on follow up at the orthopedic and pediatric clinics in the local hospital. keywords: challenges in diagnosis, chronic osteomyelitis, debridement, staphylococcus aureus. correspondence to: dr. kavinda dayasiri, department of pediatrics, base hospitalmahaoya, sri lanka. e-mail: kavindadayasiri@gmail.com 1. honorary consultant pediatrician&amp; senior lecturer, faculty of health care science, eastern university, sri lanka. 2. consultant pediatrician department of pediatrics, base hospital mahaoya, sri lanka. international journal of human and health sciences vol. 05 no. 01 january’21 page : 118-121 doi: http://dx.doi.org/10.31344/ijhhs.v5i1.246 introduction chronic osteomyelitis frequently affects long bones of arms and legs in children, but other bones are not exempt1. it often represents a catastrophic continuum of delay in diagnosis2. the main causative organisms are bacteria but other organisms include fungi and tuberculosis especially in immunocompromised children3. the organisms spread to bone either from blood or adjacent tissues4.diagnosis is naturally based on clinical features and supported by microbiological and radiological confirmation5. variable and unusual clinical presentations often hinder accurate diagnosis of osteomyelitis6. although chronic osteomyelitis is a rare disease in children7, it might cause severe sequelae such as growth failure, septic arthritis, destruction of joints, and permanent disability8. while delayed diagnosis can cause anxiety and apprehension in parents, the disease can have a lifelong impact due to complications9. we report a child, in whom chronic osteomyelitis was initially mistakenly diagnosed as rheumatic fever and chorea, and 4-weekly prophylaxis with benzathene penicillin was given for one year, before the diagnosis of chronic osteomyelitis was confirmed in retrospect. case report a-13-year old child presented with right knee joint pain and right sided limp for one year and right knee joint swelling for one month duration. one year ago, he had been investigated for right knee joint pain, and fever with blood and radiological investigations at the local hospital.the investigations revealedelevated c-reacting protein (crp), increased erythrocyte sedimentation rate (esr), antistreptolysin o titre (asot) >800 u/ mland increased white blood cells. x-ray and ultrasound of right knee joint had been reportedly normal. subsequently, he was treated as for acute rheumatic fever and had been on 4-weekly intramuscular benzathene penicillinup to the current presentation. notably, there had been no improvement in knee joint pain while on antibiotic prophylaxis and limp persisted. then he was reevaluated forabnormal lower limb movements which were misinterpreted as rheumatic chorea and treatment was continued.over the course, he was on antibiotic prophylaxis, several courses 119 international journal of human and health sciences vol. 05 no. 01 january’21 of oral antibiotics and non-steroidal antiinflammatory drugs (nsaids) were prescribed as for pharyngitis and knee joint pain by the general practitioner; however, the clinical improvement of right knee joint pain was only temporary and pain recurred upon discontinuation of antibiotics. there had been no history of falls or trauma to right lower limb. physical examination revealed an ill-looking, mildly febrile (37.8c), and limping child with objectively demonstrable swelling over anterior aspect of the right knee joint. the movements of the right knee joint were restricted by pain. rest of the musculoskeletal and other system examination were normal.investigations revealed leucocytosis (15.6x103, n-74%), elevated crp (190mg/dl), and esr(78mm/hour). x-ray right knee joint showed periosteal elevation which was suggestive of osteomyelitis (figure 1). this was further explored by ct right knee joint as mri(magnetic resonance imaging) was not available and ct revealed evidence of periosteal reactions, cortical destruction, and sequestrum formation. pus and necrotic tissues were drained and sent for cultures by orthopedic surgeon; pus cultures grew staphylococcus aureus and were sensitive to intravenous cloxacillin.blood cultures yielded no growth.following diagnosis of chronic osteomyelitis, he was initially treated with intravenous ampicillin and cefotaxime, and later changed to intravenous cloxacillin for total of two weeks, followed by further 4-week course of oral antibiotics. repeated x-ray, non-contrast ct and blood investigations 4 weeks after commencement of antibiotics revealed normal findings. in addition, he was free of pain and limping had completely resolved. he was able to resume his normal day-to-day activities. at 6 months review, he was found to have normal function of right knee joint and was discharged from care. figure 1 shows periosteal erosions of proximal anterior tibia and figure 2 shows sclerotic changes which are suggestive of osteomyelitis. discussion this report highlights the importance of revisiting initial diagnosis when clinical features persist despite initial management. clinical features of rheumatic fever often overlap with suppurative arthritis and adjacent osteomyelitis10. during the first two weeks of the course of osteomyelitis, x-ray findings are often normal and repeating x-ray is crucial for children with persistent joint and bone pains managed in centers with limited figure 1: periosteal erosions in proximal anterior tibia (x-ray image). figure 2: sclerotic bone changes in proximal anterior tibia (ct image). diagnostic facilities. although ultrasound is helpful in early detection of septic arthritis, the value of ultrasound in diagnosing osteomyelitis is limited11. a low index of suspicion of chronic osteomyelitis is one of the main reasons for its delayed diagnosis12. osteomyelitis is seen more commonly in children with risk factors such as indwelling intravascular catheters, systemic diseases such as sickle cell anemia and chronic granulomatous disease13. children who have had penetrating or puncture wounds are also at risk of direct inoculation of bacteria causing osteomyelitis14. the disease has been reported predominantly in male children15. in the absence of specific risk factors, the likely route of entry of infection in the reported child is international journal of human and health sciences vol. 05 no. 01 january’21 120 hematogenous. in addition to clear radiological evidence of osteomyelitis, pus cultures yielded the etiological agent in this child. however, blood culture was negative. studies have reported that cultures could be negative in up to 50% of cases with osteomyelitis16. this group of children had a longer duration of bone pain but excellent response to a course of empirical anti-staphylococcal antibiotics with better long term outcomes. acute osteomyelitis almost unvaryingly happens in children because of the rich blood supply to growing bones. further, long bones are commonly involved in children compared to adults17. microorganisms infect bone through one or more of three basic methods which are via the bloodstream (haematogenous), nearby areas of infection (as in cellulitis) and penetrating trauma. staphylococcus aureusis the most common organism causing osteomyelitis18.other organisms include group b streptococci, escherichia coli, streptococcus pyogenes, and haemophilus influenza18. gram-negative bacteria, including enteric bacteria, are significant pathogens in splenectomized patients and intravenous drug users19. pus culture grew staphylococcus aureus in our child which was sensitive to several antibiotics including cloxacillin. once the infection enters into metaphysis of the bone via the blood stream, leucocytes march to engulf the organism and lyse and form pus in the bone20. pus, in turn, tracts into blood vessels and impedes blood flow leading to formation of sequestra20. subsequently, body tries to form a new bone at the place of sequestra. when this process is chronic, organisms start exhibiting resistance to antibiotics21. the continuum of this pathological process leads to chronic disability22. the gold standard for diagnosis of chronic osteomyelitis is considered to be supportive histopathological findings in bone biopsy and positive bone cultures23. magnetic resonance imaging (mri) is superior to other radiological methods in soft tissue characterization in chronic osteomyelitis and is the imaging modality of choice24. a high index of suspicion is crucial for early diagnosis and early treatment prevents complications of bone destruction. mri and specific histopathological evaluation facilities were not available in current treatment facility; however, empirical treatment led to complete resolution of clinical and radiological features and physical disability. osteomyelitis frequently needs lengthy antibiotic therapy for several weeks or months with or without surgical debridement. antibiotics are selected empirically by the patient’s history and epidemiological pattern of common infective organisms. a number of centers suggest treatment for 6 weeks25. our child received 6 weeks treatment with surgical intervention. whilst chronic osteomyelitis is rare in the pediatric age group, early diagnosis could be challenging due to overlap with other rheumatological diseases and variability in clinical presentation. high index of suspicion is required for early diagnosis. aggressive treatment with parenteral antibiotics and surgical debridement are likely to prevent long term physical disability. acknowledgement we thank dr.d.m.c.l bopitiya, consultant orthopedic surgeon, teaching hospital, batticaloa, sri lanka. funding:not applicable conflict of interest: none declared ethical approval issue: written consent has been obtained from index patient’s parents. 121 international journal of human and health sciences vol. 05 no. 01 january’21 references: 1. chiappini e, mastrangelo g, lazzeri s. a case of acute osteomyelitis: an update on diagnosis and treatment. int j environ res public health. 2016;13(6):539. 2. jerzy k, francis h. chronic osteomyelitis bacterial flora, antibiotic sensitivity and treatment challenges. open orthopaedics journal.2018;12:153-63. 3. bi s, hu fs, yu hy, et al. nontuberculous mycobacterial osteomyelitis. infect dis (lond). 2015;47(10):673‐85. 4. schmitt sk. osteomyelitis. infectious disease clinics of north america. 2017;31(2): 325-38. 5. giurato l, meloni m, izzo v, uccioli l. osteomyelitis in diabetic foot: a comprehensive overview. world j diabetes.2017;8(4):135‐42. 6. fritz jm, mcdonald jr. osteomyelitis: approach to diagnosis and treatment. physician and sports medicine. 2008;36(1):nihpa116823 7. bar-on e, weigl dm, bor n, et al. chronic osteomyelitis in children: treatment by intramedullary reaming and antibioticimpregnated cement rods. journal of pediatric orthopedics. 2010;30(5):508-13. 8. colston j, atkins b. bone and joint infection. clin med (lond). 2018;18(2):150‐4. 9. mantero e, carbone m, calevo mg, boevo s. diagnosis and treatment of paediatric chronic osteomyelitis in developing countries: prospective study of 96 patients treated in kenya. musculoskeletal surgery. 2011;95(1):13-8. 10. sato s, chiyotanda m, hijikata t, ishida y, oana s, yamanaka g, et al. acute suppurative oligoarthritis and osteomyelitis: a differential diagnosis that overlaps with acute rheumatic fever. journal of infection and chemotherapy. 2015;21(8):610-2. 11. lee yj, sadigh s, mankad k, kapse n, rajeswaran g. the imaging of osteomyelitis. quantitativeimaging in medicine and surgery. 2016;6(2):184-98. 12. chawdhary g, hussain s, corbridge r. delayed diagnosis of central skull-base osteomyelitis with abscess: case report and learning points. annals of the royal college of surgeons of england. 2017;99(1):e24-e27. 13. wald er. risk factors for osteomyelitis. american journal of medicine. 1985;78(6b):206-12. 14. malhotra r, chan cs, nather a. osteomyelitis in the diabetic foot. diabet foot ankle. 2014;5:10.3402/dfa.v5.24445. 15. popescu b, tevanov i, carp m, ulici a. acute haematogenous osteomyelitis in paediatric patients: epidemiology and risk factors of a poor outcome. journal of international medical research 2020;48(4):300060520910889. 16. floyed rl, steele rw. culture-negative osteomyelitis. pediatric infectious disease journal. 2003;22(8):731-6. 17. thakolkaran n, shetty ak. acute hematogenous osteomyelitis in children. ochsner j. 2019;19(2):116‐22. 18. birt mc, anderson dw, bruce toby e, wang j. osteomyelitis: recent advances in pathophysiology and therapeutic strategies. j orthop. 2016;14(1):45‐52. 19. weinstein l, knowlton ca, smith ma. cervical osteomyelitis caused by burkholderiacepacia after rhinoplasty. journal of infection in developing countries 2008;2(1):76-7. 20. desimpel j, posadzy m, vanhoenacker f. the many faces of osteomyelitis: a pictorial review. j belg soc radiol. 2017;101(1):24. 21. ciampolini j, harding kg. pathophysiology of chronic bacterial osteomyelitis. why do antibiotics fail so often?. postgrad med j. 2000;76(898):479‐83. 22. luqmani r, robb j, daniel p, et al.orthopaedics, trauma and rheumatology (second ed.). mosby. 2013:96. 23. panteli m, giannoudis pv. chronic osteomyelitis: what the surgeon needs to know. efort open reviews. 2017;1(5):12835. 24. manaster bj. musculoskeletal imaging: the requisites, 3rd ed. philadelphia, pa: mosby elsevier. 2007:545-64. 25. keren r, shah ss, srivastava r, rangel s, bendel-stenzel m, hank n, et al. comparative effectiveness of intravenous vs oral antibiotics for post discharge treatment of acute osteomyelitis in children. jama pediatrics. 2015;169(2):120-8. international journal of human and health sciences vol. 04 no. 01 january’20 70 case report: a child with solitary thyroid nodule: what’s next? adam mohamad1,, suhaimi yusuf2, irfan mohamad3 abstract: paediatric thyroid nodule is a rare occurrence. it occurs about 1.5% in childhood while 4-7% in adulthood. the presentations include anterior neck swelling which moves with deglutition. the treatments of choice are either conservative treatment or complete surgical excision if there is presence of obstructive symptoms or malignancy. we describe an 8-year-old girl presented with left solitary thyroid nodule. malignancy must be ruled out before conservative management was instituted. keywords: paediatric, thyroid nodule, ultrasonography correspondence to: associate professor dr. irfan mohamad, department of otorhinolaryngologyhead-neck surgery, school of medical sciences, universiti sains malaysia, 16150, kota bharu, malaysia. e-mail: irfankb@usm.my 1. dr. adam mohamad, postgraduate orl-hns candidate, department of otorhinolaryngologyhead-neck surgery, school of medical sciences, universiti sains malaysia, 16150, kota bharu, kelantan, malaysia. 2. dr. suhaimi yusuf, pediatric otorhinolaryngologist, department of otorhinolaryngology-headneck surgery, hospital tengku ampuan afzan, 25100, kuantan, pahang, malaysia. 3. associate professor dr. irfan mohamad, departmentof otorhinolaryngology-head-neck surgery, school of medical sciences, universiti sains malaysia, 16150, kota bharu, kelantan, malaysia. international journal of human and health sciences vol. 04 no. 01 january’20 page : 70-72 doi: http://dx.doi.org/10.31344/ijhhs.v4i1.124 introduction thyroid nodular disease consists of disorders ranging from either isolated thyroid nodule or multinodular goiter. the most common mode of presentation is with an asymptomatic midline mass which moves with deglutition1. it is lesser in occurrence among children and adolescent as compared to adult. thyroid nodule has much higher incidence of malignancy in pediatric population as compared to adult, whereby about 26% of it are malignant in children, while in adult reported case was 5-10%2,3. commonest thyroid malignancy in children is papillary thyroid carcinoma (ptc) which accounts for 90% of all childhood cases4, while follicular thyroid cancer (ftc) is uncommon. poorly differentiated tumors and undifferentiated (anaplastic) thyroid carcinomas are otherwise rare in young patients5. there are few risk factors to develop thyroid nodules in children such as female sex, post puberty age, previous history of thyroid disease, previous radiation to neck and familial thyroid disorder6. case report an 8-year-old malay girl presented with left anterior neck swelling for the past 3 years. it was initially noticed at the age of 6-year old when the child was underweight at that time. till now, the swelling did not increase in size, painless and she had no compressive symptoms. she also had no hypo or hyperthyroidism symptoms. there was no history of thyroid swelling or malignancy in the family. on examination, patient was alert and conscious. there was no stridor. she was afebrile, and not tachycardic. there was no fine tremor, brittle nail, lid lag, proximal myopathy or exophthalmos. upon neck examination, there was a left paratracheal swelling measuring 4 cm x 3 cm which moves upon deglutition (figure 1). the differential diagnosis includes congenital cyst, cervical lymphadenopathy and thyroglossal duct cyst. however, the mass did not move upward during tongue protrusion and there was no cervical lymph node palpable. her thyroid function test was normal. neck 71 international journal of human and health sciences vol. 04 no. 01 january’20 ultrasonography (usg) revealed left large thyroid nodule measuring 2.3 cm x 1.7 cm x 3.6 cm. there was no calcification seen. fine needle aspiration and cytology (fnac) of the thyroid swelling revealed colloid nodule. she was planned for 6-monthly usg thyroid assessments. figure 1: left thyroid nodule (arrow) which move during deglutition. discussion when a child comes with thyroid nodule, the first and foremost things to do is to exclude malignancy7. data from the two large studies consisting of pediatric thyroid nodules over several decades collecting nearly 20% of the solitary thyroid mass were malignant, in which majority are papillary carcinoma (table 1)1,3. table 1. classification of solitary thyroid nodules detected in 128 children and adolescents. malignant nodules (19%) • papillary carcinoma 17 (13%) • follicular carcinoma 4 (3.6%) • anaplastic carcinoma 2 (1.6%) • medullary carcinoma 1 (0.8%) benign nodules (81%) • colloid nodule/adenoma 67 (52%) • cyst 19 (15%) • lymphocytic thyroiditis 18 (14%) thyroid nodules can be solid, cystic or mixed in nature. a study on 24 children with cystic thyroid nodules with mean age of 13 revealed pure cysts in 5 of them, and mixed cystic/solid lesions in 19 of the patients8. diagnostic steps for thyroid nodules in pediatric and adolescent as compared to adults are not much of difference. daniel et al reported that goitrogenesis does occur in pregnancy and therefore repeated pregnancies could play a role in development of thyroid disorder later on. they suggested that thyroid enlargement in pregnancy should be investigated along the similar step, including thyroid function test, usg as well as screening for thyroid autoantibodies9,10. the risk factors for malignancy of thyroid nodules includes fast growing nodule, family history of carcinoma especially in medullary carcinoma, hoarseness in the case of recurrent laryngeal nerve involvement, very firm nodule, fixity of the nodule to the surrounding structures, presence of cervical lymphadenopathy and lastly previous history of neck irradiation. shafford et al in 1999, reported incidence of thyroid nodules after neck irradiation for 93 cases of childhood hodgkin’s disease whereby thyroid ultrasonography after 10 years later revealed abnormalities in all of them including focal lesions in 37% and thyroid cancer in 5.4 % of them11. mazonaki et al in 2006 studied the associated risk for thyroid cancer induction from head and neck computed tomography (ct) examination during childhood. they concluded that scattered dose to the thyroid from ct scanning is not significant and can lead to a low but not negligible risk for the development of thyroid malignancies12. first and foremost step is the clinical examination of the patient, in which detailed history must be taken to rule out likelihood of malignancy. further investigations consist of blood test which includes thyroid stimulating hormone (tsh) and calcitonin if medullary carcinoma is suspected, thyroid scan in cases of suppressed tsh, usg of thyroid to look for features of malignancy and fnac in suspicious nodules as well as nodules more than 1 cm. usg characteristic of malignancy in thyroid nodules include hypoechogenicity, absence of cystic lesion, tall more than wide, presence of calcification and invasion to adjacent organs13. in our case, her thyroid function test was normal and the fnac revealed only colloid nodule. the patient was planned for a 6-monthly follow up with neck usg in view of assessing the size international journal of human and health sciences vol. 04 no. 01 january’20 72 and symptoms. apart from that, papillary cancer has been reported to occur in 5 to 14% of cystic lesions14. so if such changes happen on the next follow up as well as presence of compressive symptoms, surgical intervention should be considered. conclusion though pediatric solitary thyroid nodule is rare, a detailed evaluation which includes thyroid function test, ultrasonography and fine needle aspiration cytology must be done to rule out thyroid malignancy before conservative management can be considered. conflict of interest: no conflict of interest has been disclosed by theauthors. funds: this study did not receive any funding. authors contributions: conception and design: am, im collection and assembly of data: am,sy,im critical revision of the article for important intellectual content: am,im references: 1. hung w, anderson kd, chandra rs, kapur sp, patterson k, randolph jg, et al. solitary thyroid nodules in 71 children and adolescents. journal of pediatric surgery. 1992;27(11):1407-9. 2. niedziela m. pathogenesis, diagnosis and management of thyroid nodules in children. endocrine-related cancer. 2006;13(2):427-53. 3. raab ss, silverman jf, elsheikh tm, thomas pa, wakely pe. pediatric thyroid nodules: disease demographics and clinical management as determined by fine needle aspiration biopsy. pediatrics. 1995;95(1):46-9. 4. demidchik ye, demidchik ep, reiners c, biko j, mine m, saenko va, et al. comprehensive clinical assessment of 740 cases of surgically treated thyroid cancer in children of belarus. annals of surgery. 2006;243(4):525. 5. koo js, hong s, park cs. diffuse sclerosing variant is a major subtype of papillary thyroid carcinoma in the young. thyroid. 2009;19(11):1225-31. 6. wiersinga wm. management of thyroid nodules in children and adolescents. hormones (athens). 2007;6(3):194-199. 7. lafferty ar, batch ja. thyroid nodules in childhood and adolescence-thirty years of experience. journal of pediatric endocrinology, metabolism 1997;10(5): 479-86. 8. yoskovitch a, laberge jm, rodd c, sinsky a, gaskin d. cystic thyroid lesions in children. journal of pediatric surgery. 1998;33(6):866-70. 9. glinoer d, lemone m. goiter and pregnancy: a new insight into an old problem. thyroid. 1992;2(1):65-70. 10. lazarus j, othman s. review thyroid disease in relation to pregnancy. clinical endocrinology. 1991;34(1):91-8. 11. shafford e, kingston j, healy j, webb j, plowman p, reznek r. thyroid nodular disease after radiotherapy to the neck for childhood hodgkin’s disease. british journal of cancer. 1999;80(5-6):808-814. 12. mazonakis m, tzedakis a, damilakis j, gourtsoyiannis n. thyroid dose from common head and neck ct examinations in children: is there an excess risk for thyroid cancer induction? european radiology. 2007;17(5):1352-7. 13. koike e, noguchi s, yamashita h, murakami t, ohshima a, kawamoto h, et al. ultrasonographic characteristics of thyroid nodules: prediction of malignancy. archives of surgery. 2001;136(3):334-7. 14. papotti m, volante m, saggiorato e, deandreis d, veltri a, orlandi f. role of galectin-3 immunodetection in the cytological diagnosis of thyroid cystic papillary carcinoma. european journal of endocrinology. 2002;147(4):515-21. international journal of human and health sciences vol. 05 no. 02 april’21 246 original article: preoperative intravenous paracetamol reduces postoperative opioid consumption in laparoscopic cholecystectomypatients an experience of a tertiary specialized hospital in bangladesh sultan reza1, tamanna habib2, mohammad ifta khiarul hasan1, anik roy chowdhury1, saifuddin mohammad mamun3, sm farhad sazib4, sm ahsanul habib5 abstract: background: afferent blockade of nociceptive (pain) impulses by paracetamol can bein effect throughout intraoperative and postoperative period. objective: to see the effect of preoperative intravenous paracetamol administration in laparoscopic cholecystectomy patients. methods: this single blind, randomized, prospective, case-control studywas conducted in department of anesthesiology, square hospitals, dhaka, bangladesh, between july and december of 2014. a total of 60 adult patients scheduled for laparoscopic cholecystectomy under general anesthesiawere enrolled in this study. patients were randomly allocated equally into two groups – a (cases) and b (controls), through a computerized random table, with 30 patients in each group. patients of group a (cases) received intravenous paracetamol 10mg/kg (in 100ml of normal saline) 10 minutes before skin incision, while group b (controls) received only 100 ml of normal saline 10 minutes before skin incision. postoperative pain score, duration of demand of first analgesic after operation and amount of opioid requirement were noted down. results: the mean age of group a was 39.3±4.3 years and in group b 37.4±4.4 years (p>0.05).the mean pain score after 1 hour of operation was 4.4±0.3 in group a and 4.7±0.3 in group b, which reduced to 2.7±0.3 and 2.9±0.2 after 6 hours, then 1.7±0.2 and 1.8±0.2 after 12 hours and 1.0±0.1 and 1.1±0.2 after 24 hours respectively (p<0.05). early demand of postoperative analgesic within 10 minutes was observed much less in the group a, compared to group b (p<0.001). the mean amount of pethidine required at 1st hour was 34.8±5.4 mg and 36.6±5.0 mg in group a and group b respectively, which increased up to 77.3±10.7 mg and 92.1±8.5 mg respectively at 6th hour. however, the amount steeply decreased at 12th hour to 29.4±5.4 mg and 28.1±4.7 mg respectively (p<0.001). the total amount of pethidine needed was significantly lower in the group a than that of group b (126.8±14.4 vs. 139.6±9.5 mg; p<0.05). conclusion: preoperative load of intravenous paracetamol increases the duration of further analgesic requirement as well as reduces postoperative opioid consumption in laparoscopic cholecystectomy patients. keywords: intravenous paracetamol, opioid consumption, pain score, laparoscopic cholecystectomy. correspondence to: dr. sultan reza,associate consultant, neuro icu, square hospitals ltd., dhaka-1205, bangladesh. e-mail: sultanrezamanha@gmail.com 1. neuro icu, square hospitals ltd., dhaka-1205, bangladesh. 2. department of physiology, answer khan modern medical college, dhaka-1205, bangladesh. 3. department of anesthesiology, square hospitals ltd., dhaka-1205, bangladesh. 4. department of medicine, bangabandhu sheikh mujib medical university (bsmmu), dhaka-1000, bangladesh. 5. department of anesthesia, icu and pain medicine, apollo hospitals, dhaka-1229. bangladesh. international journal of human and health sciences vol. 05 no. 02 april’21 page : 246-250 doi: http://dx.doi.org/10.31344/ijhhs.v5i2.268 introduction: preoperative analgesia by administering intravenous paracetamol (acetaminophen) is a method of analgesia that starts before the noxious stimulus comes into action, blocking peripheral and central nociception1. it is assumed that this afferent blockade of nociceptive (pain) impulses can be in effect throughout intra-operative and post-operative periods1,2.any antinociceptive treatment inducing before surgery to prevent establishment of altered central afferent input from injuries and pain sensation by timing the analgesic’s peak pharmacodynamic effect with anticipated onset of pain or peak pain response, is termed as ‘preemptive analgesia’2,3. paracetamol when given before tissue damage (pre-emptive) may play an important role in preoperative pain management by reduction of the inflammation 247 international journal of human and health sciences vol. 05 no. 02 april’21 mechanism and decreasing sensitization of peripheral nocicptors2. paracetamol is more safein comparison to risks related to opioid and can act on both central and peripheral pain pathways byinhibiting n-methyl-d-aspartate receptors and blocking the cyclooxygenase 2 (cox2) pathway of inflammation4,5. paracetamol is known for itscapacity of ‘preemptiveanalgesia’ in different operative procedures, such as laparoscopic cholecystectomy6-8, total abdominal hysterectomy9,10, orthopaedic surgery11,12. all those studies were done in the western countries. however, no such reports are available in our country to date. given the circumstances, the present study was designed with the aim tosee the ‘preemptive effect’ of preoperative intravenous paracetamol administration in laparoscopic cholecystectomy patients in terms of how much it increases the duration of further analgesic requirement as well as reduces postoperative opioid consumption.as proper pain management, particularly postoperative pain management, is a major concern for the clinicians, the findings of the present study are expected to enrich our information pool in pain medicineas well asfacilitate to planpostoperative pain management more efficiently and cost effectively. methods: a single blind, randomized, prospective, casecontrol studywas conducted in department of anesthesiology of square hospitals, dhaka, bangladesh, one of the largest tertiary specialized hospitals in the country, between july and december of 2014. all the patients enrolled for laparoscopic cholecystectomy surgery in department of surgery of the same hospital during the study period. however, we adopted the convenient sampling technique. the patients were selected after fulfilling the following inclusion and exclusion criteria: inclusion criteria: 1. adult surgical patients for laparoscopic cholecystectomy who are mentally sound and able to understand the procedure; and 2. fulfilled asa physical status classification i or ii (according to sweitzer)13. exclusion criteria: 1. unable to understand the procedure or declined consent; 2. known allergy to paracetamol (acetaminophen); 3. history of usage of paracetamol, opioids, or any other nsaids for a long time (≥3 months); 4. uncontrolled hypertension or diabetes mellitus, severe renal or hepatic impairment or chronic obstructive airway disease. then a total of 60 adult patients were randomly enrolled in this study. primary data collection was done after taking written informed consent from each patient who fulfilled the criteria. demographic profile, pulse, blood pressure, body weight, height, waist circumference – all were recorded. patients were randomly allocated equally into two groups – a (cases) and b (controls), through a computerized random table, with 30 patients in each group. pre-anaesthetic check-up was done on the day before surgery. each patient was kept fasting for at least 6-8 hours pre-operatively. each patient was administered with ringer’s lactate solution 30 minutes before the induction of anesthesia, and the infusion was maintained at 8-10ml/kg/hour throughout the operative procedure. after standard monitorization, baseline heart rate (hr), non-invasive blood pressure (bp), oxygen saturation (spo2), and respiratory rate (rr) values were recorded. general anesthesia was intravenously induced with 5mg/ kg thiopental and 1μg/kg fentanyl, and the trachea was intubated with an endotracheal tube under muscle relaxant (0.5 mg/kg atracurium). anesthesia was maintained with isoflurane (1.5%) in 50% nitrous oxide with oxygen. patients of group a (cases) received intravenous paracetamol 10mg/kg(100ml) 10 minutes before skin incision, while group b (controls) received only 100 ml of normal saline 10 minutes before skin incision. each patient was sent to postoperative ward and observed for 24 hours. both groups received opioid through patient-controlled analgesia (pca)14 in postoperative ward and postoperative pain was assessed using visual analogue scale (vas)15. total opioid dose measured in the both groups. intensity of pain (vas –painscore), duration between operation and first analgesic demand after operation and opioid requirement to manage postoperative pain – all were noted down in the data collection sheet. the results were presented in tables. quantitative data were expressed as mean and standard deviation and qualitative data were expressed as frequency and percentage. statistical analyses were performed using spss (statistical packages international journal of human and health sciences vol. 05 no. 02 april’21 248 for social sciences) version 17.0 (spss inc, chicago, il, usa). association between variables were done by unpaired student ‘t’ test, repetitive measure paired t-test and chi-square (χ2) test. p value <0.05 was considered as statistically significant. results: in the present study, 30 patients were enrolled in each group – group a (cases) and b (controls). the mean age of the patients of group a was somewhat higher than that of the group b (39.3±4.3 years vs. 37.4±4.4 years). however, the difference was not statistically significant (p>0.05) (table 1). female patients were predominant in the both group a (63.33%) and groupb (66.67%). the mean pain score at 1 hour after operation was 4.4±0.3 in group a and 4.7±0.3 in group b, which reduced to 2.7±0.3 and 2.9±0.2 after 6 hours, 1.7±0.2 and 1.8±0.2 after 12 hours and 1.0±0.1 and 1.1±0.2 after 24 hours respectively (p<0.05 ) (table 2).over half of the patients in the group a required postoperative analgesic (pethidine) at>20 minutes after operation (53.33%), while 40% required between 10-20 minutes and the rest (6.67%) within 10 minutes. in contrast, majority (80%) of patients in the group b required postoperative analgesic within 10 minutes and rest (20%) between 1020 minutes. early demand of postoperative analgesicwithin 10 minutes was observed much less in the groupa,in comparison togroupb, which was statistically significant (p<0.001)(table 3). the mean amount of pethidine required at 1st hour was 34.8±5.4 mg and 36.6±5.0 mg in group a and group b respectively, which increased up to 77.3±10.7 mg and 92.1±8.5 mg respectively, after 6 hours. however, the amount steeply decreased at 12th hour to 29.4±5.4 mg and 28.1±4.7 mg respectively (p<0.001). the total amount of pethidine required was significantly lower in the group a than that of group b (126.8±14.4 vs. 139.6±9.5 mg; p<0.05) (table 4). table 1.comparison of age between two groups age (in years) group a (n=30) group b (n=30) p value <35 4 (13.33%) 10 (33.34%) 35-40 16 (53.33%) 13 (43.33%) >40 10 (33.34%) 7 (23.33%) mean±sd 39.3±4.3 37.4±4.4 >0.05 student’s t test was used to reach p value. table 2.comparison of postoperative pain score (vas) between two groups duration group a(n=30) group b (n=30) p value after 1hour 4.4±0.3 4.7±0.3 <0.05 after 6 hours 2.7±0.3 2.9±0.2 after 12 hours 1.7±0.2 1.8±0.2 after 24 hours 1.0±0.1 1.1±0.2 data presented as mean±sd; repetitive measure paired t-test was used to reach p value. table 3. comparison of first postoperative analgesic demand between groups duration (in min.) group a (n=30) group b (n=30) p value <10 2(6.67%) 24(80%) <0.001 10-20 12(40%) 6(20%) >20 16 (53.33%) chi-square (χ2) test was used to reach p value. table 4. comparison of postoperative pethidine requirement between groups duration group a (n=30) (in mg) group b (n=30) (in mg) p value at 1st hour 34.8±5.4 36.6±5.0 at 6th hour 77.3±10.7 92.1±8.5 <0.001 at 12th hour 28.1±4.7 29.4±5.4 total 126.8±14.4 139.6±9.5 <0.05 data presented as mean±sd; student’s ttest was used to reach p value. discussion: apart from affecting patients’ well-being and satisfaction from medical care, postoperative pain results in tachycardia and hyperventilation, gradual transition towards chronic pain, subsequent disruption in wound healing and insomnia – all together worsen the operative outcomes16. in the present study, our data showed that the preemptive intravenous paracetamol administration reduces opioid requirements through prolongation of duration of first demand of analgesia and a tremendous reduction in post-operative pain scores in our patients. similarly, salihoglu et al.6 studied on a total of 40 patients (20 in each group) 249 international journal of human and health sciences vol. 05 no. 02 april’21 and found that verbal and visual pain scores of the paracetamol group were significantly lower than control group (p<0.05). first morphine requirement and total administered morphine dose and duration of staying in recovery room were significantly decreased in the paracetamol group (p<0.05). arslan et al.8 also found that time to first analgesic requirement was longer in paracetamol preemptive group, compared to placebo group (p<0.05), along with a significant reduction in total analgesic consumption and postoperative vas pain scores (p<0.05).however,goushehet al.7studied on 30 patients (15 in each group) and concluded that the pain score was lower in paracetamol preemptive group in comparison to placebo group (p=0.01), but the morphine consumption showed no significant difference between the groups (up to 6 hours postoperatively).hence, our findings are more or less supported by salihoglu et al.6, gousheh et al.7 and arslan et al.8. the results of these controlled clinical studies, as mentioned above, demonstrated that the recommended therapeutic dose of intravenous paracetamol is safe and well tolerated, with a profile that supports the high reliability similar to placebo. the reduction in total opioid consumption may result from opioid sparing effect of preemptive load of paracetamol which was observed in those studies as well as in others’ studies6-12. moreover, paracetamol is considered a safe drug with no or minimum gastrointestinal and central nervous system side effects like opioids and other nsaids4,5,17-19. limitations of the study: this was a single-center trial. the study population was selected from an urban hospital setting for a short period of time, which was confined to dhaka city only. hence, the results of the study may not be generalized and does not necessarily reflect the overall picture of the country. small sample size was another limitation of the present study. conclusion: our study revealed that preoperative load of intravenous paracetamol increases the duration of further analgesic requirement as well as reduces postoperative opioid consumption in laparoscopic cholecystectomy patients. however, we recommend further multi-center trials with larger sample and high technical back up. conflict of interest: none to disclose. ethical approval issue: the study was approved by the institutional ethical committee of square hospitals ltd., dhaka, bangladesh. funding statement: no funding. authors’ contribution: concept and study design: sr; data collection and compilation: sr, th, mikh, arc, smm, smfs, smah; data analysis: sr, smfs, smah; critical writing, revision and finalizing the manuscript: sr, th, mikh, arc, smm, smfs, smah. international journal of human and health sciences vol. 05 no. 02 april’21 250 references: 1. grape s, tramèr mr. do we need preemptive analgesia for the treatment of postoperative pain? best pract res clin anaethesiol. 2007;21(1):51-63. 2. pogatzki-zahn em, zahn pk. from preemptive to preventive analgesia. curropinanaesthesiol. 2006;19(5):551-5. 3. dahl jb, møiniche s. pre-emptive analgesia. br med bull. 2005;71(1):13-27. 4. duggan st, scott lj. intravenous paracetamol (acetaminophen). drugs. 2009;69(1):101-13. 5. jóźwiak-bebenista m, nowak jz. paracetamol: mechanism of action, applications and safety concern. acta pol pharm. 2014;71(1):11-23. 6. salihoglu z, yildirim m, demiroluk s, kaya g, karatas a, ertem m, et al. evaluation of intravenous paracetamol administration on postoperative pain and recovery characteristics in patients undergoing laparoscopic cholecystectomy. surg laparoscendoscpercutan tech. 2009;19(4):321-3. 7. gousheh sm, nesioonpour s, javaherforoosh f, akhondzadeh r, sahafi sa, alizadeh z. intravenous paracetamol for postoperative analgesia in laparoscopic cholecystectomy. anesth pain med. 2013;3(1):214-8. 8. arslan m, celep b, ciçek r, kalender hü, yılmaz h. comparing the efficacy of preemptive intravenous paracetamol on the reducing effect of opioid usage in cholecystectomy. j res med sci. 2013;18(3):172-7. 9. arici s, gurbet a, türker g, yavaşcaoğlu b, sahin s. preemptive analgesic effects of intravenous paracetamol in total abdominal hysterectomy. agri. 2009;21(2):54-61. 10. herring bo, ader s, maldonado a, hawkins c, kearson m, camejo m. impact of intravenous acetaminophen on reducing opioid use after hysterectomy. pharmacotherapy. 2014;34(suppl 1):27-33. 11. delbos a, boccard e. the morphine-sparing effect of propacetamol in orthopedic postoperative pain. j pain symptom manage. 1995;10(4):279-86. 12. sinatra rs, jahr js, reynolds lw, viscusi er, groudine sb, payen-champenois c. efficacy and safety of single and repeated administration of 1gram intravenous acetaminophen injection (paracetamol) for pain management after major orthopedic surgery. anesthesiology. 2005;102(4):822-31. 13. sweitzer bj. preoperative preparation and intraoperative management. in: pardo mc jr., miller rd. eds. basics of anesthesia, 6th ed. philadelphia: elsevier; 2011: p.165-88. 14. macintyre pe. safety and efficacy of patientcontrolled analgesia. br j anaesth. 2001;87(1):36-46. 15. mccormack hm, horne dj, sheather s. clinical applications of visual analogue scales: a critical review. psychol med. 1988;18(4):1007-19. 16. shoar s, esmaeili s, safari s. pain management after surgery: a brief review. anesth pain med. 2012;1(3):184-6. 17. prescott lf. paracetamol: past, present, and future. am j ther. 2000;7(2):143-7. 18. memis d, inal mt, kavalci g, sezer a, sut n. intravenous paracetamol reduced the use of opioids, extubation time, and opioid-related adverse effects after major surgery in intensive care unit. j crit care. 2010;25(3):458-62. 19. brodner g, gogarten w, van aken h, hahnenkamp k, wempe c, freise h, et al. efficacy of intravenous paracetamol compared to dipyrone and parecoxib for postoperative pain management after minor-tointermediate surgery: a randomised, double-blind trial. eur j anaesthesiol. 2011;28(2):125-32. 267 international journal of human and health sciences vol. 07 no. 03 july’23 case report surgical tips; removal of bent intramedullary nail haidar nasuruddin1, aminudin che-ahmad1, jeffrey jay2, muhamad syafiz ahmad ismani3. abstract intramedullary nailing is the gold standard for diaphyseal femoral shaft fractures. it has been shown to lead to a high union rate with a low incidence of complications. however, refracture with subsequent nail bending has always been challenging to remove and more challenging as compared to removal of a broken nail. removal has been reported using expensive and not readily available tools such as diamond tipped drill or high-speed burr. we are reporting a case of a successful bent intramedullary nail removal using a relatively cheap and available tool, which is the lowman clamp. keywords: bent intramedullary nail; femur fracture; refracture; fracture fixation, device removal. correspondence to: department of orthopaedic, traumatology and rehabilitation, kulliyyah of medicine, iium, kuantan, pahang, malaysia. e-mail: drhaidar@iium.edu.my 1. department of orthopaedic, traumatology and rehabilitation, kulliyyah of medicine, iium, kuantan, pahang, malaysia 2. department of orthopaedic, hospital tengku ampuan afzan, kuantan, pahang, malaysia. 3. department of orthopaedic, traumatology and rehabilitation, sultan ahmad shah medical centre, iium, kuantan, pahang, malaysia introduction there are few surgical options in managing diaphyseal femoral shaft fractures. intramedullary nailing has consistently led to a high union rate, with a low incidence of complications. it is considered as the gold standard for this kind of fracture (wild et al, 2010). however, refracture with subsequent nail bending had been reported in the literature and has always been described as technically very challenging to remove. case reports a 19-year-old gentleman who was successfully treated with an interlocking nail insertion for closed right femur fracture 4 months prior to current admission, involved in another motor vehicle accident and sustained refracture over the previous united fracture site. the refracture was complicated with a bent interlocking nail approximately 45° with anterolateral apex. otherwise, he had no other known medical illnesses. figure 1. x-ray showing the bent angle around 45° international journal of human and health sciences vol. 07 no. 03 july’23 page : 267-270 doi: http://dx.doi.org/10.31344/ijhhs.v7i3.585 https://content.sciendo.com/search?f_0=keyword&q_0=bent&searchtitles=false https://content.sciendo.com/search?f_0=keyword&q_0=fracture&searchtitles=false international journal of human and health sciences vol. 07 no. 03 july’23 268 removal of bent nail and reinsertion of a largerdiameter intramedullary nail was planned. related literature was studied through and preoperative planning was done. the patient however could not financially afford assistive orthopaedic devices available in market. under general anaesthesia, the patient was put supine on traction table. proximal and distal screws were removed percutaneously. initially, straightening of nail in situ using external force (closed manipulation) including f tool was attempted but failed. then, retrograde removal using intramedullary extractor had caused slight comminution of the cortex, so the attempt was aborted. attempt to remove antegradely the protruding nail antegradely using k-nail extractor was also tried but futile. figure 2. protruded nail tip finally, the nail was successfully extracted by applying lowman clamp tool to the part of the nail which distal to the bent and clamping it towards the bone. the nail was then gradually extracted retrogradely using the standard nail extractor. post removal measurement showed that the bent angle had reduced to 20°. a larger nail was then inserted antegradely with no difficulty. total surgical time was approximately 4 hours. estimated blood loss was around 500ml. post-operative care was uneventful. the patient was discharged well. unfortunately, the patient did not return for follow up, due to financial constraint. figure 3. gradual retrograde extraction with lowman device clamping the distal segment of the nail to the bone figure 4. the extracted nail with less bent angle discussion implant failure reported in intramedullary fixation is rare. it occurs mostly secondary to trauma. it is more challenging to remove a bent nail than a 269 international journal of human and health sciences vol. 07 no. 03 july’23 broken one because it is difficult to retrieve the bent nail through the intramedullary canal. there is no universally accepted guideline or method but there is a few individual case reports discussing on different successful methods in extracting bent nail. the writer will discuss and summarize the various techniques in removing bent intramedullary nail which have been used and reported in the literature. the first approach is by using external force to straighten the nail in situ. patterson and ramser in 1991 were among the first to report removal of bent intramedullary nail. in their case, the nail was rusell-taylor femoral nail which was inserted for midshaft femur fracture. the nail was deformed after approximately 2 years later by subsequent trauma. the bent nail was straightened extra corporeally without using any specific device, removed using standard method, then replaced with a larger nail6. the fracture healed without complications. however, the degree of bent was not mentioned in the report. this method was later applied and elaborated further by shishir et al. the femoral nail was bent around 30° with varus angulation. under general anesthesia, they put the patient on the floor, with a sandbag placed at the apex of the deformity, acting as a fulcrum. one assistant literally stood on the distal thigh, giving controlled pressure over the distal femur, distal to the bent, causing straightening of the nail8. in addition to the usage of body weight, an f-tool can also be used to assist the straightening. this approach however, does not work in high strength nails. excessive forces on the other hand, may break the bone cortex or bent the nail in s-shaped fashion making it more difficult for removal3. the second approach is by weakening the nail prior to straightening it. sameer et al reported a case of removal of bent intramedullary tibia nail. it was angulated posteromedially but the degree of bent was not mentioned. correction of deformity as described by patterson and ramser was tried but failed. the anterolateral part of the tibia was opened up, exposing the nail. trial of cutting the nail with metal cutting saw caused injury to the surrounding soft tissue, therefore they made a window on the anterolateral aspect of the nail with the help of metal cutting drill. as the nail had been weakened, the deformity was partially corrected by applying external force7. a similar approach but with different tools had also been reported. ahsan and kasper used a high speed drill in 2 cases with 25° bent angle to perforate the nail and thus weakening it1. while heffernan et al used similar approach but they used a high speed burr with diamond cutting head to partially section the bent femoral nail at the apex (anterior), leaving a thin remnant of metal at the posterior aspect of the nail. the nail was then straightened using an f tool2. vaseileious et al used a more radical approach. the case reported by him was a bent femoral nail with a relatively larger apex angle, approximately 60°. after a futile effort of trying to straighten or cut the nail (the method tried was not mentioned), they created a longitudinal bone window along the anterolateral part of the femoral shaft, starting from the fracture site, extending proximally to the greater trochanter. a new nail was inserted and the osteotomized bone window was secured using plate and cerclage wire9. in authors’ opinion, the usage of lowman tool in this case could be improved by clamping it to another plate, in addition to the bone. this will reduce the risk of a new fracture. the use of this tool for removal of intramedullary nail could not be found during literature review but other lowcost options were recorded in a few case reports. odendaal et al had shown that using standard industrial materials was inexpensive yet fruitful. in those country, specialized orthopaedic instrumentation such as diamond tipped drill and high speed burr were expensive and not obtainable. they used a 30mm diameter cutting disk which was mounted on regular orthopaedic drill and another 100mm diameter cutting disk which was mounted on common angle grinder5. another inexpensive device that can be used is a jumbo cutter4. in malaysia, the industrial grinder and cutting disks would cost only around myr100 while jumbo cutter would cost below myr200. however, using these industrial devices are off label. further ethical discussion is needed before applying them. conclusion in conclusion, removal of a bent intramedullary poses a great challenge to the operating surgeon. it needs a meticulous and thorough pre-operative preparation. all the options available should be well planned and used in step-by-step ladder, from the minimally invasive to an open technique. lowman international journal of human and health sciences vol. 07 no. 03 july’23 270 clamp could be used in the attempt to remove the bent nail as it is relatively easy to apply, less force needed, less costly, and most of the time readily available in the common orthopaedic surgery set. conflict of interest authors declare that they have no conflicts of interest. ethical clearance authors declare that they have no conflicts of interest. authors’ contribution authors were involved equally in the patient management, literature review and manuscript preparation. references 1. ahsan a.f., kasper s.n. how to remove a bent intramedullary nail. acta orthopaedica scandinavica 2011, 69:6, 638-639. 2. heffernan m.j., leclair w., li x. use of f-tool for the removal of bent intramdulllary femoral nail with a sagittal plane deformity. orthopaedics 2012 35(3):e438-e441. 3. kockesen t.c., tezer m., tekkesin m., kuzgun u. traumatic femoral diaphyseal fracture and a bent intramedullary nail in a case with a completely healed femoral diaphyseal fracture. acta orthopaedica et traumatologica turcica. 2002;36:177-80. 4. dhanda, m. s., madan, h. s., sharma, s. c., ali, n., & bhat, a. (2015). jumbo cutter for removal of a bent femoral interlocking nail: a cost effective method. journal of clinical and diagnostic research : jcdr, 9(6), rd06–rd7. 5. odendaal,j., peacock, e., cruz,j., noor,s. & gollogly,j. (2016). how to remove a bent intramedullary nail inexpensively: a technical trick. asian biomedicine,10(3) 277-280. 6. petterson r.h., ramser j.r. tachnique for treatment of a bent russell-taylor femoral nail. j orthop trauma 1991; 5(4) 506-8. 7. sameer a, ahswani s, uttam c, nitesh g. removal of a bent tibial intramedullary nail: a rare case report and review of literature. chinese journal of traumatology 2011. vol 14 107-110. 8. shishir s.m., deniese p.n., kanagasabai r., najimudeen s., gnanadoss j.j. a worthwhile attempt to remove a bent intra-medullary femoral nail before attempting extensive procedures. j curr res sci med 2015;1:44-8. 9. vaseileious i.s., stamatis k., helias k., ioannis p.s. bent intramedullary femoral nail: surgical technique of removal and reconstruction. case reports in orthopaedics. vol 2011; 614509. 10. wild m, gehrmann s, jungbluth p, hakimi m, thelen s, betsch m, windolf j, wenda k. treatment strategies for intramedullary nailing of femoral shaft fractures. orthopedics. 2010 oct 11;33(10):726. international journal of human and health sciences vol. 01 no. 02 july’17 56 correspondence to: prof. dr. m. ihsan karaman, istanbul medeniyet university medical faculty, istanbul, turkey, president, fima, email: mikaraman@hotmail.com international journal of human and health sciences vol. 01 no. 02 july’17. page : 56-58 5656 addiction is enslavement! we, the humanity, have to be against all kinds of addiction! and, currently there is a global initiative combatting against all kinds of addiction called green crescent which emerged in ottoman turkey one century ago and now expanded worldwide. i, first, would like to give a general framework of the problem of addiction and some brief information about the history, vision, objectives and activities of the green crescent; including the tactics for the mobilization of the public against addiction. one of the ways to prevent evil and addiction is to fight through scientific methods against the power groups that promote addiction. we are aware of the fact that the addiction industry reaches out, and intends to reach out even further, to our people and our youth, legally and illegally, through various ways that change and develop by the day. we see that stopping them by using ordinary slogans and methods gets more and more difficult. for this reason, the best instruments that we can use to stop them is to conduct serious scientific studies on how the problems emerge and spread, to follow up with this scientific data and share them with the public and authorities, to research on the ways of fighting against addiction and how they can be applied through national as well as international scientific meetings. the problems related to addiction do not only derive from our own social, administrational and moral structure, but are open to the influence area of a broader spectrum. today, through the tools of mass communication and the tools and carriers of the global culture, a structure with an expanding influence area has emerged in our society as in the rest of the world. as the green crescent, we care about the world’s way of fighting against this experience that it is going through, and about the scientific knowledge accumulated in this field. we think it is necessary to transfer this knowledge into healthy channels by making use of local dynamics as well. we are initiating a more active process in the international arena, with the hope and aim that the whole world will act upon conscience. just as the evil does not emerge only from our own internal structure, the solution is not a process that we can handle on our own, either. we want to speed up the activities carried out in coordination with other organizations working in this field throughout the world, in the name of our goal to prevent the evil and addiction before it even starts. we believe that there is a lot to do, especially in the countries where addiction and the production of addictive substances are widespread. for this purpose, the green crescent, with its experience of almost a century, will remain determined to carry its knowledge and efforts to the international arena, and to mobilize the collective conscience of humanity in the fight against addiction. there are many causes of addiction. it is impossible to focus on just one single cause and achieve results from methods based on only that specific cause, where many psychological, physiological, cultural and environmental factors exist. taking such an easy way out is no different than what an ostrich does when it sees its hunter. addiction of smoking, alcohol, drugs and the recently developed technology can pass through many doors and find new spaces and victims. beside the causes of addiction, what we really need to pay attention to is the tools of addiction, namely, the means that influence and push individuals, the youth, into addiction. when individuals step out of didactic education processes in their families and schools through the marketing strategies of the media and addiction industry, they become easier targets that are more prone to influence, under the name of freedom. this opening that comes along with getting out of teachings and restrictions of their families and schools that interfere in, limit and push in an unpleasant way, makes the children/youth open to ideas of “being free” and “realizing oneself”. this a global movement against addiction: green crescent karaman mi1 57 international journal of human and health sciences vol. 01 no. 02 july’17 pursuit of independence of individuals suddenly becomes a tool for addiction. this concept of freedom combined with the pressure of the ideas inflicted on has two authorities and elements. one, this idealized and marketed world; and two, the acknowledgement of the peers sharing the same interests and expectations. peers are the only place where the individuals who turn their backs to the difficulties of being good and responsible find acknowledgement and appreciation. this situation that we can call “the peer effect” provides two benefits to individuals. first, finding an authority that likes and appreciates the situations and tendencies that are not approved by authorities such as the family and school. second, the psychological confidence resulted by seeing the peers also sharing the same evil by doing things considered as bad. as a result of that, the individuals isolated by the increasing criticism and pressure of the families and schools, are left even weaker in their peer groups. at that point, these individuals are now forced to behave according to the interests and tendencies of their peers, and making the expected sacrifices and attempts to get accepted by and belong to the group. and then it is difficult to predict where these individuals will stop. on the other hand, we cannot undervalue the number of young people who have received good family discipline, good education and who have made healthy progress, and have strong personalities and characters. what needs to be done and what the green crescent has adopted as a method is to encourage the youth in the right direction. the youth constitutes the most important part of the purest and cleanest times in terms of emotions and thoughts, because the demand for justice and tendency to sacrifice oneself in the name of what is right, and of their ideals, exist intensively in young people. and that is why we have the opportunity to educate our youth and make them volunteer to fight against the addictions of their peers by setting good role models. young people diverted to quests outside of the teachings and ideas of families and schools, will easily accept their peers who are mentally and physically healthy, and who look to life and the future with confidence. this way, peer groups will move from being a tool of the evil and addiction to leading the way for raising educated generations who will look to the future with confidence. also, generations who have chosen this path of commitment to benefit and human-oriented thinking will safeguard the future of our nations. it must be our primary goal to bring together around an ideal the quests, which are presented to our youth under the name of freedom, and which trap them in the web of addiction industry, and to raise our youth as responsible individuals with strong minds, morals and personalities of the future. for our social values and healthy family structure to be carried into the future in the hands of mentally and physically healthy generations, we have adopted an understanding and determination beyond daily philosophical and political debates. we aim to transform the “green crescent” idea into a structure that is more efficient and more active both in the service of our nation and of humanity, through ideals and ideas that we have preserved since the first day of our inception, by opposing to the misinterpretation of the definition and requirements of freedom as well as some negative mentalities that stand out as the values of our era. the green crescent society is the oldest public health organization in turkey. it was established in 1920 in solidarity with the international temperance movements, which were significant mass movements during the post war years. turkish green crescent society was founded by a group of patriotic intellectuals from a diverse set of backgrounds in 1920, following the period when the british army occupied istanbul, as a response to the british attempts to distribute booze and drugs free of charge in istanbul in an effort to undermine the resistance against the occupation. the founders sensed the upcoming dangers of alcohol and drug addiction that resulted in a decline in the resistance against the occupation especially among young people. the patriotic intellectuals established the “green crescent”, with the name of “hilal-i ahdar” in istanbul in order to warn the turkish society. the green crescent is a non-profit and nongovernmental organization that empowers the youth and adults through factual information about drugs so they can make informed decisions against different kinds of addictions including alcohol, tobacco, drug, gambling etc. the society historically focused on alcohol policies until 1960. today, however, it deals with not only alcohol, but also addiction of tobacco, drugs, gambling and recently, technology. the green crescent society contributes to public health by developing evidence-based prevention programs international journal of human and health sciences vol. 01 no. 02 july’17 58 and advocating for legal, social and environmental changes on the fight against addiction. we fight against addictions that destruct the mental and physical health of the youth in cooperation with the private sector, governmental bodies and international organizations.we work to develop contemporary strategies for dealing with consumption of addictive substances and for the prevention of addiction by using evidence-based scientific methods. our efforts are especially focused on carrying out preventive social and advocacy activities aiming to create public opinion and raise awareness of the decision-makers and the general public. parallel to our national struggle against addiction, we have recently intended to widen our scope and promote establishment of similar institutions worldwide. first, as a decision made by fima council, an “addiction working group” was formed in fima and some member imas took lead in this initiative and played an important role in the enlargement process of green crescent. moreover, the turkish green crescent started this initiative in 2013; and so far, 40 national green crescents have been officially established. in addition to the national green crescents, the international federation of green crescents was launched as a global umbrella organization with the leadership of the turkish green crescent society in istanbul in 2016 and later signed a protocol of cooperation with fima. speaking of its works, the international federation of green crescents and member organizations will focus on prevention, advocacy, rehabilitation and coordination by using evidence-based methods in the struggle against addiction. it will seek solutions to local problems of member countries, by considering local values and cultural characteristics. the federation will coordinate addiction-related studies, researches and activities in member countries. the federation and member green crescents together will develop active collaborations with different social groups and other international organizations. taking this opportunity, i would like to encourage all fima members and responsive health professionals to take an initiative to form and improve green crescents in their countries for the social welfare of our ummah and the humanity in general. i hope, in the near future, we can achieve jointly to make our world smoke-free, alcohol-free, drugfree and to protect our next generations from all kinds of addictions that are the evils of the modern world. international journal of human and health sciences. supplementary issue: 2019 doi: http://dx.doi.org/10.31344/ijhhs.v0i0.142 s24 gadget addiction: opioid of the era? rozanizam zakaria dept. of psychiatry, kulliyyah of medicine, international islamic university malaysia (iium) abstract technology has certainly helped human race to advance forward and created the informa t io n revolution. gadgets armed with internet have transformed our lives in many ways and shifted our paradigm regarding human relationship, works and life in general in this era of instant gratification. while technology has nurtured the human race, questions raise regarding the limit in which these two are interconnected. does this advancement simplify life or actually make it more complex? as per suggested by the hooked theory, business model of internet, social medial and digital applications revolve around satisfying human needs, targeting our very own brain reward circuit. this has created concerns among sociologists, psychiatrists and psychologists regarding the potential rise of ‘new opioid’ for the era – the gadgets. we will discuss range of epidemiological data to visualize the severity of the situation and highlights different views on the concept of gadget addiction. this includes understanding the diffic ult y in coming to term regarding whether our over-attachment to gadget is a form behaviour a l addiction or merely a transient social trend. from hikikomori phenomenon to cyber-induced depression, the topic will also elaborate various impacts of gadget addiction, primarily on mental and psychological health, interpersonal relationship and human behavior. in particular, the focus will be on the impact of gadget addiction towards vulnerable groups, especially children and adolescents. the discussion will also integrate various practical holistic solutio ns to the problem without denying the integral role that technology has in our life. international journal of human and health sciences. supplementary issue: 2019 doi: http://dx.doi.org/10.31344/ijhhs.v0i0.154 s36 effects of holy quran listening on physiological s tress response in intensive care unit patients naeemah abd aziz, saedah ali, mohamad hasyizan hassan department of anaesthesiology and intensive care, school of medical sciences, universiti sains malaysia, kelantan, malaysia abstract introduction: the intensive care unit (icu) is one of the most stressful environments among various clinical settings. icu patients are not only compromised by the illness, but they also faced with a wide range of stressors such as pain, unfamiliar environment and loss of interactio n with family and friends. stress and anxiety will increase the sympathetic tone (sympathet ic nervous system) and stimulate the hypothalamus-pituitary-adrenal (hpa) axis response. stressful circumstances as well as chronic diseases may alter the normal cortisol mechanis ms resulting in marked increases in plasma levels. thus, high stress response will lead to delayed healing and prolong stays in icu. recitation of quran by the sick person or for the sick person has shown to have direct healing effect on the sick person. holy quran listening is the most suitable way for the patients in reduces stress responses during icu stay. objectives: to examine the effectiveness of holy quran listening (hql) in reducing stress response among icu patients. methods: a randomized controlled clinical trial was conducted in the intensive care unit. total 94 subjects were recruited and randomly assigned to either control (n=49) or holy quran listening (n=45) group respectively. the hql given via headphone for 7 hours while control group given no music. primary measures include mean blood pressure, heart rate, systolic blood pressure, diastolic blood pressure, serum cortisol level and serum blood sugar. secondary outcomes include duration of stay in intensive care unit, total usage of insulin and sedation. results: the hql group show clinically significant in reducing hr and sbp over time. serum cortisol level is stable in hql group. however, there are no significantt reduction in duration of stay, total usage of sedation and insulin. conclusion: hql is one of the adjunct methods that can be used to reduce stress response among icu patients. keywords: listening, intensive, care, unit, stress, response, physiological. international journal of human and health sciences vol. 05 no. 02 april’21 148 review article: cns stimulants currently available for treatments in patients suffering with worldwide pandemic of coronavirus disease khatija aslam1, somia gul2 abstract: outbreak of coronavirus disease is worldwide pandemic declared by who. patients either suffered from coronavirus infection or not both are physically and mentally disturbed. patient whom suffered with such pandemic diseases or infections, have a greater risk of mental illnesses such as depression, attention deficit hyperactivity disorder (adhd), obsessive compulsive disorder (ocd), schizophrenia and mania.cns stimulants are psychoactive drugs available from resources like from nature (herbal/crude drugs) or from synthetic routes, are used to treat such diseases.in current research, extensive research review is done to find the best cns stimulants currently available for treatments for such diseases. it is concluded from this research that stimulants that prescribed more frequently are amphetamine, methylphenidate and lisdexamfetamine. moreover, stimulants that are not prescribed or illicit are like cocaine as such agents caused highly dependency, tolerance and addiction. keywords : cns stimulants, amphetamine, methylphenidate, lisdexamfetamine, coronavirus. correspondence to: somia gul, department of pharmaceutical chemistry, faculty of pharmacy jinnah university for women, karachi, 74600, pakistan. e-mail: drsomi1983@yahoo.com 1. department of pharmaceutical chemistry, faculty of pharmacy, jinnah university for women, karachi,pakistan. 2. associate professor, department of pharmaceutical chemistry, faculty of pharmacy, jinnah university for women, karachi,pakistan. international journal of human and health sciences vol. 05 no. 02 april’21 page : 148-153 doi: http://dx.doi.org/10.31344/ijhhs.v5i2.251 introduction mr. zia, 50 years old businessman, lived in karachi. after the death of his wife, his son became addicted to drugs and also suffered from covid-19, then committed suicide. his daughter noticed that he was suffering from depression. she took appointment and treatment started with counselling by then medicines such as antidepressants, cns stimulants and multivitamins to subside the adverse effects. after a while, he recovered from depression and returned back to life. outbreak of coronavirus disease is worldwide pandemic declared by who. patients either suffered from coronavirus infection or not both are physically and mentally disturbed.1 according to a recent research published 11 may, 2020, in pakistan 29 suicide cases were reported.2patient whom suffered with such pandemic diseases or infections, have a greater risk of mental illnesses such as depression, attention deficit hyperactivity disorder (adhd), obsessive compulsive disorder (ocd), schizophrenia and mania.3 moreover, in pakistan cases were increased day by day (figure 1 and figure 2). figure 1:total coronavirus cases in pakistan from february 15–july 08, 2020. (source: https://www. worldometers.info/coronavirus/country/pakistan/) 149 international journal of human and health sciences vol. 05 no. 02 april’21 figure 2: outcome of cases (recovery or death) in pakistan from february 15 – july 08. (source: https://www.worldometers.info/coronavirus/ country/pakistan/) naturally a type of stimulant presents in our body to maintain and regulates the normal mechanism. dopamine, serotonin and noradrenaline are the three main chemical agents present in body. dopamine a neurotransmitter, its high levels may lead to enhance mood and increase motor activity. if too many dopamine presents then its lead to schizophrenia, nervousness and irritability whereas too little levels may lead to paralysis and tremors. according to past researches it is thought that dopamine is a master molecule of addiction.4 5ht serotonin is a natural mood stabilizer present in central nervous system, digestive track and blood platelets help to reduce anxiety, depression, digestion, sleeping, healing of wound and control nausea.5 noradrenaline also known as norepinephrine, act as neurotransmitter and hormone. it consists of catecholamine and phenethylamine. norepinephrine is a mediator to responsible for fight and flight, produced by adrenal glands. it increases heart rate, anxiety, alertness, restlessness and improve memory.6 these chemical substances regulate normal physiological function in body, but sometimes toomuch or too-little levels may lead to pathological condition which are prevented or/and treated by medication either natural or synthetic drugs (table 1 and table 2).caution may be taken by the use medication agents such as amphetamine, cocaine, caffeine and methylphenidate caused addiction and dependency in patient if they use long term., usually these medications are used by sport players for anaerobic exercise.7 on the other hand, new generation also suffered from addiction of drugs, such as cocaine, khat, ecstasy, alcohol, smoking, also with substance use disorder (sub) reported recently.8variety of drugs are now available to treat or prevent such type of illness and disorders. cns stimulants are psychoactive drugs available from resources like from nature (herbal/crude drugs) or from synthetic routes, are used in number of diseases such as attention deficit hyperactivity disorder (adhd), obsessive compulsive disorder (ocd), depression, narcolepsy, neonatal apnea and sleep disorder.9 nature has provided countless blessings for human mankind including number of herbs, plants, animals and marine creatures as resources for treatment of different diseases and ailments. naturally a vast number of cns stimulants10-13 are present as herbal or crude form of drug such as caffeine, khat, and cocaineetc. as some most common and advanced herbs are summarized in table 1. table 1. brief summary of naturally available cns stimulants. s.no herbal drugs description structure 1 caffeine it had been used ancient as cns stimulant in china. pseudoephedrine and ephedrine are the main constituents which increases the heart rate, and stimulates the brain. ephedra also used in weight loss therapy, but having severe side effects.10,11 2 ephedra khat is a psychoanaleptic found in leaves and plants shoots. khat contain cathinone as a main constituent responsible for its activity. cathinone is structurally resembling to amphetamine. it reduces the appetite by increasing the feeling of fullness.11 international journal of human and health sciences vol. 05 no. 02 april’21 150 s.no herbal drugs description structure 3 khat ginkgo is a cognitive enhancer, used for the treatment of lack of attention, vertigo, cerebral vascular diseases and loss of short-term memory.12 4 ginkgo centella asiatica is a medicinal herbal plant used to improve cognative functions, having antianxiety properties also improves memory gotukola used traditionally by chines, its roots and leaves are used to support the healthy tissues of skin and hairs.12 5 gotukola panax ginseng dried roots are used in the treatment of alzheimer’s disease. it reduces fatigue, cholesterol and stress also maintain high blood pressure, heart rate and boost up immune system.12 6 ginseng alkaloidal extract derived from the coca plant. it produces local anesthetic effect by blocking sodium channel also produce convulgenic effect by blocking nmda receptors. cocaine long term use may produce cardiotoxicity.13 7 cocaine it had been used ancient as cns stimulant in china. pseudoephedrine and ephedrine are the main constituents which increases the heart rate, and stimulates the brain. ephedra also used in weight loss therapy, but having severe side effects.10, 11 advance research in the field of medicine and new technologies made our lives easier. cns stimulants are easily available as synthetic form to treat numerous of disease for example; adhd, ocd, depression, narcolepsy, neonatal apnea and sleep disorder. caffeine,10 amphetamine, benzphetamine, modafinil, methylphenidate, lisdexamfetamine, dextroamphetamine, metamfetamine, megastrol acetate, pemoline, benzphetamine, minaprine, armodafinil and fencamfamin are currently available for treatment of such types of diseases. they are available in oral, injectable and also in inhaled form (table 2). stimulants that prescribed more frequently are amphetamine, lisdexamfetamine, caffeine, methylphenidate and benzphetamine are commercially available.14 table 2. brief summary of currently available synthetic cns stimulants. s.no cns stimulants description structure different renowned brands available worldwide available dosage form 1 amphetamine cns stimulant currently available, used to treat adhd and also used as recreational purpose, highly addicted and also caused weight loss because it suppresses appetite.14 adzenys xr-odt, dyanavel xr, evekeo. extended relaease oral disintegrating tablets (adzenys xr-odt) extended relaease oral suspension (dyanavel xr) 151 international journal of human and health sciences vol. 05 no. 02 april’21 s.no cns stimulants description structure different renowned brands available worldwide available dosage form 2 dextroamphetamine sympathomimetic agent used to treat narcolepsy and attention deficit hyperactivity disorder.14 1. dexedrine 2. dexedrine spansules 3. dextrostat 4. liquadd 5. procentra 6. zenzedi extended release capules (dexedrine) oral solution (procentra) immediate release tablets (zenzedi) 3 modafinil used to treat narcolepsy, sleep disorder and promote wakefulness. sometimes causes allergy or skin rashes.15 provigil tablets are available. 4 methylphenidate cns stimulant agent used to treat attention deficit disorder add and narcolepsy by increasing dopamine and norepinephrine levels in brain. methylphenidate are controlled release drugs available in capsule, tablets, oral solution and oral suspension form. methylphenidate long term may cause addiction and dependency in patient.16 ritalin aptensio xr ritalin la metadate cd adhansia xr jornay pm methylin ritalin sr quillichew er generics tablet (ritalin) extended release capules(aptensio xr ritalin la metadate cd adhansia xr) extended/delayed release capules (jornay pm) extended release tablets (methylin, ritalin sr, generics) extended release chewable tablets (quillichew er) and transdermal patches are also available. 5 dexmethylphenidate it is a nor epinephrine dopamine reuptake inhibitor used in conjugation with other therapies in the treatment of adhd.16 focalin, focalin xr tablets and extended release capsules are available. 6 lisdexamfetamine cns stimulant drug used to treat adhd, severely eating disorder, decrease restlessness in children and also used to improve hyperactivity.17 vyvanse available in capsule and chewable tablets. 7 metamfetamine sympathomimetic agents used in the treatment of exogenous obesity and attention deficit hyperactivity disorder.18 desoxyn tablets 8 megastrol acetate megastrol acetate is a progestin used in the treatment of cachexia, anorexia, weight loss and as an antineoplastic agent.19 megace, megace es. tablets oral suspension. 9 picrotoxin an analeptic class of drug used for relieving respiratory distress. it is also used as an antidote for barbiturate poisoning and gaba receptor antagonist.20 cocculin, coques du levant, cocculine, cocculus, fish berry, oriental berry currently not available international journal of human and health sciences vol. 05 no. 02 april’21 152 s.no cns stimulants description structure different renowned brands available worldwide available dosage form 10 doxapram an analeptic class of drug act as short acting respiratory stimulant available as injectable solution.21 dopram injectable solution 11 armodafinil used in the treatment of narcolepsy, improve wakefulness, sleep disorders, shift work disorders and sleep apnea available for orally administration22 nuvigil available in tablets form. 12 pemoline cns stimulant used in the treatment of narcolepsy and attention deficit hyperactivity disorder but it may cause severe hepatic failure in patient so that not be used as first line agent.23 cylert available in tablets and chewable tablets. 13 benzphetamine sympathomimetic shortterm agent similar to amphetamine used in the treatment of obesity but not indicating under 17 years of age.24 didrex available as tablet form. 14 fencamfamin psychostimulant class of drug used to treat lack of concentration, depressive fatigue and lethargy.25 reactivan available in syrup and tablet form. investigation and research in the field of cns stimulants reported that, to improve adhd, jornay pm was the only medication dosing in evening to control the symptoms in morning, day and also in evening time (in phase 3 trail). in august 2018, cns stimulant drug methylphenidate hcl was approved by fda used for treating adhd in children 6 years or greater.26 conclusion: from among the above mention both natural and synthetic central nervous system stimulants,it is found that stimulants that prescribed more frequently are amphetamine, methylphenidate and lisdexamfetamine. these agents are used for the treatment of attention deficit hyperactivity disorder, depression, and narcolepsy and sleep disorder. methylphenidate (ritalin) is used as first line agent in attention deficit hyperactivity disorder. amphetamine (addrella, addrella xr) is a most potent cns stimulant and potential for abused was discovered hundreds of years ago and still it is used for adhd. lisdexamfetamine (vyvanse) is a prodrug of amphetamine used for the treatment of adhd and narcolepsy. stimulants that are not prescribed or illicit are like cocaine as such agents caused highly dependency, tolerance and addiction. conflict of interest: no conflict of interest exists. funding: no funding exists. ethical approval issue:not applicable. authors’ contribution: data gathering and idea owner of this study: somia gul and khatija aslam; study design: somia gul; data gathering: khatija aslam and somia gul; writing and submitting manuscript: khatija aslam and somia gul; editing and approval of final draft: somia gul. 153 international journal of human and health sciences vol. 05 no. 02 april’21 references: 1. world health organization. critical preparedness, readiness and response actions for covid-19: interim guidance, 24 june 2020. no. who/ covid-19/community actions/2020.4. world health organization, 2020. 2. mamun ma, ullah i. covid-19 suicides in pakistan, dying off not covid-19 fear but poverty? the forthcoming economic challenges for a developing country. brain, behavior, and immunity, 2020;87:163-6. 3. thakurv, jain a. covid 2019-suicides: a global psychological pandemic.brain, behavior, and immunity, 2020;88:952-3. 4. berkejd. what does dopamine mean? nature neuroscience, 2018;21(6):787-93. 5. bergerm, gray ja, roth bl. the expanded biology of serotonin.annual review of medicine, 2009;60:355-66. 6. o’donnellj, zeppenfeld d, mcconnel e, et al. norepinephrine: a neuromodulator that boosts the function of multiple cell types to optimize cns performance.neurochemical research, 2012;37(11):2496-512. 7. george aj. central nervous system stimulants. bailliere’s best practice & research. clinical endocrinology & metabolism. 2000;14(1):79-88. 8. dubey mj, ghosh r, chatterjee s, biswas p, chatterjee s, dubey s. covid-19 and addiction. diabetes metabsyndr. 2020;14(5):817-23. doi: 10.1016/j.dsx.2020.06.008 9. kumar v. potential medicinal plants for cns disorders: an overview. phytother res. 2006;20(12):1023-35. doi:10.1002/ptr.1970 10. durrantkl. known and hidden sources of caffeine in drug, food, and natural products.journal of the american pharmaceutical association (washington,d.c. : 1996), 2002;42(4):625-37. doi:10.1331/108658002763029607 11. griffithsp, lopez d, et al. khat use and monitoring drug use in europe: the current situation and issues for the future.journal of ethnopharmacology, 2010;132(3):578-83.doi: 10.1016/j.jep.2010.04.046 12. gyllenhaalc, merritt sl, et al. efficacy and safety of herbal stimulants and sedatives in sleep disorders. sleep medicine reviews. 2000;4(3):229-251. 13. parrottac, hayleyac, downey, la. recreational stimulants, herbal, and spice cannabis: the core psychobiological processes that underlie their damaging effects. hum psychopharmacol clin exp. 2017;32(3):e2594. 14. healdj, smith sl, et al.amphetamine, past and present--a pharmacological and clinical perspective. journal of psychopharmacology, 2013;27(6):479-96. 15. hashemiansm, farhadit.a review on modafinil: the characteristics, function, and use in critical care. journal of drug assessment, 2020;9(1):82-6. 16. storebøoj, pedersen n, et al. methylphenidate for attention deficit hyperactivity disorder (adhd) in children and adolescents assessment of adverse events in non-randomised studies. the cochrane database of systematic reviews, 2018;5(5);cd012069. 17. najibj, wimer d, et al. review of lisdexamfetaminedimesylate in adults with attention-deficit/hyperactivity disorder. journal of central nervous system disease 2017;9:1179573517728090. 18. radfarsr, richard ra.current research on methamphetamine: epidemiology, medical and psychiatric effects, treatment, and harm reduction efforts. addiction &health, 2014;6(3-4):146-54. 19. yeh ss, michael ws.megestrol acetate in cachexia and anorexia.international journal of nanomedicine, 2006;1(4):411-6. 20. craigcr.stimulants. in kirk‐othmer encyclopedia of chemical technology, (ed.). doi: 10.1002/047123 8961.1920091303180109.a01.pub2, 2007. 21. cunninghamkp, macintyre de, et al. effects of the ventilatory stimulant, doxapram on human task-3 (kcnk9, k2p9.1) channels and task-1 (kcnk3, k2p3.1) channels.acta physiologica (oxford, england), 2020;228(2):e13361. 22. lolandcj, mereu m, et al. r-modafinil (armodafinil): a unique dopamine uptake inhibitor and potential medication for psychostimulant abuse.biological psychiatry, 2012; 72(5):405-13. 23. corteses, et al. safety of methylphenidate and atomoxetine in children with attention-deficit/ hyperactivity disorder (adhd): data from the italian national adhd registry.cns drugs, 2015;29(10):865-77. 24. de sousaa, gurvinder k. drug therapy of attention deficit hyperactivity disorder: current trends. menssana monographs, 2012;10(1):45-69. 25. garcia-mijaresm,delucia r, silva mta. fencamfamine-induced changes in the parameters of the matching law and the effect of previous exposure to the drug. behaviouralpharmacology, 2004;15(8):577-584. 26. gomeni r, komolova m, incledon b, faraone sv. model-based approach for establishing the predicted clinical response of a delayed-release and extended-release methylphenidate for the treatment of attention-deficit/hyperactivity disorder. journal of clinical psychopharmacology, 2020;40(4):350-8. 245 international journal of human and health sciences vol. 03 no. 04 october’19 case report: high unprotective anti-hbs antibodies level among vaccinated students in a tertiary teaching hospital in north-eastern malaysia murnihayati hassan1,2, zeehaida mohamed1, nabilah ismail1, habsah hasan1, zakuan zainy deris1,3*. abstract introduction: universal hepatitis b vaccination to all newborns have been implemented in malaysia, since 1989, with nationwide coverage of 96.26%. in this study, we aimed to assess the prevalence of anti-hbs and hbsag among selected undergraduate students who presumably had completed hepatitis b vaccination during their early childhoods. methods: results of hepatitis b screening were obtained retrospectively from 239 newly enrolled undergraduate students at health campus, universitisains malaysia, in 2018. serum samples were previously tested for the presence of anti-hbs and hbsag using chemiluminescence immunoassay. epidemiological data, anti-hbs and hbsag were analysed using a descriptive statistical method. results: anti-hbs was undetected in 82.2 % (n = 194/236) of the tested students. none of these students had detectable hbsag. conclusion: this study showed anti-hbs level weaned after almost two decades of vaccination. therefore, an alternative new testing algorithm such as the administration booster dose of hepatitis b vaccination can be considered in order to ensure that the new students are protected against potential exposure to hepatitis b during their clinical practices. keywords: seroprevalence, student, anti-hbs, hbsag, memory persistence. correspondence to: zakuan zainy deris, department of medical microbiology and parasitology, school of medical sciences, universitisains malaysia, health campus, 16150 kubang kerian, kelantan, malaysia. e-mail : zakuan@usm.my 1. department of medical microbiology and parasitology, school of medical sciences, universiti sains malaysia, 16150 kota bharu, kelantan, malaysia 2. department of pathology, hospital raja perempuan zainab ii, 15150 kota bharu, kelantan, malaysia 3. infection control and epidemiology unit, hospital universitisains malaysia, 16150 kota bharu, kelantan, malaysia international journal of human and health sciences vol. 03 no. 04 october’19 page : 245-248 doi: http://dx.doi.org/10.31344/ijhhs.v3i4.111 introduction hepatitis b virus (hbv) is an oncogenic virus that causes acute hepatitis and chronic complications, such as chronic hepatitis and hepatocellular carcinoma. in 2015 alone, it was estimated that 887 000 people succumbed to the long-term complications of hbv infection. in most circumstances, hbv infection is effectively preventable by vaccination with highly immunogenic hbv surface antigen (hbsag). this vaccine is typically administered via intramuscular injection, usually at the anterolateral thigh muscle, in three doses (10 g intramuscular (im) dose), during birth, followed by at 1 month and 6 months of age 1. in malaysia, hbv vaccination is compulsory and included in the expanded programme on immunisation (epi) since 1989 2. subsequently, the coverage of hbv vaccination rate in this country improved, and was reported as high as 96.29%, with the effectiveness rate of up to 98% of the immunecompetent population 3,4. despite the effectiveness of the hbv vaccination program, hepatitis b infection remains as a major occupational health hazard among the healthcare personnel5. as such, majority academic and healthcare institutions employ mandatory screening of hbv infection and anti-hbs antibody level among the prospective students upon admission. this preventative measure is undertaken to reduce the risk of students with undetectable protective antihbs of contracting hepatitis b infection from the international journal of human and health sciences vol. 03 no. 04 october’19 246 reactive patients and vice versa6. therefore, in this study, we aimed to assess the level of anti-hbs antibody among newly enrolled-undergraduate students in the year 2018 at health campus, universiti sains malaysia. these students are presumed to have completed all three doses of hepatitis b vaccination, during their early childhood. in addition, the prevalence of hbsag among those students and the effectiveness of screening for anti-hbs were also evaluated. methodology this is a retrospective study involving analysis of serum results of 236 undergraduate students who were enrolled at health campus, universiti sains malaysia for the year 2018. all studentswere presumed to have received complete hepatitis b vaccination during infancy. their samples were screened for the presence of anti-hbs antibody and hbsag using elecsys hbs antigen ii and elecsys anti-hbs ii chemiluminescenceassays on roche cobas e 601 analyser. the limit of detection and limit of quantification of hbsag were 2.0 iu/l and 1.5 million iu/l respectively. adequate serological protection is defined as an anti-hbs antibody level of≥ 10iu/l. all serum with reactive hbsag and anti-hbs were retested using the same analyser. only samples repeatedly reactive hbsag were reported as hbsag reactive. epidemiological data and serology results were analysed for descriptive statistics using spss statistical software. result as shown in table 1, the age distributions of the 239 students were between 18 and 25 years old (median: 19 years old). of all, 78% were female and most were of the malay ethnicity. in terms of hbsag reactivity, none of the tested samples was positive. noticeably, the vast majority of the students did not have a protective level of antihbs antibodies (82.2%, n = 194/236). of those with a protective level of anti-hbs antibodies, the mean antibody titre was 99.1 iu/l (range: (11.1 – 1000.0). all serum with reactive anti-hbs yield consistent results when retested. discussion in this study, a low number of new students had a protective anti-hbs antibody level. this scenario of weaning of anti-hbs level occurs after ~two decades of hbv vaccination and is consistent with findings from a similar taiwanese group which evaluated their college students who received hbv vaccine during infancy 7. theoretically, the production of anti-hbs peaks after 1 – 2 month of the primary vaccination, and can last for approximately 10 – 31 years8. therefore, a distant anti-hbs result cannot readily distinguish between a responder and a non-responder. according to the centre for disease control and prevention (cdc), a non-responder is defined as an individual with an anti-hbs level of 10 iu/l, after completion of two hbv vaccination doses6. meanwhile, lifetime persistence of anti-hbs level at a concentration of ≥10 iu/l may be not necessary for protection because of the memory persistence that confers effective protection against infection as well as against disease (i.e. acute hepatitis, prolonged viremia, carriership, and chronic infection). such immune response can be re-activated even though the vaccinated individuals have weaning or undetectable anti-hbs titres8. cdc does not recommend routine serological anti-hbs testtable 1. epidemiological distribution and serological prevalence among newly enrolled students (n = 236) parameters number (% or range) age average median 19 (18 – 25) < 18 years 0(0.0) 18-20 years 224 (94.9) 21-23 years 7 ( 3.0) >23 years 5 (2.1) gender male 52 (22.0) female 184 (78.0) race malay 201 (85.2) chinese 15 (6.3) indian 14 (5.9) others 6 ( 2.5) hbsaglevel negative 236 (100.0) positive 0 ( 0.0) anti-hbsantibody titres nonprotective level (< 10iu/l) 194 (82.2) protective level ( ≥10 iu/l) 42 (17.8) range of detectable level of anti-hbs mean 99.1 (11.1 – 1000.0) 247 international journal of human and health sciences vol. 03 no. 04 october’19 ing for newly recruited healthcare practitioners (hcp)1. nevertheless, upon enrolment, the new recruits should provide written and dated records of hbv vaccination with documented post vaccination anti-hbs antibody titre of ≥10 iu/l 1. for a fully vaccinated group with nonprotective anti-hbs titres, a challenge dose of hbv vaccine may be administered to determine the presence of vaccine-induced immunologic memory through the generation of an anamnestic response1. an immunologic response (anti-hbs) of ≥10 iu/l following a challenge dose is considered protected, regardless of the subsequent titre (i.e. declines of anti-hbs)6. meanwhile, the unvaccinated and incompletely vaccinated group should receive complete doses of hbv retested for a serological response after 1 – 2 months of vaccination 1. post-vaccination testing is useful as lu et al. (2008) found that 28.7% of subjects who had received a complete series of hbv vaccine failed to mount an adequate anamnestic response. moreover, the team also reported that a proportion of these subjects(27.2%) lost the hepatitis b vaccine conferred protective memory response, as evident by the lack of hbsag-specific ifn-gamma or il5-secreting pbmcs7. similarly, a local study in malaysia by othman et al. (2018) involving 352 completely hbv-vaccinated individuals reported that only 27.6% had a protective level of anti-hbs titre9. meanwhile, the remaining subjects had a nonprotective level of anti-hbs and been given abooster dose of hepatitis b vaccine. of the latter group, 208 students (59.1%) mounted an adequate anamnestic response, while the rest of the subjects were given acomplete a series of hepatitis b vaccine. two students (0.6%) weredetermined as non-responder9. these reports reflect the necessity of booster dose in order to mount adequate memory response in a high-risk group such as the hcp, medical students and volunteers. moreover, this strategy is more valuable than conducting a generalized distant anti-hbs testing in fully vaccinated group6-7. to date, cdc reaffirmed that booster dose is not necessary for the immunocompetent individuals with a protective level of anti-hbs antibodies1. however, a booster dose of hepatitis b vaccine remains as an important strategy that is employed as a screening tool for evaluating memory persistence due to the lack of documentation of post-vaccination baseline of anti-hbs titre among the subjects2,9,10. furthermore, a booster dose after almost twenty years of vaccination can benefit certain occupation groups of fully vaccinated individuals that had loss vaccine-conferred memory persistence. thus, this study allows the institution to identify this special group which is indicated to complete the second series of hepatitis b vaccination before deem as non-responders1. conclusion weaning of anti-hbs level in fully vaccinated individuals is evident after two decades of hbv vaccination. academic institutions or healthcare providers should employ a more comprehensive strategy to determine the level of immunity against hbv infections among the fully vaccinated students/healthcare worker. furthermore, such institutions should consider a booster vaccination strategy to demonstrate vaccine-conferred memory persistence, instead of continuing the traditional routine screening policy of anti-hbs titres for all students. acknowledgements we thank the staffs at the medical microbiology & parasitology laboratory of universitisains malaysia for the direct and indirect contribution, especially to mr muhammad amiruddin abdullah. the authors would like to thank the director of hospital universiti sains malaysia for the permission to access medical data and permission to publish this paper. conflict of interests : none declared. ethics statement the institutional human research ethics committee indicated this report is exempted from ethical review. authors’ contributions: conception and design: mhh, ni, zzd analysis and interpretation of the data: mhh, zm drafting of the article: mhh critical revision of the article for important intellectual content: zm, zzd, hh final approval of the article: all authors international journal of human and health sciences vol. 03 no. 04 october’19 248 references: 1. centers for disease control and prevention (cdc). immunization of health-care personnel recommendations of the advisory committee on immunization practices (acip) morbidity and mortality weekly report 2011. available from: http://www.cdc.gov/mmwr/cme/conted.html. [cited 2019 feb 11] 2. raihan r. hepatitis in malaysia: past, present, and future. euroasian journal of hepatogastroenterology 2016;6 (1):52–5 3. raihan r, mohamed r, radzi abu hassan m, md said r. chronic viral hepatitis in malaysia: where are we now? euroasian journal of hepatogastroenterology 2017;7(1):65–7 4. centres for disease control and prevention (cdc). appendix b: immunization management issues. morbidity and mortality weekly report 2005. available from: https://www.cdc.gov/mmwr/preview/ mmwrhtml/rr5416a3.htm [cited 2019 feb 11] 5. goniewicz m, włoszczak-szubzda a, niemcewicz m, witt m, marciniak-niemcewicz a, jarosz mj. injuries caused by sharp instruments among healthcare workers--international and polish perspectives. annals of agricultural and environmental medicine 2012;19 (3):523–7 6. schillie s, murphy t v, sawyer m, ly k, hughes e, jiles r, et al. cdc guidance for evaluating healthcare personnel for hepatitis b virus protection and for administering postexposure management. morbidity and mortality weekly report 2013. available from: http://www.ncbi.nlm.nih.gov/ pubmed/24352112[cited 2019 feb 11] 7. lu c, ni y, chiang b, chen p, chang m, chang l, et al. humoral and cellular immune responses to a hepatitis b vaccine booster 15–18 years after neonatal immunization. journal of infectious diseases 2008;197 (10):1419–26 8. leuridan e, van damme p. hepatitis b and the need for a booster dose. clinical infectious diseases 2011;53(1):68–75 9. othman sn, zainol rashid z, abdul wahab a, abdul samat mn, ding ch, ali uk, et al. hepatitis b seroepidemiology and booster vaccination in preclinical medical students in a malaysian university. malaysian journalof pathology 2018;40 (3):295-302 10. yang s, tian g, cui y, ding c, deng m, yu c, et al. factors influencing immunologic response to hepatitis b vaccine in adults. scientific reports 2016; 27251 (6): 1-12 international journal of human and health sciences vol. 05 no. 01 january’21 90 original article: spinal anaesthesia induced hypotension and related adverse effects in caesarean section delivery and neonatal outcome: a comparison of using crystalloid pre-loading and coloading in caesarean patients taneem mohammad1, moinul hossain chowdhury2, shamima akter1,mohammad abdul karim miah1,mohammad mohsin3, sm ahsanul habib4, arifa sultana5 abstract: background: volume loading by rapid infusion of crystalloid solution before/during induction of spinal anaesthesia may effectively reduce the incidence of anaesthesia induced hypotension. objective:to compare the efficacy of crystalloid pre-loading and co-loading to preventhypotension and related adverse effects as well aspoor neonatal outcome in caesarean section delivery under spinal anaesthesia. methods:this single blinded randomized controlled clinical trial was conducted in the department of anaesthesia, analgesia & intensive care, dhaka medical college hospital, dhaka, between january 2013 and december 2014. a total of 90 patients were selected –45patients of group i received co-loading with ringer’s lactatesolution, while another 45 patients of group ii received a pre-loading of the same fluid.blood pressure and heart rate were recorded. ephedrine and adrenaline were administered as needed to treat hypotension.apgar scores of the newborn were recorded at 1st minute and 5th minute after delivery. adverse effects like nausea, vomiting, light headedness and shivering was observed all through during operation and post-operative phase in all patients, if any, and recorded.results:the incidence of hypotension was 17 (37.8%) in group i (co-loading) and 27 (60%) in group ii (pre-loading), which was significantly higher in group ii (p<0.05).adverse effects – nausea, vomiting, light headedness and shivering was observed more in group ii patients; however, the difference was not statistically significant. in neonates, apgar score at 1 minute was found ≤7 in 18 (40.0%) from group i, while 28 (62.2%) from group ii; the difference was statistically significant (p<0.05). no significant difference was observed in apgar score at 5 minutes, as found ≤7 in 6 (13.3%) and 3 (6.7%) in group i andgroup ii respectively.conclusion:severity of hypotension, increased ephedrine requirement and poor apgar score wereevident in patients who received crystalloid pre-loading group(group ii), which meanscrystalloid co-loading group(group i) procedurewas more effective in preventing spinal anaesthesia induced hypotension and secured better neonatal outcome. keywords: crystalloid pre-loading, crystalloid co-loading, spinal anaesthesia, hypotension, neonatal outcome, apgar score. correspondence to: dr. taneem mohammad, assistant professor, department of anaesthesia, analgesia, palliative and intensive care medicine, dhaka medical college hospital, dhaka-1000, bangladesh. email: mtaneem@yahoo.com 1. assistant professor, department of anaesthesia, analgesia, palliative and intensive care medicine,dhaka medical college hospital, dhaka-1000, bangladesh. 2. assistant professor, department of anaesthesia and intensive care medicine,shaheed tajuddin ahmad medical college hospital,gazipur-1700, bangladesh. 3. assistant professor, department of critical care medicine, dhaka medical college hospital, dhaka-1000, bangladesh. 4. senior registrar, department of anaesthesia, icu and pain medicine, apollo hospitals, dhaka-1229, bangladesh. 5. senior registrar, department of obstetrics & gynaecology, apollo hospitals, dhaka-1229, bangladesh. international journal of human and health sciences vol. 05 no. 01 january’21 page : 90-95 doi: http://dx.doi.org/10.31344/ijhhs.v5i1.240 introduction: spinal anaesthesia has become a commonly used technique for elective and emergency caesarean section operation, as it is relatively cheaper, easily administered and rapidly acting technique, havinggood quality of sensory and motor block1,2. it helps the mother remain awake for the birth and comfortable afterwards as well 91 international journal of human and health sciences vol. 05 no. 01 january’21 as avoids complications and risks associated with general anaesthesia3,4. however, spinal anaesthesia is also not without disadvantages;it is associated with high incidence of hypotension, which is more common and profound in pregnant population that can result in both maternal and neonatal morbidities2-5.spinal anaesthesia causes sympathetic blockade and this reduces blood pressure by systemic vascular resistance and venodilatation in the lower extremity of the body, which becomes more aggravated in pregnancy by the effect of gravid uterus and associated aorto-caval compression2,5,6.moreover, increased sensitivity to spinal anaesthetics in pregnancy due to higher progesterone levels, hypotension induce more nausea and vomiting, cardiovascular collapse and loss of consciousness in the mother2,6. besides, prolonged hypotension can cause fetal hypoxia and acidosis resulting in a possibility of lower apgar score in newborns due to consequence ofreductionin uterine blood flow, which is ultimately pressure dependent6.hence, prevention of episodes of hypotension due to spinal anaesthesia for caesarean section operation always remains as an important issue for an anaesthesiologist. the practice of volume loadingapparently reduce the high incidence of hypotension in obstetric patients, as first introduced over 50 years back7. though some of the earlier studies demonstrated immense success of crystalloid preloading8,9, the results of those studies have been questioned by the other investigators10-12. in the recent past, coloading has generated interest for the prevention of spinal-induced hypotension and suggested that it is more rational approach for the prevention of post spinal hypotension13,14. co-loading might be physiologically more appropriate because the maximum effect can be achieved during the time of the block and possibly increase intravascular volume expansion during vasodilatation from the sympathetic blockade and limit fluid redistribution and excretion13,14.hence, present study was designed to compare the efficacy of crystalloid pre-loading and co-loading to prevent spinal anaesthesia induced hypotensionand related adverse effects in caesarean section delivery and neonatal outcome in those two groups. methods: this single blinded randomized controlled clinical trial was conducted in the department of anaesthesia, analgesia,palliative and intensive care medicine care, dhaka medical college hospital, dhaka, from january 2013 to december 2014.our study population was all the patients admitted in department ofobstetrics &gynaecology in the same hospital who underwent caesarean section operation.however, convenient sampling technique was adopted. the patients were selected after fulfilling the following inclusion and exclusion criteria: inclusion criteria: 1. patients(pregnant women) with singleton, uncomplicated pregnancy who underwent caesarean section done under spinal anaesthesia. exclusion criteria: 1. patients with congenital heart disease, chronic hypertension, gestational hypertension, pre-eclampsia, eclampsia; 2. patients contraindicated for spinal anaesthesia; and 3. patients refused to participate in the study. after fulfilling the inclusion and exclusion criteria, finally 90 pregnant women were allocated into two groups with 45 in each group. they were grouped by odd and even number and allocated to receive either crystalloid pre-loading or co-loading during caesarean section operation. the co-loading group was named group-i and pre-loading group was named group-ii. group ii (pre-loading) received of 20ml/kg of ringers lactate solution over a period of 20minutes before spinal anaesthesia and group i (co-loading) received20ml/kg of ringers lactate solution after the spinal anaesthesia by pressurized infusion pump. in the operation theatre, blood pressure, heart rate was measured, heart and lung were examined and recorded. the anaesthesia procedure was explained to the patient. intravenous access was secured with 18g iv cannula. ringer’s lactate fluid was infused at the rate of 5 drops per minute to keep the cannula patent and monitoring of electrocardiogram and pulse oximetry was applied.the patients of group ii (pre-load) received 20ml/kgringer’s lactate solution over a period of 20 minutes before spinal anaesthesia. spinal anaesthesia was conducted with the patient in the right lateral position. with all aseptic preparation, the skin and subcutaneous tissue were infiltrated with local anaesthetics. spinal anaesthesia was given using 2.5 ml of 0.5% of hyperbaric bupivacaine, injected slowly over 12 seconds at the l2-3 or l3-4 level with a 25g quincke needle.patients of group i (coload) received same ringers lactate fluid load of international journal of human and health sciences vol. 05 no. 01 january’21 92 20ml/kg fluid by pressurized infusion pump after observing the free flow of cerebrospinal fluid. after spinal anaesthesia injection, dressing was applied and immediately put into supine position. urinary catheter was inserted in all patients, and a wedge was placed for 15 degree left lateral tilt. once the fluid bolus was given, infusion rate decreased to a maintenance rate of 100ml/hour. the quality of the sensory block was assessed by swab soaked in alcohol. surgery was proceeded after confirmation of block to t4 level.blood pressure and heart rate were recorded in both the groups with 3-minute intervals from the beginning of the subarachnoid block for the first 20 minutes, and then with 5-minute intervals up to one hour. spinal anaesthesia induced hypotension was defined as a decrease in the systolic arterial pressure (sap)>20% from the baseline reading or a decrease of sap to less than 80 mmhg as an absolute value. hypotension was treated by bolus doses of ephedrine (5mg). if the systolic arterial blood pressure decreases to less than 80 mm of hg or less than 80% of the calculated baseline value, 5 mg ephedrine doses were administered until systolic arterial pressure recovered to normal limit. the patients who did not respond with ephedrine, inj. adrenaline was given in doses of 10µg. after delivery of the baby, all patients received 10 iu of inj. oxytocin bolus and 20 iu was mixed in the ringer’s lactate solution, which was infused slowly. apgar scores of the newborn were recorded at 1st minuteand 5th minute after delivery. adverse effects like nausea, vomiting, light headedness andshivering was observed all through during operation and post-operative phase in all patients, if any, and recorded. statistical analyses were done using the spss version 19.0 for windows (spss inc., chicago, illinois, usa). the mean values were calculated for continuous variables. the qualitative observations were counted by frequencies and expressed in percentages. chi-square test was used to analyze the categorical variables, while student t-test was used for continuous variables. p values <0.05 was considered as statistically significant. results: most of the patients belonged to age group ≤30 years in both trial groups. the mean age was 24.4±4.4 years in group i (co-loading) and 25.5±4.0 years in group ii (pre-loading). mean age difference was not statistically significant between the groups (table 1).the incidence of hypotension was 17(37.8%) in group i (co-loading) and 27(60%) in group ii (pre-loading), which was significantly higher in group ii(p<0.05) (table 2).ephedrine was required in 17 cases (37.8%) in group i and 27 cases (60%) in group ii.mean ephedrine required was 9.2±3.6 mg in group i and 11.5±4.3 mg in group ii. the difference was statistically significant (p<0.05) (table 3). adrenaline was administeredin 1 case (2.2%) in group i and in 2 cases (4.4%) in group ii.however, the difference was not statistically significant (p>0.05) (table 3).among the side effects of hypotension, nausea and vomiting werereported by14(31.1%) and 3 (6.7%) in group i, while 12(26.7%) and9(20.0%) ingroup ii respectively. light headedness wasreported by 10(22.2%) and 11(24.4%), while shivering was reported by 9(20.0%) and 12(26.7%) of group i and group ii respectively.however, the difference was not statistically significant among the variables between two groups(p>0.05) (table 4).in the neonates, apgar score at 1 minute was found ≤7 in 18(40.0%) from group i, while 28(62.2%) from group ii, which was statistically significant (p<0.05). apgar score at 5 minutes was found ≤7 in 6(13.3%) from group i, while in 3(6.7%) from group ii. the difference was not statistically significant (p>0.05) (table 5). table 1: distribution of the study patients by age (n=90) age (years) group-i (n1=45) group-ii (n2=45) p value 0.211ns frequency % frequency % ≤30 38 84.4 37 82.2 >30 7 15.6 8 17.8 mean±sd 24.4±4.4(18-35) 25.5±4.0 (19-36) figures in the parentheses indicate range. ns = not significant; p value reached from unpaired student-t test. table 2: distribution of the study patients by hypotension (n=90) hypotension group-i (n1=45) group-ii (n2=45) p value frequency % frequency % 0.034s no hypotension 28 62.2 18 40.0 hypotension occurred 17 37.8 27 60.0 s = significant; p value reached from chi-square test. 93 international journal of human and health sciences vol. 05 no. 01 january’21 table 3: ephedrine and adrenaline requirement in management of hypotension (n=90) medication group i group ii p value ephedrine requirement 17 (37.8%) 27 (60.0%) 0.006s mean ephedrine requirement (mg) 9.2±3.6 11.5±4.3 0.007 s adrenaline requirement 1 (2.2%) 2 (4.4%) 0.500ns figures in the parentheses indicate percentage. s = significant, ns = not significant; p value reached from unpaired student-t test. table 4: distribution adverse effects of hypotension (n=90) complications group-i (n1=45) group-ii (n2=45) p value frequency % frequency % nausea present 14 31.1 12 26.7 0.641ns absent 31 68.9 33 73.3 vomiting present 3 6.7 9 20.0 0.062ns absent 42 93.3 36 80.0 light headedness present 10 22.2 11 24.4 0.803ns absent 35 77.8 34 75.6 shivering present 9 20.0 12 26.7 0.454ns absent 36 80.0 33 73.3 ns = not significant; p value reached from chi-square test. table 5: neonatal outcome by apgar score (n=90) apgar score group-i (n1=45) group-ii (n2=45) p value frequency % frequency % 1 minute ≤7 18 40.0 28 62.2 0.034s >7 27 60.0 17 37.8 5 minutes ≤7 6 13.3 3 6.7 0.242ns >7 39 86.7 42 93.3 s = significant, ns = not significant; p value reached from chi-square test. discussion: in this present study, most of the patients belonged to age ≤30 years in both groups. the mean age was 24.4±4.4 years in group i (co-loading group) and 25.5±4.0 years in group ii (pre-loading group). the difference was not statistically significant (p>0.05) between two groups. dyer et al.14 reported mean age 26.8±4.9 and 27.4±6.0 years for pre-load and co-load respectively, while jacob et al.15 found mean age 26.9±2.4 years in co-load and 26.7±2.6 years in pre-load group. oh et al.16 showed the mean age of patients in co-load group 33.7±4.0 years as compared to 33.5±3.5 years in pre-load group. the differences were not statistically significant in those studies and the results were found similar toour study. in this present study, we observed episodes of hypotension more in group ii (pre-loading) in comparison to group i (co-loading), which was statistically significant. mojica et al.13 conducted a randomized clinical trial to evaluate the efficacy of crystalloids in preventing spinal-induced hypotension (sih) and cardiovascular side effects (cvse) in a group of surgical patients. the incidence of sih was similar in all treatment groups. however, compared to placebo, crystalloid administration at the time of spinal block resulted in a significant reduction in the proportion of patients developing cvse from 9.9% to 2.3% (p<0.05). administration of crystalloids at the time of spinal block seems to be effective because it provides additional intravascular fluids during the period of highest risk of cvse after spinal anesthesia13. dyer et al.14 reported 84% hypotension in the preload group and 60% in the co-load group. jacob et al.15 reported that 60% of patients in the preloading group developed hypotension. previous studies using 15 ml/kg of lactated ringer’s as pre-load in the obstetric population reported the incidence of hypotension as 55%, as studied by gajraj et al.17 and 45.5%, as found by tercanli et al.18. however, oh et al.16 studied comparing systolic blood pressure between the two groups at baseline, with 1 minute interval and found that hypotension occurred in 83% cases in pre-loading group and 53% in the co-loading group, which was statistically significant (p=0.026). we observed adverse effects like nausea, vomiting, light headedness and shivering more in group ii patients; however, the difference was not statistically significant.conversely, jacob et al.15 observed significant difference – nausea19 vs. 10 and vomiting 14 vs. 6 in pre-load and co-load international journal of human and health sciences vol. 05 no. 01 january’21 94 respectively (p<0.05), while oh et al.16observed nausea 60% and 27% respectively. dyer et al.14 reported that the co-load group required a lower median dose (p=0.03) and a lower median number(p=0.04) of ephedrine doses for the treatment of maternal hypotension predelivery. nevertheless, there was no difference in either the total cumulative dose, or in the total number of doses of ephedrine between groups. jacob et al.15 showed that the mean number of doses of ephedrine required 2.6 vs. 1.8 and the total dose of ephedrine used 14.2 mg vs. 12.6 mg in pre-load andco-load respectively which were statistically significant. oh et al.16 reported that smaller dose of ephedrine (7.5 mg) required in the co-load group than the pre-load group (15 mg). evidence suggested that neonatal outcomes in terms of apgar score was not statistically significant between pre-load and co-load groupsas recorded at birth, 1 minute and 5 minutes after birth, despite a difference in the episodes of hypotension among the groups15, unlike the findings of the present study. this reflects previous experience that transient decreases in blood pressure rapidly treated by vasopressor do not usually affect the fetal outcome19. limitations of the study: this was a single-centre trial. the study population was selected from an urban hospital for a short period of time in dhaka city. hence, the results of the study may not be generalized and does notnecessarily reflect the overall picture of the country.small sample size was another limitation of the present study.the lack of a control group or placebo group precluded determination of an absolute reduction in the incidence of hypotension (as we did not include a placebofor ethical reasons). moreover, the study did not investigate the correlation between umbilical artery ph and spinal-delivery interval, uterine incision-delivery interval and duration of hypotension.apgar score was taken for rapid evaluation of neonatal (fetal) outcome in place of umbilical blood ph and blood gas status as the same was not readily available in the department ofobstetrics &gynaecology facility. conclusion: in summary, severity of hypotension, increased ephedrine requirement and poor apgar score were evident in patients who received crystalloid pre-load, which means crystalloid coloadprocedure was more effective in preventing spinal anaesthesia induced hypotension and secured better neonatal outcome. further studies with larger sample and multi-centre trials along with high technical back up are recommended. conflict of interest:none declared. ethical approval issue: the study was approved by the ethical review committee of dhaka medical college, dhaka, bangladesh. funding statement: no funding. authors’ contribution: conceptand study design: tm; data collection and compilation: tm, mhc, sa, makm, mm, smah, as; data analysis: tm, smah; critical writing, revision and finalizing the manuscript: tm, mhc, sa, makm, mm, smah, as. 95 international journal of human and health sciences vol. 05 no. 01 january’21 references: 1. shibli ku, russell if. a survey of anaesthetic techniques used for caesarean section in the uk in 1997. int j obstetanesth. 2000;9(3):160-7. 2. birnbach dj, brown im. anesthesia for obstetrics. in: miller rd, cohen nh, eriksson li, fleisher la, wiener-kronish jp, young wl. eds. miller’s anesthesia. 8th ed. philadelphia: elsevier/churchill livingstone; 2005. 3. hawkins jl, koonin lm, palmer sk, gibbs cp. anesthesia-related deaths during obstetric delivery in the united states, 1979-1990. anesthesiology. 1997;86(2):277-84. 4. at a, so o. failed spinal anaesthesia for caesarean section. j west afr coll surg. 2011;1(4):1-17. 5. van de velde m. spinal anesthesia in the obstetric patient: prevention and treatment of hypotension. acta anaesthesiol belg. 2006;57(4):383‐6. 6. maayan-metzger a, schushan-eisen i, todris l, etchin a, kuint j. maternal hypotension during elective cesarean section and short-term neonatal outcome. am j obstet gynecol. 2010;202(1):56. e1‐5. 7. greiss fc, crandell dl. therapy for hypotension induced by spinal anesthesia during pregnancy: observations on gravid ewes. jama. 1965;191(10):793-796. 8. wollman sb, marx gf. acute hydration for prevention of hypotension of spinal anesthesia in parturients. anesthesiology. 1968;29(2):374‐80. 9. clark rb, thompson ds, thompson ch. prevention of spinal hypotension associated with cesarean section. anesthesiology. 1976;45(6):670‐4. 10. rout c, rocke da. spinal hypotension associated with cesarean section: will preload ever work? anesthesiology. 1999;91(6):1565‐7. 11. tamilselvan p, fernando r, bray j, sodhi m, columb m. the effects of crystalloid and colloid preload on cardiac output in the parturient undergoing planned cesarean delivery under spinal anesthesia: a randomized trial. anesthanalg. 2009;109(6):1916‐21. 12. mcdonald s, fernando r, ashpole k, columb m. maternal cardiac output changes after crystalloid or colloid coload following spinal anesthesia for elective cesarean delivery: a randomized controlled trial. anesthanalg. 2011;113(4):803‐10. 13. mojica jl, meléndez hj, bautista le. the timing of intravenous crystalloid administration and incidence of cardiovascular side effects during spinal anesthesia: the results from a randomized controlled trial. anesthanalg. 2002;94(2):432-7. 14. dyer ra, farina z, joubert ia, du toit p, meyer m, torr g, et al. crystalloid preload versus rapid crystalloid administration after induction of spinal anaesthesia (coload) for elective caesarean section. anaesth intensive care. 2004;32(3):351-7. 15. jacob jj, williams a, verghese m, afzal l. crystalloid preload versus crystalloid coload for parturients undergoing cesarean section under spinal anesthesia. j obstetanaesthcrit care. 2012;2(1):1015. 16. oh a-y, hwang j-w, song i-a, kim m-h, ryu j-h, park h-p, et al. influence of the timing of administration of crystalloid on maternal hypotension during spinal anesthesia for cesarean delivery: preload versus coload. bmc anesthesiol. 2014;14:36. 17. gajraj nm, victory ra, pace na, van elstraete ac, wallace dh. comparison of an ephedrine infusion with crystalloid administration for prevention of hypotension during spinal anesthesia. anesthanalg. 1993;76(5):1023‐1026. 18. tercanli s, schneider m, visca e, hösli i, troeger c, peukert r, et al. influence of volume preloading on uteroplacental and fetal circulation during spinal anaesthesia for caesarean section in uncomplicated singleton pregnancies. fetal diagn ther. 2002;17(3):142-146. 19. macarthur a. solving the problem of spinal induced hypertension in obstetric anaesthesia. canj anaesth. 2002;49(6):536-9. 171 international journal of human and health sciences vol. 07 no. 02 april’23 original article occurrence of transfusion transmitted infections among transfusion dependent thalassemia patients in a tertiary care hospital in india banduriap lyngdoh1,sunita bagdi1, sulekha ghosh2,tapan k. ghosh3 abstract background: blood transfusion is an important treatment modality in the modern health care system; however, transfusion transmitted infections(tti) could be fatal or life-threatening in some cases. objective: to determine the occurrence of transfusion transmitted infections among transfusion dependent thalassemia patients and to study the socio-demographic characteristics of the recipients. methods: this hospital-based descriptive longitudinal studywas conducted between february 2019 and june 2020, on 102 transfusion-dependentthalassaemic patients receiving blood transfusion at bankura sammilani medical college & hospital, bankura,west bengal, india. they were tested for hiv, hbv, hcv, syphilis and malaria by elisa (enzyme linked immunosorbent assay) lisa scan em, merilisa hbsag, merilisa hcv, rpr kit and maleriscan malaria pf/pv. results: out of 102 patients, 5.90% were positive for tti. the highest occurrence was found to be of hcv 3.90%. hbv and hiv showed similar occurrence of 0.98% and none came out positive for syphilis or malaria. the highest occurrence of tti was found among females 66.7%. the average age of the participants was 7.97±3.27years. the average number of blood transfusion received per year was 11.95±2.71units. majority of the participants belong to low socioeconomic group family 62(60.8%). in respect to ethnicity 14.7%were tribal, while 85.3%were non-tribal population. conclusion: the cause of high prevalence of hcv may be due to donors being asymptomatic in early stages and failure of detection due to window period of infection. more sensitive screening tests should be done for hiv, hbv, and hcv. all donors must be screened by nat if not possible the patients must be screened for tti regularly.thalassemia patients being the most affected, premarital screening for thalassemia should be done.every patient should be vaccinated with hepatitis b vaccine. keywords: transfusion transmitted infections, blood transfusion, thalassemia correspondence to: dr. banduriap lyngdoh, senior resident and demonstrator, department of pathology, bankura sammilani medical college & hospital, bankura, west bengal, india. email: banduriap@gmail.com 1. senior resident and demonstrator, department of pathology, bankura sammilani medical college& hospital, bankura, west bengal, india 2. professor, shantiniketan medical college, bolpur, west bengal, india.. 3. blood bank centre,shantiniketan medical college central laboratory, bolpur, birbhum, west bengal, india introduction fda defines a tti as a pathogen that is known to be fatal, to be life-threatening, or to cause severe impairment and that is potentially transmissible through the blood supply.1 blood transfusion is an important treatment modality in the modern health care system and though lifesaving but unfortunately it can be one of the sources of infective diseases.2a number of blood-borne infectious agents can be transmitted through transfusion of blood and blood products donated by apparently healthy and asymptomatic donors.3 international journal of human and health sciences vol. 07 no. 02 april’23 doi: http://dx.doi.org/10.31344/ijhhs.v7i2.570 international journal of human and health sciences vol. 07 no. 02 april’23 172 the diversity of infectious agents includes human immunodeficiency viruses 1 and 2, hepatitis a to e (hav, hbv, hcv, hdv and hev), malaria, syphilis, human t-lymphotropic virus types 1 and 2 ( htlv type 1 and 2) and in certain circumstances cytomegalovirus, parvovirus b19, and many more.4-6 besides, the established viral, bacterial, and parasitic diseases, novel agents have now appeared and are still emerging as potential threats in transfusion medicine.7the most common tti are due to viral infections. incidence of bacterial contamination is greatly reduced due to improved collection techniques and use of antibiotics in patients. according to naco guidelines, all mandatory tests should be carried out on donor’s blood samples for hiv, hbv, hcv, syphilis and malaria.8in india, it is mandatory to screen donated blood for anti-hiv 1 and 2 (since 1991), anti-hcv (since 2001), hbsag, syphilis, and malaria. blood ttis mainly occur in patients who are dependent on blood transfusion such as haemoglobinopathies, myelodysplastic syndromes and some haemato-oncology patients, receiving multiple transfusion episodes, either over long periods or over shorter periods.9beta thalassemia major is a hemoglobinopathy also known as cooley’s anemia, is a global health problem characterized by severe hemolysis.10 though regular blood transfusion improves the overall survival of patients with β-thalassemia, a definite risk of infection with blood-borne viruses occurs.11while in the past it was believed that transfusion transmitted infections were unavoidable, but a low risk of blood supply is expected today.12the provision of safe blood for transfusion involves a number of processes, from the selection of blood donors to collection, processing and testing of blood donors by sensitive methods to the testing of patient samples for detection of various infections. methods this hospital-based descriptive longitudinal study was conducted between february 2019 and june 2020, on 102 transfusion-dependent thalassaemic patients receiving blood transfusion at bankura sammilani medical college & hospital, bankura, west bengal, india. inclusion criteria:all the seronegative thalassemia patients receiving blood transfusion from bsmc&hospital, bankura, west bengal, india during the study period from february 2019 to june 2020 were included in the study by complete enumeration. exclusion criteria: seriously ill recipients and seropositive thalassemic patients all transfusion dependent thalassaemicpatients receiving blood transfusion from the blood bank of the study site hospital were tested for hiv, hbv, hcv, syphilis and malaria by elisa(enzyme linked immunosorbent assay) microwell plate, lisa scan em, merilisa hbsag, merilisa hcv, rpr kit and maleriscan malaria pf/pv. history of educational status of the parents, income, address was taken. then seronegative recipients were approached. after obtaining consent they were included in the study. they were interviewed with the help of a structured questionnaire. their blood samples were tested at the time of presentation and thereafter every five months for hiv, hbv and hcv, syphilis, and malaria for a period of twelve months. techniques: • hiv status is detected by elisa (enzyme linked immunosorbent assay) microwell plate, lisa scan em for the detection of antibodies to hiv1 and hiv 2 • hepatitis b status is detected by using merilisa hbsag for the detection of hepatitis b surface antigen • hepatitis c status is detected by using merilisa hcv for the detection of antibodies to hepatitis c virus • syphilis status is detected by rapid plasma reagin kit test • malaria is tested by rapid diagnostic kit (maleriscan) statistical analysis:all data were analyzed through standard statistical methods by using statistical package for social science (spss) software version 22.0 (spss inc., chicago, usa). results all the 102 participants were tested for hcv antibodies by merilisa hcv in february 2019 and all were seronegative for hcv. the patients 173 international journal of human and health sciences vol. 07 no. 02 april’23 were further tested in august 2019 and showed two hcv positive patients. in february2020, the patients were again tested, and another two new patients were positive as shown in the table 1.the same participants were tested for hiv antibodiesby elisa (enzyme linked immunosorbent assay) microwell plate, lisa scan em on different dates in february 2019 and were seronegative. they were again tested in the month of august 2019 and february 2020 and one patient as shown positive in the table 2. the same patients were tested for hbv antigen by merilisa hbsag in february 2019, august 2019, february 2020 and one patient came positive during the last test (table 3). none of the patients showed double positivity for the infection. the participants were tested for syphilis by (rpr) and malaria (maleriscan pf/pv) in february 2019, august 2019, and february 2020. none were positive for syphilis and malaria. among 102 patients, 6/102 (5.90%) were positive for tti (figure 1). the highest occurrence of was hcv 4/102 (3.90%), followed by hbv and hiv 1/102 (0.98%) (figure 2). none of the patients were positive for syphilis and malaria during the study. the average age of the participants was7.97±3.27 years. out of 102 patient 35were females and 67were males, showing ratio of male:female=1.9:1, and the average number of blood transfusion received per year was 11.95±2.71 units. majority of the participants came from low socioeconomic group family 62(60.8%), 30(29.4%) from middle group of socio-economic status and 10(9.8%) from high socio-economic group. in respect to ethnicity 14.7% (15) were tribal and 85.3% (87/102) were non-tribal population. table 1:result of hcv screening no of patient tested date report of hcv elisa n=102 feb 2019 all non reactive n =102 august 2019 2 seropositive n =102 feb 2020 2 patient sero reactive total 4 figure 2:result of hiv screening no of patients tested date report of hiv elisa n=102 feb 2019 all non reactive n =102 august 2019 all seronegative n =102 feb 2020 one patient sero-reactive total 1 table 3: result of hbsag screening no of patient tested date report of hbs ag elisa n=102 feb 2019 all negative n =102 august 2019 all negative n =102 feb 2020 1 patient sero reactive total 1 figure 1: percentage of tti positive patient figure 2:incidence of hcv, hiv, hbv discussion the probability of acquiring ttis is related to the probability of being exposed to the infected units of blood. the probability of being exposed to infectious units of blood depends on the number of units transfused and prevalence of carriers among the donor population .variations in the prevalence of ttis amongst thalassemics could be related to geographical differences in prevalence of the viral infections among blood donors and the nature of blood donors whether replacement or voluntary. the countries with a higher prevalence of hcv in the general population had a higher prevalence of hcv among thalassemia patients too.13 there international journal of human and health sciences vol. 07 no. 02 april’23 174 is high prevalence of hcv in thalassemics in all countries because of the unique profile of hcv with very long window period for antibody development. our study showed highest occurrence of hcv infection 4/102 (3.90%). the highest prevalence of hcv was also seen in studies like gugnani et al.14 of 13.4%, sidhu et al.15 of 13.04%, manisha et al.16of 18.2%. post-transfusion transmission of hcv has still remained a major health concern in multi-transfused patients. hepatitis b infection was found in one patient out of 102 patients (0.98%). gugnani et al.15 found the prevalence of hbv to be 0.79% which was comparable to the present study being 0.98%. jain et al.17showed positivity of 1.04% for hbv.the reduction in the prevalence of hbv may be due to hepatitis b vaccination prior blood transfusion. however, only few studies have been done on transfusion transmitted syphilis and malaria.15,16 those two previous studies also found no positive cases for syphilis and malaria, which is similar to our study finding. the highest incidence of tti was found among females 66.7% (4/6) in our study, although the male participants were in higher number i.e., 65.7% (67/102). our finding is notcongruent with the findings ofahmed kiani et al.18, which showed that male became more tti positive than in females (73.4% vs. 26.6%). in the present study 60.8% (62/102) participants belong to low socioeconomic status. yasmeen & hasnain19studied that post transfused tti positivity is more in low socioeconomic status.19 the average age of the participants was 7.97±3.27 years. the average number of blood transfused per year 11.95±2.71 units and majority of the recipients 85.3% (87/102) were non-tribal population. over the decade, tti magnitude has significantly reduced, but hepatitis c is still a main hazard. hbv vaccination have led to a dramatically decrease in prevalence of ttis particularly hbv during the last decades in various countries. ttis can still occur even after regular screening for the markers for these infections, as found in different indian and international studies. this risk of acquiring a tti from screened blood depends upon the sensitivity of the screening tests used, window-period of the virus, and other reasons, such as mutant strains. nucleic acid testing (nat) is widely recommended for the screening of donor blood. it reduces the window period of 2.93 days for hiv, to 10.24 days for hbv, and to 1.37 days for hcv and better chances of detecting false negative cases.19 though the cost for nat testing is considered unaffordable for a medium development country such as india, the burden of ttis will place an unmanageable cost burden on the society. now with the introduction of the fourth-generation elisa test that detects p24 antigen along with antibodies, the window period can be reduced to 2 weeks. conclusion the highest occurrence was found to be hcv which reflects the unsafe practices. the causes of high prevalence of hcv may be due to donors being usually asymptomatic in early stages, despite being screened for hcv possibly due to missing early window period infections. awareness about screening should be made so that more patients are diagnosed early. thalassemia patients being the most affected, premarital screening for thalassemia should be done. screening of all the registered pregnant women for thalassemia status must be done. parents should be counselled for prenatal testing of thalassemia. every patient should be vaccinated with hepatitis b vaccine. more sensitive screening tests should be used for hiv, hbv, and hcv. all donors must be screened by nat if not possible the patients must be screened for tti regularly. proper precautions for safe transfusion practices should be adhered to. conflict of interest:none declared. funding statement: no funding. ethical clearance: the study was approved by the ethical review committee of bankura sammilani medical college & hospital, bankura, west bengal, india. authors’ contribution:all authors were equally involved in data collection, analysis, manuscript preparation, revision and finalization. 175 international journal of human and health sciences vol. 07 no. 02 april’23 references 1. code of federal regulations. title 21 (food and drugs). washington, dc: u.s. government printing office.; 2017. 2. fessehaye n, naik d, fessehaye t. transfusion transmitted infections a retrospective analysis from the national blood transfusion service in eritrea. pan afr med j. 2011;9:40. 3. jaiswal sp, chitnis ds, jain ak, inamdar s, porwal a, jain sc. prevalence of hepatitis viruses among multi-transfused homogenous thalassaemia patients. hepatol res. 2001;19(3):247-53. 4. ministry of health and family welfare, government of india. voluntary blood donation programme – anoperational guideline. new delhi, india: national aids control organisation, mohfw, government of india; 2007. 5. kaur p, basu s. transfusion-transmitted infections: existing and emerging pathogens. j postgrad med. 2005;51(2):146-51. 6. bove jr. transfusion-transmitted diseases other than aids and hepatitis. yale j biol med. 1990;63(5):34751. 7. murphyhm. the transmission of infectious hepatitis by blood transfusion. gastroenterology. 1945;5:44956. 8. brecher me. technical manual. 15th ed. maryland, usa:american associations of blood banks;2005. 9. mishra k, shah a, patel k, ghosh k, bharadva s. seroprevalence of hbv, hcv and hiv-1 and correlation with molecular markers among multitransfused thalassemia patients in western india. mediterr j hematol infect dis. 2020;12(1):e2020038. 10. khandros e, kwiatkowski jl. beta thalassemia: monitoring and new treatment approaches. hematol oncol clin north am. 2019;33(3):339-53. 11. chakrabarty p, rudra s, hossain ma. prevalence of hbv and hcv among the multi-transfused beta thalassemic major patients in a day care centre of blood transfusion department of mymensingh medical college hospital. mymensingh med j. 2014 apr;23(2):235-41. 12. bihl f, castelli d, marincola f, dodd ry, brander c. transfusion-transmitted infections. j transl med. 2007;5:25. 13. sinha mk, raghuwanshi b, mishra b. menace of hepatitis c virus among multitransfused thalassemia patients in balasore district of odisha state in india. j family med prim care. 2019;8(9):2850-4. 14. gugnani p, oberoi l, arora m. prevalence of transfusion transmitted infections in multiple blood transfused ß-thalassemia patients from a tertiary care centre in north india. int jcontemp med res. 2019;6(12):l14-l17. 15. sidhu m, meenia r, yasmeen i, sawhney v, dutt n. prevalence of transfusion-transmitted infections in multiple blood transfused thalassemia patients: a report from a tertiary care center in north india. ann trop med public health. 2015;8:202-5. 16. manisha s, sanjeev k, seema n, dilip c, rashmi d. a cross-sectional study on burden of hepatitis c, hepatitis b, hiv and syphilis in multi-transfused thalassemia major patients reporting to a government hospital of central india. indian j hematol blood transfus. 2015;31(3):367-73. 17. jain r, perkins j, johnson st, desai p, khatri a, chudgar u, et al. a prospective study for prevalence and/or development of transfusion-transmitted infections in multiply transfused thalassemia major patients. asian j transfus sci. 2012;6(2):151-4. 18. ahmed kiani r, anwar m, waheed u, asad mj, abbasi s, abbas zaheer h. epidemiology of transfusion transmitted infection among patients with β-thalassaemia major in pakistan. j blood transfus. 2016;2016:8135649. 19. yasmeen h, hasnain s. epidemiology and risk factors of transfusion transmitted infections in thalassemia major: a multicenter study in pakistan. hematoltransfus cell ther. 2019;41(4):316-23. 297 international journal of human and health sciences vol. 05 no. 03 july’21 introduction the repercussions of covid -19 pandemic on mental health have been profoundly palpable, with an exponential rise in cases of anxiety, depression, suicidal attempts, relationship discord etc. this is being witnessed to different extent by the entire global community and is not restricted by boundaries of age, socio-economic status, gender, education level or profession. the adverse psychological impact gains especial relevance amongst doctors, who constitute an important component of frontline workers in the war against the novel coronavirus-19. the reasons for negative psychological consequences range from professional to personal. the former includes a high risk of contracting infection, inadequate personal protective equipment [ppe], lack of experience in management of the disease, prolonged working hours etc, whereas the latter reasons include significant lifestyle changes, concern for other family members especially young children and elderly parents, lack of family support, perceived stigma etc. while majority of studies have focused on the mental health of persons directly involved in treating patients with covid-19 infection, we have lack of data focusing on doctors who are not directly posted with covid-19 patients. this study was therefore planned to assess the impact on mental health on this subgroup of doctors. the authors wanted to study the psychological effects including stress levels, anxiety and depression and examine the association with different sociodemographic variables. abstract objective:doctors experienced unprecedented levels of workload and pressure since the outbreak of covid-19, making them more vulnerable to adverse psychological outcomes. while frontline healthcare workers face a substantially higher risk of susceptibility to infection due to excessive covid-19 exposure, little is known about its impact on doctors not directly posted with covid-19 patients. our study was focused on studying the impact of covid-19 pandemic on mental health of this subgroup of doctors.materials and methods: from april 1st to july 31st, 2020, a cross sectional web-based survey was conducted at a covid-19 dedicated tertiary care hospital. the study was conducted using standard questionnaires measuring adverse psychological outcomes including dass-21 and who-5. univariate and multivariate logistic regression were used to examine the determinants of adverse psychological outcomesresults and discussion: 145 doctors completed the survey questionnaire with over 71% females and 29% males. the overall prevalence of anxiety, depression and stress among doctors was 38.6%, 41.37% and 32.42% respectively. the overall well-being score was found to be 52.77 + 24.19 with a median [iqr] of 52.conclusion: a high incidence of adverse psychological outcomes are observed amongst doctors during covid-19 pandemic, even when they are not directly involved in the care of covid-19 patients. stress, anxiety and depression have an inverse relationship with age and marital status. anxiety has an inverse relationship with religious beliefs. keywords: covid-19, coronavirus, anxiety, depression, stress correspondence to: ayesha ahmad, associate professor, dept. of obst. &gynaecology, era’s lucknow medical college and hospital, lucknow, india. email: docayeshaahmad@gmail.com 1. dept. of obst. &gynaecology, era’s lucknow medical college and hospital, lucknow, india 2. dept. of psychiatry, era’s lucknow medical college and hospital, lucknow, india original article: covid-19 pandemic and mental health of doctors: an observational analytical study from a dedicated covid hospital. khatoon f 1, singh a1, jilani aq2, ahmad a1, haq m1, pandey s1 international journal of human and health sciences vol. 05 no. 02 april’21 page : 297-306 doi: http://dx.doi.org/10.31344/ijhhs.v5i3.279 international journal of human and health sciences vol. 05 no. 03 july’21 298 materials and methods research design the present study is a cross sectional, observational analytical study conducted at era’s lucknow medical college and hospital, after prior approval from the institutional ethical committee. the hospital is one of the major facilities of uttar pradesh, designated as a dedicated covid-19 hospital during the pandemic. it caters to patients with covid-19 infection only. the study observation period was from 1st of april till 31st of july. it was a questionnaire-based study containing both openand closeended questions, using social media platform to conduct the survey. the questionnaire was derived from dass-21 and who-5 questionnaires, both of which are in english language, standardized and pre-validated. the final questionnaire constructed for the study was validated on 10 study subjects. the participants were explained the purpose of study and invited to participate in the questionnaire. anonymity was ensured and explained to the participants. informed consent was taken prior to the survey. socio-demographic data was collected including age, gender, education, marital status, and occupation. questions were included on health care variables and variables related to covid-19 infection, perceived stress, anxiety, depression and threat due to covid19 infection. lastly, there were questions related to the general wellbeing of the doctors. the duration of filling up the questionnaire roughly averaged 10 minutes. dass-21 [the depression, anxiety and stress scale-21 items] was used to measure symptoms of new onsetdepression, anxiety and stress during our study. it is a set of three self-report scales designed to measure the emotional states of depression, anxiety and stress. each of the three dass-21 scales contains 7 items, divided into sub-scales with similar content. scores for depression, anxiety and stress are calculated by summing the scores for the relevant items. cut – off scores for normal, mild, moderate, severe and extremely severe were [0-9], [10-13], [14-20], [21-27] and 28+ respectively. who-5 well-being index was used to assess quality of life [qol] parameters. the raw score is calculated by summing figures of five answers. the score ranges from 0-25, 0 representing the worst possible and 25 representing best possible quality of life. to obtain a percentage score ranging from 0-100, the raw score is multiplied by 4. a percentage score of 0 represents worst possible, whereas a score of 100 represents best possible quality of life. inclusion and exclusion criteria doctors who were not posted in covid-19 wards were included for the study. those with previously known mental disorders, taking selfadministered medication for mental disorders or anti-depressants, those who had to face loss of any family member due to covid-19 and those posted directly with covid-19 patients were excluded from the study. analysis of data normality of data was confirmed using kolmogorov-smirnov test. parametric data was used for normally distributed data and nonparametric tests applied for cases where data was not normally distributed. categorical variables were presented as numbers and percentage whereas continuous variables were expressed as mean +/ sd and median values. quantitative variables were analysed using mann -whitney test [for two groups] and kruskal wallis test [for more than two groups] to calculate association. qualitative variables were assessed using chisquare test and fisher’s exact test. univariate and multivariate logistic regression was used to calculate odds ratio. significance was calculated as a ‘p value’ <0.05. limitations of the study the study is limited by numbers as well as restriction of profession. a general categorisation has been done and subjects recruited from doctors not directly posted in care of covid-19 patients. there may be differences in perceptions based on specialty also, which was not taken into account. data collection for the study was done from april to july, which was the period of lockdown in uttar pradesh and was at variance with the peak of pandemic in the state. protocols were still in the initial stages and there was a lot of uncertainty and unease with regards to how the pandemic would shape up and health facilities cope. another subjective feature which limits the impact is that we don’t really know the mental health of participants before the pandemic and can only rely on the version of participants themselves that the symptoms pertain to new onset stress, depression and anxiety. 299 international journal of human and health sciences vol. 05 no. 03 july’21 results 145 out of 300 doctors completed the survey questionnaire. response rate was 48.33%. of those 103[71%] were female and 42 [29%] male. table 1 shows socio-demographic characteristics of the study population. mean age of subjects was 32.65 +/9 years. majority had attained a postgraduate [pg] degree [62.76%] and 50 [34.48%] were pg students. almost half of the subjects were married [51.03%]. 61.38% were living in a nuclear family. table 2 shows the distribution of co-existing medical disorders. more than 90% of the participants did not have any co-morbidities. table 3 demonstrates association of gender and age with depression, stress and anxiety using dass-21 questionnaire. the overall prevalence of stress was found in 47 [32.42%] subjects with a mean score of 5.67 ± 4.8. the overall prevalence of anxiety was found in 38.6% and depression in 41.37 % doctors. participants were classified into 4 groups on the basis of age viz. 20-30 [group a]; 31-30 [group b]; 41-50 [group c] and >50 years [group d]. stress was found in 48% subjects in group a, 40.9% in group b, 12.5% in group c and 33.3% in group d. anxiety was found in 41.55% subjects in group a, 45.45% in group b, 25% in group c and 0% in group d. depression was found in 49.35 % subjects in group a, 45.45% in group b, 6.25% in group c and 12.5% in group d. observations in females and males, as examined for stress, depression and anxiety were found to be 32.03% and 33.33%; 42.7% and 28.57%; 42.7% and 38.09% respectively. the overall well-being score was found to be 52.77 ± 24.19 with a median [iqr] as 52[3276]. [table 4]. no differences were observed on the basis of age or gender. [table 4]. univariate and multivariate logistic regression was used to find significant risk factors of stress, anxiety and depression [table 5]. discussion this study collates psychological impact of covid-19 infection amongst doctors who are not directly involved in management of patients of covid-19 infection. we observed that majority of subjects did not have high levels of stress, anxiety and depression.salari et al conducted a systematic review and meta-analysis in the general population studying the same parameters and found the prevalence of stress, anxiety and depression as 29.6, 31.9 and 33.7% respectively.1 in another study, temsah et al showed that hcws were more anxious about transmitting covid-19 to a family member rather than acquiring the infection themselves [2.71/5 [1.22] versus 2.57/5 [1.10]. anxiety levels were as follows: mild in 68.25%, moderate in 20.8%, high moderate in 8.1% and very high in 2.9% .2 we observed higher prevalence of anxiety, stress and depression in women during the covid-19 pandemic as compared to men. [figure 1] this is in concordance with observations of other authors on the subject. 3,4,5,6 epidemiological studies have shown that women are more vulnerable than men with respect to psychological stress, anxiety, depression and post-traumatic stress disorder. there could be several reasons for this observation including the obvious one pertaining to inherent predisposition to psychological problems seen with gender. another important reason, unique to the pandemic could be non-availability of house helps due to the long period of lockdown imposed to combat the spread of infection. another corollary of the lockdown was closing of schools, entertainment or recreation places and social distancing measures, confining children to houses. this was associated with psychological stresses of varying degrees in majority of children which was a major factor of concern especially for mothers. although no differences were noted on the basis of type of religion, we did have an interesting observation wherein two subjects who declared themselves as agnostic, were found to have highly significant parameters on dass-21 [aor 24.20 (1.0-51 to 557.256) ]although the number is too small to draw any conclusion from the result, it does give food for thought and consideration. it is a well-known fact that social support in the form of family and relatives, religion and meditation all serve to provide a sense of mental well-being to individuals. kowalczyk et al found that 64% of study subjects believed faith would protect them from covid-19 infection. faith levels were found to be higher in elderly.7 we found that the age group of 41-50 years showed the best profile for psychological strength during the pandemic. [figure 2] the worst affected was the age group of 20-30 years. this corresponds to the seniority level of doctors, with group a comprising of mostly resident doctors, and those who are or would constitute the first tier of care. group c was best protected in terms of duty profile international journal of human and health sciences vol. 05 no. 03 july’21 300 as well as succumbing to complications of the infection. group d fared best in terms of anxiety, however depression and stress were considerably higher than group c. this group comprises of doctors at a higher risk of contracting infection and suffering complications of the same. the observations of this group are limited by the fact that we did not impose an upper limit for the age bracket. so, group d includes individuals with wider variations in age. conclusion doctors who were not directly involved in the care of covid-19 patients showed adverse psychological reactions such as stress, anxiety and depression. suggestions for implementation mental health of doctors should be given its due importance and tailored psychological support be advanced to them. this would serve to ensure that they themselves are in a position to tackle the extreme challenges of the pandemic. specific psychological interventions for medical staff have been instituted by many hospitals to empower health care workers [hcws] and strengthen them mentally. these include support teams, counselling, providing adequate breaks and time offs, providing a place to rest and sleep, leisure activities such as yoga, exercise, meditation and motivational sessions. these measures will ensure increase in qol and well being of hcws.8 we need to develop similar interventions on an urgent basis, with a view to empower doctors by provision of interventions to enhance their psychological resilience such as counseling, periodic screening for mental health, appropriate treatment of relevant conditions and helping develop and innovate positive coping strategies of self-help. this should be an immediate as well as an ongoing process, applicable to other disaster situations as well. source of fund: none conflict of interest: none ethical clearance: the study was duly approved by the hospital ethical committee. authors’ contribution: dr. fareha khatoon: concept, design, definition of intellectual content, creation of google form, submission of project for ethical clearance dr. amrita singh: proof reading, review and editing of the manuscript dr. abdul qadir jilani: definition of intellectual content, proof reading of manuscript dr. ayesha ahmad: concept, research question, manuscript writing, data interpretation, submission of manuscript dr. mariyam haq: literature search, statistical analysis dr. sonakshi pandey: creation of google form, data acquisition table 1: distribution of socio-demographic characteristics of study subjects variable frequency n [%] age [in years] 20-30 77 [53.1] 31-40 44 [30.34] 41-50 16 [11.03] >50 8 [5.52] mean ± stdev 32.65 ± 9 median[iqr] 30[26-38] range 20-72 gender female 103 [71.03] male 42 [28.97] education group i 50 [34.48] 301 international journal of human and health sciences vol. 05 no. 03 july’21 variable frequency n [%] age [in years] group ii 91 [62.76] group iii 4 [2.76] religion hindu 92 [63.45] muslim 43 [29.66] christian 6 [4.14] sikh 3 [2.07] others 1 [0.69] marital status married 74 [51.03] unmarried 68 [46.9] other 3 [2.07] type of family joint 51 [35.17] nuclear 89 [61.38] others 5 [3.45] domicile rural 17 [11.72] urban 128 [88.28] table 2: distribution of co-morbidities of tudy subjects co-morbidities frequency n [%] cardiac illness no 144 [99.31] >5 year 1 [0.69] diabetes no 143 [98.62] upto 2 year 1 [0.69] >5 year 1 [0.69] respiratory disorders no 136 [93.79] upto 2 year 1 [0.69] 2-5 year 3 [2.07] >5 year 3 [2.07] >10 year 2 [1.38] mental illness no 144 [99.31] 2-5 year 1 [0.69%] international journal of human and health sciences vol. 05 no. 03 july’21 302 co-morbidities frequency n [%] neurological illness no 144 [99.31] upto 2 year 1 [0.69] any other illness no 136 [93.79] table 3: association of dass 21 with age and gender dass-21 variables overall age [in years] n[%] gender n[%] n[%] 20-30 31-40 41-50 >50 female male stress normal 98 [67.59] 52[67.53] 26 [59.09] 14 [87.50] 6 [75] 70 [67.96%] 28 [66.67%] mild 22 [15.17] 11[14.29] 9[20.4] 2[12.5] 0[0] 17 [16.50%] 5 [11.90%] moderate 11 [7.59] 4[5.19] 5[11.36] 0 [0] 2[25] 6 [5.83%] 5 [11.90%] severe 9 [6.21] 6[7.79] 3[6.82] 0[0] 0[0] 6 [5.83%] 3 [7.14%] extremely severe 5 [3.45] 4[5.19] 1[2.27] 0[0] 0[0] 4 [3.88%] 1 [2.38%] mean ± stdev 5.67 ± 4.8 5.69+5.08 6.61+4.69 3.81 + 2.9 4 + 4.81 5.78 ± 4.7 5.4 ± 5.08 median[iqr] 5[2-8] 4[2-8] 7[3-8.25] 4[ 1.756] 2[0.755.75] 6[2-8] 3.5[2-9] range 0-21 0-21 0-20 0-9 0-12 0-20 0-21 statistical analysis p = 0.13 [kruskal wallis; chi sq= 5.624] p = 0.707 [chi sq= 2.156] anxiety normal 89 [61.38%] 45[58.44] 24[54.55] 12[75] 8[100] 59 [57.28%] 30 [71.43%] mild 20 [13.79] 11[14.29] 6[13.64] 3[18.75] 0[0] 17 [16.50%] 3 [7.14%] moderate 15 [10.34] 11[14.29] 3[6.82] 1[6.25] 0[0] 13 [12.62%] 2 [4.76%] severe 13 [8.97] 6[7.79] 7[15.91] 0[0] 0[0] 8 [7.77%] 5 [11.90%] extremely severe 8 [5.52] 4[5.19] 4[9.09] 0[0] 0[0] 6 [5.83%] 2 [4.76%] mean + stdev 3.47 ± 3.62 3.61 + 3.39 4.27 + 4.38 1.88 + 1.89 0.88 + 0.99 3.62 ± 3.42 3.1 ± 4.09 303 international journal of human and health sciences vol. 05 no. 03 july’21 dass-21 variables overall age [in years] n[%] gender n[%] n[%] 20-30 31-40 41-50 >50 female male median[iqr] 2[0-5] 3[1-6] 3[0-6.5] 2[0-3.25] 0.5[0-2] 3[1-6] 2[0-4] range 0-17 0-17 0-16 0-6 0-2 0-16 0-17 statistical analysis p = 0.02 [kruskal wallis; chi sq = 9.655] p = 0.26 [chi sq= 5.281] depression normal 85 [58.62] 39[50.65] 24[54.55] 15[93.75] 7[87.50] 59 [57.28%] 26 [61.90%] mild 16 [11.03] 14[18.18] 1[2.27] 0[0] 1[12.5] 11 [10.68%] 5 [11.90%] moderate 27 [18.62] 13[16.88] 13[29.55] 1[6.25] 0[0] 23 [22.33%] 4 [9.52%] severe 6 [4.14] 5[6.49] 1[2.27] 0[0] 0[0] 3 [2.91%] 3 [7.14%] extremely severe 11 [7.59] 6[7.79] 5[11.36] 0[0] 0[0] 7 [6.80%] 4 [9.52%] mean + stdev 4.71 ± 4.72 5.13 + 5.05 5.45 + 4.7 2.19 + 2.04 1.62 + 2.26 4.76 ± 4.51 4.6 ± 5.23 median[iqr] 3[1-7] 4[1-7] 4[2-8] 2[0.75-3] 0.5[0-2.5] 4[2-7] 2[1-6.75] range 0-21 0-21 0-17 0-8 0-6 0-20 0-21 statistical analysis p = 0.01 [kruskal wallis;chi sq= 11.11] p = 0.359 [chi sq= 4.36] table 4: association of well being [who-5] with age and gender variable well being score mean +stdev median [iqr] range age [in years] n 20-30 77 51.32 + 24.66 52[32-72] 0-100 31-40 44 49.55 + 24.11 44[31-72] 12-100 41-50 16 62 + 17.63 70[42-80] 20-92 >50 8 66 + 17.63 72[58-76] 32-88 p value 0.124[kruskal wallis test ;chi square=5.752] gender male 42 55.33 + 26.87 62[32-80] 0-96 female 103 51.73 + 23.06 48[32-74] 0-100 p value 0.311[mann whitney test ; 1931] international journal of human and health sciences vol. 05 no. 03 july’21 304 table 5: logistic regression to find out significant risk factors of stress, anxiety and depression. stress anxiety depression variable r² r² r² age 7.20% 9.46% 17.88% female 6.54% 8.65% 6.67% male education group i 10.26% 11.50% 9.87%group ii group iii religion hindu 18.20% 24.27% 17.97% agnostic muslim others sikh marital status married 11.13% 15.51% 16.98%other unmarried joint family 9.82% 10.43% 9.90%nuclear family others rural 8.11% 8.00% 8.58% urban cardiac illness no 7.90% 6.62% 6.67% >5 year diabetes 305 international journal of human and health sciences vol. 05 no. 03 july’21 stress anxiety depression variable r² r² r² no 12.38% 10.67% 10.57% upto 2 year >5 year respiratory illness no 21.17% 20.44% 18.91% upto 2 year 2-5 year >5 year >10 year mental illness no 7.90% 7.44% 7.28% 2-5 year neurological illness no 6.56% 6.62% 6.67% upto 2 year any other illness no 18.89% 16.58% 15.99% 2-5 year >5 year >10 year r² is the proportion of variance in the dependent variable that is predictable from the independent variable. range = 0 to 100%. an r² of 100% means that all movements of a security (or other dependent variable) are completely explained by movements in the index (or the independent variable(s).9 international journal of human and health sciences vol. 05 no. 03 july’21 306 references: 1. salari n, hosseinian f, ajalali, r. et al. prevalence of stress, anxiety, depression among the general population during the covid-19 pandemic: a systematic review and meta-analysis. global health 16, 57 (2020). https://doi.org/10.1186/ s12992-020-00589-w 2. temsah m-h, sohime f-a, nurah a, et al. the psychological impact of covid-19 on healthcare workers in a mers cov endemic country.j infect public health. 2020;13[6]: 877–882 3. moghanibashi-mansourieha. assessing the anxiety level of iranian general population during covid-19 outbreak. asian j psychiatry.2020;51:102076 4. zhou s-j, zhang l-g, wang l-l, guo z-c, wang j-q, chen j-c, et al. prevalence and sociodemographic correlates of psychological health problems in chinese adolescents during the outbreak of covid-19. eur child adolesc psychiatry. 2020;29:1–10 5. liu d, ren y, yan y, et al. psychological impact and predisposing factors of the coronavirus disease 2019 (covid-19) pandemic on general public in china (3/7/2020). available at ssrn: https://ssrn. com/abstract=3551415 or http://dx.doi.org/10.2139/ ssrn.3551415 6. wang y, di y, ye j, wei w. study on the public psychological states and its related factors during the outbreak of coronavirus disease 2019 [covid-19] in some regions of china. psychol health med.2020;30:1–10 7. kowalczyk, o, roszkowski k, montane x. et al. religion and faith perception in a pandemic of covid-19. j relig health [2020]. https://doi. org/10.1007/s10943-020-01088-3].in 8. shaukat n, ali d.m & razzak j. physical and mental health impacts of covid-19 on healthcare workers: a scoping review. int j emerg med 13, 40 (2020). https://doi.org/10.1186/s12245-020-00299-5 9. fernando j. r-squared definition. the investopedia express podcast. https://www.investopedia.com/ terms/r/r-squared.asp [last accessed 28.11.2020] international journal of human and health sciences. supplementary issue: 2019 doi: http://dx.doi.org/10.31344/ijhhs.v0i0.129 s11 use of virtual reality in rehabilitation fazah akhtar hanapiah1.2 1faculty of medicine, universiti tek nologi mara, sungai buloh, selangor. 2daehan rehabilitation hospital putrajaya. abstract recovery of severe impairment as a result of acquired brain injury from conditions such as stroke and trauma can be limited. however, with neuroplasticity and re-learning of lost skills, the impairment can be overcome or reduced. the use of technology in rehabilitation has become synonymous in most advanced rehabilitation facilities. the outcome of chronic impairment is dependent on the rehabilitation approaches and new ways to address conventional strategies using technology. technology in rehabilitation is an exciting avenue for research. the use of 3-dimensional virtual reality (3-d vr) in gaming has escalated in the past few years. however, the therapeutic use of 3-d vr in rehabilitation medicine is still lagging, although small studies have shown some potential on its use. we, at faculty of medicine uitm embarked on a study to create a platform for 3-d vr application, (mrvr: medical rehabilitation virtual reality) with known neuroplastic strategies for individuals with acquired brain injury during rehabilitation. outcome measures used will be that of standard and validated parameters before and after the application of mrvr. specific aspects of rehabilita t io n parameters were addressed during the programme development. a low cost commercial 3 -d vr system was chosen (htc vive™) to be used for the mrvr and our team developed a number of therapeutic programmes. individuals with brain injur y undergo a sequence of immersive first person experience with the mrvr programme in a safe virtual environme nt. the mrvr also promote recovery through other theories of rehabilitation such as, enriched environment, imagery, increased engagement and participation, accessibility and gamificat io n. we hypothesize that individuals that uses mrvr will have improved outcome parameters post intervention. these findings will assist in changing the standards for neurorehabilitation, by improving functional outcome, productivity, quality of life and overall longevity of individ ua ls with disability. this study is funded by uitm research grant: 600-irmi/dana 5/3 bestari (057/2017) keywords: rehabilitation, virtual reality, neurorehabilitation international journal of human and health sciences vol. 01 no. 01 january’17 26 original article assessing the learning environment at habib medical school, islamic university in uganda aisha n1, kamada l2, zakia t3, handan a4, seyit a5 abstract background: the learners’ environment is crucial for development of professionals. in uganda, there was no studies assessing the learning environment have been found. objective: this study was performed to assess the undergraduate students’ perceptions of medical education in general and educational environment in a newly established faculty of medicine in islamic university in uganda. materials and methods: the dundee ready education environment measure (dreem), a validated inventory was distributed among undergraduate students in the first year of bachelor of medicine and bachelor of surgery study. this scale consists a 50 item inventory each of the50 items is scored on a 5-point likert scale (0 to4). results: the average total dreem score was found to be 127.5 (maximum point is 200 in the scale) for the students. this score was interpreted according to the practical guide of mcaleer and roff those students’ perceptions of their learning environment were more positive than negative. in addition, the descriptive values of 5 subdimensions of the scale were found as follows. the perceptions of learning dimension average is 33.69 ± 6.10, the perceptions of teachers dimension average is 25.89 ± 4.44, students’ academic self-perception 23.35 ± 3.91, perceptions of learning atmosphere dimension average 29.83 ± 7.01 and social self-perceptions dimension average 13.90 ± 3.92.only the mean social self perceptions sub-dimension score were below the expected average score (maximum score/2), and all of the other mean of dimensions were higher than the expected average. the best score is obtained from perceptions of learning. the items with low scores (less than 2) on the dreem questionnaires were identified as in need of rehabilitation. conclusion: on the whole, the study showed that the students’ perception of the educational environment and the teaching delivered were positive but the student’s social self-perception was not good. measures to improve student’s social self-perception will be adopted. keywords: medical educational environment, dreem, student’s perceptions, classroom environment correspondence to: ankarali handan, department of biostatistics, istanbul medeniyet university, email:handanankarali@gmail.com 1. nazziwa aisha, department of public health, islamic university in uganda 2. lwere kamada, department of community health, islamic university in uganda, 3. tebetyo zakia, department of chemistry, islamic university in uganda 4. ankarali handan, department of biostatistics, istanbul medeniyet university, turkey 5. ankarali seyit, department of physiology, istanbul medeniyet university, turkey international journal of human and health sciences vol. 01 no. 01 january’17. page : 26-29 introduction the learners’ environment is very crucial to the development of professionals. the world federation for medical education emphasized the learning environment as one of the targets for appraisal of medical education programs.1assessing the learning environment, provides a holistic, comprehensive, systematic and detailed picture of the overall state of affairs in the education process. students’ perceptions of their environment has been shown to influence their behavior, progress and sense of well being.24research in the field of medical education can help to understand the learning process and the learning environment. at least 15 tools have been developed to assess the 27 learning environment at habib medical school learning environment of undergraduate medical school, but none provide strong validity evidence.5 the most widely-used learning environment assessment tool is the dundee ready educational environment measure (dreem) is an universal, validated instrument, which provides medical teachers, a diagnostic aid to measure the overall state of affairs in the learning environment of theircollege.6-8 habib medical school at islamic university in uganda, started in 2014. it gives a traditional 5-year course: the first 2 years are devoted to basic medical sciences and the last 3 are for clinical rotations. these parts are separate and the overcrowded curriculum depends heavily on the use of lectures. some activities are teacher centered with few open discussions and some are problem-solving sessions. current annual intake of students is approximately 100. the aim of our study was to assess the educational environment at habib medical school, using the dreem inventory and to determine whether a high quality learning environment was established during the first 3 years of the implementation of the habib medical school islamic university in uganda. we also aimed to identify the gaps and weaknesses in the existing educational environment in order to suggest feasible and appropriate remedies. soon, the medical school will be reviewing its curriculum. this current study will produce baseline pre-change data. to our knowledge this is the first study assessing the educational environment of a medical school using dreem inventory in uganda. materials and methods participants and scale a copy of the original dundee education environment measure (dreem) was obtained. a covering letter indicating the purpose of the study, the anonymity of respondents and the optional status of the response were attached to the questionnaire. the dreem was given to all the students present in the class at the time of their lecture. a total of 82 students participated in the study. the dreem comprises 50 items, divided into 5 subscales: students’ perceptions of learning, 12 items, and maximum score 48; students’ perceptions of teachers, 11 items, and maximum score 44; students’ academic self-perception, 8 items, maximum score 32; students’ perceptions of atmosphere, 12 items, and maximum score 48; students’ social self-perception, 7 items, maximum score 28. the total possible score is 200. each item is scored 0–4 (4 = strongly agree, 3 = agree, 2 =unsure, 1 = disagree and 0 = strongly disagree). there are 9 negative items scored in reverse manner (items 4, 8, 9, 17, 25, 35, 39, 48, and 50). all items, should be presented so that the higher the score the more positive the reading (more favorable educational environment). a score of 0 is the minimum and would be a very worrying result for any medical educator. the overall score could be interpreted as 0-50 very poor; 51-100 plenty of problems; 101-150 more positive than negative; 151-200 excellent. a score of 100 can be interpreted as an environment which is viewed with considerable ambivalence by the students and as such needs to be improved. an approximate guide to interpreting the subscales is; students’ perception of learning; 0-12 very poor; 13-24 teaching is viewed negatively; 2536 a more positive perception; 37-48 teaching is highly thought of. students’ perception of teachers; 0-11 abysmal; 12-22 in need of some retraining; 23-33 moving in the right direction; 34-44 model teachers. students’ academic self perception; 0-8. feelings of total failure; 9-16 many negative aspects; 17-24. feeling more on the positive side and 25-32 confident. for students’ perception of atmosphere; 0-12 a terrible environment; 13-24 there are many issues which need changing; 25-36 a more positive attitude; 37-48 a good feeling overall. for students’ social self perceptions; 0-7 miserable; 8-14 not a nice place; 15-21 not too bad; 22-28 very good socially. data management and statistical analysis data was entered and analyzed in spss, version 20. the mean and standard deviation were calculated for all of the items. for each of the five domains, scores were calculated as the cumu lative total of individual responses for all of the items in that domain. ethical approval was taken prior the study. results dreem was administered to 83 students. the overall dreem score, was 127.99 ± 19.6 out of a maximum possible score of 200 which indicates that students’ perception was more positive than negative. out of the 50 items, 11 items scored above 3. twenty-nine items scored between 2 and 3 and 10 items scored less than 2. the four most highly rated were ‘i feel i am being well prepared for my profession, the teachers are knowledgeable, i aisha n, kamada l, zakia t, handan a, seyit a 28 am confident about my passing this year and the teaching helps to develop my competence’. four items that students had the greatest problem with were; the teachers get angry in class, i find the experience disappointing, iam too tired to enjoy the course, and my accommodation is pleasant. the cranach alpha coefficient for internal consistency of this scale is 0.88. the students’ perception of learning domain means score was 33.69± 6.10 which translated to a more positive perception. this domain has 12 items, maximum score is 48.the items that were highly scored was “the teaching helps to develop my competence” and “the teaching helps to develop my confidence”. only one item “the teaching is too teacher centered” received a less than 2 points. the students’ perception of teachers domain mean score was25.89 ± 4.44. this domain has 11 items, maximum score is 44. this score is interpreted as, “moving in the right direction”. items in this domain that scored less than 2 points pertained to the teacher’s ridicule the students, the teachers get angry in class and the students irritate the teachers. the teacher’s anger suggests that teachers in our institution, as elsewhere, are inclined towards traditional styles of teaching. it is important to remind teachers that respect for the student is critical to the learning process. the students’ academic self-perception domain mean score was 23.35 ± 3.91 which means that the perception was feeling more on the positive side. this domain scored the highest with no item scoring less than 2 points. the highest scoring item was “iam confident about my passing this year” with a mean of 3.4 and “much of what i have to learn seems relevant to a career in health care” with a mean of 3.23 out of a maximum of 4. this domain has 8 items, maximum score is 32. all items in students’ perception of atmosphere domain scored above 2 except for “i find the experience disappointing”. students reported that the atmosphere is relaxed during lectures, were happy with their friends and had a good social life. the overall mean score for the domain was 29.83± 7.01 which meant a more positive attitude. this domain has 12 items, maximum score is 48 the students’ social self-perception domain mean score was 13.89 ± 3.92 which can be interpreted as their social self-perception was that this was “not a nice place”. this domain has 7 items, maximum score is 28 discussion educational environment is one of the most important factors in determining the success of an effective curriculum and effective learning. assessing the educational environment is therefore of vital importance. this study originated from a desire to learn how students perceive the educational environment in this institution. habib medical school, is a new medical school in islamic university in uganda. it is located in an urban area and has students from various ethnic backgrounds. dreem was used, as it is appropriate for evaluating health professions and is also known to be culturally non-specific. the findings of the research indicated that overall mean dreem score for our medical school was 127/200, which indicated that students’ perceptions was more positive than negative. being a new medical school, habib scored better than some other new medical schools and also other existing medical schools.9-10 no item received a mean score ≥ 3.5. scores that are above 3.5 are considered to represent a positive aspect of the curriculum. it is hoped that future assessment will show more items scoring more than 3.5 after corrective intervention is applied. a number of our students scored some items above 3. these include items such as the teaching helps to develop my competence; the teachers are knowledgeable, iam confident about my passing this year. i have learnt a lot about empathy in my profession. the scores whose performance was not good were the emphasis on factual learning. habib medical school, practices a problem based learning method. it calls for more student-centered and student selfdirected learning (sdl). the staff need to be more oriented, trained and motivated in the approach. it is suggested that this area be emphasized in our professional development. the students’ social self perceptions domain had the lowest scores. all the scores had less than 2 points apart from “i have good friends on this course and my social life is good”. many institutions globally report similar concerns. some researchers (kohli & dhaliwal, 2013; hasan & gupta, 2013; khursheed & baig, 2014) have reported not having a good support system for students who get stressed.11-13al-kabbaa et al (2012) has reported that students are too tired to enjoy the course.14these difficulties are not impossible to work on and interventions can be made to solve them. 29 learning environment at habib medical school more studies can be done taking into consideration demographics of the students like, nationality, religion, year of study. some studies have shown differences in perception due to demographics. alayed & sheik(2008) showed that the perception of first year is higher than other years. it could also be explained by the enthusiasm and the illusion of first year students on successfully gaining entry into medical college.15roff (2005) reported that men had a mean score of27.6/44 for their perception of teachers while for women this was 33.0/44; overall, the males’ dreem score was 129 and the women’s was 135.6 our results indicate a need for the creation of a supportive environment as well as designing and implementing interventions to remedy unsatisfactory elements of the environment if effective and successful learning is to be realized. conclusion the study showed that habib medical school scored more than some other new medical schools. some defects in the educational environment in the school were identified. the information obtained in the present study has identified areas for improvement and will enable the program leaders to facilitate changes. it will also provide other educational institutions with data on which they can make comparisons with their own programs. acknowledgements we express our sincere thanks to all the students who responded to the questionnaire. references 1. karle h. global standards and accreditation in medical education: a view from the wfme. acad med, 2006;81(12):43-48. 2. genn jm. amee medical education guide no. 23 (part 1): curriculum, environment, climate, quality and change in medical education--a unifying perspective. med teach 2001;23(4), 337–344. 3. veerapen k, and mcaleer s. students’ perception of the learning environment in a distributed medical programme. med educ online 2010;15:1-10,https:// doi.org/10.3402/meo.v15i0.5168. 4. soliman m, sattar k, alnassar s, alsaif f, alswat k, alghonaim m et al. medical students’ perception of the learning environment at king saud university medical college, saudi arabia, using dreem inventory. adv med educ pract 2017;8:221–227. https://doi.org/10.2147/amep.s127318 5. pololi lh, evans at, nickell l, reboli ac, coplit ld, stuber ml et al. assessing the learning environment for medical students: an evaluation of a novel survey instrument in four medical schools. acad psychiatry 2017;41:354-359. 6. roff s. the dundee ready educational environment measure (dreem)-a generic instrument for measuring students’ perceptions of undergraduate health professions curricula. med teach 2005;27(4):322–325. 7. tackett s, shochet r, shilkofski na, colbertgetz j, rampal k, bakar ha, wright s. learning environment assessments of a single curriculum being taught at two medical schools 10,000 miles apart. bmc med educ 2015;15(1):2-8. 8. tontuş öh. dreem; dreams of the educational environment as its effect on education result of 11 medical faculties of turkey. ondokuz mayis univ. tipderg 2010;27(3):104–108. https://doi. org/10.5835/jecm.omu.27.03.002 9. taheri m.students’ perceptions of learning environment in guilan university of medical sciences, j med educ 2009;13(4):126–133. 10. kim h, jeong h, jeon p, kim s, park yb, kang y. perception study of traditional korean medical students on the medical education using the dundee ready educational environment measure. evidbased compl alt 2016; article id 6042967:1-7. https://doi.org/10.1155/2016/6042967 11. kohli v, dhaliwal u. medical students’ perception of the educational environment in a medical college in india: a cross-sectional study using the dundee ready education environment questionnaire. j educ eval health prof 2013;10:5. https://doi.org/10.3352/ jeehp.2013.10.5 12. hasan t, gupta p. assessing the learning environment at jazan medical school of saudi arabia. med teach 2013;35(sup1):90–96. https://doi.org/10.3109/01421 59x.2013.765546 13. khursheed i, baig l. students ’ perceptions of educational environment of a private medical school in pakistan. j pak med assoc 2014;4(11):1244–1249. 14. al-kabbaa af, ahmad hh, saeed aa, abdalla am, mustafa aa. perception of the learning environment by students in a new medical school in saudi arabia: areas of concern. j taibah univ med sci 2012;7(2):69–75. https://doi.org/10.1016/j. jtumed.2012.11.001 15. al-kabbaa af, ahmad hh, saeed aa, abdallaam, mustafa aa. perception of the learning environment by students in a new medical school in saudi arabia: areas of concern. j taibah univ med sci 2012;7(2):69–75. https://doi.org/10.1016/j. jtumed.2012.11.001 183 international journal of human and health sciences vol. 07 no. 02 april’23 original article: the pesticidal influence of clove extract against the rusty flour beetle, tribolium castaneum gadah al-zarie1, noorah saleh al-sowayan1 abstract background: the use of conventional insecticides to repel or kill insects leads to environmental pollution and harms human and animal health. researchers are thus actively attempting to find natural ways of getting rid of insect pests in more environmentally sustainable ways. objective: behavioral response of the rusty flour beetle, tribolium castaneum, to aqueous extract from clove was investigated here. methods: in our study, the effect of the aqueous extract of cloves was tested for its potential to repel rusty flour beetle as the chemicals present in clove extract can trigger an olfactory response in this common pest. results: our findings indicate that the aqueous extract of cloves is a an effective repellant against the rusty flour beetle. conclusion: this is a natural way to get rid of insect pests in more environmentally sustainable ways, as the use of traditional insecticides to repel or kill insects pollutes the environment and harms human and animal health. keywords: rusty flour beetle, tribolium castaneum, clove plant, syzygium aromaticum, insect repellant correspondence to: noorah saleh al-sowayan, department of biology, faculty of science, qassim university, p.o. box 30230, buraydah (51477), saudi arabia. email: nsaoiean@qu.edu.sa 1. department of biology, college of science, qassim university, buraydah-51477, saudi arabia. introduction the world depends upon safe and healthy agricultural crops for food; to protect fields and post-harvest crops, synthetic chemicals have become pesticides of choice. however, they pose immense risks to human and animal health, as well as cause significant environmental pollution. therefore, there is an urgent need to search for alternative methods of controlling agricultural pests.1-3 natural insect and/or pest repellants have low environmental impact and are safe for biota. these are generally natural extracts and secondary compounds derived from plants to fight against pest attacks. a number of studies have reported testing plant extracts as pesticides. taluker et al.4 evaluated the potential of extracts from seeds of aphanamixis polystachya to repel the rusty flour beetle, tribolium castaneum. the authors demonstrated that the extract was highly repellent, although mildly nutritive, and was toxic to rusty flour beetles. similarly, islam et al.5 studied the biological activity of the essential oil extracted from coriandrum sativum l. against the eggs, larvae, and adult stages of the rusty flour beetle. biological tests have shown that essential oils perform fumigation activity against eggs, and their toxicity increases gradually as concentrations are strengthened and repeated doses are applied. coriander oil is reported to have a strong repellant activity against adult stages of the rusty flour beetle. iqbal et al.6 confirmed that ethanol extracted from sugar cane, acorus calamus, and turmeric, curcuma longa, can effectively repel the rusty flour beetle. elham et al.7 experimented with the toxicity of acetylcholine seed extract against several types of insect pests to demonstrate that the extract had a repellant effect on the rusty flour beetle. jema et al.8 used essential vegetable oils from bay leaf plant, laurus nobilis, to evaluate their repellant and toxicity effect against two main pests of stored international journal of human and health sciences vol. 07 no. 02 april’23 doi: http://dx.doi.org/10.31344/ijhhs.v7i2.572 mailto:nsaoiean@qu.edu.sa international journal of human and health sciences vol. 07 no. 02 april’23 184 products: the smaller grain bore, rhyzopertha dominica, and the rusty flour beetle. they observed that volatile oils in the bay leaf plant not only repelled but were toxic to adult smaller grain bores and rusty flour beetles as well. garcia et al.9 reported essential oil from baccharis salicifolia to be toxic to adult rusty flour beetle. other than essential oils and extracts, direct use of powdered plant parts has been demonstrated to be effective against insecticides by tripathi et al.,10 who used a 100% clove powder at a dose of 1.5 g/50 g against rusty flour beetles. at a dose of 5g/100 g, powdered large cardamom, cinnamon, and clove completely inhibited the reproduction of callosobruchus maculatus and the rusty flour beetle. methods insect collection and rearing: the rusty flour beetle was obtained from several sources (flour shop and a baker’s warehouse) in al-qassim region of the kingdom of saudi arabia. the rusty flour beetle was reared under laboratory conditions of 30°c temperature, 60% relative humidity, and 24 hours of complete darkness, following al-shuraym.11 the experimental setups were prepared in 50 cm3 glass jars that were filled with 1 kg of flour and 500 gm of yeast. intact insects of the rusty flour beetle were isolated from an infested flour; 50 pairs were introduced into glass jars. the jars were covered with a mucilin cloth to prevent the escape of insects and to ensure adequate ventilation; the jar was fixed with a rubber strap. plant species and chemical composition: flower buds of the carnation plant, clove, that is scientifically known as syzygium aromaticum, were used in this study. table 1 shows the major chemical constituents released in the clove bud that is generally used for a variety of purposes. table 1: major chemical constituents and their average quantities in clove flower buds compound percentage furan, tetrahydro-3-methyl 2.5 2-propanone, methylhydrazone 5.6 cyclopentane, methyl 4.0 pyrrolidine, 2-butyl-1-methyl 0.1 2h-pyran-2-one, tetrahydro-6,6-dimethyl 0.4 eugenol 49.0 copaene 0.5 caryophyllene 7.5 alpha-caryophyllene 1.4 preparation of clove extract – cold method: fifty grams of cloves were added to 500 ml of distilled water and stirred on a magnetic stirrer at room temperature for half an hour. the solution was then filtered with a cloth to remove plant parts; the plants were then put in the centrifuge device at 3000 rpm for a period of 15 minutes to obtain a clear solution. the solution was poured into a glass petri dish and placed in a drying oven at 35°c. once all water had evaporated, the residue was scraped off the bottom of the petri dish.12 we obtained 0.2 grams of the residue that we scraped off after drying and placed it inside a graduated cylinder; the volume was then made up to a 100 ml total. experimental design to observe the olfactory response of rusty flour beetle: the design of the experimental treatments was adapted from the study of stamopoulos et al.13 a custom-built small-scale device was prepared by using three plastic petri dishes for three treatments as shown in figure 1. in our study, dish 2 was prepared with two holes on the edge and was placed in the center of two other dishes, dish 3 and 1. each hole had a diameter of 6 mm; dishes 1 and 3 were connected via plastic tubes of 75 mm length. in dish 3, we had a treatment containing a semi-industrial environment made up of 5 grams of food (flour and yeast); this petri dish had a fixed cover. on its inside, a piece of sponge measuring 1×1 cm was placed with the test substance (residue prepared before). this dish had one hole to connect it to one of the holes in dish 2. dish 1 was the control experiment that contained the same components as dish 3, except that the test substance was not placed on the sponge. the treatments: the aqueous extract of cloves (0.5μl) was placed in a graduated measuring flask, and a drop of acetone was added to it; the volume was made up to 1 ml with distilled water. this gave a final concentration of 0.05%. following rigorous shaking, 1μl of the solution was placed on the sponge piece installed in the petri dish 3. in the control dish (dish 1), no test material was placed. the number of intact rusty flour beetles was calculated in each dish after two hours had passed from the time that the set up was completed and insects were introduced in dish 2. the rate of attraction and expulsion of the insects was calculated according to the following equation as described previously by gunn & cosway.14 intensity of reaction =100 185 international journal of human and health sciences vol. 07 no. 02 april’23 figure 1. a custom-built device for the study comprising three petri dishes where, s is the number of insects attracted to a substance, a is the number of insects attracted to the control. the classification of attractiveness or repulsion of a material is done using the following criteria: <1% = non attractive repellent; 1-10% = very weakly attractive; 11-20% = weakly attractive; 21-40% = attractive; and ≤41% = very attractive. results the results presented in table 2 show that the aqueous extract of cloves led to an expulsion of the rusty flour beetle from the treatment in dish 3; while some attraction of beetles was recorded in the control, i.e., dish 1. table 2 and figure 2 depict the average ejection ratio according to the method of gunn & cosway.14 table 3 presents a summary of the response of the rusty flour beetle to the aqueous extract of cloves. table 2: expulsion of the rusty flour beetle from the treatment in dish 3 (aqueous extract of cloves) intensity of reaction (%) s+cs-cc.s. replicate number -100%2-220replicate 1 0%2011replicate 2 0%6033replicate 3 0%6033replicate 4 25%82 35 replicate 5 -100%2-220 replicate 6 s: the number of insects attracted to the scent of the test substance; c: the number of insects attracted to the control. table 3: response of the rusty flour beetle to the aqueous extract of cloves replicate number 5016.89-70.83-100replicate 1 850.8929.170replicate 2 850.8929.170replicate 3 850.8929.170replicate 4 2934.3954.1725replicate 5 5016.89-70.83-100replicate 6 15520.84 x result of duplicate; x ̅  the result of the arithmetic mean; n: replicate number figure 2. intensity of reaction in percent with respect to the expulsion of insects by the aqueous extract of cloves discussion the efficacy of allomones from the aqueous extract of cloves in repelling rusty flour beetle is clear from the results presented in table 3. we tested the release of allomones with an olfactometer, international journal of human and health sciences vol. 07 no. 02 april’23 186 which revealed repellent compounds to make up 29.17% of the total constituents in the aqueous extract of cloves. our results are in agreement with previous research by natalia et al.15 that reported volatile oils to have a repellent effect on larvae and adult insects of the rusty flour beetle. on the contrary, saim & meelan16 stated that the α-pinene complex present in laurel leaves has attractive properties. numerous scientific studies have proven that insects have receptors that control their olfactory response, e.g., jonsson & anderson17 demonstrated that the antennae of the cotton leaf worm are equipped with sensory filaments through which they can detect plant odors with high sensitivity. these odors are generally caused by volatile chemical compounds. hansson et al.18 studied olfactory receptor nerves in male scarab beetles, phyllopertha diversa, that were capable of detecting and responding to volatile compounds emitted by green leaves, as well as the pheromones. the researchers indicated that the olfactory receptor nerves had the ability to distinguish between these volatile substances and molecules with a high degree of specificity and sensitivity. all these chemical compounds play an important role in the insect’s behavior toward its plant hosts, which ensures its survival and reproduction in a given environment. this also explains the behavioral response of rusty flour beetles to many of the compounds that have been tested till now in our study, as well as others, such as essential oils, extracts, or terpenes. the different sensory properties are incurred by different organs distributed all over the body of the rusty flour beetle. conclusion pesticides extracted from plants have been demonstrated to repel insect pests; this is a safe and environmentally friendly method of preventing pest attack on agricultural crops at small and large scales. based on our findings, we propose that aqueous extract of clove buds can effectively be used to protect storage warehouses and to keep insects away from stored food and prevent them from laying eggs. conflict of interest: the authors declare no conflict of interest. funding statement: no funding. ethical approval: the experiment was approved by the departmental ethical committee for care and use of animals. author’s contribution: both the authors contributed to the concept, design, literature search and drafting of the manuscript. they also revised and approved the final manuscript. 187 international journal of human and health sciences vol. 07 no. 02 april’23 references 1. tabashnik be. evolution of resistance to bacillus thuringiensis. ann rev entomol. 1994;39:47-79. 2. isman mb. plant essential oils for pest and disease management. crop protection. 2000;19:603-8. 3. yang p, yajun ma, shuiqing z. adulticidal activity of five essential oils against culex pipiens quinquefasciatus. j pesticide sci. 2005;30:84-9. 4. taluker fa, howse pe. evaluation of aphanamixis polystachya as asource of repellents, antifeedants toxicants and protectants in storage against tribolium castaneum (herbst). j stored products res. 1995;31(1):55-6. 5. islam ms. fumigant and repellent activities of essential oil from coriandrum sativum (l.) (apiaceae) against red flour beetle tribolium castaneum (herbst) (coleoptera: tenebrionidae). j pest sci. 2009;82(2):171-7. 6. iqbal j, qayyum a, mastafa sz. repellent effect of ethanol extracts of plant materials on tribolium castaneum (herbst) (tenebrionidae: coleoptera). pak j zoology. 2010;42(1):81-6. 7. elham s, kamal a, zamani dr, amin p, mohammad th. toxic and repellent effect of harmal (peganum harmal l.) acetonic extract on several aphids and tribolium castaneum (herbst). chilean j agric res. 2012;72(1):147-51. 8. jema jmb, tersim n, toudert kt, khouja ml. insecticidal activities of essential from leaves of laurus nobilis l. from tunisia, algeria and morocco, and comparative chemical composition. j stored products res. 2012;48:97-104. 9. garcia m, donadel oj, ardanaz ce, tonn ce, sosa me. toxic and repellent effects of baccharis salicifolia essential oil on tribolium castaneum. pest manag sci. 2005;61(6):612-8. 10. tripathi ak, singh ak, upadhay s. contact and fumigant toxicity some common spices against the storage insects callosobruchus maculates (coleoptera: bruchidae) and tribolium castoreum (coleoptera: tenebrionidae). int j trop insect sci. 2009;23(3):1517. 11. al-shuraym lam. evaluate the toxic effect of cyfluthrin on the biochemical mechanism and histological strtures of some body systems in the red flour beetle, tribolium castaneum (h.) (coleoptera: tenebrionidae). [m.s. thesis]. girl’s college of education, riyadh, saudi arabia. 2004. 12. harborne jb. phytochemical methods: a guide to modern techniques of plant analysis. 2nd ed. new york, usa: chapman & hall; 1984. 13. stamopoulos dc. effects of four essential oil vapours on the oviposition and fecundity of acanthoscelides obtectus (say) (coleopteran: bruchidae): laboratory evaluation. j stored products res. 1991;27(4):199203. 14. gunn dl, cosway ca. the temperature and humidity reactions of the cockroach. j of exp biol. 1938;16:555-63. 15. natalia s, teodoro s, adriana f. composition and toxic repellent and feeding deterrent activity of essential oils against the stored-grain pests trifolium castaneum (coleoptera: tenebrionidae) and sitophilus oryzae (coleoptera: curculionidae). pest manag sci. 2011;67(6):639-46. 16. saim n, melaan ce. compounds from leaves of bay (laurus nobilis) as repellents for tribolium castaneum (herbst) when added to wheat flour. j stored products res. 1986;22(3):141-4. 17. jonsson m, anderson p. electrophysiological response to herbivore‐induced host plant volatiles in the moth spodoptera littoralis. physiol entomol. 1999;24(4):377-85. 18. honsson bs, lorsson mc, leal ws. olfactory receptor neurons detecting plant odours and male volatiles in anomala cuprea beetles (coleoptera: scarabaeidae). j insect physiol. 2001;47(9):1065-76. international journal of human and health sciences vol. 07 no. 03 july’23 244 original article the early days of the covid-19 pandemic: clinical features and findings of the chest radiograph of the patients in the east coast of malaysia justin tan yu kuan1, liyana ahamad fouzi2, norhaya mohd razali1, teoh kok meng3, ahmad kashfi ab rahman4, zariah abdul aziz2, mohd nazri mohd nasir3, wan zulkafli wan ibrahim3, norsima nazifah sidek2 abstract background: the use of chest radiographs in managing covid-19 is more practical than computed tomography scan in malaysia, because of its limited resources. objective: to describe chest x-ray (cxr) characteristics and relevant parameters in covid-19 patients. methods: this is a retrospective study of 98 covid-19 cases admitted to general hospital in terengganu, malaysia. cxrs of these patients were reviewed to describe the features and distribution of the abnormalities. clinical characteristics and laboratory parameters were extracted from the electronic medical records. results: the mean age was 42 (17). forty-four (45%) patients had co-morbidity; the commonest were hypertension (29%) and diabetes mellitus (14%). sixty-seven (68%) cases were symptomatic. the most common symptoms were fever (42%) and cough (45%). the mean alc was 2.39×109/l (0.81) and mean crp 17.51 mg/l (55.94). cxr abnormalities were detected in 37 patients (38%) which include interstitial opacity in 21 (57%) patients, consolidation in 17 (46%) patients, and ground-glass opacities 12 (32%). these changes predominantly distributed bilaterally (19 [51%] of cases), located at the lower zones (49%) and peripherally (51%). total mean score for cxr severity was 2.43 (1.48) and the mean cxr severity score for each clinical staging was found to be increasing with the advancing clinical stage of the disease. conclusion: cxr features described here were in line with previous publications on covid-19 cxr findings. patients with mild to moderate staging may not have low alc or increased crp levels. crp was increased in patients with advanced clinical staging. keywords: corona virus disease-19, chest radiograph, lung imaging. malaysia correspondence to: liyana ahamad fouzi, clinical research centre, hospital sultanah nur zahirah, kuala terengganu, malaysia. email: lynnfouzi@gmail.com 1. respiratory unit, hospital sultanah nur zahirah, kuala terengganu, malaysia. 2. clinical research centre, hospital sultanah nur zahirah, kuala terengganu, malaysia. 3. department of radiology, hospital sultanah nur zahirah, kuala terengganu, malaysia. 4. infectious disease unit, hospital sultanah nur zahirah, kuala terengganu, malaysia. introduction on december 2019 there were a series of pneumonia of unknown etiology detected in the city of wuhan (china) [1], and on the 31st of december 2019, the chinese authorities reported the new severe acute respiratory syndrome coronavirus 2 (sars-cov-2) to the world health organization. currently, as of 14th september 2020 the number of confirmed coronavirus disease 2019 (covid-19), the disease caused by sarscov-2, cases have reached 29,192,519 with 928,471 deaths worldwide (who coronavirus disease dashboard, https://covid19.who.int/). in malaysia, the first case of the new covid-19 was detected on the 25th january 2020. at the time of this article completion, the number of confirmed cases in malaysia have reached 10,031 with 128 deaths. as of 31st december 2021, the confirmed cases have reached 2,758,086 with 31,487 deaths. a number of publications worldwide have international journal of human and health sciences vol. 07 no. 03 july’23 page :244-251 doi: http://dx.doi.org/10.31344/ijhhs.v7i3.581 245 international journal of human and health sciences vol. 07 no. 03 july’23 described radiological changes of the lung of the covid-19 patients but are more focused on the computed tomography (ct) scan findings as it had been shown to be more sensitive in detecting changes during the early phase of the illness [2-4]. unfortunately, the limited availability of ct scan facility in malaysian hospitals, coupled with the limitation of the strict infection control procedures precludes the rapid use of ct scan in managing covid-19 patients. hence the use of chest radiograph using portable machine was seen to be more practical and it reduces the need to mobilize covid-19 patients around thus limiting the risk of in-hospital transmission. two studies from italy and hong kong described the most common chest radiographs findings from covid-19 patients which includes consolidation (39-47%) and ground-glass opacity (33-91%) with bilateral involvement (50-67%) and distributed peripherally (41-55%) [5,6]. pleural effusion was reported as an uncommon finding (3-10%). studies from other countries have shown differing percentage of covid-19 patients having abnormalities in their initial chest radiograph. studies in china reported up to 60%, while in korea only 33% have changes on the initial chest radiographs [4]. while hospitals in malaysia rely more on the reverse transcription polymerase chain reaction (rt-pcr) for diagnosis, the use of imaging through cxr is still heavily used especially for detecting the presence and the extent of pneumonia and the monitoring of the progression of the lung abnormalities in these patients. we have found a few studies that reported the use of scoring system to score the severity of the cxr abnormalities [79]. however, these studies were using different scoring systems. stevens et al applied the british society of thoracic imaging (bsti) cxr report proforma which has a coding system to classify covid-19 findings on a cxr image into normal, classic/probable covid-19, indeterminate for covid-19 or non-covid-19 [7]. borghesi et al used their own experimental chest x-ray scoring system which scores each of the six lung zones according to the severity of the findings (from 0 to 3) and then adds up to overall cxr score that ranges from 0 to 18 [8]. in another study, taylors et al devised a five-point cxr scoring tool to score the overall appearance of the cxr abnormalities for patients presented with severe acute respiratory illness (sari) [9]. however, this study was published in 2015 and hence its usage is not specific to covid-19 patients but for sari in general. of note, orsi et al employed the cxr severity score similar to wong et al which divided the lungs into eight zones and score from 0 to 8 for the cxr according to the number of zones involved with abnormalities [5,6]. this scoring system was originally adapted and simplified from the radiographic assessment of lung oedema score proposed by warren et al [10]. oris et al also reported that the cxr severity score was positively correlated to c-reactive protein and lactate dehydrogenase level [5]. the study aims to describe the covid-19 patients in terengganu based on these findings which includes 1. demographics and clinical characteristics, 2. laboratory parameters, 3. clinical staging, 4. mean crp according to clinical staging 5. chest radiograph features, 6. mean cxr severity score with positive findings in their cxr. the cxr interpretations were based on recommendation by the college of radiology malaysia in 2020. methods patient selection: the majority of covid-19 patients who were seen in terengganu came mainly from the person under investigation (pui) category, of the cluster from a tabligh gathering in seri petaling mosque, petaling jaya, malaysia. the tabligh gathering was a religious congregation of muslim free preachers which were male only group, held on the 28th of february to 1st of march of 2020. the number of attendees was stipulated between 12500 to 16000 men. by the time the first positive case among the attendees was reported, these men have travelled back to various destinations. thus, active case detection was launched nationwide. due to this, cases were detected in terengganu and hence began the influx of cases into hospital sultanah nur zahirah (hsnz) as the covid-19 admitting hospital in terengganu state. while waiting for the confirmatory diagnosis, the symptomatic puis were being admitted to hospital for quarantine while others were given the order for home quarantine. in malaysia, all positive cases were admitted to hospital for treatment, monitoring and quarantine. the tabligh cluster has contributed to the most cases of covid-19 in the beginning of the second wave of cases nationwide. real-time reverse transcription polymerase chain international journal of human and health sciences vol. 07 no. 03 july’23 246 reaction (rt-pcr): as per standard protocol in malaysia, oropharyngeal and/or nasopharyngeal swab was/were sampled from these patients and were sent to hsnz laboratory as the authorized laboratory for terengganu state running the covid-19 testing. the laboratory uses bio-rad cfx 96 touch real-time pcr detection system and use real-time rt pcr method for diagnostic test of covid-19. image acquisition and analysis: chest radiographs were acquired for patients with rt-pcr confirmed covid-19 positive within 24 hours of their admission, using a single cr (computed radiography) mobile x-ray machine (ge amx-4 plus). the average exposure for chest radiographs was 68kv and 5.0 mas. chest radiographs were acquired with the patients in supine position, antero-posterior (ap) projection and source-to-image distance (sid) of 100 cm. mobile radiography was chosen to make it more feasible to comply with strict infection control procedures. the chest radiographs were then reviewed and reported by radiologists on a pacs workstation (infinitt) with monochromatic liquid crystal display (barco) of 2 mp (1600×1200 pixels). in our study, all included chest radiographs were reviewed again together by the three reviewers who were the senior radiologist, respiratory physician and infectious disease physician involved in this study. the consensus of the findings of the radiographs must be agreed at least by two out of the three reviewers. the chest radiographs were described based on features of clear, consolidation, ground glass opacity, interstitial opacity, nodular opacity, location (left, right or bilateral), zones (upper, middle, and lower zones) and distribution (central or peripheral) of the lung changes, based on the recommendations by college of radiology, academy of medicine, malaysia. data collection: all patients admitted to hsnz with rt-pcr confirmed covid-19 positive were included in this study. (total n=98). paediatrics patients and patients on whom no cxr was done were excluded from this study (n=16). demographic data and data on clinical characteristics, treatment and outcome were extracted from the electronic medical record and transcribed into the study case report forms. demographic data include age and sex, while clinical characteristic data include presence of comorbidities, smoking status, and presenting symptoms. laboratory parameters that were extracted include white blood cell (wbc) count, absolute lymphocyte count (alc), c-reactive protein (crp), lactate dehydrogenase (ldh), liver function test and renal function test. clinical outcomes include data on clinical classification of the disease and fatality. chest radiographs and clinical presentation data were reviewed by respiratory physician and infectious disease physician to confirm the clinical classification for each selected case. chest radiographs were reviewed and discussed by respiratory physicians, a radiologist and an infectious disease physician to confirm the cxr findings. data from the crfs were entered into and analysed using ibm spss statistics for windows, version 26 (ibm corp., ny, usa) licensed for clinical research center, hospital sultanah nur zahirah. for data analysis, continuous variables were expressed as median and iqr while categorical variables were expressed by number and percentage. results a total of 98 patients with positive rt-pcr for covid-19 and chest radiographs were included. demographics and clinical characteristics of patients infected with covid-19 were summarized in table 1. the patients were predominantly males, (76 [77.6%]). the mean age was 42 (17) with the youngest being 13 and the oldest being 68 years old. twenty-six patients (26.5%) were aged 51-60 years old (figure 1). of the 98 patients, 44 (44.9%) had at least one underlying medical comorbidity. the common comorbidities were hypertension (28 [28.6%]), diabetes mellitus (14 [14.3%]) and dyslipidaemia (7 [7.1%]). smoking status was only documented for 30 patients and among them, 18 were nonsmokers, eight active smokers and four exsmokers. regarding presenting symptoms, 31 (31.6%) cases were asymptomatic and 67 (68.4%) had at least one of the symptoms, with the most common symptoms consisting of cough (44 [44.9%] of 98 patients), fever (41 [41.8%]), runny nose (15 [15.3%]) and sore throat (10 [10.2%]). the laboratory parameters upon admission were analysed and the mean crp was found to be elevated at 17.51 mg/l (55.94). while the mean for alc, wbc, platelet, ldh, alanine aminotransferase (alt), aspartate aminotransferase (ast), alkaline phosphatase (alp), urea, creatinine, albumin and total bilirubin were within the normal range. the 247 international journal of human and health sciences vol. 07 no. 03 july’23 laboratory parameters findings are summarized in table 2. following the clinical staging as outlined by malaysian ministry of health guidelines for covid-19 management [12], the patients were classified into stage 1 to 5 according to the disease severity. the description for each stage and the number of patients according to it is as in table 3. we looked further into the mean for crp for each category of disease severity and found that it increases with increasing severity of illness (table 3). on admission, 37 patients (37.8%) had abnormality detected from their chest radiographs. of these patients with lung changes, the features that were found were interstitial opacity in 21 of 37 (56.8%) patients, consolidation in 17 of 37 (45.9%), ground-glass opacity in 12 of 37 (32.4%) and nodular opacity in five of 37 (13.5%) (figure 2). ten of them (27.0%) had a mixture of two types of changes, while four patients (10.8%) had three different changes in their chest radiographs. refer to table 5 for the details of the lung changes per patient. these changes predominantly involved bilateral sides (19 [51.4%]), 10 (27.0%) on the left side only, and 8 (21.6%) had it on right side only. the lower zone was predominant (18 [48.6%]) and involved multiple zones in 12 patients (32.4%). with regard to lesion distribution, 19 of 37 (51.4%) were peripheral lesions, 10 (27.0%) central and 8 (21.6%) had both central and peripheral lesions. we found no pleural effusion on any of the cxr included in this study. we then further looked into the chest radiograph findings, and scored the severity of cxr changes according to number of zones involved for every patient. the zones were divided based on upper, middle and lower zones, and can be from left, right or both sides. thus, the total number of zones gave the maximum score of 6 for severity of cxr findings. the total mean score for cxr severity was 2.43 (1.48). twelve patients (12.2%) were observed only and later discharged without requiring any treatment for covid-19. almost half of the patients, 43 (43.9%) received a combination of hydroxychloroquine and lopinavir/ritonavir (kaletra). 30 (30.6%) patients received hydroxychloroquine only, seven (7.1%) received chloroquine only, four (4.1%) received chloroquine and lopinavir/ritonavir (kaletra), while two (2.0%) patients received the combination of hydroxychloroquine lopinavir/ ritonavir (kaletra), and then escalated to include ribavirin and interferon beta. oseltamivir was also given to 11 (11.2%) patients. seventeen patients (17.3%) were also given antibiotics for superimposed bacterial infections. these antibiotics include amoxicillin/clavulanic acid, azithromycin, ceftriaxone and meropenem. for the outcome, the sole patient in stage 5 clinical staging died on day 22 of illness (day eight of admission). while all the other patients recovered well and were discharged home. figure 1: age distribution of covid-19 patients. table 1: demographic and clinical characteristics of covid-19 patients mean (sd) n (%) age, years 42 (17) sex male 76 (77.6%) female 22 (22.4%) any comorbidity 44 (44.9%) hypertension 28 (28.6%) diabetes mellitus 14 (14.3%) dyslipidaemia 7 (7.1%) ischemic heart disease 4 (4.1%) ba/copd 4 (4.1%) ckd/esrf 2 (2.0%) old pulmonary tb 1 (1.0%) stroke 1 (1.0%) any symptom 67 (68.4%) cough 44 (44.9%) fever 41 (41.8%) runny nose 15 (15.3%) sore throat 10 (10.2%) vomiting 8 (8.2%) dyspnoea 5 (5.1%) anosmia 3 (3.1%) lethargy 2 (2.0%) international journal of human and health sciences vol. 07 no. 03 july’23 248 mean (sd) n (%) loose stool 2 (2.0%) loss of appetite 2 (2.0%) dysgeusia 2 (2.0%) myalgia 4 (4.1%) rash 1 (1.0%) table 2: laboratory parameters of covid-19 patients mean (sd) laboratory parameters wbc, x 109/l 7.84 (2.27) alc, x 109/l 2.39 (0.81) platelet, x 109/l 284.91 (73.55) ldh, u/l 259.99 (83.75) crp, mg/l 17.51 (55.94) alt, u/l 30.85 (28.06) ast, u/l 28.86 (16.29) alp, u/l 92.35 (50.8) urea, mmol/l 4.23 (1.74) creatinine, µmol/l 74.16 (26.63) sodium, mmol/l 137.28 (3.08) potassium, mmol/l 3.88 (0.52) albumin, g/l 41.50 (4.96) total bilirubin, µmol/l 14.75 (6.25) table 3: clinical staging of covid-19 patients clinical stage description n (%) 1 asymptomatic 22 (22.4%) 2 symptomatic, no pneumonia 39 (39.8%) 3 symptomatic, with pneumonia 28 (28.6%) 4 symptomatic, with pneumonia and requiring supplemental oxygen 8 (8.2%) 5 critically ill, with multi organ involvement 1 (1.0%) discussion severe acute respiratory syndrome coronavirus 2 (sars-cov-2) is a newly emerged virus of the twenty first century which can cause symptoms from a mild cold to a fatal acute respiratory distress syndrome. this virus belongs to the sarbecovirus subgenus of the coronaviridae family, and it is the seventh latest known coronavirus that infects human. global death rate of covid -19 was 3.18% while the malaysian covid-19 death rate stands was 1.28% when the study was conducted in 2020. in our study, we report a cohort of 98 patients with positive rt-pcr results during the covid-19 outbreak in malaysia terengganu state. all recruited cases had chest radiograph and baseline blood investigation done upon admission. there is a predilection for male gender (77%) in this cohort, which is similar to a study in wuhan that reported 73% males in their cohort of 41 patients [3]. however, another study reported no obvious difference in men (52%) and women (48%) getting the infection, from their cohort of 81 patients [2]. the discrepancy in these findings might not be significant due to the small cohort sizes. in the case of our study, it can be partly explained by the fact that the cluster involved had originated from the tabligh gathering, a religious congregation which was attended by only men. fever and cough were the predominant symptoms found in 42% and 45% of cases respectively, consistent with findings from other studies [2,3,5,6]. the presence of dyspnoea as presenting symptoms varies among studies. while some studies reported dyspnoea rate ranging from 37% to 55% [2,3,5], only 5% of the patients in our cohort had the symptom. one other study in hong kong similarly reported 6% of their patients as having dyspnoea. a possible explanation for the lower rate of dyspnoea in our study is that our cohort consisted of patients who were being actively screened for the infection due to their risk factor of having attended the tabligh gathering or being in close contact with one. all these patients who tested positive were admitted to the hospital regardless of their symptoms. so, we might have captured the cases early on before more symptoms developed. for the record, another 4% of patients in our study developed dyspnoea later on during the course of admission and required supplemental oxygen. chest x-ray is an indispensable tool for assessment as covid-19 is a disease of the respiratory system. in our study setting, cxr was used in the management of patients already tested positive using rt-pcr. thus, it was to detect the presence of pneumonia in these patients, define the severity of the disease and monitor progress. in other settings where the prevalence of covid-19 is higher and more moderate to severe patients present and are admitted, cxr also gains a more important role in the diagnosis of the disease [5]. in orsi et al, the rate of reported commonest symptoms were high, fever (81%) and cough (54%), and 92% of their patients had abnormalities found on their cxr [5]. this is very high compared to findings from our cohort, where the commonest 249 international journal of human and health sciences vol. 07 no. 03 july’23 figure 2a: normal chest radiograph in a stage 1 patient. figure 2b: stage 3a patient with bilateral ground glass opacities and interstitial opacities. figure 2c: stage 4 patient with bilateral ground glass opacities and interstitial opacities. radiographic features are overlapping with those of stage 3a. figure 2d: stage 5 patient with bilateral consolidation, ground glass opacities and interstitial opacities. symptoms were less prevalent (fever in 42% and cough in 45%), while only 38% had positive findings detected on their cxr. their study was done in italy and said to have included patients who presented to their emergency department with symptoms of covid-19 and were at a more advanced disease stage [5]. among the patients with cxr abnormalities in our study, the most common features were interstitial opacity (57%), consolidation (46%) and groundglass opacities, ggo (32%). wong et al reported 47% consolidation and 33% ggo [6]. while in orsi et al, ggo were present in 99% of positive cxr, followed by consolidation in 42% [5]. both studies did not describe interstitial opacities in their papers, but focused on consolidation, ggo and nodules according to the fleischner society international journal of human and health sciences vol. 07 no. 03 july’23 250 glossary of terms, which was different from the malaysian college of radiology recommendation followed by our radiologists in malaysia. the changes observed in our cohort were predominantly involving bilateral sides, with lower zones and peripheral distribution. this corresponds to the findings from other studies [2,5,6,16]. while we have found no pleural effusion, some studies have reported 3-10% of patients to have pleural effusion on their cxr [5,6]. severity of the chest radiographs lesions are based on the distribution of these lung lesions according to zonesupper zone, mid zone and lower zone. there are 3 zones on each lung field, making up a total of 6 zones. lesions involving more zones are considered to be more severe hence have a higher cxr severity score. we have found that the mean cxr severity score increases with increasing disease severity. the sole stage 5 patient in our study showed the most severe radiographic findings at admission with a combination of consolidation, ground glass opacities and interstitial opacities with highest cxr severity score of 6. this finding cannot be easily compared to other studies due to the different scoring systems used and the way they were reported. the limitation of this study is our small number of subjects (n=98) resulting in inability to measure some key statistics. a larger subject number would show more robust data and correlation. in addition, as this was a retrospective study utilising medical records review, it relies heavily on the quality of the data that was available from the records. some important variables, for example, smoking history, are missing. a more standardised guideline or protocol would be helpful in determining when to repeat chest radiograph and blood investigation. conclusion we described the cxr features of our cohort of covid-19 patients, which were in line with the findings from other publications in 2020. patients with mild presentation and disease severity may not have changes in their cxr, low white blood cell, absolute lymphocyte counts or increased c-reactive protein level. however, we noted that c-reactive protein showed an increased trend in a more advanced clinical staging especially in those with fever, requiring supplementary oxygen and advanced age. acknowledgement: we would also like to thank the director general of health malaysia for his permission to publish this article. conflict of interest: all authors declared that there was no conflict of interest involved in the writing of this article. funding statement: no funding. ethical clearance: this study was conducted in accordance with the amended declaration of helsinki. the local independent ethics committee of malaysia, the medical research and ethics committee of the ministry of health has approved the protocol on 16th april, 2020. the approval reference number is kkm/nihsec/p20-901(6). authors’ contribution: all authors were equally involved in conception and design of the study. 251 international journal of human and health sciences vol. 07 no. 03 july’23 references 1. lu h, stratton cw, tang yw. outbreak of pneumonia of unknown etiology in wuhan, china: the mystery and the miracle. j med virol. 2020;92(4):401-2. 2. shi h, han x, jiang n, cao y, alwalid o, gu j, et al. radiological findings from 81 patients with covid-19 pneumonia in wuhan, china: a descriptive study. lancet infect dis. 2020;20(4):42534. 3. huang c, wang y, li x, ren l, zhao j, hu y, et al. clinical features of patients infected with 2019 novel coronavirus in wuhan, china. lancet. 2020;395(10223):497-506. 4. he f, deng y, li w. coronavirus disease 2019: what we know? j med virol. 2020;1-7. 5. orsi ma, oliva g, toluian t, pittino cv, panzeri m, cellina m. feasibility, reproducibility, and clinical validity of a quantitative chest x-ray assessment for covid-19. am j trop med hyg. 2020;103(2), 822-7. 6. wong hyf, lam hys, fong ah, leung st, chin tw, lo csy, et al. frequency and distribution of chest radiographic findings in patients positive for covid-19. radiology. 2020;296(2):e72-8. 7. stevens bj. reporting radiographers’ interpretation and use of the british society of thoracic imaging’s coding system when reporting covid-19 chest x-rays. radiography (lond). 2021;27(1):90-4. 8. borghesi a, maroldi r. covid-19 outbreak in italy: experimental chest x-ray scoring system for quantifying and monitoring disease progression. la radiologia medica. 2020;125(5):509-13. 9. taylor e, haven k, reed p, bissielo a, harvey d, mcarthur c, et al. a chest radiograph scoring system in patients with severe acute respiratory infection: a validation study. bmc med imaging. 2015;15:61. 10. warren ma, zhao z, koyama t, bastarache ja, shaver cm, semler mw, et al. severity scoring of lung oedema on the chest radiograph is associated with clinical outcomes in ards. thorax. 2018;73(9):840-6. 11. chu cm. role of lopinavir/ritonavir in the treatment of sars: initial virological and clinical findings. thorax. 2004;59(3):252-6. 12. ministry of health, malaysia. guidelines covid-19 management in malaysia no.5/2020, https:// covid-19.moh.gov.my/garis-panduan/garis-panduankkm 13. guan wj, liang wh, zhao y, liang hr, chen zs, li ym, et al. comorbidity and its impact on 1590 patients with covid-19 in china: a nationwide analysis. eur respir j. 2020;2000547. 14. rodriguez-morales aj, cardona-ospina ja, gutiérrez-ocampo e, villamizar-pena r, holguinrivera y, escalera-antezana jp, et al. clinical, laboratory and imaging features of covid-19: a systematic review and meta-analysis. travel med infect dis. 2020;34:101623. 15. long c, xu h, shen q, zhang x, fan b, wang c, et al. diagnosis of the coronavirus disease (covid-19): rrt-pcr or ct? eur j radiol. 2020;126:108961. 16. cleverley j, piper j, jones mm. the role of chest radiography in confirming covid-19 pneumonia. bmj. 2020;370:m2426. 17. rubin gd, ryerson cj, haramati lb, sverzellati n, kanne jp, raoof s, et al. the role of chest imaging in patient management during the covid. chest. 2020;158(1):106-16. 18. rubin gd, ryerson cj, haramati lb, sverzellati n, kanne jp, raoof s, et al. the role of chest imaging in patient management in the covid-19 pandemic: a multinational consensus statement from the fleischner society. radiology. 2020;296(1):172-80. international journal of human and health sciences. supplementary issue: 2019 doi: http://dx.doi.org/10.31344/ijhhs.v0i0.174 s56 scarred heart: a case series huzairi s1, nada s.z2 1universiti tek nologi mara, medical faculty, uitm sungai buloh, selangor, malaysia; 2pathology department, penang general hospital, ministry of health, malaysia 2 abstract introduction: as of february 2018, around 900,000 rohingyans have fled to bangladesh to seek refuge – 80% of which were women and children.1 from satellite analyses, at least 288 villages were destroyed by fire in northern rakhine since august 2017.2 as a tertiary medical facility catering to these refugees, the malaysian field hospital (mfh) has attended to a myriad of diseases both physical and mental. the most challenging yet are burn injuries with deformities. case 1: as a result of being torched alive, a rohingyan woman was left with facial burns that caused visual and eating difficulties. her scars had disfigured her so badly that her own children were terrified to look her in the face. nonetheless, she persevered through her daily livin g. case 2: a young boy who lost his father in a military attack sustained burn injuries to his left hand while escaping his burning house. as a result, he sustained a fixed deformity and total loss of function to the hand. surgical intervention is due, however functional recovery is slim. case 3: a young girl who sustained permanent contractures to her left foot came for treatment with mfh after many years of living with the disability. fortunately for her, mfh was able to offer surgical intervention so she was able to regain function of her left foot. discussion & conclusion: while many are aware of the world’s fastest-growing humanitar ia n crisis, its origin, details and aftermath are scantily exposed. burmese journalists have been pressured and their press freedom undermined by bureaucratic threats, budget constraints and difficult visa approvals for on-site reporting in bangladesh.3 volunteers should therefore share their experiences to raise awareness on the dire situation faced by refugees. however, w hile social media serves as a great platform to spread awareness, one has to be mindful of the refugee’s privacy and consent should be sought especially when photos and identities are shared. keywords: rohingya, refugee, burn injury international journal of human and health sciences. supplementary issue: 2019 doi: http://dx.doi.org/10.31344/ijhhs.v0i0.162 s44 malaysian bee bread attenuates apoptosis and improves cell proliferation in testis of high-fat diet-induced obese rats joseph bagi suleiman1, 3, ainul bahiyah abu bakar1, mahaneem mohamed1, 2 1department of physiology, school of medical sciences, universiti sains malaysia, kubang kerian, kelantan, malaysia;2unit of integrative medicine, school of medical sciences, universiti sains malaysia, kubang kerian, kelantan, malaysia; 3department of science laboratory technology, ak anu ibiam federal polytechnic, unwana, afikpo ebonyi state, nigeria abstract introduction: obesity has been reported to impair male reproductive function and testicular apoptosis while bee bread has been traditionally consumed to enhance male fertility. objective: the objective of this study was to determine the effects of malaysian bee bread on apoptosis and proliferation of testicular germ cells in high-fat diet-induced obese rats. methods: twenty-four adult male sprague dawley rats weighing between 250-300 g were randomised into four groups (n=6/group), namely normal control (nc), high-fat diet (hfd), hfd plus bee bread (hfd+b) and hfd plus an anti-obesity drug orlistat (hfd+o) groups. bee bread (0.5g/kg/day) and orlistat (10 mg/kg/day) were suspended in distilled water and given by oral gavage for 12 weeks. markers for apoptosis and proliferation of testicular germ cells were assessed. results: mrna transcript levels of caspase-3, caspase-8, caspase-9, p53 and bax/bcl2 ratio in the testis of hfd group were significantly increased while immunohistochemical staining of cleaved caspase-3 increased and proliferating cell nuclear antigen (pcna) immunoexpress io ns decreased relative to nc group. treatment with bee bread significantly decreased the apoptotic markers, significantly decreased mrna transcript levels of anti-apoptotic markers (bcl2) and increased pcna immunoexpression in hfd+b, relative to nc group and hfd+o. conclusion: bee bread improved proliferation of testicular germ cells by attenuating apoptosis in highfat diet-induced obese male rats. keywords: bee bread, high-fat diet, testis, apoptosis international journal of human and health sciences vol. 05 no. 03 july’21 330 abstract: objective: menstrual disorders constitute one of the major problems faced by medical students globally. amongst the various factors attributed as causative factors in menstrual cycle variations, include body mass index [bmi] is the most easily modifiable factor. as we still do not have clear answers, this study was planned to study the association of menstrual disorders with bmi. methodology: this is a cross sectional study, done in undergraduate female medical students in the age group of 18 to 30 years. exclusion criteria included pregnancy, breast feeding, <12 months post-partum, <6 months post abortion/miscarriage, concomitant medical disorders and intake of hormonal medication. data was collected for socio-demographic variables, detailed menstrual history, obstetric and medical history. examination recorded anthropometric details, hirsutism, acne, any signs of virilization. menstrual cycle variables were studied for their association with bmi. results: a total of 254 students participated in the study with an average age of 23.9 years. dysmenorrhea was globally found. majority of cases were mild dysmenorrhea. premenstrual syndrome [pms] was seen commonly, commonest symptoms being mood swings and abdominal cramps. there was no association between mean menstrual blood loss [mbl], pms and bmi and poor association with dysmenorrhea. conclusion: dysmenorrhea and pms were very commonly seen and were not related to bmi. the mean mbl was independent of bmi. a rise in bmi had a positive association with cycle irregularity. keywords: dysmenorrhea, premenstrual syndrome, menstrual blood loss, menstrual disorders. 1. dept. of obst. and gynaecology, career institute of medical sciences & hospital, lucknow, uttar pradesh, india. 226020. 2. dept. of obst. and gynaecology, era’s lucknow medical college and hospital, uttar pradesh, india. 226003. introduction: menstrual disorders constitute one of the major problems faced by medical students globally with an estimated prevalence of 87-91%.1 the disorders range from amenorrhea, cycle irregularity, abnormal flow, dysmenorrhea and premenstrual syndrome [pms]. it is hypothesized that due to disproportionate degree of stress in medical education, the trainees are vulnerable to menstrual abnormalities. the stress includes both physical and psychological factors such as irregular and long working hours, insufficient sleep, irregular food and exercise habits.2,3 important factors responsible for variations in menstrual cycle include genetic and racial characteristics, hormonal changes, associated medical disorders and body mass index [bmi]. amongst these, bmi is the most easily modifiable factor which has been seen to affect the patterns of menstrual cycle in many studies. however, we still do not have clear answers and need to study the effect of bmi on menstrual patterns in greater detail. this study was therefore planned to observe the association of variations in menstrual patterns with body mass index [bmi]. original article: association of menstrual disorders with body mass index in undergraduate medical students shabnam rizvi1, fareha khatoon2, ayesha ahmad2, kashish ayaz khan2, ekta2, kajal singh2 correspondence to: ayesha ahmad, associate professor, dept. of obst. and gynaecology, era’s lucknow medical college and hospital, uttar pradesh, india. 226003. e-mail: docayeshaahmad@gmail.com international journal of human and health sciences vol. 05 no. 02 april’21 page :330-335 doi: http://dx.doi.org/10.31344/ijhhs.v5i3.283 331 international journal of human and health sciences vol. 05 no. 03 july’21 methodology: this is a cross-sectional study done in a medical college from october to november 2020. it was approved by the institutional committee. subjects were recruited on the basis of inclusion and exclusion criteria, after xplaining the purpose and components of the planned study. anonymity and confidentiality were ensured, and those willing to participate were asked to sign a consent form before inclusion in study. inclusion and exclusion criteria: all undergraduate female medical students in the age group of 18 to 30 years who consented to be part of the study were included. exclusion criteria included pregnancy, breast feeding, <12 months post-partum, <6 months post abortion/ miscarriage, concomitant medical disorders and intake of hormonal medication. data collection: data was collected for socio-demographic variables, detailed menstrual history, obstetric and medical history. dysmenorrhea was calculated none, mild [able to do routine activities without medication], moderate [able to do routine activities with medication] and severe [not able to do routine activities despite medication +/absence from classes]. menstrual blood loss [mbl] was calculated on the basis of subjective perception of respondents and number of pads used per cycle as light, medium and heavy. physical activity >/=45 times per week was considered regular and 1-3 times as occasional. it included walking, dancing, yoga, exercise in gym or sports. pms was classified as absent, mild, moderate and severe depending on number of symptoms [0,1,2-3,>/=4 respectively]. examination recorded anthropometric details, hirsutism, acne, any signs of virilization. statistical analysis: calculation of sample size: the minimum required sample size was calculated on the basis of data by lakkawar et al4, with 7% margin of error and 5% level of significance. to reduce margin of error, minimum sample of 150 was proposed as per the formula: n ≥ [p [1 p]]/[me/zα] 2 where zα is value of z at two sided alpha error of 5%, me is margin of error and p is proportion of study subjects with abnormal menstrual disorder. n > = [ [ . 2 2 5 * [ 1 . 2 2 5 ] ] / [.07/1.96]2=136.71=137[approx.] analysis: data was entered in ms excel spreadsheet and analysis done using statistical package for social sciences [spss] version 21.0. data was assessed for normality by kolmogorov-smirnov test and depending on results, parametric and non-parametric tests were used. the categorical variables were presented as numbers, percentage and continuous variables as mean + sd, and median. a p-value of <0.05 was considered statistically significant. observations: a total of 254 students were included for the study. table 1 gives socio-demographic variables of the subjects. the average age of students in the present study was 23.9 years and the mean age of menarche was 13 +/1 years. table 1. socio-demographic factors, bmi and exercise details of study subjects. variables n[%] age mean = 23.9 years median [iqr] = 23 [22-26] height [cm] mean = 160.66 +/7.16 median [iqr] = 160 [155165.2] weight [kg] mean = 59.40 +/11.32 median [iqr] = 58 [50-65] bmi mean <18.4 [underweight] 33 [12.9] 18.5 22.99 [normal weight] 107 [42.0] 23 27.49 [normal weight] 74 [29.0] >27.50 [obese] 41 [16.1] residence hostel 169 [66.5] day scholar 85 [33.46] exercise negligible 55 [21.65] mild 82 [32.2] moderate 61 [24.0] heavy 56 [22.04] family history diabetes mellitus 103 [40.55] hypertension 99 [38.97] hypothyroidism 48 [18.89] carcinoma cervix 04 [1.57] carcinoma ovary 01[0.39] carcinoma endometrium 04 [1.57] international journal of human and health sciences vol. 05 no. 03 july’21 332 variables n[%] carcinoma breast 06 [2.36] tea intake none 1-4 cups/day >4 cups/day 103 [40.5] 151 [59.5] 0 coffee intake none 1-4 cups/day >4 cups/ day 173 [68.1] 80 [31.5] 1 [0.4] table 2 shows the pattern of menstrual cycle in the study population. dysmenorrhea was reported by every respondent, however, in 65.8% of cases it was mild and did not require any medication. a lower incidence of mild dysmenorrhea was found in women with bmi in normal range [p <0.01]. 7.9% subjects reported severe dysmenorrhea resulting in absence from classes. majority of subjects had regular cycles. there was a negative association between bmi and cycle irregularity [p value = 0.04]. table 2. detailed menstrual cycle pattern. menarche mean age = 13 +/1 years n[%] dysmenorrhea none mild moderate severe 0 167 [65.8] 67 [26.3] 20 [7.9] cycle regularity regular irregular 206 [81.1] 48 [18.9] cycle duration <2 days 2-8 days >8 days 5 [2.8] 242 [95.2] 4 [2.0] cycle length menarche mean age = 13 +/1 years n[%] <21 days 22-45 days >45 days 8 [34.64] 206 [81.1] 40 [15.74] menstrual blood loss light medium heavy 3 [1.18] 113 [44.48] 138 [54.3] type of pad used commercial tampon home made 250 [98.43] 4 [1.57] 0 no. of pads used per day [with maximum flow] 1-2 3-5 >5 3 [1.18] 250 [98.43] 1 [0.39] pms symptoms nausea vomiting headache fatiguability abdominal bloating abdominal cramps mood swings irritability lack of concentration breast tenderness backache 103 [40.6] 17 [6.7] 78 [30.7] 165 [64.9] 193 [76.1] 45 [17.7] 210 [82.7] 208 [81.9] 154 [60.6] 103 [40.6] 186 [73.2] most of the subjects had moderate mbl. there was no association of mean blood loss [mbl] with bmi. pms was found commonly. the most common symptoms were mood lability and abdominal cramps. pms was assessed by 11 symptoms and most of them did not have an association with bmi; abdominal cramps were seen less frequently in obese women as compared to others [p=0.01] (table 3). 333 international journal of human and health sciences vol. 05 no. 03 july’21 table 3. association of bmi with premenstrual syndrome symptoms in study subjects. pms symptoms underweight n[%] normal n[%] overweight n[%] obese n[%] p value nausea 9 [27.3] 25 [32.7] 22 [29.7%] 6 [14.6%] 0.17 vomiting 4 [12.1] 8 [7.5] 4 [5.4%] 1 [2.4%] 0.38 headache 10 [30.3] 33[30.8%] 26 [35.1%] 8 [19.5%] 0.37 fatigue 24 [72.7] 67 [62.6%] 51 [68.9%] 23 [56.1%] 0.38 abdominal bloating 22 [66.7] 82 [76.6%] 61 [82.4%] 28 [68.3%] 0.20 abdominal cramps 27 [81.8] 95 [88.8%] 60 [81.1%] 27 [65.9%] 0.01 mood swings 27 [81.8%] 95 [88.8%] 59 [79.7%] 30 [73.2%] 0.11 irritability 28 [84.8%] 92 [86.0%] 57 [77.0%] 32 [78.0%] 0.39 lack of concentration 19 [57.6%] 68 [63.6%] 44 [59.5%] 23 [56.1%] 0.82 breast tenderness 14 [42.4%] 39 [36.4%] 31 [41.9%] 19 [46.3%] 0.70 backache 25 [75.8%] 81 [75.7%] 52 [70.3%] 28 [68.3%] 0.73 discussion: previous studies have noted that the prevalence of menstrual problems in medical students has risen and bmi seems to be an important contributory factor. dysmenorrhea and pms are important contributors to absence from classes, leading to significant loss in terms of academics as well as clinical work.5 mbl and cycle irregularity has also been observed to have a direct association with bmi. however, the findings are controversial, and many investigators have found contrary results. this study was thus planned to study the menstrual cycle variations in medical students and find out the variables that change with bmi. dysmenorrhea: in the present study, we found that dysmenorrhea was universally present to varying degrees in the subjects. similar high prevalence of pain during periods has been observed in indians. kural et al [2015]6 found a prevalence of 84.2% in college going girls. we observed a negative association of mild dysmenorrhea and bmi. subjects with lower bmi had a higher incidence of pain (table 4). most of the investigators have similar observations. lakkawar et al [2014]4 studied 200 medical students, mirfat [2020]7 studied 3213 undergraduate students. both studies observed a negative association. rai et al [2020]8 found that a rise in bmi above 23 is highly associated with higher pain scores. however, in the present study, we did not find any significant association of bmi with moderate or severe dysmenorrhea. therefore, the association with mild dysmenorrhea is at the most, probably weak. table 4. association of bmi with dysmenorrhea, menstrual blood loss, cycle regularity. symptom bmi <18.4 18.5 22.99 23 27.49 >27.50 p value dysmenorrhea mild 22 [66.7%] 58 [54.2%] 55 [74.3%] 33 [80.5%] <0.01 moderate 8 [24.2%] 36 [33.6%] 16 [21.6%] 7 [17.1%] 0.12 severe 3 [9.1%] 13 [12.1%] 3 [4.1%] 1 [2.4%] 0.11 menstrual blood loss mild 14 [42.4%] 43 [40.2%] 21 [28.4%] 15 [36.6%] 0.35 moderate 16 [48.5%] 62 [57.9%] 48 [64.9%] 21 [51.2%] 0.33 international journal of human and health sciences vol. 05 no. 03 july’21 334 mbl: we did not observe any association of mean mbl and bmi (table 4). this is in contrast with findings of tang et al [2020]11, who studied 1012 women and found mbl to be positively related with an increase in bmi; with an or 2.28 for obese and or 1.26 for overweight. bmi is related to anovulatory cycles, which may have a role in increased mbl observed by the authors. this effect theoretically should be found more in obesity and morbid obesity. however, we did not have the sufficient numbers of subjects in this range, therefore, it is difficult to comment on this finding. we feel that larger studies are required before any conclusion can be drawn on the subject. cycle regularity: we observed a significant association between cycle regularity with bmi (table 4). a rise in bmi was negatively associated with regularity of cycles. this is in accordance with most of the studies on the subject. rai et al [2020]8 studied 300 female medical students over 18 months and found significant association of cycle regularity with bmi. [underweight: p= 0.0001; bmi >23: p = 0.001]. there is a strong association with bmi, prevalence of pcos and anovulatory cycles. we think that many subjects with higher bmi may be having anovulatory cycles, hence more prevalence of irregular cycles. conclusion: • dysmenorrhea and premenstrual syndrome were very common among undergraduate medical students, and not related to body mass index. • mean menstrual blood loss was independent of body mass index. • a rise in body mass index had a positive association with cycle irregularity. limitations of the study: we anticipated that medical undergraduates have higher menstrual cycle abnormalities as compared to general age matched population, due to lifestyle patterns. however, we did not study the menstrual cycle abnormalities in controls. besides, we did not examine the psychological factors and their association with menstrual cycle, which may be strong confounders. as the study is recall based, the subjects may not be able to give accurate answers to changes in menstrual cycle pattern during periods of stress such as examination. recommendations: prospective studies with long term follow up are needed to find out how bmi affects menstrual cycle patterns, with sufficient numbers to exclude common confounders. conflict of interest: the authors declare no conflict of interest. funding statement: none ethical approval issue: the study was duly approved by the hospital ethical committee. authors’ contribution: dr. shabnam rizvi: concept, design, definition of intellectual content; dr. fareha khatoon: definition of intellectual content, proof reading, review and editing manuscript; dr. ayesha ahmad: concept, research question, manuscript writing, data interpretation, submission of manuscript; dr. kashish ayaz khan: data acquisition, statistical analysis; dr. ekta: data acquisition, statistical analysis; dr. kajal singh: preparation of protocol, literature search. symptom bmi <18.4 18.5 22.99 23 27.49 >27.50 p value heavy 3 [9.1%] 2 [1.9%] 5 [6.8%] 5 [12.2%] 0.08 cycle regularity regular 29 [87.9%] 93 [86.9%] 54 [73.0%] 30 [73.2%] 0.04 irregular 4 [12.1%] 14 [13.1%] 20 [27.0%] 11 [26.8%] 335 international journal of human and health sciences vol. 05 no. 03 july’21 references: 1. verma i, joshi g, sood d, soni rk .menstrual problems in undergraduate medical students: a cross-sectional study in a medical college of north india. j south asian feder obst gynae 2020;12(2):85–90. 2. rafique n, al-sheik mh. prevalence of menstrual problems and their association with psychological stress in young female students studying health sciences. saudi med j 2018;39(1):67–73. 3. sreelakshmi u, bindu vt, subhashini t, saritha k. impact of dietary and lifestyle choices on menstrual patterns in medical students. int j reprod contraception obstet gynecology. 2019;8(4):1271-6. 4. lakkawar nj, jayavani rl, arthi pn, alaganandam p, vanajakshi n. a study of menstrual disorders in medical students and its correlation with biological variables. sch. j. app. med. sci., 2014; 2(6e):31653175 5. khamdan hy, aldallal km, almoosa em, alomani nj, haider asm, et al. the impact of menstrual periods on physical conditions, academic performance and habits of medical students. j women’s health care 2014;3:185. 6. kural mr, noor nn, pandit d, joshi t, patil a. menstrual characteristics and prevalence of dysmenorrhea in college going girls. j family med prim care. 2015; 4(3):426–31 7. mirfat mla-k. interrelation between menstrual problems and body mass index among undergraduate female students: cross sectional study. asian j. sci. res.,2020;13 (2):164-9. 8. rai p, kumari g, kumari k, jaiswal d. evaluation of correlation between body mass index with menstrual cycle pattern among young female medical students. int j clin obstet gynaecol 2020;4(1):97-100 9. bertone-johnson er, hankinson se, willett wc, johnson sr, manson je. adiposity and the development of premenstrual syndrome. j womens health (larchmt). 2010;19(11):1955–62. 10. mahishale a, mesquita jc. association of premenstrual syndrome with body mass index and its effect on quality of life: a cross-sectional study. j south asian feder obst gynae 2019;11(3):181–84. 11. tang y, chen y, feng h. et al. is body mass index associated with irregular menstruation: a questionnaire study. bmc women’s health 2020;20:226. international journal of human and health sciences vol. 03 no. 04 october’19 196 original article: factors associated with mothers’ perceived quality of life among young children with pneumonia in dhaka, bangladesh happy bandana biswas1, nujjaree chaimongkol2, yunee pongjaturawit3, abstract: objective: this study aimed to examine factors associated with quality of life among young children with pneumonia. a simple random sampling was used to recruit a sample of 100 mothers of young bangladeshi children with pneumonia admitted in pediatric wards at the dhaka medical college hospital, dhaka, bangladesh from january to march 2014. materials and methods: research instruments included a demographic questionnaire, the perceived severity of illness’ scale, the parenting stress index and the quality of life scale for pneumonia module. their reliability were .79, .91 and .77, respectively. data were analyzed by using descriptive statistics, pearson correlation, independent t-test and one-way anova. results: results revealed that mean total score of quality of life of the children with pneumonia was 50.05 (s.d. = 11.11), and at a moderate level. there was a significant relationship between maternal stress and quality of life of pneumonia children (r = -.48, p < .01). however, there was no relationship between perceived severity of illness and quality of life. no significant difference of quality of life of pneumonia children was also found between levels of maternal education and yes/no co-morbidity. conclusion: these findings indicate that maternal stress is a significant factor. pediatric nurses and related health care providers should plan and intervene to lessen stress of the mothers, and that would result in increasing quality of life of young children with pneumonia. keywords: quality of life, pneumonia, mothers’ perception, young children, bangladesh correspondence to: happy bandana biswas, rn, mnsc. faculty of child health nursing, national institute of advanced nursing education and research (nianer), dhaka, bangladesh. email: bandana.happy@yahoo.com 1. happy bandana biswas, rn, mnsc. faculty of child health nursing, national institute of advanced nursing education and research (nianer), dhaka, bangladesh. 2. nujjaree chaimongkol, rn, phd. associate professor, dean of faculty of nursing, burapha university, thailand 3. yunee pongjaturawit, rn, phd. assistant professor, faculty of nursing, burapha university, thailand international journal of human and health sciences vol. 03 no. 04 october’19 page : 196-200 doi: http://dx.doi.org/10.31344/ijhhs.v3i4.102 introduction pneumonia is the world’s leading killer of children under the age of five. one child dies from pneumonia every 15 seconds1. it is an inflammatory conditions of the lung-affecting primarily the microscopic air sacs known as alveoli. each year, pneumonia takes the life of two million children before they reach their fifth birthday. according to the united nation international children’s emergency fund (unicef) in 2012 reports, pneumonia continues to be the number one killer of children around the world-causing 18% of all child mortality, an estimated 1.3 million child deaths in 2011 alone2. only 30 percent of under 5-year-old children with suspected pneumonia are taken to an appropriate health care provider. the mortality rate in this age group under 5 years is estimated to be 0.29 episodes per child-year in developing and 0.05 episodes per child-year in developed countries. remarkably, pneumonia is common in bangladesh with significant mortality and morbidity. about 25% of all childhood death occurs in bangladesh, due to pneumonia3. young children with pneumonia commonly decreased their quality of life (qol) due to fast breathing, cough, malaise to high fever, loss of appetite, fatigue and chest in 197 international journal of human and health sciences vol. 03 no. 04 october’19 drawing at the beginning of their life. usually at this age, child’s qol depends upon a mother who always takes care of her child. qol is an indicator of well-being and contentment of life which was the highest goal of a human being4. recent studied have shown mothers’ education that means knowledge or perception and level of understanding about various aspects of respiratory diseases including signs and symptoms, primary management and care, immunization and prevention of those respiratory diseases is closely related to qol among young children. parvez et al. (2010) also presented in bangladesh that lower health related quality of life was associated with a lower level of education in household, especially the mother. relatively, children with more severe illness reporting lower health related quality of life5. consequently, child’s severity of illness and frequency of illness was a health related factor influencing on maternal stress6. on the other hand, co-morbidity and delay in seeking appropriate treatment are the main risk factors for severe pneumonia7. pneumonia can be managed to improve quality of life, as well as by controlling factors in the environment, education, and close monitoring. in addition, if the qol is cumulative in the sense that problems in early childhood manifest themselves in adolescence and adulthood, then focusing on children’s qol at an early age may be an effective way of reducing problems later in development. further, it is typically parents’ perceptions of their children’s qol that influences healthcare utilization8. for these reasons, this study aimed to determine association between potential influencing factors, including maternal education, severity of illness, co-morbidity of pneumonia and maternal stress of mother having young children with pneumonia. findings from this study would be beneficial for nurses and related health care personnel to plan an effective intervention to enhance and promote quality of life of young bangladeshi children with pneumonia. materials and methods: this study was a survey descriptive design. sample: two days a week per ward, except friday, were randomly selected to collect the data in each of 3 pediatric wards at dhaka medical college hospital from january 2014 to march 2014. inclusion criteria were age of 18 years old or older, able to communicate and reading ability in bangla language, and the children were admitted for 24 hours or more. setting: bangladesh, is approximately 147,570 km2, and in 2013 the population more than150, 039,000 million. the number of children under five years old was 53.6 % of registered. dhaka is the capital and largest city in center of bangladesh and the area of dhaka approximately 815.85 sq. kilometers, and population in dhaka approximately 7 million. however, for conducting of study about qol of pneumonia in young children dhaka medical college hospital inpatient department or pediatrics ward was selected to be the study settings. the dhaka medical college hospital is the central point of public health services of all the government hospitals in bangladesh, there are 2300 bed with 25 departments, 48 units, and 45 wards including 3 pediatrics wards in this hospital at present. in addition, there were about 50-70 children with pneumonia who admitted in pediatrics ward monthly. research instruments: a demographic questionnaire contained information about mother’s information, including age and education, and the child’s characteristic, including age, sex and co-morbidity of pneumonia. the perceived severity of illness’s scale was a visual analogue scale (vas) developed by wongcheree et al9. it was used by asking the mother rating within the range from none (0) to very severe illness (10). zero score indicates not being perceived as ill and ten scores indicate being perceived as very severely ill. moreover, scores between 1-3 was classified as mild, 4-6 scores as moderate, and 7-10 as a severely ill child with pneumonia. the parenting stress index-short form (psi-sf) developed by abidin10 was used to assess the stress in the parent-child system. it consisted of 36 items with three subscales of parental distress (pd), parent-child dysfunctional interaction (p-cdi) and difficult child (dc). the mothers were asked to rate each item of 1-5 response from 1 (strongly agree) to (strongly disagree). higher scores indicate higher level of maternal stress. it was also categorized as low (scores 36 to <84), moderate (scores 84 to <132) and high (scores 132 to <180) level of maternal stress. the quality of life scale for pneumonia module was developed by varni et al11. it was used to measure quality of life of young children specifically with pneumonia by asking the mother to complete. the scale contained a total of 20 items comprising 2 dimensions pneumonia symptoms (11 items), and treatment problems (9 items). the mother chose one response among international journal of human and health sciences vol. 03 no. 04 october’19 198 five rating scales (0-4) from ‘never=0’to ‘almost always=4’. for the ease of interpretability, items were reversed scores and linearly transformed to a 0-100 scale. to reverse answers, transform the 0-4 scale items to 0-100 points as follows: never = 100, almost = 75, sometimes = 50, often = 25, and then almost always = 0, so that higher scores indicate better quality of life. all research instruments were in english and translated into bangla by using back-translated method as recommended by cha et al12. reliability testing of the instruments were .79, .91 and .77, respectively. data collection procedures: after the proposal was granted ethical approval from the faculty of nursing, burapha university, institutional review board, the letters of asking permission to collect the data by the researcher from the dean of the faculty of nursing, burapha university was issued to the director of the dhaka medical college hospital in dhaka, bangladesh. then, the researcher was obtained the permission from the director of the hospital as well as from nursing superintendent to collect the data. data were collected at the dhaka medical college hospital. two days a week per 1 of 3 pediatric wards of the hospital, except friday as a regular holiday of bangladesh, were randomly selected to collect the data. after receiving the written consent from the participants, all questionnaires were delivered hand to hand to the participants by the researcher. the participants were asked to complete them and return them directly to the researcher. the researcher was available nearby the completion and collection the responses. the researcher was review all the data and ask the subjects to make sure whether or not they had completes all responses if there were some missing answers. then the researcher entered the data into the computer for subsequent analyses. data analyses: data were analyzed by using a statistical software computer program. the alpha level of significance was set at <.05. descriptive statistics included frequency, percent, mean, standard deviation were utilized to describe the demographic characteristics of the mothers and their young children with pneumonia, quality of life of the children, perceived severity of illness, maternal stress and co-morbidity. pearson correlation coefficient was used to determine correlation between independent variables with continuous data (severity of illness and maternal stress) and quality of life among young bangladeshi children with pneumonia. independent t-test and one-way anova was used to determine the differences between independent variables with categorical data (maternal education and co-morbidity) and quality of life among young bangladeshi children with pneumonia. results demographic data: mean age of mothers was 25.0 years (sd = 4.67, range = 18-40). forty-nine percent of the mothers had their education level up to high school, 40.0% had completed up to primary school, and the rest (11.0%) had completed college/university degree. the children with pneumonia were 61.0% for boys and 39.0% for girls. their mean age was 8.66 months (s.d. = 9.50, range = 1-53). seventy three % of the children had co-morbidity, and 27% had no co-morbidity of pneumonia. among those with co-morbidity, there were diarrhea (11.0%), malnutrition (34.0%), vomiting (28.0%), heart disease (10.0%), and others (17.0%). descriptive data of the children’s quality of life, severity of illness and maternal stress: mean total score of quality of life for pneumonia scale was 50.05 (s.d. = 11.11, range = 25.00-75.00), and at a moderate level. in addition, it contained to two subscales of pneumonia symptoms with mean score of 55.09 (s.d. = 10.81, range = 27.2784.09) and treatment problems with mean score of 43.88 (s.d. = 14.77, range = 11.11-75.00) (table 1). table 1: mean, standard deviation, and range of quality of life, specifically for pneumonia, among young bangladeshi children (n=100) quality of life m s.d. range interpretation total scores 50.05 11.11 25.00-75.00 moderate subscale pneumonia symptoms 55.09 10.81 27.27-84.09 moderate treatment problem 43.88 14.77 11.11-75.00 moderate the mothers perceived children’s severity of illness with a mean score of 6.58 (s.d. = 2.90, range = 1-10). the mothers perceived that 57.0%, of the children had severely illness, 22.0% had moderate and 21.0% had mild. mean total score of maternal stress was 115.14 (s.d. = 23.03, range = 61154). in terms of its subscales, mean score of parental distress (pd) was 35.61 (s.d. = 8.44, range = 19-54), parent-child dysfunctional interaction (p-cdi) was 40.95 (s.d. = 9.55, range = 17-53), and for difficult child (dc) was 38.58 (s.d. = 8.45, 199 international journal of human and health sciences vol. 03 no. 04 october’19 range = 17-51). for the level of stress, more than half (62.0%) of the mothers had moderate stress, 24.0% had high stress, and 14.0% had low stress level. association between the study variables and quality of life among young children with pneumonia: it was found that there was a negatively significant relationship between total score of maternal stress and quality of life. when considering each subscale of maternal stress, there were negatively relationships between each subscale of parental distress (pd), parent-child dysfunctional interaction (p-cdi), and difficult child (dc) and quality of life (table 2). table 2: relationships between perceived severity of illness, maternal stress, and pneumonia quality of life by pearson correlation coefficient (n = 100) variable quality of life (r) perceived severity of illness -.08ns maternal stress -.48** subscales parental distress (pd) -.22* parent-child dysfunctional interaction (p-cdi) -.47** difficult child (dc) -.56** *p < .05, **p < .01, ns = non-significant (p >.05) there was no significant difference of pneumonia quality of life between yes and no co-morbidity (t = -.119, p > .05). likewise, it was found that there was no statistical significant difference of pneumonia quality of life between three educational levels of mother in primary school, high school, and college /university (f2, 97 = 2.60, p >.05). discussion: quality of life of pneumonia children and in overall, symptoms and treatment problems were at moderate level, which were acceptable. it could be explained that mothers could monitor the changes for her child’s health status or in detecting responses to treatment. it could be also explained that in this study that the mother was concerned more during admitted in the hospital. the study results showed that there was a negatively significant relationship between mean total score of maternal stress and quality of life which was similar to findings by cummings et al13, laurvick et al14 and yamada et al15. they reported that mothers in the high stress group perceived their children’s disability as being more severe than the mothers in low stress group and contributed to perceptions of high quality of life scores for child’s illness. in regard of considering each aspect of parenting stress subscales, the pd subscale incorporates the mother’s perception of their child rearing abilities, availability of social support and restrictions in their other life roles15. the mother of this study feel more stress which could be because most of the children were infants (74.0%) and unable to speak or tell about their problem regarding to infant development, but crying. therefore, the mothers might feel more stress to carry on her young children with this condition. the p-cdi subscale assessed the mother’s perception of whether the child meets their expectations and the interactions with her child that not reinforcing to her as a mother15. lastly, the dc subscale focused on the mother’s perception of their child behavior and temperament, which make them difficult to manage15. limitations: in regard to study limitations, all of this study measures were based on mothers self-report. therefore, the researcher cannot rule out potential biases because of social desirability or faulty recollection. the present study was conducted during winter season in bangladesh, which was the peck time for respiratory infection especially for the children. recommendations: intervention studies to improve quality of life of bangladeshi children under 5-year-old with pneumonia need to be further study. it is also important to focus both generic and disease specific of quality of life, then it will be easier to relate the factors which are affected their growth and developmental status due to disease conditions. in addition, research in specific age of children, for example, infant, toddler, or preschooler will be clearer to determine the children quality of life. comparing settings between government and non-government hospitals would also be of interest. pediatric nurses, especially who are taking care of the hospitalized children, need encourage and provide more information to the mother with supportive educative nursing system to prevent maternal stress as well as to improve quality of care versus quality of life among under 5-year-old children with pneumonia. acknowledgements: the authors would like to thanks faculty of nursing, burapha university, thailand, dhaka medical college hospital, dhaka, bangladesh and all participants who made this study possible. international journal of human and health sciences vol. 03 no. 04 october’19 200 references: 1. world health organization (who). pneumonia fact sheet: pneumonia the forgotten killer. 2010. retrieved june 15, 2013, from: url: http://www.who. int/ media centre/factsheets/fs 331 /en / index.html 2. united nation international children emergency fund (unicef). pneumonia progress report, international vaccine access center (ivac), 2012; 1-7 3. parvez, m. m., wiroonpanich, and naphapunsakul. the effects of educational program on child care knowledge and behaviors of mothers of children under five years with pneumonia. bangladesh journal of medical science. 2010; 9:136-142 4. varni, j. w., seid, m., and rode, c. a. the pedsqltm, measurement model for the pediatric quality of life inventory. medicine care. 1999; 37: 126-139 5. brubaker, j. a. sleep and health related quality of life in children with cardiac disease. doctoral dissertation, frances payne bolton school of nursing, case western reserve university, 2012 6. howard, e. parental stress and perceived quality of life in adolescents with asthma. master’s thesis, department of human development and family studies, texas tech university, 2009 7. onyango, d., kikuvi, g., amukoye, e., and omolo, j. risk factors of severe pneumonia among children aged 2-59 months in western kenya. a pan african medical journal. 2012; 45:1-13 8. campo, j. v., comer, d. m., jansen-mcwilliams, l., gardner, w., and kelleher, k. j. recurrent pain, emotional distress, and health service use in childhood. journal of pediatrics 2002; 141: 76-83 9. abidin, r. r. parenting stress index: professional manual (3rd ed.). psychological assessment resources, odessa, fl, 1995 10. wongcheree, t., chaimongkol, n., and pongjaturawit, y. factors influencing parent participation in the care of hospitalized children. the journal of faculty of nursing burapha university. 2011;19: 23-36 11. cha, e. k., kim, k. h., and erlen. j. a. translation of scales in cross-cultural research: issues and techniques. journal of advanced nursing. 2007; 58: 386-395 12. cummings, a. j., knibb, r. c., king, r. m., and lucas, j. s. the psychosocial impact of food allergy and food hypersensitivity in children, adolescents and their families. allergy. 2010; 65: 933-945 13. laurvick, c. l., msall, m. e., sillburn, s., bower, c., klerk, n. d., and leonard, h. physical and mental health of mothers caring for a child with rett syndrome. pediatrics. 2006; 118: 1152-1164 14. yamada, a., suzuki, m., kato, m., suzuki, m., tanaka, s., and shindo, t. emotional distress and its correlates among parents of children with pervasive developmental disorders. psychiatry and clinical neurosciences. 2007;61: 651-657 15. reitman, d., rhode, p., hupp, s. d. a., & altobello, c. development and validation of the parental authority questionnaire-revised. journal of psychopathology and behavioral assessment. 2002; 24:119127 233 international journal of human and health sciences vol. 07 no. 03 july’23 original article: association of parents’ educational factor with low birth weight of children in bangladesh: analysis from a nationwide cross-sectional data md. ahsanul kabir1, motahara islam tania 2, zenat zebin hossain3 abstract background: low birth weight (lbw) is a leading public health problem especially in a developing country like bangladesh. objective: to identify the extend of low birth weight and its associated factors among bangladeshi children with a countrywide data. methods: data were used from bangladesh demographic and health survey (bdhs) 2017. a total of 2204 child data has been observed and descriptive analyses were performed to determine various social and demographic characteristics. logistic regression model was used to present parents’ education associated with low birth weight and results were described in terms of odds ratio (or) with 95% ci for both adjusted (aor) and unadjusted (uor) models. results: prevalence of low birthweight is 21.26% vs 14.11% among the unwanted and wanted children in the rural area and this difference is statistically significant. uor and aor of having low birthweight is lower among the children from higher educated mother (aor=0.48, 95% ci= 0.24, 0.98) and children from richest economic group (aor=0.52, 95% ci= 0.31, 0.89). this odd is significant in 95% ci (p-value= <0.05) for both adjusted and unadjusted model. odds of having low birthweight in child is 37% higher (aor=1.37, 95% ci= 0.75, 2.46) among the unplanned children. this association is statistically significant for both unadjusted and adjusted model (p-value= <0.05). conclusion: to summarize, the prevalence of low birthweight among children is high in the rural areas in comparison to urban areas in bangladesh. children of uneducated and low educated parents are at risk of having low birth weight. special antenatal care should be given to the mothers who have less educational qualifications. keywords: low birth weight, children, parents’ education, bangladesh correspondence to: dr. md. ahsanul kabir, senior program manager, jhpiego bangladesh (john hopkins university affiliate), dhaka, bangladesh. email: drahsanul@gmail.com 1. senior program manager, jhpiego bangladesh, john hopkins university affiliate, dhaka, bangladesh. 2. mentoring and supportive supervision coordinator, pathfinder international, dhaka, bangladesh. 3. assistant professor, department of public health, independent university, bangladesh (iub), dhaka, bangladesh. introduction low birth weight (lbw) is still a serious public health problem, particularly in emerging economies1 , but it is also linked to cardio metabolic illnesses, psychiatric conditions, and mortality in both childhood and adulthood in both developed and developing countries 2,3,4,5. between 15% and 20% of all deliveries globally are projected to be lbw (defined by the world health organization (who) as <2500 g) or extremely low birth weight (defined as 1500 g), resulting in a minimum of 20 million children worldwide. the 2500 g cut point is based on epidemiologic research that suggests newborns weighing less than 2500 g are 20 times more likely to die in infancy 6,7,8. international journal of human and health sciences vol. 07 no. 03 july’23 page :233-238 doi: http://dx.doi.org/10.31344/ijhhs.v7i3.579 international journal of human and health sciences vol. 07 no. 03 july’23 234 the large majority of lbw births (95.6%) take place in poor and middle-income nations9 . the rate of lbw births in south asia is almost doubles that of the rest of the world. around 70% of all infants with lbw are born in asia, with central and south asia having the highest prevalence (28%) of any area globally10 . during the most recent national survey, lbw prevalence was high in bangladesh, even in established urban regions, which are generally linked with lower frequency. according to bangladesh’s national low birth weight survey (nlbws), around 23% of infants were born with lbw11 . still now, the prevalence of children underweights, stunting, and wasting are high in bangladesh is comparably high than the other asian countries12 . these nutritional statuses are directly associated with the birthweight of the child11 . to meet the sustainable development goals, a significant reduction in the prevalence of lbw is required, taking into account the implications for child mortality (sdgs). to assess and identify the determinants of lbw, a significant amount of research has been done. mother’s age, food habit and fetal growth during pregnancy and pregnancy weight gain, mother’s body composition before conception, early and let pregnancy are associated with low birth weight12,13,14,15,16 . methods bdhs 2017-18 based on a cross-sectional study design, covers entire population taking a nationally representative sample using stratified two-stage random sampling procedure and used a sampling frame [complete list of enumeration areas (eas)] of 2011 population and housing census of the people’s republic of bangladesh, provided by the bangladesh bureau of statistics (bbs). in the first stage, 600 eas with 207 eas in urban areas and 393 in rural areas were selected and made of household list in all the selected eas. in the second stage, 30 households per cluster were selected with an equal probability of systematic sampling procedure from the newly generated household list. a total of 20,376 evermarried women age 15-49 were selected and with a 98.4% response rate a total of 20,127 interviews were successfully conducted. further explanation about sampling design and other related issues of the 2017-18 bdhs are accessible elsewhere17. if the birth weight of a child is less than 2500 gram, it was considered as low birth weight, while a child weighing 2500 grams or more at birth was considered as having normal birth weight. this cut off has been defined by world health organization (who). results table 1 shows that prevalence of low birthweight is comparatively high among the rural child (15.29%) compared to the children from urban area (14.45%). almost 97.7% of mother have attended formal education among them 15.52% completed primary education and 50.86% completed secondary education. prevalence of completing primary education is higher among urban women compared to rural women but this rate is reverse for secondary education. majority of the urban family are from richer (24.82%) and richest (55.18%) economic quartile in this research while majority of the rural families are from poorer (20.82%) and middle (23.3%) economic quartile. 66.02% of the women do not involve in any formal work and this rate is almost the same in the urban (72.15%) and rural (61.33%) areas. among the working groups, majority of the mothers are working as agriculture-based workers or skilled or unskilled workers. fathers from the rural household are mostly passed secondary 35.44% or higher education (32.76%). 50.28% fathers’ occupation is skilled or unskilled worker in rural areas and 18.82% are involved agriculture base profession. frequency of the fathers’ profession as skilled or unskilled worker is also similar in urban areas (49.63%). in our study 88% of the household is headed by the father. table 2 shows that prevalence of low birthweight is higher in both urban and rural areas of chittagong and sylhet division in bangladesh. prevalence of low birthweight 20.34% and 20% in urban and rural areas of chittagong division and 21.95% and 17.86% in sylhet division respectively. prevalence of low birthweight is higher among those children whose mothers are less educated. prevalence of low birthweight is 34.38% among those children whose mother has no educational attainment compare to that, children whose mother are highly educated, prevalence is 12.93% among them in the rural area. this prevalence follows same track for urban area also, but this differences among various group of educational status is statistically significant for rural area also. moreover, the prevalence of low birthweight is associated with father’s education in the same way. table 3 shows the results of bi-variate and multivariable analysis of low birthweight of children in bangladesh. 235 international journal of human and health sciences vol. 07 no. 03 july’23 unadjusted and adjusted odds ratio (uor and aor) of having low birthweight of children have been presented in the table. odds of having low birthweight for children reduce with the increase of educational status. aor of having low birthweight for children is 50% less (aor= 0.5, 95% ci= 0.27, 0.95) when mother have completed at least secondary education and 52% less (aor= 0.48, 95% ci= 0.24, 0.98) when mother have higher education qualification compared to the women who have no education. both of the association is statistically significant for both adjusted and adjusted model (p-value=<0.05). odds of having low birthweight are also associated with father’s educational status. odds of having low birthweight are lower among the children when father has completed higher education. this association is statistically significant in the unadjusted model, but not significant for the adjusted model. table 1: sociodemographic characteristics of the participants variables urban n (%) rural n (%) total n (%) mother’s education level no education 28 (2.93) 32 (2.56) 60 (2.72) primary 151 (15.81) 191 (15.29) 342 (15.52) secondary 412 (43.14) 709 (56.77) 1121 (50.86) higher 364 (38.12) 317 (25.38) 681 (30.9) father’s education level no education 66 (6.91) 99 (7.93) 165 (7.49) primary 194 (20.31) 342 (27.38) 536 (24.32) secondary 311 (32.57) 470 (37.63) 781 (35.44) higher 384 (40.21) 338 (27.06) 722 (32.76) wealth index poorest 32 (3.35) 209 (16.73) 241 (10.93) poorer 53 (5.55) 260 (20.82) 313 (14.2) middle 106 (11.1) 291 (23.3) 397 (18.01) richer 237 (24.82) 285 (22.82) 522 (23.68) richest 527 (55.18) 204 (16.33) 731 (33.17) mother’s occupation not working 689 (72.15) 766 (61.33) 1455 (66.02) agriculture based profession 88 (9.21) 372 (29.78) 460 (20.87) variables urban n (%) rural n (%) total n (%) skilled or unskilled workers 78 (8.17) 67 (5.36) 145 (6.58) professional and technical 100 (10.47) 44 (3.52) 144 (6.53) father’s occupation agriculture based profession 31 (3.25) 235 (18.82) 266 (12.07) skilled or unskilled workers 474 (49.63) 628 (50.28) 1102 (50) service holders or businessman 215 (22.51) 128 (10.25) 343 (15.56) small business 227 (23.77) 238 (19.06) 465 (21.1) others 8 (0.84) 20 (1.6) 28 (1.27) birthweight normal birthweight 817 (85.55) 1058 (84.71) 1875 (85.07) low birthweight 138 (14.45) 191 (15.29) 329 (14.93) sex of hh head male 856 (89.63) 1074 (85.99) 1930 (87.57) female 99 (10.37) 175 (14.01) 274 (12.43) discussion the cross-sectional study aimed to provide evidence on determinants of low birthweight using nationally representative data. the major objective of this study was to examine the association between low birthweight with parent’s educational status, household economic status, parent’s occupation. lbw is a public health problem linked to a wide range of possible predictors. despite efforts to decrease the proportion of newborns with lbw, success has been quite limited and the problem persists in both developing and developed countries. one of the predictors of lbw is parent’s educational status. women’s and her partner’s educational status is associated with child birthweight. women who are comparatively higher educated gives less low birthweight childbirth. also female employment creates more conscious about health and nutritional condition for them and their children; also women employment is an obstacle for childbearing within the household which is identified as another cause for less childbirth for working women18 . studies from bangladesh and estonia also have found similar association with parent’s education and child low birthweight status4,19. these results are aligned with our study result. also, several studied from india and botswana mentioned that there are no association of low birthweight with international journal of human and health sciences vol. 07 no. 03 july’23 236 table 2: urban and rural distribution of low-birth-weight children variable urban rural child birth weight p-value child birth weight p-value normal low normal low mother’s education level no education 22 (78.57) 6 (21.43) 0.058 21 (65.63) 11(34.38) 0.01 primary 124 (82.12) 27(17.88) 157 (82.2) 34 (17.8) secondary 346 (83.98) 66(16.02) 604(85.19) 105(14.81) higher 325 (89.29) 39(10.71) 276(87.07) 41 (12.93) father’s education level no education 59 (89.39) 7 (10.61) 0.032 78 (78.79) 21 (21.21) 0.024 primary 159 (81.96) 35(18.04) 283(82.75) 59 (17.25) secondary 257 (82.64) 54(17.36) 395(84.04) 75 (15.96) higher 342 (89.06) 42(10.94) 302(89.35) 36 (10.65) division barisal 62 (83.78) 12(16.22) 0.047 105 (87.5) 15 (12.5) 0.17 chittagong 94 (79.66) 24(20.34) 164 (80) 41 (20) dhaka 215 (84.98) 38(15.02) 123(86.62) 19 (13.38) khulna 118 (90.08) 13 (9.92) 144(83.24) 29 (16.76) mymensingh 81 (88.04) 11(11.96) 146(90.68) 15 (9.32) rajshahi 83 (85.57) 14(14.43) 123(83.11) 25 (16.89) rangpur 100 (92.59) 8 (7.41) 161(85.64) 27 (14.36) sylhet 64 (78.05) 18(21.95) 92 (82.14) 20 (17.86) table 3: logistic regression of low birthweight with parents’ education level variables uor (95% ci) p value aor (95% ci) p-value mother’s education level (ref: no education) primary 0.55(0.29,1.03) 0.061 0.54(0.28,1.03) 0.063 secondary 0.46(0.25,0.82) 0.008 0.5 (0.27, 0.95) 0.033 higher 0.34(0.18,0.62) <0.001 0.48(0.24,0.98) 0.043 father’s education level (ref: no education) primary 1.04(0.65,1.65) 0.866 1.22 (0.75, 2) 0.423 secondary 0.97(0.62,1.52) 0.887 1.23(0.75,2.03) 0.41 higher 0.59(0.37,0.95) 0.029 0.9 (0.5, 1.61) 0.726 mother’s educational attainment, and studies from ghana also found same result 20,21,22. this finding contradicts with our result. our result shows that children from chittagong and sylhet division are at more risk of being low birthweight compare to the other division of bangladesh. bangladesh demographic and health survey 2017 indicates that prevalence of wasting, stunting and child malnutrition is also high in these divisions17 . family income and economic status is another 237 international journal of human and health sciences vol. 07 no. 03 july’23 determinant of lbw. previous study has mentioned that women from poorer economic condition gives birth of more lbw child compare to the women from middle or rich economic condition22. our study result also identified that risk of lbw is lower among the child from richer and richest family compare to the children from poorer and poorest family. the findings show a strong association between birth weight and socioeconomic status which is consistent with other studies which showed that higher socioeconomic status reduced the risk of lbw23,24,25,26. this shows that poverty is an important determinant of birth weight as shown in other contexts26,27. low birth weight could be due to poor maternal nutritional intake among mothers with lower socioeconomic status as found in other studies28,29. limitations of this study include the main exposure variable i.e., lbw. since the bdhs 2017 collected information retrospectively and actual birth weight measurements were unavailable, lbw was defined based on mother’s perception of the size of child at birth. underreporting is therefore expected since most mothers would be able to recall whether the baby was underweighting only if the baby was very small in size (i.e., << 2500gm). thus, the prevalence of lbw was found to be 14.93% in our study, which is much lower than 23% obtained by recent national low birth weight survey which measured lbw from actual birth weights. conclusion in conclusion, the results showed that the prevalence of lbw is still high among the children in bangladesh. risk of being lbw is higher among the children whose parents are less educated. nevertheless, the burden of lbw is still high among the children of skilled or unskilled worker mother and child from poorer economic quartile. the existence of lbw may leads to adverse clinical consequences in later stage of life as well as to an unfavorable growth of the future generation. our results emphasize the necessity of effective public health approaches to address the issue of malnutrition among the children in bangladesh. recommendations 1. special consideration for maternal health and nutrition should be given for chittagong and sylhet division 2. special attention on health, nutrition and education should be given for the mother from lower economic condition and who are less educated. 3. nutrition education should be given emphasize for adolescent girls and pregnant women. 4. vitamin a and ifa supplementation should be ensured for every pregnant woman. 5. nutritional status of the mother should be given concern. conflict of interest: none. funding statement: nil. ethical clearance: approval of this study was given by the ethics review committee of the department of public health, independent university, bangladesh (iub), dhaka, bangladesh. author’s contribution: all authors were equally involved in conception, study design, data collection, statistical analysis, writing, editing, and final approval of the manuscript. references 1. world health organization (who): regional consultation towards the development of a strategy for optimizing fetal growth and development. cairo: who; 2005. 2. barker dj, forsén t, uutela a, osmond c, eriksson jg. size at birth and resilience to effects of poor living conditions in adult life: longitudinal study. bmj. 2001;323(7324):1273-6. 3. eriksson jg, forsén t, tuomilehto j, winter pd, osmond c, barker dj. catch-up growth in childhood and death from coronary heart disease: longitudinal study. bmj. 1999;318(7181):427-31. 4. khatun s, rahman m. socio-economic determinants international journal of human and health sciences vol. 07 no. 03 july’23 238 of low birth weight in bangladesh: a multivariate approach. bangladesh med res counc bull. 2008;34(3):81-6. 5. risnes kr, vatten lj, baker jl, jameson k, sovio u, kajantie e, osler m, morley r, jokela m, painter rc, sundh v, jacobsen gw, eriksson jg, sørensen ti, bracken mb. birthweight and mortality in adulthood: a systematic review and meta-analysis. int j epidemiol. 2011;40(3):647-61. 6. mccormick mc. the contribution of low birth weight to infant mortality and childhood morbidity. n engl j med. 1985;312(2):82-90. 7. mcintire dd, bloom sl, casey bm, leveno kj. birth weight in relation to morbidity and mortality among newborn infants. n engl j med. 1999;340(16):12348. 8. whincup ph, kaye sj, owen cg, huxley r, cook dg, anazawa s, et al. birth weight and risk of type 2 diabetes: a systematic review. jama. 2008;300(24):2886-97. 9. fund uncs, world health organization (who): low birthweight: country, regional and global estimates. unicef; 2004:1-31. 10. world health organization (who). global nutrition targets 2025: low birth weight policy brief. geneva: who; 2014. 11. khan jr, islam mm, awan n, muurlink o. analysis of low birth weight and its co-variants in bangladesh based on a sub-sample from nationally representative survey. bmc pediatr. 2018;18(1):100. 12. unicef: strategy to reduce maternal and child undernutrition. east asia & pacific regional office health and nutrition working paper. bangkok: unicef east asia and pacific regional office; 2003. 13. kramer ms. determinants of low birth weight: methodological assessment and meta-analysis. bull world health organ. 1987;65(5):663-737. 14. sharma v, katz j, mullany lc, khatry sk, leclerq sc, shrestha sr, et al. young maternal age and the risk of neonatal mortality in rural nepal. arch pediatr adolesc med. 2008;162(9):828-35. 15. khoshnood b, wall s, lee ks. risk of low birth weight associated with advanced maternal age among four ethnic groups in the united states. matern child health j. 2005;9(1):3-9. 16. rice f, thapar a. estimating the relative contributions of maternal genetic, paternal genetic and intrauterine factors to offspring birth weight and head circumference. early hum dev. 2010;86(7):425-32. 17. national institute of population research and training (niport). bangladesh demographic and health survey 2017-18. in. dhaka, bangladesh, and rockville, maryland: niport & icf; 2020. 18. khuda b, hossain mb. fertility decline in bangladesh: an investigation of the major factors. mch-fp extension project (rural). international centre for diarrhoeal disease research, bangladesh (icddr, b) working paper no. 48. dhaka: icddr, b; 1996. 19. koupilova i, rahu k, rahu m, karro h, leon da. social determinants of birthweight and length of gestation in estonia during the transition to democracy. int j epidemiol. 2000;29(1):118-24. 20. molly p, jain p, prasad b. a study of premature births at sat hospital trivandrum. j obstet gynaecol india 1970;20:66-7. 21. ubomba-jaswa s. correlates of low birth weight in botswana. southern afr j demography. 1996;6(1):64-73. 22. manyeh ak, kukula v, odonkor g, ekey ra, adjei a, narh-bana s, et al. socioeconomic and demographic determinants of birth weight in southern rural ghana: evidence from dodowa health and demographic surveillance system. bmc pregnancy childbirth. 2016;16(1):160. 23. schulpis kh, karakonstantakis t, vlachos gd, gavrili s, mentis a-fa, lazaropoulou c, et al. the effect of nutritional habits on maternal–neonatal zinc and magnesium levels in greeks and albanians. e-spen. 2009;4(4):e176-80. 24. dowding vm. new assessment of the effects of birth order and socioeconomic status on birth weight. br med j (clin res ed). 1981;282(6265):683-6. 25. fosu mo, munyakazi l, nsowah-nuamah n. low birth weight and associated maternal factors in ghana. j biol agric healthcare. 2013;3(7):205-11. 26. janevic t, stein cr, savitz da, kaufman js, mason sm, herring ah. neighborhood deprivation and adverse birth outcomes among diverse ethnic groups. ann epidemiol. 2010;20(6):445-51. 27. conley d, bennett ng. birth weight and income: interactions across generations. j health soc behav. 2001;42(4):450-65. 28. shrivastava sr, shrivastava ps. a longitudinal study of maternal and socioeconomic factors influencing neonatal birth weight in pregnant women attending an urban health center. saudi j health sci. 2013;2(2):87-92. 29. michael o, iddrisu a, riskatu y. maternal risk factors for low birth weight in a district hospital in ashanti region of ghana. res obstet gynecol. 2013;2(4):48-54. international journal of human and health sciences vol. 03 no. 01 january’19 14 original article: prevalence of depression among emp loyees of lorestan university of medical sciences and its relationship with demographic variables in 2017, west of iran babak khodadadi1, maedeh yousefnezhad2, saeed dashti dargahloo3, nadia alipour4, morteza mohammadirokh5 abstract introduction: depression is one of the psychiatric disorders and is the most common mood disorder. stably and sometimes unstable, depression can involve and interfere with different aspects of life. by disrupting tasks, reducing motivation, causing anxiety, fear, and concern, depression impairs a significant part of the intellectual ability. complications of depression have been proven on presence and absenteeism, accuracy in performing duties and efficiency. this study tends to determine the prevalence of depression among employees of lorestan university of medical sciences and its relationship with demographic variables in 2017. method: this cross-sectional study was conducted on employees of the lorestan university of medical sciences in 2017. the subjects were 270 people who filled in adult bdi-ii (including 21 3-point questions). the inventory is scored from 0 to 63(013 minimal depression (normal)), 14-19 mild depression, 20-28 moderate depression, and 28-63 severe depression). data were analyzed using spss version 23. results: the mean depression score was 10.7; 48.1% had depression. prevalence of depression was 12.6% mild depression, 11.1% moderate depression and 6.3% severe depression; 89 (33%) were single and 181 (67%) were married; prevalence of depression was 29.47% in women and 30.28% in men. discussion: men were more likely to develop depression than women (27%), which is contrary to many reports. this study showed a significant relationship between age and prevalence of depression. there was a significant relationship between prevalence of depression and marital status; there was a significant relationship between workplace and the kind of work done by people and depression. there was a significant relationship between parental education and depression. there was no significant relationship between education and depression. however, some studies did not report this significant relationship. keyword: depression, employees, psychiatric correspondence to: morteza mohammadirokh, birjand university of medical sciences, ghafari street, birjand, southern khorasan, iran. email: mohammadirokh.sci@gmail.com 1. young researchers and elite club, khorramabad branch, islamic azad university, khorramabad, iran. 2. student of dentistry, school of dentistry, student research committee, mazandaran university of medical sciences, sari, mazandaran, iran 3. medical student, student research committee, faculty of medicine, mazandaran university of medical sciences, sari, iran 4. ph.d. student of biostatistics, department of biostatistics, faculty of medical sciences, tarbiatmodares university, tehran, iran 5. student research committee, birjand university of medical sciences, birjand, iran. introduction: according to the world health organization (who) definition, depression is one of the most important mood disorders which is associated with decreased mood, loss of interest, sleep disturbance or appetite loss, reduced energy and poor concentration. depression is an occasionally stable and sometimes unstable mood which can involve and interfere with different aspects of life. change in mood means severe to mild sorrow, sadness, and irritability which affects people. depression is a widespread traumatic disease which can affect any person of any race or any population.1 depression is a psychiatric disorder and is one of the most common mood disorders which affects 12% of men and 25% of women over a lifetime.2 research international journal of human and health sciences vol. 03 no. 01 january’19 page : 14-18 doi: http://dx.doi.org/10.31344/ijhhs.v3i1.67 15 international journal of human and health sciences vol. 03 no. 01 january’19 shows that about 19 million americans experience depression annually.1 mental problems lead to impairment in doing duties, reduced motivation, anxiety, fear, and concern, and cause people to devote a significant part of their mental work to these problems; thus it is clear that they will not have sufficient ability and interest to work in the organization. depression is the cause of many physicals distresses, including fatigue, insomnia, decreased sexual desire, diarrhea, constipation, throbbing, tenderness, and numbness. depression in the workplace has many effects; depressed employees lose more production time than nondepressed people.3-5 several studies have shown that depression is a common and costly disorder which affects work and job performance.4,6-9; depressed employees are less likely to report workplace safety and more likely to cause job injuries. these people play a significant role in poisoning the workplace atmosphere and creating tension in interpersonal relationships and the process of doing things.10,11. epidemiologic studies show that depression is one of the most costly diseases in the workplace. patients suffering from this disorder are facing more than healthy people with deficiency and inability to perform tasks, which account for 30% of reduced productivity and absenteeism and 70%of mistakes and inability to do things because of the symptoms or complications of treatments.11,12 complications of depression have been proven on presence and absenteeism, accuracy in performing duties and efficiency.6dehghanet al. reported more than 40% prevalence of depression among employees in the larestan health care network.13fallah et al.reported 40% prevalence of depression among employees of zanjan university of medical sciences.14 the prevalence of depression among employees of the sarab health care network was reported at 41.4% (25% in men and 75% in women).15 as a result, it is necessary to examine the status of depression among employees of each system. considering the importance of maintaining employee strength and health, first, as human being, and second, as people who are directly involved in maintaining health and well-being of other members of the society, it is necessary to take steps to maintain and improve mental health of employees based on the results obtained from examining the status of depression in employees of the university of medical sciences.16 therefore, a study was conducted to determine the prevalence of depression among employees of the lorestan university of medical sciences and its relationship with demographic variables in 2017. methods and materials: this cross-sectional (descriptive-analytic) study was conducted in lorestan university of medical sciences in 2017. the studied population included employees of the lorestan university of medical sciences. inclusion criteria included more than one year of work experience, willingness to participate in the study and lack of state mental diseases. moreover, people taking drugs which have an effect on psyche, chronic and incurable physical diseases and severe familial conflicts were excluded from the study. in this study, a random classification was used for sampling. each associate was considered as a class; proportional to personnel size in each class, samples were randomly selected. to select the research sample, subgroups should be present in the sample with the same proportion they exist in the population (university) as representative of that population. in this method, the percentage of subjects randomly selected from each group is equal to the percentage of the same group in the considered population. based on fallah et a14, the sample size was set at 270 assuming 40% prevalence of depression using . in this study, adult beck depression inventory (bdiii) was used to measure the level of depression by using 21 questions. each question had 3 points from 0 to 3; a total score of the inventory varied from 0 to 63. evaluation of depression was based on the total score (0-13: minimal depression (normal); 14-19: mild depression; 20-28: moderate depression;28-63: severe depression). this inventory is an international standard scale devised by the american psychologist dr. beck in 1960. reliability and validity of this inventory have been confirmed worldwide. reliability of bdi was reported at 78% by kuder-richardson method and 75% by re-test method. in iran, pourshahbaz also estimated the correlation coefficient of this inventory at 23-68% and its internal consistency at 85%. demographic characteristics of the subjects including age, gender, marital status, education, parental education, and birth rate of the subjects were added by demographic questionnaire to the original inventory. the questionnaires were distributed anonymously; objectives of the study international journal of human and health sciences vol. 03 no. 01 january’19 16 were explained to people and all subjects were ensured of confidentiality of their information. it is noteworthy that a score equal to or greater than 10 in bdi-ii was considered as having depression. the collected data was analysed using descriptive statistics (mean, standard deviation, absolute and relative frequency) and inferential statistics (logistic regression test). for data analysis, spss software version 23 was used (p-value<0.05). results: out of 270 subjects, 175 (64.8%) were male. the age of the subjects varied from 24 to 61 years (41.59 ± 7.88); 61 (22.6%) were younger than 35 years, 108 (40%) were 35-45 years old, and 101 (37.4%) were older than 45 years. the mean depression score was 10.7. according to the cut-off score of 10, 48.1% had depression. according to bdi, 30% of people experienced some degrees of depression. prevalence of depression was 12.6% mild depression, 11.1% moderate depression and 6.3% severe depression; 89 (33%) were single and 181 (67%) were married. an education level of 55.2% of the fathers was under high school diploma and 72.2% of the mothers were under high school diploma. prevalence of depression was 29.47%in women and 30.28%in men. to select variables for the multivariate logistic regression model, all variables were evaluated using univariate logistic regression and variables with a p-value<0.3 were incorporated into the model. for data analysis, confidence intervals, as well as odds ratios obtained from analysis of the results, were used to interpret the effect of risk factors on depression/no depression. the collected data was analyzed using spss 24 software (p-value<0.05). according to univariate logistic regression analysis, there was a significant relationship between gender (or = 1.276), marital status (or = 0.757), paternal education, maternal education, department, work experience, age, and depression. that is, men were 27% more likely to have depression than women. married people were 76% less likely to have depression than single people. multivariate regression analysis showed that those who worked in department of development were 3 times more likely to develop depression than those who worked in development of education. those who worked in other departments were less likely to develop depression than those who worked in development of education and this was statistically significant. using the table below (table 1), frequency and prevalence of depression can be reported in subgroups of variables. table1: number and percentage of patients grouped based on their depression severit classification of depression minimal depression mild depression moderate depression severe depression total nn % n % n % n % g en de r female 67 70.5 13 13.6 7 7.37 8 8.42 95 male 122 69.7 21 12.0 23 13.1 9 5.14 175 a ge <35 45 73.7 5 8.20 6 9.84 5 8.20 61 35-45 80 74.0 11 10.1 12 11.1 5 4.63 108 >45 64 63.3 18 17.8 12 11.9 7 6.93 101 ex pe rie nc e (y ea r) <10 95 73.6 11 8.5 14 10.8 9 6.98 129 10-20 69 62.7 21 19.0 12 10.9 8 7.27 110 >20 24 80.0 2 6.67 4 13.3 0 0.00 30 m ar ita l st at us single 63 70.7 10 12.3 7 7.87 9 8.99 89 married 126 69.6 24 13.2 23 12.7 8 4.41 181 ed uc at io n associate 8 66.6 3 25.0 1 8.33 0 0.00 12 ba 166 69.7 31 13.0 25 10.5 16 6.72 238 ma and higher 15 75.0 0 0 4 20.0 1 5.0 20 pa te rn al ed uc at io n under diploma 99 66.4 21 14.1 16 10.7 13 8.72 149diploma 52 76.4 6 8.82 8 11.7 2 2.94 68 associates 9 64/2 2 14.3 3 21.4 0 0 14 ba 25 78.1 3 9.38 2 6.25 2 6.25 32 ma and higher 4 57.1 2 28.6 1 14.3 0 0.00 7 ma tern al e duc atio n under diploma 135 69.23 25 12.8 18 9.23 17 8.72 195 diploma 42 72.41 6 10.3 10 17.2 0 0 58 associates 1 33.33 1 33.33 1 33.3 0 0 3 ba 10 83.33 1 8.33 1 8.33 0 0 12 ma and higher 1 50.00 1 50.00 0 0 0 0 2 nat ive no 41 66.13 10 16.13 8 12.9 3 4.84 62 yes 148 71.15 24 11.54 22 10.6 14 6.73 208 dep artm ent education 44 65.67 9 13.43 10 14.93 4 5.97 67 research 33 73.33 5 11.11 6 13.33 1 2.22 45 culture 36 70.59 4 7.84 7 13.73 4 7.84 51 treatment 22 61.11 7 19.44 3 8.33 4 11.11 36 health 26 83.87 3 9.68 1 3.23 1 3.23 31 development 10 47.62 5 23.81 3 14.29 3 14.29 21 food and drug 18 94.7 1 5.3 0 0 0 0.00 19 total 189 70.0 34 12.6 30 11.1 17 6.30 270 17 international journal of human and health sciences vol. 03 no. 01 january’19 discussion: in the present study, the prevalence of depression was 30%among the studied people. the risk of depression in men was 27% higher than that of women, contrary to many reports13,17-19, which can be due to the low number of female participants compared to men and economic pressures considering payments in iran for providing the family. however, some studies have claimed that there is no significant relationship between gender and prevalence of depression.1,14,20 this study, contrary to nabipouret al, dehghanet al, fallahet al., found a significant relationship between age and prevalence of depression.13,14,18 there was a significant relationship between prevalence of depression and marital status,which is consistent with some studies.21 this can be attributed to mental relaxation. prevalence of depression was lower in married people than single people; the risk of depression in married people was 76% less than that of singles, which is contrary to pouretemad et al.22 however, several studies have shown that there is no significant relationship between prevalence of depression and marital status.14,23 prevalence of depression was about 52% in the department of development and about 34% in the department of education. thus, the risk of depression in those who worked in the department of development was 3 times higher than those who worked in the department of education. those who worked in other departments were less likely to develop depression than those who worked in development of education and this was statistically significant. workplace and the type of work that people do have been studied in several studies, which is consistent with the results of this study; there is a significant relationship between workplace and depression.14 even this difference is seen in cities of service, as suggested by janice et al.24 there was a significant relationship between parental education and depression; this is consistent with yousefi et al, rostamzadeh and khalilzadeh, who claim that depression symptoms also become clearer by increasing parental education. however, in this study, it cannot be claimed that this relationship is direct or inverted; this may be due to the low number of samples at some levels of education. the lowest depression was observed in those whose parents had a bachelor’s degree. the highest severe depression was observed in people whose parents had less than high school diploma. sheikh ahmadi et al. reported no significant relationship between depression and parental education.25 the relationship between education and depression was inconsistent with other studies; in this study, this relationship was insignificant.14,18,26 however, some studies did not report this significant relationship.6,23 inconsistent with fallah, there was a significant relationship between work experience and depression. the highest prevalence of depression was observed in employees with 10-20 years of experience. in other studies, this relationship was also significant; however, depression was higher in people with more than 20 years of experience, which can be due to the low number of people with 20 years of experience.14,18,23 there was no significant relationship between place of birth (native or non-native) and depression. limitations and problems: limitations and problems of this study include the lack of cooperation of employees in filling in the questionnaire, the lack of willingness to participate in the study, incomplete filling of the questionnaire, use of drugs for depression and those who were in grief. ethical approval: this research proposal was accepted by the ethics committee of lums, iran conflict of interest: none declared acknowledgement: we acknowledge and thank all people who dedicated their time and participated in this study. author’s contributions: data gathering and idea owner of this study: bk study design: my data gathering: sdd data analysis and consultation: na writing and submitting manuscript: mm international journal of human and health sciences vol. 03 no. 01 january’19 18 references: 1. baghiani moghaddam mh, ehrampoush mh, rahimi b, aminian ah, aram m, prevalence of depression among successful and unsuccessful students of public health and nursing-midwifery schools of shahid sadoughi university of medical sciences in 2008, the journal of medical education & development center 2011;6(1): 17-24. 2. shah miri h, ghorayshizade sma. relationship between coping strategies and demographic characteristics and severity of depression in patients with major depression, medical journal of tabriz university 2006,28(1): 81-6. 3. stewart wf, ricci ja, chee e, hahn sr, morganstein d. cost of lost productive work time among us workers with depression. jama. 2003;289(23):3135-44. 4. adler da, mclaughlin tj, rogers wh, chang h, lapitsky l, lerner d. job performance deficits due to depression. am j psychiatry. 2006;163(9):1569-76. 5. wang ps, beck al, berglund p, mckenas dk, pronk np, simon ge, et al. effects of major depression on moment-in-time work performance. am j psychiatry. 2004;161(10):1885-91. 6. kessler rc, akiskal hs, ames m, birnbaum h, greenberg p, hirschfeld rm, et al. prevalence and effects of mood disorders on work performance in a nationally representative sample of u.s. workers. am j psychiatry. 2006;163(9):15618. 7. dehghan bahabadi h. the prevalence of depression among staff of shahid sadoughi university of medical sciences. [dissertation]. [yazd]: shahid sadoughi university of medical sciences and health services; 1999.96p 8. tatari f, amiri h. comparing depression among farabi psychiatry hospital with staff of imam khomeini hospital in kermanshah [dissertation]. [kermanshah]: kermanshah university of medical sciences; 2000. 113p 9. lerner d, henke rm. what does research tell us about depression, job performance, and work productivity? j occup environ med. 2008;50(4):401-10. 10. williams cd, schouten r. assessment of occupational impairment and disability from depression. j occup environ med. 2008;50(4):441-50. 11. kendler ks, gardner co, prescott ca. toward a comprehensive developmental model for major depression in men. am j psychiatry. 2006;163(1):115-24. 12. kouzis ac, eaton ww. emotional disability days: prevalence and predictors. am j public health. 1994;84:1304-7. 13. dehghan a, ghavami l, ghahramani f, bazrafshan m, namavar s. prevalence of depression and its relation with their performance in larestan rural health workers in 2010. j rafsanjanuniv med sci. 2012;11(1):79-84. 14. fallah r, farhadi s, amini k, mohajeri m. prevalence of depression in personnel of zanjan university of medical sciences. j zanjanuniv med sci. 2011;19(75):107-13. 15. laalisarab m, ekhtiyari a. the prevalence of depression among sarab health workers.9th iranian nutrition congress tabriz. 2006 sep 4-7; tabriz university of medical sciences; 2006. 16. andrews g, henderson s, hall w. prevalence, comorbidity, disability and service utilisation: overview of the australian national mental health survey. br j psychiatry. 2001;178:145-53. 17. zinn-souza l, nagai r, teixeira l, latorre m, roberts r, cooper s, et al. factors associated with depression symptoms in high school students in são paulo, brazil. revista de saúdepública. 2008;42:34-40. 18. nabipour ar, gholami h, amini a, riahi sm, ghanbarifar s, moradlou hz. prevalence of depression and its related factors in pishva district health network employees in 2013. journal of health and development. 2015;3(4):323-32. 19. musarezaie a, momeni-ghalehghasemi t, musarezaie n, moeini m, khodaee m. investigate the prevalence of depression and itsassociation with demographic variables in employees. iranian journal of psychiatric nursing. 2014;2(3):37-45. 20. patti e, acosta j, chavda a, verma d, marker m, anzisi l. prevalence of anxiety and depression among emergency department staff. nursing. 2007;48(2):8. 21. ettinger a, reed m, cramer j. depression and comorbidity in community-based patients with epilepsy or asthma. neurology. 2004;63(6):1008-14. 22. pouretemad hr, naghavi hr, malekafzali h, noorbala aa, davidian h, ghanizadeh a, mohammadi mr, yazdi sa, rahgozar m, alaghebandrad j, aminih. prevalence of mood disorders in iran. iranian journal of psychiatry. 2006;1(2):59-64. 23. vakili m, eslamifarsani sh, hossein smh, dehghanitafti mh. prevalence of depression and its related factors among truck drivers in yazd province -2008. ioh. 2010;6(4):69-76. 24. probst jc, laditka sb, moore cg, harun n, powell mp, baxley eg. rural-urban differences in depression prevalence: implications for family medicine. family medicine. 2006;38(9):653-60. 25. shaikhahmadi s, taymoori p, yousefi f, raoshani d. the relationship between education level and occupation of parents of students with internet dependency, depression and anxiety in sanandaj. shenakht. 2014;1(2):58-72. 26. chevalier a, feinstein l. sheepskin or prozac: the causal effect of education on mental health. (july 2006). iza discussion paper no. 2231. available at ssrn:https://ssrn.com/abstract=923530 international journal of human and health sciences vol. 02 no. 01 january’18 18 review article: the objectionable practises of the in vitro fertilization-embryo transfer method with respect to islamic law (fiqh) ülfet görgülü1 abstract upon discovery of the in vitro fertilization and embryo transfer method (ivf-et), outcomes such as production of a great number of embryos, pre-implantation genetic screening and diagnosis, sex selection and multi-parent ivf have gradually become possible. these developments need to be evaluated in the context of the general principles of islam as well. islamic communities have accepted the ivf-et technology, which allows infertile couples to have children, as an exceptional solution and treatment. nevertheless over time, the ivf method introduced expansions that contradict with religious, ethical and social values. keywords: test-tube baby, embryo, genetic diagnosis, sperm and egg donation, fiqh correspondence to: assoc. prof. ülfet görgülü, expert in high board of religious affairs, presidency of religious affairs,ankara-turkey. e-mail: ulfetgorgulu@gmail.com international journal of human and health sciences vol. 02 no. 01 january’18. page :18-24 introduction the rapid progress in the fields of biomedicine and genetics, while leading to increased knowledge and new hopes to cure diseases, have also led to ethical, legal and religious discussions. in general, scientific research can be evaluated within the context of examining and demonstrating2 the actions of allah. it could be argued that islam encourages scientific efforts that prevent disease or provide treatments with an aim to benefit humanity. however, when the issue is the potential human that is the embryo and the termination of its life, it is not sufficient to approach the topic from the perspective of benefit. this issue also needs to be discussed in relation to the harm avoidance (daf al-mazarrah) principle. moreover, it is worrisome that a human being, the best of creations (ashrafalmahlukat)3 created by allah, has become a topic of engineering and is reduced to a laboratoryproduced object. it is not possible to find direct information on how to interpret today’s scientific and technological advances and their problems in the two main sources of islam, qur’an and sunnah, and fiqh (islamic law) that was established based on these sources. however, these issues can be analyzed through secondary (al-far’iyyu) evidence such as “al-istishab”4, “al-maslahah”5 and “sadazzarai‘”6 and general principles that were obtained from the main sources of islam. this paper will examine the practices associated with the ivf-et technique that are problematic within the context of the islamic law, with respect to the principles mentioned above. multiple embryo production, cryopreservation, and destruction in ivf-et the ivf-et technique refers to the co-incubation and fertilization of an oocyte, which has been retrieved using a specific method, with sperm, and implantation of the resulting eight or sixteen-cell embryo to the uterus of the woman.7 more than one embryo is produced through ivfet because it is thought that this provides both economic and psychological advantages. the healthiest embryos are selected to be transferred to the uterus.8 embryos that are not transferred can be used for scientific research or be frozen for later use. embryo cryopreservation has some social risks and involves ethical and legal problems. can an embryo be subject to ownership? should frozen embryos be donated or destroyed? can embryo donation be considered in the same way as tissue donation or child adoption?9 what will be the fate of frozen embryos if a marriage ends or one of the spouses renounces to have a child or dies? who will make decisions on the future of the embryos of deceased parents? could the risk of other people 19 international journal of human and health sciences vol. 02 no. 01 january’18 using these embryos be prevented? embryo cryopreservation brings along many questions and problems such as those mentioned above. according to islam, just like the desire to get married, having children is a natural need. the qur’an asks believers to marry.10 in addition, prophet muhammed (pbuh) encourages spouses to have children.11 if pregnancy cannot be achieved through sexual intercourse, on the condition that the sperm, egg, and womb belong to the married couple, having a baby with artificial insemination is considered a medical therapy and generally accepted by muslim scholars and fatwa commissions.12 however, production, freezing, and destruction of surplus embryos add a different dimension to the issue. the decision of the international islamic fiqh academy, under the organization of islamic cooperation, on this issue is following: “in in vitro fertilization, only the number of eggs that will be implanted into the uterus should be fertilized each time. if surplus embryos are produced, these should be abandoned to the natural way of death without any medical protection.”13 “the protection of human life” is one of thefive higher goals (ad-daruriyyahad-diniyyah)of islamic law.14 in the verses of the qur’an that are related to the creation of human beings, the zygote is mentioned. moreover, it is indicated that the zygote is the core of a human being.15therefore ontologically, the life of a human being begins with the fertilization of an egg and a sperm that belong to two alive and different human beings. thus, the life of an embryo, which is an independent living being from the first moment, should be protected. the viewpoint of an embryo as only a cluster of cells cannot be approved according to the islamic view. on the other hand, an increase in the number of frozen embryos will make their protection more demanding.16 preventing harm (al-mafsadah)is prioritized over obtaining benefit (al-manfaah), according to the understanding of islam. at the present time, since the egg and sperm can be separately frozen, only a medically required minimum number of embryos should be produced by the ivf method. preimplantation genetic diagnosis destruction of embryos with genetic disorders preimplantation genetic diagnosis (pgd) is a method that is practiced to identify the genetic disorders of the embryo that is produced through ivf, before implanting it to the uterus of the mother.17 through pgd, pregnancy is controlled from the very beginning for couples that have a high risk of having a child with a genetic defect. thus, families that request the use of pgd first receive ivf treatment.18 the cells taken from the embryos that belong to families that are carriers of a genetic disorder (the same embryos produced through ivf) are examined. therefore, genetically disordered embryos are determined and healthy embryos are transferred to the mother. this leads to the birth of healthy children who don’t possess a genetic disorder.19 although pgd is one of the most significant applications within the newest ivf technologies, it gives way to many ethical discussions. pgd practices are primarily discussed in the context of the right to live and dignity of life of the embryo. the method is criticized on the basis of discrimination, as the diseased embryos are destroyed in favor of healthy embryos.20 in addition, it is pointed out that being human is a divine gift and cannot be turned into a product. people should be valued based on their characteristics, however, they may be evaluated depending on their genetics due to the pgd method. moreover, it is proposed that the genetic engineering product “designer babies” may become the routine.21 in fact, the technique allows selecting an embryo’s physical characteristics such as height, eye and hair color, level of intelligence, and health status. nevertheless, using the pgd method not for the treatment of all diseases but for some such as serious blood disorders is met with a general acceptance due to its considerable benefits.22 there are no restrictions for pgd in international law. it is indicated that in the case of a violation of general human rights and general principles of law, restraints may be imposed. however, it is also argued that pgd does not break any universal human rights and it does not apply to discrimination against genetically disabled people.23 as of 2004, genetic diagnosis is prohibited in germany, italy, switzerland, and australia. whereas it is permitted in denmark, sweden, france, and norway. in countries such as turkey where there are no legal regulations on the issue, the method is allowed under particular conditions.24 additionally, some countries only permit polar body biopsy, which is the genetic analysis of oocyte.25 on the other hand, in the judgement of international islamic fiqh academy on the genetic treatment provisions, it is allowed to perform a genetic diagnosis on the embryo before implanting it into international journal of human and health sciences vol. 02 no. 01 january’18 20 the womb.26 as previously mentioned, destroying an embryo which has the potential of a human being or using it as an experimental tool without a compulsive reason is religiously objectionable. nevertheless, according to articles 21 and 22 of mecelle -islamic norms and doctrines-: “necessities remove restrictions” and “if it is a necessity, the islamic law can be broken only for eliminating the necessity.”27 therefore, applying the pgd method and having children through ivf may be allowed for those who are the carriers of genetic disorders. production of a healthy sibling for the treatment of a diseased sibling the only treatment for serious blood disorders such as fanconi anemia is allogeneic stem cell transplant using stem cells from a tissue compatible donor. in the case of such blood disorders, it is possible to select non-disease carrying embryos via genetic diagnosis pre-implantation and to concurrently use the human leukocyte antigen genotyping (hla) procedure. for these reasons, families that are carriers of such disorders may prefer the pgd method. for the treatment of diseased children, families can have a new child whose genetic structure is compatible with the diseased children through this method. the use of pdg for these reasons brings up the following questions: is it ethical to use a living being that cannot decide for themselves as an experiment object? who will decide when they can be used? how can it be guaranteed that the child conceived in order to obtain the required stem cells would not face any psychosocial problems such as feelings of worthless or perceive himself/herself as a “spare part”? the aforementioned questions and the process of ending embryos’ lives based on their genetic incompatibility with the diseased sibling make this practice objectionable with respect to islam. it is important to mention one of the sayings (hadith) of prophet muhammed (pbuh) here: “there is not to be any causing of harm nor is there to be any reciprocating of harm.”28 sex selection – deciding on the sex of the offspring forming an embryo with the preferred sex or selecting the sex of an embryo is possible through pgd technology. the chromosomes of the gamete (germ cells) determine sex. sperm cells have x (female) or y (male) chromosomes whereas an egg cell contains only the x chromosome. the sperm that fertilizes the oocyte determines the sex of the embryo. if the sperm carrying an x chromosome fertilizes the egg, the embryo will be female. if the sperm carrying a y chromosome fertilizes the egg, the embryo will be male.29 therefore, the sex of a baby is determined during fertilization. the pgd method, which allows for sex selection, is accepted as a positive medical practice since it allows for the detection of sex-linked disorders in the embryo.30 in cases where female members of the family are carriers of disorders such as hemophilia, having a male baby may be desired. thus, sex selection that prevents the passing down of such genetic disorders is considered reasonable.31 however, couples in many societies desire to have a male child first due to cultural reasons. in addition, parents may demand to have a second child of a different sex than the first. performing pgd due to such reasons is considered sex discrimination. it is also proposed that sex selection through pgd can become widespread among wealthy people due to the high costs associated with this method.32 it is also assumed that using the pgd for sex selection without medical reasons poses both personal and societal risks and a waste of healthcare resources. using a method that was developed for diagnosing genetic disorders for sex selection due to above-mentioned reasons is considered a distortion of its aim. indeed, according to the convention on human rights and biomedicine, signed under the council of europe, sex selection without medical reasons is considered illegal.33 different arguments have been put forth regarding the permissibility of embryonic sex selection in islam. the current islamic law experts study the interference with the sex of an embryo in two categories using natural ways or medical ways for the process. some posit that couples using natural methods such as paying attention to their nutrition and arranging the time of intercourse are religiously acceptable. related to the issue, the international islamic fiqh academy underlines submission to allah’s qadar (destiny) and qadaa (decree) and adopts the view that the natural intervention to the sex of an embryo is permissible, however, sex determination through medical methods is not.34 it should be noted that the existing medical knowledge posits the futility of the traditional methods. conversely, it is suggested that intervening with the sex of an embryo through both medical and natural procedures means altering the demographic balance of the world, and thus, impermissible..35 in addition, it is indicated in the relevant fatwa 21 international journal of human and health sciences vol. 02 no. 01 january’18 of the high board of religious affairs in turkey that sex selection by medical interferences may cause a disruption of the balance of sex division. therefore, sex selection is against natural disposition, cosmic and ecological balance, and the divine will, thereby impermissible.36 according to islamic scholars who perceive sex selection as a personal preference that is in the interest of couples, sex selection is permitted if the spouses are both alive and give consent, there is a necessity for this process, it is performed safely in a way that prevents any mix-ups in the lineage, and the private parts37 are exposed only as required.38 related to the issue, yusuf karadavi states that the sex of a baby is determined by allah and the equilibrium is supervised herein.39 in fact, humans wish by the wish of allah and act by the hand of allah. based on that, sex selection is religiously permissible according to karadavi. however, this allowance is only by virtue of necessities or narrow circumstances. nevertheless, what is favorable is leaving it to the wisdom and desire of allah.40 in the qur’an it is said that: “to allah belongs the dominion of the heavens and the earth; he creates what he wills. he gives to whom he wills female children, and he gives to whom he wills male children.”41 this verse clearly emphasizes the will of allah on the offspring’s sex. everything in the universe has been created in a certain form and balance, and every action that disrupts this balance is condemned in the qur’an.42 someone is valuable not due to their sex but due to being human according to islam.43 although sex selection is possible through technological advances, the adverse consequences of the practice cannot be ignored. in addition, without a medical necessity, the natural fertilization that happens with sexual intercourse is transferred to the laboratory, an artificial environment. thus, natural birth is converted into an artificial fabrication. hormones are injected into the female, the private parts of the female are opened unduly in order to gather the oocytes, which violates the principles of privacy in the religion. additionally, effort and money are wasted. most importantly, the development of the embryo is prevented and its life is terminated because of its sex. due to these reasons, applying sex selection and ivf electively cannot be considered permissible. however, in cases of medical necessities such as having a genetic disorder in the family, the process of the healthy male or female embryo formation through the sperm sorting method may be done. single and multi-parent babies surrogate motherhood-sperm, egg and embryo donation the sperm, oocyte and embryo donation, and surrogate motherhood practices have led to various discussions in relation to ethical, religious, social, and legal perspectives first in the west and later in the muslim societies. surrogacy, sperm and oocyte banks have started to threaten the future of the family institution and safety of progeny. these techniques transfer the process of having a child outside of the family institution, lead to births of children with unknown lineage, and degenerate the generations. at the present time, some men who don’t want to get married and take the responsibility of a family, women who are unwilling to go through maternity and childbirth pains, and people who have homosexual tendencies see surrogacy, and sperm and oocyte banks as a solution to fulfill their inherent feelings of fatherhood and motherhood, and they can have children for a certain fee.44 within the capitalist system, womb renting and sperm and oocyte trading have turned into a business connections network.45 these are serious social problems for societies. one of the basic rights that islam aims to protect is “the preservation of lineage and progeny”. moreover, this right is categorized as an extreme necessity (ad-darurah) in terms of the norms and values hierarchy. islam objects to any danger that weakens the family institution and damages the lineage and progeny. lineage refers to the bloodline of each person with their father-mother and grandfather-grandmother. this reality is stated in the qur’an as: “it is he who has created from water a human being and made him [a relative by] lineage and marriage. your lord is all-powerful.”46 every child deserves to be born with a precise lineage and it is their natural right to know their own bloodline. accordingly, providing the continuity of progeny through a marriage that is built by a legitimate marriage covenant is one of the major aims of islam. in fact, the necessity of marriage to have a child is emphasized in the qur’an in several verses.47 the certainty of lineage is also important since the uncertainty may create an obstacle for marriage, and cause problems with alimony, custody and inheritance conditions. for the protection of lineage which has a special position in the sense international journal of human and health sciences vol. 02 no. 01 january’18 22 of child rights, many mandatory and prohibitory provisions are constituted in islam.48 with these provisions, the conservation of good sense and dispositionare promoted, the honor and respectability of all humans, the peace and lasting of family and society are aimed. in addition, practices which may cause mixing of bloodlines are not allowed. hence, the essential precautions are taken for the proper protection of progeny. in the case that there is no possibility to have a child with sexual intercourse, artificial insemination, where the sperm and oocyte belong to married couples, by using the assisted reproductive techniques is accepted as a marital intercourse. since it allows to determine the lineage. however, using the womb, embryo, sperm or oocyte that belong to others in order to have a child is not permissible due to the violation of the principles of islam on privacy, marriage, preservation of progeny and personality, protection of people’s soul and physical health, and human dignity. indeed, the certain fiqh rules of the islamic world and majority of contemporary islamic law scholars judge that the use of womb, embryo, sperm or oocyte that belong to others and surrogacy technique are unlawful.49 additionally, according to islamic understanding, a human is an honorable being. thus, none of the cells and organs of a human including sperm, oocyte, and womb can be the subject of commerce. turning children, who are the most innocent and precious beings on earth, into a good that can be acquired with money is not acceptable in islam. conclusion the allowance of tube-baby treatment for people who cannot have a child through sexual intercourse is given by islamic scholars in terms of the law of necessity. however, the ivf treatment transfers the reproduction process from natural way to laboratory, an artificial field. gradually, many religiously unacceptable practices of the ivf method have been faced. according to islam, not only the protection of the life of fetus in mother’s womb but also the life of the embryo which is produced through artificial fertilization is significant and a great responsibility. in addition, from the beginning of fertilization, the embryo should be treated as a potential human being. therefore, it should be considered that producing surplus embryos by ivf, destroying embryos for genetic diagnosis, sex selection or other reasons, and using others’ sperm, oocyte and embryos involves many religious and ethical problems. there is no doubt that as muslims, we need a perspective to determine our view towards the biotechnological progress and practices. accepting all technological advances and treatment-purpose studies for the sake of the absolute benefit of human beings is not a rational approach. a costbenefit analysis should be done. in fiqh terms, it may sometimes be required to prevent costs (sad az-zarai‘), whereas prioritize benefits other times (calb al-manafi‘) due to the concept of maslahah. it should be reminded that the concept of maslahah does not contradict with the basic principles of islam, refers to private and public interest, and can be adopted unhesitatingly by people with good senses. ultimately, biotechnological practices and medical methods should not involve an interference with the honor and prestige of mankind, should not be a threat to the personal characteristics of people, should provide absolute benefit for humanity rather than harm, should not turn a human being into an experimental object, create discomfort in our conscience, destroy the social fabric, family and kinship connections, and damage the safety of lineage. the genetic and technological studies should not be directed by poisonous power passion and commercial concerns but for the sake of humanity. 23 international journal of human and health sciences vol. 02 no. 01 january’18 reference: 1. al-ghashiyah, 88/17-20. 2. al-isrâ, 17/70. 3. al-istishâb: islamic legal term for the presumption of continuity, where a situation existing previously is presumed to be continuing at present until the contrary is proven. “istishab.” the oxford dictionary of islam, 2017; a. bardakoglu, “istishâb”, dia, vol. 23, 2001, p. 376. 4. al-maslahah: public interest; a basis of law. according to necessity and particular circumstances, it consists of prohibiting or permitting something on the basis of whether or not it serves the public’s benefit or welfare. “maslahah.” the oxford dictionary of islam, 2017; donmez, i. k. “maslahat”, dia, vol. 28, 2003, p. 79. 5. sadaz-zarâi‘: prohibiting the permissible actions that will certainly or high-likely cause objectionable results.donmez, i. k. “sedd-izerâi”, dia, vol. 36, 2009, p. 277. 6. şeftalioglu, a.i̇nsanembriyolojisi, ankara 2009, p. 84. 7. there is a limit in turkey regarding the number of embryos implanted into the uterus in order to prevent multiple pregnancies. according to the related legislation, until the age of 35, a single embryo in the first and second implementation, and two embryos in the third and following implementations can be transferred. after the age of 35, maximum two embryos can be transferred in the implementations. see.chapter 18/8b. http://www.ttb.org.tr/mevzuat/ index.php?option=com_content&view=article&id= 741:emeye-yardimci-tedavuygulamalari-ve-emeyeyardimci-tedavmerkezlerhakkinda yetmel&catid=2:y melik&itemid=33(accessed:30.12.2014) 8. for a research on the approaches of parents to this issue,see.de lacey, s. “decisionsforthefate of frozenembryos: freshinsightsintopatients’ thinking and the irrationales for donatingordiscard in gembryos.” human reproduction, vol. 22, no. 6, june 2007, pp. 1751–1758. 9. an-nur, 24/32. 10. ibn mâce, marriage, 1. 11. h t t p : / / w w w. f i q h a c a d e m y. o r g . s a / ( a c c e s s e d : 11.12.2013); karârâtu mecmeı’l-fıkhı’l-i̇slâmî, mekke 1977-2002, p. 165; karaman h., i̇slâm’da kadın ve aile, istanbul 1995, p. 404. 12. mecelletü mecmaı’l-fıkhi’l-i̇slâmî, vol.3,no.6, 1990, p. 2102. 13. “ad-daruriyyah ad-diniyyah”, the five higher goals of shariah law,: 1protection of human life, 2protection of progeny, 3protection of the mind, 4-protection of property, and 5protection of religion. gazzâlî,elmustasfâ min ‘ılmi’l-usûl, mısır 1322, i, p. 287; şâtıbî,el-muvâfakât fî usûli’l-ahkâm, beyrut, ii, p. 4. 14. al-mu’minun, 23/13; al-insan, 76/2. 15. it is indicated that only in the u.s.a, are there more than 400.000 frozen embryos. see,singer, p.pratik etik. translated by nedim çatlı, istanbul 2012, p. 192. 16. robertson, j. a. “extending preimplantation genetic diagnosis: the ethical debate”, human reproduction, vol. 18, no. 3, 2003, p. 465; kahraman, s. güncel dini meseleleri̇stişaretoplantısı ii, dib yay., ankara 2008, p. 192. 17. petersen, n. “the legal status of the human embryo in vitro: general human rights instruments”, zaörv, vol. 65, 2005, p. 464; robertson, j. a. “extending preimplantation genetic diagnosis: the ethical debate”, p. 466. 18. vatanoğlu lutz, e.e. “preimplantation genetic diagnosis (pgd) according to medical ethics and medical law”, journal turkish-german gynecol assoc., vol. 13, no. 1, 2012, p. 53. 19. petersen, n. “the legal status of the human embryo in vitro: general human rights instruments”, p. 464465. 20. robertson, j.a. “extending preimplantation genetic diagnosis: the ethical debate”, p. 466. 21. de wert, g. “preimplantation genetic diagnosis: the ethics of intermediate cases.” human reproduction, vol. 20, no. 12, 2005, pp. 3261–3266;robertson, j.a. “extending preimplantation genetic diagnosis: the ethical debate”, p. 468. 22. petersen, n. “the legal status of the human embryo in vitro: general human rights instruments”, p. 465. 23. hakeri, h.tıp hukuku, seçkinyayınları, ankara 2013, p. 253; de wert, g. “preimplantation genetic diagnosis: the ethics of intermediate cases”, p. 3261. 24. robertson, j.a. “extending preimplantation genetic diagnosis: the ethical debate”, p. 465. 25. http://www.fiqhacademy.org.sa/ (accessed: 13.03.2015) 26. suyûtî, el-eşbahve’n-nezâir, mısır 1959, p. 84; i̇bn nüceym, el-eşbâhve’n-nezâir, beyrut 1993, p. 86. 27. dârakutnî, es-sünen, beyrut 2004, iv, 51. 28. şeftalioglu, a. i̇nsanembriyolojisi, p. 78. 29. harris, j. “in vitro fertilization: the ethical issues”, p. 221;kahraman, s. güncel dini meseleleri̇stişaretoplantısı ii, p. 192. 30. de wert, g. “preimplantation genetic diagnosis: the ethics of intermediate cases”, p. 3265. 31. robertson, j.a. “extending preimplantation genetic diagnosis: the ethical debate”, p. 469. 32. vatanoğlu lutz, e. e. “preimplantation genetic diagnosis (pgd) according to medical ethics and international journal of human and health sciences vol. 02 no. 01 january’18 24 medical law”, p. 54-55. 33. k a r â r â t ü ’ l m e c m a ı ’ l f ı k h ı ’ l i̇ s l â m î , mekke1977-2010, p. 503-504. 34. h t t p : / / f i q h . i s l a m m e s s a g e . c o m / n e w s d e t a i l s . aspx?id=9063 (accessed: 19.02.2015); http://www. fetva.net/yazili-fetvalar/genlere-mudahale-edilerekcinsiyet-belirlenmesi-caiz-midir.html (accessed: 28.01.2015). 35. https://kurul.diyanet.gov.tr/soru/dinisorular. aspx?menu=422# (accessed: 28.01.2015) 36. infiqh, thisrefersto a women’sentire body expecttheface, hands, and (according to some fuqahas) feet. see. zeylaî, tebyînü’l-hakâıkşerhukenzi’ddekâık, bulak 1314, i, 96. 37. h t t p : / / f i q h . i s l a m m e s s a g e . c o m / n e w s d e t a i l s . aspx?id=9063 (accessed: 19.02.2015); http://www. awqaf.ae/fatwa.aspx?sectionid=9&refid=3111 (accessed: 22.12.2014). the pray of prophet zakariya for asking from allah to give him a male child (maryam, 19/5) is put forward to justify this assumption. 38. in the qur’an, it is stated that “and your lord creates what he wills and chooses; not for them was the choice. exalted is allah and high above what they associate with him.” (al-qasas, 28/68). 39. karadâvî, y.minhedyi’l-islâmfetâvâmuâsıra, elmektebetü’l-islâmî,beyrut 2003, i, 610. 40. ash-shuraa, 42/49. 41. al-baqarah, 2/205; ar-rum, 30/41. 42. al-isra, 17/70. 43. for instance, through these banks, the donor of the sperm or oocyte can be selected based on their psychical characteristics, education level, profession, and interests. see. https://cryobank.com/search/ (accessed: 11.10.2017); http://eggdonorideas.com/ (accessed: 11.10.2017) 44. see the prices determined by a center which makes sperm, oocyte and embryo donation. http:// www.kibristupbebekmerkezleri.com/index.php/ tedavi-sureniz/tuep-bebek-fiyatlar-i/93-yumurtadonasyonu-fiyatlari (accessed: 20.09.2017) 45. alfurqan, 25/54. 46. an-nahl, 16/72; ar-ra’d, 13/38. 47. an-nisâ, 4/23; alisrâ, 17/32 48. karârâtü ve’t-tavsiyyâtü mecmaı’l-fıkhı’l-islâmî ed-devlî 1985-2011, uae, p. 112; karârâtü mecmaı’l-fıkhı’l-islâmî, mekke 1977-2002, p. 165; https://kurul.diyanet.gov.tr/soru/gelismisarama. aspx(accessed: 22.08.2017); y. karadâvî, fetâvâ muâsıra, iii, p. 529; câdelhak ali câdelhak, buhûs ve fetâvâ i̇slâmiyye fî kadâyâ muâsıra, kâhire 2005, ii, p. 169. short title: estimation of serum level of vascular endothelial growth factors and soluble vascular endothelial growth factors with placental pathogenesis of pregnancy induced hypertensive mothers. international journal of human and health sciences vol. 04 no. 03 july’20 206 original article poor glycemic control: prevalence and risk factors among patients with type 2 diabetes mellitus in northeast state of peninsular malaysia hafizuddin awang1, siti mariam ja’afar1, nurul adhiyah wan ishak2, muhamad yusofzainal2, abdul mukmin mohamed aminuddin2, zawiyah dollah2 abstract: background: poor glycemic control remains an on-going public health concern worldwide. with the increasing prevalence of diabetes mellitus in malaysia, good control of blood glucose level is paramount to avert life-long complications of diabetes mellitus. hence, this study aimed to determine the prevalence of poor glycemic control and its associated factors to assist clinicians in achieving good glycemic control among diabetic patients. materials and methods: a comparative cross-sectional study between groups of good glycemic control and poor glycemic control patients was conducted among type 2 diabetes mellitus (t2dm) patients who fulfilled study criteria in pasir puteh district, kelantan, a northeast state of peninsular malaysia. eligible samples registered in the national diabetes registry from 1st january 2019 until 31st december 2019 were recruited into the study. descriptive statistics, simple and multiple logistic regressions were used for data analysis. results: the prevalence of patients with poor glycemic control in pasir puteh district was 79.6%% (95% ci: 0.78, 0.81). multivariable analysis using multiple logistic regression revealed age, duration of diabetes, cigarette smoking, presence of hypertension and presence of dyslipidaemia were the significant factors associated with poor glycemic control among t2dm patients in pasir puteh district with an adjusted odds ratio (aor) of 0.93 (95%ci:0.91, 0.94); p<0.001), aor 1.19 (95%ci:1.14, 1.25; p<0.001), aor 2.75 (95%ci:1.52, 4.97; p=0.001), aor 2.19 (95%ci:1.32, 3.62; p=0.002) and aor 2.16 (95%ci:1.45, 3.21; p<0.001) respectively. conclusion: this study provided important criteria for clinicians to improve management of diabetes mellitus and optimize glycemic control based on the pinpointed significant risk factors. keywords: type 2 diabetes mellitus, poor glycemic control, associated factors, kelantan, malaysia. correspondence to: dr. hafizuddin awang. department of community medicine, school of medical sciences, universiti sains malaysia, 16150 kubang kerian, kelantan. e-mail: drhafizuddin@mail.ru 1. department of community medicine, school of medical sciences, universiti sains malaysia, 16150 kubang kerian, kelantan. 2. pasir puteh district health office, 16800 pasir puteh, kelantan. international journal of human and health sciences vol. 04 no. 03 july’20 page : 206-214 doi: http://dx.doi.org/10.31344/ijhhs.v4i3.202 introduction diabetes mellitus is one of non-communicable diseases that developed over a long period of time. it is a condition when one has an elevated blood sugar levels with disruption of carbohydrate, fat and protein metabolism. it may be due to failure of pancreas to excrete insulin (type 1) or inability of body cells to react to insulin (type 2). it also could happen during pregnancy due to hormonal changes (gestational diabetes)1,2. worldwide, the prevalence of type 2 diabetes mellitus (t2dm) is more than 6% across all continents. world health organization (who) in their work on global report on diabetes has illustrated trend of diabetes prevalence. across all class of income group countries, high income group has shown small range of increment compared to lower, lower-middle and upper-middle income group. nonetheless, countries across all income group has shown an increasing trend since 1980, 207 international journal of human and health sciences vol. 04 no. 03 july’20 with upper-middle income group has the highest prevalence in 2014 at more than 8%2. in malaysia, a national health morbidity survey (nhms) conducted in 2015 found that 17.5% of adults aged 18 years and above has t2dm with 8.3% are known to have diabetes while 9.2% are previously undiagnosed with diabetes3. percentage of those who were unknown to have diabetes is higher than those who were diagnosed might suggest low health seeking behavior among malaysian that may be contributed by low awareness of diabetes or low accessibility to quality healthcare4. late diagnosis of diabetes mellitus may contribute to poorly controlled diabetes and therefore, might increase risk for complications in diabetes such as retinopathy, nephropathy and cardiomyopathy5. in diagnosing diabetes mellitus, glycated hemoglobin (hba1c) is used as the gold standard measurement6. hba1c test tells the average level of blood sugar over the past 2 to 3 months. according to malaysia’s clinical practice guideline on management of diabetes mellitus, hba1c of > 6.3% is used to diagnose diabetes mellitus7. for those who are newly diagnosed, at younger age, no cardiovascular complication, has low risk of hypoglycemia and has longer life expectancy, the targeted hba1c is between 6.0 – 6.5%. while those who has comorbidities (such as coronary disease, heart failure, kidney failure and liver dysfunction), prone to hypoglycemia and has shorter life expectancy, an hba1c range of 7.1 – 8.0% is aimed. those who are not in both categories, the target a1c is 6.6-7.0%. therefore, patients with an hba1c level of more than the range in the individualized group is considered to have poor glycemic control7. factors that are associated with poor glycemic control are modifiable and non-modifiable factors such as younger age (<50 years old)8, female, overweight, longer duration of diagnosis, had more diabetic complications, hypertension and dyslipidemia9,10. therefore, it is important to manage diabetes as a whole by tackling modifiable risk factors such overweight and obesity. timely treatment of patients with poor glycemic control is critical to prevent its dangerous complications. besides, uncontrolled diabetes mellitus is highly associated with increased susceptibility to certain infections such as tuberculosis and skin infections due to impaired host immunity11-14. knowing the predisposing factors for poor glycemic control can be effective in controlling diabetes mellitus and avert the lifelong complications. therefore, this study is aimed to estimate the prevalence of patients with poor glycemic control and determine its associated factors among t2dm patients in pasir puteh district, kelantan. materials and methods from 15th december 2019 until 15th january 2020, we conducted a comparative cross-sectional study in eight primary healthcare facilities in the district of pasir puteh, kelantan, a northeast state of peninsular malaysia. the clinics involved were pasir puteh health clinic, selising health clinic, cherang ruku health clinic, jeram health clinic, gaal health clinic, banggol pak esah health clinic, gong kulim health clinic and sungai petai health clinic15. the reference populations were all t2dm patients in pasir puteh district, and the study samples were all t2dm patients who fulfilled study inclusion and exclusion criteria in the eight selected health clinics. the inclusion criteria were t2dm patients who actively underwent diabetes clinic follow-up for at least 3 visits at any of the eight recruited health clinics until 31st december 2019. t2dm patients who died or lost to diabetes clinic followup were excluded from the study. the sample size was calculated for each variable of associated factors for poor glycemic control among t2dm patients using power and sample size calculation software16, as well to compare two independent proportions. the largest estimated sample for each group was 341 using the proportion of patients with good glycemic control by the factor of hypertension (0.34)17, an estimated proportion of 0.24, 5% type 1 error, 80% power and additional of 10% missing data. therefore, the total sample size required is 682 t2dm patients. we employed simple random sampling for subject recruitment from the total t2dm patients in pasir puteh district which fulfilled the study criteria. data were collected from national diabetes registry; an online database for diabetes mellitus international journal of human and health sciences vol. 04 no. 03 july’20 208 under the governance of ministry of health malaysia18, and recorded in patient’s pro forma. the retrieved information for independent variables included socio-demographic characteristics (age, gender) and clinical characteristics (duration of diabetes mellitus; cigarette smoking status; presence of comorbidities such as hypertension and dyslipidaemia; presence of diabetic complications such as retinopathy, nephropathy, diabetic foot ulcer, cerebrovascular disease and cardiovascular disease). the dependent variable was the diabetic control status either good control or poor control of diabetes mellitus. the hba1c level of patients which served as indicator of glycemic control status was retrieved from the dynamic management system, an online database for clinical laboratory findings. in this study, good glycemic control is defined as hba1c level ≤6.5%. meanwhile, hba1c level beyond 6.5% is considered as poor glycemic control7.in this study, hypertension in diabetic patient is defined as systolic blood pressure of >140 mmhg and/or diastolic blood pressure of >90 mmhg7. dyslipidaemiain diabetic patient is defined as levels of either ldl>2.6mmol/l, hdl≤1.0 mmol/l, or triglycerides ≥1.7mmol/l7. statistical analysis we used spss statistics (ibm corp. released 2013. ibm spss statistics for windows, version 22.0. armonk, ny: ibm corp) for data entry and analysis. descriptive statistics with mean and standard deviation (sd), frequency and percentages were calculated. simple and multiple logistic regression analysis were used to determine factors associated with poor glycemic control among t2dm patients. all significant variables with a p-value <0.25 from univariable analysis and clinically important variables were chosen for multiple logistic regression analysis. a p-value<0.05 was considered statistically significant. results from the national diabetes registry, as of 31st december 2019, there were a total of 1780 diabetic patients who fulfilled the study criteria in pasir puteh primary healthcare facilities. the prevalence of patients with poor glycemic control were 79.6% (95% confidence interval (ci): 0.78, 0.81) or 1417 out of 1780 patients. out of 1780 patients, 341 samples were randomly selected for each of the comparison group in accordance to sample size calculation. socio-demographically, the mean (±sd) age for t2dm patients with poor glycemic control was 59.87 (±9.77) years old. majority of t2dm patients with poor glycemic control were female and nonsmoker. as for duration of diabetes since diagnosis, the mean (±sd) duration for t2dm patients with poor glycemic control was 7.42 (±5.22) years. as for complications in t2dm patients, majority of those with poor glycemic control had no retinopathy, no nephropathy, no diabetic foot ulcer, no cerebrovascular disease and no cardiovascular disease. for comorbidities, majority of patients with poor glycemic control had hypertension and dyslipidaemia. details are summarized in table 1. in the univariable analysis, age, duration of diabetes, smoking status, presence of nephropathy, hypertension and dyslipidaemia were the statistically significant and clinically important factors selected for multivariable analysis. details are summarized in table 2. multivariable analysis using multiple logistic regression revealed age, duration of diabetes, cigarette smoking, presence of hypertension and presence of dyslipidaemia were the significant factors associated with poor glycaemic control among t2dm patients in pasir puteh district with an adjusted odds ratio (aor) of 0.93 (95%ci:0.91, 0.94); p<0.001), 1.19 (95%ci:1.14, 1.25; p<0.001), 2.75 (95%ci:1.52, 4.97; p=0.001), 2.19 (95%ci:1.32, 3.62; p=0.002) and 2.16 (95%ci:1.45, 3.21; p<0.001) respectively. details are shown in table 3. discussion the prevalence of patients with poor glycaemic control in pasir puteh district was 79.6% (95% ci: 0.78, 0.81) which is higher than the prevalence reported by eid, mafauzy (2003) among t2dm patients on follow up at hospital universiti sains malaysia, kubang kerian, kelantan which was 73%19. besides, a study in one of the health clinics in sarawak also reported lower prevalence of patients with poor glycemic control which was only 38% out of 1031 patients on diabetic clinic follow up20. similarly, another local study done in 209 international journal of human and health sciences vol. 04 no. 03 july’20 tampin district, negeri sembilan reported lower prevalence of poor glycemic control (66.4%) in relative to our finding21. due to high prevalence of patients with poor glycemic control in pasir puteh district in relative to other studies of local settings, it justified the need for our inferential study to be done to delve the risk factors for poor glycemic control in the setting of pasir puteh district. age is one of the significant factors associated with poor glycemic control in this current study. it is found that older patient has lower risk of having poor glycemic control (aor: 0.93; 95%ci: 0.91, 0.94; p<0.001). it is congruent to another local nationwide study in 2015 which reported that young-old and middle-old age group was a significant predictor of poor glycemic control as compared to those of age beyond 80 years old22. studies from other international settings reported similar findings23,24. a south korean study has found important factors that influenced older adult’s view on glycemic control. through qualitative exploration, they found that older adults considered ‘positive attitude and self-confidence’ are important in achieving good glycemic control besides technical coaching from medical staff25. therefore, empowering the elderly to self-manage their health condition could be a turning point in management of diabetes. detailed information must be given to them such as advices on healthy diet, physical activity and medication compliance. duration of diabetes mellitus plays a substantial role as well. we found that patient with longer duration of diabetes has higher risk of having poor glycemic control (aor: 1.19; 95%ci: 1.14, 1.25; p<0.001). similar finding was observed in another local study in the state of johor, malaysia26. longer t2dm duration is related to progressive loss of pancreatic beta cell function which subsequently will cause poor glycemic control regardless of treatment regime27. besides that, it is also postulated that “metabolic memory” plays important role in the development of macro and microvascular complication in later life28. those who has longer episode of hyperglycemia has poorer outcome. hyperglycemia will lead to oxidative stress that causes harm to endothelial epithelium of blood vessels. if the insult left uninterrupted, the damage to the endothelium will be irreversible. therefore, intensive intervention at early stage of disease has protective effect to the development of complications 24,28,29. we also found significant association between cigarette smoking with poor glycemic control. patient who smoke cigarette has 2.75 higher odds of having poor glycemic control. this finding is similar with a swedish study which reported cigarette smoking is independently associated with poor glycemic control30. an australian study had suggested that there is an association between cigarette smoking and diabetes. those who is a carrier of c-allele gene in cyp1a1 enzyme (a detoxification enzymes of polycyclic aromatic hydrocarbons (pah) which is a toxin component produced by cigarette smoking) and who is also a smoker, has more than two times the risk of having diabetes. this enzyme not only detoxify pahs but also plays a role in intracellular oxidative metabolism. when the enzyme is affected by the toxins from cigarette smoking, it could lead to disturbances in intracellular oxidative metabolism that further affect insulin-related metabolic abnormalities in diabetes31. therefore, cigarette smoking could disturb cyp1a1 enzyme function and hence further affecting the control of diabetes. apart from that, our study found that patients with dyslipidaemia were more likely to have poor glycemic control (aor: 2.16; 95%ci: 1.45, 3.21; p<0.001 respectively). similarly, a study in montenegro reported that low level of high-density lipoprotein cholesterol (hdl-c) was found to be the independent predictor of higher hba1c (aor: 0.44, 95%ci: 0.20–0.67, p=0.039), and increase in hdl-c by 1 mmol/l reduced the probability of higher hba1c by 56%32. it is postulated that lipid-related genetic loci may affect glycemic metabolism, suggesting potentially causal relationship between genetically determined low hdl-c or high triglycerides levels and increased risk of t2dm33. interestingly, a study done in a malaysian teaching hospital found that hypertensive patients with dyslipidaemia who were prescribedstatin showed higher a1c levels regardless of diabetes status34. therefore, focus should be given to diabetic patients who are on statin. if controlling glucose level in these patients is difficult, it is best to replace statin with other lipidlowering medications to achieve better glycemic control. international journal of human and health sciences vol. 04 no. 03 july’20 210 another statistically significant determinant for poor glycemic control was presence of hypertension in which hypertensive patients were more prone to have poor glycemic control (aor: 2.19; 95%ci: 1.32, 3.62; p=0.002). this finding is consistent with few studies which also echoed the association of hypertension with glycemic control22,35. hypertension and t2dm usually coexist. the prevalence of hypertension in t2dm is higher than that in the general population. at the age of 75 around 60% of patients with t2dm are hypertensive36.the pathophysiological mechanisms explaining the association between blood pressure and incidence of t2dm are not clearly understood, but several postulations were proposed. high blood pressure was shown to induce microvascular dysfunction, which may contribute to the pathophysiology of diabetes development and impairment in blood glucose control37. besides, endothelial dysfunction which is related to insulin resistance is also strongly linked with hypertension, and biomarkers of endothelial dysfunction were found to be independent predictors of impaired blood glucose regulation38. limitation of the study: as for the study limitation, we did not include family history of t2dm and diabetic treatment regime as part of the studied factors. these two factors are among the well-known significant predictors for poor glycemic control as reported by few malaysian studies previously21,39,40. conclusion and recommendations in conclusion, poor glycemic control among t2dm patients is quite prevalent in pasir puteh district. younger age, longer duration of diabetes mellitus, cigarette smoking, presence of hypertension and dyslipidaemia were the significant risk factors for poor glycemic control. hence, it is recommended that focus on diabetic care and education should be given to all groups of patients, not necessarily to elderly group only as our study reported that younger population was more prone towards poor glycemic control. our study also revealed the link between longer duration of diabetes with poorer glycemic outcome, thus, it is imperative for us to manage diabetes optimally for patients who are diagnosed with diabetes mellitus at a very young age as they will have diabetes for quite a long time. diabetes educators or counselors in clinics should educate young diabetic patients on the importance of medication adherence and healthy lifestyle in order to achieve good glycemic control. besides that, all diabetic patients who smoke cigarette should be referred to quit smoking clinic to help them with cigarette smoking cessation. smoking cessation would reduce the likelihood of getting poor glycemic control among t2dm patients. co-morbidities in diabetic patients such as hypertension and dyslipidaemia should be controlled optimally. equal priority should be given to both blood glucose control and co-morbidities during follow-up session as failure to optimize blood pressure and lipid level would lead to failure in glycemic control. blood pressure should be monitored regularly during each diabetes follow-up session while lipid levels should be checked every 6 months in diabetic patients to achieve optimal management of comorbidities and good glycemic control7. conflict of interest: none declared. the authors have no financial, consultative, institutional, and other relationships that might lead to bias or conflict of interest. disclosure statement: the authors declare no conflicts of interest. ethical approval issue: this study was approved by the medical review and ethical committee from national institute of health, ministry of health malaysia nmrr-19-3530-52294. individual authors contribution: conceptionh.a., s.m.j, z.d.; writer-h.a., s.m.j.;data collection and/or processing-h.a., s.m.j., n.a.w.i., m.y.z., a.m.m.a.; supervision-z.d.; analysis and/or interpretation-h.a., s.m.j. funding statement: this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. acknowledgement: the authors would like to thank the director general of health malaysia for allowing us to use the secondary data from national diabetes registry. our gratitude also goes to staffs at non-communicable diseases (ncd) unit, pasir puteh district health office for their assistance during data collection. 211 international journal of human and health sciences vol. 04 no. 03 july’20 table 1: socio-demographic and clinical characteristics of t2dm patients in accordance to glycemic control outcomes (n=682). characteristics frequency (%) poor glycemic control (n=341) good glycemic control (n=341) age (years)* 59.87 (±9.77) 64.87 (±10.60) duration of diabetes (years)* 7.42 (±5.22) 4.83 (±4.22) gender male female 97 (28.4) 244 (71.6) 98 (28.7) 243 (71.3) cigarette smoking no yes 289 (84.8) 52 (15.2) 315 (92.4) 26 (7.6) retinopathy absent present 325 (95.3) 16 (4.7) 331 (97.1) 10 (2.9) nephropathy absent present 291 (85.3) 50 (14.7) 307 (90.0) 34 (10.0) diabetic foot ulcer absent present 336 (98.5) 5 (1.5) 339 (99.4) 2 (0.6) cerebrovascular disease absent present 337 (98.8) 4 (1.2) 335 (98.2) 6 (1.8) c a r d i o v a s c u l a r disease absent present 334 (97.9) 7 (2.1) 333 (97.7) 8 (2.3) hypertension absent present 54 (15.8) 287 (84.2) 79 (23.2) 262 (76.8) dyslipidaemia absent present 75 (22.0) 266 (78.0) 133 (39.0) 208 (61.0) *mean (±sd) table 2: factors associated with poor glycemic control among t2dm patients in pasir puteh district by simple logistic regression (n=682). factors β s.e. wald statistics (df) crude or (95% ci) p-value age (years) -0.05 0.008 36.40 (1) 0.95 (0.93, 0.97) <0.001 duration of diabetes (years) 0.12 0.02 43.43 (1) 1.13 (1.09, 1.17) <0.001 gender male female -0.01 0.17 0.01 (1) 1.00 0.93 (0.73, 1.41) 0.932 cigarette smoking no yes 0.78 0.25 9.44 (1) 1.00 2.18 (1.22, 3.58) 0.002 retinopathy absent present 0.49 0.41 1.41 (1) 1.00 1.63 (0.73, 3.64) 0.234 nephropathy absent present 0.44 0.24 3.44 (1) 1.00 1.55 (0.98, 2.47) 0.064 diabetic foot ulcer absent present 0.93 0.84 1.21 (1) 1.00 2.52 (0.49, 13.09) 0.271 cerebrovascular disease absent present -0.41 0.65 0.40 (1) 1.00 0.66 (0.19, 2.37) 0.527 cardiovascular disease absent present -0.14 0.52 0.07 (1) 1.00 0.87 (0.31, 2.43) 0.794 hypertension absent present 0.47 0.20 5.78 (1) 1.00 1.60 (1.09, 2.35) 0.016 dyslipidaemia absent present 0.82 0.17 22.79 (1) 1.00 2.27 (1.62, 3.17) <0.001 international journal of human and health sciences vol. 04 no. 03 july’20 212 table 3: factors associated with poor glycemic control among t2dm patients in pasir puteh district by multiple logistic regression (n=682). factors β s.e. wald statistics (df) adjusted or (95% ci) p-value age (years) -0.08 0.01 64.13 (1) 0.93 (0.90, 0.94) <0.001* duration of diabetes (years) 0.18 0.02 60.42 (1) 1.19 (1.14, 1.25) <0.001* cigarette smoking no yes 1.01 0.30 11.11 (1) 1.00 2.75 (1.52, 4.97) 0.001* nephropathy absent present -0.33 0.29 1.34 (1) 1.00 0.72 (0.41, 1.26) 0.717 hypertension absent present 0.78 0.26 9.31 (1) 1.00 2.19 (1.32, 3.62) 0.002* dyslipidaemia absent present 0.77 0.20 14.32 (1) 1.00 2.16 (1.45, 3.21) <0.001* *p-value <0.05 no multicollinearity and no interaction found. hosmer lemeshow test, p-value=0.174 classification table 70% correctly classified. area under receiver operating characteristics (roc) curve was 76.6%. 213 international journal of human and health sciences vol. 04 no. 03 july’20 references: 1. fatin a, alina t. proportion of women with history of gestational diabetes mellitus who performed an oral glucose test at six weeks postpartum in johor bahru with abnormal glucose tolerance. malaysian family physician. 2019;14(3):2-9. 2. roglic g. who global report on diabetes: a summary. international journal of noncommunicable diseases. 2016;1(1):3. 3. chan yy, lim kk, lim kh, teh ch, kee cc, cheong sm, et al. physical activity and overweight/ obesity among malaysian adults: findings from the 2015 national health and morbidity survey (nhms). bmc public health. 2017;17(1):733. 4. beagley j, guariguata l, weil c, motala aa. global estimates of undiagnosed diabetes in adults. diabetes research and clinical practice. 2014;103(2):150-60. 5. lotfy m, adeghate j, kalasz h, singh j, adeghate e. chronic complications of diabetes mellitus: a mini review. current diabetes reviews. 2017;13(1):3-10. 6. sato a. indicators of glycemic control--hemoglobin a1c (hba1c), glycated albumin (ga), and 1, 5-anhydroglucitol (1, 5-ag). rinshobyori the japanese journal of clinical pathology. 2014;62(1):45-52. 7. ministry of health. clinical practice guidelines. management of type 2 diabetes mellitus. 5th ed. malaysia: ministry of health; 2015 december 2015. 8. siddiqui fj, avan bi, mahmud s, nanan dj, jabbar a, assam pn. uncontrolled diabetes mellitus: prevalence and risk factors among people with type 2 diabetes mellitus in an urban district of karachi, pakistan. diabetes research and clinical practice. 2015;107(1):148-56. 9. de pablos‐velasco p, parhofer kg, bradleyc, eschwege e, gönder-frederick l, maheux p, et al. current level of glycaemic control and its associated factors in patients with type 2 diabetes across europe: data from the panorama study. clinical endocrinology. 2014;80(1):47-56. 10. ishak naw, awang h, aziz ra, abdullah aj, bahari n. prevalence and determinants for insulin therapy refusal among type 2 diabetes mellitus patients in primary healthcare facilities in east coast region of peninsular malaysia. international journal of public health and clinical sciences. 2019;6(2):160-71. 11. awang h, husain nrn, abdullah h. pediatric tuberculosis in a northeast state of peninsular malaysia: diagnostic classifications and determinants. oman medical journal. 2019;34(2):110-117. 12. awang h, husain nrn, abdullah h. chest radiographic findings and clinical determinants for severe pulmonary tuberculosis among children and adolescents in malaysia. russian open medical journal. 2019;8(2). 13. peleg ay, weerarathna t, mccarthy js, davis tm. common infections in diabetes: pathogenesis, management and relationship to glycaemic control. diabetes/metabolism research and reviews. 2007;23(1):3-13. 14. awang h, raub n, alias ana, rahman naa, dollah z. predictors of tuberculosis relapse in pasir puteh district, kelantan: a case-control study. international journal of public health and clinical sciences. 2020;6(6):133-47. 15. awang h, ja’afar sm, ishak naw, dollah z. determinants of neonatal jaundice among newborns in pasir puteh district, kelantan. international journal of public health and clinical sciences. 2020;6(6):109-122. 16. dupont wd, plummer jr wd. power and sample size calculations: a review and computer program. controlled clinical trials. 1990;11(2):116-28. 17. khattab, m., khader, y. s., al-khawaldeh, a., &ajlouni, k. factors associated with poor glycemic control among patients with type 2 diabetes. journal of diabetes and its complications. 2010; 24(2), 8489. 18. feisul mi, azmi s. national diabetes registry report 2009-2012 malaysia: non-communicable disease section, disease control division, ministry of health malaysia; 2013 [available from: http://www.moh. gov.my/moh/resources/penerbitan/rujukan/ncd/ diabetes/national_diabetes_registry_report_ vol_1_2009_2012.pdf. 19. eid m, mafauzy m, faridah a. glycaemic control of type 2 diabetic patients on follow up at hospital universitisains malaysia. the malaysian journal of medical sciences: mjms. 2003;10(2):40. 20. wong j, rahimah n. glycaemic control of diabetic patients in an urban primary health care setting in sarawak: the tanah puteh health centre experience. med j malaysia. 2004;59(3):411-7. 21. wan hamdzan wff, juni mh, salmiah m, azuhairi a, zairina a. factors associated withglycaemic control among type 2 diabetes mellitus patients. international journal of public health and clinical sciences. 2016;3(3):89-102. 22. sazlina s-g, mastura i, cheong at, mohamad ab, jamaiyah h, lee py, et al. predictors of poor glycaemic control in older patients with type 2 diabetes mellitus. international journal of human and health sciences vol. 04 no. 03 july’20 214 singapore medical journal. 2015;56(5):284. 23. ali mk, mckeever bullard k, imperatore g, barker l, gregg ew. characteristics associated with poor glycemic control among adults with self-reported diagnosed diabetes—national health and nutrition examination survey, united states, 2007–2010. mmwr morb mortal wkly rep. 2012;61(2):32-7. 24. crowley mj, holleman r, klamerus ml, bosworth hb, edelman d, heisler m. factors associated with persistent poorly controlled diabetes mellitus: clues to improving management in patients with resistant poor control. chronic illness. 2014;10(4):291-302. 25. choi s, song m, chang sj, kim s-a. strategies for enhancing information, motivation, and skills for selfmanagement behavior changes: a qualitative study of diabetes care for older adults in korea. patient preference and adherence. 2014;8:219. 26. mahmood m, daud f, ismail a. glycaemic control and associated factors among patients with diabetes at public health clinics in johor, malaysia. public health. 2016;135:56-65. 27. uk prospective diabetes study group. uk prospective diabetes study 16: overview of 6 years’ therapy of type ii diabetes: a progressive disease. diabetes. 1995;44(11):1249-58. 28. ihnat m, thorpe j, ceriello a. hypothesis: the ‘metabolic memory’, the new challenge of diabetes. diabetic medicine. 2007;24(6):582-6. 29. juarez dt, sentell t, tokumaru s, goo r, davis jw, mau mm. peer reviewed: factors associated with poor glycemic control or wide glycemic variability among diabetes patients in hawaii, 2006–2009. preventing chronic disease. 2012;9. 30. nilsson p, gudbjörnsdottir s, eliasson b, cederholm j, register scotsnd. smoking is associated with increased hba1c values and microalbuminuria in patients with diabetes—data from the national diabetes register in sweden. diabetes &metabolism. 2004;30(3):261-8. 31. wang xl, greco m, sim as, duarte n, wang j, wilcken de. effect of cyp1a1 mspi polymorphism on cigarette smoking related coronary artery disease and diabetes. atherosclerosis. 2002;162(2):391-7. 32. klisic a, kavaric n, jovanovic m, zvrko e, skerovic v, scepanovic a, medin d, ninic a. association between unfavorable lipid profile and glycemic control in patients with type 2 diabetes mellitus. j res med sci. 2017;22:122. 33. qi q, liang l, doria a, hu fb, qi l. genetic predisposition to dyslipidemia and type 2 diabetes risk in two prospective cohorts. diabetes. 2012;61(3):74552. 34. liew sm, lee py, hanafi ns, ng cj, wong ssl, chia yc, et al. statins use is associated with poorer glycaemic control in a cohort of hypertensive patients with diabetes and without diabetes. diabetology &metabolic syndrome. 2014;6(1):53. 35. toh mphs, wu cx, leong hss. association of younger age with poor glycemic and cholesterol control in asians with type 2 diabetes mellitus in singapore. journal of endocrinology and metabolism. 2011;1(1):27-37. 36. hypertension in diabetes study group. i. prevalence of hypertension in newly presenting type 2 diabetic patients and the association with risk factors for cardiovascular and diabetic complications. j hypertens. 1993;11:309-17. 37. feihlfo, liaudet l, waeber b, levy bi. hypertension: a disease of the microcirculation? hypertension. 2006;48(6):1012-7. 38. meigs jb, hu fb, rifai n, manson je. biomarkers of endothelial dysfunction and risk of type 2 diabetes mellitus. jama. 2004;291(16):1978-86. 39. abdullah na, ismail s, ghazali ss, juni mh, kadir h, shahar nraa. predictors of good glycemic controls among type 2 diabetes mellitus patients in two primary health clinics, kuala selangor. malaysian journal of medicine and health sciences. 2019;15(suppl 3):58-64. 40. ahmad ns, islahudin f, paraidathathu t. factors associated with good glycemic control among patients with type 2 diabetes mellitus. journal of diabetes investigation. 2014;5(5):563-9. 41 international journal of human and health sciences vol. 04 no. 01 january’20 original article: evaluation of human resources planning within the framework of turkey’s health transformation program (htp) with regards to principles of justice ahmet özdinç abstract objective: health transformation program (htp) which is a health sector reform began in 2003 in turkey has changed many parameters within the health sector. in the years when the reform was proposed, it can be said that most of the limitations of the health system are related to the insufficiency of resources and the inability to organize them properly. it is clear that the limitations of human resources, like all resources, bring out the justice problem in distribution. justice requires fair participation to the resources that will be used in the field of health and fair, honest, and equal distribution of the allocated resource according to needs. our study will evaluate the human resources policy of the health transformation program in terms of need, equality, utilitarianism, and equity which are the sub-principles of justice.materials and methods: this research is an example of retrospective study. the health justice principle has been tried to be tested as a new health policy, the health transformation program, was declared in turkey in 2003 by comparing human resources data between the beginning and end of the process up to 2013. the data acquired in our country will be compared with the data of the world and oecd countries before and after the program. human resources data will be obtained from the ministry of health, state planning organization, who, wb and oecd.results and discussion: as a result of the evaluations, it is observed that the principles of justice are generally pursued in the planning and implementation of the health transformation program. on the other hand, it is possible for people to have access to health services according to their needs, as the program claims, by applying the need principle. however, the lack of tangible criteria to determine needs and the ambiguity of the definition of need delimitate the usage of this sub-principle of justice.conclusion: it is difficult to fully observe the principle of justice in health policies. fair planning human resources as well as physical resources is significant for both patients and health care workers themselves. keywords: human resources, health transformation program, justice, healthcare management correspondence to: ahmet özdinç, md, phd., researcher, istanbul, turkey. e-mail: ozdincahmed@gmail.com. international journal of human and health sciences vol. 04 no. 01 january’20 page : 41-50 doi: http://dx.doi.org/10.31344/ijhhs.v4i1.118 introduction the aim of health services is to increase the health level of the society. the way to increase health level is to protect the society from health risks and to provide the best health service to those in need.1 the problems that arise in accessing health services are related to the principle of justice in medicine. therefore, justice requires fair participation to the resources that will be used in the field of health and fair, honest, and equal distribution of the allocated resource according to needs.2 the distribution of health resources is provided in two ways. this macro and micro distribution is based on individual distribution and general distribution. accordingly, micro-level distribution is the transfer of the resources allocated for a particular treatment in relation to clinical ethics by choosing among the candidates for this treatment. and this brings with it certain ethical problems. macro-level distribution is the distribution of the share allocated from the general budget in the health sector within the framework of health policies.3 justice appears to work in two directions in macro distribution; horizontal and vertical justice. the distribution of costs and benefits among those with similar socio-economic or health structures is called horizontal justice and the distribution of international journal of human and health sciences vol. 04 no. 01 january’20 42 those belonging to different structures is called vertical justice. ensuring vertical justice in the society depends on ensuring justice in the areas of access, finance, expenditure and health indicators.4 pluralistic justice theorists acknowledge that justice is composed of various elements that cannot be reduced to one another. by applying this theory to health services, a number of sub-justice principles can be reached in the literature. cookson and dolan, who concentrated their work on health inequality, speak of three basic principles. the principle of need, utilitarianism (upgrading to the highest level), and equality. the principle of need envisages the distribution of health services at the rate of need, the principle of utilitarianism (the principle of upgrading to the highest level) stipulates the distribution of health services for the highest benefit, and the principle of equality foresees the distribution of services to minimize inequalities.5 apart from these, we include the principle of equity which can be considered as the fourth principle in the classification. the principle of equity is the absence of socially unjust and unjustified health differences. we chose the health transformation program (htp) which was in force between the years 2003-2011 in turkey as the field of application to practice the principles of justice. turkey set out in the health care system in 2003 and foresaw a major change with the conversion program as a public health reform. the htp is defined as a structured, planned and sustainable system based on the “people-centered” ethical approach, which aims to ensure equal access to quality health services for citizens, in line with the socioeconomic realities of the country.6 the htp has designated its main objectives as effectiveness, efficiency and equity. health care workers are the main actors for the labor intensive health sector. the quality, safety and success of the service depend on the effective and efficient use of human factor. the focus of our study will be on the creation of human resources in health care during the htp period and the analysis of its distribution within the framework of the above-mentioned sub-principles of justice. when we say human resources or health professionals in health, we are talking about employees who are involved in the delivery of all health services, who have received prior training for this complex and collaborative service and who are bound by legal and ethical principles. within this framework, we put specialist physicians, general practitioners, dentists, nurses, midwives, and pharmacists assigned in turkey under a microscope in our study. issues related to health workforce planning, one of the basic principles of the health transformation program, have taken their place as a component.7 the planning of human resources is based on systematic analysis of total resources, predetermining in terms of quality and quantity with regards to future and planning how much of the needs can be met.8 while creating a future perspective, it is necessary to collect and analyze today’s and yesterday’s data accurately and securely. the health transformation program which aims to organize, finance, and provide health services in an effective, efficient and equitable manner has made the same claims in human resources management. it is planned to reduce the cost by using the resources appropriately and to produce more services with the same resource. in addition, it was among the aims of people to have access to health services according to their needs. the health transformation program has promised to introduce voluntary policies that encourage the distribution of health care workers across the country. as a result of this approach, abolishing mandatory service is aimed. measures will be taken to encourage more willing and efficient work in public enterprises.9 methodology this research is an example of retrospective study. the health justice principle has been tried to be tested as a new health policy, the health transformation program, was declared in turkey in 2003 by comparing human resources data between the beginning and end of the process up to 2013. findings when it comes to human resources in health, the number and density of physicians should be examined first. we will analyze the distribution of physicians in turkey and the world by data acquired from the ministry of health, oecd, and world bank (wb). 43 international journal of human and health sciences vol. 04 no. 01 january’20 table1: total number of physicians per 100.000 people by region, 1993 2013 1993 1996 2000 2002 2013 (source) western anatolia 228 274 moh (2014) 10 aegean 155 191 “ istanbul 193 184 “ turkey 101 110 125 138 174 spo (1997) 11, moh (2014) central anatolia 117 164 “ mediterranean 123 161 “ eastern black sea 113 160 “ west marmara 105 154 “ middle east anatolia 95 146 “ southeastern anatolia 68 124 “ although physician deficit in turkey has been tried to be closed for many years, it can be said that this, as a problem, has affected all policy processes. it is possible to talk about the increase in the number of physicians per population while moving from 1993s to 2002s and from 2002s to 2013s. this increase is around 36% for the first period, while it is around 24% for the second period in which the htp is in force. looking at the whole country in general, the number of physicians per population in western anatolia, aegean, and istanbul is over the average while remaining regions are below the average of turkey. according to the data, the lowest number of physicians is in the middle east and southeastern anatolia regions. however, even in regions that can be considered low in terms of physician density, it is outstanding that the number of physicians has almost doubled in the 11-year period. table2: number of applications to physicians per person by region, all sectors, 2002-2013 2002 2013 (source) eastern black sea 4.1 9 moh (2014) western black sea 4 8.9 “ aegean 3.9 8.8 “ east marmara 3.2 8.7 “ mediterranean 3.4 8.7 “ western anatolia 3.5 8.7 “ turkey 3.1 8.2 “ central anatolia 3.3 8 “ istanbul 2.3 7.6 “ southeastern anatolia 2.3 7.6 “ middle east anatolia 2.5 6.7 “ the number of applications per person per physician in turkey has increased more than double. when looked at the regions, the highest increase is seen in southeastern anatolia. an approximately equal number of applications can be mentioned when all regions are compared. although the increase in the number of applications shows that access to the physician is easier, it is clear that it cannot be an indicator of health. international journal of human and health sciences vol. 04 no. 01 january’20 44 table3: changes in the number of physicians in turkey between the years 1994-2002-2013 1994 2002 2013 2002-2013 change (%) source specialist physician 27 564 45 457 73 886 62 moh (200212; 2014) general practitioner 38 268 30 900 38 572 24 “ resident physician 15 592 21 317 36 “ total number of physicians 65 832 91 949 133 775 45 “ the most important factor of the change in the total number of physicians between 2002 and 2013 is the increase in specialist physicians. the increase in the number of experts in 11 years is more than 60%. on the other hand, the numerical increase of general practitioners is only 24%. this reveals that the number of specialist physicians per population has increased, but that of general practitioners has decreased. thus, it is possible to say that physicians tend to specialize more. table4: proportion of general practitioners and specialist physicians to the total number of physicians 1995 2006 2013 oecd 2013 source general practitioner 60 34 31 22.5 oecd (2017) 13 specialist physician 40 66 69 62 “ pediatry 5.22 5.28 4.67 “ gynecology and obstetrics 5.44 5.13 4.52 “ psychiatry 1.99 2.46 4.98 “ total surgical branches 21.96 23.5 18.7 “ examining the specialization trends in turkey, this table reveals that according to the ratio of 1995, the ratio of 2013 of general practitioners and specialist physicians has almost replaced. according to the data we can reach, there is a significant increase in the proportions of surgical branches and especially psychiatric expertise. nevertheless, there is a decrease in the obstetrics specialty, which is one of the risky professions. when compared with the oecd average, the rate of pediatric and obstetrics departments is almost the same among all physicians, but the psychiatry department is half. table5: international comparison of the total number of physicians per 100,000, 2013 2000 2013 (source) who european region 331 moh (2014) european union 320 325 moh (2014), wb (2017)14 high-income group countries 294 moh (2014) turkey 130 174 moh (2014), wb (2017) medium-high income group countries 155 moh (2014) world 130 141 moh (2014), wb (2017) oecd 250 280 wb (2017) 45 international journal of human and health sciences vol. 04 no. 01 january’20 when turkey’s health human resources in proportion to the population is compared with the oecd and european countries’ data, it is conferred that the number of physicians per population of 100.000 people is significantly lower. however, it is noted that it is slightly above the world average. compared to 2000 and 2013, the increase in physician density in turkey will be recognized as high in comparison with the other regions. while 8% in the world, 12% in oecd countries, 1% in the eu, this increase rate is 25% in our country. the primary health care service is the area where the citizen has first contact with the health system. significant progress has been made in this area, in which the htp is particularly concerned. the family medicine system, which is the primary health care model of the htp, is designed to cover the country in terms of prevalence and accessibility. although human resources and examination will be examined in a separate section at primary health care, the number of examinations in particular is exhibited here. table6: annual number of examinations per physician 2002-2013 2002 2013 (source) number of annual examinations per physician in first step 3734 >10.000 moh (2007;2014) total number of examinations per physician in our country 3200 8200 “ number of patients per physician in oecd countries 6462 6960 “ between 2002 and 2013, considering the decrease in the density of general practitioners mentioned earlier, the number of examinations per physician in primary health care increased 3 times. in addition, there were 10,317 examinations per polyclinic room in 2002 and 10,000 examinations in 2013. this number is 45% of the number of polyclinic rooms in the primary health care, while it is 100% in 2013. this change enabled physicians who were idle due to lack of space to provide more active services. the increase in the number of examinations per physician in primary health care by 3 times in 11 years is an indication of the public’s demand for primary health care and access to health care services. the introduction of family medicine system can be considered as the most important development in primary health care. family medicine practice started in düzce for the first time in 2005 as a pilot scheme. after 2009, it has become widespread in turkey. while the average number of populations per family physician is 3,400 in turkey among the countries applying family medicine this figure is around 1,200.15 this necessitates the increase of family medicine units in the medium and long term. table7: the dentist ratio between the years 1991-2002-2013 in turkey and oecd countries total number of dentists number of dentists per 100.000 people source turkey turkey oecd 1991 10 623 19 59 oecd (2017) 2002 16 371 25 65 moh (2014), oecd (2017) 2013 22 295 29 68 moh (2014), oecd (2017) when we look at dental health, which is another field of service, we can say that the increasing trend in the number of dentists in the country since 1991 has partially decreased in 2002-2013. we can see that when we compare the turkey and oecd average of the number of dentists per population. although partial increase has been detected, the density of dentists in turkey is less than half of the oecd average. and this reinforces the thesis that serious measures should be taken in this field. ensuring quality patient care is possible with the presence of a sufficient number of qualified nurses. the difference between the health services provided in hospitals and those offered in other areas is the nursing services. therefore, the increase in the quality of nursing services is directly proportional to the increase in the efficiency of hospitals.16 international journal of human and health sciences vol. 04 no. 01 january’20 46 table8: the number of nurses and midwives in the world, turkey, and oecd countries between the years 1991-2013 total number of nurses total number of midwives number of nurses and midwives per 100.000 people source turkey turkey oecd world 1991 150 644 wb (2017) oecd (2017) 1994 56 280 35 604 160 moh (2002) 2002 72 393 41 479 171 700 236 moh (2014), wb (2017) 2013 139 544 53 427 252 770 292 moh (2014), wb (2017) it can be said that a 25% increase is observed from 1990s to 2000s in the number of nurses and midwives in turkey. this increase is around 70% for the 11 years that the htp is in force. comparing the number of nurses and midwives per population with the world and oecd countries, it can be said that the situation in our country is not heartwarming. the density of nurses and midwives, which are in a continuous upward trend, is slightly lower than the world average and even less than one third of the oecd average. according to these figures, questions arise about the effective and quality maintenance of patient care. table9: the number of pharmacists in the world, turkey, and oecd countries between the years 1991-2013 total pharmacists number of pharmacies per 100.000 people source turkey turkey oecd who europe world 1991 16 002 28 56 oecd (2017) 2002 22 322 33.6 72 46 ? moh (2014), oecd (2017) who (2017)17 2013 27 012 35.2 85 55 60 moh (2014), oecd (2017), fip (2012)18 who(2017) the majority of pharmacists in the private sector had a 40% increase from 1991 to 2002, while this increase was only 21% between 2002 and 2013. the number of pharmacists per 100.000 people is 12% increase for the first period in all sectors and 4% for the htp period. with these figures, turkey is below the oecd, who, european region, and world average. when assessing the number of pharmacists in turkey, it is noteworthy that most of the pharmacists work in the private sector and outside the hospital. it should be acknowledged that healthcare worker planning is more a matter of training providers than service providers. it is necessary to plan the training processes of the number and quality of health workers that should exist by considering the current situation, future population and need projections. health education has come some stages in our country. 47 international journal of human and health sciences vol. 04 no. 01 january’20 table10: the situation of health education in turkey between the years 2002-2013 total number number of students number of instructors number of students per instructor 2002 2013 2002 2013 2002 2013 2002 2013 medical faculty 44 75 31 719 54 455 7 172 11 741 4.4 4.4 dentistry 14 35 5 256 11 113 606 1 151 8.7 9.7 pharmacy 11 20 4 120 7 693 354 526 11.6 14.6 nursing 76 109 16 423 38 112 528 574 31.1 66.4 source:republic of turkey ministry of health, general directorate of health research. annual of health statistics 2013 [sağlıki̇statı̇stı̇klerı̇ yıllığı 2013], ankara, 2014. there has been a significant increase in the number of universities in turkey in recent years. the number of universities increased from 73 in 2002 to 168 in 2012. parallel to this increase, we see that the number of health schools has also increased. there has been a significant increase in the number of medicine, dentistry, and pharmacy faculties and nursing schools between 2002-2013 academic year in turkey. almost all of them reached a doubling number in the process. there has been an increase in the number of students in the escalating health schools, but it is hard to say that the same rate of increase is observed in the number of teaching staff. the number of people per faculty member was preserved only in medical faculties, increased in faculties of dentistry and pharmacy, and doubled in nursing schools. it seems that the increase in the number of faculty members despite the increase in the number of institutions will affect the quality of education. according to the available data, the number of students per faculty member in medical faculties was 2.73 in the world and 1.11 in the usa in 2001.19 according to these data, it can be said that the figure in our country is very low. the fact that the number of teaching staff in nursing schools has not changed according to the increase in the number of institutions and students, this resulted in a doubled number of students, 66 students, per teaching staff. discussion we examined the change of health care workers employed in turkey within the framework of the health transformation program. in this section, we will try to evaluate personnel policy, which is one of the significant actors of health system, on the basis of the principles of justice presented in the theoretical section. the variation and distribution of the number of specialist physician, general practitioner, dentist, midwife, nurse, and pharmacist will be examined in terms of the principles of need, equality, utilitarianism, and equity. the principle of need human resources planning is vital in the labor intensive health sector. the question of what planning will basically refer to is the main element of this importance. in this section, we draw attention to the principle of need in the planning of human resources. the number of physicians has increased year by year since the early 1990s in turkey. in order to compare the number of physicians with international standards, it is necessary to look at the number of physicians per person. it is clear that there is also an increase from year to year. it appears that there was less increase in the 11 years of the htp compared to the previous 11 years. however, even after this increase, the oecd average is more than 1.5 times per capita in our country. according to the increase in the number of examinations per physician in our country in 11 years, the increase in the number of physicians is quite limited. likewise, the fact that the rate of general practitioners falls in the total number of physicians in terms of both the number of examinations per physician and the services provided in primary health care makes the principle of need questionable. another area of human resource planning is the change in the number of specialist physicians. obstetrics and gynecology specialists decreased in the proportion of all physicians, whereas international journal of human and health sciences vol. 04 no. 01 january’20 48 psychiatry and all surgical branches increased. in this case, we have not found any evidence that we can relate to disease burden or health need. it can be said that there is no significant increase in the number of dentists per person compared to the increase in the number of applications in dental services. however, in addition to the knowledge that dentistry services are carried out mostly with the private sector in our country, the 100% increase in the number of physicians working within the ministry of health can be explained by the principle of need. another parameter is related to midwives and nurses providing care, which is considered as one of the main components of health services. it is seen that during the htp period, when the number of midwives-nurses per capita increased from year to year, it was observed that this number increased more than the previous 11 years. however, the fact that this increase is much lower than both the world average and the oecd average gives the impression that it does not adequately meet our needs. however, the increase in htp compared to the previous period coincides with the principle of need. in turkey, the basic approach related to the conduct of pharmacy services is free pharmacy. with this in mind, the increase in the number of pharmacists per capita both during the htp period is less than in the previous period and despite this increase it is recorded that it is lower than oecd, who european and world average. the answer to the question of whether the increase in the previous period decreased because the needs decreased during the htp period will show compliance with the principle of need. the situation of health education is one of the serious problems and dilemmas in our country. while planning health education, on the one hand the number of health care workers in need of the country should be increased, but on the other hand, quality should not be reduced with more students and inadequate physical conditions and instructors. during the htp period, a significant increase in the number of health institutions in turkey is provided. this can be explained by the principle of need, but the number of students per instructor has increased, as well. and this raises questions about quality compared to the world average. the principle of equality we expect health care workers to be distributed to ensure equality in all regions. when we look at the number of physicians per capita in 2013, we notice that there is a difference between regions. while the western anatolia region had the highest average in 2002, it increased again in 2013 and maintained its highest rank. on the other hand, there is a decrease in istanbul average. one of the data that draws attention here is that this region is the region that provides the highest increase in 11 years, although the physician density in southeastern anatolia is at least on both dates. in 2013, the ratio of increase is high in regions in which the number of physicians per population was lower than the average in 2002. although the same physician density is not attained in all regions, it is seen that one of rawls’ principles of justice which is “the most disadvantageous ones benefit the most” is experienced. as we have stated, although there is no absolute equality in the number of physicians per population, the average number of applications to physicians per capita is between 7 and 9. this shows that a standard is reached in the citizen’s accessibility to the physician and that the principle of equality is more complied. when we look at the change in the number of physicians in terms of sub-branches, we can assume that one family physician falls for 3800 population in turkey. in this case, we can say that family physicians are equally distributed to all regions. on the other hand, there is no data on the distribution of sub-specialties of medicine in all regions. since family health personnel have to be included in the family medicine system together with family physicians, we can say that this group of employees is equally distributed throughout the country. with the increase in health schools, the number of students increased considerably. we can express that this situation strengthens regional equality due to equality of opportunity and distribution of schools. however, in the theoretical framework, opportunities that are the basis of equality of opportunity, which is the previous process of equality, primary and secondary education processes should be considered. 49 international journal of human and health sciences vol. 04 no. 01 january’20 the principle of utilitarianism the principle of upgrading health is the manifestation of the classical utilitarian view in health. therefore, the main approach we will take is how much services benefit us. an application is true if it yields benefits in total and it is false if it does not. one of the benchmarks of our study is the oecd averages. considering welfare focus, which is one of the three basic elements of classical utilitarianism, approaching the oecd average will put the action into the category of beneficial action as it will increase the welfare level. in other words, if the rate of increase between the years is higher than the rate of increase in the oecd average, we can say that we are approaching the high standard of welfare. the increase in the number of physicians per capita in turkey when considered together with the increase in the oecd average, the difference in 2013 is less than difference in 2000. the available data show that there is an increase in the density of physicians in our country and according to thefirst data, our country is converging to the oecd average. hence, we can say that our progress towards achieving the oecd standard welfare level has improved. on the other hand, the significant increase in the number of examinations per physician as a data showing the availability of physicians, and even higher levels compared to the oecd, coincide with results-oriented and cumulative factors of utilitarianism. since 1991, there has been an increase in the number of midwives and nurses per capita in our country. the rate of increase between the years of 2002-2013 in particular, when the htp was in force, is higher than the rate of increase in the oecd average. therefore, it can be mentioned that a useful policy is applied in the number of nurses and midwives. it is difficult to mention that the same level of pharmacist numbers is maintained. in 2002-2013, the rate of increase in the number of pharmacists in our country is below the oecd. although the partial increase recorded seems to be beneficial for the outcome, it distances us from the principle because it moves away from the high welfare level. we will evaluate the principle of utilitarianism by comparing the number of students with the number of schools opened in health education. our data relate to medical school, dentistry, pharmacy, and nursing schools between 2002-2013. there is an increase between periods in all four educational institutions. however, the highest increase in the number of students according to the number of institutions opened was seen in nursing schools. the most beneficial investment in terms of results seems to be in nursing schools. however, it is not possible for the medical faculties or the faculties of dentistry to increase to the same level as nursing schools due to the difficulty of both the educational processes and the capacity to create physical facilities. the principle of equity we said that the number of physicians increased with the htp. we have some data to see if this increasing number is distributed in accordance with the principle of equity. in eastern black sea, middle east anatolia, and southeastern anatolia regions, which are known as geographically disadvantaged regions, the number of physicians per capita has increased more than other regions in order to provide “equal opportunities”. the number of applications, which are around 2% in terms of the result, approached the country average and remained around 7%. we do not have access to the data as to whether it is equitable increase in the number of specialist physicians in turkey. there is no supportive data to suggest that the ratio of practitioners/specialists in 1995 increased in favor of specialists in 2013 and decrease in some basic branches and increase in others is to provide “equal opportunities”. in general, based on the data obtained from physicians, dentists, pharmacists, midwives, and nurses, we can say that there is an increase in per capita numbers. this increase also affects the distribution. it can be said that especially compulsory service practice leads practitioners and specialist physicians to less advantageous areas and thus the principle of equity is complied with. however, although this practice is not the case for health professionals other than physicians, we know that there are some incentives for working in those regions. conclusion it would be appropriate to say that the main component of the health sector is human resources. while the need for manpower is expected to international journal of human and health sciences vol. 04 no. 01 january’20 50 decrease with the development of technology, today we see that even more specialized manpower is needed. we can say that there are big problems in the distribution of human resources as well as the distribution of physical facilities. these problems which can be addressed within the ethical framework will increase the defensibility in practice. in this study that examines the creation and distribution of human resources within the htp, we can only estimate that the principle of need is complied with. because we have not reached clear criteria to determine what is needed. according to the principle of equality, it is possible to say that the planning is done correctly. the increase in the total number and the increase in the per capita distribution of human resources in particular corresponds to the principle of utilitarianism. finally, we can say that we have obtained data in line with the principle of equity, as the htp initially claimed. the subject of the study is to determine concrete criteria such as disease burden especially in determining the need. otherwise, the lack of reference in the increase or decrease in the number will also affect the defensibility. in general, it is difficult to fully implement the principle of justice in health policies. however, especially in human resource planning, applying this principle together with the sub-principles is vital for both beneficiaries and healthcare providers. references: 1 akdur r. health services and scattering of limited resources [sağlık hizmetlerive sınırlı kaynakların dağıtımı (tartışılması gerekensorular)]. türkiye klinikleri journal of medical ethics-law and history 2000;8(1):38-45. 2 aydın e and ersoy n. the principle of justice in medical ethics [tıbbietik’te “adaleti̇lkesi”]türkiye klinikleri tıbbi etik dergisi 1994;2(2): 61-63. 3 atıcı e. ethical issues related to distribution of health resources [sağlıkkaynaklarının dağıtımıilei̇lgili etik sorunlar] türkiyeklinikleri journal of medical ethics-law and history 2006;14 (2):111-115. 4 arabacı yüksel r. türkiye’deyoksullukve bölgelerarası gel işmişlikfarklarıaçısın dansağlıkta adalet. uludağ üniversitesi i̇ktisadivei̇dari bilimler fakültesi dergisi 2009;28(1):1-25 5 cookson r and dolan p. principles of justice in health care rationing. journal of medical ethics 2000;26(5):323-329 6 akdağ r. turkey’s health transformation program. istanbul: 24 february2011 bab-ı ali meetings. accessed 15.04.2015 http://dosyasb. saglik.gov.tr/ eklenti/ 1610,babi-ali-toplantilari-24-subat2011pdf. pdf?0 7 republic of turkey ministry of health. workshop on establishing human resources and policies in health. [sağlıktai̇nsan kaynaklarıve politika oluşturma çalıştay]. ankara, t.c. sağlık bakanlığı refik saydam hıfzıssıhha merkezi başkanlığı hıfzıssıhha mektebi müdürlüğü, 2007. 8 özkan ş and uydacı m. workload-based medical specialist planning in public hospitals: the case of kocaeli. [kamu hastanelerindei̇ş yüküne dayalı uzman hekim planlaması: kocaeli örneği]amme i̇daresi dergisi 2016;49(1):147–174. 9 republic of turkey ministry of health. health transformation [sağlıktadönüşüm]. ankara, 2003. 10 republic of turkey ministry of health, general directorate of health research. annual of health statistics 2013 [sağlıki̇statı̇stı̇klerı̇ yıllığı 2013] ankara, 2014. 11 state planning organization. comparison of health care policy and indicators in turkey and the european union [türkiyeve avrupa birliği’ndeki sağlık politikalarıve göstergelerinin karşılaştırılması] ankara, 1997. 12 republic of turkey ministry of health. presidency of research, planning and coordination committee. health statistics 2001 [sağlık i̇statistikleri 2001] ankara, 2002. 13 oecd statistics. accessed 29.09.2016 http://stats. oecd.org/ 14 world bank open data. accessed 29.05.2016 https://data.worldbank.org 15 oecd and wb. oecd sağlıksistemii̇ncelemeleri türkiye, 2008. 16 bal m d. nursing manpower planning approaches in hospital [yataklı tedavi kurumlarında hemşire i̇nsangücü planlama yaklaşımları] sağlıkve hemşirelik yönetimi dergisi 2014;3(1):148-154. 17 constitution of the world health organization. accessed 29.08.2016. http://apps.who. int/gb/bd/ pdf/bd47/ en/constitution-en.pdf? ua=1 18 fip. 2012 fip global pharmacy workforce. international pharmaceutical federation (fip), 2012. 19 boelen c and boyer m h. a view of the world’s medical schools defining new roles, 2001. accessed 29.09.2016 http://www.iaomc.org/ who rept medschools.pdf international journal of human and health sciences vol. 04 no. 03 july’20 194 original article: comparing diagnostic value of renal parenchymal resistive index and cortical echogenicity in chronic kidney disease patients dria anggraeny sutikno1, nurdopo baskoro2 abstract: background: chronic kidney disease (ckd) is a clinically impaired kidney degradation syndrome, which commonly is diagnosed based on glomerulus filtration rate (gfr). renal parenchymal resistive index and the renal cortex echogenicity are ultrasound parameters that have been reported correlate with gfr values. this study aims to determine the sensitivity, specificity, positive predictive value, and negative predictive value between renal intra-parenchymal resistive index and renal cortical echogenicitybased on gfr in ckd patients. materials and methods: this study is a cross sectional design. a renal ultrasound examination was performed to forty one ckd patients to assess the resistive index of the renal intra-parenchymal artery and the echogenicityof the renal cortex. the creatinine serum levels were obtained from the patients, as the gold standard of ckd diagnosis. statistical data processing uses diagnostic test and inter class correlation coefficients (icc). results: the sensitivity, specificity, positive predictive value, and negative predictive value of renal intraparenchymal resistive indexes were 23%, 79%, 33%, and 69% respectively. sensitivity, specificity, positive predictive value, and negative predictive value between renal cortex echogenicity were 23%, 96%, 75%, and 73% respectively. the icc analysisreported a single rater value of 0.1538 and average of raters 0.3528. conclusion: renal intra-parenchymal resistive artery was more specific than renal cortex echogenicity for diagnosing patients with chronic kidney disease. keywords: resistive index, renal cortex echogenicity, chronic kidney disease, glomerulus filtration rate (gfr). correspondence to: dria anggraeny sutikno, md. radiologist, department of radiology; universitas islam sultan agung jl. kaligawe km 4 semarang indonesia 50112. phone number : +6281326707161, email : dria.anggraeny@unissula.ac.id 1. dria anggraeny sutikno, department of radiology, faculty of medicine, universitas islam sultan agung 2. nurdopo baskoro, department of radiology, faculty of medicine, diponegoro university / dr, kariadi hospital international journal of human and health sciences vol. 04 no. 03 july’20 page : 194-199 doi: http://dx.doi.org/10.31344/ijhhs.v4i3.200 background chronic kidney disease (ckd), also known as endstage renal disease, is a syndrome characterized by progressive and irreversible kidney loss, and the incidence of chronic kidney disease nowadays is increasing rapidly. the incidence of chronic kidney disease significantly increases annually. the increasing number of patients with chronic kidney disease also leads to an increase in the number of patients undergoing hemodialysis. based on a survey conducted by association of nephrology indonesia in 2009-2012, it was reported that there was an increase in the percentage of new ckd patients by 50% in indonesia.1the prevalence of chronic kidney disease increases along with the increasing number of elderly population and the incidence of diabetes mellitus and hypertension. about 1 of 10 global populations experiences chronic kidney disease at a particular stage. the global prevalence of chronic kidney disease of 13.4% and was reported as the 27th leading cause of death in the world in 1990 and increased to 18th in 2010.1,2 in indonesia, renal disease treatment is the second largest financing ranking of national 195 international journal of human and health sciences vol. 04 no. 03 july’20 health insurance, it is ranked after heart disease. according to the data obtained from pt askes (one of indonesian health insurance), there were approximately 14.3 million people with late stage renal failure currently undergoing treatment with a prevalence of 433 per population. this number is expected to increase to over 200 million by 2025.1,2 clinically, the basic diagnosis for chronic kidney disease is to assess the glomerulus filtration rate. glomerular filtration rates and renal tubules have a strong contribution in maintaining renal function known as glomerulus tubular balance and negative glomerulus tubular feedback. glomerulus and renal tubules play a vital role in maintaining fluid balance.any condition that causes an increase in fluid and na in the macula densa (distal tubule) will eventually trigger a feedback mechanism that will cause a decrease in the filtration rate of the nephron.3 the classification of chronic kidney disease based on glomerulus filtration rate (gfr) was reported on table 1. table 1 classification of chronic kidney disease based on gfr.(4) stadium lfg (ml/ mnt/1.73m2) description i ≥90 kidney damage with normal or increased lfg ii 60-89 kidney damage with mild lfg decrease iii 30-59 kidney damage with moderate lfg decline iv 15-29 kidney damage with severe lfg decline v <15 kidney failure in the field of nephrology, diagnostic techniques would include various aspects such as clinical history, physical examination, laboratory tests, scintigraphy, diagnostic imaging techniques and renal biopsy. in the case of nephropathy, ultrasonography is a first-line imaging technique, which; through careful sonographic scanning, it can be a helpfulinstrument to distinguish acute and chronic renal failure.4 in addition, ultrasound can also be used to follow up the treatment of the disease, to guide the biopsyneedle and others. ultrasound techniques can visualize renal pelvic conditions, assess renal dimensions and parenchymal echogenicity, visualize doppler color-power signals and measure parenchymal resistive index. taken together, this data can provide useful clues to the diagnosis and help to reduce the possible differential diagnoses.5 a positive correlation between the echogenicity of the renal cortex and interstitial changes was reported in 25 patients, but it was found no association between these changes and glomerular lesions.5 however, hricak et al. in 1982, found a positive correlation between echogenicity increase of the renal cortex and glomerular changes.7meanwhile, according to a study conducted by siddappa et al in 2013, it was evident that the echogenicity of the renal cortex was one of the parameter that had significant correlation with serum creatinine levels compared to other sonographic parameters such as renal axis length, parenchymal thickness, and cortical thickness.7 echogenicity grading of the renal cortex is shown in table 2. table 2. classification of renal parenchymal echogenicityaccording to brenbridge et al.8 grade 1 echogenicity is less than liver/spleen grade 2 echogenicity is similar to liver/spleen grade 3 echogenicity are more than liver/spleen grade 4 echogenicity equals central renal sinus or portal vein examination of renal intra-parenchymal artery resistive index happened to have a correlation with estimated renal glomerular filtration rate in hypertensive disease. in another study, it was also mentioned that renal doppler ultrasound examination had an important role in the prognosis in patients with chronic kidney disease. in chronic kidney disease, vascular compliance might occur and increased peripheral resistance, which led to a decrease in blood flow to the kidney and glomerular filtration rate. doppler ultrasound examination, especially resistive index could provide useful information related to the above disorder.9 the normal resistivescore of the renal index is about 0.60 to 0.65 which is maintained constantly as long as the structure of the parenchyma and renal function remains normal. in neonate patients, the resistive index appears to be higher and gradually decreases by increasing of age and will be persists at 8-10 years of age. this score is similar to the resistive index of normal adult. however, in the elderly (> 50 years) the resistive index appears elevated, associated with changes in vascular structures. therefore, normal resistive index score ranges from 0.6 to 0.7.9 international journal of human and health sciences vol. 04 no. 03 july’20 196 figure 1. resistive index is normal in healthy female patients, 25 years of age. color doppler sonogram is used to identify interlobar artery (arrow).9 based on the description above, resistive index examination and echogenicity of renal cortex are ultrasound parameters, which could be related to glomerulus filtration rate. however, to the best of our knowledge, there has been no publication that focused on which parameter that contributes the most on the depletion of glomerulus filtration rate in patients with chronic kidney disease. considering that, the authors would like to examine sensitivity, specificity, positive predictive value, and negative predictive value of renal intra-parenchymal artery resistive index andechogenicity of the renal cortex based on renal glomerular filtration rate as gold standard diagnosis in patients with chronic kidney disease. research methods this study was a cross sectional study with a diagnostic test conducted at dr. kariadigeneral hospital from august to october 2017. the study sampleswere patients with chronic kidney disease with inclusion criteria: gfr ≤ 90 ml/min/1.73m2 (based on gfr mdrd formula), age ≥ 19 years, and underwent ultrasound examination at dr. kariadi general hospital radiology diagnostic department, and agreed to be the subject of thestudy. patients with nephrolithiasis, renal anatomic abnormalities, hydro-nephrosis, renal malignancies, undergoing kidney replacement therapy (hemodialysis, peritoneal dialysis, and renal transplant), fatty liver, and ascites were excluded from the sample. the total samples was 41 patients, and were collected using consecutive sampling method, which was selected based on their arrival to the department of radiology diagnostic dr. kariadi, semarang to undergo renal ultrasound (abdominal). the result of creatinine serum examination was obtained from the hospital laboratory test and the result of the test was attached to the medical record of the patients. ckd patients who agreed to take part the study and had signed a written informed consent agreement with gfr ≤90 ml/min/1.73 m2 were underwent renal ultrasound. the ultrasound was performed using the curve probe with b-mode ultrasound and doppler ultrasound to obtain a resistive index of the renal intra-parenchymal artery in the upper, mid and lower poles. the sample volume was set as small as possible (1 mm) into the inter-lobar artery with a narrow angle. the final result of the resistive index value was the average of the three measurements mentioned above. however, if it was not possible to obtain a renal intra-parenchymal artery in all three poles, then only one intraparenchymal artery could be visualized. there was also an examination of the echogenicity of the renal cortex by using b-mode ultrasound. one person counted as one sample, where ultrasound examination was performed on both kidneys in each sample. resistive index scores and the degree of parenchymal echogenicitywere taken from one of the kidneys that had the highest scores. processing techniques and data analysis. data were expressed in 2 x 2tables, and then diagnostic values of resistive index of renal intraparenchymal artery and the echogenicity of the renal cortex were calculated. furthermore, kappa conformity testing was performed between the renal intra-parenchymal resistive index and renal cortical echogenicity index to gfr. results the prevalence of female ckd patients (63.4%) was higher than that of the male ckd patients (36.6%) and the most prevalent agewas 41-60 years (56.1%). table 3. general characteristics of subjects characteristics sample percentage (%) age 21-40 6 14.6 41-60 23 56.1 >60 years 12 29.3 gender male 15 36.6 female 26 63.4 gfr gfr ≥ 15 ml/min 13 31.7 gfr < 15 ml/min 28 68.3 echogenicity grade 1 4 9.8 grade 2-4 37 90.2 resistive index (ri) 0.60 – 0.70 9 22.0 > 0.70 32 78.0 there were 13 patients categorized as normal to severe kidney function depletion, with gfr score ≥ 15 ml/min, and there were 28 patients 197 international journal of human and health sciences vol. 04 no. 03 july’20 suffered from very severe kidney function depletion, with the gfr score<15ml/min. based on the echogenicity of the renal cortex obtained by b-mode ultrasound examination, 4 patients were considered as normal with homogeneity grade 1 and there were 37 patients withhomogeneity grade 2-4. meanwhile, based on the resistive index (ri) of renal intra-parenchymal artery obtained by doppler ultrasound examination, there were 9 patients with normal ri scores, 0.60 to 0.70 and there were 32 patients had ri scores more than 0.70. the analysis indicated that the sensitivity, specificity, positive predictive value, and negative predictive value of renal cortex echogenicity were 23%, 96%, 75%, and 73% respectively and the sensitivity, specificity, positive predictive value, and negative predictive value of renal intraparenchymal resistive index were 23%, 79%, 33%, and 69% respectively. table 4. diagnostic test of renal cortex echogenicity on the gfr value ekogenisitas gfr totaln tn (≥ 15 ml/min) (< 15 ml/min) n 3 1 4 (grade 1) 23.1% 3.6% 9.8% tn 10 27 37 (grade 2-4) 76.9% 96.4% 90.2% total 13 28 41 100.0% 100.0% 100.0% table 5. diagnostic test of renal cortex echogenicity on the gfr value resistive index gfr totaln tn (≥ 15 ml/min) (< 15 ml/min) n 3 6 9 (0.60 – 0.70) 23.1% 21.4% 22.0% tn 10 22 32 (> 0.70) 76.9% 78.6% 78.0% total 13 28 41 100.0% 100.0% 100.0% the results of kappa testindicated that the kappa coefficient of the echogenicity of the renal cortex to gfr was 0.239 (p=0.05) whereas the coefficient of kappa of resistive index of renal intra-parenchymal artery to gfr was 0.018 (p = 0.91).the icc indicated poor agreement among the variables. discussion based on the echogenicity of the renal cortex, it was indicated that ckd patients with echogenicity grade 2-4were higher in number compared to those whose normal echogenicity. this result was in accordance with previous study which reported a linear correlation between sonographic grading in renal parenchyma with gfr scores. the stud reported that ckd patients with grade 2-4 cortical echogenicity were four times as much as patients with the grade 1echogenicity.10other literature reported a positive correlation between the increase of renal cortex echogenicity and glomerular changes. the increase of echogenicity of the renal cortex could be due to changes in perfusion, cell infiltration and deposition of connective tissue, calcium, and fat.5in addition, there was further nephron damage in ckd patients that led to tubule-interstitial fibrosis.7 this study reported that ckd patients with a resistive index more than 0.70 were higher in number compared to ckd patients with normal resistive index. previous stud also reported that 77% patients with high score of gfr would have high resistive index (>0.70).10 this can be understood as ckd patients might suffer from nephron damage and tubule-interstitial fibrosis, which associated with renal intra-parenchymal fibrosis. those situations might lead to resistive index increase.9 the finding indicated that echogenicity of the renal cortex had a more significant diagnostic value in ckd patients based on gfr than the renal intra-parenchymal resistive index. it wasalso reportedpreviously that the echogenicity of the renal cortex had a good correlation with the severity of interstitial changes in biopsy.11focal interstitial changes tend to cause minimal increase in the echogenicity of the cortex and diffuse cicatrix tissue leading to wider changes in the echogenicity of the renal cortex. it was also reported that renal echogenicity has a strong correlation to histologic parameters, such as glomerular sclerosis, tubular atrophy, interstitial fibrosis, and interstitial inflammation. renal cortical echogenicity had statistically significant positive correlation with the severity of global sclerosis, focal tubular atrophy, and the number of hyaline cylinders in the glomerulus and focal leukocyte infiltration.11 on the other hand, however, it was reported previously that there was similarities of resistive index in patients with normal and moderately thickened intima layers. however, the resistive index was reported tend to increase in patients with severe arteriosclerosis. there was no correlation between resistive index and glomerulosclerosis as well.10this study concluded that the resistive index was less sensitive to histologic changes of international journal of human and health sciences vol. 04 no. 03 july’20 198 renal parenchyma when compared to renal cortex echogenicity. a study conducted by yaprak et al12 reported that the renal cortex echogenicity had the strongest sonography parameter correlation against e-gfr than the length of the kidney and the thickness of cortex. in addition, in renal biopsy studies, it was shown that the renal cortex echogenicity was also associated with glomerulosclerosis, tubular atrophy, and interstitial fibrosis leading to irreversible kidney function disorder.moreover, based on a study by tublin et al9 it was known that the resistive index relied on volume (compliance) and blood vessel resistance, and became less dependent on blood vessel resistance when compliance was reduced, and became increasingly independent when volume was equal to zero. the study also reported that the resistive index alone, without considering other factors, could not be used to determine the differential diagnosis of intrinsic renal disease due to the complex histologic effects on compliance and blood vessel resistance.9 thus, in the absence of other abnormalities affecting resistance renal intra-parenchymal blood vessels, resistive index might give false negative results. considering that, the authors suggested that the echogenicity of the renal cortex was more representative of the histologic changes of the renal parenchyma in ckd patients. these factors also led to a poor agreement among the three research variables. conclusions and suggestions the study indicated that renal intra-parenchymal resistive artery was more specific than renal cortex echogenicity for diagnosing patients with chronic kidney disease. this may be due to the echogenicity of the renal cortex being more likely to visualize the histologic condition of the kidneys than the resistive index,which depends not only on renal intra-parenchymal vascular conditions. the absence of other abnormalities affecting intraparenchymal renal resistance resistive index may give false negative results. for further study, the authors suggest that resistive index examination could be performed by using linear probes to obtain accurate data of arcuate artery or renal inter-lobar artery. to eliminate the effect of subjectivity in the assessment of the echogenicity of renal parenchyma, further study could be done with more than one assessor. in addition, a longer duration of researchwas needed for obtaining accurate resistive index examination. acknowledgement the author would like to thank the head of department of radiology, dr. kariadi hospital and research associates in the center for their assistance in conducting the study. the authors also wish to thank faculty of medicine universitas islam sultan agung, for funding the project. they also would like to thank endang lestari for language editing, darminto md for his assistance in the statistical analysis and putri rohimah ayuningtyas for her assistance in submitting the manuscript. conflict of interest the authors declare that they have no competing interests. the authors alone are responsible for the writing and content of this paper. ethical approval and consent to participate the study was approved by the bioethics committee for medical/ health research faculty of medicine, diponegoro university and dr. kariadi hospital (letter no. 573/ec/fk-rsdk/ ix2017) and was conducted at the department of radiology dr. kariadi hospital. participants would not pose to physical risk for taking part this study. the respondents were informed that their participation in this study was on a voluntary basis. consent was implied by the participants’ agreements to take part the study and their signature on written informed consent agreement. to ensure confidentiality we anonymized the data. source of funding this project was funded by faculty of medicine universitas islam sultan agung, under the scheme of internal research funding. authors contribution: study design: dria a. sutikno, nurdopo baskoro data gathering: dria a. sutikno, nurdopo baskoro writing and submitting manuscript: dria a. sutikno, nurdopo baskoro editing and approval of final draft: dria a. sutikno, nurdopo baskoro consent for publication not applicable 199 international journal of human and health sciences vol. 04 no. 03 july’20 references: 1. prodjosudjadi wsa. end stage renal disease in indonesia: treatment development. spring. 2009;19:33–6. 2. prodjosudjadi wsa incidence, prevalence, treatment and cost of end-stage renal disease in indonesia. ethn dis. 2006;16:14–6. 3. sandilands ea, dhaun n, dear jw, webb dj. measurement of renal function in patients with chronic kidney disease. br j clin pharmacol. 2013;76(4):504–15. 4. nainggolan t. the correlation between cortical thickness and renal lenght and estimated glomerular filtration rate (egfr) in chronic kidney disease. vol. 1. makassar: universitas hasanuddin, 2014. 5. fiorini f, barozzi l. the role of ultrasonography in the study of medical nephropathy. j ultrasound. 2007;10(4):161–7. 6. hricak h, cruz c, romanski r, uniewski m., levin nw, madrazo bl, et al. parenchymal disease. radiology. 1982;144:141–7. 7. siddappa jk, singla s, al ameen m, rakshith sc, kumar n. correlation of ultrasnographic parameters with serum creatinin in chronic kidney disease. j clin imaging sci. 2013;3(28):1–6. 8. brenbridge an, chevalier rl, kaiser dl. increased renal cortical echogenicity i n pediatric renal disease : histopathologic correlations. j clin ultrasound. 1986;14(october):595–600. 9. tublin me, bude ro, platt jf. the resistive index in renal doppler sonography: where do we stand? am j roentgenol. 2003;180(4):885–92. 10. shivashankara vu, shivalli s, santhosh pai bh, acharya kd, gopalakrishnan r, srikanth v, et al. a comparative study of sonographic grading of renal parenchymal changes and estimated glomerular filtration rate (egfr) using modified diet in renal disease formula. j clin diagnostic res. 2016;10(2):tc09-tc11. 11. singh a, gupta k, chander r, vira m. sonographic grading of renal cortical echogenicity and raised serum creatinine in patients with chronic kidney disease. j evol med dent sci [internet]. 2016;5(38):2279–86. 12. yaprak m, çakır ö, nuri m, ramazan t. role of ultrasonographic chronic kidney disease score in the assessment of chronic kidney disease. int urol nephrol. 2017;49:123–31. international journal of human and health sciences vol. 04 no. 03 july’20 156 review article: transforming growth factor – β and glioma harrison handoko1, novi silvia hardiany2 abstract: transforming growth factor-beta (tgf-β) is a regulatory cytokine secreted by various types of cell such as stromal cell, immune cells and tumor cells. signaling of tgf-β plays an important role in proliferation, differentiation and apoptosis regulation of various cell, including glial cell. disruption in the signaling pathway of tgf-β is commonly seen in tumor cells and is believed to contribute to the initiation and progression of cancer cells. changes in the chromosome accompanied by genetic mutation has been observed which causes tgf-β to act as an oncogene, a substance which promote normal cells to differentiate to cancer cells.increased level expression of tgf-β molecules has been seen in more malignant gliomas which yields a lower prognosis for the patient compared to those with lower expression of tgf-β. malignant gliomas are characterized by rapid proliferation, invasion of parenchyma and angiogenic capabilities, are most common type of primary brain tumors. studies have now implemented specific targeted therapy which act as a treatment for glioma cases. this review will focus on the role of tgf-β in glioma and its application in the treatment of glioma. keywords: signaling pathway, tgf-β, glioma, targeted therapy correspondence to: novi silvia hardiany, department of biochemistry& molecular biology, faculty of medicine, universitas indonesia, e-mail: novi.silvia@ui.ac.id 1. faculty of medicine, universitas indonesia, jakarta, indonesia 2. department of biochemistry& molecular biology, faculty of medicine, universitas indonesia, jakarta, indonesia international journal of human and health sciences vol. 04 no. 03 july’20 page : 156-160 doi: http://dx.doi.org/10.31344/ijhhs.v4i3.194 introduction glioma are neoplasms of the central nervous system (cns) which originate from glial cell, cells which surround the neurons providing insulation and support to sustain their function. according to the national cancer institute, brain tumors account for 85-90% of all cns tumors. it is estimated that there are 23.880 new cases of brain tumor, with 16.830 deaths in the united states in 2018.5 furthermore, in 2012 it was estimated that there were 256.213 of brain tumor, with an estimated death count of 189.382 cases worldwide. glioma accounts for approximately 30% of cns tumors and 80% of malignant brain tumor, this shows that glioma has a significant impact with relation to brain tumors.6 etiology the etiology of brain tumor, similar to many other tumor, is hard to determine. this is due to the rise of tumor cells are multi-factorial and is unique to each case and individuals, and most brain tumors have no known cause. currently there are little studies to a specific cause of tumors, however there are some factors which can contribute to the development of tumor such as genetics and infections by viruses such as epstein-barr virus which has been correlated to lymphoma.7 screening and diagnosis currently there are no effective ways to screen glioma cases especially those that do not present with symptoms. the symptoms of cns tumors can have a variety of outcome, some can have mild headache while others can have generalized or focal neurologic symptoms.7 as in other tumors, gliomas are categorized into 4 categories by the world health organization (who), grades i-iv.8 role of tgf-β. tgf-β is a cytokine that has various functions to regulate cell proliferation and differentiation along with tissue homeostasis.1 the important 157 international journal of human and health sciences vol. 04 no. 03 july’20 aspect of tgf-β is present in all cell, it can affect the differentiation, proliferation, movement, adhesion, communication and death of various types of cell.9 tgf-β acts as a ligand which binds to two pairs of receptor on the surface of cells, these are transmembrane serine/threonine kinases. the binding of tgf-β to the receptor initiates a sequence of event, starting from the activation of the receptor leading to the phosphorylation of smad proteins.10 normally smad proteins are inactive and shuttle between the nucleus and cytoplasm, when they are phosphorylated they will be activated and accumulate within the nucleus. there, they will bind to loci which will both suppress and activate hundreds of gene, including those which affect cell lineage specification and differentiation.9 as tgf-β plays a crucial role in differentiation and specification, it is not a surprise that it plays an important role in cancer tumor progression. tgf-β is famous for having two sided nature which can both aid and suppress the growth and proliferation of cancer cells, specifically it acts as a tumor suppressor in pre-malignant stages of cancer while also a tumor promotor in the later stages of malignant cancer cells.11-12 tumor suppressor in normal and early stages of tumor growth tgf-β is able to modulate and regulate tumor via inhibiting proliferation and stimulating apoptosis. tgf-β inhibits proliferation by targeting cell-dependent kinase (cdk), which are molecule needed within the cell cycle allowing cells to progress past the g1 phase. this is action is accomplished by the production of p15, p21 and p27 which has binds to cdk molecule, preventing the cell from moving past the g1 phase thus inhibiting proliferation of the cell.13 mutation in this particular gene can be detrimental which causes a sustained proliferation without inhibition leading to progression of tumor. there is evidence which suggest that restoring the sensitivity to tgf-β molecule through the tgf-β receptor type 2 (tβrii) inhibits the proliferation of human breast cancer.14 tgf-β can also help reduce tumor cells by upregulating apoptosis of cell, smad protein can also help stimulate the production of pro-apoptotic proteins such as tgf-β induced early response gene (tieg1), inositol-5-phospate (ship), and death-associated protein kinase (dapk). similarly, mutation can also occur here which lead to decrease in apoptosis.15 tumor promotor despite the fact that tgf-β can inhibit the initiation of cancer, however when cancer cells are formed it has been noted that there were increased expression of tgf-β ligands in various cancers which include colorectal, gastric, lung, esophageal, breast and pancreatic cancers.16-17 the increased expression of tgf-β molecules in more advanced cancer has been correlated with increased levels of invasiveness, progression and prognosis. the increased levels of tgf-β can be accounted due to the increased production by the cancer cells themselves or by the cells which make up the microenvironment surrounding the cancer, this can be macrophages, stromal cells and others.18-19 despite the tumor suppressive effects mentioned above one might speculate that this will help prevent the formation of more malignant cancer cells, however this not so true due to the fact that most of the more malignant cancer types have lost their sensitivity which makes them unresponsive to the tgf-β signaling. despite this, normal cells within the microenvironment are still susceptible to the signaling altering them to promote tumor progression. this can be achieved by promoting angiogenesis, changes in extracellular matrix and suppression of immune system towards the cancer cells.9 during the process of angiogenesis, the main targeted cells are the endothelial cells. when stimulated, endothelial cells will express an increased level of permeability, proliferation, migration and invasion as they are trying to form new blood vessels.20 one of the components which help regulate angiogenesis is tgf-β. in an experiment using mice models it was shown that mice which has mutation within the tgf-β receptor type 1 (tβri) and tβrii have dysregulated angiogenesis.21 angiogenesis is a particularly important role in tumor growth, like any other tissue they require a constant supply of blood in order to meet the metabolic demand of an actively replicating tissue. the demand for supplies such as oxygen and nutrient are elevated in tumor cells as they are replicating at a higher rate compared to normal cell, therefore they require more nourishment compared to normal cells. increased levels of tgf-β within the microenvironment has been shown to increase the vascular density and tumor progression in small cell lung cancer which leads to a worse prognosis.22 international journal of human and health sciences vol. 04 no. 03 july’20 158 another role that tgf-β has in the promotion of cancer cell is the inhibition of immune surveillance. tgf-β has the ability to suppress cytotoxic t-cells, dendritic cells and natural killer cells while simultaneously creating a proinflammatory condition by recruiting neutrophils and macrophage. the pro-inflammatory condition creates a positive feedback loop which induces the release of more tgf-β molecule, the summation of this promotes the progression of tumor cells even further.23 tgf-β and its application due to the increasing amount of evidence which suggest that the increase in tgf-β signaling is prominent in malignant tumors, the clinical application of tgf-β is being investigated further. the implications of using tgf-β inhibitors are being studied, some are now in clinical development. tgf-β inhibition can be accomplished in 3 different levels of the signaling pathway: (1) ligand level, (2) ligand-receptor level and (3) intracellular level.at the ligand level, antisense oligonucleotide (aon) can be given to the patient.24 a study using a phosphonothioatemodified aon named ap12009 which specifically targets tgf-β2 mrna sequence has been shown to reduce the expression of tgf-β2 expression by up to 73%.25 apart from that, this specific aon has also demonstrated the ability to reduce proliferation, migration and the immune suppression.26 there has been clinical trials regarding the administration of ap12009 to glioma patients, where administration of the drug was shown to increase the median survival of glioma patient suffering from anaplastic astrocytoma was 39 months when treated with ap12009 as when compared to the median survival of 21 month when treated with chemotherapy. despite the positive outcome shown from the research due to the limited number of patients, the result was determined to not be statistically significant. although this effect is not seen in glioblastoma (gb).27 another benefit mentioned by research conducted was the reduced amount of side effects when compared to glioma treatment using chemotherapy.27 at the ligand-receptor level, an anti-tgf-β neutralizing monoclonal antibody (1d11) which binds to the tgf-β molecules prevent them from interacting with the receptors on the surface of the cells, inhibiting their actions. the drug can be administered intravenously and enters both the subcutaneous and intracranial.28 however, the results of this experiment showed varying results when tested on immunocompetent and immunodeficient mice. when 1d11 was administered to the immunocompetent it was observed that the mice experienced complete remission from the drug, however when the same medication was administered, for unknown reasons, to immunedeficient mice the complete opposite effect was observed.28 current research has focused on the usage of human analogue of 1d11 antibody, gc1008, for the treatment of glioma has been done.2989zirkonium (zr)-gc1008 was shown to have excellent and specific uptake toward patients suffering from recurrent glioma, this was determined by using a positron emission tomography (pet) scan.29 other compounds such as ligand traps, in the form of soluble receptor, are able to bind to tgf-β molecules which prevent them from binding to the actual receptors on the cell surface. a study conducted by naumann et al, using adenoviral gene transfer to express tβrii which resulted in reduced smad2 phosphorylation in the tgf-β signaling pathway along with enhanced natural killer (nk) cell activity against glioma. mice model which expresses the tβrii was shown to have significantly delayed glioma growth compared to untreated mice.30 on the intracellular level, it is possible to reduce the kinase activity by blocking the activity of the tgf-β receptors on the cell. this prevents the formation of tgf-β signaling and thus downregulates the downstream proteins such as r-smad, it was shown that this can downregulate the proliferation and migration of glioma cells in vitro.31 the success of kinase inhibitor has been seen in other in vivo cancers such as basal cell carcinoma32, pancreatic carcinoma33, melanoma34, and mammary carcinoma.35 conclusion gliomas are malignancies within the cns which arise from glial cells and are characterized by aggressive proliferation and diffuse infiltration. tgf-β signaling plays a key role in the glioma progression as it can act as both a tumor promotor and tumor suppressor depending on the stage and degree of the malignancy. due to increasing evidence of increased tgf-β signaling in more advance stages of cancer the therapeutic benefit of inhibiting tgf-β signaling is being studied. the therapeutic benefits of inhibiting tgf-β has been observed in several other malignancies, 159 international journal of human and health sciences vol. 04 no. 03 july’20 and some trials has been conducted for glioma. the inhibition of tgf-β can be accomplished in several different levels which are (1) ligand level, (2) ligand-receptor level and (3) intracellular level. acknowledgments the authors would like to thank to directorate of research & community engagement, universitas indonesia for pitta grant. conflict of interest [the authors declared no conflict of interest) authors’s contribution: data gathering and idea owner of this study: hh, nsh study design: nsh data gathering: hh writing and submitting manuscript: hh, nsh editing and approval of final draft: nsh ethical clearence: evidence/ ethical clearance from dept source of funding:direcotorate of research & community engagement, universitas indonesia reference: 1. han j, alvarez-breckenridge ca, wang q-e, yu j. tgf-β signaling and its targeting for glioma treatment. am j cancer res. 2015;5(3):945–55. 2. kaminska b, kocyk m, kijewska m. tgf beta signaling and its role in glioma pathogenesis. in: barańska j, editor. glioma signaling [internet]. dordrecht: springer netherlands; 2013. p. 171–87. 3. roy l-o, poirier m-b, fortin d. transforming growth factor-beta and its implication in the malignancy of gliomas. targeted oncology. 2015 mar;10(1):1–14. 4. frei k, gramatzki d, tritschler i, schroeder jj, espinoza l, rushing ej, et al. transforming growth factor-β pathway activity in glioblastoma. oncotarget. 2015 mar 20;6(8):5963–77. 5. pdq adult treatment editorial board. adult central nervous system tumors treatment (pdq®): health professional version. in: pdq cancer information summaries [internet]. bethesda (md): national cancer institute (us); 2002. 6. goodenberger ml, jenkins rb. genetics of adult glioma. cancer genetics. 2012 dec;205(12):613–21. 7. naidich tp, editor. imaging of the brain. philadelphia: saunders/elsevier; 2013. 1052 p. (expert radiology series). 8. louis dn, perry a, reifenberger g, von deimling a, figarella-branger d, cavenee wk, et al. the 2016 world health organization classification of tumors of the central nervous system: a summary. acta neuropathologica. 2016 jun;131(6):803–20. 9. david cj, massagué j. contextual determinants of tgfβ action in development, immunity and cancer. nature reviews molecular cell biology. 2018 jul;19(7):419–35. 10. inman gj, nicolás fj, hill cs. nucleocytoplasmic shuttling of smads 2, 3, and 4 permits sensing of tgf-beta receptor activity. mol cell. 2002 aug;10(2):283–94. 11. lebrun j-j. the dual role of tgf β in human cancer: from tumor suppression to cancer metastasis. isrn molecular biology. 2012;2012:1–28. 12. huang jj, blobe gc. dichotomous roles of tgf-β in human cancer. biochemical society transactions. 2016 oct 15;44(5):1441–54. 13. suryadinata r, sadowski m, sarcevic b. control of cell cycle progression by phosphorylation of cyclindependent kinase (cdk) substrates. bioscience reports. 2010 mar 17;30(4):243–55. 14. 7929366 14. sun l, wu g, willson jk, zborowska e, yang j, rajkarunanayake i, et al. expression of transforming growth factor beta type ii receptor leads to reduced international journal of human and health sciences vol. 04 no. 03 july’20 160 malignancy in human breast cancer mcf-7 cells. j biol chem. 1994 oct 21;269(42):26449–55. 15. edison n, zuri d, maniv i, bornstein b, lev t, gottfried y, et al. the iap-antagonist arts initiates caspase activation upstream of cytochrome c and smac/diablo. cell death and differentiation. 2012 feb;19(2):356–68. 16. walker ra, dearing sj. transforming growth factor beta1 in ductal carcinoma in situ and invasive carcinomas of the breast. european journal of cancer. 1992 feb;28(2–3):641–4. 17. pasche b. role of transforming growth factor beta in cancer. j cell physiol. 2001 feb;186(2):153–68 18. wakefield lm, smith dm, flanders kc, sporn mb. latent transforming growth factor-beta from human platelets. a high molecular weight complex containing precursor sequences. j biol chem. 1988 jun 5;263(16):7646–54. 19. de wever o, demetter p, mareel m, bracke m. stromal myofibroblasts are drivers of invasive cancer growth. international journal of cancer. 2008 nov 15;123(10):2229–38. 20. tian m, schiemann wp. the tgf-β paradox in human cancer: an update. future oncology. 2009 mar;5(2):259–71. 21. oshima m, oshima h, taketo mm. tgf-β receptor type ii deficiency results in defects of yolk sac hematopoiesis and vasculogenesis. developmental biology. 1996 oct;179(1):297–302. 22. hasegawa y, takanashi s, kanehira y, tsushima t, imai t, okumura k. transforming growth factor-beta1 level correlates with angiogenesis, tumor progression, and prognosis in patients with nonsmall cell lung carcinoma. cancer. 2001 mar 1;91(5):964–71. 23. yang l. tgfβ and cancer metastasis: an inflammation link. cancer and metastasis reviews. 2010 jun;29(2):263–71. 24. neuzillet c, tijeras-raballand a, cohen r, cros j, faivre s, raymond e, et al. targeting the tgfβ pathway for cancer therapy. pharmacology & therapeutics. 2015 mar;147:22–31. 25. hau p, jachimczak p, schlingensiepen r, schulmeyer f, jauch t, steinbrecher a, et al. inhibition of tgf-beta2 with ap 12009 in recurrent malignant gliomas: from preclinical to phase i/ii studies. oligonucleotides. 2007;17(2):201–12. 26. hau p, jachimczak p, bogdahn u. treatment of malignant gliomas with tgf-beta2 antisense oligonucleotides. expert rev anticancer ther. 2009 nov;9(11):1663–74. 27. bogdahn u, hau p, stockhammer g, venkataramana nk, mahapatra ak, suri a, et al. targeted therapy for high-grade glioma with the tgf-β2 inhibitor trabedersen: results of a randomized and controlled phase iib study. neuro-oncology. 2011 jan;13(1):132–42. 28. hülper p, schulz-schaeffer w, dullin c, hoffmann p, harper j, kurtzberg l, et al. tumor localization of an anti-tgf-β antibody and its effects on gliomas. int j oncol. 2011 jan;38(1):51–9. 29. den hollander mw, bensch f, glaudemans aw, enting rh, bunskoek s, oude munnink th, lubde hooge mn, pearlberg j, gietemaja, de vries eg, walenkamp am. 89zr-gc1008 pet imaging and gc1008 treatment of recurrent glioma patients. 30. naumann u, maass p, gleske a-k, aulwurm s, weller m, eisele g. glioma gene therapy with soluble transforming growth factor-beta receptors ii and iii. int j oncol. 2008 oct;33(4):759–65. 31. hjelmeland md, hjelmeland ab, sathornsumetee s, reese ed, herbstreith mh, laping nj, et al. sb-431542, a small molecule transforming growth factor-beta-receptor antagonist, inhibits human glioma cell line proliferation and motility. mol cancer ther. 2004 jun;3(6):737–45. 32. fan q, he m, sheng t, zhang x, sinha m, luxon b, et al. requirement of tgfbeta signaling for smomediated carcinogenesis. j biol chem. 2010 nov 19;285(47):36570–6. 33. gaspar nj, li l, kapoun am, medicherla s, reddy m, li g, et al. inhibition of transforming growth factor beta signaling reduces pancreatic adenocarcinoma growth and invasiveness. mol pharmacol. 2007 jul;72(1):152–61. 34. mohammad ks, javelaud d, fournier pgj, niewolna m, mckenna cr, peng xh, et al. tgf-beta-ri kinase inhibitor sd-208 reduces the development and progression of melanoma bone metastases. cancer res. 2011 jan 1;71(1):175–84. 35. ge r, rajeev v, ray p, lattime e, rittling s, medicherla s, et al. inhibition of growth and metastasis of mouse mammary carcinoma by selective inhibitor of transforming growth factorbeta type i receptor kinase in vivo. clin cancer res. 2006 jul 15;12(14 pt 1):4315–30. international journal of human and health sciences vol. 04 no. 02 april’20 120 original article: encouragement and challenge for lecturers at faculty of medicine in writing mcq questions afridatul luailiayah1, gandes retno rahayu2, mora claramita3 abstract: objective: to explore factors that was being a challenge and an encouragement for lecturers in writing mcq questions. methods: this was a content analysis qualitative research. determination of the research subject was done with a maximum variation purposive sampling that was choosing faculty of medicine at states university with an a accreditation, and faculty of medicine at private university with a b accreditation. then research subjects was selected from each of these institutions with variations in teaching time, clinical and non-clinical lecturers, active and not active in writing mcq questions. the amount of research subject was 16. the results of the interview were transcripted and conducted with an open coding using open code 4.3 program by a researcher and a research assistant. coding results were analyzed using a thematic analysis approach. results: results from the qualitative analysis showed factors that was being an encourage for lecturers in writing mcq questions were the fulfillment of basic needs such as an autonomy, competence, relatedness, and religiosity. while the factors that was being a challenge for lecturers were not fulfilling these basic needs. conclusions: autonomy, competence, relatedness, and religiosity were basic needs that was influence lecturers in writing mcq questions. if the institutions aimed to conducted appropriate development programs for lecturers, they must pay attention to the basic human needs of life such as autonomy, relatedness, competence and religiosity. keywords: encouragement in writing mcq questions, challenge in writing mcq questions, selfdetermination theory, assessment correspondence to: afridatul luailiyah, department of parasitologi, faculty of medicine universitas islam sultan agung, semarang, central java, indonesia. email: dr.afrida06@gmail.com 1. afridatul luailiayah, lecturer, parasitology department at faculty of medicine, sultan agung islamic university, semarang. 2. gandes retno rahayu and mora claramita, lecturers, medical education department at faculty of medicine, public health and nurse, gadjah mada university, yogyakarta introduction multiple choice question (mcq) is one of the multiple choice assessments that is often used in the assessment of medical students. mcq has many advantages if written well, among others. it can be used to test students in large numbers, it also can be used to test wide knowledge contents. this assessment is accurate and consistent compared to other types of assessments.1 most writers find it difficult to make good mcq questions, so the results of mcq only tests a simple knowledge. it is only a repetition of facts and it is not a problem analysis.2 although the principles of writing effective mcq questions have been widely publicized but violations of the principles of writing questions mcq is common in medical education.3 writing mcq is difficult and requires a long time, even for lecturers who have attended mcq question writing training.4 based on previous research, it was found that bad mcq questions are often used during faculty examinations. the quality of mcq questions becomes poor when the author does not follow the standard principles of writing questions and lack of attention in the process of writing questions.2 there are several things that are suspected to be the cause of bad written mcq questions, international journal of human and health sciences vol. 04 no. 02 april’20 page : 120-127 doi: http://dx.doi.org/10.31344/ijhhs.v4i2.187 121 international journal of human and health sciences vol. 04 no. 02 april’20 including a lack of commitment from lecturers to prepare mcq exam questions, lecturers have not received training to make mcq questions and only a few lecturers have made strong preparations and have strong knowledge about writing a good mcq.2 faculty of medicine lecturers have a dual duty, apart from being teaching staff they also have the responsibility of being clinicians who provide care to patients and as researchers.5 previous research related to encouragement and challenge faced by lecturers when teaching have been widely studied, but it is still minimal that it is necessary to conduct more specific research on the factors that challenge and encourage lecturers in writing mcq questions. writing mcq questions is one of the tasks of teaching. but the encouraging and challenging factors in the teaching field are generally the same as the ability to make mcq questions. therefore, it is necessary to investigate further on what are the factors that encourage and challenge lecturers in writing mcq questions. the purpose of this study was to explore the factors that challenge and encourage the lecturers in writing mcq questions. materials and methods this content analysis approach qualitative research was conducted at the faculty of medicine in indonesia with the inclusion criteria as faculty of medicine at states university with an a accreditation, and faculty of medicine at private university with a b accreditation. the research subjects were taken with a maximum variation purposive sampling approach with variables: state and private university status, clinical and preclinical departments, length of teaching less than 5 years and more than 5 years and active or not actively making questions. each subject was taken for in depth interview. characteristics of research subjects can be seen in table 1 research data were collected by in depth interview of the research subjects. the results of the interview were transcripted at the end of each interview. the results of the transcripts were analyzed by the researchers, then the existing coding were grouped into themes and emerged sub themes. the coding determination was done by researchers and research assistants. coding was conducted by open code software version 4.3. the results of coding from researchers and research assistants were to conduct discussions to determine the coding used. research assistants were medical education graduates who have conducted qualitative research.6,7,8,9,10 table 1. characteristics of research subjects status clinical lecturers non clinical lecturers total active non active active non active <5th >5th <5th >5t h <5th >5th <5th >5th states university 1 1 1 1 1 1 1 1 8 with an a accreditation private university with a b accreditation 1 1 1 1 1 1 1 1 8 efforts to achieve credibility in this research were carried out in several ways including triangulation of sources of the assessment sections, presenting results using verbatim, member checking to respondents, and peer debriefing related to the results of coding with research assistants. efforts were made to write a research report in detail, clearly, systematically, and reliably. confirmability of this study was carried out by writing in full how the researchers in obtaining themes from all interview transcripts that were obtained.6,7,8,9,10. this study was approved by the gajah mada university ethical committee. results the challenging factors among the lecturers in writing mcq questions were the basic needs such as autonomy, relatedness and competence were not fulfilled. the low commitment of lecturers in learning is part of the autonomy of lecturers who are the most complained about. lecturers’ commitment in learning includes low commitment to write questions and poor time management. this commitment was what drives lecturers to carry out their work properly or not. this low commitment was influenced by the difficulty of lecturers in writing mcq questions. the difficulty of lecturers to write mcq questions were due to the rules in writing mcq questions and the difficulty of writing five homogeneous answer international journal of human and health sciences vol. 04 no. 02 april’20 122 choices . the rules for writing mcq questions made many lecturers complainined when they had to write mcq. the difficulties experienced by lecturers during the writing of mcq cannot be separated from the lack of competence of lecturers in writing mcq questions. another challenge complained that there were many responsibilities that the faculty of medicine lecturers have. faculty of medicine lecturers had responsibilities in the fields of teaching, research, and medical services. these responsibilities made the lecturers have less time to write mcq questions. especially if they are involved in structural management, then there will be less time to write questions. other factors that challenge lecturers in writing mcq questions can be seen in table 2 table 2. factors that challenge lecturers in writing mcq questions theme category ∑ coding 1. autonomy limited material 2 the commitment of lecturers in learning is low 6 2competence low competence in writing questions 3 the lecturer development program is uneven 1 hard in writing mcq questions 5 not according to competency 2 backup lecturer 3 3.relatedness poor facilities 7 poor communication 6 poor team work 8 poor management in writing questions 7 health problem 1 multitasking 3 no feedback 2 no award 3 no obligation 1 encouragement factors in writing mcq questions consist of autonomy, competence, relatedness, and religious. high commitment in writing questions is the main factor that drives lecturers to carry out their duties in writing mcq. this commitment is not obtained just like that but it is influenced by many extrinsic things. the material that is determined together with the block team makes the lecturer able to make questions in accordance with the competencies that medical students must have. the existence of lecturer development programs that are designed effectively and regularly held has an effect on the competence of doctors in writing mcq questions. lecturers who have good competency in making mcq questions tend to get various achievements related to questions that have been made. professionalism also encourage lecturers to carry out their duties properly in writing mcq questions. a good team work in the department makes the work atmosphere conducive. good communication when giving feedback, good appreciation, and the existence of a clear schedule for writing questions is a linking factor that encourage lecturers in writing mcq questions. other factors that encourage lecturers in writing mcq questions can be seen in table 3. table 3. factors that encourage lecturers in writing mcq questions theme category ∑ coding autonomy material autonomy 4 time autonomy 3 high commitment of lecturers in education 5 competence lecturer development programs 3 good competence in writing questions 8 lecturer achievement 3 student achievement 4 professionality 5 competency 1 relatedness assessment system policy 5 good team work 3 123 international journal of human and health sciences vol. 04 no. 02 april’20 policy involvement 3 facility availability 11 good communication 2 length of work 2 student encouragement in studying 4 giving feedback 6 arrangement about writing schedule 5 good award 5 religious sincerity 3 obedience 4 table 4 encouragement and challenging factors in writing mcq questions. kategori verbatim low commitment of lecturers “no, because the questioning is time-related, so even though there is time, if we are lazy to make questions then we will not make questions” (3kts respondent). “laziness hinders the process of writing questions.” (8nts respondent) multitasking “business. because if one course credit is counted from the teaching process until writing questions, then the clinical doctor will feel heavy. this is because the clinical doctor’s job is not just about writing questions. so there is a lot of additional work in the service that makes time run out, making it difficult to fulfill the obligations of 1 course credit. “(4ktn respondent) backup lecturers “in addition, when i asked to write questions where i did not give the material in lectures, it also added to the difficulty. so i had to know what material was given and lectured at the time. that made me lazy if i should made questions that the material was given by others lecturer.” (5ntn respondent) high commitment “so i have to work until late at night. this is because my job as a clinical doctor, so if i fill in the morning lectures, then after that i have to do clinical practice and complete obligations at the hospital, then at night do clinical practice at another hospital. so i went home at 9 pm this caused me to coordinate with the question-making team if i would send the question at 12 o’clock at night. “(1kan respondent) lecturer development programs “i thought that i was happy if i wrote the questions at the base camp. at that time accidentally i was in the obsgyn department where there were outdoor activities every 6 months. lecturers were collected and given a refreshing about writing questions. maybe it was good for each department to make an outdoor activities to make questions. “ (3ktn respondent) religious “charity that is not interrupted until the end of life is useful knowledge. when i taught and students can took advantage of what i said, then that was enough for me, because god will replace it with uninterrupted blessings until the end of my life. “(2kas respondent) feedback “a special meeting will be very helpful. the meeting with the ukmppd team was very helpful because i was being able to find out the types of questions that were tested, errors, solutions, then were given a new theme and asked to make it again. it was very good and useful, but it was difficult to determine the right time “(2kan respondent) policy involvement “this is very influential, because our involvement in the preparation of the curriculum made us understand the material that must be mastered by general practitioners, so the questions to be made can be adjusted to the curriculum designed. “(2kas respondent) good award “the best lecturer award on teacher’s day should not only be given to 1 person. the best 20 lecturers should be chosen as a nomination in writing the mcq questions, then the winner is chosen. it is an honor and pride to be able to enter the nomination, thus increasing the enthusiasm to make works in the form of questions. “(6nan respondent) discussion autonomy, relatedness and competence are basic needs that affect the encouragement of lecturers in writing mcq questions. autonomy, relatedness and competence can be divided into internal or intrinsic and external or extrinsic factors. intrinsic factors are factors that originate from themselves, while extrinsic factors are external factors that affect a person’s performance. intrinsic encouragement is obtained at all lecturers both clinical and preclinical who actively make questions in the faculty of medicine at private university with b accreditation. this intrinsic international journal of human and health sciences vol. 04 no. 02 april’20 124 encouragement is in the form of good lecturer competence in making questions, sincerity, obedience, high lecturer commitment in learning and professionalism. whereas in the faculty of medicine at state university with a accreditation, this intrinsic encouragement is also obtained by all clinical and preclinical lecturers who are actively making questions. intrinsic encouragement that is obtained at state lecturers includes good lecturer competence in making questions, high lecturer commitment in learning and professionalism. in this case there are differences between state and private faculty of medicine in terms of religiosity. the private and state lecturers who actively made problems did not get obstacles that came from intrinsic factors of previous research related to selfdetermination theory also explained the relation of autonomy relatedness and competence in learning 11,12,13 high commitment in writing questions is the main factor that encourages lecturers to carry out their duties in writing mcq. high commitment in writing questions obtained in clinical and preclinical lecturers who are active in making questions. this commitment is obtained because of various factors, one of which is the opportunity for lecturers to participate in determining material which will be taught and tested to medical students. when the opportunity to jointly discuss the material to be selected makes both lecturers in state and private faculty of medicine feel motivated to make mcq questions this is also in accordance with previous research that discusses communication and related issues. opportunities given to someone will increase their commitment at work.14,15 extrinsic factors greatly influence the encouragement of both private and state lecturers. these extrinsic factors include their need to feel related to their environment and the need to be competent in their field. the lecturer development programs that is carried out effectively and regularly is a driving force for faculty of medicine lecturers in writing questions both for clinical and preclinical lecturers who are active or not actively making questions. the lecturer feels that they make enough provision to make mcq questions. there is a program for making routine questions is a motivation needed by lecturers in writing mcq. the existence of this program makes lecturers have a regular schedule to contribute to writing mcq questions. the training held by the institution has an impact on increasing the competence of lecturers and making lecturers achieve achievements in writing mcq questions. in a study by bland et al. and pololi et al. that well-provided and regular mentoring is positively associated with the career satisfaction of lecturers in the faculty of medicine.14,16 the responsibility as a lecturer to write mcq questions is the biggest encourage for both clinical and preclinical lecturers who are actively creating questions. relatedness factors that encourage lecturers to continue writing about mcq include good cooperation within the department, policy involvement, facilities availability, good communication. good team work within the department make the work atmosphere conducive. the division of rights and obligations in one the department becomes clear so that the relationship is positive. good communication in delivering feedback is an encouragement for both clinical and preclinical lecturers in writing mcq questions. good appreciation from the institution for both clinical and preclinical lecturers provides their own encouragement for making mcq questions. previous research on meeting the need for good cooperation among members in one department is a strong predictor for increasing lecturer productivity.14,17,18,19 setting clear question in writing schedules makes lecturers both clinical and preclinical lecturers can arrange their time to make mcq questions in the midst of their busy life as a lecturers. the deadline makes the lecturer encouraged to write mcq questions immediately. the obedience and sincerity of a lecturer in carrying out his role has a positive impact on his encourage in making questions. lecturers in islamic-based faculty of medicine in private university got results that their trust in charity is unbroken, the concept of making questions as worship, and responsibility towards god keeps them motivated to carry out 125 international journal of human and health sciences vol. 04 no. 02 april’20 their duties well. this is in accordance with the hadith of buhori’s history. if adam’s child dies, his deeds are cut off except for three cases, almsgiving (wakaf), useful knowledge, and righteous children who pray to him.20 private and state university lecturers who do not actively write questions do not have intrinsic encouragement in carrying out their tasks. but the obstacles they face one of them is their own factors, among others: difficulty making mcq questions, low commitment in learning and low competency in making questions. the basic psychological needs for autonomy provide the main basis for understanding the internalization of extrinsic rules. humans have a strong desire to integrate rules to regulate their own behavior and determine the behavior that will be undertaken. an environment consisting of friends, parents, and teachers can influence the type and strength of one’s encouragement or in other words can affect the internalization process.21. the same obstacle is experienced by all faculty of medicine lecturers, both faculty of medicine at private and state university. lecturers who are active in writing questions or not, clinical and preclinical is low commitment to learning, difficulty in writing mcq questions, and many other responsibilities by lecturers. this commitment underlies a person’s behavior to carry out their duties properly or not. commitment cannot be obtained just like that but influenced by external factors in the form of a lecturer’s need to feel competent and the need to feel related to his environment. this is in accordance with the research in jozefowicz et al about the quality of mcq questions in the faculty of medicine which states that one of the factors that influence the quality of mcq questions is the lack of lecturer commitment in writing mcq questions.2,22 the difficulty of lecturers in writing mcq questions was experienced by almost all lecturers both clinical and preclinical lecturers. the rules for writing mcq questions that make it difficult for many lecturers to write mcq questions. lecturers need a lot of time and concentration in writing mcq questions. the next difficulty is related to the answer options which must be five and homogeneous. both clinical and preclinical lecturers claim that it is difficult to make answer choices five and homogeneous. this difficulty is related to not all of the answers to be tested are five and homogeneous. this is also in accordance with the research.2,23 junior lecturers in faculty of medicine at state university complained that the obstacle they experienced was being a backup lecturer. this backup lecturer makes junior lecturers to be ready to be a substitute when senior lecturers were unable to give lectures or write questions. this delegation is sometimes sudden before the exam is held so that junior lecturers are limited to prepare mcq questions. the large number of responsibilities and heavy workload made faculty of medicine lecturers lack the time to write mcq questions. this is complained especially by clinical lecturers both junior and senior. previous research also found that faculty of medicine lecturers were faced with a solid practice schedule and research obligations, so that the teaching obligation is abandoned. 5,24,25, based on the results of the study, policy holders in both public and private institutions when going to improve the quality of lecturer resources must pay attention to various things including: intrinsic and extrinsic factors that challenge and encourage lecturers to engage in learning. intrinsic factors in the form of professionalism and high commitment to be involved learning does not appear by itself but requires needs from external factors, namely the need for relatedness and competence. the need for relatedness that is most needed by both private and state lecturers is good team work, involved in curriculum development, and interaction in recovery. competence needs that need to be considered by the institution are conducting effective questioning training, providing feedback analysis items, writing questions according to their competencies, and becoming competent lecturers in their fields. the factors which challenge the writing of questions also need to be known by the institution. these factors are influenced by internal and external factors of the lecturers. this internal international journal of human and health sciences vol. 04 no. 02 april’20 126 factor is low commitment. the low commitment of lecturers must be an evaluation material for policy holders regarding what influences it. as for the external factors are the difficulty of making questions. the difficulty of making questions is due to the rules that must be obeyed in making mcq questions. this difficulty must be solved by holding an effective problemmaking training. the next factor is related to the many responsibilities assigned to the lecturers of the faculty of medicine. conclusion acknowledgments the conclusion of this study is the factors that challenge and encourage lecturers in writing mcq questions consisting of basic physical needs in the form of autonomy, competence, relatedness, and religiosity. in addition, we can conclude that if an institution wants to conduct an appropriate development program for lecturers, it must pay attention to the basic human needs of life which include autonomy, relatedness, competence and religiosity. authors’s contribution: data gathering and idea owner of this study: afridatul luailiayah, gandes retno rahayu, mora claramita study design: afridatul luailiayah, gandes retno rahayu, mora claramita data gathering: afridatul luailiayah, gandes retno rahayu, mora claramita writing and submitting manuscript: afridatul luailiayah editing and approval of final draft: afridatul luailiayah ethical clearence: this study was approved by the gajah mada university ethical committee source of funding: this research is supported by faculty of medicine, unissula. 127 international journal of human and health sciences vol. 04 no. 02 april’20 references: 1. case s.strategies for performing well on multiplechoice question tests. in: al alwan i, magzoub me, elzubeir m, eds. an international handbook of 1. medical education: a guide for students. london:2012:247-53. 2. jozefowicz rf, koeppen bm, case s, dkk. the quality of in-house medical school examinations. acad med ;2002;77(2):156-61. 3. collins j. education techniques for lifelong learning: writing multiplechoice questions for continuing medical education activities and selfassess mentmodules. radiographics 2006; 26:543–551 4. van hoozer h..the teaching process: theory and practice in nursing. norwalk, conn: appletoncenturycrofts.1987. 5. lowenstein sr, fernandez g, crane la. medical school faculty discontent: prevalence and predictors of intent to leave academic careers. bmc med educ. 2007;7:37. doi:10.1186/1472-6920-7-37. 6. creswell, j. w. research design: qualitative, quantitative, and mixed methods approaches (2nd ed). thousand oaks; sage publications, inc; 2003. 7. creswell, j. research design qualitative, quantitative, and mixed methods approaches. uk: sage publications, 2009. 9. moleong, lexy j. metodologi penelitian kualitatif. bandung: remaja rosdakarya.2007 10. satori, djam’an & komariah, aan. metodologi penelitian kualitatif(cetakan kedua). bandung: alfabeta.2010 11. sugiyono. metodologi penelitian pendidikan, pendekatan kuantitatif, kualitatif, dan r&d. bandung: alfabeta. 2008. 12. gagne m, deci e.l. selfdetermination theory and work motivation.jounalof organizational behavior.2005.26.331-362. 13. jeffrey g. bailey academics’ motivation and self‐efficacy for teaching and research, higher education research & development, 1999;18:3:343359, doi:10.1080/0729436990180305 14. ryan rm and deci edward l,: intrinsic and extrinsic motivations: classic definitions and new directions: contemporary educational psychology.2000. 54–67. 15. simpson de, rediske va, beecher a, coger d, meurer l, lawrence s, wolkomir m: understanding the careers of physician educators in family medicine. acad med 2001, 76:259-265 16. bland cj, seaquist e, pacala jt, center b, finstad d: one school’s strategy to assess and improve the vitality of its faculty. acad med 2002; 77:368-376. 17. darosa da, skeff k, friedland ja, dkk. barriers to effective teaching. acad med. 2011;86:453–9. 18. pololi lh, knight sm, dennis k, frankel rm: helping medical school faculty realize their dreams: an innovative, collaborative mentoring program. acad med 2002, 77:377 19. morzinsky ja, fisher jc: a nationwide study of the influence of faculty development programs on colleague relationships.acad med 2002, 77:402-406 20. hitchcock ma, bland cj, hekelman fp, blumenthal mg: professional networks: the influence of colleagues on the academic success of faculty. acad med 1995, 70:11081116. 21. van den berg bam, bakker ab, ten cate thj. key factors in work engagement and job motivation of teaching faculty at a university medical centre. 2013.3:264-27 22. ten cate tj, kusurkar ra, williams gc. how self determination theory can assist our understanding of the teaching and learning processes in medical education. amee guide no. 59. med teach.2011;33:961–73. 23. tarrant m &ware j, impact of itemwriting flaws in multiple-choice questions on student achievement in high-stakes nursing assessments. medical education 2008: 42: 198– 206 24. gerrity ms, pathman de, linzer m, steiner bd, winterbottom lm, sharp mc. career satisfaction and clinical-educators—the rewards and challenges of teaching. j gen intern med. 1997;12:s90–7. 25. dybowski c ,sehner s ,harendza s, influence of motivation, self-efficacy and situational factors on the teaching quality of clinical educators. bmc medical education (2017) 17:84.doi 10.1186/s129090170923-2. 26. van den broeck a, vansteenkiste m, witte h, lens w. explaining the relationships between job characteristics, burnout, and engagement: the role of basic psychological need satisfaction. work stress. 2008;22:277–94. international journal of human and health sciences. supplementary issue: 2019 doi: http://dx.doi.org/10.31344/ijhhs.v0i0.155 s37 the importance of fatigue management for healthcare workers from islamic perspective khairil idham ismail1,2, hanizah mohd yusof1, ahmad faidhi m.z.3, basri, i.4 1department of community health, faculty of medicine, universiti kebangsaan malaysia medical centre, jalan yaacob latiff, kuala lumpur, ma laysia; 2ministry of health malaysia, federal government administrative centre, putrajaya, malaysia; 3universiti islam malaysia, cyberjaya, malaysia / hospital angk atan tentera tuank u mizan, kuala lumpur, malaysia; 4universiti islam malaysia, cyberjaya, malaysia / faculty of islamic contemporary studies, universiti sultan zainal abidin, terengganu, malaysia. abstract introduction: fatigue is common among healthcare workers (hcws). long continuous duty hours, sleep loss with minimal recuperation and shift work are among work-related factors contributing to fatigue. being fatigued will impair physical, cognitive, and emotional functio n. substantially, it will impact the occupational and patient safety along with quality of healthcare delivery. nevertheless, there are still paucity of islamic perspective on the importance of fatigue management for hcws. objectives: our aim is to outline the islamic perspective of fatigue management for hcws. methods: review of literature in relevance to fatigue among hcws were carried out. document analysis from islamic jurisprudence (fiqh) references including literature from maqasid syariah (the objective of syariah) and qawaid fiqhiyyah (islamic legal maxims) perspective. interviews with expert from both islamic scholars and clinicians are conducted. results: our findings provide islamic perspective on the importance of fatigue manageme nt for healthcare workers. the consequences of fatigue such as slowed reaction time, reduced vigilance, reduced decision-making ability, poor judgment, distraction during complex task and loss of awareness in critical situations raise the issue on the integrity of patient safety and occupational safety. this is in contrary with the principle of maqasid syariah which highly emphasize protection of life (hifz an-nafs) and intellect (hifz ‘aql) of both group of hcws and patients. while qawaid fiqhiyyah strongly against inflicting harm to themselves nor bring harm to others (la darar wa la dirar); which serve as basis to support this fatigue manageme nt framework in a holistic manner. conclusion: this study may serve as an added perspective in the angle of islamic view on the importance of fatigue management for healthcare workers. keywords: fatigue, healthcare workers, islamic, maqasid international journal of human and health sciences. supplementary issue: 2021 s1 committee members of islamic medical association of malaysia (imam) symposium 2020 on covid-19: planning for the future doi: http://dx.doi.org/10.31344/ijhhs.v5i0.293 organizingcommittee advisor dr jeffrey bin abu hassan event director dr ahmad yusuf bin yahaya secretary dr aneesa binti abdul rashid treasurer dr muhamad syafiz ahmadbin ismani sponsorship dr asma alhusnaabang abdullah secretariat nur amalina binti rosli participant technical support humaira nursahira binti omar logistics ummi faten nabila binti saiful anuar live event operator nurul atiqah binti ishak q&a engagement dr amir haqeem bin amirfizal website & technical support dr fatinizlailizaini stream producer dr ahmad zahin bin zulkipli http://dx.doi.org/10.31344/ijhhs.v5i0. international journal of human and health sciences. supplementary issue: 2021 s2 scientific committee chairperson dr elsa haniffah mejia mohamed members dr muhamad yusri musa dr nur aizati athirah binti daud professor dr dinsuhaimisidek assoc. professor dr wan ahmad hafiz bin wan md adnan professor dr irfan mohamad international journal of human and health sciences. supplementary issue: 2019 doi: http://dx.doi.org/10.31344/ijhhs.v0i0.168 s50 marginalised medical officers; do we care? ahmad zulfahmi mohd kamaruzaman1, mohd ismail ibrahim1, anees abdul hamid2. 1department of community medicine, school of medical sciences, universiti sains malaysia, kelantan, malaysia; 2kelantan state health department, 15200 kota bharu, kelantan, malaysia abstract introduction: medical officers are responsible to give health services to population. ironically, they also suffer from unhealthy consequences in the mould of job strain. objective: thus, the main aim of this study is to determine the job strain among medical officers in health clinics (hcs), kelantan and its associated factors. methods: this was a cross-sectional study of the prevalence and risk factors of job strain among medical officers in hcs. the study was conducted between january and april 2019 using simple random sampling involving a total number of 232 medical officers. the selected medical officers were given the malay version of validated job content questionnaire (jcq) in order to investigate job strain. there were three components investigated and two of them; decision latitude and psychological demands were applied to define job strain. the median score was utilized as the cut-off point to separate high and low result of the data. high psychological demand with concurrent low decision latitude resulted in high job strain. the last component investigated was social support (co-worker and supervisor support). the data were presented descriptively and logistic regression was used to find the association for the job strain. results: the prevalence of high job strain among medical officers serving in hcs, kelantan was 22.4 percent. supervisor support was significantly associated with job strain. conclusion: a high proportion of medical officers in hcs suffered high job strain. supervisor support proved to be substantial in relieving job strain. keywords: job strain, job content questionnaire, health clinics international journal of human and health sciences vol. 02 no. 03 july’18 112 review article: tobacco dependence; the whole story hawari fi abstract: the use of tobacco dates back to hundreds of years and is considered highly addictive. nicotine is the predominant substance that causes tobacco dependence. nicotine exerts its effect via similar neurological pathways used by other recreational drugs resulting in high level of dependence. all forms of exposure to tobacco including active use of tobacco, second-hand as well as third-hand exposure to tobacco smoke are known to be harmful. tobacco is the only risk factor that is common between all non-communicable diseases including cardiovascular diseases, respiratory illnesses, cancer and diabetes mellitus. international consensus regarding the harms of tobacco is now evident. many international organizations are mapping the way for the end of tobacco. until then, aggressive treatment for those subjects interested in quitting must be provided in order to prevent a significant surge in non-communicable diseases especially in low income countries. tobacco dependence is a chronic relapsing disorder that requires a multidisciplinary approach using psychological and pharmacological techniques. keywords: tobacco dependence, tobacco harms, tobacco control, tobacco dependence treatment correspondence to: : feras i. hawari, md, fccp, chief, section of pulmonary and critical care, director, cancer control office, king hussein cancer center, jordan email: fhawari@khcc.jo the history of tobacco: tobacco is a naturally deadly plant that initially was grown only in north and south america. it belongs to the same family as potatoes and pepper. following the discovery of america, sailors brought tobacco with them to europe and then to the rest of the world. in the 1500’s it was thought that tobacco can cure all diseases and was promoted as such by physicians and recommended to be taken daily. later in the 1600’s, tobacco became so popular and was used instead of money to complete business transactions. during those times the first hints that tobacco might be harmful began to surface. in 1610 the first evidence that tobacco might be addictive and that smokers might be interested in quitting was concluded from a statement made by sir francis bacon who noted that ” trying to quit the bad habit was really hard”. by mid-1600’s it became morally unacceptable to smoke in certain states of the united states of america such as massachusetts due to the fact the tobacco may be harmful1-2. in 1760, pierre lorillard established a company in new york city to process tobacco, cigars, and snuff and became the oldest tobacco company. the tobacco industry became well established since then and played a role in financing governmental actions including military operations. following that and in 1826 specifically, nicotine was isolated in its pure format and was declared few years later poisonous and that it can be used as an insecticide. in 1836 the first statement was made regarding the lethal effect of nicotine as a chemical that might be able to kill a human being. cigarettes were firs manufactured in 1847. by the year 1900 cigarettes became the major tobacco product made and sold. in 1901 for example, 3.5 billion cigarettes and 6 billion cigars were sold. cigarettes continued to spread after that to a point that they were part of soldiers’ rations during world war ii. finally, in international journal of human and health sciences vol. 02 no. 03 july’18 page : 112-125 doi: http://dx.doi.org/10.31344/ijhhs.v2i3.38 113 international journal of human and health sciences vol. 02 no. 03 july’18 1964 the first usa surgeon general report came out carrying the title “smoking and health” focusing on health effects of tobacco and providing the first document for governments to start regulating and controlling the spread of tobacco. later, more surgeon general reports began to shed the light on the harmful effects of tobacco till the year 1982 when second hand smoke exposure was declared a risk factor for the development of lung cancer resulting in the gradual banning on smoking in public places. throughout the years, all efforts by governments to curb the spread of tobacco were constantly faced by counter novel and misleading tactics by the tobacco industry that encouraged the use to tobacco through marketing to teenagers, females using products designed specifically to attract such consumers. in addition, they started diversifying their products to include food and clothing. lately, the tobacco industry moved into a new line of production; electronic cigarettes in order to face global efforts aiming at putting an end to this industry and reducing tobacco prevalence to less than 5% by 2040. worldwide, 3.8 million hectares of agricultural land are used in tobacco agriculture distributed over 124 countries. china grows 43% of the world’s tobacco cigarettes accounting for 92% of the value of all tobacco products sold globally. forms of tobacco and tobacco smoke exposure: tobacco is used either by burning dry or processed leaves of the tobacco plant and inhaling the smoke or as smokeless tobacco which is usually consumed either orally or nasally, without burning or combustion. both forms of tobacco consumption increase the risk of cancer and lead to nicotine addiction. combustion, however, uses heat to create new chemicals that are not found in unburned tobacco such as carbon monoxide, tobacco-specific nitrosamines (tsnas) and benzopyrene, and allows them to be absorbed through the lungs.1 manufactured cigarettes are the most commonly consumed tobacco products worldwide.1 they consist of tobacco that is processed with chemicals and flavors such as menthol and rolled into a paper-wrapped cylinder. as it burns from one end, smoke is inhaled from the other end through a cellulose acetate filter. cigars are made of air-cured and fermented tobaccos rolled in tobacco-leaf wrappers. this process of aging and fermentation result in high concentrations of carcinogenic compounds inhaled by smokers and they amount to higher concentration than in cigarettes. waterpipe, also known as shisha, hookah, narghile, or hubble-bubble constitutes now a world-wide epidemic.3 the additional use of charcoal in waterpipe smoking to indirectly heat and burn tobacco represents a significant added risk that contributes to the carcinogenicity of this method of smoking. when smoking waterpipe, smoke is drawn through the water to be partially cooled and inhaled into the lungs through a hose. flavored tobacco maybe used too. kreteks, another form of smoking tobacco, are usually clove-flavored and contains eugenol which has an anesthetic effect.4 flavoring in general usually allow for deeper and thus more harmful smoke inhalation. this form of smoking tobacco is commonly used in countries in southeast asia such as indonesia. contrary to the belief of the general public, roll-your-own cigarettes which are handfilled by the smoker from fine-cut loose tobacco and a cigarette paper contains high concentrations of tobacco particulates, tar, nicotine, and tsnas resulting in increased risk for developing cancers of the head and neck, lungs, and esophagus. it is most prevalent in europe and new zealand. bidis on the other hand, consist of a small amount of crushed tobacco, hand-wrapped in dried temburni or tendu leaves, and tied with string. bidis deliver more tar and carbon monoxide than manufactured cigarettes due to the fact that users should puff harder to keep them lit. bidis are most prevalent in south asia and india. pipes are made of briar, slate, clay, or other substances. after placing tobacco in a special bowl, it is burned and smoke is inhaled through the stem. pipes are prevalent worldwide. sticks are made from sun-cured tobacco and wrapped in cigarette paper. smokeless tobacco forms include chewing tobacco, moist tobacco and dissolvable tobacco. all these forms deliver nicotine through buccal mucous membranes. dry snuff is inhaled through the nose or taken orally. second-hand smoking (passive smoking) is another form of exposure to tobacco smoke. this type of exposure does not only contribute to the initiation of smoking, development of tobacco dependence5 and significant irritation to those who are exposed to it, but it also contributes to significant mortality and morbidity in the community.6 passive smoking can significantly elevate the level of carbon monoxide, increase risk of lung cancer, coronary artery disease and international journal of human and health sciences vol. 02 no. 03 july’18 114 sudden cardiac arrests in those expose to it.7 in the 1960s the adverse effects of maternal smoking on the developing fetus and on children exposed to secondhand smoke in smoking households were reported.8,9 those fetuses who were exposed to environmental tobacco smoke suffered from decreased lung function.10 all that led to a conclusion by the usdhhs 1986, that “simple separation of smokers and nonsmokers within the same air space may reduce, but does not eliminate, exposure of nonsmokers to environmental tobacco smoke”. such conclusion was then the basis for strict implementation of banning the exposure to second hand smoke in public places.11 another form of exposure to tobacco smoke is the newly described third-hand smoking. this refers to the chemical and products that precipitate on the surfaces after second hand smoke is cleared.12 third-hand smoke contaminate surfaces, furniture and clothing with carcinogenic chemicals such as radioactive polonium-210 and tobacco-specific nitrosamines.13,14 these chemical could potentially pose great deal of danger to infants and young children who are more likely to crawl and eat with their hands without washing them. research is underway to expose the real health risks associated with thirdhad smoking.15 tobacco in the region: epidemiology, expected health tolls and finance despite efforts to control the spread of tobacco, currently 20% of the world’s population smokes with mails constituting around 80% of the total percentage of smokers resulting in around one billion active smoker. such large number of smokers is not only causing a rise in morbidity and mortality due to various diseases that result directly from smoking, but also contributing significantly to death resulting from second hand smoking especially in women and children while current death toll from second hand smoking is estimated to be at 600,000 individuals annually,1 it is also estimated that 75% of these deaths are among women and children. in general, males contribute to the majority of percentage of smokers in the world. more than half the countries of the world have a female smoking prevalence rate of less than 10%. smoking rates among boys and girls are more comparable and differ by less than five percentage points in almost half of the world’s countries. smokers consumed nearly 5.9 trillion cigarettes in 2009. tobacco taxation is considered a significant source of revenue income for most countries. despite the fact that governments collect nearly $133 billion in tobacco tax revenues each year, they spend less than $1 billion on tobacco control. further increase in revenue is expected if illicit trade were to be eliminated. governments worldwide would gain at least $31.3 billion a year in tax revenue. the world health organization (who) recommends that at least 70% of the retail price of tobacco products come from excise taxes. at least 86% of who member states imposed a tobacco excise tax, and at least 14% use a portion of tobacco tax revenue for health purposes. some countries are now envisioning an end game for tobacco, with prevalence targets of under 5%. the who frame work convention on tobacco control (fctc) treaty covers 87.4% of the world population. approximately 3.8 billion people are covered by at least one of the six mpower strategies that will be discussed below at the highest level of achievement. the number of people protected by comprehensive smoke-free laws has doubled from 2008 to 2010.1 tobacco initiation and dependence: tobacco initiation typically occurs during childhood or adolescence. it is an acquired social behavior.16 social learning occurs in children as they adopt behaviors in part through observation of parents, peers, and other role models. during the teenage years, peer pressure becomes the dominant social influence.16 media plays an important role in promoting and normalizing the appearance and the behavior of smokers through projecting famous figures smoking in public. initially, initiation is mostly voluntary, however, upon the development of addiction, self-control can become seriously difficult and impaired. the cycle of nicotine addiction starts when nicotine containing products are used for pleasure and enhancing mood and performance. as tolerance and physical dependence develop over time continuous use of nicotine products are used to self-medicate withdrawal symptoms in addition to the above sought after effects.17 tobacco dependence and withdrawal syndromes are classified as substance use disorders under world health organization international statistical classification of diseases and related health problems (icd 10),18 an important step in justifying and encouraging governments to offer treatment to smokers. in general, dependence 115 international journal of human and health sciences vol. 02 no. 03 july’18 develops when the neurons adapt to the repeated drug exposure and only function normally in the presence of the drug.19 tobacco dependence is driven by the highly addictive nature of nicotine. as a psychoactive drug, nicotine induces euphoria, serves as a reinforcer of its use and act as both a stimulant and a depressant. strong and overwhelming withdrawal symptoms develop in its absence. tobacco dependence fulfils all diagnostic and statistical manual of mental disorders, 4th edition criteria for substance abuse. it is ranked third after heroin and cocaine and higher than alcohol and cannabis in its ability to cause dependence.20 the combination of its highly addictive property as well as the severe harms that it inflicts on its active users as well as the severe detrimental health effects second and third hand smoking have on the population, caused religious islamic leaders in many muslim countries such as jordan, egypt, many countries in gulf cooperation council as well as islamic countries in southeast asia to issue a fatwa that using tobacco products is forbidden according to islamic rules (haram).21,22,23,24 it is important to note that nicotine mechanism of action and the targeted areas in the brain are similar to other recreational drugs such as cocaine which its principle mechanism of action is thought to be by targeting areas in the brain such as the nucleus accumbens and increasing levels of dopamine which in return result in the desirable effects and inhibit the withdrawal symptoms that may results from abstinence from the drug.25 nicotine reaches the brain through either the lungs when smoked or mucous membranes when smokeless tobacco forms are used. although the levels of many substances are reported to increase in the brain upon exposure to tobacco smoking such as serotonin and endogenous opiates, however, dopamine remains the main chemical involved in the process of positive reinforcing aspects of nicotine addiction and the desired feelings sought by those who use tobacco. as nicotine reaches the brain it binds to a special receptor known as α4β2 nicotinic acetylcholine receptor (nachr). located in the ventral tegmental region and results in the release of dopamine.26 27 28 29 30 31 32 33 as nicotine binds to α4β2 nicotinic acetylcholine receptor (nachr) occupancy on glutamatergic terminals, glutamate, an excitatory neurotransmitter, is released which results in an increased release of dopamine in the nucleus accumbens and the frontal cortex.34 35 36 37 38 39 in addition nicotine binds to α4β2 nicotinic acetylcholine receptor (nachr) occupancy on gamma-aminobutyric acid (gaba)-releasing terminals.40,38 this binding cause and increase in the levels of gaba, an inhibitory neurotransmitter. furthermore, nicotine binds to a specific receptor in regions of the brain such as the nucleus accumbens and result in the production of dopamine. 41 these chain reactions start as nicotine reaches the brain in 10-20 seconds after inhalation mainly due to due to the large surface area in the lung available for absorption and is the main basis for the development of nicotine dependence.42 in general, nicotine dependence follows a similar definition of dependence that occurs with other substances and that is characterized by both the persistence of a drug-seeking behavior and the emergence of withdrawal symptoms upon the abrupt cessation of nicotine administration.41 in the end, chronic nicotine exposure result in a neuro-biologic adaptation and desensitization of the receptors with the need to increase those receptors through further increase in the quantities of tobacco consumed. however, not all forms of nicotine delivery pose an equal risk in establishing or maintaining nicotine addiction. nicotine replacement therapy used in treating tobacco dependence for example is less likely to cause dependence and easier to discontinue once the treatment goals are achieved. although it has been always emphasized that nicotine is the most important chemical in cigarettes that contributes to its highly addictive properties, other compounds such as acetaldehyde, ammonia compounds, and menthol also make cigarettes more addictive through increasing free-base nicotine, making it easier to produce larger puffs (filter-tip ventilation) and other factors that reduce the concerns for smokers and increase the attractiveness of the products.43 nicotine is metabolized primarily by the liver enzymes cyp2a6, udp-glucuronosyltransfease (ugt), and flavin-containing monooxygenase (fmo). many factors influence the metabolism of nicotine such as genetic factors, diet, age, sex, use of estrogen-containing hormone preparations, pregnancy and kidney disease, other medications, and smoking itself.44 nicotine is further metabolized to cotinine, which may be measured in blood, urine, saliva, hair, or nails. cotinine levels are used to distinguish smokers from nonsmokers. levels exceeding 3 ng ml−1 indicate international journal of human and health sciences vol. 02 no. 03 july’18 116 active smoking status in countries with low exposure to second hand tobacco smoke exposure. second hand smoke exposure is believed to play an important role in the occupancy of α4β2 nicotinic acetylcholine receptor occupancy. recent evidence45 utilizing positron emission tomography scanning measured whether moderate shs exposure results in brain α4β2* nicotinic acetylcholine receptor occupancy in smokers and nonsmokers. the study concluded that nicotine from shs exposure results in substantial brain α4β2* nachr occupancy in smokers and nonsmokers. in addition, the finding suggested that such occupancy would be sufficient to deliver a priming dose of nicotine to the brain that contributes to continued cigarette use in smokers. it was also important to note that while moderate exposure tested in this study was sufficient to cause an increase in plasma nicotine concentration of approximately 0.2 ng/ml and a mean 19% brain α4β2* nachr occupancy in young adults heavy shs exposure (in enclosed rooms with multiple smokers) demonstrated increases in plasma nicotine levels greater than 2 ng/ml and greater than 70% α4β2* nachr occupancy. 46 these alarming findings have greater implication in countries where second hand exposure control are not implemented resulting in significant exposure in nonsmokers especially prepubescent children and infants who have a 1-minute ventilation per kilogram of bodyweight that is approximately 2 to 3 times higher than adults increases in plasma nicotine concentration and occupancy of brain α4β2* nachrs from similar levels of shs exposure may be even greater for children than for adults, thus setting them up to be dependent on nicotine during early childhood. such studies that link shs exposure and craving in smokers as well as priming nonsmokers especially children is highly relevant to public policy and laws that aim at limiting shs exposure in closed public places.47, 48, 49 health effects of tobacco: every year more than 5 million people die from tobacco-related diseases. by the year 2030, this number is expected to near 10 million.50 with high income countries making efforts to limit the spread of tobacco in their areas and consequently succeeding in decreasing the prevalence of smoking, it is expected that more than 80% of these tobacco-related deaths will occur in low income countries.1 tobacco is currently the most preventable cause of death and is the only risk factor that is common among all non-communicable diseases namely cardiovascular disease, cancer, respiratory illnesses and diabetes mellitus. however, the world economic forum estimates that the cost of these diseases in low income countries is expected to exceed usd 20 trillion over the next 15 years, thus exerting enormous pressures on countries with limited resources to enforce their tobacco control regulations.51 ncds related deaths are expected to increase by more than 25% in low income countries over the next 15 years.52 cardiovascular diseases occupy the number one spot among all ncds that cause death in humans. the relation between tobacco use and cardiovascular diseases was recognized in the first surgeon general report in 1964.53 cigarette smoking accelerates atherosclerosis and contributes to cardiovascular diseases through many mechanisms that precipitate thrombosis, hemorrhage, or vasoconstriction resulting in the end in vascular occlusion and ischemia. cigarette smoking affects blood lipids profile and hemostasis.41 smokers have lower concentration of high density lipoproteins, a risk factor for coronary artery diseases. carbon monoxide resulting from the combustion of tobacco and that is significantly elevated in the blood of smokers is known to have an affinity for hemoglobin of more than 200 times of that of oxygen, thus reducing directly oxygen delivery to the tissues. overall, smoking causes cvd through multiple mechanisms including: endothelial dysfunction, increasing prothrombotic effect, enhanced platelet activation in response to different stimuli, inflammation through activation of nf-κb pathway,54 altered lipid metabolism, increased demand for myocardial oxygen and blood. all these proposed mechanisms would result in a decreased supply of myocardial blood and oxygen either directly through narrowing of the lumen (due to atherogenesis plaque formation and vascoconstriction) or through the increased demand (due to nicotine mediated sympathetic stimulation and increased heart rate, blood pressure and myocardial contractility). the 2010 surgeon general’s report55 reported an increase in chd risk with more cigarettes smoked per day only up to about 25 cigarettes. others showed such relation to continue up to 40 cigarettes per day.56 these effects are not exclusive for active tobacco 117 international journal of human and health sciences vol. 02 no. 03 july’18 smoking, in fact, secondhand smoke is also associated with chronic inflammation and a nonlinear dose-response relationship between such exposure and cardiovascular effects.57 jefferis et al showed that serum cotinine in nonsmokers was positively associated with white blood cell count and with levels of crp, il-6, fibrinogen, and matrix metalloproteinase 9. the crp levels of nonsmokers were about one-third lower than the levels of active smokers, but crp levels increased more sharply among nonsmokers at higher exposure levels.58 these findings emphasize again the benefits of banning smoking in public places. in addition to coronary heart disease, a growing sufficient body of evidence indicates that smoking causes sudden death,59 aortic aneurysms,60 and peripheral vascular disease.61,62 there is a doseresponse relationship between smoking and cerebrovascular disease;63,64,65 and a new sufficient evidence that demonstrates a causal relationship between exposure to secondhand smoke and increased risk of stroke up to 30%.66,67 smoking and cancer: it has been established that smoking increases the risk for certain cancers such as head and neck cancers, lung cancer, urinary bladder cancer and leukemia. tobacco smoke contains more than 7,000 chemicals, and at least 69 of these can cause cancer.68 an example of these chemicals include aromatic amines, polycyclic aromatic hydrocarbons (pahs); tobacco-specific nitrosamines; formaldehyde, acetaldehyde, 1,3-butadiene, and benzene. when inhaled, these substances cause dna damage, inflammation and mutations in oncogenes and tumor suppressor genes leading to loss of normal growth controlled mechanisms.55 recently, new evidence concluded a causal relationship between colon cancer and liver cancer.41 in addition, evidence is suggestive that exposure in both its forms, active smoking and exposure to second-hand tobacco smoke might cause breast cancer. in general, smoking has been associated with decreased survival in patients with a variety of cancers such as head and neck, breast, colorectal cancer, prostate cancer and others.69 this negative effect on survival outcome is multifactorial. for example, smoking has been associated with poor nutrition, co-morbidities, impaired immune function and accelerated carcinogenesis and disease progression.70,71,72,73,74 second, patients who continue to smoke while they are receiving chemo and radiotherapy are at risk of receiving suboptimal therapy for their cancer75 and have a higher chance of developing adverse events related to these modalities of treatment.76,77,78 third, the development of a second malignant primary tumor and the negative impact of smoking on the life of cancer survivors are other significant risks that cancer patients who continue to smoke must deal with.79,80,81 smoking and pulmonary diseases: smoking is known to cause and affect many respiratory illnesses such as chronic obstructive pulmonary disease (copd), asthma, tuberculosis and pulmonary fibrosis. smoking causes all elements of the copd phenotypes including emphysema and damage to the airways of the lung. smoke recruits inflammatory cells such as macrophages and liberates proteases from viable lung cells which in return disrupt the function of protease inhibitors like α1-antitrypsin. this results in facilitating the effect of proteases and the destruction of extracellular matrix. evidence is suggestive that women who smoke are more susceptible to develop severe chronic obstructive pulmonary disease at younger ages.41 similarly, asthma is impacted by smoking through many mechanisms. chronic airway inflammation, impaired mucociliary clearance, impaired growth of the lungs during childhood, and increased bronchial hyperresponsiveness are all enhanced by smoking.82,83,55 immunologic mechanisms include effects on t cell function and a higher ratio of th2/th1, increased production of ige, and greater allergic sensitization. cigarette smoke may increase neurogenic inflammation in the bronchial airway84,85 resulting in further inflammation of the airway. in summary, the evidence is suggestive of a causal relationship between active smoking and the incidence of asthma in adults as well as exacerbation of asthma among children and adolescents, and adults.41 serious lung infections can also be promoted by smoking. for example, risk of mycobacterium tuberculosis disease, mortality from the disease and disease recurrence are all higher in smokers.86 lastly, some evidence suggests a possible relationship between cigarette smoking and idiopathic pulmonary fibrosis.87 cigarette smoking causes many other diseases such as diabetes mellitus. the risk of developing diabetes is 30–40% higher for active smokers than nonsmokers.41 there is a positive dose-response relationship between the number of cigarettes smoked and the risk of developing diabetes. furthermore, smoking aggravates insulin resistance in persons international journal of human and health sciences vol. 02 no. 03 july’18 118 with diabetes resulting in suboptimal control of blood sugars.41 recently, smoking was implicated in the pathogenesis of rheumatoid arthritis. the mechanism appears to involve both the effects of oxidizing chemicals in the smoke and the sympathomimetic effects of nicotine.41 neovascular and atrophic forms of age-related macular degeneration are also caused by smoking. multiple pathways are likely responsible for the degenerative changes in the macula. in genetically susceptible persons, smoking causes changes in retinal pigment epithelium, bruch’s membrane, and choroidal endothelium and generate a local inflammatory response.88 oxidative stress and vascular insufficiency are proposed mechanisms for smoking-related damage to retinal structures.89 ,90 additional evidence is sufficiently conclusive that smoking is associated with many other conditions such as erectile dysfunction, ectopic pregnancy and contributes significantly to infertility in both males and females. maternal active smoking might be also linked to spontaneous abortion in the mother and orofascila clefts, clubfoot, gastroschisis, and atrial septal heart defects in the fetus.41 tobacco control strategies: the who through its international treaty the frame work convention on tobacco control lists six evidence-based strategies that aim to address the various articles in this treaty including policy, regulatory and economic interventions.91 summarized in the word mpower, the components stand for the following: monitor tobacco use and prevention policies. national data are collected periodically to track tobacco use and consumption. the global adult tobacco and the global youth tobacco surveys are examples. unfortunately, many countries in the world are not capable of conducting these surveys due to their high cost. protect people from tobacco smoke: implementing bans on smoking in public places is the corner stone of this strategy. while this has been a very successful strategy in high-income countries to reduce the spread and harms of tobacco, it has been very challenging to implement in low income countries due to the significant lack of governmental commitment and a strong tobacco lobby that has been transferring its markets to those vulnerable regions. offer help to quit tobacco use: this strategy will be discussed in details in the following section. warn about the dangers of tobacco: mass media campaigns as well as the use of pictorial warning are known successful methods to attract public attention, deliver necessary health messages and drive up the intention to quit among smokers. pictorial warnings on cigarette packs are usually graphic and occupy at least 50% of the surface area of the cigarette pack. in the eastern mediterranean region, jordan, egypt and iran introduced those warnings and in the process of upgrading them. raise taxes on tobacco: this strategy is considered by far the most effective strategy for tobacco control. typically, national governments would impose high taxes on tobacco products in order to increase the price and making cigarettes less accessible to the public especially children. revenues from these taxes are then invested in strengthening tobacco control measures, improving customs and border controls, and curbing tobacco illicit trade. furthermore, such revenues can be invested in building health care systems and train health care providers. currently, worldwide variation in successful implementation of this strategy exists. high income countries took steady steps in implementing this strategy while low income countries continue to fall for the tobacco industry promises of guaranteed short term profits and discouraged from taking aggressive moves by the misleading evidence provided by the tobacco industry to governments that such profits might be hindered should higher taxes were implemented due to the increase in smuggled tobacco, an action typically promoted and supported by the tobacco industry. tobacco dependence treatment and the gains of quitting: the benefits of quitting occur simultaneously with the cessation of the act of smoking. for example, normalization of the heart rate, blood pressure and decrease in coughing and production of phlegm occurs within hours to days from quitting.92 in the long-term, quitting tobacco reduces premature death by 90% for those who quit before the age of 30 and by 50% for those who quit before the age of 50.92 in five years, the risk of stroke falls to that of a non-smoker, and the risk of head and neck cancers and bladder cancers is reduced by half.93 better control of respiratory diseases like asthma and copd including symptoms, exacerbations of the disease, hospital admissions and finally mortality form copd has been clearly 119 international journal of human and health sciences vol. 02 no. 03 july’18 demonstrated in the literature.94 however, despite these documented short and long-term benefits of quitting smoking, and despite listing o – offer help to quit as one of the recommended who strategies for tobacco control, tobacco dependence treatment (tdt) services continue to be scarce and inconsistent across the world. many factors contribute to this shortage of tdt, including the lack of training opportunities for health care providers in basic skills needed to deliver tdt services. tobacco dependence treatment is an integral component of any comprehensive tobacco control effort. comprehensive tdt services include the techniques of brief advice, motivational interviewing and counseling, establishing effective quitlines, and availing low-cost pharmacotherapy. in 1999, the world bank -building on data published by peto et al. estimated that if adult consumption of tobacco is halved by 2020 the world can prevent about 200 million deaths by 2050. in comparison, the short-term effect on mortality of halving the number of young people who take up smoking was negligible. accordingly, the report urged governments seeking health and economic gain to encourage smokers to quit.95 likewise, the world health organization (who) -through article 14 of the fctcmandates parties to design and implement effective programs to promote cessation of tobacco use and provide adequate treatment for tobacco dependence.96 the who recommends inclusion of cessation advice in primary healthcare services, establishing accessible and free quitlines, and availing lowcost pharmacotherapy.97 inclusion of cessation advice in primary healthcare settings proves to be a low-cost strategy where the major investment is in training of providers and in providing informational materials to tobacco users.97 pharmacotherapy, while more expensive than offering cessation advice, has been shown to double or triple quit rates.97 overall, tdt interventions are extremely cost effective when compared to treatment of other chronic diseases such as hypertension. while a specialist may average two hours for treatment of one tobacco dependence case, treatment of hypertension over the lifetime of the patient consumes more time.98 in general the cost-effectiveness of tdt exceeds that of other commonly provided clinical preventive services, including pap tests, mammography, colon cancer screening, treatment of mild to moderate hypertension, and treatment of high levels of serum cholesterol.99 the american college of chest physicians recommends dealing with tobacco dependence as a chronic relapsing condition similar to asthma. various forms of treatments are used in a controller and reliever fashion.100 in most subjects combination pharmacotherapy is used for better outcome. a long acting nicotine replacement therapy (nrt) such as the nicotine patch is usually combined with as needed doses of a short acting nrt such as nicotine gum, lozenges, inhaler or nasal spray. all nrt doses are titrated to control subjects’ withdrawal and craving symptoms. bupropion, an antidepressant and/or varenicline (α4β2 nicotinic acetylcholine receptor partial agonist) are combined with nrt for better control of symptoms and enhanced cessation rates.101 in both choices, doses are titrated up over few days to avoid side effects. treatment is usually continued for at least three months or as long as it is needed. safety data are now available for the chronic use of all these medication. relapse is very common in subjects trying to quit smoking and must be addressed early on in the course of treatment. behavioral and cognitive key techniques in tdt and preventing relapse. many challenges face establishing effective tobacco dependence treatment programs. tobacco education and training in healthcare disciplines continues to be lacking. a 2009 survey of 171 countries indicated that only 27% of medical schools taught a specific module on tobacco.102 however, progress is being made via international collaborations through training hcps on delivering effective tdt, the emr continues to face other challenges that hinder service expansion. king hussein cancer center (khcc), a comprehensive cancer care facility in jordan that has been offering tdt services to cancer patients and the general public since 2008, recognized early on that such gaps in capacity and competence limit the reach of services and patients’ access to help. realizing the importance of training hcps in evidence-based treatment, khcc started in 2011 to offer tdt training to countries of the emr through collaboration with global bridges; an international healthcare alliance for tobacco dependence treatment that was founded by mayo clinic, the american cancer society, and the university of arizona. global bridges seeks to create opportunities to share treatment and advocacy expertise and to provide state-of-the-art training to help countries fulfill fctc’s article 14. while other organizations represent global international journal of human and health sciences vol. 02 no. 03 july’18 120 bridges throughout latin america, africa, and europe, khcc is the regional host and partner for global bridges in the emr. to date, khcc has trained over 1500 hcps and advocates from emr on tobacco control and tdt through more than 20 workshops and conferences spanning the region from morocco to uae. political commitment to tobacco control is not uniform across the region, and the tobacco industry (ti) has been gaining traction in some countries. as developed nations tighten their regulations on the tobacco industry, the developing nations of the emr -with their relaxed tobacco control regulationspresent themselves as a safe haven to the ti. while tobacco companies are state-owned in eight emr countries,1 multi-nationals are establishing their operations in other countries such as the situation is in jordan.103 another challenge that may hinder expansion of tdt services in the region is tobacco use among physicians and other healthcare workers. the prevalence of ever smoking cigarettes among medical students in 2010 in the region ranged between 24% and 42%.104 this undermines the role that healthcare providers should play in reducing the social acceptability of tobacco use and their credibility in promoting tdt services.105 it is thus imperative that teaching and training programs for hcps address tobacco control and tdt early on, and that special attention is given to helping these professionals quit tobacco use as an initial step. furthermore, the lack of health coverage by national or private health care plans as well as the inconsistency in the availability of necessary pharmacological drugs use in tdt and the prices of these drugs are all considered real obstacles facing smokers who are trying to quit. in conclusion, tobacco is highly addictive and poses great danger to those who consume it. dependence and harms of tobacco as well as the benefits of quitting are clearly documented in the literature. international strategies for tobacco control must be implemented globally in effort to lower the prevalence by the year 2040 to less than 5% worldwide. 121 international journal of human and health sciences vol. 02 no. 03 july’18 references: 1. eriksen m, mackay j, ross h. the tobacco atlas. fourth ed. atlanta, ga: american cancer society; new york, ny: world lung foundation; 2012 2. history of tobacco: http://academic.udayton.edu/ health/syllabi/tobacco/history.htm 3. eriksen m, mackay j, ross h. the tobacco atlas. fourth ed. atlanta, ga: american cancer society; new york, ny: world lung foundation; 2012 4. mackay j, eriksen m, shafey o. the tobacco atlas, 2nd ed. atlanta, ga,american cancer society, 2006. 5. malson jl et al. clove cigarette smoking: biochemical, physiological, and subjective effects. pharmacology, biochemistry, and behaviour, 2003,74:739–745. 6. brody al, mandelkern ma, london ed, khan a, kozman d, costello mr, vellios ee,archie mm, bascom r, mukhin ag. effect of secondhand smoke on occupancy of nicotinic acetylcholine receptors in brain. arch gen psychiatry. 2011 sep;68(9):953-60. doi: 10.1001/archgenpsychiatry.2011.51. epub 2011 may 2. 7. u.s. department of health and human services. the health consequences of involuntary exposure to tobacco smoke: a report of the surgeon general– executive summary. rockville, md: u.s. department of health and human services, centers for disease control and prevention, coordinating center for health promotion, national center for chronic disease prevention and health promotion, office on smoking and health, 2006 8. hurt rd, weston sa, ebbert jo, mcnallan sm, croghan it, schroeder dr, roger vl. myocardial infarction and sudden cardiac death in olmsted county, minnesota,before and after smoke-free workplace laws. arch intern med. 2012 nov 26;172(21):1635-41. 9. comstock gw, lundin fe jr. parental smoking and perinatal mortality. am j obstet gynecol. 1967 jul 1;98(5):708-18. 10. colley jr, holland ww, corkhill rt. influence of passive smoking and parental phlegm on pneumonia and bronchitis in early childhood. lancet. 1974 nov 2;2(7888):1031-4. 11. white, j. r. and froeb, h. f.:small airways dysfunction in nonsmokers chronically exposed to tobacco smoke. n. eng. j. med. 302:720-23,1980. 12. u.s. department of health and human services. the health consequences of involuntary smoking. a report of the surgeon general. rockville (md): u.s. department of health and human services, public health service, centers for disease control, center for health promotion and education, office on smok ing and health, 1986. dhhs publication no. (cdc) 87-8398. 13. ballantyne c, what is third-hand smoke? is it hazardous? scientific american. january 6, 2009. < h t t p : / / w w w. s c i e n t i f i c a m e r i c a n . c o m / a r t i c l e . cfm?id=what-is-third-hand-smoke > 14. sleiman m, gundel la, pankow jf, jacob p 3rd, singer bc, destaillats h. formation of carcinogens indoors by surface-mediated reactions of nicotine with nitrous acid, leading to potential thirdhand smoke hazards. proc natl acad sci u s a. 2010 apr 13;107(15):6576-81. doi: 10.1073/pnas.0912820107. epub 2010 feb 8. ) 15. caryn rabin, r. , a new cigarette hazard — ‘thirdhand smoke. the new york times. january 2, 2009. <http://www.nytimes.com/2009/01/03/health/ research/03smoke.html?_r=0 > 16. matt ge, quintana pj, destaillats h, gundel la, sleiman m, singer bc, jacob p,benowitz n, winickoff jp, rehan v, talbot p, schick s, samet j, wang y, hang b,martins-green m, pankow jf, hovell mf. thirdhand tobacco smoke: emerging evidence and arguments for a multidisciplinary research agenda. environ health perspect. 2011 sep;119(9):1218-26. doi: 10.1289/ehp.1103500. epub 2011 may 31. review. 17. sargent, j. d. and difranza, j. r. (2003), tobacco control for clinicians who treat adolescents. ca: a cancer journal for clinicians, 53: 102–123. doi: 10.3322/canjclin.53.2.102 18. mcneill ad, west rj, jarvis m, et al. cigarette withdrawal symptoms in adolescent smokers. psychopharmacology 1986; 90:533–536. 19. world health organization. the icd-10 classification of mental and behavioral disorders. clinical descriptions and diagnostic guidelines. geneva, switzerland: world health organization; 1992 20. robinson te, berridge kc. the neural basis of drug craving: an incentive-sensitization theory of addiction. brain res brain res rev. 1993 sepdec;18(3):247-91.) 21. nutt d, king la, saulsbury w, blakemore c. development of a rational scale to assess the harm of drugs of potential misuse. lancet. 2007 mar 24;369(9566):1047-53.24;369(9566):1047-53. 22. jordan: http://www.aliftaa.jo/decision. aspx?decisionid=111 23. ksa http://www.sha.org.sa/arabic/patients_info_a/ islam/fatwa_smoking_inhibition.htm 24. egypt http://www.dar-alifta.org/viewfatwa. aspx?id=3699 25. indonesia http://www.jakartaupdates.com/37smoking-is-haram-muhammadiyah 26. spanagel r, weiss f (1999). “the dopamine hypothesis of reward: past and current status”. trends international journal of human and health sciences vol. 02 no. 03 july’18 122 neurosci. 22 (11): 521–7. doi:10.1016/s01662236(99)01447-2. 27. grenhoff j, aston-jones g, svensson th. nicotinic effects on the firing pattern of midbrain dopamine neurons. acta physiologica scandinavica 1986;128(3):351–8. 28. nisell m, nomikos gg, svensson th. infusion of nicotine in the ventral tegmental area or the nucleus accum bens of the rat differentially affects accumbal dopa mine release. pharmacology and toxicology 1994a; 75(6):348–52. 29. nisell m, nomikos gg, svensson th. systemic nicotine-induced dopamine release in the rat nucleus accum bens is regulated by nicotinic receptors in the ventral tegmental area. synapse 1994b;16(1):36–44. 30. pidoplichko vi, debiasi m, williams jt, dani ja. nicotine activates and desensitizes midbrain dopamine neurons. nature 1997;390(6658):401–4. 31. pidoplichko vi, debiasi m, williams jt, dani ja. nicotine activates and desensitizes midbrain dopamine neurons. nature 1997;390(6658):401–4. 32. watkins ss, stinus l, koob gf, markou a. reward and somatic changes during precipitated nicotine with drawal in rats: centrally and peripherally mediated effects. journal of pharmacology and experimental therapeutics 2000;292(3):1053–64. 33. picciotto mr, corrigall wa. neuronal systems underly ing behaviors related to nicotine addiction: neural cir cuits and molecular genetics. journal of neuroscience 2002;22(9):3338–41. 34. balfour dj. the neurobiology of tobacco dependence: a preclinical perspective on the role of the dopamine pro jections to the nucleus accumbens [corrected]. nico tine & tobacco research 2004;6(6):899–912. 35. gray r, rajan as, radcliffe ka, yakehiro m, dani ja. hip pocampal synaptic transmission enhanced by low con centrations of nicotine. nature 1996;383(6602):713–6. 36. gioanni y, rougeot c, clarke pb, lepouse c, thierry am, vidal c. nicotinic receptors in the rat prefrontal cortex: increase in glutamate release and facilitation of medio dorsal thalamo-cortical transmission. european jour nal of neuroscience 1999;11(1):18–30. 37. fu y, matta sg, gao w, brower vg, sharp bm. systemic nicotine stimulates dopamine release in nucleus accumbens: re-evaluation of the role of n-methyl-d-aspartate receptors in the ventral tegmental area. jour nal of pharmacology and experimental therapeutics 2000;294(2):458–65. 38. grillner p, svensson th. nicotine-induced excitation of midbrain dopamine neurons in vitro involves ionotropic glutamate receptor activation. synapse 2000; 38(1):1–9. 39. mansvelder hd, mcgehee ds. long-term potentiation of excitatory inputs to brain reward areas by nicotine. neuron 2000;27(2):349–57. 40. reid ms, fox l, ho lb, berger sp. nicotine stimulation of extracellular glutamate levels in the nucleus accum bens: neuropharmacological characterization. synapse 2000;35(2):129–36. 41. schilström b, svensson hm, svensson th, nomikos gg. nicotine and food induced dopamine release in the nucleus accumbens of the rat: putative role of alpha7 nicotinic receptors in the ventral tegmental area. neu roscience 1998;85(4):1005–9. 42. u.s. department of health and human services. the health consequences of smoking: 50 years of progress. a report of the surgeon general. atlanta, ga: u.s. department of health and human services, centers for disease control and prevention, national center for chronic disease prevention and health promotion, office on smoking and health, 2014. 43. henningfield je, keenan rm. nicotine delivery kinetics and abuse liability. journal of consulting and clinical psychology 1993;61(5):743–50 44. national center for health statistics. health, united states, 2012: with special feature on emergency care. hyattsville, md. 2013. 45. benowitz nl, hukkanen j, jacob p 3rd. nicotine chemis try, metabolism, kinetics and biomarkers. handbook of experimental pharmacology 2009;(192):29–60. 46. brody al, mandelkern ma, london ed, khan a, kozman d, costello mr, vellios ee,archie mm, bascom r, mukhin ag. effect of secondhand smoke on occupancy of nicotinic acetylcholine receptors in brain. arch gen psychiatry. 2011 sep;68(9):953-60. doi: 10.1001/archgenpsychiatry.2011.51. epub 2011 may 2. 47. jarvis mj, russell ma, feyerabend c. absorption of nicotine and carbon monoxide from passive smoking under natural conditions of exposure. thorax. 1983;38(11):829–833. 48. martin rj, okken a, katona pg, klaus mh. effect of lung volume on expiratory 49. time in the newborn infant. j appl physiol respir environ exerc physiol. 1978 50. jul;45(1):18-23. 51. tobin mj, chadha ts, jenouri g, birch sj, gazeroglu hb, sackner ma. breathing patterns. 1. normal subjects. chest. 1983 aug;84(2):202-5. 52. bennett wd, zeman kl. effect of body size on breathing pattern and fine-particle deposition in children. j appl physiol (1985). 2004 sep;97(3):8216. epub 2004 apr 23. 53. world health organization, global report, 2012: mortality attributable to tobacco. geneva, who. http://www.who.int/tobacco/publications/ 123 international journal of human and health sciences vol. 02 no. 03 july’18 surveillance/rep_mortality_attributable/en/ 54. bloom, d.e., cafiero, e.t., jané-llopis, e., abrahams-gessel, s., bloom, l.r., fathima, s., feigl,a.b., gaziano, t., mowafi, m., pandya, a., prettner, k., rosenberg, l., seligman, b., stein, a.z., & weinstein, c. (2011).the global economic burden of noncommunicable diseases. geneva: world economic forum 55. world health organization, preventing chronic diseases report , 2005 http://www.who.int/chp/ chronic_disease_report/en/ 56. u.s. public health service. smoking and health: report of the advisory committee to the surgeon general of the public health service . washing-ton, dc: u.s. government printing office, 1964. 33. 57. goncalves rb, coletta rd, silverio kg, benevides l, casati mz, da silva js, nociti fh, jr. impact of smoking on inflammation: overview of molecular mechanisms. inflammation research 2011;60(5):409–24. 58. u.s. department of health and human services. how tobacco smoke causes disease: the biology and behavioral basis for smoking-attributable disease: a report of the surgeon general. atlanta, ga: u.s. department of health and human services, centers for disease control and prevention, national center for chronic disease prevention and health promotion, office on smoking and health, 2010. 59. thun mj, carter bd, feskanich d, freedman nd, prentice r, lopez ad, hartge p, gapstur sm. 50year trends in smoking-related mortality in the united states. new england journal of medicine 2013;368(4):351–64. 60. national center for health statistics. health, united states, 2010: with special feature on death and dying. hyattsville, md. 2011.. 61. jefferis bj, lowe gd, welsh p, rumley a, lawlor da, ebrahim s, carson c, doig m, feyerabend c, mcmeekin l, wannamethee sg, cook dg, whincup ph. secondhand smoke (shs) exposure is associated with circulating markers of inflammation and endothelial function in adult men and women. atherosclerosis. 2010 feb;208(2):550-6. doi: 10.1016/j.atherosclerosis.2009.07.044. epub 2009 jul 30. 62. burns dm. epidemiology of smoking-induced cardiovascular disease. prog cardiovasc dis. 2003 jul-aug;46(1):11-29. 63. mcgill hc jr, mcmahan ca, gidding ss. preventing heart disease in the 21st century: implications of the patho biological determinants of atherosclerosis in youth (pday) study. circulation 2008;117(9):1216–27. 64. meijer wt, grobbee de, hunink mg, hofman a, hoes aw. determinants of peripheral arterial disease in the elderly: the rotterdam study. archives of internal med icine 2000;160(19):2934–8. 65. ness j, aronow ws, ahn c. risk factors for symptomatic peripheral arterial 66. disease in older persons in an academic hospitalbased geriatrics practice. j am geriatr soc. 2000 mar;48(3):312-4. 67. u.s. department of health and human services. the health consequences of smoking: cardiovascular dis ease. a report of the surgeon general. rockville (md): u.s. department of health and human services, public health service, office on smoking and health, 1983. dhhs publication no. (phs) 8450204. 68. u.s. department of health and human services. women and smoking. a report of the surgeon general. rock ville (md): u.s. department of health and human services, public health service, office of the surgeon general, 2001. 69. u.s. department of health and human services. the health consequences of smoking: a report of the sur geon general. atlanta (ga): u.s. department of health and human services, centers for disease control and prevention, national center for chronic disease pre vention and health promotion, office on smoking and health, 2004. 70. stallings-smith s, zeka a, goodman p, kabir z, clancy l. reductions in cardiovascular, cerebrovascular, and respiratory mortality following the national irish smoking ban: interrupted timeseries analysis. plos one 2013;8(4):e62063. 71. mackay df, haw s, newby de, langhorne p, lloyd sm, mcconnachie a, pell jp. impact of scotland’s compre hensive, smoke-free legislation on stroke. plos one 2013;8(5):e62597. 72. u.s. department of health and human services. how tobacco smoke causes disease—the biology and behavioral basis for smoking-attributable disease: a report of the surgeon general. atlanta (ga): u.s. department of health and human services, centers for disease control and prevention, national center for chronic disease prevention and health promotion, office on smoking and health, 2010 73. ogle ks, swanson gm, woods n, azzouz f: cancer and comorbidity: redefining chronic diseases. cancer 2000; 88: 653–663. 74. thomas w, holt pg, keast d: effect of cigarette smoking on primary and secondary humoral responses of mice. nature 1973; 243:240–241. 75. thomas wr, holt pg, keast d: recovery of immune system after cigarette smoking. nature 1974; 248: 358–359. 76. feder m, siegfried jm, balshem a, litwin s, keller sm, liu z, testa jr: clinical relevance of international journal of human and health sciences vol. 02 no. 03 july’18 124 chromosome abnormalities in non-small cell lung cancer. cancer genet cytogenet 1998; 102: 25–31. 77. sanchez-cespedes m, ahrendt sa, piantadosi s, rosell r, monzo m, wu l, westra wh, yang sc, jen j, sidransky d: chromosomal alterations in lung adenocarcinoma from smokers and nonsmokers. cancer res 2001; 61: 1309–1313. 78. gan x, zhou y, cai l: prognosis of laryngeal carcinoma in youth (in chinese). zhonghua er bi yan hou ke za zhi 1996; 31: 201–202. 79. tammemagi cm, neslund-dudas c, simoff m, kvale p: smoking and lung cancer survival:the role of comorbidity and treatment. chest 2004; 125: 27– 37. 80. garipidou v, vakalopoulou s, zafiriadou e, kaloutsi v, tziomalos k, perifanis v: uncommon manifestation of bleomycin-induced pulmonary toxicity in a patient with hodgkin’s disease. ann oncol 2005; 16: 514–515. 81. o’sullivan jm, huddart ra, norman ar, nicholls j, dearnaley dp, horwich a: predicting the risk of bleomycin lung toxicity in patients with germ-cell tumours. ann oncol 2003; 14: 91–96. 82. monson jm, stark p, reilly jj, sugarbaker dj, strauss gm, swanson sj, decamp mm, mentzer sj, baldini eh: clinical radiation pneumonitis and radiographic changes after thoracic radiation therapy for lung carcinoma. cancer 1998; 82: 842–850. 83. garces yi, schroeder dr, nirelli lm, croghan ga, croghan it, foote rl, hurt rd: second primary tumors following tobacco dependence treatments among head and neck cancer patients. am j clin oncol 2007; 30: 531–539. 84. do ka, johnson mm, lee jj, wu xf, dong q, hong wk, khuri fr, spitz mr: longitudinal study of smoking patterns in relation to the development of smoking-related secondary primary tumors in patients with upper aerodigestive tract malignancies. cancer 2004; 101: 2837–2842. 85. zhou w, heist rs, liu g, park s, neuberg ds, asomaning k, wain jc, lynch tj, christiani dc: smoking cessation before diagnosis and survival in early stage non-small cell lung cancer patients. lung cancer 2006; 53: 375–380. 86. u.s. department of health and human services. the health consequences of smoking: a report of the surgeon general. atlanta, ga: u.s. department of health and human services, centers for disease control and prevention, national center for chronic disease prevention and health promotion, office on smoking and health, 2004. 87. u.s. department of health and human services. the health consequences of involuntary 88. exposure to tobacco smoke: a report of the surgeon general. atlanta, ga: u.s. department of health and human services, centers for disease control and prevention, coordinating center for health promotion, national center for chronic disease prevention and health promotion, office on smoking and health, 2006. 89. bessac bf, sivula m, von hehn ca, escalera j, cohn l, jordt se. trpa1 is a major oxidant sensor in murine airway sensory neurons. journal of clinical investiga tion 2008;118(5):1899–910. 90. simon sa, liedtke w. how irritating: the role of trpa1 in sensing cigarette smoke and aerogenic oxidants in the airways. journal of clinical investigation 2008; 118(7):2383–6. 91. ariyothai n, podhipak a, akarasewi p, tornee s, smithtikarn s, thongprathum p. cigarette smoking and its relation to pulmonary tuberculosis in adults. southeast asian journal of tropical medicine and public health 2004;35(1):219–27 92. baumgartner kb, samet jm, stidley ca, colby tv, waldron ja. cigarette smoking: a risk factor for idiopathic pulmonary fibrosis. american journal of respiratory and critical care medicine 1997;155(1):242–8 93. wang al, lukas tj, yuan m, du n, handa jt, neufeld ah. changes in retinal pigment epithelium related to ciga rette smoke: possible relevance to smoking as a risk factor for age-related macular degeneration. plos one 2009a;4(4):e5304. 94. rahman i, macnee w. role of oxidants/antioxidants in smoking-induced lung diseases. free radical biology and medicine 1996;21(5):669–81. 95. bettman jw, fellows v, chao p. the effect of cigarette smoking on the intraocular circulation. a.m.a. archives of ophthalmology 1958;59(4):481–8. 96. world health organization. controlling the smoking epidemic. report of the who expert committee on smoking control. world health organization technical report series no. 636. geneva (switzerland): world health organization, 1979. available: http:// whqlibdoc.who.int/trs/who_trs_636.pdf 97. national cancer institute. factsheet on harms of smoking and health benefits of quitting. http:// www.cancer.gov/cancertopics/factsheet/tobacco/ cessation) accessed: feb 2014 98. american cancer society. guide to quitting smoking. http://www.cancer.org/healthy/ stayawayfromtobacco/guidetoquittingsmoking/ guide-to-quitting-smoking-benefits accessed: feb 2014. 99. godtfredsen ns, vestbo j, osler m, prescott e. thorax. 2002 nov;57(11):967-72. anthonisen nr, skeans ma, wise ra, manfreda j, kanner re, connett je; lung health study research group. ann 125 international journal of human and health sciences vol. 02 no. 03 july’18 intern med. 2005 feb 15;142(4):233-9. 100. jha p, chaloupka fj. curbing the epidemic: governments and the economics of tobacco control. washington dc: world bank. 101. world health organization. protocol to eliminate illicit trade in tobacco products. geneva: world health organization. http://apps.who.int/iris/ bitstream/10665/80873/1/9789241505246_eng. pdf?ua=1) 102. who report on the global tobacco epidemic, 2008: the mpower package. geneva, world health organization, 2008 103. hughes jr. tobacco treatment specialists: a new profession. journal of smoking cessation 2007; 2:2-7. 104. u.s. department of health and human services. reducing tobacco use: a report of the surgeon general—executive summary. atlanta, georgia: u.s. department of health and human services, centers for disease control and prevention, national center for chronic disease prevention and health promotion, office on smoking and health, 2000. 105. mclellan at, lewis dc, o’brien cp, et al. drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. jama. 2000 oct 4;284(13):1689-95. 106. cahill k, stead lf, lancaster t. nicotine receptor partial agonists for smoking cessation. cochrane database syst rev. 2012 apr 18;4:cd006103. 107. richmond r, zwar n, taylor r, hunnisett j, hyslop f. teaching about tobacco in medical schools: a worldwide study. drug alcohol rev. 2009 sep;28(5):484-97. 108. awraq investments. al-eqbal investment company equity report. 2011. http://www.awraq.com/uploads/ ch/033a1e112edd533f5ef22504ed856594740a1c88. pdf accessed: feb 2014 109. world health organization. global health professions student survey fact sheets and country reports. http://www.emro.who.int/images/stories/tfi/ documents/gyts_fs_jor_2009.pdf accessed: feb 2014 110. guidelines for implementation of article 14 of the who framework convention on tobacco control. h t t p : / / w w w. w h o . i n t / f c t c / g u i d e l i n e s / a d o p t e d / article_14/en/ accessed: feb 2014 international journal of human and health sciences. supplementary issue: 2021 s5 forum forum chair covid-19: the pandemic that unites muhamad yusri musa executive committee of imam consultant ent surgeon, advanced medical and dental institute, universitisains malaysia (usm) doi: http://dx.doi.org/10.31344/ijhhs.v5i0.296 the pandemic caused by the corona virus disease 2019 (covid-19) has caused enormous challenges to almost every aspect of life worldwide. in malaysia, one of the earliest nations affected by the pandemic has responded valiantly both by the government through the ministry of health (moh) and various groups in the communities especially by the non-governmental associations (ngo) to fight the virus and adversities caused by pandemic. the support of ngos in malaysia has tremendously assisted the country and supports the ministry of health’s efforts to flatten the infection curve successfully during the nationwide lockdown started in march. here, we selected 4 organisations that have directly contributed in various ways and methods which was utterly unique and inspiring. their immense efforts and contributions in helping multi-ethnic, multi-religious and multi nationalities people may go unnoticed but the impact to the recipients were beyond words. keywords: communities, ngo, multiethnic, multi-religious, lockdown http://dx.doi.org/10.31344/ijhhs.v5i0. 19 international journal of human and health sciences vol. 03 no. 01 january’19 original article relationship between the level of community knowledge about dengue hemorrhagic fever and larvae of aedes aegypti examination in deli serdang regency, north sumatra, indonesia ismatul fauziah rambe1, meizly andina1, nurfadly1 abstract dengue hemorrhagic fever is one of the major public health problems in the world. this disease that is transmitted through aedes aegypti mosquitoes is classified as dangerous because it can cause dengue shock syndrome. its spread can attack anyone, anywhere and can be several people at the same time resulting in this disease has a fairly high incidence rate, especially in tropical climates such as indonesia. the most effective prevention is breaking the chain of transmission of dhf. this termination is done by preventing larvae found in their breeding places from developing into adult mosquitoes. objective: to determine the relationship of the level of public knowledge about dengue hemorrhagic syndrome (dhf) with the presence of aedes aegypti mosquito larvae in deli serdang regency, north sumatra, indonesia. materials and methods: this is a crosssectional analytic study used quota sampling method with a total of 78 samples. results and discussion: this study shows that the highest level of knowledge from respondents is enough as many as 38 people (48.7%). the houses that were found to have positive larvae containers were 26 houses (33.3%) and the most were located outside the house were 15 (19.2%). chi-square results showed p-value = 0.984. conclusion: there is no correlation between the levels of community knowledge about dhf with the presence of aedes aegypti mosquito larvae. keywords: knowledge, dengue hemorrhagic fever, aedes aegypti correspondence to: meizly andina, faculty of medicine, university of muhammadiyah sumatera utara, indonesia, e-mail: meizlyandina@umsu.ac.id 1. faculty of medicine, university of muhammadiyah sumatera utara, indonesia introduction: dengue fever is a viral disease transmitted by mosquitoes that spread most rapidly in the world.1 dengue hemorrhagic fever (dhf) is a disease that travels quickly and can cause death in a short time. outbreaks of dengue fever are the main public health problems in indonesia, which are in the tropical rain and equatorial zones where aedes aegypti is widespread in urban and rural areas.2 the increasing number of dengue cases is closely related to the increase in the mosquito population, especially when it rains a lot. high levels of rainfall also trigger the development of mosquito populations. the character of aedes mosquitoes who like to lay their eggs in clean water is one of the trigger factors. these mosquitoes usually only lay eggs in bathtubs where there is clean water stagnant, but when it rains a lot, nesting places can move to the channels where the water has changed due to rain or a basin that holds clean water. 4 dhf eradication efforts are focused on mobilizing the potential of the community to be able to participate in eradicating mosquito nests through draining, closing and burying plus sowing larvacide, spreading fish in water reservoirs, mobilizing larvae monitoring and introduction symptoms of dhf and its handling in the household.4 given this reality, counseling about vectors and their control methods are still very much needed by the community on an ongoing basis. the program will be able to have leverage in breaking the chain of transmission carried out by the community in community participation in empowerment programs. the results of this study are expected to provide information about the relationship between the level of community knowledge about dhf with the presence of aedes aegypti mosquito larvae in international journal of human and health sciences vol. 03 no. 01 january’19 page : 19-22 doi: http://dx.doi.org/10.31344/ijhhs.v3i1.68 international journal of human and health sciences vol. 03 no. 01 january’19 20 muliorejo village, sunggal district, deli serdang regency, north sumatra, indonesia. materials and methods: this is a cross-sectional study using quota sampling as the sampling technique. there are 78 samples selected based on the inclusion criteria, namely housewives or adults who are indigenous people of muliorejo village in deli serdang regency, can communicate well and are willing to become respondents. primary data was obtained from interviews and questionnaires from each respondent as well as observations of aedes aegypti larvae at water reservoirs located at home. results: as many as 52 houses (66.7%) were examined there was no larva. and 26 of its houses (33.3%) of the other houses are aedes aegypti larvae. most of the locations are outside the house (57.7%) and the type of water shelters in the form of buckets are 20 (41.7%). table 1: examination larva of aedes aegypti examination larva of aedes aegypti n (%) larva of aedes aegypti + 26 52 33,3 66,7 position of container with positive larva in house outside inside outside and inside 15 6 5 57,7 23,1 19,2 type of container with positive larva drum buckets cans bathtub others 17 20 6 4 1 35,4 41,7 12,5 8,3 2,1 respondents classified into good categories amounted to 25 people (32.1%), sufficient categories were 38 people (48.7%), and less categories were 15 people (19.2%). table 2: knowledge level of respondent category n (%) good 25 32,1 sufficient 38 48,7 less 15 19,2 there are 78 respondents, women were 64 (82.1%) and men 14 (17.9%) with the highest number of respondents aged 36-40 years was 16 people (20, 5%). the most recent level of education was a high school with 29 people (37.2%) and not having jobs was 38 people (48.7%). table 3: frequency distribution of characteristics of respondents characteristics n (%) sex men women 14 64 17,9 82,1 age (years) 26-30 31-35 36-40 41-45 46-50 51-55 56-60 12 13 16 13 15 4 5 15,4 16,7 20,5 16,7 19,2 5,1 6,4 last education not educated primary school junior high school senior high school bachelor 5 8 16 29 20 6,4 10,3 20,5 37,2 25,6 occupation none teacher/ lecturer enterpreuner employee farmer trader 38 11 15 7 3 4 48,7 14,1 19,2 9,0 3,8 5,1 chi-square statistical test results showed that p=0.984 which indicate that the hypothesis was not accepted, which means that there was no relationship between the level of community knowledge about dhf with the presence of aedes aegypti mosquito larvae in muliorejo village, sunggal district, deli serdang regency. 21 international journal of human and health sciences vol. 03 no. 01 january’19 table 4: relationship between the level of community knowledge about dhf with aedes aegypti larvae examination level of knowledge about dhf total good sufficient less larvae of aedes aegypti positive 8 13 5 26 negative 17 25 10 52 total 25 38 15 78 p value = 0,984 discussion and conclusion: the highest level of knowledge of respondents is sufficient, amounting to 38 people (48.7%). where most respondents know enough about some basic things about dengue fever. according to the results of the interview, the community claimed to receive information on dhf from television, print media, or counseling. the level of knowledge is a factor that plays a role in determining or adopting a person’s behavior in the results of this study, the value-free numbers larvae obtained 66%. this was obtained from the results of the division between the number of houses without larvae, and the number of houses examined then multiplied by one hundred percent. this 66% result means that the value-free numbers larvae obtained are likely to still be far from the national value free numbers larvae which should be achieved at 95%. most containers that are positively wiggled in muliorejo village are containers located outside the house. this container is mostly used as a shelter for rainwater which is sometimes rarely used and drained. as for inside the house, most residents do not use baths but use containers such as buckets or drums for daily use. this causes the containers needed to tend to be more in accordance with the requirements. muliorejo villagers who mostly do not use the bath because the water in the village tends to be cloudy. therefore, muliorejo villagers use containers or landfills for daily use in the form of buckets. this is why the community often cleanses and also replaces the water that will be used. however, in containers found larvae, most of them are in bucket-type containers and outside the house. this is because the community makes the container to hold rainwater, while this water is not routinely used. chi-square statistical test results showed that p = 0.984 (p> 0.05) which showed that the hypothesis was rejected or there was no relationship between the level of public knowledge about dhf with the presence of aedes aegypti mosquito larvae in muliorejo village, sunggal district, deli serdang district in 2012. this is in accordance with research conducted by suyasa (2008), santoso (2008) and nugrahaningsih, et al (2010)7,8. however, the results of this study are not in accordance with the research conducted by yudhastuti (2005) and respati (2007)9.10. ethical approval: this research proposal was accepted by the ethics committee of faculty of medicine, university of muhammadiyah, sumatera utara, indonesia conflict of interest: none declared author’s contributions: conception and design: ifr, ma, n analysis and interpretation of the data: ifr, n drafting of the article: ifr, ma critical revision of the article for important intellectual content: ifr, ma, n final approval of the article: ifr, ma, n statistical expertise: n collection and assembly of data: ifr international journal of human and health sciences vol. 03 no. 01 january’19 22 references: 1. world health organization. dengue guidelines for diagnosis, treatment, prevention, and control [document on the internet]; 2009 [cited 2012 may 25]. available from: http://whqlibdoc.who.int/ publications/2009/9789241547871_eng.pdf 2. departemen kesehatan republik indonesia. profil kesehatan indonesia [document on the internet]. jakarta; 2009 [cited 2012 june 2]. available from: http://www.depkes.go.id/downloads/publikasi/ profil%20kesehatan%20indonesia%202008.pdf 3. asmara, l. hubungan angka bebas jentik (abj) dengan insidens rate kasus tersangka demam berdarah dengue di tingkat kecamatan kotamadya jakarta timur tahun 2005-2007 [document on the internet]. depok: fkm ui; 2008 [cited 2012 june 2]. available from: http://lontar.ui.ac.id/file?file=digital/122836-s5428-hubungan%20angka-lampiran.pdf 4. dinas kesehatan provinsi sumatera utara. profil kesehatan provinsi sumatera utara tahun 2008 [document on the internet]. medan; 2009 [cited 2012 june 2]. available from: http://www.depkes.go.id/ downloads/profil/prov%20sumut%202008.pdf 5. kementerian kesehatan republik indonesia. buletin jendela epidemiologi demam berdarah dengue 2010 volume 2 [document on the internet]. jakarta; 2010 [cited 2012 may 28]. available from: http:// www.depkes.go.id/downloads/publikasi/buletin/ buletin%20dbd.pdf 6. notoatmodjo s. promosi kesehatan dan ilmu perilaku. jakarta: rineka cipta; 2010 7. suyasa, i n gede, adi putra, i w redi aryanta. hubungan faktor lingkungan dan perilaku masyarakat dengan keberadaan vektor demam berdarah dengue (dbd) di wilayah kerja puskesmas i denpasar selatan [document on the internet]. denpasar; 2008 [cited 2012 june 12]. available from: http:// ojs.unud.ac.id/index.php/ecotrophic/article/ download/2484/1712. 8. nugrahaningsih, m. hubungan faktor lingkungan dan perilaku masyarakat dengan keberadaan jentik nyamuk penular demam berdarah dengue (dbd) di wilayah kerja puskesmas kuta utara. [document on the internet]. kuta utara; 2010 [cited 2013 february 3]. available from: http://isjd.pdii.lipi.go.id/admin/ jurnal/52109397_1907-5626.pdf 9. yudhastuti, ririh. hubungan kondisi lingkungan, kontainer, dan perilaku masyarakat dengan keberadaan jentik nyamuk aedes aegypti di daerah endemis demam berdarah dengue 2007 [document on the internet]. surabaya: fkm ua; 2005 [cited 2012 may 28]. available from: http://www.journal.unair. ac.id/filerpdf/kesling-1-2-08.pdf 10. respati, y.k, soedjajadi keman. perilaku 3m, abatisasi dan keberadaan jentik aedes hubungannya dengan kejadian demam berdarah dengue. fakultas kesehatan masyarakat universitas airlangga [document on the internet]. surabaya; 2007 [cited 2013 february 14]. available from: http://journal.lib. unair.ac.id/index.php/jkl/article/download/625/625 international journal of human and health sciences vol. 02 no. 04 october’18 220 original article: tuberculosis related knowledge among the high school students in a selected area of bangladesh karim f abstract tuberculosis (tb) is one of the major global public health challenge. in some countries, it is a re-emerging infectious disease. this descriptive type of cross sectional study was carried out among the 200 high school students in a selected semi urban area under dhaka division of bangladesh to evaluate their tuberculosis related knowledge. data were collected by face to face interview of the respondents and analyzed by using spss version 16. in this study 53% respondents were male and others were female. mean age of the respondents was 13.5 years. among the respondents all of them heard the term tuberculosis. about 36% respondents told that they obtained some information about tuberculosis from television, 29% told book, 17.5 % told radio, 12.5% told newspaper. majority of the respondents told that tuberculosis is a serious disease whereas 7% told that it is not very serious disease. majority of the respondents told that cough lasts more than three weeks is the symptom of tuberculosis. more than half of the respondents told that tuberculosis can be transmitted by infected person to person. among the respondents only 42% told that tuberculosis must be treated by medicine prescribed by doctor. others (40.5%) said that it is cured by herbal or homeopathy treatment. about 12.5% respondents told that tuberculosis is non curable and 05% told that no treatment is required for this type of disease. about 40% respondents told that they do not know how to prevent tuberculosis disease, 22.5% told that avoidance of tb patients can prevent tb infection. from this study findings it may be concluded that tuberculosis related knowledge among the respondents was not adequate. keywords: tuberculosis, knowledge, high school children correspondence to: dr. farzana karim, assistant professor, department of pediatric dentistry marks medical college (dental unit), mirpur 14, dhaka, bangladesh. e-mail: farzanakarim25@ gmail.com introduction tuberculosis (tb) is a wide-reaching public health issue. it is one of the uppermost 10 reasons of death worldwide.1 it is a specific disease caused by infection with mycobacterium tuberculosis, the tubercle bacillus, which can affect almost any tissue or organ of the body, the most common location of the disease being the lungs. 2 according to the world health organization, more than 8.8 million people worldwide are infected with tuberculosis, and almost 1.6 million people per year die from tuberculosis. 3 tb is completely curable if it is diagnosed and treated properly at early stage. common symptoms of tuberculosis are cough (2-3 weeks or more), coughing up blood, chest pains, fever, night sweats, feeling weak and tired, losing weight without trying, decreased or no appetite etc. symptoms may vary depends on what kind of tb occur. in some cases people do not face any kind of sign and symptoms of tb and this is called inactive stage of tb. these people get affected by the disease when their immune system become deteriorated by diabetes, kidney disease, hiv infection etc. 4-7 students are the future of the nation. many of them become the upcoming leaders of the country. disease related knowledge is one of the powerful part of life. these knowledge encourage people to contribute to build up a healthy, disease free nation. the aim of this study was to investigate the tuberculosis related knowledge among the high school children in a selected area of bangladesh. methodology this was a descriptive type of cross sectional study. the study was carried out from august to november 2016. the study population were the high school students in a selected semi urban area under dhaka division, bangladesh. inclusion international journal of human and health sciences vol. 02 no. 04 october’18 page : 220-223 doi: http://dx.doi.org/10.31344/ijhhs.v2i4.59 221 international journal of human and health sciences vol. 02 no. 04 october’18 criteria were high school students who had agreed to participate and given verbal consent to the study. the students who were not willing to participate were excluded. the sample size was 200. the sample was collected by non-probability purposive sampling. a structured questionnaire was developed based on the objectives and variables of the study. it was finalized after modification and correction based on the findings of questionnaire pretesting. before collection of data permission was taken from the respondents. the purpose of the study was explained to the respondents prior to administering the interview. with the consent of the respondents data were collected by face to face interview by using bengali version questionnaire. the privacy of the respondents was maintained strictly. this study was not involved any physical, mental and social risk of the respondents. after collection of information through questionnaire, the data were coded, entered and analyzed in a computer. data analysis was done using statistical package for social sciences or spss version 16. result in this study among 200 respondents 53% were male and rest were female. the age of the respondents ranged from 12 to 15 years (mean 13.5). most of them belongs to middle class socio economic condition. among 200 respondents all of them are heard the term tuberculosis. figure 1 shows the distribution of the respondents according to their sex table 1: distribution of the respondents according to get the source of tb information source of tb information frequency percentage television 72 36 radio 35 17.5 book 58 29 newspaper 25 12.5 family members 10 05 total 200 100 table 1 shows that among the respondents 36% respondents told that they acquire knowledge about tuberculosis from television, 29% told book,17.5 % told radio, 12.5% told newspaper and only 5% told from family members. table 2: distribution of the respondents according to their opinion about seriousness of tb knowledge about seriousness of tb frequency percentage very serious 116 58 not very serious 14 07 somewhat serious 70 35 total 200 100 table 2 shows that 58% respondents told that tuberculosis is a very serious disease whereas 7% told that it is not very serious disease. figure 2 shows the distribution of the respondents according to their knowledge about sign and symptoms of tb *multiple answer table 3: distribution of the respondents according to knowledge about mode of transmission of tb mode of transmission of tb frequency percentage bacteria 26 13 virus 13 6.5 infected person to person 112 56 infected blood transfusion 44 22 un boiled milk 05 2.5 total 200 100 table 3 shows that among the respondents 56% told that tuberculosis can be transmitted by infected person to person, 22 % told by infected blood transfusion, 13% told by bacteria,6.5% told by virus and 2.5% told by un boiled milk. table 4: distribution of the respondents according to knowledge about treatment of tb treatment of tb frequency percentage no treatment is required 10 05 medicine prescribed by doctor 84 42 it is non curable 25 12.5 homeopathy treatment 50 25 herbal treatment 31 15.5 total 200 100 table 4 shows that among the respondents 42% told that tuberculosis must be treated by medicine prescribed by doctor, 25% told homeopathy treatment, 15.5% told by herbal treatment. about 12.5% respondents told that tuberculosis is non curable and 05% told that no treatment is required for this type of disease. table 5: distribution of the respondents according to knowledge about prevention of tb prevention of tb frequency percentage avoidance of tb patients 45 22.5 by taking a healthy diet 12 06 by using a mask while handling an infected person 38 19 by living in ventilated houses 25 12.5 do not know 80 40 total 200 100 table 5 shows that 22.5% respondents told that avoidance of tb patients can prevent tb infection, 06% told by taking a healthy diet , 19% told by using a mask while handling an infected person, 12.5% told by living in ventilated houses and international journal of human and health sciences vol. 02 no. 04 october’18 222 40% told that they do not know how to prevent tuberculosis disease. discussion according to who global tb report 2016, bangladesh is one of the world’s 30 high tb burden countries with annual occurrence of 362,000 new tuberculosis cases. about 73,000 people die annually due to tuberculosis. 2 many people of our country are not properly knowledgeable about the seriousness of tb disease. they have some wrong conception about this. this study was conducted with a view to assess the tuberculosis related knowledge among the high school students. in this study among 200 respondents 53% were male and rest were female. the age of the respondents ranged from 12 to 15 years. most of them belongs to middle class socio economic condition. among 200 respondents all of them are heard the term tuberculosis. near about similar findings were found from yousif et al and abebe et al.8,9 respondents of this study acquired tuberculosis related information from television more commonly , similar findings were reported in a study done by mushfiq et al.10 this result seems that mass media plays an important role to spread any kind of information among general population. others gained tb information from book, newspapers and family members. most of the respondents told that tuberculosis is a serious disease which was similar to a study done by agboatwalla 11 wheras only few numbers told that it is not very serious disease. majority of the respondents told that main symptom of tb is cough more than 3 weeks which was similar to a study done by mushfiq et al.10 there was a misconception about the transmission of tb infection among the respondents. only 13.5% knew that it is a bacterial disease and 6.5% told that it is a viral disease. more than half of the respondents told that tuberculosis can be transmitted by infected person to person which was near about similar to a study done by yadav. 12 less than half of the respondents believed that tb is cured by medicine prescribed by doctor; rest of them believed homeopathy, herbal remedy are enough for tb cure. some respondents told that it is a non-curable disease so no treatment is necessary for this. this type of conception may be due to their traditional belief. about 40% respondents told that they do not know how to prevent tb. it is a worrying news for us. some of them told that avoidance of tb patient can save people to get the disease. similar report have been found in a study done by mushfiq et al. 10 conclusion from this study findings, it reveals that tuberculosis related knowledge among the respondents was not sufficient. recommendation public health workers must educate the general people about tb. health education program should be arranged regularly. mass media play an important role to convey the effective message of tb infection through general population concerned authority should take more steps to eradicate the miss conception of people about tb. 223 international journal of human and health sciences vol. 02 no. 04 october’18 references: 1 h t t p : / / w w w . s e a r o . w h o . i n t / b a n g l a d e s h / enbanworldtb2017/en/ (last accessed on march 2018) 2. www.medilexicon.com/dictionary/94586 (last accessed on march 2018) 3. https://www.webmd.com/lung/news/20070601/ tuberculosis-17-questions-and-answers#1 (last accessed on february 2018) 4. who (2009). who policy on tb infection control in health-care facilities, congregate settings and households. who/htm/tb/2009.419, world health organization, geneva, switzerland. 5. lawn sd, wilkinson r (2006).extensively drug resistant tuberculosis. british medical journal 33: 559-560. 6. revised national tuberculosis control programme training manual for mycobacterium tuberculosis culture and drug susceptibility testing. central tuberculosis division, new delhi, india, 2009. 7. sethi s, mewara a, dhatwalia sk, singh h, yadav r, et al. (2013) prevalence of multidrug resistance in mycobacterium tuberculosis isolates from hiv seropositive and seronegative patients with pulmonary tuberculosis in north india. bmc infect dis 13: 137. 8. yousif t. k., donaldson r. i., & husseynova s. tuberculosis in iraq: a post-invasion survey of knowledge, attitude and practice in the anbar governorate. middle east journal of family medicine 2011; 2(1). 9. abebe g., deribew a., apers l., woldemichael k., shiffa j.,tesfaye m.,abdissa a., deribie f., jira c.,bezabih m. knowledge,health seeking behavior and perceived stigma towards tuberculosis among tuberculosis suspects in a rural community in southwest ethiopia. plos one 2010; 5(10): 10421045. 10. mushtaq m. u., shahid u., abdullah h. m., saeed a., omer f., shad m. a., siddiqui a. m., akram j. urban-rural inequities in knowledge, attitudes and practices regarding tuberculosis in two districts of pakistan’s punjab province. international journal for equity in health2011; 10(1): 8. 11. agboatwalla m., kazi g. n., shah s. k.,tariq m. gender perspectives on knowledge and practices regarding tuberculosis in urban and rural areas in pakistan. eastern mediterrian health journal 2003; 9(4): 732-740. 12. yadav, s. p., mathur, m. l., & dixit, a. k. knowledge and attitude towards tuberculosis among sandstone quarry workers in desert parts of rajasthan. indian journal of f tuberculosis 2006; 53(4): 187-195. 31 international journal of human and health sciences vol. 07 no. 01 january’23 original article morphometric study of the asterion in adult dry human skulls of nigerian origin okoro ogheneyebrorue godswill1, oyovwi mega o2, onoriode andrew udi1, igben vincent-junior onoriode3, owhefere great owhefere2 abstract background: the asterion, where the temporal, occipital, and parietal bones converge on the posterolateral aspect of the skull, is a critical reference point for surgeons when approaching the structures of the posterior fossa. objective: this cross-sectional study wasconducted to assess the linear distances of asterion from various bony landmarks and their proximity to the transverse sinus, as well as to categorizeasterion types based on the presence or absence of suture bone. methods: a total of 20 skulls were examined and the type of asterion was determined as type i and type ii depending on the presence or absence of sutural bone. the distance from the centre of asterion to tip of the mastoid process and supramastoid process weremeasured. data were analyzed with student t-test. results: our data revealed that type ii (absence of sutural bones) was commoner than type i (presence of sutural bones)asterion. the asterion was 55.72±2.60 mm from tip of the mastoid process on the right side and 51.07±1.43 mm on the left, p value being statistically significant (p=0.001). the distance of asterionfrom supramastoid crest was 47.16±1.47 mm on the right and 43.80±1.97 mm on the left. p value 0.002 was statistically significant. conclusion:the asterion is usually located either at or below the level of the transverse sinus, according to the data collected. neurosurgeons can adopt this knowledge to lessen the danger of posterior fossa surgery. keywords: morphology, asterion, dry human skull, nigeria correspondence to: okoro ogheneyebrorue godswill, department of human anatomy, achievers university, owo, ondo state, nigeria. email: thomasgodswill23@gmail.com 1. department of human anatomy, achievers university, owo, ondo state, nigeria 2. department of human physiology, adeleke university, ede, osun state, nigeria 3. department of human anatomy and cell biology, delta state university, abraka, nigeria introduction the intersection of the parietal, mastoid, temporal, and occipital bones of the skull, visible in the norma occipitalis, is called the asterion. in addition, it serves as a critical surgical landmark for the posterior cerebral fossa where the transverse sinus is located.1internally, the transverse and sigmoid cavities and the asterionare firmly connected. the densegroups of neurovascular systems that make up the posterior fossa are concentrated in a tiny space. owing to the numerous existing venous sinuses, invasive approaches in this area are exceptionally dangerous.2 during or after a range of neurosurgical procedures, improper posterior fossa access can bring about a high incidence of bleeding thromboembolism and infection. to avoid accidental injury or to gain access to the intracranial structures, it is necessaryto have a detailed insight of the associations between the numerous surface features on the posterolateral surface of the skull.3 the asterionis the major reference point on the posterolateral surface of the skull.3,4 the goals of this present study were to categorize asterion types based on the presence or absence of suture bone and to estimate the linear distances of the asterions from various bony landmarks, and their proximity to the transverse sinus, which are relevance to thepractices of anthropologists, anatomists, forensic pathologists, and neurosurgeons. international journal of human and health sciences vol. 07 no. 01 january’23 page : 31-34 doi: http://dx.doi.org/10.31344/ijhhs.v7i1.493 international journal of human and health sciences vol. 07 no. 01 january’23 32 methods twenty (20) skulls with unknown gender and age available in the department of human anatomy, achievers university, owo, ondo state and delta state university, abraka, nigeria,were used for this study.only those skulls with no obvious deformity or malformation were selected. the type of asterion was determined as type i or type ii depending on the presence or absence of suture respectively. type i asterion is one where all three suture are present, whilein type ii asterion, there is only one or two are present. the topographical measurements were taken bilaterally using digital vernier calipers with an accuracy of 0.01 mm (fig. 1). the following distances were measured: 1) amp: distance from the centre of the asterion to tip of the mastoid process; and 2) asc: distance from the centre of the asterion to supramastoid crest. data were expressed as mean±sd. for statistical analysis, unpaired student’s ‘t’-test was performed. p value <0.05 was considered as statistically significant. all the analyses were done using the spss version 23.0 for windows (spss inc., chicago, illinois, usa). results the incidence of type ii asterion(absence of sutural bone) was 75.0% and type i (presence of sutural bone) was 25.0% (table 1, fig. 2).the bony landmarks of the asterion were calculated. mean distances from centre of pterion to the tip of mastoid process were 55.72±2.60 (right side) and 51.07±1.43 (left side),asterionto supramastoid crest; 47.16±1.47 (right side) and 3.80±1.97 (left side). in addition, there was a statistically significant difference in the measured parameters between the right and left side (p<0.05)(table 2). we also observed relationship of the asterion with that transverse sinusand found 60% at the level of the transverse sinus, while 30% below the sinus and 10% above the sinus. (table 3). table 1:incidence of different type of asterion incidence frequency percentage type i 5 25.0 type ii 15 75.0 table 2:topographical measurements on dry skull parameters right (mean±sd) left (mean±sd) p value amp 55.72±2.60 51.07±1.43 0.001s asc 47.16±1.47 43.80±1.97 0.002s amp: asterion to tip of mastoid process; asc: asterion to supramastoidcrest; p value reached from student’s t-test, s=significant. figure 1:measurements on the dry skullamp: mastoid crest (left); asc: supramastoid crest on right side of posterolateral surface of skull (right). 33 international journal of human and health sciences vol. 07 no. 01 january’23 discussion type ii asterion was more common than type i in all populations tested. the results of the current study are comparable to thestudydone by berry and berry,5which was done in the egyptian and indo-burmese populations. indians, nepalese, kenyans, mexicans, and australians had higher type i rates than americans and turks.3-12the mechanism by which suture bone forms is still a matter of debate. some authors believe that pathogenic elements such as hydrocephalus can contribute to the development of suture bone.7,8others have addressed the role of specific genes such as msx2 in the development of craniofacial structure.5genetic or environmental factors may account for differences in different ethnic populations as well.5,6,8,9 in the present study, we measured the distances on both the left and right side. we observed that the mean on the right was consistently greater than the mean on the left. our results are in agreement with the studydone by sinem et al.10in a turkish population. leon et al.11discovered that in 82.4% of cases figure 1:pie chart showing type i (presence of sutural bone) and type ii (absence of sutural bone) asterion (n=20) figure type i type ii 25% 75% the level of the transverse sinus coincides with the asterion.martinez et al.12 discovered that this was the case 76.2% of the time. current analysis shows that the transverse sinus is at the level of the asterion 60% of the time and below it 30%. the drill hole should therefore be placed away from the asterion for posterolateral approaches, ideally posteroinferior (table 3). table 3:relationship of the asterion with the transverse sinus (ts) study level of ts (%) below ts (%) above ts (%) martinez et al. (2000)12 76.2 23.8 leon et al. (2013)11 82.4 12.5 5.1 present study (2022) 60 30 10 conclusion the morphological patterns of asterions in skulls of nigerian origin are more or less similar to those studies done in the past on different populations. however, the outcome of the current investigation can be comparedto other contemporary methods that are frequently used, such as radiological assessment, whichmight more precisely predict the structure of the asterion and enhance surgical safety and efficacy. conflict of interest: none declared. ethical clearance: the study was approved by the ethical review committee of department of human anatomy, achievers university, owo, ondo state, nigeria and delta state university, abraka, nigeria. source of fund: nil. authors’ contribution: all authors were equally involved in data collection, analysis, manuscript preparation, revision and finalization. international journal of human and health sciences vol. 07 no. 01 january’23 34 references 1. williams pl, bannister lh, berry mm, collins p, dyson m, dussek je, et al. the skull. in: gray’s anatomy. 38th ed. london: churchill livingstone; 1995. 2. dutta ak. introduction to skull. in: essentials of human anatomy. part ii: head &neck. 3rd ed. calcutta: current books international; 1999. 3. deepak s, dakshayani kr. morphometric features of asterion in adult human skulls. int jres med sci.2015;3:1325-8. 4. enaohwo tm, okoro og. morphometric study of hypoglossal canal of occipital bone in dry skulls of two states in southern nigeria. bangladesh j med sci.2020;19:670-2. 5. berry ac, berry aj. epigenetic variation in the human cranium. janat. 1967;101:361-79. 6. khan ga. morphometric study on types of asterion in dry human skull of nepalese origin.med-phoenix: jnmc. 2022;7(1):31-5. 7. mwachaka pm, hassanali j, odula p. sutural morphology of the pterion and asterion among adult kenyans. brazilian jmorpholsci. 2009;1:4-7. 8. day jd, kellog jx, tschabitscher m, fukushima t. surface and superficial surgical anatomy of the posterolateral cranial base: significance for surgical planning and approach. neurosurgery. 1996;38:1079-84. 9. singh r. incidence of sutural bones at asterion in adult indian skulls. int jmorphol.2012;30:(3):1182-6. 10. sinem a, mine f, hilal aa, hakan o, omur de, mustafa fs, et al. evaluation of asterion morphometry in terms of clinical anatomy. eastern j med.2019;4:520-3. 11. leon sg, rodriguez an, avalos rm, theriot giron m, omana ree, lopez sg. morphometric characteristics of the asterion and the posterolateral surface of the skull: relationship with dural venous sinuses and neurosurgical importance. circular j.2013;81:251-5. 12. martinez f, laxague a, vida l, prinzo h, sgarbi n, soria vr, bianchi c. anatomíatopográfica del asterion [topographic anatomy of the asterion]. neurocirugia (astur). [article in spanish]. [abstract]. 2005;16(5):441-6. 241 international journal of human and health sciences vol. 03 no. 04 october’19 case report drug-related postural hypotension: to withdraw or not to withdraw (a case series) fadzilah mohamad1, navin kumar devaraj2, aneesa abdul rashid3, abdul hadi abdul manap4 abstract orthostatic hypotension is a common presentation in the primary care setting. concise management is important as it can lead to falls, particularly in the elderly and can lead to significant morbidity and mortality. its management presents as a challenge as there are differing guidelines on managing these patients. this case report illustrates two cases of drug-related orthostatic hypotension with similar presentation, however both were managed differently. keywords: orthostatic hypotension, primary care, drug-related, management correspondence to: fadzilah mohamad, family medicine specialist & medical lecturer, department of family medicine, faculty of medicine & health sciences, universiti putra malaysia, selangor, malaysia. e-mail: ilafadzilah@upm.edu.my 1. dr. fadzilah mohamad, family medicine specialist & medical lecturer, department of family medicine, faculty of medicine & health sciences, universiti putra malaysia, selangor, malaysia 2. dr. navin kumar devaraj, family medicine specialist & medical lecturer, department of family medicine, faculty of medicine & health sciences, universiti putra malaysia, selangor, malaysia 3. dr.aneesa abdul rashid, family medicine specialist & medical lecturer, department of family medicine, faculty of medicine & health sciences, universiti putra malaysia, selangor, malaysia 4. dr. abdul hadi abdul manap, family medicine specialist & medical lecturer, department of family medicine, faculty of medicine & health sciences, universiti putra malaysia, selangor, malaysia international journal of human and health sciences vol. 03 no. 04 october’19 page : 241-244 doi: http://dx.doi.org/10.31344/ijhhs.v3i4.110 introduction orthostatic hypotension may be cardiovascular and / or neurodegenerative in origin. it is defined as a persistent drop in systolic of more than 20 mmhg and or diastolic blood pressure of more than 10 mmhg upon standing1. it may be asymptomatic but its most common symptoms include lightheadedness, dizziness, blurred vision, weakness or syncope. this case report looks at two cases of orthostatic hypotension presented to the primary care clinic with the complaint of dizziness. it summarizes how these two patients initially presented, and how they were managed differently despite having the same underlying issue. management includes acquiring a detailed history, performing thorough physical examination and adjustment of the treatment regimens. the management of postural hypotension is absolutely necessary to avoid the possibility of falls secondary to postural hypotension which can lead to significant morbidity especially in the elderly age group. despite limited resources available in the primary care setting, these two cases were managed well and their issues were subsequently resolved. case summary case 1: mr. h, a 59–year-old man presented with a month history of giddiness on standing. he has underlying hypertension and ischaemic heart disease of which angioplasty was performed three years ago. there were no symptoms of angina or dyspnoea on exertion, paroxysmal nocturnal dyspnoea, orthopnoea, pedal oedema or palpitations prior to this. he was on cozaar plus ® (losartan 100mg and hydrochlorothiazide 25mg) and amlodipine 5mg, both were taken as daily doses and at the same time. the giddiness usually starts about two hours after the anti-hypertensives were taken. due to the giddiness, he encountered many near fall episodes and this has caused him to be less active than before. mr. h’s home blood pressure monitoring (hbpm) revealed a pre-breakfast blood pressure readings ranging between 136-158/72-80 mmhg while pre-dinner blood pressure readings were 112-128/67-78 mmhg. repeated examination international journal of human and health sciences vol. 03 no. 04 october’19 242 of his blood pressure in the clinic revealed a significant drop in his systolic reading from 143 to 115 mmhg (a difference of 28 mmhg) from sitting to standing. diastolic blood pressured dropped slightly from 78 to 74mmhg. to overcome this postural drop, mr. h agreed to adjust his anti-hypertensives. as his blood pressure monitoring was normotensive, diuretics were omitted and the other two anti-hypertensives, losartan and amlodipine were continued the same. since then, mr. h had no longer postural related giddiness. his hbpm showed a pre-breakfast and pre-dinner range of 124-144/72-82 mmhg and 116-126/64-76 mmhg, respectively. measurement of his blood pressure in sitting and standing after two minutes showed no significant drop in both systolic and diastolic readings. his blood pressure remained normotensive at each of his follow up and he is no longer experiencing giddiness or near fall episode due to postural hypotension. case 2: mr. d, a 73-year-old man came for his routine diabetes and hypertension follow up. he complaint of giddiness for the past few years, especially upon standing up. he was previously treated with prochlorperazine for this problem. further history noted the symptom usually peaks around lunch. he is on atenolol 100mg daily, perindopril 8mg daily, amlodipine 5mg daily, metformin 500 mg twice daily and diamicron 40mg twice daily. his cardiovascular systems examination was unremarkable. resting electrocardiogram was normal while random blood sugar measurements was 6.7mmol/l. again abnormalities in bp measurements were noted (even without intake of anti-hypertensives) which is summarised in table 1. table 1. blood pressure measurement preintervention (case 2) blood pressure sbp (mmhg) dbp (mmhg) first occasion • sitting (a) • standing 2min (b) • difference (b-a) 144 118 -26 75 68 -7 second occasion • sitting (a) • standing 2min (b) • difference (b-a) 140 114 -26 76 70 -6 sbp: systolic blood pressure; dbp: diastolic blood pressure the diagnosis of postural hypotension was made at this point of time. a different strategy was adopted in this case. mr. d was asked to reduce all his anthypertensives doses to half of his current dose and was asked to do hbpm for the next two days. he was also prescribed with prochlorperazine 5mg daily. upon review three days later, there was significant improvement in patient’s symptoms and there was no longer any significant drop in his sitting and standing blood pressure as illustrated in table 2. table 2. blood pressure measurement on first follow-up (case 2) blood pressure sbp (mmhg) dbp (mmhg) first occasion • sitting (a) • standing 2min (b) • difference (b-a) 138 128 -10 74 69 -5 second occasion • sitting (a) • standing 2min (b) • difference (b-a) 140 130 -10 74 70 -4 sbp: systolic blood pressure; dbp: diastolic blood pressure even though there was no more postural drop in the bp, however he is still having intermittent giddiness. hence, further adjustment on his anti-hypertensives were made. timing of the medications were adjusted as follow: oral amlodipine 2.5mg and perindopril 4mg to be taken in the morning and oral atenolol 25mg to be taken at night. mr. d was then seen three days later. hbpm was as following: pre breakfast ranging from 126-134/70-76 mmhg and pre dinner 132137/73-78 mmhg. bp measurement in the clinic (without medication intake) is summarised in table 3. table 3. blood pressure measurement on second follow-up (case 2) blood pressure sbp (mmhg) dbp (mmhg) first occasion • sitting (a) • standing 2min (b) • difference (b-a) 128 124 -4 72 69 -3 second occasion • sitting (a) • standing 2min (b) • difference (b-a) 130 126 -4 70 70 0 sbp: systolic blood pressure; dbp: diastolic blood pressure 243 international journal of human and health sciences vol. 03 no. 04 october’19 by this visit, his giddiness has resolved. his subsequent follow up three months later also showed no evidence of postural hypotension. he is currently stable on the same anti-hypertensives regime. discussion these two cases demonstrates how a common presentation of giddiness could be a presentation of orthostatic hypotension (oh). it may occur in any age group but more common in elderly. the prevalence of oh varies widely worldwide, from 5% to 34%2. this differences in prevalence is associated with different population demography and study protocols3. there is a long list of aetiologies related to oh. this includes volume depletion, medication or disorder of cardiovascular, or endocrine system. however, the commoner causes of postural hypotension is iatrogenic whereby drugs like psychotropic, alcohol and anti-hypertensives are the common causes of postural hypotension especially in the elderly4. anti-hypertensives known to cause postural hypotension includes diuretics, calcium channel blocker, beta blockers, methyldopa and nitrates5. thorough assessment must be conducted to avoid mismanagement of the presenting issue. these two cases showed both of these patients were on polypharmacy medications. thus getting detailed medication list, including both prescription or non-prescription drugs, is somewhat very important to identify the possible cause of postural hypotension. measurement of lying/sitting and standing blood pressure should be routinely done to all patients who are at risk of postural hypotension such as elderly, hypertensive patients and those on polypharmacy treatments6. generally, treatment of orthostatic hypotension depends on the underlying cause and it should be aimed to improve the functional status and also the symptom that the patient’s experienced6. some may benefit from pharmacological treatment but some may not. education about this condition and the aim of the treatment is important and should be well informed to all patients suffering from oh. in these cases, the cause of oh seems to be due to be iatrogenic. the treatment of postural hypotension secondary to drugs can be very challenging. it requires a complete drug review, adjustment of medications and frequent appointments. the decision to withdraw, withhold, dose reduction or timing adjustment of the anti-hypertensives must be made after considering all aspects. close monitoring must ensued in order to avoid worsening of the oh or bp control. other than adjusting the medications, patients may also benefit from diet modification (increase salt and water intake) and physical activities such as avoid standing for long period, doing isometric exercise, wearing elastic stockings and sleep with slight elevated head1. however, some may need medication therapy such as fludrocortisone or midodrine to help alleviate the symptom. an interesting study showed that while postural hypotension can be dose-dependent when using anti-hypertensive drugs, using natural herbs may not produce similar effects7,8. conclusion giddiness is a common presentation of orthostatic hypotension. inappropriate management of this condition predisposes the patient to fall and may results to significant morbidity and mortality. therefore it is very important to investigate the cause of oh and treat accordingly. the cause may be the same but the treatment may need to be personalized as long as the aim to improve the symptom, functional status and also harm prevention is achieved. acknowledgement the authors would like to thank the patients for their kind permission in publishing of this case report. there was no ethical approval sought other than getting consent from the patients. conflict of interest no conflict of interest has been disclosed by the authors. funds this study did not receive any funding. individual authors contribution conception and design: nkd, aar critical revision of the article for important intellectual content: fm, nkd, aham final approval of article: fm, nkd, aar, aham international journal of human and health sciences vol. 03 no. 04 october’19 244 references 1. ricci f, de caterina r, fedorowski a. orthostatichypotension: epidemiology, prognosis, and treatment. j am coll cardiol. 2015;66(7):848– 60.doi: 10.1016/j.jacc.2015.06.1084. 2. zhu qo, tan csg, tan hl, wong rg, joshi cs, cuttilan ra, et al. orthostatic hypotension: prevalence and associated risk factors among the ambulatory elderly in an asian population. singapore med j. 2016;57(8):444–51. doi: 10.11622/ smedj.2016135. 3. low pa. prevalence of orthostatic hypotension. clin auton res off j clin auton res soc. 2008;18suppl 1:8–13. doi: 10.1007/s10286-007-1001-3. 4. hakala sm, tilvis rs. how stable is postural hypotension in the general aged population? arch gerontol geriatr. 1996;23(2):129–38. available from:https://www.ncbi.nlm.nih.gov/ pubmed/15374157. 5. sathyapalan t, aye mm, atkin sl. postural hypotension. bmj. 2011;342:d3128. doi: 10.1136/ bmj.d3128. 6. shibao c, lipsitz la, biaggioni i. evaluation and treatment of orthostatic hypotension. j am soc hypertens jash. 2013;7(4):317–24. doi: 10.1016/j. jash.2013.04.006. 7. borhanuddin m. study of antihypertensive effects of ocimum sanctum. bangladesh journal of medical science. 2016;15(3):357-361. 8. sohail t, saleem n, imran h, yaqeen z, urrehman a, jamil k, rauf m. nutritional and toxicological analysis of phoenix dactylifera (date palm) powder used as a drink. bangladesh journal of medical science. 2018;17(2):263-269 449 international journal of human and health sciences vol. 06 no. 04 october’22 case report dilemma behind post-spinal tetraplegia: is conversion disorder really the culprit? farah nasreen1, atif khalid2, sobia manaal siddiqui3, mohd. ahsan4 abstract: the occurrence of intra-operative conversion disorder with tetraplegia in a patient undergoing emergency appendectomy under spinal anaesthesia has been described in this case report. a 19-year-old female patient was given spinal anaesthesia for an emergency appendectomy. she had a block up to the t10 level as per assessment. following confirmation of sensory and motor blockade level, the patient became apnoeic and appeared to stop responding abruptly. her vitals remained constant except for tachycardia. she was taken on bag and mask ventilation and preparation for endotracheal intubation was underway. the patient began to respond again after a few minutes of continual stimulation and bag mask ventilation. rest of the perioperative period was uneventful. postoperative psychiatry consultation was done, and she was diagnosed as a case of conversion disorder. keywords: conversion disorder, spinal anaesthesia, tetraplegia correspondence to: dr. farah nasreen,assistant professor, department of anaesthesia and critical care, jnmch, amu aligarh, india. email: kazmifarah@gmail.com 1. assistant professor, department of anaesthesia and critical care, jawaharlal nehru medical college hospital, aligarh muslim university, aligarh, india 2. senior resident, department of anaesthesia and critical care, jawaharlal nehru medical college hospital, aligarh muslim university, aligarh, india 3. junior resident, department of anaesthesia and critical care, jawaharlal nehru medical college hospital, aligarh muslim university, aligarh, india 4. junior resident, department of psychiatry, jawaharlal nehru medical college hospital,aligarh muslim university, aligarh, india introduction conversion disorder (cd) is defined as a psychiatric illness in which symptoms and signs affecting voluntary motor or sensory function cannot be explained by a neurological or medical condition. psychological factors, such as conflicts or stress are judged to be associated with the deficits. it has a presentation that suggests a neurologic or general medical condition.the pathology cannot be explained by available investigations, nor can it be attributed to anything else such as the patient’s participation in culturally sanctioned behaviours (e.g., ceremonial trances) or substance consumption. there are four types of conversion disorder: those who have motor symptoms or deficits, those who have sensory symptoms or deficits, those who have pseudo-seizures, and those who have a mixed presentation.1,2 in the general population, the lifetime prevalence of cd has been estimated to be between 11 and 300 per 100,000 persons.2 isolated case report have highlighted the varied presentation of perioperative conversion disorder. 2 patients with distinct features such as sudden onset, young age, female gender, low educational level, low socioeconomic status, neurological disorders with abnormal anatomical pattern, bizarre movements, and the presence of psychological features such as current or early diagnosis of a psychiatric disorder, or traumatic experience have been identified in published literature.3,4 we present a case of acute intraoperative conversion disorder with tetraplegia that arose after spinal anaesthesia was administered. this is international journal of human and health sciences vol. 06 no. 04 october’22 page : 449-451 doi: http://dx.doi.org/10.31344/ijhhs.v6i4.487 international journal of human and health sciences vol. 06 no. 04 october’22 450 the first account of a cd presenting with symptoms of tetraplegia after spinal anaesthesia, to the best of the authors’ knowledge. case presentation a 19-year-old female patient presented with a two-day history of fever and stomach pain, and she was diagnosed as a case of acute appendicitis. she was nervous and concerned about the surgery, and she was counselled about it. the anaesthetic technique was explained to the patient. she gave her informed consent. inside the operation theatre, routine monitoring equipmentwas attached. in the sitting position, spinal anaesthesia was conducted with a 26g quincke needle, and 12.5 mg of 0.5% percent bupivacaine (heavy) was administered intrathecally. the sensory and motor blockade were both evaluated and found to be at t10 level. the patient was becoming concerned about the loss of motor power in her lower limbs at this time, and she was told that she would regain full functionality within a few hours. she then abruptly closed her eyes and stopped answering. stimulation elicited no response. there was tachycardia in the range of 150 beats per minute. the blood pressure and saturation levels were both normal. as there was absence of respiratory efforts, she was placed on bag mask ventilation. despite the patient being apnoeic, saturation was maintained throughout. this episode lasted for around 7 mins. subsequently, the patient’s respiratory efforts resumed, and pulse began to settle, and she opened her eyes. she described her entire body as being paralysed and her inability to respond to verbal commands. her vitals remained stable throughout the surgery, and the rest of the procedure went smoothly. within four hours, she was transferred out in a stable state and had restored all motor and sensory functions in both lower limbs. after surgery, the patient was evaluated by a psychiatry unit due to inexplicable symptoms. the patient underwent a thorough history and mental status examination, during which it was discovered that the patient had been experiencing sudden episodes of intense fear, as well as palpitations, sweating, trembling, shortness of breath, and the feeling that she was about to die. “i think i’m going crazy,”she said of herself. these episodes were abrupt and episodic occurring rarely once in a month or not at all from past 3-4 months and often during the episode, patient experienced a sudden onset generalized weakness, unable to move her arms and legs, lasting for a few minutes, not associated with any residual weakness, with full gain of functionality of pre-morbid level. further it was discovered that her parents had recently separated one year back, following long spells of verbal violence against each other. in mental status examination (mse), general appearance and behaviour was normal with perplexed facial expression. in thought content, patient was pre-occupied with her anxiety symptoms and family problems. her physical, neurologic workup was unremarkable, and neuroimaging (mri brain) and laboratory parameters were also within normal limits. patient was classified as a case of conversion disorder and was prescribed a selective serotonin reuptake inhibitor (ssri) with supportive benzodiazepines (tab. escitalopram 10 mg once along with tab. etizolam 0.5 mg twice a day) with psychotherapy sessions planned for subsequent follow-ups. discussion conversion disorder, also known as functional neurological symptom disorder, is a psychiatric illness characterised by symptoms and signs that are not explained by a neurological or medical problem and impact voluntary motor or sensory function5. the term “conversion” refers to the substitution of a somatic symptom with a repressed idea. monoparesis, hemiparesis, paraparesis, altered sensorium, visual loss, pseudocoma, seizure-like behavior, irregular gait, aphonia/ dysphonia, lack of coordination, or odd movement disorders are all symptoms of conversion disorder. patients are not attempting to imitate symptoms, rather they are experiencing them.6 our patient was anxious about anaesthesia and surgery prior to surgery, and she was concerned intraoperatively about the lack of motion in her lower limbs when spinal anaesthesia was administered. the possibility of high spinal can be ruled out as the patient did not go into bradycardia, hypotension, or low saturation.7 in fact, tachycardia was noted, and she was taken on bag and mask ventilation as a precautionary measure. after regaining complete consciousness, the patient described feeling paralysed or trapped in her body, as well as breathing difficulties. she was given 1mg midazolam after ensuring that normal function had returned to her upper limbs and that she was completely cognizant, after which she fell asleep. 451 international journal of human and health sciences vol. 06 no. 04 october’22 following general anesthesia, there has been case reports of plegia (hemi/para) that led to complete recovery.8 many significant stressor events were associated with anxiety episodes in this case, eventually leading to conversion symptoms at the sub-conscious level, but they went unnoticed, and no psychiatric consultation was sought, ultimately leading to precipitation during the operative period. a search into literature revealed isolated case reports of respiratory arrest after spinal anaesthesia in parturients9,10. subdural block, drug impurities, neuraxial opioids and oxytocin, all have been attributed as possible cause for such event, but the dilemma remains unsolved. however, in our case, short duration of the episode in presence of haemodynamic stability and unremarkable neurologic workup precludes these possibilities and point more in favour of conversion disorder. conversion disorder demands a multidisciplinary approach to treatment. psychotherapy, physical therapy, and stress management are all vital components, as is timely referral to psychiatric services. care professionals must be aware of the patient’s current life circumstances, previous stress responses, and current support systems. stressful life experiences have been documented to precipitate conversion disorder, which can be acute (lasting only a few hours to days) or chronic (lasting weeks or months). there is no set age for this condition, and it affects both adults and children. to be able to foresee such situations, it is critical to have a complete psychiatric evaluation during the preanesthetic workup which may help identify high risk patients for conversion disorder. anaesthetists sometimes overlook psychiatric issues which may lead to most unusual events as seen in our case also. conclusion to conclude, psychiatric disorder may be a rare cause of neurologic deficit following spinal anaesthesia and should be made part of a complete pre-anaesthesia workup. intraoperative conversion disorder should be considered in cases with unexplainable symptoms not attributable to medical disorder or anaesthesia related complications. conflict of interest:none declared. funding statement: nil. authors’ contribution: all authors were involved equally in patient selection, data collection, manuscript writing, revision and finalizing. references 1. feinstein a. conversion disorder: advances in our understanding. cmaj. 2011;183(8):915-20. 2. ito a, nakamoto t, ohira s, kamibayashi t. postoperative tetraplegia due to conversion disorder upon emergence from general anesthesia. ja clin rep. 2020;6(88):1-3. 3. letonoff ej, williams trk, sidhu ks. hysterical paralysis: a report of three cases and a review of the literature. spine. 2002;27(20):e441-5. 4. kanaan ra, armstrong d, wessely sc. neurologists’ understanding and management of conversion disorder. j neurol neurosurg psychiatry. 2011;82(9):961-6. 5. diagnostic and statistical manual of mental disorder: dsm-5, 5th ed. arlington, virginia: american psychiatric association; 2013. 6. binzer m, andersen p, kullgren g. clinical characteristics of patients with motor disability due to conversion disorder: a prospective control group study. j neurol neurosurg psychiatry. 1997;63(1):83-8. 7. cooper j. cardiac arrest during spinal anesthesia. anesth analg. 2001;93:245. 8. tsetsou a, karageorgou e, kontostathis n, karadimos a. conversion disorder: tetraplegia after spinal anesthesia. greek e-journal perioper med. 2017;17(a):71-7. 9. acharya sp, marhatta mn, amatya r. unexplained apnoea and loss of consciousness during sub arachnoid block for caesarean section. kathmandu univ med j (kumj). 2009;7(4):419–22. 10. chan yk, gopinathan r, rajendram r. loss of consciousness following spinal anaesthesia for caesarean section. br j anaesth. 2000;85(3):474-6. 79 international journal of human and health sciences vol. 01 no. 02 july’17 original article: oral hygiene awarness among the primary school childrenin a rural areaof bangladesh karim f abstract: background: now-a-days dental problem is one of the most common diseases in the world.proper oral hygiene practicingin a regular basis are great ways to prevention of dental disease. methodology: this cross sectional study was carried out with a view to assess the oral hygiene awareness among the primary school children of a rural area under dhaka division of bangladesh. data about oral hygiene related knowledge and practices were collected by face to face interview of the children. oral examination was done by disposable dental mirror and probe under sufficient light. data were analyzed using spss version 16. results: among the 114 respondents 53.51% are male and rest are female. age range of the respondents were 6 to 11 years.oral hygiene related knowledge: among the respondents 78.07% told that regularteeth cleaning is important,60.52% respondents told that teeth should be cleaned once daily,62.29% told that teeth should be cleaned by tooth brush and tooth paste,70.17% told that teeth should be cleaned before breakfast. oral hygienerelated practice: among 114 respondents 64.04% cleaned their teeth everyday,51.75%used tooth paste and toothbrush to clean their teeth, 38.60%respondents cleaned their teeth in their convenient time. among the tooth brush users, most of them changed their toothbrush when it was damaged or lost. all the respondents used match stick or coconut leaf stick if food was deposited in between their teeth. oral hygiene status: among the respondents 68.32 % had caries in their mouth. about 53.42% caries found in the lower jaw. caries were more prevalent in molar teeth. about 69.34% respondents had plaque or calculus, 46.54% experienced gingival bleeding. conclusion: oral hygiene awareness among the respondents were very low. keywords: oral hygiene, children,caries correspondence to: dr. farzana karim, assistant professor, department of pediatric dentistry marks medical college (dental unit), mirpur 14, dhaka, bangladesh. e-mail: farzanakarim25@gmail.com international journal of human and health sciences vol. 01 no. 02 july’17. page : 79-82 introduction: oral health is an essentialpart of general health. it has become clear that causative and risk factors in oral diseases are often the same as those implicated in the major general diseases.1 without a healthy mouth, it is impossible to eat, speech clearly or smile without difficulties. in the developing country like bangladesh rural children may be more susceptible to dental diseases due to socio-economic and demographic factors like lack of awareness, inadequate access to expert dental care etc. children are the future of the nation. school going children spend considerable period of time in the school. it is one of the best platform to gather wide range of basic knowledge in different disciplines. the proper guidance help them to develop proper awareness about oral health behavior. many research shows thatin many countries, the number of children clean their teeth appropriately is very much disappointing. many of them do not clean their teeth at all, some of them clean their teeth inadequately and many of them have no experience of using tooth brush and paste. oral health education of the school children as effective method for prevention of various orodental problems.2,3the aim of this study was to investigate the oral hygiene related awareness among the rural primary school children. methodology: this was across sectional type of descriptive study. the study was carried out in a rural primary school under dhaka division of bangladesh.the present study was comprised of 114 respondents. data were collected from all the students attended on the school on that day of 2015. face-to-face interview were taken from the children by using structured questionnaire. the oral hygiene status was measured from all the students by clinical examination using disposable mirror and probe international journal of human and health sciences vol. 01 no. 02 july’17 80 under sufficient light. ethical approval for the study was taken from concerned authority.a verbal informed consent was obtained from the respondents beforeclinical examination. all the data were tabulated and statistically analyzed using statistical package for social sciences (spss) version 16. results: socio demographic status of the respondents: most of the respondents came from lower socio economic condition. table 1: distribution of the respondents according to their sex sex frequency percentage male 61 53.51 female 53 46.49 total 114 100.00 table 1 shows that among the respondents 53.51% are male and 46.49% are female. table 2: distribution of the respondents according to their age age ( in years) frequency percentage 6 15 13.15 7 18 15.80 8 24 21.05 9 17 14.91 10 19 16.67 11 21 18.42 total 114 100.00 table 2 shows that the age range of the respondents were 6 to 11 years. oral hygiene related knowledge of the respondents: table -3: distribution of the respondents by knowledge on importance of regular teeth cleaning regular teeth cleaning is important frequency percentage yes 89 78.07 no 25 21.93 total 114 100.00 table 3 shows that among the respondents 78.07% respondents told that teeth cleaning in regular basis is important whereas others said not. table4: distribution of the respondents by knowledge on frequency of tooth cleaning frequency of teeth cleaning frequency percent once daily 69 60.52 twice daily 10 08.78 do not know 35 30.70 total 114 100.00 table 4 shows that60.52% respondents told that teeth should be cleaned once daily whereas 08.78% told twice daily and 30.70% told that they did not know the answer. table 5: distribution of the respondents by knowledge on materials used for tooth cleaning materials used for teeth cleaning frequency percentage tooth brush & tooth paste 71 62.29 ash 14 12.28 coal 29 25.43 do not know 00 00.00 total 114 100.00 table 5 shows that among the respondents 62.29% told that teeth should be cleaned by tooth brush & tooth paste whereas 25.43% told coal and 12.28% told ash. table -6: distribution of the respondents by knowledge on time of tooth cleaning time of teeth cleaning frequency percentage before breakfast 80 70.17 after breakfast 08 07.02 after breakfast & before going to bed 05 4.39 do not know 21 18.42 total 114 100.00 table 6 shows that among the respondents about 70.17% told that teeth should be cleaned before breakfast, 7.02% told after breakfast, 4.39% told after breakfast and before going to bed and 18.42% did not know the answer. oral hygiene related practice among the respondents: table 7: distribution of the respondents by cleaning of teeth everyday clean teeth everyday frequency percentage yes 73 64.04 no 41 35.96 total 114 100.00 table 7 shows that among the 114 respondents 64.04% cleaned their teeth everyday whereas others did not clean their teeth everyday. table 8:distribution of the respondents by frequency of tooth cleaning frequency of teeth cleaning frequency percentage once daily 64 87.67 twice daily 07 9.59 thrice daily 02 2.74 total 73 100.00 table 8 shows that among 73 respondents 87.67% 81 international journal of human and health sciences vol. 01 no. 02 july’17 cleaned their teeth once daily, 9.59% cleaned twice daily and 2.74% cleaned thrice daily. table 9: distribution of the respondents by materials usedfor tooth cleaning materials used for teeth cleaning frequency percentage tooth brush & tooth paste 59 51.75 ash 23 20.18 coal 32 28.07 total 114 100.00 table 9 shows that among the respondents 51.75% used tooth brush & tooth paste for teeth cleaning whereas 20.18% used ash and 28.07% used coal. among 59 respondents 89.23% respondents changed their toothbrush when it damaged or lost whereas others changed their tooth brush after every six months to one year. among the respondents all of themused match stick or coconut leaf stick if food was deposited in between their teeth. table -10: distribution of the respondents by knowledge on time of tooth cleaning time of teeth cleaning frequency percentage before breakfast 62 54.39 after breakfast 03 2.63 after breakfast & before going to bed 05 4.38 no specific time 44 38.60 total 114 100.00 table 10 shows that among the respondents about 54.39% cleaned their teeth before breakfast, 2.63% after breakfast, 4.38% after breakfast and before going to bed and 38.60% told that they cleaned their teeth according to their convenient time. oral hygiene status:among the respondents 68.32 % had caries in their mouth. about 46.58% caries found in the upper jaw whereas 53.42% caries present in the lower jaw. caries were more prevalent in molar teeth. among the respondents about 69.34% respondents had plaque or calculus, 46.54% experienced gingival bleeding. discussion: the cross sectional study was carried out with a view to assess the oral hygiene awareness among the primary school children in a rural area under dhaka division of bangladesh. the present study was comprised of 114 respondents.among the respondents 53.51% are male and 46.49% are female.age range of the respondents were 6 to 11 years. oral hygiene related knowledge: among the respondents 78.07% respondents told that teeth cleaning in regular basis is important whereas others said not. about that 60.52% respondents told that teeth should be cleaned once daily whereas 08.78% told twice daily and 30.70% told that they did not know the answer. among the respondents 62.29% told that teeth should be cleaned by tooth brush & tooth paste whereas 25.43% told coal and 12.28% told ash. about 70.17% told that teeth should be cleaned before breakfast, 7.02% told after breakfast, 4.39% told after breakfast and before going to bed and 18.42% did not know the answer. oral hygiene practice: among the 114 respondents 64.04% cleaned their teeth everyday whereas others did not clean their teeth everyday which is near about similar to a study done by humagain.4 among the respondents 51.75% used tooth brush & tooth paste for teeth cleaning which is lower than a study done by ahmedet al 5 and others used ash, coal. this differences may be due to socio-economic condition or wrong conception or traditional belief of the respondents. among 59 respondents 89.23% respondents changed their toothbrush when it damaged or lost whereas others changed their tooth brush after every six months to one year. this may be due to lack of proper dental health education. socio economic condition may also attribute the factor. among the respondents all of them used match stick or coconut leaf stick if food was deposited in between their teeth. dental floss or other inter dental cleaning device is costly compare to match stick. coconut leaf stick is easily available in the bangladeshi rural area.that’s why rural people use this kind of stick for inter dental cleaning. among the respondents about 54.39% cleaned their teeth before breakfast, 2.63% after breakfast, 4.38% after breakfast and before going to bed and 38.60% told that they cleaned their teeth according to their convenient time. oral hygiene status: among the respondents 68.32 % had caries in their mouth. this is similar to a study done by sarwar et al6 and more than twice than the study done by edward et al7. about 46.58% caries found in the upper jaw whereas 53.42% caries present in the lower jaw. caries were more prevalent in molar teeth. which is similar to international journal of human and health sciences vol. 01 no. 02 july’17 82 a study done by zhu et al8. among the respondents about 69.34% respondents had plaque or calculus, 46.54% experienced gingival bleeding which is lower than a study done by sarwaret al.6 knowledge vs practice: among the respondents 78.07% told that regular tooth cleaning is important but only 64.04% cleaned their teeth everyday. among the respondents 62.29% told that teeth should be cleaned by tooth brush and tooth paste but 51.75% used tooth brush and paste to clean their teeth. these show that there is no association between their knowledge and practice. similar findings were found in the study done by krawczyk.9 conclusion: oral hygiene awareness among the rural primary school children was very little associated with poor oral hygiene.dental caries is a common public health problem among the school children. it is still probably important to promote good oral hygiene practices among young children to reduce the risk of caries and other dental problem. recommendation: health educational program on oral hygiene and periodic free dental checkup should be arranged on school. references: 1. world health organization. world oral health report 2003.geneva. 2. petersen pe, zhou e. dental caries and oral health behavior situation of children, mothers and schoolteachers in wuhan,peoples republic of china. int j dent j 1998; 48: 210-16. 3. petersen pe, kaka m. oral health status of children and adults in the republic of niger, africa. int dent j 1999; 49:159-64. 4. humagain m. evaluation of knowledge, attitude and practice (kap) about oral health among secondary level students of rural nepal a questionnaire study. webmed central dentistry,2011;2(3):wmc001805 5. ahmed nam, astrom an, bergen ns,petersen pe.dental caries prevalence andrisk factors among 12-year old schoolchildren from baghdad,iraq: a post-war survey.international dental journal 2007;57:36-44 6. sarwarafma, kabirmhb, rahman afmme, haqueaakasemmaa, ahmad sac et al.oral hygiene practice among the primary school children in selected rural areas of bangladesh.j. dhaka national med. coll. hos. 2011; 18 (01):43-8 7. edward cml, loo eky, lee ck. dental health status of hong kong preschool children.hong kong dent j 2009;6:6-12 8. zhu l, petersen pe, wang hy, bian jy,zhang bx. oral health knowledge, attitudes and behaviour of adults in china. international dental journal 2005;55:231–41 9. krawczyk d, pels e, prucia g, kosek k, hoehne d. students’ knowledge of oral hygiene vs its use in practice. advances in medical sciences. 2006;51:122-5. 229 international journal of human and health sciences vol. 04 no. 03 july’20 case report: challenges during modified constraint induced movement therapy (mcimt) in hemiplegic cerebral palsy mazatulfazura sf salim1, aneesa abdul rashid2, muhammad hibatullah romli3 abstract: two cases involving children with hemiplegic cerebral palsy aged 1 and 8 year receiving mcimt were reported. challenges faced by the clinicians and family members were discussed in detail. mcimt is rarely implemented in pediatric rehabilitation in malaysia. the intensive protocol of mcimt yielded challenges in terms of high commitment from the family members and non-adherence from the children. clinicians and family members should properly plan and discuss when consideringmcimt for intervention. keywords: cerebral palsy, hemiplegia, pediatrics, modified constraint induced movement therapy. correspondence to: mazatulfazura sf salim, department of medicine, faculty of medicine and health sciences, upm, 43400 serdang, malaysia. e-mail: fazurasf@upm.edu.my. 1. department of medicine, faculty of medicine and health sciences, upm, 43400 serdang, malaysia. 2. department of family medicine, faculty of medicine and health sciences, upm, 43400 serdang, malaysia. 3. department of nursing and rehabilitation, faculty of medicine and health sciences, upm, 43400 serdang, malaysia. international journal of human and health sciences vol. 04 no. 03 july’20 page : 229-231 doi: http://dx.doi.org/10.31344/ijhhs.v4i3.206 case 1 sni is a 1 year and 3 months old girl, who was born premature at 27 weeks poa and was complicated with respiratory distress syndrome that required intubation and nicu admission for almost a month. the child’s mother noted that at 9 months old, she had developed right hand dominance and her left hand was kept fisting. her mother also noted that at 1 year old, sni was moving around with her bottom shuffling. she was unable to pull herself in order to stand and this was mainly limited by her left upper and lower limb weakness. upon examination, she was not moving much of her left hand however able to open fingers occasionally. when standing, it was observed that she bears weight only at the right lower limb. besides the neurodevelopmental therapy (ndt) approach, we had discussed with the patient’s mother regarding the benefit of mcimt to improve her daughter’s left upper limb function. the unaffected upper limb is restrained during therapy session for 2 hours per day, every day for two weeks at home. the home programme was provided by the clinicians for the caregivers to follow. two one-hour therapy sessions every week at the clinic was conducted to monitor the intervention. crepe bandage was used as restrainer. intensive and repetitive practices of motor activities were incorporated. activities such as reaching, grasping, holding, manipulating an object and bearing weight on the arm were introduced. after 1 week of treatment, the parents had expressed difficulties to comply with the protocol at home as itconsumed their time. furthermore, they noted that sni was feeling uncomfortable with the restraint and at times, managed to remove it on her own. the parents were unable to proceed with the protocol due to the time factor and also, they felt uncomfortable when their child became more distressed and frustrated after being restrained. case 2 jol is an 8 years old boy with underlying hypoplastic left heart. he underwent multiple surgeries at the age of 5 but developed thromboembolic complication post-surgery. since then, he developed left hemiparesis. he had typicaldevelopmental milestone, attending normal school and able to participate in the normal learning and teaching session. he was able to ambulate independently without aids. he independently performed his personal activity of daily livings however a little slow in dressing international journal of human and health sciences vol. 04 no. 03 july’20 230 and bathing. on examination, his left shoulder abduction and elbow extension/flexion were 4/5, wrist extension/flexion were 3/5 and his finger extension and flexion were 3/5 with fair grip strength. he had mild spasticity over his biceps, fcu and fcr with modified ashworth scale (mas) of 1. his left lower limb proximal muscles were 4/5 and distal muscles were 3/5. there was only mild spasticity over his hamstring and gastrocsoleus with mas of 1+. he had hemiplegic gait with extensor synergy pattern with good ground clearance. he underwent physiotherapy for stretching and strengthening exercise. mcimt was suggested as an additional intervention. the mcimt program was introduced to the patient whereby restraint of the unaffected upper limb is applied, and 2 hours per day of therapy is provided to the affected limb for 2 weeks whereby 2x per week (2 hours per week) sessions are with the therapist and at least 2 hours per day structured practice with the caregivers. the type of restraint for this patient is by also using a crepe bandage, and intensive, repetitive practices of motor activities were incorporated. task such as reaching, grasping, holding, manipulating an object and bearing weight on the arm were introduced to the patient. these tasks were also taught to the parents as they are supposed to apply it daily to the patient. interesting age-appropriate activities such as games, puzzle, ‘blocks and hole’ and kid’s clay is provided. the mother of this patient is a housewife and she was able to spend time and focused on the intensive therapy needed while at home. however, being a bright kid, jol had always found a way or giving excuses not to restraint his non paretic hand and refused to participate during the therapy. he will refuse to eat or bathe if he was restrained and was persuaded to use his paretic hand. due to the patient’s own noncompliance, the mcimt was unable to be completed. discussion cimt and related interventions (mcimt and forced use cimt) are one of the promising interventions to reduce impairment and improve functional use of the affected upper limb of children with hemiplegia and cerebral palsy1. however, several factors need to be considered to ensure its efficacy. in this article, several factors have been identified on the unsuccessful in initiating mcimt. cimt and its related interventions are relatively new and rarely implemented in malaysia. studies indicated that the protocol on restraining, and dosage is varied among literature and there is no standard accepted practice available1. even in western countries, the cimt is criticized on its high-intensive protocol1. cimt is originally developed in the western countries and thus,its feasibility to be implemented in southeast asian especially in malaysia is not explored. culture, perception and lifestyle of malaysian community such as long working hours of parents, pessimistic social perception towards disabilities and limited inclusion of children with disabilities into prime school settings may explain why poor adherence on cimt intervention happen. this case report indicates active involvement from the parents or caregivers on giving feedback about the intervention. therefore, it is an opportunity to conduct rectifying measure to overcome the challenges to successfully carrying the mcimt intervention rather than stopping the intervention. clinicians have role to be equipped with knowledge on cimt, develop a detail home programme. they should actively involve with the parents, family members, caregivers and the child in the discussion and planning the intervention goal and expectation2. proper preand post-assessment should be performed to show the parents on the benefits of cimt and constant explanation should be given to motivate the parents and the child to continue the intervention. innovative approach on cimt should be introduced. rather than 2 hours continuous, the dosage could be break into several sessions with the cumulative time to be 2 hours per day. the cimt is conducted when the child doing daily activities such as during dinner time (feeding activities using the affected hand) and during doing the homework. this may help the child to be more engage, increase attention and reduce the parents’ commitment time. the clinicians and therapists play a major role in implementing mcimt. guideline and recommendation for cimt by cincinnati children hospital 2009, emphasized on the needs for the clinicians and therapists to have skills and knowledge in cimt/mcimt theory, evidence based practice, clinical guidelines, assessments, goal setting, and development of home programming materials. they also recommended that the clinicians and therapists to be able to give in-depth education to the caregivers prior to implementing cimt to assist them in understanding the commitment necessary for successful completion of the cimt program3. in our cases that we presented here, there was 231 international journal of human and health sciences vol. 04 no. 03 july’20 lack of assessment prior to initiating mcimt and there were possibilities that the caregivers were not given in depth explanation on mcimt and the importance or needs for compliancy to the structured home programming. patient factors also play a major role in ensuring efficacy of cimt. there were several factors that might affect the compliancy towards the program. one of the factors is the method and fabrication of the constraint. various constraints have been studied in the literature but there is insufficient evidence to support the use of a specific type4. older children who are able to understand the reason for constraint use may be able to use less restrictive constraints such as ace wrap to the unaffected arm. however younger children might require a more robust constraint i.e. cast from which they cannot slip out1. some parents were concerned with the possible negative effects of mcimt on the child. with the constraint used especially in children, lead to possibility of increased frustration which impacts the self-esteem. studies of group therapy reported that parents and therapists observed that their children had higher self-esteem and increased motivation to participate in difficult activities. in group therapy, they also showed improvements in performance because they could model their actions after their peers, and they were more willing to persist in difficult or frustrating activities. furthermore, they felt a sense of belonging, and appreciated seeing other children with similar motor deficits5,6. our patients that we presented above might also benefit from a group therapy. to conclude, there are needs of commitment and participation of children, their families, the clinicians and therapists during mcimt in order to ensure efficacy of the treatments in this pediatric group of patients. shared decision making and goal setting between caregivers, the clinicians and therapists are also paramount. conflict of interest no conflict of interest has been disclosed by the authors. ethical approval issue the authors acknowledged that consent has been obtained from the patients in regard to the details included in this report. reporting of this study has been checked and verified in accordance with the care (consensus based clinical case reporting guideline development) checklist. funding statement this study did not receive any funding. authors contributions conception and design: mss, mhr, aar; critical revision of the article for important intellectual content: mss, aar, mhr. references: 1. chiu hc, ada l. constraint‐inducedmovement therapy improves upper limb activity and participationin hemiplegic cerebral palsy: asystematic review. journal of physiotherapy 2016;62(3):130‐7. 2. adamsjr, drake re, shared decision-making and evidence-based practice. community ment health j, 2006;42(1):87-105. 3. pediatric modified constraint induced movement therapy (mcimt/bit) team, cincinnati children’shospital medical center: evidence-based clinical care guideline pediatric modified constraint induced movement therapy (mcimt) plus bimanual training (bit), http://www.cincinnatichildrens. org/svc/alpha/h/health-policy/evbased / pediatric modified constraint induced movement therapy (mcimt) plus bimanual training (bit).htm, guideline 34, pages 121, december, 2014. 4. hoarebj, et al., constraint-induced movement therapy in the treatment of the upper limb in children with hemiplegic cerebral palsy. cochrane database syst rev, 2007;(2):cd004149. 5. eliassonac, et al., feasibility of a day-camp model of modified constraint-induced movement therapy with and without botulinum toxin a injection for children with hemiplegia. phys occup ther pediatr, 2009;29(3):311-33. 6. kruijsen-terpstra, aj, et al., parents’ experiences with physical and occupational therapy for their young child with cerebral palsy: a mixed studies review. child care health dev, 2014;40(6):787-96. international journal of human and health sciences vol. 07 no. 03 july’23 262 case report is hypereosinophilia a sign of underlying tuberculosis? a case report and review of literature majed abdul basit momin1, abhijeet ingle1, g vamshi krishna reddy2, r rahul dev singh1, rubina hassan1 abstract eosinophilia is a common haematological problem that we see in our clinical practice. it is unusual to find hypereosinophilia at the onset of inguinal tuberculous lymphadenitis and hepatic non-granulomatous eosinophilic necrosis. we present the case of a 67-yearold man who complained of a dry cough for three months and a fever for one month. the right inguinal lymph node was palpable on clinical examination and initial haematological investigation revealed marked hypereosinophilia, mimicking myeloproliferative disorder. a thorough imaging workup revealed extensive thoracic lymphadenopathy as well as multiple liver lesions. further liver mass core biopsy revealed hepatic, non-granulomatous necrosis with eosinophilic infiltration, whereas excision biopsy of inguinal lymph node revealed granulomatous inflammation with positive acid-fast bacili on histopathological examination. the patient responded to anti-tubercular treatment with steroids and hydroxyurea. the case emphasizes the association of eosinophilia in tuberculosis with tendency to forming mass lesions in liver and also the role of eosinophilic proteins in tissue injury. keywords: hypereosinophilia; inguinal tuberculosis; hepatic necrosis correspondence to: dr. r. rahul dev singh, consultant pathologist, department of laboratory medicine, yashoda hospitals, malakpet branch, hyderabad, telangana state, india. email: rahuldevsingh16@gmail.com 1. department of laboratory medicine, yashoda hospitals, malakpet branch, hyderabad, telangana state, india. 2. department of medical oncology, yashoda hospitals, malakpet branch, hyderabad, telangana state, india. introduction eosinophilia is defined as a peripheral blood (pb) eosinophil count greater than 500 per microliter. hypereosinophilia (he) is defined by a marked increase in eosinophils in pb ≥1.5x109/l. the disorder would be categorized as hypereosinophilic syndrome (hes) if he is persistent (lasting longer than 6 months)1. the consistent presence of a high number of eosinophils in the pb can eventually cause multiple organ tissue damage as these eosinophils infiltrate different tissues and cause inflammation. consequently, identifying an underlying condition that requires effective treatment is a key goal of early he assessment. tuberculous lymphadenitis remains a common extrapulmonary manifestation of tuberculosis (tb). tuberculous lymphadenitis most commonly involves cervical group of lymph nodes and involvement of inguinal group of lymph nodes is uncommon2. the precise function of eosinophils in the host immune responses in tb remains poorly understood. the function of eosinophils in the host protection and inflammatory pathology related to hypereosinophilia in tb is not well described in literature3. case summary a 67-year-old male presented with complaints of dry cough for three months, fever for one month and one episode of bleeding per rectum. the cough was insidious in onset, dry in nature and not associated with sputum. the patient was hemodynamically stable except for a mild fever 1000 f. on international journal of human and health sciences vol. 07 no. 03 july’23 page :262-266 doi: http://dx.doi.org/10.31344/ijhhs.v7i3.584 mailto:%20rahuldevsingh16%40gmail.com%20?subject= 263 international journal of human and health sciences vol. 07 no. 03 july’23 examination, the patient was thin built with no signs of anemia, icterus, cyanosis or clubbing. the deep right inguinal nodes were palpable, matted, non-tender and mobile, measuring 2.0 × 2.0 cm in size. the systemic examination was unremarkable. initial lab investigation, hemogram revealed (table1) mild anemia, hyperleukocytosis with marked hypereosinophilia with 92% eosinophils on differential white blood cells count, absolute eosinophil count was 3,63,400/cumm. the platelet count was normal in number and morphology. peripheral blood film showed normocytic normochromic rbcs, mild anisocytosis and marked eosinophilia. morphologically eosinophils were mature, bilobed, with few trilobed forms. eosinophilic orange granulation with no evidence of dysplastic eosinophils (nuclear hypersegmentation or hypo segmentation, sparse granulation or cytoplasmic vacuolation) was seen. no blast cells or no hemoparasite were seen in peripheral smear. the liver function test revealed (table 1) increased transaminases and alkaline phosphatase levels. renal function tests were normal. viral screening for hiv-1 and hiv-2, anti-hepatitis c antibody and hepatitis b surface antigen were negative. erythrocyte sedimentation rate was 20 mm in the first hour. complete urine examination was normal and stool examination did not reveal any ova or cyst. bone marrow aspirate showed prominence of eosinophils and its precursors with no prominence of blast. mantoux test was less than 10 mm. stool culture after 48-hour aerobic incubation was negative. serological tests for filarial antigen/antibody and test for ecchinococcus were also negative. clonal cytogenetic or molecular genetic abnormality was not detected. chest radiograph showed normal findings except mild prominence of bronchovascular markings. pet-ct showed multiple enlarged nodes in pre, para tracheal, bilateral axillae, bilateral supraclavucular region and right inguinal lymph nodes. patchy peripheral consolidation of superior segment lower lobe of right lung was also seen. multiple nodular lesions were seen in liver with retro-peritoneal and peritoneal lymphadenopathy. ultrasound guided liver nodule core biopsy was performed. on histological examination it showed large areas of necrosis with viable areas densely infiltrated by eosinophils. there were no atypical or malignant cells (figure 1). fig. 1: (a) liver core biopsy (h&e stain, ×10); (b & c) necrosis (red arrow) eosinophilic infiltration (blue arrow) (h&e stain, ×40). excision biopsy of right inguinal node on histological examination showed multiple, confluent epithelioid granulomata along with langhan`s type giant cells, areas of necrosis and hyalinization. special stain (ziehl-neelsen) for acid-fast bacilli (afb) highlighted few of the organisms (afb). fig. 2: inguinal lymph node (h&e stain) shows granuloma (green arrow), langhan`s giant cells (2b) (red arrow) and hyalinization and caseous necrosis (red arrow). overall histologic features were suggestive of caseating granulomatous lymphadenitis of tuberculous etiology. based on histological findings patient was treated with anti-tubercular drugs, steroids and hydroxyurea. patient`s fever and cough subsided, and eosinophils and absolute eosinophil count gradually decreased (table 1). international journal of human and health sciences vol. 07 no. 03 july’23 264 sl. no. lab parameters test results biological reference interval 1 hemogram day 1 day 4 day7 day 10 hemoglobin 10.5 9.2 9.0 9.0 12-15 gm% white blood cells 3,95la khs 1.93la khs 86,900 40,800 4000-11000/cumm eosinophils (%) 92% 95% 90% 84% 00%-06% absolute eosinophil count 3,6340 0 1,838 25 78,210 34272 40-440/cumm platelets 2.0 2.2 2.0 1.90 1.5 -4.5 lacs/cumm 2 lft total bilirubin 1.3 0.4 0.8 0.2-1.3 mg/dl direct 0.2 0.1 0.2 0-0.3 mg/dl indirect 1.1 0.3 0.6 0-1 mg/dl sgot 128 30 26 14-60 u/l sgpt 46 16 15 0-35 u/l alkaline phosphatase 501 364 296 38-126 u/l total proteins 8.1 5.5 5.0 6.3 8.5 gm/dl albumins 3.1 2.2 2.0 3.5-5.0 gm/dl globulins 5.0 3.3 3.0 2.3 -3.5 gm/dl 3 serum creatinine 0.5 0.8 0.7 0.71.2 mg/dl discussion the case presented here is that of an elderly male who presented with a prolonged history of fever and dry cough. at the time of the initial hospitalization, the patient had severe eosinophilic leukocytosis and a high absolute eosinophilic count, which suggested chronic eosinophilic leukemia. however, clinically palpable inguinal lymph nodes and an imaging study that revealed multiple nodular lesions in the liver and extensive lymphadenopathy made distinguishing it from metastasis difficult. further testing, including bone marrow aspiration cytology, stool routine, and culture examinations, ruled out all common secondary causes of hypereosinophilia and cytogenetic and molecular testing later ruled out clonal eosinophilia. finally, histological table 1: laboratory test results e x a m i n a t i o n revealed that the patient had e x t r a p u l m o n a r y t u b e r c u l o s i s ( i n g u i n a l t u b e r c u l o u s l y m p h a d e n i t i s ) with hepatic nong r a n u l o m a t o u s e o s i n o p h i l i c necrosis. e o s i n o p h i l s comprise 1–3% of total leukocytes and the normal percentage of eosinophils in blood varies between 0.0 to 6.0%. allergic and intestinal parasitic infections are considered among common causes of eosinophilia4. table 2 lists the causes based on absolute eosinophil counts5. there is no mention of tuberculosis in medical literature as a cause of eosinophilia. table 2: degree of eosinophilia severity of eosiniophilia aec levels per micro liter differential diagnosis mild 500-1000 allergic diseases atopy asthma drug allergy bacterial and viral infections moderate 15005000 parasitic infections hes churg-strauss syndrome cancers sezarys syndrome severe >5000 hypereosinophilic syndrome (hes) eosinophilic leukemia cancer 265 international journal of human and health sciences vol. 07 no. 03 july’23 tissue he is defined as (1) eosinophils >20% of all nucleated cells in a bone marrow aspirate (2) tissue infiltration by eosinophils that, in the opinion of an experienced pathologist, is markedly increased; or (3) extensive extracellular deposition of eosinophil-derived proteins in tissue as demonstrated by immunostaining4. the hypereosinophilic syndromes (hes) are a group of disorders marked by the sustained overproduction of eosinophils, in which eosinophilic infiltration and mediator release cause damage to multiple organs including heart, gastrointestinal tract, liver, lungs, central nervous system and kidneys. some hes remain idiopathic and some are associated with significant predisposition to myeloproliferative disorder and leukemia like syndrome.6 hepatic involvement of hypereosinophilic syndrome is uncommon. the eosinophilic infiltration with hepatic necrosis is commonly seen in the case of visceral larvae migrans, in which many charcot-leyden crystals are also seen in liver histology. other rare causes are drug induced hypersensitivity, primary biliary cirhosis and primary sclerosing cholangitis 7. the histological changes are because of cytotoxic effect of discharge of toxic biologically active proteins from eosinophils, including cationic proteins [such as major basic protein (mbp), eosinophil peroxidase (epo), eosinophil cationic protein (ecp) and eosinophil-derived neurotoxin (edn)], cytokines, chemokines and growth factors 6. imaging findings in these cases show multiple mass lesions which are difficult to differentiate from hepatocellular carcinomas, metastatic carcinoma or malignant lymphoma. image guided core biopsy or fine needle aspiration cytology plays a crucial role for histopathological or cytological confirmation in these cases7. eosinophil recruitment is common in tb infections, but their actual contribution to mycobacterium tuberculosis growth is unknown. however, several studies have found that eosinophil cationic proteins are mycobactericidal and promote lysis. ray et al. proposed that in susceptible patients, an early hypersensitivity reaction to the mycobacterium antigen could cause florid tropical pulmonary eosinophilia and il-5 has been identified as the most important cytokine responsible for the expansion of peripheral eosinophilia8. peripheral eosinophilia in abdominal tb was described by gill et al. he determined through a histological examination of the peritoneal biopsy9. flores et al. reported a case of peripheral blood eosinophilia with tuberculosis in a patient with weight loss and lymphadenopathy, which was similar to our case. a lymph node biopsy revealed a granulomatous lesion10. furthermore, haftu et al. described a case of hepatic tuberculosis in a 9-year-old child who had hepatic nodules and peripheral blood eosinophilic leucocytosis11. the goal of hypereosinophilic treatment is to reduce eosinophil levels in blood and tissues, thereby preventing tissue damage. the treatment modalities includes glucocorticoids like prednisone and chemotherapeutic agents such as hydroxyurea, chlorambucil and vincristine9. conclusion to conclude, hypereosinophilia, as pronounced at diagnosis, is rare in patients with tuberculous inguinal lymphadenitis and should be considered in the differential diagnosis, especially when more common causes have already been ruled out. he is one of the mass-forming diseases in the liver and liver biopsy is a useful diagnostic tool. although the link between hypereosinophilia and tuberculosis is still being researched, eosinophil proteins have been proven to cause histological changes in tissues. conflict of interest: none declared. source of fund: nil. authors contribution: concept and design: mbm, ai, gvkr, rds, rh; major revision: mbm, rds, rh, final approval of the manuscript: mbm, ai, gvkr, rds, rh. international journal of human and health sciences vol. 07 no. 03 july’23 266 references 1. gotlib j. world health organizationdefined eosinophilic disorders – update on diagnosis, risk stratification, and management. am j hematol. 2015;90:1077-89. 2. farhad m, arafat sm, mazumder mk, kabir mr, mohaimenul haq sm, uddin mj, et al. persistence of granuloma or granulomatous inflammation after six months of cat-1 anti tuberculosis therapy in tubercular lymphadenitis patients. bangladesh j med sci. 2023;22(1):216-21. 3. prakash babu s, narasimhan pb, babu s. eosinophil polymorphonuclear leukocytes in tb: what we know so far. frontier in immunol. 2019;10:2639. 4. muhammad f rozi, dewi m darlan, rodiah rahmawati, dewi is siregar. intestinal parasitic infections and eosinophilia: a cross-sectional study among primary school-aged children in medan, indonesia. int j hum health sci (ijhhs). 2020;4(4):277-81. 5. rothenberg me, hogan sp. the eosinophils. ann rev immunol. 2006;24:147-74. 6. lehrer ri, szklarek d, barton a, ganz t, hamann kj, gleich gj. antibacterial properties of eosinophil major basic protein and eosinophil cationic protein. j immunol 1990;142:4428-34. 7. keda h, katayanagi k, kurumaya h, harada k, sato y, sasaki m. case of hypereosinophilia – associated multiple mass lesions of liver showing non-granulomatous eosinophilic hepatic necrosis. gastroenterol res. 2011;4(4):168-73. 8. ray d, abel r. hypereosinophilia in association with pulmonary tuberculosis in a rural population in south india. indian j med res. 1994;100:219-22. 9. gill am. eosinophilia in tuberculosis. br med j. 1990;2:220-1. 10. flores m, merino-angulo j, tanago jg, aquirre c. late generalized tuberculosis and eosinophilia. arch intern med. 1983;143:182. 11. haftu h, tadese k, gebrehiwot t, gebregziabher h. how common is eosinophilia in tuberculosis? case report. pediatric health med ther. 2020;11:59-63. international journal of human and health sciences vol. 05 no. 02 april’21 154 review article: acute care surgery preparedness for covid-19 pandemic: an experience from qatar ahmad abutaka1, omar aboumarzouk1, nizar bouchiba1, sherif abdelaziem1, hesham el gohary1, hijran mahdi1, shameel musthafa1, and ahmad zarour1 abstract: most cases of covid-19 pandemic are now being reported outside wuhan, china where the first case was detected. it is highly contagious and has engulfed the world in a short span of time. the burden on healthcare resources to care for the public has mounted multifold due to its fast transmission. non-operative management of covid-19 positive or the clinical suspicious cases is preferred. personal protective equipment (ppe) should be utilized to protect the healthcare professionals’ safety. the ministry of public health, qatar has launched a series of virtual health care facilities to manage patient appointments, medical consultation, sick leave and drug distribution to avoid hospitalization and to minimize the spread of covid-19 infection to non-emergency patients by dialing hotline number to provide appropriate services. we would like to share and disseminate the experiences at the acute care surgery (acs) section, hamad medical corporation (hmc). ethical considerations, social distancing and optimum utilization of the available resources are essential to overcome the pandemic situation. keywords: covid-19, emergency surgery, sars-cov-2. correspondence to: ahmad zarour, md, facs. head, acute care surgery division hamad medical corporation. e-mail: azarour@hamad.qa 1. acute care surgery division, hamad medical corporation, doha, qatar. international journal of human and health sciences vol. 05 no. 02 april’21 page : 154-158 doi: http://dx.doi.org/10.31344/ijhhs.v5i2.252 introduction on february 29, 2020, our country announced the recording of its first covid-19 case1, since then the number of confirmed cases has risen to 117,226 cases after running 594,215 tests, at the time of this written article. as part of the response to the pandemic, a protocol was devised by our team at hamad medical corporation (hmc), doha, qatar. the disease causes a respiratory illness with symptoms such as cough, fever, and difficulty in breathing. it spreads mainly through contact with the diseased person when he/she coughs or sneeze and can be prevented taking precautions like washing hands frequently, avoiding touching the face and avoiding close contact with people suffering from it2. the novel coronavirus (sars-cov-2) also shows evidence of causing gastrointestinal symptoms such as diarrhea, nausea, vomiting, and abdominal discomfort and has the potential to be transmitted by the fecaloral route. the sars coronavirus showed up in the stool specimens, after the patients have been discharged from the hospital3. we would like to share our experience in the acute care surgery section in dealing with the surgical services during covid-19 as an example of a middle-eastern experience, in managing this pandemic. our strategy is anticipatory and preemptive. in addition to the general strategies implemented during this pandemic crisis, we undertook additional strategies, with the aim of limiting cross contamination between covid-19 positive and negative cases, utilizing a wellestablished protocol and pathway for managing surgical emergencies during this crisis. the acute care surgery division at hamad medical corporation provides emergency tertiary general surgical services. to ensure the safety of the staff and to allow for continual care for patients we have reduced the number of staff to try and mitigate the risk of exposure. we have restructured the manpower and staggered the staff into four teams (on-call, post-call, pre-call and standby 155 international journal of human and health sciences vol. 05 no. 02 april’21 teams). this reduces the number of staff who are present in the hospital simultaneously. each team is composed of the attending consultants, fellows and residents carrying out the day to day patient care activities. this structure allows a backup coverage in case of illness or exposure to covid-19 to the onboard team and restricts the non-essential personnel from the operating rooms and the emergency department. furthermore, the minimum number of medical personnel are allowed at the bedside during the ward rounds and in the operating rooms. we supported physical distancing practices by allowing physicians and team members with no direct contact with the patients to work from home, where they carried out administrative duties and virtual clinics. regular staff meetings were all cancelled and were converted into virtual meetings. morbidity, mortality and business meetings have been reduced to four attending physicians, to ensure patient safety and continuity of safe surgical practice of these vital meetings. vital to the success of these major changes were continued education of staff, patients, and visitors. these included education on physical distancing, self-isolation in case of mild symptoms, and protective measures ranging from hand washing to mask wearing. we have revised the recommendations of best practices during the pandemic issued by the major surgical societies, namely, the american college of surgeons, sages, and the intercollegiate royal college of surgeons4-6. our consultants, fellows and residents discussed the emerging guidelines to make sure we continue to update our protocols and practices to conform with the global surgical community. four days a week, our patients are followed up in our tele-clinic. the patients are contacted by phone, all clinical issues are addressed over the phone wherever possible. the patient is only brought to the clinic if a physical examination is considered to be crucial. refill medications are also ordered for the patient to be picked up from the nearest pharmacy. covid-19 positive patients who require admission for emergency surgical care are referred to the general hospital which has been designated as the covid-19 positive base. dedicated wards as well as operating theatres were established for these patients. this further decreases the probability of transmission to other emergency patients. our full pathway and protocol are shown in figure 1 and figure 2. the interventions undertaken by our section specifically and the hospital as a whole was carried out even before the outset of an outbreak. by limiting staff numbers to the bare minimum required, carrying out day-to-day patient care remotely where possible, isolating surgical covid-19 positive patients to one specific site, and implementing a protocol based on the experiences of our chinese colleagues, we have managed to limit and decelerate covid19’s spread across our surgical floors and units. therefore, we recommend our colleagues in an emergency surgical setting to modify their local guidelines early and put in place early protocol pathways to prevent further spread of covid-19. conclusion covid-19 is a highly transmissible disease. guidelines on the management of emergency surgical patients is the need of the hour. each institution should put together their set of guidelines and institute changes that are in line with the international recommendations and local regulations. conflict of interest: all authors declare no relevant conflict of interest. ethical approval: not needed as the per our mrc regulations. funding statement: none. authors’ contribution: drafting the manuscript and literature review: a.a.; drafting the manuscript and proofreading: o.a.; review of manuscript and protocols development: n.b.; review of manuscript and protocols development: s.m.; review of manuscript and registry: h.e.; review of manuscript and literature review: h.m.; algorithm design and development: s.m.; drafting the manuscript and study concept: a.z. international journal of human and health sciences vol. 05 no. 02 april’21 156 figure 1: algorithmic guideline for management of suspected and positive covid-19 patients in emergency surgery. جـراحـة الــحاالت الحـرجـة acute care surgery virtual review of the patient by the consultant (full investigation, consultant to consultant) patient examination with full ppe using “buddy system” tele instructions follow-up in the clinic covid-19 positive or highly suspected pending pcr result preoperative a emergency outpatient inpatient respect or protocols go to dedicated or for covid-19 ppe, n95 mask with face shield assure smooth post-operative course short procedure (absorbable sutures for skin) non-operative management medical prescriptions follow-up as inpatient follow-up in the clinic team leader will assign consultant and/or specialist to evaluate the patient life saving or clear indication for surgery intraoperative b p a t i e n t n e e d s s u r g e r y patient needs to be seen by a surgeon in-person same team consultant and specialist /fellow assigned will do the procedure. c o v i d 1 9 guidelines for management of suspected and positive covid-19 patient in emergency surgery steps to wear ppe hand rub wear disposable gown (ensure back and legs are covered) wear n95 mask (fit checked) wear face shield goggles wear double gloves steps to remove ppe remove gloves hand rub & hygiene remove gown hand rub & hygiene remove mask hand rub & hygiene post operative c all ppe should be removed inside the operating room. follow ppe removal and disposal as per guidelines, take shower if possible. return to work at the assigned facility. site marking, consent and appropriately informing family members should be completed as usual. the surgeon must wait till the patient become intubated then enter the or. sign in at reception should be modified to ensure minimal staff exposure. s u r g i c a l c o n s u l t a t i o n yes no no yes 157 international journal of human and health sciences vol. 05 no. 02 april’21 figure 2: narrative details of the algorithmic guideline for management of suspected and positive covid-19 patients in emergency surgery ask 3 questions to all patients (respiratory symptoms, history of travel to affected countries, contact with confirmed covid-19 patient in the last 14 days) screening (as per cdc guidelines) a all highly suspicious / positive patient must be referred to id team as per cdc protocol. universal precautions b suspected patients should wear a properly fitted mask. the number of managing staffs should be kept to a minimum. the medical personnel in contact have to wear ppe during treatment. treat the body fluids, tissues, and other apparatus in contact with the patient as having potential biohazard. the operating theatre should be cleaned as per biohazard based on current available protocols. surgical team c each surgical unit should have a core team to manage covid-19 using the hotline. a dedicated team on standby for all suspected patients. this team should be optimally trained in handling the personal protective equipment. surgical consultation d patient should be reviewed virtually by the consultant on call. it must be a consultant to consultant referral and communication. team leader will make the decision go / no go and select the team to evaluate the patient +/do the procedure. all investigations must be thorough before surgeon examines the patient in person. head and neck examination is high risk for aerosol transmitted infection. surgeon in contact with the patient e staff must use full ppe in addition to universal precautions , use coverall and disposable scrubs, n95 masks, goggles with full eye protection ,face shield , shoe cover , double gloves , waterproof gown (if not available use plastic apron underneath standard gown ). time spent with patients should be kept to the minimum. take shower following contact with the patient if possible. if need to go for surgery add to above the following instructions: instruct the anesthesiologist and or nurses to do the necessary steps. surgeon should not be in the operating room or intubation unless concurrent management of bleeding etc requires their presence. under no circumstances should staff enter the operating room without properly applied ppe. all personal devices should be kept outside the or. consultation phone to be kept with a nurse to answer urgent calls. shorten the operative time as much as possible. nonoperative management should be selected whenever feasible as an option without compromising patient safet y. open techniques is preferable over laparoscopy whenever it is an option . with laparoscopy , use low pneumoperitoneum pressure. strict hemostasis , electrocautery at low settings , avoid using harmonic or ultrasound dissection, , liberal use of suction , reduce trendelenburg position patient safet y should always be a priorit y . don’t go home with scrubs , clean your phone , general considerations in surgical covid-19 patient f all tertiary hospitals should have a dedicated or for patients suspected with covid-19. it should ideally be easily accessible from the point of contact. any non-urgent surgery should be deferred for at least 14 days. version 2-2020 prepared and approved by acute care surgery (acs) section. international journal of human and health sciences vol. 05 no. 02 april’21 158 references: 1. covid-19 information page on the ministry of public health website – qatar. accessed 25.08.2020 https://covid19.moph.gov.qa/en/ pages/default.aspx 2. coronavirus disease (covid-19) advice for the public. accessed 25.08.2020 https:// www.who.int/emergencies/diseases/novelcoronavirus-2019/advice-for-public 3. chen y, chen l, deng q, et al. the presence of sars-cov-2 rna in the feces of covid-19 patients [published online ahead of print, 2020 apr 3]. j med virol. 2020;10.1002/jmv.25825. doi:10.1002/jmv.25825 4. covid-19 and surgery, resources for the surgical community. accessed 25.08.2020 https://www.facs.org/covid-19 5. sages covid-19 / coronavirus announcement archives. accessed 25.08.2020 https://www.sages.org/category/ covid-19/ 6. updated intercollegiate general surgery guidance on covid-19. accessed 25.08.2020 https://www.rcseng.ac.uk/coronavirus/jointguidance-for-surgeons-v2/ 109 international journal of human and health sciences vol. 03 no. 02 april’19 original article: clinical evaluation of direct composite resin and indirect micro ceramic composite resin restorations in class-i cavity of permanent posterior teeth a h m zakir hossain shikder1, kamrunnaher shomi2, nushrat saki3,ferdousi begum4, kazi hossain mahmud5, mdshamsul alam6 abstract background:previous studies have indicated that the clinical performance of direct composite restoration mainly depends on the polymerization shrinkage. the use of micro ceramic inlay technique has proved to be elegant approach to overcome the polymerization shrinkage and improve the marginal adaptation, reduce wear and leakage of posterior restorations. objectives:to compare the clinical performance between direct composite restorations and indirect micro ceramic composite restorations in occlusal surface of permanent posterior teethof class-i cavity. results: the result of this study showed that there was no statisticallysignificant difference between two groups in the treatment of occlusal surface ofclass-i cavity of permanent posterior teeth (p > 0.05). it was concluded that indirect micro ceramic composite resin shows no better clinical efficacy than that of direct composite resin in occlusal surface of class-i cavity of permanent posterior teeth. correspondence to: dr. a h m zakir hossain shikder, assistant professor department of pedodontics, bsmmu, cell 02-01552354186 e-mail:zakirendo@gmail.com 1. assistant professor, department of pedodontics, bsmmu, dhaka. 2. assistant professor, department of conservative dentistry & endodontics, dhaka dental college & hospital, dhaka. 3. assistant professor, dept. of oral anatomy & physiology, bangladesh dental college. 4. junior consultant, department of conservative dentistry & endodontics, rangpur medical college & hospital. 5. assistant professor, department of conservative dentistry & endodontics, update dental college & hospital, dhaka. 6. professor and chairman, department of conservative dentistry & endodontics, bsmmu, dhaka. introduction: amalgam is one of the most commonly used direct restorative materials in occlusal surface of class-i cavity of permanent posterior teeth. amalgam doesn’t bond to tooth structure, contains mercury and it is not aesthetic, but its low cost, easy manipulation, rapid application and good track record of clinical performance, it become a most convenient restorative material in occlusal surface of class-i cavity of permanent posterior teeth. in recent years, the popularity of amalgam has been declined due to public health concerns over its mercury content.1 now-a-days patients are reluctant to accept any display of metal in their oral cavity due to its unacceptable aesthetics and health hazards. the validity of most of these negative claims is yet to be determined by environmental based study reports. nevertheless, these ideas have reduced the metallic restoration in dentistry and influenced the greater use of nonmetallic restorations.2 dental resin composites were introduced initially for use as anterior restorative materials. later, with technological improvements, the prospect of restoring posterior teeth with composite was introduced. though there are numerous causes for failure of clinical restorations made of direct composites, the major cause with the earlier posterior composites was poor wear resistance.3while the newest direct composite resin offers excellent optical and mechanical properties, its use in larger posterior restorations international journal of human and health sciences vol. 03 no. 02 april’19 page : 109-115 doi: http://dx.doi.org/10.31344/ijhhs.v3i2.85 international journal of human and health sciences vol. 03 no. 02 april’19 110 is still a challenge since polymerization shrinkage remains a concern in cavities. though there have been numerous advances in adhesive systems, it is observed that the adhesive interface is unable to resist the polymerization stresses in enamel-free cavity margins.4,5 this leads to improper sealing, which results in microleakage, postoperative sensitivity, and recurrent caries. the achievement of a proper interproximal contact and the complete cure of composite resins in the deepest regions of a cavity are other challenge related to direct composite restorations. various approaches have been developed to improve some of the deficiencies of direct placement composites.6, 7 however, no method has eliminated the problem of marginal microleakage associated with direct composite.4 indirect resin composites were introduced to reduce polymerization shrinkage and improve the properties of restorative material. direct resin composites were composed mostly composed of organic resin matrix, inorganic filler, and coupling agent. the first-generation indirect restorative composites had a composition identical to that of the direct resin. for inlay composites, an additional or secondary cure is given extra orally, which improves the degree of conversion and also reduces the side effects of polymerization shrinkage. it was observed that the first-generation indirect restorative composites showed improved properties only in vitro studies but had failure in clinical studies.8first generation composites showed poor clinical performance. deficient bonding between organic matrix and inorganic fillers was the main problem leading to unsatisfactory wear resistance, high incidence of bulk fracture, marginal gap, microleakage, and adhesive failure in the first attempts to restore posterior teeth. measures to solve these problems included increasing of inorganic filler content, reduction of filler size, and modification of the polymerization system. the second-generation composites have micro hybrid filler. by increasing the filler load, mechanical properties and wear resistance is improved, and by reducing the organic resin matrix, the polymerization shrinkage is reduced.9 the new composite resins contain high amounts of filler contents, which make them adequate for restoring posterior teeth. ceramage is a micro ceramic polymer system with 73% of zirconium silicate filler (pfs-progressive fine structured filler) supported by an organic polymer matrix which ensures a durable surface quality with excellent polishability and high resistance to plaque. this extra ordinary structure of ceramage shows properties similar to porcelain making it an ideal choice for posterior restorations. the aim of this study is to compare the clinical performance of direct composite resin restoration and indirect micro ceramic composite resin restorations at 3, 6, 9, and 12 months, using the modified usphs criteria as the main evaluation. materials and methods: this was an experimental clinical trialof one year. study was performed at the department of conservative dentistry and endodontics, faculty of dentistry, bangabandhu sheikh mujib medical university (bsmmu), dhaka, bangladesh. patient attending the outdoor patient department of conservative dentistry and endodontics, bsmmu was included in the study. simple random sampling (lottery method) was used to allocate the samples. thirty-six teeth that fulfilled the inclusion criteria were selected for the study from outpatient department of conservative dentistry and endodontics. these samples were randomly assigned to two groups; group 1 (direct composite restorations) and group 2 (indirect micro ceramic composite restorations). restoration was assessed bymodified ryge’s criteria by means of color matching, marginal adaptation, and secondary caries. patients were recalled after 3, 6, 9, and 12 months for follow up visit to evaluate the colour match, marginal adaptation and secondary caries. chi-square test was used for testing differences between the two groups. results: the study was conducted with 18 patients with 36 restorations could be evaluated. the restorations were evaluated for color matching (stability of color), marginal adaptation and secondary caries. using chi-square test, no statistically significance differences among the restorative materials were shown all the evaluation criteria. the result of the clinical evaluation of the 36 restorations using modified usphs criteria are summarized in tables i, ii &iii tablei shows comparison of color matching (stability of color) between direct and indirect micro ceramic composite restoration during follow up period. it was observed that at the evaluation period the difference was not statistically significant (p > 0.05) between two groups. 111 international journal of human and health sciences vol. 03 no. 02 april’19 table i: comparison of color matching between two groups (n=18 teeth) color matching (ratings) group1 (n=18 teeth) group2 (n=18 teeth) p value no. % no. % base line aalpha (100% color match) 18 100% 18 100% a bbravo (slight mismatched) 0 0% 0 0% a ccharlie (total mismatched) 0 0% 0 0% a after 3 months aalpha (100% color match) 18 100% 18 100% a bbravo (slight mismatched) 0 0% 0 0% a ccharlie (total mismatched) 0 0% 0 0% a after 6 months aalpha (100% color match) 18 100% 18 100% a bbravo (slight mismatched) 0 0% 0 0% a ccharlie (total mismatched) 0 0% 0 0% a after 9 months aalpha (100% color match) 15 83.3% 16 88.9% 0.62ns bbravo (slight mismatched) 3 16.7% 2 11.1% 0.62ns ccharlie (total mismatched) 0 0% 0 0% a after 12 months aalpha (100% color match) 14 77.8% 16 88.9% 0.37ns bbravo (slight mismatched) 4 22.2% 2 11.1% 0.37ns ccharlie (total mismatched) 0 0% 0 0% a n = number of samples a = no statistics are computed because of identical numbers in both groups ns = not statistically significant group1: direct composite restoration group2: indirect micro ceramic composite restoration (ceramage) tableii: comparison of marginal adaptation between two groups (n=18 teeth) marginal adaptation (ratings) group1 (n=18 teeth) group2 (n=18 teeth) p value no. % no. % base line aalpha (no crevice along margin) 18 100% 18 100% a bbravo (crevice along the margin) 0 0% 0 0% a ccharlie (fractured, missing) 0 0% 0 0% a after 3 months aalpha (no crevice along margin) 18 100% 18 100% a bbravo (crevice along the margin) 0 0% 0 0% a ccharlie (fractured, missing) 0 0% 0 0% a after 6 months aalpha (no crevice along margin) 18 100% 18 100% a bbravo (crevice along the margin) 0 0% 0 0% a ccharlie (fractured, missing) 0 0% 0 0% a after 9 months aalpha (no crevice along margin) 16 88.9% 17 94.4% 0.54ns bbravo (crevice along the margin) 0 0% 0 0% a ccharlie (fractured, missing) 2 11.1% 1 5.6% 0.54ns after 12 months aalpha (no crevice along margin) 16 88.9% 17 94.4% 0.54ns bbravo (crevice along the margin) 0 0% 0 0% a ccharlie (fractured, missing) 2 11.1% 1 5.6% 0.54ns n = number of samples a = no statistics are computed because of identical numbers in both groups ns = not statistically significant group1: direct composite restoration group2: indirect micro ceramic composite restoration (ceramage) international journal of human and health sciences vol. 03 no. 02 april’19 112 tableii shows comparison of marginal adaptation between direct and indirect micro ceramic composite restoration during follow up period. it was observed that at the evaluation period the difference was not statistically significant (p > 0.05) between two groups. after the time of 3 and 6 months, no changes occur in marginal adaptation. usphs ratings of the marginal adaptation of direct and indirect composite restorations were not statistically significant difference (p > 0.05) (tableii). table iii: comparison of secondary caries between two groups (n=18 teeth) secondary caries (ratings) group1 (n=18 teeth) group2 (n=18 teeth) p value no. % no. % base line alpha (no evidence of caries) 18 100% 18 100% a bravo (evidence of caries) 0 0% 0 0% a after 3 months alpha (no evidence of caries) 18 100% 18 100% a bravo (evidence of caries) 0 0% 0 0% a after 6 months alpha (no evidence of caries) 18 100% 18 100% a bravo (evidence of caries) 0 0% 0 0% a after 9 months alpha (no evidence of caries) 18 100% 18 100% a bravo (evidence of caries) 0 0% 0 0% a after 12 months alpha (no evidence of caries) 18 100% 18 100% a bravo (evidence of caries) 0 0% 0 0% a = number of samples a = no statistics are computed because of identical numbers in both groups ns = not statistically significant group1: direct composite restoration group2: indirect micro ceramic composite restoration (ceramage) tableshows comparison of secondary caries between direct and indirect micro ceramic composite restoration during follow up period. it was observed that at the evaluation period the difference was not statistically significant (p > 0.05) between two groups. at the time of evaluation period, there was no secondary caries in either direct or indirect composite resin restoration was found (table iii). 113 international journal of human and health sciences vol. 03 no. 02 april’19 discussion in this present study when direct restorations were examined at 3 and 6 months, it was found that all direct and indirect restorations showed acceptable color matching and marginal adaptation. furthermore, neither secondary caries nor any post-operative sensitivity or discoloration of restoration was observed. the differences between two groups were not statistically significant. however, at nine months, two direct and one indirect composite (ceramage) restorations showed loss of marginal adaptation due to chipping at margin of the restoration and they were not replaced. a careful examination of these restorations revealed that all chipping occurred due to direct contact with opposing cusp. the problems highlighted here could have been avoided by the operator. direct and indirect composite restorations (ceramage) should not be placed in direct contact with opposing cusp. this is also supported by some of the previous studies.10 when the color of the restorations was verified, it was found that 3 (16.7%) direct and 2 indirect (11.1%) restorations were slightly mismatched with the adjacent teeth. careful examinations of the restorations showed that mismatch of the colors of the restorations were due to body discoloration of the materials. previous studies have reported that mismatch of the composite restoration could be happen due to gradual discoloration of the monomer component of the material. the results found in that present study were correspondent to previous study of ali riza cetin and nimet unlu.11 this study compared direct and indirect composite restoration in posterior teeth and found that all the restoration demonstrated clinically satisfactory performance with no significance differences among them. at 12 months observation period, the results of marginal adaptation did not changed. again, 2 direct and 1 indirect restorations showed loss of marginal adaptation. at this stage, these restorations were not replaced but they were repaired by composite resin. furthermore, 4 (22.2%) direct and 2 (11.1%) indirect restorations showed slight mismatch with the adjacent teeth. again, the reason was due to body discoloration. furthermore, no restorations showed secondary caries at this observation period. the results between two groups were not statistically significant. aesthetic dentistry continues to evolve through innovations in restorative material and conservative preparation technique. the use of direct composite restoration in posterior teeth is limited to relatively small cavities due to polymerization stresses. indirect composites offer an esthetic alternative to micro ceramic composite for posterior teeth. many evaluation criteria are available for evaluation of clinical study. united states public health (usphs) criteria were used for the clinical evaluation of toothcolored restorations in posterior teeth, which is originally based on ryge criteria.12in this study, direct composite restorations and indirect micro ceramic composite (ceramage) restorations were assessed to ensure comparability of the results using usphs criteria. in the present one-year clinical studyboth the direct and indirect composite restorations were rated as clinically acceptable according to the evaluation criteria used and that there were no statistically significant differences in performance among the tested materials. on the lack of statistically significant differences, it could be due to the multiple similaritiesin terms of chemical composition and high filler content underlying the composites used in this study. however, differences might emerge over longer periods of use. nevertheless, better clinical performance might be obtained using ceramage, since they are indirect composite resins specifically designed for restoring posterior teeth. furthermore, it is claimed that indirect composite, when tempered with heat and light, could have an enhanced degree of cure, thereby leading to improved physical properties. according to a previous study, it was found that indirect ceramic inlays reveal better clinical results than direct composite restorations (ivoclarvivadent’sheliomolar) in terms of marginal adaptation, color matching and secondary caries. the results of this present study showed that there were no statistically significant differences between direct and indirect restorations in respect of marginal adaptation, color matching and secondary caries. so, this study will help the clinician that indirect micro ceramic composite resin shows no better clinical efficacy than that of direct composite resin in occlusal surface of class-i cavity of permanentposterior teeth. international journal of human and health sciences vol. 03 no. 02 april’19 114 all patients strictly followed the instructions during the course of treatment. this study had controlled the confounders which were induced by the participants. so, these study findings are unlikely to be influenced by other confounding variables. conclusion: it can be concluded that indirect micro ceramic composite resin shows no better clinical efficacy than that of direct composite resin in occlusal surface of class-i cavity of permanent posterior teeth. 115 international journal of human and health sciences vol. 03 no. 02 april’19 references: 1. mario bernardo, henrique luis, michael d martin, brian gleroux, tessa rue, jorge leitao, et al. survival and reason for failure of amalgam versus composite posterior restorations placed in a randomized clinical trial. j am dent assoc 2007; 138:775-83. 2. gordon j christensen. indirect restoration use: a changing paradigm. jada 2012; 143:398-400. 3. dietschi d, scampa u, campanile g, holz j. marginal adaptation and seal of direct and indirect class ii composite resin restorations: an in vitro evaluation. quintessence int 1995; 26:127-38. 4. loguercio ad, bauer jr, reis a, grande rh. microleakage of packable composite in class ii restorations. quintessence int 2004; 35:29-34. 5. thonemann b, federlin m, schmalz g, glunder w. total bonding vs selective bonding: marginal adaptation of class ii composite restorations. oper dent 1999; 24:261-71. 6. carvalho rm, pereira jc, yoshiyama m, pashley dh. a review of polymerization contraction: the influence of stress development versus stress relief. oper dent 1996; 21:17-24. 7. davidson cl, feilzer aj. polymerization shrinkage and polymerization shrinkage stress in polymer based restoratives. j dent 1997; 25:435-40. 8. garber da, goldstein re. porcelain and composite inlays and onlays. illinois: quintessence publishing co inc 2009; 194:117-33. 9. miara p. aesthetic guidelines for secondgenerationinlays and onlay composite restorations. pracperiodontaesthetdent 1998; 10:423-31. 10. hossain m, kawakami s, shimokobe h. effect of gap dimension on wear of prototype glass ionomer luting cements in margin of ceramic restorations: in vivo. j conserve. dent 1995; 38:212-24. 11. ali riza cetin and nimet unlu, 2009. one-year clinical evaluation of direct nanofilled and indirect composite restorations in posterior teeth. dental materials journal 2009; 28:620-26. 12. ryge g, snyder m. evaluating the clinical quality of restorations. j am dent assoc 1973; 87:369-77. 519 international journal of human and health sciences vol. 05 no. 04 october’21 case report: dengue fever complicated by sickle cell crisis with multiple splenic infarcts dr. b saroj kumar prusty 1 dr. kiran kumar ramineni 2 dr. abhijeet ingle 3 dr. krishna mohan reddy g4 dr. safina perveen 1 dr. majed abdul basit momin 3 abstract: dengue infections typically present with fever and thrombocytopenia. although good number of patients improve with supportive care, few can have a fulminant course with multiorgan dysfunction. in endemic zone co-occurring illness like sickle cell disease can contribute to poor outcome. various splenic complications of sickle cell disease include massive splenomegaly with sequestration, large infarcts and abscess requiring splenectomy. we report an interesting case of dengue fever, who developed shock and acute abdomen during hospital stay. further evaluation revealed multiple splenic infarcts with correlating histopathology and etiological work up including hemoglobin electrophoresis helped in the de novo detection of the underlying sickle cell trait. keywords: sickle cell trait, sickle cell disease, dengue fever, splenectomy correspondence to: mustafa dogan, md. afyonkarahisar health sciences university, faculty of medicine, department of ophthalmology. 03200, afyonkarahisar, turkey e-mail: mustafadogan@yahoo.com international journal of human and health sciences vol. 05 no. 04 october’21 page : 519-524 doi: http://dx.doi.org/10.31344/ijhhs.v5i4.367 1. department of critical care, yashoda hospitals, malakpet branch, hyderabad, telangana state, india. 2. depatment of neurology, yashoda hospitals, malakpet branch, hyderabad, telangana state, india. 3. department of laboratory medicine, yashoda hospitals, malakpet branch, hyderabad, telangana state, india. 4. department of medicine, yashoda hospitals, malakpet branch, hyderabad, telangana state, india. introduction: dengue fever is a mosquito borne tropical infection caused by flavivirus. the epidemiology of dengue fevers in the indian subcontinent has been very complex and has substantially changed over the past six decades in terms of prevalent strains, and severity of disease. the classical clinical presentation of dengue virus infection is well known; however, several atypical clinical presentations have also been reported 1. sickle cell trait is an inheritable condition with heterozygous allele which usually has asymptomatic or milder course of disease. under stressful conditions there may be decompensation and significant clinical complications can manifest. the disease of the asian haplotype is generally milder because of the mutation occurring against a genetic background which is likely to inhibit sickling2. we report a case of dengue fever which had a complicated course because of underlying sickle cell trait which was previously undiagnosed. case report: a 30-year-old male presented with complaints of high grade fever for six days associated with chills, myalgia, lethargy, headache, mild right hypochondrial pain with multiple episodes of vomitings. he did not have any significant past medical history. he was alert and conscious. vital signs were temperature of 38.3 degree celsius, pulse rate of 108 beats per minute regular rhythm, normal volume with normal capillary refill time and warm peripheries, blood pressure of 110/70 mm of hg, respiratory rate of 20 breaths per minute and spo2 of 97% under room air. there was no evidence of cutaneous or mucosal rashes or hemorrhagic lesions. abdominal examination revealed mild right hypochondrial tenderness, mild ascitis without hepatomegaly. respiratory and cardiovascular system examination was unremarkable. he did not have any focal international journal of human and health sciences vol. 05 no. 04 october’21 520 neurological deficits or neck stiffness. basic laboratory investigations on day 6 of illness revealed hemoglobin of 15gm/dl, hematocrit of 48%, white blood cell count 6700/cu mm, thrombocytopenia of 54,000/cmm and increased transaminases level suggestive of mild hepatitis (table 1). patient was admitted to the intensive care unit, with a provisional diagnosis of dengue fever with warning signs like abdominal tenderness, lethargy and vomiting. further etiological work up confirmed dengue with strongly positive igm titer. other possible differentials such as malaria, leptospirosis and scrub typhus were negative. ultrasonography of the abdomen revealed mild ascites with gall bladder wall edema and bilateral minimal pleural effusion suggestive of polyserositis. treatment was initiated with hydration guided by hematocrit levels, ultrasound based volume status on inferior venacava status (ivc status) and other supportive measures. on day 9 of illness the patient developed left upper abdominal pain with left hypochondrial tenderness, tachycardia and hypotension with complaining of passing brown coloured urine. ultrasound abdomen was repeated and showed multiple heterogeneous areas of hypodense lesions in the spleen. patient was suspected to have multiple splenic infarcts with diffuse altered echotexture and moderate perisplenic collection. patient was provisionally diagnosed to have multiple splenic infarcts with splenic rupture leading to perisplenic hematoma. hemoperitoneum was confirmed by ultrasound guided diagnostic aspiration. subsequent laboratory evaluation showed fall in hemoglobin level, with disproportionate elevation of indirect bilirubin, increased reticulocyte count and increase in ldh , suggestive of hemolysis (table–1) possibly due to splenic syndrome secondary to hemoglobinopathy disorder of sickle cell. however, there were no sickle cells found in peripheral smear. sickling test and hemoglobin electrophoresis were advised . in view of splenic rupture, perisplenic hematoma and hemodynamic instability, the patient was taken up for emergency laparotomy. intraoperative findings were table :1 laboratory data s. no. laboratory parameters test results 1 day of illness 6th day of illness 9th day of illness day 0 of splenectomy 2nd day of post splenectomy 5th day of post splenectomy 10th day of post splenectomy biological reference intervalhaemogram hemoglobin 15 7.8 8.5 9.7 11.2 12 15 gm% hct 48 27 27 29 34 36 45 % mcv 80 90 90.6 88 86 83 101 fl mch 33 32 30.4 31 32 27 32 pg mchc 34 33 33.5 32 32 31.5 34.5 gm% white blood cells 6700 24000 21500 15400 10,000 4000 11000 / cumm platelets 0.54 1.2 4.8 7.2 6.24 1.5 4.5 lakhs/cumm 2 esr 10 0 15 mm end of one hr 3 reticulocyte count 1.5% 6.0% 3% 2.0% 0.2 2.5 % 4 lft total bilirubin 1 4.7 2 1.8 1.2 0.2 1.3 mg/dl direct 0.2 0.8 0.4 0.6 0.2 0 0.3 mg/dl indirect 0.8 3.9 1.6 1.2 1 0 1 mg/dl sgot 646 542 187 94 57 14-60 u/l sgpt 328 284 163 75 55 0-35 u/l alkaline phosphatase 172 168 102 98 78 38 126 u/l 5 s. creatinine 0.9 1.6 1.2 1.12 0.9 0.7 1.2 mg/dl 6 s ldh 90 1380 436 110 120-246 u/l 521 international journal of human and health sciences vol. 05 no. 04 october’21 hemoperitoneum (1.5l hemorrhagic peritoneal fluid) with subcapsular splenic bleed with soft, congested, fragile patchy brownish colored spleen. splenectomy was done. the patient was hemodynamically stabilized by transfusing intravenous fluids, blood and blood products. patient was shifted to a medical icu post operatively for monitoring vitals and kept on ventilator support. as the patient was further stabilized hemodynamically and tolerated the spontaneous breathing trial on the second postoperative day, the patient was weaned off from the ventilator. gross examination of spleen showed markedly congested capsule and focal irregular brownish and geographic whitish areas. on serial slicing cut sections showed geographic yellowish areas with brownish areas in between (figure 1a). microscopic examination showed large areas of coagulative necrosis rimmed by markedly congested blood vessels, neutrophilic infiltrates consistent with multiple splenic infarcts (fig – 1b&c). congested blood vessels engorged with sickled rbcs (fig – 1d) sickling test in peripheral blood performed using 2% sodium metabisulphite was positive for delayed sickling (after 24 hours incubation) (figure 2). hemoglobin electrophoresis by high performance liquid chromatography method ( hplc ) showed hemoglobin s of 20.7 %, suggestive of sickle cell trait ( table 2) post splenectomy platelet count and wbc counts increased as a physiological response, mentioned in (table – 1). he was started on tablet aspirin 75mg once daily and discharged successfully on seventh postoperative day in stable condition. during follow ups he maintained improvement and was independent for all activities of daily living. post splenectomy vaccination was completed. based on the clinical features supported with figure1: splenectomy specimen cut section & microscopic findings figure1a: spleen cut section show yellowish areas (blue arrow) with brownish areas in between (red arrow) figure1b &c: microscopic examination (h&e stained 40x) areas of necrosis (blue arrow), congested blood vessels (green arrow) and preserved splenic parenchyma figure 1d: microscopic examination (h&e stained 40x) blood vessels engorged with sickled rbcs figure : 2 sickling test (2% sodium metabisulphite) show positive sickle cells table 2: hemoglobin electrophoresis (hplc) investigation observed value unit biological reference interval hemoglobin a 75.1 % 95-98% hemoglobin a2 2.8 % 2.0-3.7 hemoglobin f 0.7 % 0.11.2 hemoglobin s 20.7 % 0.0-0.0 hemoglobin d 0.0 % 0.0-0.0 hemoglobin c 0.0 % 0.0-0.0 unknown unidentified 0.7 % 0.0-2.0 international journal of human and health sciences vol. 05 no. 04 october’21 522 laboratory and histopathology evidence, final diagnosis of sickle cell vaso-occlusive crisis resulting in multiple splenic infarcts (called as splenic syndrome) in a de novo detected sickle cell trait during acute dengue fever was made. discussion: the case presented here is a young male who presented with acute febrile illness, with thrombocytopenia, polyserositis, hepatitis and warning signs of abdominal pain, vomiting, lethargy, fluid accumulation, and increased hematocrit. in hospital evaluation, confirmed the diagnosis of dengue fever with warning signs. he had a complicated course and developed acute onset left hypochondrial pain, hypotension, pallor, thought of patient developed severe dengue, but the multiple heterogeneous areas of hypodense lesions in the spleen (multiple splenic infarcts), perisplenic blood collection (splenic rupture), and altered splenic echotexture in rapid bedside ultrasound with brown coloured urine, with features of hemolysis from laboratory values of fall in hemoglobin, increased indirect bilirubin, ldh, and reticulocyte count, led to high clinical suspicion of acute hemolytic anemia with splenic syndrome, secondary to sickle cell disease. evaluated by hemoglobin electrophoresis, peripheral smear and spleen biopsy while emergency laparotomy with splenectomy, which confirmed the diagnosis of sickle cell trait (sct). high clinical suspicion and emergency surgical management, helped in better outcome, otherwise abdominal pain, shock status, hepatitis could have been easily misinterpreted as part of severe dengue illness. dengue fever is a viral illness caused by rna flavivirus, transmitted by aedes aegypti mosquito. indian subcontinent is endemic for dengue because of the tropical climate. dengue virus has five identified serotypes. most of the dengue cases are asymptomatic or cases with mild symptoms only. the actual incidence of dengue in endemic countries like india is unknown because of under reporting of mild symptomatic cases 3 . the clinical presentation of dengue can vary from mild dengue fever with or without warning signs to severe dengue with multiorgan dysfunction leading to death. as per world health organization (who-2009 ) criteria for warning signs, may be any one of the following, includes, abdominal pain or tenderness, persistent vomiting, clinical fluid accumulation, mucosal bleeding, lethargy, restlessness, liver enlargement more than 2 centimeter, and an increase in hematocrit (hct) accompanied by decrease platelet count. criteria for severe dengue, any one of following includes, severe plasma leakage leading to dengue shock syndrome and fluid accumulation with respiratory distress, severe bleeding, and severe organ involvement including the liver (ast or alt levels more than 1000) the central nervous system (impaired consciousness), the heart and other organs4. our patient presented as dengue with warning signs at the time of admission, later developed a clinical picture similar to severe dengue, but turned out as sickle cell trait (sct ) complicated with splenic syndrome, previously not diagnosed. sickle cell trait (sct) is usually less severe with minimal or no manifestations 5. sct is diagnosed by detecting the presence of hbs ( 20-40 % ), and hba (80-60 %) on hemoglobin electrophoresis. the peripheral smear in sct has normal rbc morphology, with the exception of a few target cells, however a sickling test with 2% sodium metabisulphite yields a positive result. sct does not cause vaso-occlusive crisis, unlike that of sickle cell disease. the susceptibility of red blood cells to sickle depends on the concentration of hbs. however, patients with sickle cell trait could have the same presentation as sickle cell anemia if they are exposed to conditions that favor sickling and vaso-occlusive crisis. conditions include less oxygen content of the inspired air (hypoxia), cardiac & pulmonary status, dehydration, infections, hypothermia or hyperthermia and release of inflammatory cells. the hbs will result in the clogging of tiny capillary vessels most especially in the bones and organs by sickled red blood cells. development of splenic infarcts in sct is reported with high altitude hypoxemia and infections 5. in our case, at the time of crisis , on 9th day of illness, routine peripheral smear was negative for sickle cell, but a sickling test using 2% sodium metabisulphite showed positive sickle cells after 24 hr incubation(delayed sickling). further hemoglobin electrophoresis confirmed the sct. dengue fever complicated by sickle cell crisis with multiple splenic infarcts in sct has not been reported in india. however, there are reports of severe dengue with deaths in patients of sickle cell disease and trait from central and south america. the highest frequency of sickle cell disease is found in tropical regions particularly sub-saharan africa, few tribal regions of india 523 international journal of human and health sciences vol. 05 no. 04 october’21 and the middle east6. dengue infection in sickle cell anemia (hbss) has poor outcomes 7. the data available on association of sickle cell disease and dengue infection is based on case series and some retrospective studies. existing literature suggests that the risk of fatal dengue may be higher among patients with a relatively mild genotype (hemoglobin sc hbsc), although exact incidence and extent of risk is unclear6. the evidence of poor outcomes in sickle cell disease patients infected with dengue can be extrapolated to the following mechanism. patients with hbsc are more susceptible to fatal dengue because red blood cells (rbc) are more prone to dehydration secondary to potassium loss from rbcs. this leads to a greater propensity for dense cell formation compared to hbss (sickle cell disease) 6. the higher mean cell hemoglobin concentration (mchc) in these dense cells causes both an increase in hemoglobin s polymerization and may reduce the time for sickling. the dengue virus either alters the hbsc red blood cell rheology by triggering dehydration or changes the endothelial adhesivity resulting in a massive vascular leak syndrome and intravascular dehydration which further leads to massive sickling8 . neo-angiogenesis is the other possible mechanism which could explain a higher morbidity in hbsc patients8. endothelial cells of blood vessels produced by neo-angiogenesis become more permeable in response to inflammatory cytokines such as high mobility group box 1 (hmgb1) . the increased expression of hmgb1 protein is well described in sickle cell vaso-occlusive crises 9 . same protein is thought to play an important role in dengue shock syndrome resulting in massive vascular leakage and intravascular dehydration 10. the rbcs and endothelium are probably the common targets for both dengue and sickle cell disease 11. massive splenic infarction which is arbitrarily defined as infarction involving more than 50% of the spleen size is almost unknown among adults with sickle cell trait, but there are reports of massive splenic infarcts in patients with sickle cell disease, and hemoglobin sc disease, seen particularly in association with stress, hypoxia or following air travel especially in unpressurized aircrafts 12. here in our case because of dengue with warning signs, might have complicated the undiagnosed sct with multiple splenic infarcts, acute hemolysis, and splenic rupture with a possible mechanism of severe intravascular dehydration in spite of fluid resuscitation due to worsening capillary leak syndrome. clinical picture was confused with severe dengue, however early high index of clinical suspicion and diagnosis have saved the patient . conclusion: multi organ dysfunction is known to occur in dengue infection. co-existing previously undiagnosed pathologies like sickle cell trait may contribute to acute deterioration. high index of clinical suspicion for timely diagnosis of comorbidities and close monitoring help in the appropriate management of complicated dengue cases. source of fund: not applicable conflict of interest: none declared ethical clearance: written consent has been obtained from the patient. authors contribution: concept and design: dr. b saroj kumar prusty(skp) , dr. kiran kumar ramineni (kkr), dr. safina perveen (sp) dr. majed abdul basit momin (mbm) major revision of the article: skp, kkr, mbm final approval of the article: skp, kkr, mbm,ai, kmr and sp. international journal of human and health sciences vol. 05 no. 04 october’21 524 references: 1. gupta n, srivastava s, jain a, chaturvedi uc. dengue in india. indian j med res 2012;136(3):373–90. 2. serjeant gr, ghosh k, patel j. sickle cell disease in india: a perspective. indian j med res 2016;143(1): 21-4. 3. das s, sarfraz a, jaiswal n, das p. impediments of reporting dengue cases in india. j infect public health 2017;10(5):494-8. 4. guzman, m., gubler, d., izquierdo, a. et al. dengue infection. nat rev dis primers 2016;16055(8): 1-25. 5. sears da. the morbidity of sickle cell trait. the american journal of medicine 1978;64(6): 1021-36. 6. wilder-smith a, leong wy. risk of severe dengue is higher in patients with sickle cell disease: a scoping review. j travel med 2019;26(1): 937-41. 7. moesker fm, muskiet fd, koeijers jj, fraaij pl, gerstenbluth i, van gorp ec et al. fatal dengue in patients with sickle cell disease or sickle cell anemia in curaçao: two case reports. plos negl trop dis 2013;7(8):e2203. 8. rankine-mullings a, reid me, moo sang m, richardsdawson m, knight-madden jm. a retrospective analysis of the significance of haemoglobin ss and sc in disease outcome in patients with sickle cell disease and dengue fever. ebio med 2015; 2(8): 935–9. 9. xu h, wandersee nj, guo y, jones dw, holzhauer sl, hanson ms et al. sickle cell disease increases high mobility group box 1: a novel mechanism of inflammation. blood 2014;124(26): 3978-81. 10. ong sp, lee lm, leong yfi, ng ml, chu jjh. dengue virus infection mediates hmgb1 release from monocytes involving pcaf acetylase complex and induces vascular leakage in endothelial cells. plos one 2012;7(7):e41932. 11. iversen po, abisay m, seleki f, majigo m, luzzatto l, makani j. sickle cell disease, malaria and dengue fever: a case of triple jeopardy. journal of travel medicine 2019;26(7):1-2. 12. al-salem, ah. splenic complications of sickle cell anemia and the role of splenectomy. isrn hematol 2011;2011: 864257. 237 international journal of human and health sciences vol. 04 no. 04 october’20 review article: impact of spiritual meditation on drug addiction recovery and wellbeing: a systematic review rozeeda kadri1, rohayah husain1, syed hadzrullathfi syed omar2 abstract: it is well recognized throughout the history that religiosity, spirituality and the meditation practice have significant effects to the physical and mental health. hence, this paper interested to evaluate the effectiveness of spiritual meditation on drug addiction recovery and its effects on psychological and mental health aspects. three main databases in medicinal and psychology field were screened to identify the eligible studies which are pubmed, cochrane and scopus by using boolean expression. fourteen papers were included in this review. standardized mean differences were calculated based on the intergroup mean difference and standard deviation followed by cochran’s q and i2 determination for heterogeneity analysis. the mean differences were statistically pooled in the meta-analysis and presented as a forest plot. the risk of bias was high for each study and assessed using the jadad scale. the meta-analysis showed significant differences in across studies for addiction related outcome (i2=27%, 95% ci: -1.703, -0.454), anxiety (i2=0%, 95% ci: -0.874, -0.634) and stress (i2=100%, 95% ci: -0.874, -0.634). in general, spiritual meditation may promote the addiction recovery as well as improve the psychological and mental health outcomes by reducing the depression, anxiety and stress symptoms. in conclusion, randomized control trial on spiritual meditation gave positive impact on the addiction behavior as well as mental health and clarifies its reliability on addiction therapy problems. keywords: spiritual meditation, spirituality, meditation, systematic review. correspondence to: rozeeda kadri, psychological medicine, faculty of medicine, university sultan zainal abidin (unisza), terengganu, malaysia. e-mail: rozeedakadri@gmail.com 1. psychological medicine, faculty of medicine, university sultan zainal abidin (unisza), terengganu, malaysia. 2. faculty islamic contemporary, university sultan zainal abidin (unisza), terengganu, malaysia. international journal of human and health sciences vol. 04 no. 04 october’20 page : 237-250 doi: http://dx.doi.org/10.31344/ijhhs.v4i4.208 1. introduction it is well recognized throughout the history that religiosity, spirituality and the meditation practice have significant effects on the physical and mental health.1 whereas the meditation gains a significant momentum on literature yet, according to koenig, only in the last decade spirituality is considered as the important impact in treatment and healing process of patients.2 after decades of rapid increase, it appears that spiritual meditation gave positive impacts on depression, anxiety, stress, post-traumatic stress disorder (ptsd), cancer, schizophrenia, chronic pain, attention-deficit hyperactivity disorder (adhd) and addiction.3-7 some conceptual clarification around spiritual meditation may be remarkable. spiritual meditation derived from terms spiritual and meditation. spiritual is under term of spirituality. the meaning of spirituality has no universal definition. nevertheless, it can be defined as the sacred connections of self with universe or others may or may not include in the belief of higher power, god or transcendent and its journey to identify the purpose of life, meaning of life, values, and moral along the specific practice, movement or ritual.8-9 in terms of meditation, it is a generic term that covering a wide range of movements in the variety of practices along with its specific purpose.10-11 as a result, spiritual meditation can be defined as any particular movements or practices that have a sacred connection and meaning with self or universe or others. mindfulness based meditation, mantra-based meditation, twelve steps practice, dhikr, solah, compassion therapy, psychotherapy program with spirituality elements or practice fallen under umbrella of spiritual international journal of human and health sciences vol. 04 no. 04 october’20 238 meditation term. the considerable amounts of systematic review on spiritual meditation and addiction were published in the last decade. in a systematic review of 105 literatures on religiosity and substance use by chitwood, weiss and leukefeld has proved the positive association between religiosity/spirituality interventions can reduce the risk of substance used, even though the relationship between them is insufficient.12 then, walton-moss, ray, and woodruff, supports the evidence by reviewing 29 eligible studies on spirituality effects on addiction.13 this study proposed that spirituality may affect the abstinence, treatment retention, alcohol or drug use severity, and discharge status. moreover, the following systematic review and meta-analysis by gonçalves, lucchetti, menezes and vallada postulated that spiritual intervention reduces stress alcoholism and depression.14 however, to date no systematic review on spiritual meditation on drug addiction has been carried out. hence, this paper intends to evaluate the effectiveness of spiritual meditation on drug addiction recovery and its effects on psychological and mental health aspects. the proposed systematic review will answer the following questions: 1. what is the impact of spiritual meditation on the cessation of drug addiction? 2. what is the impact of spiritual meditation on the psychological and mental health outcomes among drug addiction patient? 3. what are the methodological characteristics of each study and its quality? considering the heterogeneity in result, the metaanalysis was performed if the studies were capable through the reported clinical outcomes. 2. methodology 2.1 eligibility criteria this paper included the published randomized control trials studies examining the adult drug addiction population including methadone and buprenorphine participant from january 2015 to january 2019. any types of relevance spiritual meditation were eligible if they reported the effects of spiritual meditation on addiction related, psychological and mental health outcomes. this study also included mindfulness, based meditation techniques, twelve steps interventions, motivation therapy, dhikr therapy and other therapies that can be categorized as spiritual meditation. 2.2 search strategy three main databases in medicinal and psychology field were screened to identify the eligible studies which are pubmed, cochrane and scopus by using boolean expression. electronic searches were specific to title, abstract and keyword only. the search strategy highlighted all related terms for spiritual meditation in order to yield all relevant literature. the terms were as follows: (spiritu* or religio* or faith or isla* or christ* or hindh* or buddha or pray or mosque or church or bible) and (treatment or therapy or assistance or meditation or group or mantra or chanting or incantation or dua or dhikr or supplement) and (substance abuse or drug abuse or heroin or opiate or cocaine or psychedelics or drug addiction or marijuana or psychoactive drugs or illicit or stimulant or meth* or hallucinogen or steroid or polydrug) and (clinical trial or randomized controlled trial or controlled clinical trial). 2.3 study selection first, all eligible studies were imported, and the duplicate articles were identified and removed by using mendeley. later, one of the researchers examined the title and abstract of the studies to remove those against a mentioned eligibility criterion such reviews, off topic, and repeated versions in other databases. second, both of the researches were screened the full text of selected studies. each study reviewed extensively on intervention and randomization process. 2.4 data items outcome extracted from each studies were: (1) participant with drug addiction problems; (2) sample size; (3) intervention protocols such as type of intervention, frequency and duration of therapies or interventions or meetings, number of follow up if present; (4) instruments and outcomes measures and; (5) results of each study. addiction related such as abstinence, frequency symptoms, psychological effects, cognitive, attention, depression, anxiety and stress were further analyzed in the meta-analysis if the data are acceptable. 2.5 evaluation of studies / risk of bias individual studies risk of bias for individual studies (assessment on methodological quality of article) were rated by using jadad score15-16 consists of pre and post study, randomized and nonrandomized control trial. jaded score consists three parts which are randomization (2 sub score), blinding (2 sub score) and account on study (1 score). therefore, 5 marks are the highest, suggestive the lowest risk of bias. the 3 considered fair and below 3 are poor 239 international journal of human and health sciences vol. 04 no. 04 october’20 and above 3 considered good. 2.6 evaluation data synthesis the authors evaluated the data using microsoft excel 2010. cohen’s d was used to quantify the effect size (standard mean difference) for each possible outcome. the effect size of each outcome was calculated by using the differences of intergroup means and standard deviation between post treatment of spiritual meditation and controls groups. quantified standard mean difference was considered small for 0.2, medium and large for 0.5 and 0.8 respectively.17-18 a positive value shown that intervention preferred the control group or treatment as usual, while a negative value stipulated that the intervention preferred to spiritual meditation group.19 p-values of less than 0.05 were accounted as statically significant. if the effect size cannot be evaluated, the studies were eliminated from meta-analysis. regarding the meta-analysis, cochrane’s q and i2 were calculated based on the study of neyeloff, fuchs and moreira.20 cochrane’s q was justified the heterogeneity among the studies by enumerating the weight sum of squared differences between individual study effects and the pooled effect across the studies with the weight used in the pooling method. calculated q was distributed as chi-square statistics with number of studies minus with 1 degree of freedom, (k-1) which is k is the total number of studies. then, q values were compared against a table of critical values to gain p-value. if the evaluated q was lower than the table of critical value, it can be defined as the studies are similar or homogenous. next, the formula for i2 represent as percentage of the total variability in a set of effect size due to the true heterogeneity. i2 was considered as statistical heterogeneity of meta-analysis. negative values of i2 defined to be zero which means the studies were similar whereas positive values, 25 percent (%), 50% and 75% shown the heterogeneity a low, moderate and high respectively.21-22 random effects model was chosen due to the possible heterogeneity in studies, with 95% confidence interval for each measure. the forest plot was used to present the pooled effect size in the meta-analysis. 3. results 3.1 selection of studies an overview of selection of articles was presented in the figure 1. 5951 articles were identified from three main databases. after removing the 215 duplications, 5736 articles were screened by their title and abstract. then, at the end of phase one, 173 published articles were selected and went further into the screening on full articles. phase two excluded 158 articles for not meeting the eligibility criteria: 107 were out of from drug addiction theme such behavioral addiction, internet addiction, gambling and alcohol addiction, 29 had a different methodology, 14 were removed for not examining spiritual meditations and 9 were eliminated because of inadequate randomization. out of 14 papers that included in the qualitative synthesis, 10 papers were selected for quantitative meta-analysis. 3.2 characteristics of study the summary outcomes for qualitative analysis were provided in table 1. total sample size from 14 studies was 1402 participant, varying from substance used disorder population such as opioid dependence, amphetamine, methamphetamine and stimulant abuser. two papers reported on substance used disorder with other illness which is depression and hiv. all of the studies investigated adolescence population. six studies came from mindfulness meditation, 12-step program and yoga each covered three studies and one study for each spiritual meditation namely acceptance commitment therapy (act) and hope therapy protocol. the comparison groups were varying such as cbt, relapse prevention (rp), 12-step, methadone maintenance therapy (mmt) and physical exercise. duration of session for the intervention was around four to 12 weeks for 45 to 90 minutes per session. moreover, the most frequently used tools for primary outcomes were tlfb and asi. in addition, the spiritual meditation either gives a positive effect or neutral when compared with control group. no negative effects have been reported. two mainstreams for spiritual meditation was spirituality-based intervention and meditationbased intervention. the themes such as beliefs in god, ‘higher power’, transcendence, mindfulness, pastoral service such as attendance to a church, moral values, meaning of life, self-knowledge and consciousness were included in spiritual meditation approaches. the interventions were conducted as psychotherapies, psychoeducation, meditation and pastoral services. two studies were used psychotherapy approaches which are act and htp. first, act included the values and mindfulness exercise as part of its protocol, while the htp highlighted the meaning of life as one of the significant elements in the treatment. meditation approach was found on nine papers. mindfulness international journal of human and health sciences vol. 04 no. 04 october’20 240 based meditation was predominant in the selected papers; mindfulness based intervention (mbi), mindfulness based treatment (mbt), mindfulness based cognitive group (mbcg), mindfulness based relapse prevention (mbrp) and, mindfulness based group therapy (mbgt) followed by three studies on yoga techniques; yoga, raja yoga and hatha yoga. mindfulness is the trend meditation nowadays in western culture. mindfulness meditation was adapted from buddhism technique and was introduced by kabat zinn,23-24 which aims to bringing a certain quality of attention to produce positive outcomes. another type of spiritual meditation that included in this paper is yoga techniques based on the influence of hindhuism. the main significant program in yoga is the breathing (pranayama) and repetition of mantra.25 12-step based intervention was found in three studies whereas two were the conventional 12-stage intervention and the other one was the integrated twelve step-based intervention. the integrated 12-step is the enhancement program to fill the gap between sciences and practice of classical programs such as alcoholic anonymous (aa), narcotics anonymous (na) and marijuana anonymous (ma). 3.3 outcomes measures the primary outcomes measured for this current study was the impacts of spiritual meditation on the frequency, symptoms and intensity of drug consumption and the secondary outcomes were psychological and mental health aspects. ten2635 out of 15 papers reported on addiction related outcomes such as effects on the frequency, symptoms and intensity of drug consumption, while 13 papers26, 28-39 discussed on psychological and mental health impacts such as depression, stress, anxiety, attention, psychological, emotion and aggressiveness. total 54 studies were found by obtaining the effect size and confidence interval for each study ranging from small to large effect size. 3.4 risk of bias in individual studies table 2 provided the risk of bias in the individual studies scoring on randomization, blinding and participants accounts based on jadad score. it illustrated that most of the studies shown high risk of bias with scoring values under two and below (11 studies). four studies show a lowest risk of bias with an average (3 studies) and good risk of bias (one study) respectively. 3.5 meta-analysis for the primary outcomes, six papers26, 28-30, 37, 39 with seven studies were usable in the result for the meta-analysis whereas the other six papers27, 29, 3133, 35 did not present sufficient data for statistical test (mean, or standard deviation/standard error). for the psychological and mental health problems, five studies reported on depression,29-30, 37, 39 three studies on anxiety29-30 and two studies on stress33, 39 were selected for statistical meta-analysis. figure 2 presented the forest plot using the random effects model for the standardized differences between spiritual meditation and control group. the meta-analysis demonstrated significant heterogeneity on stress effect (i2=100%, 95% ci: -0.874, -0.634), favoring the spiritual meditation group as shown in figure 2. surprisingly, metaanalysis also presented a significant differences in pooled effects across studies in addiction related outcome (i2=27%, 95% ci: -1.703, -0.454) and anxiety symptom (i2=0%, 95% ci: -0.874, -0.634) and favoring spiritual meditation group in spite of low and no evidence of heterogeneity respectively. on the other hand, a moderate heterogeneity but no significant differences in pooled effect size (i2=51%, 95% ci: -1.903, 0.246) was observed for depression symptoms as also illustrated on figure 2. medium effect size was reported for the addiction related outcome which is (smd=0.222). on the other hand, large effect size was reported for depression and anxiety symptoms while, stress symptoms yield medium effect size respectively (smd=-0.829, -1.522 and -0.754). the remaining results of the psychological and mental that were not usable in meta-analysis due to the small number of studies or outcome measured were resulted either positive or neutral feedback. a study38 showed that spiritual yoga increases the attention level of experimental group compared with the control group. on the other hand, mindfulness meditation surprisingly reported no significant difference when compared with control group as reported by esmaeili and others.36 another study by mallik and others35 also found that yoga exercise does not affect the psychological distress among substance used disorder. moreover, the other psychological and mental health also showed a promising result with the significant reductions on perseverance, sensation, urgency, social and hostility.29, 39 discussions the present study was performed the systematic review and meta-analysis in order to response to the need of empirical evidence on the spiritual meditation on drug addiction. the findings 241 international journal of human and health sciences vol. 04 no. 04 october’20 clearly indicated that spirituality element and meditation technique even in different programs could enhance the cessation of drug addiction comparing post-result between control and intervention group. the meta-analysis findings showed a remarkable reduction in addiction related consequences, stress and anxiety level. in spite of several data reported on association between spiritual meditation and recovery of drug addiction yet, to date no systematic review and meta-analysis has been carried out (to the authors knowledge) to gather a comprehensive overview of the scientific literature in spiritual meditation field for drug addiction population. despite the diversity of therapy program, the element of spirituality and meditation was targeted or integrated or added in order to improve the quality of therapeutic programs. a possible explanation for this might be that interference of spirituality cannot be ruled out in drug addiction recovery.40, 13 relationship is consistent with the study of chapmann, seghastoleslam and others,41-42 which suggested that component of spirituality is the key role in the treatment of addiction. moreover, another study also emphasized that feeling of spirituality can enhance the recovery process and act as a protective agent for cessation of addiction.43-45 furthermore, one surprising variable that was found to be significantly associated with addiction was spiritual struggle.46-47 this finding may support the hypothesis that spirituality element plays a significant role to in long term recovery of addiction as it can be categorized as spiritual illness. although there is no definite meaning on spirituality on addiction, study by cook48 managed to explore 13 conceptual meaning of spirituality in addiction field; relatedness, transcendence, humanity, soul, meaning and purpose of life, authenticity, values, nonmateriality, non-religiousness, self-knowledge, wholeness, creativity and consciousness. at least one of these components of spirituality was found in the protocol of the therapeutic programs. table 1 shows that all spiritual meditation produced a positive or neutral result for addiction related consequences, psychological and mental health outcomes. this finding is consistent with systematic evidence by koenig49 which stated there has good evidence of the religious involvement is correlated on the better mental health including the substance abuse. most of the studies reported on addiction showed inverse relationship between religiosity and substance abuse as reviewed by bonelli and koenig.50 moreover, in accordance with the review by walton-moss and colleagues, spiritual intervention decreased the frequency and intensity of substance abuse and incorporated with spiritual meditation and stronger level of belief.13 in addition, a systematic review on meditation51 also supported that drug addiction dependence was reduced when introducing meditate as alternative tools to control and suppress the mind related on drug addiction. this study confirmed that spiritual practice such as transcendental meditation (tm), mbrp, yoga, qigong and relaxation response (rr) has been introduced as a good practice to treat substance abuse. another source of study demonstrated that spiritual meditation reduced the risk of substance use.12 however, the study also highlighted that only a few studies on the drug abuse than alcohol abuse were reported. the most popular study is marijuana. very few studies reported on other powder, cocaine, opiates, amphetamines and other major street drugs. thus, the present studies focused on the drug addiction population. the most obvious finding to emerge from the meta-analysis was the spiritual meditation reduced significantly the addiction related consequences. this finding also accords with earlier discussion, which showed that spiritual meditation gave a positive impact on the cessation of drug addiction. this was parallel with the previous studies52-54 that spirituality element may act as a promising agent on the healing process as well as may decrease the intensity of consumption and promotes abstinence. in addition, research by miller showed that spirituality dimensions play a profound association with the drug addiction recovery.55 although there was also a study reported that spiritual meditation may result on negative coping such as punishment of god, abandonment, karma, and guilt that lead to depression and stress,58-60 these results should be interpreted with caution. this conflicting result could be associated with the nature of the philosophy of religion perspective in different culture, orientation and dimension.59-61 in terms of mental health outcomes, present meta-analysis found significant reduction of anxiety and stress symptoms. contrary to the expectation, the meta-analysis evaluation did not find significant on depression symptoms yet, the trend moves towards the spiritual meditation group. generally, spiritual meditation showed strong evidence in reducing the anxiety, stress and depression and addiction recovery symptoms.1, international journal of human and health sciences vol. 04 no. 04 october’20 242 51, 62 it seems possible that these results were due to the relaxation element during spiritual meditation process. there were several techniques and mechanism that demonstrated on how the spiritual meditation can bring calmness. first, the breathing technique is the most popular in the meditation techniques. it can be found in yoga, mindfulness meditation. second, mindfulness and contemplate mind also can relax the mind with the focus oneself into the present time.63-64 third, focusing the mind by repetition the word with or without spiritual meaning made the soul calmer, which is applied in mantra meditation, tm, dhikr, chanting, and dua’.65-67 forth, a specific movement during meditates or pray such as a movement of salah and kirtan kirya.68-69 fifth, connection with god also contributed to the feeling of calmness.70 consistent with the literature, a qualitative observation also found those participants were using spiritual meditation to overcome their illness and problems.71-72 these findings may reflect the increasing popularity of alternative and complementary medicine field to treat chronic disease, physical pain and mental health illness. furthermore, the increasing knowledge in the brain imaging technology nowadays also assisted in the proof of spiritual meditation effectiveness on addiction recovery and mental health treatment. the studies73-74 showed that the addiction problem cause a distortion in the brain system such as reward system, motivation system emotion and control system. several parts of the brain that take an important role in those functional systems are ventral tegmental area, amygdala, prefrontal cortex, hippocampus, dorsal striatum and cerebellum.75 as a result, witkiewitz, lustyk and bowen demonstrated that the neural changes responded to the craving negative effect of drug during mindfulness meditation,76 may subsequently reduce the risk of relapse. other than that, stress and depression were considered as factors of relapse.77-78 thus, spiritual meditation may have cross-cultural universality in stress and depression regulation. study by chanu and devi79 resulted on activation of alpha and beta wave during spiritual mantra meditation by electroencephalogram (eeg) reading. this study proposed that repetition of spiritual words bring calmness even in a short time. then, the study by gao and colleagues80 also found that repetitive religious chanting stabilized the emotions during stress condition. however, the mechanism on how spiritual meditation produced the calm still not established thus further investigation is recommended. one of the issues that emerged from spiritual meditation was the spirituality connection with human body were ambiguous and sacred due to the element of soul and spirit.81-82, 9 thus, this issue came up with disagreement with the etiology of spiritual elements in medicinal field.83 critics have argued whether to accept it as a therapeutic agent due to the lack of proof and understanding on the spiritual effect on mental and physical health.84 however, literally nobody can disapprove with the effects of spirituality on human self. therefore, there were many qualitative explorations supported that the patient with critical illness were used spirituality practice or belief to give them motivation to survive and acceptance to overcome the hurdles of life.85-86 in addition, the exploration on spiritual transformation also gives researcher a peek of the key of spirituality as a healing treatment.87 another point worth to discuss was the twisted relationship of spiritual meditation with religiosity. most of the spiritual meditation came from religious practice across the generation. for example, the 12step facilitation derived from christianity concept and it’s secularized into aa, ma, na, cocaine anonymous and pills anonymous to suit with the non-religious group.88 it is also the same concept of mindfulness and compassion, derived from the buddhism89 then develop into mindfulness or compassion-based therapy such as mbrp, mbcg, mbt, mbi or act, compassion meditation. it also showed the same pattern with yoga, mantra meditation and tm that derived from hinduism concept.90 another interesting perspective for abstinence and addiction are islamic concept. the root of islam is the oneness of allah and the illness and recovering also come from him.91-93 then, most of the existing psychotherapy also tried to integrate the spirituality element into the protocols such as cbt, rp and motivational interviewing.94 therefore, the diversity concept of spirituality, religiosity and human-self needed to be accounted during the intervention in order to achieve the optimum goal. there are several factors that could explain the poor-quality risk of bias for the including papers. one of the explanations is the limitation of ‘double blinding’ component and the ‘intention to treat’. this problem rose because the active participation between the facilitator and the participant, which resulted on the impossible to cut off the relations. moreover, the involvement between the therapist 243 international journal of human and health sciences vol. 04 no. 04 october’20 and the patient may improve the commitment and the motivations of the patient during the therapy session. this relationship may partly explain because of the protocol of therapy intervention that needs at least the applicant aware of with the procedure performed.95-96 hence, the use of ‘third party blind’ may be a method to overcome the double-blinding problems. further study on the strategy is needed. the limitations of this review must be considered regarding the diversity of the spiritual meditation protocols. other than that, the spirituality elements in the protocols are not well defined in the intervention group. next, the possible study just assessed within the three main databases of medicinal field thus limited the exploration on other studies as well as articles published on the unpublished site such as book, thesis and proceeding. conclusions the main purpose of this systematic and metaanalytic review was to examine the empirical evidence of spiritual meditation on the variables of addiction, psychological and mental health outcomes, as well as its quality of clinical study and the methodological characteristic. spiritual meditation made a significant difference compared with control groups on the cessation of drug and psychological and mental health symptoms especially levels of stress and anxiety. this study clarifies the reliability of spiritual meditation on addiction therapy problems, a point that has not yet been adequately established. therefore, it is recommended that further studies investigated the mechanism of action of spiritual meditation on drug addiction as one of the complementary treatments and a specific and more focussing discussion on spiritual meditation to a specific type of drug addiction populations. acknowledgement the authors would like to thank to their supervisor and friends for the advice and support. financial support this research received no specific grant from any funding agency, commercial or not-for-profit sectors. declaration of interest the authors declare no conflict of interest. table 1. list of addiction related, psychological and mental health outcomes. author, year participant number of participant scale (1st outcome) scale (2nd outcome) type of intervention control group intervention (number of session) intervention (duration of a session) follow -up result (1st outcome) results (2nd outcome) addiction psychology & mental health session minute month addiction psychology & mental health kelly, et al., 2017 sud 59 tlfb sip-2r bsi mdm-has pastoral cbt, met once a week, 10 60 to 90 3,6,9 n/+ n/+ bowen, et al., 2014 sud 286 asi tlfb sds meditation tau (12step) & rp once a week, 8 120 3,6,12 +/n/+ fahmy et al., 2018 opioid dependence 19 asi dtq upps-p fmi meditation tau (cbt, matrix) once a week, 4 5 to 40 n +/+/+ jenaabadi & jahangir, 2017 opioid dependence 57 dsm v scl-90-r meditation cr & mmt once a week, 8 90 na n + zullig et al., 2018 opioid dependence 32 ddq tlfb odsis oasis ffmq meditation tau & mat once a week, 8 90 n/+/+/+ esmaeili et al., 2018 sud 60 cero ffmq meditation tau once a week, 8 90 n/+ wells et al., 2014 sud 234 suc asi dtcq 8 socrates syraap pss pastoral tau once a week, 8 90 3,6 n/+/+ n/+/+ sadeghi et al., 2015 ampethamine 50 bdi shs therapy cr once a week, 8 na +/+ gaihre & rajesh, 2018 sud 96 scwl wdsp slct meditation physical exercise once in two weeks, 6 90 +/+/+ international journal of human and health sciences vol. 04 no. 04 october’20 244 author, year participant number of participant scale (1st outcome) scale (2nd outcome) type of intervention control group intervention (number of session) intervention (duration of a session) follow -up result (1st outcome) results (2nd outcome) addiction psychology & mental health session minute month addiction psychology & mental health guydish et al., 2014 stimulant abuse 234 asi suc tsf aces shaq 2 pastoral tau once a week, 12 90 3 +/+ +/n wimberly et al., 2018 sud 73 tlfb pss meditation tau once a week, 12 90 3 + + shorey et al., 2017 sud 117 pacs aaq-sa ffmq meditation tau 12 step twice a week, 8 90 + +/n ghouchani et al., 2018 methamphetamine 30 ghq bpaq therapy tau once a week, 6 na +/+ mallik et al., 2019 sud 49 ua gpdd meditation tau 12 step four times a week, 6 20-30 n n +: positive effect; -: no information; aaq-sa: acceptance and action questionnaire substance use version; act: acceptance commitment therapy; asi: addiction severity index; bdi: beck depression inventory; bpaq: buss perry aggression questionnaire; bsi: brief symptoms inventory; caps: clinician administered ptsd scale; cero: cognitive emotion regulation questionnaire; cr: do not receive any treatment; ddq: desire for drug questionnaire; dsm-5: diagnostic and statistically manual of mental disorder; dtcq 8: the drug taking confidence scale; dtq: distress tolerance questionnaire; ffmq: five facet of mindfulness questionnaire; fmi: freiburg mindfulness inventory; ghq: general health questionnaire; gpdd: general psychological distress and dysfunction; mat: medication assisted treatment; mdmhas: multi-dimensional mutual-help activity scale; n: no change; na: not define; oasis: overall anxiety severity and impairment scale; odsis: overall depression severity and impairment scale; pacs: penn alcohol and drug craving scale; pss: participation satisfaction survey; pss: perceive stress scale; ptsd: post traumatic syndrome disorder; rp: relapse preventive; scl-90-r: symptoms checklist-90–revised; scwt: stroop colour word test; sds: severity dependence scale; shaq 2: self help activities questionnaire; shs: synder hope scale; sip-2r: short inventory of problems-recent; slct: six letter cancellation task; socrates: stage of change readiness and treatment eagerness scale; suc: substance use calendar; sud: substance use disorder; syraap: survey of readiness alcoholic anonymous readiness; tau: treatment as usual; tlfb: time line follow back; tsf aces: twelve step facilitation adherence competence empathy scale; ua: urianalysis, upps-p: urgency premeditation perseverance sensation seeking impulsive behavior scale; wdst: wais-r digit span task. table 2. risk of bias in individual study. author/s randomization 1 randomization 2 blinding 1 blinding 2 account of patient total score kelly, et al. 1 1 2 bowen, et al. 1 1 2 fahmy et al. 1 1 1 3 jenaabadi & jahangir 1 1 zullig et al. 1 1 esmaeili et al. 1 1 wells et al. 1 1 sadeghi et al. 0 gaihre & rajesh 1 1 1 3 guydish et al 1 1 wimberly et al. 1 1 1 1 4 shorey et al 1 1 1 3 ghouchani et al. 1 1 mallik et al. 1 1 245 international journal of human and health sciences vol. 04 no. 04 october’20 figure 1: selection of data based on prism report. pubmed (1667) cochrane (943) scopus (3556) total paper identified in the database (5951) total paper selected by title and abstract (5736) total paper included based on eligibility criteria (173) paper included for qualitative analysis (15) papers included for quantitative analysis (11) total removed duplicate paper (215) total excluded paper by apt title and abstract (5563) not drug addiction (107) other methodology (29) not spiritual meditation (13) randomization not adequate (9) insufficient data to determine effect size (4) p h a s e 1 p h a s e 2 international journal of human and health sciences vol. 04 no. 04 october’20 246 favour experimental favour control smd, random, 95% ci author, year fahmy, et al., 2018 jennabadi & jahangir, 2017. 2 jennabadi & jahangir, 2017. 1 ghouchani et al, 2018 shorey, et al., 2017 zullig, et al., 2017 kelly, et al., 2017 effect summary smd, 95% ci -0.503 (-0.684, -0.322) -0.485 (-0.917, -0.053) -1.633 (-2.039, -1.226) -1.637 (-2.043, -1.230) -2.960 (-3.576, -2.345) -0.234 (-0.325, -0.143) -0.222 (-0.317, -0.127) -0.337 (-0.598, -0.076) random effect models (i2 = 27%) jenaabadi & jahangir, 2017. 2 ghouchani et al., 2018 sadeghi et al., 2015 zullig, et al., 2017 jenaabadi & jahangir, 2017. 1 -2.193 (-2.664, -1.722) -0.450 (-0.865, -0.034) -1.413 (-1.083, -1.742) -0.032 (-0.096, 0.032) -2.990 (-3.540, -2.440) random effect models (i2 = 51%) effect summary -0.829 (-1.903, 0.246) ghouchani et al., 2018 wimberly et al., 2018 -0.727 (-0.939, -0.515) -0.891 (-1.229, -0.553) random effect models (i2 = 100%) effect summary -0.754 (-0.874, -0.634) jenaabadi & jahangir, 2017. 1 -1.671 (-2.082, -1.260) jenaabadi & jahangir, 2017. 2 -1.989 (-2.438, -1.541) zullig, et al., 2017 -0.693 (-1.209, -0.177) effect summary -1.552 (-2.397, -0.708) random effect models (i2 = 0%) addiction related outcomes depression anxiety stress figure 2: effects of addiction related and psychological outcomes. a negative value of summary effect size suggests that spiritual meditation decrease drug addiction related outcomes and reduce depression, anxiety and stress symptoms compared to control. 247 international journal of human and health sciences vol. 04 no. 04 october’20 references: 1. sedlmeier p, eberth j, schwarz m, zimmermann d, haarig f, jaeger s, kunze s. the psychological effects of meditation: a meta-analysis. psychological bulletin. 2012;138(6):1139. 2. koenig hg. research on religion, spirituality, and mental health: a review. the canadian journal of psychiatry. 2009;54(5):283-91. 3. lang aj, strauss jl, bomyea j, bormann je, hickman sd, good rc, essex m. the theoretical and empirical basis for meditation as an intervention for ptsd. behavior modification. 2012;36(6):75986. 4. bowen s, somohano vc, rutkie re, manuel ja, rehder kl. mindfulness-based relapse prevention for methadone maintenance: a feasibility trial. the journal of alternative and complementary medicine. 2017;23(7):541-4. 5. breslin fc, zack m, mcmain s. an information‐ processing analysis of mindfulness: implications for relapse prevention in the treatment of substance abuse. clinical psychology: science and practice. 2002;9(3):275-99. 6. lee tm, leung mk, hou wk, tang jc, yin j, so kf, lee cf, chan cc. distinct neural activity associated with focused-attention meditation and loving-kindness meditation. plos one. 2012;7(8). 7. janssen l, kan cc, carpentier pj, sizoo b, hepark s, schellekens mp, donders ar, buitelaar jk, speckens ae. mindfulness-based cognitive therapy v. treatment as usual in adults with adhd: a multicentre, single-blind, randomised controlled trial. psychological medicine. 2019;49(1):55-65. 8. dowling em, scarlett wg, editors. encyclopedia of religious and spiritual development. sage; 2006. 9. belzen ja. spirituality, culture and mental health: prospects and risks for contemporary psychology of religion. journal of religion and health. 2004;43(4):291-316. 10. longe jl. the gale encyclopedia of medicine. thompson gale; 2015. 11. newberg a, waldman mr. how god changes your brain: breakthrough findings from a leading neuroscientist. ballantine books; 2009. 12. chitwood dd, weiss ml, leukefeld cg. a systematic review of recent literature on religiosity and substance use. journal of drug issues. 2008;38(3):653-88. 13. walton-moss b, ray em, woodruff k. relationship of spirituality or religion to recovery from substance abuse: a systematic review. journal of addictions nursing. 2013;24(4):217-26. 14. gonçalves jp, lucchetti g, menezes pr, vallada h. religious and spiritual interventions in mental health care: a systematic review and meta-analysis of randomized controlled clinical trials. psychological medicine. 2015;45(14):2937-49. 15. clark hd, wells ga, huët c, mcalister fa, salmi lr, fergusson d, laupacis a. assessing the quality of randomized trials: reliability of the jadad scale. controlled clinical trials. 1999;20(5):448-52. 16. jadad ar, moore ra, carroll d, jenkinson c, reynolds dj, gavaghan dj, mcquay hj. assessing the quality of reports of randomized clinical trials: is blinding necessary?. controlled clinical trials. 1996;17(1):1-2. 17. thalheimer w, cook s. how to calculate effect sizes from published research: a simplified methodology. work-learning research. 2002;1:1-9. 18. cohen j. statistical power analysis for the behavioral sciences. academic press; 2013. 19. durlak ja. how to select, calculate, and interpret effect sizes. journal of pediatric psychology. 2009;34(9):917-28. 20. neyeloff jl, fuchs sc, moreira lb. meta-analyses and forest plots using a microsoft excel spreadsheet: step-by-step guide focusing on descriptive data analysis. bmc research notes. 2012;5(1):52. 21. shamseer l, moher d, clarke m, ghersi d, liberati a, petticrew m, shekelle p, stewart la. preferred reporting items for systematic review and metaanalysis protocols (prisma-p) 2015: elaboration and explanation. bmj. 2015;349. 22. moher d, liberati a, tetzlaff j, altman dg. preferred reporting items for systematic reviews and metaanalyses: the prisma statement. annals of internal medicine. 2009;151(4):264-9. 23. kabat-zinn j. mindfulness. mindfulness. 2015;6(6):1481-3. 24. ludwig ds, kabat-zinn j. mindfulness in medicine. jama. 2008;300(11):1350-2. 25. park cl, braun t, siegel t. who practices yoga? a systematic review of demographic, health-related, and psychosocial factors associated with yoga practice. journal of behavioral medicine. 2015;38(3):460-71. 26. kelly jf, kaminer y, kahler cw, hoeppner b, yeterian j, cristello jv, timko c. a pilot randomized clinical trial testing integrated 12‐step facilitation (itsf) treatment for adolescent substance use disorder. addiction. 2017;112(12):2155-66. 27. bowen s, witkiewitz k, clifasefi sl, grow j, chawla n, hsu sh, carroll ha, harrop e, collins se, lustyk mk, larimer me. relative efficacy of mindfulness-based relapse prevention, standard relapse prevention, and treatment as usual for substance use disorders: a randomized clinical trial. jama psychiatry. 2014;71(5):547-56. 28. fahmy r, wasfi m, mamdouh r, moussa k, wahba international journal of human and health sciences vol. 04 no. 04 october’20 248 a, wittemann m, hirjak d, kubera km, wolf nd, sambataro f, wolf rc. mindfulness-based interventions modulate structural network strength in patients with opioid dependence. addictive behaviors. 2018;82:50-6. 29. jenaabadi h, jahangir ah. comparing the effectiveness of mindfulness-based group therapy and methadone maintenance therapy on psychological symptoms (obsession, interpersonal sensitivity, depression, anxiety, and aggression) among opioiddependent patients. shiraz e-medical journal. 2017;18(6). 30. zullig kj, lander lr, sloan s, brumage mr, hobbs gr, faulkenberry l. mindfulness-based relapse prevention with individuals receiving medicationassisted outpatient treatment for opioid use disorder. mindfulness. 2018;9(2):423-9. 31. wells ea, donovan dm, daley dc, doyle sr, brigham g, garrett sb, ingalsbe mh, hatch-maillette ma, perl hi, walker r. is level of exposure to a 12step facilitation therapy associated with treatment outcome?. journal of substance abuse treatment. 2014;47(4):265-74. 32. guydish j, campbell bk, manuel jk, delucchi kl, le t, peavy km, mccarty d. does treatment fidelity predict client outcomes in 12-step facilitation for stimulant abuse?. drug and alcohol dependence. 2014;134:330-6. 33. wimberly as, engstrom m, layde m, mckay jr. a randomized trial of yoga for stress and substance use among people living with hiv in reentry. journal of substance abuse treatment. 2018;94:97-104. 34. shorey rc, elmquist j, gawrysiak mj, strauss c, haynes e, anderson s, stuart gl. a randomized controlled trial of a mindfulness and acceptance group therapy for residential substance use patients. substance use & misuse. 2017;52(11):1400-10. 35. mallik d, bowen s, yang y, perkins r, sandoz ek. raja yoga meditation and medication-assisted treatment for relapse prevention: a pilot study. journal of substance abuse treatment. 2019;96:58-64. 36. esmaeili a, khodadadi m, norozi e, miri mr. effectiveness of mindfulness-based cognitive group therapy on cognitive emotion regulation of patients under treatment with methadone. journal of substance use. 2018;23(1):58-62. 37. sadeghi h, ebrahimi l, vatandoust l. effectiveness of hope therapy protocol on depression and hope in amphetamine users. international journal of high risk behaviors & addiction. 2015;4(4). 38. gaihre a, rajesh sk. effect of add-on yoga on cognitive functions among substance abusers in a residential therapeutic center: randomized comparative study. annals of neurosciences. 2018;25(1):38-45. 39. ghouchani s, molavi n, massah o, sadeghi m, mousavi sh, noroozi m, sabri a, farhoudian a. effectiveness of acceptance and commitment therapy (act) on aggression of patients with psychosis due to methamphetamine use: a pilot study. journal of substance use. 2018;23(4):402-7. 40. room r. spirituality, intoxication and addiction: six forms of relationship. substance use & misuse. 2013;48(12):1109-13. 41. chapman rj. spirituality in the treatment of alcoholism: a worldview approach. counseling and values. 1996;41(1):39-50. 42. seghatoleslam t, habil h, hatim a, rashid r, ardakan a, motlaq fe. achieving a spiritual therapy standard for drug dependency in malaysia, from an islamic perspective: brief review article. iranian journal of public health. 2015;44(1):22. 43. sussman s, milam j, arpawong te, tsai j, black ds, wills ta. spirituality in addictions treatment: wisdom to know… what it is. substance use & misuse. 2013;48(12):1203-17. 44. faigin ca, pargament ki, abu-raiya h. spiritual struggles as a possible risk factor for addictive behaviors: an initial empirical investigation. the international journal for the psychology of religion. 2014;24(3):201-14. 45. neff ja, macmaster sa. applying behavior change models to understand spiritual mechanisms underlying change in substance abuse treatment. the american journal of drug and alcohol abuse. 2005;31(4):669-84. 46. stauner n, exline jj, kusina jr, pargament ki. religious and spiritual struggles, religiousness, and alcohol problems among undergraduates. journal of prevention & intervention in the community. 2019;47(3):243-58. 47. johnson tj, sheets vl, kristeller jl. empirical identification of dimensions of religiousness and spirituality. mental health, religion & culture. 2008;11(8):745-67. 48. cook cc. addiction and spirituality. addiction. 2004;99(5):539-51. 49. koenig hg. spirituality and health research: methods, measurements, statistics, and resources. templeton foundation press; 2012. 50. bonelli rm, koenig hg. mental disorders, religion and spirituality 1990 to 2010: a systematic evidencebased review. journal of religion and health. 2013;52(2):657-73. 51. ospina m. meditation practices for health state of the research. diane publishing; 2007. 52. coleman sb, kaplan jd, downing rw. life cycle and loss—the spiritual vacuum of heroin addiction. 249 international journal of human and health sciences vol. 04 no. 04 october’20 family process. 1986;25(1):5-23. 53. avants sk, warburton la, margolin a. spiritual and religious support in recovery from addiction among hiv-positive injection drug users. journal of psychoactive drugs. 2001;33(1):39-45. 54. de bernardin gonçalves jp, vallada h. religious and spiritual interventions in health: scientific evidence. inspirituality, religiousness and health 2019 (pp. 101-113). springer, cham. 55. miller wr. researching the spiritual dimensions of alcohol and other drug problems. addiction. 1998;93(7):979-90. 56. pargament ki, koenig hg, tarakeshwar n, hahn j. religious struggle as a predictor of mortality among medically ill elderly patients: a 2-year longitudinal study. archives of internal medicine. 2001;161(15):1881-5. 57. miller wr, forcehimes a, o’leary mj, lanoue md. spiritual direction in addiction treatment: two clinical trials. journal of substance abuse treatment. 2008;35(4):434-42. 58. o’brien b, shrestha s, stanley ma, pargament ki, cummings j, kunik me, fletcher tl, cortes j, ramsey d, amspoker ab. positive and negative religious coping as predictors of distress among minority older adults. international journal of geriatric psychiatry. 2019;34(1):54-9. 59. beraldo l, gil f, ventriglio a, de andrade ag, da silva ag, torales j, gonçalves pd, bhugra d, castaldelli-maia jm. spirituality, religiosity and addiction recovery: current perspectives. current drug research reviews formerly: current drug abuse reviews. 2019;11(1):26-32. 60. al ghaferi h, bond c, matheson c. does the biopsychosocial-spiritual model of addiction apply in an islamic context? a qualitative study of jordanian addicts in treatment. drug and alcohol dependence. 2017;172:14-20. 61. chen g. the meaning of suffering in drug addiction and recovery from the perspective of existentialism, buddhism and the 12-step program. journal of psychoactive drugs. 2010;42(3):363-75. 62. pruett jm, nishimura nj, priest r. the role of meditation in addiction recovery. counseling and values. 2007;52(1):71-84. 63. mooventhan a, khode v. effect of bhramari pranayama and om chanting on pulmonary function in healthy individuals: a prospective randomized control trial. international journal of yoga. 2014;7(2):104. 64. burke a, lam cn, stussman b, yang h. prevalence and patterns of use of mantra, mindfulness and spiritual meditation among adults in the united states. bmc complementary and alternative medicine. 2017;17(1):316. 65. burchett pe. the ‘magical’language of mantra. journal of the american academy of religion. 2008;76(4):807-43. 66. alexander cn, langer ej, newman ri, chandler hm, davies jl. transcendental meditation, mindfulness, and longevity: an experimental study with the elderly. journal of personality and social psychology. 1989;57(6):950. 67. hosseini m, salehi a, fallahi khoshknab m, rokofian a, davidson pm. the effect of a preoperative spiritual/religious intervention on anxiety in shia muslim patients undergoing coronary artery bypass graft surgery: a randomized controlled trial. journal of holistic nursing. 2013;31(3):164-72. 68. saniotis a. understanding mind/body medicine from muslim religious practices of salat and dhikr. journal of religion and health. 2018;57(3):849-57. 69. wayne pm, yeh g, mehta dh. minding the mind– body literature: aging and cognitive decline. the journal of alternative and complementary medicine. 2018;24(3):1–4. 70. sellman jd, baker mp, adamson sj, geering lg. future of god in recovery from drug addiction. australian & new zealand journal of psychiatry. 2007;41(10):800-8. 71. kemp r. addiction and addiction recovery: a qualitative research viewpoint. journal of psychological therapies. 2019;4(2):167-79. 72. ku cf, koo m. association of distress symptoms and use of complementary medicine among patients with cancer. journal of clinical nursing. 2012;21(5‐6):73644. 73. pelloux y, baunez c. harnessing circuits for the treatment of addictive disorders. inneural mechanisms of addiction 2019 (pp. 271-285). academic press. 74. volkow nd, baler rd, goldstein rz. addiction: pulling at the neural threads of social behaviors. neuron. 2011;69(4):599-602. 75. herman ma, roberto m. the addicted brain: understanding the neurophysiological mechanisms of addictive disorders. frontiers in integrative neuroscience. 2015;9:18. 76. witkiewitz k, lustyk mk, bowen s. retraining the addicted brain: a review of hypothesized neurobiological mechanisms of mindfulnessbased relapse prevention. psychology of addictive behaviors. 2013;27(2):351. 77. wiers ce, stelzel c, park sq, gawron ck, ludwig vu, gutwinski s, heinz a, lindenmeyer j, wiers rw, walter h, bermpohl f. neural correlates of alcohol-approach bias in alcohol addiction: the spirit is willing but the flesh is weak for spirits. international journal of human and health sciences vol. 04 no. 04 october’20 250 neuropsychopharmacology. 2014;39(3):688-97. 78. polimanti r, peterson re, ong js, macgregor s, edwards ac, clarke tk, frank j, gerring z, gillespie na, lind pa, maes hh. evidence of causal effect of major depression on alcohol dependence: findings from the psychiatric genomics consortium. psychological medicine. 2019;49(7):1218-26. 79. chanu ll, devi kg. electro-encephalographic changes of short-term transcendental meditation. journal of medical society. 2014;28(3):154. 80. gao j, fan j, wu bw, halkias gt, chau m, fung pc, chang c, zhang z, hung ys, sik h. repetitive religious chanting modulates the late-stage brain response to fear-and stress-provoking pictures. frontiers in psychology. 2017;7:2055. 81. allamani a, godlaski tm, einstein ss. spirituality, religion, and addiction: a possible epilogue. substance use & misuse. 2013;48(12):1262-6. 82. ashy ma. health and illness from an islamic perspective. journal of religion and health. 1999;38(3):241-58. 83. koenig hg. spirituality in patient care: why, how, when, and what. templeton foundation press; 2013. 84. burke mt, chauvin jc, miranti jg. religious and spiritual issues in counseling: applications across diverse populations. routledge; 2004. 85. yodchai k, dunning t, savage s, hutchinson am. the role of religion and spirituality in coping with kidney disease and haemodialysis in thailand. scandinavian journal of caring sciences. 2017;31(2):359-67. 86. shafie aa, jailani mr, elias nf, miskam na, mahyuddin mk. the effectiveness of a guided repentance module: a qualitative analysis of psycho spiritual and drug-related locus of control. international journal of academic research in business and social sciences. 2019;9(6). 87. williamson wp, hood rw. spiritual transformation: a phenomenological study among recovering substance abusers. pastoral psychology. 2013;62(6):889-906. 88. booth j, martin je. spiritual and religious factors in substance use, dependence, and recovery. inhandbook of religion and mental health 1998 (pp. 175-200). academic press. 89. kabat-zinn, j. meditation. in b. moyer (ed.), healing and the mind 1993 (pp. 115–143). doubleday. 90. alexander cn, robinson p, rainforth m. treating and preventing alcohol, nicotine, and drug abuse through transcendental meditation: a review and statistical meta-analysis. alcoholism treatment quarterly. 1994;11(1-2):13-87. 91. ali m. perspectives on drug addiction in islamic history and theology. religions. 2014;5(3):912-28. 92. baharudin df, sumari m, hamdani sm. shame transformation using an islamic psycho-spiritual approach for malay muslims recovering from substance dependence. inthe bright side of shame 2019 (pp. 199-214). springer, cham. 93. kadri r., mohamad n, husain r., mat k c, omar shs, omar smhs. addiction and islamic based therapy in malaysia. man in india. 2017; 97(26): 233-6. 94. rangé bp, mathias ac. cognitive-behavior therapy for substance abuse. standard and innovative strategies in cognitive behavior therapy. 2012;9:157. 95. boslaugh s, editor. encyclopedia of epidemiology. sage publications; 2007. 96. devereaux pj, bhandari m, montori vm, manns bj, ghali wa, guyatt gh. double blind, you are the weakest link-goodbye!. bmj evidence-based medicine. 2002;7(1):4-5. 89 international journal of human and health sciences vol. 04 no. 02 april’20 original article correlation between age, body mass index, and blood selenium level with glutathione peroxidase activity among elderly in south jakarta annisa nurul kirana1, erfi prafiantini1, novi silvia hardiany2,3 abstract: oxidative stress contributed in aging process and several degenerative diseases. selenium was an important trace element due to as a component of antioxidants enzymes (selenoproteins), including glutathione peroxidase for protection against free radical. objective: we aimed to study the correlation between blood selenium level and plasma glutathione peroxidase activity in elderly. materials and methods: cross sectional study was held in 5 elderly communities in south jakarta. body mass index, blood selenium level and plasma glutathione peroxidase activity were measured in 95 elderly aged between 60-86 years old. nonparametric correlation was used for correlation analysis. results and discussion: the median of subject’s age was 69 years old (60-86) and for body mass index was 23.57 (13.59-36.05). the median of selenium level among subject was 0.19 (0.023-0.56). the mean of plasma glutathione peroxidase activity was 164.45 u/l ± 68.07. there was no correlation among variables. however, plasma glutathione peroxidase activity decreased with increasing age and body mass index although it was not significant. conclusion: there was no correlation between blood selenium level and plasma glutathione peroxidase activity. detection of plasma selenium level is needed to confirm this result. keywords: selenium, glutathione peroxidase, antioxidant, elderly correspondence to: novi silvia hardiany, department of biochemistry& molecular biology, faculty of medicine, universitas indonesia, e-mail: novi.silvia@ui.ac.id 1. department of nutrition, faculty of medicine, universitas indonesia – dr. ciptomangunkusumo general hospital, jakarta, indonesia 2. department of biochemistry & molecular biology, faculty of medicine, universitas indonesia 3. center of hypoxia & oxidative stress studies, faculty of medicine, universitas indonesia introduction globally people above 60 age years in 2017 are approximately 962 million, 13% from population, and increase 3% per year. in 2030 this population will be estimate reach 1.4 billion, and 2.1 billion in 2050.1 population of indonesian elderly were increase from 5.45% in 1980 to 9.77% in 2010. it has been estimated in 2020 the population would reach 11.34%.2 the health status has wide variation with increasing age. some older people have physical capacity same like the younger and the other have declined of physical capacity. the transition of epidemiology cause change of disease pattern, where chronic degenerative disease such hypertension, arthritis, stroke, diabetes are more and more increase.1, 2 aging can describe as degenerative process decline in physical function to maintain homeostasis leading to an increase possibility of death. the imbalance between oxidative stress and antioxidant defense trigger macromolecular damage, at the end can cause degenerative disease and death. accumulation of cellular oxidative stress are caused by free radical from intrinsic process like metabolism product, random error biochemical reaction, nutrition intake, and also extrinsic factors.3, 4 selenium were trace element which had important role in protection system from oxidative stress. maintaining optimal level of body selenium were crucial to prevent oxidative stress. selenium deficiency related to increasing risk of several international journal of human and health sciences vol. 04 no. 02 april’20 page : 89-93 doi: http://dx.doi.org/10.31344/ijhhs.v4i2.181 international journal of human and health sciences vol. 04 no. 02 april’20 90 chronic disease including cancer, and coronary artery disease. in recent year, selenium researches are an interested study due to its important role as selenoprotein antioxidant to against free radical.5, 6 in our body, selenium would bind with amino acid to form selenoproteinglutathione peroxidase (gpx), a selenium dependent enzyme plays critical role in reduction of lipid and hydrogen peroxides. if gpx activity is decreased, more hydrogen peroxide is present, leads to tissue damage. same as others proteins, glutathione peroxidase contains from several amino acids. for examples gpx-1, consist of 181 kinds of amino acid, the essential amino acids and non-essentials.7 there are four subspecies of gpx that catalyze the reduction of free radical in specific tissue location. 70% gpx found in cytosol and 30% in mitochondria matrix. gpx-1 found in most cells, including red blood cells, hepatocyte, and kidney tissue, gpx-2 found in gastrointestinal tract, gpx3 is selenoprotein in plasma as glycoproteins, and gpx-4 interact with complexes lipid in cell membrane.8 glutathione peroxidase catalyze reduction of hydrogen peroxides and organic hydroperoxides. if this free radical is not reduced, leads to cellular damage, including dna and other proteins damage. during the process, glutathione is needed in reduced form (gsh) and transform to be oxidized glutathione (gssg). gssg is radical so it must be reduced to gsh immediately.9, 10, 11 recently, study about selenium in elderly still rarely. baierle et al12 in 2015 found negative correlation between gpx activity with plasma carbonyl in elderly population. in 2012, savory et al13 analyzed the effect of supplementation 200 µg selenium to obese patient for 3 weeks. the result showed that selenium supplementation could reduce lipid peroxidation. cardoso et al14 in 2014 found lower selenium level in alzheimer patient compared to the mild cognitive impairment patients and the healthy group. the aim of this study was to assess the correlation between selenium level with gpx activity in indonesian elderly. we hypothesized blood selenium level would have positive correlation with gpx activity. materials and methods source population and study population cross sectional study was held in 3 different sub-districts in jakarta, that were cilandak, kebayoranbaru, and pesanggrahan. participants were recruited from a consecutive sampling in several integrative healthcare center for elderly. the inclusion criteria were men or women aged 60 years old and over as well as willing to follow all procedures and signed the informed consent. subject would be excluded if smoking or drinking alcohol in recent 1 year, had severe pain at lower extremity, or fever. we examined anthropometric assessment, blood selenium level, and plasma gpx activity. study variables & their indicator anthropometric assessment body mass index data was obtained from weight and height measurement. due to limitations in elderly, we used knee height measurement to obtain body height. body weight measurement used seca 803 digital body weight scale, and the knee height measurements used knee height caliper. the result of knee height would be conversed to body height used a formula15 men height = (1,924 x knee height) + 69,38 women height = (2,225 x knee height) + 50,25 blood selenium level blood sample was taken without fasting first. after vena puncture, whole blood from edta tube was added with1 ml ofconcentrated nitric acids, and heated up in waterbath for 1 hour. after that, 0.5 ml hydrogen peroxide was added to the sample and heated up for 2 hours. the sample must be filtered with whatman paper before measurement. blood selenium level was determined in whole blood by inductively coupled plasma-optical emission spectrometer (icp-oes). glutathione peroxidase activity gpx activity was determined in plasma using colorimetric method by spectrophotometry (thermo fisher scientific®) at 340 nm and 37°cusing a commercially available kit (glutathione peroxidase ransel kit, randox®). fifty microliters of heparinized plasma were diluted with diluting agent, incubated for 5 minute and added 1 ml of drabkin’s reagent. the solution was mixed well and read as an initial absorbance of sample after one minute and read again after 1 and 2 minutes. statistical analysis descriptive statistics were used to summarize subject characteristic including age, gender, education, and nutrition status. age, body mass 91 international journal of human and health sciences vol. 04 no. 02 april’20 index, and selenium level were categorized into 2-4 groups. correlation analysis spearman were used to examine the correlation between age, body mass index, selenium level with gpx activity. the statistical analysis used spss program. result participants of this study were 23 men and 72 women aged 60-86 years old. subjects characteristic were summarized in table 1. most of participants were women (75.8%) and 24.2% were men. for education background, 38.9% had low education. table 1. subject baseline characteristic variable result age, years, median (min-max) 69 (60-86) gender men, n (%) women, n (%) 23 (24.2) 72 (75.8) education low education, n (%) well education, n (%) high education, n (%) 37 (38.9) 30 (31.6) 28 (29.5) body mass index, kg/m2, median (minmax) nutritional status underweight, n (%) normoweight, n (%) overweight, n (%) obese, n (%) blood selenium level, µg/dl, median (min-max) optimal level, n (%) low level, n (%) 23.57 (13.59-36.05) 5 (5.3) 38 (40) 29 (30.5) 23 (24.2) 0.19 (0.0023-0.56) 74 (77.9) 21 (22.1) gpx activity in older age group (> 70 years old) was lower than the younger (figure 1a). mean of gpx activity in older age group was 158.5 µmol/min/l, while the mean of younger age group was 169.2 µmol/min/l. statistical analysis with independent t-test showed there were no significantly different in two age groups. (p>0.05). in nutritional status, gpx activity was lower in overweight and obese groups than the normal weight group (figure 1b). median of gpx activity in obese group was 136.7 µmol/min/l with range 44.2 262.9 µmol/min/l. anova test result showed there no significantly different among those groups (p>0.05). in blood selenium level groups, mean of gpx activity in low level group was 164.1 µmol/min/l lower than optimal level group (figure 1c). there no significantly different found in statistical analysis used independent t-test (p>0.05). we analyzed the correlation between age, body mass index, and blood selenium level with gpx activity used spearman correlation analysis. gpx activity decreased by age and body mass index in this study, but no significant correlation found (p>0.05).gpx activity increase by increasing blood selenium level, although we not found the significant correlation between them (p=0.05). discussion and conclusion in our study, range of age’s subject was 60-86 years old. the women participants were greater than men participants. this condition was in accordance with the data from badan pusat statistik republic of indonesia that showed elderly (aged ≥ 60 years old) were 8.97% from indonesian population, consist of 47.48% men and 52.52% women. most of elderly in indonesia aged 60-69 years old (63%) and the rest aged 70 years old and over. for educational background, more than half of indonesian elderly were only junior high school graduates or lower. in recent study, 38.9% participants had low education background.16 gpx was an enzymatic antioxidant system which protect the cells from oxidative stress. harman in 1956 described oxidative stress in aging process.3,17,18 in this study gpx activity was lower in the older age group. previous in vitro studies demonstrated that levels of gpx1 protein and enzymatic activity were significantly reduced in human endothelial progenitor cells (epc) derived from old subjects, but the blood levels of selenium were not significantly different between young and old subject. it meant that decreasing of gpx1 levels in epc of old individuals appeared was not depend on blood selenium level. as seen in our result, there was no correlation between blood selenium level with plasma gpx activity, however the subjects who had low level selenium tend to had figure 1. a. gpx activity in age groups b. gpx activity in body mass index groups c. gpx activity in blood selenium level. there were no significant different between gpx activity in all groups (p>0.05) international journal of human and health sciences vol. 04 no. 02 april’20 92 low level gpx activity. espinoza et al19 in 2008 found an inverse association between gpx and age, indicating that for each 1-year increase in age, gpx activity decrease by 2.9 µmol/min/l. our result also exhibited that gpx activity decreased with increasing age. decrease in gpx activity as the consequence of high level of oxidative stress which occur in aging process due to its role as antioxidant.20 besides in aging process, oxidative stress increase in several condition including obesity.13, 20, 21 the study of furukawa et al in 2004 showed that fat accumulation would increase systemic oxidative stress. this condition in obesity might relate to dysregulated adipocytokines production. lipid peroxidation marker significantly correlated with bmi and waist circumference.21 in this study, 23 subjects were obese. their gpx activity were lower than the normal group, but no significantly different among this groups. the gpx might be used to eliminate free radical and overcome oxidative stress, thereby its activity was low in obese group. obesity was one condition that increase oxidative stress due to low grade inflammation. study of selenium has been an interest study since its discovery as an important component of antioxidant enzymes, including glutathione peroxidase.6, 22, 23 there are a few of human studies that implicate low body selenium status in reduce longevity or health span.24,25 eva study in france 2005 explored the relationship between baseline plasma selenium concentrations and mortality. this 9-year longitudinal study indicate that low plasma selenium concentrations were associated with higher mortality.26,27 in selenium deficiency condition, transformation selenocysteine into gpx during translation decreased cause increasing gpx mrna degradation27. in this study, gpx activity was lower in low blood selenium level, but no significantly correlation between selenium level with gpx activity. it might be caused by the difference sample source in analyzing selenium and gpx. selenium level was analyzed from the hemolysate, while gpx activity was analyzed in plasma. regarding that, plasma selenium assessment is needed to determine plasma selenoprotein gpx status for the future study. glutathione peroxidase as antioxidant doesn’t work independently to prevent oxidative stress. therefore, further research is needed to assess other antioxidants and other chronic inflammation condition which influence glutathione peroxidase status. in conclusion, glutathione peroxidase activity in elderly in south jakarta was tend to decreased with increasing age and body mass index. moreover, its activity also decreased in low level of selenium, although the correlation analysis was not significant. recommendations the future research of relationship between gpx, other antioxidants, stress oxidative, and chronic diseases may greatly improve our understanding to maintain the quality of life in elderly. acknowledgments the authors would like to thank all study participants. this research was supported by ministry of research, technology and education of the republic of indonesia. authors’s contribution: data gathering and idea owner of this study:annisa nurul kirana, novi silvia hardiany study design: annisa nurul kirana, erfi prafiantini data gathering: annisa nurul kirana, erfi prafiantini writing and submitting manuscript:annisa nurul kirana, novi silvia hardiany editing and approval of final draft: novi silvia hardiany ethical clearence: issued by ethic committee of faculty of medicine universitas indonesia, number: ket-442/un2.f1/etik/ppm.00.02/2019 source of funding: ministry of research, technology and education of the republic of indonesia. 93 international journal of human and health sciences vol. 04 no. 02 april’20 references: 1. world populations prospects: the 2017 revision. new york: united nations 2017:1-10. 2. situasi dan analisislanjutusia. depkes.go.id: pusat data dan informasikementriankesehatan ri 2014:15. 3. brunk ut, terman a. the mitochondriallysosomal axis theory of aging. european journal of biochemistry. 2002;269:1996-2002. 4. sergiev pv, dontsova oa, berezkin gv. theories of aging: an ever-evolving field. acta naturae. 2015;7:9-18. 5. santos jr, gois am, mendonça dmf, freire mam. nutritional status, oxidative stress and dementia: the role of selenium in alzheimer’s disease. frontiers in aging neuroscience. 2014;6:206. 6. tinggi u. selenium: its role as antioxidant in human health. environmental health and preventive medicine. 2008;13:102-08. 7. information ncfb. gpx1 glutathione peroxidase 1 [homo sapiens (human)] available: http://www.ncbi. nlm.nih.gov/gene/2876. accessed 30 oktober 2018, 2018. 8. gropper ssas, jack l. essential trace and ultratrace minerals. dalam: advanced nutrition and human metabolism. usa: yolanda cossio 2013:519-26. 9. lobo v, patil a, phatak a, chandra n. free radicals, antioxidants and functional foods: impact on human health. pharmacognosy reviews. 2010;4:118-26. 10. hayashi s, tsubomoto y, nakanishi w. behavior of the e–e’ bonds (e, e’ = s and se) in glutathione disulfide and derivatives elucidated by quantum chemical calculations with the quantum theory of atoms-inmolecules approach. molecules. 2018;23:443. 11. mattmiller sa, carlson ba, sordillo lm. regulation of inflammation by selenium and selenoproteins: impact on eicosanoid biosynthesis. j nutr sci. 2013;2:1-13. 12. baierle m, nascimento sn, moro am, brucker n, freitas f, gauer b, dkk. relationship between inflammation and oxidative stress and cognitive decline in the institutionalized elderly. oxidative medicine and cellular longevity. 2015;2015:80419898. 13. savory la, kerr cj, whiting p, finer n, mceneny j, ashton t. selenium supplementation and exercise: effect on oxidant stress in overweight adults. obesity (silver spring). 2012;20:794-801. 14. rita cardoso b, silva bandeira v, jacob-filho w, franciscato cozzolino sm. selenium status in elderly: relation to cognitive decline. j trace elem med biol. 2014;28:422-6. 15. shahar s, pooy ns. predictive equations for estimation of stature in malaysian elderly people. asia pacific journal of clinical nutrition. 2003;12. 16. statistikpenduduklanjutusia 2017. badan pusat statistik. 2018:11-29 17. sohal rs, orr wc. the redox stress hypothesis of aging. free radical biology & medicine. 2012;52:53955. 18. cui h, kong y, zhang h. oxidative stress, mitochondrial dysfunction, and aging. journal of signal transduction. 2012;2012:646354. 19. espinoza se, guo h, fedarko n, dezern a, fried lp, xue q-l, dkk. glutathione peroxidase enzyme activity in aging. the journals of gerontology series a, biological sciences and medical sciences. 2008;63:505-09. 20. picklo mj, long ek, vomhof-dekrey ee. glutathionyl systems and metabolic dysfunction in obesity. nutrition reviews. 2015;73:858-68. 21. furukawa s, fujita t, shimabukuro m, iwaki m, yamada y, nakajima y, dkk. increased oxidative stress in obesity and its impact on metabolic syndrome. the journal of clinical investigation. 2004;114:1752-61. 22. fao/who. selenium. human vitamin and mineral requirements. rome, italy: fao 2001:235-48. 23. reeves ma, hoffmann pr. the human selenoproteome: recent insights into functions and regulation. cell mol life sci. 2009;66:2457-78. 24. hussainf, maanm, sheikh m, nawaz h, & jamil a. trace elements status in type 2 diabetes. bjms. 2009;8(3), 52-6. 25. nadiyap, lyudmylan, ivan p, taras k, &alla, k.clinical case of carpenter syndrome (autoimmunepolygundularsyndrome 2) in the practice of an endocrinologist. bjms. 2019;18(3), 646-50. 26. arnaud j, akbaraly tn, hininger i, roussel am, berr c. factors associated with longitudinal plasma selenium decline in the elderly: the eva study. j nutrbiochem. 2007;18:482-7. 27. akbaraly nt, arnaud j, hininger-favier i, gourlet v, roussel a-m, berr c. selenium and mortality in the elderly: results from the eva study. clinical chemistry. 2005;51:2117-23. international journal of human and health sciences vol. 03 no. 01 january’19 10 review article bosentan endothelin receptor antagonist kiran kumar singal1, neerja singal2, paras passi3, mohit singla4, nitin gupta5, gautam sumit6 abstract activation of the endothelin system has been demonstrated in the plasma and lung tissue of pah (pulmonary artery hypertension) patients. although it is not clear if the increases in endothelin plasma levels are a cause or a consequence of ph (pulmonary hypertension), the data supports a prominent role for the endothelin system in the pathogenesis of pah. bosentan is an endothelin receptor antagonist used in the treatment of primary pulmonary hypertension (pph) which is a progressive disease with high mortality and administration of the orally active, dual endothelin receptor antagonist bosentan improves exercise endurance, haemodynamics, and functional class over the short term. first-line bosentan therapy was found to improve survival in patients with advanced primary pulmonary hypertension. keywords: pulmonary artery hypertension, pulmonary hypertension, bosentan, endothelin receptor antagonist correspondence to: r.kiran kumar singal, department of medicine, m.m. medical college & hospital, kumarhatti, solan (h.p.) india. email: drkiranksingal@yahoo.co.in 1. dr. kiran kumar singal, professor ,department of medicine, m.m.medical college & hospital, kumarhatti, solan(h.p.) india 2. dr. neerja singal, professor, department of obstetrics and gynaecology, m.m. medical college & hospital, kumarhatti, solan(h.p.) india 3. dr. paras passi, ex.resident , department of medicine, m.m.institute of medical sciences & research, mullana, ambala(133203)india 4. dr. mohit singla, assistant professor, department of medicine, m.m. institute of medical sciences & research, mullana, ambala (133203) india 5. dr. nitin gupta, assistant professor, department of medicine, m.m. institute of medical sciences & research, mullana, ambala(133203)india 6. dr. gautam sumit, resident, department of medicine, m.m. institute of medical sciences & research, mullana, ambala (133203) india introduction activation of the endothelin system has been demonstrated in the plasma and lung tissue of pah patients.1although it is not clear if the increases in endothelin plasma levels are a cause or a consequence of ph,2 the data supports a prominent role for the endothelin system in the pathogenesis of pah.3 bosentan is an endothelin receptor antagonist used in the treatment of primary pulmonary hypertension (pph) which is a progressive disease with high mortality and administration of the orally active, dual (endothelin-a and b receptors) endothelin receptor antagonist bosentan, improves exercise endurance, haemodynamics, and functional class over the short term. first-line bosentan therapy was found to improve survival in patients with advanced primary pulmonary hypertension.4,5 in addition, a delay in time to clinical worsening was demonstrated in bosentan-treated patients compared with placebo, with clinical benefits maintained for up to 28 weeks.5 bosentan was investigated in six randomised controlled trials. four of these (channick 2001, breathe-1, breathe-5 and stride-2) compared bosentan with. another trial (breathe-2) compared the combination of epoprostenol plus bosentan with epoprostenol alone.6 the study reported data from a number of retrospective analyses and observational data to support their clinical findings. bosentan plus supportive treatment showed significant improvement in exercise capacity (6mwd) and haemodynamic outcomes compared with placebo plus supportive treatment, both in pah populations with mixed fc and specifically in fc iii. there was also a significant increase in time to clinical worsening, improvement in fc and international journal of human and health sciences vol. 03 no. 01 january’19 page : 10-13 doi: http://dx.doi.org/10.31344/ijhhs.v3i1.66 11 international journal of human and health sciences vol. 03 no. 01 january’19 pah symptom of dyspnoea, and reduced risk of serious adverse events in bosentan treated patients compared with placebo in pah populations with mixed fc. subgroup analysis of pah/connective tissue disease (ctd) patients in channick 2001 and breathe-1 showed similar results to those of the whole trial population (see pages 122–125 of the assessment report). it also used data from trials of lower quality to demonstrate that bosentan may be of benefit in patients with pah associated with hiv, and that bosentan improves patient’s quality of life. methods of randomisation and allocation concealment were not clearly described in some bosentan trials. intention-to-treat analysis was used in most trials except in stride-2. the assessment group stated that the potential bias from non-intention-to-treat analysis was expected to be small in stride-2 as the number excluded from analysis in each treatment group was very small. however, outcomes were not blindly assessed (such as clinical worsening, treatment withdrawal and adverse events) in the study, so interpretation requires greater caution, particularly in light of its open label design. breathe-2 compared the initiation of epoprostenol plus bosentan with epoprostenol alone in mixed pah populations with mixed fc (iii and iv). no significant difference was observed between both the groups for any of the outcomes assessed in the trial.6 absorption in healthy subjects, the absolute bioavailability of bosentan is approximately 50% and is not affected by food. the maximum plasma concentrations are attained within 3–5 hours.7 after a single intravenous dose of 250 mg, the clearance was 8.2 l/h. the terminal elimination half-life (t1/2) is 5.4 hours. upon multiple dosing, plasma concentrations of bosentan decrease gradually to 50%–65% of those seen after single dose administration. this decrease is probably due to auto-induction of metabolising liver enzymes. steady-state conditions are reached within 3–5 days.8 metabolism its pharmacokinetic profile in humans is characterized by a low systemic plasma clearance of 17 l/h, a volume of distribution of about 30 l.7 therapy with bosentan is initiated at 62.5 mg bid for the first month and increased to 125 mg bid thereafter.9 at the maintenance dose of 125 mg bid, bosentan trough concentrations decrease during the first days of treatment as a result of autoinduction of metabolizing enzymes, leading to an about 40% lower exposure at steady state. bosentan is metabolized in the liver (fig.1), mediated to a similar extent by cyp2c9 and cyp3a4, followed by subsequent biliary excretion. hydroxylation at the t-butyl group by cyp2c9 and cyp3a4 yields metabolite ro 485033, a metabolite that retains pharmacological activity and is present in human plasma at levels of about 10% compared with parent bosentan. ro 47-8634 is formed by oxidative demethylation of the guaiacol ether, catalyzed by cyp3a4, to the corresponding phenol, whereas metabolite ro 64-1056 is formed as a minor product from both primary metabolites. renal clearance of bosentan is negligible.10,11 bosentan is neither a substrate nor an inhibitor of the intestinal efflux pump mdr1 (p-glycoprotein, abcb1).12 bosentan is a human oatp (organic anion transporting polypeptides) substrate. the elimination process of the endothelin receptor antagonist bosentan in humans is entirely dependent on metabolism mediated by two cytochrome p450 (p450) enzymes, i.e., cyp3a4 and cyp2c9. it has been shown that the hepatic uptake of the endothelin receptor antagonist bosentan and its metabolite ro 48-5033 in humans is mediated by oatp1b1 and oatp1b3, which are responsible for its drug-drug interaction with rifampicin, cyclosporin a, and, to a minor extent, sildenafil and clearly show that inhibition of hepatic uptake may become the rate-limiting step in the overall elimination process even for drugs whose elimination is mainly dependent on metabolism.13 figure 1: ro 48-5033, 4-(2-hydroxy-1,1dimethyl-ethyl)-n-[6-(2-hydroxy-ethoxy)-5-(2methoxy-phenoxy)-[2,2_]bipyrimidinyl-4-yl]benzenesulfonamide; ro 47-8634, 4-tert-butyl-n-[6-(2-hydroxye t h o x y ) 5 ( 2 h y d r o x y p h e n o x y ) [ 2 , 2 _ ] bipyrimidinyl-4-yl]-benzenesulfonamide; ro 64-1056, 4-(2-hydroxy-1,1-dimethyle t h y l ) n [ 6 ( 2 h y d r o x y e t h o x y ) 5 ( 2 hydroxy-phenoxy)-[2,2_]bipyrimidinyl-4-yl]benzenesulfonamide; cyp3a4, cyp2c9, cytochrome p450 enzymes. international journal of human and health sciences vol. 03 no. 01 january’19 12 indications treatment of pulmonary arterial hypertension (who group 1) in functional class (mainly fc iii and iv) to improve exercise ability and decrease the rate of clinical worsening. side effects 4, 8, 14, 15 more common • blurred vision • confusion • dizziness • dark urine • faintness or light-headedness when getting up from a lying or sitting position • fever with or without chills • light-coloured stools • loss of appetite • nausea and vomiting • stomach pain • sudden sweating • unusual tiredness or weakness • yellow eyes or skin less common • swelling incidence not known • black, tarry stools • bleeding gums • blood in the urine or stools • blue lips and fingernails • chest pain • chills • clay-coloured stools • coughing that sometimes produces a pink frothy sputum • coughing up blood • dark urine • decrease in the amount of urine • difficult, fast, or noisy breathing, sometimes with wheezing • fainting • fast heartbeat • fatigue on exertion • fever • headache • hives • hoarseness • increased sweating • irritation • itching • joint pain, stiffness, or swelling • large, hive-like swelling on the face, eyelids, lips, tongue, throat, hands, legs, feet, or sex organs • noisy, rattling breathing • pale skin • pinpoint red spots on the skin • rash • redness of the skin • shortness of breath • swelling of the eyelids, face, lips, hands, fingers, legs, ankles, or feet • tightness in the chest • troubled breathing at rest • troubled breathing or swallowing • troubled breathing with exertion • unpleasant breath odour • unusual bleeding or bruising • vomiting of blood • weight gain • wheezing drug interactions 4, 8, 14, 15 some products that may interact with this drug include: cyclosporine, glyburide. other medications can affect the removal of bosentan from your body, which may affect how bosentan works. examples include anti-seizure drugs including carbamazepine, azole antifungals including itraconazole/ketoconazole, macrolide antibiotics including erythromycin, hiv protease inhibitors including ritonavir, rifamycins including rifabutin, amiodarone, cimetidine, tacrolimus, st. john’s wort, among others. this drug can speed up the removal of other drugs from your body, which may affect how they work. examples of affected drugs include “statin” cholesterol medications (such as simvastatin, lovastatin), warfarin, among others. this medication may decrease the effectiveness of combination-type hormonal birth control (e.g., pills, patch). this effect can result in pregnancy. you may need to use an additional form of reliable, non-hormonal birth control (e.g., condom, diaphragm with spermicide) while using this medication. contraindications 4, 8, 14, 15 • hypersensitivity to the active substance. • moderate to severe hepatic impairment, i.e., child-pugh class b or c.baseline values of liver aminotransferases, i.e., aspartate aminotransferases (ast) and/or alanine aminotransferases (alt), greater than 3 times the upper limit of normal. • concomitant use of cyclosporine a. • pregnancy. • women of child-bearing potential who are not using reliable methods of contraception. method of administration tablets are to be taken orally morning and evening, with or without food. the film-coated tablets are to be swallowed with water. overdose bosentan has been administered as a single dose of up to 2400 mg to healthy subjects and up to 2000 mg/day for 2 months in patients with a disease other than pulmonary hypertension. the most common adverse reaction was headache of mild to moderate intensity. massive overdose may result in pronounced 13 international journal of human and health sciences vol. 03 no. 01 january’19 hypotension requiring active cardiovascular support. note: bosentan is not removed through dialysis. cost effectiveness 14 independent economic evaluation suggests that bosentan, sitaxentan and sildenafil may be cost effective by standard thresholds and that iloprost and epoprostenol may not be cost effective. summary bosentan is a dual endothelin receptor antagonist with affinity for both endothelin a and b (eta and etb). it is licensed to treat people with pah in fc iii to improve exercise capacity and symptoms. two tablet sizes are available: 62.5 mg and 125 mg. bosentan is contraindicated in people with a known hypersensitivity to the drug, hepatic impairment (including aminotransferases of more than three times the upper limit of normal) and those taking cyclosporin. bosentan is contraindicated in pregnancy as it is assumed to be teratogenic, and women with child-bearing potential should not receive bosentan unless they are using a reliable contraceptive (bosentan may interact with and lessen the effectiveness of hormonal contraception). patients are usually admitted to hospital as day cases under specialist care for the initiation of treatment. patients return home and drugs are usually delivered to them at regular intervals. conflict of interest no conflict of interest has been disclosed by the authors. funds this study did not receive any special funding. authors contributions conception and design: ns, rm, kks analysis and interpretation of data: na critical revision of the article for important intellectual content: ns, rm, ab, nm final approval of article: ns, rm, ab, nm statistical expertise: na collection and assembly of data: na references 1. collection and assembly of data: na collection and assembly of data: na giaid a, et.al; expression of endothelin-1 in lungs of patients with pulmonary hypertension. n engl j med. 1993; 328:1732-39. 2. stewart d.j, et.al; increased plasma endothelin-1 in pulmonary hypertension: marker or mediator of disease. ann intern med. 1991; 114: 464-69. 3. galie n, et.al; the endothelin system in pulmonary arterial hypertension. cardiovasc res. 2004; 61: 22737. 4. channick rn, simonneau g, sitbon o, et al. effects of the dual endothelin-receptor antagonist bosentan in patients with pulmonary hypertension: a randomised placebo-controlled study. lancet2001; 358:1119– 1123. 5. rubin lj, badesch db, barst rj, et al. bosentan therapy for pulmonary arterial hypertension. n engl j med 2002;346:896–903. 6. nice.overview – pulmonary arterial hypertension: epoprostenol, iloprost, bosentan, sitaxentan and sildenafil. issue date: september 2007, http:// www.nice.org.uk/guidance/gid-tag382/resources/ overview2, july 25 (2014). 7. dingemanse j, giersbergen plm. clinical pharmacology of bosentan, a dual endothelin receptor antagonist. clin pharmacokinet, 2004. 43:1089–1115. 8. tracleer(bosentan),http://www.medicines.org.uk/ emc/medicine, july 25 (2014). 9. reilly jj, silverman ek, shapiro sd. chronic obstructive pulmonary disease. in: longo, fauci, kasper, hauser, jameson, loscalzo, editors. harrison’s principles of internal medicine. us, mc graw hill, 18th edition, 2012. p. 2076-82. 10. hopfgartner g, vetter w, meister w, ramuz h. fragmentation of bosentan (ro 47-0203) in ionspray mass spectrometry after collision-induced dissociation at low energy: a case of radical fragmentation of an even-electron ion. j mass spectrom, 1996. 30:69–76. 11. weber c, gasser r, hopfgartner g. absorption, excretion, and metabolism of the endothelin receptor antagonist bosentan in healthy male subjects. drug metab dispos, 1999. 27: 810–815. 12. treiber a, schneiter r, delahaye s, clozel m. inhibition of organic anion transporting polypeptidemediated hepatic uptake is the major determinant in the pharmacokinetic interaction between bosentan and cyclosporin a in the rat. j pharmacol exp ther,2004. 308:1121–1129. 13. treiber. a, schneiter. r, hausler. s, stieger.b (2007). bosentan is a substrate of human oatp1b1 and oatp1b3:inhibition of hepatic uptake as the common mechanism of itsinteractions with cyclosporin a, rifampicin, and sildenafil. the american society for pharmacology and experimental therapeutics, 2007.35:1400–1407. 14. chen yf et.al. clinical and cost-effectiveness of epoprostenol, iloprost, bosentan, sitaxentan and sildenafil for pulmonary arterial hypertension within their licensed indications: a systematic review and economic evaluation. health technol assess. 2009 oct;13(49):1320. 15. lupibose (bosentan), https://www. healthkartplus.com/details/drugs, july 25 (2014) international journal of human and health sciences vol. 06 no. 04 october’22 432 original article what is in a blood group? abo and rh blood types in covid–19: correlation with clinical outcomes in a tertiary care centre in india aparna muralidhar1,archana shetty2,nidha gaffoor1,supriya sandeepa4,kanna sandhyarani1, bhargavi kalburgi nagabhushan3 abstract background: covid-19 pandemic has immensely burdened healthcare. susceptibility and severity of infection though largely determined by an individual’s immunity, age and comorbidities; however, recent literature reported that abo blood type might be a contributory factor by virtue of its antigenic properties. objective: to explore the distribution of abo & rh blood types in covid -19 patients and correlate the same with clinical severity and mortality. methods: this retrospective study was conducted from may 2020 to september 2021 at a tertiary care centre. data of abo & rh blood type of covid-19 patients admitted to our hospital was collected. details on severity and mortality was obtained from hospital database. pearson’s chi square test was used to compare categorical data. p-value<0.05 was considered statistically significant. results: a total of 548 cases were included, with mean age of 48.8 ±7.1 years and male predominance. o positive (45.1%) and a negative (0.7%) were most and least frequently affected respectively. majority were rh positive (96.0%). 143 were severely ill requiring intensive care. among the fifty-six deceased, most belonged to o blood group. no significant association was observed between blood type with severity/mortality. conclusion: abo blood type cannot be a pivotal biomarker for predicting covid-19 associated severity and mortality. with limited literature in this field revealing diverse findings, a definitive association between blood type and covid-19 is challenging. this may indicate unexplored underlying contributing factors, not necessarily blood group or type of antibodies present. keywords: blood group antigens, covid-19 pandemic, coronavirus correspondence to: dr. archana shetty associate professor & blood transfusion officer, department of pathology, dr. chandramma dayananda sagar institute of medical education and research, a unit of dayananada sagar university, harohalli ramanagara, karnataka, india. email: archanashetty2924@gmail.com 1. assistant professor, department of pathology, dr.chandramma dayananda sagar institute of medical education and research, harohalli ramanagara, karnataka, india. email: aparna1610@gmail.com 2. associate professor & blood transfusion officer, department of pathology, dr. chandramma dayananda sagar institute of medical education and research, harohalli ramanagara, karnataka, india. 3. assistant professor, department of pathology, dr. chandramma dayananda sagar institute of medical education and research, harohalli ramanagara, karnataka, india. 4. associate professor, department of pathology, dr. chandramma dayananda sagar institute of medical education and research, harohalli ramanagara, karnataka, india. introduction covid-19outbreak has infected countries worldwide including developing countries like ours and caused enormous burden on economy and healthcare. since the declaration of this viral infection as pandemic in 2019, global research has been focussing on identifying methods of diagnosis, treating the infected and preventing its spread.the pathogenesis, progression and clinical presentation of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) have been evolving and intriguing ever since the start international journal of human and health sciences vol. 06 no. 04 october’22 page : 432-437 doi: http://dx.doi.org/10.31344/ijhhs.v6i4.483 433 international journal of human and health sciences vol. 06 no. 04 october’22 of this pandemic. recent research stated that the type of abo blood type might be a predisposing factor for covid-19.1-3 blood group antigens are recognized to serve as receptors and/or coreceptors for various biological agents, thereby playing a direct role in infection. the same antigens also enhance uptake of virus inside the infected cell, signal transduction and fastening reorganization of membrane microdomains. differences in antigen expression can alter the first line of defence or innate immune response of the body to infection.4 helicobacter pylori,5 vibrio cholerae,6 hepatitis c virus,7 human immunodeficiency virus,8 and sars,9,10 are some of the infectious agents that have been shown to be associated with human blood types.several reports and studies have cropped up regarding amenability of abo blood groups to severe covid-19infection. however, there is paucity of data in indian scenario and in our geographical area. blood grouping being an inexpensive, commonly ordered,quick and basic investigation; hence, we intended to study the distribution of abo and rh blood typesin covid-19 positive cases and correlate them with severity and mortality. methods this retrospective cross-sectional study was conducted in the haematology section of central laboratoryof dr. chandramma dayananda sagar institute of medical education and research, harohalli ramanagara, which is located at a rural geographic region in , karnataka of south india. inclusion criteria: all reverse transcriptase polymerase chain reaction (rt pcr)/ rapid antigen test (rat) positive adult patients equal to or more than eighteen years of age admitted to our hospital from may 2020 to september 2021 with blood group reports being available. exclusion criteria:patients whose blood grouping reports were not available. data regarding age, gender, intensive care units (icu) admission and mortality were obtained from hospital and laboratory database. blood grouping (abo and rh type) was ordered in patients as part of the covid profile testing. slide method was used to perform blood grouping, with normal saline being used as control.antisera used were procured from vendors approved by the hospital vendor management system after vendor feedback evaluation and review. antisera used was eryscreen from tulip diagnostics (iso13485 certified company), which is a reagent combi pack under invitro diagnostic reagents for routine blood grouping and typing. the reagents comprised ready to use solutions of anti -a, anti -b, anti -d of the immunoglobulin class igm. quality checks for affinity and avidity of the antisera were run daily as per the laboratory protocols. doubtful agglutination or groups with weak/late agglutination were confirmed by microscopic examination and gel card method when indicated. the patients were categorized into non severe and severe groups for comparison as per standard national guidelines.11 mild and moderate categories were considered as non-severe group. the severe category as per the guidelines was retained as the severe group. quantitative data was expressed as mean±sdand range. qualitative data was expressed as numbers and percentages. categorical data was compared using chi-square test. spss software version 26.0 was used for analysis. a p-value<0.05 was considered to be statistically significant. results the study sample comprised of 548 covid positive patients with an age range of 18 to 92 years, and a mean of 48.82 ± 17.12 years. the group comprised of 318 (58%) males and 230(42%) females with a male-female ratio of 1.4:1. among these, 124 patients (22.63%) belonged to blood group a, 140(25.55%) had group b, 27(4.93%) had group ab and 257(46.89%) had group o. the distribution of abo and rh blood groups in the study population is described in table 1. the most frequently and least frequently encountered blood groups were o positive and a negative respectively. rh positivity was noted in 526 (96%) of the cases with the rest being negative for the rh factor. when classified based on severity, in both non severe and severe groups, majority of the patients belonged to o positive blood group (table 2).among the 56 patients who succumbed to the disease, o positive group had the most fatalities, followed by a positive and b positive(figure 1). in the comparative analysis of rh type regarding severity and mortality, no statistically significant correlation was observed (table 3).none of the comparative analyses of o, a, b, and ab groups with other blood groups revealed a significant relationship with severity of the disease or mortality (table 4). international journal of human and health sciences vol. 06 no. 04 october’22 434 table 1. distribution of abo and rh blood groups in the study population blood group rh status of cases gender total number of cases positive negative male female a 120 04 66 58 124 b 132 08 89 51 140 ab 27 0 10 17 27 o 247 10 153 104 257 table 2.distribution of blood groups in nonsevere and severe groups blood group rh type number of patients nonseverecases severe cases a positive 120 86 (21.2%) 34 (23.8%) negative 4 03 (0.7%) 01 (0.7%) b positive 132 98 (24.2%) 34 (23.8%) negative 8 05 (1.2%) 03 (2.1%) ab positive 27 23 (5.7%) 04 (2.8%) negative 0 0 0 o positive 247 185 (45.7%) 62 (43.3%) negative 10 05 (1.2%) 05 (3.5%) total 548 405 143 figure 1. comparison of mortality between blood groups table 3. analysis of severity and mortality according to rh-factor rh status severity of cases mortality in cases severe (n=143) non severe (n=405) p-value yes (n=56) no (n=492) p-value positive 134 392 0.17 52 474 0.36 negative 9 13 4 18 table 4. analysis of severity and mortality according to abo blood groups blood group in cases category of cases mortality in cases severe non severe p-value yes no p-value group a (n=124) 35 89 0.61 16 108 0.34 other (b,ab,o) 108 316 40 384 group b (n=140) 37 103 0.99 16 124 0.69 other (a,ab,o) 106 302 40 368 group ab (n=27) 4 23 1.3 1 26 0.41 other (b,a,o) 139 382 55 466 group o (n=257) 67 190 0.93 23 234 0.43 other (b,ab,a) 76 215 33 258 discussion the emergence of sars-cov-2 virus has led to worldwide public health catastrophe and has affected healthcare systems worldwide. post emergence of the pandemic in wuhan province of china,a study reported higher risk of infection for people with blood group a, and lower risk for people with blood group o. 1subsequently, association of this infection with abo blood groups has been described in several studies from china and other countries from asia, north america, europe and middle east. abo antigens are expressed on many different cell types including the erythrocytes. they are 435 international journal of human and health sciences vol. 06 no. 04 october’22 structurally carbohydrates which constitute the terminal motifs of either n-linked or o-linked chains of glycoproteins and glycolipids. literature states that anti-a antibodies specifically hinder the adhesion of sars-cov s protein-expressing cells to angiotensin converting enzyme 2 (ace2) expressing cell lines, thereby playing a defensive role.12 activity of ace2 enzymes in blood group b is comparatively more than those of blood group o, predisposing group b persons to a higher infective risk.13 through glycosylation, abo determinants may influence host–pathogen interactions. the naturally produced anti-a and anti-b antibodies may also alter amenability to covid-19 infection. it has been shown that a group individuals have a higher and o group individuals,a lower frequency of being infected by covid-19.2,14-16 however, a multi-institutional study in massachusetts observed a higher probability of blood group b individuals to test positive for covid-19.17 an indian study too found a positive correlation between blood group b and covid-19 infection.18 overall, in most research, blood group o was associated with a lesser risk, while non-o blood groups were found to be detrimental. our data found o group to be most commonly affected, similar to a cross sectional observational study in bahrain.19 individuals with ab group and rh negative type showed a lower risk of infection, similar to other studies.1,3,14 in all the above scenarios including ours, the study groups were defined by a relatively small sample size. to analyse the association between blood group and severity of covid-19 infection, distribution of blood groups was compared between infected caseswho required icu admission (severe) and cases which did not(mild and moderate categories). the blood group distribution was analysed with respect to mortality as well. no significant association was observed between blood group and severity of infection nor blood groups and mortality rates. our results are in agreement with few other international studies.17,19 however, researches from china, bahrain and turkey found group a to be associated with higher severity and mortality. a cohort study of 383 covid positive individuals in north india found higher prevalence of moderate to severe infection in a and b positive groups.20 another prospective case control study with a large sample size conducted in usa also found no inter relationship between blood of abo and rh groups with either disease susceptibility or severity.21 our findings are based on data collected as part of hospital admission through the pandemic. the data is enriched for moderate to severely ill patients. patients with mild category of disease who treated on outpatient basis and were not included in the study. to determine susceptibility of a particular blood group in a population to covid-19, the blood type of affected individuals must be analysed with reference to blood group distribution in that region. the abo gene is highly polymorphic, and blood types have markedly different distribution across ethnic groups. the population mobility of a region may change the distribution pattern of blood groups over time. also, a review on relationship between abo blood types and covid-19 states that it isthe abo coefficient of variation, over the frequency of each individual phenotypethat determines impact of the abo system on virus transmission. this is because frequencies of abo phenotypes are immensely diverse between populations or geographical areas.22 a good organization, long duration, serious workload, and high costs are required for determination of blood group distribution in a regional population, which is challenging. strengths and limitations:the present study was undertaken when the second wave of the pandemic was at its peak in our geographical area. as affordable healthcare is challenging in developing countries like ours, using simple and affordable investigations like blood groups we have tried to correlate the clinical implications. though not generalizable the study has given insights into creating opportunities for further research regarding blood group antigens and covid-19. our study has a few limitations. it included mainly mainly cases admitted to health care facilities and not treated on outpatient basis.this could be one of the contributing factors for varied associations with different blood groups.varying protocols of international journal of human and health sciences vol. 06 no. 04 october’22 436 practice and patient management protocols during the pandemic may hinder generalization. future implications:results from literature review, and our study, reveal myriad findings making a conclusive association between blood type and covid-19 challenging. ancillary studies, with stringent control in terms of topography, genetics, and viral strain, are required to validate association between blood type and covid-19. supportive information on blood types would help propose newer treatment strategies, if significant association is proven by large scale studies. conclusion our study did not observe significant interrelation between abo and rh blood type with covid-19 severity and mortality, though blood group o patients were most affected. this may indicate presence of unexplored underlying factors that may be contributing to association, not necessarily blood group of the individual per se. source of funding:self-funded. conflict of interest: none ethical approval: ethical approval was obtained frominstitutional ethics committee ofdr. chandramma dayananda sagar institute of medical education and research, karnataka, india(cdsimer/mr/0013/iec/2021). contribution of authors:concept and design of the study: am, as; data collection and compilation: am, as, ng, bkn and analysis: am, ss; manuscript writing, editing and approval of final draft: am as, ng, ss, ks, bkn 437 international journal of human and health sciences vol. 06 no. 04 october’22 references 1. zhao j, yang y, huang h, li d, gu d, lu x et al. relationship between the abo blood group and the coronavirus disease 2019 (covid-19) susceptibility. clin infect dis. 2021;73(2):328-31. 2. samra s, habeb m, nafae r. abo groups can play a role in susceptibility and severity of covid-19. egypt j bronchol. 2021;15(1):1-5. 3. zietz m, zucker j, tatonetti np. testing the association between blood type and covid-19 infection, intubation, and death. medrxiv. 2020 jan 1. 4. cooling l. blood groups in infection and host susceptibility. clin microbiol rev. 2015;28(3):80170. 5. martins lc, de oliveira corvelo tc, oti ht, loiola rd, aguiar dc, dos santos barile ka et al. abh and lewis antigen distributions in blood, saliva and gastric mucosa and h pylori infection in gastric ulcer patients. world j gastroenterol. 2006;12(7):1120. 6. stowell cp, stowell sr. biologic roles of the abh and lewis histo-blood group antigens part i: infection and immunity. vox sang. 2019;114(5):426-442. 7. behal r, jain r, behal kk, dhole tn. variation in the host abo blood group may be associated with susceptibility to hepatitis c virus infection. epidemiol infect. 2010;138(8):1096-9. 8. onsten tg, callegari-jacques sm, goldani lz. the higher frequency of blood group b in a brazilian population with hiv infection. open aids j. 2013;7:47. 9. guillon p, clément m, sébille v, rivain jg, chou cf, ruvoën-clouet n, et al. inhibition of the interaction between the sars-cov spike protein and its cellular receptor by anti-histo-blood group antibodies. glycobiology. 2008;18(12):1085-93. 10. cheng y, cheng g, chui ch, lau fy, chan pk, ng mh, et al. abo blood group and susceptibility to severe acute respiratory syndrome. j am med assoc. 2005;293(12):1447-51. 11. clinical management protocol for covid-19 (in adults), government of india. ministry of health and family welfare.version 6; 24.05.2021:4. retrieved from: https://www.mohfw.gov.in/pdf/updateddetailedclinicalmanagementprotocolforcovid19adultsdated24052021.pdf 12. laguipo ab. blood types and covid-19 risk confirmed. n engl j med 2020. retrieved from: https:// www.news-medical.net/news/20200618/bloodtypes-and-covid-19-risk-confirmed.aspx 13. chung cm, wang ry, chen jw, fann cs, leu hb, ho hy et al. a genome-wide association study identifies new loci for ace activity: potential implications for response to ace inhibitor. pharmacogenomics j. 2010;10(6):537-44. 14. acik dy, bankir m. relationship of sars-cov-2 pandemic with blood groups. transfus med hemother. 2021;48(3):161-7. 15. halim mr, saha s, haque iu, jesmin s, nishat rj, islam aa, et al. abo blood group and outcomes in patients with covid-19 admitted in the intensive care unit (icu): a retrospective study in a tertiarylevel hospital in bangladesh. j multidiscip health. 2021;14:2429. 16. yaylacı s, dheir h, i̇şsever k, genc ab, şenocak d, kocayigit h, et al. the effect of abo and rh blood group antigens on admission to intensive care unit and mortality in patients with covid-19 infection. revista da associação médica brasileira. 2020;66:86-90. 17. latz ca, decarlo c, boitano l, png cm, patell r, conrad mf et al. blood type and outcomes in patients with covid-19. ann hematol. 2020 ;99(9):2113-8. 18. padhi s, suvankar s, dash d, panda vk, pati a, panigrahi j et al. abo blood group system is associated with covid-19 mortality: an epidemiological investigation in the indian population. transfusion clinique et biologique. 2020;27(4):253-8. 19. almadhi ma, abdulrahman a, alawadhi a, rabaan aa, atkin s, alqahtani m. the effect of abo blood group and antibody class on the risk of covid-19 infection and severity of clinical outcomes. sci rep. 2021;11(1):1-5. 20. garg i, srivastava s, dogra v, bargotya m, bhattar s, gupta u, et al. potential association of covid-19 and abo blood group: an indian study. microb pathog. 2021;158:105008. 21. anderson jl, may ht, knight s, bair tl, muhlestein jb, knowlton ku, et al. association of sociodemographic factors and blood group type with risk of covid-19 in a us population. j am med assoc. 2021;4(4):e217429. 22. le pendu j, breiman a, rocher j, dion m, ruvoënclouet n. abo blood types and covid-19: spurious, anecdotal, or truly important relationships? a reasoned review of available data. viruses. 2021;13(2):160. 277 international journal of human and health sciences vol. 04 no. 04 october’20 original article: intestinal parasitic infections and eosinophilia: a cross-sectional study among primary school-aged children in medan, indonesia muhammad f rozi1, dewi m darlan2*, rodiah rahmawati3, dewi is siregar4 abstract: background:intestinal parasitic infections (ipis) anditsimplication, such as malnutrition, growth stunting, anemia, and concentration impairment, still become a global burden. the primary immune cell that firstly involved in counteracting parasitic invasion is eosinophil. therefore, higher levels of eosinophils could be suspected of havinga parasitic infection. objective: our study aimed to revealthe prevalence of ipis and its correlation with eosinophilia.material and methods: the study was located in two different public primary schools,public primary school 060925 harjosari 1, amplas, medan, indonesia and public primary school 101747 hamparan perak, deli serdang, indonesia which enrolled 132 primary school children aged 8-12 years graded iii-vi, consisting of 22 males and 110 females,who had met the inclusion criteria between may and october 2016. parasitology examination was carried out at the department of parasitology, faculty of medicine, universitas sumatera utara using kato-katz, lugol, trichrome, and modified acid-fast stain.results: the study found intestinal protozoa infections were the most common ipis in the population, giardia lamblia as the most prevalent species (37.1%), while hookworm with the fewest findings (2.8%). additionally, the statistical analysis proved a significant correlation between ipis and eosinophilia (p-value 0.021; 95% ci 1.13-5.58). conclusion: eosinophilia patients with profound clinical manifestation should be further assessed to be considered for the administration of anti-parasitic medication. keywords: parasites, helminthiasis, eosinophils, protozoa correspondence to: dewi masyithah darlan, jln. dr. t. mansur, kampus usu padang bulan, medan 20155, indonesia, department of parasitology, faculty of medicine, universitas sumatera utara, medan, indonesia. email: dmasyithah57@gmail.com, tel: +628111644545 1. faculty of medicine, universitas sumatera utara, jl. dr. mansur kampus usu medan, indonesia 2. parasitology department, faculty of medicine, universitas sumatera utara, jl. dr.mansur kampus usu medan, indonesia 3. opthalmology department, faculty of medicine, universitas sumatera utara, medan, indonesia 4. clinical pathology department, faculty of medicine, universitas sumatera utara, medan, north sumatera, indonesia international journal of human and health sciences vol. 04 no. 04 october’20 page : 277-281 doi: http://dx.doi.org/10.31344/ijhhs.v4i4.213 introduction intestinal parasitic infections (ipis) are parasitic infections caused by helminthic and protozoal manifestations, and it remains a neglected health problem for developing countries, particularly indonesia. ipis could clinically produce mild diarrhea in humans or severe debilitating symptoms and long-term complications. chronic infection of the organism frequently leads to malnutrition, growth stunting, and cognitive impairment among children.1ipis are separated into two different groups, soil-transmitted helminth (sths) and intestinal protozoa infections, based on its etiologic agent. giardia lamblia, cryptosporidium parvum, and entamoeba histolytica are the most common intestinal protozoa infection. ascaris lumbricoides, trichuris trichiura, and hookworm are the most prevalent sth. the prevalence of ipis is varied, higher in developing regions ranging from 34.265.5 % in ethiopia2,3, 31 % in indonesia4, and 65-90.4 % in sudan.5,6 the initiation of immune response starts as early international journal of human and health sciences vol. 04 no. 04 october’20 278 as the organism firstly invaded the outer barrier of the intestinal mucosa. the recognition and effector immune cell spends for at least hours or days, but eosinophil acts a pivotal role in primary response for parasitic invasion concurrent with the other active immune reaction. eosinophil counts for 2-3% of the total leukocytes in human; it will fully function after the exposure of specific virulence factor followed by a cytotoxic effect in the mucosal environment. therefore, it will elevate or so-called ‘eosinophilia’ as a result of parasitic invasion or emerging autoimmune disease. neglecting eosinophilia patients could cause significant implication towards the patient quality of life. there must be a thorough anamnesis and precise information relating to existing risk factors and previous illnesses which supported by physical and laboratory examination.7 the major inducer for eosinophil proliferation is interleukin-5 (il-5), which produced as aresponse of parasitic infections. il-5 plays an essential role as the eosinophil activator after its secretion from the activated t-helper 2 (th2) which exposed to intestinal parasites.8 the primary objective of the study was to identify the species of human intestinal parasitic infections (ipis)among primary school-aged children and assessed the correlation between the prevalence of ipis andeosinophilia. the findings of the study would strengthen the evidence of the association between eosinophilia and parasitic intestinal infections that help the clinician to determine the diagnosis. materials and methods study location and population we conducted the cross-sectional study in medan, indonesia which is located along the northeastern coast of sumatera island with a coordinate of 3°35′n 98°40′e. there were approximately 2,097,610 people in the city based on the 2010 census. the regional climate is known as tropical rainforest climate with no significant dry season and average temperatures 270c (810f) throughout the year which is very supportive for the parasitic proliferation and development. there were 132 school-aged children, 22 males and 110 females, from two different public primary schools, public primary school 060925 harjosari 1, medan and public primary school 101747 hamparan perak, deli serdang, indonesia who enrolled into the study between may and october 2016. the study location was selected as the matter of its densely populated characteristic with poor hygiene and sanitation environment. the guardian’s consent is the main inclusion criteria for the children while the other obligatory criteria, includingaged 8-12 years, graded iii-vi, no consumption of anti-helminthic drug for the past six months, and no history of immunological disorder (allergy, asthma, atopic dermatitis, rheumatic disease, immunodeficiency, malignancies, other infectious disease or hemophilia). figure 1. the northern part of sumatera island (black marker: medan). there was a brief oral explanation to all guardians who gave permissions for the children enrollment of the study as well as filling the short questionnaire for any previous or existing illnesses. one small plastic fecal containerlabeled with the children’s name was given to the guardian for the fecal sample examination in the department of parasitology, faculty of medicine, universitas sumatera utara, medan, indonesia. parasitological examination and eosinophil count the parasitological examination for helminthic and protozoal species includes kato-katz, as its sensitivity reached 74-95%when used in places with high infection rate9,lugol, trichrome staining, and modified acid-fast staining or kinyoun-gabbet for cryptosporidium sp. infections10. in addition, eosinophil count was based on traditional technique using an improved neubauer counting method and peripheral blood smear,calculating the absolute value in 1 mm3 per high-power field, under a light microscope. blood was obtained from venous sampling via venipuncture to cubital vein as much as 3 ml which directly mixed in a tube containing edta. the interpretation for eosinophil count has two different categories, normal (1-6 %) and eosinophilia (>6%). data analysis and study approval all data were doubled-checked in microsoft excel before the final analysis using statistical package for social sciences 21 (spss inc. version 21). 279 international journal of human and health sciences vol. 04 no. 04 october’20 subsequently, the correlation between eosinophilia and ipis were demonstrated using p-value < 0.05 which extracted fromthe spearman correlation test and presented the data into a single table. the study has also obtained approval from the medical ethics committee, faculty of medicine, universitas sumatera utara, medan, indonesia. results a total of 35 children were positive for ipis consisting of 10 samples (28.5%) forsoiltransmitted helminths (sths) and25 samples (71.5%) for intestinal protozoa infections. the variation was demonstrated in table 1 with giardia lamblia as the prevalent species followed by entamoeba coli; it showed that protozoal infection still predominated the infected children in the study. the prevalence of intestinal protozoa infections outnumbered sth findings among the population (71.4% versus 28.6%). meanwhile, eosinophils were calculated under routine microscopic examination and produced the results demonstrated in table 1 and table 2. the study also obtained a significant correlation between ipis and eosinophilia (p-value=0.021) and the higher median value of eosinophil levels among ipi-infected children was evident. tabel 1. intestinal parasitic infection (ipi) species and effect on eosinophil levels ipis species n=35 % eosinophil levels (median±sd) ascaris lumbricoides hookworm trichuris trichiura giardia lamblia entamoeba coli iodoamoebabutschii g.lamblia&i.butschii 4 1 5 13 8 3 1 11.4 2.8 14.2 37.1 22.8 8.5 2.8 6.05 ± 2.21 2.5± 0.00 6.7 ± 3.2 4.7 ± 7.14 3.7 ± 2.82 3.1 ± 1.78 2.8± 0.00 table 2. correlation between intestinal parasitic infections (ipis) and eosinophil levels among school-aged children variable n=132 % eosinophil levels (median±sd) r p-value pr (95% ci) ipis (n=132) yes no 35 97 26.5 73.5 4.50 ± 5.36 3.60 ± 3.41 0.197 0.021 2.51 (1.135.58) discussions the study result demonstrated the infection rate for 26.5% of 135 children which proved on findings of the parasitological examination. they were positive for seven distinct parasitological species with specific pathogenesis and virulence factors. the high-prevalent of ipis among children gave the evidence that the infection remainsa neglected tropical infectious disease among population whereas children are significantly affected by the infection. several implications related to ipis were emphasized from recent studies particularly in densely populated areas and associated with poor sanitation, inadequate access to clean water,lack of proper hygiene and sanitation knowledge.11poverty can also lead to an increase in the prevalence of ipis as well aslow socioeconomic statusthat vulnerably suffer from a vicious circle of reinfection, leading to the higher morbidity.in the previous study, it was found that 40% ofchildren in a similar location infected with sth and more than one-third of children were categorized as underweight. underweight is noticeable as one of the clinical implications relating to chronic parasitic infection because it affects micronutrient absorption and ultimately increases the prevalence of malnutrition in the infected population.12 our study showed that intestinal protozoa infections are prevalent among children. giardia lamblia appeared as the frequent infections of all ipis (37.1 %) while the second most frequent was entamoeba coli (22.8%). similarly, mehraj et al. and chaudhry et al. conducted two different studies in pakistan discovered that intestinal protozoa infection were highly prevalent, while giardia lamblia became the main species found in the survey study.13,14giardia lamblia (also known as g.duodenalis and g.intestinalis) is a common intestinal protozoal species which infected 280 million people each year worldwide.15g.lamblia has potential to cause persistent and recurrent infections as it is ubiquitous organism which also related to several clinical implications including worsening bowel permeability, growth impairment, wasting, and cognitive impairment.16 meanwhile, sth infections are also strongly associated with poor knowledge of proper behavior related to defecation process, hand washing, and the exposure with infected soil with fertilized eggs and larvae.17additionally,the infection burden is also highly associated with the environment as well as become a modifiable risk factor causing ipis. behavior, genetically susceptible, inadequate health care, and malnutrition are also increase the susceptibility of an individual infected with ipis.18several studies conducted in different locations suggested that school-aged children international journal of human and health sciences vol. 04 no. 04 october’20 280 suffered the most from various complications of the infection, such assignificant iron deficiency anemia which may lead to decreased concentration, physical and cognitive development that are finally reducing school performance.19 blood component builds human immune system to serve as natural resources in eradicating foreign antigen invasion, including lymphocytes, neutrophils, monocyte, and eosinophils. eosinophilia can occur as a result of two pathological conditions, infectious and non-infectious process that is hard to distinguish each of two clinical entities. the clinician should consider the type of patient, concurrent symptoms, eosinophilia duration, and the severity of eosinophilia to strengthen the clinical evidence relating to the suspected diagnosis.7acute presentation of eosinophilia could represent autoimmune disease, acute schistosomiasis, or coccidiomycosis infection. helminthiasis also appears with eosinophilia, notably coinciding with larval migration through tissue. based on our study,there was asignificant correlation between ipis and eosinophilia (p-value< 0.021). ustun et al. also foundsimilar result suggesting that eosinophil levels were higher among ipis than in the control group (7.0 % versus 6.5%) but not statistically significant.20 the study also observed higher levels of il-5 in the group which was positive for a protozoal infection and statistically significant proven (p-value<0.05). kaminsky et al. conducted a study to observe ipis and eosinophilia among hiv positive population; they found that sths were highly prevalent among the people and correlated with eosinophilia (p-value< 0.05).21al-mozan et al. examined the alteration of the blood component in ipis patients, and concluded the findings ranges from the increase and decrease of each blood component still following the particular parasitic species.22 higher levels of eosinophils emerged in mixed infection (6%) as well ashymenolepsis nana and protozoa infections.in our study, it was found that single infection of soil-transmitted helminths (sths), such ast.trichiura and a.lumbricoides samples, had higher eosinophils levels (median 6.7% and 6.05% respectively) compared to other ipis and the lowest was found in hookworm and mixed infection (g.lamblia and i.butschii), with the median of 2.5% and 2.8%. conclusions intestinal parasitic infections (ipis) are described as one of neglected tropical infectious disease as it is relentlessly producing clinical implications in the general population, mainly in school-aged children. the study findings could add evidence of eosniophilia individuals who suffered from a parasitic infection that directly could help the clinician to narrow the differential diagnosis. furthermore, the presence of eosinophilia among high-risk patients will lead to further examination, including fecal examination, or eventhe administration of antihelminthic and antiprotozoal medications. additionally, further study is also needed to determine the level of eosinophil threshold that can be used as a marker of infection with larger sample size. conflict of interest declaration: there was no conflict of interest ethical clearance: the study has been approve by the ethical medical research committee, faculty of medicine, universitas sumatera utara, medan, indonesia author’s contribution: first and second author has involved in whole stages of publication process while the rest contributed for data analysis until manuscript preparation. 281 international journal of human and health sciences vol. 04 no. 04 october’20 references: 1. di genova bm, tonelli rr. infection strategies of intestinal parasite pathogens and host cell responses. frontiers in microbiology. 2016 mar 3;7:256. 2. gelaw a, anagaw b, nigussie b, silesh b, yirga a, alem m, endris m, gelaw b. prevalence of intestinal parasitic infections and risk factors among schoolchildren at the university of gondar community school, northwest ethiopia: a cross-sectional study. bmc public health. 2013 dec;13(1):304. 3. hailegebriel t. prevalence of intestinal parasitic infections and associated risk factors among students at dona berber primary school, bahir dar, ethiopia. bmc infectious diseases. 2017 dec;17(1):362. 4. uga s, kimura d, kimura k, margono ss. intestinal parasitic infections in bekasi district, west java, indonesia and a comparison of the infection rates determined by different techniques for fecal examination. southeast asian journal of tropical medicine and public health. 2002 sep;33(3):462-7. 5. siddig hs, mohammed ia, mohammed mn, bashir am. prevalence of intestinal parasites among selected group of primary school children in alhag yousif area, khartoum, sudan. int j med res health sci. 2017 jan 1;6(8):125-31. 6. al-mohammed hi, amin tt, aboulmagd e, hablus hr, zaza bo. prevalence of intestinal parasitic infections and its relationship with socio– demographics and hygienic habits among male primary schoolchildren in al–ahsa, saudi arabia. asian pacific journal of tropical medicine. 2010 nov 1;3(11):906-12. 7. o’connell em, nutman tb. eosinophilia in infectious diseases. immunology and allergy clinics of north america. 2015 aug;35(3):493. 8. huang l, appleton ja. eosinophils in helminth infection: defenders and dupes. trends in parasitology. 2016 oct 1;32(10):798-807. 9. nikolay b, brooker sj, pullan rl. sensitivity of diagnostic tests for human soil-transmitted helminth infections: a meta-analysis in the absence of a true gold standard. international journal for parasitology. 2014 oct 1;44(11):765-74. 10. mchardy ih, wu m, shimizu-cohen r, couturier mr, humphries rm. detection of intestinal protozoa in the clinical laboratory. journal of clinical microbiology. 2014 mar 1;52(3):712-20. 11. ngui r, ishak s, chuen cs, mahmud r, lim ya. prevalence and risk factors of intestinal parasitism in rural and remote west malaysia. plos neglected tropical diseases. 2011 mar 1;5(3):e974. 12. darlan dm, alexandra t, tala z. soil transmitted helminth infections in medan: a cross--sectional study of the correlation between the infection and nutritional status among elementary school children. family medicine & primary care review. 2017(2):98-103. 13. mehraj v, hatcher j, akhtar s, rafique g, beg ma. prevalence and factors associated with intestinal parasitic infection among children in an urban slum of karachi. plos one. 2008 nov 10;3(11):e3680. 14. chaudhry zh, afzal m, malik ma. epidemiological factors affecting prevalence of intestinal parasites in children of muzaffarabad district. pakistan j. zool. 2004;36(4):267-71. 15. bartelt la, sartor rb. advances in understanding giardia: determinants and mechanisms of chronic sequelae. f1000prime reports. 2015;7. 16. al-mekhlafi hm, al-maktari mt, jani r, ahmed a, anuar ts, moktar n, mahdy ma, lim ya, mahmud r, surin j. burden of giardia duodenalis infection and its adverse effects on growth of schoolchildren in rural malaysia. plos neglected tropical diseases. 2013 oct 31;7(10):e2516. 17. ziegelbauer k, speich b, mäusezahl d, bos r, keiser j, utzinger j. effect of sanitation on soil-transmitted helminth infection: systematic review and metaanalysis. plos medicine. 2012 jan 24;9(1):e1001162. 18. yap p, utzinger j, hattendorf j, steinmann p. influence of nutrition on infection and re-infection with soil-transmitted helminths: a systematic review. parasites & vectors. 2014 dec;7(1):229. 19. brooker s. estimating the global distribution and disease burden of intestinal nematode infections: adding up the numbers–a review. international journal for parasitology. 2010 aug 15;40(10):113744. 20. ustun s, turgay n, delibas sb, ertabaklar h. interleukin (il) 5 levels and eosinophilia in patients with intestinal parasitic diseases. world journal of gastroenterology: wjg. 2004 dec 15;10(24):3643. 21. kaminsky rg, soto rj, campa a, baum mk. intestinal parasitic infections and eosinophilia in an human immunedeficiency virus positive population in honduras. memórias do instituto oswaldo cruz. 2004 nov;99(7):773-8. 22. al-mozan hd, daoud yt, dakhil km. intestinal parasitic infection effect on some blood components. journal of contemporary medical sciences. 2017 mar 26;3(9):159-62. 25 international journal of human and health sciences vol. 02 no. 01 january’18 original article: detection of serum vascular endothelial growth factors (vegf) and soluble vascular endothelial growth factors (svegf / sflt-1) of pregnancy induced hypertension mothers (pih) with pathological changes of placenta in a tertiary care hospital of west bengal. ghosh s1, jana k2, mandal p3, chakraborty t4, bhattacharya d5, ghosh t6. abstract: introduction:pregnancy induced hypertension (pih) results from imbalance between pro-angiogenic factors (vegf & pigf) and antiangiogenic factors (svegfr-1/sflt1).subjects and methodology: a mixed random study comprising of random cases of different gestational ages 28-36 wks of pih mothers along with control cases till completion of pregnancy after delivery. age of enrolled mothers and their gestational age, blood pressure, serum free vegf and svegfr-1(sflt1) were compared in both groups (control n=36, pih n=36). blood pressure of both control and pih mothers just before and after delivery showed significant correlation (p<0.0001). serum levels of free vegf were lower among pih mothers at 28-36 wks (p <0.0001) and just before delivery (jbd) (p <0.0001) than normal control antenatal mothers and more or less similar in both groups at just after delivery (p <0.390). serum sflt1 level (6459.81 ±1811.07 pg/ml) of pih mothers showed higher value than control mothers (1062.19 ± 165.98 pg/ml) at the time of presentation and also just before delivery(jbd) & after delivery(jad) and was highly significant ( p < 0.0001). serum free vegf level of pih mothers was negatively correlated with systolic r= 0.247, p = 0.147) and diastolic (r =-0.220, p =0.197) blood pressure. the increased serum sflt1 level of pih mothers was positively correlated with systolic (r = 0.299, p = 0.07) and diastolic (r = 0.309, p = 0.067) blood pressure. semi quantitative expression of vegf r1 and pcna li of placenta showed increased (3+) expression of vegf r1 of 13 (43.33%) and > 50% pcna li expression of 12 (40%) cases than control. discussion &conclusion:the elevated levels of systolic and diastolic blood pressure along with alteration of proangiogenic and angiogenic growth factors among pih mothers than normotensive control may help to identify pih mothers as early as possible and referring them to higher/tertiary centers for better management and prevention of its grave complications of pih. keywords: pregnancy induced hypertension; vascular endothelial growth factors; soluble vascular endothelial growth factors. correspondence to: dr. sulekha ghosh, professor of pathology,b.s. medical college, bankura, west bengal, india 1. dr. sulekha ghosh, professor of pathology, b.s. medical college, bankura, west bengal, india 2. dr. kabayashree jana, pgt, pathology, b.s. medical college, bankura 3. dr.. pratima mandal, pgt , pathology, b.s. medical college, bankura 4. dr. trithankar chakrabarty, pgt, pathology, b.s. medical college, bankura 5. prof(dr )debasis bhattacharya, ex, principal, nrs medical college, kolkata 6. dr. tapan kumar ghosh, director, rbtc, b.s. medical college, bankura mail:ghosh.drtapan@ gmail.com international journal of human and health sciences vol. 02 no. 01 january’18 page : 25-30 d introduction: vascular growth during implantation and placentation is critical for successful gestation. it has been thought that vascular insufficiencies during placentation may play a critical role in various obstetrical complications particularly in pregnancy induced hypertension. pregnancy induced hypertension are responsible for various obstetric complications. the exact etiology of this condition is unknown. different international journal of human and health sciences vol. 02 no. 01 january’18 26 research worker stated that various factors like genetic, immunological, environmental and other factors are playing an important role for the development of this disease. extensive angiogenesis and invasion of maternal deciduas by trophoblasts are essential for the development and function of placenta. the cytotrophoblasts invade the uterine spiral arteries and switching their adhesion molecules similar to that of vascular cells and converting them to high resistant to low resistant vessels. failure of such transformation leads to defective functional vasculogenesis and angiogenesis of placenta. in pregnancies complicated by pih this trophoblastic cell invasion is inadequate, resulting in poor placental perfusion and fetal hypoxia (lim et al 19971, zhou et al 19982). vascular endothelial growth factors family (vegf) and their receptors ligands are recently known as potent angiogenic factors secreted by endometrium, decidua and placenta. trophoblastic cell proliferation and differentiation varies throughout pregnancy and alters with placental hypoxia. functional alterations of these factors are seemed to be associated with reduced placental vascular development and vascular resistance which fails to provide the developing conceptus with an optimum uterine environment to meet metabolic demand, resulting increase fetal hypoxia affecting 6-8% of all pregnancies and increase maternal & fetal morbidity & mortality (lim et al 19971, zhou et al 19982 kumar sg et al 201013). these have been thought to be one of the possible causes of pih. the purpose of present study is to find out placental expression of angiogenic factor vascular endothelial growth receptor (vegfr-1) by immunohistochemistry and measurement of serum level of soluble vegf & soluble form of vegfr-1 from serum by elisa in pregnancy induced hypertensive women in different gestational ages and histopathological changes in comparison to normal pregnancy. the term pregnancy induced hypertension is used to describe any new onset pregnancy related hypertension of which include: gestational hypertension, preeclampsia, eclampsia and chronic hypertension. preeclampsia is a life threatening complication of pregnancy characterized by hypertension, proteinuria which occurs about 6-8 % (kumar sg et al 201013) of all pregnancies and increases the pregnancyassociated deaths. it is one of the major causes of premature delivery. eclampsia is the occurrence of seizures in preeclampsia. pathological changes associated with pregnancy induced hypertension (pih) are due to generalized vasospasm and ischaemia, resulting end organ derangements of regional blood flow and endothelial dysfunction. the major cause of fetal compromise occurs as a consequence of reduced uteroplacental perfusion. the state of hypoxia and ischaemia of placenta thought to be associated with release of placental factors into the maternal circulation that cause clinical feature of pih. soluble form of vascular endothelial growth factor receptor-1 (svegfr-1/ sflt-1) a splice variant of vegfr-1 and placental growth factor (pigf) are such some factors responsible for development of pih. a number of vascular endothelial growth factors family (vegf) and their receptor ligands (vegfr) have been shown to be expressed in placenta throughout pregnancy (ahmed et al 19953, clark et al 19964, and vuorela et al 19975) and are essential for embryonic vascular development as loss of even a single allele results in embryonic death (ferrara et al 19966). expression of vascular endothelial growth factor receptors (vegfr-1 / flt-1, vegfr-2 /kdr, vegfr-3 / flt4) proteins can be studied by immunohistochemistry on placenta by using corresponding monoclonal antibody (helske s. et al 2001) 7, ( tsatsaris v .et al 2003),8. soluble form of vegf can be measured by elisa from patient’s serum (levine rj et al 2004)9. the receptors for vascular endothelial growth factor (vegf) and related ligands include vegfr1 (flt-1), vegfr-2 (kdr/ flk-1), and vegfr-3 (flt-4).the interaction may facilitate the presentation and binding of vegf to its receptor. plgf is localized to the placenta and binds only to vegfr-1. evidences from different works in this field proposed that imbalance between pro-angiogenic factors (vegf & pigf) and antiangiogenic factors (svegfr-1/ sflt-1) are responsible for pathophysiology of development of pih. circulating level of such factors of antenatal mothers may be one of the some important parameter to identify pih mothers during antenatal checkup. very little studies have been done in this field in our country of a huge population in spite of large number of occurrence causing about 8%14 of maternal mortality. aims & objectives: 1. to find out serum level of free vascular endothelial growth factor (vegf) and soluble form of vascular endothelial growth factor (svegf) / sflt1 of pih patients comparing with serum of normal term pregnancy as control. 27 international journal of human and health sciences vol. 02 no. 01 january’18 2. to find out placental expressions of vegfr-1 in pregnancy induced hypertension at different gestational ages taking normotensive term placenta as control along with histopathological changes. materials & methods: the study was conducted from june 2005 to november 2010 in the department of pathology and obstetrics & gynaecology, burdwan medical college & hospital and further study in the department of pathology bankura sammilani medical college from august 2014 to december 2015, west bengal, india after taking permission from institutional ethical committee. study design: it is a mixed random study comprising of random cases of different gestational ages of pih mothers along with control cases and also a group of patients longitudinally till completion of pregnancy after delivery. study proper: 36 control and 36 pregnancy induced hypertensive (pih) mothers were selected by standard methods and serum sample were collected for estimation of serum free vegf and soluble vegfr-1 (sflt-1) at three gestational period (random 28-36 wks, just before delivery and just after delivery) by standard elisa (sandwich type) method by corresponding antibody. serum free vegf and soluble vegfr-1 (sflt1) level were estimated (human vegf-a elisa kit bms277 and human svegf-r1 elisa kit, bms268/2) from bender medsystems gmbh vienna biocenter 2, vienna, austria, europe with sensitive values 13.5 pg/ml (ranged 20.00-13.3 pg/ml)and 0.06ng/ml (ranged 0.16-10ng/ml ) respectively. the intraassay and interassay coefficient of variation of vegf-a and sflt1 were 6.8% & 8.3% and 5.1% & 5.4% respectively. all the blood samples (10 ml each) collected kept in aliquot with proper labeling without anticoagulant and placed vertically in a rack for serum separation at room temperature. then serum was collected after centrifuge (2500 g, 15 minutes) in two different aliquots and stored in – 700c as early as possible until estimation of serum vegf and sflt1by standard elisa method. serum creatinin, liver function tests, blood coagulation profile and platelet count were done routinely and when needed. total 95 placentae from different gestational ages were examined (mtp-25, pih-40 and 30 controls) for routine histological changes and immunolocalization of vascular endothelial receptor-1 (vegfr-1) and proliferating cell nuclear antigen labeling index (pcna l1) were done by using corresponding primary antibody. out of total 25 mtp samples 6-12 weeks were 6 cases and 13-19 weeks were19 cases. out of total 40 pih placentas samples 24-32 weeks-were 10 cases and 33 weeks to term were 30 cases. control term placentas were 30 cases. haematoxylin & eosin stain & other special stains were done from histopathological sections from routinely processed paraffin embedded tissue blocks. immunolocalisation of vegfr-1 protein & proliferate cell nuclear antigen (pcna) were done by using proper primary monoclonal vegfr-1 antibody (cat –mob 457 clone flt-11 from diagnostic biosynthesis australia) & pc10 (daco) on 5 μm thick tissue sections were taken on slides coated with superior tissue adhesive tissue bond tm reagent of (catalog no k 013 by diagnostic biosynthesis) placental tissue at different gestational ages including normal control mother and pih mothers. selection of 36 normotensive control antenatal mothers: having regular antenatal checkup with 22-36 years of ages had normal body mass index may be primigravida or multigravida. gestational ages were 28-38weeks and normotensive as recorded from first antenatal visit. regular followed up with mean ± sd systolic blood pressure 114.72 ±9.49 mm hg, mean ± sd diastolic blood pressure 75.22±9.19 mm hg. urinary protein—nil, mean ± sd serum creatinine, platelet count were—0.9 ± 0.15 mg/dl and 1.9 ± 0.2 x 10 9/l respectively. no obvious clinical feature and past and family history in favor of pih. all of them were singleton pregnancy. all of them show no evidences of intrauterine growth retardation (iugr) and any past significant abnormal pregnancy. selection of 36 pregnancy induced hypertensive (pih) antenatal mothers: having regular antenatal checkup, 22-40 years of ages may be primigravida or multigravida of 28-36weeks of gestation. blood pressure—as recorded from first antenatal visit follows up were > 140/90 mm hg. their urinary protein was 1+ / more. all of them showed features of pih, singleton pregnancy, no evidences of intrauterine growth retardation (iugr) as from history sheet and no history of any risk factors for pih. statistical analysis: statistical analysis of parametric tests has been use for comparing two groups of tests. quantitative variables of all clinical data were compared using pair sample t-test and correlation of blood pressure (systolic international journal of human and health sciences vol. 02 no. 01 january’18 28 and diastolic) with serum vegf and svegfr-1 in pih mothers was done by pearson correlation/ spearman correlation using spss 17 package. different analysis of data and graphs presentations was done from mean ± sd and sd error mean values. results: age of enrolled mothers and their gestational age, blood pressure, serum free vegf and svegfr-1(sflt1) were compared in both groups (control n=36, pih n=36) (table i). age of pih (20.94±2.29) mothers was younger than control group (21.80 ±2.27) and no correlation was found with gestational age. systolic blood pressure (156.83 ±83 mm of hg) and diastolic blood pressure (107.38±22.17 mm of hg) of pih mothers at presentation were significantly compared more (p < 0.0001) with control mothers (systolic bp 114.72 ± 9.49 mm of hg, diastolic 75.22 ± 9.10 mm of hg). blood pressure of both control and pih mothers just before and after delivery showed significant correlation (p<0.0001). serum levels of free vegf (fig i) were lower among pih mothers at 28-36 wks (p <0.0001) and just before delivery (jbd) (p <0.0001) than normal control antenatal mothers and levels were increased and more or less similar in both groups at just after delivery (p <0.390) (fig i). serum sflt1 level (6459.81 ±1811.07 pg/ml) of pih mothers showed ( fig ii) higher value than control mothers (1062.19 ± 165.98 pg/ml) at the time of presentation and also just before delivery(jbd) & after delivery(jad) and was highly significant ( p < 0.0001). serum free vegf level of pih mothers was negatively correlated with systolic r= 0.247, p = 0.147) and diastolic (r =-0.220, p =0.197) blood pressure (table ii). the increased serum sflt1 level of pih mothers was positively correlated with systolic (r = 0.299, p = 0.07) and diastolic (r = 0.309, p = 0.067) blood pressure (table ii). total 85 placentae were examined from different gestational ages, out of which 25(8.25%) were mtp (medical termination of pregnancy cases (612 wks, n=6 and 13-19 wks, n=19), 40(47.05%) placentae were from pih mothers (24-32 wks, n=10 and 33-term, n=30) and 30(35.29%) were control placenta (table iii). examination of placenta on routine h&e stain showed increased numbers of areas of syncytial knot formation (p <0.0001), cytotrophoblastic cell proliferation (p <0.0001) , fibrinoid necrosis (p <0.0001) per low power field along with increased stromal fibrosis, hyalinization and calcification (p <0.0001) in pih placenta than control placenta (table iii) & (fig iii a-c). semi quantitative expression of vegf r1 and pcna li (proliferating cell nuclear antigen labeling index) (table vi) were analyzed on placentas at different gestational ages and showed increased (3+) (fig iv a-c) expression of vegf r1 of 13 (43.33%) and > 50% pcna li expression of 12 (40%) placenta of pregnancy induced hypertensive placenta than control group and placenta of lower gestational ages (fig v a-c). discussion and conclusion: pih is a complex multifactor disorder thought to be wide spread endothelial dysfunction caused by imbalance of one of the maternal serum proangiogenic (vegf) and antiangiogenic (sflt1) growth factors play a pathogenic role. the present study observed decreased level of serum vegf in pih mothers than normotensive control group by using sandwich type of elisa which estimates free form of serum vegf. continuous maintenance level of serum vegf is essential for endothelial integrity of maternal vasculature and fetoplacental development. reduced level of free vegf in the serum of pih mothers indicates endothelial dysfunction and its clinical manifestation. several workers observed increased serum level of sflt-1 and up regulation of mrna in placenta associated with pih and levels decrease within 48 hours after delivery of placenta indicates sflt-1of placental origin. the present study observed approximately > five times increase sflt-1 levels in pih mothers than control mother. thus, when maternal serum sflt-1 rises, it binds with the vegf, thereby reduces the free functional vegf for abnormal placentation in pih mothers results increase level of serum sflt 1 was proposed by maynars se 2003 10&kumar sg 201013 and histological examination showed elevation of syncytial knots, fibrinoid necrosis and regenerating trophoblastic cell hyperplasia as a result of villous injuries showed higher expression of proliferating cell nuclear antigen (pcna) as observed by gulsum ozlem elpek et al 2000 11 justify the present study. immunolocalisation of vegf r1 (3+) expression of 13 pih placenta and (> 50%) pcna li expression 12 placenta indicates state of hypoxia in placenta supports the hypothesis as observed by kurumanchi et al. data from different observation showed serum level of sflt-1 increased 5-10 weeks before the onset of clinical onset of pih. screening of early and late onset pih, significant elevated level of sflt-1 along with other routine antenatal checkup 29 international journal of human and health sciences vol. 02 no. 01 january’18 (hypertension and proteinuria) at 23-27 weeks and 32-35 weeks of gestation thought to be one of the important laboratory parameters to identify pih. the elevated levels of systolic and diastolic blood pressure along with alteration of proangiogenic and angiogenic growth factors were observed by several workers among pih mothers than normotensive control mothers. the present study showed positive and significant correlation of systolic(r=0.299, p < 0.07) and diastolic(r-0.309, p < 0.069) blood pressure with serum sflt 1 level and negative correlation with serum vegf level (systolic bp r= -0.249, p < 0.146 and diastolic bp r= -0.220, p < 0.197) of pih mothers. in regular antenatal clinic all mothers with and without risk factors for pih must be screened to find out pih before clinical development of pih. mothers who develop clinical pih showed rise sflt1starts 5-10wks before development of clinical feature of pih as observed by some investigators12. further study of these parameters in different gestational ages may help to identify pih mother occurrence causing about 8%14 of maternal mortality. in indian population less study has been done in this field and no cut off value of these parameters were specified to identify pih. the results as varies from study to study, people from different ethnic populations & different parts of the world are to be studied. proper storage of collected serum, measuring kits from different commercial preparation, thorough investigation on a larger sample size may help to standardize the cut off base line level to identify pih mothers preclinically as early as possible by referring them to higher/tertiary centers for better management and prevention of its grave complications and fulfilling the goal of getting healthy mother with healthy baby. international journal of human and health sciences vol. 02 no. 01 january’18 30 serial no parameters control pregnant mothers(mean ±sd) n=36 sd error mean pih pregnant mothers (mean±sd) n=36 sd error mean p value 1 age of mothers(years) 21.80± 2.27 (17-27, median-22) 20.94 ±2.29 (17-27, median-21) ns 2 gestational ages in wks 33.60±3.11 (28-36) 20.94±2.29 (28-38) ns 3 systolic blood pressure mm of hg 28-36 wks 114.72 ±9.49 (100-130) 1.58 156 ±14.77 (140-200) 2.46 <0.0001 just before delivery 112.30 ±9.94 (100-130) 1.65 163.72 ±20.94 (140-210) 3.49 <0.0001 just after delivery 111.94±11.35 (100-135) 1.89 154.72±24.28 (110-210) 4.04 <0.0001 4 diastolic blood pressure mm of hg 28-36 wks 75.22±9.19 (60-90) 1.53 107.38±22.17 (100-130) 3.69 <0.0001 just before delivery 70.13±9.44 (60-90) 1.57 106.30±9.00 (90-130) 1.50 <0.0001 just after delivery 69.02±8.76 (69-90) 1.46 106.58±8.63 (100-130) 1.4 <0.0001 5 serum vegf(pg/ml) 28-36 wks 65.90±13.31 (38.48-102.32) 2.21 28.12±11.52 (21.71-92.94) 1.92 <0.0001 just before delivery 61.84±9.92 (39.09-80.05) 1.65 15.37±1.7 (13.12-18.66) 0.29 <0.0001 just after delivery 70.94±12.20 (47.03-94.50) 2.03 72.57±12.44 (49.56-94.50) 2.07 <0.390 6 serum sflt-1(pg/ml)(svegfr-1) 28-36 wks 1062.19±265.98 (635.70-1925.30) 44.33 6459.81±1811.07 (2116.80-9406.20) 301.84 <0.0001 just before delivery 1602.63±415.37 (1012.80-2813.60) 69.22 7578.99±1485.34 (3011.60-9935.10) 247.55 <0.0001 just after delivery 774.74±222.64 (465.30-1504.00) 37.10 4075.79±1526.11 (1053.30-7123.60) 254.35 <0.0001 international journal of human and health sciences vol. 02 no. 01 january’18 table i. clinical parameters and serum levels of vegf & svegfr-1 of both control and pih mothers. parameters systolic blood pressure (r value) p value diastolic blood pressure (r value) p value remarks serum level of vegf -0.247 0.146 -0.220 0.197 negatively correlated serum level of svegfr-1 (sflt-1) 0.299 0.07 0.309 0.067 p o s i t i v e l y correlated and significant table ii study showing correlation of blood pressure with serum vegf & svegfr-1 in pih mothers serial no histopathology of placental villi control group pih group statistical significance 1 no of areas of syncytial knot formation / lpf* 7.67± 1.38 26.97± 2.25 <0.0001 significant 2 no of areas of cytotrophoblastic cell proliferation/lpf* 6.06±.96 15.46±1.72 <0.0001 significant 3 no of areas of fibrinoid necrosis/lpf 3.45± .90 11.38± 1.16 <0.0001 significant 4 no of areas of stromal calcification /lpf 2.79±.85 12.51±1.2 <0.0001 significant table iii comparison of histological changes of control and pih placenta lpf—low power field placenta of diff. gestational ages vegfr-1 light (+) intensity vegfr-1 moderate(++) intensity vegfr-1 severe(+++) intensity pcna li <30% pcna li 30-50% pcna li >50% mtp placenta n = 25 (8.25%) 6-12 wks n= 6 6 _ _ 4 1 1 13-19 wks n= 19 19 _ _ 13 1 5 pih placenta n=40 (47.05%) 24-32 wks n = 10 2 3 5 2 6 2 33-term n = 30 8 9 13 7 11 12 control placenta n = 30 (35.29%) 21 9 _ 13 5 3 30 a international journal of human and health sciences vol. 02 no. 01 january’18 table iv semi quantitative analysis of expression of vegfr-1 & pcna li of placenta of different gestational stage. fig i. box plot showing levels of vegf of normal control &pih mother in study i n = 36 control. n =36 pih. x-axis-3 antenatal visits, yaxis vegf pg/ml at 28-38 wks*, jbd* &jad*. (* p= <0.000.1) fig ii .box plot showing levels of vegfr-1(sflt-1) of normal control &pih mother in study i. n = 36 control. n =36 pih. x-axis-3 antenatal visits, yaxis vegfr-1 pg/mlat 28-38 wks*, jbd* &jad*. (* p= <0.000.1) 30 b international journal of human and health sciences vol. 02 no. 01 january’18 fig iii photomicrograph showing histological changes of placenta of pih placenta, a = ↑ syncytial knots of villi, b = fibrin deposition & calcification and c = atherosis. (h&e stain) fig iv photomicrograph showing nuclear positivity of expression of pcna li of pih placental villi, a=<30%, b= 30-50 % and c = >50%. fig v photomicrograph showing cytoplasmic positivity of vascular endothelial growth receptor-1(vegfr-1) of pih placental villi, a = (+), b = (++) and c = (+++). fig iiia fig iiib fig iiic fig iva fig ivb fig ivc fig va fig vb fig vc 30 c international journal of human and health sciences vol. 02 no. 01 january’18 reference: 1. lim kh, zhou y, janatpour m, mcmaster m, bass k, chun sh, fisher sj: human cytotrophoblast differentiation/invasion is abnormal in pre-eclampsia. am j pathol. 1997; 151: 1801-818. 2. zhou y, genbacev o, damsky ch, fisher sj: oxygen regulates human cytotrophoblast differentiation and invasion: implications for endovascular invasion in normal pregnancy and in pre-eclampsia. j reprod immunol.1998; 39: 197-213. 3. ahmed, a., li, x.f. dunk, c. et al: colocalization of vascular endothelial growth factor and its flt-1 receptor in human placenta. growth factors. 1995; 12, 135–143. 4. clark, d.e., smith, s.k., sharkey, a.m. and charnock-jones, d.s: localization of vegf and expression of its receptors flt and kdr in human placenta throughout pregnancy. hum. reprod. 1996; 11, 1090–1098. 5. vuorela, p., hatva, e., lymboussaki, a. et al: expression of vascular endothelial growth factor and placenta growth factor in human placenta. biol. reprod. 1997; 56, 489–494. 6. ferrara n, carver-moore k, chen h, dowd m, ly l, o shen ks et al. heterozygous embryonic lethality induced by targeted inactivation of vegf gene. nature. 1996; 380: 439-442. 7. helske s, vuorela p, carpen o, hornig c, weich h, halmesmaki e. expression of vascular endothelial growth factor receptors 1, 2 and 3 in placentas from normal and complicated pregnancies. mol hum reprod. 2001; 7(2):205-210. 8. tsatsaris v, goffin f, munaut c, brichant jf,pignon mr, neol a et al. over expression of soluble vascular endothelial growth factor receptor in preeclamptic patients: pathophysiological consequences. j clin endocrinol metab. 2003; 88(11):5555-5563. 9. levine rj, maynard se, qian c, et al. circulating angiogenic factors and the risk of preeclampsia. n engl j med 2004; 350:672-683. 10. maynard se, min jy, lim kh, mondal s, libermann ta, morgan jp, sellke fw et al. excess placental soluble fms-like tyrocin kinase 1(sflt 1) may contribute to endothelial dysfunction, hypertension and proteinuria in preeclampsia. j clin invest. 2003; 111: 649 -658. 11. gulsum ozlem elpek, seyda karaveli, nuran keles. evaluation of villous trophoblast proliferation in term placentas of preeclamptic patients. the turkish journal of pathology. 2000; 16(1-2): 10-12. 12. chaiworapongsa t, romevo r, espinoza j, bujold e, mee kim y, gonclaves le, gomez r, edwin s. evidence supporting a role for blockade of vascular endothelial growth factor system in the pathophysiology of preeclampsia. am j obstet gynecol. 2004; 190: 1541-50. 13. kumar sg, unnikrishnan b, nagaraj k, jayaram s. determinants of pre-eclampsia: a case-control study in a district hospital in south india. indian j community med 2010; 35:502-5 14. tsatsaris v, goffin f, munaut c, brichant jf, pignon mr, noel a, schaaps jp, cabrol d, frankenne f, foidart jm. j clin endocrinol metab. 2003; 88(11):5555-5563. 30 d international journal of human and health sciences vol. 07 no. 01 january’23 60 original article combating the covid-19 pandemic: experience of a tertiary care children hospital in dhaka, bangladesh nobo krishna ghosh1, sharmin afroze2, erfan ahmed3 abstract background: corona virus disease is a global health threat since december 2019 which was declared a pandemic in march 2020. objective: this study was undertaken to address various measures initiated during the pandemic in the dr. m r khan shishu (children) hospital, a tertiary level childcare hospital in dhaka, bangladesh. methods: this crosssectional, observational study was conducted over a period of 9 months from march 2020 to november 2020. necessary steps implemented during ‘lock down’ phase were tabulated. sample was collected from patients as well as health care providers with sign/ symptoms of covid-19 disease. verified reports were analyzed to observe the prevalence and trends of corona virus affected population. results: improvement of situation was observed following modification of the infrastructure as well as delivery of service to people. hand sanitization, covid sampling, ppe availability and isolation facility were improved from baseline to 100% during the study period. a total of 736 cases were tested with 246 positive cases having male predominance (64%). less than two years children infected with covid-19 required admission more comparing to other children. total 102 health care providers were tested among them 50% were found positive for covid-19. conclusion:throughout the pandemic, dr. m r khan shishu hospital & ich, have taken all affordable measures to combat the situation with a positive outcome. moreover, hundred percent testing facilities for covid-19 enabled us to diagnose significant portion of health care providers as well as patients and to take appropriate measure in management. keywords: covid-19, preventive measures, corona pandemic, bangladesh correspondence to: dr. nobo krishna ghosh, professor of pediatrics & director, dr. m. r khan shishu (children) hospital & institute of child health, mirpur-2, dhaka-1216, bangladesh. email: drnkghosh@yahoo.com 1. professor of paediatrics & director, dr. m. r. khan shishu (children) hospital & institute of child health, mirpur-2, dhaka-1216, bangladesh. 2. assistant professor, department of neonatology, dr. m. r. khan shishu (children) hospital & institute of child health, mirpur-2, dhaka-1216, bangladesh. 3. assistant director, dr. m. r. khan shishu (children) hospital & institute of child health, mirpur-2, dhaka-1216, bangladesh. introduction corona virus disease 2019 is a global health threat since its first case was identified in wuhan, china in december 2019. it is caused by severe acute respiratory syndrome corona virus 2 (sarscov-2), a newly discovered virus closely related to bat corona virus, pangolin corona viruses and sars-cov.1 it has spread worldwide, leading to an ongoing pandemic. the world health organization declared the outbreak a public health emergency of international concern in january 2020 and a pandemic in march 2020. more than 89.7 million cases have been confirmed, with more than 1.92 million deaths attributed to covid-19 as of 10 january 2021.2 covid-19 spreads from person to person mainly international journal of human and health sciences vol. 07 no. 01 january’23 page : 60-66 doi: http://dx.doi.org/10.31344/ijhhs.v7i1.498 https://en.wikipedia.org/wiki/world_health_organization https://en.wikipedia.org/wiki/world_health_organization https://en.wikipedia.org/wiki/public_health_emergency_of_international_concern https://en.wikipedia.org/wiki/public_health_emergency_of_international_concern https://en.wikipedia.org/wiki/covid-19_pandemic_cases https://en.wikipedia.org/wiki/covid-19_pandemic_deaths 61 international journal of human and health sciences vol. 07 no. 01 january’23 through the respiratory droplet when an infected person coughs, sneezes, talks or breathes. even virus containing particles when exhaled from infected person, it gets into the mouth, nose, or eyes of the other person who are in close contact with the infected person.3this is more infectious than influenza and has a major role in spreading infection in clusters.4 the clinical presentation of covid 19 is variable ranging from mild to severe illness.5-6most people (81%) develop mild to moderate symptoms (up to mild pneumonia), while 14% develop severe symptoms (dyspnea, hypoxia, or more than 50% lung involvement on imaging) and 5% of patients suffer critical symptoms (respiratory failure, shock, or multi-organ dysfunction).7-9 children usually have milder presentation than adults.10 the asymptomatic carriers can spread the virus as they are not tested during the incubation period.9,11-12 due to the huge outbreak of the virus, preventive measures have been taken worldwide including bangladesh to reduce its spread like staying at home, wearing a mask in public, social distancing, washing hands and many more. 12-16 different hospitals have also followed rules and guidelines provided by world health organization and center for disease control and prevention (cdc) to provide adequate care for the affected people.17-18 dr. m r khan shishu hospital is a tertiary care children hospital of dhaka city which has been serving the patients around the whole country since emergence of the corona pandemic. so, this study was undertaken to address the various measures initiated during the pandemic to ensure safe medical service. this study also aimed to observe the prevalence of corona virus affected population visited and or admitted to the hospital. methods this cross-sectional, observational study was conducted over a period of 9 months from march to november of 2020 in dr. m r khan shishu (children) hospital, dhaka, bangladesh. with the emergence of the disease in bangladesh, the government declared ‘lock down’ throughout the country and initiated some necessary steps to be implemented in the health facilities to protect the people as well as the health care workers. according to those rolling plans, dr. m r khan shishu hospital which is specialized for childcare, took initiatives to modify the infrastructure and service. these measures were tabulated and improvement of the situation was observed. sample collection (nasopharyngeal swab/oropharyngeal swab), patient admission and data collection were going on side by side. sample was collected for admitted patients as well as outpatients who were having clinical sign/symptoms with suspicion of covid 19 disease.health care providers (doctors, nurses, medical technologists) and other health care staffs with suspected covid 19 were also included for investigation. permission was granted from directorate general of health services under the ministry of health and family welfare to carry out rt-pcr test for suspected covid cases of dr. m r khan shishu hospital and ich. the institute does not poses a pcr machine, so a memorandum of understanding was created with our long-time partner in research, child health research foundation (chrf). they are one of the designated organisations for testing covid-19 sample since the start of the pandemic. following testing, reports were sent to iedcr for verification. the verified reports were then stored and analyzed in our institute. during the analysis, the proportion of the covid 19 affected patients compared to tested cases was measured. distribution of positive cases in different age category was identified. frequency of affected health care workers was also picked out. all data were collected in google sheet and analyzed in statistical analysis system (sas) for academics. results during the study period measures were taken related to modification of the infrastructure as well as delivery of service to people which were not present before the pandemic (table1). figure 1 shows the changes in situation throughout the study period in different sector and services of the hospital. initially, in the first three months of the study, there was increased demand but limited supply of personal protective equipment (ppe). so, the hospital decided to provide ppe only to the doctors and nurses working in the red and yellow zone which cover almost 30% of the total health care staffs in that time. in subsequent months, with increased supply, gradually the hospital avail ppe supply to all staffs. throughout the study period, the hospital ensured mask use to 100% of the patient’s attendant. limited supply compelled the institute to deliver hand sanitizer only to working front liners initially; however, it was overcome sequentially. our hospital ensured hand washing facility with soap for every staff https://en.wikipedia.org/wiki/influenza https://en.wikipedia.org/wiki/pneumonia https://en.wikipedia.org/wiki/dyspnea https://en.wikipedia.org/wiki/hypoxia_(medical) https://en.wikipedia.org/wiki/respiratory_failure https://en.wikipedia.org/wiki/respiratory_failure https://en.wikipedia.org/wiki/shock_(circulatory) https://en.wikipedia.org/wiki/organ_dysfunction international journal of human and health sciences vol. 07 no. 01 january’23 62 and attendant. the hospital provided covid-19 testing service only to admitted patients in the initial months but gradually involved the health care workers and finally included testing the outpatients as well. during the first three months, there was no isolation facility for the affected staffs. then arrangement was made to isolate the covid -19 sample collection technicians and first line of health care providers. throughout the study period, the hospital successfully provided telemedicine service as demanded (100%) by the patients. also, transport facility was provided to every first liner hcp as needed (100%). the first covid 19 confirmed case was identified on 17th march 2020, was a 5 months old boy. since the first case, a total of 736 cases were tested in suspicion of covid-19. among them male were predominant (n=473, 64%). regarding the number, male affected more than female (figure 2). however, among total tested male, 33% were found positive whereas 34% of total tested female found positive. some test results were reported as ‘inconclusive’, ‘no human rna found’ or ‘not enough quantity’ probably due to damage during transportation or faulty technique. during analysis of the positive cases, 62% were children. it was found that less than two years children required admission more for covid-19. on the other hand, 2 years-<15 years children visited outpatient more and did not require admission and preferred to be treated at home (table 2). figure 3 shows the proportion of positive and negative cases in each department. among the tested population, 86% (n=634) were patients and the rest 14% (n=102) were health care provider from which 31% patients and 50% of the hcp were found covid-19 positive respectively. only 1 case expired due to covid related complications. table1: interventions during covid-19 pandemic infrastructure 1. restricted entry of excess attendant in hospital 2. ensuring passage through disinfection chamber while entering the hospital 3. providing hand wash and sanitization facility on entering hospital premise and in every defined place inside hospital infrastructure 4. segregation of the pediatric wards depending on the presence of covid like respiratory features and further sub-classification into red zone [confirmed covid], yellow zone [respiratory sign/symptoms] and green zone [safe zone] 5. isolated covid ward for confirmed covid affected children 6. isolation of the immune-compromised patients 7. fixed cabin for covid infected hospital staff 8. covid sample collection booth where sample is being collected and sent to institute of epidemiology, disease control and research (iedcr) through chrf for rtpcr test 9. providing telemedicine facility for mild to moderate illness for ensuring minimum hospital visit 10. allowing isolation facility for the covid sample collection staff in separate cabin for 14 days. health care service 1. availability of locally made personal protective measures (ppe) for all health care personnel 2. ensuring masks for all staff 3. making use of mask mandatory for all attendants 4. collection of covid sample from the suspected patients, their parents and hospital staff 5. making three groups among health care providers for proper service implementation as well as safety purpose (to ensure 14 days isolation after 7 days duty) 6. arranging transport facility for the staff during ‘lock down’ phase 7. providing isolation facility for staffs who were uncomfortable to stay at home (concerning safety of family members) during the asymptomatic period. table 2: age distribution of covid-19 positive cases age group ipd opd less than 1 month 7 0 1 month <6 month 9 3 6 month <12 month 10 10 12 month <2 years 20 8 2 years <5 years 12 20 5 years <10 years 11 30 10 years <15 years 4 9 15 years 18 years 3 1 63 international journal of human and health sciences vol. 07 no. 01 january’23 figure 1: trends in different service delivery point during covid-19 figure 2: category of covid-19 test results according to gender discussion as a part of worldwide corona pandemic, bangladesh found its first confirmed case on 8th march 2020 by institute of epidemiology, disease control and research (iedcr).19 in order to protect population the government has adopted several measures and has implemented efficiently. in response to the initiatives taken by the government, health care facilities all over the country have taken mitigation measures to fight against covid 19 with limited resources. initially there were shortage in testing kits, ppe, masks and infra-red thermometers in the country as well as in health facilities; however, with time, these challenges were overcome.20-21 our hospital also had initial shortage of these materials due to unavailability of supply. over time, local garments started producing ppe at low cost using locally available material and who guideline for ensuring quality was maintained. the institute used those ppe to ensure safety of the health care providers. subsequently, the institute ensured regular supply of the ppe for every staff. international journal of human and health sciences vol. 07 no. 01 january’23 64 figure 3: proportion of positive and negative cases among tested hand hygiene has been recommended as an important strategy in prevention of the spread of corona virus. during our observation, we could not offer full hand washing service and hand sanitizers to the health care providers as well as the visitors due to lack of availability. from 3rd month of the study this service was improved from 20% to 50% and at the end reached to 100%. this result is similar with findings of a multi-center study where hand hygiene performance rate increased from 46 to 56% during the stages of pandemic.22 during the ‘lock down’ phase it was difficult for the people to move in emergency situations. maintaining the government order, the study institute arranged transport for the health care providers from the beginning which was essential for continuation of the health service.23 during the pandemic, our hospital has isolated wards for infectious corona positive patients and affected health care workers which is a real learning like all other hospitals worldwide in dealing of infectious diseases.24among the studied population, male were found more and this finding co-related with other reports. this may be due to the range of outdoor activities is more among males and thus having an increased risk of being exposed.25in our study, 85% of the total tested patients were children. it is slightly higher in comparison to other studies may be the fact that ours is specialized hospital for children only.26corona pandemic has taught us the importance of rotational duties for the sake of saving resource persons especially the health personnel.27 our hospital maintained this system from the initiation of the process and maintained throughout to decrease their risk of being infected.28 since the inception of the corona emergence, health care providers are working as front liners and it is found that 1 in every 10 health care workers is being infected with the deadly virus as observed in a corona dedicated hospital in bangladesh.29similar picture has been found in other hospitals including ours which is alarming. conclusion preparedness is the key to address any health crisis and so far, dr. m r khan shishu (children) hospital, being a non-profitable private institution for middle and lower middle-income people, have tried all possible measures to combat the situation. despite numerous limitations, the hospital has expanded the testing facilities for covid-19 for all the patients as well as health care staff and has identified significant proportion being affected. conflict of interest: the authors have no conflict of interest. ethical statement: the study was approved by the ethics review board of dr. m r khan shishu (children) hospital, dhaka, bangladesh. funding source: none. authors’ contribution:all authors were involved equally in data collection, manuscript writing, revision and finalizing. 65 international journal of human and health sciences vol. 07 no. 01 january’23 references 1. perlman s. another decade, another coronavirus. n engl j med. 2020;382(8):760-2. 2. wikipedia. covid-19 pandemic. retrieved from: https://en.wikipedia.org/wiki/covid-19_ pandemic. (accessed november 21, 2020) 3. european centre for disease prevention and control. transmission of covid-19.retrieved from: https:// www.ecdc.europa.eu/en/covid-19www.ecdc.europa. eu. (accessed september 18, 2020). 4. harmon a. we spoke to six americans with coronavirus. the new york times. retrieved from: https://www.nytimes.com/2020/03/04/us/ coronavirus-recovery.html. (accessed march 16, 2020). 5. centers for disease control and prevention (cdc). symptoms of coronavirus. retrieved from: https:// www.cdc.gov/coronavirus/2019-ncov/symptomstesting/symptoms.html. (accessed june 17, 2020). 6. grant mc, geoghegan l, arbyn m, mohammed z, mcguinness l, clarke el. the prevalence of symptoms in 24,410 adults infected by the novel coronavirus (sars-cov-2; covid-19): a systematic review and meta-analysis of 148 studies from 9 countries. plos one. 2020;15(6):e0234765. 7. world health organization (who). transmission of sars-cov2: implications for infection prevention precautions. scientific brief. world health organization. 2020; retrieved from: https:// www.who.int/news-room/commentaries/detail/ t r a n s m i s s i o n o f s a r s c o v 2 i m p l i c a t i o n s f o rinfection-prevention-precautions (accessed march 29, 2022). 8. nogrady b. what the data say about asymptomatic covid infections. nature. 2020;587(7835):534-5. 9. gao z, xu y, sun c, wang x, guo y, qiu s, et al. a systematic review of asymptomatic infections with covid-19. j microbiol immunol infect. 2021;54(1):12-6. 10. covid 19 in children and teens. centers for disease control and prevention. 2020; retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/dailylife-coping/children/symptoms.(accessed march 29, 2022). 11. lai cc, liu yh, wang cy, wang yh, hsueh sc, yen my, et al. asymptomatic carrier state, acute respiratory disease, and pneumonia due to severe acute respiratory syndrome coronavirus 2 (sarscov-2): facts and myths. jmicrobiol immunol infect. 2020;53(3):404-12. 12. furukawa nw, brooks jt, sobel j. evidence supporting transmission of severe acute respiratory syndrome coronavirus 2 while presymptomatic or asymptomatic. emerg infect dis. 2020;26(7):e201595. 13. coronavirus disease 2019 (covid-19): prevention & treatment. centers for disease control and prevention. archived from the original on 15 december 2019. (accessed 10 february, 2020). 14. advice for public. world health organization. archived from the original on 26 january 2020. retrieved 10 february 2020. 15. my hand-washing song: readers offer lyrics for a 20-second scrub. npr.org. archivedfrom the original on 20 march 2020. retrieved 20 march 2020. 16. scientific brief: sars-cov-2 and potential airborne transmission. covid-19 published science and research. u.s. centers for disease control and prevention (cdc). retrieved 30 october 2020. 17. what to do if you are sick. u.s. centers for disease control and prevention (cdc). archived from the original on 14 february 2020. retrieved 24 april 2020. 18. coronavirus disease 2019 (covid-19) – prevention & treatment. u.s. centers for disease control and prevention (cdc); archived from the original on 11 march 2020. retrieved 11 march 2020. 19. anwar s, nasrullah m, hosen mj. covid 19 and bangladesh: challenges and how to address them? front public health 2020;8:154. 20. molla mam. govt now scrambles for testing kits, ppe. 2020; available online retrieved from:https:// www.thedailystar.net/frontpage/news/govt-nowscrambles-testing-kits-ppe-1882633. 21. covid-19: immediate expansion of testing labs to districts needed. dhaka tribune. 2020; available from: https://www.dhakatribune.com/health/ c orona virus/2020/04/11/c ovid-19-imme diateexpansion-of-testing-labs-to-districts-needed. retrieved 11 march 2021. 22. moore ld, robbins g, quinn j, arbogast jw. the impact of covid-19 pandemic on hand hygiene performance in hospitals. am j infect control. 2021;40:30-3. 23. hospital preparedness for epidemics. world health organization 2014. available online: http://apps. who.int/ iris/rest/bitsreams/674837 (retrieved 11 march 2020). 24. pandey n, kaushal v, dutt puri g, taneja s, biswal https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7121143 https://en.wikipedia.org/wiki/covid-19_pandemic. https://en.wikipedia.org/wiki/covid-19_pandemic. https://en.wikipedia.org/wiki/european_centre_for_disease_prevention_and_control https://en.wikipedia.org/wiki/european_centre_for_disease_prevention_and_control https://en.wikipedia.org/wiki/the_new_york_times https://www.nytimes.com/2020/03/04/us/coronavirus-recovery.html https://www.nytimes.com/2020/03/04/us/coronavirus-recovery.html https://en.wikipedia.org/wiki/centers_for_disease_control_and_prevention https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7310678 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7310678 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7310678 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7310678 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7310678 https://www.who.int/news-room/commentaries/detail/transmission-of-sars-cov-2-implications-for-infection-prevention-precautions https://www.who.int/news-room/commentaries/detail/transmission-of-sars-cov-2-implications-for-infection-prevention-precautions https://www.who.int/news-room/commentaries/detail/transmission-of-sars-cov-2-implications-for-infection-prevention-precautions https://www.who.int/news-room/commentaries/detail/transmission-of-sars-cov-2-implications-for-infection-prevention-precautions https://www.nature.com/articles/d41586-020-03141-3 https://www.nature.com/articles/d41586-020-03141-3 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7227597 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7227597 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7128959 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7128959 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7128959 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7128959 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7323549 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7323549 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7323549 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7323549 https://www.cdc.gov/coronavirus/about/prevention.html https://www.cdc.gov/coronavirus/about/prevention.html https://www.cdc.gov/coronavirus/about/prevention.html https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public https://en.wikipedia.org/wiki/world_health_organization https://en.wikipedia.org/wiki/world_health_organization https://web.archive.org/web/20200126025750/https:/www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public https://www.npr.org/sections/goatsandsoda/2020/03/17/814221111/my-hand-washing-song-readers-offer-lyrics-for-a-20-second-scrub https://www.npr.org/sections/goatsandsoda/2020/03/17/814221111/my-hand-washing-song-readers-offer-lyrics-for-a-20-second-scrub https://web.archive.org/web/20200320145553/https:/www.npr.org/sections/goatsandsoda/2020/03/17/814221111/my-hand-washing-song-readers-offer-lyrics-for-a-20-second-scrub https://www.cdc.gov/coronavirus/2019-ncov/more/scientific-brief-sars-cov-2.html https://www.cdc.gov/coronavirus/2019-ncov/more/scientific-brief-sars-cov-2.html https://en.wikipedia.org/wiki/centers_for_disease_control_and_prevention https://en.wikipedia.org/wiki/centers_for_disease_control_and_prevention https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/steps-when-sick.html https://en.wikipedia.org/wiki/centers_for_disease_control_and_prevention https://en.wikipedia.org/wiki/centers_for_disease_control_and_prevention https://web.archive.org/web/20200214153016/https:/www.cdc.gov/coronavirus/2019-ncov/about/steps-when-sick.html https://www.cdc.gov/coronavirus/2019-ncov/about/prevention.html https://www.cdc.gov/coronavirus/2019-ncov/about/prevention.html https://en.wikipedia.org/wiki/centers_for_disease_control_and_prevention https://en.wikipedia.org/wiki/centers_for_disease_control_and_prevention https://web.archive.org/web/20200311163637/https:/www.cdc.gov/coronavirus/2019-ncov/about/prevention.html https://www.thedailystar.net/frontpage/news/govt-now-scrambles-testing-kits-ppe-1882633 https://www.thedailystar.net/frontpage/news/govt-now-scrambles-testing-kits-ppe-1882633 https://www.thedailystar.net/frontpage/news/govt-now-scrambles-testing-kits-ppe-1882633 https://www.dhakatribune.com/health/coronavirus/2020/04/11/covid-19-immediate-expansion-of-testing-labs-to-districts-needed https://www.dhakatribune.com/health/coronavirus/2020/04/11/covid-19-immediate-expansion-of-testing-labs-to-districts-needed https://www.dhakatribune.com/health/coronavirus/2020/04/11/covid-19-immediate-expansion-of-testing-labs-to-districts-needed international journal of human and health sciences vol. 07 no. 01 january’23 66 m, mahajan p, et al. transforming a general hospital to an infectious disease hospital for covid-19 over 2 weeks. front. public health. 2020;8:1-8. 25. world health organization (who). covid19: situation report. 2020; available online: https:// www.who.int/docs/default-source/searo/bangladesh/ c o v i d 1 9 w h o b a n g l a d e s h s i t u a t i o n r e p o r t s / who-ban-covid-19-sitrep-06.pdf?sfvrsn=36254d. (retrieved 11 march 2021). 26. cennimo dj, mirza a. corona virus disease 2019 (covid-19) in children 2021; http://emedicine. medscape.com/article/2500132. (retrieved 11 march 2021). 27. jha dn. hospitals go for rotation policy, a third of staff at any given time. the times of india. 2020. retrieved from: https://timesofindia.indiatimes.com/ city/delhi/hospitals-go-for-rotation-policy-a-third-ofstaff-at-any-given-time/articleshow/74854957.cms (accessed march 29, 2021). 28. dy lf, rabajante jf. a covid-19 infection risk model for frontline health care workers. network modelling analysis in health informatics and bioinformatics. 2020;9:57. 29. yasmin r, parveen r, azad na, paul n, azad s, haque mm, et al. corona virus infection among health care workers in a covid dedicated tertiary care hospital in dhaka, bangladesh. j bangladesh coll phys surg. 2020;38(1):43-9. https://www.who.int/docs/default-source/searo/bangladesh/covid-19-who-bangladesh-situation-reports/who-ban-covid-19-sitrep-06.pdf?sfvrsn=36254d https://www.who.int/docs/default-source/searo/bangladesh/covid-19-who-bangladesh-situation-reports/who-ban-covid-19-sitrep-06.pdf?sfvrsn=36254d https://www.who.int/docs/default-source/searo/bangladesh/covid-19-who-bangladesh-situation-reports/who-ban-covid-19-sitrep-06.pdf?sfvrsn=36254d https://www.who.int/docs/default-source/searo/bangladesh/covid-19-who-bangladesh-situation-reports/who-ban-covid-19-sitrep-06.pdf?sfvrsn=36254d https://timesofindia.indiatimes.com/city/delhi/hospitals-go-for-rotation-policy-a-third-of-staff-at-any-given-time/articleshow/74854957.cms https://timesofindia.indiatimes.com/city/delhi/hospitals-go-for-rotation-policy-a-third-of-staff-at-any-given-time/articleshow/74854957.cms https://timesofindia.indiatimes.com/city/delhi/hospitals-go-for-rotation-policy-a-third-of-staff-at-any-given-time/articleshow/74854957.cms international journal of human and health sciences vol. 03 no. 02 april’19 58 review article: diagnostic advancement in evaluating inborn errors of metabolism: past, present and future: a systematic review nazmin fatima1, shalini tripathi2, roshan alam3, mohammed haris siddiqui4, abbas ali mahdi5, gyanendra kumar sonkar6 abstract: metabolism is a delicately coordinated entity of chemical reactions. inborn errors of metabolism (iem) are rare congenital disorders that are mainly due to gene defect of enzymes or cofactors participating in a metabolic pathway or the transport of metabolites within a cell or between cells. the development of knowledge in basic sciences together with technology development in medical field has helped to better understand the molecular and biochemical basis of iem. environmental factors, ethnicity, race, consanguinity and genetic factors contribute to the increased prevalence of genetic disorders. the analytical methods have evolved over the years from thin layer chromatography (tlc), high performance liquid chromatography (hplc) to tandem mass spectrometry (tms) including gas chromatography mass spectrometry (gc/ms). their applications for è¡7�ø‹5�g of iem has opened the door for screening of conditions that previously required molecular testing or another methodology that was not practical for population-based screening. future technologies such as matrix-assisted laser desorption/ ionization timeof-flight mass spectrometry (maldi-tof ms), has the potential for rapid and reliable identification of small metabolites and disease biomarkers in daily clinical laboratories, whereas dna based screening by dna microarrays or gene chips will allow much more improved diagnosis.these can be the boon to screening programs which will require excellent detection and follow-up services keywords: iem, tlc, hplc, tms, maldi-tof ms, gc/ms correspondence to: dr. gyanendra kumar sonkar, associate professor, department of biochemistry, king george’s medical university, u.p., lucknow, india. contact no.: +919453817641. email: gyanendrakrsonkar@kgmcindia.edu, gettwinklestar@gmail.com 1. research scholar, department of biochemistry, integral institute of medical sciences & research, integral university, lucknow, uttar pradesh, india. 2. associate professor, department of pediatrics, king george’s medical university, u.p., lucknow, india. 3. prof. & head, department of biochemistry, integral institute of medical sciences & research, integral university, lucknow, uttar pradesh, india. 4. associate professor, department of bioengineering, integral university, lucknow, uttar pradesh, india. 5. former-head, department of biochemistry, king george’s medical university, u.p., lucknow, india. presently, vice chancellor, era university, lucknow 6. associate professor, department of biochemistry, king george’s medical university, u.p., lucknow, india. introduction:metabolism is a delicately coordinated entity of chemical reactions. for maintenance of tissue, growth and reproduction, the organism through various metabolic processes tries to balance between energy and nutrient intake, consumption and storage. it can be disturbed in either inherited or acquired situations. inborn errors of metabolism (iem) was first described by sir archibald garrod in 1908, during the famous croonian lectures on the inborn errors of metabolism, i.e., alkap tonuira, cystinuria, albinism and pentosuria.1 following this, the world short title: diagnostic advancement in evaluating iem international journal of human and health sciences vol. 03 no. 02 april’19 page : 58-63 doi: http://dx.doi.org/10.31344/ijhhs.v3i2.78 59 international journal of human and health sciences vol. 03 no. 02 april’19 of iems has been ever expanding, both in terms of diagnosing new affected phenotypes and in their therapeutic measures. they have also been coined different names, e.g., inherited metabolic disorders (imd), hereditary metabolic disorders (hmd), or congenital metabolic diseases (cmd). most of them cannot be cured and leads to fatal outcome with episodes of acute metabolic decompensation. treatment is limited and most often supportive and experimental. search for new therapeutic approaches is possible by gathering new information about its pathogenesis.2 iem are rare congenital disorders that are mainly due to a gene defect of enzymes or cofactors participating in a metabolic pathway or the transport of metabolites within a cell or between cells. this results in either accumulation of substrate, loss of end products, accumulation of normally minor metabolites or secondary metabolic consequences.3 it can be classified in various forms and one of the ways to classify it is based on its pathophysiology as disorders. according to this, it is classified as (i) group-i disorders, which gives rise to intoxication, (ii) group-ii disorders, involving energy metabolism, and (iii) groupiii disorders, involving complex molecules.4 accumulation of the toxic metabolite, proximal to the metabolic block including aminoacidopathies, organic acidemias, urea cycle disorders, porphyrias, mineral metabolism disorders, sugar intolerances, as well as synthesis defects of neurotransmitters etc. are categorized under first group of disorder. the second group comprises mitochondrial and cytoplasmic energy defects. the last group is the most diverse and includes lysosomal storage disorders, peroxisomal biogenesis disorders, congenital disorders of glycosylation, cholesterol synthesis defects etc.4 among the three groups of disorders, the first group of disorders can be diagnosed by simple tests such as blood and urine amino acids, organic acid and acylcarnitine profiling while the second group of disorders are identified by enzyme analysis, tissue biopsies or molecular testing and the third group is diagnosed only by molecular testing methods. additionally, among the three groups, the disorders of first group can be treated either by specific dietary patterns or medications. earlier the second and third group of disorders were untreatable but now days therapy is available in some cases.5-7 initially the pathogenesis of iem was not known. however advancement of technology helped in solving this problem. in 1957, dorfman and lorincz first revealed the biochemical basis of mucopolysaccharides by reporting excretion of mucopolysaccharides in the affected patient’s urine. later in 1961, guthrie developed screening of phenylketonuria using microbiological inhibition assay. the gradual increase of basic knowledge in iem made it possible to discover over 500 disorders. advancement in laboratory techniques helped detection of some disorders, even before the presentation of symptoms. introduction of tandem mass spectrometry (tms) in 1998 added new approach to screening program. iem is now a subject of interest for research worldwide and continues to be a scientific challenge to modern medicine.8-10 literature search and review: the literature was reviewed by performing database search such as medline, embase, science direct, cochrane library and web of science, using the keywords – ‘inborn errors of metabolism’, ‘inborn metabolic disorder’, ‘history of iem’, ‘diagnostic’, ‘incidence’, ‘advancement’, ‘technology’, ‘tms and iem’, tandem mass spectrometry’, ‘gas chromatography-mass spectrometry’, ‘high performance liquid chromatography’, ‘screening’, ‘past’, ‘present’, future’, and ‘dna microarrays’. searches were limited to english language. incidence of iem: environmental factors, ethnicity, race, consanguinity and genetic factors contribute to the increased prevalence of genetic disorders. this is the reason for such a wide variation of prevalence of iem from country to country and also within the different regions of a country.11,12 individual disorders of iem are rare but collectively numerous, leading to substantial patient burden13 with the current incidence of iems standing at 1:800 live births. it may present at any age, from infancy to adult and can affect either individual or multiple organs. depending on the severity of the disorder, they usually affect several organs.14 sanderson et al.15 has reported 1 in 784 live births as an overall incidence of iem in a five year retrospective study in united kingdom. dionisi-vici et al. from italy has reported an incidence of 1 in 3,707 live births from their 12 years of study. however using advanced technique such as tms, reduced the incidence as 1 in 6200.16 another study from canada has reported an overall incidence of 1 in 2500 with disorders of amino acid metabolism, organic acid metabolism, urea cycle disorder, glycogen storage disorder etc. as more prevalent.17 a study from middle east country like saudi arabia has reported a high international journal of human and health sciences vol. 03 no. 02 april’19 60 incidence of 1 in 666 live births.18 another study from the same area reported a prevalence of 1.25% of symptomatic newborn babies were found to be suffering from iem.19 asian and south east asian countries20 also reported a varied incidence such as 1 in 4000, 1 in 5,800 in mainland china21, 1 in 5882 in taiwan22, 1 in 2000 in korea23 and 1 in 9330 in japan.24 scarce report is available from india as we still do not have mandatory screening program for iem in newborns and infants. only few private hospitals and health centers are providing diagnostic facilities, hence only few indian studies have addressed the incidence of iem.25,26 one study has reported incidence of 1 in 360027 and another study by nagaraja et al.28 has reported a prevalence rate of 2.3%. screening of iem – past, present and future: the history of screening for iem started in 1959, when prof. guthrie first demonstrated the detection of phenylalanine level in dried blood spot based on bacterial inhibition assay.29 this technique later came to be known as guthrie test which was easy, cheap and reliable and followed by mass screening of phenylalanine in children. this mass screening was opposed by medical fraternity at that time. however in 1962, a pilot study was done for screening of phenylketonuria (pku).30 in the following years, screening for more conditions such as maple syrup urine disease (msud), galactosemia and homocystinuria were started.31 later in 1968, the wilson and jugner criteria for screening of iem was framed keeping in view its clinical validility, clinical utility, analytical validity, social and ethical issues to cost effectiveness.32 finally in 1975, the united states of america made screening of pku compulsory for all newborns. the massachusetts medical school also started the screening program with addition of more congenital disorders including congenital hypothyroidism, congenital toxoplasmosis, hemoglobinopathies, congenital adrenal hyperplasia, biotinidase deficiency and cystic fibrosis.31 soon other countries like canada, portugal and australia started screening of iem in newborns.32-34 in india, the state of karnataka was the first to start screening of iem in neonates in 1980 by appaji rao and his team. the burden of iem in neonates was reported to be 0.04% whereas it was 3.2% in high risk population and a bit higher (5.75%) in mentally retarded children.35,36 another study from kerala has reported a high incidence of aminoaciduria, organic aciduria and other iems in their studied population which extended over a period of five years.37 similar report of high incidence (1 in 1000) has been published from andhra pradesh. the common disorders that have been detected were congenital hypothyroidism (ch), congenital adrenal hyperplasia (cah) and hyperhomocystinemia38, using techniques such as chromatography, electrophoresis, elisa and tms. study from north india shows a slightly different incidence from south india. homocystinuria, alkaptonuria, msud and non ketotichyperglycinemia were common in north, whereas homocystinuria, msud, pku, mucopolysaccharidoses were common in south11,39,40 using advanced techniques such as gcms and tms. diagnostic advancements: screening for iem involves metabolic profiling of blood and urine samples. the analytical methods have evolved over the years from thin layer chromatography (tlc), high performance liquid chromatography (hplc) to tandem mass spectrometry (tms) including gas chromatography mass spectrometry (gc/ms). tlc is one of the oldest techniques introduced which is still in use. it is widely used as it simple to perform, cost effective, rapid and reproducible and requires less space.41 stationary phases commonly used for tlc include silica, alumina and cellulose, which are coated onto a backing of aluminium, plastic or glass to provide physical support. it can be used to separate amino acids, organic acids, sugars, phenolic acids, ketoacids, imidazole, steroids, lipids, purine, pyrimidine and related compounds. hence it is used in detection of aminoacidopathies in iem cases this technique enabled kaur et al. to report homocystinuria, msud, alkaptonuria, hyperglycinemia, phenylketonuria, cystinuria and general aminoaciduria in high risk infants and children from north india.42,43 this application has helped in screening more than twenty five different metabolic and transport disorders before the onset of the clinical symptoms. thus, tlc was and still a useful tool in screening of iem.41,44 hplc is used to separate compounds on the basis of their chemical characteristics, such as polarity, molecular size and degree of charge in a ph gradient. it helps to quantify the individual components. there are many forms of hplc—the most common is reverse phase hplc. the amino acids are derivatized for carrying out hplc. earlier researchers used ion exchange chromatography in combination with post column ninhydrin detection, but now day’s methods have been simplified with 61 international journal of human and health sciences vol. 03 no. 02 april’19 o-phthalaldehyde (opa) method.45 however it can be used for primary amino acids but for a mixture of secondary amino acids, phenylisothiocyanate (pitc) method is used.46,47 it has helped in detection of homocystinuria, msud, tyrosinemia, phenylketonuria, histidinemia, citturullinemia, argininemia and hyperglycinemia.48 hplc has also been used by researchers for detection of organic acids such as methyl malonic acid, lactic acid, isovaleric acid, glutaric acid, propionic acid etc. gc/ms is another chromatographic technique used to separate components in physiological samples as well as pharmaceutical, food and forensic samples using gas as the mobile phase (carrier) and a silicon based oil as the stationary phase. it accurately detects the volatile compounds in small samples. it has become one of the commonest methods used by researchers and laboratory personals for identifying organic acid metabolism disorders of iem.49 the tms technique was introduced by millington et al. in 1990. initially it was being used for detection of metabolic disorders such as phenylalanine and tyrosine.50,51 now, this technique has gained popularity and it is being used to detect and analyze acyl carnitine profile, amino acids and organic acids simultaneously. using this technology, one can detect more than 30 different types of iem. thus it has helped in screening, diagnosis and treatment52 and has been accepted in many developed countries leading to significant decrease in morbidity due to iem.53,54 the technique has high sensitivity and specificity and comparable to other modern techniques like radio-immunoassay and gc/ms.55,56 the introduction of tms has greatly influenced the screening of iem, which can detect many treatable and untreatable disorder which might be useful to give therapy as well as guidance to affected families. a study by wilcken et al.57, reported a twofold higher prevalence of iem using tms as compared to those diagnosed clinically. tms based screening of iem in newborns recorded an overall incidence of 1 in 9300 in japan.58 its application to newborn screening has opened the door for screening of conditions that previously required molecular testing or another methodology that was not practical for populationbased screening.59,60 future technologies: advancement in technology will strengthen the diagnostic abilities. new technologies such as matrixassisted laser desorption/ ionization time-offlight mass spectrometry (maldi-tof ms), has the potential for rapid and reliable identification of small metabolites and disease biomarkers in daily clinical laboratories, whereas dna based screening by dna microarrays or gene chips will allow much more improved diagnosis.61 qualitative and quantitative changes in nucleic acid sequences such as mutations, singlenucleotide polymorphisms, insertion/deletion, alternative splicing, copy number variations, gene and allele expression, modifications brought about methylations of dna, post transcriptional modifications of trnas and rrnas can be done using maldi-tof ms.62 recently it has been used for screening of iem in newborns using dried blood spot samples. in a study by hachani et al.63, this technique was used to screen sickle cell disease and thalassemia with the primary objective to determine the mass and relative abundance of primary hemoglobin (hb) α and β subunits and of the hbs subunit, indicative of sickle cell disorder. they reported a decrease in mass of 30 da in the hbs subunit. they concluded that this involved marked reduction in cost per unit analysis. dna microarrays is another future technology which will help to screen iem in newborns and infants for diseases arising due to mutations in genes.64 in conclusion, the upcoming techniques are becoming affordable, simple to handle, provides high throughput and very cost effective with high sensitivity and specificities. these can be the boon to screening programs which will require excellent detection and follow-up services. funding: we are thankful to council for science & technology, uttar pradesh, india, for providing us financial support vide sanction order no. cst/ yss/d-2874, for carrying the research work related to inborn errors of metabolism. acknowledgement:we would also like to acknowledge dr. sangeeta singh and dr. jamal. a. ansari, both postdoctoral fellows of the department of biochemistry, k.g.m.u. for their constant help and support. conflict of interest: none authors contributions: conception and design: nf, st, gks, aam analysis and interpretation of data: na critical revision of the article for important intellectual content: nf, gks final approval of article: nf, st, ra, mhs, aam, gks statistical expertise: na collection and assembly of data: na international journal of human and health sciences vol. 03 no. 02 april’19 62 references: 1. scriver cr. garrod’s croonian lectures (1908) and the charter ‘inborn errors of metabolism’: albinism, alkaptonuria, cystinuria, and pentosuria at age 100 in 2008. j inherit metab dis 2008; 31: 580–98. 2. maher ad, zirah sf, holmes e and nicholson jk. experimental and analytical variation in human urine in 1h nmr spectroscopy-based metabolic phenotyping studies. anal chem 2007; 79: 5204-11. 3. sharer jd. an overview of biochemical genetics. currprotoc hum genet 2011, chapter 17: unit 17 .1 4. saudubray jm, berghe g van den, walter jh (eds). inborn metabolic diseases: diagnosis and treatment, 2012: springer-verlag berlin heidelberg. 5. kayton a. newborn screening: a literature review. neonatal network: j neonatal nurs 2007; 26(2): 8595. 6. saudubray jm, charpentier c. clinical phenotypes: diagnosis/algorithms. in: scriver cr, beaudet al, sly w, valle d. the metabolic and molecular bases of inherited disease, 7th edition. mcgraw-hill; 1995;1995. 7. saudubray jm, sedel f and walter jh. clinical approach to treatable inborn metabolic diseases: an introduction. j inherit metab dis 2006; 29: 261-74. 8. schulze a, lindner m, kohlmüller d, olgemöller k, mayatepek e and hoffmann gf. expanded newborn screening for inborn errors of metabolism by electrospray ionization-tandem mass spectrometry: results, outcome, and implications. pediatrics 2003; 111(6): 1399-1406. 9. fang-hoffmann j, lindner m, shahbek n, barić i, thani g al and hoffmann gf. metabolic medicine: new developments in diagnosis and treatment of inborn errors of metabolism. world j pediatr 2006; 2(3): 169-176. 10. hui j, kirby dm, david r and thorburn ab. decreased activities of mitochondrial respiratory chain complexes in non-mitochondrial respiratory chain diseases. dev med child neurol 2006; 48: 132-36. 11. patil vs, jailkhani r, trivedi dj, kulkarni sp, sagare aa, mudaraddi r, et al. screening for aminoacidurias and organic acidurias in patients with metabolic or neurological manifestations. biomed res 2012; 23(2): 253-58. 12. kaur m, das gp and verma ic. inborn errors of amino acid metabolism in north india. j inhermetab dis 1994; 17: 230-33. 13. garg u anddasouki m. expanded newborn screening of inherited metabolic disorders by tandem mass spectrometry: clinical and laboratory aspects. clin biochem. 2006; 39 (4): 315-32. 14. pampols t. inherited metabolic rare disease. adv exp med biol 2010; 686: 397–431. 15. sanderson s, green a, preece ma and burton h. the incidence of inherited metabolic disorders in the west midlands, uk. arch dis child 2006; 91(11): 896-99. 16. dionisi-vici c, deodato f, roschinger w, rhead w and wilcken b. ‘classical’ organic acidurias, propionic aciduria, methylmalonic aciduria and isovaleric aciduria: long-term outcome and effects of expanded newborn screening using tandem mass spectrometry. j inherit metab dis 2006; 29 (2-3): 383-89. 17. applegarth da, toone jr and lowry rb. incidence of inborn errors of metabolism in british columbia, 1969-1996. pediatrics 2000; 105 (1): e10. 18. moammar h, cheriyan g, mathew r and alsannaa n. incidence and patterns of inborn errors of metabolism in the eastern province of saudi arabia, 1983-2008. ann saudi med 2010; 30 (4): 271-77. 19. golbahar j, al-jishi e a, altayab dd, carreon e, bakhiet m andalkhayyat h. selective newborn screening of inborn errors of amino acids, organic acids and fatty acids metabolism in the kingdom of bahrain. mol genet metab 2013; 110: 98-101. 20. han ls, ye j, qiu wj, et al. selective screening for inborn errors of metabolism on clinical patients using tandem mass spectrometry in china: a four-year report. j inherit metab dis 2007; 30 (4): 507-14. 21. gu x, wang z, ye j, et al. newborn screening in china: phenylketonuria, congenital hypothyroidism and expanded screening. ann acad med singapore 2008; 37 (12 suppl): 107-110. 22. niu dm, chien yh, chiang cc, et al. nationwide survey of extended newborn screening by tandem mass spectrometry in taiwan. j inherit metab dis 2010; 33 (suppl 2): s295-305. 23. yoon hr, lee kr, kim h, et al. tandem mass spectrometric analysis for disorders in amino, organic and fatty acid metabolism: two year experience in south korea. southeast asian j trop med public health 2003; 34 suppl 3: 115-20. 24. yamaguchi s. newborn screening in japan: restructuring for the new era. ann acad med singapore 2008a; 37 (12 suppl): 13-15. 25. verma ic. burden of genetic disorders in india. indian j pediatr 2000; 67(12): 893-8. 26. bhatt c, misra z and goyel n. detection of inherited metabolic diseases in children with mental handicap. indian j clin biochem 2008; 23(1): 10-6. 27. rama devi ar, naushad sm. newborn screening in india. indian j pediatr 2004; 71(2): 157-60. 28. nagaraja d, mamatha sn, de t and christopher r. screening for inborn errors of metabolism using automated electrospray tandem mass spectrometry: study in high-risk indian population. clin biochem 2010; 43 (6): 581-88. 29. guthrie r and susi a. a simple phenylalanine method for detecting phenylketonuria in large populations of newborn infants. pediatrics 1963; 32: 338-43. 30. cready mr. phenylketonuria screening program. n engl j med 1963; 269: 52-56. 31. comeau am, larson c and eaton rb. integration of new genetic diseases into statewide newborn screening: new england experience. am j med genet c semin med genet 2004; 125c (1): 35-41. 32. wilson jmg andjungner g. principles and practice of screening for disease. who 1968. available from: http://www.who.int/bulletin/volumes/86/4/07050112bp.pdf. 33. therrell bl and adams j. newborn screening in north america. j inherit metab dis. 2007; 30 (4): 447-65. 63 international journal of human and health sciences vol. 03 no. 02 april’19 34. vilarinho l, rocha h, sousa c, et al. four years of expanded newborn screening in portugal with tandem mass spectrometry. j inherit metab dis 2010; 33 suppl 3: s133-s138. 35. kumta nb. inborn errors of metabolism (iem) an indian perspective. indian j pediatr 2005; 72(4): 32532. 36. latheef sa. a database for inborn errors of metabolism in the indian state of andhra pradesh. bioinformation 2010; 4(7): 276-77. 37. vaidyanathan k, narayanan mp and vasudevan dm. inborn errors of metabolism and brain involvement – 5 years experience from a tertiary care center in south india. 2012, alina gonzalez-quevedo (ed.), intech, pp 57-78. 38. sahai i, zytkowicz t, rao kotthuri s, et al. neonatal screening for inborn errors of metabolism using tandem mass spectrometry: experience of the pilot study in andhra pradesh, india. indian j pediatr 2011; 78(8): 953-60. 39. rao na, devi rr, savithri h, rao sv andbittles ah. neonatal screening for amino acidaemias in karnataka, south india. clin genet 1988; 34(1): 60-3. 40. jailkhani r, patil vs., laxman hb, et al. selective screening for inborn errors of metabolism in children: single centre experience from karnataka. j clin diag res 2008; 2(4): 952-58. 41. auray-blais c, giguère r and lemieux b. newborn urine screening programme in the province of quebec: an update of 30 years’ experience. j inherit metab dis 2003; 26(4): 393-402. 42. reinecke cj andmienie lj. some inborn errors of metabolism at a local institute for mentally retarded patients. j inhermetab dis 1981; 4: 119-20. 43. kaur m, kabra m, das gp, et al. clinical and biochemical studies in homocystinuria. indian pediatr 1995; 32: 1067-75. 44. auray-blais c, cyr d and drouin r. quebec neonatal mass urinary screening programme: from micromolecules to macromolecules. j inherit metab dis 2007; 30(4): 515-21. 45. walker v and mills g a. quantitative methods for amino acid analysis in biological fluids. ann clin biochem 1995; 32: 28-57. 46. tsai v, marshall jg and josephson mw. free amino acid analysis of untimed and 24-h urine samples compared. clin chem 1980; 26(13): 1804-8. 47. heinrikson rl and meredith sc. amino acid analysis by reverse-phase high-performance liquid chromatography: precolumn derivatization with phenylisothiocyanate. anal biochem 1984; 136(1):65-74. 48. babu svs, shareef mm, shetty apk, et al. hplc method for amino acids profile in biological fluids and inborn metabolic disorders of aminoacidopathies. indian j clin biochem 2002; 17(2): 7-26. 49. kuhara t, ohse m, ohdoi c, et al. differential diagnosis of homocystinuria by urease treatment, isotope dilution and gas chromatography–mass spectrometry. j chromatog 2000; 746: 103–14. 50. millington ds, kodo n, norwood dl, et al. tandem mass spectrometry a new method for acylcarnitine profiling with potential for neonatal screening for inborn errors of metabolism. j inherit metab dis 1990; 13: 321-324. 51. naylor ew and chace dh. automated tandem mass spectrometry for mass newborn screening for disorders in fatty acid, organic acid, and amino acid metabolism. j child neurol 1999; 14 suppl 1:s4-8. 52. yoon h, ryul k, kang s, et al. screening of newborns and high-risk group of children for inborn metabolic disorders using tandem mass spectrometry in south korea: a three-year report. clin chim acta 2005; 354: 167-80. 53. chace h, millington ds, terada n andkahier sg. rapid diagnosis of phenylketonuria by quantitative analysis for phenylalanine and tyrosine in neonatal blood spots by tandem mass spectrometry. clin chem 1993; 39(1): 66-71. 54. clarke s. tandem mass spectrometry: the tool of choice for diagnosing inborn errors of metabolism? br j biomed sci 2002; 59: 42-6. 55. fang-hoffmann j, lindner m, shahbek n, et al. metabolic medicine: new developments in diagnosis and treatment of inborn errors of metabolism. world j pediatr 2006; 2(3): 169-76. 56. han ls, ye j, qiu wj, et al. selective screening for inborn errors of metabolism on clinical patients using tandem mass spectrometry in china: a four year report. j inherit metab dis 2007; 30: 507-14. 57. wilcken b, wiley v, hammond j, et al. screening newborns for inborn errors of metabolism by tandem mass spectrometry. n engl j med 2003; 348(23): 2304-12. 58. shigematsu y, hirano s, hata i, tanaka y, sudo m, sakura n, et al. newborn mass screening and selective screening using electrospray tandem mass spectrometry in japan. j chromatogr b analyt technol biomed life sci 2002; 776(1): 39-48. 59. mccandless s. a primer on expanded newborn screening by tandem mass spectrometry. prim care sep 2004; 31(3): 583–604. 60. riley c. public health follow-up of abnormal newborn screening results. epidemiology public health genetics, school of public health and community medicine. seattle, wa, university of washington. master of public health 2007; 1-104. 61. ostermann km, dieplinger r, lutsch nm, et al. matrix-assisted laser desorption/ionization for simultaneous quantitation of (acyl-) carnitines and organic acids in dried blood spots. rapid commun mass spectrom 2013; 27(13):1497-1504. 62. gao x, tan bh, sugrue rj, et al. maldi mass spectrometry for nucleic acid analysis. top curr chem 2013; 331: 55–77. 63. hachani j, duban-deweer s, pottiez g, et al. maldi-tof ms profiling as the first-tier screen for sickle cell disease in neonates: matching throughput to objectives. proteom clin appl 2011; 5: 405–14. 64. alexander d and van dyck pc. a vision of the future of newborn screening. pediatrics 2006; 117: s350 s354. 55 international journal of human and health sciences vol. 04 no. 01 january’20 original article: the relationship between nutritional status, sleep duration, stress level with blood pressure of nurse night shift in the hospital: cohort study salmawati salmawati1, ari natalia probandari2, sapja anantanyu3 abstract: objective: hypertension as a cardiovascular disease occurs due to an uncontrolled increase in blood pressure. night shift nurses with more overweight, short sleep duration, and excessive stress levels are at risk of increase blood pressure. this study aims to analyze how the relationship between obesity, nutritional status, sleep duration and stress level influence the blood pressure of the night shift nurses. materials and methods: the subjects in this study were night shift nurses in four hospitals. the dependent variable was blood pressure and the independent variables were nutritional status, sleep duration, and stress levels. this study was an observational analysis with a perspective cohort design in which the subjects were 312 night shift nurses. nutritional status were identified from body mass index (bmi) through anthropometric measurement, sleep duration by looking at average hours of sleep during the night service, stress levels through the perceived stress scale (pss-10) questionnaire. blood pressure was measured using a mercury sphygmomanometer. data were analyzed by chi-square test and logistic regression. results and discussion: there was a significant relationship between nutritional status, sleep duration, and stress levels with blood pressure. the results of the multivariate analysis showed that the shift nurses with overweight (obesity) nutritional status are at a risk of having disorder 1.97 times, the shift nurses with sleep duration < 6 hours are at risk of having disorder 3.78 times and shift nurses with intermediate stress level at risk of having disorder 2.08 times with enhancement blood pressure.conclusion: there is a relationship between nutritional status, sleep duration and stress level with blood pressure. sleep duration mostly influences the blood pressure. keywords: nutritional status, sleep duration, stress level, blood pressure, nurse night shift. correspondence to: salmawati salmawati, human nutrition, nutrition science, postgraduate school. sebelas maret university, surakarta, indonesia. e-mail: salmatata217@gmail.com 1. human nutrition, nutrition science, postgraduate school. sebelas maret university, surakarta, indonesia. 2. public health department, faculty of medicine, sebelas maret university, surakarta, indonesia. 3. development counseling/community empowerment department, faculty of agriculture, sebelas maret university, surakarta, indonesia. international journal of human and health sciences vol. 04 no. 01 january’20 page : 55-59 doi: http://dx.doi.org/10.31344/ijhhs.v4i1.120 introduction prevalence of hypertension throughout the world at the age of > 18 years is around 22.1%1. indonesia basic health research data (2018) for the age of ≥ 18 years the prevalence of hypertension is higher by 34.1%2. uncontrolled blood pressure causes hypertension and in a long time can cause damage to other body organs such as kidney failure, coronary heart disease and stroke3. blood pressure is not constant that can change in a matter of seconds in which it adjusts the situation or demands of people at that time4. shift work is one of the most obvious sources of disruption for sleep-wake time and has also been shown to increase the risk of cardiovascular disease5. nutritional status is an expression of the state of the body that is affected by certain nutrients. nutritional status of overweight and obesity can increase degenerative diseases risk, and also the workload of the heart in pumping blood so that hypertension occurs6. overweight can cause an increase in cardiac output because the greater the international journal of human and health sciences vol. 04 no. 01 january’20 56 body mass, the more the amount of blood that circulates so that cardiac output also increases and then, it results in increased blood volume7. the benchmark of nutritional status of adults aged > 18 years called body mass index (bmi) according to the standard definition of the centers for disease control (cdc): less weight is less than 18.5 kg/ m2, normal is 18.5–24.9 kg/m2, overweight is 25.0-29.9 kg/m2, and obesity is ≥ 30.0 kg/m2. 8 blood pressure for 24 hours varies in which normal sleep will reduce blood pressure by 10%. sleep disorders especially lack of sleep and obstructive sleep apnea are associated with increased blood pressure and the risk of hypertension9. sufficient sleep duration not only maintains bodily functions but also prevents harmful cardiovascular and hypertension effects10,11. increased blood pressure and sympathetic nervous system are caused by limited hours of sleep12. stress is also a cause of increased blood pressure. stress is a non-specific condition faced by patients due to emotional, physical or environmental demands that exceed the power and ability to cope effectively. prolonged stress can increase permanent blood pressure13. psychosocial factors show evidence that these factors can play an important role in the occurrence of hypertension. exposure to the stress of work, stress from social environment, and low socioeconomic status are risk factors for hypertension14. all things considered, nutritional status, sleep duration, and stress level can affect health especially to metabolic diseases such as increased blood pressure. in short, it is necessary to conduct further research on night shift nurses working in the hospitals. materials and method the subjects in this study were night shift nurses working in four hospitals in bengkulu, indonesia. the dependent variable was blood pressure and the independent variable was nutritional status, sleep duration, and stress level. the study was observational analytic using perspective cohort design. therefore, the subjects involved in this study were 312 night shift nurses chosen through random sampling and considered meet the inclusion criteria. this research was conducted from march to july 2019, in 4 hospitals. the subjects agreed to participate as respondents until the study ended and signed informed consent. nutrition status data were obtained from body mass index (bmi) through anthropometry measurements of body weight and height. sleep duration was from the figure 1:average blood pressure of shift nurses for three months average sleep hours of shift nurses during night shift. stress levels were obtained through the indonesian version of the perceived stress scale (pss-10) questionnaire. blood pressure was obtained from the blood pressure measurements of the night shift nurses’ before they did activities and the measurements used blood pressure tool called sphygmomanometer. blood pressure was monitored every month for three months during night shift. results respondent characteristics the total of samples was 312, 89.4% of the respondents were 21-30 years old and 10.6% were 31-40 years old. the highest number of sexes were female 84.6% and male ratio was 15.4 %. the initial blood pressure of respondents consisted of normal blood pressure of 132 42.3% and prehypertension of 57.3%. the description of the respondents characteristics is shown in the table 1. table 1: respondents distribution based on age, gender and early blood pressure variable n % age 21-30 years 31-40 years 279 33 89.4 10.6 gender male female 48 264 15.4 84.6 early blood pressure normal prehypertension 132 180 42.3 57.7 source: primary data (2019) blood pressure of shift nurses average systolic blood pressure (sbp) / diastolic blood pressure (dbp) of respondents at the beginning of the study was 119.5/80 mmhg, month 1 was 120.2/ 80.1mmhg, month 2 was 121.8/81,2 mmhg and month 3 was 123.1/82,1 mmhg. accordingly, there was an average increase of sbp of 3.6 mmhg and dbp of 2.1 mmhg. furthermore, average blood pressure of shift nurses for three months can be seen in figure 1. 57 international journal of human and health sciences vol. 04 no. 01 january’20 the relationship between nutritional status, sleep duration, and stress level with blood pressure the relationship between nutritional status, sleep duration and stress level with blood pressure is shown in table 2. the number of samples was 312, and the number of shift nurses with over nutritional status (obesity) experienced hypertension as many as 80.2%. less sleep duration (< 6 hours) with hypertension risk found as 75.4%. moderate stress level (score 15-26) with hypertension (prehypertension and hypertension) was 76.9%. the chi-square (bivariate) test results showed that there was significant relationship between nutritional status (p = 0.032) with blood pressure of shift nurse. there was a correlation between sleep duration (p = 0.001) and blood pressure of shift nurse. there was a significant relationship between stress level (p = 0.009) with blood pressure of shift nurses. table 2: the relationship between nutritional status, sleep duration, and stress level with blood pressure variable prehypertention and hypertension normal total p n % n % n nutritional status overweight normal 89 137 80.2 68.2 22 64 19.8 31.8 111 201 0,032 sleep duration less normal stress level heav light 212 14 170 56 75.4 45.2 76.9 61.5 69 17 51 35 24.6 54.8 23.1 38.5 281 31 221 91 0,001 0,009 source: primary data (2019) analysis results of the relationship between nutritional status, sleep duration, and stress level with blood pressure is shown in table 3. according to the multivariate analysis (logistic regression), there is a significant relationship between nutritional status rr = 1.966; p = 0.001, sleep duration rr = 3.776; p =0,021 and stress level rr = 2.075 ; p =0.008 with blood pressure. table 3: analysis results of relationship between nutritional status, sleep duration and stress level with blood pressure variables b sig rr 95% ci for rr lower upper nutritional status 0.676 0,001 1.966 1.109 3.485 sleep duration 1.329 0.021 3.776 1.733 8.228 stress level 0.730 0.008 2.075 1.206 3.571 constant -4.554 0.000 0.011 source: primary data (2019) discussion and conclusion based on a chi-square analysis, there is a relationship between nutritional status (overweight and obesity) and blood pressure with p-value (0.032). this study is in line with the studies of harsha and bray (2008) and van et al. (2011)15.16, that there is significant relationship between body weight with high blood pressure and there is a direct relationship between being obesity with prehypertension and hypertension. according to the nurses’ health study, obesity increases the hypertension risk by 40% and the framingham offspring study states that men are 78% more at risk of developing hypertension than women are at 65%. the relationship between obesity at a young age and permanentobesity status is very at risk of developing hypertension in the future17,18. overweight can cause an increase in cardiac output because the greater the body mass, the more the amount of blood that circulates so that cardiac output also increases and then, it international journal of human and health sciences vol. 04 no. 01 january’20 58 results in an increase in blood volume7,19. the relationship between obesity nutritional status with hypertension (rr = 1.966) means that nurses with obese nutritional status are 1.97 times at risk of developing hypertension. this is in line with setyawati’s20 research that there is a relationship between bmi and hypertension. women having bmi with overweight and obesity categories are 2.05 times more likely to have high blood pressure. obesity is a risk factor for hypertension with a risk of 2.16 times compared to normal bmi21. weight gain and hypertension are often reported by night shift nurses as personal health problem. they recognize that being overweight and obesity are common health threats. besides, some find difficult to cope with the demands of their work22. table 3 shows significant relationship between sleep duration and blood pressure (p = 0.001). this means that sleep duration influences blood pressure for night shift nurse. the risk of an increase in prehypertension and hypertension is caused by sleep duration of fewer than 6 hours23. relationship between sleep duration and blood pressure (rr= 3.776) means that shift nurses with sleep duration is less risk 3.78 times to have increased blood pressure. in agreement with roshifanni24 argument that people having poor sleep patterns are 9.02 times more likely to suffer from hypertension compared to people having good sleep patterns. in the contrary25 stated that short sleep duration is not in respect of the hypertension prevalence occurred in chinese adult men, but this does not apply anymore if sleep quality categorized poor is possible to be further modified by shift work schedules. sleep assessment by measuring sleep duration is not enough when exploring the relationship between sleep and hypertension. hypertension risk is reduced by 0.3207 % when sleep duration increases by 1 hour. the duration of each one-hour extra sleep can reduce hypertension risk by 0.3207% in which shorter sleep greatly affects hypertension26. the stress level with blood pressure shown in table 3 having a significant value (p = 0.009) means that there is a relationship between stress on shift nurses and blood pressure. relative risk (rr= 2.075) means that night shift nurses with moderate stress levels have a 1.3 times increased risk of developing blood pressure compared to those with mild stress. this is supported by suwazono’s studies 27,28 showing relatively consistent results pertaining to the relationship between shift work and increased blood pressure. this happens due to particular reason including changes in lifestyle factors caused by circadian rhythm disorder. it can cause mischievous changes in someone’s life, for instance, high-stress levels in the form of psychosocial, physiological and behavioral stresses associated with increased risk of cardiovascular diseases such as metabolic syndrome, diabetes, and hypertension29. relationship between job stress with high blood pressure and incidence of cvd has been proven. work-related variables include shift work schedule or irregular hours and rotating schedule, time pressure, relationships with co-workers, and others.30 the lack of shift nurses as the cause of stress levels experienced by nurses tends to be high. the workload is increased, because ratio of patients to nurses is unbalanced so that night shift nurses sometimes feel depressed and irritable to create family conflict. some night shift nurses feel that this work brings work stress and frustration at home.22,31 adults spend most of lives at work, so, chronic work stress can have a strong impact on health. the impact of stress on hypertension development is believed to involve the response of sympathetic nervous system where the release of catecholamine causes an increase in blood pressure, heart rate and cardiac output.14,30 there is a relationship between nutritional statuses, sleep duration and stress level with blood pressure. sleep duration < 6 hours risky of 3.776 time with the blood pressure on nurse night shift. ethical approval: this research proposal was accepted by the ethics committee of faculty of medicine, sebelas maret university, surakarta, indonesia no. 446/un27.06/ kepk/2019. conflict of interest: none declared. acknowledgment: we acknowledge and thank for all people who dedicated their time and participated in this research. author’s contribution: all authors contribute in this research. 59 international journal of human and health sciences vol. 04 no. 01 january’20 references: 1. who. global health observatory data repository (internet). raised blood pressure. who. 2014. accessed 17.02.208http://apps.who.int/gho/data/view. main,ncdbparegv?lang=en 2. riset kesehatan dasar. badan penelitiandan pengembangan kesehatan kementrian kesehatan ri. jakarta. 2018. 3. riset kesehatan dasar. badan penelitiandan pengembangan kesehatan kementrian kesehatan ri. jakarta. 2013. 4. herbert. reducing blood pressure. jakarta: gramedia. 2012. 5. abbott sm, weng j, reid kj, daviglus ml, gallo lc, loredo js, nyenhuis sm, ramos ar. sleep timing, stability, and bp in the sueño ancillary study of the hispanic community health study/ study of latinos. chest. 2018;09:018. 6. hardinsyahdansupariasa id. ilmugiziteoridanaplikasi. jakarta: egc. 2014. 7. sulastri d, elmatris, ramadhani r. hubungan obesitasdengan kejadian hipertensipada masyarakat etnik minangkabau di kota padang. majalah kedokteran andalas.2012;3612:188-201. 8. centers for disease control. defining adult overweight and obesity [internet]. overweight & obesity. 2017.accessed 17.04.2017 https://www.cdc. gov/obesity/adult/defining.html 9. thomas sj and calhoun d. sleep, insomnia, and hypertension.j am sochypertens. 2016;11(2):122-129. 10. cappuccino fp, cooper d, d’elia l, strazzullo p, miller ma. sleep duration predicts cardiovascular outcomes: a systematic review and meta-analysis of prospective studies. eur heart j. 2011;(32):1484–92. 11. wang y. mei h. jiang yr. sun wq. song yj. liu sj. jiang f..relationship between duration of sleep and hypertension in adults: a meta-analysis. j clin sleep med. 2015;11(9):1047–56. 12. gangwischje.feskanich d.malaspina d.shen s. and forman jp. sleep duration and risk for hypertension in women: results from the nurses’ health study am j hypertens. 2013;26(7):903–911. 13. sutanto. cekal (cegah dan tangkal) modern disease. yogyakarta: cv andi offset 2010. 14. spruill tm. chronic psychosocial stress and hypertension. currhypertens rep. 2010;12(1):10-16. 15. harsha dw, bray ga. weight loss and blood pressure control. hypertension2008;51:1420-5. 16. van da, boot cr, merkus sl, smid t, van der beek aj. the effects of shift work on body weight change—a systematic review of longitudinal studies. scandj work environ health. 2011;37:263-275. 17. forman jp, stampfer mj, curhan gc. diet and lifestyle risk factors associated with incident hypertension in women. jama2009;302:401-11. 18. juonala m, magnussen cg, berenson gs, venn a, burns tl, sabin ma .. childhood adiposity, adult adiposity, and cardiovascular risk factors. n engl j med. 2011;365:1876-85. 19. nagase m and fujita t.mineralocorticoid receptor activation in obesity hypertension.hypertens res.2009;32:649-57. 20. setyawati b. susilowati a danmaisya ib. usia dan indeks massa tubuh merupakan determinan tekanan darah di atas normal padawanitausiasubur. penelitian gizi dan makanan. 2017;40(2):45–53. 21. natalia d. hasibuan p. and hendro. hubungan obesitas dengan hipertensi pada penduduk kecamatan sintang, kalimantan barat. e-journal kedokteran indonesia. 2014;2(3):156–158. 22. phiri lp, draper ce, lambert ev, kolbe-alexander tl. nurses’ lifestyle behaviors, health priorities and barriers to living a healthy lifestyle: a qualitative descriptive study. bmc nursing 2014;13(1):38. 23. sun xm, yao s, hu sj, liu zyyang yj, yuan zyye wm, jin l, wang xf. short sleep duration is associated with increased risk of pre-hypertension and hypertension in chinese early middle-aged females. sleep breath. 2016;016:1392-2. 24. roshifannis. relationship between sleep pattern with hypertension. jurnal berkala epidemiologi. 2016;4(3):408–419. 25. lu k. chen j. wang l. wang c. ding r. wu s. hud. association of sleep duration, sleep quality and shift-work schedule in relation to hypertension prevalence in chinese adult males: a crosssectional survey. int j environ res public health. 2017;14(2):210. 26. li h, ren y, wu y, zhao x. correlation between sleep durationandhypertension: meta-analysis.j hum hypertens. 2018;33(3):218-28. 27. suwazono y, dochi m, sakata k, okubo y, oishi m, tanaka k, et al. shift work is a risk factor for increased blood pressure in japanese men: a 14-year historical cohort study. hypertension2008;52:581–6. 28. suwazono y dannogawa k. effect of shift work on blood pressure. .j clin med. 2014;72:1497–502. 29. puttonen s, härmä m, hublin c. shift work and cardiovascular disease-pathways from circadian stress to morbidity. scand j work environ health. 2010;36(2):96–108. 30. rosenthal t and alter. a review article: occupational stress and hypertension. journal of the american society of hypertension. 2012;6(1):2–22. 31. nasrabadi an, seif h, latifi m, rasoolzadeh n, emami. night shift work experiences among iranian nurses: a qualitative study. intnurs rev. 2009;56:498–503. international journal of human and health sciences. supplementary issue: 2021 s13 the importance of clinical history taking when assessing patient suspected positive covid-19 zainul ikhwan ahmad khusairi, kartik k, ahmad bilal an, chung wm emergency and trauma department, taiping hospital, perak darulridzuan, malaysia doi: http://dx.doi.org/10.31344/ijhhs.v5i0.304 introduction: covid-19 pandemic is an on-going devastating global event. it starts from december 2019 and is yet to resolve. to date, there are more than 25 million people diagnosed and 850 thousand deaths with covid-19 (cdc, 2020). healthcare services throughout the world are facing immense challenges. history taking has been inevitably the most emphasized tool in approaching all patients. however, the usefulness of medical history strongly depends on the patient’s story offered. incorrect or hidden history may not only bring wrong diagnosis but endanger health care personnel. objectives: this case series is aimed to describe the importance of clinical history-taking in assessing patients associated with covid-19 symptoms or history. methods: assessment through interview method in taking patient history was used. the focus of history taking was related to health and covid-19 history. the data collected is a type of secondary data from medical reports of patients who come to receive medical services at the emergency and trauma department, general public hospital taiping, perak. a total of three cases are taken using the purposive sampling technique. data is analysed and presented in the form of qualitative data. results: this study found that the clinical history taking through interview method has successfully identified three patients with positive covid-19 through assessment conducted. conclusion: therefore, the study proved that effective history taking implemented by paramedics was able to identify patients with positive covid-19 and to plan an appropriate management and help them get discharged without complications. all physicians and other health care practitioners in the emergency department or in the clinical ward are also advised to be more competent by increasing their level of knowledge and skills related to assessing patients through effective clinical history taking. keywords: clinical history taking, covid-19, severe acute respiratory illness (sari), emergency department http://dx.doi.org/10.31344/ijhhs.v5i0.304 international journal of human and health sciences. supplementary issue: 2021 s4 plenary lecture educating children and the new norm zabidi azhar mohd hussin professor of paediatrics pro vice-chancellor of academic, international medical university doi: http://dx.doi.org/10.31344/ijhhs.v5i0.295 the lockdown from march to november 2020 in its various forms have seriously impacted education of children, both nationally and internationally. in malaysia; more than 1 million students were affected and 100,000 teachers and 20,438 members of school support staff were forced to stay at home. unicef noted that 24 million children around the world will drop out and students from vulnerable communities will be particularly and failed to return to class. this has forced almost all education providers to switch the education deliveries online. while some of the more established educational institutions which are more prepared than others, sailed plainly through this switch, a sizable majority found this switch a devastating blow to the delivery of education especially to children. the parent group for education, malaysia reported that 66% malaysian children do not have good internet connectivity at home and the ministry of education also reported that 37% do not own devices for online learning. the outcome of these is almost predictable. 20% children were discovered to have lost interest in schoolwork and become demotivated while 7% have indeed dropped out from school. although most children are no stranger to handphones and other devices, the use of these for education is daunting. for the first 10 weeks of the mco, online teaching is noted to be adhoc, random, unstructured and even non-existent. timetable was created in may but not strictly adhered to by teachers who are not familiar with technology. the ministry of education set up a free portal such as www.eduwebtv.moe.edu.my and the digital educational learning initiative malaysia (delima) as immediate mitigation. the future and the new norm for education is predictable and we have no choice. online education delivery has to be strengthened by firm efforts to boost connectivity. school digital packages should consist of laptops or tablets, with video cams, telecommunication towers, especially in the rural areas must be built urgently. mini and micro credentialing of children and teachers must be held to train them on the basics of online teaching, while more immersive applications are being prepared. we have little choice. keywords: children, education, new norm, digital educational learning initiative malaysia (delima) http://dx.doi.org/10.31344/ijhhs.v5i0. 155 international journal of human and health sciences vol. 04 no. 03 july’20 editorial: transgenders: an insight to early progression mohammad khursheed alam1, anas imran arshad2 correspondence to: dr. mohammad khursheed alam, mailing address: associate professor, orthodontic division, college of dentistry, jouf university, ksa. e-mail : dralam@gmail.com international journal of human and health sciences vol. 04 no. 02 april’20 page : 155 doi: http://dx.doi.org/10.31344/ijhhs.v4i3.193 running title: attainment of prescribing skill lack of local and national transgender-led organisations necessitates an informatory response of researchers striving to develop standards of medical and dental care for transgender communities of developing countries. here in the universiti sains malaysia in kelantan, malaysia, we have made efforts to conduct research and develop a better understanding of health care needs for local bangladeshi transgender community. currently, we are outreaching transgender community leaders for data collection with prior permissions to facilitate at least palliative treatment provision. we aim to assess the differences in dental and craniofacial morphometry of transgenders. we also focus on identifying the associations of body mass index (bmi) and abo blood grouping with the craniofacial morphometrics. so for our knowledge goes, there is no existing database for the dental and craniofacial morphometric norms of transgenders. our study outcomes will primarily serve orthodontists, maxillofacial surgeons and on a larger scale will facilitate forensic specialists, radiologists and other health care personnel to better understand the inherent differences and plan the desired treatments according to their specific norms. this will also encourage and empower transgenders to seek health advices and enjoy a healthy social life. the fears of violence and discrimination that transgenders face in our society have suppressed their basic health care needs for long. we need to work in globalised collaboration to address the complex array of challenges that the transgender community faces. gender equity and indiscrimination is their birth right and we hold this responsibility to defend and fight for their rights to ensure their prosperous future. 1. associate professor, orthodontic division, college of dentistry, jouf university, ksa. 2. phd student, orthodontic unit, school of dental sciences, universiti sains malaysia, kelantan, malaysia. abstract: lack of local and national transgender-led organisations necessitates an informatory response of researchers striving to develop standards of medical and dental care for transgender communities of developing countries. here in the universiti sains malaysia in kelantan, malaysia, we have made efforts to conduct research and develop a better understanding of health care needs for local bangladeshi transgender community. currently, we are outreaching transgender community leaders for data collection with prior permissions to facilitate at least palliative treatment provision. we aim to assess the differences in dental and craniofacial morphometry of transgenders. we also focus on identifying the associations of body mass index (bmi) and abo blood grouping with the craniofacial morphometrics. so for our knowledge goes, there is no existing database for the dental and craniofacial morphometric norms of transgenders. our study outcomes will primarily serve orthodontists, maxillofacial surgeons and on a larger scale will facilitate forensic specialists, radiologists and other health care personnel to better understand the inherent differences and plan the desired treatments according to their specific norms. this will also encourage and empower transgenders to seek health advices and enjoy a healthy social life. the fears of violence and discrimination that transgenders face in our society have suppressed their basic health care needs for long. we need to work in globalised collaboration to address the complex array of challenges that the transgender community faces. gender equity and indiscrimination is their birth right and we hold this responsibility to defend and fight for their rights to ensure their prosperous future. 139 international journal of human and health sciences vol. 05 no. 02 april’21 review article: review of the corona viruses causing acute respiratory syndrome and covid-2019 (covid-19) pandemic an alam1 m siddiqua2, al-mahmood ak3, aminur rahman4 abstract: a new virus, severe acute respiratory syndrome corona virus-2 (sars cov-2) emerged in december 2019 and still continuing to pose a great threat all over the globe claiming to a fatality 980,031 persons. among the human corona viruses it is the third one causing acute respiratory distress syndrome. the others two are sars cov and mers cov. the objective of this study is to review the human corona viruses causing severe respiratory distresses which are detected thru analysis of some recently published documents on the deadly sars cov-2 as well as information on sars-cov and mers cov from different world class trust worthy reliable and dependable sources. genetic analysis reveals that the new human corona virus (sars cov-2) has similarities with the severe acute respiratory syndrome like (sars like) bat virus which thought to be the primary reservoir. sarscov and mers-cov also have same bat reservoir but the intermediate host are different for three human corona viruses. though the clinical picture is more or less similar but efficiency of human to human transmission is not same for these viruses. so, strict control measures are critical to contain this very big pandemic been occurring since december 2019. everyday new information has been coming causing strategy to change to control this pandemic. zoonotic origin of corona viruses indicate researchers, public health specialists should keep the continuous surveillance for early detection of new virus alike sars –cov-2. keywords: corona virus, sars-cov, mers-cov, covid-19, outbreak, pandemic, correspondence to: dr. ahmed nawsher alam, principal scientific officer, institute of epidemiology, disease control & research, government of the peoples’ republic of bangladesh (gob), mohakhali, dhaka 1212. email: anawsher@yahoo.com 1. dr. ahmed nawsher alam, principal scientific officer, institute of epidemiology, disease control & research (iedcr), government of the peoples’ republic of bangladesh (gob), mohakhali, dhaka 1212 email: anawsher@yahoo.com 2. dr. mahmuda siddiqua, professor (cc), department of microbiology, ibn sina medical college & hospital, kallyanpur, dhaka 1216 e-mail: mahmuda99@yahoo.com 3. professor abu kholdun al-mahmood, professor & head, department of biochemistry, and vice-principal, ibn sina medical college, kallyanpur, mirpur, dhaka 1216, email:kholdun@hotmail.com 4. aminur rahman, former manager, icddr,b, mahakhali, dhaka 1212, email: rahman55aminur@gmail.com international journal of human and health sciences vol. 05 no. 02 april’21 page : 139-147 doi: http://dx.doi.org/10.31344/ijhhs.v5i2.250 introduction: in last december 2019, an acute respiratory corona virus disease (covid-19), caused by the novel corona virus (sara-cov-2) was identified first in the wuhan of china and received immediate worldwide attention. the world health organization (who) named this corona virus initially as the novel corona virus 2019 (2019-ncov). later, the corona virus study group (csg) of the international committee proposed the name of new corona virus as sars-cov-21 and who officially accepted the disease as corona virus disease 2019 (covid-2019)2. the chinese scientists very fast isolated the new virus sars-cov-2 from an infected patient within a very short possible time and done genome sequencing3. the who officially declared covid-19 pandemic as a public health emergency of international concerns on 30 january 2020. as of international journal of human and health sciences vol. 05 no. 02 april’21 140 25 september 2020, a total of 32,110,656 cases were confirmed as infected by the covid-19 globally including 980,031 deaths where as in bangladesh, 356,767 covid-19 positive cases were detected including 5,093 deaths4. the emergence of sars-cov-2 considered as the third high pathogenic and large-scale epidemic corona virus into the human beings in twentyfirst century, since the outbreak of severe acute respiratory syndrome corona virus (sarscov) in 20025 and the middle east respiratory syndrome corona virus (mers-cov) in 2012. the basic reproduction number (noted as the r0) of sars-cov-2 was reported to be around 2.26 or even more range from 1.4 to 6.57. cluster of the pneumonia outbreaks within the families indicates steady human to human transmission of the pandemic covid-19 worldwide8. corona virus: the corona viruses (covs) belong to the family coronaviridae, which is the largest family within the order nidovirales orthocoronavirinae and torovirinae are two subfamilies of the coronaviridae family where orthocoronavirinae includes four genera: alpha (α)-coronavirus, beta (β)-coronavirus, gamma (γ)-coronavirus, and delta (δ)-coronavirus9. many corona viruses are significant for the animal health threats. the first description of corona virus came from the veterinarian in 1931 which was named as ‘infectious bronchitis virus (ibv) of chickens’10. covs are then found in mammals, birds, camels, cattle, cats, bats, and other animals. alpha (α) and beta (β) corona viruses are found to be circulating in the mammals including bats, whereas γ coronaviruses are found mainly in the avian species including few mammalian species, and δ coronaviruses are detected in the birds and mammals11. evidence shows that the animals covs can infect human beings rarely and could attain the ability to spread through the human-tohuman transmission12. among different human corona viruses (hcovs) cov-229e and covoc43, cause the common cold in the humans13. several other hcovs were revealed in different period after emergence of those two hcovs. severe acute respiratory syndrome-cov (sarscov) was discovered in 2002, hcov-nl63 in 2004, hcov-hku1 in 2005, and the middle east respiratory syndrome-cov (mers-cov) in 201214. the novel cov virus2019 (2019-ncov) which is recently named sars-cov-2 is seventh human corona virus detected in china1. fig-1: classification of corona viruses corona virus structure and entry in the host cell: corona viruses are the spherical enveloped virus with a positive-sense single-stranded rna genome where the spike proteins on envelope showed appearance of crown under microscope led to the name “corona virus”, a latin word means ‘the crown’15. the viral structures found primarily of structural proteins such as spike (s), membrane (m), envelope (e), and nucleocapsid (n) proteins, and hemagglutinin-esterase (he) protein in the some β-corona viruses. the s, m, and e proteins are all embedded in viral envelope. however, n protein is located in the core of the viral particle16. fig-2: corona virus structure spike (s) of protein of the virus is sole responsible for entry of covs into the host cells17. within s-1 domain, the receptor-binding domain (rbd) binds with receptor of the host cell and s-2 domain causes the fusion between the host cell membrane and the viral envelope, required for viral entry into the host cells18,19. several cellular receptors were found for different covs. for an example, aminopeptidase n (apn) receptor was identified for several α-corona viruses,20 angiotensin-converting the enzyme 2 (ace2) receptor for sars-cov,21 hcovnl63,22 and newly discovered sarscov-2,23 and dipeptidyl-peptidase 4 (dpp4) receptor for mers-cov24. 141 international journal of human and health sciences vol. 05 no. 02 april’21 genomic organization: the genome of covs including recently evolved sars cov-2 is the largest among all human beings rna viruses which range from 26 to 32 kilobases (kb) in size25. the genome codes for the nonstructural and structural proteins26. the genome for covs comprises of the 5'-untranslated region (5'-utr), the open reading frame (orf), non-structural proteins (nsp) for replication, structural proteins including the spike (s), envelop (e), membrane (m), and nucleocapsid proteins (n), accessory proteins such as orf 3, 6, 7a, 7b, 8 and 9b in the covs genome, and the 3'-untranslated region (3'-utr)27. the orf 1 translates two poly-proteins, pp1a and pp1ab, and encodes 16 non-structural proteins (nsp) which comprise about two-thirds of the whole genome, while the remaining orfs encode accessory and structural proteins. the rest one-third of the genome encodes four essential structural proteins, which includes the spike(s) glycoprotein, small envelope (e) protein, membrane protein (m) and the nucleocapsid (n) protein28. origin and evolution of sars covs there is a long history of the cross-species transmission of covs29. sars-cov has been thought to be originated from the chinese wet market where it crosses the species barrier from chinese horseshoe bats through an intermediate species palm civet and the raccoon dogs to the human beings30. a lot of studies have proved that the bats and other small animals harbor sarsrelated covs (sarsr-covs) that might be ancestral to the sars-cov in humans31. it was found that sars-cov has been circulating for a long time in bats before the genetic modification and jumping to humans. this genetic modification leads to adaptation sars-cov to the bind human ace2 as a receptor and efficiently infect human cells32. mers-cov is highly related particular to two bat corona viruses, hku4 and hku5, identified previously33. detection of the mers-related covs (mersr-covs) in bats indicates a potential bat origin34,35 but likely had an intermediate host. studies have identified that the camel mers-cov strains are almost identical to human mers-cov strains36 which could be the intermediate host. rbd of mersr-covs’ share only 60% – 70% sequence identity with that of the human and camel merscovs37. for adaptation in the human host, mersrcovs had to undergo several amino acid changes in the rbd of s-protein to become capable of infecting the camels and humans38. this amino acid changes might lead to the emergence of merscov strains that enable to bind to the human dpp4 with high affinity and infecting the humans. the early cases of sars-cov-2 pneumonia indicate that many cases have been exposed to the huanan seafood market in wuhan, hubei province of china39. the genetic analyses of the viral samples from the patients with sarscov-2 infections revealed that the sars-cov-2 shares 79.5% nucleotide (nt) identity with sars cov, only 50% identity to mers-cov and 96% identity with the bat-cov-ratg1340,41. it indicates that sars-cov-2 is new virus that is distinct from sars-cov and mers-cov but might have a bat origin, similar to sars-cov and mers-cov41. the huanan seafood market was trading variety of live animals such as the snakes, marmots, badger, hedgehog, and birds, probably pangolin but not the bats42,43 suggests that bats have less chance to direct contact with the human and direct transmission of the virus from bat to human is less likely44. therefore, like sars cov and mers cov there may be an intermediate host in the market transmitting the virus to a human. recently sars cov-2 has been isolated from pangolins, genetic sequences of which showed 99% identity with that sars cov-2 in humans. now, it has been thought that transmission and evolution path of sars cov-2 was from bat-cov to pangolins (intermediate host), from where it transmits to human45. comparison between sars-cov, mers-cov, and the newly discovered sars-cov-2: the pandemic potential human corona viruses started to cause the severe acute respiratory syndrome (sars) in humans in 2002-2003. that outbreak initiated in the guandong area in china, fig-3: genome of sars cov-2 international journal of human and health sciences vol. 05 no. 02 april’21 142 and resulted in 774 deaths out of a number of 8,098 cases over the nine months period with about 10% fatality46. the un-ciliated bronchial epithelial cells and the type ii pneumocytes were infected and resulted in fever, cough, shortness of breathing, and severe complications such as pneumonia and kidney failure ailments21,46. the incubation period for the sars-cov was observed for 2 to 14 days47. in 2012, another new cov detected in saudi arabia that causes a severe respiratory disease named mers-cov48. mers-cov caused a similar type of clinical features as that of sars-cov. the incubation period of mers-cov is quite similar to sars-cov and ranging from 2 to 14 days49. since 2012, 862 patients died out of a total 2,506 infected cases in 27 countries with a case fatality about 35%, which is more than three times than that of the sars-cov infections50. the third identified human corona virus is sarscov which causes the respiratory symptoms with the severe disease. it was isolated and sequenced from the patients that showed symptoms of respiratory illness and pneumonia in wuhan in china during december 2019 51. incubation period is the same as sars-cov and mers-cov infections39,52. similar to sars-cov and unlike mers-cov, human-to-human transmission was confirmed41. the respiratory symptoms include fever, dry cough, respiratory distress, and in severe case pneumonia. the mortality seems to be caused by acute respiratory distress syndrome (ards)53 usually associated with comorbidities and followed by multiple organ failures leading to death. education from outbreak of sars-cov, mers-cov, and sars-cov-2: alpha (α)-corona virus (hcov-229e, & hcovnl63) and β-coronavirus (hcov-oc43 and hcov-hku1) have been known to cause mild, self-limiting respiratory infections with symptoms of the common cold in a human before the outbreak of sars-cov. the severe form of the acute respiratory syndrome was found to be caused by sars-cov, mers-cov, and very recently sars-cov-2, all are β-corona virus55. the diversity of corona-viruses reflects the fact that this family of viruses has an rna dependent rna polymerase with the poor fidelity56, and high frequency of rna mutation57, and also easy transmission from one species to another12,58; all these factors may contribute to severe respiratory outbreaks in the human. corona viruses that cause severe respiratory diseases have come from ancestral covs harbored by the bats (fig3) whereas animals function as intermediate hosts (civets, raccoon dogs, camel, pangolin etc.), and the humans served as terminal hosts. in china, the live animals are sold mainly for food items or medicine at most of the wet markets. the wildlife and/or parts from the rare animals fig-3: diagram of origin of corona viruses 143 international journal of human and health sciences vol. 05 no. 02 april’21 (such as the pangolin scales and paws from a tiger) used for medicine or the magical purpose in china59. but it is to be noted that most of these folk remedies are not prescribed by the traditional chinese medicine (tcm) hospitals. the wuhan market also involved with selling of several exotic animals and their parts41. thus, sars-cov-2 disease can be considered a zoonotic disease that initially spread from animals to the humans then human-to-human transmission also confirmed60. it is found that new covs causing outbreaks repeatedly, evolved in china. the cause for this repeated occurrence of these outbreaks is not at all well understood. although, it can be assumed that those viruses may be predominantly circulating in the animals in china rather than animals of the world. one of the reasons could be the close interactions with live and the wild animals in the wholesale food market in china54 and the practice of eating raw meat. such a pandemic outbreak like the covid-19 is a concern for public health specialists to understand the magnitude of the pandemic where basic reproduction number which is known as the r0 is an important indicator61. this number measures the potentiality of the disease which represents average number of healthy people infected from an infected person in a population. the mean estimate of r0 was found in a study between 2.24 and 3.5862 and in another study with the high average value of r0 was found to be 2.5 63 which is consistent with a report from the other groups ranged from 2 to 364-66. the r0 estimates for the sars-cov-2 are consistent with the sarsand mers-covs ranging from 2 to 567,68. the r0 above 1(one) should always be taken seriously. the target should be to reduce the r0 below 1. an important point here is r0 estimates can vary from the “true” r0 values if the infected people remain asymptomatic or do not report their symptoms to the authority57. conclusion: in any sorts of natural disaster, the people come together to get rid of that disaster whereas outbreaks of highly contagious infectious diseases divide the people to prevent the spreading of viruses. but viruses cross from country to country irrespective of borders and move from birds to an animal to the human. so, controlling such a pandemic outbreak requires an active and prompt international efforts and cooperation. the climate change, changes in ecology, continuous invasion of natural habitats of the animals by human for food and shelter, advanced practices in agriculture lead the wildlife to come to the human habitat which causes spillover of viruses from natural host to human. even in this huge advancement of science, invisible viruses have been found to have devastating effects on human beings. thus sars-cov, mers-cov, h5n1, h7n9, ebola, and very recent covid-19 outbreaks give an alarm to the world for the future pandemic threats by any other novel virus. researchers should have continuous efforts and the surveillance to reduce the probability of occurrence of new infections through the sustainable investigation of animal etiology, keep strict bio-security of the high-risk pathogens, control of the wildlife trading, and decreasing direct contact with wildlife and thus control the transmission of naïve virus to human. conflict of interest: none source of fund: nil ethical clearance: not applicable authors contribution: data gathering and idea owner : an alam writing and editing final draft: all authors. international journal of human and health sciences vol. 05 no. 02 april’21 144 reference: 1. a g gorbalenya, s c baker, r s baric, et al., the species severe acute respiratory syndrome-related coronavirus: classifying 2019-ncov and naming it sars-cov-2. nat microbiol (2020), https://doi. org/10.1038/s41564-020-0695-z. 2. novel corona virus (2019-ncov) situation report–22, world health organization, 2020 available at: https://www.who.int/docs/default source/coronaviruse/situation-reports/20200211sitrep-22-ncov.pdf (accessed 12 february 2019). 3. lu r, zhao x, li j, niu p, yang b, wu h, et al. genomic characterization and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding. lancet. 2020; 395 (10224) : 565– 574. doi : 10.1016/s the 0140-6736 (20) 30251-8. 4. https://www.who.int/emergencies/diseases/novelcoronavirus-2019. accessed on 25.09.2020 5. yan-rong guo, qing-dong cao, zhong-si hong, yuan-yang tan, shou-deng chen, hongjun jin, et al.the origin, transmission and clinical therapies on coronavirus disease 2019 (covid-19) outbreak – an update on the status. mil med res. 2020; 7: 11. 6. riou j, althaus cl. pattern of early human-to-human transmission of wuhan 2019 novel coronavirus (2019-ncov), december 2019 to january 2020. euro surveill. 2020; 25(4):2000058. doi : 10.2807/15607917.es.2020.25.4.2000058. 7. liu y, gayle aa, wilder-smith a, rocklov j. the reproductive number of covid-19 is higher compared to sars coronavirus. j travel med. 2020. 10.1093/jtm/taaa021. 8. chan j f, yuan s, kok k h, to k k, chu h, yang j, et al. a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. lancet.2020; 395(10223):514–523. doi: 10.1016/s0140-6736 (20) 30154-9. 9. woo p c, huang y, lau s k, yuen ky. coronavirus genomics and bioinformatics analysis. viruses 2010,2, 1804–1820. 10. o. seifried. histopathology of infectious laryngotracheitis in chicken. j. exp. med. 1931, 54 (6), 817826. 11. woo p c, lau s k, lam cs, lau cc, tsang a k, lau j h, et. al. discovery of seven novel mammalian and avian coronaviruses in the genus delta-coronavirus supports bat coronaviruses as the gene source of alpha-coronavirus and beta-coronavirus and avian coronaviruses as the gene source of gammacoronavirus and delta-coronavirus. j. virol. 2012, 86, 3995–4008. 12. forni d, cagliani r, clerici m, sironi m. molecular evolution of human corona virus genomes. trends microbiol. 2017, 25, 35–48. 13. milek j, blicharz-domanska k. corona viruses in avian species-review with focus on epidemiology and diagnosis in wild birds. j. vet. res. 2018, 62, 249–255. 14. van der hoek, l. human coronaviruses: what do they cause? antivir. ther. 2007, 12, 651–658. 15. neuman b w, adair b d, yoshioka c, quispe j d, orca g, kuhn p, et. al. supra molecular architecture of severe acute respiratory syndrome corona virus revealed by electron cryo-microscopy. j. virol. 2006, 80, 7918–7928. 16. fehr a, perlman s. corona viruses: an overview of their replication and pathogenesis. methods mol. biol. 2015, 1282, 1–23. 17. hofmann h, hattermann k, marzi a, gramberg t, geier m, krumbiegel m, et. al. s protein of severe acute respiratory syndrome-associated coronavirus mediates entry into hepatoma cell lines and is targeted by neutralizing antibodies in infected patients. j. virol. 2004,78, 6134–6142. 18. simmons g, reeves j d, rennekamp a j, amberg s m, piefer a j, bates p, et al. characterization of severe acute respiratory syndrome-associated coronavirus (sars-cov) spike glycoprotein-mediated viral entry. proc. natl. acad. sci. usa 2004, 101, 4240– 4245. 19. he y, li j, du l, yan x, hu g, zhou y, et al. identification and characterization of novel neutralizing epitopes in the receptor-binding domain of sars-cov spike protein: revealing the critical antigenic determinants in inactivated sars-cov vaccine. vaccine 2006, 24, 5498–5508. 20. reguera j, santiago c, mudgal g, ordono d, enjuanes l, casasnovas j m. structural bases of coronavirus attachment to host amino-peptidase n and its inhibition by neutralizing antibodies. plos pathog. 2012, 8, e1002859. 21. li w, moore m. j, vasilieva n, sui j, wong s k, berne m a, et al. angiotensin-converting enzyme 2 is a functional receptor for the sars coronavirus. nature 2003, 426, 450–454. 22. hofmann h, pyrc k, van der hoek l, geier m, berkhout b, pohlmann, s. human coronavirus nl63 employs the severe acute respiratory syndrome coronavirus receptor for cellular entry. proc. natl. acad. sci. usa 2005, 102, 7988–7993. 23. wan y, shang j, graham r, baric r s, lif. receptor recognition by novel coronavirus from wuhan: an analysis based on decade-long structural studies of 145 international journal of human and health sciences vol. 05 no. 02 april’21 sars. j. virol. 2020. 24. raj v s, mou h, smits s l, dekkers d h, muller m a, dijkman r, muth d, demmers j a, zaki a, fouchier r a, et al. di-peptidyl peptidase 4 is a functional receptor for the emerging human coronavirus-emc. nature 2013, 495, 251–254. 25. lai m m. corona virus: organization, replication and expression of genome. annu. rev. microbiol. 1990,44, 303–333. 26. masters p.s. the molecular biology of corona viruses. adv. virus res. 2006, 66, 193–292. 27. muhammad adnan shereen, suliman khan, abeerkazmi, nadia bashir, rabeeasiddique. covid-19 infection: origin, transmission, and characteristics of human coronaviruses. journal of advanced research 24 (2020) 91–98 28. cui j, li f, shi zl. origin and evolution of pathogenic coronaviruses. nat rev microbiol. 2019; 17 (3) : 181–92. 29. perlman s, netland j. 2009. coronaviruses postsars: update on replication and pathogenesis. nat. rev. microbiol. 7: 439–450 30. graham r l, baric r s. 2010. recombination, reservoirs, and the modular spike: mechanisms of coronavirus cross-species transmission. j. virol. 84: 3134–3146 31. li w, shi z, yu m, ren w, smith c, epstein j h, et al. bats are natural reservoirs of sars-like coronaviruses. science 2005, 310, 676–679. 32. li w, zhang c, sui j, kuhn j h, moore m j, luo s, et al. receptor and viral determinants of sarscoronavirus adaptation to human ace2. embo j. 2005, 24, 1634–1643. 33. van boheemen s, de graaf m, lauber c et al. genomic characterization of a newly discovered coronavirus associated with acute respiratory distress syndrome in humans. mbio 3. doi:10.1128/mbio.00473-12 34. lau s k, li k s, tsang a k, lam c s, ahmed s, chen h,et al. genetic characterization of betacoronavirus lineage c viruses in bats reveals marked sequence divergence in the spike protein of pipistrellus bat corona virus hku5 in japanese pipistrelle: implications for the origin of the novel middle east respiratory syndrome coronavirus. j. virol. 2013, 87, 8638–8650. 35. memish z a, mishra n, olival k j, fagbo s f, kapoor v, epstein j h, et al. middle east respiratory syndrome corona virus in bats, saudi arabia. emerg. infect. dis. 2013, 19, 1819–1823. 36. haagmans b l, aldhahiry s h, reusken c b, raj v s, galiano m, myers r, et al. middle east respiratory syndrome corona virus in dromedary camels: an outbreak investigation. lancet infect. dis. 2014, 14, 140–145. 37. lau s k p, zhang l, luk h k h, xiong l, peng x, li k s m, et al. receptor usage of a novel bat lineage c betacorona virus reveals evolution of middle east respiratory syndrome-related coronavirus spike proteins for human di-peptidyl peptidase 4 binding. j. infect. dis.2018, 218, 197–207. 38. zhang z, shen l, gu x. evolutionary dynamics of mers-cov: potential recombination, positive selection and transmission. sci. rep. 2016, 6, 25049 39. zhu n, zhang d, wang w, li x, yang b, song j, et al. a novel coronavirus from patients with pneumonia in china, 2019. n. engl. j. med. 2020. 40. zhou p, yang xl, wang xg, hu b, zhang l, zhang w, et al. a pneumonia outbreak associated with a new coronavirus of probable bat origin. nature 2020. https://doi.org/ 10.1038/s41586-020-2012-7. 41. lu r, zhao x, li j, niu p, yang b, wu h, et al. genomic characterization and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding. lancet 2020, 395, 565–574. 42. wu f, zhao s, bin y, chen ym, wang w, song zg, et al. a new coronavirus associated with human respiratory disease in china. nature 2020. https:// doi.org/10.1038/s41586-020-2008-3 43. li q, guan x, wu p, wang x, zhou l, tong y, et al. early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia. n engl j med 2020. . 44. cui j, li f, shi zl. origin and evolution of pathogenic coronaviruses. nat rev microbiol 2019; 17: 181e92. 45. jin-yan li, zhi you, qiong wang, zhi-jian zhou, ye qiu, rui luo, xing-yi ge. the epidemic of 2019-novel-coronavirus (2019-ncov) pneumonia and insights for emerging infectious diseases in the future. https://doi.org/10.1016/j. micinf.2020.02.002 46. drosten c, gunther s, preiser w, van der werf s, brodt hr, becker s, et al. identification of a novel coronavirus in patients with the severe acute respiratory syndrome. n. engl. j. med. 2003, 348, 1967–1976. 47. chan-yeung, m.; xu, r.h. sars: epidemiology. respirology 2003, 8, s9–s14. 48. zaki a m, van boheemen s, bestebroer t m, osterhaus a d, fouchier ra. isolation of a novel corona virus from a man with pneumonia in saudi arabia.n.engl.j.med.2012, 367, 1814–1820. 49. arabi y m, balkhy h h, hayden f g, bouchama a, luke t, baillie j k, et al. middle east respiratory syndrome. n. engl. j. med. 2017, 376, 584–594. 50. killerby m e, biggs h m, midgley c m, gerber s international journal of human and health sciences vol. 05 no. 02 april’21 146 i, watson j t. middle east respiratory syndrome coronavirus transmission. emerg. infect. dis. 2020, 26, 191–198. 51. zhou p. discovery of a novel coronavirus associated with the recent pneumonia outbreak in humans and its potential bat origin. nature. 2020 52. rothe c, schunk m, sothmann p, bretzel g, froeschl g, wallrauch c, et al. transmission of 2019-ncov infection from an asymptomatic contact in germany. n. engl. j. med. 2020. 53. zhu n, zhang d, wang w. a novel coronavirus from patients with pneumonia in china, 2019. n. engl. j. med. 2020;382(8):727–733. 54. chen n., zhou m., dong x. epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study. lancet. 2020; 395 (10223) : 507– 513 55. huang c, wang y, li x, ren l, zhao j, hu y, et al. clinical features of patients infected with 2019 novel coronavirus in wuhan, china. lancet 2020; 395: 497e506 56. one health. editorial: the novel corona virus (sars-cov-2) is one health issue. https://doi. org/10.1016/j.onehlt.2020.100123 57. dolan p t, whitfield z j, andino r. mechanisms and concepts in rna viruspopulation dynamics and evolution. annu. rev. virol. 2018, 5, 69–92. 58. su s, wong g, shi w, liu j, lai ack, zhou j, et al. epidemiology, genetic recombination, and pathogenesis of coronaviruses. trends microbiol. 2016, 24, 490–502. 59. hossam m a shour, walid f elkhatib, md masudur rahman, hatem a elshabrawy. insights into the recent 2019 novel coronavirus (sarscov-2) in light of past human coronavirus outbreaks. pathogens 2020, 9,186; doi :10.3390/ pathogens9030186 60. chan j f, yuan s, kok k h, to k k, chu h, yang j, et al. a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating personto-person transmission: a study of a family cluster. lancet 2020, 395, 514–532. 61. delamater p l, street e j, leslie t f, yang y t, jacobsen k h. complexity of the basic reproduction number (r0). emerg. infect. dis. 2019, 25, 1–4. 62. zhao s, lin q, ran j, musa s s, yang g, wang w, et al. preliminary estimation of the basic reproduction number of novel corona virus (2019-ncov) in china, from 2019 to 2020: a data-driven analysis in the early phase of the outbreak. int. j. infect. dis. 2020, 92, 214–217. 63. read j m b jr, cummings da, ho a, jewell cp. novel coronavirus 2019-ncov: early estimation of epidemiological parameters and epidemic predictions. medrxiv2020. 64. li q, guan x, wu p, wang x, zhou l, tong y, ren r, et al. early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia. n. engl. j. med. 2020. 65. riou j, althaus c l. pattern of early human-to-human transmission of wuhan 2019 novel coronavirus (2019-ncov), december 2019 to january 2020. eurosurveillance 2020, 25, 2000058. 66. wu j t, leung k, leung g m. nowcasting and forecasting the potential domestic and international spread of the 2019-ncov outbreak originating in wuhan, china: a modeling study. lancet 2020. 67. lipsitch m, cohen t, cooper b, robins j m, mas, james l, et al. transmission dynamics and control of severe acute respiratory syndrome. science 2003, 300, 1966–1970. 68. lin q, chiu a p, zhao s, he d. modeling the spread of middle east respiratory syndrome corona virus in saudi arabia. stat methods med res 2018, 27, 1968– 1978.se is as nobitas dolorit erum arcim sed quundae omnim quasped min plam fugitatem volum 147 international journal of human and health sciences vol. 05 no. 02 april’21 pancreatic ductal adenocarcinoma and chronic pancreatitis using multimarker expression data and samples obtained by minimally invasive fine needle aspiration. int j cancer. 2007 jan 30,120(7):1511–7. 32. de geus swl, boogerd lsf, swijnenburg r-j, mieog jsd, tummers wsfj, prevoo hajm, et al. selecting tumor-specific molecular targets in pancreatic adenocarcinoma: paving the way for image-guided pancreatic surgery. mol imaging biol. 2016/04/29. 2016,18(6):807–19. 33. gorantla b, asuthkar s, rao js, patel j, gondi cs. suppression of the upar–upa system retards angiogenesis, invasion, and in vivo tumor development in pancreatic cancer cells. mol cancer res. 2011 apr 1,9(4):377 lp – 389. 34. hamada s, shimosegawa. t. pancreatic cancer stem cell and mesenchymal stem cell. in: grippo pj, munshi hg, editors. pancreatic cancer and tumor microenvironment. trivandrum: transworld research network, 2012. p. 111–22. 35. asuthkar s, stepanova v, lebedeva t, holterman al, estes n, cines db, et al. multifunctional roles of urokinase plasminogen activator (upa) in cancer stemness and chemoresistance of pancreatic cancer. mol biol cell. 2013 sep 1,24(17):2620–32. 36. khanna a, mahalingam k, chakrabarti d, periyasamy g. ets-1 expression and gemcitabine chemoresistance in pancreatic cancer cells. cell mol biol lett. 2011,16(1):101–13. 37. gendronneau g, lemieux m, morneau m, paradis j, têtu b, frenette n, et al. influence of hoxa5 on p53 tumorigenic outcome in mice. am j pathol. 2010 feb,176(2):995–1005. 38. shi h, sun m, liu l, wang z. chimeric antigen receptor for adoptive immunotherapy of cancer: latest research and future prospects. mol cancer. 2014,13(1):1. 39. norelli m, casucci m, bonini c, bondanza a. clinical pharmacology of car-t cells: linking cellular pharmacodynamics to pharmacokinetics and antitumor effects. biochim biophys acta (bba)reviews cancer. 2016,1865(1):90–100. 40. mirzaei hr, rodriguez a, shepphird j bc. chimeric antigen receptors t cell therapy in solid tumor : challenges and clinical applications. front immunol. 2017,8(1850):1–13. 41. cartellieri m, bachmann m, feldmann a, bippes c, stamova s, wehner r et al. chimeric antigen receptor-engineered t cells for immunotherapy of cancer. biomed res int. 2010,2010:956304. 42. zhang c, liu j, zhong jf zx. engineering car-t cells. biomark res. 2017,5(22):3–8. 43. xu x-j ty-m. cytokine release syndrome in cancer immunotherapy with chimeric antigen receptor engineered t cells. cancer lett. 2014,343(2):172–8. 44. lee dw, stetler-stevenson m, yuan cm, fry tj, shah nn, delbrook c et al. safety and response of incorporating cd19 chimeric antigen receptor t cell therapy in typical salvage regimens for children and young adults with acute lymphoblastic leukemia. am soc hematol. 2015,126(23):684. 45. arcangeli s, magnani cf, tettamanti s be. switchable chimeric antigen receptor t cells: a novel universal chimeric antigen receptor platform for a safe control of t-cell activation. transl cancer res. 2016,5(12):174–7. 46. rodgers dt, mazagova m, hampton en, cao y, ramadoss ns, hardy ir et al. switch-mediated activation and retargeting of car-t cells for b-cell malignancies. proc natl acad sci. 2016,113(4):459– 68. 47. therapies a, arbor a. expression and functional role of urokinase-type plasminogen activator receptor in normal and acute leukaemic cells. br j haematol. 1998,103:110–23. 48. zhang e, xu h. a new insight in chimeric antigen receptor-engineered t cells for cancer immunotherapy. j hematol oncol. 2017,10(1):1. 49. gao n, bozeman en, qian w, wang l, chen h, lipowska m, et al. tumor penetrating theranostic nanoparticles for enhancement of targeted and image-guided drug delivery into peritoneal tumors following intraperitoneal delivery. theranostics. 2017,7(6):1689–704. 50. warheit db, sayes cm, reed kl, swain ka. health effects related to nanoparticle exposures: environmental, health and safety considerations for assessing hazards and risks. pharmacol ther. 2008,120(1):35–42. 51. imam sz, lantz-mcpeak sm, cuevas e, rosashernandez h, liachenko s, zhang y, et al. iron oxide nanoparticles induce dopaminergic damage: in vitro pathways and in vivo imaging reveals mechanism of neuronal damage. mol neurobiol. 2015,52(2):913–26. 52. yarjanli z, ghaedi k, esmaeili a, rahgozar s, zarrabi a. iron oxide nanoparticles may damage to the neural tissue through iron accumulation, oxidative stress, and protein aggregation. bmc neurosci. 2017,18(1):51. international journal of human and health sciences vol. 04 no. 01 january’20 26 original article: stigma among patients with hiv/aids: a cross sectional study in malaysia azreen abdullah1, adibahhanim ismail2, ching siew mooi3 abstract introduction:hiv stigma refers to negative beliefs, feelings and attitudes towards people living with hiv (plwh), groups associated with plwh and other key populations at higher risk of hiv infection, such as people who inject drugs, sex workers, men who have sex with men and transgender people. despite the advancement made in the knowledge and treatment of hiv, plwh continues to be stigmatized. objective: to determine the level of hiv stigma and its predictors among people living with hiv/aids in a tertiary hospital in malaysia. methods: a cross sectional study was conducted among hiv/aids patients aged 18 and above at infectious disease clinic in hospital sungai buloh, gombak, malaysia. hiv stigma was assessed using berger’s hiv stigma scale, which is available in bahasa malaysia and english.a self-administered questionnaire was used to determine their demographic and clinical characteristics. multiple linear regression analysis was used to identify the predictors.results: 526 subjects participated in this study. the mean age of the study population was 33.5± 8.4 years. the majority of the participants were male (90.9%) and contracted hiv through sexual activities (87.8%). the mean score of hiv stigma was 104.7 ± 19.5. based on multiple linear regression analysis, patients who were unemployed (b = -8.00, 95% confidence interval (ci) = -12.12,-3.88, p = < 0.001) and being on antiretroviral treatment (b = 4.95, 95% (ci) = 0.30, 9.60, p = < 0.037) had higher level of hiv stigma.conclusions: the level of hiv stigma was high (mean score =104.7 ± 19.5). hiv/aids patients who are unemployed and on antiretroviral agents were at risks of having higher level of hiv stigma. future study is needed urgently to implement intervention that can minimize the stigmatization among patients with hiv/aids. keywords: hiv, aids, stigma, malaysia , hospital, predictors, factors correspondence to: adibah hanim ismail, family medicine department, faculty of medicine & health sciences, universiti putra malaysia, 43400, serdang, selangor, malaysia. e-mail : adibahanim@upm.edu.my 1. dr. azreen abdullah, family medicine specialist, klinik kesihatan kajang, jalan semenyih, 43500 kajang, selangor. 2. dr. adibah hanim ismail, family medicine specialist & medical lecturer, department of family medicine, faculty of medicine & medical sciences, university putra malaysia, selangor, malaysia. 3. dr. ching siew mooi, family medicine specialist & medical lecturer, department of family medicine, faculty of medicine & medical sciences, university putra malaysia, selangor, malaysia. international journal of human and health sciences vol. 04 no. 01 january’20 page :26-35 doi: http://dx.doi.org/10.31344/ijhhs.v4i1.116 introduction hiv stigma is one of the major obstacles since it was first diagnosed more than 30 years ago. research has shown that hiv stigma and discrimination discourage people living with hiv, disclosing their hiv status to their family or their partners, seeking hiv information, treatment and prevention1,2. even until antiretroviral therapy was introduced people still have high stigma thus renders the preventive measures to reduce hiv burden and prevent the spreads of the disease3. although antiretroviral treatment can halt the replication of human immunodeficiency virus (hiv), it is a major global healthissue and one of the most dreaded pandemics. experiencing hivrelated stigma has increased the risk of sexual transmission behavior, depression, anxiety, and panic disorder4. hiv-related stigma is fortified by many factors such as misconceptions, lack of access to treatment, and other socially sensitive issues which can lead to discrimination5. joint united nations programme on hiv/aids (2014) defines hiv stigma as negative beliefs, feelings and attitudes 27 international journal of human and health sciences vol. 04 no. 01 january’20 towards people living with hiv, groups associated with people living with hiv and other key populations at higher risk of hiv infection, such as people who inject drugs, sex workers, men who have sex with men and transgender people6. hivrelated stigma and discrimination are the leading hurdles for hiv treatment, preventions, alleviating impact and providing adequate care, support and treatment. stigma and discrimination can prejudice, discourage, negative feelings and abuse people living with hiv and to seek information and services7. hiv-related discrimination also refers to other populations such as sex workers, homosexual, transgender, people in prisons and others8. hiv-related stigma and discrimination weaken the ability of individuals and communities in preventing and treating hiv. globally, there are conflicting results of factors associated with hiv stigma. although, malaysia has limited study pertaining to hiv stigma, stigmatization and discrimination are widely present especially in health care and social welfare settings9. taking that into account, the purpose of this study was to determine the level of hiv stigma and its associated factors among patients with hiv/ aids. the outcome of the study will assist health care providers to detect stigmatization earlier among patients with hiv/aids. this will reduce hiv-related stigma and help to improve the lives of people affected by hiv/aids. methodology study subjects:a cross-sectional study was conducted and the patients were conveniently selected from the outpatient infectious disease clinic in hospital sungai buloh, gombak, malaysia. the sample size for the proposed study was calculated based on a previous study10. the sample size estimated was 562 at significance level of 5% and power of 80%. the respondents were initially approached by the staff nurses and subsequently interviewed by the researchers. to be eligible for this study, patients must be 18 years old and above and had been diagnosed with hiv and registered at the clinic. both male and female were included as well as all of the three main ethnics; malay, chinese and indian were recruited. data collection and instrument:the data were collected using validated, pre-tested, and standardized questionnaires in bahasa malaysia and english version. the questionnaire has two parts; part 1: sociodemographic and clinical characteristics such as age, gender, ethnicity, education level, marital status, duration of illness, high risk behavior, sexual orientation, cd4 count, and antiretroviral treatment, and part 2: hiv stigma scale. hiv stigma scale: it is a self-administered questionnaire available in english and bahasa malaysia. the 40-item, 4-point likert-type hiv stigma scale was used to measure the level of hiv-related stigma11. the scale has four subscales which are: (i) personalized stigma has 18 items and the score range 18-72, (ii) disclosure concerns has 10 items and the score range 10-40, (iii) negative self-image contains 13 items and the score range 13-52 and (iv) concerned about public’s attitude contains 20 items and the score range 20-80. if a subject selects a response in between two options (between strongly disagree and disagree), a numerical value midway between the two options would be used. items 8 and 21 are reversed items. after reversing these two items, each scale or subscale’s score is calculated by simply adding up the raw values of the items belonging to that scale or subscale. sixteen items belong to more than one subscale, reflecting the intercorrelations of the factors on which the subscales are based. the range of possible scores depends on the number of items in the scale. for the total hiv stigma scale, scores can range from 40 to 160. the higher the score, the more perceived hiv stigma experienced. the validated malay version of hiv stigma scale was used to determine the level of hiv stigma in this study. it was found to be reliable and valid instrument for measuring hiv-related stigma12. the internal consistency reliability 0.92 of the malay version is comparable to 0.96 of the original english version11. a pilot study was conducted with the estimated participants (n = 56), prior to recruiting the subjects. an anonymous self-administered questionnaire was given to all the patients with hiv (n=562) with numerical coding. if any of the participants felt uneasy or uncomfortable during the questionnaire, they were allowed not to complete the questions. the returned questionnaire was checked for completeness by the data collector. data analysis:all data were entered and analyzed using statistical package for the social sciences (spss) version 22.0. the normality of data was international journal of human and health sciences vol. 04 no. 01 january’20 28 established using histogram and kolmogorovsmirnov test. a descriptive analysis was conducted to obtain mean, frequency and percentage of the variable. a simple linear regression was calculated to predict the level of hiv stigma based on a sociodemographic and clinical characteristic of the respondent. variables with p value less than 0.25 were selected for multivariate regression analysis to determine the significant relationship between the levels of hiv stigma, while the confounders were controlled. the p value less than 0.05 was considered as statistically significant. results: out of 562 respondents, 94% (n-526) of the respondents completed the questionnaire. majority of respondents were men (90.9%, n=478). table 1 shows the sociodemographic characteristics of the respondents with hiv/aids. the mean age of the respondents was 33.5 ± 8.4 years and the majority of them were less than 50 years old. majority of the respondents were malay (59.4%, n=312), followed by chinese (30.2%, n=159), indian (6.3%, n=33), and other races (4.2%, n=22). most of the respondents were single (87.7%, n=461) and employed (79.8%, n=420). more than half of the respondents (62.8%, n=330) obtained education up to university/college. table 2 describes the clinical characteristics of the respondents with hiv/aids in this study. the mean duration of the illness was 42.3 ± 48.5 months. majority of the respondents were diagnosed with hiv less than 60 months (76.8%) and practiced homosexual orientation (46.4%, n=244), followed by heterosexual (33.7%, n=177) and bisexual (19.9%, n=20). most of the participants were infected with hiv through sexual activities which was 87.8% (n=462), followed by sharing needles 10.9% (n=57) and 85.4% (n=450) of them were on antiretroviral therapy. the mean level of cd4 count was 391.4 ± 235.3 cells/ul and most of the participants had cd4 level ≥ 200 cells/mm3 (77.2%). the total mean score of hiv stigma inour study was 104.7 ± 19.5(ranged from 40 to 160) as shown in table 3. the personalized stigma subscale scores ranged from 18 to 72 (mean 43.9 ± 10.8); disclosure stigma subscale scores ranged from 10 to 40 (mean 30.3 ± 4.8); negative self-image subscale scores ranged from 13 to 52 mean 33.0 ± 7.0 and concerned with public attitude subscales scores ranged from 20 to 80 (mean 51.7 ± 10.9). a simple linear regression was calculated to predict the level of hiv stigma based on sociodemographic characteristic among patients with hiv/aids (table 4). a significant regression equation was found (f (1,524) =13.3, p< 0.001), with an r2 of 0.025. the respondents who are unemployed had a significant relationship with the level of hiv stigma (p< 0.001). however, no significant relationship between hiv stigma, age, gender, marital status, ethnicity and education level (p> 0.05). the relationship between the level of hiv stigma and clinical characteristic among patients with hiv/aids is shown in table 5. the respondents involved in sharing needles have significant regression with f (1,524) = 7.026, p = 0.008, with r2 of 0.013. this shows that the respondents who were involved in sharing needles have a level of hiv stigma higher of 0.116 than the respondents involved in other high risk activities. the respondents involved in sexual activities also have significant regression with the law f (1,524) = 7.374, p< 0.007, with r2 of 0.014. they have lower 0.118 level of hiv stigma than the respondents involved in other high risk activities. a significant regression equation was also found in respondents who were on antiretroviral treatment (f (1,524) =4.181, p< 0.041), with an r2 of 0.008. the respondents with antiretroviral treatment have higher level of hiv stigma compared to the respondents without antiretroviral treatment. a multiple linear regression was calculated to predict the level of hiv stigma based on sociodemographic and clinical characteristics among patients with hiv/aids (table 6). all variables with p value less than 0.25 and clinically significant variables were included in multiple linear regressions. the p value was set larger (< 0.25) than the level of significance to allow for more important variables to be included in the model. the p value ≤ 0.05 was considered statistically significant in multiple linear regressions. based on the regression analysis, the respondents who were unemployed and received antiretroviral treatment were statistically significant predictors of hiv stigma f (2,523 = 8.685, p< 0.001. 3.2% of the variance in hiv stigma were explained by the variance in unemployment and receiving antiretroviral treatment. 29 international journal of human and health sciences vol. 04 no. 01 january’20 discussions: in the present study we found that the total level of hiv stigma scores was high (mean score of 104.69 ± 19.47) and the public attitudes stigma subscale scores was the highest subscale of hiv stigma experienced by the subjects in this study.similarly, a study done at the infectious disease out-patient clinic and among prisoners in northeastern of malaysia were also found that the level of hiv stigma was high with mean score of 122.7±16.8 and 99.1 ± 9.7, respectively12,13. these findings indicated that races and culture play an important role in determining the perception of stigmatization among this population. this is in contrast with another study done overseas among hiv-positive african americans had shown a low hiv stigma. this can be explained by the fact that majority of them are having higher socioeconomic status14. however, there is a controversial finding with other studies whose findings showed there was no association between the level of hiv stigma and socioeconomic status15,16. this highlights the inequality and discrimination towards people with hiv/aids are still an issues in certain countries17. most of the respondents in this study were among younger age group (94%) and males (90.9%) compared to elderly age group (5.5%) and females (9.1%), respectively. generally, most of the studies found similar findings where the majority of the hiv/aids respondents were among younger age group10,13,18,19,20. malays were the higher ethnic (59.4%) compared to the other ethnic groups. the previous local study also had similar finding12,13. in comparison, the other studies conducted in the united states reported that the majority of their respondents with hiv/aids were african american ethnic group10,21,22,23. these results may indicate that certain ethnic groups are more vulnerable in getting hiv/aids diseases than others, although hiv/aids can affect anyone. in our study, the mean duration of illness was 42.4 ± 48.5 months and most of the respondents were diagnosed with hiv/aids in less than 60 months’ duration. the majority of the participants were on antiretroviral therapy (85.5%), with a mean of cd4 level 391.5 ± 235.1 cells/ul. about 7.7% of the respondents were single and more than half of them were educated (62.8%) and still working (79.8%).nearly half of the respondents (46.4%) were homosexual and majority of them (87.9%) were infected with hiv through sexual activities. in contrast, a study in northeastern malaysia reported that most of the respondents with hiv/ aids had low economic and education status12,13. majority of their respondents with hiv/aids were married, heterosexual and infected with hiv through sharing needles13. the difference in population, cultural, job opportunities and economic status were some of the possible reasons to explain the differences in the above findings. unemployment has been recognized as a factor associated with hiv related stigma. it is also regarded as one of the major barriers that prevent hiv/aids patients from returning back to normal life and getting a job. our study also found that unemployment was significantly associated with higher hiv stigma, which is in line with the previous research21,24,25. hiv stigma is also related to those who were taking arv treatment.we also found an association between antiretroviral treatment and the level of hiv stigma. these findings are consistent with other studies in which hiv/aids patients who received antiretroviral treatment had high level of hiv stigma, possibly because they were required to regularly visit the clinic for drugs monitoring19,26. however, a few studies reported that the level of hiv stigma is independent on duration of antiretroviral treatment24,27,28,29,30. this may be due to the difference in study design in which prospective study design may start with antiretroviral treatment naïve patients’. hiv stigma is not associated with other variables such as age, gender, ethnicity, marital status, education level, high risk activities, sexual orientation, cd4 levels and duration of illness. this study ishospital-based and does not represent hiv in its wider context.the cost-effective interventions and programmatic data demonstrating the impact of stigma and discrimination reduction on hiv prevention and care outcomes are much needed. strength and limitation of the study: the strength of this study is huge sample (n=526) compared to the two previous local studies where there werearound 100 participants. secondly, there was lack of reporting on hiv stigma by the respondents’ spouses, or their sexual partners. it is pertinent to include them as part of the study, as international journal of human and health sciences vol. 04 no. 01 january’20 30 we can get more information on their occupation or relationship status. however, most of the respondents (81.4%) in this study were single and this clearly makes it difficult to obtain relevant sexual information from the spouse. thus, we have to interpret the results of this study cautiously within the context of its limitations. conclusion: the mean score of hiv stigma in our study was high (104.6±19.5) and consistent with other local studies.unemployment and on antiretroviral therapy are associated with hiv stigma. the health care professionals should identify those at risk groups for further intervention. ethical approval: approvals were obtained from ethics committee of universiti putra malaysia, national medical research register (nmrr-16765-29793), ethical review of clinical research of health department, selangor and hospital sungai buloh. informed consent was obtained and confidentiality of responses, were stringently ensured throughout the study. conflict of interest:none. acknowledgement: the author would like to thank the director general of health malaysia for the permission to publish this paper. we wish to thank the selangor state health department, director, and head of department of hospital sungai buloh who had given the permission to conduct the study in hospital sungai buloh. also not forgetting our respondents, the staff of hospital sungai buloh who had assisted in data collection. table 1: sociodemographic characteristics of the respondents (n=526) variable n % mean + sd age 33.5 + 8.4 < 50 years old 497 94.5 ≥ 50 years old 29 5.5 gender male 478 90.9 female 48 9.1 ethnicity malay 312 59.4 chinese 159 30.2 indian 33 6.3 others 22 4.2 marital married 65 12.3 single 461 87.7 employment status employed 420 79.8 unemployed 106 20.2 education no schooling 11 2.1 primary school 18 3.4 secondary school 167 31.7 university/college 330 62.8 31 international journal of human and health sciences vol. 04 no. 01 january’20 table 2: clinical characteristics of the respondents (n=526) variable n % mean + sd duration of illness 42.3 + 48.5 0 60 months 404 76.8 61120 months 88 16.7 121 180 months 17 3.2 181 240 months 17 3.2 sexual orientation heterosexual 177 33.6 bisexual 105 20 homosexual 244 46.4 high risk activities sharing needles 57 10.9 sexual activities 462 87.8 others 7 1.3 antiretroviral treatment (arv) on arv 450 85.4 not on arv 77 14.6 level of cd4 count, cells/ul 391.4 + 235.3 cd4 < 200 u/l 120 22.8 cd4 ≥ 200 u/l 406 77.2 table 3: the levels of hiv stigma and subscales among patients with hiv/aids (n = 526) stigma reference range mean + sd total 40 to 160 104.7 ± 19.5 personalised 18 to 72 43.9 ± 10.8 disclosure 10 to 40 30.3 ± 4.8 negative self-image 13 to 52 33.0 ± 7.0 concerned about public’s attitude 20 to 80 51.7 ± 10.9 international journal of human and health sciences vol. 04 no. 01 january’20 32 table 4: relationship between hiv stigma and sociodemographic characteristics among patients with hiv/aids by using simple linear regression. variables b se β (95% ci) f p value age 0.08 0.10 0.04 (-0.12,0.28) 0.69 0.407 gender female ref male 3.55 2.95 0.05 (-2.24,9.34) 1.45 *0.229 marital status married single 2.22 2.58 0.04 (-2.85,7.29) 0.74 0.39 employment employed ref unemployed -7.64 2.09 -0.16 (-11.75,-3.53) 13.3 *< 0.001 ethnicity others ref malay 1.01 1.73 0.25 (-2.39,4.41) 0.34 0.561 chinese -0.38 1.85 0.05 (-4.02,3.26) 0.42 0.838 indian -1.06 3.50 -0.13 (-7.94,5.83) 0.09 0.838 education primary school ref no schooling -2.84 5.94 -0.02 (-14.50,8.83) 0.23 0.633 secondary school 2.10 1.82 0.05 (1.48,5.68) 1.38 0.250 university/college -0.72 1.76 -0.02 (-4.17,2.73) 0.17 0.682 *p< 0.25 33 international journal of human and health sciences vol. 04 no. 01 january’20 table 5: relationship between hiv stigma and clinical characteristics among patients with hiv/ aids by using simple linear regression variables b se β (95% ci) f p value duration of illness 0.009 0.018 0.02 (-0.025,0.044) 0.268 0.605 high risk activities others ref sharing needles 7.199 2.716 0.12 (1.864,12.535) 7.026 *0.008 sexual activities -7.01 2.580 -0.12 (-12.080,-1.940) 7.037 *0.007 sexual orientation heterosexual ref bisexual 0.868 2.126 0.02 (-3.308,5.044) 0.167 0.683 homosexual 0.662 1.704 0.02 (-2.686,4.009) 0.151 0.698 arv not on arv ref on arv 4.897 2.395 0.09 (0.192,9.601) 4.181 *0.041 cd4 level 0.002 0.004 0.02 (-0.009,0.005) 0.246 0.620 *p < 0.25 table 6:relationship between hiv stigma, sociodemographic and clinical characteristics among patients with hiv/aids by using the multiple linear regression. variables b se β (95% ci) f p value unemployed -8.00 2.09 -0.16 -12.12,-3.88 8.69 <0.001 on arv 4.95 2.37 0.09 0.30,9.60 0.037 gender 5.24 2.93 0.08 -0.51,10.99 0.074 sexual activities -3.40 2.75 -0.06 -8.79,1.99 0.216 sharing needles -0.85 7.75 -0.01 -0.04,9.31 0.913 international journal of human and health sciences vol. 04 no. 01 january’20 34 references: 1. antiretroviral therapy cohort collaboration. life expectancy of individuals on combination antiretroviral therapy in high-income countries: a collaborative analysis of 14 cohort studies. the lancet 2008;372(9635):293-299. 2. kuteesa mo, wright s, seeley j, mugisha j, kinyanda e, kakembo f et al. experiences of hivrelated stigma among hiv-positive older persons in uganda–a mixed methods analysis. sahara j 2014;11(1):126-137. 3. wolfe wr, weiser sd, bangsberg dr, thior i, makhema jm, dickinson db et al. effects of hivrelated stigma among an early sample of patients receiving antiretroviral therapy in botswana. aids care 2006;18(8):931-933. 4. hatzenbuehler ml, o’cleirigh c, mayer kh, mimiaga mj, safren sa. prospective associations between hiv-related stigma, transmission risk behaviours, and adverse mental health outcomes in men who have sex with men. annals of behaviour medicine 2011;42(2):227-234. 5. hong kt, van anh nt, ogden j. because this is the disease of the century: understanding hiv and aidsrelated stigma and discrimination. washington, dc: international center for research on women (icrw) 2004, pp. 1–48. 6. joint united nations programme on hiv/aids. guidance note reduction of hiv related stigma and discrimination. geneva. 2014. 7. karim, a.q., meyer-weitz a, mboyi l, carrara h, mahlase g, frohlich ja, et al. the influence of aids stigma and discrimination and social cohesion on hiv testing and willingness to disclose hiv in rural kwazulu-natal, south africa. glob public health 2008;3(4):351–365. 8. parker r, aggleton p, hiv and aids-related stigma and discrimination: a conceptual framework and implications for action. socsci med 2003; 57(1): 13-24. 9. zulkifli sn, huang ms, low wy, wong yl. study on the impact of hiv on people living with hiv, their families and community in malaysia. kuala lumpur: united nations. 2007. 10. shacham e, rosenburg n, önen nf, donovan mf, turner overton e. persistent hiv-related stigma among an outpatient us clinic population. international journal of std & aids 2015;26(4):243250. 11. bergerbe.measurement of perceived stigma in people with hiv infection. research in nursing and health. 2001;24:518529. 12. choi p, kavasery r, desai mm, govindasamy s, kamarulzaman a, altice fl. prevalence and correlates of community re-entry challenges faced by hiv-infected male prisoners in malaysia. international journal of std & aids 2010;21(6):416-423. 13. fadzil na, othman z, mustafa m. stigma in malay patients with hiv/aids in malaysia. international medical journal 2016;23(4):1-4. 14. galvan fh, davis em, banks d, bing eg. hiv stigma and social support among african americans. aids patient care and stds. 2008;22(5):423-436. 15. wagner ac, hart ta, mohammed s, ivanova e, wong j, loutfy mr. correlates of hiv stigma in hiv-positive women. archives of women’s mental health 2010;13(3):207-214. 16. kumar n, unnikrishnan b, thapar r, mithra p, kulkarni v, holla r, bhagawan d, kumar a. stigmatization and discrimination toward people living with hiv/aids in a coastal city of south india. journal of the international association of providers of aids care (jiapac) 2017;16(3):226232. 17. sidibé m, goosby ep. global action to reduce hiv stigma and discrimination. journal of the international aids society 2013;16(3s2):1-6. 18. emlet ca, brennan dj, brennenstuhl s, rueda s, hart ta, rourke sb. the impact of hiv-related stigma on older and younger adults living with hiv disease: does age matter?. aids care 2015;27(4):520-528. 19. datta s, bhattacherjee s, sherpa pl, banik s. perceived hiv related stigma among patients attending art center of a tertiary care center in rural west bengal, india. journal of clinical and diagnostic research (jcdr) 2016;10(10):vc09. 20. li z, sheng y. investigation of perceived stigma among people living with human immunodeficiency virus/acquired immune deficiency syndrome in henan province, china. international journal of nursing sciences 2014;1(4):385-388. 21. sayles jn, hays rd, sarkisian ca, mahajan ap, spritzer kl, cunningham we. development and psychometric assessment of a multidimensional measure of internalized hiv stigma in a sample of hiv-positive adults. aids and behavior 2008;12(5):748-758. 22. relf mv, mallinson k, pawlowski l, dolan k, dekker d. hiv-related stigma among persons attending an urban hiv clinic. journal of multicultural nursing & health 2005;11(1):14. 35 international journal of human and health sciences vol. 04 no. 01 january’20 23. loutfy mr, logie ch, zhang y, blitz sl, margolese sl, tharao we, rourke sb, rueda s, raboud jm. gender and ethnicity differences in hiv-related stigma experienced by people living with hiv in ontario, canada. plos one 2012;7(12):e48168. 24. peltzer, k., &ramlagan, s. perceived stigma among patients receiving antiretroviral therapy: a prospective study in kwazulu-natal, south africa. aids care 2011;23(1): 60-68. 25. vanable, p. a., carey, m. p., blair, d. c., &littlewood, r. a. impact of hiv-related stigma on health behaviors and psychological adjustment among hiv-positive men and women. aids and behavior 2006;10(5):473–482. 26. makoae ln, portillo cj, uys lr, dlamini ps, greeff m, chirwa m et al. the impact of taking or not taking arvs on hiv stigma as reported by persons living with hiv infection in five african countries. aids care 2009;21(11):1357-1362. 27. kaai s, sarna a, luchters s, geibel s, munyao p, mandaliya k et al. changes in stigma among a cohort of people on antiretroviral therapy: findings from mombasa, kenya. horizons research summary. nairobi: population council 2007:2-4. 28. tsai ac, bangsberg dr, bwana m, haberer je, frongillo ea, muzoora c et al. how does antiretroviral treatment attenuate the stigma of hiv? evidence from a cohort study in rural uganda. aids and behavior 2013;17(8):2725-2731. 29. pearson cr, micek ma, pfeiffer j, montoya p, matediane e, jonasse t et al. one year after art initiation: psychosocial factors associated with stigma among hiv-positive mozambicans. aids and behavior 2009;13(6):1189. 30. dowshen n, binns hj, garofalo r. experiences of hiv-related stigma among young men who have sex with men. aids patient care and stds 2009;23(5):371-376. 491 international journal of human and health sciences vol. 05 no. 04 october’21 original article coronavirus disease (covid-19) outbreak among islamic missionaries in terengganu state of malaysia in 2020. goh soo ning1, hafizuddin awang2, ahmad fuad omar3, juhaida jaafar3, fatimah muda3, mohd hanief ahmad4, kasemani embong1, nor azimi yunus1 abstract background: malaysia experienced an outbreak of covid-19 after islamic missionaries returned from religious gathering in sri petaling mosque, kuala lumpur. the outbreak extended to the state of terengganu which also resulted in an outbreak in a private islamic institution known as bkmq (an anonymized name) in kuala terengganu district. materials and methods: a descriptive cross-sectional study was conducted to describe the characteristics of covid-19 cases and the experience of covid-19 outbreak containment in bkmq. results: there were six individuals diagnosed with covid-19 in bkmq. majority of them were male (83.3%), in the age group of 20 to <40 years old (50.0%) and had fever as their symptom (50.0%). the time of last exposure to diagnosis among majority of cases were 12 days, and majority of cases (66.6%) stayed in hospital between 20 days to less than 40 days. conclusion: the transmission of virus was postulated to be through household exposure and vehicle sharing. prompt action, immediate lockdown and inter-agencies collaboration were the key factors in successfully controlling the spread of covid-19 in the institution and community. keywords: covid-19, outbreak, mass gathering, islamic missionaries, terengganu. correspondence to: dr hafizuddin awang. public health medicine specialist, besut district health office, kampung raja, 22200 besut, terengganu, malaysia. e-mail: drhafizuddin@moh.gov.my international journal of human and health sciences vol. 05 no. 04 october’21 page : 491-498 doi: http://dx.doi.org/10.31344/ijhhs.v5i4.362 1. goh soo ning kasemani embong nor azimi yunus terengganu state health department, wisma persekutuan, jalan sultan ismail, 20920 kuala terengganu, terengganu, malaysia. 2. hafizuddin awang besut district health office, kampung raja, 22200 besut, terengganu, malaysia. 3. ahmad fuad omar juhaida jaafar fatimah muda kuala terengganu district health office, 20400 kuala terengganu, terengganu, malaysia. 4. mohd hanief ahmad setiu district health office, bandar permaisuri, 22100 setiu, terengganu, malaysia. introduction coronavirus disease (covid-19) is a newly emerging disease, which is caused by severe acute respiratory syndrome coronavirus (sars-cov-2) and spreads rapidly from person to person. the virus is transmitted by asymptomatic infected individuals, as well as symptomatic individuals via oral fluid droplets, mainly airborne via coughing or sneezing1. since the covid-19 outbreak on 31 december 2019, it has hit more than 200 countries or territories with 51,848,261 cases and 1,280,868 deaths as of 13th november 20202.the world health organization (who) had declared covid-19 as a pandemic on 11 march 20202. in malaysia, the first case of covid-19 was detected on 25th january 2020 among three tourists who had close contact with an infected person in singapore.1 one year later, the disease had spread international journal of human and health sciences vol. 05 no. 04 october’21 492 nationwide and there were more than 408,713 cases reported as of end of april 2021 with more than 1,506 deaths related to covid-19. malaysia had identified 1,655 covid-19 clusters as of 30th april 2021 which affected all states and federal territories of malaysia3. malaysia experienced an outbreak of covid-19 after islamic missionaries returned from a mass religious gathering known as “international qudamak and ulamak malaysia 2020” which was held from 28th february 2020 until 2nd march 2020 in sri petaling mosque, kuala lumpur4. about 30% of covid-19 cases in malaysia during the first wave of covid-19 pandemic were originated from this gathering which involved about 19,000 local and international attendees. as a result, covid-19 cases had spread to many generations via 17 sub-clusters or outbreaks when the participants of this mass gathering returned to their place of origin, as sri petaling mosque served as a headquarter for jamaah tabligh in malaysia and coordinates all the related activities5. jamaah tabligh is a group of movement to revive pure islamic teaching without any affiliation in political and conflicting jurisprudence sect, aiming to propagate good islamic practices among all muslims. tabligh simply means preacher of islamic teachings6. the sri petaling mosque cluster was declared on 11th march 2020 and ended on 8th july 20205. movement control order (mco) had been imposed in malaysia under the prevention and control of infectious disease act 1988 and the police act 1967 under eight different phases as a mitigation strategy starting from 18th march until 31st december 2020. further continuation of mco will be dependent on the current covid-19 situation in malaysia5. one of the states in malaysia which was affected by the covid-19 outbreak related to islamic missionaries is terengganu state. the first covid-19 case was detected on 13th march 2020 in terengganu state, which was related to the religious mass gathering in sri petaling mosque following voluntary screening. the disease had then spread to the next generation when the infected persons went back to a private islamic institution known as bkmq (anonymized name) to continue their islamic missionaries. bkmq is situated in the district of kuala terengganu with approximately 400 occupants, which consisted of 346 students, 36 teachers and staff, as well as their family members. it stretches over seven acres of land area with a mosque, two classrooms buildings, a four stories staff quarters and ten houses. there are 20 students in average per classroom. only boys are eligible to pursue their study in bkmq. there were also nonmalaysian students for example those originated from thailand, philippines, china, indonesia, singapore, brunei, vietnam, cambodia, yemen, france, and morocco. besides functioning as an islamic religion learning centre, bkmq also acts as the centre for non-governmental organization of islamic missionary movement, which is known as tabligh jamaat markaz (centre for tabligh movement) for terengganu state. malaysian jamaah tabligh and also those from all over the world will gather and transit in bkmq for one to two days before they were assigned to go out for dakwah (preaching activities) in local surau (smaller version of islamic religion gathering or activities centre situated in communities) or mosque for three days, 40 days or four months. bkmq also served as a weekly assembly point to all the jamaah tabligh from all over terengganu, which falls on every thursday7. an infectious disease outbreak which happened in an institution like bkmq posed risk of fast spreading to the occupants of the institution, depending on the practice of infectious control, ratio of occupants to space available, age group and immunity status of occupants, as well as the activities held in the institution.8 the routine function and the mobility nature of people in bkmq had also created great challenges to outbreak containment. apart from that, an outbreak linked to an institution will affect the reputation of an institution. therefore, infectious disease outbreak management related to an institution requires prompt decision and action; and to halt the spread of the disease in the shortest possible duration to reduce casualties and complications. in view of covid-19 as a newly emerging disease, sharing of knowledge and successful experience in outbreak management especially in an institution is particularly important to give implications and reference to other stakeholders in future management of similar condition. this paper aimed to describe the characteristics of covid-19 cases and to outline the experience of covid-19 outbreak containment in a private islamic institution in kuala terengganu district, terengganu state of malaysia. materials and methods from 1st march 2020 until 30th june 2020, a descriptive cross-sectional study was conducted in kuala terengganu district health office based 493 international journal of human and health sciences vol. 05 no. 04 october’21 on retrospective record review for covid-19 cases notified to kuala terengganu district health office, terengganu from the cluster period of 13th march 2020 until 5th april 2020. the reference populations and the study samples were all covid-19 cases in bkmq who fulfilled study inclusion and exclusion criteria. the inclusion criteria were individuals with laboratory confirmed positive test for covid-199, and they must be the occupant of bkmq at the time of diagnosis. samples with incomplete record of 30% variables will be excluded from the study. data were collected from kuala terengganu district health office via e-covid19 online registry (an online database for covid-19 under the governance of ministry of health malaysia)9. data were then being recorded in a pre-design study proforma. the retrieved information included socio-demographic features, travel history, signs and symptoms, epidemiological risk assessment, movement history 14 days prior to onset of symptoms, numbers of close contacts, laboratory investigation, control and prevention done by the kuala terengganu district health office. specific operational definitions were employed in this study. a confirmed case of covid-19 is defined as individual with positive results of reverse transcription polymerase chain reaction (rt-pcr) for covid-199. meanwhile, an outbreak is defined as two or more cases of similar infectious disease happened in close proximity or had epidemiological link to each other and happened within the same incubation period9. fever is defined as measured fever of ≥38°celcius9. time of last exposure to diagnosis is defined as time (in days) from the date of last unprotected exposure of individual to the index case/infection source until the day of being diagnosed with covid-19 by mean of rt-pcr positive result. time of first exposure to onset of symptoms (or diagnosis) is defined as time (in days) from the date of first unprotected exposure of individual to the index case/infection source until the day of onset of symptoms (or being diagnosed with covid-19 by mean of rt-pcr positive result). statistical analysis data entry and analysis were done by using spss statistics (ibm corp. released 2013. ibm spss statistics for windows, version 22.0. armonk, ny: ibm corp). descriptive statistics with frequency and percentages were calculated. results socio-demographic and clinical characteristics of among covid-19 cases the covid-19 outbreak related to bkmq, a private islamic institution in kuala terengganu district started on 13th march 2020 and ended on 5th april 2020. a total of six covid-19 cases were detected in this outbreak, among 400 tested occupants (positivity rate: 1.5%). sociodemographically, majority of them were male and in the age group of 20 to <40 years old. clinically, fever was the most common symptom among cases followed by cough, headache and coryza. the time of last exposure to diagnosis among majority of cases were 12 days, and majority of cases stayed in hospital between 20 days to less than 40 days. details are shown in table 1 and figure 1. epidemiological link between covid-19 cases initially four cases (case 1, 2, 4, 6) had attended the “international qudamak and ulamak malaysia 2020” mass gathering which was held from 28th february 2020 until 2nd march 2020 in sri petaling mosque. they stayed together in the mosque and mingled with other participants. on 3rd march 2020, all of them went back to bkmq. case 1 table 1: socio-demographic and clinical characteristics of covid-19 cases in a private islamic institution in kuala terengganu district (n=6) characteristics frequency, n (%) gender male 5 (83.3) female 1 (16.7) age group (years) < 20 1 (16.7) 20 to < 40 3 (50.0) ≥ 40 2 (33.3) time of last exposure to diagnosis (first generation of cases, n=4) 10 days 1 (25.0) 12 days 2 (50.0) 19 days 1 (25.0) time of first exposure to onset of symptoms (second generation of cases, n=2) 11 days 1 (50.0) 12 days 1 (50.0) time of first exposure to diagnosis (second generation of cases, n=2) 12 days 1 (50.0) 16 days 1(50.0) length of hospital stay < 10 days 1 (16.7) 10 days to < 20 days 0 (0.0) 20 days to < 40 days 4 (66.6) ≥ 40 days 1 (16.7) international journal of human and health sciences vol. 05 no. 04 october’21 494 and case 4 travelled back together in the same car and stayed together in a room in bkmq. they came to bkmq for the purpose of transit before being assigned for the next islamic mission. both of them were not originated from terengganu state. meanwhile, case 2 and case 6 travelled together in another car. both of them stayed with their family members in different houses in bkmq, as they also worked as religious teachers in bkmq. on the 15th march 2020, case 1 and case 2 were detected positive for covid-19 at different time of the same day, following voluntary screening program. the promotion of voluntary screening program was done by kuala terengganu district health office after a positive covid-19 case was detected from a bruneian citizen who had attended the mass gathering in sri petaling mosque. this was done with the cooperation from the bkmq managerial team and terengganu state health department. those attended the same mass gathering in sri petaling mosque were contacted by phone calls over three days, starting on 11th march 2020. the promotion of voluntary screening program cannot be done openly via mass media or social media at that time to prevent unnecessary public anxiety and stigma towards jamaah tabligh. after case 1 was detected positive for covid-19, an immediate communication was done with the highest authority of bkmq to conduct lockdown of the institution voluntarily to prevent the movement of bkmq occupants into the community. at the same time, an ambulance with a medical team was arranged to transfer case 1 from bkmq to a tertiary hospital for further treatment. an emergency meeting was held in kuala terengganu district health office with main stakeholders to discuss for further intervention until late midnight. at the same time, case 2 was reported to be positive. similarly, another medical team and transport was deployed to transfer case 2 to a tertiary hospital. however, as expected, voluntary lockdown of the institution did not prevent the bkmq occupants from going out. case 4 (at that time not yet detected as positive covid-19) and 2 other nonmalaysian bkmq occupants who stayed together in the same room with case 1, had travelled on a bus to kuala lumpur with the help of local people on the next morning, after case 1 and case 2 were sent to hospital. therefore, kuala terengganu district health office worked together with the royal malaysian police, malaysia civil defense force and rela (the people’s volunteer corps) to implement a strict mandatory lockdown under the prevention and control of infectious disease act 1988 on 16th march 2020. it was one of the earliest lockdown or movement control order taken in malaysia, prior to the national announcement of movement control order (mco) on 18th march 2020 (mco is a cordon sanitaire implemented as a preventive measure by the federal government of malaysia in response to the covid-19 pandemic in the country starting on 18 march 2020, which is extended and adjusted to different phases according to covid-19 cases burden). these agencies had arranged for several teams to guard at the main entrance and two side entrances of bkmq, as well as patrolling the whole surrounding of bkmq, to prevent anyone from going in and out of bkmq. these officers worked in shift for 24 hours a day and seven days a week. at the same time, with the cooperation of terengganu state health department, kemaman district health office and royal police malaysia, case 4 and two other non-malaysian occupants of bkmq were able to be detained in kemaman district of terengganu state, and were sent to a district hospital for quarantine and sampling. at the same time, social gatherings within bkmq such as classes, mass prayers in bkmq mosque were cancelled after communication with the highest authorities of bkmq. meanwhile, kuala terengganu district health office had also arranged several medical and health teams to go into bkmq with full personal protective equipment on daily basis. the medical teams conducted medical screening and covid-19 sampling for approximately 400 occupants every day, starting from 16th march 2020. those having symptoms suggestive of covid-19 were being sampled, retrieved and sent to hospital for further treatment. while the health teams did disinfection of every premise and common places in bkmq, with the help of the fire and rescue department. figure 1: distribution of symptoms among covid-19 cases in a private islamic institution in kuala terengganu district (n=6). 495 international journal of human and health sciences vol. 05 no. 04 october’21 the kuala terengganu district health office’s crisis, preparedness and response center (cprc) was opened 18 hours daily since 15th march 2020, to coordinate the arrangement of teams, agencies, logistic, disinfections, investigations of positive cases, contact tracing, data collections and so on. the kuala terengganu district office also became the main player in coordinating the whole process later on. the welfare department of malaysia had taken the responsibility of ensuring and sending supply of foods, drinks and basic needs to the bkmq occupants, as well as officers of all agencies during this difficult period of time. the kuala terengganu municipal council also facilitated in the maintenance of cleanliness and sanitation of the surrounding of bkmq. on 19th march 2020, case 3 and case 4 were detected positive for covid-19 following covid-19 sampling and contact screening. case 3 is a lady and the wife of case 6 (not yet detected positive at that time), who had never been to the sri petaling mosque mass gathering. this indicated that the covid-19 outbreak had further spread to another generation. on 21st march 2020, case 5 was detected positive for covid-19. case 5 is the son of case 3 and case 6, who had not been to the sri petaling mosque mass gathering. he is also one of the students in bkmq. there seem to be missing epidemiological link between these cases until case 6 was detected positive later on 21st march 2020 on his third covid-19 sample. in short, all cases had been detected as positive covid-19 on their first sample except for case 6. the illustration of epidemiological link between cases is shown in figure 2. discussion five out of the six positive covid-19 cases detected in bkmq were male. our finding is in line with finding from thailand’s covid-19 outbreak related to the same islamic mass gathering which found male group was more affected than female group4. this may be due to a male predominance in islamic religious gathering, be it in sri petaling mosque or bkmq. observational data from wuhan, china also reported male group as the more pathologically susceptible group to be infected with covid-1910. previous study had shown that female group was less susceptible to contract covid-19 as they have higher macrophage and neutrophil activity and hence, better immune response11. as for age group, young adults (20 years old until less than 40 years old) were the predominant group among all covid-19 cases in this covid-19 outbreak. similar findings were observed in thailand and beijing where majority of cases figure 2: illustration of epidemiological link between cases in covid-19 outbreak in bkmq, a private islamic institution in kuala terengganu district. first generation cases were all individuals who attended religious gathering in sri petaling mosque from 28th february 2020 until 2nd march 2020, while second generation of cases were occupants of bkmq. international journal of human and health sciences vol. 05 no. 04 october’21 496 ranged between the age of 15 years old to 40 years old4,12. these findings may be attributed to the lifestyle of young adults who tend to have many social activities with their peers, which in this case, attending religious mass gathering in group with their peers13. the duration of last exposure until the detection of positive covid-19 or presence of symptoms took 10 days or more among the bkmq cases. studies found that covid-19 incubation period differs widely across the world. it can be as short as three days or up to twelve days14,15. for example, in a chinese study, majority of covid-19 cases showed that the days from exposure to symptom onset took only three to four days13. meanwhile, the duration between day of exposure to onset of symptoms among islamic missionaries in thailand was around five days4. majority of our cases had lengthy hospital stay which was around 20 days to more than 40 days. similar findings were being reported in a systematic review on covid-19 length of hospital stay globally that it varied from less than a week to nearly 2 months. this was due to the differences in admission and discharge criteria, as well as different timing and frequencies of cases between countries, and the capacity of which the hospitals could cope with during the pandemic16,17. as for current practice in malaysia, a few criteria were set as the hospital discharge criteria for symptomatic covid-19 cases. firstly, at least 10 days have passed since symptom onset. secondly, at least 24 hours have passed since resolution of fever without the use of antipyretic medications; and thirdly improving clinically in general. as for asymptomatic covid-19 patients, they can be discharged from hospital 10 days after the date of their first positive rt-pcr test for sars-cov-29. an additional criterion for hospital discharge during the bkmq outbreak period was at least two rt-pcr sample for covid-19 was tested negative prior to discharge, as the covid-19 infectivity period was still under research at that period16. hence, the purpose of hospital stay was to provide supportive treatment to those diagnosed as positive covid-19 until their rt-pcr results turned negative at that time, as an objective measurement that they are not infective anymore. as for symptoms, most of our cases had fever followed by cough, headache and coryza. but 33% of our cases were asymptomatic. studies in other settings also pointed out similar findings with fever and cough were the predominant symptoms of covid-194,12. meanwhile in italy, a large proportion of covid-19 patients presented with common symptoms such as cough, fever, dyspnea, musculoskeletal symptoms (myalgia, joint pain, fatigue), gastrointestinal symptoms, and anosmia/ dysgeusia18. however, recent communal cluster in terengganu state showed more asymptomatic cases (64.7%) than symptomatic cases being detected, as in the biggest communal cluster known as makekar cluster in dungun district, terengganu19. regarding the transmission of virus among cases, one possible scenario is that the infected cases transmitted the virus to their friends during their journey in private transportation. it took at least five hours journey by car from sri petaling mosque to bkmq. case 1 might have infected case 4, and case 2 might have infected case 6 during their journey back from the mass gathering using private cars. previous study had reported on strong correlation between spatial transmission of covid-19 with the use of private or public transportation20, especially if the windows of the vehicle were closed throughout the journey. covid-19 has a high risk of transmission among passengers in confined spaces such as private cars and public transportations. it was reported in previous study that passengers adjacent to the index covid-19 patient had the highest attack rate, especially passengers who sat on the same row as the index patient in the same vehicle21. besides spatial transmission of virus within transport vehicles, our report also highlighted the transmission of covid-19 through household exposure. the most likely scenario is that the infected case 6 had transmitted the virus to his wife (case 3) and son (case 5) after they spent substantial amount of time together within the same house, although case 6 was asymptomatic and being the last one to be detected positive. a systematic review and meta-analysis reported that infection risk of household contacts is 10 times higher than other contacts, and sarscov-2 is more transmissible than sars-cov and mers-cov in households22. studies suggested that infected individuals can transmit the virus efficiently within household via droplets, fomites, aerosol and faecal contamination23,24. moreover, household transmission of sars-cov-2 is very efficient because the virus can survive up to 9 hours on human skin and can remain viable for up to 72 hours on plastic surface and stainless steel within the household confined space25-27. conducting immediate contact tracing and control 497 international journal of human and health sciences vol. 05 no. 04 october’21 measures were important to contain this outbreak in kuala terengganu district. the implementation of immediate lockdown of bkmq when first case was diagnosed in which no one can go in or out of the institution had prevent further transmission of the virus in the community. cancellation of social gathering and daily disinfection within bkmq had also successfully prevent further cases within bkmq. all confirmed covid-19 cases from the institution were immediately isolated and admitted to hospital for treatment, including symptomatic occupants who were not detected as positive yet. inter-agencies collaboration is utmost important in the implementation of lockdown of bkmq and deterring sars-cov-2 transmission in community28. kuala terengganu district health office had obtained continuous assistance and cooperation from various governmental and nongovernmental agencies during the lockdown period of bkmq. numerous challenges were faced during the covid-19 outbreak in bkmq. firstly, there was some degree of difficulty in isolating the residents to their own place as most of them were sharing living spaces in the institution, while no one patrol inside the institution constantly. next, most of the occupants were teenagers with no local social support as they originated from all over malaysia and abroad. language barrier is another challenge faced when dealing with non-malaysian occupants. as a newly emerging disease, covid-19 outbreak in bkmq had also led to fear of being infected, tremendous stress and anxiety to the ground level officers and front-liners who were deployed to take care of bkmq occupants on daily basis. while there were about 400 occupants that needed to be locked down in the institution for 7 weeks, kuala terengganu district health office also need to manage other covid-19 cases detected outside of the institution. this high burden of workload and mental stress led to exhaustion of manpower and the morale of work, as well as depletion of resources such as personal protective equipment and transports. however, constant communications, coordination and assistance from other agencies had provided great relief to medical and health personnel in containment of covid-19 within bkmq and from further transmission in community. this had successfully contained the covid-19 outbreak to only six positive cases in bkmq among 400 occupants. conclusions in conclusion, outbreak management in an institution requires prompt decision and action to contain the outbreak from getting worse. immediate lockdown of bkmq managed to contain the spread of covid-19 from six cases to the rest of 400 occupants. inter-agencies collaboration during the outbreak had successfully curbed the transmission of virus more effectively and relief the burden on healthcare personnel. conflict of interest: none declared. the authors have no financial, consultative, institutional, and other relationships that might lead to bias or conflict of interest. disclosure statement: the authors declare no conflicts of interest. ethical approval issue: this study was approved by the medical review and ethical committee from national institute of health, ministry of health malaysia (nmrr-20-2584-56487). individual authors contribution: conception: g.s.n., h.a., m.h.a., k.e, n.a.y, writer: h.a., g.s.n., j.j, data collection and/or processing: h.a., g.s.n., a.f.o., f.m., m.h.a., analysis and/or interpretation-h.a., g.s.n., k.e, n.a.y, funding statement: this research received no funding. acknowledgement: the authors would like to thank the director general of health malaysia for allowing us to use the secondary data from e-covid19 online registry. our gratitude also goes to public health medicine specialists, family medicine specialists, medical officers and staffs at kuala terengganu district health office and terengganu state health department for their assistance during data collection. 1. elengoe a. covid-19 outbreak in malaysia. osong public health and research perspectives. 2020;11(3):93. 2. world health organization. coronavirus disease (covid-19) pandemic: world health organization; 2020 [cited 2020 13 november]. available from: https:// www.who.int/emergencies/diseases/novel-coronavirus-2019?gclid=cjwkcaia17p9brb2eiwamvwnynimwr1zyalvlmgeno0szv33qfuk1yhjpg_ v1ophnetch1me2z19yhoca44qavd_bwe. references international journal of human and health sciences vol. 05 no. 04 october’21 498 3. ministry of health. kenyataan akhbar kpk 30 april 2021 – situasi semasa jangkitan penyakit coronavirus 2019 (covid-19) di malaysia. ministry of health malaysia; 2021 [cited 2021 30 april]. available from: https://kpkesihatan.com/2021/04/30/kenyataan-akhbar-kpk-30-april-2021-situasi-semasa-jangkitan-penyakit-coronavirus-2019-covid-19-di-malaysia/ 4. phiriyasart f, chantutanon s, salaeh f, roka a, thepparat t, kaesaman s, et al. outbreak investigation of coronavirus disease (covid-19) among islamic missionaries in southern thailand, april 2020. osir journal. 2020;13(2). 5. ministry of health. covid-19 situational report malaysia: ministry of health malaysia; 2020 [cited 2020 15 november]. available from: http://covid-19. moh.gov.my/terkini/112020/situasi-terkini-14-november-2020. 6. noor, f. a. (2012). islam on the move: the tablighi jama’at in southeast asia: amsterdam university press. available from: https://library.oapen.org/bitstream/id/ f0f3a90e-f0fb-4b21-95c6-1e45a57b9842/424530.pdf 7. terengganu state health department. covid-19 field investigation report, kuala terengganu district health office, march, 2020 (unpublished document). 8. strausbaugh lj, sukumar sr, joseph cl, high kp. infectious disease outbreaks in nursing homes: an unappreciated hazard for frail elderly persons. clinical infectious diseases. 2003;36(7):870-6. 9. ministry of health. guidelines for covid-19 ministry of health malaysia malaysia 5th edition: ministry of health; 2020 [cited 2020 13 november]. available from: http://covid-19.moh.gov.my/garis-panduan/ garis-panduan-kkm. 10. walter la, mcgregor aj. sex-and gender-specific observations and implications for covid-19. western journal of emergency medicine. 2020;21(3):507. 11. kopel j, perisetti a, roghani a, aziz m, gajendran m, goyal h. racial and gender-based differences in covid-19. frontiers in public health. 2020;8:418. 12. tian s, hu n, lou j, chen k, kang x, xiang z, et al. characteristics of covid-19 infection in beijing. journal of infection. 2020; 80(4):401-406. 13. liu t, liang w, zhong h, he j, chen z, he g, et al. risk factors associated with covid-19 infection: a retrospective cohort study based on contacts tracing. emerging microbes & infections. 2020;9(1):1546-53. 14. linton nm, kobayashi t, yang y, hayashi k, akhmetzhanov ar, jung s-m, et al. incubation period and other epidemiological characteristics of 2019 novel coronavirus infections with right truncation: a statistical analysis of publicly available case data. journal of clinical medicine. 2020;9(2):538. 15. wang m, li m, ren r, brave a, van der werf s, chen e-q, et al. international expansion of a novel sars-cov-2 mutant. journal of virology. 2020; 94(12):e00567-20 16. ministry of health. guidelines for covid-19 ministry of health malaysia malaysia 1st edition: ministry of health; 2020 [cited 2020 13 november]. available from: http://covid-19.moh.gov.my/garis-panduan/ garis-panduan-kkm. 17. rees, e. m. et al. covid-19 length of hospital stay: a systematic review and data synthesis. 2020. medrxiv, doi:10.1101/2020.04.30.20084780. 18. carfì a, bernabei r, landi f. persistent symptoms in patients after acute covid-19. jama. 2020;324(6):603-5. 19. awang, h., yaacob, e.l., aluawi, s.n.s., mahmood, m.f., hamzah, f.h., wahab, a., rashid, n.a., razali, r., ning, g.s., embong, k. and yunus, n.a., a case-control study of determinants for covid-19 infection based on contact tracing in dungun district, terengganu state of malaysia. infectious diseases (london, england). 2021;53(3):222-225. https://doi. org/10.1080/23744235.2020.1857829 20. zheng r, xu y, wang w, ning g, bi y. spatial transmission of covid-19 via public and private transportation in china. travel medicine and infectious disease. 2020; 34:101626. 21. hu m, lin h, wang j, xu c, tatem aj, meng b, et al. the risk of covid-19 transmission in train passengers: an epidemiological and modelling study. clinical infectious diseases. 2020. 22. lei, h., xu, x., xiao, s., wu, x. and shu, y. household transmission of covid-19-a systematic review and meta-analysis. the journal of infection. 2020;81(6):979. 23. goldman e. exaggerated risk of transmission of covid-19 by fomites. the lancet infectious diseases. 2020;20(8):892-3. 24. jing q-l, liu m-j, zhang z-b, fang l-q, yuan j, zhang a-r, et al. household secondary attack rate of covid-19 and associated determinants in guangzhou, china: a retrospective cohort study. the lancet infectious diseases. 2020;20(10):1141-50. 25. hirose r, ikegaya h, naito y, watanabe n, yoshida t, bandou r, et al. survival of sars-cov-2 and influenza virus on the human skin: importance of hand hygiene in covid-19. clinical infectious diseases. 2020. ciaa1517, https://doi.org/10.1093/cid/ciaa1517 26. suman r, javaid m, haleem a, vaishya r, bahl s, nandan d. sustainability of coronavirus on different surfaces. journal of clinical and experimental hepatology. 2020;10(4): 386-390. 27. awang h, hamzah fh, ahmad mh, mahmood mf, wahab a, embong k, et al. polymerase chain reaction cycle threshold value as prerequisite for reporting of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) detection. 2021;53(5):390-392. https://doi.org/10.1080/23744235.2021.1876913 28. san lau l, samari g, moresky rt, casey se, kachur sp, roberts lf, et al. covid-19 in humanitarian settings and lessons learned from past epidemics. nature medicine. 2020;26(5):647-8. international journal of human and health sciences vol. 01 no. 01 january’17 34 original article comparison of psychiatric symptoms and attitudes of coping with stress in somatization disorder and fibromyalgia and osteoarthritis and their relatives ataoğlu s1, ataoğlu a2, ankarali h3, ankarali s4, ataoğlu b5, őlmez sb6 abstract objectives: the aim of this study is to compare patients with fibromyalgia, their first degree relatives; osteoarthritis patients, their first degree relatives; patients with somatization disorder and healthy controls in terms of psychological symptoms, somatic complaints and ways of coping with stress. materials and methods: the study is planned as crosssectional.patients who presented to the düzce university faculty of medicine, physical medicine and rehabilitation outpatient clinic between june 2016 and january 2017 and who diagnosed with fibromyalgia and osteoarthritis, and their first-degree relatives, patients with somatization disorders and a healthy control group who filled out the informed consent form was included in this study. the socio-demographic information query form, coping inventory for stressful situations (cope) form, psychological symptom checklist (scl90) and the visual analog scale (vas) were applied to all volunteers. covariance analysis was used to compare groups in terms of scale scores. results: it was determined that the groups were not homogeneous in terms of age, vas, education level, sex, marital status and occupation. the groups were compared taking into account the impacts on the cope and scl-90 scores of these characteristics which are thought to be confounders. as a result of the evaluations, it was determined that the patients with fibromyalgia and somatization preferred the problem-focused coping and emotional-focused coping attitudes significantly less and the non-functional coping attitude significantly more. osteoarthritis patients were found to be in the middle of both sides on many occasions. however, there was no significant difference among the groups in terms of psychological symptoms when the effect of the confounding factors were eliminated. conclusion: since the findings achieved suggest that fibromyalgia and somatization disorder are the same diseases, it has been concluded that more research should be conducted on the subject. keywords: cope; fibromyalgia; osteoarthritis; scl-90; somatization correspondence to: ankarali handan, department of biostatistics, istanbul medeniyet university e-mail: handanankarali@gmail.com 1. ataoğlu safinaz, department of physical medicine and rehabilitation, dűzce university, turkey 2. ata ğlu ahmet, department of psychiatry, dűzce university, turkey 3. ankarali handan, department of biostatistics, istanbul medeniyet uinversity, turkey 4. ankarali seyit, department of physiology, istanbul medeniyet uinversity, turkey 5. ataoğlu bahar, department of psychiatry, dűzce university, turkey 6. őlmez safiye bahar, department of psychiatry, dűzce university, turkey international journal of human and health sciences vol. 01 no. 01 january’17. page : 34-44 introduction fibromyalgia syndrome (fms) is a complex clinical manifestation presenting itself with pain spread throughout the body and accompanied by a variety of other symptoms.1 being observed in clinical practice frequently, fms has become a major public health problem due to the high ratio of labor loss, impaired quality of life and increased treatment costs.2 osteoarthritis (oa) is the most common articular disease in the world, characterized by destruction in joint cartilage and subchondral bone.3 somatization disorder (sd) is a disease in which many somatic complaints are observed in many organ systems, lasting more than several years and causing major loss of function or the search for treatment, or both.4 in fms, complex symptoms observed in patients may be “associated with stress” since there are no 35 comparison of psychiatric symptoms and attitudes of coping with stress clinical, laboratory or radiological findings. one of the symptoms of stress is physical complaints. people presenting with physical complaints as a result of stress either model someone else in using physical symptoms, or somatic complaints replace stress to get rid of stress. people who are suffocated by the burden of stress may resort to somatization as a form of destressing, or “coping with stress may be a learned attitude”. learning occurs most frequently in the family one lives with. stress may reveal physical symptoms and emotional symptoms which are psychiatric symptoms. therefore, fms patients should be investigated to determine whether they model the ways their own family members cope with stress. or whether they use somatization to cope with stress. in order to understand this, the ways these patients and their first-degree relatives cope with psychiatric symptoms and stress should be established. the purpose of this study is to compare patients with fibromyalgia, their first degree relatives; osteoarthritis patients, their first degree relatives; patients with somatization disorder and healthy controls in terms of psychological symptoms, somatic complaints and ways of coping with stress. materials and methods study design and sample this study is planned as cross-sectional. patients who presented to the düzce university faculty of medicine, physical medicine and rehabilitation outpatient clinic between june 2016 and january 2017 and who were diagnosed with fms and oa according to the american college of rheumatology (acr)1 criteria and their firstdegree relatives were included in the study. in addition, patients diagnosed with sd according to the dsm-iv criteria who presented to the psychiatry outpatient clinic and healthy control subjects were included for comparison. an informed consent form was given to the subjects for consenting to participate in the study and to have their information used for scientific purposes. additionally, approval was received from the clinical trials ethics committee of düzce university before data collection was initiated. illiterate and smaller than 18 age and patients with psychiatric problems were excluded from the study. information obtained as a result of a five-month data collection period was transferred to the database and data quality control was performed. a total of 354 subjects meeting the inclusion and exclusion criteria volunteered to participate in the study. however, a small variance in the number of subjects occurred according to the scale or the question evaluated since some of them did not answer some questions in surveys and scales. after data quality control, data collected from 89 fms patients and 86 first-degree relatives of fms patients, 72 oa patients and 70 first-degree relatives of oa patients, 70 sd patients and 37 healthy controls were evaluated. data collection tools a socio-demographic information query form, psychological symptom checklist (scl-90)5, coping inventory for stressful situations (cope60 items)6 and the visual analog scale (vas) were applied to all volunteers to assess pain. scl-90 is a five-point likert scale with 90 items and 10 sub-domainsand is developed to determine the frequency and severity of psychiatric symptoms. as the scale score increases, the level of psychological disorder increases.an scl-90 score of greater than 1,0 indicates the presence of a mental problem, between 0,5-1 indicates a moderate problem, and below 0,5 indicates no problem (table 1 and table 2). cope is a scale comprised of 60 questions and 15 sub-domainsdeveloped to determine the coping strategies used in stressful events. these scales are defined in 3 summary scales and coping styles are explained with more general definitions.items in the cope scale are anchored by ‘‘usually do not do this at all’’ and ‘‘usually do this a lot’’ on a 4-point scale. a low score received from the subdomain of the scale indicates that those scales are used less, whereas a high score received indicates that those scales are used more.sub-domain of the scales used, questions from the sub-domainsand the meanings of sub-domainsare given in tables 1 and table 3. ataoğlu s, ataoğlu a, ankarali h, ankarali s, ataoğlu bb, ölmez sb 36 table 1.scales used in the study scale sub-domains question numbers in scales total score sc l -9 0 (9 0 qu es tio ns )5 somatization 1,4,12,27,40,42,48,49,52,53,56,58 present obsessive-compulsive 3,9,10,28,38,45,46,51,55,65 interpersonal sensitivity 6,21,34,36,37,41,61,69,73 depression 5,14,15,20,22,26,29,30,31,32,54,7 1,79 anxiety 2,17,23,33,39,57,72,78,80,86 hostility 11,24,63,67,74,81 phobic anxiety 13,25,47,50,70,75,82 paranoid ideation 8,18,43,68,76,83 psychoticism 7,16,35,62,77,84,85,87,88,90 additional items 19,44,59,60,64,66,89 total scl90 score (global severity index) average score of the 90 items c o pe (6 0 qu es tio ns )6 1. active coping 5,25,47,58 absent 2. restraint 10,22,41,49 3. planning 19,32,39,56 4. use of instrumental social support 4,14,30,45 5. suppression of competing activities 15,33,42,55 6. positive reinterpretation and growth 1,29,38,59 7. religious coping 7,18,48,60 8. humor 8,20,36,50 9. use of emotional social support 11,23,34,52 10. acceptance 13,21,44,54 11. behavioral disengagement 9,24,37,51 12. substance use 12,26,35,53 13. denial 6,27,40,57 14. mental disengagement 2,16,31,43 15. focus on and venting of emotions 3,17,28,46 su m m ar y sc al es problem focused coping (summation of 1-5 sub domain) emotional focused coping (summation of 6-10 sub domain) nonfunctional coping (summation of 11-15 sub domain) 37 comparison of psychiatric symptoms and attitudes of coping with stress table 2. sub-domainsmeanings of scl-90 scale scale sub-domains meaning scl-905 somatization this dimension reflects distress arising from bodily perceptions such as cardiovascular, gastrointestinal, respiratory, and other systems with autonomic mediation. obsessive-compulsive this dimension reflects symptoms typical of obsessivecompulsive disorder.experiences of cognitive attenuation are also included in this dimension. interpersonal sensitivity this dimension focuses on feelings of personal inadequacy and inferiority in comparisons with others. depression most of the typical symptoms of depressive syndromes according to current diagnostic criteria are included here. anxiety this dimension is composed of symptoms that are associated with manifest anxiety.some somatic correlates of anxiety are also included here. hostility thoughts, feelings, or actions characteristic of the negative affect state of anger are reflected here. qualities such as aggression, irritability, rage, and resentment are included. phobic anxiety the items of this dimension are actually all manifestations of agoraphobia. paranoid ideation paranoid ideation is represented here as a disordered mode of thinking. psychoticism items include withdrawal, isolation, and schizoid lifestyle as well as first-rank schizophrenia symptoms such as hallucinations and thought-broadcasting. additional items these items contribute to the global scores of the questionnaire but are not scored collectively as a dimension. they primarily touch upon disturbances in appetite and sleep patterns. total scl90 score (global severity index) all questions table 3. sub-domainsmeanings of cope-60 scale sub-domains meaning coping way cope606 1. active coping taking steps to eliminate the problem problem focused coping 2. restraint waiting for the right moment to act 3. planning thinking about dealing with the problem 4. use of instrumental social support seeking advice from others 5. suppression of competing activities focusing only on the problem 6. positive reinterpretation and growth reframing the stressor in positive terms emotional focused coping7. religious coping using faith for support 8. humor making light of the problem 9. use of emotional social support seeking sympathy from others 10. acceptance learning to accept the problem 11. behavioral disengagement giving up trying to deal with the problem nonfunctional coping 12. substance use using alcohol or drugs to reduce distress 13. denial refusing to believe the problem is real 14. mental disengagement distracting self from thinking about the problem 15. focus on and venting of emotions wanting to express feelings statistical analysis descriptive statistics (mean, standard deviation, minimum and maximum values, count and percent frequencies) of the data obtained were calculated and given in the tables (table 4 and table 5). the ataoğlu s, ataoğlu a, ankarali h, ankarali s, ataoğlu bb, ölmez sb 38 internal consistency between items and between sub-domainsof the scales were determined by the cronbach alpha coefficient. the relationships between scores were examined using the spearman rank correlation coefficient. a suitable chi-square test was used in the relationship between categories of socio-demographic characteristics and groups, and the variance analysis model was used in the comparison of five groups with regard to age, vas and number of siblings. since significant differences were observed between groups with regard to the age, vas, sex, education level, occupation, and marital status, these variables were taken as covariates in the model and covariance analysis was used in the comparison of groups regarding total scores and sub-domain scores and different groups were determined by the tukey hsd test. the statistical significance level was taken as p<0,05 and spss (ver. 18) was used in calculations. results a significant difference was detected in terms of age, vas and mean number of siblings among groups enrolled in the study (table 4). significant differences were found with regard to sex, marital status, education level, distribution of occupation, place of residence and substance use among the groups. this result indicates that groups are not homogenous in terms of characteristics (table 5). table 4.descriptive values of numerical variables variables fms relatives of fms oa relatives of oa control somatization disorder p n mean sd n mean sd n mean sd n mean sd n mean sd n mean sd age 89 50,6a 13,2 86 41,2b 13,8 71 61,4c 12,5 69 42,4b 15,6 37 31,4d 11,5 70 33,3d 13,4 <0.001 vas 81 6,6a 3,0 72 4,0b 3,3 53 5,8a 2,9 44 3,6b 3,0 36 0,8c 1,4 70 0,0c 0,0 <0.001 number of siblings 86 4,9 1,9 86 4,7 2,2 71 5,7 2,5 68 4,5 1,9 36 4,5 2,2 70 4,6 4,80 0.115 table 5.distribution of the categorical variables according to groups fms patients relatives of fms patients oa patients relatives of oa patients control somatization disorder p n % n % n % n % n % n % sex women 75 84,3a 53 61,6b 54 75,0ab 44 63,8b 21 56,8b 42 60,0b 0.002 male 14 15,7 33 38,4 18 25,0 25 36,2 16 43,2 28 40,0 marital status married 72 80,9 72 83,7 58 80,6 48 69,6 20 54,1 40 58,0 <0.001 single 8 9,0 12 14,0 3 4,2 17 24,6 16 43,2 27 39,1 widow 9 10,1 2 2,3 11 15,3 4 5,8 1 2,7 2 2,9 education level primary school 61 68,5 32 37,2 54 75,0 24 34,8 11 29,7 17 24,3 <0.001 middle school 10 11,2 11 12,8 7 9,7 6 8,7 5 13,5 13 18,6 high school 9 10,1 24 27,9 8 11,1 20 29,0 4 10,8 17 22,9 university 9 10,1 19 22,1 3 4,2 19 27,5 17 45,9 23 32,9 occupation housewife 57 64,0 26 31,0 45 62,5 23 33,3 6 16,2 24 34,8 <0.001 officer 4 4,5 13 15,5 5 6,9 9 13,0 8 21,6 3 4,3 worker 10 11,2 24 28,6 6 8,3 15 21,7 5 13,5 13 18,8 retired 11 12,4 7 8,3 10 13,9 8 11,6 2 5,4 2 2,9 student 3 3,4 1 1,2 1 1,4 2 2,9 11 29,7 12 17,4 other 4 4,5 13 15,5 5 6,9 12 17,4 5 13,5 15 21,7 place of residence city-town 59 66,3 59 69,4 49 68,1 58 84,1 31 83,8 55 78,6 0.049 village 30 33,7 26 30,6 23 31,9 11 15,9 6 16,2 15 21,4 substance use cigarette 19 21,3 28 32,9 10 13,9 20 29,0 14 37,8 23 74,2 <0.001 cigarette +alcohol 1 1,1 3 3,5 1 1,4 4 5,8 2 5,4 5 16,1 alcohol +substance 0 0,0 0 0,0 0 0,0 1 1,4 0 0,0 0 0,0 all 0 0,0 0 0,0 1 1,4 0 0,0 0 0,0 3 9,7 none 69 77,5 54 63,5 60 83,3 44 63,8 21 56,8 0 0,0 internal consistency were found high between the items of the scl90 and cope scales and their sub-domain (table 6). 39 comparison of psychiatric symptoms and attitudes of coping with stress table 6.internal consistencies of scales cronbach alpha coefficients ölçek fms patients relatives of fms patients oa patients relatives of oa patients control somatization disorder scl-90 (90 items) 0,981 0,980 0,973 0,971 0,981 0,985 scl-90 (10 sub-domain) 0,966 0,967 0,953 0,954 0,970 0,962 cope (60 items) 0,939 0,927 0,935 0,953 0,925 0,927 cope (15 sub-domain) 0,893 0,875 0,897 0,920 0,883 0,872 cope (3 summary measure) 0,856 0,803 0,802 0,853 0,816 0,804 due to significant differences with regard to age, vas, education level, sex, marital status, occupation and place of residence among groups, when comparing the groups in terms of scores, the effects of these factors on scale scores were taken into consideration as well. thus, corrected means were calculated when a significant relationship was found between said socio-demographic characteristics and scale scores, otherwise correction the mean was not necessary. when the effect of vas, age, education, marital status and sex on “substance use”, “denial” and “non-functional coping” in sub-domain of the cope scale were examined, the effect of education was found to be significant. as the education level increased, those who preferred substance use and the denial method decreased. it was observed that the non-functional coping method was preferred less in post-graduates. the sub-domain of “mental disengagement” was found to be significantly related to both education level and marital status. the mental disengagement attitude was preferred less in widows and as education level increased. after obtaining this score, after the effect of education and marital status was eliminated, the group means of corrected scores were compared. since the effect of age, vas, sex, marital status and education was not found to be significant on 12 other sub-domains and 2 summary scales of the cope scale, group means with regard to these sub-domains were compared without correcting according to these factors. the results achieved are given in table 7. table 7. comparison of cope scores of the groups cope fms patients (n=87) relatives of fms patients (n=86) oa patients (n=70) relatives of oa patients (n=65) control (n=36) somatization disorder (n=70) pa mean sd mean sd mean sd mean sd mean sd mean sd 1. active coping 10,72b 2,84 12,20a 2,33 11,62ab 2,88 11,82a 3,07 12,03a 2,90 10,66b 3,12 0,002 2. restraint 8,90b 2,72 10,45a 2,81 10,04a 2,68 9,46ab 2,48 9,94ab 2,38 8,80b 2,65 0,001 3. planning 10,75b 2,93 12,04a 2,43 11,37a 2,99 11,00a 3,20 11,92a 2,56 10,61b 3,20 0,012 4. use of instrumental social support 11,32 2,84 11,91 2,53 11,58 2,94 10,93 3,26 11,31 2,81 11,24 3,50 0,459 5. suppression of competing activities 10,31 2,61 10,41 2,46 10,15 2,76 9,87 2,63 9,11 2,42 9,57 2,35 0,070 6. positive reinterpretation and growth 10,75b 2,69 12,55a 2,30 11,66ab 2,68 11,88ab 2,97 11,05ab 2,62 10,64b 3,03 0,001 7. religious coping 11,72a 2,65 13,31b 2,91 13,87b 2,71 12,66ab 3,18 12,50ab 2,91 11,59a 3,02 0,001 8. humor 7,64 3,13 8,08 2,90 7,76 2,96 7,60 2,88 7,53 2,52 6,70 2,87 0,104 9. use of emotional social support 10,91 2,88 11,58 2,89 11,06 2,82 10,51 2,79 10,11 3,17 10,77 3,10 0,123 10. acceptance 9,38b 2,70 10,89a 2,48 10,39a 2,93 9,34b 2,74 9,36b 2,68 9,25b 3,05 0,001 11. behavioral disengagement 8,70a 3,15 7,53ab 2,99 7,39 2,54 7,20 2,44 7,12 2,75 8,90 2,62 0,001 12. substance use 5,93 3,26 6,00 3,06 5,88 3,18 6,23 2,98 6,22 3,00 6,61 2,93 0,743 a 13. denial 8,40a 3,08 7,87ab 2,97 7,99ab 2,10 7,08b 2,90 7,26b 2,94 8,68a 2,93 0,028 a 14. mental disengagement 10,19a 3,08 8,88b 3,06 8,70b 2,93 8,83b 2,82 9,09b 2,76 10,79a 2,84 0,010a 15. focus on and venting of emotions 10,98 2,57 11,28 2,92 10,93 2,86 10,21 2,91 10,75 3,05 11,14 2,95 0,297 problem focused coping 50,67a 10,93 55,00b 9,38 55,76b 11,75 53,07ab 11,62 53,31ab 10,61 50,69a 10,50 0,012 emotional focused coping 52,00a 9,28 56,41b 8,75 55,75b 10,12 53,99ab 10,80 53,75ab 9,42 51,21a 9,82 0,002 nonfunctional coping 43,29a 11,94 40,30ab 11,78 38,17b 11,38 38,99b 10,80 37,36b 10,56 44,66b 11,04 0,010a a: adjusted p values according to ancova model, other p values were not adjusted because covariate effects were found not significant ataoğlu s, ataoğlu a, ankarali h, ankarali s, ataoğlu bb, ölmez sb 40 when we evaluated the 15 sub-domains and 3 summary scales of the cope scale, we determined that patients diagnosed with fms and patients with somatization disorder preferred the “active coping, restraint, planning, positive reinterpretation and growth, religious coping and acceptance” strategies significantly less than other groups. on the other hand, patients diagnosed with fms and somatization patients preferred behavioral disengagement, denial and mental disengagement attitudes more compared to the other groups. no significant difference was observed with regard to other sub-domain scores. in addition, we determined when we evaluated the 3 sub-domain results which are more commonly used in the interpretation of the cope scale that the patients diagnosed with fms and patients with somatization disorder preferred “problemfocused coping and emotional-focused coping” significantly less and preferred non-functional coping significantly more. it has been observed that oa patients could be categorized in the middle of both sides on many occasions. after the effects of age, vas, education and marital status on scl-90 scores were eliminated, no significant difference was observed among groups with regard to mean 10 sub-domain scores and mean general score (table 8). according to this result, when the effect of socio-demographic factors was eliminated, it was concluded that said groups indicated no significant difference with regard to frequency and severity of psychiatric symptoms. it was determined that the relationship between all scl-90 scales and education level was negative. it was observed that as education level increased, psychiatric symptoms decreased. on the other hand, it was determined that there was a positive relationship between vas scores and somatization, and obsessive-compulsive symptoms, interpersonal sensitivity, anger and hostility decreased with age. sex was found to be associated only with somatization, and higher somatization scores were observed in women. a significant relationship was not found between marital status and scl-90 points. when the effect of these factors were eliminated, in other words, when individuals with the same sex, same age, same education level and same vas level but with different groups were considered, no difference was detected in psychological symptoms. table 8. comparison of scl-90 scores of the groups scl-90 adjusted group means results of ancova fms patients (n=87) relatives of fms patients (n=86) oa patients (n=70) relatives of oa patients (n=65) control (n=36) somatization disorder (n=70) adj. pgroup covariates with significant effectsa mean sd mean sd mean sd mean sd mean sd mean sd somatization 1,40 1,03 1,33 0,93 1,24 1,09 1,11 0,97 1,22 0,90 1,30 1,09 0,540* sex(f+), education(-), vas(+) obsessivecompulsive 1,32 1,12 1,19 1,02 1,06 1,17 1,20 1,05 1,09 1,02 1,30 1,17 0,194 age(-), education(-) interpersonal sensitivity 1,20 0,93 1,00 0,83 0,97 0,92 0,99 0,81 0,92 0,90 0,96 1,00 0,411 age(-), education(-) depression 1,23 0,93 1,03 0,83 0,98 0,92 0,93 0,81 1,01 0,84 1,20 0,92 0,168 education (-) anxiety 1,09 0,84 0,95 0,83 0,94 0,84 0,84 0,81 0,93 0,84 1,09 0,92 0,415 education (-) hostility 1,02 0,93 0,89 0,93 1,05 1,00 0,88 0,89 0,87 0,90 1,07 1,00 0,628 age(-), education(-) phobic anxiety 0,75 0,84 0,63 0,74 0,66 0,84 0,60 0,81 0,55 0,78 0,59 0,84 0,786 education(-) paranoid ideation 1,13 0,93 1,10 0,83 0,94 0,92 0,90 0,89 0,95 0,84 1,00 0,92 0,501 education(-) psychoticism 0,86 0,75 0,77 0,74 0,68 0,75 0,69 0,73 0,71 0,72 0,61 0,84 0,397 education(-) additional items 1,33 0,93 1,13 0,83 1,12 0,92 1,00 0,81 1,13 0,84 1,13 0,92 0,288 education(-) global severity index 1,18 0,75 1,03 0,74 0,97 0,75 0,93 0,73 0,95 0,72 1,02 0,75 0,288 education(-) a: (+):significantly positive correlate with scale scores, (-): significantly negative correlate with scale scores the correlations between the sub-domains of cope and scl-90 in all individuals regardless of groups are given in table 9. a significant relationship was found between all the scales of the scl-90 scale and the sub-domains“restraint, planning, positive reinterpretation and growth, humor, acceptance, behavioral disengagement, substance use, denial, mental disengagement, focusing on the problem and venting of emotions” and the “non-functional coping” scale of the cope scale. a negative correlation was found between “planning, positive reinterpretation and growth” sub-domain scores and a positive correlation was found with other sub-domains. 41 comparison of psychiatric symptoms and attitudes of coping with stress table 9.correlations between the sub-domainsof cope and scl-90 scales in all individuals cope 60 scl90 so m at iz at io n o bs es si ve -c om pu ls iv e in te rp er so na l s en si tiv ity k iş ile ra ra sı du ya rlı lık d ep re ss io n a nx ie ty h os til ity ph ob ic a nx ie ty pa ra no id pa ra no id id ea tio n ps yc ho tic is m g lo ba l s ev er ity in de x active coping r -,021 -,092 -,069 -,108 -,090 -,102 -,088 -,046 -,089 -,031 -,081 p ,684 ,067 ,171 ,032 ,073 ,043 ,079 ,361 ,076 ,537 ,108 restraint r ,159 ,208 ,236 ,215 ,205 ,157 ,251 ,228 ,226 ,141 ,229 p ,002 ,000 ,000 ,000 ,000 ,002 ,000 ,000 ,000 ,005 ,000 planning r -,048 -,141 -,099 -,111 -,116 -,118 -,119 -,062 -,113 -,099 -,118 p ,346 ,005 ,050 ,028 ,021 ,019 ,018 ,218 ,025 ,051 ,019 use of instrumental social support r -,046 -,016 -,003 ,019 -,021 -,045 ,005 -,001 -,030 -,055 -,021 p ,360 ,748 ,954 ,703 ,679 ,370 ,917 ,980 ,554 ,275 ,680 suppression of competing activities r ,112 ,083 ,103 ,093 ,115 ,066 ,102 ,072 ,083 ,067 ,105 p ,027 ,099 ,041 ,066 ,022 ,189 ,043 ,153 ,101 ,185 ,036 positive reinterpretation and growth r -,022 -,108 -,079 -,121 -,120 -,112 -,167 -,100 -,159 -,087 -,114 p ,658 ,032 ,116 ,017 ,017 ,026 ,001 ,046 ,002 ,083 ,023 religious coping r ,089 -,027 -,020 -,022 -,049 -,076 -,059 -,066 -,065 ,053 -,016 p ,080 ,591 ,696 ,659 ,329 ,131 ,242 ,194 ,200 ,291 ,746 humor r ,109 ,162 ,120 ,133 ,192 ,129 ,135 ,185 ,199 ,176 ,174 p ,032 ,001 ,017 ,008 ,000 ,010 ,007 ,000 ,000 ,000 ,000 use of emotional social support r -,018 -,044 -,007 -,018 -,026 -,036 ,008 -,029 -,034 -,051 -,030 p ,718 ,381 ,893 ,727 ,613 ,480 ,872 ,562 ,506 ,308 ,546 acceptance r ,207 ,203 ,192 ,208 ,195 ,132 ,133 ,219 ,176 ,193 ,214 p ,000 ,000 ,000 ,000 ,000 ,008 ,008 ,000 ,000 ,000 ,000 behavioral disengagement r ,174 ,292 ,308 ,324 ,316 ,268 ,355 ,299 ,348 ,246 ,332 p ,001 ,000 ,000 ,000 ,000 ,000 ,000 ,000 ,000 ,000 ,000 substance use r ,140 ,215 ,236 ,218 ,349 ,262 ,296 ,235 ,335 ,226 ,274 p ,006 ,000 ,000 ,000 ,000 ,000 ,000 ,000 ,000 ,000 ,000 denial r ,098 ,238 ,258 ,205 ,230 ,184 ,256 ,258 ,302 ,205 ,247 p ,050 ,000 ,000 ,000 ,000 ,000 ,000 ,000 ,000 ,000 ,000 mental disengagement r ,125 ,180 ,185 ,182 ,187 ,129 ,199 ,209 ,205 ,152 ,197 p ,013 ,000 ,000 ,000 ,000 ,010 ,000 ,000 ,000 ,002 ,000 focus on and venting of emotions r ,070 ,083 ,162 ,151 ,128 ,140 ,101 ,156 ,101 ,099 ,137 p ,170 ,099 ,001 ,003 ,011 ,005 ,044 ,002 ,046 ,050 ,006 problem focused coping r ,032 ,004 ,036 ,021 ,016 -,016 ,030 ,041 ,012 ,001 ,021 p ,523 ,942 ,479 ,685 ,753 ,750 ,551 ,414 ,813 ,991 ,675 emotional focused coping r ,105 ,055 ,060 ,053 ,057 ,012 ,017 ,061 ,036 ,083 ,067 p ,038 ,276 ,238 ,295 ,260 ,814 ,741 ,229 ,478 ,099 ,184 nonfunctional coping r ,168 ,289 ,329 ,308 ,348 ,284 ,347 ,333 ,371 ,266 ,341 p ,001 ,000 ,000 ,000 ,000 ,000 ,000 ,000 ,000 ,000 ,000 discussion fms is a major disease among chronic pain syndromes. even though it has diagnostic criteria and many symptoms, there are still no acceptable etiological causes, or inflammation, laboratory, or radiological findings. prognosis is uncertain, treatment is difficult and there is no certain treatment.7 fms is a difficult disease for doctors, patients and their relatives. therefore, it is one of the leading diseases for which much research is conducted. therefore, research consisting of mental and physical functions and attitudes will play an important role in the awareness of the disease. stress is any kind of compelling thought or event that challenges and disrupts the harmony of the person. stress is a major health problem because it affects many organs etiologically and causes psychological disorders.8,9when a given situation is perceived as stress, a series of physiological mechanisms is activated. these mechanisms occur with noradrenaline and cortisol secretion as a result of activation of the sympathetic and ataoğlu s, ataoğlu a, ankarali h, ankarali s, ataoğlu bb, ölmez sb 42 adrenomedullary system with hypothalamicpituitary-adrenal axis10. stress causes distress in people. the person searches for ways to cope with the stress in order to get rid of their distress. many people get rid of stress by using coping methods. however, some people use somatization to get rid of the distress caused by stress instead of coping with it. marital status, economic conditions, education level, age, pain and sex may directly affect strategies for coping with stress. in our study, the number of subjects using the method of “substance use and denial” to cope with stress decreased with higher education level. this is because educated people are more aware that substance use is hazardous and prefer to face the truth more and reduce user denial. we found that post-graduates preferred the method of “non-functional coping” more and educated people used functional coping methods that led to a result. those who used “mental disengagement” decreased in widows and as education level increased. this showed us that these people focused on solving the problem instead of being distanced from stress. psychological symptoms are affected by age, pain, sex and education level. use of psychological symptoms decreased with increased education level. we observed that most of those with a low education level used psychological symptoms more due to being in economical difficulties, not being able to cope with their problems and not being able to find a way to cope with their problems. we found a positive relationship between pain and somatization; because not only is pain a form of expression of somatization, but also somatization is mostly expressed with pain, namely it is revealed by pain. we observed that with increased age, obsessive-compulsive symptoms, interpersonal sensitivity, anger and hostility decreased. this is because people who are advanced in age have developed insight and gained experience as a result of stressful events and they can produce solutions to stressful events. we determined that sex and somatization are related and that the somatization score is high in women. we believe that this is due to the fact that women fall behind in social life and have a lower education level. due to these demographic differences, after eliminating the effect of education level, age, pain and sex on scores to be able to evaluate coping with stress directly, we achieved the corrected scores of the groups. when the effect of these factors is eliminated, we did not observe any psychological differences in individuals in any of the groups. this showed us that these factors directly affected psychological symptoms. we observed that fms relatives, oa patients, their first-degree relatives and the healthy group used problem-focused coping more. we determined that the scores of the “denial, behavioral disengagement, mental disengagement” subdomains, which are methods of non-functional coping, were significantly higher in fms patients and patients with somatization disorder compared to other groups. fms and sd patients used similar coping methods when they faced a stressful environment. this brought up the question whether the disease was used as a way to cope with stress. this raised the question “are somatization disorder and fms the same disease?” particularly, younger ages (25-30) are ages when people get married, when problems in marriage begin, expectations emerge, economic difficulties are experienced most frequently due to a need to fit in a new social environment, and when people face the facts of life. at these ages, people may face more stress. when patients with fms and somatization disorder face stress, not being able to fulfill expectations causes an internal conflict and tension. this internal tension increases sympathetic activity and cortisone. a patient, who notices symptoms occurring as a result of these, avoids stress by paying attention to somatic complaints, abandoning his/her conflicts with the outer world. some learn these physical complaints of stress from family members, they model them, and the stress and somatic complaints switch places. thus, the person deals with the physical complaints and gets rid of the distress and tension caused by stress. these people cannot produce healthy solutions and cannot find a healthy way out in coping with stress. somatization disorder is a chronic disease presenting with somatic symptoms which cannot be explained medically. the disease starts before the age of 30,is observed in a ratio of 4-7% and more frequently in women and patients with this disease visit the doctor more than other patients11.even though there are advancements in studies conducted on somatization disorder, its pathophysiology remains unclear.12emotional status is one of the statuses that affects somatization disorder.7 many studies demonstrate a relationship between emotional status and psychiatric disorders.13 43 comparison of psychiatric symptoms and attitudes of coping with stress as distinct from other rheumatic diseases, such as oa, fms is observed in patients with low socioeconomic and education level and more frequently in women. fms usually starts between the ages of 25-35 and is observed most intensely between the ages 18-50.14-16 even though clear information with regard to exact age of onset does not exist, fms can even start in childhood. the motivation of fms patients is low and they visit the doctor more. ability to cope with stress is reported to be low in these patients.17 despair may show an important correlation with any disease with chronic pain, particularly fms. fms is affected by stress more than other rheumatic diseases, particularly rheumatoid arthritis and systemic lupus erythematosus.18-20 conclusion we observed that fms and somatization share the same features, such as: both are formed only of symptoms; both share similar symptoms; no exact knowledge on their etiopathogenesis exists; both occur in women more frequently; their age of onset is close; both are observed more in people with low education and socio-economic level; the patients visit the doctor more than normal; although both have diagnostic criteria there are no certain laboratory or radiological findings; both use the same methods in coping with stress; both have no certain treatments and have uncertain prognosis. all these results suggested that fms and somatization disorder are the same disease. therefore, we concluded that more research should be conducted on the subject we addressed in this study. ataoğlu s, ataoğlu a, ankarali h, ankarali s, ataoğlu bb, ölmez sb 44 references 1. wolfe f, clauw dj, fitzcharles ma, goldenberg dl, katz rs, mease p, et al. the american collage of rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. arthritis care & research. 2010;62:600-10. 2. palacio a, uribe cl, li h, hanna j, deminski m, alvir j,et al. financial and clinical characteristics of fibromyalgia: a case-control comparison. am j manag care. 2010;16:118-25. 3. regier ng, parmelee pa. the stability of coping strategies in older adults with osteoarthritis and the ability of these strategiestopredict changes in depression, disability, and pain. aging ment health 2015;19:1113-22. 4. su q, yao d, jiang m, liu f, jiang j, xu c, dai y, yu m, long l, li h, liu j, zhang j, xiao c, guo w. i̇ncreased functional connectivity strength of right inferior temporal gyrus in first-episode, drug-naive somatization disorder. anzjp 2015;49(1):74-81. 5. kılıç m. belirtitaramalistesinin(scl.90-r) geçerlilikvegüvenirliği. psikolojikdanışmaverehber likdergisi 1991;1(2):45-52. 6. özarslan z, fıstıkçı n, keyvan a, uğurad zi, saygılı s. depresyonhastalarınınstresilebaşaçıkmastratejile ri. marmara medical journal 2013; 26:130-135. 7. hughes ek, gullone e. emotion regulation moderates relationships between body image concerns and psychological symptomatology. body image 2011;8:224-31. 8. arnetz bb, ekman r. stress in health and disease. weinhei:m wiley-vch verlaggmbhco. kgaa; 2006. 9. chrousos gp. stress and disorders of the stress system. nat rev endocrinol 2009;5:374-81. 10. gonzalez-cabrera j, fernandez-prada m, iribaribabe j, peinado m. acute and chronic stress increase salivary cortisol: a study in the real-life setting of a national examination undertaken by medical graduates. stess 2014;17(2):149-156. 11. rief w, hessel a, braehler e. somatization symptoms and hypochondriacal features in the general population. psychosomatic medicine 2001;63:595602. 12. su q, yao d, jiang m, liu f, jiang j, xu c, dai y, long l, li h, liu j, zhang j, xiao c, guo w. increased functional connectivy strength of inferior temporal gyrus in first-episode, drug-naïve somatization disorder. anzjp 2015;49(1):74-81. 13. sheybaninoghabi f, ashgharnejad aa, fathalilavasani f, noorbala aa. comparison of emotion regulation dimensions and attachment styles between people with somatization disorder and normal individuals. hormozgan med j 2015;19(4)269-74. 14. weir pt, harlan ga, nkoy fl, jones ss, hegmann kt, gren lh, lyon jl. the incidence of fibromyalgia and its associated comorbidities: a population-based retrospective cohort study based on international classification of diseases, 9th revision codes. j clin rheumatol 2006;12(3):124–8. 49. 15. anthony kk, schanberg le. juvenile primary fibromyalgia syndrome. curr rheumatol rep 2001;3(2):165–71. 50. 16. yunus mb, masi at. juvenile primary fibromyalgia syndrome. a clinical study of thirty-three patients and matched normal controls. arthritis rheum 1985;28(2):138–45. 17. schoctat t, beckmann c. socio-demographic characteristics, risk factors and reproductive history in subjects with fibromyalgia-results of a populationbased case control study. z rheumatol 2003; 62(1): 46-59. 18. reich jw, johnson lm, zautra aj, davis mc. uncertainty of illness relationship with mental health and coping processes in fibromyalgia patients. j behavioral med 2006;29:307-16. 19. burckhardt cs, bjelle a. perceived control: a comparison of women with fibromyalgia, rheumatoid artritis and systemic lupus erythematosus. scand j rheumatol. 1996;25:300-6. 20. smith tw, christensen aj, peck jr, ward jr. cognite distortion, helplessness, and depressed mood in rheumatoid arthritis: a four-year longitudinal analysis. health psychol1994;13:213-7. international journal of human and health sciences vol. 06 no. 01 january’22 24 original article: tattoo and body piercings among young adults in nigeria ebeye oladunni abimbola1,osahon roli itohan2, ehebha santos ehizokhale2,ojumah nancy chuwuma1, okoro ogheneyebrorue godswill1, akpoyibo emmanuel enatewe1 abstract: objective: both tattoo and body piercing have a long history and are well known in various cultures in african, american, asia, and oceania. although the appearance of the two varies geographically, they always possess a specific meaning for a particular culture. this study examined awareness, attitude, and knowledge of students towards tattooing and body piercing in delta state university, abraka. nigeria. material and methods: data was collected through the use of well-structured questionnaires. the study made use of 400 young adults randomly selected from six faculties in delta state university, abraka. result and discussion: findings revealed that the majority of students (85%) are aware of tattoo and body piercing and 31.3% gave fashion as the main reason why they engage in body modifications. it was however observed that 40% of the  subjects under survey regard their colleagues involved in tattooing and body piercing as irresponsible and reckless. conclusion: the study gave a growing convergence on both gender toward tattooing and a sharp difference in the involvement of both gender towards  body piercing. majority of these young adult are also aware of the health risks associated with body modifications and may not consider them in future.  keywords: tattoo, body piercing, students, religion, perception correspondence to: okoro ogheneyebrorue godswill, department of human anatomy and cell biology, faculty of basic medical sciences, delta state university, abraka, nigeria. email: thomasgodswill23@gmail.com 1. department of human anatomy and cell biology, faculty of basic medical sciences, delta state university, abraka 2. department of anatomy, college of medicine, edo university iyamho; p.m.b 04 iyamho, edo state, nigeria international journal of human and health sciences vol. 06 no. 01 january’22 page : 24-29 doi: http://dx.doi.org/10.31344/ijhhs.v6i1.372 introduction a tattoo is a form of body beautification where  indelible ink, dyes, and pigments are used to make an inscription on dermis that remains underneath the epidermis layer of the skin 1 for temporary or permanent reasons. a tattoo is temporary when the immune system of the participant can dissolve the pigments found in the tattoo ink or the use of laser treatment that requires identification of a colour  in the pigment and breakdown of the colour for macrophages to act on it2. the various pigments or colourants mixed with carriers to produce tattoo inks are sometimes made from heavy metals and minerals such as carbon, iron oxide, cinnabar. the functions of the carriers are for dissolving and movement of the pigment from the point of needle insertion to the various mapped out surfaces of the skin2. it is arguably claimed that tattooing has existed since 12,000 years bc with its purpose varying from culture to culture and its place on the timeline. tattoos are drawn to express one’s state of independence, for religious or cultural reasons, or to adorn one’s body. the importance of tattoos in ritual and tradition is seen in borneo women whose tattooed forearm symbolizes a particular craft they are skilled on. 25 international journal of human and health sciences vol. 06 no. 01 january’22 body piercing is an act of body modification done  through penetration or opening of body parts such as eyebrows, lips, tongues, nose, nipples, or genitals to insert ornaments3. both tattoo and body piercing have a long history and are well known in various cultures in african, american, asia, and oceania4. although the appearance of the two varied geographically, they always possess a very specific meaning for a particular culture. whereas  piercings are often used in initiation rites to assign their bearer to a certain social or age group 5, tattoos are utilized to signal religious affiliations,  strength, or social status6,7.  body  modifications  are potentially an important aspect of human identification8, and they have significantly aided  forensic anthropological cases in recent years9. starkie articulates that the increasing use of body modifications  encourages  those  undertaking  the  practices for their “extreme” nature to seek new  methods of modifying their bodies8. youths in higher institutions of learning, music artists, movie actor/actress, beauty experts, sportsmen/women, fashion models are now engaging in tattooing and body piercing 10,11. although there is growing popularity of tattooing and body piercing among youths in nigeria, yet, their excessive application and practice may have serious social and health body implications for body modifiers. skin damage and rashes are common  skin problems, while emotional detachments from the old image or collapsed relationships are  usually  difficult  to  remove12. according to wohlrab, stahl, and kappeler 13, tattoos can cause skin problems such as granulomas (red bumps caused by inflammation) and keloid scars. it can  also provoke allergic reactions like skin itches and break out13. also, viral infectious diseases, such as hepatitis a, hepatitis b, and hiv/aids can also be contracted via discharged body fluids and needles  used  during  modification  exercise. also,  tattoos  and body piercing in some situations can limit the opportunity, as well as accentuate the tendency to discriminate against their wearers. this study therefore, seeks to examine the awareness and attitude of young adults towards tattooing and body piercing. materials and methods a total of 400 students’aged 16-30 at various faculties of delta state university, abraka. nigeria were administered questionnaires.ethical approval was obtained from the research and ethics committee of human anatomy and cell biology department of delta state university, abraka. students were randomly selected from six faculties and were assessed using a cross-sectional survey design. questionnaires that were not accurately filled were excluded. respondents were informed of the purpose of study and their consent was sort and obtained. questionnaires were thereafter distributed to respondent whose privacy were kept confidential  by not including any of their bio data. respondents filled  the  questionnaire  after  carefully  going  through the questions with the right understanding of the questions and the questionnaires were retrieved. the data obtained were processed and analyzed through the use of statistical package for social sciences (spss), version 25. results are presented in simple percentages results from table 1: it was observed that the majority of the respondent(85.0%) are aware of tattoo and body piercing, 78%of respondent indicated males are mostly involved in tattooing as compared to female,8% had no idea of tattooing. however, fewer males were indicated to be involved in body piercing as compared to females (80.5%). table  2  &  3,  revealed  that  the  majority  of  the  respondents do not have any form of body modifications,  about  13.5%  had  a  tattoo  and  17.5% had their body pierced. also,59.0% of the respondents do not have a reason for their body modifications neither does it have any significance. table 4, showed that 31.1% of respondent engage in tattoo and body piercing purely for fashion, 14.0%claimed that students who engage in these two forms of body modifications believe that they  serve  as  a  source  of  strength  and  identification,  24.3% indicated that tattoo and body piercing enhance sexual attraction, 25.8% attributed that students involvement in tattoo and body piercing is as a result of peer pressure. 4.8% stated other reasons why students engage in piercing and tattooing. as  shown  in  table  5  &  6,  the  majority  of  the  respondents consider students who wear tattoo and engage in body piercing as irresponsible and reckless, while 23.3% are indifferent, 19.8%  international journal of human and health sciences vol. 06 no. 01 january’22 26 believe they are bad and dangerous however, 13.0% sees them as fashionable and 4.0% consider them being decent. about 44.5% see students without tattoo and body piercing as decent and responsible however 18.5% see them as not being fashionable and others see them as inferior. table 7 revealed 62.5%of respondents are aware of health risks associated with tattooing and body piercing while others are not. 61.8%of the respondents are in agreement that tattooing and body piercing can transmit infectious disease, while 9.8% of disagreed with 28.3% having no idea. table 8 showed that of the 400 respondents, 19.5% would consider tattooing in the future while majority (65.8%) would not. 68.0% of the respondents would not consider body piercing in the future, 20.3% and 11.8%would consider piercing and have no idea respectively. table 9 showed that of the400 respondents, 18.0% agreed that tattoo and body piercing is accepted in christianity, 15.8%of the respondents agreed that tattoo and body piercing is accepted in islam, however majority believed it is against their religion. table 1: respondents knowledge on tattoo and body piercing yes % no % no idea % 1 are you aware of tattoo and body piercing? 340 85.0 38 9.5 2.2 5.5 2 are males mostly involved in tattoo 313 78.3 56 14.0 31 7.8 3 are females mostly involved in tattoo 220 55.0 138 34.5 42 10.5 4 are males mostly involved in body piercing 148 37.0 202 50.5 50 12.5 5 are females mostly involved in body piercing 322 80.5 49 12.3 29 7.2 table 2: do you have any body modification? frequency percentage (%) p-value tattoo piercing none total 54 70 276 400 13.5 17.5 69.0 100 0.000 table 3: respondents reason and significance of body modification yes % no % no idea % 1 is there a reason for your body modification?  111 27.8 236 59.0 53 13.3 2 does it signify something? 92 23.0 234 58.5 74 18.5 table 4: respondents idea on why students engage in tattoo and body piercing frequency percentage (%) p-value fashion sexual attraction strength and identification  peer pressure others total 125 97 56 103 19 400 31.3 24.3 14.0 25.8 4.8 100 0.000 table 5: how respondents perceive student with tattoo and body piercing frequency p e r c e n t a g e (%) p-value bad and dangerous indifferent   irresponsible fashionable l decent 79 93 160 52 1600 19.8 23.3 40.0 13.0 4.0 0.000 table 6: how respondents perceive students without tattoo and body piercing frequency percentage (%) p-value responsible decent inferior not fashionable 113 178 35 74 28.2 44.5 8.8 18.5 0.000 table 7: respondent’s knowledge of health risk associated with tattoo and body piercing yes % no % n o idea % p-value 1 do you know about the health risk involved in tattooing and body piercing 250 62.5 91 22.8 59 14.8 2 is it risky undergoing tattooing and body piercing 225 56.3 83 20.8 92 23.0 0.000 27 international journal of human and health sciences vol. 06 no. 01 january’22 yes % no % n o idea % p-value 3 can tattooing and body piercing transmit infectious disease 247 61.8 39 9.8 114 28.5 4 are the place or instruments used for body modification  always safe 114 28.5 137 34.3 149 37.3 table 8: future consideration of tattoo and body piercing yes % no % n o idea % p-value 1 would you consider tattoo in the future 78 19.5 263 65.8 59 14.8 0.000 2 would you consider piercing in the future 81 20.3 272 68.0 47 11.8 table 9: religious view on tattooing and body piercing yes % no % no idea % p-value 1 is tattoo and body piercing accepted in christianity 72 18.0 231 57.8 97 24.3 0.000 2 is tattoo and body piercing accepted in islam 63 15.8 123 30.8 214 53.5 fig 1. shows gender distribution of respondents fig 2.shows age distribution of respondents fig 3.shows religion of respondents the figure above showed that about 87% of the  respondents were christians. fig 4. shows faculty of respondents as shown in the figure above, students of basic  medical sciences were30%, followed by those of faculty of social sciences and faculty of science 17.5% respectively, faculty of arts, 13.8%, faculty of education, 12.5%, and faculty of pharmacy, 8.8%. the study recorded an equal number of persons in gender (male or female) who gave a response about their knowledge of tattoo and body piercing. fig 1.revealed that the total number of males (n = 200, 50%) was equal to the total number of females (n = 200, 50%). this shows that the concepts of discussion are known to the populace irrespective of how it is done and who is involved in the process. international journal of human and health sciences vol. 06 no. 01 january’22 28 fig 2 showed that the majority of the respondents were within the age group 21-25 years, a total of 63%, followed by age group 16-20 years, 25.5%, and age group 26-30 years, 11.5%. discussion and conclusion in this study, we discovered from the responses obtained that majority of the students in delta state university are aware of tattoo and body piercing and these act is progressively increasing among young adults. this finding agrees with demello’s  14 observation that tattoo and body piercing has increased tremendously in popularity, rising not only in numbers but also dependent on the social classes of those involved. a similar observation was also recorded by ezeibekwe et al. 15 stating that  these  two  forms  of  body  modifications  are  increasingly gaining ground among university undergraduate students from ibadan.it is obvious that the ills and believes previously associated with tattooing and body piercing is gradually been eroded. from our study, males were mostly involved in tattooing while females are mostly involved in body piercing. these findings are in terms with the  observation of totten et al. 16 and atkinson 17 that tattoos and body piercing have been noted to be subjected to gender norms, and as such, male and female are being accessed differently. ezeibekwe  et al. 15 also stated that unlike the growing convergence in the deposition of the two sexes toward tattooing, a sharp difference still exists in  the involvement of the two sexes in body piercing. body piercing among females is usually seen as a norm in most part of the world without negative attachment as compared to body piercing among men. students wear tattoo and/or engage in body piercing  for  different  reasons  which  include:  fashion, peer pressure, sexual attractions, show for  strength  and  identification.  other  reasons  given were an imitation of role models and love for artwork. craik 18 and turner 19 have similarly observed that tattoos and body piercing today are  mainly  fashion  accessories.  these  findings  also equally corroborate the position of wessely 20 that people’s motivations for tattooing could be emotional, practical, complex, or very simple. also, currie 21 and meltzer 22 found that 62% of people who have had piercings have done so in an effort “to express their individuality.” some people  pierce, permanently or temporarily, to enhance sexual pleasure. genital and nipple piercings may increase sexual satisfaction. despite the acceptance gained by body modifiers,  40%  of  respondent  still  find  their  colleagues  who engage in tattoo and body piercing as irresponsible and reckless. a similar observation was recorded by ezeibekwe et al. 15 stating that those who engage in any of these modifications  are still largely viewed by their colleagues who do not embrace the practice, as irresponsibleand dangerous. it was given from this study that 65.8% and 68.0% maintained that they will not consider tattooing and body piercing respectively in the future. this could be a result of the health risk, personal opinion, religious and cultural believes. this  finding  implies  that  the  presence  of  these  body  modifications  may  cause  people  to  avoid  social contact and intimacy with the wearer, since they are presumed to have physical abnormalities and deviations that occur naturally12. this study disclosed that students of delta state university are aware of tattoo and body piercing and also gave a growing convergence on the two sexes toward tattooing and a sharp difference in  the involvement of the two sexes towards the body piercing. majority of these young adult are also aware of the health risks associated with body modifications and may not consider it in the future.  conflicts of interests: nil source of fund: (if any): nil conflict of interest: nil ethical clearence: permission was sought from the department of human anatomy ethics and research committee. authors’s contribution: all authors in the study read the manuscript and made great input data gathering and idea owner of this study: all authors were involved in the gathering of data editing  and  approval  of  final  draft: all  authors  were involved in the editing and approval of final  draft 29 international journal of human and health sciences vol. 06 no. 01 january’22 references: 1. tiggerman m, hopkins la. tattoos and piercings: bodily expressions of uniqueness. body image. 2011;8:245-250. 2. wood-black, f. going skin deep: the culture and chemistry of tattoos.https://inchemistry.acs.org/ content/inchemistry/en/atomic-news/tattoo-ink. html2019last accessed march 30. 3. armstrong ml. adolescent tattoos: educating vs. pontificating. pediatric nursing. 1995;21:561-564. 4. rubin a. marks of civilization. los angeles: museum of cultural history. asian society science. 1988; 4(2):37-42. 5. gritton j, jonaitis a. labrets and tattooing in native alaska. in a. rubin (ed.), marks of civilization los angeles: museum of cult history. 1988; 5(4):181191. 6. gilbert s. tattoo history: a source book 2001; juno books. 7. schildkrout e. inscribing the body. annual review of anthropology. 2004; 33:319-344. 8. starkie a. body modifications as a tool to aid human  identification. phd thesis, teesside university 2012. 9. thompson  t,  puxley  a.  body  modification.  thompson, m. and black, d (eds.), forensic human identification: an introduction crc press 2007; 379400. 10. temilola om. tattoos among youths in yaba community. ibadan journal of the social science. 2013 11(1):51-61. 11. brown k, perlmutter p, mcdermott r. relationships between  body  modifications  and  very  high  risky  behaviours in a college population. college student journal. 2010;36: 203-213. 12. sperry k. tattoos and tattooing: gross pathology, histopathology, medical complications, and applications. americanjournal of forensic medical and pathology. 1992; 13:7. 13. wohlrab s, stahl j. kappeler pm. modifying the body: motivations for getting tattooed and pierced. body image. 2007; 4:87-95. 14. demello m. bodies of inscription: a cultural history of the modern tattoo community. duke univ. press 2000. 15. ezeibekwe up, ojedokun ua, aderinto aa. love for artwork”: tattooing and body piercing among undergraduate students of university of ibadan, nigeria. african journal for the psychological study of social issues. 2016;19(3):87-95. 16. totten jw, lipscomb tj, jones ma. attitudes toward and stereotypes of persons with body art: implications for marketing management. academic of market student journal. 2009; 13.2:77-96. 17. atkinson m. tattooing and civilizing processes: body modification as self-control. canadian review  social anthropology. 2003; 41:125-146. 18. craik j. the face of fashion: cultural studies in fashion. london: routledge 1994. 19. turner bs. the possibilities of primitiveness: towards a sociology of body marks in cool societies. body and social. 1999; 5:39-50. 20. wessely md. inked and in public: tattoos and disclosure. m.sc. project, the university of wisconsin-whitewater 2013; . 21. currie-m. tattoos and body piercing. lucent overview series. lucent books. p. 11. isbn 12006; 59018-749-0. 22. meltzer  di..  “complications  of  body  piercing”.  american family physical. 2005; 72(10): 2029-2034. international journal of human and health sciences. supplementary issue: 2021 s11 e-poster presentation bridging the gap between medical students and the deaf-mute population huzairi sani1, nada syazana zulkufli2, iman wahidah1, nurul afiqah1, nur sabrina1, siti nur farahiyah1 1faculty of medicine, universititeknologi mara (uitm), sungai buloh, malaysia 2chemical pathology unit, hospital pulau pinang, ministry of health, malaysia doi: http://dx.doi.org/10.31344/ijhhs.v5i0.302 introduction: deafness is the inability to hear or impaired hearing. in 2018, more than 40,000 malaysians were registered with hearing loss. sign languages use visualization and facial expression to convey conversational meaning. however not many healthcare workers are able to converse in sign language thus hampering effective communication with deaf patients. objective: to evaluate the effectiveness of sign language in increasing awareness amongst medical students on healthcare access difficulties faced by the deaf. methods: four medical students underwent sign language classes at the malaysian federation of deaf before being formally assessed and certified by an instructor. a video on common questions used in the clinical setting using sign language was then developed and shown to a cohort of 224 medical students in uitm. awareness on the importance of sign language amongst the cohort was surveyed before and after watching the video. the four medical students were also assessed on their awareness and communication proficiency before and after attending classes. postand pre-test responses were analysed using wilcoxon signed rank test and paired sample t-test. results: the number of students who were aware of the importance of sign language in the clinical setting increased from 39.7% (n=89) to 98.2% (n=220) after watching the video. the four medical students’ post-test scores also increased significantly after attending sign language classes (mean +2.43, p<0.01). significant improvement in basic knowledge of sign language and ability to demonstrate signs such as self-introduction and gathering medical history were observed (p=0.046). in totality, awareness of the challenges faced by deaf-mute patients when communicating with healthcare workers increased significantly (p=0.046). conclusion: sign language is essential in improving communication between deaf patients and healthcare workers. it is therefore imperative that healthcare personnel gain basic skills in sign language to improve communication and provide better medical services to the deaf community. keywords: sign language, healthcare, deaf, mute http://dx.doi.org/10.31344/ijhhs.v5i0.302 microsoft word ijhhs imam 23rd asc 2022 s14 2. cyberbullying : how to stay safe on social media? ahmad firdaus mohd haris1 facebook, tiktok, instagram, twitter. there is rarely anyone without any of these social media accounts. according to 2020 internet user survey by malaysian communications and multimedia commission (mcmc), 88.7% of malaysians are internet users. out of that number, 93.3% of users use social media extensively. social media has enabled users to connect with family and friends. it has done wonders to small businesses to prosper. it has also empowered communities to grow and prosper. however, there is one dark side to it; cyberbullyng. according to the merriam webster dictionary, bullying is defined as “abuse and mistreatment of someone vulnerable by someone stronger, more powerful”. most of the time, bullying is done when a bully is in the presence of his or her victim. however, in the cyber world, bullying extends beyond the physical presence. the act of bullying can be done 24 hours a day, by anyone at any time. a victim can be harassed with harsh comments via any social media accounts and even through text messages which sometimes invade the victim’s own privacy. there is no clear guidelines and policy regarding cyberbullying. any form of enforcement is lax due to the nature of the internet being free for all. thus, it is imperative to empower oneself to understand how to use social media effectively to prevent from being cyberbullied and also not to be a cyberbully. there are also tools that can be used in each social media platform to report such cyberbullying issues and also to report to the relevant agencies such as the royal malaysian police and malaysian communications and multimedia commission. keywords: cyberbullying; social media; cyberbullying policy 1. medical mythbuster malaysia, https://www.facebook.com/medicalmythbustersmalaysia ___________________________________________________________________________ correspondence to: dr. ahmad firdaus mohd haris. medical mythbuster malaysia, https://www.facebook.com/medicalmythbustersmalaysia/. ahmad.firdaus.m3@gmail.com __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v7i70.516 microsoft word ijhhs imam 23rd asc 2022 s16 oral presentation perception of halal pharmaceuticals among state hospital outpatients in perlis, malaysia wei chern ang1,2, noorsyahiruh abdul khadir2, nurfatin amira sofia lahazir2, alia hayati baharudin2 objectives: halal pharmaceuticals have expanded globally, which is one of the elements in shariah compliance hospitals. with the emergence of covid-19 vaccines, the ‘halal’ status has become a debate causing some to reject it. the aim of this study was to explore the perception of halal pharmaceuticals among hospital outpatients. methods: a qualitative study by in-depth interviews were conducted among adult muslim outpatients collecting their medications. a malay language semi-structured interview guide was prepared and underwent content trustworthiness by the state mufti, a malaysian pharmacy professor, two pharmacists with a special interest in halal pharmaceuticals and two islamic affairs officers in the ministry of health malaysia. subjects were recruited in the waiting area of the outpatient pharmacy, hospital tuanku fauziah (htf). interview sessions were audio-recorded and transcribed verbatim. the transcripts were back-translated in english and analysed using thematic content analysis. results: ten outpatients were interviewed in which data saturation was reached. overall, the patients were proactive in observing the label to ensure they received the correct medications. however, all patients were unfamiliar and not curious about the concepts of ‘halal pharmaceuticals’ and ‘shariahcompliant hospital’. the patients also trusted that the government would provide only the safest and halal medicines. most patients did not prioritise halal status while choosing their medicines. however, if options were available, most would choose halal medication regardless of its price and effectiveness. they still would consent to receive non-halal treatments for life-saving conditions. conclusion: there was a good perception of halal pharmaceuticals among outpatients in htf. there are many opportunities for patient education on this topic as the public is currently not familiar with the terms and halal concepts in medical settings. keywords: islam, exploratory behaviour, trust, pharmaceutical preparations, halal 1. clinical research centre, hospital tuanku fauziah, ministry of health malaysia 2. department of pharmacy, hospital tuanku fauziah, ministry of health malaysia ___________________________________________________________________________ correspondence to: wei chern ang, pharmacist, clinical research centre, hospital tuanku fauziah, ministry of health malaysia, malaysia, angweichern@moh.gov.my _________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v7i70.518 microsoft word ijhhs imam 23rd asc 2022 s19 the effectiveness of menstrual education module for children and adolescent refugees:  a pilot study  nur aizati athirah daud1, muhammad aqif badrul hisham2, ahmad rashidi mohamed tahir2, sh fatimah alzahrah syed hussein al-attas3  objectives: females across lowto middle-income countries have limited knowledge and understanding about menstruation prior to reaching menarche. one of the marginalised populations prone to this challenge is the female refugees in malaysia. the objective of this pilot study is to evaluate the effectiveness of a menstrual health module developed for children and adolescent refugees. methods: this is a pilot intervention study among children and adolescents aged 9 to 17 years old attending a school for refugees and stateless children located in selayang, selangor. a menstrual health module was developed containing basic knowledge on reproductive organs, changes during menstruation, menstruation cycle, and menstrual hygiene management. activities were carried out during this program to engage the participants. a set of 20 quiz questions were given, preand postintervention. scores from the quiz were compared using paired t-test to evaluate the effectiveness of the module. results: a total of 11 children participated in the program (mean age: 12.8 + 1.3 years). all of the participants are muslims and the majority of them are myanmar refugees (n=10, 90.9%). the majority stayed with their parents (n=9, 81.8%). about half of the participants have fathers who are without any education (n=6, 54.5%), while most of the fathers were working full time (n=9, 81.8%). the majority of the participants had a monthly household income of less than rm2500 (n=10, 90.9%). the postintervention mean score for the quiz questions was significantly higher than the pre-intervention mean score (15.9 + 2.3 and 6.3 + 4.9 for postand pre-intervention, respectively) (p<0.001). conclusion: the menstrual education module was shown to be effective in increasing the knowledge of menstruation and menstrual hygiene among children and adolescent refugees. rooms for improvements were identified for further revision of the menstrual health module.  keywords: menstruation, period, refugees, menstrual hygiene education 1. school of pharmaceutical sciences, universiti sains malaysia, 11800 usm penang, malaysia  2. faculty of pharmacy, university of cyberjaya, 63000 cyberjaya, selangor, malaysia 3. department of sociology and anthropology, kulliyyah of islamic revealed knowledge and human sciences, international islamic university malaysia, 53100 kuala lumpur, malaysia ___________________________________________________________________________ correspondence to: nur aizati athirah daud, lecturer, school of pharmaceutical sciences, universiti sains malaysia, 11800 usm penang, malaysia, aizati@usm.my    __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v7i70.521 supplementary issue:02 72 histoplasmosis in eastern uttar pradesh: our five years experience at a tertiary care center ragini tilak1, munesh kumar gupta1, jaya chakravarty2, ojas gupta3, vijai tilak3 1. mycology lab, department of microbiology, institute of medical sciences, banaras hindu university, varanasi 2. department of general medicine, institute of medical sciences, banaras hindu university, varanasi 3. department of pathology, institute of medical sciences, banaras hindu university, varanasi *correspondence: dr. vijai tilak professor, department of pathology, institute of medical sciences banaras hindu university varanasi221005 email: vijaitilak@rediffmail.com abstract: histoplasmosis is an endemic fungal infection which primarily infects the immunocompetent as well as immunocompromised patients. it primarily affects the respiratory tract and disseminates hematogenously where it involves the bone marrow, lymph nodes and the adrenal glands. clinical manifestations of histoplasmosis are of three main types: acute primary, chronic cavitatory and progressive disseminated histoplasmosis. we are presenting case series of six histoplasmosis cases, in which histoplasma capsulatum strains were isolated from the bone marrow, lymph node and skin biopsy respectively whereas three cases were diagnosed based on bone marrow examination and histopathological examination and special fungal staining of relevant tissues. key words: bone marrow, histoplasma capsulatum, progressive disseminated histoplasmosis (pdh) and pyrexia of unknown origin (puo) introduction: histoplasmosis is a systemic fungal disease caused by histoplasma capsulatum, a dimorphic and ubiquitous fungus. the disease is endemic in certain areas of north, central, and south america, supplementary issue:02 73 as well as africa and asia [1]. most primary infections with h. capsulatum are either asymptomatic or result in mild influenza-like illness; however, certain forms of histoplasmosis can cause life-threatening infections with considerable morbidity [2, 3]. the natural habitat of this fungus is soil that has been contaminated with bird or bat droppings. pulmonary infection usually develops through inhalation followed by haematogenous spread to the reticuloendothelial system within a few weeks [4, 5]. highly infectious soil is found to be source of infections caused by histoplasma capsulatum. most of the time infection remains asymptomatic. those who develop clinical manifestations usually are immunocompromised or are exposed to a high quantity of inoculum. the extent of disease depends on the number of conidia inhaled and the function of the host's cellular immune system. pulmonary infection is the primary manifestation of histoplasmosis, varying from mild pneumonitis to severe acute respiratory distress syndrome. in those with chronic lung disease a chronic progressive form of histoplasmosis can occur. dissemination of h. capsulatum within macrophages is common and becomes symptomatic primarily in patients with defects in cellular immunity. case details: in all suspected cases of histoplasmosis, a diagnosis was achieved by isolation of histoplasma capsulatum by fungal culture, or visualization of appropriate morphologic fungal forms in the relevant tissues or bone marrow aspiration. culture remains the gold standard for its diagnosis, but it requires a lengthy incubation period two to four weeks (fig.1and2) fungal staining produces quicker results than culture but is less sensitive [4]. culture for acid fast bacilli was also found to be negative. serological test for leishmania was negative. fungal culture was not done in all cases. bone marrow aspirate stained by leishman stains showed oval globose yeast like cells measuring supplementary issue:02 74 3-4 mm x 2-3 mm in size, suggestive of histoplasma capsulatum(fig.3,4 and 5). pas stained revealed these yeast-like cells as bright eosinophilic structures. direct examination of smear relating to clinical symptoms helped in provisional diagnosis, isolation of organisms by culture was not successful but histomorphological features were characteristic for diagnosis in two cases. salient patient details are given in table 1. table.1 clinical & laboratory profile of patients s . n . age/ sex clinical manifestati ons retr o posi tive org an invo lved diagno sis by direct micros copy culture manage ment outcom e 1 . 50/ m fever with hepatosplen omegaly with skin rash no live r, splee n and bone marr ow yeast cell seen sample was not sent for microbiologic al work up. inj. amphote ricin b and itraconaz ole 200mg bd survive d 2 . 35/ m enlarged axillary lymph nodes yes lym ph node s negativ e on culture at 250c, there was cotton white growth. on lcb wet mount, numerous tuberculate macroconidia and few microconidia inj. amphote ricin b and itraconaz ole 200mg bd survive d 3 . 40/f puo intermittent high-grade yes bon e marr ow yeast cells seen on culture at 250c, there was cotton white growth. inj. amphote ricin b and died supplementary issue:02 75 fever with weight loss on lcb wet mount, numerous tuberculate macroconidia and few micro conidia itraconaz ole 200mg bd 4 . 67/ m puo with abdominal pain no adre nal glan ds intracell ular yeast cells sample was not sent for microbiologic al work up. inj. amphote ricin b and itraconaz ole 200mg bd died 5 . 56/ m puo with weight loss, skin lesions no skin lesio ns intracell ular yeast cells on culture at 250c, there was cotton white growth. on lcb wet mount, numerous tuberculate macroconidia and few micro conidia inj. amphote ricin b and itraconaz ole 200mg bd improve d 6 . 46/ m abdominal pain and darkening of the skin no adre nal glan ds intracell ular yeast cells no growth inj. amphote ricin b and itraconaz ole 200mg bd improve d discussion: histoplasmosis is a systemic fungal disease acquired by the inhalation of microconidia of the filamentous phase of the fungus histoplasma capsulatum. the severity of clinical manifestation depends on size of inoculum, underlying health of the person and immune status to histoplasma capsulatum. immunocompetent patients present as limited respiratory infection comprising of fever, malaise, cough and chest pain [6, 7, and 8]. these are non-specific symptoms that may also supplementary issue:02 76 occur with multiple other diseases. the majority of affected individuals remain clinically silent and display no apparent symptoms [5, 9] most of our patients were middle aged who had shown significant hepatosplenomegaly with bone marrow involvement. chronic infection tends to present in older, immunocompetent patients as pancytopenia, hepatosplenomegaly, oropharyngeal and/or skin lesions, gastrointestinal involvement, and signs and symptoms of adrenal gland dysfunction. disseminated histoplasmosis may present as acute pdh with fever, malaise cough mimicking pulmonary tuberculosis. chronic pdh presents as fever, sweats, weight loss, organomegaly and lymphadenopathy. another possible explanation of underdiagnosed is that disseminated histoplasmosis resembles visceral leishmaniasis in many aspects with feature of fever, weight loss and hepatosplenomegaly. moreover, both of these are responsive to amphotericin b. diagnostic accuracy has improved greatly with the use of an assay for histoplasma antigen in the urine; serology remains useful for certain forms of histoplasmosis, and culture is the ultimate confirmatory diagnostic test [5]. classically, histoplasmosis has been treated with long courses of amphotericin b. itraconazole is the azole of choice following initial amphotericin b treatment [6]. treatment with fluconazole 200 mg to 400 mg daily appears to be even less effective than ketoconazole and itraconazole [6]. disseminated histoplasmosis is aggressive, progresses rapidly, and requires early and effective treatment; our patients were treated with amphotericin b deoxycholate antifungal infection and itraconazole. the majority of these patients were successfully treated, whereas two of cases died. conclusion a high need of suspicion will lead to pertinent samples being sent to mycology tests for correct diagnosis. it is thus important for microbiologist to look for dimorphic fungi in fever of unknown supplementary issue:02 77 origin. this will not only lead to proper identification of microorganism but will also provide us correct treatment options. references 1. wheat lj (2006) histoplasmosis: a review for clinicians from non-endemic areas. mycoses 49: 274-282. 2. gascón j, torres jm, luburich p, ayuso jr, xaubet a, corachán m. imported histoplasmosis in spain. j travel med. 2000;7(2):89–913. 3. wheat j, freifeld a, kleiman m, baddley j, mckinsey d, loyd j, kauffman c (2007) clinical practice guidelines for the management of patients with histoplasmosis: 2007 update by the infectious diseases society of america. cid 45: 807-825 4. wang c, li a, shi q, yu z. metagenomic next-generation sequencing clinches diagnosis of leishmaniasis. lancet. 2021;397(10280):1213. 5. randhawa hs, gugnani hc (2018) occurrence of histoplasmosis in the indian subcontinent: an overview and update. j med res pract 7:71–83 6. wheat lj, freifeld ag, kleiman mb, baddley jw, mckinsey ds, loyd je and kauffman ca: clinical practice guidelines for the management of patients with histoplasmosis: 2007 update by the infectious diseases society of america. clin infect dis. 45:807–825. 2007 7. jawaid m, rao r, umabala p, sunder a, 2015. histoplasmosis presenting as an adrenal mass in immunocompetent patient: a case report. sch j med case rep 3: 954–959. 8. ghosh a, tilak r, bhushan r, dhameja n, chakravarty j. lymphnodal co-infection of cryptococcus and histoplasma in a hiv-infected patient and review of published reports. mycopathologia. 2015 aug;180(1):105-10. supplementary issue:02 78 9. choudhury ak, mishra ak, gautam dk, tilak r, tilak v, gambhir is, chakrabarti ss. case report: histoplasmosis accompanying disseminated tuberculosis in an immunocompetent adolescent boy. the american journal of tropical medicine and hygiene. 2020 feb;102(2):352. fig.2 lcb wet mount showing tuberculate macroconidia fig. 1 growth on sda at 25oc http://www.jmedicalcasereports.com/sfx_links?ui=1752-1947-5-374&bibl=b5 http://www.jmedicalcasereports.com/sfx_links?ui=1752-1947-5-374&bibl=b5 supplementary issue:02 79 fig.4 giemsa staining of bone marrow showing the yeast cells. fig 3. h&e staining of lymph node showing the yeast cells. fig 5. h& e staining of adrenal gland showing intracellular yeast cells. microsoft word ijhhs imam 23rd asc 2022 s21 e-poster presentation transformation of emergency & trauma department in response to covid-19 pandemic nurul nasibah mohd zaini1, azmir anuar1, chung wai mun1 objectives: covid-19 pandemic has caused tremendous impact on emergency & trauma department (etd) worldwide including etd hospital taiping (htpg). it is a large department with approximately 200 staff and a daily admission load that achieves an average of 250-300 patients per day, with an expected load increment during festivals and weekends. this article illustrates reorganizing strategies of etd htpg in setting up system and rules implementation in response to covid-19 pandemic since the year 2020. methods: this is a descriptive report on the transformation of dedicated facilities to cope with covid19 pandemic since the year 2020. plan-do-check-act (pdca) has been implemented to improve the systems. the report is written based on the actual clinical needs, development and advancement of emergency medical services in etd htpg. results: elimination of covid-19 pandemic virus is impossible in the near future in a start year of 2020. isolation has turned out to be the next crucial step in controlling the pandemic. the creation of triage isolation booth (tib) has reduced transmission risks while allowing staff to carry out their usual triage process. three emergent clinical areas were formed in an ad-hoc manner to cater to the pandemic, namely respiratory zone, influenza-like illness (ili) & covid zone in addition to basic 3 zones of red, yellow and green. new norms, rules and regulations are adapted to all etd staff, patients and visitors. conclusion: this article is meant to share our initiative and strategies in handling and managing covid-19 cases with multiple challenges and limitations of resources in etd htpg. as a point of success of these strategies, we have recorded only 3 isolated positive cases among etd staff in the year 2020. to date, the system is being practiced and revised from time to time to achieve better performance for patients’ needs. keywords: covid-19, transformation, emergency and trauma department 1. emergency & trauma department, hospital taiping, perak ___________________________________________________________________________ correspondence to: nurul nasibah mohd zaini, emergency & trauma department, hospital taiping, perak, c_bah88@yahoo.com.my __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v7i70.523 microsoft word ijhhs imam 23rd asc 2022 s25 multi-modality treatment of supraglottic stenosis secondary to laryngeal pemphigus: sharing experience in uitm noor shairah mat barhan1, muhammad ariff sobani1, masaany mansor1,2, intan kartika kamarudin1,2, norazila abdul rahim1,2 supraglottic stenosis is a rare subsite of laryngotracheal stenosis. in the literature, the common causes of supraglottic stenosis are radiation therapy or autoimmune disease. we present an experience in dealing with supraglottic stenosis secondary to laryngeal pemphigus. this is a case of a 36-year-old lady with supraglottic stenosis secondary to laryngeal pemphigus. she presented to our clinic with shortness of breath and mild stridor mainly on exertion. an officebased procedure of trans-nasal scope-guided with serial intralesional steroid injections (silsi) using single-use olympus injector force injection needles max 23g, was done which halted the progression of the disease. eventually, balloon dilatation under jet ventilation was performed to widen the size of the stenosis and reduce the symptoms. dilatation was performed using cre pro wire-guided balloon dilatation catheter from size 8mm to 12mm with respective pressure applied for about 2 minutes without interruption of spontaneous breathing, oxygenation, or ventilation. incision of stenosis segment with micro scissor was performed in between balloon dilatation and the procedure was completed with intralesional steroid injections. upon follow-up, we noted clinical improvement of the stenosis as well as the patient’s health perception as measured by eq-5d-5l. patients with supraglottic stenosis usually need tracheostomy for breathing. this multimodality treatment might be required to treat supraglottic stenosis.  endoscopic treatment can result in favourable outcomes for the patient without needing a tracheostomy. keywords: supraglottic stenosis, intralesional steroid injection, balloon dilatation 1. department of otorhinolaryngology, head and neck surgery, hospital al-sultan abdullah uitm, puncak alam, selangor, malaysia  2. department of otorhinolaryngology, head and neck surgery, faculty of medicine, universiti teknologi mara, sungai buloh campus, selangor, malaysia ___________________________________________________________________________ correspondence to: norazila abdul rahim, lecturer and otorhinolaryngology head and neck surgeon, department of otorhinolaryngology, faculty of medicine, universiti teknologi mara, sungai buloh, selangor, malaysia, norazila3587@uitm.edu.my _________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v7i70.527 microsoft word ijhhs imam 23rd asc 2022 s23 the classical 6-p of acute limb ischemia adib zakhi1 acute limb ischemia (ali) is a surgical emergency and often threatens limb viability. this is a case of a 45-year-old patient who presented with the classical six ps of ali.  a 45-year-old lady with underlying hypertension and heart failure presented with acute right leg pain arriving by ambulance at the emergency department within 4 hours of the symptom.  the patient was clinically obese and seemed very uncomfortable as evidenced by her writhing in pain. she was borderline tachycardic and hypertensive. the cardiopulmonary and abdominal examinations were unremarkable. on extremity examination, she was unable to move her right leg starting from the knee caudally. the leg appeared mottling and cold. on vascular examination, there was no abdominal or femoral bruit but there was a diminished pulsation of the right femoral, dorsalis-pedis and posteriortibialis arteries as confirmed by doppler compared to the contralateral side. on the neurological examination, the sensation was absent and no pain upon the passive stretch. ankle-brachial-systolic index (absi) was 0.7. as evidenced by pain, pallor, pulselessness, poikilothermia, paralysis, and paresthesia, clinical diagnosis of acute right leg ischemia was established with most likely vascular occlusion proximal to the left femoral artery. the vascular team was urgently referred. electrocardiogram showed sinus tachycardia. bedside ultrasound revealed normal aortic root size and neither aortic dissection nor aneurysm. 2-point compression tests were fully compressible and x-ray films showed no fracture. creatinine kinase was 65 units/litre whereas other blood parameters were unremarkable. she was then classified as rutherford iib and underwent a right femoral thromboembolectomy.  the presentation of ali requires rapid diagnosis and appropriate management as it is timesensitive and limb-threatening. emergency physicians should be aware of advances in endovascular therapies as a recommended option for the treatment of ali. keywords: emergency department, vascular, limb ischemia  1. hospital canselor tuanku muhriz, kuala lumpur, malaysia ___________________________________________________________________________ correspondence to: adib zakhi, medical officer, hospital canselor tuanku muhriz malaysia, adibzakhi@rocketmail.com __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v7i70.525 international journal of human and health sciences vol. 03 no. 01 january’19 32 case report: small bowel obstruction due to meckel’s diverticulum: a case report mania beiranvand1, morteza mohammadirokh2, babak khodadadi3 abstract background: meckel diverticulum is the most common congenital gastrointestinal malformation, which is 40% of cases have symptoms of intestinal obstruction. the prevalence of this disorder is between 1% and 4% of the population and the possibility of its occurring in men is twice that women. most of meckel diverticulums are asymptomatic so it is difficult to diagnose properly the meckel diverticulum before surgery it may not be detectable because of other intra-abdominal complications such as appendicitis, inflammatory bowel disease, or other causes of small bowel obstruction, case report: the patient was a 28-year-old man who had abdominal pain with repeated vomiting two days earlier. in abdominal and pelvic ct scans, the dilatation of small bowel loops with screw loops around the arterial origin and upper mesenteric vein and the mesenteric root has been reported. due to the lack of clinical improvement, the patient was transferred to the operating room for laparotomy. in the operating room, a large adhesive band of about 60 cm of the ileocecal valve was released, and the broad and inflamed diverticulitis was removed at a base of about 2 to 2.5 cm. conclusion: detecting meckel’s diverticulum with no sign from normal colon using a ct scan is difficult, but laparoscopy as a useful tool in the diagnosis of meckel’s diverticulum has been reported. the care standard of meckel’s diverticulum is a surgical procedure for the removal of complications. surgical methods used include simple diverticulectomy or removing part of the ileum that diverticulum is located. for proper diagnosis especially in patients with unusual symptoms, it is necessary that the symptoms of diverticulum are considered keywords: meckel diverticulum, small bowel obstruction, mesodiverticular band correspondence to: babak khodadadi, young researchers and elite club, khorramabad branch, islamic azad university, khorramabad, iran. e-mail:khodadadi.b@lums.ac.ir 1. assistant professor, department of surgery, faculty of medicine, lorestan university of medical sciences, khorramabad, iran 2. student research committee, birjand university of medical sciences, birjand, iran. 3. young researchers and elite club, khorramabad branch, islamic azad university, khorramabad, iran. introduction: the small bowel obstruction is responsible for about one-fifth of the surgical emergencies that it is the most common cause of adhesions caused by previous abdominal surgeries. patients without a history of abdominal surgery should consider other causes. one of the causes of small bowel obstruction is meckel diverticulum.1 so that about 40% of meckel diverticulums have signs of small bowel obstruction.2 meckel diverticulum is the most common congenital malformation of the digestive tracts.3 which is due to the presence of the proximal portion of the vitelline duct or omphalomesenteric in the 5-7 fetal weeks4 and usually found on the antimesenteric border of the ileum.5 the prevalence of this disorder is between 1% and 4% of the population6 and is more likely to occur in men two-times more than women.7 the most common manifestations of meckel diverticulum are bleeding, small bowel obstruction and diverticulitis.8 small bowel obstruction is the second most common complaint in the meckel diverticulum patients.9 which can be due to intussusception and small bowel volvulus around a diverticular band that is anchored to international journal of human and health sciences vol. 03 no. 01 january’19 page : 32-36 doi: http://dx.doi.org/10.31344/ijhhs.v3i1.72 33 international journal of human and health sciences vol. 03 no. 01 january’19 the anterior abdominal wall (axial torsion of the meckel diverticulum), a littre hernia, and a stuck in a bowel loop due to a mesodiverticular fibrotic band.6 although small bowel obstruction due to the mesodiverticular band is not common10, we report a 28-year-old patient with small bowel obstruction due to the mesodiverticular band which is around the intestine. case report: the patient referred to the hospital was a 28-yearold man who had abdominal pain with repeated nausea and vomiting two days earlier. the patient’s pain was colic and intensified after eating and healed with vomiting. the patient vomits contained the foods he had eaten. gas disposal and stool was noted. the pain of the patient intensified 24 hours before the lookup. the patient also noted anorexia. the patient did not mention a history of previous cardiac surgery and digestive problems, but occasionally the consumption of alcohol was mentioned. in the examination of vital signs, the patient’s temperature by mouth measurement 37.6, blood pressure 110/70 mmhg, pulse 86 beats per minute and breathing rate 18 times per minute were obtained. patient’s abdomen is also slightly dilated and scar surgery and hernia were not seen. sounds of the intestines were hyperactive. at the touch of the abdomen, tenderness of the abdomen was evident with the preference of the middle region of the abdomen. there was no rebound tenderness. in the patient, there was voluntary guarding. in the rectal examination, the non-bloody soft stool was obtained. the patient received fasting and started serum therapy for him. he was asked for blood cells count, electrolytes, blood gases, and other parameters related to the acute abdomen. the results of the patient’s blood cells count showed leukocytosis with 12100 cells and neutrophil counts of 70%. the patient’s hemoglobin was 14.6 g / dl and the patient was positive for crp. the results of blood gas analysis showed that blood ph, pco, po2, and hco3 were 7.42, 32, 95 and 20.8, respectively. the other parameters were na: 143, k: 3.46, cr: 1.1, urea: 29. there is no free air below the diaphragm in the standing chest radiography. in the standing stomach radiography, bowl loops are dilated but there is no fluid air level. the abdominal recumbent radiography showed the intestinal loops full of air (figure 1). in the report of the abdomen and pelvic sonography localized ileus was seen in the center of the abdomen. free fluid was seen in the prehepatic and pre-ipellinic spaces and para-colics. the stomach is dilated. abdominal and pelvic ct scans have been reported the dilatation of small bowel loops with screw-on loops around the origin of the arterial and upper mesenteric vein and mesenteric root. ischemic changes have not been made in the intestine. the transitional area is seen in the distal ileum and the colon has been overlapped so that there are several levels of mild fluid air (figures 2 and 3). international journal of human and health sciences vol. 03 no. 01 january’19 34 according to the ct scan report and the patient’s clinical unimprovement, he was transferred to the surgery room for laparotomy. the abdomen was opened by midline cutting. about 50 cc of serous fluid suctioned.the intestines were dilated but there was no ischemic change, the cecum was above the normal range of the umbilicus. about 60 cm of the terminal ileum multiple adhesive bands that caused collapse and trapping intestine were released after releasing the meckel diverticulum. appendectomy was done. the terminal ileum adhesion to retroperitoneum was released. after removing a large adhesive band of about 60 cm from the ileocecal valve, broad and inflamed diverticulum was removed from the base of about 2 to 2.5 cm (figures 4 and 5). the fluid movements in the lumen of the intestines were checked up to the cecum, stomach, cecum, ascending colon, transverse colon, descending colon and sigmoid were normal, the sample was sent for pathologic examination. after the surgery, the patient was transferred to the department and after a few days, was released from the hospital in a good general condition. pathology report of patient sample was reported meckel diverticulum with a mucosal covering of the intestine along with areas of gastric mucosa (figures 6 and 7). figure 4 and 5: after removing a large adhesive band of about 60 cm, the ileocecal lid of the broad and inflamed diverticulum was removed with a base of about 2 to 2.5 centimeters. the small bowl dilated loops are visible without ischemic changes. figures 6 & 7: h & e staining represents meckel diverticulum with all layers of normal small bowl wall with normal gastric mucosa discussion: meckel diverticulum was first described in 1598 by fabricius hildanus but due to the discovery of its embryonic structure in 1809, it was named by johann friedrich meckel in 1809.11 most of the meckel diverticulums are asymptomatic.10 that is why less than 10% of meckel diverticulum cases are detected before surgery.12,13 also, it is difficult to diagnose properly the meckel diverticulum before surgery because it may be indistinguishable from other intra-abdominal complications, such as appendicitis, inflammatory bowel disease, or other causes of small bowel obstruction. in such a situation, if the patient doesn’t have to bleed, 35 international journal of human and health sciences vol. 03 no. 01 january’19 proper diagnosis finds special importance.14 the results of a study that were performed on 776 patients with meckel diverticulum showed that 88% of patients who had been presented bleeding correctly diagnosed before surgery. in contrast, among those who presented with a symptom other than bleeding, only 11% of the cases were correctly diagnosed before surger.15 simple radiography is usually not useful in the diagnosis of meckel diverticulum. however, small bowel obstruction is usually visible on simple abdominal radiography.16 meckel diverticulum differentiation with ct scan is difficult in asymptomatic cases from the normal small intestine so that in a report of ct scan findings in 11 patients with meckel diverticulum, the presence of gangrene or secondary intestinal obstruction was associated with poor diagnostic accuracy. in a ct scan, both intravenous and oral contrast agents may help the diagnosis of meckel diverticulum and should be performed whenever necessary.17 laparoscopy has also been reported as a diagnostic tool in the meckel diverticulum.18 the mortality rate in symptomatic patients is about 6%, which is higher in elderly patients.18-21 delay in the diagnosis of meckel diverticulum with side effects can lead to patient’s death.22 care standard in meckel diverticulum is surgery to harvest complications. the surgical procedures used include simple diverticulectomy or removing a part of the ileum where diverticulum is present. removal of the ileum when there is evidence of severe inflammation, perforation, or tumor is necessary.23 in the surgery, bands attached to the abdominal wall should be removed. cumulative incidence of early postoperative complications is 12%, including mainly surgical site infection (3%), prolonged ileus (3%) and anastomotic leak (2%) with a mortality rate of 1.5%.2 conclusion: in adults, symptomatic meckel diverticulum is better diagnosed, which helps to improve surgical treatment. in young adults with small bowel obstruction, diagnosis is rarely made before surgery. due to the rare occurrence of this complication and its variable clinical manifestations, differential diagnosis of this complication is not easy and imaging techniques may be inappropriate. to overcome these problems, a ct scan is recommended with oral and intravenous contrast agents. to diagnose correctly, especially in patients with unusual symptoms, it is necessary to have symptoms of meckel diverticulum in mind. ethical approval: this case report was published after getting approval of the ethics committee of lums, iran conflict of interest:none authors’ contributions: conception and design: mania beiranvand data collection: babak khodadadi writing manuscript: morteza mohammadirokh submitting manuscript: babak khodadadi international journal of human and health sciences vol. 03 no. 01 january’19 36 references: 1. foster nm, mcgory ml, zingmond ds, ko cy. “small bowel obstruction: a populationbased appraisal.” journal of the american college of surgeons 203.2 (2006): 170-176. 2. c. cartanese, t. petitti, e. marinelli, et al., intestinal obstruction caused bytorsed gangrenous meckel’s diverticulum encircling terminal ileum, world j.gastrointest. surg. 3 (2011) 106–109. 3. nath ds, morris ta. small bowel obstruction in an adolescent. a case of meckel’s diverticulum. minn med 2004;87:46–48. 4. limas c, seretis k, soultanidis c, anagnostoulis s. axial torsion and gangrene of a giant meckel’s diverticulum. j gastrointestin liver dis 2006;15:67–68. 5. gamblin tc, glenn j, herring d, mckinney wb. bowel obstruction caused by a meckel’s diverticulum enterolith: a case report and review of the literature. currsurg 2003 janfeb;60(1):63-64. 6. seth a, seth j. axial torsion as a rare and unusual complication of a meckel’s diverticulum: a case report and review of the literature. j med case rep 2011;5:118. 7. uppal, r.s. tubbs, p. matusz, k. shaffer, m. loukas, meckel’s diverticulum: a review, clin. anat. 24 (2011) 416–422 8. gamblin tc, glenn j, herring d, mckinney wb. bowel obstruction caused by a meckel’s diverticulum enterolith: a case report and review of the literature. currsurg 2003 janfeb;60(1):63-64. 9. karatepe o, dural c, ercetin c, et al: a rare complication of meckel’s diverticulum: loop formation of diverticulum. turk j med sci 2008;38:91–93. 10. sumer a, kemik o, olmez a, dulger ac, hasirci i, iliklerden u, kisli e, kotan c. small bowel obstruction due to mesodiverticular band of meckel’s diverticulum: a case report. case reports in medicine. 2010;2010. 11. k. w. chan, “perforation of meckel’s diverticulum caused by a chicken bone: a case report,” journal of medical case reports, vol. 3, article 48, 2009. 12. k.e. bani-hani, n.j. shatnawi, meckel’s diverticulum: comparison of incidentaland symptomatic cases, world j. surg. 28 (2004) 917–920. 13. e.k. yahchouchy, a.f. marano, j.c. etienne, a.l. fingerhut, meckel’sdiverticulum, j. am. coll. surg. 192 (2001) 658–662. 14. k.g. mendelson, b.m. bailey, t.d. balint, w.e. pofahl, meckel’s diverticulum: review and surgical management, curr. surg. 58 (2001) 455–457. 15. h. kusumoto, m. yoshida, i. takahashi, h. anai, y. maehara, k. sugimachi,complications, and diagnosis of meckel’s diverticulum in 776 patients, am. j.surg. 164 (1992) 382–383. 16. k. uppal, r.s. tubbs, p. matusz, k. shaffer, m. loukas, meckel’s diverticulum: areview, clin. anat. 24 (2011) 416–422. 17. g.l. bennett, b.a. birnbaum, e.j. balthazar, ct of meckel’s diverticulitis in 11patients, ajr am. j. roentgenol. 182 (2004) 625–629. 18. h. rivas, r.n. cacchione, j.w. allen, laparoscopic management of meckel’sdiverticulum in adults, surg. endosc. 17 (2003) 620–622. 19. j.j. cullen, k.a. kelly, c.r. moir, d.o. hodge, a.r. zinsmeister, l.j. melton 3rd,surgical management of meckel’s diverticulum. an epidemiologic,population-based study, ann. surg. 220 (1994) 564–568, discussion 8–9. 20. j. dumper, s. mackenzie, p. mitchell, f. sutherland, m.l. quan, d. mew,complications of meckel’s diverticula in adults, can. j. surg. 49 (2006)353–357. 21. y. groebli, d. bertin, p. morel, meckel’s diverticulum in adults: retrospectiveanalysis of 119 cases and historical review, eur. j. surg. 167 (2001) 518–524. 22. c. limas, k. seretis, c. soultanidis, s. anagnostoulis, axial torsion and gangreneof a giant meckel’s diverticulum, j. gastrointestin. liver dis. 15 (2006) 67–68. 23. j.j. park, b.g. wolff, m.k. tollefson, e.e. walsh, d.r. larson, meckeldiverticulum: the mayo clinic experience with 1476 patients (1950–2002),ann. surg. 241 (2005) 529–533. 161 international journal of human and health sciences vol. 04 no. 03 july’20 review article: holding health care accountable: a solution to mitigate medical malpractice in pakistan fazli dayan1, gulaly1, mian muhammad sheraz2, muhammad zia-ul-haq3 abstract: medical malpractice negatively affects the health care across the globe, and the case of pakistan is not a novel. beyond the human consequences such as injuries, loss of lives, complete or partial impairment of limbs, including the factors of miseryand violence against health care has far reaching, long-term consequences which affecting the patients trust on the health-care servicesthat has negative and catastrophic impacts on the public health. indeed, malpractice results from breach of duty on the part of medical practitioner that could be negligence attracting penalty in form of damages, or be recklessness, or deliberate misconduct call for imposition of fine, or physical punishment or both, which serve as detriment for health care provider and as a relief for the aggrieved.assertively, in theabsence of research studies, the present endeavor was to attract the attention of government andlaw makers towards this issue. and thus, for this purpose, the study was conducted in peshawar district from july 17th, 2019 to october 1st, 2019. consequently, the finding of this study reflected the magnitude of non-reporting of sentinel events, unawareness among massesoflaws and remedies that could be availed at the times of malpractice complaints, and key gaps in laws, system and policies of health care dealing with malpractice. the study further demonstrates that prevention as well as establishment of fair and unbiased system of accountability is the need of the day. since, in this way, the policy and law makers will be enabled to bring reforms in health care system in order to mitigate medical malpractice in pakistan. keywords: medical malpractice, medical error, medical negligence, health care, patient’s safety, physician’s accountability & pakistani law. correspondence to: dr. fazli dayan, assistant professor, department of shariah & law, ahmad faraz block, islamia college university, peshawar, 25120, khyber pakhtunkhwa, pakistan. e-mail: dr.dayan@icp.edu.pk, dayansherpao@gmail.com 1. department of shariah & law, faculty of religious and legal studies, islamia college university, peshawar, khyber pakhtunkhwa, pakistan 2. department of law, faculty of shariah & law, iiu, islamabad, pakistan 3. director general, islamic research institute, iiu, islamabad, pakistan international journal of human and health sciences vol. 04 no. 03 july’20 page : 161-173 doi: http://dx.doi.org/10.31344/ijhhs.v4i3.195 introduction patient safety is one of the top priorities of health care system.1 since, it is affected by medical errors which result in adverse consequences. a medical error, as defined by the institute of medicine (iom), is “the failure to complete a planned action as intended or the use of a wrong plan to achieve an aim”.2 thus, in this way, it is a mistake in action or judgment. many medical errors are the result of negligence or malpractice on the part of medical practitioners. medical malpractice occurs when a medical or health care professional deviates from the standards in his/her profession, thereby causing injury to a patient.3 acts of negligence on the part of a healthcare professional can lead to severe injuries or even the death of the patient which gives rise to a medical malpractice claim. such an event in health care is termed as adverse event or sentinel event.4 there is a perception that medical practitioners are not responsible for the errors, but, rather, the quality of health care and overall management lead to these errors. thus, the focus must be on ensuring health care quality rather than blaming international journal of human and health sciences vol. 04 no. 03 july’20 162 health care provider for adverse events. in 2000, iom published “to err is human” which concluded medical errors are not caused by “bad people” but in general are caused by “good people” working in bad healthcare systems that must be made safer.5 this is not true in most of the cases of medical malpractice where the adverse events are definitely avoidable if proper care is adopted by health care provider. no doubt preventability must be the priority but providing immunity to medical practitioners from the clutches of accountability makes them reckless. in fact, fear of consequences forces society to be careful and not to breach the law. just is the case with medical practitioners; while treating patients fear of punishments, physical or monetary or any other like administrative form, will force the medical practitioner to be very careful and to follow the standard of care required. therefore, medical practitioner should be bound by hippocratic oath6 to ad-here strict duty of care. and if, in case, they deviate from the quality of care that is normally expected from them, they will be legally responsible, if the patient experience harm or injury. because, the health provider deemed to be aware of probable danger, still neglected to follow the anticipated standard of care, and thus caused the preventable harm. this attitude is completely adverse to the objectives of health care hence attract accountability and penalization. medical negligence and malpractice are increasingly becoming a common exercise in pakistan. several cases involving medical neglect on the part of physicians and hospitals are witnessed by means of defective procedure techniques, lack of competent staff; such as, ‘leaving instruments in abdomen’, ‘amputating wrong organ(s)’, ‘administration of inappropriate vaccines’, ‘use of expired drugs’, ‘making improper diagnosis’, ‘giving ill-treatment’, ‘directing erroneous amount of anesthesia’, ‘failure to wear gloves’, ‘use of used syringes’ and etc, are the common causes.7 resultantly, the situation of health care system is devastating in pakistan in which one of the contributing factors is medical malpractice. it has not only endangered those seeking health care but also health care providers. a research conducted in peshawar, khyber pakhtunkhwa, pakistan, during the year of 2017, which was explored that 51% of every second health care provider witnessed or experienced violence at hands of patients or their attendees. almost half the health care personals (49.8%) involved in the study experienced verbal violence from patients or their attendees. all of the participants gave some main common reasons behind the violence i.e. ‘lack of communication’, ‘devoid of awareness among the general public’, ‘human errors’, ‘deficient laws and regulations’, and ‘unrestricted number of attendees allowed’, etc.8 unlike other countries pakistan neglected this menace and no action is ever taken to mitigate this wicked practice. there is no comprehensive law(s) dealing with medical negligence and malpractice cases in pakistan. however, there are some provisions incorporated in other acts and regulations dealing either with negligence in general or medical malpractice in particular. such as, section 304(a) and 318 of pakistan penal code, 1860 (ppc); section 1 of fatal accident act, 1855, section 11(b) of kp consumer protection act, 1997, deals with negligence in general, and section 30 of pakistan medical and dental council ordinance 2019 (pmdc), and section 13 of khyber pakhtunkhwa health care commission act, 2015 deals with medical malpractice discretely. similarly, the punjab health care commission, act, 2010, and 26(2) of the sindh health care commission, act, 2013 are available to deal with the cases of medical malpractice. certainly, in point of fact, the problem of concern is that whether the current laws are sufficient and efficient to bring medical practitioners under the umbrella of accountability, to provide sense of security to patients, and legal course of action or way to those alleging negligence or malpractice on the part of health care provider. is the law sufficient to safeguard the rights and safety of health care providers as well as the patients? background of the study medical negligence and malpractice are an evil prevalent across the globe. the investigators for the harvard medical practice study reviewed more than 30,000 records from patients discharged in 1984 from 51 hospitals across the state of new york.9 adverse events occurred in 3.7% of these hospitalizations, most of which were preventable.10 if generalized to all hospitals in the united states, this incidence translates to more than one (1) million people experiencing an adverse event and approximately 180,000 patients dying from an adverse event every year.11 medication-related incidents were the most common type of adverse event, at a rate of 0.7 adverse drug events (ades) 163 international journal of human and health sciences vol. 04 no. 03 july’20 per 100 admissions.12 the iom released its landmark report “to err is human” at the end of 1999, heralding a new age for the field of patient safety. the report estimated that 44,000 to 98,000 patients die from medical errors annually in usa. globally, it is estimated that 142,000 patients died in 2013 from adverse effects of medical treatment; this is an increase from 94,000 in 1990.13 however, a 2016 study of the number of deaths that were a result of medical errors in the u.s. placed the yearly death rate in the u.s. alone at 251,454 deaths, which suggests that the 2013 global estimation may not be accurate.14 -15 the uk department of health, in its 2000 report, an organization with a memory, estimated that adverse events occur in around 10% of hospital admissions or about 850,000 adverse events a year. the quality in australian health care study (qahcs), released in 1995, found an adverseevent rate of 16.6% among hospital patients. the hospitals for europe’s working party on quality care in hospitals estimated, in 2000, that every tenth (10) patient in hospitals in europe suffers from preventable harm and adverse effects related to his or her care. the new zealand and canadian studies have also suggested relatively high rates of adverse events: around 10%.16 it is commonly reported that around 1 in 10 hospitalized patients experience harm, with at least 50% preventability. approximately twothirds of all adverse events happen in low-and middle income-countries but reported from highly developed countries as well. the most common adverse safety incidents are related to surgical procedures (27%), medication errors (18.3%) and health care-associated infections (12.2%). yet, in many places, fear around the reporting of errors is manifested within health care cultures.17 measures adopted to mitigate medical malpractice the history of medical negligence laws can be traced back to the code of hammurabi (the oldest codified law) which was developed by babylon’s king hammurabi in 1754 bc. the code fixed fee for treatment and penalty for improper treatment.18 also, the ancient mosaic law which was based on principle of ‘eye for eye’ and ‘tooth for tooth’ applied the same on medical errors. egyptian law and roman civil law provided for punishment of medical wrong doer. medieval law was also very strict on medical practitioners.18 islamic law holds the medical expert or professional liable if he is negligent.19 in early civilizations medical malpractice was considered as crime. no compensation or damages was awarded to the patient. factually, when the issue of medical malpractice was brought into the notice of the world through various researches and surveys, measures were soon adopted to mitigate this menace. in 2003, the world health organization (who) passed a resolution supporting a strategic global agenda for achieving patient safety.20in usa medical malpractice litigations are enormous and are decided under the law of torts. in 2011 reforms were brought in medical malpractice laws i.e. tort laws in us by the national conference of state legislatures (ncsl). the ncsl reforms sought to address three major areas: limiting the costs associated with medical malpractice, deterring medical errors, and ensuring fair compensation for patients who are harmed. the reforms were successful in its outcome. there is also an option of alternate dispute resolution (adr) where the patient and physician settle their dispute without approaching the court. a reform was also introduced by developing communication and resolution programs (crp). these programs encourage open communication and transparency with patients and their families and facilitate restitution for injured parties when appropriate. they also support physicians in disclosure conversations with patients. after full implementation of the crp, the average monthly rate of new claims decreased from 7.03 to 4.52 per 100,000 patient encounters, the average monthly rate of lawsuits decreased from 2.13 to 0.75 per 100,000 patient encounters, and the median time from claims reporting to resolution decreased from 1.36 to 0.95 per year. moreover, the average monthly cost rate decreased by at least 50% for ‘total liability’, ‘patient compensation’, and ‘no compensation-related legal cost’. 21 the focus of medical liability in england and wales is under the law of tort, specifically negligence. in cases of clinical negligence national health service trusts and health authorities are the bodies that are sued, rather than individual clinicians. under this practice, nhs trusts and health authorities are vicariously liable for the negligent acts and omissions of their employees– including doctors, nurses, and clinicians. this liability arises from the duty of care that the nhs trusts owe to their patients. this application of international journal of human and health sciences vol. 04 no. 03 july’20 164 vicarious liability has resulted in a government policy known as nhs indemnification, which arises when an employee of the nhs in the course of their work, is responsible for a negligent act or omission (commonly referred to as “clinical negligence”) that results in harm to an nhs patient or volunteer.22 around 12,000 claims payment by nhs were made during 2013-2014. this system ensures the quality of health care and encourages public to trust government hospitals. private hospitals and clinics are sued separately in courts for breach of contract or breach of legal duty.23 in australia medical malpractice was and is dealt under law of tort. in 2006 the australian commission on safety and quality in health care was established for various initiatives including better communication between patient and physician. recently, in 2017 australian public hospital were decided to be penalized for eight sentinel events. these measures incredibly reduced the chance of sentinel events to 0.000201% of the 53 million patients each year.24 medical malpractice laws in pakistan in pakistan there is no codified law which deals with medical malpractice. generally, some attempts are made to give relief to the victims of medical negligence under the general laws. the legal system of pakistan is inherited from the british legal system; therefore the principle of tort is accepted by courts in pakistan. however, the principle of tort is not in the form of codified law, and hence not binding. but, suit may be filed for damages where a person sustains injuries resulting from negligence of another person. thus, in this way or other, medical malpractice cases may be brought under pakistan penal code, 1860, under sections dealing with qatl-i-khataand hurt by negligence. the damages may be claimed by patient under consumer protection act, 1997, in cases where the danger associated with services is not disclosed to the patient. the claimant may also complain to the health care commission, health department and pmdc. it has the power to cancel the license of medical practitioner. further, details of these provisions related to medical malpractice are as under: 1. pakistan penal code section 304-aof pakistan penal code, 1860, states that, “whoever causes the death of any person by doing any rash or negligent act not amounting to culpable homicide, shall be punished with imprisonment of either description for a term which may extend to two years, or with fine, or with both”.25 similarly, section 318 of ppc deals with qatl-i-khata, the section implies that “whoever, without any intention to cause death of, or cause harm to, a person causes death of such person, either by mistake of act or by mistake of fact, is said to commit qatl-i-khata”.25 while, section 319 provides punishment for qatl-i-khata that is diyat (blood money) but special proviso is given in the section for qatl-i-khata committed by rash or negligent act other that negligence driving than in addition to diyat, the offender may also be punished with imprisonment for up to 5 years. under this section a medical practitioner when causes death to a person by negligent act, then he will not only be liable for payment of blood money but also be physically punished.25section 337-h, maintained that, “whoever causes hurt by rash or negligent act, other than rash or negligent driving, shall be liable to arsh (compensation fixed by pakistan penal code) or daman (compensation to be determined by court) specified for the kind of hurt caused and may also be punished with imprisonment of either description for a term which may extend to three years as ta’zir”.25 and, section 337-i prescribe punishment for hurt caused even by mistake, it maintains that, “whoever causes hurt by mistake (khata) shall be liable to arsh or daman specified for the kind of hurt caused”.25all these sections can be invoked in cases of medical negligence or malpractice. 2. fatal accident act 1855 section 1 of fatal accident act, 1855, provides remedy to compensate the family of a person whose death is caused by wrongful act, default, or neglect and the act of neglect or default is such if the death had not being caused, the person injured would have been entitled to maintain suit and recover damages, notwithstanding the death of the person injured, and although the death shall have been caused under such circumstances as amount in law to felony or other crime.26this section could also be invoked in cases of medical negligence or malpractice. where the death is caused by neglect or default than the family of deceased, besides other remedies, may also claim compensation. 3. the khyber pakhtunkhwa consumer protection act, 1997 section 7-a:(2) of kp consumer protection act, 1997, requires the disclosure of any material information regarding the services 165 international journal of human and health sciences vol. 04 no. 03 july’20 provider or products intended to be used when such information is material to the decision of consumer to enter into contract.27 thus, when the duty of disclosure is breached then complaint may be made to the consumer court under section 13.27 but, if where the right of consumer is infringed, the person responsible for infringement may be punished with rigorous imprisonment which shall not be less than seven days or with fine which shall be extended to fifty hundred thousand (50,000) rupees but not less than ten thousand rupees or with both and shall also be liable to provide such compensation or relief to the consumer as may be determined by the court, under section 16.27 4. pakistan medical dental council ordinance, 2019 under section 30 of pmdc, 2019, if any registered medical practitioner is found guilty of misconduct or professional negligence or incompetence or violation of the code of conduct or who failed to maintain minimum standard of the national continues medical education, the council may direct the registrar to, permanently or for some specific period, remove his name from the roll of register.28 the complaint, under this ordinance, of misconduct or professional negligence may be made to the committee of council. the committee of council, for the purpose of inquiry and disposal, will be having power of civil court.28 5. khyber pakhtunkhwa health care commission act, 2015 section 13, of the said act, maintain that a person aggrieved may, within sixty days from the date of knowledge of the cause of action, file a complaint against a health care service provider or health care establishment for ‘malpractice’, ‘negligence’ or ‘failure to provide standard care with commission’.29 however, an anonymous or pseudonymous complaint against a private health care service provider or healthcare establishment could not be entertained.29under section 6, the commission got the power to cancel licenses of the medical practitioner if found guilty of malpractice.29 methodology hypothesis present laws dealing with medical malpractice failed to mitigate and alleviate medical malpractice in pakistan. therefore, there is an immense need for specific legislation to penalize medical malpractice. thus, holding health care accountable will ensure health security, consequently, improves overall health system. objectives of research the main objective of this research is: i. to determine whether the laws dealing with medical negligence is enough and efficient to hold health care accountable in pakistan. ii. to find out whether the present laws are enough to provide security and assurance to those feeling aggrieved from services of health care that justice will be served upon them. iii. to explore the awareness of general public about these laws. iv. to explore ways that would contribute in mitigating medical malpractice, and v. to find out loopholes in the present laws. it is hoped that by achieving these aims, this research will attract the attention of law makers towards this serious issue and will be helpful in future legislation on malpractice. by this research it is intended to find a solution to curb the growing menace of malpractice in pakistan. research questions this research study seeks to answer the following questions: a. which laws deal with medical negligence in pakistan? b. are the laws presently dealing with medical malpractice efficiently redress the grievances of victims of malpractice? c. are the public aware of the present remedies available to them in case they experience medical negligence? d. do these laws hold health care accountable? e. does holding health care accountable mitigate medical malpractice? study design and settings this research study is conducted during july 17th, 2019 to october 1st, 2019, in peshawar district of khyber pakhtunkhwa. both quantitative and qualitative methods of data collection were adopted in this study. the data were collected from three main government hospitals namely, lady reading hospital (lrh), khyber teaching hospital (kth), and hayatabad medical complex (hmc), peshawar. the selection is based on judgmental or purposive sampling method. the reasons for selecting these three hospitals are; firstly, these are government hospitals, staff employed is expected international journal of human and health sciences vol. 04 no. 03 july’20 166 to be well qualified and skilled, large number of general public visit these hospitals for health care, surgeries and other treatments are done on daily basis. secondly, these hospitals run an emergency round the clock (24 hours) on regular basis and also in time of natural or human-instigated disasters. total sample size in fact, total sample size was 150 participants. 50 attendants were selected through quota sampling considering only adult participants from each of the three tertiary hospitals and the hospital was divided into five section, collecting data from 10 participants from each section. keeping in view that most of the public visiting these hospitals are not educated enough to understand and answer questionnaire, therefore, structured interview was selected as data collection tool. the records of medical malpractice complaints were obtained from hospitals mentioned above, khyber pakhtunkhwa health care commission, pakistan medical and dental council, and health department peshawar. the records obtained are of january 2018 to june 2019. moreover, to achieve other objectives attracting qualitative study methods multiple case study approach was chosen. health-care personnel including doctors, nurses, administrative officers, lawyers and police were included for exploring perceptions regarding health care accountability, effectiveness of present laws, and reason for growing cases of malpractice and suggestions to mitigate the menace of medical malpractice. interviews were conducted from total twenty participants. in addition to primary data secondary data were also collected. research materials used in this paper is legal books, statutory laws, articles, reports, journals, and other on internet, inter alia. findings quantitative results:the complaints of malpractice the records of medical malpractice complaints were obtained from lady reading hospital (lrh), khyber teaching hospital (kth), hayatabad medical complex (hmc), khyber pakhtunkhwa health care commission (kpkhcc), pakistan medical and dental council kp (pmdc-kp), and health department peshawar. the record obtained is of january 2018 to june 2019. according to the record obtained there were 48 complaints in lrh, 59 in kth, and 21 complaints in hmc. pmdc received 76 complaints some forwarded by hospitals and by complainants directly. while, kpkhcc received only 2 complaints from the individuals patients affected by malpractices of physicians. interestingly, health department peshawar maintained that no such complaints are made as it only deals with cases where complaint of non-action is made against hospital(s) or pmdc. figure 1: complaints of medical malpractice during the period of january 1st, 2018 to july 30th, 2019. action taken on the basis of complaints data was also obtained about the fate of complaints. that out of these complaints how many were\are a) rejected, b) under inquiry, c) concluded, d) forwarded to pmdc. according to the records provided out of 48 complaints filed in lrh; 11 complaints are pending, 15 were disposed of, 13 were not maintainable thus rejected and 9 were forwarded to pmdc. in kth, out of 59 complaints 26 were disposed of, 9 rejected, 18 under inquiry and 6 were forwarded to pmdc. according to hmc data, 5 complaints are under inquiry, and 2 were rejected, 14 disposed of. pmdc data provide that out of 76 complaints; 18 are under inquiry and 48 disposed of. kpk health care commission disposed of both cases. figure 2: number of complaints under inquiry, concluded, forwarded, and rejected. 167 international journal of human and health sciences vol. 04 no. 03 july’20 action taken against medical practitioner accused of medical malpractice during january 2018 and june 2019, pmdc suspended licenses of three physicians and three nurses permanently, while eleven physicians had been temporarily suspended. the registration of five physicians was canceled and further five were reprimanded. figure 3: number of cases action has been taken against health care provider accused of medical malpractice. how many complainants/aggrieved were compensated? according to the records obtained, no complainant was compensated in term of monetary compensation. the three tertiary hospitals, pmdc and health care commission take action against physicians only. since, these authorities do not compensate the damages done; the aggrieved has to invoke civil court for damages. data collected to explore perception of general public and awareness among public of malpractice laws: 1. demographic & characteristics of study population table 1 shows the demographic and characteristics of participants and their association with gender. of the total 150 individuals, 21 (14%) were women and 129 (86%) were men. while more than half of male were literate, the female were mostly illiterate. variables overall male female n, (%) 150(100) 129(86) 21(14) n: number of individuals, %: percentage (out of 100) n: 129, 86% n: 21, 14% variables age and no male female age (no.) m & f: 36(10) 59 (9) 55 (9) a: age in years, ni: number of individuals m&f=18x2, ni: 10 a: 59, ni: 9 a: 55, ni: 9 variables overall male female literate (no.) 150 (100) 106 (79) 44 (21) ti: total individuals, lf: literate in figures (out of 100) ti: 106, lf: 79 ti: 44, lf: 21 2. concern about negligence in hospitals participants were asked whether they are concerned about negligence or malpractice that could result in harm to them or their loved ones while receiving health care. about 73% were worried and the remaining 27% said that they were not worried at all. this data were collected in order to determine the trust or confidence of people in health care provider. figure 4: responses to the question: ‘are you worried about negligence or malpractice on part of health care provider?’ 3. response to negligence or malpractice respondents were asked about their response to negligence or malpractice if they ever experienced it. the participants answered differently. 24% (36) answered that they will file fir against the health care provider. 18% (28) said that they will file a complaint with hospital. 34% (51) answered that they will protest until action is taken against the health care provider accused of malpractice. 8% (12) replied that they will take legal assistance of a lawyer and will take action on his\her advice. 12% (18) answered that they will file complaint with pmdc. 3% (5) said that they will leave the matter to allah almighty and will do nothing. figure 5: responses to the question: ‘in case of malpractice, what would you do if damage is caused by neglect of health care provider to you or your family? 4. awareness of malpractice laws participants were asked whether they know about any authority to which complaints malpractice or negligence on part of medical practitioner can be made. 88% (132 out of 150) said that they know international journal of human and health sciences vol. 04 no. 03 july’20 168 nothing about such authority. 12% (18) answered that they are aware of it. figure 6: awareness of malpractices laws. qualitative data results for the qualitative part, multiple case study approach was chosen. health care personnel including physicians and nurses, public health professionals, media personnel and police were included for exploring perceptions regarding accountability of health care personnel. two focus group discussions and structured interviews were conducted with a total of 20 participants. to maintain integrity using qualitative methods, the consolidated criteria for reporting qualitative research was used when planning the focus group study.30 in addition, guba and lincoln’s criteria for judging the quality of qualitative evaluation were followed. the outlined criteria are credibility, transferability, dependability and conformability.31credibility is parallel to internal validity and was achieved through building rapport with the stakeholders. transferability is parallel to external validity, which must be evidenced in future studies, but was accommodated by using participants from a wide sample of representative areas. dependability is parallel to reliability, concerned with stable data over time. by outlining the data collection methods, replication may be achieved, and dependability is supported. finally, conformability is parallel to the criterion of objectivity and was achieved through the use of direct quotes displayed in the following section. more than 30 open codes were identified using open coding technique, one of the processes for analyzing textual contexts. it included labeling concepts, laying-down and developing categories. the categories were later classified into subthemes and their respective super-ordinate themes. four distinct recurrent themes emerged from the responses of different stakeholders. these were: 1) causes of malpractice or negligence; 2) stress on accountability; 3) loopholes in present system of accountability; 4) recommendation for reforms. thus, each of these themes was further categorized into sub-themes. theme 1: causes of malpractice or negligence sub-themes:for this theme, further sub-themes were identified. these are; a) malpractice cannot be justified; b) nepotism and favoritism (lack of skill); c) lack of administration; d) lack of fear of accountability; e) burden of work on health care provider; f) non reporting of cases; g) unawareness of general public. accordingly, the first theme of the qualitative study indicated that though there are multiple causes that can result in sentinel event, it cannot be justified. the categories describing causes/ contributing factors of malpractice. resultantly, in the present study it was explored that one of the causes of malpractice is the ‘unskilled staff’ which are recruited/employed by means of nepotism or favoritism. these unskilled staff is usually the perpetrator of malpractice. such medical practitioners do not disclose their error on time which further exacerbates the damage thus result in irreparable loss to patients. according to a physician interviewed, said that;  “if the medical practitioner started getting punished for their errors, no one would dare to practice in such a consequential field without having enough skill and knowledge of their respective work”. different stakeholders provided their opinions regarding the causes and contributing factors of malpractice or professional negligence on part of health care providers. they believed that absence of stringent policy, lack of laws, and inadequate management by administration and lack of collaboration among staff at health care institutes, followed by delayed attention or long waiting time and burden of large number of patients on limited staff create a chaotic workplace environment resulting in improper service delivery. patients were desensitized to incidents of malpractice and considered them as a part of health care routine. majority of stakeholders were of the opinion that lack of accountability is the most important cause of negligence in the health care facilities. they think that lack of accountability is lack of fear which results in negligence and recklessness. as a resultthe medical practitioners loss caution in absence of fear of consequences. but they stressed that there must be law which not only safeguard 169 international journal of human and health sciences vol. 04 no. 03 july’20 patients but also health providers from all kind of psychological pressure and exploitation.  “lack of accountability is the major cause of such incidents. people do not understand how to report such incident; therefore, the health care providers remain unaccountable. the incidents occur routinely. i think we are desensitized to such incidents now”, said a physician. the present study identified that, such incidents of malpractice had an injurious impact on individual’s health and institution’s integrity. victims suffered from medical practitioner’s negligent acts and remained silent most of the time. they said that such incidents affected patient care and overall health system. theme 2: loopholes in present accountability system sub-themes:a) no special and holistic law; b) no transparent investigation; c) impartiality not assured; d) no difference between civil and criminal incidents; e) no compensation for victims of malpractice; f) no vicarious liability; g) complainants responsibility to provide evidence of malpractice; h) no penalization in term of incarceration or fine. the respondents were of the view that there was no single legislation that specially and holistically deals with malpractice cases. they maintain, all the laws mentioned that deals with health care contain small number of provisions dealing with malpractice cases. the present laws do not provide mechanism for conducting investigation, insuring impartiality and transparency, differentiating between sentinel events that attract tort or civil laws and those which are criminal in nature nor give a time frame in which the complaints will be disposed of. some respondents were of the view that the weakest role in this regard has been played by the pmdc.victimized patients having admittance to information and still find them-selves twisted in the procedural requirements constructed by pmdc’s rules and regulations. medical litigation experts provided that in proceeding before pmdc, the burden of proof is on the complainant which means that the complainant has to provide all the evidences to prove medical malpractice. thus, it is difficult for complainants to prove malpractice, since it is matter that must be investigated by expert of medicine and the documents such as reports, etc., are retained by physicians or hospital as the case may be, thus make it more complicated for complainants to prove. one legal expert pointed out another crucial issue which is pertinent to lays eyes on is that even where such complaints are being investigated by the pmdc, it is often alleged that such investigations are biased. the likelihood of a fair trial is minimal as inquiry committee compromises of physicians investigating physicians. those enquiring into his illegal behavior are his own fellow colleagues. apart from that, some interviewees expressed concern that there is no provision for vicarious liability due to which hospitals and other health care centers are not held responsible for any wrongdoing. according to one public health specialist, pmdc punish the wrongdoer by cancelling license only. it does not have any authority to compensate the aggrieved person for loss incurred to him/her as a result of malpractice. therefore, for compensation the complainant has to file suit under tort or civil law separately. some members of legal fraternity said that there were no mentions of cases of criminal nature such as conducting unnecessary surgeries just for material gains, etc. in such cases one has to file first information report (fir). the majority of stakeholder opined that a layman, especially in our society where large numbers of people are illiterate, will be definitely confused in choosing from a buffet of laws, even they are not aware of any such authority.  “lack of awareness and knowledge among the general public about their health rights is at the lowest level. even, the educated class is unaware of their very basic healthcare rights”, said media personal.  according to one ofthe lawyers interviewed said that, “due to long delay in cases and heavy costs incurred on litigations very small number of people file suit in courts”. a police officer stated that in state of such bewilderment, unawareness and trust deficit people will take law in their own hands in form of mob lynching or other kind of aggression which endanger the life of not only the medical health provider accused of malpractice but also the life of other patients and attendees in hospital, which is evident from incidents of violence happening on daily basis as the people feels aggrieved but find international journal of human and health sciences vol. 04 no. 03 july’20 170 no other way that would give them justice. he said that such incidents are reported to police on daily basis. the present study identified that the present laws and system of accountability are not effective enough to mitigate malpractice and ensure health care safety as well as assure both patients and health care providers that justice will be served upon them. theme 3: solution to mitigate menace of malpractice; a new system of accountability sub-themes:1) future without preventable errors; 2) establishment of system of health care accountability; 3) awareness of general public; 4) transparency in investigation; 5) impartiality assured; 6) health care providers must be encouraged and incentivized to not conceal error but disclose it so that further damage is prevented; 7) there must be stress on laws and liability. the third theme emerging from the study described the various strategies for prevention of malpractice. these include strategies for prevention of medical errors in future, ensuring safe health care and making health care provider responsible for their conducts. the current study suggested that separate legislation in line with world health organization (who) guidelines is necessary for curbing this rapidly growing menace. there must be such laws that make the future without preventable errors.  “there are separate laws aimed at curbing prevailing evils in a particular society. each law separately deals with that problem keeping in view the special characteristics of each case. medical malpractice is one of such issue which is in dire need of attention of law makers”, said a lawyer. most of the participants evinced that the health care must be made accountable. unless and until there is sense of legal responsibility and fear of accountability, patients will be at mercy of medical practitioner.there is dire need of special legislation which would cover all cases of negligence and will provide such mechanism that will give surety to all those who feel aggrieved that these allegations will be thoroughly and impartially investigated, and justice would be served upon them. there will also be a sense of responsibility and fear of accountability on part of medical health providers which will make them more cautious and responsible. all other provision related to medical malpractice in present acts should either be incorporated in new special law or removed as a whole. the new law when enacted should prevail on all other general laws. a legal expert suggested that the investigation in malpractice must be impartial and for this purpose there must be a committee which not only have medical professionals but also have retired judges and involve police officers for investigation purpose in order to insure impartiality. it was also suggested that the investigation must be conducted by investigation team and burden of proof must be on investigation team not on complainants. furthermore, it was suggested that the new law must differentiate between civil or tort cases and cases that attract criminal liability. there must be clear list of all preventable errors which evoke one or the other liabilities. it was also recommended by some specialists of public health that the hospital and other medical institutions should be brought under the umbrella of accountability. the medical practitioners must be encouraged and incentivized that they must not conceal medical errors committed by them but take immediate action to cure and prevent further damage. they should be incentivized to do so by ensuring them and giving them sense of security by practical examples that if they do not conceal their mistake then the law will be easy on them. one doctor recommended coordination between hospital and staff, also between staff and patients in order to build trust among all. all the participants agreed that awareness of laws and possible remedies among general public is crucial for both accountability and also for preventing violence in hospital. consequently, both patients and doctors would be secured. there is a desperate need that the general public of pakistan must understand that the medical negligence cases must not go unreported. it is obligatory upon every citizen particularly the victims of medical negligence and their families at least to write a complaint to the authority.  “people should be made aware about the possible remedies which they could avail to get compensation for wrong and also to seek punishment for wrongdoer”, said a coordinator health reforms. conclusion consequently, the research data of malpractice complaints werecollected from lrh, kth, hmc, pmdc, and kpk hcc. the data also include 171 international journal of human and health sciences vol. 04 no. 03 july’20 attendees and patients in the major tertiary public health care facilities in peshawar district of kp. the health care experts, lawyers, police officers and media personal were included in data collection and quota sampling was employed for selecting participants of the study. resultantly, a number of complaints to the concerned authorities were explored which was total, 206 during: january1st, 2018 to july 30th, 2019. out of these complaints,105 complaints were disposed of, 24 complaints were rejected, while 23 complaints are pending. during the same year, action was taken against 27 health care providers on the grounds of misconduct. the study reveals that, even not a single, complainant was compensated by neither hospitals nor pmdc. from the qualitative arm it was revealed that the procedure of complaint is complex and involves number of formalities due to which people do not report incidents. evidently,there is lack of information; to whom’ the cases of incident may be reported. thus, the findings reflected that the cases of malpractice reported are far less than the actual magnitude of medical malpractice which is evident from media reports as well as in comparison with other developedcountries such as united states, switzerland, uk, etc., accordingly, the issue identified by the study is that cases of malpractice go unreported most of the time. the study further revealed that 74% of people do not trust health care system in pakistan. the prevalence of unawareness of present laws of medical malpractice among general was explored through the study. and hence, it was founded that only 12% were aware of authorities to whom malpractice could be reported.the other 88% had no acquaintance.during the study, health care personnel, lawyers, media personnel and police officers were able to identify key gaps in present system of medical malpractice dealing and made recommendations for its prevention. the majority of health professionals surveyed responded in the affirmative when asked if the event could have been prevented. they were able to identify ‘lack of awareness among the general community’, ‘complex procedure of complains’, ‘lack of surveillance’, ‘deficient coherent laws’, ‘in-attention by government’, ‘no compensation’, ‘no-fear of accountability’, ‘absence of vicarious liability’, ‘non-difference in criminal’ and ‘tort liability’, etc. therefore, ‘enhancing the provision of health care services’, ‘raising awareness in the general community’, ‘enacting special laws’, ‘making health care provider accountable for wrongdoing’, ‘appropriate system of investigation’, and ‘adjudication according to principles of natural justice’ were listed as the key recommendations to curb medical malpractice in pakistan. recommendations medical malpractice in hospitals of peshawar district should be considered a serious public health issue. as demonstrated by the results of the present study, the prevalence of malpractice issue is neglected by the government. the absence of an organized effort to curb this serious humanitarian concern is alarming. safety of the patients is important for provision of essential services. therefore, a holistic effort is needed to ensure that the patients have access to such health care which relieve their suffering not exacerbating them, but consequently; safe and secure. it is also evident from the findings of the study that tackling this issue is not just the health care community’s concern, but also needs the support and facilitation from government, civil administration, lawmakers, law enforcement agencies, civil society, and international organizations. following are the recommendations to prevent medical malpractice through the process of accountability: 1. conduct a national representative study to know the full magnitude, patterns and dynamics of medical malpractice in pakistan. 2. medical malpractice is a pressing public health issue and should be advocated for as such. while the realization of the problem exists within certain quarters, facilitation from health care community, health-care administration, law enforcement authorities, civil society, international organizations and media is required to ensure initiation of conscious and sustained efforts for safeguarding health care and ensuring safe health care. 3. there is a need to adopt legal framework for ensuring the protection of patients. in the context of kp, this means developing and promoting legislation protecting the rights of patients and forcing medical practitioners to perform their duties in line with standard of care. a new bill is required to be passed by legislature to hold the health care provider accountable and to preserve free and fair inquiry as well as adjudication, not only to protect patients but also health care provider. 4. there is dire need of an independent body which acts as a quasi-judicial body to international journal of human and health sciences vol. 04 no. 03 july’20 172 order investigation and decides cases of malpractice. such a body like any other court should act on basis of law and principles of administration of justice. this body should dispose of complaints of malpractice without delay. most importantly, impartiality must be ensured. 5. the knowledge of existing legislation and new legislation when enacted protecting health care should be spread among all the stakeholders, i.e. law enforcement authorities, civil servants, health care personnel and the general public. 6. the kp government should regularly collect data on medical malpractice and take preventive measures based on the data. institutional incident reporting systems and response mechanisms need to be developed and implemented in health care facilities. 7. seminars and conferences must be held to remind the health care personnel of their responsibility towards patients. 8. experiences and best practices with proven effectiveness need to be incorporated in the kp healthcare system. 9. government of kp needs to ensure provision of health care services suitable for the needs of the population and to ensure that the workload of personnel is in conformity with the recommended standards. 10. continuous engagement with the media to promote responsible, balanced and informed reporting on health care. 11. the rights, roles and responsibilities of all stakeholders should be promoted on all fronts. conflict of interest: the authors declared that there is no conflict of interest. funding statement: nil & the authors declared that they have not competing financial interests. individuals author contributions: fd & g perceived, conceived and designed the study, while mms participated in study design and helped fd & g in critical review. g & fd both did data collection in peshawar. fd & g both did statistical data analysis.mms & mzh helped fd & g in analysis. fd & g did manuscript writing & drafting, while fd did manuscript editing and incorporated the reviewer’s and editor’s suggestions. mzh & fd both did final review of the manuscript. fd & g takes responsibility/ accountability for all aspects of the work in ensuring that all queries related to the integrity of the research study are appropriately investigated and resolved. all the authors read and approved the study. 173 international journal of human and health sciences vol. 04 no. 03 july’20 references: 1. world health organization. patient safety: making health care safer. who: avenue appia 20, ch-1211 geneva 27, switzerland; 2017, p. 1. 2. rockville, md. medical errors: the scope of the problem, md: agency for healthcare research and quality; 2000, p. 2 (adapted from huber, c.h; 1999. ethical legal, and professional issues in the practice of marriage and family therapy. upper saddle river, nj: prentice hall, inc.) 3. dr. medlaw. proving a medical malpractice case i–proving negligence (part i). physician’s weekly. march 14, 2017. 4. hf, hayes firm legal blog. difference between medical error and medical malpractice. august 11, 2016. 5. kohn, l. t., corrigan, j., & donaldson, m. s. to err is human: building a safer health system. institute of medicine, the national academies press, washington, dc; 2000, p. 4. 6. ludwig edelstein. the hippocratic oath: text, translation, and interpretation. baltimore: johns hopkins press, 1943. hippocratic oath means: “an oath taken by physicians to observe medical ethics deriving from hippocrates; a medical practitioner who is regarded as the father of medicine and also the author of the hippocratic oath during the era 460-377 bc, which is still held sacred by physicians: to treat the ill to the best of one’s ability, to preserve a patient’s privacy, to teach the secrets of medicine to the next generation, and so”. william c. shiel jr. medical definition of hippocratic oath. medicinenet. 7. arsalan raja. medical negligence must not go unchecked. pakistan today. may 4, 2017. 8. icrc & kmu. addressing violence against health care peshawar, a mixed methods study. international committee of the red cross. plot 31, shabbir sharif road, g-11 markaz, islamabad; 2018, pp. 1-41. 9. brennan ta, et al. incidence of adverse events and negligence in hospitalized patients–results of the harvard medical practice study i. the new england journal of medicine.1991; 324(6):370-376. 10. leap ll, et al. the nature of adverse events in hospitalized patients–results of the harvard medical practice study ii. the new england journal of medicine. 1991;324(6):377-84. 11. bates dw, cullen dj, et al. incidence of adverse drug events and potential adverse drug events, implications for prevention, ade prevention study group. jama. 1995; 274(1):29-34. 12. bates dw, et al. relationship between medication errors and adverse drug events. journal of general internal medicine. 1995;10(4):199-205 13. abubakar, ii, et al. global, regional, and national agesex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the global burden of disease study 2013. the lancet. 2015;385(9963):117-171. 14. frellick, marcia. medical error is third leading cause of death in us. medscape. may 3, 2016. 15. martin a makary, michael daniel. medical error— the third leading cause of death in the us. bmj. 2016;353:i2139 16. world health organization. world alliance for patient safety: forward program. who: 20 avenue appia, ch-1211, geneva 27, switzerland; 2004, p. 1. 17. world health organization. patient safety: making health care safer. who: avenue appia 20, ch-1211 geneva 27, switzerland; 2017, p. 2. 18. gigi p.v. law and medical negligence. school of indian legal thought: mahatma gandhi university, kerala, india; 2011. 19. al-shafi, kitab al umm. cairo: matbakah al kubra; 1325(h), vol. 6, p.175. 20. the joint commission. sentinel events policy and procedure. joint commission policy. 1996. 21. kass js, rose rv. medical malpractice reform: historical approaches, alternative models, communication and resolution programs. ama journal of ethics. 2016;18(3):299-310. 22. richard west. medical malpractice liability: united kingdom (england and wales). the law library of congress: global legal research center. may 2012. 23. retrieved from: https://www.loc.gov/law/help/medical-malpractice-liability/uk.php, (last accessed on dated: 11thjuly, 2019) 24. medical malpractice centre. united kingdom medical malpractice laws in medical malpractice laws by state. 25. joseph ibrahim, john mcneil. punishing medical error won’t improve hospital safety or quality. the conversation au: academic rigour, journalistic flair. march 16, 2017. 26. pakistan penal code, 1860. 27. fatal accident act, 1855. 28. the khyber pakhtunkhwa consumer protection act, 1997. 29. pakistan medical dental council ordinance, 2019. 30. the khyber pakhtunkhwa health care commission act, 2015. 31. allison tong, et al. consolidated criteria for reporting qualitative research (coreq): a 32 item checklist for interviews and focus groups. international journal for quality in health care.2007;19(6):349357. 32. yvonna s. lincoln egon g. guba. but is it rigorous? trustworthiness and authenticity in naturalistic evaluation. new directions for program evaluation. 1986;(30):73-84. international journal of human and health sciences vol. 02 no. 03 july’18 174 letter to editor: obituary khan mi correspondence to: mohammad iqbal khan,md; frcs (glasg); frcs (eng.); dvs (uk); mhpe (neth), professor of surgery/medical education,vice-chancellor,shifa tameer e millat university (stmu) consultant surgeon shifa international hospital, h-8/4 islamabad pakistan tel 0092518464211/8463142; mail: vc@stmu.edu.pk/ mikhandr@gmail.com professor dr mohammad tariq was great a scholar, scientist, renowned clinician and eminent neuro physician of the current era. he was born in september 1953, after his primary education at abbottabad, he moved to islamabad and completed his premedical education. during this time, he joined islamijamiat e talba, and was appointed the first nazim of the islamabad chapter. during his medical education at khybar medical college peshawar, he also remained the nazim of the local chapter and member of provincial shura. he enjoyed very special relationship with br. matee ur rehamannizami then nazim allah, where he used to narrate several special events spent with him and with tasnneemalam manzar. after his house job at abbottabad, he worked as demonstrator at ayub medical college for sometimes prior to moving to iran. in iran he worked in a primary health care, during the time when revolutionary process was on its full swing and used to narrate several very interesting and lesson learning incidences and how he used to confront those. thereafter he moved to uk where he got higher training initially in general medicine and thereafter in neurology. he worked as consultant neurologist prior to relocating to islamabad where he was appointed as neurologist at pakistan institute of medical sciences (pims). he revolutionized the neurological services, teaching and training in pakistan. his main interest was neuro muscular disorders and he established portable plasmapheresis in pakistan, initially in pims and latter in all big cities of the country free of cost through his ngo called myasthenia professor dr mohammad tariq international journal of human and health sciences vol. 02 no. 03 july’18 page : 174-175 doi: http://dx.doi.org/10.31344/ijhhs.v2i3.51 175 international journal of human and health sciences vol. 02 no. 03 july’18 welfare organization. he was teacher of teachers and trained several neurologists of international repute who occupy prestigious positions nationally and globally. professor tariq discovered the rarest gene responsible for myasthenia and largest family suffering from inherited neuromuscular disorders in collaboration with the department of neurology at oxford university. he was the man of integrity, extreme honesty, commitment and scholarship. i enjoyed cordial friendship with him for over thirty years. he was my mentor, friend, brother and benefactor. i travelled with him around the globe and wherever we went, it remained highly focused and beneficial for humanity in pursuance of pleasure of almighty allah and nothing less or more. we travelled the most difficult terrains across europe, asia and africa for relief purposes, i found brother tariq, very sound and stress sacking person where even in difficult stints, he remained always composed and never showed wrath or anxiety. he also remained the president of pakistan neurological society, president pima islamabad. i remember how he accepted general secretary ship of pima center and when suddenly nominated and elected pima president at biennial convention held in karachi. he was not ready to take the oath of president until he was strongly persuaded by his predecessor prof dr ahmed saeed for whom he had great regards. he took on vow to remained with him during his tenure as a general secretary and alkhamdullillah we managed difficult time of 2005, earth quake in pakistan. during this period pima got national and international recognition. prof tariq remained general secretary of fima as well and worked hard for the expansion fima projects. professor tariq had in depth knowledge of qur’an and sunnah and used to discuss challenging ethical issues in medical practice. dr tariq had ahabit of doing hafiz e qur’an all the time, never wasted his time and used to say iqbalbahi“never opt for inferior, go ahead and take challenges with sincerity, allah will help us. he was a very developed habit of taking every challenge with smiling face used to say, “in my life time i want to see pima as an actual driving force for every doctor in pakistan.”in october 2014 he was diagnosed localized prostatic cancer, we had meeting with world renowned urologists with vast experience in prostatic diseases and ultimately, he had radical proctectomy by my best friend and very competent urologist prof saeed akhter. he was provided all sort of treatment available in pakistan and abroad looking at the literature and best practices, we all including tariqbahi remained hopeful, his last three months were really very critical where even he could not get up and move himself. he used to say don’t bother brothers, they will be disturbed because of my illness, why to grind all in my desolations. he never complained about the disease and for all emerging situation. i remained very close to him during his illness and was the first to know about that as well but in my thirty-year clinical experience i have never encountered such patience, serenity and pious and virtuous man in my life, who was valiant enough to live with dignity and died with dignity and the day he died prayed his maghrib but could not attain the moment to say his ish’aon that day. may allah raise him the highest place in jannah bestows patience to all his concerns. i salute mrs. m tariq our sister and great lady, who looked after him with exemplary passion, love and affection. international journal of human and health sciences vol. 03 no. 02 april’19 120 case report patellofemoral pain: a not so trivial knee injury (a case report) aneesa abdul rashid1 , navin kumar devaraj2, johan abdul kahar3 abstract knee injuries are very common in sports, ranging from trivial knee strains to severe ligament, tendon and/or meniscus tear, knee joint fracture or dislocations. the treatment ranges from the basic rest, ice, compression and elevation (rice) approach to oral medications and/or surgery. it usually entails some form of physiotherapy especially during the post injury period and with functional loss of motion or stiffness. for the professional sportsman, rehabilitation tends to be more intensive due to pressure to return to the sport as soon as possible. this case report will look at a-not-so-trivial knee injury diagnosed as patellofemoral pain syndrome (pfps) in a 28 year old recreational athlete keywords: knee strain; nsaids; pain; sports; patellofemoral pain correspondence to: aneesa abdul rashid, family medicine specialist & medical lecturer, department of family medicine, faculty of medicine & medical sciences, university putra malaysia, selangor, malaysia. e-mail: aneesa@upm.edu.my 1. dr. aneesa abdul rashid, family medicine specialist & medical lecturer, department of family medicine, faculty of medicine & medical sciences, university putra malaysia, selangor, malaysia 2. dr. navin kumar devaraj, family medicine specialist & medical lecturer, department of family medicine, faculty of medicine & medical sciences, university putra malaysia, selangor, malaysia 3. dr. johan abdul kahar, medical officer & trainee lecturer, department of orthopaedics, faculty of medicine & medical sciences, university putra malaysia, selangor, malaysia introduction knee injuries are common injuries in sports, said to be caused by knee loading activities during sport.1,2 anterior knee pain in athletes may be caused by conditions such as patellofemoral pain syndrome (pfps), sinding-larsen-johansson disease, osgood-schlatter disease and plica syndrome. these conditions may be associated with structural damages which include chondral and osteochondral damage, osteoarthritis (oa), overuse injuries of the extensor apparatus (tendonitis and insertional tendinosis), and patellar instability. 3 as a joint is principally involved in gait, any impairment of its function will have some telling effect on activities of daily living as pain in general may cause activity limitation. in fact, a number of recreational athletes quit their sport due to the pain.3 for an active sportsman, injury trends are influenced by a variety of factors, including increased time spent in competitive sports, changes in national body rules and policies and also increased role of sports medicine.4 it is said, rather surprisingly that injuries may be more frequently encountered during off season period, due to possibility of the athlete having poor physical conditioning pre-season, thereby susceptible to injuries due to high pressure and load training activities designed to prepare the athletes for competitions and sport seasons.4 this lead us into this case of an athlete with a rather trivial injury which caused recurrent symptoms over a period of more than one year before proper recovery took place. case summary a 28 year-old man previously well, complained of pain over his left knee after a volleyball game. he recalled that he twisted his knee while attempting to return the ball during the match. he had twisted his left knee just two minutes after starting the game but managed to play till end of the game 45 minutes later. there was no swelling or any limping. on examination of the left knee, the inflammation was localized over the medial joint line region with no obvious bruises or effusion. the range of motion was normal with maximal pain felt on full extension. the cruciate and the collateral ligaments were taut, and the mc murray test was negative. international journal of human and health sciences vol. 03 no. 02 april’19 page : 120-122 doi: http://dx.doi.org/10.31344/ijhhs.v3i2.87 121 international journal of human and health sciences vol. 03 no. 02 april’19 gait was also normal with corresponding normal findings over the ankle and hip joints. the diagnosis of palletofemoral pain syndrome was made. the pain persisted for the next two days and improved with prescription of regular non-steroidal anti-inflammatory drugs (nsaids). however, the pain was intermittent for the next year especially when climbing stairs, running and when doing fast paced sports such as futsal. this had restricted the choice of sporting activities that the patient was able to do, along with a weight gain of 5 kg during that year. pain during this period was treated with nsaid analgesics and a knee guard. after one year, the recurrences happened only occasionally. there were 1-2 minor episodes of recurrences with no further recurrences in the subsequent 2 years. discussion pfps is a common presentation among athletes with non-structural damage. it is a very common diagnosis in primary care.3 diagnosis is usually made clinically without any radiological investigations especially in those below 50 years old with no history of trauma, surgery or any knee joint effusion when examined.5 treatment for this condition is of course individualised, but management is mostly illustrated by this case which are: rest from activities causing stress loading of the knee, physiotherapy, orthoses and analgesia.5 other forms of treatment that may be helpful include bracing and patellar taping. surgical referral may be warranted if the symptom persists more than six months.5 given that knee injuries are common during sporting activities, preventive steps are important to prevent its occurrence6. therefore it is very important to recognise risk factors associated with knee injuries.6 this can be divided into intrinsic and extrinsic factors.7 intrinsic factors are usually player related such as physical conditioning, insufficient warm-ups, older age, higher body mass index and episodes of instability and extrinsic factors are environmental related factors such as adverse weather, pitch or track condition and unfavourable mechanism of injury.8 a unique training programme employed for athletes named neuromuscular training programme has been associated with less risk of ankle and knee injuries.1 it consists of 2 components; intervention which focuses on trunk and lower limbs exercises and exercises that consists of elastic bandcontrolled resistance running.1 this may be useful in addition to the core rice methods ± analgesics and surgeries in severe cases. encouraging a healthy lifestyle is one of the top priorities in prevention of cardiovascular disease, hence the awareness of the exercise in the community. therefore, sport injuries are not only amongst sportsmen but also the community at large. to encourage this type of lifestyle, doctors, especially in the primary care setting should advise more than the traditional focus of frequency of exercise. emphasis on prevention of injuries that are common such as knee injury and what can be done when an injury occurs should be also be a priority depending on the level of athletic involvement of the patient. this case presented in a primary care setting of someone who was actively involved in sports even in his late twenties, continuing during his school years. in this case, he was compliant to treatment and was able to resume his active lifestyle. however, the situation would have been changed, as it is not common for athletes to quit sports altogether due to injury leading to a more sedentary lifestyle. conclusion knee strains are a common sport injury that may impede activities of daily living and run a chronic course. aggressive initial management may reduce the severity and length of the initial injury to enable normal gait and result in less risk of disabling pain. therefore, any sports injuries involving the knee should treated with initial rice therapy after ruling out more severe injury such as ligament, tendon or meniscus, dislocation or patella fracture. physiotherapy including neuromuscular training program may help before the actual competition starts to prevent injuries as well regular checks and treatment of minor injuries. these type of treatment are readily available in the primary care setting, and if treated early and properly will prevent serious complication to the patient. therefore it is imperative, this be done at the primary point of contact and should be referred should the need arise. acknowledgement the authors would like to thank the patient for his kind permission to publish this case report. conflict of interest no conflict of interest has been disclosed by the authors. funds this study did not receive any special funding. authors contributions conception and design: nkd, aar critical revision of the article for important intellectual content: aar, jak final approval of article: aar, nkd, jak international journal of human and health sciences vol. 03 no. 02 april’19 122 references 1. foss kd, thomas s, khoury jc, myer gd, hewett te. a school-based neuromuscular training program and sport-related injury incidence: a prospective randomized controlled clinical trial. journal of athletic training. 2018;53(1):20-8. 2. hiemstra la, kerslake s, irving c. anterior knee pain in the athlete. clin sports med. 2014;33(3):437–59. 3. petersen w, rembitzki i, liebau c. patellofemoral pain in athletes. open access j sport med. 2017; 8:143–54. available from: https://www.dovepress.com/patellofemoralp a i n i n a t h l e t e s p e e rr e v i e w e d a r t i c l e oajsm 4. hootman jm, dick r, agel j. epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. journal of athletic training. 2007;42(2):311-9. 5. dixit s, difiori jp, burton m, mines b. management of patellofemoral pain syndrome. am fam physician. 2007;75(2):194–202. 6. hägglund m, waldén m. risk factors for acute knee injury in female youth football. knee surgery, sports traumatology, arthroscopy. 2016;24(3):737-46. 7. bahr r, holme i. risk factors for sports injuries—a methodological approach. br j sports med 2003; 37:384–92. 8. salem hs, shi wj, tucker bs, dodson cc, ciccotti mg, freedman kb, cohen sb. contact versus noncontact anterior cruciate ligament injuries: is mechanism of injury predictive of concomitant knee pathology? arthroscopy 2018;34(1):200-4. international journal of human and health sciences vol. 06 no. 04 october’22 442 case report the mystery of the disappearing nasal packs wong kim yew richard1, shamim rahman bin s.m.a. abdul rasheed1 abstract nasal packing is commonly used for hemostasis post nasal surgeries. it is cheap, easily available and is routinely practiced in many centres. however, they may be associated with complications. some of the complications include pain during nasal packing removal, damage or injury to the nasal mucosa leading to synechiae formation, crusting, and septal perforation. we describe a case of a 39-year-old gentleman who underwent a septoturbinoplasty procedure, to address his nasal problem and subsequently nasal packing was inserted into bilateral nasal cavity for hemostasis. however, prior to extubation, it was noted that the nasal packing were not in situ. nasoendoscopy and direct laryngoscopy were performed but were unable to trace the missing nasal packs. an oesophagogastroduodenoscopy (ogds) was done and revealed the presence of the nasal packing in the stomach. this case highlighted the risk of nasal packing to be dislodged from the nasal cavity into the stomach if not secured properly, and therefore we recommended securing the nasal packing in its position by tying a knot using the strings attached with the nasal packing together. keywords: haemostasis,nasal surgery,polyvinyl acetal correspondence to: dr. wong kim yew richard, resident, department of otorhinolaryngology-head & neck surgery, kulliyyah of medicine, international islamic university malaysia,kuantan, pahang, malaysia. e-mail: richardwky@gmail.com 1. department of otorhinolaryngology-head & neck surgery, kulliyyah of medicine,international islamic university malaysia, kuantan, pahang, malaysia. introduction there are multiple modalities of nasal hemostasis post nasal surgery. one commonly used modality is by inserting nasal packing into the nasal cavity. we present a rare case of nasal packing which was inserted into the nasal cavity for hemostasis, and subsequently dislodged into the stomach. we also review the associated literatures to determine the available methods of nasal hemostasis post nasal surgery, discussing on the benefits and disadvantages of each modality. case report a 39-year-old malay gentleman, with underlying bronchial asthma; presented with history of daily rhinorrhea & bilateral nasal blockage which became worse for the past three years. it is associated with sneezing and nasal itchiness, which worsens with seafood intake. examination of the nose via nasoendoscopy shows narrow internal nasal valve area bilaterally, hypertrophy of bilateral inferior turbinates, and left septal deviation with right sided septal spur. there were no abnormality detected in the bilateral osteomeatal complexes and nasopharynx. based on the symptoms and finding, he was diagnosed as allergic rhinitis with deviated nasal septum. he was initially treated with fluticasone intranasal steroid spray, which did not help much with the symptoms. he was then advised to undergo a septoturbinoplasty procedure in view of persistent nasal symptoms despite being on intranasal corticosteroids. intra-operative findings confirmed the clinic nasoendoscopic findings of a left sided nasal septal deviation, and bilateral inferior turbinate hypertrophy. the procedure was done in the usual manner and was uneventful with no intraoperative complication. at the end of the surgical procedure, merocel® nasal packs, enveloped with an outer layer of glove; were inserted into bilateral international journal of human and health sciences vol. 06 no. 04 october’22 page : 442-444 doi: http://dx.doi.org/10.31344/ijhhs.v6i4.485 443 international journal of human and health sciences vol. 06 no. 04 october’22 nasal cavity for hemostasis. the strings at the end of the nasal pack were not tied, but placed onto the patient’s nasal tip using a surgical tape.. figure 2:nasal packs, enveloped with an outer layer using glove, after removal from the stomach. discussion bleeding is the most frequent complication of endoscopic nasal surgeries. it may occur intraoperatively or post-operatively, increasing the risk of morbidity to the patient.1 therefore, various methods of nasal hemostasis have been developed to address the problem of bleeding. this ranges from the usage of formed nasal packs, thrombogenic foams and gels, and usage of cautery devices. nasal packs are extremely useful tools for hemostasis in endoscopic nasal surgeries. with an increased demand, there is also an increasing number of products on the market made of different materials. the advantages of nasal packs are that they not only provide hemostasis after surgery, but they also provide support for the cartilaginous and bony nasal structures, or soft tissues which require time to regain their strength via the wound healing process post-operatively. they may also prevent adhesions or stenosis, especially following functional endoscopic sinus surgery. nasal packs also reduce the risk of the formation of septal hematomas. nasal packs can be generally divided into two main groups made of different materials, which are the formed nasal packs (e.g. polyvinyl acetal, carboxymethylcellulose and alginates) and the new generation of hemostatic or resorbable and biodegradable packs (e.g. gelatin, thrombin, and polyurethane foams) polyvinyl acetal (pva) nasal packs are expandable type which increases in volume after the contact with blood or water. the classic type of pva nasal pack is the merocel®. merocel® is soft and elastic, as they can absorb up to 20 times their weight in fluid. this property allows them to apply light to moderate pressure in the nasal cavity.2 as it is packed in a compressed and dehydrated state, it requires rehydration with saline to activate it. the pores within the merocel® swells, causes haemostasis, and exerts equal pressure on both sides of the septum, thus keeping the septum straight following the surgery. conclusion to conclude, there are multiple methods of haemostasis which can be used post nasal surgery, which includes the usage offormed nasal packs, thrombogenic foams and gels, and usage of cautery devices. formed nasal packs, especially those of the polyvinyl acetal type (e.g., merocel®) is widely used in many centres. we would like to highlight the rare but possible complication of nasal packs being dislodged into the stomach if not anchored properly.therefore, if polyvinyl acetal nasal packs are used, we recommend that a knot is tied between the strings of the two nasal packs to prevent dislodgement out of the nasal cavity. conflict of interest: the authors declare no conflict of interest. funding statement: nil author’s contribution: wkyrand srsar contributed to the concept, design and drafting of the manuscript. srsar contributed to obtaining the clinical and radiological images. all authors revised and approved the final manuscript. figure 1: view of the dislodged merocel® nasal packs in the body of the stomach located using an ogds. international journal of human and health sciences vol. 06 no. 04 october’22 444 references: 1. pagella f, pusateri a, berardi a, zacchari d, avato i and matti e. a novel device for intraoperative cauterization of bleeding points in endoscopic sinus surgery.european archives of oto-rhino-laryngology. 2016;273(8):2257-2260. 2. weber r. nasal packing and stenting. gms current topics in otorhinolaryngology head and neck surgery. 2009;8:1-16. 3. kaur j, singh m, kaur i, singh a and goyal s. a comparative study of gloved versus ungloved merocel® as nasal pack after septoplasty. nigerian journal of clinical practice. 2018;21:1391-5. 4. garzaro m, dell’era v, rosa ms, cerasuolo m, garzaro g, aluffivalletti p. effects of glove fingerversus lidocaine-soaked nasal packing after endoscopic nasal surgery: a prospective randomized controlled trial. european archives of oto-rhino-laryngology. 2019;277(2):439–43. 5. eta ra, eviatar e, pitaro j, gavriel h. postturbinectomy nasal packing with merocel versus glove finger merocel: a prospective, randomized, controlled trial. ear, nose & throat journal. 2018;97(3):64–8. 6. rohit k, shivakumar am, munish ks, mohan kumar c and jeyashanthriju j. unusual foreign bodies of the nasal cavity: a series of four cases. iosr journal of dental and medical sciences. 2015;14(5):100-104. 7. eipe n, choudhrie a. nasal pack causing upper airway obstruction. anesthesia & analgesia. 2005;100(6):1861. 8. novoa e, junge h. nasal packing: when a routine practice becomes a life‐threatening emergency. clinical case reports. 2020;8:2638-2640. 9. badran k, malik th, belloso a and timms ms. randomized controlled trial comparing merocel® and rapidrhino® packing in the management of anterior epistaxis. clinical otolaryngology. 2005;30(4):333– 337. 10. chevillard c, rugina m, bonfils p, bougara a, castillo l, crampette l, et al. evaluation of calcium alginate nasal packing (algostéril) versus polyvinyl acetal (merocel) for nasal packing after inferior turbinate resection. rhinology. 2006;44(1):58-61. 11. weitzel ek, wormald pj. a scientific review of middle meatal packing/stents.american journal of rhinology. 2008;22(3):302-307. 12. wang j, cai c, and wang s. merocel versus nasopore for nasal packing: a meta-analysis of randomized controlled trials. plos one. 2014;9(4):e93959. 13. mcleod rwj, price a, williams rj, smith me, smith m, owens d. intranasal cautery for the management of adult epistaxis: systematic review. the journal of laryngology & otology. 2017;131(12):1056–64. 14. weber r, keerl r, hochapfel f, draf w, toffel ph. packing in endonasal surgery. american journal of otolaryngology. 2001;22(5):306–20. 107 international journal of human and health sciences vol. 02 no. 03 july’18 review article: biological mechanisms underlying addiction ilhan yargic keywords: addiction, mechanism, abuse, dependence, neurobiology correspondence to: prof. dr. ilhan yargic, m.d. (psychiatrist) private practice, istanbul, turkey e-mail: iyargic@hotmail.com introduction drug addiction is a chronic, relapsing disorder that is characterized by a craving for drug, compulsive drug use, loss of control in limiting intake; and emergence of an aversive state (withdrawal) when drug is not accessed1. although any drug use has a potential for further abuse or dependence, clinical experience and animal studies show that neurobiological effects of occasional and limited use of a drug, like alcohol, is different from those of a chronic dependent state2. addiction develops as a result of a transition from the first neurobiological state to the second. drug intake, accompanied by a biological vulnerability causes some permanent functional and structural changes3 in various parts of the central nervous system (cns) and several neuroendocrinological modulator systems. while talking about the health hazards of alcohol and drugs, usually their deteriorative effects on bodily functions and organs like liver and lung are mentioned first. however, maybe the worst effect of alcohol and drugs is on brain, because they cause long term neuroadaptive changes in the cns which lead to compulsive drug use despite bad consequences and relapse even long after acute withdrawal symptoms abate. modern research on drug abuse has demonstrated the biochemical, cellular, genetic, epigenetic and circuitry mechanisms that mediate the progression from experimenting with a drug to addiction. addiction is a brain disease that starts with drug use. it is not just a matter of will power. a person who uses a drug is taking the risk of starting this disease process in his body and brain because drug use triggers a series of biological cascades. these changes in the brain have a potential to continue for a long time after drug use has stopped. addiction is a biopsychosocial disorder similar to other chronic physiological disorders such as diabetes mellitus that are progressive and influenced by environmental factors and stressors. a diabetic person cannot claim that he will use his will power to keep a normal blood glucose level after he consumes a large amount of carbohydrate. just like that, an addict cannot keep limiting his drug use and avoid bad consequences forever. but like a diabetic person who should avoid food that is rich from carbohydrates, an addict should take every precaution to stay away from drugs for good. alcohol and drugs have effects on four interrelated biological systems in the brain that underlie addiction. these are brain reward system, brain stress systems, autonomic nervous system (related to physical withdrawal) and prefrontal cortex function (related to cognitive inhibitory control). drug use produces biological changes that ruin the homeostatic operation of the cns and a new international journal of human and health sciences vol. 02 no. 03 july’18 page : 107-111 doi: http://dx.doi.org/10.31344/ijhhs.v2i3.37 abstract addiction is a behavioral disorder related to alterations in neurobiological systems involved in reward system, brain stress response, physical withdrawal, inhibition and executive control. alcohol or drug addiction does not occur without using these substances but genetic and epigenetic variations in these neurobiological systems cause individual differences. the current review summarizes the literature on the biological basis of drug addiction. in addition, this review tries to explain the path from occasional recreational substance use to the compulsive, addicted state. it will help understand why avoiding psychoactive drugs or not to start using is very crucial. international journal of human and health sciences vol. 02 no. 03 july’18 108 state of chronic dysregulation (an allostatic state) is shaped4. brain reward systems reward system is the fuel of life. mesolimbic dopaminergic system that connects nucleus accumbens and ventero-tegmental area and gives projections to the prefrontal cortex is the neural structure of the reward pathway. this brain circuit is present in human and all animals and it gives an appetitive stimulus to obtain innate needs (food and sex) that are necessary for survival of the individual and continuation of the generations. the pleasure imbedded in them is like a small fee given to the creatures to turn the wheel of physical existence. through this mechanism, allah has programmed us to want things that we need to survive. for example, eating food is not a burden that we just have to do but it is a pleasure we seek for. rewards serve as positive reinforcers because they affect the behavior towards obtaining a goal that results in pleasure and satisfaction. when someone uses a psychoactive drug, he is abusing the reward system outside its special purpose. almost all drugs of abuse stimulate mesolimbic dopaminergic system much stronger than the natural stimuli, thus they produce pleasurable effects initially. repetitive stimulation of this system causes sensitization that is responsible of craving for drug. drugs act like computer viruses that change the original program of a computer (the brain) and reorganize the system to perceive them as a basic need, re-program the system to produce an urge for them (drugs). drug user imagines this strong desire for drug as his natural will. especially in the initial phases of addiction, they say “i use it as i want to use it”. they do not take into consideration that this urge is not innate and it develops after drug use. this strong feeling of desire (impulse) for drug use that affects decision-making process of the person is one of the key elements of addiction. most of the drugs of abuse increase dopamine in the mesolimbic system directly or indirectly to produce a reward or a high. for example, opiates act on opioid receptors which than stimulate dopamine receptors; cocaine competes with dopamine in the synaptic cleft for the dopamine reuptake pump and keeps dopamine in the cleft. activation of dopamine neurons is a motivational factor that produces reward-anticipation. when a reward is higher than expected, sensitization of dopamine neurons increases. this sensitization increases the urge or motivation for the reward5. drugs may produce different effects on individuals6. for example, cocaine or methylphenidate use increases dopamine levels in human brain and this increase is associated with pleasure. if drug-naïve subjects had low levels of dopamine d2 receptors, they experienced pleasure. but if they originally had high receptor levels, they experienced unpleasant feelings. this study explains the biological mechanism of why drug use is pleasurable for some people and tends to be repetitive while it is unpleasant and not repetitive for other6. neurotransmitters other than dopamine also play a role in reward system7. dopamine independent reward mechanisms have been described for opioids and alcohol. serotonergic receptors in the nucleus accumbens mediate the reinforcing effects of psychostimulant drugs. stimulation of μ-opioid receptors in the nucleus accumbens and ventral tegmental area are responsible for the reinforcing effects of opioids. opioid receptors in the ventral striatum and amygdala mediate the reinforcing effects of ethanol. acute intoxicating doses of alcohol also increase inhibitory γ-aminobutyric acid (gaba) in the amygdala. activation of the mesolimbic dopamine system produces an incentive salience linked to the environmental stimuli and drives goal-directed behavior1. pleasure (hedonic state) provided by the reward starts a learning process including conditioning with cues that are associated with drug use, assigning value and motivational status to the reward. motivational state produced by drug withdrawal is like hunger and sexual arousal that increase the incentive salience of the reward and related cues8. as the hunger or withdrawal rises, struggle to get the reward will accelerate. brain has a plastic property and it rapidly develops an adaptation to the effects of drugs. this is called tolerance. repetitive use of a drug increases reward thresholds (decreases reward). for this reason, drug use does not produce satiety as in natural rewards like food. a person can eat up to a certain amount of his favorite food each time but increases the amount of a drug in subsequent uses. the person cannot get the same high from a drug during chronic use but he still experiences a high level of urge to use it. in other words, tolerance does not extinguish this desire. the brain keeps the value of possible actions in memory according to the amount of reward it produced in the past5. this stored value is used to evaluate possible results of future actions as reward or punishment. 109 international journal of human and health sciences vol. 02 no. 03 july’18 brain stress systems stress system is the brain alarm circuit that is triggered by danger or unpleasant stimuli. some neurochemicals that are activated by acute or chronic stressors initiate some typical behavioral responses. in animals various behavioral responses like freezing or flight may be observed1. brain stress systems include neurocircuitry mediated by glucocorticoids, corticotropin-releasing factor (crf), norepinephrine, and dynorphin. there are also neurochemicals like neuropeptide y (npy), nociceptin, and endocannabinoids that oppose the brain stress systems. stimulation of nucleus accumbens, the reward system, also activates brain stress systems that subsequently feedback to decrease dopamine release in the mesolimbic dopamine system. brain stress systems aim to neutralize the effects of the drug and restore normal function despite the presence of drug. this causes tolerance to the effects of the drug use and dysphoric syndrome when the use is stopped because the change in stress systems continues although the drug use is avoided1. adrenocorticotropic hormone (acth) and corticosterone are elevated during withdrawal and this disturbs the hypothalamic-pituitaryadrenal (hpa) axis and extrahypothalamic brain stress system mediated by crf. withdrawal and protracted abstinence from drugs produce anxiety and irritability mediated by crf1. dynorphin activation mediates depressive responses to stress and dysphoric responses during withdrawal from drug9. animal studies10 show that when primates were conditioned to associate a cue with a pleasurable object like food, increased dopaminergic activity was a response to the cue and not to the food. absence of food caused a drop in dopaminergic function. reduction in the dopaminergic activity is considered to be associated with negative affect like dysphoria. so when an addict comes across with a cue (e.g. needle, money), and cannot access the drug he may feel dysphoric. this negative feeling will also increase the drive to get the drug. physical withdrawal withdrawal is the emergence of specific behavioral and physical symptoms following sudden discontinuation of a drug in subjects who had been under its chronic influence. it is the result of reversal of homeostatic mechanisms which had been disturbed by the drug before discontinuation11. in other words, withdrawal is the result of sudden backward change of the homeostatic mechanisms that caused tolerance to the drug. actually in stimulants and heroin, tolerance starts to develop very early on and the person cannot get the same effect from the same amount of drug and needs progressively higher drug doses to get the same effect, so that the person gets into the vicious cycle of tolerance. acute physical withdrawal is related to the somatic effects of drug use. long term use of many drugs leads to adaptations within the autonomic nervous system and its target organs. this adaptation is disturbed when drug use is avoided12. for this reason, medications that modulate the autonomic nervous system, such as clonidine and propranolol are effective at reducing acute withdrawal symptoms. acute somatic symptoms of withdrawal abate in days to weeks after the drug is discontinued; however, a chronic or protracted withdrawal state, where the patient suffers from unpleasant psychological symptoms especially triggered by drug cues, lasts for months to years. permanent changes in the brain may induce relapses to drug abuse long after detoxification. gamma-aminobutyric acid (gaba)-ergic system and the glutamatergic system play important role in alcohol withdrawal13. increased glutamatergic nmda function is involved in seizures and cell death. amygdala and hippocampus are critical sites for glutamatergic hyperactivity. reduction in dopamine plays role in both early abstinence and protracted withdrawal from many drugs of abuse14. neuroimaging studies have shown reduced dopaminergic activity in opiate, cocaine and alcohol addictions. even partial recovery of this change takes several months6. altered reward neurotransmitters increase brain reward thresholds (a higher set point for drug reward) during abstinence. this in turn produces the negative motivational state in withdrawal (psychological symptoms of withdrawal) and makes the patient vulnerable to relapse1. withdrawal symptoms are aversive for the drug user; therefore, he starts to seek the drug not for pleasure but to avoid withdrawal symptoms. impulse control and decision making inhibitory control and decision making are key executive functions for the development of addiction and they are mediated by the forebrain. prefrontal cortex (pfc) is involved in regulation of both limbic reward regions and higher-order executive functions. therefore, in addiction, pfc dysfunction is not only related to compulsive international journal of human and health sciences vol. 02 no. 03 july’18 110 drug use but also underlines the dysfunctional behavioral pattern of drug addicts. impairment of the pfc functions is also related to salience attribution in addiction. “salience attribution” is ascribing excessive prominence to the drug and drug related cues, decline in sensitivity to non-drug reinforcers and less ability to inhibit maladaptive behaviors15. this impairment makes drug seeking and drug use the main motivational drive even though it leads to long term losses. it leads to neglecting other activities and the person can engage in extreme behaviors in order to obtain drugs16. the process ends in the weakening of free will. administration of drugs of dependence to drug naïve laboratory animals produces changes in pfc similar to those in human drug addicts. pfc impairment seen in drug addicts is a result of drug use that enables further use. however, pfc impairment is also present in several other psychiatric and neurological conditions such as borderline personality disorder, attention deficit and hyperactivity disorder (adhd), schizophrenia and bipolar disorder and traumatic brain injury17. the presence of pfc impairment makes those patient groups more vulnerable to drug use and dependence. executive functions mediated by the prefrontal cortex are gained through biological maturation of the brain during adolescence. therefore, adolescent brain is more vulnerable to the harmful effects of drug abuse18. different parts of the pfc are related to distinct features of addiction; for example, medial orbitofrontal cortex and ventromedial prefrontal cortex to craving, orbitofrontal cortex to drug expectation, anterior cingulate cortex to attention bias and dorsolateral prefrontal cortex to drug-related memories15. glutamatergic pathway starting from the pfc and controlling the dopaminergic neurons in the nucleus accumbens are associated to addiction.19. several other neurotransmitter systems such as endogenous opioid, serotonergic, cannabinoid and dopaminergic systems are also involved in prefrontal impairment15. inhibitory control enables to take appropriate actions to accomplish complex tasks and provides adaptation to new environmental conditions by suppressing immediate or habitual responses. impairment in the inhibitory control is a key element in repetitive substance misuse and dependence17. deficit in impulse control can be demonstrated with neurocognitive tests like color word stroop task, continuous performance test and the stopsignal task. in laboratory gambling task where risky decision making is accessed, drug addicts tend to take actions associated with short-term gains although they can bring long-term losses17. the individuals with impulsive personality traits are more prone to try and be addicted to drugs and drug use puts these individuals into a vicious cycle of further impulsivity20. impairment in impulse control leads to a weakening in self control (the ability to postpone or avoid an activity that may not be appropriate or is perceived as the incorrect)21. this explains the inability of drug addicts to inhibit excessive drug use although they are aware of the destructive consequences. impairment in impulse control and self control also underline engagement in criminal activities and aggression. young individuals who already have weak self-control are more prone to substance dependence21. conclusion addicted brain is in state of chronic dysregulation (allostasis) where function of reward circuits are impaired and stress systems are activated both of which lead to increased impulses to use drugs. somatic withdrawal symptoms as well as emotional dysregulation also increase the urge of drug use. on top of these, dysregulation of the frontal cortex which is supposed execute thoughts, impulses and emotions results in compulsive drug seeking and loss of control over intake. this is a process initiated by drug use and can be avoided primarily by staying away from drugs. 111 international journal of human and health sciences vol. 02 no. 03 july’18 references 1. koob gf. addiction is a reward deficit and stress surfeit disorder. front psychiatry. 2013; 4:72. 2. koob gf. theoretical frameworks and mechanistic aspects of alcohol addiction: alcohol addiction as a reward deficit disorder. curr top behav neurosci. 2013; 13:3–30. 3. denier n, schmidt a, gerber h, et al. association of frontal gray matter volume and cerebral perfusion in heroin addiction: a multimodal neuroimaging study. front psychiatry. 2013; 4:135. 4. edwards s, koob gf. neurobiology of dysregulated motivational systems in drug addiction. future neurol. 2010; 5:393–401. 5. arias-carrión o, pŏppel e. dopamine, learning, and reward-seeking behavior. acta neurobiol exp (wars). 2007; 67:481-488. 6. volkow nd, fowler js, wang gj. imaging studies on the role of dopamine in cocaine reinforcement and addiction in humans. j psychopharmacol. 1999; 13:337-345. 7. nestler ej. is there a common molecular pathway for addiction? nat neurosci. 2005; 8:1445-1449. 8. karoly hc, harlaar n, hutchison ke. substance use disorders: a theory-driven approach to the integration of genetics and neuroimaging. ann n y acad sci. 2013; 1282:71-91. 9. chartoff e, sawyer a, rachlin a, et al. blockade of kappa opioid receptors attenuates the development of depressive-like behaviors induced by cocaine withdrawal in rats. neuropharmacology 2012; 62:1167–1176 10. schultz w. reward signaling by dopamine neurons. neuroscientist. 2001; 7:293-302. 11. vetulani j. drug addiction. part ii. neurobiology of addiction. pol j pharmacol. 2001; 53:303-317. 12. naqvi nh, bechara a. the insula and drug addiction: an interoceptive view of pleasure, urges, and decisionmaking. brain struct funct. 2010; 214:435-450 13. roberto m, gilpin nw, siggins gr. the central amygdala and alcohol: role of γ-aminobutyric acid, glutamate, and neuropeptides. cold spring harb perspect med. 2012; 2:a012195. 14. murphy a, taylor e, elliott r. the detrimental effects of emotional process dysregulation on decision-making in substance dependence. front integr neurosci. 2012; 6:101 15. goldstein rz, volkow nd. dysfunction of the prefrontal cortex in addiction: neuroimaging findings and clinical implications. nat rev neurosci. 2011; 12:652-669. 16. volkow nd, li tk. drug addiction: the neurobiology of behaviour gone awry. nat rev neurosci. 2004; 5:963-970. 17. li cs, sinha r. inhibitory control and emotional stress regulation: neuroimaging evidence for frontallimbic dysfunction in psycho-stimulant addiction. neurosci biobehav rev. 2008; 32:581–597. 18. selemon ld. a role for synaptic plasticity in the adolescent development of executive function. transl psychiatry. 2013; 3:e238 19. lingford-hughes a, nutt d. neurobiology of addiction and implications for treatment. br j psychiatry. 2003; 182:97-100. 20. dawe s, loxton nj. the role of impulsivity in the development of substance use and eating disorders. neurosci biobehav rev. 2004; 28:343-351. 21. moffitt te, arseneault l, belsky d, et al. a gradient of childhood self-control predicts health, wealth, and public safety. proc natl acad sci u s a. 2011; 108:2693-2698. international journal of human and health sciences. supplementary issue: 2021 s18 healthcare practitioner’s views on the teddy bear hospital (tbh) by imacats in malaysia aneesa abdul rashid1, cheong ai theng1, ranita hisham shanmugam2, nurainul hana shamsuddin1, dalila roslan3 1jabatan perubatankeluarga, fakultiperubatan dan sains kesihatan, upm 2um library, university of malaya, jalan universiti, 50603 kuala lumpur,3ministry of health, 62000 putrajaya, wilayah persekutuan putrajaya, malaysia doi: http://dx.doi.org/10.31344/ijhhs.v5i0.309 introduction: this is a part of a bigger study entitled “exploring the views of healthcare practitioners on the teddy bear hospital (tbh) as a personal safety module towards prevention of child sexual abuse (csa): a qualitative study”. tbh is a make-believe-play hospital utilising soft toys to demonstrate a pretend clinical setting with the aim to educate children on health issues. studies has shown its effectiveness and reducing anxiety towards the hospital setting and increasing health-related knowledge. imam children’s and teen super teen (imacats) is one of the non-governmental organisations (ngo) which has adopted this concept to tailor to the local community. the volunteers are healthcare practitioners who are engaged with children in their practice. objective: to explore the views of healthcare professional towards tbh by imacats in malaysia. methods: in-depth qualitative audio recorded interviews were conducted with a purposive sample of 18 healthcare professionals. the data obtained were transcribed and analysed thematically. results: three themes were derived from the interviews: i) awareness of the tbh concept. seven participants have volunteered in tbh previously. however, there was a speculation that many doctors are still unknowing of this concept. ii) benefits of tbh. this includes reducing children’s anxiety, changing children’s presumption on healthcare, increasing children’s health knowledge and encouraging healthy behaviour and bridging the gap between the public and healthcare. iii) suggestion of module for future tbh: (a) more school-based programmes should be organised in addition to hospital and community based; (b) ministry of health (moh) should encourage children health screening using this concept; (c) a module for hospitalised children should be conducted. conclusion: participants interviewed suggested for tbh to be organised in a wider scale as it is an approachable concept for educating children. there are many ways in which it can benefit this community. keywords: teddy bear hospital, health education, healthcare professionals, children, malaysia http://dx.doi.org/10.31344/ijhhs.v5i0.309 s40 2nd place winner, e-poster presentation an observational study on clinical characteristics and outcomes of covid-19 patients urgently hospitalised from covid assessment centres in seremban, malaysia nor-azila mi1, ahmad-baihaqi a1, nur-aslizah a2, nur-haizumraimi ar3, nur-saadah mar4 objectives: covid-19 emerged as a major global health problem in late 2019. at present, malaysia has recorded more than 2 million cases since its first case; detected in january 2020. this study describes the clinical characteristics and outcome of covid-19 patients urgently hospitalised in seremban district from its local covid assessment centre (cac). methods. clinical records of all confirmed covid-19 cases admitted urgently from three designated cacs between july and september 2021 in seremban district were retrieved. the demography and clinical characteristics were captured, and the covid vaccination status and clinical outcomes of each case were obtained and descriptively analysed using spss version 22.0. results. a total of 240 samples were analysed. about 54.6% were female and 45.4% were male. the median age was 51 years. majority of the cases were malay, followed by indian and chinese, which was 67.5%, 17.5% and 12.1% of all cases, respectively. the median day of the illness was day 5, and the vast majority (77.1%) of cases were covid-19 category 4. most (72.5%) cases have underlying medical illnesses. the average body mass index (bmi) among the cases was 29.9 kg/m2 whereby 40.4% of them were obese with a bmi of 30 kg/m2 and above. breathlessness was the most reported symptom (39.2%), followed by cough (28.7%). about 25.3% of them did not report any symptoms. of all the cases urgently hospitalised, the recorded fatality was 9.6%, whereby 91.3% of them were not completely vaccinated. conclusion. the majority of these urgently hospitalised patients were admitted due to covid-19 category 4 infection. most of them already had underlying medical problems and nearly half were obese. most of the patients admitted who ended with mortality did not complete their vaccination. keywords: covid-19, malaysia, characteristics ___________________________________________________________________________ 1klinik kesihatan nilai, seremban, malaysia 2klinik kesihatan kuarters klia, seremban, malaysia 3klinik kesihatan desa rhu, seremban, malaysia 4klinik kesihatan sendayan, seremban, malaysia correspondence to: ahmad baihaqi azraii, family medicine specialist, klinik kesihatan nilai, seremban, malaysia, drbaihaqi@yahoo.com __________________________________________________________________________________ doi: http:// dx.doi .org/1 0.313 44/ijh hs.v6i 0.430 mailto:drbaihaqi@yahoo.com s46 100 top cited covid-19-related publications rafidah hod1, idayu badilla idris2, rozita hod2 objectives: bibliometric analysis scrutinizes documents quantitatively using key parameters such as number of publications, subject area, citation metrics and collaborative networks. this study was conducted to answer these research questions: 1) what is the current publication trend globally on covid-19?; 2) which publications are in the top 100 most cited articles?; 3) who are the most influential authors on covid-19?; and 4) which themes of covid-19 are the most popular among scholars. methods: a bibliometric search was conducted in scopus database using keywords such as `covid19’ or ‘covid19’ or ‘covid’ or ‘sars-cov-2’ in the article title. document type was limited to original articles, review articles, conference papers and book chapters. a total of 139,888 documents were retrieved. the data is further analysed using harzing’s publish or perish and vosviewer to obtain the relevant citation metrics as well as visualization of collaborating networks. results: out of the total documents, 39% were published in the ‘medicine’ subject area. other subject areas include ‘social sciences’ (8.6%), ‘computer science’ (4%), ‘engineering’ (3.1%) and ‘psychology’ (2.8%). the most productive institution is harvard medical school which produced a total of 1921 documents. the top three leading countries are the united states, china and the united kingdom, while the most productive author is mahase, e. with 218 documents. the most influential publication, which had 11,279 citations, was titled `clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study” published in the lancet, 2020. the 100 top-cited publications have citations ranging from 802 – 11279. these top publications were published in 52 source titles, with the majority of the top-cited articles being published in the lancet. conclusion: publications in covid-19 are increasing exponentially and are mainly dominated by the united states. extensive research is still ongoing, with more new discoveries in vaccine areas and related effects of covid-19 are anticipated. keywords: covid-19, bibliometric, citations, vosviewer, scopus ___________________________________________________________________________ 1department of human anatomy, faculty of medicine & health sciences, universiti putra malaysia, malaysia. 2department of public health, faculty of medicine, national university of malaysia. correspondence to: rafidah hod, medical lecturer, department of human anatomy, faculty of medicine & health sciences, universiti putra malaysia, malaysia. email:rafidahhod@upm.edu.my _________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v6i0.436 mailto:rafidahhod@upm.edu.my 3 international journal of human and health sciences vol. 07 no. 01 january’23 editorial: faculty development in medical education: what, why and how. salam a1, abdelhalim at2, begum h3, pasha ma4. keywords: faculty development, medical, what, why, how. correspondence to: dr abdus salam, medical educationalist and public health specialist, associate professor and head of medical education unit, faculty of medicine, widad university college, bandar indera mahkota, 25200 kuantan, pahang, malaysia. email: abdussalam.dr@gmail.com orcid id: https://orcid.org/0000-0003-0266-9747 1. abdus salam, medical education unit, faculty of medicine, widad university college (wuc), kuantan, malaysia. 2. abdelbaset taher abdelhalim, paediatric unit and pharmacology unit, faculty of medicine, wuc, kuantan, malaysia 3. hamida begum, obstetrics and gynaecology unit, faculty of medicine, wuc, kuantan, malaysia 4. mehboob alam pasha, surgery unit, faculty of medicine, wuc, kuantan, malaysia faculty development in medical education: what, why, how. introduction higher education has a great role in the continued development of a community. teachers form the bulk of the human resource by virtue of their training, education and other activities like acquisition of knowledge through participation in workshops, seminars, paper presentations at conferences, research and community services. in essence, the teaching profession can be considered to be the mother of all professions1. most universities have missions to accomplish and faculty members are essential resources2,3. in medical school, faculty members facilitate the teaching and learning process, clinical and health services, research and scholarly activities to fulfill the mission and vision of the medical school or institution. the various roles of the faculty member have to be acknowledged in order to develop the faculty3,4. faculty development also includes proper selection, evaluation and management of the faculty2. in higher education, faculty development is very important to enable the faculty to accomplish their roles and responsibilities2. what medical education has evolved from a teachercentric approach to a student-centric approach, creating new demands and responsibilities on the part of faculty members5. the newer transformations involve integrated teaching, problem-based learning, community-based learning6, and simulation-based learning7. also, the assessment methodology has transformed into multiple choice questions (mcq), modified essay questions (meq), short answer questions (saq), objective structured practical examination (ospe), objective structured clinical examination (osce). besides use of log books, mini clinical evaluation exercises (minicex), mimicking real life scenarios, directly observed procedural skills (dops), portfolio assessment, and self-assessment have also been introduced as part of assessment process6.8. in the current transformed medical education system, many roles and responsibilities are played by the medical faculty. harden & crosby (2000)6 has recommended twelve roles of medical teachers, grouped in six areas as showed in table-1. international journal of human and health sciences vol. 07 no. 01 january’23 page : 3-7 doi: http://dx.doi.org/10.31344/ijhhs.v7i1.489 mailto:abdussalam.dr@gmail.com https://orcid.org/0000-0003-0266-9747 international journal of human and health sciences vol. 07 no. 01 january’23 4 table-1. the twelve roles of the medical teacher grouped under six areas no. role of medical teacher 1 information provider in the lecture and clinical context 2 role model on-the-job and in formal teaching setting 3 facilitator as mentor and learning facilitator 4 student assessment and curriculum evaluator 5 curriculum and course planner 6 resource material creator and study guide producer faculty development is defined as “a planned program, or set of programs, designed to prepare institutions and faculty members for their various roles, to improve individual instructors’ knowledge and skills in the areas of teaching, research, service and administration”9. it includes the actions taken to improve the knowledge and skills such as teaching skills, research skills, administrative skills etc., in medical education which are vital to carry out the performance of a faculty member in an academic institution10,11. to meet the need of the student, faculty, and institution, faculty development programs are essential to modify the attitudes, skills, and behavior of faculty members and thereby to increase their competence3. a wellorganized faculty development program should be able to enhance faculties’ skills in all the five desired domains, i.e., teaching, assessment, curriculum support, organizational leadership and mentoring12. why formerly, faculty development programs were designed to improve the teaching roles only. but in present times, due to expanding faculty roles, the range of faculty development activities also changed, aiming to assist faculty with their scholarship, leadership, and career development needs, in addition to their teaching skills12. it plays an important role in organizational and curricular change, in promoting teaching as a scholarly activity and in constructing an educational environment that encourages and rewards educational leadership, innovation and excellence13. the faculty development strengthens their role in higher education and positively affects the institution14. the many roles played by the faculty leads to stress unless they possess or are provided by the resources and strategies to relieve the stress15. this was highlighted in a study which showed that stress and conflicts arise from heavy workload, conflicting demands from colleagues and superiors, incompatible demands from different personal and organizational roles, insufficient resource materials to optimize performance, inadequate competency, inadequate autonomy for decision making, or a feeling of underutilization15. with regard to physicians, clinical competency was equated with professional competency16. however good communication skill was noted to be a measure of good clinical practice and hence was incorporated in the curriculum of medical schools globally17. as a result of the transformation leading to different roles and responsibilities to the faculty and the stress following it, many medical schools felt the need for faculty development programs3,12. lack of objectivity, overloaded content, improper organization of curricular content resulting in improper content delivery, inappropriate assessment procedures, insufficient orientation of new recruits, and teacher-centered mindset with autocratic faculty leaderships are major issues in medical education that affects the quality of a curriculum and consequently the quality of an institution.18,19,20. there should be seamless integration between planned curriculum, taught curriculum, and learned curriculum. this is highly dependent on appropriate faculty development19,21. a well developed program can improve the quality of faculty, resulting in improved quality of curriculum and the higher education institution22. lack of funding and limited budget resources is one of the major challenges22. improper time management caused by heavy workload and other commitments also present a challenge22,23. other factors preventing faculty from participating in faculty development programs can be lack of motivation, lack of financial reward and recognition of teaching excellence and high volume of workload23. generation gap, resistance to newer concepts, work or institutional culture are also identifiable challenges22. traditionally medical teachers are assumed to be teachers by virtue of content knowledge, or prior experience rather than having formal training21. these concerns have to be overcome by good institutional leadership, resource provision, 5 international journal of human and health sciences vol. 07 no. 01 january’23 recognition for research and teaching excellence24. efficiency of faculty development program can also be improved by assessment of specific need, knowledge and priorities of teaching staff25. studies have shown that in spite of regular faculty development programs, some concerns remain as to standards of the programs. this needs to be addressed by the leaders of the respective educational organizations26. how the faculty development model identifies programs that fulfill faculties’ needs, and academic and institutional demands22. wilkerson and irby27 suggest that the faculty development program is based on (i) faculty members’ professional development, (ii) instructional development, (iii) leadership development and (iv) organizational development. a good leader must plan welldesigned curricula and academic programs and advance medical education. organizational development with appropriate policies and procedures supports and rewards the faculty, so that faculty members exhibit their roles as educators27. ambarsarie et al.22 have developed a faculty development model consisting of: content, process and system. the content component includes materials needed to be delivered, such as instructional development, professional development, leadership skills, soft skills, and spiritual development. the process component includes the aspects required for implementing the faculty development program, from needs analysis, preparation, and execution to the evaluation at the end of the program. the system component includes the aspect of the educational system that affects the faculty development program, which are leadership, institutional policy and the availability of experts22. input, process and output are the system approach in education, where identification of objectives and selection of contents based on objectives considered -as input; choosing appropriate methods of content delivery -as process; and deciding relevant assessment -as to measure output, are very important which should interrelate or align with each other19. the value of a good teacher is to know how to do academic planning or scheduling and following it, what to include and what not to include in the syllabus, where to begin and leave out, and by what stages to lead a student to mastery of the subject28. a global shortage of qualified medical teacher has been reported29,30. moreover, ongoing challenges has been observed on cultural diversity issue causing ethnical minority to feel discrimination having negative experience and negative impact on educational environment31. teaching and evaluation by intimidation hinders to frame own professional identities and prevent future ethical leadership development. emphasis has been given to culturally competent faculty to educate culturally competent physicians who can work with diverse group of patient population and communities32. a good knowledge of cultural background and a good role modelling in faculty members affect students’ insight33. hence, understanding of educational environment is very important, and educators must strive to maintain a multicultural environment in instructional methodologies to lead and promote a sustainable organisational development34. leadership role of the managers has a great role on the organization and its success through staff motivation, execution of the strategies to achieve the goal and objectives35. good leadership prioritizes the faculty development program through their understanding and commitment to faculty development. institutional policies determine the programs’ necessity and finally, the availability of experts make it feasible to implement a faculty development program22. with the need of medical faculties to be socially accountable, there is growing pressure for teaching excellence and professionalization of teaching practices24. to be talented teachers, mentors, educators, researchers and leaders, medical education requires faculty development, which is not an easy task. it needs supportive institutional leadership, appropriate resource allocation and recognition for teaching and research excellence24. workable faculty development requires a medical education department operated by respected faculty developers who are academic role models. faculty development should be methodical involving planning, implementation and evaluation. it should be task oriented and tailored to suit the needs of individuals, disciplines and the institution and strive for collaboration across medical disciplines, and across professions24. the activities included in the faculty development program are designed to improve the efficiency of the faculty members’ work and also to achieve both personal goals and institutional objectives3. the most common faculty development program includes instructional material to improve teaching in lectures, small group discussion, teaching international journal of human and health sciences vol. 07 no. 01 january’23 6 in the hospital and in community settings, and honest feedback and evaluation 9,36. other areas include personal and professional development of teachers, educational leadership, or organizational development and change. organizational and leadership skills are necessary to promote more productive educational environments. effective leadership providing educational mentorship is critical for sustained development of the organization. professional academic skills include understanding the underlying values, norms, and expectations of academia, good career development and good networking with skills in information technology9.22 . faculty development program varies from independent learning to formal program through seminar, workshop, continuing education program and organizational development strategies such as curriculum development, professional development programs etc22. the common form of faculty development program includes seminars, workshops, short courses, fellowships, observations of workplace teaching followed by feedback and integrated longitudinal programs, decentralized activities, peer coaching, mentoring, self-directed learning, and computer-aided instruction3,9,12 conclusion higher education is important for the development of a community. this is dependent on a knowledgeable and highly trained workforce or faculty. medical education has transformed over time from a teacher centric to a student centric approach. this led to challenges to the faculty by way of increased workload and greater number of roles in teaching with consequent work-related stress. these and other concerns have led to development of programs to improve the faculty. these faculty development programs are designed to overcome the many challenges facing medical education today. it is hoped that their successful implementation will see an improvement in the education and quality of the medical institutions. funding no funding was received for this paper. conflict of interest: nil. authors’ contribution all authors participated ably in the preparation of this paper and approved the final version for submission to the journal for publication. 7 international journal of human and health sciences vol. 07 no. 01 january’23 references: 1. salam a. tea to entertain outcome-based education for 21st century educators to produce safe human capitals for a sustainable global development. international journal of human and health sciences 2022; 06(02): 153-154. doi: http://dx.doi. org/10.31344/ijhhs.v6i2.437. 2. fooladvand m, changiz t, yousefy a. developing indicators for preparation of faculty description in a medical university. procedia social and behavioral sciences 2011; 15: 2387–2390. https://doi. org/10.1016/j.sbspro.2011.04.113. 3. ahmady s. faculty development in medical education: a comprehensive approach. published by karolinska institutet. printed by universitetsservice us-ab. 2009. 4. salam a, begum h, zakaria h, allaw baq, han t, algantri kr, mofta ag, elmahi meb, mohamed eme, elkhalifa maa, zainol j. core values of professionalism among fresh medical gin a malaysian private university. international journal of human and health sciences 2021; 05(04): 463-472. doi: http://dx.doi.org/10.31344/ijhhs.v5i4.358 5. abolbashari s, moonaghi hk, bazzaz mm. medical faculties’ view about the importance of educational roles. adv med educ pract. 2018; 9:417-422. doi: 10.2147/amep.s163218. 6. harden rm, crosby j. amee guide no 20: the good teacher is more than a lecturer the twelve roles of the teacher. medical teacher 2000, 22: 334-347. https://doi.org/10.1080/014215900409429. 7. salam a, saiboon im, jaafar mj, hamzah fa, balakrishnian, kamarudin ma, et al. tutors perception on a training workshop on simulation based medical education. bangladesh journal of medical science 2016; 15(02):195-20. 8. salam a, yousuf r, bakar sma. multiple choice questions in medical education: how to construct high quality questions. international journal of human and health sciences 2020; 04(02): 79-88. doi: http://dx.doi.org/10.31344/ijhhs.v4i2.180 9. steinert y, mann kv. faculty development: principles and practices. j vet med educ 2006; 33(3): 317-324. doi: 10.3138/jvme.33.3.317 10. bilal, guraya sy, chen s. the impact and effectiveness of faculty development program in fostering the faculty’s knowledge, skills, and professional competence: a systematic review and meta-analysis. saudi journal of biological sciences 2019; 26 (4): 688-697. https://doi.org/10.1016/j. sjbs.2017.10.024 11. kwan d, barker k, richardson d, wagner s, austin z. effectiveness of a faculty development program in fostering interprofessional education competencies. j. res. interprof. pract. educ 2009; 1(1): 24-41. https:// doi.org/10.22230/jripe.2009v1n1a4 12. leslie k, baker l, egan-lee e, esdaile m, reeves s. advancing faculty development in medical education: a systematic review. acad med. 2013; 88:1038–1045. doi: 10.1097/ acm.0b013e318294fd29 13. steinert y. perspectives on faculty development: aiming for 6/6 by 2020. perspect med educ 2012; 1:31–42. doi 10.1007/s40037-012-000614. guraya sy, guraya,ss, mahabbat na, fallatah ky, al-ahmadi ba, alalawi hh. the desired concept maps and goal setting for assessing professionalism in medicine. j. clin. diagn. res 2016; 10: je01-je05. doi: 10.7860/jcdr/2016/19917.7832. 15. ahmady s, changiz t, masiello i, brommels m. organizational role stress among medical school faculty members in iran: dealing with role conflict. bmc medical education 2007; 7:14. doi:10.1186/1472-6920-7-14. 16. salam a, allaw baq, begum h, abdelhalim at, alsharkawy a, hassan km, satwi s, zainol j. audit on clinical competency of fresh medical graduates in a malaysian private university using kirkpatrick level-1 evaluation model. education in medicine journal 2021;13(4): 57–70. https://doi.org/10.21315/ eimj2021.13.4.5 17. salam a, zakaria h, abdelhalim at, choon lc, alsharkawy a, taibi mkbm, satwi s, hassan km, zainol j. communication skills of fresh medical graduates in a malaysian private university. bangladesh journal of medical science 2022; 21(02): 404-412. doi: http://doi.org/10.3329/bjms. v21i2.58074 18. salam a. issues of objectives, content, methods and assessment in the development of relevant curriculum in medical schools. malaysian medical association (mma) news 2010; 22-24. 19. salam a. input, process and output: system approach in education to assure the quality and excellence in performance. bangladesh journal of medical science 2015; 14(01): 1-2. 20. zhang z, wu q, zhang x, xiong j, zhang l, le h. barriers to obtaining reliable results from evaluations http://dx.doi.org/10.31344/ijhhs.v6i2.437 http://dx.doi.org/10.31344/ijhhs.v6i2.437 https://doi.org/10.1016/j.sbspro.2011.04.113 https://doi.org/10.1016/j.sbspro.2011.04.113 http://dx.doi.org/10.31344/ijhhs.v5i4.358 https://doi.org/10.1080/014215900409429 http://dx.doi.org/10.31344/ijhhs.v4i2.180 https://doi.org/10.1016/j.sjbs.2017.10.024 https://doi.org/10.1016/j.sjbs.2017.10.024 https://doi.org/10.22230/jripe.2009v1n1a4 https://doi.org/10.22230/jripe.2009v1n1a4 https://doi.org/10.21315/eimj2021.13.4.5 https://doi.org/10.21315/eimj2021.13.4.5 http://doi.org/10.3329/bjms.v21i2.58074 http://doi.org/10.3329/bjms.v21i2.58074 international journal of human and health sciences vol. 07 no. 01 january’23 8 of teaching quality in undergraduate medical education. bmc medical education 2020; 20:333. https://doi.org/10.1186/s12909-020-02227-w. 21. salam a, mohamad mb. teachers’ perception on what makes teaching excellence: impact of faculty development programme. international medical journal 2020; 27(1): 1-4 22. ambarsarie r, mustika r, soemantri d. formulating a need-based faculty development model for medical schools in indonesia. malays j med sci. 2019;26(6):90–100. https://doi.org/10.21315/ mjms2019.26.6.9 23. steinert y, mcleod pj, boillat m, meterissian s, elizov m, macdonald me. faculty development: a ‘field of dreams’? med educ. 2009;43(1):42-9. doi: 10.1111/j.1365-2923.2008.03246.x. 24. mclean m, cilliers f, van wyk jm. faculty development: yesterday, today and tomorrow. med teach. 2008;30(6):555-84. doi: 10.1080/01421590802109834 25. opre a, zaharie m, opre d. faculty development: teaching staff needs, knowledge and priorities. cognition, brain, behavior 2008; 12(1): 29-43. 26. salam a, yaman mn, hashim r, suhaimi fh, zakaria z, mohamad n. analysis of problems posed in problem-based learning cases: nature, sequence of discloser and connectivity with learning issues. bangladesh journal of medical science 2018;17(03):417-423. doi: http://dx.doi. org/10.3329/bjms.v17i3.36997 27. wilkerson l, irby dm. strategies for improving teaching practices: a comprehensive approach to faculty development. academic medicine 1998; 73(4): 387-396. 28. salam a. best teaching method used, very good in teaching, the best lecturer ever: secrets of teaching online during covid-19 pandemic. international journal of human and health sciences 2021; 05(04): 377-380. doi: http://dx.doi.org/10.31344/ijhhs. v5i4.34 29. ali smi, talukder mhk, khatun m, khanom ra, miah ma, ahmed mw, et al. views of medical teachers regarding the need of training or course on medical education. bangladesh journal of medical education 2014; 2 (2): 2011: 7-11. doi:10.3329/ bjme.v2i2.18135. 30. ping cs, jing rts, yan lw. improving the quality of medical education in malaysia. policy brief pol2021-02. malaysian medics international 2021. retrieved on 12 november from: policy-2021-02medical-education.pdf (squarespace.com). 31. forrest d, george s, stewart v, dutta n, mcconville k, pope l, et al. cultural diversity and inclusion in uk medical schools. clin teach. 2022;19(3):213– 220. 10.1111/tct.13472. 32. sorensen j, norredam m, dogra n, essink-bot ml, suurmond j, krasnik a. enhancing cultural competence in medical education. int j med educ. 2017;8:28-30. doi: 10.5116/ijme.587a.0333. 33. dutta n, maini a, afolabi f, forrest d, golding b, salami rk, kumar s. promoting cultural diversity and inclusion in undergraduate primary care education, education for primary care 2021; 32(4):192-197, doi: 10.1080/14739879.2021.1900749. 34. salam a, akram a, mohamad n, siraj hh. measures of educational environment in a higher educational institution using dundee ready educational environment measure -dreem. international medical journal 2015; 22(2): 98-102. 35. akparep y, jengre e, mogre aa. the influence of leadership style on john organizational performance at tumakavi development association, tamale, northern region of ghana. open journal of leadership 2019; 8 (1): 1-22. doi: 10.4236/ ojl.2019.81001. 36. steinert y. faculty development in the new millennium: key challenges and future directions. med teach 2000; 22:44–50. https://doi.org/10.1080/01421590078814 https://doi.org/10.1186/s12909-020-02227-w https://doi.org/10.21315/mjms2019.26.6.9 https://doi.org/10.21315/mjms2019.26.6.9 http://dx.doi.org/10.3329/bjms.v17i3.36997 http://dx.doi.org/10.3329/bjms.v17i3.36997 http://dx.doi.org/10.31344/ijhhs.v5i4.346 http://dx.doi.org/10.31344/ijhhs.v5i4.346 https://static1.squarespace.com/static/5e477eb18ae6b644167d06ab/t/6043d5e56856623a539759b3/1615358675970/policy-2021-02-medical-education.pdf https://static1.squarespace.com/static/5e477eb18ae6b644167d06ab/t/6043d5e56856623a539759b3/1615358675970/policy-2021-02-medical-education.pdf https://doi.org/10.1080/01421590078814 187 international journal of human and health sciences vol. 02 no. 04 october’18 editorial article: dr. aly was a father, mentor and friend, an inspiration to the fraternity of physicians and allied health professionals in islamic medical associations (ima) in 50 countries. his stewardship of the federation of islamic medical associations (fima) since her early beginnings in the 1980s has been outstanding and unrivaled. is it any wonder that he was decorated with the fima lifetime achievement award in 2010 in beirut, lebanon. he helmed fima for 2 terms from 2001-2005. i had the unenviable task of filling his giant shoes from 2005-2009 but this arduous job was relieved by dr. aly always being by our side as fima’s executive director from 2005 until his demise.he has unfailingly attended virtually all of fima’s council and exco meetings except for the post-istanbul, march 2018 exco in madinah. and sheikh aly was a favorite guest at all our ima national conferences. our latest rendezvous was at the pima national conference in allama iqbal memorial hall in lahore in april 2018. the previous year in 2017 we were pima’s guests at their conference in peshawar. so our pakistani brothers in pima loved him ever so much, just like all our other imas did. they never got tired of inviting sheikh aly to their annual conferences. and sheikh aly despite his deteriorating health never refused their invitations. he was the pioneer and brainchild behind most of fima’s medical and humanitarian relief programs. his visit to darfur, sudan in 2004, unleashed the now infamous fima save vision, which has seen in excess of 1.5 million outpatients in 600 eye camps in 20 different countries, operating 150,000 cataract surgeries, involving more that 2,000 ophthalmologists. for this charitable achievement, fima was awarded the linda rosenthal foundation award 2009 by the american college of physicians. he previously served as the chief of medical staff (1986-2009) of the islamic hospital (ih), amman, jordan and until his passing was the chairman of its institutional review board (1987-2018). the ih was the flagship model of a shari’ah driven hospital correspondence to: prof. musa mohd nordin, chairman fima advisory council email: musamn@gmail.com international journal of human and health sciences vol. 02 no. 03 july’18 page : 187-188 doi: http://dx.doi.org/10.31344/ijhhs.v2i4.53 international journal of human and health sciences vol. 02 no. 04 october’18 188 which inspired the establishment of the fima islamic hospital consortium (ihc) at the 18th fima council in sarajevo, bosnia in june 2001. his life long passion of mainstreaming the islamic perspectives of medical ethics was manifested in his editorial leadership of the fima year book (2002-2018). and more recently fima’s international journal of human & health sciences. which contributed a lot in enriching our knowledge on medical humanities1-9. he did his residency training in the university of illinois, chicago (1971-1974) and is board certified in internal medicine (1976) and endocrinology & metabolism (1983) whenever we were at his home in amman, he would show us the keys to his ancestral home in al-quds (jerusalem). among his many projects for palestine, the latest was the provision of safe and clean water through well drilling and the installation of a desalination plant in gaza. many doctors in gaza owe their training in various medical and surgical specialties to the initiatives of draly in the islamic hospital in amman. upon learning of the massacre of the rohingyas in august 2017, he raised funds from muslim physicians in al-quds, who despite being persecuted under zionist occupation, contributed towards the mobile clinics in the refugee camps in cox’s bazaar. his dedication and commitment to islamic works and the betterment of humanity was unparalleled. he has left a large void in our hearts and we already miss him ever so much. the only way we can heal our souls and cherish his memories in our broken hearts is to continue his unfinished work and uphold his medical and humanitarian legacy. o allah! our father al-marhum sheikh dralymishal has led a truly blessed life in your service and in the service of your deen. o allah! accept all our father’s deeds as amalsoleh and bless him bountifully. o allah! bless our father with your highest gardens of paradise in jannatulfirdaus. o allah! bless his family, friends and the palestinian community with patience and forbearance, upon this great loss of their palestinian son. [to the righteous it will be said], “o reassured soul, return to your lord, well-pleased and pleasing [to him], and enter among my [righteous] servants and enter my paradise.” (al-fajr 27-30) your son and mentee, musa mohd nordin chairman, fima advisory council, email: musamn@gmail.com 28 june 2018 / 14 shawal 1439 references: 1. misha’l, aly a. the concept of successful aging. international journal of human and health sciences (ijhhs), 2017;01(01): 22-25. doi:http:// dx.doi.org/10.31344/ijhhs.v1i1.4. 2. ali, albar mohammed; hassan, chamsi pasha. artificial nutrition and hydration. international journal of human and health sciences (ijhhs), 2017;01(01): 18-21. doi:http://dx.doi.org/10.31344/ ijhhs.v1i1.3. 3. a, misha’l aly. drug prescribing to the elderly patients. international journal of human and health sciences (ijhhs),2017;01(02): 65-69, doi:http:// dx.doi.org/10.31344/ijhhs.v1i2.12. 4. hassan, chamsi pasha; ali, albar mohammed. withdrawing or withholding treatment. international journal of human and health sciences (ijhhs), 2017;01(02):59-64, doi:http://dx.doi.org/10.31344/ ijhhs.v1i2.11. 5. mohammed ali, albar; hassan, chamsi pasha. futility of medical treatment. international journal of human and health sciences (ijhhs),2018;02()1): 13-17. doi:http://dx.doi.org/10.31344/ijhhs.v2i1.19. 6. hassan, chamsi pasha; mohammed ali, albar. do-not-resuscitate orders: islamic viewpoint. international journal of human and health sciences (ijhhs),2018;02()1): 8-12. doi:http://dx.doi.org/10.31344/ijhhs.v2i1.18. 7. ahmad, wafa ‘a qasem. spiritual care at the end of life: western views and islamic perspectives. international journal of human and health sciences (ijhhs),2018;02(02):65-70. doi:http://dx.doi.org/10.31344/ijhhs.v2i2.28. 8. akhtar, sohail; memon, abdul majeed. physician’s role at time of death. international journal of human and health sciences (ijhhs), 2018;02(03): 126-130, oi:http://dx.doi.org/10.31344/ ijhhs.v2i3.39. 9. al-arouj m, bouguerra r, buse j, hafez s, hassanein m, ibrahim ma, ismail-beigi f, el-kebbi i, khatib o, kishawi s, al-madani a, mishal aa, al-maskari m, nakhi ab, al-rubean k.recommendations for management of diabetes during ramadan. diabetes care. 2005;28(9):2305-11. international journal of human and health sciences vol. 06 no. 01 january’22 6 review article conducting a fima lifesaver course in the covid-19 setting by imam in malaysia noor hafizah abdul salim 1, 3, aneesa abdul rashid2,3 ahmad luqman md pauzi1, 3 mohd hisham isa3,4 abstract: every year, the federation of islamic medical association (fima) conducts a basic life support (bls) course for the public, not just in one, but in several countries. it is held in mosques as a method of raising awareness on the importance of bls among the public, apart from highlighting the function of a mosque as a place of obtaining knowledge. traditionally, it was conducted as face-to-face training. however, with the 2019 novel coronavirus pandemic, the training was changed to a hybrid method to balance between the needs to teach bls skills to the public and the necessity of avoiding the spread of infection. this article discussed the islamic medical association of malaysia (imam)’s experience in organizing a mass bls course for public in the midst of the covid-19 pandemic while utilising a small mosque as a hub of learning. keywords: basic life support, layperson, mosque, training, malaysia correspondence to: noor  hafizah  binti  abdul  salim.  department of medicine, faculty of medicine and health sciences, universiti putra malaysia, 43400 serdang, malaysia. email: noorhafizah_as@upm.edu.my 1. department of medicine, faculty of medicine and health sciences, universiti putra malaysia, 43400 serdang, malaysia 2. department of family medicine, faculty of medicine and health sciences, universiti putra malaysia, 43400 serdang, malaysia 3. the islamic medical association of malaysia (imam), (the office of imam response & relief  team), no 1-2, jalan sp1, selayang point 68100 batu caves, malaysia 4. department of emergency medicine, faculty of medicine, universiti kebangsaan 5. malaysia medical centre, jalan yaacob latif, bandar tun razak, 56000 cheras, kuala lumpur, malaysia international journal of human and health sciences vol. 06 no. 01 january’22 page : 6-10 doi: http://dx.doi.org/10.31344/ijhhs.v6i1.369 background the federation of islamic medical association (fima) is a society that comprises of islamic medical societies (imas) from around the world.1 to date, it has members from 29 countries. the fima lifesaver project is reported to be a successful programme that focus on teaching basic life support (bls) in the community.2 being setup at mosques around the world, the aim is to raise awareness on the importance of bls among the public, while instilling the idea of the mosque being an institution for not only religious events but also factors that are important in the religion such as education, health and bringing society closer with social events. the lifesaver project was initially the brainchild of the british islamic medical association (bima) and began in 2014.3 due to the lifesaver’s program positive response along with essential needs worldwide to increase the bystander rate of cardiopulmonary resuscitation (cpr) for out-of-hospital cardiac arrest (ohca), the program has evolved to a worldwide event. the islamic medical association of malaysia (imam) was one of the countries involved in the expansion. cardiac arrests and bls 7 international journal of human and health sciences vol. 06 no. 01 january’22 the global incidence of ohca is reported to be 55 incidence per 100,000 person in a year 4. in malaysia, the leading cause of death because of cardiac arrest is ischaemic heart disease 5. furthermore, the rate of bystander cpr is still low in malaysia 6,7. therefore, there is a dire need to improve the cpr literacy among public by providing a training of knowledge and psychomotor skills of basic life support. this is supported by pan asian resuscitation council outcomes study (paros) that showed only 22% of out-of-hospital cardiac arrest patients received bystander cpr in malaysia 7. prompt initiation of the chain of survival has been proven to increase survival rate for cardiac arrests 8. the chain of survival are: 1)early recognition of signs of cardiac arrest, 2) early activation of emergency medical services, 3) early initiation of basic cardiopulmonary resuscitation, 4) early defibrillation  and  5)  early  initiation  of  advance  cardiac support. initiating the early part of the chain depends on bystander involvement. a delay or break in any part of the chain will reduce the chance of survival in cardiac arrest8. therefore, the necessity to train the community is of utmost importance. teaching bls in the pandemic the sars-cov-2 (covid-19) outbreak, which began in wuhan, china since october 2019 has led to the global pandemic and was declared as the 6th public health emergency of international concern by the world health organization (who) on 30th january 20209. the malaysian government had enforced several phases of movement control order (mco) to curb the spread of covid-19 virus. as the country moved to the phase of recovery movement control order (rmco), some liberation was allowed. following this, the fima lifesaver event was resumed. conducting a community training during the covid-19 pandemic warrants precautionary measures to prevent the spread of the virus. the traditional teaching through face-to-face can still be conducted with strict adherence to the safety protocol (hisham et al. 2020).10 the need to reach out to the community must be balanced with the safety of those involved. therefore, imam conducted a hybrid module which combines face-to-face  and  online  training.  there  are  five  main  objectives  of  the  programme.  the  first  objective is to unite the medical community in the task of serving the public. secondly, improving community  participation  and  confidence  in  facing a cardiac arrest situation. next, promoting mosque as the hub for education and the place to unite the community. subsequently, conducting a community basic cardiopulmonary life support training that adheres to infectious disease precaution and lastly, combining on-site and online training to reach a larger target population. planning and delivery of the course planning 1. trainers and organizer the programme was a collaboration between imam and three malaysian universities, namely universiti kebangsaan malaysia (ukm), universiti putra malaysia (upm) and universiti teknologi mara(uitm). imam handled promotion of the event, recruiting participants, event location for onsite training and coordination of online platform and broadcasting. the universities were in charge of recruiting trainers, providing bls training equipment, preparing teaching module, online live video demonstration of bls skills and on-site face-to-face training. 2. advertisement the advertisement of event was made through several platforms, including social media such as  facebook  and  instagram,  flyers  and  posters.  registration of participants was made through organizer, google form and onsite registration. in order to adhere to standard operating procedure by the government of malaysia in conducting faceto-face training, the number of participants was limited to 40 persons. 3. training module the focus of the training was on adult cpr, paediatric cpr and managing chocking for adult and paediatric victim. the trainer performed a live demonstration of basic life support on manikins. following each session, online participants were given question-and-answer session with the trainer. as for onsite training, four stations were allocated, equipped with trainers and bls mannequin. moreover, in this pandemic situation, the teaching of basic life support has been adapted, considering if the victim is infected with covid-19. international journal of human and health sciences vol. 06 no. 01 january’22 8 4. venue training place takes into consideration the size of the place relative to the number of participants at a time. mosque was chosen in view of its spacious corridor, good aeration and being the place of community gathering. the layout is provided in  figure  1.  at  each  station,  distance  between  participants, management of participants flow and  management of mannequin is detailed out in table 1. delivery of the course 1. precautionary measures to prevent the spread of 2019-ncov infection. in order to prevent the spread of infection, several factors concerning the participants, place of training, screening of covid-19 infection symptoms, enforcement of hygiene and equipment handling was taken into consideration. 2. participants and organizers preparation all participants, trainers and programme organizers were screened for possibility of covid-19 infection based on history of fever, ili symptom, recent travel and recent contact. temperature will be taken, and those with fever were not allowed to enter the mosque. hands need to be sanitized before and after each training session. wearing a face mask was compulsory throughout the programme. reaching large target population in teaching bls while adhering to sop for covid-19 could be achieve through a combination of online and onsite training. details of the participants and organisers are detailed in table 2. 3. training place and training station’s management during the event, social distancing and avoidance of crowding were maintained at all times. the measures taken were limiting the number of onsite participants, organizers and trainers, conducting the training in an area with good ventilation and spacious enough to allow social distancing. the distance between each station was 10 meters. additionally, the number of participants allowed in a station were limited to the number of available manikin, with a ratio of one to one between manikin and participants. table 1:onsite management in limiting spread of 2019-ncov infection item description covid-19 screening all participants were screened for the possibility of covid -19 infection based on history of fever, ili symptoms, recent travel and recent contact with covid-19 patients before entering the mosque temperature screening temperature were taken for all participants, facilitators and organizers before entering the mosque. those with temperature are not allowed to enter. number of participants at a station each stations had only one entry and exit point to limit number of participants at one time. participants were only allowed to enter the station area when manikin and instructor become available for training. ratio between manikin to participants only one participant to one manikin is allowed at a time mask it was made compulsory for participants and instructors to wear mask at all time during the programme. hand sanitization hands need to be sanitized before and after each session manikin all manikins are sanitized before and after usage of each participant. figure 1: map of onsite training area at surau alhjrah, kota warisan 9 international journal of human and health sciences vol. 06 no. 01 january’22 table 2: number of participants and volunteers n % volunteers n=44 age mean (sd) 27.9 (+5.82) gender male 18 40.00 female 27 60.00 medical staff & drs upm 7 15.91 uitm 10 22.73 ukm 5 11.36 imam 7 15.91 students (upm) 15 34.09 participants n=133 online 100 75.19 onsite 33 24.81 identifying weaknesses in the event the covid-19 pandemic has a significant impact  in bls training method, which was traditionally conducted through face-to-face method of learning. the running of a traditional bls course is groups of people learning chest compression and ventilation through sharing of the same manikin with a simple personal face shield. it is particularly important that the risk of covid-19 transmission is taken into consideration given that the training was done in the midst of the pandemic. the approach to our mass bls training was changed to a hybrid approach of onsite and online training. this is in accordance with guidelines from american heart association and uk resuscitation council.11 the hybrid approach adopted during this training was to limit the number of onsite participants but simultaneously spread the awareness to a large number of mass public through online participation. the factors to ensure successful hybrid session were seamless coordination between onsite and online organizer, an additional multimedia team for recording and streaming and multimedia platform with high viewer rating. the main issues in conducting onsite training was social distancing and minimizing transfer of droplet. among social distancing measures taken were selection of mosque with spacious area, the arrangement of the station to guarantee distancing, limitation in the number of participants in the stations and minimising the ratio between trainer and trainee. however, there were several challenges that we face. in ensuring the desired ratio of trainer to trainee of 1:1, the number of mannequins has to be increased. this was achieved through the join resources of three universities in providing the mannequin. furthermore, additional manpower needed to oversee the flow of participants in and  out of a station in view of limited placement in each station. this was achieved with the help of medical students from one of the universities. as we know, covid-19 virus can be transmitted through contact, droplet and airborne transmission. 12. this outbreak has negative impacts on public perceptions and attitude towards cpr.13 so, this module that has been produced should give confidence to the general public that there are safe  ways to provide cpr to the victim. apart from that, the initiatives to reduce the risk of infection during training session was strictly follow the training protocol which were screening of participants for covid-19 symptoms, ensuring all participants and trainers were wearing facemask, use of hand sanitizers before and after handling the manikin, sanitizing the manikin after each use and exclusion of mouth-to-mouth ventilation during practice sessions. conclusion conducting mass bls training in a pandemic environment is unique and challenging. there are multiple angles that need to be taken into consideration. minimizing risk, maximizing benefit,  good communication and collaborative working are key factors in ensuring the success of this training. lastly, think outside the box, be receptive to new ideas and adaptable to circumstance. acknowledgements: we thank the fima lifesaver committee and imam secretariat committee, surau al-hijrah, kota warisan and all the volunteers involved in this event. conflict of interest: the authors declare no conflict of interest. funding statement: none ethical approval: not applicable author’s contribution: conception: aar, nhas collection and assembly of data: aar writing manuscript: aar, nhas, alp , mhmi editing and approval of final draft: aar, nhas,  alp, mhmi international journal of human and health sciences vol. 06 no. 01 january’22 10 references: 1. abdul rahman ar, mahmood aka. the birth of the international journal of human and health sciences (ijhhs ). int j hum health sci ijhhs. 2017 dec 17;1(1):5. 2. jamaluddin a, azalea s, noviar ra, suwarto dep, nugroho  nt.  the  effect  of  “mosque  lifesaver  training” on lay persons’ knowledge and willingness to perform basic life support in indonesia. int j hum health sci ijhhs. 2020 oct 4;5(2):202. 3. lifesavers | british islamic medical association [internet]. 2019 [cited 2021 aug 30]. available from: https://britishima.org/lifesavers/ 4. berdowski j, berg ra, tijssen jgp, koster rw. global incidences of out-of-hospital cardiac arrest and survival rates: systematic review of 67 prospective studies. resuscitation. 2010;81(11). 5. mahidin mu. department of statistics malaysia press release: statistics on causes of death, malaysia, 2020. dep stat malays. 2020;(november):1–8. 6. chew ks, mohd idzwan z, nik hishamuddun nar, wan aasim wa, kamaruddin j. how frequent is bystander cardiopulmonary resuscitation performed in the community of kota bharu, malaysia? singapore med j. 2008 aug;49(8):636–9. 7. marcus eng hock onga, sang do shinc, nurun nisa amatullah de souza, hideharu tanaka, tatsuya nishiuchi, kyoung jun song, patrick chow-in kog, benjamin sieu-hon leongi, nalinas khunkhlai, ghulam yasin narook, abdul karim sarah, yih yng n wyl. outcomes for out-of-hospital cardiac arrests across 7 countries in asia: the pan asian resuscitation outcomes study (paros). 2015;96:100–8. 8. panchal ar, bartos ja, cabañas jg, donnino mw, drennan ir, hirsch kg, et al. part 3: adult basic and advanced life support: 2020 american heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. vol. 142, circulation. 2020. 366–468 p. 9. who. who director-general’s opening remarks at the media briefing on covid-19 - 11 march 2020  world health organization. world health organ. 2020; 10. mohd hisham i, abd samat ah, saibon i. the preparation, delivery and outcome of covid-19 pandemic training program among the emergency healthcare frontliners (ehfs): the malaysian teaching hospital experience. med health. 2020 jun 30;15(1):250–65. 11. nolan jp, monsieurs kg, bossaert l, böttiger bw, greif r, lott c, et al. european resuscitation council covid-19 guidelines executive summary on behalf of the european resuscitation council covidguideline writing groups 1. 2020; 12. the lancet respiratory medicine. covid-19 transmission—up in the air. lancet respir med. 2020;8(12):1159. 13. chong k-m, chen j-w, lien w-c, yang m-f, wang h-c, liu ss-h, et al. attitude and behavior toward bystander cardiopulmonary resuscitation during covid-19 outbreak. savastano s, editor. plos one. 2021 jun 23;16(6):e0252841. 499 international journal of human and health sciences vol. 05 no. 04 october’21 original article neutrophil-lymphocyte ratio in branch retinal vein occlusion doğan m1, polat o2, baysal z3, ulu ms4, i̇nan s1, yavaş gf5, i̇nan üü6 abstract: objective: branch retinal vein occlusion (brvo) is the most common retinal vascular disease following diabetic retinopathy. pathogenesis of brvo is multifactorial and could not be clarified enough yet. as brvo is a disease that goes with thrombosis and inflammatory processes, inflammatory markers could help to predict the risk of brvo. the aim of this study was to evaluate the association between neutrophil-lymphocyte ratio (nlr) and the brvo. materials and methods: forty-three patients with brvo were included to this retrospective study. forty age and sex-matched healthy volunteers were recruited as the control group. demographic characteristics, white blood cell (wbc), neutrophil, lymphocyte, monocyte, platelet counts and nlr were recorded and compared between the patients and the control group. results and discussion: the mean wbc, neutrophil and nlr were significantly higher in the brvo patients compared with control group (7.89±1.8fl vs 6.97±1.4fl, p=0.014, 4.85±1.4fl vs 4.01±0.9fl, p=0.002, 2.40±1.2 vs 1.87±0.5, p=0.026, respectively). there were no difference between two groups in terms of lymphocyte, monocyte and platelet counts (p=894, p=0.22, p=0.589, respevtively). conclusion: nlr was higher in patients with brvo and higher nlr may contribute to development of brvo associated with systemic and/or local inflammation. key words: biomarker; inflammation; branch retinal vein occlusion; nlr, neutrophil correspondence to: mustafa dogan, md. afyonkarahisar health sciences university, faculty of medicine, department of ophthalmology. 03200, afyonkarahisar, turkey e-mail: mustafadogan@yahoo.com international journal of human and health sciences vol. 05 no. 04 october’21 page : 499-502 doi: http://dx.doi.org/10.31344/ijhhs.v5i4.363 1. afyonkarahisar medical sciences university, faculty of medicine, ophthalmology department, afyonkarahisar, turkey 2. dunyagoz hospital, ophthalmology clinic, bursa, turkey 3. batman state hospital, ophthalmology clinic, batman, turkey 4. afyonkarahisar medical sciences university, faculty of medicine, internal medicine department, afyonkarahisar, turkey 5. hacettepe university, faculty of medicine, ophthalmology department, ankara, turkey 6. parkhayat hospital, ophthalmology clinic, afyonkarahisar, turkey introduction branch retinal vein occlusion (brvo) is recognized as the most common retinal vascular disease following diabetic retinopathy and may result in severe loss of vision (1). the pathogenesis of brvo is multifactorial and underlying causes could not be clarified enough yet. numerous systemic and ocular risk factors were considered to be involved in the etiology of brvo (2). the most important systemic risk factors are hypertension and arteriolosclerosis (3,4). the count of the white blood cell which is one of the basic cells for inflammation and sub-types are used as a classical marker for the inflammatory state especially in cardiovascular diseases (5). beyond cardiac diseases, there are studies indicating that a low-grade inflammation exists in some conditions such as diabetes, hypertension, metabolic syndrome and obesity (6-9). recently, neutrophil-lymphocyte ratio (nlr) is used as a well indicator of inflammation together with other inflammatory markers for cardiac and non-cardiac diseases and ocular pathologies (10-13). suggestions about effectiveness of systemic and international journal of human and health sciences vol. 05 no. 04 october’21 500 local inflammation on physiopathology of brvo were made in the literature (2-4). to the best of our knowledge, there is few studies about nlr in patients with brvo in the litareture (14,16). the aim of the present study is to review nlr levels in the patients with brvo and to determine if any association exists between these. materials and methods patients files of the patients who have referred our clinic due to the complaint of decreased visual acuity and been diagnosed with brvo were reviewed retrospectively. patients with signs of an acute stage of brvo within a week and no history of previous treatment were included in the study. the study protocol was arranged in accordance with principles of the helsinki declaration and ethics committee approval was received for this study from local ethics committee. informed consent was obtained from all subjects. exclution criteria age, gender, ocular findings, systemic diseases and drug usage history of the patients were recorded. patients with hypertension were under control medication. patients with diabetes, chronic heart or liver disease, acute or chronic kidney failure, acute infectious disease, inflammatory bowel diseases, chronic obstructive pulmonary disease or smoking, using anticoagulant agents or nonsteroidal anti-inflammatory drugs as well as the patients whose biochemical analyses have not been ordered at diagnosis were excluded. control group along with 43 patients meeting these criteria, 40 patients without any systemic disease except for hypertension whose routine preoperative laboratory tests were ordered because of cataract were included as the control group. procedures anterior and posterior segment examination, ocular blood pressure measurement, optic coherence tomography and fundus fluorescein angiography imaging were performed for all patients. brvo was diagnosed by venous dilatation and folding increase on the arteriovenous crossing site, flame-shaped and spot-stain hemorrhages limited with distribution of the vein in the retina, retinal exudates and/or macular edema on the affected retinal site in the fundus examination performed by a split lamp. laboratory measurements blood samples were collected into the tubes (vacuette) including ethylenediaminetetraacetic acid (edta); an automated blood count device (beckman-coulter lh 780 analyzer, miami, florida, usa) was used for biochemical analysis. white blood cell (wbc), neutrophil, lymphocyte, monocyte and platelet levels which are automatically detected in complete blood count were recorded. nlr was obtained by diving the neutrophil count to the lymphocyte count. reference values were determined as 4-10 x 103/ mm3 for wbc, 1.5-7 x 103/ mm3 for neutrophil, 1-3.7 x 103/ mm3 for lymphocyte, 0-0.7 x 103/ mm3 for monocyte and 160-450 x 103/ mm3 for the platelet. statistical methods a package program for statistics (spss for windows, version 18.0, spss, chicago, il, usa) was used for statistical analysis. distribution of the variables used in the study was analyzed by kolmogrov-smirnov test. quantitative values were assessed by chi-square test; comparison of continuous variables was performed by parametric student t-test and non-parametric mann-whitney u test. data were reported as mean±standart deviation (±sd). p<0.05 values were accepted as significant. results the mean age of 43 patients (23 females, 20 males) included into the study was 63.09±13.14 years and 40 control subjects (23 females, 17 males) group was 63.87±11.38 years. the patient group and the control group were similar in terms of age and gender (p=0.77, p=0.82, respectively). there was no statistical difference in the brvo and control groups, according to presence of hypertension and intraocular pressure (table 1). mean wbc and neutrophil were detected as 7.89±1.8fl and 4.85±1.4fl, respectively in the patients with brvo whereas 6.97±1.4fl and 4.01±0.9fl, respectively in the control group; these values were significantly higher in the patient group than the control group (p=0.014, p=0.002, respectively). nlr was 2.40±1.2 in the patient table 1. baseline characteristics of patients and the control group. brvo n=43 control n=40 p gender (f/m) 23/20 23/17 0.82 age (years) 63.09±13.14 63.87±11.38 0.77 hypertension 23/43 20/40 0.75 iop (mm/hg) 15.51±2.79 16.11±2.38 0.30 brvo: branch retinal vein occlusion; f: female; m: male; iop: intraocular pressure 501 international journal of human and health sciences vol. 05 no. 04 october’21 group and 1.87±0.5 in the control group; and the difference between both groups was significant (p=0.026). there was not any statistical difference between both groups in terms of lymphocyte, monocyte and platelet counts (p=0,89, p=0,22 and p=0.59, respectively). numeric data of both groups were summarized in table 2. discussion and coclusion the most important risk factors in development of brvo are hypertension and arteriolosclerosis. the other risk factors include diabetes mellitus, hyperlipidemia, smoking, cardiovascular disease, pregnancy, oral contraceptive, age, increased body mass index, hyperviscosity, protein c or s failure and primary open angle glaucoma (1-3). however, to explain all these cases with these risk factors is difficult and exact pathophysiology of brvo is not known completely (4). arteries and veins appear in a common glia sheath on crossing sites in the retina. hypertension cause venous occlusion as a result of compression of the sclerotic artery onto the vein at arteriovenous crossing sites and lamina cribrosa level (17). numerous similar studies showed that systemic atherosclerosis is a significant risk factor for development of brvo (18,19). as the sclerotic changes and thickening occurred in the fibrous tissue by aging increase the arterial compression and cause stasis of the venous flow and hemodynamic changes. compression of the vein causes increased retinal venous blood flow velocity, turbulence of blood flow, endothelial injury, secondary thrombosis and may lead occur inflammation (20). although inflammation plays a role in pathophysiology of many diseases, it also contributes to clinical outcomes of these diseases (21). white blood count and sub-types are used as a classical marker of the inflammatory state (5). since nlr, in particular, is accepted as an independent prognostic factor in coronary artery diseases, it has attracted attention lately (21). furthermore, inflammation has a important role in pathophysiology of the vascular diseases. inflammation is important in hypertensive vascular changes and atherosclerotic process. white blood cells and sub-types are critical in arrangement of the inflammation which appears during atherosclerotic process (22). there are studies reporting that nlr values are significantly affected in atherosclerosis and systemic hypertension (21-24). the cause for detection of wbc, neutrophil count and nlr higher in the patients with brvo than the control group may depend to underlying atherosclerotic and hypertensive vascular changes. as is known, venous stasis, vascular wall injury and hypercoagubility are known as virschow’s triad. another mechanism of action involving inflammation in development of brvo may be through increasing the hypercoagubility. interleukin-1β, interleukin-6 and tumor necrosis factor-α are known as prothrombotic cytokines and cause changes in the blood flow (25). similarly, increased plasma homocysteine levels cause chronic inflammation as well as hypercoagubility, injury on the vascular endothelium and blood flow deceleration (26). there are studies indicating that systemic inflammatory risk factors along with local inflammation contribute to the etiology of brvo (27-29). the aqueous flare level appeared as a result of the destruction of the blood-aqueous barrier were reported to be detected higher in the patients with brvo than the patients in the control group (27). moreover, detection of increased levels of vegf and inflammatory cytokines were reported in vitreous fluids of the patients with brvo (29). to the best of our knowledge, there are few studies analyzing the nlr and mean platelet volume level in the patients with brvo in the litareture and shown similar results with our results. (15,16). unlike, in one study, the authors detected no difference in nlr values between brvo patients and healty control group (14). further investigations regarding its potentially use as a prognostic biomarker in patients with brvo are needed. one of the limitations of the current study is that it has a retrospective design and relatively low number of patients. furthermore, since serum levels of other inflammatory factors such as c-reactive protein, interleukin-1β, interleukin-6 table 2. laboratory data in the patient and the control group. brvo n=43 control n=40 p wbc (fl) 7.89±1.8 6.97±1.4 0.014 neutrophil (fl) 4.85±1.4 4.01±0.9 0.002 lymphocyte (fl) 2.21±0.7 2.24±0.6 0.89 monocyte (fl) 0.61±0.2 0.53±0.1 0.22 platelet (x103 µl) 247.65±47.3 253.71±51.5 0.59 nlr 2.40±1.2 1.87±0.5 0.026 brvo: branch retinal vein occlusion; wbc: white blood cell count; nlr: neutrophillymphocyte ratio international journal of human and health sciences vol. 05 no. 04 october’21 502 and tumor necrosis factor-α could not be known, the strength of the present study is reduced. in conclusion, consequently, higher nlr levels detected in the patients with brvo support the hypothesis that systemic and local inflammation may be effective in the etiology of brvo. however, large-scaled, randomized controlled and prospective studies including more patients are required. conflict of interest: the authors declared that there is no conflict of interest. funding: this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. ethical clearance: ethics committee approval was received for this study from the ethics committee of afyon kocatepe university faculty of medicine. authors’ contributions: concept m.d, o.p.; design o.p., g.f.y., s.i̇.; supervision m.s.u., s.i̇., ü.ü.i̇.; resource z.b., m.s.u., g.f.y.; materials z.b, g.f.y., s.i̇.; data collection &/or processing -o.p. z.b, s.i̇.; analysis &/or interpretation m.d. g.f.y., ü.ü.i̇.; literature search m.s.u., s.i̇., ü.ü.i̇.; writing m.d., o.p. z.b..; critical reviews m.d., s.i̇, g.f.y., ü.ü.i̇. 1. zhao j, sastry sm, sperduto rd, chew ey, remaley na. arteriovenous crossing patterns in branch retinal vein occlusion: the eye disease case control study group. ophthalmology 1993;100(3):423-428. 2. sperduto rd, hiller r, chew e, seigel d, blair n, burton tc. risk factors for hemiretinal vein occlusion: comparison with risk factors for central and branch retinal vein occlusion: the eye disease case-control study. ophthalmology 1998;105(5):765-771. 3. kolar p. risk factors for central and branch retinal vein occlusion: a meta-analysis of published clinical data. j ophthalmol 2014 doi: 10.1155/2014/724780. 4. jaulim a, ahmed b, khanam t, chatziralli ip. branch retinal vein occlusion: epidemiology, pathogenesis, risk factors, clinical features, diagnosis, and complications. an update of the literature. retina 2013;33(5):901-910. 5. furman mi, becker rc, yarzebski j, savegeau j, gore jm, goldberg rj. effect of elevated leukocyte count on in-hospital mortality following acute myocardial infarction. am j cardiol 1996;78(8):945-948. 6. pitsavos c, tampourlou m, panagiotakos db, skoumas y, chrysohoou c, nomikos t et al. association between low-grade systemic inflammation and type 2 diabetes mellitus among men and women from the attica study. rev diabet stud 2007;4(2):98-104. 7. nakanishi n, sato m, shirai k, suzuki k, tatara k. white blood cell count as a risk factor for hypertension; a study of japanese male office workers. j hypertens 2002;20(5):851-857. 8. bell ds, o’keefe jh. white cell count, mortality, and metabolic syndrome in the baltimore longitudinal study of aging. j am coll cardiol 2007;50(18):18101811. 9. marsland al, mccaffery jm, muldoon mf, manuck sb. systemic inflammation and the metabolic syndrome among middle-aged community volunteers. metabolism 2010;59(12):1801-1808. 10. tamhane uu, aneja s, montgomery d, rogers ek, eagle ka, gurm hs. association between admission neutrophil to lymphocyte ratio and outcomes in patients with acute coronary syndrome. am j cardiol references microsoft word ijhhs imam 23rd asc 2022 s15 3. ngo efforts and their role in the junior doctor plight aneesa abdul rashid1,2 over the years, we are faced with many issues surrounding junior doctors, as they make their way into the professional working platform. to address this matter, many non-governmental organizations (ngos) have been actively involved to improve the welfare of the fraternity. among one of the earliest and ongoing concerns frequently brought up is the house officers (ho) wellbeing, which is said to be associated with high levels of stress leading to mental health problems, and sometimes leaving the medical profession altogether. in malaysia, the number of hos not completing training within the allocated time is slowly declining with dropout rates increasing yearly. this causes a lot of constraints on the ho, their family, sponsors, patients, and not to mention our healthcare system. there are many identified reasons for this matter, therefore, the islamic medical association of malaysia (imam)’s ho preparatory course was one of the pioneer courses organised to address this since its commencement in 2010. this module is frequently re-evaluated, and imam has actively pursued research on its effectiveness. next, is the road crash injury among doctors in which imam has been involved in addressing this matter by actively seeking dialogues with stakeholders, organising campaigns, workshops and obtaining grants for research in the matter. imam on its own or in collaboration has consistently backed efforts to improve wellbeing of the healthcare fraternity. other efforts include issuing press statements on concerns of unfair treatment of the contract doctors, addressing importance of mental state of doctors during the covid 19 pandemic and reminding on the dangerous consequences of sleep deprived doctors. the ngo’s role, specifically in imam, apart from serving the community is also to be a voice for its members and associates for our overall safety, wellbeing, and the community we serve. keywords: non-governmental organisation, research, junior doctor, house officer 1. department of family medicine, faculty of medicine & health sciences, universiti putra malaysia, 43400 serdang, malaysia 2. head of imam research, islamic medical association of malaysia, no 1, 2, jalan sp1, selayang point, 68100 batu caves, selangor ___________________________________________________________________________ correspondence to: aneesa abdul rashid, associate professor and medical lecturer, department of family medicine, faculty of medicine & health sciences, universiti putra malaysia, 43400 serdang, malaysia. aneesa@upm.edu.my __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v7i70.517 international journal of human and health sciences vol. 07 no. 01 january’23 40 original article: quality of life and activity of daily living of ischaemic stroke patients in north-eastern of peninsular malaysia: the effect of bal-ex stroke home rehabilitation nurzaitil aswani zainuddin1,2, juwita shaaban1, rosediani muhamad1, zuraida zainun3, azzyati muhamad nor4, najib majdi yaacob5, siti suhaila mohd yusoff1, rosnani zakaria1 and nani draman1. abstract stroke is a leading cause of adult disability. reduced stroke mortality leads to increasing need for rehabilitation services. home-based stroke rehabilitation is an alternative to inpatient rehabilitation to help stroke survivors improve their functions. we assess the effect of bal-ex stroke video module on the quality of life (qol) and activity of daily living (adl) of stroke patients. this study is an opened labelled randomised controlled trial (rct) involving 80 patients with recent mild to moderate ischemic stroke. they were divided into control group and intervention group using randomisation of block of four. the intervention group received a bal-ex stroke module and twice weekly outpatient follow-up at rehabilitation unit, university hospital. the control group received only weekly outpatient therapy sessions. both groups were assessed with barthel index (bi) for activity of adl and at baseline, end of month 2 and month 4. the level of adl total scores was analysed using a repeated measure anova. 80 patients were recruited and all participants successfully completed the study. the majority of the participants were male (81.2%). their average mean age was 59.78 (7.56) years old. there was no significant difference between qol score of both groups at baseline assessment. intervention group demonstrated a significantly greater mean in adl, at 2 months [(66.00; 95% ci: 60.34, 71.66) vs. (42.25; 95% ci: 36.59, 47.91)]; and even at 4 months [(77.00; 95% ci: 72.42, 81.58) vs 61.38; 95% ci: 56.79, 65.96)] as compared to control group. using balex stroke home module in early ischaemic stroke can leads to better improvement of patients’ quality of life than usual care. keywords; activity of daily living, bal-ex stroke, home rehabilitation, quality of life correspondence to: dr. rosediani muhamad, associate professor, and family medicine and public health specialist, universiti sains malaysia, health campus, 16150 kubang kerian 1. family medicine specialist, family medicine department, school of medical sciences, universiti sains malaysia, health campus, 16150 kubang kerian, kelantan, malaysia 2. family medicine specialist, ministry of health, malaysia 3. medical audiologist and cognitive neuroscientist, department of neuroscience, school of medical sciences, universiti sains malaysia, health campus, 16150 kubang kerian, kelantan, malaysia 4. physiotherapist, rehabilitation unit, hospital universiti sains malaysia, 16150 kubang kerian, kelantan, malaysia 5. assoc. professor and head, biostatistics and research methodology unit, school of medical sciences, universiti sains malaysia, 16150 kubang kerian, kelantan, malaysia introduction more than half the patients who survive the first month after a stroke will require specialised rehabilitation.1 effective rehabilitation interventions that are initiated early after stroke onset can enhance the recovery process and minimise functional disability.2 however, the effectiveness of rehabilitation interventions also relies on a multidisciplinary team approach and regular team meetings, as well as meetings with the patient, family and caregiver.1 stroke rehabilitation can be administered as international journal of human and health sciences vol. 07 no. 01 january’23 page : 40-47 doi: http://dx.doi.org/10.31344/ijhhs.v7i1.495 41 international journal of human and health sciences vol. 07 no. 01 january’23 inpatient rehabilitation, at the patient’s home or at an outpatient facility. home-based rehabilitation (hbr) is defined as a ‘rehabilitation programme provided in the patient’s place of residence’.2 hbr programmes provide the greatest flexibility in terms of the schedule, frequency and intensity of rehabilitation. they are most convenient for patients who are homebound because of lack of transportation or because they require only this therapy.2 in malaysia, only a limited number of centres provide inpatient rehabilitation. most patients who have had a stroke are discharged soon after they have been confirmed to be medically stable and have attended outpatient rehabilitation programmes. these outpatient programmes also have limited resources in terms of either a limited number of rehabilitation centres or insufficient physiotherapists trained in neurological rehabilitation.3 the cost and time for travelling may also be contributing factors that have caused patients not to continue rehabilitation after being discharged from the hospital.3 hbr is recommended as a safe programme that does not have negative impacts on the patients’ independence and is not stressful for caregivers.3 thus, hbr,which does not require the presence of a physiotherapist, is a practical alternative to the current rehabilitation programme available in malaysia. this has provided the justification for this study,which aimed to evaluate whether hbr using the bal-ex module would improve the activities of daily living (adl) and quality of life (qol) of patients with stroke,without patients and their caregivers having to frequently attendroutine outpatient rehabilitation, which could be troublesome. methods study design and participants this was a single-centre, parallel, open-label randomised control trial (rct) study, with an allocation ratio of 1:1. eighty participants recently diagnosed (less than 3 months) with mild to moderate ischaemic stroke (national institutes of health stroke scale <16) attended the rehabilitation centre at the university tertiary hospital in this region between may 2014 and april 2015. those with severe speech disorders, hearing loss and any concurrent neurological disorder,for example, mental retardation, mental illness or epilepsy, were excluded. eligibility criteria were maintained throughout the study. after they provided consent, eligible participants were equally randomised in groups of four to either the intervention group (ig) or control group(cg). the allocation was concealed using a sealed envelope and the randomisation sequence was executed without any adaptation. ig the ig underwent a hbr programmeusing a balex module (a combination of a digital video disc (dvd) with a pictographic manual) and outpatient follow-up twice amonth at the rehabilitation unit of the husm. the frequency and types of therapy were recorded in the diary provided at the back of the manual. patients were required to performthe exercises ten times for each step, at least two times per day. during the visit, they performed exercises similar to thecg,depending on their disabilities. the patients and their caregivers were taught individually by physiotherapists and hands-on bal-ex exercises were shown depending on each patient’s disability andthesteps needed during each visit. cg patients in the cg underwent their weekly outpatient follow-ups at the rehabilitation unit of the husm. they were individually taughtthe hands-on exercises tobe performed as rehabilitation therapy at home. although the frequency of therapy performedat home was not recorded, patients and their caregivers weretaught how to perform home exercises during every visit and were advised to do so at home. research tools 1. bal-ex module the bal-ex module is a self-instructional 40-min audiovisual dvd of standardised rehabilitation procedures and a pictographic manual produced by local researchers.4 this module consists of 56 movements divided into seven different stages for patients who have had a stroke. this module is a combination of a prayer’s movements, bobath techniquesand customised cawthorne–cooksey techniques. it involves orderly audiovisual physical movements to assist caregivers and patients to perform exercises at home. it consists of passive, active and resistance exercise and adl, including eating activities, putting on and taking off trousers and a shirt and activity during international journal of human and health sciences vol. 07 no. 01 january’23 42 ‘solah’. bal-ex stroke exercises can be performed in an orderly and systematic manner according to the patient’s capability. the movements are done step-by-step from stages1 to 7. each movement is advised to be performed 10 times and repeated 2–3 times daily by patients or assisted by the caregiver. after patients have successfully completed a movement, they may proceed to the next movement in the sequence. the seven stages of movement include the patient’s position; activities while in a prone position–body and hand movements, leg movements and lifting the hip in a prone position while both knees are bent; patient transferring technique and self-grooming activity; activities while sitting–exercise movements and daily routine activities; activities while standing; walking exercises and stairs exercises. 2. barthel index (bi) all patients were assessed on the bi for adl at baseline and the second and fourth months. the bi has ten items of basic activities, including feeding, bathing, grooming, dressing, bowels, bladder, toilet use, chair/bed transfers, mobility and stairs. the total score ranges from 0 to 100, with 100 representing complete independence and 0, complete dependence. the 10-item scale, scoring 0 to 100 with 5-point increments, has been used in several multi-centre stroke trials and in the absence of any clearly superior ‘barthel’, it seems reasonable that this should become the uniform stroke trial bi.5 the criteria for classifying patients with a favourable outcome varied substantially from trial to trial. granger et al.found that 60 was a pivotal score at which patients move from assisted independence to dependence.6 therefore, the bi scoring used for this study was >60 for independent patients and <60 for dependent patients. 3. stroke-specific quality of life (ss-qol) questionnaire the ss-qol is a single stroke-outcome measure that aims to efficiently assess the various domains important in determining stroke-specific hrqol across the spectrum of stroke symptoms and severity. this self-administered ss-qql questionnaire consist of 49 items,with 12 domains: energy, family roles, language, mobility, mood, personality, self-care, social roles, thinking, upper extremity function, vision and work/productivity. each item is ranked on a 5-point likert scale: (1) the amountof help required to do specific tasks, ranging from no help to total help;(2) the amountof trouble experienced when attempting tasks, ranging from unable to do a taskto no trouble at all and (3)the degreeof agreement with statements regarding their functioning, ranging from strongly agree to strongly disagree. the point of reference for all items was the previous week. the highest score indicates better function and qol.7 among patients, the ss-qol questionnaire appears to be a valid tool to measure mild to moderate deficits resulting from a stroke.8 the minimum score is 49 points and the maximum is245 points;the higher the points obtained,the better the patient’s qol. the cut-off point of 60% from 245 points (>147) was used to determine good qol.9 these disease-specific hrqol measures are more sensitive to meaningful changes in poststroke hrqol and may aid in identifying specific aspects of post-stroke function that clinicians and ‘trialists’can target to improve patients’ hrqol after stroke.10 sample size the sample size calculation was based on the comparison effect of the bal-ex module on the changes of adl and qolscores between the ig and cg among patients with ischaemic stroke using powerand sample size calculation software for comparing two mean scores, as recommended by gbiri et al.11 the required sample size was determined to be 40 patients per group after considering the probability of a 20% dropout rate. statistical analyses data entry and statistical analyses were performed using ibm statistics spss software version 22.0. age was presented as the mean score and standard deviation (sd) and sex was presented as the frequency (n) and percentage (%). characteristics of the study participants in the ig and cg were compared using the independent sample t-test for age and the chi-squared test for sex. an alpha value of 0.05 was used as the cut-off level for significance. comparisons of adl and qol between the ig and cg based on time (time-treatment interaction) were made using repeated-measures analysis of variance. the overall time–treatment interaction was assessed using wilk’s lambdatest statistic and the f-value. the overall time–treatment interaction was statistically significant when the f-statistic was smaller than the critical alpha value of 0.05. at each time level (baseline, month2 and month4), the differencesin adl and qol between 43 international journal of human and health sciences vol. 07 no. 01 january’23 the two groups werestatistically significant when the 95% confidence interval (ci) of the cg did not overlap with the 95% ci of the ig. results a total of 164 patients who had a stroke were screened at the rehabilitation unit of the husm during the recruitment period. eighty patients who met the inclusion criteria consented to participate in the study. forty patients were randomised to each group. no adverse events were reported during the study period. the randomisation flowchart is shown in figure 1. characteristicsof participants of the 80 participants included, all completed the study, yielding a 100% response rate. the majority of participants were male (81.2%), with a mean age of 59.78 (sd7.56) years. the comparison of age and sex between bothgroups showed that there was no statistically significant difference (table 1). throughout the study, no harmful or unintended effects were reported in both groups. time–intervention interaction effect on patients’ adl the p-value for the f-statistic for the time– intervention interaction was smaller than the critical alpha value of 0.05 (wilk’s lambdaf (2, 77) = 20.35, p<0.001). the null hypothesis that the average adl between groups was the same for all time periods was rejected and the time– intervention interaction was significant. at baseline, there was no significant difference in the mean adl between the cg and ig. at months 2 and 4, patients in the ig had significantly higher adl scores than patients in the cg (table 2). the figure 1: consort flow chart of the study international journal of human and health sciences vol. 07 no. 01 january’23 44 estimated marginal mean adl for patients in both groups is shown in figure 2. table 2: differences of adl between control and intervention group based on time. time group mean adl (95% ci) f-statistics (df) p-value baseline control 32.88 (28.50, 37.25) 20.35 (2, 77) <0.001 intervention 29.13 (36.59, 47.91) month 2 control 42.25 (36.59, 47.91) intervention 66.00 (60.34, 71.66) month 4 control 61.38 (56.79, 65.96) intervention 77.00 (72.42, 81.58) the p-value for the f-statistic for the time–treatment interaction was smaller than the critical alpha value of 0.05 (wilk’s lambda f (2, 77) = 32.48, p<0.001). the null hypothesis that the average qol between groups was the same for all time periods was rejected and the time–treatment interaction was significant. at baseline, there was no significant difference in the mean qol between the cg and ig. at months 2 and 4, patients in the ig had significantly higher qol scores than patients in the ig (table 3). the estimated marginal mean qol for patients in both groups is shown in figure 3. table 3: differences of qol between control and intervention group based on time time group mean qol (95% ci) f-statistics (df) p-value baseline control 80.73 (74.66, 86.79) 32.48 (2, 77) <0.001 intervention 87.70 (81.64, 93.77) month 2 control 110.78 (103.81, 117.74) intervention 143.15 (136.18, 150.12) month 4 control 143.45 (137.10, 149.80) intervention 161.28 (154.93, 167.62) table 1: comparison of sociodemographic characteristics between control and intervention group variables control group (n=40) intervention group (n=40) mean diff (95% ci) p-value age, mean (sd) 58.63 (6.66) 60.93 (8.29) -2.30 (-5.65, 1.05) 0.175 sex, n(%) male female 33 (50.8) 7 (46.7) 32 (49.2) 8 (53.3) 0.775 there was no significant difference in sociodemographic data between the groups. figure 2: profile plot showing estimated marginal mean of adl for patients in control and intervention group based on time. time–intervention interaction effect on patients’ qol figure 3: profile plot showing estimated marginal mean of qol for patients in control and intervention group based on time. discussion in recent years, home rehabilitation in patients who have had a stroke has been increasingly used to improve their ability to perform adl and to prevent the loss of motor function. this study provides important information onthe effectiveness of an early home rehabilitation intervention in patients with ischaemic stroke as 45 international journal of human and health sciences vol. 07 no. 01 january’23 other studies,5,13-15 although the latter used different approaches for hbr programmes. sociodemographic data overall, 80 subjects were enrolled in this study. there was no dropout in this study probably because the participants who attended the rehabilitation unit did not have any problem to attend the follow-up, lived near the hospital, had a good support system and were themselves willing to participate in this study. from the data, both groups had a majority of male participants. the mean age of the cg and ig was comparable with that in other studies.5,13-14 we did not divide the mean age according to sex differences because of the small percentage of female participants that might have contributed to bias. globally, men have higher age-specific stroke rates than women and are more likely to have their first-ever stroke at a younger age.15 effect of bal-ex module on adl from the baseline data, the results showed no significant difference of the mean adl score between the cg and ig. the mean adl score showed that patients in both groups were dependent in their adl, which was <60 at baseline. most previous studies had findings similar to our study, which showed low adl scores at baseline. this is because most participants in these studies had recently had a stroke and had not yet started their physiotherapy as outpatients. similar baseline mean scores were also found in studies conducted by chaiyawat et al., elena sirbu et al.and redzuan et al.5,13-14 however, duncan et al. had a higher mean bi score at baseline, at 82.5, leaving little range for improvement after the intervention.16 the patients recruited in this study had completed inpatient rehabilitation before the intervention, which may contribute to the higher baseline bi score. a lower mean baseline bi score for adl seems to yieldhigher chances for improvement after the intervention. the results showed statistically significant improvements in the adl score regardless of time compared to the cg. in the ig, the resultsshowed early accelerated improvement of the adl score from baseline to month 2 compared to the cg. the mean bi score showed that adl in both groups changedto independent (bi score >60) after 4 months of rehabilitation. however,themean adl score was higher in the ig (77.00 vs. 61.38). this result demonstrated that individuals with stroke could gain benefitsfrom home rehabilitation programmesin motor functions and adl beyond those that occurwith usual care. the outcomes of the bi for adl among patients who have had a stroke are similar with different interventions. duncan et al.demonstrated that the rct of a post-stroke home-based exercise programmeis feasible.16 this programmeinvolved patients who had mild to moderate stroke within 30–90 days after astroke and who had completed acute rehabilitation. the ig received a therapistsupervised home-based exercise programmethree times per week for 8 weeks. from the intervention, neurological impairments and lower extremity function showed the greatest improvements. however, the effects of the intervention on adl were equivocal in both groups,with the mean bi score at baseline for these individuals beinghigher (82.5), leaving little range for improvement even after 12 weeks of intervention.16that hbr study differed from our study in that those patients had regular home visitsby the physiotherapist and their study participants underwentinpatient rehabilitation before the intervention, even though their stroke severity was similar to our participants. in thailand, chaiyawat et al. used a similar method, combining an individual’s exercise programmeprovided by a physical therapist once a month for 6 months and standard materials on an audiovisual cd of rehabilitation procedures. the bi also improved in both groups, but was significantly better for the ig, with 97.2(2.8) vs. cg 76.4(9.4), p<0.001.14 similar findings werereported by elena sirbu et al., in which the intervention provided significantly better outcomes in adl, as well as motor and balance functions. however, their study used a small number of participants (14 patients who had a stroke) and did not use audiovisualexercises for home rehabilitation.13 a localstudy by redzuan et al. also combined home rehabilitation with a dvdcontaining therapy techniques.5 they conducted twicemonthly follow-ups for 44 patients with stroke for 3months and measured their primary outcome international journal of human and health sciences vol. 07 no. 01 january’23 46 using the modifiedbi. both groups had significant increases in the mbi score (p<0.001);however, there were no significant differences with regard to the number of patients with improved mbi scores.5 all thesestudies suggest an early home rehabilitation programmein the first few months after an ischaemic stroke as it leads to more rapid improvements in function and reduces disability compared to usual care. effect of bal-ex module on qol the results showed that a home-based dvd rehabilitation programmeis feasible and improves the qol among patients who have had a stroke compared to usual care. unfortunately, we could not find asimilar intervention study using the ssqol to measure the qol for home rehabilitation interventions. evaluation of patient improvement is essential to monitor a patient’s progress and to assess the effectiveness of the module. zuraida et al. suggested pre-and post-intervention therapy assessments for patients’ qol measured by using the ss-qol.4 the minimum score is 49 points and the maximum is 245 points andthe higher the points obtained, the better the qol. however, in this study, we used a cut-off point of 60% from 245 points (>147) as a good qol, as suggested by rangel et al.6 the bi, which has a ceiling effect and captures only physical domains of health status, is not adequate inassessing the full impact of strokerelated disability and is ineffective in detecting the psychosocial dimensions of impaired function.16 thus, other health status measures, such as the ssqol, wereused in addition to the biwhen stroke outcomes are assessed. it is necessary to measure the qol to provide a more accurate and complete picture of the post-stroke level of disability.17 this is why this study assesses the qol besides functional improvement in survivors of ischaemic stroke. a similar finding was found in a study involving brazilian patients with stroke who attended a rehabilitation programme for more than 3 months, in which their total ss-qol mean (sd) score was 139.7(38.4).9 this result shows that rehabilitation helps improve the qol of survivors of stroke. however, that study differs from ours because it included all types and severity of stroke, including haemorrhagic and ischaemic stroke andpatients spentat least 3 months in the outpatient rehabilitation programme. no home intervention was conducted in thatstudy. limitations and recommendations our research had several limitations. participants in this study did not represent the overall survivors of stroke in kelantan or even in the husm, as the patients who willingly participated in this study are those who lived nearby, could afford the money and time to attend follow-ups, or had good social support. there was also no evaluation of patients’ comorbidities, which may affect the rehabilitation and process of stroke recovery. this rct studied only the early effectsof the intervention on stroke rehabilitation,which may be confused with the natural healing process of astroke. most spontaneous stroke recovery occurs in the first 30 days and may continue up to 6 months after the stroke.16 the long-term outcomes and lasting effectsof the intervention, which are the foremost important goals in managing stroke,cannot be evaluated. there are a few recommendations to improve the stroke rehabilitation intervention studies in the future. more rcts comparing rehabilitation approaches are required to investigate the effects of different combinations of physiotherapy approaches for patients who have had a stroke. long-term studies are needed to measure the lasting effectsof the intervention for patients with stroke and which groups of patients benefit most from hbr programmes. conclusion this study has provided additional data supporting the remarkable benefits of a hbr programme for stroke patients in malaysia. after 4months of home rehabilitation, it was found that the intervention had produced greater gains and higher rates of functional independence and better qol among these patients than among patients receiving usual care without such an intervention. moreover, there were significant changes in adl and qol with the bal-ex module among patients in the ig compared to thoseof patients in the cg. although patients in the ig seemed to experience accelerated recovery within 4 months compared to patients in 47 international journal of human and health sciences vol. 07 no. 01 january’23 the cg, the changes may not be associated solely with the bal-ex module. the effect of baseline physiotherapy follow-up sessions, which were different between bothgroups,also plays some role. thus, a bal-ex module would provide a way to improve the patients and caregivers’ skills and serve as a motivation as well as a reminder to perform therapy more often. acknowledgement we thanked all the participants, their caregivers and staffs in rehabilitation unit for helping and supporting research team throughout the study period. conflict of interest and funding all authors did not have any conflict of interest to declare. ethical clearence: this study was approved by the usm human research ethics committee in 2014 (usmkk/ ppp/jepem [253.3.(5)]. authors’s contribution: data gathering and idea owner of this study: r.m., and z.z. study design and supervision: r.m., j.s., z.z. n.m.y., a.m.n., s.s.m.y., n.d., and r.z. data gathering and analysis: n.a.s., n.m.y., and a.m.n. writing and submitting manuscript: n.a.s., and r.m. editing and approval of final draft: r.m., j.s., z.z., n.m.y., a.m.n., s.s.m.y., n.d., and r.z. references 1. truelsen t, begg s, mathers cd, satoh t. global burden of cerebrovascular disease in the year 2000. gbd 2000 working paper. who, geneva, switzerland. http://www.who/evi-dence/bod ; 2002 [accessed february 5 2016]. 2. donnan ga, fisher m, macleod m, davis sm. stroke. lancet 2008;371(9624):1612-23. 3. pollack mrp, disler pm. rehabilitation of patients after stroke.med j aust 2002;177(8): 452-456. 4. zuraida z, shahriman ab, zunaidi i, geshina ms. japanese version of the home-based management module for stroke rehabilitation (bal ex stroke: home-based management for stroke rehabilitation). imj 2016; 23(3): 225-229. 5. redzuan ns, engkasan jp, mazlan m, freddy asj. effectiveness of a video-based therapy program at home after acute stroke: a randomized controlled trial. arch phys med rehabil 2012;93(12):2177-183. 6. granger cv, dewis ls, peters nc, sherwood cc, barrett je. stroke rehabilitation: analysis of repeated barthel index measures. arch phys med rehabil 1979;60(1):14-17 7. whoqol: measuring quality of life. world health organization 1997. 8. williams ls, weinberger m, harris le, clark do, biller j. development of a stroke-specific quality of life scale. stroke. 1999;30(7):1362-1369. 9. rangel ess, belasco ags, diccini s. quality of life of patients with stroke rehabilitation. acta paul enferm. 2013; 26:205-12. 10. williams ls, weinberger m, harris le, biller j. measuring quality of life in a way that is meaningful to stroke patients. neurology. 1999;53(8):1839-1843. 11. gbiri ca, akinpelu ao. quality of life of nigerian stroke survivors during first 12 months post-stroke. hkpj 2012; 30: 18-24. 12. chaiyawat p, kulkantrakorn k, sritipsukho p. effectiveness of home rehabilitation for ischemic stroke. neurol int 2009;1(1):36-40. 13. sîrbu e. evaluation of a home-based physical therapy program in ischemic stroke patients. tperj 2012;5(9):17-23. 14. chaiyawat p1, kulkantrakorn k. effectiveness of home rehabilitation program for ischemic stroke upon disability and quality of life: a randomized controlled trial. clin neurol neurosurg 2012;114(7):866-70. 15. appelros p, stegmayr b, terént a. sex differences in stroke epidemiology: a systematic review. stroke 2009;40(4):1082-90. 16. duncan p, richards l, wallace d, stoker-yates j, pohl p, luchies c, et al. a randomized, controlled pilot study of a home-based exercise program for individuals with mild and moderate stroke. stroke 1998;29(10):2055-60. 17. kranciukaite d, rastenyte d. measurement of quality of life in stroke patients. medicina (kaunas). 2006;42(9):709-716. microsoft word ijhhs imam 23rd asc 2022 s17 a cross-sectional study on menstrual health practice and needs among female rohingya residing in malaysia: an interim analysis muhammad aqif badrul hisham1, ahmad rashidi mohamed tahir1, sh fatimah alzahrah syed hussein al-attas2, nur aizati athirah daud3 objectives: not much is known about the menstrual practices and needs among rohingya females residing in malaysia. this knowledge gap needs to be addressed, in line with the efforts toward family planning. the objectives of the study are to describe menstrual practices among female rohingya and to assess whether their menstrual needs are met during their last period. methods: this is a cross-sectional study involving rohingya females aged 18 to 55 years old attending qffd clinic run by imaret in selayang, selangor between april to july 2022. menstrual practices and needs were assessed using self-administered questionnaires; the menstrual practices questionnaire (mpq) and the menstrual practice needs scale (mpns-36), respectively.  results: a total of 40 respondents have completed the questionnaire. only 42.5% (n=17) of respondents have good experiences during their past menstrual cycle despite most of the respondents were able to meet their materials and home environment needs (n=27, 67.5%) and are less concerned when managing the disposal of their menstrual materials (n=25, 62.5%). though, only 12.5% (n=5) of respondents have their transportation and school environment needs were met during their past menstrual cycle and 37.5% (n=15) of the respondents have concerns with the quality of their menstrual materials. the most common menstrual materials used by respondents at home and while away from home are disposable sanitary pads (n=35, 87.5% and n=36, 90.0% respectively). many of the respondents prefer to dispose them inside the household rubbish bin which is inside the latrine when at home (n=36, 90.0 %) while the bin in the public latrine or toilet is used when disposing menstrual materials while away from home (n=32, 80.0%). conclusion: most of the female rohingya refugees were able to practice safe and clean menstrual management. though, some of their needs were not met, especially during transportation and away from home. it is important for non-government organizations like unhcr to fight for their legal status in malaysia so that they can feel safe and secure without it impacting their health negatively. keywords: menstrual health, menstrual management, refugees, women’s health 1. faculty of pharmacy, university of cyberjaya, 63000 cyberjaya, selangor, malaysia 2. department of sociology and anthropology, kulliyyah of islamic revealed knowledge and human sciences, international islamic university malaysia, 53100 kuala lumpur, malaysia 3. school of pharmaceutical sciences, universiti sains malaysia, 11800 usm, penang, malaysia ___________________________________________________________________________ correspondence to: nur aizati athirah daud, lecturer, school of pharmaceutical sciences, universiti sains malaysia, 11800 usm, penang, malaysia, aizati@usm.my __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v7i70.519 127 international journal of human and health sciences vol. 06 no. 01 january’22 original article total phenolic content and antioxidant activity of germinated black rice variety krisna extract, indonesia sudana fatahillah pasaribu 1 , budiyanti wiboworini2, lilik retna kartikasari3 abstract: background: indonesia is an agricultural country and the third-largest rice producer in the world. pigmented rice tends to contain a lot of nutrients and bioactive compounds, namely  phenols,  anthocyanins,  fiber,  amino  acids,  tocopherols,  and  γ-oryzanol, and has antioxidant properties. phenols are bioactive compounds and antioxidants which are beneficial for health. since the synthetic antioxidants have carcinogenic properties,  natural antioxidants used in this study. one of the plants that have the potential to have antioxidant activity and phenol content is black rice variety krisna from sleman district, di yogyakarta, indonesia. the germination process in rice can theoretically increase its bioactive compounds, thereby increasing the potential for antioxidant activity. objective: to analyze the antioxidant activity and total phenol content of the germinated black rice extract variety krisna in sleman district, d.i. yogyakarta, indonesia. materials and methods: this type of research was quantitative with laboratory experimental methods. the research sample was germinated black rice of a variety krisna from indonesia. the extraction method used maceration, the total phenol analysis method used the folinciocalteu method, and the antioxidant activity analysis used the dpph-method free radical scavenging assay. results and discussion: the germinated black rice extract of varieties krisna indonesian has a total phenol content of 2269 mg/g and antioxidant activity 71.05%. conclusion: germinated black rice extract of variety krisna indonesian contains total phenol and antioxidant activity so that it has the potential to have health benefits. keywords: germinated black rice, antioxidant, phenol, indonesia. correspondence to: sudana fatahillah pasaribu, dept. of nutrition sciences, postgraduate program, universitas sebelas maret, surakarta, indonesia. e-mail: sudanafatahillah@gmail.com 1. dept. of nutrition, postgraduate program, universitas sebelas maret, surakarta, indonesia. 2. dept. of nutrition, faculty of medicine,universitas sebelas maret, surakarta, indonesia. 3. dept. of animal science, faculty of agriculture, universitas sebelas maret, surakarta, indonesia. international journal of human and health sciences vol. 06 no. 01 january’22 page : 127-135 doi: http://dx.doi.org/10.31344/ijhhs.v6i1.388 introduction indonesia is an agricultural country where significant part of the population plays a role in  the crop and food sector1. this is in line with the bps research report 2018, in which indonesia is the third-largest rice producer in the world2. according to world agricultural production 2020, rice is a staple food ingredient for some people in the world and including indonesia, with a total rice consumption of 90%1,3,4. rice consists of various types, namely white, brown, red, purple, and black rice5. pigmented rice tends to contain a lot of nutrients and bioactive compounds, namely phenols, anthocyanins, fiber, amino acids,  tocopherols, and γ-oryzanols, therefore consuming they  will  have  health  benefits  because  they  are  antioxidants6. antioxidant compounds in food are generally called exogenous antioxidants7. exogenous antioxidants are needed by the body to prevent and reduce international journal of human and health sciences vol. 06 no. 01 january’22 128 oxidative stress in the body8. the antioxidant mechanism works, namely by giving one electron to a compound that has oxidant properties. antioxidant activity is the ability of components of a nutrient or bioactive compound to counteract oxidation reactions from free radicals which can be determined from the amount of antioxidants9. free radicals are compounds that have unpaired electrons which are reactive, unstable, and cause damage to important molecules and cells in the body. the body can also produce free radicals in the form of secondary oxygen from metabolism. the body can also balance the production of endogenous antioxidants, but if there is oxidative stress, its activity can decrease7. phenolic compounds are secondary metabolite bioactive compounds produced in shikimic acid and pentose phosphate through phenylpropanoid metabolism. phenolic compounds are antioxidants and have one or more hydroxyl groups attached to the benzene ring and have variations from simple molecules to complex polymers10. phenol compounds are divided into several subgroups, namely  phenolic  acids,  flavonoids,  tannins,  lignans, lignins, coumarins, and stilbenes11. these phytochemical compounds have many functions such as giving color and taste to food and  are  beneficial  for  health12. several studies reported phenol compounds and antioxidant activity  to  have  many  health  benefits  such  as  antidiabetic,  anti-inflammatory,  anti-cancer,  and  anti-hypertensive13–17. therefore, humans need antioxidants to prevent and treat disease. the human body does not have large amounts of antioxidant reserves, so it is in dire need of exogenous antioxidants. antioxidants based on the source consist of two, namely natural and synthetic antioxidants. natural antioxidants are antioxidant compounds that are sourced from fruits, vegetables, spices, and other plants18. meanwhile, synthetic  antioxidants  are  artificial  antioxidants  such as butylated hydroxytoluene (bht), propyl galat (pg), and butylated hydroxyanisole (bha). these synthetic antioxidants are carcinogenic, so it is feared that they can have side effects that are  harmful to health19. there are concerns about the side effects of synthetic antioxidants so that natural  antioxidants are an alternative to be developed in this study. plants that have antioxidant activity and phenol compounds are mostly found in grain plants20 one of the grains that have the potential to have antioxidant activity and high phenol content is the black rice krisna variety from sleman district, di yogyakarta, indonesia. according to research wanti and parnanto,21 black rice (oryza sativa l) contains components of phytochemical compounds that can act as high antioxidants compared to brown and white rice21. black rice can also be enhanced the content of bioactive compounds with process germination3. germination is a process of embryo growth that causes physiological changes in black rice after absorbing water. the germination process will change the value of phytochemical compounds and the nutritional content to be better22. this is because in germination an active enzymatic process occurs, thus affecting changes in bioactive  compounds23. therefore, germinated black rice extract variety of krisna has the potential to contain antioxidant activity and total phenol. however, currently, the research that examines the analysis on the germinated black rice extract of krisna variety has never been carried out. based on this study, the researchers aimed to analyze the antioxidant activity and total phenol content of the germinated black rice extract krisna variety in sleman district, di yogyakarta, indonesia. materials and methods research design the type of research was quantitative with laboratory experimental methods. preparation of germinated black rice, extraction of germinated black rice, phenol analysis, and antioxidant activity were carried out at the laboratory of the center for food and nutrition studies, gadjah mada university, yogyakarta, from march to may 2021. the rice samples used were local black rice varieties krisna obtained from sleman yogyakarta, indonesia. materials perforated trays, flannelette, filters, digital scales,  containers, cabinet dryer, disk mill machines, 60  mesh  filters,  rotary  evaporators,  filter  paper,  spatulas, measuring cups, micropipettes, orbital shakers, black rice spectrophotometers, water, germinated  black  rice  flour,  80%  ethanol,  3%  citric acid and distilled water. germination of black rice black rice was sorted and cleaned, then soaked black rice with water (1: 1 = water: rice) for 6 129 international journal of human and health sciences vol. 06 no. 01 january’22 hours at room temperature then drain. in the next stage, the black rice was sprinkled on a hollow container that has been placed in a wet flannel and  covered with a wet flannel cloth. every 12 hours,  flush with water for 48 hours. if the black rice has  germinated with a shoot length of 0.5-1 mm, then the germinated black rice can be dried in a cabinet dryer with a temperature of 50°c for 5 hours. then the germinated black rice was powdered with a disk mill and filtered using a 60 mesh filter3,24. germinated black rice extract the  germinated  black  rice  flour  weighed  100  g  and add 80% ethanol at a ratio of 1: 5. the solvent was acidified with 3% citric acid (ratio 85:15 (v /  v) then let stand for 1 x 24 hours, and the solution is stirred with an orbital shaker for 4 hours at a speed of 150 rpm. furthermore, the solution was centrifuged at a speed of 4000 rpm for 30 minutes. the supernatant was filtered with a paper filter and  rotary evaporator temperature of 50°c to obtain germinated black rice extract3,25,26. determination of antioxidant activity determination activity antioxidant extracts of germinated black rice used dpph-free radical scavenging assay27. 1. determination of the maximum wavelength of dpph by measuring 4.0 ml of 50 ppm dpph solution with a uv-vis spectrophotometer in the wavelength range (400-600 nm), so that the maximum wavelength was found. 2. the extracted sample was diluted to a concentration of 10 mg / ml using methanol which was put into a test tube. 3. reagent solution was added 1 ml of 2,2-diphenyl-1picrylhydrazyl (dpph) 200 µm. 4. the mixed solution was then incubated in a dark room for 30 minutes. 5. the solution was further diluted to 5 ml used methanol. make a blank solution (1 ml of dpph solution + 4 ml of ethanol). 6. then take the absorbance measurement with a wavelength of 515 nm using a spectrophotometer uv-vis. 7. the measurement of the percentage of free radical scavenger (% total antioxidant activity) was calculated used the equation: a0: absorbance standard a1: absorbance sample determination of total phenol levels phenol levels were determined using the folinciocalteu method, and the research of chatatikun et al. was referred28. it was observed weighed a sample of 50 µl of germinated black rice extract, dissolved in 50 µl of distilled water, and made with a concentration of 10,000 ppm. the solution was added with 50 µl of 10% folin and 50 µl of bicarbonate (60 g / l). the solutions were incubated for 60 minutes at room temperature. the absorbance was seen using a spectrophotometer at a wavelength of 730 nm. the absorbance obtained was recorded and then calculated using the phenol standard curve. the standard solution for the total phenol test used was phenolic acid 114 mg diluted with 1000 ml distilled water at a concentration so that the phenol solution used was 0.114 mg/ml. results data on percentage yield of germinated black rice extract dry powder of germinated black rice was macerated using 80% ethanol and 3% citric acid as solvents. maceration is done by soaking germinated black rice powder with solvent and allowed to stand for 24 hours. the obtained filtrate was concentrated  to produce a thick extract of germinated black rice with a dark purple color. the results of the thick germinated black rice extract were listed in table 1. table 1 shows that the percentage yield of germinated black rice extract was 9.94%, from the initial weight of 100g of simplicia. after becoming a thick extract, it was 9.94 g. table 1. percentage results of yield germinated black rice extract sample flour weight thick extract yield germinated black rice 100 g 9.94 g 9.94% data antioxidant activity analysis antioxidant activity of the germinated black rice extract was analyzed using the dpph-free radical scavenging assay parameters % method. table 2 shows that analysis of the highest germinated black rice extract was found in the second analysis, which was 71.11%, while the second analysis of international journal of human and health sciences vol. 06 no. 01 january’22 130 antioxidant activity was 71%. the results of the analysis antioxidant activity of the two germinated black rice extracts when averaged, results were 71.05%. then, the standard deviation value from the first and second analysis of antioxidant activity  was calculated, which was + 0.07. table 2. antioxidant activity of germinated black rice extract result antioxidant activity mean sd analysis 1 71.00% 71.05% + 0.07 analysis 2 71.11% data total phenol analysis total phenolic extract germinated black rice was analyzed by using the folin-ciocalteu method by making a standard phenol curve to produce a linear regression equation. total phenolic content was calculate using a regression linear presented in figure 1. then the results of these equations are used to calculate the total phenolic content in the germinated black rice extract, by entering the absorbance of the extracted sample obtained on the spectrophotometer as the y value. the results of analysis total phenol are given in table 3. table 3 shows that the analysis of the highest germinated black rice extract was found in the first analysis,  which was 227.4 mg/g, while the second analysis of total phenol was 226.5 mg/g. the results of the analysis of the total phenol of the two germinated black rice extracts when averaged, the results were 226.9 mg/g. next, the standard deviation value from the first and second analysis of antioxidant  activity was calculated, which was + 0.63. table 3. total phenol germinated black rice extract result total phenol mean sd analysis 1 227.4 mg/g 2269 mg/g + 0.63 analysis 2 226.5 mg/g discussion and conclusion the germinated black rice was used krisna from local varieties, sleman, d.i.yogyakarta, indonesia. the germination process is carried out to increase the bioactive content of black rice. cho et al.,29 found pigmented rice after germination process would changed in bioactive chemical compound so that it will affect the addition of new bioactive  chemical compounds, increased of bioactive chemical compounds, and nutrients in germinating rice. after the black rice was germinated, the drying process was carried out to reduce the moisture content in the germinated black rice to prevent  damage  and  rot  which  is  influenced  by  enzymatic reactions, fungi, and bacteria30,31. the germinated black rice flour used was 100g,  then extracted using the maceration method. maceration method was an extraction method that used room temperature and recommended for this study. in addition, hot extraction methods will have an impact on decreasing the total phenol content and antioxidant activity in germinated black rice. in general, maceration extraction uses a solvent. the function of solvent fluids was to push  out bioactive compounds from the cell through the entry of solvents into the cell walls and into the cell cavities in plants that have bioactive substances30. in another study dhianawaty et al.,32 observed that that maceration methods was applied in isolating total phenolic and antioxidant activity. in addition, maceration extraction yields high yield amounts33–36. the germinated black rice flour was then macerated  with 80% ethanol and 3% citric acid as a solvent (85:15). in a similar study by kristiana et al.,37found ethanol and citric acid solvents more effective than  others to binding phenol bioactive compounds, in addition mold cannot live in ethanol. ethanol solvent compared to aquadesh has a high effect on  binding phenolic compounds25. the thick purple extract results were listed in table 1 showing the amount of thick extract was 9.94 g and the yield of germinated black rice extract was 9.94%. the thick extract obtained in table 1 has a dark purple color with a yield of 9.94%. a recent study stated the greater yield produced would more efficient treatment applied without compromising  other properties38. the yield of this study was higher than that of maulida and guntari39. it was found that the average yield value of black rice extract  was  6.7%.  the  difference  in  results  is  presumably because the filter size used was 20/40  mesh  so  that  it  affects  the  size  of  the  simplicia  particles  filtered. ardyanti  et  al.,40 reported that different  of  yield  influenced  by  particle  size  of  simplicia and maceration time so that our research findings are in line with antari’s study stated the  particle  of  simplicia  with  60  mesh  filtering  had  the highest average yield value compared to the simplicia particles filtering 40 mesh. 131 international journal of human and health sciences vol. 06 no. 01 january’22 total phenolic the compounds are the largest group of distributed secondary metabolites that have an aromatic ring20. phenolic compounds can be found in both edible and non-edible plants. phenolic bioactive components are widely found in cell walls and plant vacuoles which have a distinctive aroma and function to prevent decay20,42. the analysis of the total phenolic content of germinated black rice extract was shown in table 2. these results were obtained using the folinciocalteu method. this method was often used as a standard in assessing total phenolic content because it was a fast and simple method. the absorbance of that suspension was spectrophotometrically measured at 730nm wavelength and then total phenolic was calculated using a regression linear y = 8.137x + 0042, with a correlation value of r2= 0.997. the linear calibration curve showed in figure 1. figure 1: the linear calibration curve for phenol standards based on the results of the calculation of the total phenolic content in the germinated black rice extract, it was 226.9 mg/g. phenolic compounds are bioactive substances that have antioxidant properties, especially through their redox properties, which allow phenolic compounds to act as reducing agents, hydrogen donors, and have biological activity that can help maintain the body’s metabolic system43. total phenolic of germinated black rice extract in our study has potential to beneficial effects as  antioxidant. antioxidant activity the activity of phenolic compounds has different  structures such as oh bonds, dissociation energy, delocalization of phenol radical resonances, and steric inhibitions derived from hydrogen substitution in an aromatic ring44. the phenolic compounds as antioxidants through their ability to scavenge free radicals. the higher the percentage of synthetic free radical inhibition, the greater the antioxidant potential45. dpph is a method of analyzing antioxidant activity which is widely used in plants. dpph oxidant activity analysis method is to use stable free radicals on dpph which have unpaired electrons on the nitrogen atomic bridge46. the solvent used in the dpph analysis is methanol or methanol buffer, each of which is appropriate as an analysis  of the antioxidant activity of extracts that are less polar or nonpolar. dpph assay is considered a simple, easy, fast and sensitive method to applied therefore it requires a small sample size. it is easy to apply because the dpph radical compound used is relatively stable compared to other methods47. the working principle of the dpph method is through a donation of hydrogen atoms (h +) from the substances tested on the dpph radicals to become non-radical compounds of diphenyl picryl hydrazine which will be shown by color changes. dpph will react to the reducing agent according to the electrons so that it becomes paired, and the solution loses color stoichiometry depending on the number of electrons taken47,48. the extract contains antioxidant activity which can be seen through its ability to reduce the purple color of the dpph radical so that it becomes a yellow color of the dpph-h compound which can be detected at 515-517 nm49. the results of our study reported that germinated black rice extract has ability to scavenging free radicals showed in table 3. the data show that the inhibitory ability of phytochemical compounds in germinated black rice extract was 71.05% + 0.07 and it is caused germinated blck rice extract has phenolic compounds. phenolic compounds have been shown to provide hydrogen atoms to purple dpph free radicals to form yellow dpph compounds. the presence of antioxidant activity in germinated black rice extract shows potential as a source of antioxidants. the balance of oxidants and antioxidants is very important because it is related to body health. antioxidants will protect the body’s cells against oxidative damage and inhibit the formation of international journal of human and health sciences vol. 06 no. 01 january’22 132 oxidative products. the imbalance resulting from high oxidants compared to antioxidants has an impact on the production of reactive oxygen species (ros) and excess oxidative stress cause several degenerative diseases50,51. several studies have also stated that antioxidants have many health benefits such as anti-diabetes, anti-obesity,  anti-aging  anti-inflammatory,  anti-hypertension,  prevention of cardiovascular disease, and alzheimer’s52–56. conclusion based on the results and discussion of this study, it can be concluded that the germinated black rice extract of the indonesian krisna variety has a total phenol content of 226.9 mg/g and an antioxidant activity value of 71.05%. germinated black rice extract also has the potential to have health benefits such as anti-diabetes, anti-dyslipidemia,  anti-obesity, and other health benefits due  to  its  phenolic content and antioxidant activity. recommendations it is necessary to carry out further research related to the effect of giving germinated black rice extract  on various degenerative diseases. acknowledgement: the authors gratefully acknowledge  all  staff  at  the  central  laboratory  of food and nutrition studies, gadjah mada university yogyakarta, indonesia who help in this study, the germinated black rice, extraction of germinated black rice, and analysis of bioactive compounds. conflict of interest: the authors declare there is no conflict in the publication of this article. ethical approval issue: this research has not used human and animal subjects funding statement: none declared. authors’ contribution: sudana fatahillah pasaribu conceived and planned the experiments, carried out the experiment, wrote the manuscripted. both budiyanti wiboworini and lilik retna kartikasari authors contributed to the final version  of the manuscript. all authors discussed the results and contributed to the final manuscript. data gathering and idea owner of this study: sudana fatahillah pasaribu study design: sudana fatahillah pasaribu writing and submission of manuscript: sudana fatahillah pasaribu, budiyanti wiboworini, lilik retna kartikasari. editing and approval of final draft: sudana fatahillah pasaribu, budiyanti wiboworini, lilik retna kartikasari. 133 international journal of human and health sciences vol. 06 no. 01 january’22 references 1. setyawati f, juliprijanto w and jalunggono g. analisis pengaruh kurs, produksi beras dan konsumsi beras terhadap impor beras di indonesia tahun 1999-2017. din dir j econ 2019;1(4):383– 398. 2. badan pengkajian dan penerapan teknologi. ringkasan eksekutif luas panen dan produksi beras di indonesia 2018. jakarta: bps press, 2018: 1-25. 3. ekowati n and purwestri y. analisis kandungan gamma aminobutyric acid (gaba), fenol total dan aktivitas  antioksidan  “beras  kecambah”  kultivar  lokal (oryza sativa l.) di yogyakarta. agicola 2016;6(2):117–127. 4. world agricultural production. world rice production 2020/2021; 2020. accesed 8 april 2021. availabel online at: http://www.worldagriculturalproduction. com/crops/rice.aspx/ 5. mbanjo egn, tobias k, huw j, nelzo e, christopher b, lesley ab and ns. the genetic basis and nutritional benefits of pigmented rice grain. front  genet 2020;11(229):1–18. 6. ito vc and lacerda l. black rice (oryza sativa l): a review of its historical aspects, chemical composition, nutritional and functional properties, and applications and processing technologies. food chem 2019;(301):1–13. 7. palupi nsb and slamet kr. aktivitas antioksidan dan antiproliferasi sel kanker kolon widr dari makaroni berbasis beras hitam dan kacang berpigmen. ipb university, 2021. 8.   mareta  ca.  efektifitas  pegagan  (centella  asiatica)  sebagai antioksidan. j med hutama 2020;2(1):390– 394. 9. ramadhan h, baidah , lestari np and yuliana ka. aktivitas antioksidan ekstrak etanol 96% daun, buah dan kulit terap (artocarpus odorratissimus) menggunakan metode cuprac. farmasains j ilm ilmu kefarmasian 2020;7(1):7–12. 10. singh b, singh jp, kaur and singh n. phenolic composition and antioxidant potential of gain legume seeds: a review. food res int 2017;(101):1–16. 11. kumar n and goel n. phenolic acids: natural versatile molecules with promising therapeutic applications. biotechnol reports 2019;1(24):1–10. 12. diniyah n and lee s. komposisi senyawa fenol dan potensi antioksidan dari kacang-kacangan. j agroteknologi 2020;14(1):91–102. 13. wei q, yishu z, bingzhi c, baoguix, ting f, sadhana r and jiang y. assessment of antioxidant and antidiabetic properties of agaricus blazei murill extracts. food sci nutr 2020;8(1):332–339. 14. tungmunnithum d, areeya t, apinan p and yangsabai a. flavonoids and other phenolic compounds from medicinal plants for pharmaceutical and medical aspects: an overview. medicines 2018;5(3):1–16. 15. luo y, bin p, weiqian w, xiaofei t and wu z. antioxidant and anti-diabetic activities of polysaccharides from guava leaves. molecules 2019;24(7):1–14. 16. shahidi f and yeo j. bioactivities of phenolics by focusing on suppression of chronic diseases: a review. int j mol sci 2018;19(1573):1–16. 17. al-ishaq rk, abotaleb m, kubatka, kajo, and büsselberg d. flavonoids and their anti-diabetic effects: cellular mechanisms and effects to improve  blood sugar levels. biomolecules 2019;9(430):1–35. 18. tahir m, asriani s and rahim y. potensi aktivitas antioksidan ekstrak etanol dan fraksi n-heksan buah jeruk pamelo (citrus maxima (burm) merr) asal kabupaten pangkep. j2urnal fitofarmaka indones 2020;7(2):18–22. 19. katrin ba. aktivitas antioksidan ekstrak, fraksi dan golongan senyawa kimia daun premna oblongata miq. pharm sci res 2015;2(1):21–31. 20. diniyah n and lee sh. komposisi senyawa fenol dan potensi antioksidan dari kacang-kacangan. j agroteknologi 2020;14(1):91–102. 21. wanti s, andriani ma and parnanto nhr. pengaruh berbagai jenis beras terhadap aktivitas antioksidan pada angkak oleh monascus purpureus. asian j nat prod biochem 2015;13(1):1–5. 22. aminah s and wikanastri h. karakteristik kimia tepung kecambah serealia dan kacang-kacangan dengan variasi blanching. pros semin nas int 2012;1(1):209-217 23. pertiwi sf and aminah s. aktivitas antioksidan, karakteristik kimia, dan sifat organoleptik susu kecambah kedelai hitam berdasarkan variasi waktu perkecambahan. j pangan dan gizi 2014;4(2):1–8. 24. nurhidajah n and nurrahman n. efek hipoglikemik kecambah beras merah pada tikus yang diinduksi stzna dengan parameter kadar insulin, indeks homair dan homa β. agritech 2017;36(4):433–439.  25. putri d. ekstraksi antosianin beras hitam (oryza sativa l.) dengan berbagai pelarut dan evaluasi international journal of human and health sciences vol. 06 no. 01 january’22 134 stabilitasnya pada suhu tinggi. universitas gadjah mada, 2015. 26. chaiyasut c, sivamaruthi bs, pengkumsri n, keapai w, kesika p, saelee m, tojing p, sirilun s, chaiyasut k, peerajan s and lailerd n. germinated thai black rice extract protects experimental diabetic rats from oxidative stress and other diabetes-related consequences. pharmaceuticals 2017;10(1):1–16. 27.  adaramola b and onigbinde a. effect of extraction  solvent  on  phenolic  content,  flavonoid  content  and  antioxidant capacity of cove bud. iosr j pharm biol sci 2016;11(3):33–38. 28. chatatikun m and chiabchalard a. phytochemical screening and free radical scavenging activities of orange baby carrot and carrot (daucus carota linn.) root crude extracts. j chem pharm res 2013;5(4):97– 102. 29. cho dw and lim st. germinated brown rice and its bio-functional compounds. food chem 2016;196:259–2571. 30. wahyulianingsih hs and malik a. penetapan kadar flavonoid total ekstrak daun cengkeh (syzygium aromaticum(l.) merr dan perry. j fitofarmaka indones 2016;3(2):188–193. 31. yulianingtyas a and kusmartono b. optimasi volume pelarut  dan  waktu  maserasi  pengambilan  flavonoid  daun belimbing wuluh (averrhoa bilimbi l.). j tek kim 2016;10(2):61–67. 32. dhianawaty d. kandungan total polifenol dan aktivitas antioksidan dari ekstrak metanol akar imperata cylindrica (l) beauv(alang-alang). maj kedokt bandung 2015;47(1):60–64. 33. suhendra s, corry pi, wayan rw and wiadnyani aais. pengaruh konsentrasi etanol terhadap aktivitas antioksidan ekstrak rimpang ilalang (imperata cylindrica (l) beauv.) pada ekstraksi menggunakan gelombang ultrasonik. j ilmu dan teknol pangan 2019;8(1):27–35. 34. hianawaty d. kandungan total polifenol dan aktivitas antioksidan dari ekstrak metanol akar imperata cylindrica (l) beauv. (alang-alang). maj kedokt bandung 2015;47(1):60–64. 35. mukhriani m. ekstraksi, pemisahan senyawa, dan identifikasi  senyawa aktif.  j  kesehat  2014;7:361– 367. 36. hasnaeni h and wisdawati w. pengaruh metode ekstraksi terhadap rendemen dan kadar fenolik ekstrak tanaman kayu beta-beta (lunasia amara blanco). galen j pharm 2019;5(2):175–182. 37. kristiana hd, ariviani s and khasanah l. ekstraksi pigmen antosianin buah senggani (melastoma malabathricum auct. non linn) dengan variasi jenis pelarut. j teknosains pangan 2012;1(1):105–109. 38. dewatisari wf and rumiyanti lr. rendemen dan skrining fitokimia pada ekstrak daun sanseviera sp. j penelit pertan terap 2017;17(3):197–202. 39. maulida r and guantarti . pengaruh ukuran partikel beras hitam (oryza sativa l.). j pharm 2015;5(1):9– 16. 40. ardyanti nknt, suhendra l and puta gg. pengaruh ukuran partikel dan lama maserasi terhadap karakteristik ekstrak virgin coconut oil wortel (daucus carota l.) sebagai pewarna alami. j rekayasa dan manaj agroindustri 2020;8(3):423– 434. 41. antari nmro, wartini nm and mulyani s. pengaruh ukuran partikel dan lama ekstraksi terhadap karakteristik ekstrak warna alami buah pandan (pandanus tectorius). j rekayasa dan manaj agroindustri 2015;3(4):30–40. 42. dhurhania ce and novianto a. uji kandungan fenolik total dan pengaruhnya terhadap aktivitas antioksidan dari berbagai bentuk sediaan sarang semut (myrmecodia pendens). j farm dan ilmu kefarmasian indones 2018;5(2):62–68. 43. adawiah ds and muawanah a. aktivitas antioksidan dan kandungan komponen bioaktif sari buah namnam. j kim val j penelit dan pengemb ilmi kim 2015;1(2):130–136. 44. hadad nd and patihul h. review: penentuan kandungan senyawa antioksidan dalam rosella (hibiscus  sabdariffa  l.).  farmaka2  2019;17(1):17– 23. 45. sedjati s, suryono s, adi s, endang s and ridlo a. aktivitas antioksidan dan kandungan senyawa fenolik makroalga coklat sargassum sp. urnal kelaut trop 2017;20(2):124–130. 46. widyawati ps, sutedja am, suseno tip, monika p, saputrajaya w and liguori c. pengaruh perbedaan warna pigmen beras organik terhadap aktivitas antioksidan. agit j teknol pertan 2014;34(4):399– 406. 47.  rahmawati r, muflihunna a and sarif lm. analisis  aktivitas antioksidan produk sirup buah mengkudu (morinda citrifolia l.) dengan metode dpph. j fitofarmaka indones 2015;2(2):97–101. 135 international journal of human and health sciences vol. 06 no. 01 january’22 48.  azizah z, zulharmita z  and zulfian e. uji aktivitas  antioksidan dan penetapan kadar vitamin c ekstrak buah naga merah keunguan (hylocereus lemairei (hook.)britton & rose) secara spektrofotometri uvvis. j farm higea 2017;9(1):41–47. 49. anokwuru cp, esiaba i, ajibaye o, and adesuyi ao. polyphenolic content and antioxidant activity of  hibiscus  sabdariffa  calyx.  res  j  med  plant  2011;5(5):557–566. 50. situmorang n and zulham z. malondialdehyde (mda)(zat oksidan yang mempercepat proses penuaan). j keperawatan dan fisioter 2020;2(2):117– 123. 51. berawi bkn and theodora a. efek aktivitas fisik pada proses pembentukan radikal bebas sebagai faktor risiko aterosklerosis. j major 2017;6(2):86– 91. 52. ali am, gabbar ma, abdel-twab sm, fahmy em, ebaidh, alhazza im and ahmed om. antidiabetic potency,  antioxidant  effects,  and  mode  of  actions  of citrus reticulata fruit peel hydroethanolic extract, hesperidin, and quercetin in nicotinamide/ streptozotocin-induced wistar diabetic rats. oxid med cell longev 2020;1–21. 53. wilson dw, paul n, harpal sb, keith g, ram s, fabien dm, rie h and toru t. the role of food antioxidants,  benefits  of  functional  foods,  and  influence of feeding habits on the health of the older  person: an overview. antioxidants 2017;6(4):1-20. 54. grosso g, urszula s, agnieszka m, magdalena k, denes s, martin b and andrzej p. dietary polyphenol intake and risk of hypertension in the polish arm of the hapiee study. eur j nutr 2018;57(4):1535–1544. 55. vernarelli ja and lambert jd. flavonoid intake is inversely associated with obesity and c-reactive protein, a marker for inflammation, in us adults. nutr  diabetes 2017;7(5):276–276. 56. de-andrade trb, diniz tc, costa ptc, de oliveira júnior rg, gama e silva m, de lavor ém, fernandes awc, de oliveira ap, de almeida rfpr, da silva aam and cavalcante tc. flavonoids as therapeutic agents in alzheimer’s and parkinson’s diseases: a systematic review of preclinical evidences. oxid med cell longev 2018;1–21. 89 international journal of human and health sciences vol. 06 no. 01 january’22 international journal of human and health sciences vol. 06 no. 01 january’22 page : 3-7 doi: http://dx.doi original article the relation between hba1c variability and diabetic autonomic neuropathy among type-2 diabetic patients md. azad hossain1, mukul kumar sarkar2, imtiaj mahbub3, s m shahinul islam1 abstract: background: diabetic autonomic neuropathy (dan) is the most neglected major and widespread microvascular complication of type-2 diabetes mellitus, involving multiple body organs. dan is a subtype of diabetic peripheral neuropathy. objective: to investigate the relationship between the variability of hba1c and diabetic autonomic neuropathy in type-2 diabetes patients. materials and methods: this study recruited a total of 150 type-2 diabetic patients to screen for diabetic autonomic neuropathy and estimated quarterly levels of hba1c were performed within the year before enrollment. with a noninvasive procedure, dan was validated by careful history taking, anthropometric assessment, clinical manifestations and neurological assessment. results: out of 150 type2 diabetic patients, recruited randomly, where 81 were female and 69 were male. among all patients 29 (19.33%) had been screened positive for dan which showed higher hba1c than non-dan patients. different autonomic neuropathic dysfunction among total diabetic patients were also studies and found that the highest prevalence of sexual dysfunction among all autonomic dysfunction prevalence which is 16.66% whereas the lowest prevalence was postural hypotension that is 6.66%. the second higher prevalence is urinary incontinence (10.66%). abnormal sweating (9.33%) and nocturnal diarrheas (7.33%) are in third and fourth position respectively. no significant (p>0.05) differences were found in the case of bmi, sex, systolic, and diastolic blood pressure between dan and non-dan. data shows  a  major  (p<0.05)  risk  factor  for  dan  has  also  been  the  prolonged period of diabetes and older age. conclusion: the study indicates that the increased level of hba1c in type-2 diabetic patients is closely correlated with dan and may be considered a potent predictor of dan in the recruited patients. keywords: diabetic autonomic neuropathy, diabetic peripheral neuropathy, hba1c, diabetes mellitus, type-2 diabetes. introduction: the most severe and overlooked complication of diabetic peripheral neuropathy that induces parasympathetic and/or sympathetic nerve damage in people with diabetes, excluding other causes of neuropathy, is diabetic autonomic neuropathy1. a leading cause of autonomic neuropathy is diabetes. its prevalence depends on the form of diagnosis, patient cohort features, and the type of diabetes evaluated2. consistent hyperglycemia and hypoglycemia cause oxidative stress in nerves, ultimately resulting in autonomic neuropathy3. 1. plant biotechnology and genetic engineering lab., institute of biological sciences, university of rajshahi, rajshahi-6205, bangladesh. 2. department of neurology, rajshahi medical college, rajshahi-6100, bangladesh. 3. department of endocrinology, sheikh hasina national institute of burn and plastic surgery, dhaka-1000, bangladesh. correspondence to: s m shahinul islam, plant biotechnology and genetic engineering lab., institute of biological sciences, university of rajshahi, rajshahi-6205, bangladesh. email: shahinul68@gmail.com international journal of human and health sciences vol. 06 no. 01 january’22 page : 89-95 doi: http://dx.doi.org/10.31344/ijhhs.v6i1.382 international journal of human and health sciences vol. 06 no. 01 january’22 90 as a result of damage to the sensory, autonomic, and motor nerves, diabetic peripheral neuropathy develops and may have different effects and deficits. somatic and autonomic neuropathy manifestations are the most common, and early diagnosis of these subtypes is recommended4. globally, diabetes mellitus is a massive health problem5. the worldwide prevalence of diabetes was 9.3%, according to the international diabetic federation, which will be raised 10.9% in 2045 (between 20-79 years)6. this immense pressure is related to complications7. 4.2 million peoples have died from complications related to diabetes6. chronic hyperglycemia as calculated by hba1c is a known risk factor for diabetes-related microvascular disease and is used to evaluate and guide clinical care of people with diabetes8-9. glycosylated hemoglobin (hba1c) serves as a long-term diabetes regulation index and hba1c is considered to be good glycemic control by 7.0% of patients10. the sympathetic, parasympathetic, and enteric nerves are affected in the autonomic disease. myelinated and non-myelinated nerve damage has been reported11. they also reported that autonomic neuropathies have been found irreversible by several experts. the initial symptoms linked to diabetes neuropathy are traceable to john rollo’s writings, and in pavy’s papers, the sweating symptom was described12. in type-2 diabetes cases, subclinical autonomic dysfunction can develop within a year of diagnosis, but clinical signs of autonomic neuropathy occur long after diabetes starts. in symptomatic autonomic neuropathy, the symptoms and signs differ greatly as they affect every organ of the body. the symptoms and signs of dan differ significantly and depend on the affected organ, such as postural hypotension (cardiac), nocturnal diarrhea (gastrointestinal), abnormal sweating (skin), urinary incontinence and sexual dysfunction (genitourinary system), etc.13-14. dan is normally intermittent and can survive without deterioration for several years, but full remission is rare15. for patients with type-2 diabetes, aggressive blood glucose regulation is important, as it can avoid microvascular and macrovascular complications16. in type-2 diabetes, glycemic control can help to delay the progression of diabetic peripheral neuropathy17. to improve the manifestation, decrease sequence and improve personal satisfaction american diabetes association rule suggested early acknowledgment and treatment of dan18-19. a survey in bangladesh estimated that dpn prevalence was 19.7% in type-2 diabetic patients20 and also 24% dpn (sensory and motor) neuropathy in bangladesh21, but there is no dan study in bangladesh as far as our knowledge is concerned. the main objectives of this research were to consider the relationship amid the variability of hba1c and diabetic autonomic neuropathy for the early assessment of the risk factors of dan among diabetic patients and control of hba1c and appropriate preventive measures. material and methods: this study was performed in the outpatient department of the rajshahi diabetic association general hospital, rajshahi, bangladesh, from july 2017 to december 2020. a total of 150 patients with type-2 diabetes were randomly included with or without diabetic autonomic neuropathy and met the inclusion requirements (age>25,  both male and female, patients meeting the who type-2 diabetes mellitus criteria) and exclusion criteria (other known cause of autonomic neuropathy, taking any drugs to cause autonomic neuropathy, other types of diabetics rather than dm-2). this study was done mainly depend upon the careful history taking, sign symptom and simple bedside non-invasive examinations and investigations. data were collected from the outpatient department by a self-prescribed data collection sheet containing a questionnaire to assess the autonomic neuropathy symptoms from the patient’s diabetic record book containing personal demographic data, investigation records, treatment, and other diseases, through careful personal interview of patients and their spouses, anthropometric measurement, investigation, examination with the written consent of all patients. the hba1c level was determined once every 3 months using ionic exchange hplc (ie-hplc) in the d-10 hemoglobin analysis system (bio-rad). postural hypotension was confirmed by measuring blood pressure in sitting and laying the patient. nocturnal diarrhea, sexual dysfunction, urinary incontinence, abnormal sweating was depended upon the careful history taking examination and investigation records on which outdoor patient primary treatment is started. diabetic peripheral neuropathy (dpn) was assessed by neuropathy symptom score (nss) and neuropathy disability score (nds). at least one autonomic symptom with dpn confirms the diagnosis of dan. all of the data are articulated as mean±sd (standard deviation) of the mean. data have been analyzed with ibm spss software (version 20) and compared by student t-test. p-value <0.05  was  considered  statistically significant. 91 international journal of human and health sciences vol. 06 no. 01 january’22 as a result of damage to the sensory, autonomic, and motor nerves, diabetic peripheral neuropathy develops and may have different effects and deficits. somatic and autonomic neuropathy manifestations are the most common, and early diagnosis of these subtypes is recommended4. globally, diabetes mellitus is a massive health problem5. the worldwide prevalence of diabetes was 9.3%, according to the international diabetic federation, which will be raised 10.9% in 2045 (between 20-79 years)6. this immense pressure is related to complications7. 4.2 million peoples have died from complications related to diabetes6. chronic hyperglycemia as calculated by hba1c is a known risk factor for diabetes-related microvascular disease and is used to evaluate and guide clinical care of people with diabetes8-9. glycosylated hemoglobin (hba1c) serves as a long-term diabetes regulation index and hba1c is considered to be good glycemic control by 7.0% of patients10. the sympathetic, parasympathetic, and enteric nerves are affected in the autonomic disease. myelinated and non-myelinated nerve damage has been reported11. they also reported that autonomic neuropathies have been found irreversible by several experts. the initial symptoms linked to diabetes neuropathy are traceable to john rollo’s writings, and in pavy’s papers, the sweating symptom was described12. in type-2 diabetes cases, subclinical autonomic dysfunction can develop within a year of diagnosis, but clinical signs of autonomic neuropathy occur long after diabetes starts. in symptomatic autonomic neuropathy, the symptoms and signs differ greatly as they affect every organ of the body. the symptoms and signs of dan differ significantly and depend on the affected organ, such as postural hypotension (cardiac), nocturnal diarrhea (gastrointestinal), abnormal sweating (skin), urinary incontinence and sexual dysfunction (genitourinary system), etc.13-14. dan is normally intermittent and can survive without deterioration for several years, but full remission is rare15. for patients with type-2 diabetes, aggressive blood glucose regulation is important, as it can avoid microvascular and macrovascular complications16. in type-2 diabetes, glycemic control can help to delay the progression of diabetic peripheral neuropathy17. to improve the manifestation, decrease sequence and improve personal satisfaction american diabetes association rule suggested early acknowledgment and treatment of dan18-19. a survey in bangladesh estimated that dpn prevalence was 19.7% in type-2 diabetic patients20 and also 24% dpn (sensory and motor) neuropathy in bangladesh21, but there is no dan study in bangladesh as far as our knowledge is concerned. the main objectives of this research were to consider the relationship amid the variability of hba1c and diabetic autonomic neuropathy for the early assessment of the risk factors of dan among diabetic patients and control of hba1c and appropriate preventive measures. material and methods: this study was performed in the outpatient department of the rajshahi diabetic association general hospital, rajshahi, bangladesh, from july 2017 to december 2020. a total of 150 patients with type-2 diabetes were randomly included with or without diabetic autonomic neuropathy and met the inclusion requirements (age>25,  both male and female, patients meeting the who type-2 diabetes mellitus criteria) and exclusion criteria (other known cause of autonomic neuropathy, taking any drugs to cause autonomic neuropathy, other types of diabetics rather than dm-2). this study was done mainly depend upon the careful history taking, sign symptom and simple bedside non-invasive examinations and investigations. data were collected from the outpatient department by a self-prescribed data collection sheet containing a questionnaire to assess the autonomic neuropathy symptoms from the patient’s diabetic record book containing personal demographic data, investigation records, treatment, and other diseases, through careful personal interview of patients and their spouses, anthropometric measurement, investigation, examination with the written consent of all patients. the hba1c level was determined once every 3 months using ionic exchange hplc (ie-hplc) in the d-10 hemoglobin analysis system (bio-rad). postural hypotension was confirmed by measuring blood pressure in sitting and laying the patient. nocturnal diarrhea, sexual dysfunction, urinary incontinence, abnormal sweating was depended upon the careful history taking examination and investigation records on which outdoor patient primary treatment is started. diabetic peripheral neuropathy (dpn) was assessed by neuropathy symptom score (nss) and neuropathy disability score (nds). at least one autonomic symptom with dpn confirms the diagnosis of dan. all of the data are articulated as mean±sd (standard deviation) of the mean. data have been analyzed with ibm spss software (version 20) and compared by student t-test. p-value <0.05  was  considered  statistically significant. results: the clinical parameters of all participants are summarized in table 1. out of 150 type-2 diabetic patients, recruited randomly, where 81 were female and 69 were male. among all patients 29 (19.33%) had been screened positive for dan. out of 29 dan patients, 17 patients were male and 12 patients were female. however, when compared to the without dan patient, dan patients presented significantly (p<0.05) higher age 55.00±5.57 years, higher diabetic duration 9.79±5.78, higher hba1c 11.75±2.21 level than non-dan patients where mean age was 50.42±8.96 years, mean duration of diabetes 5.94±3.72 and mean hba1c 9.72±1.89 has been shown. in our study, no significant (p>0.05)  deferent was found in the case of bmi, sex, systolic, and diastolic blood pressure between dan and nondan. data shows the prevalence of this investigation of diabetic autonomic neuropathy is 19.33% (table 1). [table 1: statement on autonomic neuropathy of type-2 diabetes (n = 150) parameters age body mass index blood pressure (systolic) blood pressure (diastolic) duration of diabetes hba1c level total (male, female) diabetic autonomic neuropathy 55.00 ± 5.57 26.14 ± 3.91 128.42 ± 14.78 76.87 ± 8.12 9.79 ± 5.78 11.75 ± 2.21 29 (19.33%) (m-17, f-12) without diabetic autonomic neuropathy 50.42 ± 8.96 25.72 ± 2.83 123.74 ± 12.17 77.14 ± 13.61 5.94 ± 3.72 9.72 ± 1.89 121 (80.66%) (m-52, f-69) p-value 0.000 0.134 0.104 0.756 0.000 0.000 hba1c = glycosylated hemoglobin, m = male, f = female. figure 1. frequency of impaired autonomic neuropathic signs in patients with dan according to sex (among 17 males, and 12 females). 5 7 7 14 8 5 4 9 11 6 0 2 4 6 8 10 12 14 16 postural hypotention nocturnal diarrhea urinary incontinance sexual dysfunction abnormal sweating male female international journal of human and health sciences vol. 06 no. 01 january’22 92 the most frequently observed symptoms were sexual dysfunction in the case of males while urinary incontinence was the most frequent one in females and the number was 14 and 9 respectively. the second most frequent symptom in males was abnormal sweating. the signs like postural hypotension, nocturnal diarrhea, and urinary incontinence were observed in 5, 7, 7 males in each case among the total number of male patients. on the other hand, the least frequent symptom with dan was nocturnal diarrhea in the case of females (figure 1). figure 2. prevalence distribution of different autonomic neuropathic dysfunction among total diabetic patients. figure 2 shows the highest prevalence of sexual dysfunction among all autonomic dysfunction prevalence which is 16.66% whereas the lowest prevalence was postural hypotension that is 6.66%. the second higher prevalence is urinary incontinence (10.66%). abnormal sweating (9.33%) and nocturnal diarrheas (7.33%) are in third and fourth position respectively. discussion: the present study explored the relationship of hba1c with dan in type-2 diabetic patients in the present study. the strength of the analysis is that an important and independent contributor to dan was found to be the increased variability of hba1c. in our study, the mean age of the dan patients was 55.00±5.57 years, the mean duration of diabetes of dan patients were 9.79±5.78 years and mean hba1c level 11.75±2.21 significantly higher than mean age 50.42±8.96, mean duration 5.94±3.72 and mean hba1c level 9.72±1.89 of non-dan patients. these is important and indicating that increasing age, prolong duration of diabetes and higher hba1c level raise the risk of dan compare to non-dan patients. according to this study it means that the mean age, mean duration of diabetes and mean hba1c level of dan participants is more than the mean age, mean duration of diabetes and mean level of hba1c of dpn (diabetic sensory and motor neuropathy)21. that’s means diabetic sensory and motor neuropathy ultimately progress to autonomic neuropathy with increasing age, duration of diabetes and hba1c level. according to thekkur et al.22, older age has an independent impact on autonomic neuropathy and diabetes duration also has a positive correlation with autonomic neuropathy screening. valensi et al.23 and kempler et al.24 also demonstrate that the continuation of the course of the disease phase and its occurrence increases in the progression and degree of dan in direct proportion to the duration of the disease. dimitropoulos et al.1 reported dan prevalence in type-2 diabetes range from 20% to 73%, which is consistent with the present study. another community-based survey from a diabetic center in india recorded that dan prevalence among diabetic patients is 10.6 %, as reported by thekkur et al.22, which is significantly lower than the current study that is 19.33%. this indicates dan prevalence of outpatients is more than community-based diabetes patients. ziegler et al.25 reported the same statement. this difference may also due to our study were among only type-2 diabetic patients but indian studies included all types. the prevalence of dan dependent on the type of diabetes, cohort and diagnostic method26. signs of diabetic autonomic neuropathy (dan) are found in 3.5-6% of patients at the onset of the disease, and in 100% of patients with prolonged 6.66% 7.33% 10.66% 16.66% 9.33% postural hypotention nocturnal diarrhea urinary incontinence sexual dysfunction abnormal sweating 93 international journal of human and health sciences vol. 06 no. 01 january’22 the most frequently observed symptoms were sexual dysfunction in the case of males while urinary incontinence was the most frequent one in females and the number was 14 and 9 respectively. the second most frequent symptom in males was abnormal sweating. the signs like postural hypotension, nocturnal diarrhea, and urinary incontinence were observed in 5, 7, 7 males in each case among the total number of male patients. on the other hand, the least frequent symptom with dan was nocturnal diarrhea in the case of females (figure 1). figure 2. prevalence distribution of different autonomic neuropathic dysfunction among total diabetic patients. figure 2 shows the highest prevalence of sexual dysfunction among all autonomic dysfunction prevalence which is 16.66% whereas the lowest prevalence was postural hypotension that is 6.66%. the second higher prevalence is urinary incontinence (10.66%). abnormal sweating (9.33%) and nocturnal diarrheas (7.33%) are in third and fourth position respectively. discussion: the present study explored the relationship of hba1c with dan in type-2 diabetic patients in the present study. the strength of the analysis is that an important and independent contributor to dan was found to be the increased variability of hba1c. in our study, the mean age of the dan patients was 55.00±5.57 years, the mean duration of diabetes of dan patients were 9.79±5.78 years and mean hba1c level 11.75±2.21 significantly higher than mean age 50.42±8.96, mean duration 5.94±3.72 and mean hba1c level 9.72±1.89 of non-dan patients. these is important and indicating that increasing age, prolong duration of diabetes and higher hba1c level raise the risk of dan compare to non-dan patients. according to this study it means that the mean age, mean duration of diabetes and mean hba1c level of dan participants is more than the mean age, mean duration of diabetes and mean level of hba1c of dpn (diabetic sensory and motor neuropathy)21. that’s means diabetic sensory and motor neuropathy ultimately progress to autonomic neuropathy with increasing age, duration of diabetes and hba1c level. according to thekkur et al.22, older age has an independent impact on autonomic neuropathy and diabetes duration also has a positive correlation with autonomic neuropathy screening. valensi et al.23 and kempler et al.24 also demonstrate that the continuation of the course of the disease phase and its occurrence increases in the progression and degree of dan in direct proportion to the duration of the disease. dimitropoulos et al.1 reported dan prevalence in type-2 diabetes range from 20% to 73%, which is consistent with the present study. another community-based survey from a diabetic center in india recorded that dan prevalence among diabetic patients is 10.6 %, as reported by thekkur et al.22, which is significantly lower than the current study that is 19.33%. this indicates dan prevalence of outpatients is more than community-based diabetes patients. ziegler et al.25 reported the same statement. this difference may also due to our study were among only type-2 diabetic patients but indian studies included all types. the prevalence of dan dependent on the type of diabetes, cohort and diagnostic method26. signs of diabetic autonomic neuropathy (dan) are found in 3.5-6% of patients at the onset of the disease, and in 100% of patients with prolonged 6.66% 7.33% 10.66% 16.66% 9.33% postural hypotention nocturnal diarrhea urinary incontinence sexual dysfunction abnormal sweating duration of diabetes mellitus27-28 and our result within the above range. the prevalence of postural hypotension in our sample is 6.66%, which is consistent with the 7.4% recorded in type-2 diabetes patients in a study. gupta et al.29 and sharma et al.30 recorded a 5.7% and 6% occurrence of postural hypotension respectively. in dan patients, nocturnal diarrhea and fecal incontinence are common. prevalence of diarrhea reported 20% (type-1 and type-2), bladder dysfunction 25% in type-2 diabetic patients31-32 whereas our results 7.33% and 10.66% respectively. this variation may be due to our study included only nocturnal diarrhea and urinary incontinence compared to their various symptoms, various types of diabetes, study time frame and different population, etc. sexual disorder encompasses erectile dysfunction (ed), retrograde ejaculation, and female sexual dysfunction, which is more prevalent in diabetes33. in our sample, the incidence of sexual dysfunction (sd) in males (9.33%) is marginally higher than in females (7.33%), similarly reported by vapaeimanesh et al.34 that women report sd at a rate slightly lower than men. there was no significant association between systolic and diastolic blood pressure and peripheral neuropathy35, which is the same as our results. assessment of hba1c variability reflects the long-term glycemic variability and may promote oxidative stress36. oxidative stress deprives the nerve cells of oxygen, impedes growth, and leads to cellular apoptosis or cell death; this contributes to the development of progressive neuropathy or dan37-38. in this study, increasing levels of hba1c above almost 9.0% were found to be significantly correlated with increased dan prevalence. the results of this study were consistent with others39, who suggested that peripheral neuropathy in increasing hba1c groups had a higher prevalence. it has been shown that reducing hba1c below or around 7% decreases microvascular and neuropathic risks by the american diabetes association and others18. the duration of diabetes and the degree of glycemic regulation depends on the magnitude of diabetic peripheral neuropathy40. poor glycemic control is an important determinant of the progression of autonomic nerve dysfunction in type-2 dm41. so, the variability of hba1c is an independent risk factor for dan. conclusion: findings of this study suggest that increasing hba1c level is significantly associated with increased prevalence of dan and the risk increases markedly at hba1c levels ≥9.72%. the prevalence and risk of dpn also increased with advanced age, longer duration of diabetes, etc. careful assessment of the risk factors of dan among diabetic patients and control of hba1c and appropriate preventive measures are thus recommended. acknowledgement: the authors are extending their heartfelt thanks to the outpatient department of the rajshahi diabetic association general hospital, rajshahi, bangladesh for data collection and related assistance and cooperation. conflict of interest: the authors declare that there is no competing interest. funding statement: the authors are grateful to the institute of biological sciences, university of rajshahi, for providing fellowship and funding to this project work. ethics approval: this study was approved by ethical research committee of institutional animal, medical ethics, biosafety and biosecurity committee (iamebbc) for experimentations on animal, human, microbs and living natural sources at the institute of biological sciences, university of rajshahi, bangladesh. author’s contributions: mah designed the study, performed the experimental work, collected data, interpreted data, performed the statistical analysis, and wrote the first draft of the manuscript. smsi, mks, im supervised the work and contributed scientific advice and helped in study design. smsi provided technical support, editing and approval of final draft. all authors reviewed and approved the final version of the manuscript. international journal of human and health sciences vol. 06 no. 01 january’22 94 references: 1. dimitropoulos g, tahrani aa, stevens mj. cardiac autonomic neuropathy in patients with diabetes mellitus. world journal of diabetes. 2014;5(1):17-39. 2. vinik ai and erbas to. diabetic autonomic neuropathy. handbook of clinical neurology. 2013;117:279-94. 3. guo q, zang p, xu s, song w, zhang z, liu c, guo z, chen j, lu b, gu p and shao j. time in range, as a novel metric of glycemic control, is reversely associated with presence of diabetic cardiovascular autonomic neuropathy independent of hba1c in chinese type 2 diabetes. journal of diabetes research. 2020; doi: 10.1155/2020/5817074. 4. asghar o, petropoulos in, alam u, jones w, jeziorska m, marshall a, ponirakis g, fadavi h, boulton aj, tavakoli m and malik ra. corneal confocal microscopy detects neuropathy in subjects with impaired glucose tolerance. diabetes care. 2014;37(9):2643-6. 5. hall v, thomsen rw, henriksen o and lohse n. diabetes in sub-saharan africa 1999-2011: epidemiology and public health implications. a systematic review. bmc public health. 2011;11(1):112. 6. idf diabetes atlas9th edition, 2019. https://www. diabetesatlas.org/en. 7. vinik ai and erbas to. recognizing and treating diabetic autonomic neuropathy. cleveland clinic journal of medicine. 2001;68:928-44. 8. uk prospective diabetes study group. intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (ukpds 33). the lancet. 1998;352(9131):837-53. 9. diabetes control and complications trial research group. the effect of intensive treatment of diabetes on the development and progression of long term complications in insulin-dependent diabetes mellitus. new england journal of medicine. 1993; 329(14):977-86. 10. booya f, bandarian f, larijani b, pajouhi m, nooraei m and lotfi j. potential risk factors for diabetic neuropathy: a case control study. bmc neurology. 2005;5(1):1-5. 11. stevens mj, raffel dm, allman kc, schwaiger m, wieland dm. regression and progression of cardiac sympathetic dysinnervation complicating diabetes: an assessment by c-11 hydroxyephedrine and positron emission tomography. metabolism. 1999;48(1):92-101. 12. samal kc, tripathy bb. diabetic neuropathy. the journal of the association of physicians of india. 1993;1:47-55. 13. pop-busui r. cardiac autonomic neuropathy in diabetes: a clinical perspective. diabetes care. 2010;33:434-41. 14. deli g, bosnyak e, pusch g, komoly s and feher g. diabetic neuropathies: diagnosis and management. neuroendocrinology. 2013; 98(4):267-80. 15. watkins pj. diabetic autonomic neuropathy. the new england journal of medicine. 1990;322(15):1078-9. 16. lai yr, huang cc, chiu wc, liu rt, tsai nw, wang hc, lin wc, cheng bc, su yj, su cm, hsiao sy, wang pw, chen jf, lu ch. hba1c variability is strongly associated with the severity of cardiovascular autonomic neuropathy in patients with type 2 diabetes after longer diabetes duration. frontiers in neuroscience. 2019;13:458. 17. american diabetes association. standards of medical care in diabetes. diabetes care. 2021;44(1): 151-67. 18. american diabetes association (2010). standards of medical care in diabetes. diabetic care, 33: 11-61. 19. american diabetes association. standards of medical care in diabetes. diabetes care. 2017;40(1):38-94. 20. mørkrid k, ali l, hussain a. risk factors and prevalence of diabetic peripheral neuropathy: a study of type 2 diabetic outpatients in bangladesh. international journal of diabetes in developing countries. 2010;30(1):11-7. 21. hossain ma, sarkar mk, mahbub i and islam sms (2021). hba1c variability has a strong relationship with peripheral sensory and motor neuropathy in type-2 diabetes mellitus. journal of bio-science, 29(1): 93-100. 22. thekkur p, muruganandam v, narayan ka and boovaragasamy c. screening for autonomic neuropathy using validated non-invasive scale among diabetes patients treated in the selected primary health centres of puducherry, india: an operational research. international journal of community medicine and public health. 2019;6(9):3984-92. 23. valensi p, paries j, attali jr and french group for research. cardiac autonomic neuropathy in diabetic patients: influence of diabetes duration, obesity and microangiopathic complications-the french multicenter study. metabolism. 2003;52(7):815-20. 24. kempler p, tesfaye s, chaturvedi n, stevens lk, webb dj, eaton s, kerényi z, tamás g, ward jd, fuller jh and eurodiab iddm complications study group. autonomic neuropathy is associated with increased cardiovascular risk factors: the eurodiab iddm complications study. diabetic medicine. 2002;19(11): 900-9. 25. ziegler d, gries fa, spüler m, lessmann f, diabetic cardiovascular autonomic neuropathy multicenter study group. the epidemiology of diabetic neuropathy. journal of diabetes complications. 1992;6(1):49-57. 26. vinik ai, erbas t and casellini cm. diabetic cardiac autonomic neuropathy, inflammation and cardiovascular disease. journal of diabetes investigation. 2013;4(1):4-18. 27. ziegler d. cardiovascular autonomic neuropathy: clinical manifestations and measurement. diabetes rev. 1999;7:300-315. 28. low pa, benrud-larson lm, sletten dm, opfergehrking tl, weigand sd, o’brien pc, suarez ga, dyck pj. autonomic symptoms and diabetic neuropathy: a population-based study. diabetes care. 2004;27(12): 2942-7. 29. gupta op, rastogi dk and agarwal bl. cardiovascular reflexes in long-term diabetics. evaluation by bed side techniques. indian heart journal. 1978;30(1):105. 30. sharma rk, singh j, saraf r. autonomic neuropathy in diabetes mellitus. the journal of the association of physicians of india. 1989;37(1):89. 31. tesfaye s, boulton aj, dyck pj, freeman r, horowitz m, kempler p, lauria g, malik ra, spallone v, vinik a, bernardi l. diabetic neuropathies: update on definitions, diagnostic criteria, estimation of severity, and treatments. diabetes care. 2010; 33(10):228593. 32. vinik ai, maser re, mitchell bd and freeman r. diabetic autonomic neuropathy. diabetes care. 2003;26(5):1553-79. 33. bacon cg, hu fb, giovannucci e, glasser db, mittleman ma and rimm eb. association of type and duration of diabetes with erectile dysfunction in a large cohort of men. diabetes care. 2002;25(8):145863. 95 international journal of human and health sciences vol. 06 no. 01 january’22 references: 1. dimitropoulos g, tahrani aa, stevens mj. cardiac autonomic neuropathy in patients with diabetes mellitus. world journal of diabetes. 2014;5(1):17-39. 2. vinik ai and erbas to. diabetic autonomic neuropathy. handbook of clinical neurology. 2013;117:279-94. 3. guo q, zang p, xu s, song w, zhang z, liu c, guo z, chen j, lu b, gu p and shao j. time in range, as a novel metric of glycemic control, is reversely associated with presence of diabetic cardiovascular autonomic neuropathy independent of hba1c in chinese type 2 diabetes. journal of diabetes research. 2020; doi: 10.1155/2020/5817074. 4. asghar o, petropoulos in, alam u, jones w, jeziorska m, marshall a, ponirakis g, fadavi h, boulton aj, tavakoli m and malik ra. corneal confocal microscopy detects neuropathy in subjects with impaired glucose tolerance. diabetes care. 2014;37(9):2643-6. 5. hall v, thomsen rw, henriksen o and lohse n. diabetes in sub-saharan africa 1999-2011: epidemiology and public health implications. a systematic review. bmc public health. 2011;11(1):112. 6. idf diabetes atlas9th edition, 2019. https://www. diabetesatlas.org/en. 7. vinik ai and erbas to. recognizing and treating diabetic autonomic neuropathy. cleveland clinic journal of medicine. 2001;68:928-44. 8. uk prospective diabetes study group. intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (ukpds 33). the lancet. 1998;352(9131):837-53. 9. diabetes control and complications trial research group. the effect of intensive treatment of diabetes on the development and progression of long term complications in insulin-dependent diabetes mellitus. new england journal of medicine. 1993; 329(14):977-86. 10. booya f, bandarian f, larijani b, pajouhi m, nooraei m and lotfi j. potential risk factors for diabetic neuropathy: a case control study. bmc neurology. 2005;5(1):1-5. 11. stevens mj, raffel dm, allman kc, schwaiger m, wieland dm. regression and progression of cardiac sympathetic dysinnervation complicating diabetes: an assessment by c-11 hydroxyephedrine and positron emission tomography. metabolism. 1999;48(1):92-101. 12. samal kc, tripathy bb. diabetic neuropathy. the journal of the association of physicians of india. 1993;1:47-55. 13. pop-busui r. cardiac autonomic neuropathy in diabetes: a clinical perspective. diabetes care. 2010;33:434-41. 14. deli g, bosnyak e, pusch g, komoly s and feher g. diabetic neuropathies: diagnosis and management. neuroendocrinology. 2013; 98(4):267-80. 15. watkins pj. diabetic autonomic neuropathy. the new england journal of medicine. 1990;322(15):1078-9. 16. lai yr, huang cc, chiu wc, liu rt, tsai nw, wang hc, lin wc, cheng bc, su yj, su cm, hsiao sy, wang pw, chen jf, lu ch. hba1c variability is strongly associated with the severity of cardiovascular autonomic neuropathy in patients with type 2 diabetes after longer diabetes duration. frontiers in neuroscience. 2019;13:458. 17. american diabetes association. standards of medical care in diabetes. diabetes care. 2021;44(1): 151-67. 18. american diabetes association (2010). standards of medical care in diabetes. diabetic care, 33: 11-61. 19. american diabetes association. standards of medical care in diabetes. diabetes care. 2017;40(1):38-94. 20. mørkrid k, ali l, hussain a. risk factors and prevalence of diabetic peripheral neuropathy: a study of type 2 diabetic outpatients in bangladesh. international journal of diabetes in developing countries. 2010;30(1):11-7. 21. hossain ma, sarkar mk, mahbub i and islam sms (2021). hba1c variability has a strong relationship with peripheral sensory and motor neuropathy in type-2 diabetes mellitus. journal of bio-science, 29(1): 93-100. 22. thekkur p, muruganandam v, narayan ka and boovaragasamy c. screening for autonomic neuropathy using validated non-invasive scale among diabetes patients treated in the selected primary health centres of puducherry, india: an operational research. international journal of community medicine and public health. 2019;6(9):3984-92. 23. valensi p, paries j, attali jr and french group for research. cardiac autonomic neuropathy in diabetic patients: influence of diabetes duration, obesity and microangiopathic complications-the french multicenter study. metabolism. 2003;52(7):815-20. 24. kempler p, tesfaye s, chaturvedi n, stevens lk, webb dj, eaton s, kerényi z, tamás g, ward jd, fuller jh and eurodiab iddm complications study group. autonomic neuropathy is associated with increased cardiovascular risk factors: the eurodiab iddm complications study. diabetic medicine. 2002;19(11): 900-9. 25. ziegler d, gries fa, spüler m, lessmann f, diabetic cardiovascular autonomic neuropathy multicenter study group. the epidemiology of diabetic neuropathy. journal of diabetes complications. 1992;6(1):49-57. 26. vinik ai, erbas t and casellini cm. diabetic cardiac autonomic neuropathy, inflammation and cardiovascular disease. journal of diabetes investigation. 2013;4(1):4-18. 27. ziegler d. cardiovascular autonomic neuropathy: clinical manifestations and measurement. diabetes rev. 1999;7:300-315. 28. low pa, benrud-larson lm, sletten dm, opfergehrking tl, weigand sd, o’brien pc, suarez ga, dyck pj. autonomic symptoms and diabetic neuropathy: a population-based study. diabetes care. 2004;27(12): 2942-7. 29. gupta op, rastogi dk and agarwal bl. cardiovascular reflexes in long-term diabetics. evaluation by bed side techniques. indian heart journal. 1978;30(1):105. 30. sharma rk, singh j, saraf r. autonomic neuropathy in diabetes mellitus. the journal of the association of physicians of india. 1989;37(1):89. 31. tesfaye s, boulton aj, dyck pj, freeman r, horowitz m, kempler p, lauria g, malik ra, spallone v, vinik a, bernardi l. diabetic neuropathies: update on definitions, diagnostic criteria, estimation of severity, and treatments. diabetes care. 2010; 33(10):228593. 32. vinik ai, maser re, mitchell bd and freeman r. diabetic autonomic neuropathy. diabetes care. 2003;26(5):1553-79. 33. bacon cg, hu fb, giovannucci e, glasser db, mittleman ma and rimm eb. association of type and duration of diabetes with erectile dysfunction in a large cohort of men. diabetes care. 2002;25(8):145863. 34. vafaeimanesh j, raei m, hosseinzadeh f and parham m. evaluation of sexual dysfunction in women with type 2 diabetes. indian journal of endocrinology and metabolism. 2014;18(2):175-9. 35. ramachandran a, snehalatha c, satyavani k, latha e, sasikala r and vijay v. prevalence of vascular complications and their risk factors in type 2 diabetes. the journal of the association of physicians of india. 1999;47(12):1152-6. 36. chang, cm, hsieh, cj, huang jc and huang ic. acute and chronic fluctuations in blood glucose levels can increase oxidative stress in type 2 diabetes mellitus. acta diabetologia. 2012;49(1):171-7. 37. albers jw and pop-busui r. diabetic neuropathy: mechanisms, emerging treatments, and subtypes. current neurology and neuroscience reports. 2014;14(8):473. 38. babizhayev ma, strokov ia, nosikov vv, nosikov, ekaterina l, yeva els, sitnikov vf, yegorov ye and lankin vz. the role of oxidative stress in diabetic neuropathy: generation of free radical species in the glycation reaction and gene polymorphisms encoding antioxidant enzymes to genetic susceptibility to diabetic neuropathy in population of type i diabetic patients. cell biochemistry and biophysics. 2015;71(3):1425-43. 39. sabanayagam ch, liew g, tai es, shankar a, lim sc, subramaniam t and wong ty. relationship between glycated haemoglobin and microvascular complications: is there a natural cut-off point for the diagnosis of diabetes? diabetologia. 2009;52(7):127989. 40. el-salem k, ammari f, khader y and dhaimat o. elevated glycosylated hemoglobin is associated with subclinical neuropathy in neurologically asymptomatic diabetic patients: a prospective study. journal of clinical neurophysiology. 2009;26(1):503. 41. mustonen j, uusitupa m, mäntysaari m, länsimies e, pyörälä k and laakso m. changes in autonomic nervous function during the 4-year follow up in middle aged diabetic and non-diabetic subjects initially free of coronary heart disease. journal of internal medicine. 1997; 241(3):231-9. microsoft word ijhhs imam 23rd asc 2022 s22 metastatic breast carcinoma with cutaneous metastasis and right pleural effusion adib zakhi1 cutaneous metastasis is when cancerous cells spread from a primary tumour to the skin. this is a case of a 75-year-old patient who developed skin metastasis with underlying primary breast. a 75-year-old lady presented with a 3-week history of the progressive appearance of multiple asymptomatic nodular lesions on the chest. eight months earlier, she was diagnosed with right breast carcinoma and underwent neoadjuvant chemotherapy followed by a right modified radical mastectomy. she presented with progressive skin lesion over the right upper limb and anterior chest wall. she denied any fever, pain or pruritus and any preceding burn or trauma. she also completed a course of antibiotic for the lesion. physical examinations revealed an erythematous lesion with multiple exophytic nodules. it was painless and extended from the anterior chest wall to the right upper limb. lung auscultation revealed reduced air entry over the right upper zone. she was then referred to the oncology department and diagnosed with metastatic breast carcinoma with right pleural effusion and cutaneous metastases. as she was unfit for further systemic therapy, she was discharged home and continuation of supportive care. chest radiograph revealed right upper lobe opacity and bedside ultrasound confirmed right upper lobe pleural effusion. other investigations were unremarkable. cutaneous metastasis accounts for 24% of breast carcinoma and may manifest as the presenting lesion or after the tumour diagnosis. the commonest manifestation is the presence of nodules in the ipsilateral chest wall to the primary tumour, their size varies, is painless and are commonly spread via lymphatic drainage. skin biopsy helps in diagnosis confirmation. definitive treatment depends on the management of the primary malignancy. as it may mimic benign lesions, one should be highly suspicious of skin metastasis as he might be the first person to identify the primary tumour. keywords: emergency department, cutaneous metastasis, pleural effusion  1. hospital canselor tuanku muhriz, kuala lumpur, malaysia  __________________________________________________________________________________ correspondence to: adib zakhi, medical officer, hospital canselor tuanku muhriz malaysia, adibzakhi@rocketmail.com __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v7i70.524 microsoft word ijhhs imam 23rd asc 2022 s20 beyond two decades of rumah solehah: the time for extended scope of programs matron fadzilah bt haji abd hamid, fathiiah bt hamzah. rumah solehah has been handling residents in the halfway house since its inception in 1998 with various issues. through education particularly on the mode of transmission, society has learned to accept people living with hiv (plhiv) to stay with them at home except for the very few. thus, rumah solehah introduced other extended programs. 1. home-based program: the discharged infected ladies from rumah solehah are assisted to adjust themselves to their family’s environment. the families are guided in issues such as compliance to medication. the ladies will come to rumah solehah periodically for continuation of spiritual and vocational training. during those visits, they will receive cash for their fare and kinds. the families are often reassured and counselled. 2. tele-counselling: plhiv and families often call rumah solehah for counselling. issues discussed vary, the recent ones becoming more chronic, calling late at night. 3. community education: every month public or private universities will send their students for hiv awareness program on topics such on hiv 101. masters and post basic ministry of health (moh) students will be given the chance to practise their hiv counselling to our infected cases. rumah solehah also accepts invitations for public talks in other states. 4. studies and research: several studies have been performed by university students in collaboration with um and iium on issues related to women and children infected with hiv. the current research with iium is for the ministry of health to develop programs or assistance for orphans infected with hiv. the extended programmes are very timely and cost effective. to have residents for long period of time is expensive. infected women and children have a better and happier life staying with their extended or adopted family with continuous follow up care, thus ensuring quality time for the cases of rumah solehah. keywords: hiv, home-based, compliance, awareness, hiv-related-studies 1. rumah solehah, kampung pandan, kuala lumpur _________________________________________________________________________ correspondence to: matron fadzilah bt haji abd hamid, rumah solehah exco member, rumah solehah, kampung pandan, kuala lumpur. rumahsolehah@gmail.com __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v7i70.522 s11 covid-19 experiences in malaysia ahmad munawwar helmi salim adapting the whole society approach, imaret complements the effort by the ministry of health in battling the pandemic by working with various parties, which includes united nation agencies, government agencies, corporate sectors and ngos. since 16th march 2020, imaret has responded to the covid-19 pandemic by mobilizing medical and non-medical volunteers, and providing medical equipment and supplies to support the healthcare facilities throughout malaysia. keywords: covid-19 response, imaret, ngos, malaysia __________________________________________________________________________ correspondence to: imam response & relief teamimaret, jalan sp1, selayang point, batu caves selangor. email: bowlatt@gmail.com __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v6i0.401 mailto:bowlatt@gmail.com 183 international journal of human and health sciences vol. 06 no. 02 april’22 original article study on post-traumatic stress disorder (ptsd) among traumatic amputated patients using dsm-5 revised criteria refat zahan1, md. abdur rahman2, md. shamsul huda mamun3, farhana ferdaus4, akhiruzzaman5, rasheda yasmin6, sunjida shahriah7, mazharul islam8 abstract: background: limb amputation is a common surgical procedure done for therapeutic reasons to prevent further deterioration and save lives. objective: to assess the level of post-traumatic stress disorder (ptsd) among trauma related amputated patients. methods: this cross-sectional study was conducted between january and december of 2016 on 296 amputated patients who were admitted in the national institute of traumatology and orthopedic rehabilitation (nitor), dhaka, and bdm hospital and diagnostic center, dhaka, bangladesh. a semi-structured, questionnaire was developed both english and bangla (local language) using the variables of the study and validated. using that tool, face to face interview was taken. the checklists were used to collect their socio-demographic characteristics, information regarding amputation and stress severity and diagnosis of ptsd, collectively termed as dsm-5. results: among 296 respondents, 213(72%) were male and 83(28%) were female. the mean age of the respondents was 32.013±5.35 years. ptsd was found in221 (75%), while the rest 75 (25%) had acute traumatic stressdisorder. among ptsd patients, 10(50%) with digit amputated, 41(68.33%) of upper limb amputated, 155(77.11%) of lower limb amputated, and 15(100%) of both or multiple limbs amputated respondents. 61% had extreme level of stress. ptsd had significant association with sex, age, habitat, occupationposition and part of limb loss (p<0.05). conclusion: in our country, ptsd is very common in amputated patients and has significant association with sex, age, habitat, occupation as well as part of limb loss. multidisciplinary team of health professionals should emphasize on the need of amputees, both physically and psychologically and provide an effective rehabilitation plan. keywords: post-traumatic stress disorder (ptsd), amputated patient, caps-5, pcl-5, lec-5. correspondence to: dr. refat zahan, assistant professor and head, department of community medicine, ad-dinakij medical college, khulna, bangladesh. email:dr.refat1986@gmail.com 1. assistant professor and head, department of community medicine, ad-dinakij medical college, khulna, bangladesh. 2. assistant professor, department of pharmacology &therapeutics, ad-dinakij medical college, khulna, bangladesh. 3. assistant professor, department of forensic medicine, ad-dinakij medical college, khulna, bangladesh. 4. assistant professor and head, department of community medicine, khulna city medical college, khulna, bangladesh. 5. assistant professor, department of community medicine,diabetic association medical college,faridpur, bangladesh. 6. assistant professor, department of community medicine, nightingale medical college, ashulia, dhaka, bangladesh. 7. professor and director, phoenix wellness centre, dhaka, bangladesh. 8. professor and head,department of community medicine, mugda medical college, dhaka, bangladesh. international journal of human and health sciences vol. 06 no. 02 april’22 page : 183-187 doi: http://dx.doi.org/10.31344/ijhhs.v6i2.443 introduction limb amputation is a common surgical procedure performed by orthopedic, general, vascular and trauma surgeons to prevent further deterioration and save lives. however, loss of a limb due to trauma has a devastating emotional impact on a patient, escalating to mental trauma that may be more harmful than that the loss of the limb1. we know that in case of organic, tumoral, or infections, amputation is planned; in contrast, in traumatic amputations are unplanned. thus, there is a certain sequential order regarding risk for developing mental disorders, starting from the immediate reaction to the acute stress disorder leading to and ending with the post-traumatic stress disorder (ptsd). it is mostly related to ones perceived image, which further aggravates the disability2. it has profound economic, social and psychological effects3. international journal of human and health sciences vol. 06 no. 02 april’22 184 post-traumatic stress disorder (ptsd) is an anxiety disorder that can occur following the experience or witnessing of a traumatic event4-6. a traumatic event is a life-threatening event such as military combat, natural disasters, terrorist incidents, serious accidents or physical or sexual assault in adult or childhood5. ptsd develops in response to traumatic event. about 60% of men and 50% of women experience a traumatic event in their lifetime7. most people who are exposed to a traumatic event will have some of the symptoms of ptsd in the days and weeks after the event. for some people these symptoms are more severe and long lasting. there are biological, psychological and social factors that affect the development of ptsd8,9. due to the differences in indication and pattern of amputation between different countries and even different cities in a country. this study was performed to identify the traumatic events causes amputation, diagnose post-traumatic stress disorder (ptsd), by using dsm-5 published by the american psychiatric association (apa) in 2013,10 and to determine association between socio demographic factors with the development and severity of amputation (part of limb loss). methods this cross-sectional study was conducted between january and december of 2016 on 296 amputated patients who were admitted in the inpatient departments of national institute of traumatology and orthopedic rehabilitation (nitor), dhaka, and bdm hospital and diagnostic center, dhaka, bangladesh. patients were selected based on the following inclusion and exclusion criteria: inclusion criteria: 1) amputated respondent with traumatic history; 2) hospital admitted respondent. 3) respondent will be included irrespective of sex. 4) respondent’s willingness to participate in this study. 5) day after amputation not more than 6months. 6) children more than 7 years. exclusion criteria: 1) mentally unsound people; 2) non-traumatic amputated patients; 3) severely ill patient who will be unable to take part in the interview; 4) child under 7 years. convenience sampling technique was followed. after fulfilling the eligibility criteria,a total of 296 amputated respondents were taken in the study.informed written consent was taken from the respondent before interview. privacy of the respondents was ensured, and interview was not disclosed to any unauthorized person. complete assurance was given that all information provided by the respondent will be kept confidential. a semi-structured questionnairewas developed both english and in bangla (local language) using the variables and specific objectives of the study from the patients by face-to-face interview. it contained questions related to their socio-demographic characteristics, information regarding amputation and ptsd checklist (as follows): 1. a checklist was used to collect the trauma related information ofamputated patients by lec-5 (life event checklist -5).11 a single indextrauma was identified in an individual; 2. then, criteria a was used for applicability of pcl-5 and caps-5;12 3. after met the criteria a, pcl-5 was used to provisional diagnosis andassess ptsd severity; 4. after provisional diagnosis, caps-5 (past week, past month and worst month versions where applicable) was used for clinical diagnosis. however, before data collection, pre-testing of the questionnaire and checklist were used in the in-patient unit of prime orthopedic hospital, dhaka, bangladesh. according to the finding of pre-testing necessary modifications were in the questionnaire and checklist. data were analyzed by statistical package for social science (spss) version 24.0. for descriptive statistics, means, standard deviation and ranges for categorical data were calculated as required. data were presented in frequency table. for inferential statistics, chi-square(ꭓ2) test was done to analyze association of ptsd with different parameters. results the mean age of the respondents was 32.013±5.35 years.among 296 respondents, 128 (43.3%) were from the age group 20-29 years while about 52 (17.5%) of them were from the age group 185 international journal of human and health sciences vol. 06 no. 02 april’22 table 1. socio-demographic characteristics of the participants (n=296) variables frequency percentage age group 7-19 50 16.85 20-29 128 43.3 31-49 52 17.5 50-59 48 16.2 60 and above 18 6.1 mean age 32.013±5.35 sex male 213 72 female 83 28 habitat rural 172 58.1 sub-urban 46 15.5 urban 78 26.4 education illiterate 75 25.3 self-educated 6 2 primary 97 32 junior secondary 38 12.8 secondary 47 15.9 higher secondary 21 7.1 graduate 12 4.1 occupation unemployed 11 3.7 student 50 16.9 housewife 46 15.5 transport driver andhelper 37 12.5 day labourer 51 17.23 industrial worker 51 17.23 business 34 11.5 civil service 16 5.4 marital status married 152 51.34 unmarried 144 48.65 income level <10000 bd taka (lower income group) 87 29.39 <25000 bd taka (lower middle income group) 170 57.43 <50000 bd taka (uppermiddle income group) 28 9.46 >50000 bd taka (high income group) 11 3.71 30-49 years, 50(16.85%) were child and adolescents and 48 (16.2%) from 60 years and above. 213 (72%) were male and 83 (28%) were female. most of the respondent 172 (58.1%) came from rural area, 78 (26.4%) from urban area and rest were from sub-urban area 46 (15.5%). most of the respondent 97 (32%) completed primary education. the remaining 25.3% were illiterate, 15.9% were completed secondary education, while 12.8%, 7.1%, 4.1%, and 2% were completed junior secondary education, higher secondary, graduate studies, and self-educated respectively. by occupation, industrial worker 11 (3.7%), 51 (17.23%), whereas 50 (16.9%), 46 (15.5%), 37 (12.5%), 51 (17.23%), 51 (17.23%), 34 (11.5%) and 16 (5.4%) were unemployed, students, housewives, transport driver and helper, day labourer, industrial worker, businessman, drivers, in civil service respectively. 152 (51.35%) were married and 144 (48.65%) were unmarried. majority of the respondent 170 (57.43%) were from lower middle socioeconomic status) had monthly family income of taka 11000-25000 (lower socio-economic status), 87 (29.4%), 28 (9.5%) had monthly family income up to 10000 taka, and 26000 -50000 (upper middle socio-economic status) taka while lowest no of the respondent 11 (3.71%) had monthly family income 51000-100000 (upper socio-economic status) taka(table 1). age, sex, habitat and occupation are associated to events of ptsd among the respondents(table 2).most of the events231 (78%) happened due to road traffic accidents, while 56 (19%) at working place, 6 (2%) at home working and 3 (1%) by explosion through bombs/firearms.among the respondents diagnosed with ptsd, 10 (50%) had only digits amputated, while 41 (68.33%) had upper limb amputated, 155 (77.11%) lower limb, and 15 (100%) had both/multiple limbs amputated. the difference was statistically significant (p<0.05)(table 3). international journal of human and health sciences vol. 06 no. 02 april’22 186 table 2. association of prevalence of ptsd with age, sex, living and occupation variables distribution of ptsd chisquare (ꭓ2) p value yes no age group 7-19 40 10 13.7916 0.007991 20-29 106 22 31-49 32 20 50-59 30 18 60 and above 13 5 sex male 148 65 10.7683 0.001033 female 73 10 habitant rural 155 17 55.5071 0.00001sub-urban 20 26 urban 46 32 occupation unemployed 11 0 52.769 0.00001 student 40 10 housewife 40 6 transport driver andhelper 17 20 day labourer 45 6 industrial worker 46 5 business 16 18 civil service 6 10 table 3. association between ptsd and part of limb loss amputation distribution of ptsd chisquare (ꭓ2) p value yes no digit 10 10 13.43 0.003793 upper limb 41 19 lower limb 155 46 both limbs 15 0 discussion in the present study, the mean age of the respondents was 32.013±5.35 years; 72% of the respondents were male and 28% female. in a study done by dar et al.13in kashmir region of india, there was a higher rate of morbidity in females than in males following trauma (45.87% vs. 40.68% respectively). in another study done by mansoor et al.14, males out-numbered females by approximately 4:1 ratio (79% vs. 21%). higher prevalence of ptsd in females was also reported in the study done by bryant & harvey15. male predominance could be derived from the reason that ours is a patriarchal type of society, where men are the bread earners of the family and the women usually prefer to stay at home. another reason could be that men report for rehabilitation and also seek help for their psychological problems more readily than women. in the present study, the young age group suffered most trauma and subsequent morbidities. dar et al.13 reported that maximum number of cases with trauma and subsequent morbidities belonged to 20-40 years age group (p <0.001). mansoor et al.14reported that majority (45%) of the amputees were males in the age group of 15-30 years, followedby 30% in the age group of 31-45 years and 25% in the age group of 46-60 years. similar evidence was produced by the study done by pooja & sangeeta.16 the amputees in that report were at young age. this may be due to the fact that most amputations were due to trauma, which occurred more frequently in younger people who led more active lives. however, victim suffering from ptsd at a young age may not benefit from powerful confronting strategies and need more times to be able to develop effective coping strategies and implement them.17 we observedthat majority (81%) of the cases were from rural areas with low literacy rates. similar results were found in the study done by mansoor et al.14 most likely explanation for this observation is that the majority (74.9%) of the population in the sub-continent region are from rural background and the literacy rate is low that of urban areas. limitations of the study although optimum care had been tried by the researcher in every step of this study, still some limitations exist.the study population was not taken from the population of all the amputated cases of the community, rather the sample was representative of only those amputated cases who got admitted in in-patient unit of specialized hospitals. no follow up of amputated respondent was possible as because they came from different areas of the country. there were no similar studies conducted before in the country, making our task arduous in finding out relevant information. our study period was short and sample size was small, due to the budget constraint. 187 international journal of human and health sciences vol. 06 no. 02 april’22 conclusion our data suggest that ptsd is very common in amputated patients in our country and symptom severity has significant association with sex, age, socio-economic status as well as part of limb loss and time passed after amputation. multidisciplinary team of health professionals should emphasize on the need of amputees, both physically and psychologically and provide an effective rehabilitation plan. conflict of interest: none declared. ethical approval issue: ethical clearance was taken from the institutional ethical committee of national institute of preventive and social medicine (nipsom), dhaka, bangladesh. funding statement: no funding. authors’contribution: conception and design of the study: rz, mi; data collection and compilation: rz, mar, mshm, ff, az, ry, ss; data analysis: rz, ss; manuscript writing, revision and finalizing: rz, mar, mshm, ff, az, ry, ss, mi. references: 1. monson cm, resick pa, rizvi sl. posttraumatic stress disorder. in: barlow dh. ed. clinical handbook of psychological disorders. new york: guilford press; 2014: p.80-113. 2. mckechnie ps, john a. anxiety and depression following traumatic limb amputation: a systematic review. injury. 2014;45(12):1859-66. 3. clasper j, ramasamy a. traumatic amputations. br j pain. 2013;7(2):67-73. 4. cavanagh sr, shin lm, karamouz n, rauch sl. psychiatric and emotional sequelae of surgical amputation. psychosomatics. 2006;47(6):459-64. 5. giummarra mj, fitzgibbon bm, tsao jw, gibson sj, rich an, georgiou-karistianis n, et al. symptoms of ptsd associated with painful and nonpainful vicarious reactivity following amputation. j trauma stress. 2015;28(4):330-8. 6. abeyasinghe nl, de zoysa p, bandara km, bartholameuz na, bandara jm. the prevalence of symptoms of post-traumatic stress disorder among soldiers with amputation of a limb or spinal injury: a report from a rehabilitation centre in sri lanka. psychol health med. 2012;17(3):376-81. 7. copuroglu c, ozcan m, yilmaz b, gorgulu y, abay e, yalniz e. acute stress disorder and post-traumatic stress disorder following traumatic amputation. acta orthop belg. 2010;76(1):90-3. 8. margoob ma, sheikh aa. community prevalence of adult ptsd in south asia-experience from kashmir. jkpractitioner. 2006;13:s18-25. 9. radhakrishnan m, masand p. prevalence of ptsd following surgical amputation. curr psychiatry rep. 2007;9(3):215-6. 10. american psychiatric association(apa). diagnostic and statistical manual of mental disorders (dsm– 5). 2013. 11. gray mj, litz bt, hsu jl, lombardo tw. psychometric properties of the life events checklist. assessment. 2004;11(4):330-41. 12. bovin mj, marx bp, weathers fw, gallagher mw, rodriguez p, schnurr pp, et al. psychometric properties of the ptsd checklist for diagnostic and statistical manual of mental disorders-fifth edition (pcl-5) in veterans. psychol assess. 2016;28(11):1379-91. 13. dar ma, wani ra, margoob ma, haq i, hussain a, chandel rk, et al. the association between adult mental health problems and childhood trauma: a retrospective community based study from kashmir. int j emerg mental health hum resilience. 2015;17(2):447-52. 14. mansoor i, margoob ma, masoodi n, mushtaq h, younis t, hussain a, et al. prevalence of psychiatric comorbidities in traumatic amputees – across sectional study from kashmir (indian part). br j med pract. 2010;3(4):a347. 15. bryant ra, harvey ag. gender differences in the relationship between acute stress disorder and posttraumatic stress disorder following motor vehicle accidents. aust nz j psychiatry. 2003;37(2):226-9. 16. pooja gd, sangeeta l. prevalence and aetiology of amputation in kolkata, india: a retrospective analysis. hong kong physiother j. 2013;31(1):36-40. 17. barmparas g, inaba k, teixeira pg, dubose jj, criscuoli m, talving p, et al. epidemiology of post-traumatic limb amputation: a national trauma databank analysis. am surg. 2010;76(11):1214-22. international journal of human and health sciences vol. 06 no. 02 april’22 208 original article correlation between matrix metalloproteinase-9 (mmp-9) serum levels and alteration of nihss score in acute ischemic stroke naili sofi riasari1, dodik tugasworo2, amin husni2 abstract objective : mmp-9 is a proteolytic enzyme that plays a role in stroke pathological process. its secretion increases rapidly after ischemic stroke onset. it gives a promising biomarker of stroke prognosis.the nihss (national institute of health stroke scale) is a clinical scale for predicting post stroke clinical outcomes. the study aim is to determine the correlation between mmp-9 serum levels and alteration of nihss score in acute ischemic stroke.material and methods :this was a prospective cohort study at kariadi hospital semarang during october 2018 january 2019. subjects met the inclusion and exclusion criteria were taken for 5 cc venous blood samples ≤48 hours of stroke onset to examine the mmp-9 serum levels andmeasured alteration of nihss scores between the 2nd, 7thand 14th day of stroke onset.results : there were 51 subjects with a mean mmp-9 serum levels of 1.223,24 ng/ml (normal 169-705 ng/ml). elevated mmp-9 serum levels were correlated with worsening clinical outcomes on 7th and 14th day of stroke onset (p=0.007 ; p=0.005). roc curve analysis obtained mmp-9 serum levels ≤48 hours of stroke onset with a cutoff point of 899.5 ng/ml, which mmp-9 serum levels above 899.5 ng/ml as a predictor of worsening clinical outcome.conclusion :there was correlation between mmp-9 serum levels ≤48 hours of ischemic stroke onset with clinical outcome on 7th and 14th day of stroke onset. keywords: mmp-9 serum levels, alteration of nihss score, acute ischemic stroke correspondence to: naili sofi riasari. department of neurology, faculty of medicine unissula, jalan kaligawe raya km.4, terboyokulon, genuk, semarang, central java, indonesia 50112 email: dr.sofianaili27@gmail.com 1. department of neurology,faculty of medicine unissula, semarang, indonesia 2. senior lecturer department of neurology, faculty ofmedicine diponegoro, semarang, indonesia international journal of human and health sciences vol. 06 no. 02 april’22 page : 208-212 doi: http://dx.doi.org/10.31344/ijhhs.v6i2.448 introduction the acute blockage of cerebral blood flow may cause many pathological conditions including homeostatic disorders, neuron excitotoxicity, intracellular calcium build-up, peri-infarct depolarization, free radical build-up, lipid peroxidation, and disruption of protein synthesis that trigger irreversible neuronal damage. dead neuron cells trigger the release of immune response which then stimulate the activation and infiltration of pro-inflammatory cells. the activation of these pro-inflammatory cells will produce cytotoxic substances, such as matrix metalloproteinases (mmps).1 mmps can damage the extracellular proteins such as collagen, proteoglycans, elastin, or fibronectin.2 among the many mmps, mmp9 (gelatinase b, 92kda collagenase) is the most common in ischemic stroke cases, and its expression increases rapidly after a stroke onset.3,4 gelatinase is able to activate a number of proinflammatory agents such as chemokine, il-iβ (interleukine-1β), or tnf-α (tumor necrosis factor-α) resulting in damage to type iv collagen. it also can enter the endothelium through the mediation of leukocytes.2it is associated with the neuroinflammation process that results in bloodbrain barrier damage, fluid leakage, leukocyte infiltration, cerebral edema, and increasing risk of hemorrhagic transformation.1mmp-9 also contributes to various complications, for example excitotoxicity, apoptosisand associated with the expansion of cerebral infarction area. thus, it 209 international journal of human and health sciences vol. 06 no. 02 april’22 may cause poor clinical output of ischemic stroke patients.1,5,6 many studies had been conducted to find blood biomarker as a predictor of clinical outcome in acute ischemic stroke patients in terms of clinical severity.4, 7 nihss is a clinical scale used to examine stroke patients. it provides useful information in predicting clinical outcomes in post-stroke patients. it is very easy, fast to do, and can be examined by bedside.8 the study that determine the correlation between mmp-9 serum levels with the clinical outcome of ischemic stroke, assessed by the alteration of nihss score was promising.4,9therefore, we intended to conduct the study. material and methods this was an observational analytic studywith cohort prospective design. the subjects of this study were 51 patients determined by consecutive sampling (non probability), with acute ischemic stroke who were admitted and hospitalized to the neurology department ward atkariadi hospital, semarang, central java, indonesia; during october 2018 january 2019. the inclusion criteria were first acute ischemic stroke with an onset of ≤48 hours as evidenced by a non-contrast head ct scan and agreed to participate in the study. exclusion criteria were patients with hemorrhagic strokes, severe systemic disease (ckd, chf, chronic liver disease, malignancy), history of drug use that affected mmp-9 levels (tetracycline, minocycline, doxycycline, nsaids, statins), peripheral arterial disease, patients receiving thrombolysis therapy. the drop out criteria were patients who die before the 7th and 14th day of stroke onset. patients who met the inclusion and exclusion criteria received informed consent; measured nihss score of 2nd day of stroke onset (k0), nihss score of 7th day of stroke onset (k1) and nihss score of 14th day of stroke onset (k2). thus, measuredthe alteration of nihss scores between 2nd with 7thday (k1-0), and between 2 nd with 14th day (k2-0). as much as 5 cc of venous blood sampling was taken ≤48 hoursstroke onset for measured mmp-9 serum levels. examination of mmp-9 serum levels at prodia clinical laboratorysemarang, used the elisa (enzyme linked immunosorbent assay) method with the quantikine®elisa human mmp-9 reagent kit (r&d systems, inc., minneapolis, usa) stain: dmp900, lot: p176247. the calibration standard range was 0.313-20 ng/ml, with detection limits ≤0.156 ng/ml, 100x dilution factor, measurements using microplate reader bio-rad model 680 (usa) instruments with microplate manager ver 5.2.1 software (bio-rad laboratories inc., ca, usa), with a normal range in healthy subjects was 169-705 ng/ml. the data were analyzed with spss for windows version 22. hypothesis testing of mmp-9 serum levels with alterations of the nihss score on a numerical scale, initially the kolmogorov smirnov test was carried out to see the normality of the data, because the data distribution was not normal then it was followed by the spearman rank correlation test.the cutoff point for mmp-9 serum level ≤48 hours of stroke onset as a predictor of clinical outcome in ischemic stroke patients was measured by a receiver operating characteristic (roc) curve prediction model test. results fifty one patients as subjects study follow the procedures. the characteristicof subjects shown in table 1. table 1. the characteristic of subjects variable(n=51) f % mean ± sd median(min-max) sex male female 28 23 54.9 45.1 age <65 years ≥65 years 32 19 62.7 37.3 dm yes no 18 33 35.3 64.7 hypertension yes no 41 10 80.4 19.6 bmi non obese obese 37 14 72.5 27.5 number and extent of infarct single lacunar multiple lacunar single territory 4 40 7 7.8 78.4 13.7 mmp-9 serum level ≤48 hours of stroke onset 1.223±719.72 1.035 (219 2928) normal (169-705 ng/ml) 12 23.53 high (>705 ng/ml) 39 76.47 nihss k0 (2 nd day onset) k1 (7 th day onset) k2 (14 th day onset) 7.47±3.512 6.86±3.715 5.88±3.675 7 (3 s/d 15) 6 (1 s/d 15) 4 (1 s/d 13) ∆ nihss k1-0 k2-0 -0.61±1.429 -1.59±1.824 -1 (-3 s/d 4) -2 (-5 s/d 4) international journal of human and health sciences vol. 06 no. 02 april’22 210 the characteristic subjects obtained that most of subjects were male (54.9%), (62.7%) were aged <65 years. there were (80.4%) suffering from hypertension, (35.3%) suffering from diabetes, (27.5%) suffering from obesity. the highest number and area of infarction were multiple lacuners (78.4%). the mean mmp-9 serum levels ≤48 hours of stroke onset was higher than the normal value, about 1,223.24±719.72 ng/ml, with a range of 219-2,928 ng/ml (median 1.035 ng/ml), and increased mmp-9 serum levels was present in majority of subjects (76.47%). the mean nihss score on 2nd day of stroke onset was 7.47±3.512, 7th day was 6.86±3.715, and 14th day was 5.88±3.675. the mean alterations of nihss score between 2nd and 7th day (k1-0) was -0.61±1.43, the mean alterations of nihss score between 2nd and 14th day (k2-0) was -1.59±1, 82. based on the results (table 2), the hypothesis that there is a significant correlation between mmp-9 serum levels ≤48 hours of stroke onset with alteration nihss score in 2nd and 7th day of stroke is proven (p 0.007) with a correlation coefficient 0.374. table 2. statistical test of the correlation between mmp-9 serum levels and alteration of nihss score between 2nd and 7th day of stroke onset variable n correlation coefficient(r) p** mmp-9 serum level ∆ nihss k1-0 51 0.374 0.007 ∫ statistical analysis using spearman’s test, ** significant when p <0.05 mmp-9 serum levels figure 1. correlation between mmp-9 serum levels ≤48 hours of stroke and alteration of nihss score between 2nd with 7th day of stroke onset (k1-0) figure 1 showed that increasing mmp-9 serum levels ≤48 hours of stroke onset there was a tendency for an increasing nihss score on the 7th day of stroke onset, this indicates a worsening clinical outcome. based on the results (table 3), the hypothesis that there is a significant correlation between mmp9 serum levels ≤48 hours of stroke onset with alteration nihss score in 2nd and 14th day of stroke is proven (p 0.005) with a correlation coefficient 0.386. table 3. statistical test of the correlation between mmp-9 serum levels and alteration of nihss score between 2nd with 14th day of stroke onset variable n correlation coefficient(r) p** mmp-9 serum level ∆ nihss k2-0 51 0,386 0.005∫ statistical analysis using spearman’s test, ** significant when p <0.05 mmp-9 serum levels figure 2. correlation between mmp-9 serum levels ≤48 hours of stroke and alteration of nihss score between 2nd with 14th day of stroke onset (k2-0) figure 2 showed that increasing mmp-9 serum levels ≤48 hours of stroke onset there was a tendency for an increasing nihss score on the 14th day of stroke onset, this indicates a worsening clinical outcome. discussion bloodbiomarkers are beginningtoshow a role in determiningthe diagnosis, management, and prognosis ofischemic stroke patients. althoughimagingtestplaythebiggestrole in determiningtherapy, blood biomarkers may 211 international journal of human and health sciences vol. 06 no. 02 april’22 havean important role when imagingis not available, orwhen making predictionsaboutfuture stroke complications and recurrentstroke events. many biomarker examinations have been investigated, andlevelsthat are higherthan normal in thepathophysiologyof stroke are consistently associated with worse outcomes.10 higher mmp-9 serum levelsin the acute phase of ischemic stroke was associated with an increased risk of mortality (or 1.29 95% ci 1.01-1.66) and major disability (or 1.12 95% ci 1.011.23). thus, mmp-9 serum levelscould be one of the important prognosis predictors in ischemic stroke.3 in this study,76.47% had high mmp-9 serum levels≤48 hours of stroke onset. the mean mmp-9 serum level was 1.223.24 ± 719.723 ng / ml, higher than its normal value of 169-705 ng / ml. this is consistent with previous study which stated that the increasing of mmp-9 activity was seen in human brain tissue at two days after cerebral infarction.5 stroke causes disruption of blood supply and oxygen in the brain, so stroke not only needs to be handled in post event, but also needs to be understood the cause of the occurrence by molecular. inflammation is correlated with secondary injury mechanism in acute ischemic stroke.11many studies conclude that mmp-9 serum levels that circulate in the acute phase of stroke were related to infarct volume and severity of stroke.12the results of this study were in accordance with previous studies, which reported that mmp-9 serum level ≤48 hours of stroke onset significantly correlated withthe alteration of nihss score; where there was a tendency for an increase in the nihss score on the 7th and 14th day follow-up of stroke onset by increasing mmp-9 serum level ≤48 hours of stroke onset. auc asymp. sig. sensitivity specificity cut-off point 0.797 0.001 0.730 0.714 899.5 figure 3. roc curve analysis related to the efficacy of mmp-9 serum levels for identifying clinical outcomes in acute ischemic stroke figure 4. mmp-9 serum levels related to clinical output in acute ischemic stroke based on the analysis of the roc curve, the optimal cut-off point for mmp-9 serum levels on the 21st axis is 899.5 ng / ml, which can identify the clinical outcome of acute ischemic stroke patients. mmp-9 serum level above 899.5 ng / ml is a predictor of worsening clinical outcomes, and auc value of 79.7% with a sensitivity of 73.0% and specificity of 71.4% (95% ci 0.643 0.952) indicated that the results of the above prediction model was statistically quite good. the limitations of this study was blood sampling only performed once on ≤48 hours of stroke onset and was not repeated either on the 7th or 14th day of stroke onset, so that it can be seen the difference in mmp-9 serum levels was correlated with the clinical outcome of acute ischemic stroke patients. measurement of biomarkers as a predictor of clinical outcome in this study is only one type (mmp-9 serum levels), so it is necessary to examine another panel of potential biomarkers related to the neuroinflammatory process in acute ischemic stroke, such as mmp-2, mmp-13, tnf-α, il-1β, etc. conclusion increasing of mmp-9 serum levels ≤48 hours of stroke onset are significantly correlated with worsening of nihss score between 2nd , 7th and 14thday of stroke onset in acute ischemic stroke. acknowledgement this study was supported by author and cointernational journal of human and health sciences vol. 06 no. 02 april’22 212 authors, faculty of medicine unissula, faculty of medicine undip, dr. kariadi hospital semarang, indonesia. ethical clearance was issued by the health research ethics commission of diponegorouniversity and dr. kariadi hospital no. 51/ec/fk-rsdk/2018. data gathering and idea owner of this study by author and co-authors, writing and submitting manuscript by author, editing and approval of final draft by author and co-authors. contribution of authors: data gathering and idea owner of this study: naili sofi riasari study design:naili sofi riasari and amin husni data gathering: naili sofi riasari writing and submission of manuscript: naili sofi riasari editing and approval of final draft:naili sofi riasari and dodiktugasworo references 1. misbach j. in : jannis j, soertidewi l. stroke; aspekdiagnostik, patofisiologi, manajemen. jakarta: badan penerbit fk ui. 2011 2. misbach j, lamsudin r, aliah a, basyiruddin a, suroto, nasution d, et al. guideline stroke. 2011. jakarta : perdossi. 2011 3. konstantin a, hossman, heiss wd. etiology, pathophysiology and imaging. neuropathology and pathophisiology of stroke 2nd ed. cambridge university press. 2014: p.1-10 4. miao y, liao jk. potential serum biomarkers in the pathophysiological processes of stroke. nih public access. expert rev neurother. 2014: 14(2): p.173185 5. rossel a, aznar ao, sabin ja, cadenas if, ribo m, molina ca, et al. increased brain expression of matrix metalloproteinase-9 after ischemic stroke and hemorrhagic human stroke. neurovascular research laboratory, barcelona spain. 2006 6. abdelnaseer mm, elfauomy nm, esmail e, kamal mm, elsawy eh. matrix metalloproteinase-9 and recovery of acute ischemic stroke. journal of stroke and cerebrovascular disease. 2016 7. kurzepa j, golab p, czerska s, bielewicz j. the significance of mmp-2 and mmp-9 in the ischemic stroke. international journal of neuroscience. 2014: p.1-10 8. maas mb, furie kl. molecular biomarkers in stroke diagnosis and prognosis. nih public access. biomark med. 2009; 3(4): p.363-83 9. zhao jh, xu ym, xing hx, su ll, tao sb, tian xj, et al. associations between matrix metalloproteinase gene polymorphisms and the development of cerebral infarction. genetic and molecular research. 2015; 14(4): 19418-424 10. katan m, elkind msv. the potential role of blood biomarkers in patients with ischaemic stroke : an expert opinian. clinical and translational neuroscience. january-june 2018; 1-7 11. endahwulandari, rr ayu fitrihapsari, hnedrobirowo. analysis of tgf-β1 and p53 expression in the blood of stroke patient. international journal of human and health sciences. vol. 05 no. 01 january’21, p: 35-40 12. wang b, wang y, zhao l. mmp-9 gene rs3918242 polymorphism increase risk of stroke : a metaanalysis. journal of cellular biochemistry wiley. 2018;1-8 international journal of human and health sciences vol. 03 no. 02 april’19 74 original article: comparing sociodemographicpredisposing factors in major depressive disorders (mdd) and controlsin kelantan, malaysia noor suryani mohd ashari1, mohd azhar mohd yasin2, siti nor fairus mohamed sanusi1, mohd nazri shafei3 abstract introduction: major depressive disorder (mdd) isexpected to become the second leading cause of worldwide disability by the year 2020 and the major contributor to the overall global burden of disease. objective: this study was done to compare sociodemographicpredisposingfactors in mdd patients and controls in kelantan, malaysia. methods: a total of 47 mdd patients and 47 healthy controls participated in this study. mdd patients were recruited from psychiatric clinic, husm and they were diagnosed according to dsm-v criteria. patients’ biodata, medical and psychiatric history were taken by physician. data were analysed using pearson chi-square and multiple logistic regression. results: in mdd group, 61.7% were females and 38.3% were males. forty two percent of mdd were in the age group of 45 to 65 years old and almost 12.8% of mdd patients had family history of depression, while all healthy controls were in good general health and had no family history of depression. pearson chi-square revealed that there were significant associations between smoking status (p=0.027), marital status (p=0.007) educational level (p=0.022) and area of living (p=0.0.036) with mdd. the results showed that unmarried person were less likely to have mdd compared to those married with adjusted odds ratio (or) of 0.31. smoker were 5.16 at odds of having mdd as compared to non-smoker, while individuals with a low education were more likely to have mdd compared to those highly educated with adjusted or of 2.04. the result also showed those living in urban area were less likely to have mdd compared to those living in rural area with adjusted or of 0.48. conclusion: higher age, female and positive family history possess a higher tendency of having mdd. in addition, smokers, married, less educated and living in rural area were more likely to have mdd compared to healthy controls. keywords: sociodemographic, predisposing factor, major depressive disorder correspondence to: noor suryani mohd ashari, department of immunology, school of medical sciences, , health campus, universiti sains malaysia, 16150, kubang kerian, kelantan. email: suryani@usm.my 1. department of immunology 2. department of psychiatry, 3. department of community medicine, school of medical sciences, health campus, universiti sains malaysia, 16150, kubang kerian, kelantan introduction major depressive disorder (mdd) is a common mental disorder characterized by sadness, loss of interest or pleasure, feelings of guilt or low selfworth, disturbed sleep or appetite, feelings of tiredness and poor concentration. it is a serious condition that can cause a variety of physical and emotional problems. mdd can affect all people regardless of age, geography, demography, or social position. according to the world health organization (who), an estimated 350 million people of all ages suffer from depression. mdd is projected to be the second leading cause of worldwide disability by the year 2020 and major contributor to the overall global burden of disease.3 in 2014, about 6.7% of the u.s population aged 18 and older had mdd. across the asia pacific region, the rates of current to 1-month mdd ranged from 1.3 to 5.5%, while in the previous year ranged from 1.7 to 6.7% . the lifetime occurrence of mdd worldwide is between 8 to 10% . in malaysia, mdd is expected to affect about 2.3 million people irrespectiveof the geographical international journal of human and health sciences vol. 03 no. 02 april’19 page : 74-79 doi: http://dx.doi.org/10.31344/ijhhs.v3i2.80 75 international journal of human and health sciences vol. 03 no. 02 april’19 differences of the study setting. while in the primary care population, the prevalenceranged from 6.7 to 14.4%.2 numerous studies have demonstrated that sociodemographic factors that may contributed to the development of this disease.this study was done to compare sociodemographicpredisposing factorsof mdd patients with healthy controls in kelantan, malaysia. methodology this was a cross-sectional study which was conducted among adult (aged between 18 to 65 years old) mdd patients and healthy controls. mdd patients were recruited from psychiatric out-patient clinic, hospital universitisains malaysia. the diagnosis of all eligible subjects were confirmed by a psychiatrist, according to the diagnostic and statistical manual for mental disorder v (dsm-v) and all those who consented and met the inclusion and exclusion criteria were enrolled into this study. all participating subjects continued to receive standard pharmacological and non-pharmacological treatments for mdd from the treating doctors at the clinic. control subjects were randomly recruited from hospital employees and students.all subjects were asked to complete depression anxiety scoring system (dass 21) questionnaire in order to ensure that they were in good general health and had no depressive symptoms. after getting the written consent, subject’s demographic data such as age, sex, race, family history, smoking status,marital status, educational level, and area of living were obtained through individual interview and from the patients’ medical record. all sociodemographic data were recorded in a study form. data were analysed using pearson chi-square and multiple logistic regression.this study was approved by research and ethics committee, universitisains malaysia. results a total of 47 mdd patients and 47 healthy controls were recruited in the study within january 2015 to february 2016.the mean age (sd) of mdd patients was 39.7 (13.07) years old with 42.5% of them were in the age group of 45 to 65 years old. while for healthy control, the mean age was 28.0 (8.69) years old and 46.8% of them were in the age group of 18 to 24 years old. the mean age (sd) of onset of mdd was 36.26 (11.88) years old. in mdd group, 29 (61.7%) were females and 18 (38.3%) were males, while in healthy control, 32 (68.1%) were females and 15 (31.9%) were males. majority of mdd patients and healthy controls were malays which accounted for 95.7% of study population, while the other 4.3% were chinese. almost 12.8% of mdd patient had family history of depression, while all healthy controls were in good general health and had no family history of depression. table 1: sociodemographic characteristics of mdd patients and healthy control mdd (n=47) healthy control (n=47) age mean (sd) 39.7 (13.07) 28.0 (8.69) age group, n (%) 18-24 9 (19.2) 22 (46.8) 25-44 18 (38.3) 21 (44.7) 45-65 20 (42.5) 4 (8.5) gender, n (%) male 18 (38.3) 15 (31.9) female 29 (61.7) 32 (68.1) race, n (%) malay 45 (95.7) 45 (95.7) chinese 2 (4.3) 2 (4.3) indian 0 (0.0) 0 (0.0) family history of dd, n (%) yes 6 (12.8) 0 no 41(87.2) 47 (100) age of onset of mdd mean (sd) 36.26 (11.88) chi-square analysis showed that sociodemographics factors including marital status (p = 0.007), smoking status (p = 0.027), educational level (p = 0.022) and area of living (p=0.036) were significantly associated with mdd.further analysis using multiple logistic regression revealed thatonly marital status (p = 0.011) was significantly associated with mdd after or (odds ratio) adjustment, while smoking status (p = 0.150) educational levels (p = 0.132) and area of living (p=0.174) were not significantly associated. the results also showed that unmarried individuals were less likely to have mdd compared to those married with adjusted or of 0.31. smokers were 5.16 at odds of having mdd as compared to nonsmoker, while lower educated individuals were international journal of human and health sciences vol. 03 no. 02 april’19 76 more likely to have mdd compared to higher educated with adjusted or of 2.04. the result also showed urban residents were less likely to have mdd compared to those living in rural area with adjusted or of 0.48. table 2: predisposing factors of major depressive disorder mdd n (%) control n (%) crude or (95% ci) p-valuea adjusted or (95% ci) p-valueb marital status unmarried 19 (37.25) 32 (62.75) 0.32 (0.14,0.74) 0.007* 0.31 (0.13,0.77) 0.011* married 28 (65.12) 15 (34.88) 1.00 1.00 smoking status smoker 7 (87.5) 1 (12.5) 8.05 (0.95,68.26) 0.027* 5.16 (0.55,48.04) 0.150 non-smoker 40 (46.51) 46 (53.49) 1.00 1.00 educational level low 26 (63.41) 15 (36.59) 2.64 (1.14,6.12) 0.022* 2.04 (0.81,5.14) 0.132 high 21 (39.62) 32 (60.38) 1.00 1.00 area of living urban 30 (43.48) 39 (56.52) 0.36 (0.14,0.91) 0.036* 0.48 (0.17,1.39) 0.179 rural 17 (68.00) 8 (32.00) 1.00 a pearson chi-square, bmultiple logistic regression (wald statistic), or: odds ratio, cl: confidence interval *results was significant as p<0.05 discussion in this study, the age of mdd patients range from 18 to 65 years old andthe rates was highest in those aged 45 to 65 years. few studies suggestedthat the age group may varies with sex8,9. rait et al. (2009) reported that the highest incidence for mdd was 25 to 44 years old for women and 44 to 65 years old for men.8 this finding was consistent with our study which also showed that the highest incidence rate for men was 44 to 65 year old, while for women was between 25 to 44 years old. mdd patients consists of 61.7% females and 38.3% males. epidemiological studies had consistently shown that women have greater incidence rates of mdd than men with a 2:1 female to male ratioregardless of racial, ethnicity or economic background10-12. the cause of this sex differences remain unclear. however, several hypotheses have been proposed. some studies suggested that biological factors such as genetic differences and hormonal changes may account for the sex difference13. other studies stated that psychosocial factors such as relationship issues, lack of social support and adverse experiences in life especially during childhood may have a greater impact in women than men, thereby increasing the incidence rate for mdd14,15, women also reported to have more depressive symptoms than men16. majority of our mdd patients were malays. however, a study on the prevalence of mdd in selangor, malaysia reported that the prevalence was highest among minority ethnic groups (e.g. iban, kadazan, orang asli, siam) (17.6%), followed by chinese (13.8%), malays (10.8%) and indians (6.1%).the fact that mdd patients and controls in this study population consists of mostly malays (95.7%) merely reflects the racial distribution in kelantan, where majority of the population are malay ethnicity. in this study, 12.8 % of mdd patients had family history of depression. it has been found that individuals with a first-degree depressivefamily memberswill experiencedtwo to tenfold greater risk of developing mdd18,19. perris and colleagues 77 international journal of human and health sciences vol. 03 no. 02 april’19 stated that patients without family history of depression would be genetically less vulnerable and, consequently that such patients would need more massive traumatic events to trigger depression than the patients with a family history of the disorder20. marital status has been found to be highly associated with the prevalence of mdd. this study showed that married person were at higher risk of having mdd compared to those unmarriedperson which include divorced/separated or single. few studies examine marital status differences in mdd in few countries showed different finding. a study in kangwha island,south korea, reported higher risk of mdd in married person compared to unmarried21, which is parallel with our study. however, survey studies in western countries like canada, netherland and united states showed that unmarried persons were more likely to have mdd22. stegenga et al. (2012) suggested that marital disruption enhance the risk of mdd among women, while being unmarried was a crucial risk factor for men23. our result showed that smokers were more likely to develop mdd compared to non-smokers. our results are in agreement with previous studies which also reported an increased odds of depression in smokers24,25. a population-based longitudinal norwegian studydemonstrateda dose-dependent relationship between smoking and depression; heavy smokers (>20 cigarettes per day) showedfourfold greater risk compared to those who had never smoked26. meanwhile, a retrospective australian study (10 years) found that the risk for developing mdd among heavy smokers were doubled25. these findings have shown that smoking is infact a major risk factor in the causal network leading to development of depression. a researcher indicated that nicotine use may increase susceptibility to depression because it influences several neurochemical systems (e.g acetylcholine and catecholamine systems)27, which may play an etiological role in depression28. futhermore, tobacco smoke generates free radicals, causing protein oxidationand subsequently,tissue damage29. depression has also been characterized byelevated levels of oxidative stress that are positively correlated with the severity of the depression30. epidemiological studies of mdd support an inverse association between the prevalence of mdd and the educational level31,32. in paneuropean study, higher education was associated with lower risk of mood disorder. the findings were consistent with our study which indicated that patients with lower educational level (primary and secondary school) have higher risk for mdd compared to those with higher educational level (diploma and above). in some developing countries, educational level were recognized as an important element that determine socioeconomic position and income obtained in later life33. people with a lower educational level generally have lower socioeconomic position and faced economic hardship like unemployment,financial strain and poverty. these standard of living were associated with an increase risk of mdd33,34. urban vs. rural residence was commonly cited as a risk factor for mdd and was identifiedas an etiology of this disorder35. rural area is defined as area with population less than 10 000 people, agriculture area, forests and water bodies. while urban area is characterized by higher population density of more than vast human features in comparison to area surrounding it. similar to breslau et al. (2014) and probst et al. (2006), our study showed that people living in rural area have higher risk for mdd compared to those living in urban area36,37, probstet al. (2006) suggested that rural communities were more likely to experienced mdd because of the circumstances, conditions, and behaviors that challenge their health37. conclusion higher age, female and positive family history possess a higher tendency of having mdd. in addition, smokers, married, less educated and living in rural area were significantlywere more likely to have mdd compared tohealthy control. ethical approval: the study was supported by a short term grant (304/ppsp/61313069) from universitisains malaysia conflict of interest: none acknowledgement: we are grateful to lecturers and staffs at department of immunology, doctors and nurses at psychiatric clinic, hospital universiti sains malaysia for their assistance throughout this study international journal of human and health sciences vol. 03 no. 02 april’19 78 references: 1. fava m, kendler ks. major depressive disorder. neuron 2000;28 (2):335-341. 2. mukhtar f, oei tps. a review on the prevalence of depression in malaysia. current psychiatry reviews 2011;7 (3):234-238. 3. world health organization. depression, http://www. who.int/mediacentre/factsheets/fs369/en/ (2016, accessed 14 june 2016). 4. national institute of mental health. brain stimulation therapies, http://www.nimh.nih.gov/health/topics/ brain-stimulation-therapies/brain-stimulationtherapies.shtml (2016, accessed 20 september 2016). 5. chiu e. epidemiology of depression in the asia pacific region. australasian psychiatry 2004;12 (sup1):s4-s10. 6. malaysian psychiatric association. depression, h t t p : / / w w w. p s y c h i a t r y m a l a y s i a . o rg / a r t i c l e . php?aid=56 (2006, accessed 4 september 2016). 7. ng cg. a review of depression research in malaysia. the medical journal of malaysia 2014;69 (suppl a):42-45. 8. rait g, walters k, griffin m, buszewicz m, petersen i, nazareth i. recent trends in the incidence of recorded depression in primary care. the british journal of psychiatry 2009;195 (6):520-524. 9. lee ct, chiang yc, huang jy, tantoh dm, nfor on, lee jf et al. incidence of major depressive disorder: variation by age and sex in low-income individuals: a population-based 10-year follow-up study. medicine 2016;95 (15):e3110. 10. kessler rc, berglund p, demler o, jin r, koretz d, merikangas kr et al. the epidemiology of major depressive disorder: results from the national comorbidity survey replication (ncs-r). jama 2003;289 (23):3095-3105. 11. bottomley c, nazareth i, torres-gonzález f, švab i, maaroos hi, geerlings mi et al. comparison of risk factors for the onset and maintenance of depression. the british journal of psychiatry 2010;196 (1):13-17. 12. van de velde s, bracke p, levecque k. gender differences in depression in 23 european countries. cross-national variation in the gender gap in depression. social science & medicine 2010;71 (2):305-313. 13. nolen-hoeksema s. gender differences in depression. current directions in psychological science 2001;10 (5):173-176. 14. piccinelli m, wilkinson g. gender differences in depression. the british journal of psychiatry 2000;177 (6):486-492. 15.accortt ee, freeman mp, allen jj. women and major depressive disorder: clinical perspectives on causal pathways. journal of women’s health 2008;17 (10):1583-1590. 16. poutanen o, koivisto am, mattila a, joukamaa m, salokangas rk. gender differences in the symptoms of major depression and in the level of social functioning in public primary care patients. the european journal of general practice 2009;15 (3):161-167. 17. kader maideen sf, sidik sm, rampal l, mukhtar f. prevalence, associated factors and predictors of depression among adults in the community of selangor, malaysia. plos one 2014;9 (4):e95395. 18. wallace j, schnieder t, mcguffin p. genetics of depression. in i. h. gotlib & c. l. hammen (eds.), handbook of depression 2002; new york, ny, us: guilford press:169-191. 19. goodwin fk, jamison kr. manic-depressive illness: bipolar disorders and recurrent depression (vol. 1) 2007;oxford university press. 20. perris h, von knorring l, perris c. genetic vulnerability for depression and life events. neuropsychobiology 1982;8 (5):241-247. 21. lee h. the kangwha epidemiological study of mental disorders: methodological considerations. methods and applications in mental health surveys: the todai health index 1991;211-227. 22. andrade l, caraveo‐anduaga jj, berglund p, bijl rv, graaf rd, vollebergh w et al. the epidemiology of major depressive episodes: results from the international consortium of psychiatric epidemiology (icpe) surveys. international journal of methods in psychiatric research 2003;12 (1):3-21. 23. stegenga bt, king m, grobbee de, torres-gonzález f, švab i, maaroos hi et al. differential impact of risk factors for women and men on the risk of major depressive disorder. annals of epidemiology 2012;22 (6):388-396. 24. hamalainen j, kaprio j, isometsa e, heikkinen m, poikolainen k, lindeman s et al. cigarette smoking, alcohol intoxication and major depressive episode in a representative population sample. journal of epidemiology and community health 2001;55 (8):573-576. 25. pasco ja, williams lj, jacka fn, ng f, henry mj, nicholson gc et al. tobacco smoking as a risk factor for major depressive disorder: population-based study. the british journal of psychiatry 2008;193 (4):322-326. 26. klungsøyr o, nygård jf, sørensen t, sandanger i. cigarette smoking and incidence of first depressive episode: an 11-year, population-based follow-up study. american journal of epidemiology 2006;163 (5):421-432. 27. pomerleau of, pomerleau cs. neuroregulators and the reinforcement of smoking: towards a biobehavioral explanation. neuroscience & biobehavioral reviews 1985;8 (4):503-513. 28. carmody tp, vieten c, astin ja. negative affect, emotional acceptance, and smoking cessation. journal of psychoactive drugs 2007;39 (4):499-508. 29. ozguner f, koyu a, cesur g. active smoking causes oxidative stress and decreases blood melatonin levels. toxicology and industrial health 2005;21 (10):21-26. 30. yanik m, erel o, kati m. the relationship between potency of oxidative stress and severity of depression. acta neuropsychiatrica 2004;16 (4):200-203. 31. lorant v, deliège d, eaton w, robert a, philippot p, ansseau m. socioeconomic inequalities in depression: a meta-analysis. american journal of 79 international journal of human and health sciences vol. 03 no. 02 april’19 epidemiology 2003;157 (2):98-112. 32. alonso j, angermeyer mc, bernert s, bruffaerts r, brugha ts, bryson h et al. (2004). 12‐month comorbidity patterns and associated factors in europe: results from the european study of the epidemiology of mental disorders (esemed) project. acta psychiatrica scandinavica 2004, 109(s420),28-37. 33. shi j, zhang y, liu f, li y, wang j, flint j et al. associations of educational attainment, occupation, social class and major depressive disorder among han chinese women. plos one 2014;9 (1):e86674. 34. lorant v, croux c, weich s, deliège d, mackenbach j, ansseau m. (2007). depression and socioeconomic risk factors: 7-year longitudinal population study. the british journal of psychiatry 2007;190 (4):293-298 35. wang jl. rural–urban differences in the prevalence of major depression and associated impairment. social psychiatry and psychiatric epidemiology 2004;39 (1):19-25. 36. breslau j, marshall gn, pincus ha, brown ra. are mental disorders more common in urban than rural areas of the united states? journal of psychiatric research 2014;56:50-55. 37. probst jc, laditka sb, moore cg, harun n, powell mp, baxley eg. rural-urban differences in depression prevalence: implications for family medicine. family medicine-kansas city2006;38 (9):653-660. s18 effect of health messages during dental treatment in improving covid-19 preventive health behaviour: a randomised controlled trial normaliza ab malik, azlan jaafar, aws hashim ali al-khadim objectives. preventive health behaviour is essential during dental visits to ensure the environment is safe for dental healthcare providers and patients attending the dental clinic. this study investigates the effectiveness of informational health messages during dental treatment to enhance covid-19 preventive health behaviour among dental patients. methods. a randomised controlled trial was conducted among patients visiting dental practices during the covid-19 pandemic. the test group was given an audio device containing health messages related to covid-19 and the importance of preventive health behaviour. a piece of relaxing instrumental music accompanied the information. the control group was given the same relaxing instrumental music only without any health information. a questionnaire, comprising five sections, was adapted and extracted from the who resources, guidance and protocol to suit the study objectives related to pandemic knowledge and preventive health behaviour. results. a total of 130 patients participated in the study, with 65 patients in each group. the participants’ age ranged from 18 to 77 years old. more than half of the participants were female (65.4%), and 91.5% claimed no chronic illnesses. more than half of the participants in the test group performed hand cleaning behaviour immediately after treatment (62.5%) and at the counter after completing the treatment (52.8%) compared to the control group. however, there was no significant difference between the two groups. both groups showed significant differences in their preventive health behaviour before and after treatment (p<0.001). higher knowledge and self-efficacy levels were found in the test group compared to the control group, but there were no significant differences between the two groups (p>0.05). there was a significant difference in the awareness level between the test and control group (p=0.007). conclusion. an informational health message delivered using an audio device during dental treatment was effective in improving covid-19 preventive health behaviour among dental patients. thus, this study has shown the potential effect of using an audio device during dental treatment to disseminate health information, particularly during unprecedented health events such as the covid-19 outbreak. keywords: covid-19, music, dental patient, behaviour _________________________________________________________________________ correspondence to: dr normaliza ab malik, associate professor, faculty of dentistry, universiti sains islam malaysia, liza_amalik@usim.edu.my, liza_arie2004@yahoo.com __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v6i0.408 mailto:liza_amalik@usim.edu.my mailto:liza_arie2004@yahoo.com microsoft word ijhhs imam 23rd asc 2022 s18 management in maeps 2.0 quarantine centre: burnout and quality of life of moh healthcare workers  noraziani khamis1, muniamal krishnan1, fairuz nadiah nordin1, sunita s. shanmugam1, ku anis  shazura indera putera1   objectives: malaysia agro exposition park serdang, maeps was established as a covid-19 quarantine and low-risk treatment centre that was aimed to reduce the burden of hospitals. various categories of healthcare workers (hcws) were deployed nationwide. being far from home and friends, working in an unfamiliar environment, and being concerned about one's own risk of covid-19 exposure may exacerbate burnout in hcws or affect their quality of life. assessment on burnout and quality of life among moh hcws stationed at maeps 2.0 and the management of the healthcare workforce during the pandemic are shared. methods: a cross-sectional survey was conducted between september 2021 to may 2022. the copenhagen burnout inventory and the world health organization quality of life questionnaire were used to assess burnout and quality of life of moh hcws respectively. the checklist for the management of health workers in response to covid-19 consisting of 8 essential actions was given to heads of divisions in charge to obtain their perspective. one point assigned to the intervention answered “yes” by the majority of respondents. cumulative marks were then converted to percentages according to each essential action. results: the rate of burnout ranged between 18% to 32% among the 377 respondents.  majority of hcws had a good and very good perception of their quality of life and were satisfied with their overall health. there were moderate to strong correlations (r = 0.44 0.67) between burnout and quality of life (p<0.001). more than half of the eight essential actions in the checklist scored 100%. conclusion: management of workers is important to ensure preparedness for response, enhance surge capacity and maintain crucial health services during the pandemic. some hcws experienced burnout and it relates to their quality of life. nonetheless, moh hcws management at maeps 2.0 was managed with minimum gaps against the checklist.  keywords: burnout, quality of life, healthcare management, healthcare workforce, quarantine centre 1. institute for health management, nih, moh ___________________________________________________________________________ correspondence to: noraziani khamis, head of center, institute for health management, nih, moh, malaysia, noraziani17@yahoo.com _________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v7i70.520 s29 identification of the use of substances among orthodontic patients lim yan jia1, tan jia yi1, nurul asyikin yahya2, asma alhusna abang abdullah3 objective: substance abuse among the youth is rising and may cause abnormal manifestation in the oral cavity. hence, the orthodontic dental setting is a potential venue to detect substance abuse among these young patients. this study aimed at identifying the use of substances among young adults attending orthodontic clinics and describing their oral manifestations related to the substances. methods: a cross-sectional study was conducted between the periods of october 2020 to january 2021. identification of substance abuse was done to 138 orthodontic patients aged 15 to 30 years old using an online validated questionnaire. the validated questionnaire included the patient's demographic data and their use of substances i.e. tobacco, vape and alcohol. 47 subjects were clinically assessed for intraoral manifestations of substance use. ethical approval and consent from all subjects were sought prior to the start of the recruitment. results: the prevalence of subjects who smoke was 2.9%. a total of 4.35% and 15.22% of the respondents were identified as vape users and alcohol users, respectively. however, none of the respondents were abusers or dependents based on the frequency and duration of the usage. for the clinical examination, nicotine stomatitis was detected in one subject (2.13%). periodontal status with bpe ≥ 3 was identified in 24 subjects (51.06%). tooth staining was detected on 5 subjects (11.90%) and dental erosion was identified in one subject (2.13%). dental attrition was found on 15 subjects (31.91%). conclusion: a minority of young adults attending an orthodontic clinic are light users of either cigarettes, vapes or alcohol. intraoral manifestations of substance usage were also minimal. keywords: smokers, substance abuse, orthodontic clinic ___________________________________________________________________________ 1final year dental student, faculty of dentistry, universiti kebangsaan malaysia 2dental public health specialist/lecturer, faculty of dentistry, universiti kebangsaan malaysia 3orthodontic specialist/lecturer, faculty of dentistry, universiti sains islam malaysia correspondence to: dr asma alhusna abang abdullah, associate professor, faculty of dentistry, universiti sains islam malaysia, malaysia, asmaabdullah@usim.edu.my __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v6i0.419 mailto:asmaabdullah@usim.edu.my microsoft word ijhhs imam 23rd asc 2022 s24 qualitative exploration of men’s opinion on the features of male-friendly primary health services in kelantan, malaysia muhammad zikri ab aziz1, tengku alina tengku ismail1, mohd ismail ibrahim1, najib majdi yaacob1, zakiah mohd said2 objectives: this study explores men’s opinions on the features of male-friendly primary health services in kelantan, malaysia. methods: a qualitative study using in-depth interviews was conducted among 15 men from six primary health clinics in kelantan, malaysia. the participants were selected using a maximum variation sampling method. an interview guide was used, and the interviews were audio-recorded. the finding was transcribed verbatim and analysed using thematic analysis techniques. results: the age of the participants ranged from 31 to 70 years old. their opinions on how malefriendly primary health services should be were explained under four themes:(i) meeting the men’s needs in primary health services, (ii) approaching men through effective health promotion strategies, (iii) standards of a healthcare provider from men’s viewpoint, and (iv) a comfortable physical environment for men. the participants view that health services should be efficient by providing short waiting times and high-quality services, including men’s health services. in addition, the health promotion approaches and styles should consider local men’s culture and interests and be appropriately implemented. besides that, they expected a standard of healthcare provider’s characteristics, including commitment to work, admirable attitudes and behaviour, and professional work practices. they also expected the health clinics to have a comfortable environment to wait, discuss with the doctors, and be equipped with visitor-friendly amenities. conclusion: understanding the men’s opinions on the features of male-friendly primary health services would give clear and accurate information about their needs and demands in relation to this service. in addition, the identified themes and features may guide the improvement of the services and men’s engagement in the future. keywords: opinions, male-friendly, primary health, qualitative   1. school of medical sciences, health campus, universiti sains malaysia, kubang kerian, 16150, kota bharu, kelantan, malaysia 2. family health development division, ministry of health malaysia, 62590, putrajaya, malaysia ___________________________________________________________________________ correspondence to: muhammad zikri ab aziz, drph candidate, school of medical sciences, universiti sains malaysia, kubang kerian, 16150, kota bharu, kelantan, malaysia, zikriabaziz89@gmail.com __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v7i70.526 161 international journal of human and health sciences vol. 06 no. 02 april’22 original article a cross sectional study on scaling the depression, anxiety and stress level of medical students during covid-19 in a tertiary level medical institution in india anamika nath 1 , amarantha donna ropmay2, daunipaia slong3, amar jyoti patowary4, dev ashis ramu damu5, ankith jonpelly6, kishanth shankar6, prabal das6 abstract background: social distancing, closure of institutions and lockdown has impacted the minds of all. medical students are no exception to this. objective: this study was taken up to find out the level of depression, anxiety and stress of medical students during covid-19. methods: it was a crosssectional study done at a tertiary institute for a period of one month in the middle of 2021. an online questionnaire, based on dass 21 (depression, anxiety, and stress scale 21) scale, consisted of 7 questions each for each category viz. depression, anxiety and stress. while completing the dass 21 questionnaire, each individual was required to indicate the presence of a symptom over the previous week. chi-square test was used to analyze between the categorical variables. results: out of 183 study subjects, 16.39% had extremely severe depression, 13.66% extremely severe anxiety and 7.65% extremely severe stress. development of anxiety with sex (p=0.04), and age (p=0.03), depression with age (p=0.02), development of depression with place of stay (p=0.04), and year of mbbs (p=0.0007) and anxiety with year of mbbs (p=0.0006) were found to be statistically significant. conclusion: development of depression, anxiety and stress in medical students must be recognized by the institution and measures for prevention like counselling facilities should be provided. keywords: depression, anxiety, stress, medical students, covid-19. correspondence to: dr. amar jyoti patowary, professor & head, department of forensic medicine & toxicology, north eastern indira gandhi regional institute of health & medical sciences (neighrims), shillong, meghalaya, india, email: drajpatowary@gmail.com 1. demonstrator, department of forensic medicine & toxicology, tezpur medical college and hospital (tmch), tezpur, assam, india. 2. associate professor, department of forensic medicine & toxicology, north eastern indira gandhi regional institute of health & medical sciences (neighrims), shillong, meghalaya, india. 3. assistant professor, department of forensic medicine & toxicology, north eastern indira gandhi regional institute of health & medical sciences (neighrims), shillong, meghalaya, india. 4. professor & head, department of forensic medicine & toxicology, north eastern indira gandhi regional institute of health & medical sciences (neighrims), shillong, meghalaya, india. 5. assistant professor, department of forensic medicine & toxicology, sikkim manipal institute of medical sciences (smims), sikkim, india. 6. postgraduate trainee, department of forensic medicine & toxicology, north eastern indira gandhi regional institute of health & medical sciences (neighrims), shillong, meghalaya, india. international journal of human and health sciences vol. 06 no. 02 april’22 page : 161-167 doi: http://dx.doi.org/10.31344/ijhhs.v6i2.439 introduction covid-19 is a pandemic which has been spreading like a wildfire. there is no country which is spared from it. along with any pandemic, comes the aftermaths of scarcity of resources, mortality and morbidity. one such morbidity is psychiatric and psychological diseases. on top of it, social distancing has made humans crave for human interactions and as such isolations and quarantines have possibly affected the minds of all. restrictions on social gatherings and festivities have created a new normal situation. social stigmas and taboos towards healthcare professionals are also seen to increase in recent times. adjusting to this current scenario is a herculean task for all. medical students who are the future care providers must be mentally strong in order to overcome any inadvertent situations that may arise during their international journal of human and health sciences vol. 06 no. 02 april’22 162 trainings, medical practice or home affairs. who in its preamble to the constitution has taken a holistic approach of health, which includes a state of complete physical, mental and social wellbeing and not merely absence of disease or deformity as stated by the world health organization in its definition of health.1 also, this pandemic has shown us increase in suicide rates amongst medical professionals. also worries regarding completion of medical graduation may be there. hence, the future doctors should be assessed for any psychological or psychiatric symptoms from time to time, in order to prevent any misadventure or tragedies. this study intended to assess the depression, anxiety and stress level in medical students of a centralized medical college in the northeast part of india. depending on the results obtained from it, preventive measures and lifestyle modifications will be suggested. this research is the need of the hour as covid-19 and the new normal situation it has brought, has affected the minds of all. anxiety and depression are on the rise. medical students, who are the future doctors, are no exception in this. this is the first of its kind research in meghalaya state, india. methods this was a cross-sectional study done in a tertiary level medical institution in india for a period of one month in the middle of 2021. medical students who gave consent for participation in this research study were taken as study participants. convenience sampling method was used. online google forms were provided to them through their email address. age, sex, study year of mbbs, place of stay – all were noted as independent variables. the dependent variables were the level of depression, anxiety and stress. the participation was totally anonymous. consent forms were provided before the questionnaires if they agreed to participate in this study and then they were given an option to select and accordingly the page of questionnaire consisting of 21 questions; each could have been opened. questionnaires were based on dass 21 (depression, anxiety, and stress scale 21) scale and scores were given accordingly.2 it consisted of 7 questions each for each category viz. depression, anxiety and stress. while completing the dass 21 questionnaire, each individual was required to indicate the presence of a symptom over the previous week. each item was scored from 0 (did not apply to me at all over the last week), 1(applied to me to some degree, or some of the time), 2(applied to me to a considerable degree or a good part of time) and 3(applied to me very much or most of the time over the past week). based on the scores, level of depression, anxiety and stress were determined. for depression, scores of 0-9 were considered normal, 10-14 as mild, 14-20 as moderate, 21-27 as severe, and more than 27 as extremely severe. for anxiety, scores of 0-7 were considered normal, 8-9 as mild, 10-14 as moderate, 15-19 as severe, and more than 19 as extremely severe. for stress, scores of 0-14 were considered normal, 15-18 as mild, 19-25 as moderate, 26-33 as severe, and more than 33 as extremely severe. data were entered in microsoft excel software and had been analysed accordingly. chi-square test was used to compare the categorical variables. results out of 183 participants, 22 (12.02%) were found to be having mild depression, 32 (17.49%) were found to have moderate depression and 22 (12.02%) were found to have severe depression, 30 (16.39%) were found to have extremely severe depression (tables 1-4). out of 183 participants, 8 (4.37%) were found to have mild anxiety, 36 (19.67%) were found to have moderate anxiety, 22 (12.02%) were found to have severe anxiety and 25 (13.66%) were found to have extremely severe anxiety (tables 5-8). out of 183 participants, 23 (12.56%) were found to have mild stress, 33 (18.03%) were found to have moderate stress, 28 (15.30%) were found to have severe stress, 14 (7.65%) were found to have extremely severe stress (tables 9-12). chi-square test was conducted to test significance of age, sex, year of mbbs and place of stay with development of depression, anxiety and stress. there was no statistically significant difference in development of depression with sex (p=0.866) and stress (p=0.564), but significant difference found in case of anxiety (p=0.04). development of depression and anxiety with age was statistically significant (p=0.03 and p=0.02 respectively), but not with stress (p=0.11). development of depression with place of stay was found to be statistically significant (p=0.04) except in anxiety (p=0.14) and stress (p=0.78). difference in development of depression and anxiety with year of mbbs was found to be statistically significant (p=0.0007 and p=0.0006 respectively), except in stress (p=0.45). 163 international journal of human and health sciences vol. 06 no. 02 april’22 table 1: distribution of levels of depression among participants based on sex level of depression male female total percentage normal 42 (44.21%) 35 (39.77%) 77 42.08 mild 12 (12.63%) 10 (11.36%) 22 12.02 moderate 16(16.84%) 16 (18.18) 32 17.49 severe 12 (12.63%) 10 (11.36%) 22 12.02 extremely severe 13 (13.68%) 17 (19.31%) 30 16.39 total 95 88 183 100 table 2: distribution levels of depression among participants against age level of depression 18 years 19 years 20 years 21 years 22 years 23 years 24 years 25 years 26 years total percentage normal 0 2(20%) 7 (25.92%) 13 (40.62%) 21 (42%) 22 (64.70%) 10 (52.63%) 2 (25%) 0 77 42.08 mild 0 2(20%) 4 (14.81%) 3 (9.37%) 4 (8%) 3 (8.82%) 3 (15.79%) 2 (25%) 1 (50%) 22 12.02 moderate 0 0 4(14.81%) 9 (4.92%) 9 (18%) 5 (14.70%) 1 (5.26%) 3 (37.5%) 1 (50%) 32 17.49 severe 1(100%) 3 (30%) 4 (14.81%) 1 (3.12%) 7 (14%) 2 (5.88%) 4 (21.05%) 0 0 22 12.02 extremely severe 0 3 (30%) 8 (29.63%) 6 (18.75%) 9 (18%) 2 (5.88%) 1 (5.26%) 1 (12.5%) 0 30 16.39 total 1 10 27 32 50 34 19 8 2 183 100 table 3: distribution levels of depression among participants against place of stay level of depression home institution total percentage normal 26 (45.61%) 51 (40.48%) 77 42.08 mild 3 (5.26%) 19 (15.08%) 22 12.02 moderate 14 (24.56%) 18 (14.28%) 32 17.49 severe 9 (15.79%) 13 (10.32%) 22 12.02 extremely severe 5 (8.77%) 25 (19.84%) 30 16.39 total 57 126 183 100 table 4: distribution levels of depression among participants against year of mbbs level of depression 1st year 2nd year 3rd year part-i 3rd year part-ii total percentage normal 11 (25.58%) 15 (35.71%) 35 (66.04%) 16 (35.55%) 77 42.08 mild 2 (4.65%) 8 (19.05%) 4 (7.55%) 8 (17.77%) 22 12.02 moderate 8 (18.60%) 10 (23.81%) 7 (13.21%) 7 (15.55%) 32 17.49 severe 7 (16.28%) 4 (9.52%) 4 (7.55%) 7 (15.55%) 22 12.02 extremely severe 15 (34.88%) 5 (11.90%) 3 (5.66%) 7 (15.55%) 30 16.39 total 43 42 53 45 183 100 international journal of human and health sciences vol. 06 no. 02 april’22 164 table 5: distribution level of anxiety among participants based on sex level of anxiety male female total percentage normal 56(58.95%) 36 (40.91) 92 50.28 mild 2(2.10%) 6 (6.81) 8 4.37 moderate 19(20%) 17 (19.32) 36 19.67 severe 10(10.53%) 12 (13.64) 22 12.02 extremely severe 8(8.42%) 17 (19.32) 25 13.66 total 95 88 183 100 table 6: distribution levels of anxiety among participants against age level of anxiety 18 years 19 years 20 years 21 years 22 years 23 years 24 years 25 years 26 years total percentage normal 0 6 (60%) 9 (33.33%) 13 (40.62%) 23 (46%) 26 (76.47%) 12 (63.16%) 2 (25%) 1(50%) 92 50.28 mild 0 0 1 (3.70%) 1 (3.12%) 2 (4%) 2 (5.88%) 1 (5.26%) 1 (12.5%) 0 8 4.37 moderate 0 0 4 (14.81%) 10 (31.25%) 10 (20%) 4 (11.76%) 4 (21.05%) 3 (37.5%) 1 (50%) 36 19.67 severe 1 (100%) 0 5 (18.52%) 5 (15.62%) 7 (14%) 2 (5.88%) 0 2(25%) 0 22 12.02 extremely severe 0 4 (40%) 8 (29.63%) 3 (9.37%) 8 (16%) 0 2 (10.52%) 0 0 25 13.66 total 1 10 27 32 50 34 19 8 2 183 100 table 7: distribution levels of anxiety among participants against place of stay level of anxiety home institution total percentage normal 28 (49.12%) 64 (50.79%) 92 50.28 mild 1 (1.75%) 7 (5.55%) 8 4.37 moderate 15 (26.31%) 21 (16.66%) 36 19.67 severe 9 (15.79%) 13 (10.32%) 22 12.02 extremely severe 4 (7.01%) 21 (16.66%) 25 13.66 total 57 126 183 100 table 8: distribution levels of anxiety among participants against year of mbbs level of anxiety 1st year 2nd year 3rd professional part-i 3rd professional part-ii total percentage normal 14 (32.56%) 21 (50%) 35 (66.03%) 22 (48.88%) 92 50.28 mild 2 (4.65%) 1 (2.38%) 2 (3.77%) 3 (6.66%) 8 4.37 moderate 5 (11.63%) 9 (21.43%) 8 (15.09%) 14 (31.11%) 36 19.67 severe 7 (16.28%) 7 (16.66%) 6 (11.32%) 2 (4.44%) 22 12.02 extremely severe 15 (34.88%) 4 (9.52%) 2 (3.77%) 4 (8.88%) 25 13.66 total 43 42 53 45 183 100 165 international journal of human and health sciences vol. 06 no. 02 april’22 table 9: distribution of levels of stress among participants based on sex level of stress male female total percentage normal 46 (48.92%) 39 (44.32%) 85 46.46 mild 14 (14.74%) 9 (10.22%) 23 12.56 moderate 15 (15.79%) 18 (20.45%) 33 18.03 severe 15 (15.79%) 13 (14.77%) 28 15.30 extremely severe 5 (5.26%) 9 (10.22%) 14 7.65 total 95 88 183 100 table 10: distribution levels of stress among participants against age level of stress 18 years 19 years 20 years 21 years 22 years 23 years 24 years 25 years 26 years total percentage normal 0 3 (30%) 9 (33.33%) 13 (40.62%) 24 (48%) 20 (58.82%) 11 (57.89%) 5 (62.5%) 0 85 46.46 mild 0 2 (20%) 6 (22.22%) 3 (9.37%) 4 (8%) 4 (11.76%) 1 (5.26%) 1 (12.5%) 2 (100%) 23 12.56 moderate 1 (100%) 3 (30%) 4 (14.81%) 8 (25%) 10 (20%) 2 (5.88%) 4 (21.05%) 1 (12.5%) 0 33 18.03 severe 0 1 (10%) 6 (22.22%) 3 (9.37%) 7 (14%) 8 (23.53%) 2 (10.53%) 1 (12.5%) 0 28 15.30 extremely severe 0 1 (10%) 2 (7.41%) 5 (15.62%) 5 (10%) 0 1 (5.26%) 0 0 14 7.65 total 1 10 27 32 50 34 19 8 2 183 100 table 11: distribution levels of stress among participants against place of stay level of stress home institution total percentage normal 23 (40.35%) 62 (49.20%) 85 46.46 mild 9 (15.79%) 14 (11.11%) 23 12.56 moderate 11 (19.30%) 22 (17.46%) 33 18.03 severe 10 (17.54%) 18 (14.28%) 28 15.30 extremely severe 4 (7.01%) 10 (7.94%) 14 7.65 total 57 126 183 100 table 12: distribution levels of stress among participants against year of mbbs level of stress 1st year 2nd year 3rd professional part-i 3rd professional part-ii total percentage normal 15 (34.88%) 18 (42.85%) 31 (58.49%) 21 (46.66%) 85 46.46 mild 5 (11.62%) 6 (14.28%) 8 (15.09%) 4 (8.88%) 23 12.56 moderate 10 (23.25%) 7 (16.66%) 9 (16.98%) 7 (15.55%) 33 18.03 severe 8 (18.60%) 7 (16.66%) 3 (5.66%) 10 (22.22%) 28 15.30 extremely severe 5 (11.62%) 4 (9.52%) 2 (3.77%) 3 (6.66%) 14 7.65 total 43 42 53 45 183 100 international journal of human and health sciences vol. 06 no. 02 april’22 166 discussion on march 18, 2020, who has released one pamphlet named “mental health and psychosocial considerations during the covid-19 outbreak”, where special mention has been given to mental wellbeing of healthcare professionals since it is expected that they will be under increased pressure of work and deprivation of sleep. many might cope up stress by unhelpful strategies like addiction to tobacco, alcohol, drugs also being victims of taboos and social stigma from family members and community; they might undergo anxiety and mental depression.3 one article published in journal of intensive and critical care published on 10 june, 2020 stated that “during the covid-19 out-break, the front-line health care workers have experienced various levels of stress, anxiety, and insomnia. targeted interventions are needed to enhance psychological wellbeing of health care workers and strengthen the healthcare systems’ capacity during pandemic.4 another article published in journal of experimental and therapeutic medicine states similar scenarios where healthcare workers are dealing with unparalleled amount of stress during covid-19.5 many researchers are promoting digital learning packages for healthcare workers on how to cope up with stress as per an article published in international journal of environmental and public health.6 one research conducted on australian medical students show that there was moderate psychological distress amongst them. there were main concerns about returning back to normal procedures of study and graduation. deterioration of mental health since the onset of covid-19 was reported by 68% of students. main negative impacts were on social connectedness, studies and stress levels.7 one systemic review and metaanalysis shows that even before covid-19 the overall prevalence of depression or depressive symptoms among medical students was 27.2%, and the overall prevalence of suicidal ideation was 11.1%. among medical students who screened positive for depression, 15.7% sought psychiatric treatment.8 in pakistan journal of medical sciences, one article was published regarding the impact of quarantine on medical students’ mental wellbeing and learning behaviours had findings that 44.1% showed a sense of being emotionally detached from family, friends and fellow students, 23.5% medical students felt disheartened. 56.2% of the total students stated that they had difficulty in studying and the time of studying was remarkably reduced. medical students of both sexes has been found to have done work which were not satisfactory as compared to their earlier individual performances.9 nicholas et al. summarized different studies conducted by researchers on medical students’ wellbeing and found out that near about 25% experienced tension manifestations, which were emphatically associated with expanded worries about scholarly deferrals, monetary impacts of the pandemic, and effects on day by day life.10 hence anxiety and depression has been seen on rise amongst medical students therefore, this current study will provide an insight about similar conditions here and hence remedial measures can be taken. in our study we have found out that 42.08% of the subjects were normal while remaining had some levels of depression. in our study it is stated that 50.28% of the study subjects were normal while the rest had some levels of anxiety. moreover, it was found out that 46.46% of the study participants were normal while the others had some levels of stress. it is, indeed, a sad state of affair that nearly half of the medical students have some or other levels of depression, anxiety and stress. a study conducted at kathmandu university school of medical sciences, nepal, revealed that 11.8% of students had anxiety, 5.5% had depression, and 9.4% had both anxiety and depression.11 another study conducted at jamnagar city by vala and colleagues only on 1st year mbbs students during covid-19 pandemic found that 17.20% of the students had anxiety, 15.60% of them had stress, and 10.80% had depression.12 another study conducted by pandey and colleagues, they found female medical students had higher anxiety and depression as compared to their male counterparts.13 in our study, females had more extreme levels of depression, anxiety and stress than the male participants. those who lived in the institutional campus during the lockdown and could not go to their respective homes bore extreme levels of depression, anxiety and stress as compared to their friends who stayed at their homes with their families. another study conducted by saraswathi et al. found that levels of stress and anxiety in medical students had increased in covid-19 and had factors affecting like gender, age, year of mbbs and place of stay but not prevalence of depression.14 all these studies put a light on the dark situation of medical students on matters of the mind which are often ignored by the institution, their teachers and even their family 167 international journal of human and health sciences vol. 06 no. 02 april’22 and friends. these issues need to be addressed by formation of counselling cells for medical students and appointment of psychologists and psychiatrists who would be devoted for upliftment of mind and treating mental illnesses of medical students in every institute. limitations this study was conducted on undergraduate students in a single medical institution. more studies in different institutes can be compiled for a better understanding on the levels of depression, anxiety and stress born by medical students in the current covid-19 pandemic. conclusion our data suggest that among 183 study subjects, 16.39% had extremely severe depression, 13.66% extremely severe anxiety and 7.65% extremely severe stress. development of anxiety with sex (p=0.04), and age (p=0.03), depression with age (p=0.02), place of stay (p=0.04), and year of mbbs (p=0.0007) and anxiety with year of mbbs (p=0.0006) were found to be statistically significant. development of depression, anxiety and stress in medical students must be recognized by the respective institution and measures for prevention like counselling facilities should be provided. conflict of interest: none declared. ethical clearance: ethical clearance received from institutional ethics committee of north eastern indira gandhi regional institute of health & medical sciences (neighrims), shillong, meghalaya, india (neigr/iec/m13/f3/2020). funding statement: no funding. authors’ contribution: concept and design: an, adr, ds, ajp; data collection and analysis: an, dard, aj, ks, pd; manuscript writing and revision: an, adr, ds, ajp, dard, aj, ks, pd. references: 1. world health organization (who). who_ constitution_en.pdf [internet]. [cited jan 12, 2021]. available from: https://www.who.int/governance/eb/ who_constitution_en.pdf. 2. lovibond pf, lovibond sh. the structure of negative emotional states: comparison of the depression anxiety stress scales (dass) with the beck depression and anxiety inventories. behav res ther. 1995;33(3):335-43. 3. world health organization (who). mental-healthconsiderations.pdf [internet]. [cited jan 8, 2021]. available from: https://www.who.int/docs/defaultsource/coronaviruse/mental-health-considerations.pdf. 4. jansson m, rello j. mental health in healthcare workers and the covid-19 pandemic era: novel challenge for critical care. j intensive crit care. 2020;6(2):6. 5. tsamakis k, rizos e, manolis aj, chaidou s, kympouropoulos s, spartalis e, et al. covid-19 pandemic and its impact on mental health of healthcare professionals. exp ther med. 2020;19(6):3451-3. 6. blake h, bermingham f, johnson g, tabner a. mitigating the psychological impact of covid-19 on healthcare workers: a digital learning package. int j environ res public health. 2020;17(9):2997. 7. lyons z, wilcox h, leung l, dearsley o. covid-19 and the mental well-being of australian medical students: impact, concerns and coping strategies used. australas psychiatry. 2020;28(6):649-52. 8. puthran r, zhang mwb, tam ww, ho rc. prevalence of depression amongst medical students: a meta-analysis. med educ. 2016;50(4):456-68. 9. meo sa, abukhalaf aa, alomar aa, sattar k, klonoff dc. covid-19 pandemic: impact of quarantine on medical students’ mental wellbeing and learning behaviors. pak j med sci. 2020;36(covid19s4):s43-8. 10. grubic n, badovinac s, johri am. student mental health in the midst of the covid-19 pandemic: a call for further research and immediate solutions. int j soc psychiatry. 2020;66(5):517-8. 11. risal a, shikhrakar s, mishra s, kunwar d, karki e, shrestha b, et al. anxiety and depression during covid-19 pandemic among medical students in nepal. kathmandu univ med j (kumj). 2020;18(72):333-9. 12. vala n, vachhani m, sorani a. study of anxiety, stress, and depression level among medical students during covid-19 pandemic phase in jamnagar city. natl j physiol pharm pharmacol. 2020;10(12):1043-5. s24 challenges in managing head and neck cancer during pandemic: experience of an institution muhamad yusri musa1, jasmin jalil1, siti hajariah kamarrudin2, gokula kumar appalanaido1 objectives: head and neck cancers are not uncommon, they represent approximately eight percent of all malignancies according to the site and specifically, nasopharyngeal carcinoma is the fourth most common malignancy in malaysia. the challenges in managing these tumours are often reflected by multimodality treatment which requires a multidisciplinary team and multicentre involvement. head and neck cancers often require postoperative chemoradiotherapy to achieve a complete response. before the pandemic, patients were already at risk of delayed treatment due to multiple factors mentioned and the lack of radiotherapy centres in the country. the outbreak of covid-19 added significant challenges and treatment dilemmas caused by quarantines, hospitalisation, screening protocols, illnesses and lockdowns interfering with patients' movement. method: our centre received 144 newly diagnosed head and neck cancer patients during the period of march 2020 to august 2021. standard treatment protocol for these patients includes uninterrupted chemoradiotherapy and multiple imaging scans and ct simulation. results: three patients infected by covid-19 during the treatment with additional 13 patients faced interruptions and delayed management due to the quarantine order as close contacts. an average delay of 10 days was observed during the period. all patients managed to complete treatment planned for them despite the challenges mentioned, made possible by vigorous team efforts, repeated rtk screenings whenever indicated, extra man-hours and multiple reminders and advice. subsequent followups and clinical surveillance will determine whether the treatment response and survival rate are affected by disruption in the treatment process. conclusion: in conclusion, the covid-19 pandemic has significantly caused difficulties in managing head and neck cancers in our centre. however, multiple solutions created managed to minimise the risk of incomplete treatment. keywords: head and neck cancer, chemoradiotherapy, pandemic ___________________________________________________________________________ 1oncology and radiological sciences cluster, advanced medical and dental institute (amdi), universiti sains malaysia, bertam, penang, malaysia 2department of nuclear medicine, radiotherapy and oncology, school of medical science universiti sains malaysia (husm), kubang kerian, kelantan, malaysia. correspondence to: muhamad yusri musa, orl specialist, oncology and radiological cluster, amdi, usm, bertam, myusrim@usm.my __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v6i0.414 mailto:myusrim@usm.my supplementary issue:02 65 comparison of placental weight in pregnancies with stillbirth and live birth controls. midhat muttaqui1, nema usman1, m. tariq zaidi1, tamkin khan2, nishat afroz3 1. department of anatomy, jnmc, amu, aligarh. 2. department of obstetrics and gynecology, jnmc, amu, aligarh. 3. department of pathology, jnmc, amu, aligarh. *correspondence: namedr. midhat muttaqui addressdepartment of anatomy, jnmc, amu, aligarh ph. no.9045043660 email iddrmidhatfatima@yahoo.co.in abstract introduction: a foetus born after 20 weeks of gestation that shows no signs of life on direct observation or a zero apgar score at 1 and 5 minutes defines stillbirth. it can be due to maternal, foetal, or placental causes. according to who, annually about 2 million stillbirths occurs placenta being a multitalented organ alone fulfils the nutritive, respiratory, excretory functions during intrauterine life the ability of foetus to grow in uterus depends on the placental perfusion. weight of placenta is a measure of its function. the ratio between weight of placenta and neonatal weight is 1:6. at term. material and methods: this study was conducted on 100 pregnant women with stillbirth and on 100 pregnant women with live birth. the placentas were taken from the department of obstetrics and gynecology, jnmc, and weighed. results: median (25th-75th percentile) of placental weight(gm) in cases was 355(285.25-480) which was significantly lower as compared to controls [460(387.5-502.5)]. (p value <.0001; odds ratio (95% ci): -0.994(0.991 to 0.997. conclusion(s): with the increase in placental weight, risk of still birth significantly decreases with adjusted odds ratio of 0. 993.low placental weight is a cause of still births. key words: stillbirth, placental weight. introductionpregnancythe blessed period in the life of a woman justifies the adage “life begets life” as it leads to the beginning of new life. this complex physiological process results from a critically planned relationship between maternal-foetal-placental factors. any pathogenic supplementary issue:02 66 factor that perturbs them can result in the deviation of pregnancy outcomes to an unfavourable one.1 according to who, annually about 2 million stillbirths occurs.1 in a multi-centre study, out of 552,547 births (500 g or 20 weeks’ gestation), 15,604 were stillbirths2. in an indian study, the rate of stillbirth rate was 16/1000 birth.3 placenta being a multitalented organ alone fulfils the nutritive, respiratory, excretory function during intrauterine life. among amongst the numerous causes of stillbirth, placenta is still the least explored one. considering the indispensable, multifunctional role of placenta in pregnancy more research into this mysterious organ can help in prevention of stillbirth by unmasking the anatomical and histological aspects. placental weight is thought to reflect function and the feto-placental weight ratio has been suggested as a possible indicator of placental reserve capacity in iugr4,5,6,7. in 2014, every newborn action plan (enap), was endorsed by the world health assembly which has a global target of 12 or fewer stillbirths per 1000 total births in every country by 2030. by 2019, 128 mainly high-income and upper middle-income countries had met this target.8,9,10the present study aims to find the association of placental weight with adverse pregnancy outcomes to prevent the occurrence of adverse pregnancy outcomes through antenatal prevention and care. material and methods-the study followed women who had fetal death between 29 -37 weeks of clinical gestational age (cases). the study also included women who delivered an appropriate for gestational age live birth between 29 -37 weeks (control) in the department of obstetrics and gynecology, jnmch, amu, aligarh. the study population was divided into two groups of cases and controls. group i (cases) the placenta from the stillbirth cases. group ii (control) -the placenta from the live birth pregnancies between 29 -37 weeks of gestation. placental weight: each placental weight was recorded with a weighing machine in gram (gm). supplementary issue:02 67 observation and results table no. 1 in present study, median (25th-75 th ) of placental weight (gm) in cases was 355 (285.25-480) which was significantly lower as compared to controls (355 vs. 460, p<.0001), with an overall odds ratio of 0.994 [460(387.5-502.5)]. (p value <.0001; odds ratio (95% ci): 0.994(0.991 to 0.997)) table no. 2 supplementary issue:02 68 discussiona case-control study was done wherein 100 cases of pregnant women who had still births were compared with 100 pregnant women who had live births, with the main objective to find the weight of placenta in the two groups and to compare them so as to find whether there is association between weight of placenta and pregnancy outcomes. in our study, we found that compared to controls, cases had significantly lower placental weight (355 vs. 460, p<.0001), with an overall odds ratio of 0.994. this was in accordance with findings of previous studies as åmark h et al error! bookmark not defined. found that compared to women with live births, those with stillbirths had significantly lower placental weight (423 vs. 480 g) (p<0.05). similarly, bukowski r et al12 found that compared to live births, still births had significantly lesser placental weight (300 vs. 435 g, p<0.001). even, tiwari et al13 also observe that smaller placentas showed significant association with stillbirths particularly term stillbirths. ananthan et al14 reported that in comparison with live birth, still birth cases had lower placental weight (360.83 vs. 373.81 g, p=0.40), however difference was not significant. thus, the findings indicate that placental weight is lower in still births as compared to live births, which can be explained by the fact that low level of pro-angiogenic factor results in small-sized placenta, leading to inadequate nutritional support to fetus as well as adverse maternal and fetal supplementary issue:02 69 outcomes. moreover, the role of high levels of antiangiogenic proteins as well as low levels of proangiogenic proteins are observed among small-for-gestational age fetus.13 table no. 3showing comparison of placental weight (grams) in different studies the increased risk of stillbirth associated with low placental weight supports the hypothesis that a decreased placental surface area for gas and nutrient exchange may lead to fetal compromise.i placental abnormalities are a common cause of death in stillbirth. thus, histopathological examination of the placenta is recommended to determine the cause of stillbirth. many maternal medical disorders are related to adverse pregnancy outcomes. biologic mechanisms are proposed that describes how anaemia is related to adverse pregnancy outcomes. iugr and preterm delivery are main determinants of stillbirth, which are related to maternal anaemia. a stress response can be activated by anemia in the mother and fetus by increasing levels of “corticotrophin‐releasing hormone or cortisol” leading to adverse pregnancy outcomes. conclusion: the placenta provides nutrition to the growing foetus and is a pertinent determinant of fetal growth. it provides surface for gas exchange. studies have shown positive correlation between placental weight and foetal weight. low placental weight has also been found to be associated with iugr, post-natal abnormalities. through antenatal ultrasound monitoring , the weight of the placenta can be accurately calculated and thus adverse pregnancy outcomes like 11 14 15 supplementary issue:02 70 iugr, stillbirth etc can be prevented by providing pregnant women with vigilant antenatal monitoring and care. references: 1. goldstein ja, gallagher k, beck c, kumar r, gernard ad. maternal-fetal inflammation in the placenta and the developmental origins of health and disease. front immunol 2020; 11:531543. 2. stillbirth collaborative research network writing group. causes of death among stillbirths. jama 2011; 306:2459–68. 3. tavares da silva f, gonik b, mcmillan m, keech c, dellicour s, bhange s, et al; brighton collaboration stillbirth working group. stillbirth: case definition and guidelines for data collection, analysis, and presentation of maternal immunization safety data. vaccine 2016;34(49):6057-68hutcheon ja, mcnamara h, platt rw, benjamin a, kramer ms. placental weight for gestational age and adverse perinatal outcomes. obstetr gynecol 2012;119(6):1251–8. 4. hutcheon ja, mcnamara h, platt rw, benjamin a, kramer ms. placental weight for gestational age and adverse perinatal outcomes. obstetr gynecol 2012;119(6):1251–8. 5. tomashek km, ananth cv, cogswell me. risk of stillbirth in relation to maternal haemoglobin concentration during pregnancy. matern child nutr 2006;2(1):19-28. 6. hutcheon ja, mcnamara h, platt rw, benjamin a, kramer ms. placental weight for gestational age and adverse perinatal outcomes. obstetr gynecol 2012;119(6):1251–8. 7. tomashek km, ananth cv, cogswell me. risk of stillbirth in relation to maternal haemoglobin concentration during pregnancy. matern child nutr 2006;2(1):19-28. supplementary issue:02 71 8. world health organization. stillbirths. available from https://www.who.int/healthtopics/stillbirth#tab=tab_1 [accessed may 15, 2022]. 9. mcclure em, saleem s, goudar ss, garces a, whitworth r, esamai f, et al. stillbirth 20102018: a prospective, population-based, multi-country study from the global network. reprod health 2020;17(suppl 2):146. 10. newtonraj a, kaur m, gupta m, kumar r. level, causes, and risk factors of stillbirth: a population-based case control study from chandigarh, india. bmc pregnancy childbirth 2017;17(1):371. 11. åmark h, westgren m, sirotkina m, hulthén varli i, persson m, papadogiannakis n. maternal obesity and stillbirth at term; placental pathology-a case control study. plos one 2021;16(4):e0250983 12. bukowski r, hansen ni, pinar h, willinger m, reddy um, parker cb, et al; eunice kennedy shriver national institute of child health and human development (nichd) stillbirth collaborative research network (scrn). altered fetal growth, placental abnormalities, and stillbirth. plos one 2017;12(8):e0182874. 13. tiwari p, gupta mm, jain sl. placental findings in singleton stillbirths: a case-control study from a tertiary-care center in india. j perinat med 2021;50(6):753-62. 14. ananthan a, nanavati r, sathe p, balasubramanian h. placental findings in singleton stillbirths: a case-control study. j tropical pediatr 2019;65:21–8. 15. bukowski r, hansen ni, pinar h, willinger m, reddy um, parker cb, et al; eunice kennedy shriver national institute of child health and human development (nichd) stillbirth collaborative research network (scrn). altered fetal growth, placental abnormalities, and stillbirth. plos one 2017;12(8):e0182874. https://www.who.int/health-topics/stillbirth#tab=tab_1 https://www.who.int/health-topics/stillbirth#tab=tab_1 s43 effects of a structured pulmonary rehabilitation program in covid-19 pneumonia patients izwan zuhrin1, nurulhuda2, doreen shamala2, saari mohd yatim2 objective: to evaluate the functional outcome and psychological function among post-covid-19 patients who joined a structured outpatient pulmonary rehabilitation (pr) program. methods. this is a retrospective study conducted at the rehabilitation department, hospital serdang from january until august 2021. individuals with a diagnosis of covid-19 infection category 3, 4 and 5 underwent 4 weeks of pr program as outpatients. outcome measures include 6 minute walk test (6mwt), duke activity status index (dasi), and grip strength (gs) of the dominant hand. data from preand post-program were analysed using wilcoxon signed ranks test. depression, anxiety, stress scale (dass-21 item) preand post-program were analysed using the likelihood ratio test. results. a total of 20 patients completed the program, with the majority of them had covid-19 category 5 (47.6%), being male (66.7%) and with a median age of 47 ± 11.9. there was a significant difference in 6mwt, dasi (both p < 0.001) and gs of the dominant hand (p < 0.05). mean difference of the 6mwt preand post-program was 73 meters. there was an improvement in the severity level of dass-21 items. conclusion. this study demonstrated that the pr program is beneficial to improve functional outcomes for covid-19 survivors. with regards to the psychological assessment, there was an improvement in the level of depression, anxiety and stress severity. keywords: covid-19, outpatients; activities of daily living; community participation ___________________________________________________________________________ 1department of rehabilitation medicine, faculty of medicine & health sciences, university putra malaysia. 2department of rehabilitation, hospital serdang, malaysia. correspondence to: dr izwan zuhrin bin abdul malek, medical lecturer, department of rehabilitation medicine, faculty of medicine & health sciences, university putra malaysia. email:ewan_1999@upm.edu.my __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v6i0.433 mailto:ewan_1999@upm.edu.my s38 the agreement between state-trait-anxiety-inventory (stai) and beck anxiety inventory (bai) on measuring anxiety level among adult patients before venepuncture procedure izzaty dalawi1, mohamad rodi isa1,2, mohd faizul harris mohd hatta1, mohamad fairuz rahmat1 objectives: venepuncture procedure is painful, and anxiety associated with venepuncture is common. there are many tools for assessing the anxiety level in an outpatient setting. hence, this study assessed the agreement between state-trait-anxiety-inventory (stai) and beck anxiety inventory (bai) on measuring anxiety levels among adult patients before the venepuncture procedure. methods: a cross-sectional study was conducted among patients while waiting for venepuncture procedure in the phlebotomy unit, uitmmc, from april until may 2020. the malay validated version of the stai and bai were used to assess the anxiety level. data were analysed using ibm spss version 26.0. the differences between data sets were plotted as described by bland-altman to determine the agreement between these two assessment tools. results: a total of 330 patients participated in the study with a mean age of 46.34 ± 14.34 years old, and gender were equally distributed. the scores of state-anxiety (stai-s), trait-anxiety (stai-t) and bai were 30.04 ± 20.74, 29.51 ± 19.11, and 40.98 ± 20.45, respectively. the score of anxiety using bai was higher compared to stai-s (p<0.001) and stai-t (p<0.001). there was a positive correlation between stai-s and bai (r=0.600, p<0.001) and between stai-t and bai (r=0.740, p<0.001). the mean difference between the stai-s and bai was -10.94 (95%ci: -53.01, 26.87) and between the stai-t and bai was -11.47 (95%ci: -42.26, 19.32). however, very few patients’ scores outside the 95% limit of agreement (loa) for both differences. conclusion: the stai and bai have an agreement on measuring anxiety levels among patients waiting for venepuncture procedures based on a good degree of concordance. however, the anxiety score using bai was significantly higher compared to stai. thus, healthcare providers can use both assessment tools in clinical practice, especially in measuring anxiety in the outpatient setting. keywords: state-anxiety, trait-anxiety, beck anxiety inventory, agreement, venepuncture ___________________________________________________________________________ 1department of public health medicine, faculty of medicine, universiti teknologi mara (uitm) sungai buloh campus, 47000 sungai buloh, selangor, malaysia. 2ministry of health, 62675 putrajaya, wilayah persekutuan putrajaya, malaysia. correspondence to: mohamad rodi isa, public health medicine specialist, department of public health medicine, faculty of medicine, universiti teknologi mara, jalan hospital, 47000 sungai buloh, selangor, malaysia, email: rodi@uitm.edu.my_ _________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v6i0.428 mailto:rodi@uitm.edu.my_ s37 development of health education booklet on heart failure for public readers syafiqah h, nurul a, nurul s, nur s.a, huzairi sani objectives: heart failure is a condition that is commonly seen in the community, however, there is still a major gap in understanding the diagnosis. this is our effort to spread awareness and share key information on heart failure to patients and carers by a printable booklet as a platform for the public to increase their knowledge about heart failure during the covid-19 pandemic. methods. a literature review from clinical guidelines and established medical websites’ information was gathered and made in a concise manner, suitable for public understanding. a designed booklet was filled with essential information and images for reference. results. a 21-pages reading material with coloured images was divided into sections describing heart failure, types and classification, its management as well as lifestyle modifications. the first section includes cardiac anatomy, physiological function and definition of heart failure. the prevalence in malaysia was highlighted and compared to the other countries. the leading causes of heart failure in adult malaysians are ischaemic heart disease (68%), valvular/rheumatic heart disease (29%), and nonischaemic cardiomyopathy (28%). heart failure is a significant cause of hospitalisation, accounting for approximately 6% to 10% of all acute medical admissions in malaysia. the list of investigations and types of treatment were included for a better understanding of each management. patients’ understanding of the disease and lifestyle modification is essential, which will prevent hospital admission and improve clinical outcomes. conclusion. information shared through the booklet about the condition of heart failure and its effect on people's life was hoped to assist patients to manage their heart failure better. keywords: heart failure, awareness, live with heart failure, booklet ___________________________________________________________________________ 1faculty of medicine, universiti teknologi mara, sungai buloh, selangor, malaysia correspondence to: syafiqahhazirahazman@gmail.com syafiqah hazirah binti azman, faculty of medicine, universiti teknologi mara, sungai buloh, selangor, malaysia. __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v6i0.427 mailto:syafiqahhazirahazman@gmail.com 47 international journal of human and health sciences vol. 06 no. 01 january’22 original article: correlation between the indonesian versions of montreal cognitive assessment (moca-ina) and visual cognitive assessment test (vcat-ina) as cognitive screening tools fasihah irfani fitri1*, aldy s rambe 1, paulus anam ong2 , ika mariana gultom 1 abstract background and purpose: screening for cognitive impairment has become increasingly important as the population ages, especially using tools that is not mainly affected my  translational process so it can be used in multilingual population. the aim of this study was to determine the correlation between the indonesian version of montreal cognitive assessment (moca-ina) and visual cognitive assessment test (vcat-ina) as cognitive screening tools. methods: this was a cross sectional study involving subjects recruited for cognitive screening in general population and memory clinic adam malik general hospital medan indonesia between december 2019 and april 2020. all subjects underwent physical and neurologic examination and cognitive assessment including moca-ina and vcat-ina, that was adapted from the original version. results: a total of 104 subjects were studied, consisted of 41 (39.4%) males and 63 (60.4%) females. the mean age of subjects was 64.4±10.07 years and ranged from 41-82 years. most of the subjects had 12 years of education (45 subjects; 43.3%). most of the subjects had abnormal moca-ina and vcat-ina scores. both scores showed comparable result but vcatina showed lower average and a broader range of scores. there was a strong positive significant correlation between the scores (r=0.815; p < 0.001).  conclusions: mocaina score is strongly correlated with vcat-ina score. as visual-based test, vcat-ina can be applied as a cognitive screening tool in daily clinical practice without significant  language barrier. keywords: cognitive screening, dementia, montreal cognitive assessment, visual cognitive assessment test correspondence to: fasihah irfani fitri, email : fasihah.irfani@usu.ac.id, orcid : 0000-0002-0883-3029 1. department of neurology faculty of medicine, universitas sumatera utara, adam malik general hospital, medan, indonesia 2. department of neurology faculty of medicine, universitas padjadjaran, hasan sadikin general hospital, bandung, indonesia international journal of human and health sciences vol. 06 no. 01 january’22 page : 47-54 doi: http://dx.doi.org/10.31344/ijhhs.v6i1.376 introduction it is estimated that there are over 50 million people living with dementia globally, a figure predicted  to increase to 152 million by 2050. someone develops dementia every three seconds and the current annual cost of dementia is estimated at us  $1  trillion,  a  figure  set  to  double  by  2030.1 the increased prevalence of dementia is highly correlated with the growing proportion of the ageing population that has become a worldwide universal concern. the number of elderly people in the world is projected to increase from 420 million in 2000 to nearly 1 billion by 2030, with the proportion of elderly people increasing from 7–12%. the most rapid and greatest increase in absolute numbers of older persons will occur in lowand middle-income countries (lmic) such as china, india, and other south asian nations. as a result, the lmic share of the worldwide ageing international journal of human and health sciences vol. 06 no. 01 january’22 48 population will increase from around 60% to more than 70%. thus, as a strongly age-dependent disorder, dementia or alzheimer’s disease will have a huge impact on public health, healthcare, and social service systems in all countries throughout the world. therefore ad has indeed become a global challenge and remains a global health priority.1-3 the issue of screening for dementia and cognitive impairment will become more increasingly important. other that the increased prevalence of ad, the improvements in survival rates following stroke also mean that there will be an increase in vascular and post-stroke dementias since approximately 30% of stroke patients will develop dementia.4 early diagnosis and intervention of dementia may allow the patient to compensate for the disability, minimize disease-related and medication complications, improve quality of life and optimize the use of resources.5 screening tests for cognitive impairment in the clinical setting generally include asking patients to perform a series of tasks that assess at least 1 cognitive domain (memory, attention, language, and visuospatial or executive functioning). neuropsychological testing is the gold-standard for assessing dementia and cognitive impairment, but it is time-consuming and requires adequate training.6 therefore it is highly  important  for  clinicians  to  use  effective  short cognitive tests as appropriate to the clinical setting for suspected dementia.7 one of the most widely used cognitive screening tool currently is the montreal cognitive assessment (moca), that was developed as a brief cognitive screening tool to detect mild-moderate cognitive impairment. the moca assess several cognitive domains including executive fuction, visuospatial function, attention and concentration, memory, language, calculation and orientation. the indonesian version of moca, namely moca-ina has been developed and validated in indonesia and so it can be used as a cognitive screening tool.9 it has been found to have high sensitivity and specificity for the detection of mild cognitive  impairment (mci and mild dementia.10 with a cutoff score of 26, the mini mental state examination  (mmse) had a sensitivity of 17% to detect subjects with mci, whereas the moca detected 83%.11 several previous studies have found the superiority of moca compared to mmse in detecting cognitive impairment in various clinical setting including mild cognitive impairment and dementia10,11,elderly population12,13,14,post-stroke patients15, parkinson’s disease16, aneurysmal subarachnoid hemorrhage17, epilepsy18 and hivassociated neurocognitive disorders (hands).19 while the moca-ina has been translated from the original moca and has been culturally validated in indonesia9, nevertheless, as like any other existing cognitive screening tools, it was designed for use in  specific  language.  cognitive  screening  tools  that have been modified and translated more likely  to result in overdiagnosis of cognitive impairment in non-english speakers.20 the visual cognitive assessment test (vcat) is a cognitive screening tool that is developed as a visual-based test. its diagnostic performance and discriminative validities were superior compared to mmse and comparable to moca. 21 the vcat has been validated in four southeast asian countries including indonesia, without language translation or cultural adaptation. it was found to be effective  in discriminating between healthy control and subjects with cognitive impairment (mci and mild ad dementia).22 the indonesian version of vcat, namely vcat-ina has also showed good diagnostic performance in post stroke cognitive impairment, compared to moca-ina and mmse-ina.23 no study has yet evaluated its use as cognitive screening test. the objective of this study was mainly to compare and determine the correlation between the moca-ina and vcatina scores as cognitive screening tool. materials and methods this was a cross sectional study involving 104 subjects consisted of 71 subjects which were recruited from medan helvetia district, medan, north sumatera, indonesia, because it was one of the most densely populated district in medan and 33 subjects recruited from memory clinic neurology department adam malik general hospital medan north sumatera, indonesia between december 2019 and april 2020. inclusion criteria were able  to  speak  bahasa  indonesia  fluently,  able  to  read  and  write,  had  no  significant  vision  or  hearing impairments and gave written consent to be included in the study. we excluded subjects who were medically unstable (delirium), had psychiatric disorders or had an aphasia. all subjects underwent physical and neurologic examination and cognitive assessment including mocaina and vcat-ina. the moca-ina assesses 49 international journal of human and health sciences vol. 06 no. 01 january’22 several cognitive domains which are visuospatial/ executive, naming, memory, attention, language, abstraction, delayed recall and orientation (to time and place). visuospatial abilities are assessed using a clock-drawing task and a trail-making task which is said  to be useful  in assessing fitness  to drive.  attention, concentration and working memory are evaluated using a sustained attention task (target detection using tapping), a serial subtraction task and digits forward and backward. its score range is 0-30, higher score indicates better cogntive performance,and  a  cut  off  of  more  than  26  is  considered normal. the moca adds one point for those whose educational level is 12 or fewer years.8 there are several adjusments of moca-ina compared to the original version in assessment of naming, memory and delayed recall and language function because of transcultural validation.9 the visual cognitive assessment test is a visualbased cognitive screening tool designed to detect early cognitive impairment. it is language neutral and encourages simple application to multilingual populations without the need for translation of test content.21 the vcat is a 30-point test that evaluates memory, executive function, visuospatial function, attention, and semantic knowledge. the test items for each cognitive domain are visual based, with pictures and figures selected from the international  picture naming project and locally validated in older adults.22 the episodic memory domain consists of seven test items assessing immediate and delayed recall using a scenario, shapes and objects. the executive function domain consists of four items evaluating pattern recognition-completion, mechanics of gear movement and grouping of pictures based on categories. the visuospatial function domain contains two items assessing visuospatial abilities via cube reconstruction, visual depth perception and grid navigation. in the language domain with two items, participants were required  to  name  pictures.  the  semantic  fluency  were assessed using four categories which were countries, vegetables, modes of transport and kitchen utensils. a symbol recognition cancellation task was used to assess attention domain. the vcat scale range was 30 with lower score indicating greater impairment. the cut offs were: normal 23-30, mci  18-22 and dementia 0-17. 21 all statistical procedures were performed with spss. the correlation between moca-ina and vcat-ina scores was measured using the pearson correlation. both scores were also compared based on level of education and age group. our study had been approved by the faculty of medicine universitas sumatera utara/haji adam malik general hospital ethical committee. results a total of 104 subjects were studied, consisted of 41 (39.4%) males and 63 (60.4%) females. the mean age of subjects was 64.4±10.07 years and ranged from 41-82 years. most of the subjects belong to age group of 66-70 years and 71-75 years; each of the group consisted of 20 subjects (19.2%). most of the subjects had level of education of senior high school, meaning had 12 years of education (45 subjects; 43.3%). there were 24 subjects (23.1%) with normal moca-ina score (26-30), and there was 27 subjects (26%) with normal vcat-ina score (23-30). based on vcat-ina score there was 48 subjects (46.2%) with dementia (score 0-17) and 29 subjects (27.9%) with mci (score 18-22). the characteristics of the subjects are shown in table 1. table 1. characteristics data of the subjects characteristics frequency (n=104) percentage (%) gender male female 41 63 39.4 60.6 age (years), mean + sd 64.4±10.07 age groups 41-45 years old 46-50 years old 51-55 years old 56-60 years old 61-65 years old 66-70 years old 71-75 years old 76-80 years old     >81 years old 7 4 9 9 25 20 20 8 2 6.7 3.8 8.7 8.7 24.0 19.2 19.2 7.7 1.9 educational level elementary school junior high school senior high school university 15 19 45 25 14.4 18.3 43.3 24.0 moca-ina score, mean + sd 20.96±4.81 moca-ina      normal (≥26)      abnormal (<26) 24 80 23.1 76.9 vcat-ina score, mean + sd 18.76±6.09 vcat-ina normal (23-30) mild cognitive impairment (18-22)      dementia (<18)  27 29 48 25.9 27.9 46.2 international journal of human and health sciences vol. 06 no. 01 january’22 50 the average moca-ina score was 20.96±4.81 (range 10 to 30). the average vcat-ina score was 18.76 ± 6.09 (range 4 to 30). both scores showed comparable result but vcat-ina showed lower average and a broader range of scores.(table 2) there was a significant difference  in mocaina and vcat-ina scores based on age group and level of education.(table 3). the pearson’s correlation  coefficient  between  the  scores  was  0.815 (p < 0.001). a graph showing the correlation  between the moca-ina and vcat-ina scores is shown in figure 1 table 3. moca-ina and vcat-ina scores based on age and educational level groups moca-ina score mean±sd p vcat-ina score mean±sd p age groups 41-45 years old 46-50 years old 51-55 years old 56-60 years old 61-65 years old 66-70 years old 71-75 years old 76-80 years old     >81 years old 25.00±6.60 26.50±3.31 20.89±4.75 21.67±4.00 21.68±3.56 21.55±4.88 18.70±4.24 17.38±4.20 15.00±4.24 0.002 25.14±6.61 24.00±6.68 20.33±5.91 19.78±5.78 18.96±5.56 19.25±5.49 15.9±5.68 13.88±3.04 15.00±8.48 0.003 educational level elementary school junior high school senior high school university 16.27±3.39 18.16±3.50 21.80±3.98 24.40±4.55 <0.001 13.13±4.62 15.16±3.53 19.07±5.14 24.32±5.16 <0.001 anova table 4. correlation between moca-ina and vcat-ina scores variables vcat-ina r p moca-ina 0.815 <0.001 table 2. comparison of moca-ina dan vcat-ina scores cognitive domains (moca-ina) mean±sd range cognitive domains (vcat-ina) mean±sd range total 20.96±4.81 10-30 total 18.76±6.09 4-30 visuospatial/executive 2.98±1.63 0-5 memory 8.04±3.12 0-13 naming 2.76±0.55 0-3 language 3.92±0.99 1-5 attention 4.55±1.50 1-6 visuospatial 2.17±0.84 0-3 language 2.10±0.86 0-3 executive function 3.26±1.68 0-6 abstraction 1.13±0.67 0-2 attention 1.30±1.35 0-3 delayed recall 1.81±1.19 0-5 orientation 5.81±0.48 3-6 figure 1. correlation between moca-ina and vcat-ina scores discussion dementia is a disabling syndrome characterized by progressive deterioration in multiple cognitive domains that is severe enough to interfere with daily functioning, including social and professional functioning.3 in addition to identifying patients who may benefit from pharmacotherapy and non  pharmacologic interventions, early detection of dementia helps families anticipate the patient’s needs and helps physicians identify those in need of additional support.6 as the population ages, 51 international journal of human and health sciences vol. 06 no. 01 january’22 there is an increasing need for effective cognitive  screening that can be widely used in multilingual population  and  can  be  used  without  significant  language barrier. this study compared the mocaina and vcat-ina scores as cognitive screening tools. the vcat-ina is adapted from the original vcat  but  without  significant  translation  other  than instructions for the assessors. it is a visualbased cognitive test that can be applied in participants with various language.21 kandiah et al, has developed and studied the use of vcat in multilingual populations to detect dementia at an early stage and found that  vcat  had  good  sensitivity  and  specificity  for the diagnosis of mild cognitive impairment (mci) and mild ad. they validated vcat in a sample comprised of 206 subjects. the diagnostic performance of vcat was generally satisfactory and comparable to moca in sensitivity (85.6%), specificity  (81.1%)  and  overall  discriminative  ability (auc=93.3; ci 90.1-96.4) for diagnosis of cognitive impairment (mci and mild ad).21 the vcat has also been validated in four south southeast asian countries including indonesia. in a prospective, multicenter study involving 284 participants carried out across singapore, malaysia, indonesia and philippines, the vcat, without local translation or adaptation, was found to be effective in discriminating between healthy  controls and cognitively impaired subjects. areas under the curve for montreal cognitive assessment (0.916, 95% ci 0.884–0.948) and the vcat (0.905, 95% ci 0.870–0.940) in discriminating between healthy controls and cognitively impaired subjects were comparable. the multiple languages used to administer vcat in  four  countries  did  not  significantly  influence  test scores.22 a study by ong, et al in indonesia, which included 38 healthy subjects and 91 post-stroke cognitive impairment (psci) subjects has also found the satisfactory diagnostic performance test of vcatina: it detected 80.8% of psci (auc 0.7340.882). with cut-off 21, vcat-ina differentiated  healthy subjects from psci patients with sensitivity of 74.7 and specificity of 62.2. using  cut  off  17,  vcat-ina  can  differentiate  psci  non-dementia from those with dementia with sensitivity 0f 83.3 and specificity of 65.1. their  study also showed the diagnostic performance of vcat-ina is comparable to moca-ina and mmse-ina.23 the results of this study showed that the mocaina and vcat-ina showed comparable results but vcat-ina showed lower average with wider range of scores. our study found the mean mocaina score was 20.96±4.81 and vcat-ina 18.76±6.09. these scores were lower than those reported in previous studies. study by kandiah et al found a median score of moca 28, vcat 26 in healthy control and moca 23, vcat 17 in cognitively impaired group, respectively.21 lim et al reported mean (sd) moca 25.52 (3.37) and vcat 22.48 (3.50) in healthy control and mean (sd) moca 16.59 (5.75) and vcat 14.17 (5.05) in subjects with cognitive impairment.22 these lower  scores  might  be  affected  by  educational  level and age although most subjects in our study had level of education of senior high school, meaning had at least 12 years of education, but we also found significant differences in these scores  based on level of education and age groups. this needs to be evaluated further in future studies. interestingly, using either moca-ina or vcatina, the proportion of subjects with cognitive impairment was greater than normal subjects. there were 80 subjects (76.9%) subjects with abnormal moca-ina score and 77 subjects (74.1%) with abnormal vcat-ina score, 29 (27.9%) with mci and 48 (46.2%) with dementia respectively. considering the fact that the subjects in this study were recruited from general population and memory clinic also,  this finding  might emphasize the importance of cognitive screening not only in daily clinical practice but also in general population for early detection of dementia. it can be argued that the main purpose of the cognitive screening test is to show the likelihood of cognitive dysfunction. it is usually done by comparing the patient’s score with the normal reference score in the general population. a very impaired score along with detail history may lead a clinician to make a diagnosis without further detailed investigation; a borderline score may need referral for more comprehensive international journal of human and health sciences vol. 06 no. 01 january’22 52 neuropsychological assessment.4 although no single  tool  is  recognized  as  the  “gold  standard”  for detection of cognitive impairment, an initial structured assessment should provide either a baseline for cognitive surveillance or a trigger for further evaluation.24 the cognitive screening tool is not intended to replace a full neuropsychological assessment. it can be used to obtain clue about cognitive domains that  are  affected  in  a  short  assessment  time.     neuropsychological testing has consistently shown that subtypes of dementia are characterized by different patterns of  impairment.4 the vcat was designed to detect deficits in wide range of  cognitive domains with greater emphasize on episodic memory and executive function, two of the most affected domains in eraly ad and vad,  the two most common type of dementia.21 in population with diverse cultures and languages, a cognitive screening tool that is relatively free from translation bias becomes very important. this study was conducted in medan, the capital of the province of north sumatra, which was inhabited by various tribes in various languages. although with an adequate educational background it can be said that knowledge in bahasa indonesia is also adequate, but it does not rule out the possibility of variations in vocabulary understanding and words familiarity used in cognitive screening tools, along with other issues in translated tools for non english speakers, as some of the basic neuropsychological basis of specific  test  items might be  lost during  translations.21 this issue needs to be studied in more detail in further studies, but it might give an insight in using translated tools in multilingual populations. conclusion in conclusion, we found a strong positive correlation between moca-ina and vcat-ina scores. as visual-based test, vcat-ina can be applied as a cognitive screening tool in daily clinical  practice  without  significant  language  barrier. declaration of interest and funding disclosure the  authors  report  no  conflicts  of  interest.  the  authors alone are responsible for the content and writing of this article. this research did not receive any financial support. acknowledgement this  research  did  not  receive  any  specific  grant  from funding agencies in the public, commercial, or not-for-profit sectors.  ethical clearence: ethical clearance was obtained from faculty of medicine universitas sumatera utara/haji adam malik general hospital ethical committee. author’s contribution: data gathering, and ideas, study design, writing, submitting of manuscript, editing and approval of final draft, were all events  conducted by the authors. 53 international journal of human and health sciences vol. 06 no. 01 january’22 references: 1. alzheimer’s disease international. 2019. world alzheimer report 2019: attitudes to dementia. london: alzheimer’s disease international. available at : https://www.alz.co.uk/research/ worldalzheimerreport2019.pdf 2. alzheimer’s association. 2019 alzheimer’s disease facts and figures. alzheimers dement 2019;15(3):321-87. available at: https://www.alz. org/media/documents/alzheimers-facts-and-figures2019-r.pdf 3. qiu c, fratiglioni l. epidemiology of alzheimer’s disease. in waldemar g, burns a, editors. alzheimer’s disease. 2nd ed. oxford university press 2017;17-26. 4. cullen b, o’neill b, evans jj, et al. a review of screening tests for cognitive impairment. j neurol neurosurg psychiatry 2007; 78: 790-799. available at: https://doi.org/10.1136/jnnp.2006.095414 5. santacruz ks, swagerty d. early diagnosis of dementia. american family physician 2001; 63(4). available at: https://www.aafp.org/afp/2001/0215/ p703.pdf 6. moyer va. screening for cognitive impairment in older adults: u.s. preventive services task force recommendation statement. ann intern med 2014;160:791-797. available at: https://doi. org/10.7326/m14-0496 7. velayudhan l, ryu s, raczek m, philpot m, lindesay j, critchfield m,et al. review of brief cognitive tests  for patients with suspected dementia. international psychogeriatrics 2014:26(8);1247-1262. available at: https://doi:10.1017?s10416102214000416 8. nasreddine zs, phillips na, bedirian v, charbonneau s, whitehead v, collin i, et al. the montreal cognitive assessment, moca: a brief screening tool for mild cognitive impairment. j am geriatr soc 2005;53(4):695–9. available at:https://doi. org/10.1111/j.15325415.2005.53221.x 9. husein n, silvia l, yetty r, dkk. uji validitas dan reabilitas montreal cognitive assessment versi indonesia (moca-ina) untuk skrining gangguan fungsi kognitif. neurona neuro sains 2010; 27(4): 15-22. 10. roalf dr, moore tm, hamilton dm, wolk da, arnold se, weintraub da, et al. bridging cognitive screening tests in neurologic disorders: a crosswalk between the short montreal cognitive assessment and mini-mental state examination. alzheimer’s &  dementia 2017;1-6. 11. smith t, gildeh n, holmes c. the montreal cognitive assessment: validity and utility in a memory clinic setting. can j psychiatry 2007; 52(5): 329-32. available at: https://doi. org/10.1177/070674370705200508 12. rambe a, fitri fi. correlation between the montreal cognitive assessment indonesian version (mocaina) and the mini mental state examination (mmse) in elderly. open access macedonian journal of medical sciences 2017;5(7):915-919. available at : https://doi.org/10.3889/oamjms.2017.202 13. trzepacz pt, hochstetler h, wang s, et al. relationship between the montreal cognitive assessment and mini-mental state examination for assessment of mild cognitive impairment in older adults. bmc geriatrics 2015: 15:107. available at:https://doi.org/10.1186/s12877-015-0103-3 14. untari i, subijanto aa, mirawati dk, sanusi r. the montreal cognitive assessment (moca-ina) versus the mini-mental state examination (mmse-ina) for detecting mild cognitive impairment among the elderly. bangladesh journal of medical science vol. 20 no. 01 january’21. page : 164-169 doi: https:// doi.org/10.3329/bjms.v20i1.50364 15. godefroy o, fickl a, roussel m, auribault c, bugnicourt jm, lamy c, et al. is the montreal cognitive assessment superior to the mini-mental state examination to detect poststroke cognitive impairment? a study with neuropsychological evaluation. stroke 2011;42:1712-1716. available at: https://doi.org/10.1161/strokeaha.110.606277 16. ohta k, osada t, shinohara y, suzuki n, takahashi k, seki m, et al. comparing the montreal cognitive assessment with mini-mental state examination in japanese parkinson’s disease patients. neurology and clinical neuroscience 2014;2:44-49. available at: https://doi.org/10.1111/ncn3.80 17. wong gwc, lam sw, wogi a, et al. comparison of montreal cognitive assessment and minimental state examination in evaluating cognitive domain deficit  following  aneurysmal  subarachnoid  haemorrhage. plos one 2013: 8(4). available at: https://doi.org/10.1371/journal.pone.0059946 18. nathami r, amirthalingam p, mukunthu international journal of human and health sciences vol. 06 no. 01 january’22 54 et al.sensitivity of montreal cognitive assessment in comparison with mini mental status examination in testing cognitive status in epilepsy patients with phenytoin monotherapy. ajpct 2015 : 3(03) 237-244 19. fitri fi, rambe as, fitri a. correlation between lymphocyte cd4 count, treatment duration, opportunistic infection and cognitive function in  human  immunodeficiency  virus-acquired  immunodeficiency syndrome (hiv-aids) patients.  open access macedonian journal of medical sciences 2018; 6(4):643-647. available at : https:// doi.org/10.3889/oamjms.2018.152 20. siedlecki kl, manly jj, brickman am, schupf n, tang mx, stem y. do neuropsychological tests have the same meaning in spanish speakers as they do in english speakers? neuropsychology 2010;24:402–11. 21. kandiah n, zhang a, bautista dc, silva e,ting sks, ng a, assam p. early detection of dementia in multilingual populations: visual cognitive assessment test (vcat). j neurol neurosurg psychiatry 2015;0:1-5. available at: http://dx.doi. org/10.1136/jnnp-2014-309647. 22. lim l, ng pt, ong ap, tan mp, cenina ar, gao qi, et al. a novel language-neutral visual cognitive assessment test (vcat): validation in four southeast asian  countries.  alzheimer’s  research  &  therapy  2018;10:6. available at: doi 10.1186/s13195-0170333-z 23. ong pa. diagnostic performance of visual cognitive assessment test (vcat) in post stroke cognitive impairment. a pre eliminary study from indonesia. 2018. the 5th jakarta neurology exhibition, workshop and symposium (jaknews). jakarta. 24. cordell cb, borson s, boustani m, chodosh, reuben d, verghesei j, et al. alzheimer’s association recommendations for operationalizing the detection of cognitive impairment during the medicare annual wellness visit in a primary care setting. alzheimer’s &  dementia  2013;9:141-150.  available  at:  http:// dx.doi.org/10.1016/j.jalz.2012.09.011 153 international journal of human and health sciences vol. 06 no. 02 april’22 editorial: tea to entertain outcome based education for 21st century educators to produce safe human capitals for a sustainable global development. salam a keywords: tea, outcome-based education, safe human capitals, sustainable global development. correspondence to: dr. abdus salam, associate professor and head, medical education unit and community medicine unit, faculty of medicine, widad university college, kuantan, pahang, malaysia. email: abdussalam.dr@gmail.com, orcid id: https://orcid.org/0000-0003-0266-9747 international journal of human and health sciences vol. 06 no. 02 april’22 page : 153-154 doi: http://dx.doi.org/10.31344/ijhhs.v6i2.437 education is a broad concept comprised of both teaching and learning. teaching is an interaction between a teacher and learners in order to provide opportunities for learning. learning is a process that leads to change in the learners’ behaviour as a result ofexperience and teaching1. outcomebased education (obe) is a teaching-learning methodology where teaching and assessment methods are planned and aligned to achieve the stated or expected objectives. the achieved objectives are the learning outcomes. well written learning objectives are the heart of any curriculum, and learning outcomes can be prespecified if constructed clearly2. the obe focuses on the assessment of students’ learning outcomes at different cognitive, affective and psychomotor levels. teaching is a difficult multifaceted task where teachers play many roles3.the role of the teachers here adjusts into instructor, facilitator and assessor. in obe the desired outcomes of teaching are spelled out clearly and unambiguously at the beginning of teaching in order to bring the expected changes in the learners. teachers are the scholarly assets of educational institutions, and teachers’ development program by the institutions is fundamental for its educational development4. implementing obe is a challenging task, and it cannot be attained without proper teachers development5,6. clear communication is an important issue here7. this paper briefly highlights the importance of three key teaching practices that promote obe and thereby ensure the production of safe or competent and confident graduates. the purpose of teaching is to facilitate learning, while the purpose of stating the learning outcomes at the beginning of teaching is to communicate in order to facilitate learning. however, excessive details or a vague statement of learning outcomes is a common educational concern. among the difficulties facing educational institutions is how the curriculum should be customized4. the sort of outcome-contents that has to be covered, the mode of delivery of selected contents and the assessment strategies that need to be adopted must be clearly articulated before to promote obe8. just like everyone needs nourishment in order to function properly, the art of teaching as well needs its share of nourishment for adequate functionality. to ensure proper implementation of obe during teaching, this nourishment could be best served in the form of tea: the acronym of tell, explain, assess9-11. telling the learning outcomes of teaching topic to the students at the beginning is necessary for filtering the important contents from the unimportant ones. explaining the topic using different audio-visual aids and relevant examples during teaching is crucial for better understanding of the topic.assessment drives learning and learning drives practice6. it is vital to assess how much students grasped from what has been told and explained during teaching. question is how to assess during teaching? the simple answer is by asking questions and making the communication two way ensuring a supportive learning environment. assess the students’ learning progress during teaching and it is important to reshape or improve the teaching practices based on assessment results. additionally, it is of utmost-importance to summarise the topic before closing the teaching session to refine something if missed early; it is also encouraged to provide international journal of human and health sciences vol. 06 no. 02 april’22 154 resources to the students for further readings in their convenient. so, tea can be used by the educators as an entertaining agent to remember the three important key practices‘tell, explain and assess’that need to be ensured during teaching to promote obe. teaching is a profession that creates other professions3. the aim of obe is to make clear link between education and practice such that education is made-to-order to the requirement of practice12. this paper offers tea as nourishing agent for the 21st century educators around the globe in order to execute obe by remembering three key teaching practices ‘tell, explain, assess’ and improve the teaching based on assessment result at individual and institutional level, ultimate aim of which is to produce competent and confident or safe human capitals for a sustainable global development. funding no funding was received for this paper. conflict of interest the author declared no conflicts of interest. authors’ contribution the author conceptualised, designed,drafted and finalised this paper and approved for submission to the journal for publication. reference: 1. ambrose s, bridges m, dipietro m, lovett m, & norman m. how learning works: 7 research-based principles for smart teaching. san francisco: jossey-bass. 2010. 2. salam a. issues of objectives, content, methods and assessment in the development of relevant curriculum in medical schools. malaysian medical association (mma) april 2010;22-24. 3. salam a, begum h, zakaria h, allaw baq, han t, algantri kr, mofta ag, elmahi meb, mohamed eme, elkhalifa maa, zainol j. core values of professionalism among fresh medical graduates in a malaysian private university. int j of human and health sci. 2021; 05(04): 463-472. doi: http://dx.doi. org/10.31344/ijhhs.v5i4.358 4. salam a, mohamad n, siraj hh, kamarudin ma, yaman mn, bujang sm. team-based learning in a medical centre in malaysia: perspectives of the faculty. natl med j india 2014; 27(6):350. 5. salam a, allaw baq, begum h, abdelhalim at, alsharkawy a, hassan km, satwi s, zainol j. audit on clinical competency of fresh medical graduates in a malaysian private university using kirkpatrick level-1 evaluation model. education in medicine journal 2021;13(4): 57–70. https://doi.org/10.21315/ eimj2021.13.4.5 6. salam a, mohamad mb. teachers’ perception on what makes teaching excellence: impact of faculty development programme. int med j. 2020; 27(1): 1–4. 7. yousuf r, salam a. teaching medical education during the era of covid-19 pandemic: challenges and probable solutions. bangladesh j med sci. 2021; 20(special issue on covid-19): 3-6. doi: https://doi. org/10.3329/bjms.v20i5.55394 8. harden rm. amee guide no. 14: outcome-based education: part 1-an introduction to outcome-based education, medical teacher 1999; 21(1): 7-14. doi: 10.1080/01421599979969 9. zainol j, salam a. an audit on mentormentee program: mentees perceptions on mentors. bangladesh j med sci. 2021; 20(4): 840-847. doi: https://doi.org/10.3329/bjms. v20i4.54143 10. salam a. best teaching method used, very good in teaching, the best lecturer ever: secrets of teaching online during covid-19 pandemic. int j of human and health sci. 2021; 05(04): 377-380. doi: http://dx.doi. org/10.31344/ijhhs.v5i4.346 11. salam a, wahab mkba, ahamad a, aziz nba. faculty perspectives on “foundations in teaching and learning” training workshop. australas medical j. 2017;10(7): 645-646. 12. salam a, zainuddin z, latiff aa,ng sp, soelaiman in, mohamad n, moktar n. assessment of medical graduates competencies. annals academy of medicine 2008; 37(9):814-816. 75 international journal of human and health sciences vol. 06 no. 01 january’22 original article: effect of comorbidities and polypharmacy on fall risk among older adults hand f mahmoud1, hebatullah emz elmedany1 abstract introduction: fall is considered by far one of the leading causes of morbidity and mortality in the elderly population. fall is almost always multifactorial. this study looks into the relation between different comorbidities, polypharmacy and falls. methods: a descriptive and prospective study, the study population comprised 150 elderly patients aged > 60 years  old, males and females, patients with previous history of falls are excluded. comorbidity burden, polypharmacy and risk of falls were assessed. results and discussion: there was a significant positive correlation between number of comorbidities, medications and risk  of falls and there was a significant association between high risk of falls and presence of  dm, pvd, old cva and ui. also, there was a significant positive correlation between  age and risk of falls. conclusion: multiple comorbidities, polypharmacy and increasing age increase risk of falls. keywords: falls, comorbidities, polypharmacy. correspondence to: hand f mahmoud, geriatrics and gerontology department, faculty of medicine, ain shams university, cairo, egypt. e-mail: hend.fawzy@med.asu.edu.eg 1. geriatrics and gerontology department, faculty of medicine, ain shams university, cairo, egypt. international journal of human and health sciences vol. 06 no. 01 january’22 page : 75-79 doi: http://dx.doi.org/10.31344/ijhhs.v6i1.380 introduction life expectancy is increasing all over the world. most people nowadays are expected to live into their sixties and beyond. by 2050, the world’s population aged 60 years and older is expected to total 2 billion up from 900 million in 2015. with increased life expectancy, some elderly will age gracefully, others will experience decreased mobility and functional decline and increase susceptibility to falls.1 falls defined as an unanticipated incident in which  a person come to rest on the ground or a lower level 2. falls are the most common type of accidents among older people 3. one in three people over 65 years of age experience at least one fall every year, and injuries occur in approximately 20% of such cases 4 and it has been estimated that nearly 40% of falls in older people are preventable 5. the etiology of falls has always known to be multifactorial. both intrinsic and extrinsic factors are involved in falls in older adults. intrinsic factors include comorbidities leading to decreased mobility, physiological changes with ageing in balance and coordination. extrinsic factors including environmental hazards as slippery floors,  unsecure stairs and poor lighting 6. this research project focuses on the impact of the comorbidity burden on the risk of falls. medications are a well-recognized cause of falls in elderly. classes of medications that have long been known as culprits are antipsychotics, sedatives, and hypnotics 7. this current study investigates the effect of polypharmacy and correlation with  falls. polypharmacy  is  defined  as  the  prescription  of  multiple medications and it has been identified as  one of the most important factors associated with falls among older people 8-9. adverse  effects  of  falls  range  from  injuries  to  decrease mobility and fear of falling. physical injuries include major lacerations, hip fractures, non-vertebral fractures. other complications of international journal of human and health sciences vol. 06 no. 01 january’22 76 falls and long lie include rhabdomyolysis, acute kidney injury, dehydration, aspiration pneumonia. psychological adverse effects of falls are not by  any means less important. these include fear of falling, decreased mobility, social isolation, depression, and institutionalization.1 materials and methods this descriptive and prospective study was conducted in geriatrics and gerontology department ain shams university hospitals. the study population comprised 150 elderly patients aged > 60 years old, males and females, patients  with previous history of falls are excluded, consent was obtained from all participants, all patients underwent comprehensive geriatric assessment (detailed medical history and examination, minimental state examination, geriatric depression scale, activities of daily living (adls), instrumental activities of daily living (iadls) all patients underwent assessment with charlson comorbidity index and hendrich fall risk model. comorbotidy burden was determined using the charlson comorbidity index, it was first developed  in 1987 by mary charlson and colleagues as a weighted index to predict risk of death within 1 year of hospitalization for patients with specific  comorbid conditions. nineteen conditions were included in the index, each category is assigned a score of 1,2,3, and 6. these scores are summed up for an overall cci score 10. this study utilizes the hendrich fall risk model, a tool originally invented by nurses to be utilized in the acute care setting, it was designed to be quickly administered. it utilizes eight independent risk factors. confusion, disorientation, and impulsivity; symptomatic depression; altered elimination; dizziness or vertigo; male gender; administration of antiepileptics (or changes in dosage or cessation); administration of benzodiazepines; and poor performance in rising from a seated position in the get-up-and-go test 11. data analysis analysis of data was performed by the 16th version of statistical package for social science (spss). description of quantitative data was done in the form of mean (m), standard deviation (sd) and range. frequency and percentage were done for qualitative variables. comparison of qualitative variables was done using the chi-square test. correlation of two quantitative variables was done using the pearson correlation. significance level measured according to p value  (probability), p>0.05 for insignificant, p<0.05 for  significant and p<0.01 for highly significant. results the study included 150 participants. the patients’ mean age was (65.95) ± 4.724 years. (48.7%) of them were women and (51.3%) were men. (72%) of them were not working and (28%) were working. (20.7%) of our patients were living alone but the rest (79.3%) living with others. (53.3%) were illiterate, (34%) educated for less than or equal 5 years and (12.7%) for more than 5 years education, and (64.7%) of them were nonsmokers but smokers were (35.3%) of patients (table 1). number of comorbidities, number of medications had highly significant positive correlation with  risk of falls so, patients suffer from multiple  comorbidities and receiving multiple medications had higher risk of falls than others. age also had high significant positive correlation with risk of  falls so, risk of falls increases as age of the patient increases (table 2). the patients were classified as regard risk of falls  to two groups (patients with high risk of falls and patients with low risk of falls) to evaluate the effect of different comorbidities on risk of falls  and found that there was a significant association  between high risk of falls and presence of dm, pvd, old cva and ui (table 3). table 1. demographic data. minimum maximum mean sd age 60 80 65.95 4.724 n % gender male 77 51.3% female 73 48.7% occupation working 42 28% not working 108 72% living arrangement with others 119 79.3% alone 31 20.7% education >5 yrs education 19 12.7% <5 yrs education 51 34% illiterate 80 53.3% smoking no 97 64.7% yes 53 35.3% 77 international journal of human and health sciences vol. 06 no. 01 january’22 table 2. correlation of fall risk with number of comorbidities, medications and age. hendrich ii fall risk pearson correlation p value charlson comorbidity index (no. of comorbidities) .788** .000 no. of medications .690** .000 age .387** 0.000 **. correlation is significant at the 0.01 level  (2-tailed discussion falls are one of the most common causes of injuries and dependence among the older population12-13. the falls frequency increases with increasing age.14 many factors may contribute to falls such as biological, social, environmental, and behavioral risk factors among older adults 15. medications and polypharmacy are very important items to be considered during comprehensive geriatric assessment as one of the adverse events related to medications and polypharmacy in the elderly are falls 16 and comorbidities are considered one of the most frequent intrinsic factors associated with falls 17 although the relationship between comorbidities and falls has not been studied well. this study examined factors increase risk of falls among elderly people especially polypharmacy and comorbidities association with the risk of falls in elderly patients. it involved 150 elderly patients both males and females underwent comprehensive geriatric assessment and evaluation for comorbidities and polypharmacy and risk of falls. the current study provided evidence for the presence of association between comorbidities especially dm, pvd, old cva or ui, polypharmacy and increasing age and high risk of falls. the  results  of  this  study  showed  a  significant  positive correlation between number of comorbidities and risk of falls, patients with dm, pvd, old cva and ui had higher risk of falls and also there was a significant positive correlation  between number medications (polypharmacy), age and risk of falls. these results are consistent with the results of the study done by bittencourt et al. who concluded that there was an association found between the risk of falls and comorbidities and found that diabetes mellitus was associated with high risk for falls (51.6% of diabetic patients presented a high risk of falls and it was 62.2% in the current study) 18. also, wenhua et al. observed that the risk of falls in the comorbidity group was higher than that in the group without comorbidity and in patients more than 75 years old higher than in those less than 75 years old 19. zaninotto et al. and ziere et al. conducted a study on 6220 participants and found that 7.9% of falls occurred among people with polypharmacy (5–9 medications) and 14.8% among those reporting heightened polypharmacy (10 + medications) and this agreed with the results of the current study, however other studies suggest that polypharmacy alone is unlikely to be the risk factor for falls 2021. the association between increased falls risk and polypharmacy appears more when the older person is taking a medication that is known to cause falls as a side effect which may double the  risk of falls 20-21. conclusion multiple comorbidities, polypharmacy and increasing age increase risk of falls and risk of falls also can be affected with different  comorbidities as shown in the previous results if the patient had diabetes mellitus, peripheral vascular disease, old cerebrovascular accidents or urinary incontinence made patient more liable and had higher risk of falls. recommendations: • screening for falls in older adults is considered a very important preventive method. • patients with multiple comorbidities are more liable for falls, so frequent assessment of falls is recommended in patients with multiple comorbidities and treatment of their comorbidities as possible. • physicians should try to avoid polypharmacy as possible in older adults to decrease risk of falls. • patients with dm, pvd, cva or ui need special care to decrease risk of falls. • more future studies to investigate the effect  of  individualized  medications  on  risk of falls. international journal of human and health sciences vol. 06 no. 01 january’22 78 table 3. comparison between patients with high risk and low risk of falls as regards different  comorbidities. comorbidities high risk of falls low risk of falls total n % n % x2 p value dm no 68 25 36.8% 43 63.2% 9.618 0.002* yes 82 51 62.2% 31 37.8% htn no 28 10 35.7% 18 64.3% 3.079 0.079 yes 122 66 54.1% 56 45.9% ishd no 104 50 48.1% 54 51.9% 0.910 0.340 yes 46 26 56.5% 20 43.5% pvd no 113 47 41.6% 66 58.4% 15.090 0.000* yes 37 29 78.4% 8 21.6% chf no 138 67 48.6% 71 51.4% 3.090 0.079 yes 12 9 75% 3 25% copd no 98 47 48% 51 52% 0.829 0.363 yes 52 29 55.8% 23 44.2 cva no 135 63 46.7% 72 53.3% 8.642 0.003* yes 15 13 86.7% 2 13.3% oa no 92 41 44.6% 51 55.4% 3.544 0.060 yes 58 35 60.3% 23 39.7% ui no 123 57 46.3% 66 53.7% 5.114 0.024* yes 27 19 70.4% 8 29.6% acknowledgement: the authors thank to all the staff  of  geriatrics  and  gerontology  department,  faculty of medicine, ain shams university, cairo, egypt for providing the research facilities. conflict of interest: the authors declare that they have no conflict of interest. funding statement: none declared. ethical consideration: verbal consent was taken from every participant in this study. authors’ contribution: hf mahmoud, collected patient and data, analysed the results, wrote the paper and edited the manuscript. hemz elmedany, collected some of the patients and wrote part of the paper. 79 international journal of human and health sciences vol. 06 no. 01 january’22 references 1khow ksf, visvanathan r. falls in the aging population. clin geriatr med 2017;33(3):357–368. 2lamb se, jorstad-stein ec, hauer k, becker c. prevention of falls network europe and outcomes consensus group. development of a common outcome data set for fall injury prevention trials: the prevention of falls network europe consensus. j am geriatr soc. 2005;53(9):1618–22. 3gale cr, cooper c, aihie sa. prevalence and risk factors for falls in older men and women: the english longitudinal study of ageing. age ageing 2016;45(6):789–94. 4lord s, sherrington c, menz h. falls in older people. risk factors and strategies for prevention. cambridge: university press 2001;1989. 5tinetti me, speechley m. prevention of falls among the elderly. n engl j med 1989;320(16):1055–9. 6de moraes sa, soares wjs, lustosa lp, bilton tl, ferrioli e, perracini mr. characteristics of falls in elderly persons residing in the community: a population-based study rev. bras. geriatr. gerontol, rio de janeiro t.l. 2017;20(5):691-701. 7al-aama t. falls in the elderly, spectrum and prevention. canadian family physician 2011;57:7716. 8zia a, kamaruzzaman sb, tan mp. polypharmacy and falls in older people: balancing evidencebased medicine against falls risk. postgrad med 2015;127(3):330–7. 9burt j, elmore n, campbell sm, rodgers s, avery aj, payne ra. developing a measure of polypharmacy appropriateness in primary care: systematic review and expert consensus study. bmc med 2018;16(1):91. 10glasheen wp, cordier t, gumpina r, haugh g, davis j, renda a. charlson comorbidity index: icd9 update and icd-10 translation, american health & drug benefits june/july. 2019;l(12):4. 11 hendrich a. predicting patient falls using the hendrich ii fall risk model in clinical practice. am j nurs, 2007;107(11):10. 12kwok t, liddle j, hastie ir. postural hypotension and falls. postgrad med j, 1995:278–80. centers for disease control and prevention. falls among older adults: an overview. 2013. accessed 10.07.2014 http://www.cdc.gov/homeandrecreationalsafety/ falls/adultfalls.html. 13von heideken, wagert p, gustafson y, kallin k, jensen j, lundin-olsson l. falls in very old people: the population-based umea 85+ study in sweden. arch gerontol geriatr 2009;49:390–6. 14bergland a. fall risk factors in community-dwelling elderly people. norsk epidemiologi 2012;22(2):151– 164 15wilson nm, hilmer sn, march lm, cameron id, lord sr, seibel mj, mason rs, chen js, cumming rg, sambrook pn. associations between drug burden index and falls in older people in residential aged care. j am geriatr soc 2011;59(5):875-80. 16chianca tcm, andrade cr, albuquerque j, wenceslau lcc, tadeu lfr, macieira tgr, ercolei ff. prevalência de quedas em idosos cadastrados em um centro de saúde de belo horizonte-mg. rev bras enferm brasília 2013;66 (2):234-40. 17bittencourt vll, graube sl, stumm emf, battisti ide, loro mm, winkelmann er. factors associated with the risk of falls in hospitalized adult patients. rev esc enferm usp 2017;51. 18wenhua b, dapeng h, xiaohong s, liang s, xiaoquan z, huiping y, yige y, yuhong z, yi z, caiyou h, zeping l, yuetao s, zheng c, leilei d, yuliang e, wei t, ze y. comorbidity increased the risk of falls in chinese older adults: a cross-sectional study. int j clin exp med 2017;10(7):10753-63. 19zaninotto p, huang yt, gessa gd, abell j, lassale c, steptoe a. polypharmacy is a risk factor for hospital admission due to a fall: evidence from the english longitudinal study of ageing. bmc public health 2020;20:1804. 20 ziere g, dieleman jp, hofman a, pols ha, van der cammen tj, stricker bh. polypharmacy and falls in the middle age and elderly population. br j clin pharmacol 2006;61(2):218-23. 21weber v, white a, mcilvried r. an electronic medical record (emr)-based intervention to reduce polypharmacy and falls in an ambulatory rural elderly population. j gen intern med 2008;23(4):399-404. international journal of human and health sciences vol. 03 no. 03 july’19 134 original article: an in vitro study to elucidate the effects of artemisia afra, aspalathus linearis (rooibos) and septilintm on immune pathways hoosen m 1, pool e j 2 abstract objective: herbal immunomodulatory preparations are increasing in popularity. in vitro, in vivo and clinical trial studies are needed to ensure safety, quality and efficacy of these herbal medicines. septilintm, a proprietary herbal medicinal product has been reported to have immunomodulatory effects. aspalathus linearis (rooibos) is a commercialised south african (sa) tea recognised for its phytopharmaceutical potential. artemisia afra is a well known sa herbal medicine used for various inflammatory conditions. this study assessed the effects of artemisia afra, aspalathus linearis (rooibos) and septilintm on inflammatory biomarkers using raw 264.7 cells, a murine macrophage cell line. materials and methods: raw 264.7 cells and lipopolysaccharide (lps) activated raw 264.7 cells were treated with various concentrations of the above mentioned samples after which the culture supernatants were assayed for specific inflammatory biomarkers namely, il-6 and nitric oxide (no). results: artemisia afra, aspalathus linearis (rooibos) and septilintm were shown to be non-cytotoxic on unstimulated raw 264.7 cells across all concentrations tested (31-1000µg/ml). addition of aspalathus linearis (rooibos) to unstimulated raw 264.7 cells significantly up regulated (p<0.001) no and il-6 production at concentrations of 500µg/ml and 1000µg/ml when compared to the control, whilst septilintm and artemisia afra had no effect. artemisia afra and aspalathus linearis (rooibos) were shown to be noncytotoxic on stimulated raw 264.7 cells across all concentrations tested (31-1000µg/ml). however, septilintm significantly (p<0.001) decreased metabolic activity at the highest concentration tested (1000µg/ml). addition of artemisia afra to stimulated raw 264.7 cells significantly down regulated (p<0.001) no and il-6 production when compared to the control. aspalathus linearis (rooibos) and septilintm samples had no effect on the synthesis of no and il-6 in stimulated raw 264.7 cells when compared to the controls. conclusion: artemisia afra has anti-inflammatory effects while aspalathus linearis (rooibos) up regulated the immune system. this study also shows that septilintm had no effects on raw 264.7 cells. keywords: artemisia afra, aspalathus linearis (rooibos), septilintm, nitric oxide, interleukin 6 (il-6), immunomodulatory, raw 264.7 cells correspondence to: mujeeb hoosen, school of natural medicine, faculty of community and health sciences, university of the western cape, south africa. email: mahoosen@uwc.ac.za / mujeebh786gmail.com 1. dr mujeeb hoosen, (coordinator of unani-tibb) school of natural medicine, faculty of community and health sciences, the university of the western cape, bellville, south africa 2. professor edmund john pool (professor of microbiology), the department of medical biosciences, faculty of natural sciences, the university of the western cape, bellville, south africa introduction herbal immunomodulatory preparations have been observed to exert anti-inflammatory effects1. these formulas may modify the actions of the immune system by influencing the regulation of messenger molecules like cytokines, nitric oxide, hormones, neurotransmitters, and other peptides. these herbal medicinal products (hmps) are often prescribed for inflammatory and immunerelated illnesses2. aspalathus linearis (rooibos) tea is a commercialized popular health drink from sa well known for its numerous health benefits including anti-inflammatory and antioxidant effects3,4,5. artemisia afra remains one of the most popular sa herbal medicines used for a variety of immune related illness conditions6. septilintm international journal of human and health sciences vol. 03 no. 03 july’19 page : 134-145 doi: http://dx.doi.org/10.31344/ijhhs.v3i3.91 135 international journal of human and health sciences vol. 03 no. 03 july’19 is a phytopharmaceutical formulation which is recommended for the treatment and management of several immune related illnesses6. despite the popularity of the above mentioned hmps there are limited in vitro and in vivo studies available. in light of the above, this study was undertaken to investigate the in vitro effects of artemisia afra, aspalathus linearis (rooibos) and septilintm on inflammatory biomarkers (il-6 and no) using raw 264.7 cells, a murine macrophage cell line. in this study artemisia afra (ethanolic extract), aspalathus linearis (rooibos) (aqueous extract) and septilintm (aqueous extract) were tested according to the traditional (common) methods of preparations. in vitro dosages of the above mentioned herbal medicines were calculated in relation to common use. materials and methods: this experimental study was conducted at the university of the western cape (south africa), medical biosciences department from june 2013 to december 2014. sample preparation: a 20% (w/v) plant extract of artemisia afra was prepared using 94.4% ethanol (parceval (pty) ltd pharmaceuticals, south africa). the aerial parts of the artemisia afra plant were milled (sieve size 2-3mm) and mixed with 94.4% ethanol (20g artemisia afra: 100ml ethanol). the milled leaves were separated from the remaining tincture. the tincture was sterilised by filtration using a 0.50nm sterile filter and stored at 4°c. the final extract was air dried and re-suspended in dmso. final samples contained a 50% (wet leaf w/v) extract. aspalathus linearis (rooibos) in a tea bag form (net weight: 25g; manufacture date 02/06/2013; expiry date 01/06/2014) was seeped in 500ml of boiling water. the sample was allowed to cool to room temperature. the sample was sterilised by filtration using a 0.50nm sterile filter. aliquots of the extract 1ml/vial were stored at -80 °c. septilintm (net weight: 452mg; batch nr: e281004; manufacture date: 10/08/2011; expiry date: 04/2014) in tablet form was crushed by means of a sonicator then diluted in 35ml of distilled water. the sample was incubated on a shaker for 1 hour at ambient temperature. the sample was then centrifuged at 40 000 rpm for 10mins. after that it was sterile filtered using 0.50nm sterilized filters and stored in 1ml aliquots at -80oc. preparation of raw 264.7: cultures were prepared under sterile conditions. mouse macrophage raw 264.7 cell line (atcctb-71) was cultured in dulbecco’s modified eagle’s medium (dmem) supplemented with 10% heat inactivated foetal bovine serum (fbs), 1% antibiotic/antimycotic (sigma, germany), 0.05% gentamycin (sigma, germany), and 1% glutamaxtm, at 37ºc and 5% co2. the cells were cultured in 96 well plates at a density of 5x105 cells/ml till they were almost confluent. at this stage the following solutions were prepared: control medium for unstimulated cultures was just the normal culture medium, while stimulation medium for cultures was supplemented with 1µg/ml lps from escherichia coli 0111:b4 (sigma, germany). extracts of the various products (aspalathus linearis, artemisia afra and septilin™) were diluted in normal medium to give a concentration range from 0-2000µg/ml. at confluence half the plate received normal medium (unstimulated cultures), while the other half plate received lps containing medium (stimulated cultures) at 100µl/well. this was followed by the addition of a further 100µl/well of the medium containing various extract concentrations. final concentration ranges of the extracts were between 0-1000µg/ml. after overnight incubation at 37ºc and 5% co2, culture supernatants were collected for no and il-6 assays. the cells on a plate were used for cell viability assays. metabolic activity and cytotoxicity (wst-1): the cell metabolic activity and cytotoxicity of raw 264.7 cells were evaluated using the wst1 cell proliferation reagent (rosche, almere, the netherlands). the wst-1 conversion assay is based on the mitochondrial integrity of whole cells which allows them to metabolise the stable tetrazolium salt wst-1 (4-[3-(4-iodophenyl)-2-(4-nitrophenyl)2h-5-tetrazolio]-1,3-benzene disulfonate) to a soluble violet formazan product. the metabolic conversion of wst-1 by the cells exposed to various concentrations of the above extracts was assessed in a 96-well microtitre plate. the assay was conducted according to the manufacturer’s specifications. briefly, cells were exposed to various concentrations (0-1000µg/ml) of the above extracts for 24 hours and subsequently incubated with wst-1 reagents for 1 hour. absorbance was measured using a spectramax® spectrophotometer at a wavelength of 450nm. the absorbance of the international journal of human and health sciences vol. 03 no. 03 july’19 136 extracts in the culture medium, measured in the absence of cells, was subtracted from the total absorbance of the extract treated cells. measurement of nitrite formation: nitrite production was determined in the supernatant of the media by griess reaction. the reagents for the griess assay were purchased from sigma (usa). after the 24 hour incubation of the test cells, cell culture supernatant (100µl/well) was added to a solution of griess reagent (1% sulfanilamide, 0.1% naphythyl ethylene diaminedihydrochrolide in 5% h3po4), incubated at ambient temperature for 15 minutes to form a purple azodye. the absorption reading at 540nm was determined using a spectramax® spectrophotometer. excel was used to generate a standard curve. cytokine analysis (il-6 elisa): the release of the inflammatory biomarker il-6 was measured in the supernatant of the raw 264.7 cells after exposure to various concentrations of the plant extracts and septilintm for 24 hours at 37°c in a humidified atmosphere of 5% co2. the effects of the extracts on il-6 released from the raw264.7 cells were assessed using the mouse cytokine il-6 elisa kit (e-bioscience kit, biocom biotech). cytokine analysis was performed according to the manufacturer’s instructions. briefly, 96 well plates were coated with primary antibody against the il-6 and incubated overnight at -4˚c. after incubation, the plates were washed with phosphate buffered saline containing 0.05 % tween-20. non-specific binding sites were then blocked with assay diluent for 1 hour at ambient temperature after which the wells received either recombinant mouse il-6 standards or sample. the plate was sealed and incubated for 2 hours at ambient temperature on a shaker. after incubation the wells were washed. the wells then received biotin-conjugated antibody against il6. the plate was incubated for 1 hour at ambient temperature on a shaker followed by washing as before. the wells then received avidin-hrp conjugate. the plate was incubated for 30 minutes at ambient temperature on a shaker followed by washing as before. after the last wash, the bound peroxidase was monitored by addition of tetramethyl benzidine substrate (sigma) solution to each well, after which the plate was incubated for approximately 15 minutes. the reaction was stopped by adding 50µl of 2m h2so4 to each well. the absorbance was read at 450nm on an elisa plate reader. excel was used to generate a standard curve for each elisa plate. this was then used to determine the cytokine concentrations of the culture supernatants. statistical analysis: raw 264.7 cells experiments was performed in triplicate to confirm reproducibility. all data was captured on excel spreadsheets and were expressed as mean ± standard deviation (sd). the statistical significance of data was analysed via one-way analysis of variance and regression analysis (anova). results: figure 1a. cell metabolic activity of unstimulated raw 264.7 cells exposed to various concentrations of artemisia afra, aspalathus linearis (rooibos) and septilintm. the statistical significance (p<0.001) compared to the control is designated by an asterisk (*). figure 1b. cell metabolic activity of lps stimulated raw 264.7 cells exposed to various concentrations of artemisia afra, aspalathus linearis (rooibos) and septilintm. the statistical significance (p<0.001) compared to the control is designated by an asterisk (*). figure 2a. standard curve for no assay. this standard curve shows a good correlation (r2= 0.9995) between absorbance readings and no concentration. 137 international journal of human and health sciences vol. 03 no. 03 july’19 discussion: lps, a bacterial antigen, is a potent activator of a wide range of signalling pathways particularly pathways of inflammation. inflammatory mediators includes pro-inflammatory cytokines like tnf-α, il-1, il-6, il-8 and also no and prostaglandins amongst others. no is a metabolite produced by enzymes, which include inducible nitric oxide synthase (inos). the enzymatic activity of inos in diverse cell types contributes to the overproduction of no which is responsible for inflammation in several pathophysiological conditions like cancer, rheumatoid arthritis, diabetes and liver cirrhosis amongst others8. an unstable molecule that has lost an electron is referred to as a free radical. free radicals can oxidise dna, nucleic acid, proteins or lipids which contributes to degenerative illnesses like cardiovascular diseases and cancers. the production of reactive oxygen species is mechanistically linked to inflammation9. the excessive production of no and its oxidation product, peroxynitrite has been implicated in several inflammatory conditions. inhibition of no has become the main focus area in the field of anti-inflammatory research10. macrophages and monocytes play a crucial role in innate and adaptive immunity. macrophages affect various immune responses when encountering invading pathogens. the versatile role of macrophages includes antigen recognition, capture, clearance and transport of foreign products. macrophages stimulated by lps and microbes elicit the release of various proteins like inos which leads to the production of no11. international journal of human and health sciences vol. 03 no. 03 july’19 138 the use of raw 264.7 mouse macrophage cell lines is a well-established model to determine no production9. the lps stimulated cell system has become popular in the area of new antiinflammatory drug discovery1. the effect of artemisia afra, aspalathus linearis (rooibos) and septilintm on the metabolic activity of unstimulated and lps stimulated raw 264.7 cells: cellular proliferation refers to an increase in the number of cells due to cell growth and cell division which result in the increase in subcellular organelles like mitochondria. in all living organisms, tissue growth is dependent on a balance between cell proliferation and cell death. many drugs affect particular stages of the cell cycle. cell injury and cell death is a consequence of specific interferences with cell metabolism. abnormal cell proliferation is the underlying factor to many pathological conditions. alterations to the cell cycle and cell proliferation plays and important role in immunity12. the results on metabolic activity of unstimulated raw 264.7 cells exposed to various concentrations of artemisia afra, aspalathus linearis (rooibos) and septilintm were evaluated using the wst-1 cell proliferation reagent (figure 1a.). artemisia afra induced a significant increase in metabolic activity (p<0.001) at a concentration of 500µg/ml whilst aspalathus linearis (rooibos) induced significant increases in metabolic activity (p<0.001) across the concentrations of 31-250 and 1000µg/ml in unstimulated raw 264.7 cells. septilintm induced significant increases in metabolic activity (p<0.001) across the concentrations of 63-1000µg/ ml in unstimulated raw 264.7 cells. these findings suggest that artemisia afra, aspalathus linearis (rooibos) and septilintm are non-cytotoxic at the above mentioned concentrations in unstimulated raw 264.7 cell activity. these findings agree with a study on the toxicity of artemisia afra by mukinda and syce, who reported that the extract of artemisia afra is non-toxic in acute doses13. in a similar study on scoparone, a major constituent of artemisia capillaris, no cytotoxic effects were reported in unstimulated macrophage cells14. another study on the inhibition potential of the extract of artemisia capillaris on cytokine-induced nitric oxide formation and cytotoxicity on rinm5f cells reported no significant difference in cell viability in the absence of a stimulus even at the highest concentrations15. possible differences that exist amongst studies could be due to differences in activities of these two species of artemisia. these current findings with regards to aspalathus linearis (rooibos) also agrees with previously mentioned studies which confirmed the safety of aspalathus linearis (rooibos). aspalathus linearis (rooibos) has shown no cytotoxic effects at all concentration tested in vitro using whole blood cell cultures16. aspalathus linearis (rooibos) has gained popularity globally as an accepted nutraceutical. the health-promoting benefits of aspalathus linearis (rooibos) have been confirmed in several in vitro and in vivo studies4. these findings also agree with previously mentioned studies which refer to the safety of septilintm as it is widely used as a health supplement1,7. a nonrandomized non-placebo controlled pilot study using septilintm in chronic periodontitis reported no adverse effects in patients indicating to its relative safety35. the results of the cell metabolic activity of lps stimulated raw 264.7 cells exposed to various concentrations of artemisia afra, aspalathus linearis (rooibos) and septilintm were evaluated using the wst-1 cell proliferation reagent (figure 1b.). figure 1b (stimulated raw 264.7) compared to figure 1a. (unstimulated raw 264.7) shows that the cell metabolic activity of raw 264.7 cells exposed to lps (control) increased cell proliferation. lps is a well known mitogen (a substance which induces cell mitosis)33. artemisia afra induced significant increases in metabolic activity (p<0.001) across concentrations of 63-500µg/ml in lps stimulated raw 264.7 cells. these findings agree with the previously mentioned study on artemisia capillaris which reported no cytotoxic effects on stimulated macrophage cells33. in the previously mentioned study on the extract of artemisia capillaris on rinm5f cells it was reported that the extract restored the cell proliferation potential proportional to its concentration15. these findings are more significant than that of the effect of artemisia afra in unstimulated raw 264.7 cells (figure 1a.). septilintm significantly decreased metabolic activity (p<0.001) at the highest concentration tested (1000µg/ml) in lps stimulated raw 264.7 cells. these findings are contrary to the results in unstimulated raw 264.7 (figure 1a.). septilintm may be cytotoxic at high doses however further investigation would be needed. this could indicate to the importance of dosage 139 international journal of human and health sciences vol. 03 no. 03 july’19 optimisation when prescribing this medication for infectious conditions. septilintm is indicated for acute infectious conditions as mentioned in previous studies. wiesner and knoss reports that globally, most patients believe that hmps are safe which improves compliance. the misconception regarding the safety of hmps may cause patients to misuse these medicines37. this is the first study to note decreased metabolic activity at the above mentioned dose (1000 µg/ml) in lps stimulated raw 264.7 cells. no toxicological studies have been done on this herbal preparation and the current literature lacks sufficient evidence regarding its safety and toxicity therefore further studies are recommended. aspalathus linearis (rooibos) had no effects on the metabolic activity of lps stimulated raw 264.7 cells at all concentration tested indicating that this herbal extract is nontoxic even at high concentrations. the popular use of aspalathus linearis (rooibos) over time has contributed to the assumption of its relative safety36. many studies have looked at aspects of safety and toxicity of aspalathus linearis (rooibos) however no toxicological studies have been done as yet. the minor component of aspalathus linearis (rooibos), quercetin is suggested to be implicated in its mutagenic effects. however these effects were seen in concentration of 220-230 times more than that of the normal tea drinking quantities36. the present study provides in vitro evidence suggesting that the product is non-toxic. a limitation to this study was that aspalathus linearis (rooibos) was introduced to cells after stimulation which mimics the therapeutic approach to infection. aspalathus linearis (rooibos) is most commonly consumed for prolonged periods as a daily beverage or health drink therefore to have tested aspalathus linearis (rooibos) as a preventative would add more value for in vivo application. the effects of artemisia afra, aspalathus linearis (rooibos) and septilintm on no production in unstimulated and lps stimulated raw 264.7 cells: the overproduction of no is responsible for inflammation in several pathophysiological conditions like cancer, rheumatoid arthritis, diabetes, liver cirrhosis and septic shock. inhibition of no has become the main focus area in the field of anti-inflammatory research10. herbal medicines may be valuable in the modulation of no. inos is a popular investigated enzyme system utilised for in vitro, ex vivo, in vivo, animal, or human research on herbal products. research on herbal medicines in whole, standardized or extract forms are frequently investigated with regards to nitric oxide activity38. the standard curve for the no assay is shown in figure 2a. the standard curve was used to calculate the concentrations of no in samples. the standard curve displays a good correlation (r2= 0.9995) between the absorbance and no concentration. nitrite production, a marker of no synthesis, was determined in the supernatant of unstimulated raw 264.7 cells exposed to various concentrations of artemisia afra, aspalathus linearis (rooibos) and septilintm (figure 2b). there were no significant differences on no secretion in unstimulated raw 264.7 cells exposed to various concentrations of artemisia afra. aspalathus linearis (rooibos) significantly increased (p<0.001) no production at concentrations of 500µg/ml and 1000µg/ml in unstimulated raw 264.7 cells. this suggests that aspalathus linearis (rooibos) possess pro-oxidant potential at these concentrations in absence of a stimulus. these findings are contrary to several studies who reports on the antioxidant effects of aspalathus linearis (rooibos) in vitro and in vivo3,4,5,8,9. however, these findings agrees with persson et al., who reported increased no production of aspalathus linearis (rooibos) in vitro on cultured human umbilical veins endothelial cells at doses of 0-730µg/ml39. in a follow up in vivo study, persson et al., reported no effect on no activity in human subjects who consumed 400ml of aspalathus linearis (rooibos) per week for 4 weeks in a randomized three-phase crossover design. differences between the in vitro and in vivo studies may be due to differences in the content of the flavonoids or/and the metabolism of the components in the different teas as well as the use of different models40. waisundara and hoon reported on the antioxidant effects of aspalathus linearis (rooibos) but cautioned against the in vivo application of these findings due to the prooxidant reports of aspalathus linearis (rooibos) in other studies41. aspalathus linearis (rooibos) is mainly consumed as a health promoting beverage as mentioned in previous studies. its pro-oxidant potential should be considered especially in chronic inflammatory conditions. no stimulation is responsible for cellular and tissue damage which contributes to numerous inflammatory conditions affecting different organs1. in this study, septilintm had no effect on no secretion in unstimulated raw 264.7 septilintm had no significant anti-inflammatory effects international journal of human and health sciences vol. 03 no. 03 july’19 140 (no inhibition) in unstimulated raw 264.7 cells1. this is the second known study which followed a similar model to that of varma et al., 2011 by assessing anti-inflammatory effects (no inhibition) of septilintm and hence its importance since this herbal preparation is widely used as an anti-inflammatory agent. the no production was also determined in the supernatant of lps stimulated raw 264.7 cells exposed to various concentrations of artemisia afra, aspalathus linearis (rooibos) and septilintm (figure 2c.). artemisia afra significantly decreased no production (p<0.001) at all concentrations tested (31,25-1000ug/ml) in lps stimulated raw 264.7 cells. these findings agree with the previously mentioned study on artemisia capillaris which reported significant (p<0.01) inhibition of no production in lps stimulated macrophage cells14. the previously mentioned study on the extract of artemisia capillaris on rinm5f cells reported potent dose dependant inhibition of no secretion15. three in vitro studies on artemisia species has reported on the inhibition/reduction of no secretion in macrophages15,42,43. these results suggest the antiinflammatory potential of artemisia species. the results supports the anecdotal uses of artemisia species for inflammatory conditions as previously mentioned. in depth study of the effect of herbal medicine on the immune system requires the use of both in vitro and in vivo experimentation. in vitro models are valuable in evaluating the immunomodulatory effects of herbal constituents44. aspalathus linearis (rooibos) and septilintm showed no effect on no activity on stimulated raw 264.7 cells. these findings are contrary to that of varma et al who reported significant inhibition (p<0.001) of no in lps stimulated macrophages by septilintm1. the findings of varma et al were tested at concentrations of 2.5% and 5% of septilintm which are 25 to 50 fold higher than the concentrations of septilintm (31-1000ug/ml) used in this study. such high concentrations of the herbal product could be unrealistic and problematic if these concentrations were to be extrapolated for in vivo application. mansour et al., reported on the reduction of no secretion in an in vivo, radiation induced rat model. in this study liquid preparation of septilintm was injected intraperitonially (100 mg/kg b.wt.) for five consecutive days45. sharma and ray, 1997 conducted a study using an oral dose of 500mg/ kg of septilintm in rodents which is equivalent to an intake of 25-50g in humans. these dosages are clearly too high which is a common problem found in in vitro and in vivo studies on herbal medicines31. pre-clinical evaluation of hmps should begin with in-vitro models, by testing cytotoxicity, mutagenicity and acute and sub-chronic safety. these safety studies should be followed up by in-vivo models at appropriate doses of the hmp’s according to internationally accepted standards. extrapolating doses of the hmps for in vivo application proves to be challenging. dose-finding studies before formal animal studies are crucial in the preliminary phase to establish efficacy of hmps46. in a comparative study on the nitric oxide (no) scavenging activities of traditional polyherbal drugs, septilintm was tested at the same concentrations (31-1000ug/ml) as this current study. it was reported that septilintm inhibited the production of no in a dose dependent manner up to 125 µg/ml (69.66%) which was followed by a gradual increase of no production thereafter at the higher doses46. the results of jagetia et al showed far less efficacy of no inhibition by septilintm to that of varma et al. this could be due to the differences in the concentrations tested. another contributing factor to differences in findings of these two studies could be attributed to variations that exist in different batches of hmps. the chemical composition of hmps differ depending on various factors which includes the botanical species, the anatomical part of the plant used, storage methods, sun, humidity, type of soil, time of harvest, geographic location amongst others. batch to batch variations can be found within the same manufacturing company which can result in significant variations in pharmacological activities influenced by pharmacodynamics and/ or pharmacokinetic factors46. several in vitro and in vivo studies on the individual ingredients of septilintm were conducted on various models with varying effects on no activity. commiphora mukul, rubia cordifolia, emblica officinalis and moringa pterygosperma has shown decreased no secretion in previous studies49,50,51,52. most studies of tinospora cordifolia reported increased no production53,54. glycyrrhiza glabra studies reported either increased no production or decreased no production55,56. many studies on the molecular modes of activities of individual herbs have little relevance to its practical application as most herbal medicines are formulations 141 international journal of human and health sciences vol. 03 no. 03 july’19 (combinations of several herbs)2. these formulas introduce extremely complex mixtures of compounds that may act synergistically to produce therapeutic effects. the overall effect of the formulation may be different to the sum of the individual effects of each herb which makes the study on herbal medicines extremely challenging due to its complex chemistry2. the current results are contrary to several in vitro and in vivo studies reporting on the antioxidants and/or ant effects of aspalathus linearis (rooibos) previously mentioned. most of these in vitro studies used the ethanolic extract of aspalathus linearis (rooibos) which may account for differences in findings. however, in a previous study joubert et al., also reported on the pro-oxidant activity of the aqueous extracts of aspalathus linearis (rooibos)57. the effects of artemisia afra, aspalathus linearis (rooibos) and septilintm on il-6 production in unstimulated and lps stimulated raw 264.7 cells: the cytokine, il-6 is involved in the systemic changes associated with inflammation and infection28. il-6 concentrations were determined using a das-elisa. the standard curve for the il-6 elisa is shown in figure 3a. the standard curve was used to calculate the concentrations of il-6 in samples. the standard curve displays a good correlation (r2= 0.9991) between the absorbance and il-6 concentration. il-6 was used as a biomarker to determine the inflammatory response of lps on unstimulated raw 264.7 cells exposed to various concentrations of artemisia afra, aspalathus linearis (rooibos) and septilintm (figure 3b.). the significant difference (p<0.001) is designated by an asterisk (*). artemisia afra had no effect on il-6 production in unstimulated raw 264.7. these findings correspond to the previously mentioned results for figure 2b. aspalathus linearis (rooibos) significantly increased (p<0.001) il-6 production at concentrations of 500µg/ml and 1000µg/ml in unstimulated raw 264.7 cells. these findings are contrary to most of the previous studies which reports on the anti-inflammatory properties of aspalathus linearis (rooibos) in vitro and in vivo3,4,5,8,9. most of these in vitro studies were conducted using similar concentrations of aspalathus linearis (rooibos) (0-1000µg/ml) as this study however within different models which may account for variations in findings. mueller et al., conducted a similar study on aspalathus linearis (rooibos) on raw 264.7 macrophages. results showed decreased il-6 at concentrations of 500µg/ml58. studies on the pro-inflammatory effects of aspalathus linearis (rooibos) are few4. however these studies tested the aqueous extract of aspalathus linearis (rooibos) whilst the majority of anti-inflammatory studies on aspalathus linearis (rooibos) were conducted on the ethanolic extract. this maybe due to the presence of different bioactives in aqueous extracts compared to ethanol extracts. these current findings suggest the proinflammatory effects of aspalathus linearis (rooibos) in vitro in absence of a stimulus which corresponds to the results in figure 2b., showing that aspalathus linearis (rooibos) induced il-6 production at concentrations of 500µg/ml and 1000µg/ml in unstimulated raw 264.7 cells. up regulation of il6 could potentially activate hepatocytes to produce acute phase proteins leading to complement activation allowing phagocytosis. cellular responses to microbial pathogens could be improved by consuming aspalathus linearis (rooibos) tea16. this suggests that the consumption aspalathus linearis (rooibos) tea could potentially be used for prophylactic purposes. however, important consideration should be given to its possible pro-inflammatory action in midst of inflammation which could lead to or worsen tissue damage. il-6 is well known to mediate the involvement of inflammatory cells in acute and chronic inflammation1. il-6 is involved in the systemic changes associated with tissue damage, inflammation and infection59. in an in vitro whole blood culture study on unstimulated wbc, aspalathus linearis (rooibos) also induced higher il-6 secretion at concentrations between 7.8125µg/ml 250µg/ml16. septilintm had no effects on unstimulated raw 264.7 cells. these findings correspond to the previously mentioned results which reported that septilintm did not effect no secretion in unstimulated raw 264.7 cells (figure 2b.). il-6 was used as a biomarker to determine the inflammatory response on lps stimulated raw 264.7 cells exposed to various concentrations of artemisia afra, aspalathus linearis (rooibos) and septilintm (figure 3c.). artemisia afra significantly decreased (p<0.001) production of il-6 by lps stimulated raw 264.7 cells in a concentration dependant manner (63-1000ug/ ml). these results suggest the anti-inflammatory potential of artemisia afra which also corresponds to the results in figure 2c. showing that artemisia afra significantly decreased no production of international journal of human and health sciences vol. 03 no. 03 july’19 142 stimulated raw 264.7 cells. these results supports the use of artemisia afra as an anti-inflammatory for infectious conditions as seen in previous studies and anecdotal uses mentioned previously15,42,43. several previous studies reported on the antiinfective properties of the active constituents of artemisia afra which includes; camphene, 1,8-cineole, artemisia ketone, camphor, borneol, terpineol, chrysanthenyl acetate, amyrin amongst others6,60. these constituents amongst several others were present in the artemisia afra ethanolic extract tested in this study (gcms analysis of artemisia afra extract data not included) which may have contributed to the anti-inflammatory effects. aspalathus linearis (rooibos) did not induce significant changes in il-6 secretion by stimulated raw 264.7 cells. these findings are consistent with the results shown in figure 2c. (aspalathus linearis did not induce significant changes in no secretion) but inconsistent with the majority of previous studies which reported on the antiinflammatory effects of aspalathus linearis by inhibiting/reducing il-6 secretion 4,59,61. septilintm showed no effects in il-6 secretion by stimulated raw 264.7 cells. these findings are contrary to that of varma et al., 2011 and others who reported significant inhibition (p<0.001) in il-6 secretion in lps stimulated macrophages by septilintm. the anti-inflammatory effect of septilintm has been observed in previous studies which indicated that septilintm suppressed various inflammatory mediators like tnf-α, il-6 and il-8 in lps stimulated in vitro cell culture models1,7,21,22. studies also showed that septilintm inhibits inos gene expression, cox-2 enzyme activity and pde4b gene expression. these are suggested to be the anti-inflammatory modes of action of this herbal product1. the current findings are contrary to the previously mentioned studies with regards to the anti-inflammatory effects of septilintm. a possible reason for this could be due to the use of an aqueous preparation of septilintm in this study. a study by raveendran nair and chanda, on the efficacy of medicinal plants against pathogenic bacterial strains reported greater effects by the ethanol extract of the samples than the aqueous extract62. an anti-cancer in vitro study compared the effects of fifteen crude aqueous herbal extracts to the ethanol herbal extracts against human cancer cell lines. this study reported that the aqueous herbal extracts decreased cell proliferation by more than 50% when compared to the ethanol herbal extracts. another study also suggested that the ethanol extracts contained the herbal active constituents responsible for the significant results63. further studies should include both ethanol and aqueous extracts of septilintm, aspalathus linearis (rooibos) and artemisia afra within the same model. conclusion: the overall findings of this study suggest the anti-inflammatory effects of artemisia afra and pro-inflammatory effects of aspalathus linearis (rooibos) in raw 264.7 cells. septilintm showed no effects in raw 264.7 cells. conflict of interest: none declared 143 international journal of human and health sciences vol. 03 no. 03 july’19 references: 1. varma, r, ashok, g, vidyashankar, s, patki, p, nandakumar, ks, anti-inflammatory properties of septilin in lipopolysaccharide activated monocytes andmacrophage. journal of immunopharmacology and immunotoxicology 2011;33(1):55-63 2. burns, j.j, zhao, l, taylor, ew, spelman, k, the influence of traditional herbal formulas on cytokine activity. toxicology 2010;278:140-159 3. nel, e, binns, t, bek, d, alternative foods and community-based development: aspalathus linearis (rooibos) tea production in south africa’s west coast mountains. applied geography 2007;27(2):112-129 4. smith, c, swart, ac, rooibos (aspalathus linearis) facilitates an anti-inflammatory state, modulating il-6 and il-10 while not inhibiting the acute glucocorticoid response to a mild novel stressor in vivo. journal of functional foods, 2016;27: 42-54 5. van wyk, be, a broad review of commercially important southern african medicinal plants. journal of ethnopharmacology 2008;119:342-355 6. liu, nq, van der kooy, f, verpoorte, r, artemisia afra: a potential flagship for african medicinal plants? south african journal of botany 2009;75:185-195 7. manal, m. therapeutic index. bangalore: himalaya global holdings ltd, 2014 8. erickson, l, rooibos tea: research into antioxidant and anti-mutagenic properties. the journal of the american botanical council, 2003;59:34-45 9. ku, sk, kwak, s, kim, y, bae, js, aspalathin and nothofagin from rooibos (aspalathus linearis) inhibits high glucose-induced inflammation in vitro and in vivo. inflammation 2015;38: 445-455 10. konkimalla, vd, blunder, m, korn, b, soomro, sa, jansen. h, chang, w, posner, gh, bauer, r, efferth, t, effect of artemisinins and other endoperoxides on nitric oxide-related signalling pathway in raw 264.7 mouse macrophage cells. nitric oxide 2008;19:184-191 11. bisht, k, choi, wh, park, sy, chung, mk, koh, ws, curcumin enhances non-inflammatory phagocytic activity of raw264.7 cells. biochemical and biophysical research communications 2009; 379: 632-636. 12. underwood, jce, general and systemic pathology, 4th edition. edinburgh: churchill livingstone, 2004 13. mukinda, jt, syce, ja, acute and chronic toxicity of the aqueous extract of artemisia afra in rodents. journal of ethnopharmacology 2007;112: 138-144 14. jang, si, kim, yj, lee, wy, kwak, kc, baek, sh, kwak, gb, et al, scoparone form artemisia capillaris inhibits the release of inflammatory mediators in raw 264.7 cells upon stimulation cells by ifnγ plus. archives of pharmacal research 2005;28(2):203-208 15. kim, ek, kwon, kb, han, mj, song, my, lee, jh, lv, na, et al, inhibitory effect of artemisia capillaris extract on cytokine-induced nitric oxide formation and cytotoxicity of rinm5f cells. international journal of molecular medicine 2007;19:535-540 16. hendricks, f, pool, ej the in vitro effects of aspalathus linearis and black tea on the immune system. journal of immunoassay and immunochemistry 2010;31(2):169-180 17. mukherjee, pk, houghton, pj, evaluation of herbal medicinal products: perspectives on quality, safety, and efficacy. london: pharmaceutical press, 2009 18. mahlangeni, nt., moodley, r, jonnalagadda, sb, elemental composition of cyrtanthusobliquus and lippiajavanica used in south african herbal tonic, imbiza. arabian journal of chemistry 2014;1-9 19. tan, bkh, vanitha, j, immunomodulatory and antimicrobial effects of some traditional chinese medicinal herbs: a review. current medicinal chemistry 2004;11:1423-1430 20. mahima, rahal, a, deb, r, latheef, sk, abdul samad, h, tiwari, r, verma, ak, dharma, ak, dharma, k, immunomodulatory and therapeutic potentials of herbal, traditional/indigenous and ethnoveterinary medicines. pakistan journal of biological sciences 2012;15(16):754-74 21. daswani, br, yegnanarayan, r, immunomodulatory activity of septilin, a polyherbal preparation. phytotherapy research, 2002;16:162-165 22. khanna, n, sharma, sb anti-inflammatory and analgesic effect of herbal preparation: septilin. indian journal of medical sciences 2003;55:195-202 23. ndhlala, ar, ncube, b, van stade, j, ensuring quality in herbal medicines: toxic phthalates in plastic-packaged commercial herbal products. south african journal of botany 2012;82:60-66 24. silliman, cc, wang, m, the merits of in vitro versus in vivo modelling in investigation of the immune system. environmental toxicology and pharmacology, 2006;21: 123-134 25. damsgaard, ct, lauritzen, l, calder, pc, kjaer, tmr, frokaer, h, whole blood culture is a valid low-cost method to measure monocytic cytokines a comparison of cytokine production in cultures of human whole-blood, mononuclear cells and monocytes. journal of immunological methods 2009;340:95-101 26. schmid, d, woehs, f, svoboda, m, thalhammer, t, chiba, p, moeslinger, p, aqueous extracts of cimicifuga racemosa and phenolcarboxylic constituents inhibit production of proinflammatory cytokines in lps-stimulated human whole blood. journal of physiolology and pharmacology 2009;87:963-972 27. pool, ej, bouic, p, il-6 secretion by ex vivo whole blood cultures upon allergen stimulation. journal of immunoassay and immonchemistry, 2001;22(3):225-234 28. kisten, n, pool, ej, the immune-modulating activity of sutherlandia frutescens. western cape: uwc. (m.sc. immunology) 2010;3:40-48 29. medeiros, r, figeiredo, cp, passons, gf, calixo, jb, reduced skin inflammatory response in mice lacking inducible nitric oxide synthase. biochemical pharmoacology, 2009;78: 390-395 international journal of human and health sciences vol. 03 no. 03 july’19 144 30. spelman, k, burns, jj, nichols, d, winters, n, ottersberg, s, tenborg, m, modulation of cytokine expression by traditional medicines: a review of herbal immunomodulators. alternative medicine review 2006;11(2):128-150 31. gertsch, j, viveros-paredes, jm, taylor, p, plant immunostimulants-scientific paradigm or myth? journal of ethnopharmacology 2010;1-7 32. mion, f, tonon, s, toffoletto, b, cesselli, d, pucillo, ce, vitale, g, il-10 production by b cells is differentially regulated by immune-mediated and infectious stimuli and requires p38 activation. molecular immunology, 2014;62:266-276 33. murphy, k, immunobiology 8th edition. new york: garland science, 2012 34. sharma, sb, ray, s, effect of herbal preparation on immune response of immunosuppressed mice. indian journal of physiology pharmacology 1997;41(3):293-296 35. deore, gd, gurav, an, patil, r, shete, ar, naiktari, rs, inamdar, sp, herbal antiinflammatory immunomodulators as host modulators in chronic periodontitis patients: a randomized, doubleblind, placebo-controlled, clinical trial. journal of periodontal and implant science 2014;44: 71-78 36. wiesner, j, knöss, w, future visions for traditional and herbal medicinal productsa global practice for evaluation and regulation? journal of ethnopharmacology 2014;1-3 37. joubert, e, gelderblom, wca, louw, a, de beer, d, south african herbal teas: aspalathus linearis, cyclopia spp. and athrixiaphylicoidesa review. journal of ethnopharmacol 2008;119: 376-412 38. bouchard, j, mazzarella, l, spelman, k, a review of medicinal plants that modulate nitric oxide activity. alternative medicine studies 2012; 2:e6 39. persson, ial, josefsson, m, persson k, andersson, rgg, tea flavanols inhibit angiotensin-converting enzyme activity and increase nitric oxide production in human endothelial cells. j pharm pharmacol 2006;58: 1139–1144 40. persson, ial, persson k, hagg, s, andersson, rg g, effects of green tea, black tea and aspalathu slinearis (rooibos) tea on angiotensin-converting enzyme and nitric oxide in healthy volunteers. public health nutrition, 2010;13(5):730-737 41. waisundara, vy, hoon, ly, free radical scavenging ability of aspalathus linearis in two in vitro models of diabetes and cancer. journal of traditional and complementary medicine, 2015;5:174-178 42. yoon, wj, moon, jy, song, g, lee, yk, han, ms, lee, js, et al, artemisia fukudo essential oil attenuates lps-induced inflammation by suppressing nf-kb and mapk activation in raw 264.7 macrophages. food and chemical toxicology 2010;48:1222-1229 43. froushani, sma, zarei, l, ghaleh, heg, motlagh, bm,estragole and methyl-eugenol-free extract of artemisia dracunculus possesses immunomodulatory effects. avicenna journal of phytomedicine, 2016;1-9 44. silliman, cc, wang, m, the merits of in vitro versus in vivo modelling in investigation of the immune system. environmental toxicology and pharmacology 2006;21:123-134 45. mansour, hb, rifaat ismael, ne, hafez, hf, ameliorative effect of septilin, an ayurvedic preparation against γ-irradiation-induced oxidative stress and tissue injury in rats. indian journal of biochemistry & biophysics 2014;51:135-141 46. gericke, n, muthi to medicine. south african journal of botany 2011;77:850-856 47. jagetia, gc, balinga, ms, polyherbal extract of septilin protects mice against whole body lethal dose of gamma radiation. phytotherapy research 2004;18:619-623 48. firenzuoli, f, gori, lherbal medicine today: clinical and research issues. evidence-based complementary and alternative medicine 2007;4:37-40 49. matsuda, h, morikawa, t, ando, s, oominami, h, murakami, t, kimura, i, yoshikawa, m, absolute stereostructures of polypodaneand octanordammarane-type triterpenes with nitric oxide production inhibitory activity from guggul-gum resins. bioorg med chem 2004;12:3037-3046 50. zhang, jh, shangguan, zs, chen, c, zhang, h j, lin, y, anti-inflammatory effects of guggulsterone on murine macrophage by inhibiting lps induced inflammatory cytokines in nf-κb signaling pathway. drug design development therapy 2016;10:1829-1835 51. ghosh, s, das, sm, patra, a, hazra, b, antiinflammatory and anticancer compounds isolated from ventilago madraspatana gaertn., rubia cordifolia linn. and lantana camara linn. journal of pharmceutical pharmacology 2010;62(9):1158-66 52. yokozawa, t, kim, hy, kim, hj, okubo, t, chu, d, juneja, lr, raj, l, amla (emblica officinalis gaertn.) prevents dyslipidaemia and oxidative stress in the ageing process. british journal of nutrition, 2007;97:1187-1195 53. desai, vr, ramkrishnan, r, chintalwar, gj, sainis, kb, g1-4a, an immunomodulatory polysaccharide from tinospora cordifolia, modulates macrophage responses and protects mice against lipopolysaccharide induced endotoxic shock. international immunopharmacology 2007;7:1375-1386 54. upadhyaya, r, pandey rp, sharma v, verma anita, k, assessment of the multifaceted immunomodulatory potential of the aqueous extract of tinospora cordifolia. research journal of chemical sciences 2011;1(6): 71-79 55. thiyagarajan, p, chandrasekaran, cv, deepak, hb, agarwal, a, modulation of lipopolysaccharideinduced pro-inflammatory mediators by an extract of glycyrrhiza glabra and its phytoconstituents. inflammopharmacol 2011; 19:235-241 56. franceschelli, s, pesce, m, vinciguerra, i, ferrone, a, riccioni, g, patruno, et al, licocalchone-c extracted from glycyrrhiza glabra inhibits lipopolysaccharide145 international journal of human and health sciences vol. 03 no. 03 july’19 interferon-g inflammation by improving antioxidant conditions and regulating inducible nitric oxide synthase expression. molecules 2011;16: 5720-5734 57. joubert, e, winterton, p, britz, tj, gelderblom, w, ca, antioxidant and pro-oxidant activities of aqueous extracts and crude polyphenolic fractions of rooibos (aspalathus linearis). journal of agriculture and food chemistry, 2005;53 (26):10260-10267 58. mueller, m, hobiger, s, jungbauer, a, antiinflammatory activity of extracts from fruits, herbs and spices. food chemistry 2010;122:987-996 59. hack, ce, de groot, er, felt-bersma, rj, nuijens, jh, strack van schijndel, rj, eerenberg-belmer, aj, increased plasma levels of interleukin-6 in sepsis. american society of hematology 1989;74:1704-1710 60. abad, mj, bedoya, lm, apaza, l, bermejo, p, the artemisia l. genus: a review of bioactive essential oils. molecules 2012;17(3):2542-2566 61. swart, ac, schloms, l, smith, c, storbeck, kh, roos, m, marnewick, jl, swart, p, aspalathus linearis (rooibos) tea: a functional food in the management of metabolic disorders. pharmanutrition, 2013;2:75-119 62. raveendran nair, pk, rodriguez, s, ramachandran, r, alamo, a, melnick, sj, escalon, e, garcia, pi, et al, immune stimulating properties of a novel polysaccharide from the medicinal plant tinospora cordifolia. international immunopharmacology 2004;4:1645-1659 63. sun, j, liu, br, hu, wj, yu, lx, qian, xp, in vitro anticancer activity of aqueous extracts and ethanol extracts of fifteen traditional chinese medicines on human digestive tumor cell lines. phytotherapy research 2007;21:1102-1104 international journal of human and health sciences vol. 06 no. 03 july’22 332 case report dilemma behind post-spinal tetraplegia: is conversion disorder really the culprit? farah nasreen1, atif khalid2, sobia manaal siddiqui3,mohd ahsan4 abstract the occurrence of intra-operative conversion disorder with tetraplegia in a patient undergoing emergency appendectomy under spinal anaesthesia has been described in this case report. a 19-year-old female patient was given spinal anaesthesia for an emergency appendectomy. she had a block up to the t10 level as per assessment. following confirmation of sensory and motor blockade level, the patient became apnoeic and appeared to stop responding abruptly. her vitals remained constant except for tachycardia. she was taken on bag and mask ventilation and preparation for endotracheal intubation was underway. the patient began to respond again after a few minutes of continual stimulation and bag mask ventilation. rest of the perioperative period was uneventful. postoperative psychiatry consultation was done, and she was diagnosed as a case of conversion disorder. keywords:conversion disorder, spinal anaesthesia, tetraplegia correspondence to: dr. atif khalid, senior resident, department of anaesthesia and critical care, jawaharlal nehru medical college hospital, aligarh muslim university, aligarh, uttar pradesh, india.email: atifkhalid2k11@gmail.com 1. assistant professor, department of anaesthesia and critical care,jawaharlal nehru medical college hospital, aligarh muslim university, aligarh, uttar pradesh, india 2. senior resident, department of anaesthesia and critical care, jjawaharlal nehru medical college hospital, aligarh muslim university, aligarh, uttar pradesh, india 3. junior resident, department of anaesthesia and critical care, jawaharlal nehru medical college hospital, aligarh muslim university, aligarh, uttar pradesh, india 4. junior resident, department of psychiatry, jawaharlal nehru medical college hospital, aligarh muslim university, aligarh, uttar pradesh, india international journal of human and health sciences vol. 06 no. 03 july’22 page : 332-334 doi: http://dx.doi.org/10.31344/ijhhs.v6i3.468 introduction conversion disorder (cd) is defined as a psychiatric illness in which symptoms and signs affecting voluntary motor or sensory function cannot be explained by a neurological or medical condition. psychological factors, such as conflicts or stresses are judged to be associated with the deficits. it has a presentation that suggests a neurologic or general medical condition.the pathology cannot be explained by available investigations, nor can it be attributed to anything else such as the patient’s participation in culturally sanctioned behaviours (e.g., ceremonial trances) or substance consumption. there are four types of conversion disorder: those who have motor symptoms or deficits, those who have sensory symptoms or deficits, those who have pseudo-seizures, and those who have a mixed presentation.1,2 in the general population, the lifetime prevalence of cd has been estimated to be between 11 and 300 per 100,000 persons.2 isolated case reports have highlighted the varied presentations of perioperative conversion disorder. 2 patients with distinct features such as sudden onset, young age, female gender, low educational level, low socioeconomic status, neurological disorders with abnormal anatomical pattern, bizarre movements, and the presence of psychological features such as current or early diagnosis of a psychiatric disorder, or traumatic experience have been identified in published literature.3,4we present a case of acute intraoperative conversion disorder with tetraplegia that arose after spinal anaesthesia was administered. 333 international journal of human and health sciences vol. 06 no. 03 july’22 case report a 19-year-old female patient presented with a twoday history of fever and stomach pain, diagnosed as a case of acute appendicitis. she was nervous and concerned about the surgery, and was administered about it. the anaesthetic technique was explained to the patient. she gave her informed consent. inside the operation theatre, routine monitoring equipments were attached. in the sitting position, spinal anaesthesia was conducted with a 26g quincke needle, and 12.5 mg of 0.5% bupivacaine (heavy) was administered intrathecally. the sensory and motor blockade were both evaluated and found to be at t10 level. the patient was becoming concerned about the loss of motor power in her lower limbs at this time, and she was told that she would regain full functionality within a few hours. she then suddenly closed her eyes and stopped answering. stimulation elicited no response. there was tachycardia in the range of 150 beats per minute. the blood pressure and saturation levels were both normal. as there was absence of respiratory efforts, she was placed on bag mask ventilation. despite the patient being apnoeic, saturation was maintained throughout. this episode lasted for around 7 mins. subsequently, the patient’s respiratory efforts resumed, pulse began to settle, and she opened her eyes. she described her entire body as being paralysed and an inability to respond to verbal commands. her vitals remained stable throughout the surgery, and the rest of the procedure went smoothly. within four hours, she was transferred out in a stable state and had restored all motor and sensory functions in both lower limbs. after surgery, the patient was evaluated by a psychiatry unit due to the inexplicable symptoms. the patient underwent a thorough history and mental status examination, during which it was discovered that she had been experiencing sudden episodes of intense fear, as well as palpitations, sweating, trembling, shortness of breath, and the feeling that she was about to die. “i think i’m going crazy,”she said of herself. these episodes were abrupt and episodic occurringone or less than once a month since the past 3-4 months and often during the episode, patient experienced a sudden onset generalized weakness, inability to move her arms and legs, lasting for a few minutes, not associated with any residual weakness, with full gain of functionality of pre-morbid level. further it was discovered that her parents had recently separated one year back, following long spells of verbal violence against each other. in mental status examination (mse), general appearance and behaviour was normal with perplexed facial expression. in thought content, patient was preoccupied with her anxiety symptoms and family problems. her physical, neurologic workup was unremarkable, and neuroimaging (mri brain) and laboratory parameters were also within normal limits. patient was classified as a case of conversion disorder and was prescribed a selective serotonin reuptake inhibitor (ssri) with supportive benzodiazepines (tab. escitalopram 10 mg once along with tab. etizolam 0.5 mg twice a day) with psychotherapy sessions planned for subsequent follow-up. discussion conversion disorder, also known as functional neurological symptom disorder, is a psychiatric illness characterised by symptoms and signs that are not explained by a neurological or medical problem and impact voluntary motor or sensory function5. the term “conversion” refers to the substitution of a somatic symptom with a repressed idea. monoparesis, hemiparesis, paraparesis, altered sensorium, visual loss, pseudocoma, seizure-like behavior, irregular gait, aphonia/ dysphonia, lack of coordination, or odd movement disorders are all symptoms of conversion disorder. patients are not attempting to imitate symptoms, rather they are experiencing them.6 our patient was anxious about anaesthesia and surgery prior to the procedure, and was concerned intraoperatively about the lack of motion in her lower limbs when spinal anaesthesia was administered. the possibility of high spinal can be ruled out as the patient did not go into bradycardia, hypotension, or low saturation.7 in fact, tachycardia was noted, and she was taken on bag and mask ventilation as a precautionary measure. after regaining complete consciousness, the patient described feeling paralysed or trapped in her body, as well as breathing difficulties. she was given 1mg midazolam after ensuring that normal function had returned to her upper limbs and that she was completely cognizant, after which she fell asleep. following general anesthesia, there has been a case report of plegia (hemi/para) that led to complete recovery.8 many significant stressor events were associated with anxiety episodes in this case, eventually leading to conversion symptoms at the international journal of human and health sciences vol. 06 no. 03 july’22 334 sub-conscious level. they went unnoticed, and no psychiatric consultation was sought, ultimately leading to precipitation during the operative period. a search into literature revealed isolated case reports of respiratory arrest after spinal anaesthesia in parturients9,10. subdural block, drug impurities, neuraxial opioids and oxytocin, all have been attributed as possible cause for such event, but the dilemma remains unsolved. however, in our case, short duration of the episode in presence of haemodynamic stability and unremarkable neurologic workup precludes these possibilities and point more in favour of conversion disorder. conversion disorder demands a multidisciplinary approach to treatment. psychotherapy, physical therapy, and stress management are all vital components, as is timely referral to psychiatric services. care professionals must be aware of the patient’s current life circumstances, previous stress responses, and current support systems. stressful life experiences have been documented to precipitate conversion disorder, which can be acute (lasting only a few hours to days) or chronic (lasting weeks or months). there is no set age for this condition, and it affects both adults and children. to be able to foresee such situations, it is critical to have a complete psychiatric evaluation during the preanesthetic workup which may help identify high risk patients for conversion disorder. anaesthetists sometimes overlook psychiatric issues which may lead to most unusual events as seen in our case also. conclusion to conclude, psychiatric disorder may be a rare cause of neurologic deficit following spinal anaesthesia and should be made part of a complete pre-anaesthesia workup. intraoperative conversion disorder should be considered in cases with unexplainable symptoms not attributable to medical disorder or anaesthesia related complications. conflict of interest:the authors have no conflict of interest to declare. ethical issue:this case report is being published with the written informed consent of the patient, for academic interest. authors’ contribution: all authors were involved equally in patientmanagement, data collection, literature review, analysis, manuscript writing, revision and finalizing. references 1. feinstein a. conversion disorder: advances in our understanding. cmaj. 2011;183(8):915-20. 2. ito a, nakamoto t, ohira s, kamibayashi t. postoperative tetraplegia due to conversion disorder upon emergence from general anesthesia. ja clin rep. 2020;6(1):88. 3. letonoff ej, williams trk, sidhu ks. hysterical paralysis: a report of three cases and a review of the literature. spine (phila pa 1976). 2002;27(20):e441-5. 4. kanaan ra, armstrong d, wessely sc. neurologists’ understanding and management of conversion disorder. j neurolneurosurgpsychiatr. 2011;82(9):961–6. 5. diagnostic and statistical manual of mental disorder: dsm-5, 5th ed. arlington, virginia: american psychiatric association; 2013. 6. binzer m, andersen p, kullgren g. clinical characteristics of patients with motor disability due to conversion disorder: a prospective control group study. j neurolneurosurgpsychiatr. 1997;63(1):83-8. 7. cooper j. cardiac arrest during spinal anesthesia. anesthanalg.2001;93:245. 8. tsetsou a, karageorgou e, kontostathis n, karadimos a. conversion disorder: tetraplegia after spinal anesthesia. greek e-j perioper med. 2017;17(a):71-7. 9. acharya sp, marhatta mn, amatya r. unexplained apnoea and loss of consciousness during sub arachnoid block for caesarean section. kathmandu univ med j (kumj). 2009;7(4):419-22. 10. chan yk, gopinathan r, rajendram r. loss of consciousness following spinal anaesthesia for caesarean section. br j anaesth. 2000;85(3):474-6. supplementary issue:02 80 assessment of knowledge of typhoid fever diagnosis and management amongst the interns and residents in the teaching hospital of india ritik garg, bhanu chaudhary, shariq ahmed, fatima khan, asfia sultan, syed zeeshan ahmad hashmi, urfi jawaharlal nehru medical college, amu, india correspondence: dr. shariq ahmed, assistant professor, department of microbiology, jnmch, amu emailshariqahmed0105@gmail.com abstract introduction-there are estimates that typhoid fever occurs between 10/100,00 and 100/100,00 times a year, making it an important global health issue, hence the accurate diagnosis of typhoid fever at an early stage is very important for proper management. india is endemic for typhoid fever and widal is the most commonly prescribed diagnostic test in cases of fever. objectives-the present study was undertaken to evaluate the knowledge about the diagnosis and management of typhoid fever amongst the interns and residents in the teaching hospital of northern india. methodology-a semi-structured, self-administered questionnaire, was used in this cross-sectional study. the study population comprised of interns and postgraduate students of a medical college situated in northern india. results-the study included 101 participants. data analysis showed, only 11% of the participants had good knowledge, 55.4% had moderate knowledge and 33.6% had poor knowledge about the test and the disease. however, most of the participants had good knowledge about the clinical features, treatment and availability of the diagnostic tests but only a few had thorough awareness of the proper implementation and utilization of the available diagnostic tests. only 25% knew about the right time to order widal test for diagnosis of typhoid fever and just 60.4% knew about blood culture as the confirmatory test during the first week of illness. supplementary issue:02 81 conclusion-majority of the participants had a fair knowledge of clinical features and treatment. however, for proper patient management, correct diagnosis at the right time plays a crucial role. education and training are essential for the utilization and application of the available diagnostic tests which are an essential component of antimicrobial stewardship. keywordstyphoid fever, widal test, knowledge introduction there are estimates that typhoid fever occurs between 10/100,00 and 100/100,00 times a year, making it an important global health issue (1). asystemic prolonged febrile illness, caused by various salmonella serotypes like salmonella typhi, s. paratyphi a, s. paratyphi b and s. paratyphi c (2). disease is transmitted by faecally contaminated water and food in endemic areas, especially by carriers handling food, as human are the only reservoir host for typhoid fever (2). this disease is usually associated with low socio-economic status and poor hygiene. for finding the etiological agent and potential carriers, that may be responsible for acute typhoid fever outbreaks, an accurate diagnosis of typhoid fever at an early stage is very important (3). a french physician and bacteriologist, georges fernand-isidore widal, developed the widal test in 1896 (4,5). most hospitals in the tropics cannot perform cultures owing to lack of material, equipment, expertise, and finances (2), hence, the widal test, a serological agglutination test, has been used in the diagnosis of typhoid fever for decades (4,5), even now, the test's value for diagnosing typhoid fever has been debated for as long as it's been available (5) in endemic regions, ideally a fourfold rise of antibodies in paired sera is considered diagnostic, however, a positive single acute-phase serum sample, with clinical signs and symptoms may also suffice (6). widal test has been reported creating huge problem, in having different cut-offs for different places (7,8). hence, when antibody titres of the normal population are unknown, doctors practicing in endemic regions find it difficult to interpret widal test results (9). false positive reactions have been also observed due to nontyphoidal fevers (10). widal test's requiring low training in comparison with tests such as culture and polymerase chain reaction (pcr), in addition to sheer habit (11), it is very overprescribed in india. the purpose of this present study is to evaluate the knowledge about the widal test among intern and resident doctors in teaching hospital in india, which are generally the first medical personnel encountered by the patients, and to bring light on various pitfalls and limitations of the test. supplementary issue:02 82 methodology study designa semi-structured, self-administered questionnaire, cross-sectional study was used to assess the knowledge of typhoid fever diagnosis and management amongst the interns and residents in a teaching hospital of india. ethical clearance was obtained from the institutional ethical committee, jnmch, amu. participants: the study population comprised of medical undergraduate students currently doing internship (mbbs, bums) and medical postgraduate students of a medical college situated in northern india. a total of 101 responses were recorded. questionnairethe questionnaire consisted of 21 questions assessing the knowledge regarding epidemiology, clinical manifestations, treatment, and prevention. these questions consisted of three types of formats i) single correct answer ii) multiple correct answer iii) one-word answer; for questions that had single correct answer, 1 point was given for a correct response and 0 was given for a wrong response. in multiple correct answer type questions, 1 point were given for all correct responses, 0.5 points for partially correct response and 0 points were given when all responses were wrong. results a total of 101 participants consisting of medical undergraduates including interns and medical postgraduate students of a medical college situated in northern india were included in the study to access knowledge about the widal test and typhoid fever. when the questionnaire data were analyzed only 11% of the participants had good knowledge, 55.4% had moderate knowledge and 33.6% had poor knowledge. (table 2) (figure 1) it was good to see that 75(74.3%) doctors were able to make provisional diagnosis of the clinical case scenario as a patient of typhoid fever, however, only 25(25%) knew when to order widal test for diagnosis of typhoid fever(figure2). 70(69.3%) doctors knew about the significant titre of widal test and 81(80.2%) interpret the widal test report of a positive case correctly however, only 11(10.9%) were able to interpret the post tab vaccination widal test report correctly. participants who answered correctly the causes of false positive and false negative results in widal test, was 52(51.5%) and 3(3%) respectively and it was surprising to see that nearly 88(87.1%) lacked supplementary issue:02 83 knowledge of the amnestic response. only 61(60.4%) of the participants answered correctly about the utilization of blood culture as the confirmatory diagnostic test during the first week of fever. regarding typhoid carriers diagnosis, 69(68.3%) knew about the correct antigen for which antibodies to be tested; however, only 43(42.6%) knew about the drug of choice for the same (table 1) it was good to see, that 86(85.1%) participants correctly answered, how to treat typhoid fever in admitted patients, although only 73(72.3%) knows about the outpatient care treatment of typhoid fever. table 1questionnaire and responses s.no. questions options response(%age) 1. what is the principle on which widal test is based? don’t know 10(9.9) agglutination reaction 83(82.2) wrongly answered 8(7.9) 2. mr. rakesh, comes to your clinic with complaint of high-grade fever, headache, abdominal pain and diarrhoea for last 6 days. he also has decreased appetite for 3 days. o/e you find, temperature 101.5-degree f, pulse rate – 90bpm, abdominal tenderness, white coated tongue and rashes on his body. what will you suspect in this pt.? don’t know 1(1.0) typhoid fever 75(74.3) typhoid fever and other diseases 19(18.8) other than typhoid fever 6(5.9) supplementary issue:02 84 3. tests for typhoid fever confirmation? cbc, blood culture, lft 1(1.0) wrongly answered 41(40.6) other tests along with cbc, blood culture and lft 59(58.4) 4. after how many days of symptoms, a doctor should advice widal test in the patient? don’t know 1(1.0) after 2-4 days of symptoms 15(14.9) after 5-7 days of symptoms 60(59.4) after 8-10 days of symptoms 25(24.8) 5. based on this report, whether you’ll prescribe antimicrobial therapy for this pt.? don’t know 3(3.0) yes 10(9.9) no 81(80.2) supplementary issue:02 85 may be 7(6.9) 6. what is the significant titre of the widal testto and th antibodies respectively? don’t know 2(2.0) >1/100 &>1/200 70(69.3) >1/60 &>1/30 22(21.8) >1/40 &>1/20 5(5.0) >1/20 &>1/10 2(2.0) 7. paired testing should be done after how many weeks of initial testing and how much fold increase in titre should be present to called as positive? don’t know 1(1.0) 2nd&4th week 51(50.5) 1st& 2nd week 31(30.7) 1st& 3rd week 10(9.9) 2nd& 3rd week 8(7.9) 8. false positive results in widal test can be due to sle, vaccination post typhoid vaccine 5(5.0) sle, vaccination post typhoid vaccine, malaria 11(10.9) sle, vaccination post typhoid vaccine, cross 33(32.7) supplementary issue:02 86 reaction to non-typhoidal salmonella sle, vaccination post typhoid vaccine, malaria, cross reaction to non-typhoidal salmonella 52(51.5) 9. false negative results in widal test can be due to don’t know 3(3.0) early presentation, carrier status, following a typhoid relapse 6(5.9) early presentation, carrier status, technical errors, following a typhoid relapse 82(81.2) early presentation, technical errors 3(3.0) carrier status, technical errors, following a typhoid relapse 7(6.9) 10. typhoid fever caused by what all species of salmonella? s. typhi and s. para typhi a+b+c 16(15.8) wrongly answered 9(8.9) supplementary issue:02 87 s. typhi and s. para typhi a/b/c 76(75.2) 11. widal test report given below. this is suggestive of don't know 14(13.9) post tab vaccination 11(10.9) wrongly answered 76(75.2) 12. antibodies to which antigen you'll check in typhoid carriers? don't know 9(8.9) vi antigen 69(68.3) d antigen 9(8.9) a and b antigen 14(13.9) 13. what is the doc for typhoid carriers? don't know 4(4.0) azithromycin 25(24.8) ciprofloxacin 43(42.6) cefixime 19(18.8) supplementary issue:02 88 amoxicillin 10(9.9) 14. which of the following tests can be used for diagnosis of typhoid fever? don't know 5(5.0) blood culture, bone marrow culture, igm typhidot assay, widal test, bile culture, coagglutination test 6(5.9) blood culture/ bone marrow culture/ igm typhidot assay/ widal test/ bile culture/ coagglutination test 90(89.1) 15. a patient (mr. x) presented with fever and rashes, was advised malaria, dengue and widal test. his results are as follows – a. mpqbc: +ve b. ns1ag: non-reactive c.typhoid titre: h100; o-50; what will be the most suitable diagnosis in this pt.(mr. x)? don't know 26(25.7) malaria 44(43.6) wrongly answered 31(30.7) 16. how will you confirm false positive widal test or dual infection in pt. (mr.x)? don't know 13(12.9) supplementary issue:02 89 repeat mpqbc 16(15.8) repeat widal titre 33(32.7) repeat both mpqbc and widal titre 39(38.6) 17. what is the best suitable explanation of such widaltiters in above pt. (mr.x)? don't know 53(52.5) amnestic response 13(12.9) wrongly answered 35(34.7) 18. confirmatory diagnostic test for typhoid fever during first week? don't know 2(2.0) blood culture 61(60.4) widal test 19(18.8) urine culture 2(2.0) stool culture 17(16.8) 19. are you aware of national antibiotic policy? yes 62(61.4) no 39(38.6) 20. what is the recommended antibiotic for inpatient care of pt., suffering from typhoid fever? don't know 1(1.0) ceftriaxone i.v. 86(85.1) ciprofloxacin oral 8(7.9) supplementary issue:02 90 azithromycin oral 1(1.0) cefixime oral 5(5.0) 21. what is the recommended antibiotic for outpatient care of pt., suffering from typhoid fever? don't know 4(4.0) cefixime 73(72.3) ofloxacin 19(18.8) ampicillin 5(5.0) table 2level of knowledge of participants level of knowledge score total n(%age) poor <10 34(33.6) moderate 10-15 56(55.4) good >15 11(11) figure1-pie chart showing level of knowledge of participants good knowledge 24% moderate knowledge 73% poor knowledge 3% 0% overall participant% supplementary issue:02 91 figure 2bar graph showing responses reagarding widal test anumber of participants were able to make, provisional diagnosis of the clinical case scenario as a patient of typhoid fever bnumber of participants knew about when to order widal test cnumber of participant knew about confirmatory test during the first week of illness. discussion endemic infections continue to be a major problem for healthcare, in a country. there are many endemic diseases in india, which accounts for high mortality and having impact on country’s expenditure on health infrastructure. typhoid fever is one among them, it continues to be a global health problem, especially in the tropics and subtropics part of the world (1). an attempt has been made to assess the knowledge about the diagnostic tests for typhoid fever, especially most prescribed test, the widal test in an area where salmonella typhi is endemic by various different clinical scenarios, several factors, which have led to confusion in the interpretation of the test. in order to make the healthcare personnel aware of the diseases and diagnostic tests, it will be necessary to assess their knowledge of the diseases and diagnostic tests. in the present study 74.3% 25% 60.4% 0 10 20 30 40 50 60 70 80 a b c supplementary issue:02 92 medical undergraduate students currently doing internship (mbbs, bums) and medical post graduate students of a medical college situated in northern india answered a questionnaire regarding the typhoid fever diagnosis and management. it was seen that only 11% of the participants had good knowledge, 55.4% had moderate knowledge and 33.6% had poor knowledge. the widal test is based on agglutination principle, which measures specific antibody titres in patient’s serum. by using the bacterial suspensions of salmonella typhi and s. paratyphi a and b, it detects the antibody against salmonella o(somatic) and h(flagellar) antigen in patient’s serum (5). this test therefore, work on the principle that antibody present in the patient’s serum can agglutinate the homologous antigens in killed salmonella suspensions. early appearing antibody, igm, represent acute typhoid fever which is targeted against o agglutinins and late appearing antibody, igg, persist for longer time and targeted against h agglutinin (5) in developing countries, like india, where there is a shortage of more complex test like pcr, blood culture, widal test comes out to be a relatively cheap and readily available test, though it has its own pitfalls, making it difficult to interpretate because of many factors, because of which, either results comes out to be a false positive or false negative result as listed below (list not exhaustive) (2,3,5,12,13). factors leading to false positive widal test 1. prior vaccination against salmonella typhi or paratyphi 2. past history of typhoid fever 3. cross-reaction with infections like malaria 4. cross-reaction with non-typhoidal salmonella antibodies 5. anamnestic reaction 6. sle, rheumatoid arthritis and ulcerative colitis 7. technical error factors leading to false negative widal test 1. use of antibiotics before test supplementary issue:02 93 2. test before the end of first week of infection 3. technical error 4. “hidden organisms” in bone and joints 5. poorly immunogenic strains of infecting organism titres of antibodies begin to rise in first week and keep on increasing through the second to fourth week, after which they begin to decline gradually, hence, timing of the order of widal test is very important, otherwise test may show negative result, which is a unnecessary burden on patient being financially and also according to health perspective. prior use of antibiotics before collecting the sample for widal test, might show a false negative result (2,3,5). “hidden organisms” in bones and joints and poorly immunogenic strains of infecting organisms, sometimes shows false negative results (3,13). undoubtedly, culture isolation of the organisms, remain the gold standard for diagnosis (5,14), as it considered to be 100% specific(14). samples that can be used for culture are namely blood, bone marrow, stool, urine, rose spot, gastric and intestinal secretions. to ensure the good and genuine results of widal test, some factors have to be taken into account: 1. one should know about baseline antibody titre in their area of practising, and titre, therefore, should be interpretated in relation to the baseline antibody titre; 2. do not always decide the diagnosis according to one widal test report, always repeat the widal test and the titre should be increased significantly, 4 fold rise; 3. if patient has signs and symptoms of disease, a negative test should not be used as exclusion of typhoid fever; 4.always ensure to take out the sample for culture, before starting the antimicrobial therapy (15). we used our study as an opportunity to find out, whether the budding physicians know about the national antibiotic policy or not, and 62(61.4%) participants do know about that. participants were having good knowledge about the inpatient and outpatient care of typhoid fever patient, which is the ultimate goal desire by a patient and as well as community. overall, the results of this study were unsatisfactory, as most of the participants did not have proper knowledge of widal test, which either lead to underdiagnosed or overdiagnosis of the disease. both the scenarios have their pitfalls, underdiagnosis lead to worsening of the patient condition because supplementary issue:02 94 of not getting proper treatment at required time, while overdiagnosis lead to irrational use of antibiotics in the patient. conclusion majority of the participants had a fair knowledge of clinical features and treatment. however, for proper management of the patient diagnosis plays a crucial role, we can thus determine that in regions where typhoid fever is common, the widal test can still be useful if it is interpreted carefully and with knowledge of relevant data, particularly regarding the amount of agglutinin present in healthy people and those suffering from other non-typhoidal fevers in the area. education and training are essential for utilization and application of the available diagnostic tests which are an essential component of antimicrobial stewardship. financial support and sponsorship nil references 1. crump ja, luby sp, mintz ed. the global burden of typhoid fever. bull world health organ. 2004 may;82(5):346–53. 2. andualem g, abebe t, kebede n, gebre-selassie s, mihret a, alemayehu h. a comparative study of widal test with blood culture in the diagnosis of typhoid fever in febrile patients. bmc res notes. 2014 sep 17;7(1):653. 3. gopalakrishnan v, sekhar wy, soo eh, vinsent ra, devi s. typhoid fever in kuala lumpur and a comparative evaluation of two commercial diagnostic kits for the detection of antibodies to salmonella typhi. singapore med j. 2002 jul;43(7):354–8. 4. agarwal. enteric fever: resurrecting the epidemiologic footprints [internet]. [cited 2023 mar 27]. available from: http://www.astrocyte.in/article.asp?issn=23490977;year=2016;volume=3;issue=3;spage=153;epage=161;aulast=agarwal 5. olopoenia la, king al. widal agglutination test 100 years later: still plagued by controversy. postgrad med j. 2000 feb;76(892):80–4. 6. house d, chinh nt, diep ts, parry cm, wain j, dougan g, et al. use of paired serum samples for serodiagnosis of typhoid fever. j clin microbiol. 2005 sep;43(9):4889–90. 7. ley b, mtove g, thriemer k, amos b, von seidlein l, hendriksen i, et al. evaluation of the widal tube agglutination test for the diagnosis of typhoid fever among children admitted to a rural hdospital in tanzania and a comparison with previous studies. bmc infect dis. 2010 jun 22;10(1):180. supplementary issue:02 95 8. bhutta za. current concepts in the diagnosis and treatment of typhoid fever. bmj. 2006 jul 6;333(7558):78–82. 9. pang t, puthucheary sd. significance and value of the widal test in the diagnosis of typhoid fever in an endemic area. j clin pathol. 1983 apr 1;36(4):471–5. 10. reynolds dw, carpenter rl, simon wh. diagnostic specificity of widal’s reaction for typhoid fever. jama. 1970 dec 21;214(12):2192–3. 11. wasihun ag, wlekidan ln, gebremariam sa, welderufael al, muthupandian s, haile td, et al. diagnosis and treatment of typhoid fever and associated prevailing drug resistance in northern ethiopia. int j infect dis. 2015 jun 1;35:96–102. 12. verma d. comparative evaluation of various tests for diagnosis of concurrent malaria and typhoid fever in a tertiary care hospital of northern india. j clin diagn res [internet]. 2014 [cited 2023 mar 27]; available from: http://jcdr.net/article_fulltext.asp?issn=0973709x&year=2014&volume=8&issue=5&page=dc41&issn=0973-709x&id=4403 13. wariso kt. re-appraising widal test as a diagnostic tool in nigeria. niger health j. 2016;16(4):249–249. 14. sattar a, yusuf ma, islam m, jahan w. different diagnostic procedure of typhoid fever: a review update. j curr adv med res. 2014 jul 1;1. 15. zorgani a, ziglam h. typhoid fever: misuse of widal test in libya. j infect dev ctries. 2014 jun 11;8(06):680–7. international journal of human and health sciences vol. 05 no. 04 october’21 424 original article regression model for socio-demographic, behavioural and occupational risk factors in lumbar disc herniation (ldh) and lumbar disc degeneration (ldhd)-in comparison to apparently healthy subjects. withanage nd1*, perera s2, peiris h3, prathapan s4& athiththan lv3 objective: present study was aimed to develop a regression model for selected sociodemographic, behavioural and occupational factors with lumbar disc herniation (ldh) and lumbar disc hearniation and degeneration (ldhd) in a selected population in comparison to healthy individuals. materials & methods: the study was conducted using 104 cases with disc herniation and controls (n=104) without ldh. analysis was conducted in sub groups of patients with ldh (n=67) and ldhd (n=37) in comparison to control subjects. pre-tested questionnaire was administered to all participants to gather information. results & discussion: among the cases 35.6 % presented with ldhd while 64.4 % had only ldh. among the socio-demographic characters, body mass index <25 kgm-2 was a significant protective factor for both ldhd (or=0.31; 95% ci=0.13-0.72) and ldh (or=0.39; 95% ci=0.20-0.77). involvement in daily activities with heavy (or=5.1; 95 % ci=2.1-11.8) and moderate strain (or=3.1; 95 % ci=1.5-6.6) to back, sitting more than eight hours per day (or=5.1; 95 % ci=1.0-25.7), smoking (or=5.0; 95 % ci=1.5-16.4) and sleeping in supine position (or=2.09; 95% ci=1.09-4.06) were significant risk factors for ldh. only daily physical activities with heavy strain act as a significant risk factor (or=3.1; 95 % ci=1.1-8.5) for the development of ldhd. types of mattresses used did not have a significant difference among cases and controls. majority of cases (56.7 %) did not know the causative factor that led to ldh. according to the regression model, bmi, smoking and involvement in physical activities with moderate and heavy strain to back were considered as significant risk factors for the development of ldh or ldhd. conclusion: in regression model bmi, smoking and daily physical activities with moderate and heavy strain to back were found to be the significant risk factors for development of ldh or ldhd. key words: lumbar disc herniation, lumbar disc herniation and degeneration, regression model. correspondence to: niroshima dedunu withanage, department of medical laboratory sciences, faculty of allied health sciences, university of sri jayewardenepura, sri lanka. e-mail: withanagend@ sjp.ac.lk international journal of human and health sciences vol. 05 no. 04 october’21 page : 424-434 doi: http://dx.doi.org/10.31344/ijhhs.v5i4.352 1. department of medical laboratory sciences, faculty of allied health sciences, university of sri jayewardenepura, sri lanka. 2. the central hospital, colombo 8, sri lanka. 3. department of biochemistry, faculty of medical sciences, university of sri jayewardenepura, sri lanka. 4. department of community medicine, faculty of medical sciences, university of sri jayewardenepura, sri lanka. introduction lumbar disc herniation (ldh) is considered as a major socio-economic problem not only in sri lanka but also in many developed countries. although there are numerous determinants for lower back pain (lbp), lumbar disc herniation (ldh) is the most common concern.1, 2 evidence suggest that annual cost spent on lbp associated with ldh in united states exceeds 100 billion dollars each year whereas in united kingdom it is estimated as 12 billion pounds per annum. in netherlands it was reported as 1.7 % of the 425 international journal of human and health sciences vol. 05 no. 04 october’21 gross national production, these data support the evidence that lbp is a major burden for the economy of the country.2, 3 studies have reported that 60-80 % of the population have suffered of lbp associated with ldh at least once during their lifetime. 2, 4 in addition to the direct costs, indirect costs such as, significant percentage of sick leaves among affected employees, costs of lost wages, reduced productivity, psychological distress and costs for additional care given are major problems linked with ldh associated lbp.1 it is suggested that ldh is one of the main determinants in limiting activities among adults below 45 years of age.5 despite several studies carried out worldwide to determine the cause for ldh, yet the exact cause/s are unknown. 4, 6 it is hypothesized that some conventional factors such as age, gender, severe mechanical and physical loading, trauma, strenuous sporting activities, vibrations and smoking as main causative factors for ldh.7-10 evidences suggest that degeneration usually start at a very early stage of life where mild changes could be seen in first decade of life and more significant changes from second decade onwards causing lumbar disc herniation and degeneration (ldhd) however, studies emphasized that lbp associated ldh or ldhd are most common during fourth to fifth decade of life. 3, 11-13 furthermore, studies carried out on ldh have indicated that males are more vulnerable for ldh compared to females. 13-15 further, evidences confirm that there is a significant association of sporting activities with ldh. 16-18 although there is an increased trend for hospitalization of patients with ldh, the information pertaining to behavioural and occupational risk factors that lead to ldh is not available in sri lankan context. thus, the present study was carried out to identify the association of selected socio-demographic, behavioural, sports and occupational factors contributing to ldh. although several biochemical factors have been considered in the risk of developing lbp associated with ldh, there were less information available on the effect of different firmness of mattresses and sleeping positions on this regard. therefore, more importantly the present study focused on sleeping positions and the sleeping systems (mattresses used) used by the study participants as these factors were not considered much in reported literature pertaining to ldh, but conventionally considered as crucial factors for lbp associated with ldh. further, there are no reported studies on development of a regression model incorporating these factors. as regression models give a better view on risk factors, present study aimed to investigate possible sociodemographic, behavioural and occupational factors and development of a regression model associated with ldh and lumbar disc herniation and degeneration (ldhd). materials and methods study design and setting cases (subjects with disc herniation) were recruited from a hospital in the capital of sri lanka which drains patients from all over the country and thereby representing almost all districts of sri lanka. controls represented several districts of sri lanka. the analysis was carried out at university of sri jayewardenepura sri lanka. subgroup analysis was conducted in ldh subjects (n=67) and subjects with ldhd (n=37) in comparison to control subjects (n=104). ethical approval was obtained by the ethics review committee of faculty of medical sciences, university of sri jayewardenepura, colombo, sri lanka (29/14). after detailing out the study protocol, informed written consent was obtained from all participants. study population the 104 cases were patients who had low back pain with lumbar disc herniation confirmed by magnetic resonance image (mri) by a consultant neurosurgeon and consultant radiologist. inclusion criteria for controls (n=104) were adult volunteers without low back pain at least for the past onemonth period of the study and did not have ldh. both case and control subjects were between 1874 years of age. the concomitant presence of other bone disorders such as osteoarthritis, osteoporosis and pregnancy and, malignancies were exclusion criteria for both cases and controls, while cases with trauma and accidents related ldh were also excluded. cases presented with ldh with concomitant degeneration was grouped as ldhd subjects (n=37) whereas cases with herniation only grouped as ldh subjects (n=67). sample size calculation where, n = sample size z= standard normal deviate for chosen confidence level. since 95 % confidence level was used the value is 1.96 international journal of human and health sciences vol. 05 no. 04 october’21 426 σ = standard deviation δ = precision of 0.5 at 5% significance level and with a precision of 0.5 the total sample size was calculated. data collection a pre-test was carried out to validate the questionnaire (data not included in the study). a standardized, interviewer administered questionnaires lasting 10-15 minutes was administered to each patient by the principal investigator enquiring their demographic data, daily activities, physical and behavioural activities, occupational status, sleeping pattern, type of mattress used, general health status and current health condition. major causative factor stated by the patients for disc herniation was noted from the clinical history. participants were given the opportunities to clarify their doubts in a familiar and comfortable language of the individual (english, tamil or sinhala). age had been calculated to the nearest completed year and educational levels were categorized according to the national criteria. bmi was calculated according the standard formula and height of each participant was measured without shoes in straight standing style and when the heels of the foot, buttocks and head was stuck to the wall using a standard stadiometer with a moveable ruler to the closest 0.1 cm while weight measured without shoes, using an electronic weighing scale to the closest 0.1 kg. smokers were defined as individuals who smoked any tobacco in the past twelve months of the study and included those who stopped smoking within past year and consumption of alcohol was defined as individuals who consumed alcohols usually or occasionally in the past twelve months of the study and also included who stopped consuming alcohol within past year. 19 severity of daily physical activities were categorized according to the yusuf et al (2004) and seidler et al (2003). 20 individuals who regularly engaged in lifting heavy weights, frequent climbing of stairs and involved in vigorous physical exercises more than 4 hours per week were categorized as heavy strain to back, while individuals regularly engaged in activities which elicit moderate strain such as gardening, cycling, standing and driving more than 4 hours per week were categorized as moderate strain to back. statistical data analysis data were coded and captured on excel and spss version 20.0. frequencies and percentages were calculated for all data. odds ratio was calculated to assess the risk factors for disc herniation in the study population and p value ≤ 0.05 was considered statistically significant. risk estimates for developing either ldhd or ldh was calculated using logistic regression analysis. crude odds ratio (or) and 95 % confidence interval (ci) were calculated for age, bmi, gender, marital state, education and employment at the enrollment for the study using chi-square test. an unadjusted ors were calculated for severity of daily physical activities, occupational exposure, engaged in sports, duration of sitting, smoking and consumption of alcohol. the exposure categories (0, 1, 2 etc.) were included as internal scaled variables in logistic regression model. measures of exposure were based on self-declaration of the subjects. for the purpose of analysis, cases were further categorized into two subgroups; patients who presented with both degeneration and herniation (ldhd group) and patients who presented only with lumbar herniation (ldh group). missing values were analysed as a separate category (results not shown here). results socio-demographic characteristics of the study subjects as investigators have checked the eligibility criteria for both controls and cases prior to the study by clinical examination (conducted by a consultant radiologist and a consultant neurosurgeon) and by an interviewer administered questionnaire, all eligible study participants (cases=104; controls=104) were included for the analysis of all variables mentioned except for variable bmi (table 1) and sleeping positions (table 2). socio-demographic characteristics of the study subjects are presented in table 1. disc herniation and degeneration was present in 37 (35.6%) of the cases (ldhd) and rest of the subjects had only lumbar disc herniation (ldh= 64.4 %). in cases, the mean age (sd) for subjects with ldh was 41.5 (±14.8) years, while subjects with ldhd was 47.4 (±17) years. control subjects showed a mean age of 43.2 (±15.2) years. majority of the cases with ldhd (51.5%), ldh (64.2%) and controls (60.5%) were less than 50 years of age. however, there was no significant difference in the age between ldhd group (or=0.69; 95% ci=0.32-1.46) and ldh group (or=1.16; 95% ci=0.62-2.20) when compared to that of control group (table 1). 427 international journal of human and health sciences vol. 05 no. 04 october’21 response rate for bmi in controls, cases with ldhd and cases with ldh was 95.1%, 83.8% and 86.6% respectively. few cases were reluctant to participate in height and weight measurement due to the severity of pain where control subjects declined to remove foot ware for the weight measurement. these were the limitations for calculating bmi. it was recorded that majority of cases with ldhd (67.7%) and ldh (62.1%) were in over weight and obese category (≥ 25 kgm-2). the mean (sd) bmi in both ldhd and ldh groups was above the normal limits, 39.1 (27.5) kgm-2 and 36.7 (24.3) kgm-2 respectively. the bmi of the control subjects (27.1±16.6 kgm-2) was also above the normal limits but significantly lower than the case subjects (ldhd and ldh group). bmi less than 25 kgm-2 acts as a protective factor for ldhd (or=0.31; 95% ci=0.13-0.72) and ldh group (or=0.39; 95% ci=0.20-0.77). significant difference was not observed between groups for gender difference. in this cohort of study, majority of the subjects in both cases (ldhd=81.1%; ldh=77.6%) and controls (73.1%) were married. similarly, there was no significant difference in marital status among the study groups. majority of the subjects in cases (ldhd=67.6%; ldh=73.1%) and controls (62.5%) had secondary or higher level of education with no significant difference between study groups. in all study groups higher percentages of subjects were employed (ldhd (64.9%), ldh (65.7%) and controls (80.8%) respectively). employment at the time of enrollment did not indicate a significant difference among the three study groups (table 1). behavioural and occupational physical workload it was reported that ldhd and ldh were associated with behavioural and occupational physical workload that caused strain to the lower back. when occurrence of ldh was assessed in relation to behavioural and occupational risk factors among cases and controls, majority of the cases (ldhd=56.7%; ldh=68.6%) were engaged in activities which causes heavy or moderate strain to back when compared to controls (36.5%) (table 2). the odds ratio (or) for daily activities with heavy strain to back yielded a statistically significant risk value of 3.1 (95% ci=1.1-8.5) in cases with ldhd and odds ratio of 5.1 (95% ci=2.1-11.8) in cases with ldh only. although daily activities with moderate strain to back did not show a statistically significant association table 1. baseline demographic characteristics in case groups and control group. characteristics control subjects (n=104) ldhda (n=37) ldhb (n=67) n (%) n (%) or (95% ci) n (%) or (95% ci) age < 50 years ≥ 50 years 63 (60.5) 41 (39.4) 19 (51.5) 18 (48.6) 0.69 (0.32-1.46) 43 (64.2) 24 (35.8) 1.16 (0.62-2.20) bmi < 25 kgm-2 ≥ 25 kgm-2 60 (60.6) (n=99) 39 (39.3) (n=99) 10 (32.2) (n=31) 21 (67.7) (n=31) 0.31 (0.13-0.72) * 22 (37.9) (n=58) 36 (62.1) (n=58) 0.39 (0.20-0.77) * gender female male 50 (48.1) 54 (51.9) 19 (51.3) 18 (48.6) 1.14 (0.53-2.41) 31 (46.2) 37 (55.2) 0.93 (0.50-1.72) marital status married unmarried 76 (73.1) 28 (26.9) 30 (81.1) 7 (18.9) 1.58 (0.62-4.00) 52 (77.6) 15 (22.4) 1.28 (0.62-2.62) educational level primary secondary or higher 39 (37.5) 64 (62.5) 12 (32.4) 25 (67.6) 0.80 (0.30-1.77) 18 (26.9) 49 (73.1) 0.61 (0.31-1.19) employment at enrollment employed unemployed 84 (80.8) 20 (19.2) 24 (64.9) 13 (35.1) 0.44 (0.19-1.01) 44 (65.7) 23 (34.3) 0.45 (0.22-0.91) aldhd-patients with lumbar disc herniation and degeneration; bldh-patients with lumbar disc herniation international journal of human and health sciences vol. 05 no. 04 october’21 428 for ldhd group, it appeared as a risk factor for the cases with ldh only, with or of 3.1 (95% ci=1.5–6.6) (table 2). when the physical demanding nature of the occupation was concerned, majority of the subjects in control (91.3%), ldhd (86.5%) and ldh (88.1%) groups were not employed in physical demanding occupations. occupations with moderate to high physical work load revealed a non-significant risk association in both ldhd (or=5.9 (95% ci=0.52–67.7) and or=2.9 (95 % ci=0.18–8.8)) and ldh (or=6.4 (95% ci=0.70– 9.0) & or=1.6 (95% ci=0.09–26.2) group (table 2). results also indicated that engaging in sports and duration of sitting does not have a significant association in patients with ldhd. however, sitting more than 8 hours a day revealed a statistically significant or of 5.1 (95% ci=1.0– 25.7) in subjects with only ldh in table 2. smoking showed a significantly elevated or of 5.0 (95% ci=1.5–6.4) in patients with ldh only which acts as a strong contributory risk factor for ldh. although there was a risk or of 3.1 (95% ci=0.78–2.8) in patients with ldhd, it was not significant. consumption of alcohol was not a significant risk factor for both ldh and combined degeneration (table 2). when the supine sleeping posture was compared with other sleeping postures including prone and table 2. behavioral and occupational risk factors in case groups and control group variable control subjects (n=104) ldhda (n=37) ldhb (n=67) n (%) n (%) unadj. or (95 % ci) n (%) unadj. or (95 % ci) 1.severity of daily physical activities a)light strain to back or sedentary b)moderate strain to back c)heavy strain to back 66 (63.5) 25 (24) 13 (12.5) 16 (43.2) 11 (29.7) 10 (27) 1 (-) 1.8 (0.7-4.4) 3.1 (1.1-8.5) 21 (31.3) 25 (37.3) 21 (31.3) 1 (-) 3.1 (1.5-6.6) * 5.1 (2.1-11.8) * 2.occupational groups a)occupations without physical work b)occupations-light physical work load c)occupations-moderate physical work load d)occupations-high physical work load 95 (91.3) 7 (6.7) 1 (1) 1 (1) 32 (86.5) 2 (5.4) 2 (5.4) 1 (2.7) 1 (-) 0.8 (0.16-4.3) 5.9 (0.52-67.7) 2.9 (0.18-48.8) 59 (88.1) 3 (4.5) 4 (6) 1 (1.5) 1 (-) 0.7 (0.17-2.8) 6.4 (0.70-59.0) 1.6 (0.09-26.2) 3.engaged in sports a)not engaged in sports b)moderately strenuous sporting activities c)strenuous sporting activities 57 (54.8) 5 (4.8) 42 (40.4) 16 (44.4) 3 (8.3) 17 (47.2) 1 (-) 2.0 (0.44-9.6) 1.2 (0.6-2.8) 37 (55.2) 4 (6) 26 (38.8) 1 (-) 1.1 (0.28-4.7) 0.73 (0.37-1.4) 4.duration of sitting (hrs) a)2-4 b)5-8 c)>8 61 (58.7) 41 (39.4) 2 (1.9) 25 (67.6) 8 (21.6) 4 (10.8) 1 (-) 0.47 (0.19-1.1) 4.8 (0.8-28.3) 42 (62.7) 18 (26.9) 7 (10.4) 1 (-) 0.6 (0.32-1.2) 5.1 (1.0-25.7) * 5. smoking a)smoking b)not smoking 5 (4.8) 99 (95.2) 5 (13.5) 32 (86.5) 3.1 (0.78-12.8) 1 (-) 12 (17.9) 55 (82.1) 5.0 (1.5-16.4) * 1 (-) 6. alcohol consumption a)consuming alcohol b)not consuming alcohol 29 (27.9) 75 (72.1) 12 (32.4) 25 (67.6) 0.96 (3.9-2.3) 1 (-) 21 (31.3) 46 (68.7) 0.78 (0.36-1.7) 1 (-) 7. sleeping positions a)supine b)other postures 26 (25.5) (n=102) 76 (74.5) (n=102) 9 (25) (n=36) 27 (75) (n=36) 0.97 (0.41-2.34) 1 (-) 28 (41.8) (n=67) 39 (58.2) (n=67) 2.09 (1.09-4.06) * 1 (-) 8. types of sleep system a)firm b)moderately firm 22 (21.2) 82 (88.8) 7 (18.9) 30 (81.1) 0.87 (0.33-2.24) 1 (-) 7 (10.4) 60 (89.6) 0.43 (0.17-1.08) 1 (-) 429 international journal of human and health sciences vol. 05 no. 04 october’21 lateral supine posture, it yielded a significant risk odds ratio of 2.09 (95% ci=1.09-4.06) in patients with ldh. however, supine posture was not considered as a risk posture for the patients with ldhd. majority of the patients in two case groups (ldhd=81.1% & ldh=89.6%) and control group (88.8%) have used moderately firm mattresses for sleeping which did not show a significant difference between study groups (table 2).according to the regression model, bmi has been considered as a significant risk factor for the development of lumbar spine diseases for both ldhd (or=1.02 (95% ci=1.0–1.04)) and ldh (or=1.02 (95%ci=1.02–1.04)). smoking and heavy to moderate strain to back revealed statistically significant ors of 6.44 (95% ci=1.69–24.51) and 3.36 (95% ci=1.57–7.09) in the regression model for patients with only ldh (table 3). discussion evidences suggests that degeneration starts at a very early stage of life where mild changes are seen in the first decade of life and more significant changes from second decade onwards. 3,11,21 it is reported that lbp, lumbar disc herniation and degeneration are common in the fourth to fifth decade of life. 5,12,22 one study has indicated that mean age for ldh as 37 years, 12 while other studies have reported mean ages as 45 ± 13 years and 42 ± 10 years 15 and 41 ± 10 years. 21 mean ages in all study groups of the present study were in fifth decade of life which was similar to the previous reported findings mentioned above. however, contrast to our findings, one study has recorded 61 70 years as the peak age for ldhd in both genders. 23 we observed a significant difference in bmi between cases and control indicating majority of the patients in ldhd group (67.7%) and ldh group (62.1%) were in overweight or obese categories according to bmi. however, control group had 51% subjects with normal bmi. although there were many heterogeneous data available regarding the association of bmi and ldh, majority of the data emphasized that increased bmi or obesity is a risk factor for ldh. present study also confirms the above fact as bmi less than 25 kgm-2 as a protective factor with odds ratio of 0.31 (95% ci=0.13-0.72) in ldhd group and 0.39 (95 % ci=0.20-0.77) in the ldh group. studies conducted on histological assessment of intervertebral disc tissue further confirmed that high degree of degeneration is also associated with elevated bmi. 23 as overweight and obesity encounters an increased pressure and weight on the intervertebral tissue thus, initiate herniation and degeneration of the intervertebral discs. study findings regarding gender and ldh in the present study are in accordance with reported similar studies. a study conducted with 205 surgical patients reported that men to women ratio in patients who are undergoing lumbar surgery was 1.5:1 in surgical setting.13 this was in accordance with the study carried out by kelsey and co-workers (1984). however, in non-surgical setting it was reported that men to women ratio was 1:1. in addition, another study showed that prevalence ratio for male:female was 1:0.61 with table 3. association of risk models for lumbar disc herniation and lumbar disc herniation and degeneration in study population variable subjects with ldhd subjects with ldh adjusted or 95 % ci adjusted or 95 % ci 1.age 1.01 0.98-1.04 0.99 0.96-1.0 2.bmi 1.02 1.00-1.04* 1.02 1.02-1.04* 3.gender 3.30 0.96-11.42 2.00 0.79-5.12 4.smoking 3.43 0.72-16.36 6.44 1.69-24.51* 5.alcohol 1.83 0.48-7.08 1.27 0.43-3.75 6.sports a)strenuous sports b)moderately strenuous sports 1.28 2.54 0.49-3.31 0.39-16.32 0.59 1.2 0.26-1.29 0.23-6.03 7.moderate and heavy strain to back 1.99 0.78-5.03 3.36 1.57-7.09* 8.physically demanding occupations a)severely demanding b)moderately demanding c)less demanding 0.71 3.85 0.65 0.03-20.21 0.27-54.69 0.11-4.00 0.29 3.81 0.59 0.07-12.27 0.35-41.64 0.12-2.99 9.sitting more than 8 hours per day 5.34 0.79-36.02 3.65 0.63-21.11 international journal of human and health sciences vol. 05 no. 04 october’21 430 a significance of p=0.0001. 23 similar observations were noted in a study which recruited 48 patients with lbp. above study affirmed similar male prominent gender distribution with 67% males and 33% females. 15 further, a reported study has also indicated that ldh is found in 4.8% men over 35 years and 2.5% women over 35 years suggesting that men are more prone to ldh. 12 the present study finding in sri lankan subjects with ldh also adds to the study findings that males are more prone to develop ldh compared to females. majority of cases (both ldhd and ldh groups) and controls had secondary or higher educational level. experts suggest that subjects who are employed with higher education level having more sedentary lifestyle and they lack of exercise on back muscles, which leads to weaken the power of the muscles. this could trigger the herniation of the intervertebral disc, when the vertebral column encounters a sudden load. however, according to the present study control group also had a good educational level, hence this phenomenon cannot be applied to the present scenario. in the present study, there was a significant difference in smoking among cases and controls (p=0.012) with high frequency of smoking reported in cases (16.3%) compared to controls (4.8%). our findings are in accordance with previous studies which affirm the association between smoking and ldh. studies have reported that smoking in past years is associated with increased risk of ldh. 14 further studies have highlighted that nicotine in cigarettes may cause narrowing of blood vessels hence impair the blood flow to the disc tissue causing disc degeneration. 22,24 a twin study reported by battie et al (1995) remarked that there were 18% greater mean disc degeneration scores in lumbar spine of smokers when compared to non-smokers. interestingly, a study has stated that smoking cannot be regarded as a risk factor for disc degeneration although there was considerable percentage (41 %) of smokers in the study. 25 therefore, this present study finding on smoking further adds evidence to previously reported studies on the positive association between ldh/ldhd and cigarette smoking. further, studies have identified that intervertebral disc being the largest avascular tissue in the human body, narrowing of blood vessels by nicotine can interrupt the diffusion process via cartilage end plate, thus leading the disc to degenerate. to further strengthen the study, the present study also attempted to distinguish the relationship between the sleeping postures and type of mattress used in ldh subjects. these factors are considered as critical conventional factors contributing to lbp associated with ldh. however, present study did not find any significant association with types of mattresses used and ldh/ldhd. however, there were limited literature on these parameters. a study conducted in 313 adults with lbp has proven that medium firm mattresses had better outcome for pain while in bed (or=2.35; 95% ci=1.13-4.93) compared to the pain on rising on the same mattress type (or=1.92; 95% ci=0.97-3.86) when compared to patients using firm mattresses. finally, authors have concluded that medium firm mattresses could improve the pain and disability in patients with chronic lower back pain. 26 further, it was also believed that mattresses with soft surfaces increase lbp due to incorrect support to the vertebral column and decrease the quality of sleep. 27 it is believed that loading of the intervertebral disc is an important factor which determines ldhd and ldh. therefore, different impact on the disc by different sleeping postures could not be disregarded in the etiology of ldhd and ldh. however, studies done on direct measurement of spinal loading is limited and studies on sleeping postures are scarce. interestingly, present study has observed that sleeping in supine posture as a significant risk factor with odds ratio of 2.09 (95% ci=1.09-4.06) in patients with ldh. however, this phenomenon could not be observed in patients with ldhd. it was stated that proper sleeping system could align the spine on to its neutral posture as do in upright position, whereas non-neutral postures can apply unbalanced loading on intervertebral discs and facet joints. further, intervertebral discs tend to restore and grow through hydration during sleeping. as the gravity changes during sleeping, intervertebral disc tissues are unloaded and can rehydrate to restore its elasticity. 28 therefore, findings related to sleeping postures and type of mattress used adds valuable insight to the studies on risk factors associated with ldh and ldhd. in the current analysis of the study, we specially focused on the association between physical workload and ldh. accordingly, results of this case-control study on occupational risk factors associated with ldh are well correlated with the reported studies on similar theme. heavy physical work such as lifting and carrying heavy objects are proposed risk factors for ldh associated 431 international journal of human and health sciences vol. 05 no. 04 october’21 lbp. 16 another study on identical twins also found similar findings. 29 it is also reported that heavy lifetime occupational and physical loading have an association with disc degeneration in upper lumbar levels (p=0.055 0.01) whereas sedentary work was associated with less significant degeneration (p=0.006). 29 contrast to our findings, observations by a different study conducted in monozygotic twins stated that there was no significant difference observed in the level of leisure time physical activities when the monozygotic twins were compared to entire twin cohort in finland. 30 similarly, a review has shown that workers with many sedentary activities had higher prevalence rates for lbp symptoms and sick leaves due to lbp [or=1.46; (95% ci=1.18– 1.29) for sedentary leisure activities)]. they have also indicated that physical activities in leisure time (either sports or daily physical activities) do not associate with prevalence rates for low back morbidity. 31 a review study concluded contradictory findings stating that sedentary lifestyle and leisure time is not associated with lbp. 32 our study further confirmed that severity of daily physical activities causing strain to back have a considerable effect on ldhd. occupation was recorded as a risk factor by manek and macgregor (2005). the authors stated that occupations with night shifts, lifting, bending, twisting, pulling and pushing favours ldhd. 16 according to the present study authors found heavy lifting, bending and twisting as severe or moderate risk occupations that had a strong significant association with ldh [or=5.96 (95% ci=1.22–29.18)]. another study also emphasized that main causes for lbp associated with ldh in workplace are heavy lifting, repeated loads from manual handling, work postures incurring postural stress and whole-body vibrations. 33 contradictory to our findings a twin population study stated that there is no significant association with occupational loading and ldhd. 34 therefore, our findings with perceived work strains on ldh cannot be disregarded. there are several reported literatures that suggest the relationship between sports and ldhd. hence, present study also hypothesized sports as a contributory factor for ldhd. however, authors could not find significant association with ldh/ldhd and sports. according to published literature, evidence have stated that there was high incidence of radiographic abnormalities of spondylolysis in college level football players (80.5%). 16 in addition, above study also stated that spondylolysis as a significant risk factor for lbp in football players. observations from another study was in agreement with previous studies stating that football players were at increased risk of developing lbp and disc degeneration. 17 another study conducted in japan among rugby players (n=327) also supported the above relationship of lbp and strenuous sporting activities. that study also emphasized radiographic abnormalities seen in spondylolysis as a significant radiological risk factor for lbp in high school rugby players. 18 a similar study conducted in elite athletes also revealed that disc degeneration is significantly higher in elite athletes (75%) when compared to non-athletes (31%). 35 however, a similar case control study carried out in former elite athletes showed that odds ratios for back pain was significantly lower among athletes than among control subjects suggesting contradictory findings of the above report. authors have also stated that lbp is less common in athletes when compared to control subjects [or=0.62; (95 % ci=0.37 – 0.98) for endurance sports: or=0.60; (95% ci=0.44– 0.82) for sprinting and games: or= 0.67; (95% ci=0.47-0.96) for contact sports such as wrestling and boxing]. the study further commented that maximal weightlifting is associated with disc degeneration of the entire lumbar spine, whereas soccer associated degeneration confined to lower lumbar spine region only. authors further emphasized that there was no accelerated disc degeneration in runners and shooters. 36 number of factors could have interfered with the results of present study with ldh and sports. majority of participants of the present study were unable to mention the duration of involvement in sports, reason for stop playing and unable to recall the specific sporting activities they were engaged during school time. therefore, these factors could have greatly reduced the specificity of sports definitions and might also lead to numerous misclassifications of the type of sports (strenuous sports or mild strenuous or etc.). though there is no significant association between sports and ldh, present study could highlight some valuable information regarding sports and ldh. according to the history of involvement in sports among the recruited subjects in our study emphasizes that improper training or lack of back muscle strengthening exercise may attribute for sports associated lbp and ldhd in sri lankan context. further, according to expertise experience it is international journal of human and health sciences vol. 05 no. 04 october’21 432 hypothesized that people who have engaged in sports have developed a good muscle tone during the period of active involvement in sports, but when they quit or stop regular sporting activities the developed muscle tone will decrease and as a result when they participate in strenuous work or sports, the load that comes to the body will directly pass through the vertebral column without involvement of back muscles. hence, the intervertebral disc tends to herniate which is enhanced by the excessive load that triggers degeneration. traditionally it was believed that traumatic occupations and heavy physical/mechanical loading were the major contributing factors that leads lbp and ldhd. 7, 9 however, according to the present study more than half of the study subjects (56.7%) did not have any of the above predisposing factors associated with ldh. therefore, it is suggested that there could be other factors associated with regular or occupational behavior that is related to lbp in this cohort of patients. recurrence of ldh in the present study was 13.5% and was in agreement to previous findings of recurrence of lumbar disc disease (5–15%). 37, 38 however, above published studies further commented that there was no significant association of age, sex and level of herniation and the recurrence of ldh. the limitations of the present study include a convenience sample with case-control study design. secondly, assessment of bmi had a limitation as some of the cases were reluctant to measure height and weight due to severity of pain while some controls refused to remove foot ware to measure the weight. further, social behavior also had a limitation as it was based on direct questioning of the participants only. also, selfreported data on sleeping posture and data on daily physical activities were regarded as limitations of the study. there are several notable strengths in our study such as assessing of sleeping postures, types of sleeping systems and developing of a regression model associated with ldh are considered as strengths. though the sample size was adequate to detect the hypothesized effects of socio-demographic, behavioural and occupational factors associated with disc herniation among sri lankan subjects, large studies would add more comprehensive findings in the etiology of disc herniation. conclusion according to the regression model bmi, smoking and daily physical activities with moderate to heavy strain to back are significant risk factors for development of ldh or ldhd. in addition, present study highlights that there was no significant association between type of mattress used by the study participants although these were considered as triggering factors for ldh and ldhd. further, more than 50% of the subjects who presented with ldh or ldhd were less than fifty years of age. declarations sources of funds financial assistance by university grants commission, sri lanka (vc/dric/pg/ sjp/2013/02). conflicts of interest the authors report no conflicts of interest either financially or non-financially. the authors alone are responsible for the content and writing of the paper. ethical approval all procedures performed in studies involving human participants were in accordance with the ethical standards of the ethics review committee, faculty of medical sciences, university of sri jayewardenepura, colombo, sri lanka (29/14) with the 1964 helsinki declaration and its later amendments. informed consent to participate informed consent was obtained from all individual participants included in the study. competing interests the authors declare that they have no competing interests either financially or non-financially. author’s contribution athiththan lv, withanage nd and perera s conceived the study concept and contributed in the study design. withanage nd wrote the first draft of the first manuscript, conducted experimental studies and carried out data analysis. prathapan s supported in results interpretation. athiththan lv, prathapan s and peiris h contributed in manuscript editing. withanage nd and athiththan lv are guarantors of the work and withanage nd has the full access to data and takes responsibility for the study. 433 international journal of human and health sciences vol. 05 no. 04 october’21 references 1. katz jn. lumbar disc disorders and low-back pain: socioeconomic factors and consequences. j bone joint surg am. 2006; 88:21-24. 2. pietri f, leclerc a, boitel l, chastang jf, morcet jf, blondet m. low-back pain in commercial travelers. scand j work environ health. 1992; 52-58. 3. urban j, roberts s. degeneration of the intervertebral disc. arthritis res ther. 2003; 5:120-138. 4. freemont a. the cellular pathobiology of the degenerate intervertebral disc and discogenic back pain. rheumatology. 2009; 48:5-10. https://doi. org/10.1093/rheumatology/ken396 5. zhang yg, guo tm, guo x, wu sx. clinical diagnosis for discogenic low back pain. int j biol sci. 2009; 5:647. 6. smith lj, nerurkar nl, choi ks, harfe bd, elliott dm. degeneration and regeneration of the intervertebral disc: lessons from development. dis. models mech. 2011; 4:31-41. http://doi.org/10.1242/ dmm.006403 7. eskola pj, lemmelä s, kjaer p, solovieva s, männikkö m, tommerup n, lind-thomsen a, husgafvelpursiainen k, cheung km, chan d. genetic association studies in lumbar disc degeneration: a systematic review. plos one. 2012; 7:e49995. https:// doi.org/10.1371/journal.pone.0049995 8. colombini a, brayda-bruno m, lombardi g, croiset sj, vrech v, maione v, banfi g, cauci s. fok i polymorphism in the vitamin d receptor gene (vdr) and its association with lumbar spine pathologies in the italian population: a case-control study.2014. https://doi.org/10.1371/journal.pone.0097027 9. adams ma, roughley pj. what is intervertebral disc degeneration, and what causes it? spine. 2006; 31:2151-2161. 10. eser b, cora t, eser o, kalkan e, haktanır a, erdogan mo, solak m. association of the polymorphisms of vitamin d receptor and aggrecan genes with degenerative disc disease. gene test mol bioma.2010; 14:313-317. https://doi.org/10.1089/gtmb.2009.0202 11. antoniou j, steffen t, nelson f, winterbottom n, hollander ap, poole ra, aebi m, alini m. the human lumbar intervertebral disc: evidence for changes in the biosynthesis and denaturation of the extracellular matrix with growth, maturation, ageing, and degeneration. j clin invest. 1996; 98:996. http:// doi.org/10.1172/jci118884. 12. vialle lr, vialle en, henao jes, giraldo g. lumbar disc herniation. revi bras ortop (english edition). 2010; 45:17-22. 13. an hs, silveri cp, simpson jm, file p, simmons c, simeone fa, balderston ra. comparison of smoking habits between patients with surgically confirmed herniated lumbar and cervical disc disease and controls. clin spine surg. 1994; 7:369-373. 14. kelsey jl, githens pb, o’conner t, weil u, calogero ja, holford tr, white iii a a, walter sd, ostfeld am, southwick wo. acute prolapsed lumbar intervertebral disc an epidemiologic study with special reference to driving automobiles and cigarette smoking. spine. 1984; 9:608-613. 15. scuderi gj, brusovanik gv, golish sr, demeo r, hyde j, hallab n, vaccaro ar. a critical evaluation of discography in patients with lumbar intervertebral disc disease. spine j. 2008; 8:624-629. https://doi. org/10.1016/j.spinee.2006.10.005 16. manek nj, macgregor a. epidemiology of back disorders: prevalence, risk factors, and prognosis. curr opin rheumatol. 2005; 17:134-140. http://doi. org/10.1097/01.bor.0000154215.08986.06 17. gerbino pg, d’hemecourt pa. does football cause an increase in degenerative disease of the lumbar spine? curr sports med rep. 2002; 1:47-51. http:// doi.org/10.1249/00149619-200202000-00009 18. iwamoto j, abe h, tsukimura y, wakano k. relationship between radiographic abnormalities of lumbar spine and incidence of low back pain in high school and college football players. am j sports med. 2004; 32:781-786. https://doi. org/10.1177/0363546503261721 19. yusuf s, hawken s, ôunpuu s, dans t, avezum a, lanas f, mcqueen m, budaj a, pais p, varigos j. effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the interheart study): case-control study. the lancet. 2004; 364:937-952. 20. seidler a, bolm-audorff u, siol t, henkel n, fuchs c, schug h, leheta f, marquardt g, schmitt e, ulrich p. occupational risk factors for symptomatic lumbar disc herniation; a case-control study. occup environ med. 2003;60:821-830. 21. roberts s, evans e, kletsas d, jaffray d, eisenstein s. senescence in human intervertebral discs. eur spine j. 2006; 15:312-316. 22. taher f, essig d, lebl dr, hughes ap, sama aa, cammisa fp, girardi fp. lumbar degenerative disc disease: current and future concepts of diagnosis international journal of human and health sciences vol. 05 no. 04 october’21 434 and management. adv orthp.2012; http://dx.doi. org/10.1155/2012/970752 23. weiler c, lopez-ramos m, mayer hm, korge a, siepe cj, wuertz k, weiler v, boos n, nerlich ag. histological analysis of surgical lumbar intervertebral disc tissue provides evidence for an association between disc degeneration and increased body mass index. bmc res notes. 2011; 4: 497. http://doi. org/10.11886/174-0500-4-497 24. hadjipavlou a, tzermiadianos m, bogduk n, zindrick m.the pathophysiology of disc degeneration a critical review. bone joint j. 2008; 90:1261-1270. https://doi. org/10.1302/0301-620x.90b10.20910 25. kanayama m, togawa d, takahashic, terai t, hashimoto t. cross-sectional magnetic resonance imaging study of lumbar disc degeneration in 200 healthy individuals. j neurosurg spin. 2009; 11:501507. 26. kovacs fm, abraira v, peña a, martín-rodríguez jg, sánchez-vera m, ferrer e, ruano d, guillén p, gestoso m, muriel a, zamora j. effect of firmness of mattress on chronic non-specific low-back pain: randomised, double-blind, controlled, multicentre trial. the lancet. 2003;15;362(9396):1599-604. 27. leilnahari k, fatouraee n, khodalotfi m, sadeghein ma, kashani ya. spine alignment in men during lateral sleep position: experimental study and modeling. biomed. eng. online. 2011;10 (1):103. 28. wilke hj, neef p, caimi m, hoogland t, claes le. new in vivo measurements of pressures in the intervertebral disc in daily life. spine. 1999; 15;24(8):755-62. 29. battié mc, videman t, gibbons le, fisher ld, manninen h, gill k. determinants of lumbar disc degeneration: a study relating lifetime exposures and magnetic resonance imaging findings in identical twins. spine. 1995; 20:2601-2612. 30. battié mc, videman t, kaprio j, gibbons le, gill k, manninen h, saarelaj,peltonen l. the twin spine study: contributions to a changing view of disc degeneration. spine j. 2009; 9:47-59. https://doi. org/10.1016/j.spinee.2008.11.011 31. hildebrandt v, bongers p, dul j, van dijk, f, kemper h. the relationship between leisure time, physical activities and musculoskeletal symptoms and disability in worker populations. int arch occup environ health. 2000; 73:507-518. 32. chen sm, liu mf, cook j, bass s, lo sk. sedentary lifestyle as a risk factor for low back pain: a systematic review. int arch occup environ health. 2009; 82:797806.https://doi.org/10.1007/s00420-009-0410-0 33. battié mc, videman t, gibbons le, manninen h, gill k, pope m, kaprio j. occupational driving and lumbar disc degeneration: a casecontrol study. the lancet. 2002; 360:1369-1374. https://doi.org/10.1016/ s0140-6736(02)11399-7 34. videman t, battié mc, gibbons le, manninen h, gill k, fisher ld, koskenvuo m. lifetime exercise and disk degeneration: an mri study of monozygotic twins. med. sci. sports exerc.1997; 29:1350-1356. http://doi.org/10.1097/00005768-199710000-00012 35. ong a, anderson j, roche j. a pilot study of the prevalence of lumbar disc degeneration in elite athletes with lower back pain at the sydney 2000 olympic games. br j sports med. 2003; 37:263-266. 36. videman t, sarna s, battié mc, koskinen s, gill k, paananen h, gibbons l.the long-term effects of physical loading and exercise lifestyles on backrelated symptoms, disability, and spinal pathology among men. spine. 1995; 20:699-709. 37. swartz kr, trost gr. recurrent lumbar disc herniation. neurosurg focus. 2003; 15:1-4. 38. cinotti g. ipsilateral recurrent lumbar disc herniation. j bone joint surg [br]. 1999; 81: 368. international journal of human and health sciences vol. 03 no. 02 april’19 64 review article: end-of-life: old age in contemporary society, self-perception of aging and ‘an’ islamic perspective mohammad yousuf rathor1, muhammad muzaffar ali khan khattak,2 nazri mohd yusof3 abstract: population aging is a global phenomenon which has important and far-reaching implications for many facets of human life. although it is an achievement of public health policies and socioeconomic development; it is generally greeted with alarm as it is assumed that elderly will be ill and dependant due to age-related chronic diseases which will require long term care. despite the fact that many older adults continue to work and contribute to the society, they are seen as a burden and a drain on resources, rather than as a resource in themselves. ageism and discrimination towards elderly is prevalent at individual and institutional levels that affect their physical and mental health, putting them at risk of depression and social isolation. according to the world health organization’s (who) combatting ageism has great potential for achieving healthy ageing for all people as they age. individual health and longevity is influenced by biological, environmental, and psychosocial factors, however modifiable risk factors are especially relevant as they are amenable to intervention. there is enough evidence that religiosity and spirituality (r/s) are among such factors which allow older adults to age in a more positive way. further r/s activities are prevalent globally and elderly tend to have high rates of involvement in religious activities. health benefits that may stem from r/s involvement could be important for the future of global health which suggests that they could be incorporated into the idea of positive ageing. islamic perspective on old age is deeply rooted in the very texts of revelation and as such is divinely based. this review article intends to create awareness of the elderly on the ageing process, their status in the contemporary society and how by adopting positive attitude toward ageing they can enjoy better functional health, self-esteem and satisfaction in life. keywords: ageing, health, islam, spirituality, religious practices. correspondence to: prof dr mohammad yousuf rathor, dept. of internal medicine, kulliyyah of medicine, international islamic university malaysia bandar indera mahkota campus, jalan sultan ahmad shah, 25200 kuantan, pahang, malaysia email:drmyrathor@yahoo.com. rathor@iium.edu.my 1. dr mohammad yousuf rathor, professor dept. of internal medicine, kulliyyah (faculty) of medicine, international islamic university malaysia 2. dr muhammad muzaffar ali khan khattak, associate professor, dept. of nutrition sciences, kulliyyah of allied health sciences, international islamic university malaysia 3. dr nazri mohd yusof associate professor, dept. of orthopaedic, traumatology and rehabilitation, kulliyyah of medicine, international islamic university malaysia introduction: the phenomenon of population ageing is a global phenomenon, which is unprecedented in human history, as the proportion of the elderly is increasing relative to the younger generation.1 it is projected that by the year 2020, there will be one billion elderly people (65+ years) in the world and 71% of whom will live in low-income countries.2malaysia is expected to reach ageing population status by the year 2035, when 15% of its total population will be 60 years and above.3 although population ageing is an achievement of public health, policies and advances in medical technology, rather than evoking celebration it is generally greeted with alarm, fear and anguish by individuals and policymakers. it is assumed that longer the people will live, the longer they will be ill and dependant due to age-related chronic diseases which will international journal of human and health sciences vol. 03 no. 02 april’19 page : 64-73 doi: http://dx.doi.org/10.31344/ijhhs.v3i2.79 65 international journal of human and health sciences vol. 03 no. 02 april’19 require long term care.4the old age and ageing has become the subject of research and debate all over world; being discussed by politicians, economists, policymakers and to ordinary people. ageism has deeply entrenched in the culture of both developed and developing countries which is reinforced by the mass media which presents them as frail, infirm, dependent; highlighting them as a burden and drain on resources.5-7 public is consciously and subconsciously primed to follow the negative ageing story. this age related negative perceptions have been particularly restrictive for women who sought to engage in various forms of physical activity. a recent analysis carried out by the world health organization (who) using world values survey data of 83 034 adults from 57 countries found low respect for older adults.8 the lowest levels of respect were reported in high income countries. even the medical profession is not immune to this prejudice.9 elderly receive less screening, less preventive care and poorer management and treatment.10 labelling them as ‘geriatric’ can be used as an excuse to provide inferior medical care. they are not encouraged to be physically active. many common, functional problems such as reduced vision and hearing are overlooked or accepted as a normal part of ageing. the world report on ageing and health highlights great diversity in health and functioning in older age and marked health inequities in this group.11 this prevalent age-related bias towards old people can have detrimental effects to their health and wellbeing in the long-term. they often internalize the negative stereotyping and adopt “ageing myths” and see decline as inevitable.12 they perceive and accept that it is socially desirable for them to slow down and become less active with advancing age. on the contrary individuals with positive self-perception of aging enjoy better functional health and longevity as they transition into the later stages of life (across a twenty-year span of 50 year olds to 70 year olds) and live on average 7.5 years longer.13-17 society can benefit from ageing population if they age more healthily. for example, in the united states of america (1940–1990) population ageing contributed to around 2% of the increase in health expenditures, compared to 51% related to technology innovation in medical practice.18 japan is currently the only country in the world with 30% of its population aged 60 or over. however, there is a very limited effect of population ageing on their economic growth.19 medical researches on preventing or reversing aging; should focus on modifiable risk factors, especially those that are amenable to intervention; and can improve the quality of life until the fixed moment of death what allah swt has ordained. they should develop preventative strategies and therapies that can delay or prevent the onset of age-related diseases.20the concept of positive ageing is gaining importance in academic and public sphere in recent years. ‘positive ageing’ denotes the aspirations of individuals and communities to plan for, approach and live life’s changes and challenges as they age and approach the end of their lives, in a productive, active and fulfilling manner.’21 religion and spirituality (r/s) is among the modifiable risk factors that help older adults to live positive lives despite many challenges of old age. religion plays a great role in the formation of conscience of people. it is an integrative force in the society which provides cohesion in the social order by promoting a sense of belonging and collective consciousness. it provides answer to the purpose of life and up to a certain extent regulates their life. studies have consistently shown potential benefits of r/s on health, well-being and quality of life as well as comfort and hope in difficult times.22-24 each religion has its own ideals and values towards elderly. in islam elderly have a special status, which is deeply rooted in the very texts of revelation and as such is divinely based. older adults who attend religious gatherings develop social contacts, which promote their health, social support and self-esteem. they feel less lonely. r/s is not regularly attended in clinical practice, while it is among the nursing care priorities. therefore health care personnel should give value to r/s in professional practice, which will make practice of medicine more holistic, ethical and compassionate. this review article intends to create awareness of the aged on the healthy ageing process, their status in the contemporary society and how by adopting positive attitude towards ageing they can enjoy self-esteem and satisfaction in life. definition of old age ageing is a normal, inevitable and universal phenomenon that starts from the day we are born and begin our journey back towards our creator. it is an inescapable reality of ones life and a biological reality which has its own dynamic, largely beyond human control. it is highly individualized and occurs at different rates in different people determined by genetic, socioeconomic, regional, international journal of human and health sciences vol. 03 no. 02 april’19 66 dietary, and disease factors.25, 26 despite slow progression, it almost always catches people with a decline in strength, immunity and body resources.27 there is no consensus on a universal definition of old age. opinions vary according to the economic situation and cultural level, and even among scholars there is no unanimity. according to the world health organization (who), old age is fixed at 60 years for developing and the third world countries, and at 65 for developed countries, a classification based on economic and social situation in the country.28 the united states social security act of 1935 held that old age occurred at 65 years of age. this was later increased to 70 in 1979, and by 1986, retirement age was totally abolished. (tout, 1989). many countries now don’t have a retirement age. a person can continue to work and earn a living as long as he can. therefore, old age should be understood in its wholeness, but it is still a social and cultural fact. the process of human aging is complex which is influenced by biologic, psychological, social, functional, and spiritual factors.29 in primitive societies, old age was generally determined by physical and mental conditions rather than by chronological age (number of years a person has lived). biological age is synonymous with functional and physiological age, and is an indicator of the general health status of individuals, a natural and irreversible process. it is characterized by changes in metabolism and physicochemical properties of cells and structural changes in tissues and organs. these changes affect mood, physical condition and social activity. because these changes affect some people sooner than others, some people are biologically old at 40 and others at later ages. psychological age refers to a person’s adaptive capacities to the ageing process and his/her mental functioning and personality. for example, an 80-year-old who participates in daily activities, plans and looks forward to future events is considered psychologically young. social age is related to social roles and ones habits relative to society’s expectations, one’s relationships with relatives and friends and in formal organizations where one has worked. it has been observed that people with strong social networks report greater emotional well-being in day-to-day life. many sociologists believe that old age is socially constructed and is the result of the interaction between the individual and the society where he/she exists and what is the concept of old age in that society.30, 31 gerontology (field of medicine and social science that seeks to understand the process of aging) defines old age as the process of a system’s deterioration through time.32 it classifies old age into three periods: the period from age sixty-five to seventy-five sometimes called the ‘young old’ which denotes relatively healthy and financially independent elders; the period from age seventyfive to eighty-five are called the ‘old’; and the period post age eighty-five, is referred to as the ‘old old’ when activities are limited due to functional disabilities. in islamic ideology old age is classified in a similar manner but with specific terminology.33 kahel (young old person): a person who is between the age of 60 and 75 and still contributes to social life; sheikh (old): a person who is between the age of 75 and 85 and whose contribution to society is reduced. haarm refers to extreme old age (aqsa al-kibar): a person who is 85 or more who is frail and usually home bound, musinn refers to every old person unable to care for himself due to age, yet not necessarily as a result of disability or other reasons” al-moamer (centurion): a person who reaches 100 or more.34 life beyond the age of 100 years is rare but is possible; the prophets isa and nuh lived more than 1000 years35 the age of 60 has a special connotation; if someone reaches this age he is expected to have a new lease of life.36 whatever classification we choose the salient point to note is that there is great amount of variability among oldagers depending upon the region, climate, race, heredity and life style, and has varied at different times in each historical period. in contrast to the chronological age, the term ’old age’ refers to anyone who is unable to take care of him/herself due to old age and not due to handicap or disability. medical advances in the twentieth century have produced a new stage in the life course, what is called “the third age”. 37 this stage is generally defined as the period in the life course that occurs after retirement but prior to the onset of disability, revealing a period in which individuals have the capacity to remain actively engaged; and today would roughly fall between the ages of 65 and 80+. at the individual level, this period can last a few years or even two decades or more. for many elderly these are the “golden years” when typically they have fewer responsibilities.38 a survey of 2,500 seniors in a los angeles community revealed that, they continued to grow, create, and engage in 67 international journal of human and health sciences vol. 03 no. 02 april’19 activities related to education and travel. some of them become active in their families or proactive in their communities, or enter the political arena. a sizeable proportion of the elderly in malaysia (professionals, scientists, scholars) still maintain a high level of mental acuteness and hence, are able to contribute to society. 39 the modern prosperous multi-cultural society of malaysia is the result of diligence and sacrifice of previous generations, some members of which are still living and contributing to the country like the current prime minister, tun dr mahathir bin mohamad. a world health organization (who) study and the malaysian component of an asean study revealed that the aged, particularly in rural areas, continue to work until 75 years of age or older.39,40 the contribution made by active older people goes well beyond monetary influence. they have much to offer to younger generations through their rich experience, knowledge and skills. grandmothers now provide half of all informal work-related child care, with more than a third of employed women having a grandmother look after their children when at work. therefore it is important that society does not belittle the importance of elderly nor does consider them as burdensome and redundant. in accordance with the practice of islam, we must accord them special status and position, maintain their rights and respect, and look after their daily needs. ageing process: old age is the sunset of life, characterized by various processes which involve all the systems of the body and ultimately lead to death within the course of time. the most obvious changes are wrinkles on the face; the greying of hair, decline in strength, hearing impairment, weakening vision, and the increasing susceptibility to infection, hypertension, heart disease, diabetes, and osteoporosis followed by restriction of movement, but these changes are very variable. elderly are susceptible to degenerative joint diseases such as arthritis causing aches and pains. osteoporosis and bone resorption affects their strength and functional performances. they develop fractures often with trivial trauma. the knee is the most frequently affected synovial joint followed by the hip and facet joints of the cervical and lumbar spine causing a significant reduction in mobility. this in turn causes difficulty in living alone, and caring for personal needs (bathing, dressing, etc.). similarly the gastro-intestinal tract (git) function is affected leading to reduction of gastric acid, intrinsic factor and pepsin secretion, which then reduce the absorption of vitamin b6, b12, folate, iron and calcium. other git problems include gastritis and gastrointestinal cancers which reduce nutritional status.41in addition to the “anorexia of ageing” physical, social, cultural, environmental and financial reasons can lead to inadequate diet. 42 the cognitive impairment is linked to vitamin b 12 deficiency, however it is highly variable from one person to another, and it does not typically interfere with activities of daily living. it typically leads to difficulty in learning new languages and increased forgetfulness. holy qur’an appraises us and specifically mentions about the changing nature of humans in old age, characterized by certain reduction in energy, fragility and vulnerability.43 it also makes special mention of an age termed ardhal al-‘umur, “it is allah who creates you and takes your souls at death; and of you there are some who are sent back to a feeble age, so that they know nothing after having known (much); for allah is all-knowing, all-powerful” 44 ardhal al-‘umur as is one’s lowest point of inability, whereby one becomes similar to an immature child (la ‘aqla lahu).45 in the final stages of life, elderly often regress to a state of childish dependency both physically and mentally what is interpreted in medicine as the second childhood. human life starts out as dependent and through aging ends-up as dependent which holy qur’an informs us very articulately in the following verses. ‘‘and he whom we grant long life, we reverse him in creation (weakness after strength). will they not then understand?’’ 46 reverse him in creation,” means that in old age allah swt turns him back to the state of childhood. “it is allah who created you in a state of (helpless) weakness, then gave you strength after weakness, then after strength gave you weakness and a hoary head: he creates whatever he wills, and it is he who has all knowledge and power”47 “o mankind! if you have doubt about the resurrection, (consider) that we created you out of dust, then out of a drop, then out of a leechlike clot, then out of a morsel of flesh, partly formed and partly unformed, in order that we may manifest (our power) to you; and we cause whom we will to rest in the wombs for an appointed term, then we bring you out as babes, then (foster you) that you may reach your age of full strength; and some of you are called to die, and some are sent back to the feeblest old age, so that they know nothing after having known (much), and (further), international journal of human and health sciences vol. 03 no. 02 april’19 68 you see the earth barren and lifeless, but when we pour rain down on it, it is stirred (to life), it swells, and it puts forth every kind of beautiful growth (in pairs).”48 hence, during this latter stage of life, elderly may be perceived to behave and act like children and this is the time when they need more affection and care from their family members. these physical incapacities make advanced age, ardhal al umr a stage of extreme weakness and senescence that precedes death.49 the prophet saw used seek refuge from allah swt from reaching this dwindled stage of life al ta’awudh min ardhal al ‘umr.50he (saw) used seek refuge in these words after prayers: “o allah, i seek refuge with you from cowardice, miserliness and from being sent back to a feeble age (‘wa aʿudhu bika min an uradda ila ardhalil-‘umur’) and, seek refuge with you from the trials of this life and those of the grave.”51 old age and religion religion plays a vital role in people’s lives. it is an integrative force in the society which provides cohesion in the social order by promoting a sense of belonging and collective consciousness. all religions strive to raise individuals above themselves, to help them achieve a life better than they would lead if left to their own impulses. religion functions as a stabilizing force at a time when one’s own strengths are dwindling as happens in old age. many old people face important existential challenges, mainly due to chronicdegenerative diseases, widowhood, death of close friends and relatives, loss of social roles, isolation, financial difficulties and the heightened awareness of the reality of death. human beings choose a variety of threads to cope with these concerns especially when their physical, mental, and cognitive abilities are declining.52 many of them turn to r/s, perhaps for the first time as a source of comfort that helps them to surpass suffering and the knowledge of sure death. 53 with few exceptions studies conducted in different countries repeatedly show that religion can be a powerful source of meaning, coping, and successful adaptation to life’s changing circumstances.54-56 there are a number of empirical and theoretical reviews on the topic that indicate valuable benefits arising from r/s involvement across a number of health domains and the findings apply across regions with differing ideologies, practices and religions. 24, 57-59 r/s beliefs and practices are associated with healthy behaviours, stronger immune function, better cardiovascular function, and a longer life 57 a study of mexican americans aged 65 to 80 found that those who frequently attended religious activities had higher life satisfaction and lower levels of depression than those who did not.58 from an islamic perspective, old age provides the individual with the opportunity for selfpurification and reform while also emphasizing their social role in the community. the holy qur’an speaks that life in this world is but a brief stopover; the final destination will be determined by allah (swt) on the basis of one’s deeds in this world. ‘‘…the life of this world as compared with the hereafter is but a brief passing enjoyment’’60 the purpose of life is made clear in these three verses of the qur’an: ‘‘say: ‘verily, my prayer, my sacrifice, my living, and my dying are for allah, the lord of the alamin (mankind, jinns and all that exists)’ 57 ; ‘did you think that we had created you in play (without any purpose), and that you would not be brought back to us?’ 61; ‘and i (allah) created not the jinns and humans except they should worship me (alone)’ 62 this explains the significance of spiritual and moral refinement of character as outlined in the following tradition of prophet muhammad saw, “none of you should wish for death or pray for it before it comes to him, for when one of you dies, his good deeds come to an end and nothing increases a believer’s lifespan but good” 63 according to islam greying of hair should not viewed as getting old with hopelessness and depression, but should rather be a motivating drive for personal reform and righteous deeds. islam shows a deep appreciation for a long life that is full of righteousness and moral goodness. history recapitulates the intellectual contributions made by early muslim scholars during their old age. everybody knows that life in this world is not eternal and one day we have to depart it. the heedlessness and vigour of youth makes us forget that one day we are also going to be old. time passes very quickly and each day brings on further physical weakness and more impaired thinking rather than fresher dynamism and a younger figure. “when their specified time arrives, they cannot delay it for a single hour nor can they bring it forward,”64 muslims are promised great rewards in the hereafter. “do not fear or grieve; but rejoice in the glad tidings of paradise which you have been promised.65 and allah swt says, “o you who believe! do not let your wealth or children divert you from the remembrance of allah. whoever does that is lost. give from what we have provided for you before death comes 69 international journal of human and health sciences vol. 03 no. 02 april’19 to one of you and he says, ‘o lord, if only you would give me a little more time so that i can give sadaqa and be one of the righteous.’ allah will not give anyone more time, once their time has come. allah is aware of everything you do.” 66this mind set leads them to prayers and supplications to seek the pleasure of allah swt, and hoping for the highest abode in heaven. muslim spiritual practices should not be seen as mere mystical or ritualistic exercises, but interpreted in terms of positive intellectual, emotional and behavioural outputs. remembrance of death is thus perceived as an opportunity to draw closer to allah swt to earn his pleasure during this life, in preparation for the hereafter – the ‘eternal home’ – to which all human beings ultimately go. every person will be rewarded [or punished] according to their attitude, appreciation and efforts during their stay on earth. thus, a muslim would experience both hope and fear in his or her relationship with allah swt. we should always remember allah swt, asking forgiveness to expiate past sins and earn his pleasure, readying to meet him and hoping for the highest abode in heaven. discussion old age is an unavoidable problemridden phase of life, but there is much evidence that personnel attitude and belief about aging has a noticeable impact on overall health and quality of life. 15,17,67,68 elderly need to accept the changes inherent to the aging process but take up new interests and continue to learn and experience new situations. healthy ageing is the focus of who on ageing; between 2015 – 2030, which replaces the previous active ageing policy developed in 2002. it emphasizes the need for actions across multiple sectors to enable older people remain a resource to their families, communities and economies. this process involves invoking personal choices and assuming responsibility for personal wellbeing. despite the fact that certain physical and cognitive declines are a normal part of aging, staying intellectually tuned in and socially engaged appears to contribute to successful aging.69there is promising evidence that older adults can benefit from brain plasticity/ neuroplasticity to reduce age-related cognitive decline. 70, 71 these benefits can be achieved by challenging aging brains through cognitive training, leisure activities, intellectual engagements, and learning new skills. 72 maintaining a healthy brain is a critical factor for their quality of life and the preservation of their independence. further to counter ageism, they should actively participate in talks, group discussions and physical activities. people who age within the context of friends, work associates, neighbours and family members feel optimistic about life by their active participation in various social activities or local events. muslims are eagerly encouraged to know one another, share and benefit from fellow human beings, irrespective of colour, race, gender, or status. this is demonstrated by attending congregational prayers five times a day, the prayer of friday and the prayer of eid celebration. they should interact with family and friends regularly and help in household’s tasks or looking after and raising grandchildren. they should contribute to the younger generation by their experience, knowledge, skills, and wisdom. islam, arguably, provides more coherent foundations than many other belief systems when it comes to health.73 islamic texts have many health promoting verses. the prophet saw taught his followers to have a peaceful mind through acceptance of life changes. he has warned not to be engulfed with anxiety, depression, or anger. he has said “take advantage of five things before five things seize you; your youth before your old age, your health before your sickness, your wealth before your poverty, your spare time before your being busy and your life before you death.” positive thinking and sustaining a healthy mind is religious obligation and an act of worship as allah swt says, “do not fear or grieve; but rejoice in the glad tidings of paradise which you have been promise”. 65 such a belief translates into a positive reaction to any adversity or stress. they should consciously desire to live a long and healthy life through good nutritious diet and living active life, as it is important to maintain their energy and health. they should eat meals with family or friends as research has shown that meals eaten in groups are up to 46 percent larger than meals eaten alone. islam emphasizes sharing food with neighbours, friends and the poor. they should eat in moderation – not too much and not too little. it has been proved beyond doubt that over eating is the root of many diseases like obesity, diabetes, hypertension, coronary heart disease and premature senility. the holy qur’an stresses the importance of limiting caloric intake, “eat and drink, yet not in excess, for the lord loves not those who commit excess.74it also discusses a healthy diet as there are eighteen verses specific to this topic. it focuses on fruit consumption with a progressive focus on plant based dietary international journal of human and health sciences vol. 03 no. 02 april’19 70 patterns, “then, eat of all fruits, and follow the ways of your lord made easy for you”75 and “it is he who produced gardens… and date palms, and crops of different shape and taste and olives, and pomegranates, similar in kind and different in taste. eat of the fruits when they ripen.”76 prophet muhammad saw has said,” “the best of you are those who live the longest and do the best deeds.” 77 and he saw has also said, “no one of you should wish for death or pray for it before it comes to him, for when one of you dies, his good deeds come to an end, and nothing increases a believer’s lifespan but good.”63 islam encourages exercise as the prophet saw said, “a strong believer is better and dearer to allah swt than a weak believer, though both are good.” the one who is physically stronger is better before allah swt because they are more active and energetic in the performance of worship and taking care of the needs of others. elderly should continue to exercise even in moderation as it reduces morbidity, lessens body pain, and helps maintain bone strength. exercise can also have profound effect on the brain, helping prevent memory loss, cognitive decline, and dementia. walking is one of the best ways to stay fit. other choices include swimming, biking, gardening, etc. yoga and tai chi are the perfect exercises as they are both low-impact, slow-motion exercises, plus have some other incredible benefits. they strengthen core muscles and improve balance, which can reduce the likelihood of a hazardous fall. prayer (salat) is the most practical religious strategy used to cope with stress and remain healthy. according to a hadith, prophet saw has said, “verily there is a cure in salat”. it keeps our body active as certain positions during salat activate different groups of muscles and thus save us from muscle and joint diseases. it strengthens the muscles of the knee joints to mitigate the strain on them and avoid osteoarthritis. during sajda blood supply to the brain is improved. conclusion living a long and happy life is the objective and hope for the great majority of people. however the gift of a long life may to be useless and cumbersome for many or it can be status worthy of respect; depending on cultural norms, beliefs, and standards. while the problems of old age cannot be averted entirely, healthy ageing is a positive and constructive view of growing older which accepts aging as the continuous and normal development of human life78,79. old age does not mean your life is without a purpose. you are much wiser and need to contribute to the society/ world by your experiences and social participation. evidence has shown that exercising, quitting smoking, participating in cultural events and social activities can help to prevent the loss of functional capacity, thus maintaining sense of joy and improving quality of life. islam emphasises positive thinking and sustaining a healthy mind. further to counter ageism we need to raise awareness among younger generations and give realistic portrayals about elderly through education, religious sermons and the media to prevent the culture of indifference. islam consistently holds elderly in high regard and respect, and grooms its youth to show respect, honour and dignity towards them. in malaysia, the elderly care is provided both by private, ngos and governmental bodies. currently, the elderly care centres have more percentages of non-muslim patrons. the concept of retirement home/ facilities/ villages does not exist since it is the obligation for all muslims in looking after their parents. at present muslim retirees choose the pondok system (islamic teaching system descended from ‘ulama and guided by religious teachers) to spend their time after retirement which deepens their understanding in islam. it enhances their knowledge and practice and also keeps them intellectually stimulated. in islam, serving one’s parents is a duty second to prayer, and it is their right to expect it. the holy qur’an clearly states, “your lord has commanded that you worship none but him, and that you be kind to your parents. if one of them reaches old age with you, do not say to the word of disrespect, or scold them, but say a generous word to them. and act humbly to them in mercy, and say, “my lord, have mercy on them, since they cared for me when i was small.” 80 further prophet saw has said: “let him be humbled into dust; let him be humbled into dust” on further enquiry, he said: “he who sees either of his parents during their old age or he sees both of them, but he does not enter paradise (neglecting his / her duties towards them)” 81 this understanding of islamic values towards elderly would perhaps contribute towards the effective development of culturally sensitive approaches on elderly issues from different faith groups; including muslims. this will create a better society for people of all ages. acknowledgements this on-going study on end of life issues in esrd patients [rigs16-297-0461] is funded by international islamic university malaysia 71 international journal of human and health sciences vol. 03 no. 02 april’19 references: 1. united nations department of economic and social affairs, population division (2011). world population prospects: the 2010 revision, volume ii: demographic profiles. http://esa.un.org/unpd/wpp. 2. solomons, n. w., flores, r. and gillepsie, .s. health and nutrition: emerging and re-emerging issues in developing countries. journal of health and ageing. 2001; 3: 3–6. 3. department of statistic malaysia. demographic indicator malaysia. 2015. http://www.statistic.gov. my/portal/download_population/files 4. bähler, c., huber, c.a., brüngger, b. and multi morbidity, o.r. health care utilization and costs in an elderly community-dwelling population: a claims data based observational study. bmc health service research. 2015; 15:23. https://doi.org/10.1186/ s12913-015-0698-2 5. martin, r., williams, c. and o’neill, d. retrospective analysis of attitudes to ageing in the economist: apocalyptic demography for opinion formers. bmj. 2009; 339:b4914. https://doi.org/10.1136/bmj.b4914 6. levy, b.r. mind matters: cognitive and physical effects of aging self-stereotype. j. gerontol. b. psychol sci. soc. sci. 2003; 58: 203–211. https://doi. org/10.1093/geronb/58.4.p203 7. dahmen, n. and cozm, r. media takes: on aging. international longevity centre. 2009. http://www. aging.org/files/public/media.takes.book.pdf 8. world values survey. wave 6. 2010-2014. official aggregate v.20150418. world values survey association. vienna: institute for comparative survey research; 2016. http://www.worldvaluessurvey.org/ wvsdocumentationwv6.jsp 9. nash p, stuart-hamilton i, mayer p. the continuation of prejudice: addressing negative attitudes in nurse training and continuing professional education. educ gerontol. 2014; 40(1):53–60. 10. dixon-woods m, cavers d, agarwal s, annandale e, arthur a, harvey j, et al. conducting a critical interpretive synthesis of the literature on access to healthcare by vulnerable groups. bmc med res methodology. 2006; 6(1):35. 11. world report on ageing and health. geneva: world health organization; 2015. 12. bennett, t. and gaines, believing what you hear: the impact of aging stereotypes upon the old. educational gerontology. 2010; 36 (5): 435–45. https://doi. org/10.1080/03601270903212336 13. levy b.r.; slade, m.d.; kunkel, s.r. and kasl, s.v. longevity increased by positive self-perceptions of aging. j. pers. soc. psychol. 2002; 83: 261–270. https://doi.org/10.1037/0022-3514.83.2.261 14. levy b.r.; slade m.d. and kasl s.v. longitudinal benefit of positive self-perceptions of aging on functional health. j. gerontol. b. psychol. sci. soc. sci. 2002; 57: 409–17. https://doi.org/10.1093/ geronb/57.5.p409 15. lara, j., godfrey, a., evans, e., heaven, b., brown l.j.e., barron, e., rochester, l, meyer t.d. and mathers, j.c. towards measurement of the healthy ageing phenotype in life style based intervention studies. j maturitas. 2013; 76(2):189–99. http:// dx.doi.org/10.1016/j.maturitas. 16. levy, b.r., slade, m.d., murphy, t.e. and gill, t.m. association between positive age stereotypes and recovery from disability in older persons. jama 2012; 308 (19) 1972–3. https://doi.org/10.1001/ jama.2012.14541 17. mclaughlin, s.j., jette, a.m. and connell, c.m. an examination of healthy aging across a conceptual continuum: prevalence estimates, demographic patterns, and validity. j. gerontol. a. biol. sci. med. sci. 2012; 67(7):783-9. https://doi.org/10.1093/ gerona/glr234 18. kingsley de. aging and health care costs: narrative versus reality. poverty public policy. 2015; 7(1):3– 21. 19. bussolo m, koettl j, sinnott e. golden aging: prospects for healthy, active, and prosperous aging in europe and central asia. innov aging. 2017; 1(suppl 1): 1271. https://doi.org/10.1093/geroni/igx004.4631 20. world health organization, geneva. world report on ageing and health. 2015 21. stock, j.; schofield, p.; docking, r.e. what is positive ageing? in international handbook of positive ageing; docking, r.e., stock, j., eds.; routledge: oxford, uk, 2017; 5–15, isbn 9781138933057. 22. lavretsky, h. spirituality and aging. aging health 2010; 6: 749–769. 23. linda k. george, david b. larson, harold g. koenig, and michael e. mccullough. spirituality and health: what we know, what we need to know. j of social and clinical psychology. 2000; 19:102-16. 24. hummer ra, ellison cg, rogers rg, moulton be, romero rr. religious involvement and adult mortality in the united states: review and perspective. south med j. 2004;97(12):1223-30 25. christina r. victor, old age in modern society; a text book of social gerontology, 1994. 26. gail wilson, understanding old age: critical and global perspectives, sage, london, 2009. http:// eprints.lse.ac.uk/id/eprint/12813 27. hunt, s. e. the life course: a sociological introduction. 2nd. basingstoke: palgrave. 2016 http:// eprints.uwe.ac.uk/26748 international journal of human and health sciences vol. 03 no. 02 april’19 72 28. world health organization. (2009). definition of an older or elderly person. available from: http://www. who.int/healthinfo/survey/ageingdefnolder/en/index. ht 29. leisure, health and well-being: a holistic approach https://link.springer.com/book/10.1007/978-3-31933257-4. 30. berger, l. and thomas luckmann. the social construction of reality, in: a treatise in the sociology of knowledg: by hockey, j. and james. growing up and growing old: ageing and dependency in the life course, london: sage. 1993:33e, new york, anchor press, 1967: 4. 31. james e. birren, suresh i. s. rattan, victor w. marshall etc. encyclopaedia of gerontology. academic press, london 2006. 32. neugarten, b. l., moore, j.w., and lowe, j. c. age norms, age constraints, and adult socialization,” a.j.s. 1965; 70 (6): 710–17. https://doi.org/10.1086/223965 33. abdulhamid, a. m. social care for the elderly. cairo, egypt: dar al-ma’refeh. 1982. 34. mukhtasar bukhari hadith no. 368 35. mukhtasar bukhari hadith no. 2095 36. thane pat. a history of old age. london: thames & hudson ltd. 2005; 264 37. dawn c. carr, kathrin s. komp. gerontology in the era of the third age. implications and next steps, 2011. isbn 13 9780826105967 38. abeles, n. what practitioners should know about working with older adults? professional psychology research and practice. 1998; 29(5): 413-27. https:// doi.org/10.1037/0735-7028.29.5.413 39. chen, a.j. ageing in asean: its socio-economic consequences. singapore: institute of southeast asian studies. 1989 40. pirlich m. and lochs, h. nutrition in the elderly. best pract res clin gastroenterol. 2001; 15(6): 86984. https://doi.org/10.1053/bega.2001.0246 41. wysokiński, a., sobów, t., kłoszewska, i., kostka, t. mechanisms of the anorexia of aging-a review. age (dordr); 2015; 37(4): 81. https://doi.org/10.1007/ s11357-015-9821-x 42. baltes pb, kunzmann u. wisdom. psychologist. 2003; 16:131–33. 43. alqur’an, 17: 23 44. alqur’an, 16:70. 45. qurtubi, m. al-ansari. al-jami‘ li-ahkam al-qur’an. cairo: maktabat al-safa’, 2005. 46. alqur’an 36:68. 47. alqur’an 30:54 48. alqur’an, 22:5. 49. al-bukhari hadith no. 6374. 50. mukhtasar sahih al bukhari no. 1750, ks 79. 51. al-bukhāri on the authority of sa’d b. abī waqqas 52. mcfadden, s. (1996). religion, spirituality and aging. in: b. james and k. s. warner (eds.), handbook of the psychology of aging. san diego: academic press. 53. ghufran, m. impact of religious practices on mental health of elderly people belonging to muslim community. indian journal of community psychology. 2011; 7(2), 380-87. 54. maltby, j., lewis, c. a., freeman, a., day, l. and cruise, s.m. religion and health: the application of a cognitive-behavioural framework. mental health, religion & culture. 2010; 13(7-8), 749-59. https:// doi.org/10.1080/13674670802596930 55. yeager, d.m., glei, d.a., au, m., lin, h.s., sloan, r.p. and weinstein, m. religious involvement and health outcomes among older persons in taiwan. soc’ sc. med. 2006; 63(8): 2228-41. https://doi. org/10.1016/j.socscimed.2006.05.007 56. koenig, h. g., king, d., & carson, v. b. in: handbook of religion and health. new york: oxford university press. 2012. 57. koenig, h.g., george, l.k. and titus, p. religion, spirituality, and health in medically ill hospitalized older patients. j. amer. geriatr. soc. 2004; 52(4):554-62. https://doi.org/10.1111/j.15325415.2004.52161.x 58. levin, j., markides, k., and ray, l. religious attendance and psychological well-being in mexican american: a panel analysis of three generation data. gerontologist 1996; 36: 454-63. https://doi. org/10.1093/geront/36.4.454 59. thomas a arcury, jeanette m. stafford ms, ronny a. bell, etc. the association of health and functional status with private and public religious practice among rural, ethnically diverse, older adults with diabetes. j rural health. 2007; 23(3): 246-53 60. alqur’an 13:26 61. alqur’an 23:115 62. alqur’an 16:61. 63. muslim, 2006, 1: 1236 64. al-qur’an 29:5. 65. alqur’an 41:30. 66. alqur’an 63:9-11. 67. bryant, c., bei, b., gilson, k., komiti, a. and jackson, h. the relationship between attitudes to aging and physical and mental health in older adults. international psychogeriatrics. 2012; 24(10): 167483. https://doi.org/10.1017/s1041610212000774 68. low, g., molzahn, a.e., schopflocher, d. attitudes to aging mediate the relationship between older peoples’ subjective health and quality of life in 20 countries. health quality of life outcomes. 2013; (28) 11:146 73 international journal of human and health sciences vol. 03 no. 02 april’19 http://doi.org/10.1186/1477-7525-11-146 69. garrett, b. brain & behavior: an introduction to biological psychology (2nd ed.). thousand oaks, ca: sage.2009. 70. whalley, l.j., deary i.j., appleton, c.l., starr, j.m. cognitive reserve and the neurobiology of cognitive aging. ageing res. rev. 2004; 3(4):369-82. https:// doi.org/10.1016/j.arr.2004.05.001 71. greenwood, p. and parasuraman, r. neuronal and cognitive plasticity: a neurocognitive framework for ameliorating cognitive aging. frontiers in aging neuroscience. 2010; 2:150. https://doi.org/10.3389/ fnagi.2010.00150 72. williams, k. and kemper, s. interventions to reduce cognitive decline in aging. journal of psychosocial nursing and mental health services 2010; 48(5):4251. https://doi.org/10.3928/02793695-20100331-03 73. leeuw, evelyne d “islamic health promotion and interculturalization” health promotion international. 1999; (14)4 : 347-353 74. alqur’an, 7:31 75. alqur’an, 16:69 76. alqur’an, 6:141 77. saheeh al-jaami’, 3263. 78. rowe, j.w. and kahn, r.l. successful aging. gerontologist. 1997; 37: 433–440. https://doi. org/10.1093/geront/37.4.433 79. kendig, h., colette, j. browning, s.a. health, lifestyle, and gender influences on aging well: an australian longitudinal analysis to guide health promotion. front public health. 2014; 2: 70. https:// doi.org/10.3389/fpubh.2014.00070 80. alqur’an, 17:23-24 81. saheeh muslim 6189 international journal of human and health sciences vol. 06 no. 01 january’22 136 case report point-of-care ultrasound (pocus) and epsilon wave wong choc ky1, mohd hashairi fauzi1,3, andey rahman1,3, mohd faiz mohd shukri1, tuan hairulnizam tuan kamauzaman1, mohd najib abdul ghani2 abstract arrhythmogenic right ventricular cardiomyopathy (arvc) is often underdiagnosed in ruling out the cardiac cause for any syncope. it is an inherited cardiomyopathy characterized by fibro-fatty replacement of right ventricular myocardium. arvc is the  second most common cause of sudden cardiac death (scd) after hypertrophic obstructive cardiomyopathy (hocm), causing up to 20% of scd in younger patients (age <35 yo).  the prevalence is 1:5000 people overall. we described a case report of suspected arvc and the role of bedside electrocardiography (ecg) and point-of-care ultrasound (pocus) in emergency department. keywords: arvc, electrocardiography, pocus, emergency department correspondence to: mohd hashairi fauzi, department of emergency medicine, school of medical science, universiti sains malaysia health campus, 16150 kubang kerian, kelantan, malaysia. e-mail: hashairi@usm.my 1. department of emergency medicine, school of medical science, universiti sains malaysia health campus, 16150 kubang kerian, kelantan, malaysia 2. department of emergency & trauma, hospital raja perempuan zainab ii,15586, kota bharu,  kelantan, malaysia 3. department of emergency, hospital universiti sains malaysia, health campus, 16150 kubang kerian, kelantan, malaysia international journal of human and health sciences vol. 06 no. 01 january’22 page : 136-139 doi: http://dx.doi.org/10.31344/ijhhs.v6i1.389 introduction arrhythmogenic right ventricular cardiomyopathy (arvc) is a rare genetic disorder (autosomal dominant trait) which is characterised by progressive replacement of the rv myocardium by  fatty  and/or  fibrofatty  tissue.1 subsequently, leads to poor contractility and right ventricle dilatation.2 this condition will predispose patient to developed fatal arrythmias such as ventricular tachycardia and risk of sudden cardiac death especially in young athletes.2,3 in hectic and busy emergency department (ed), the diagnosis is quite challenging. however, in the presence of abnormal right ventricular features on point-ofcare ultrasound (pocus) aided with epsilon wave on electrocardiogram (ecg) it will expedite early detection of possible arvc and facilitate timely management this rare condition especially in resource-limited setting. case report a 17-year-old boy presented with syncope while riding a motorbike. prior to this, he was well and had no preceded complaints. there was no loss of consciousness after the road traffic injury. on  further  questioning,  he  denied  any  significant  history of cardiac related death or sudden death in his family primary and secondary survey revealed no lifethreatening injuries. cardiac monitor showed sinus arrhythmias with no evidence of ventricular arrythmias or ectopic features. ct brain showed no evidence intracranial bleed or infarction. ck/ck-mb ratio was normal. blood results showed normal blood glucose level (6 mmol/l) and normal renal/liver function test. resting ecg showed epsilon wave at v1, t wave inversion from v1-v3, prolonged s wave 137 international journal of human and health sciences vol. 06 no. 01 january’22 upstroke (55ms), localised qrs widening (110ms) in v1-v3, rsr pattern at precordial leads. no other remarkable findings were detected on ecg.  (figure 1 & 2) focused cardiac ultrasound (focus) showed right atrial and ventricular dilation as shown in figure 3. subsequently, patient was referred to cardio team and planned for holter and mri in ccu (coronary care unit). throughout the stay he was stable and discharge after 3 days of admission with normal holter and was planned for early outpatient mri appointment. unfortunately, he didn’t turn up for follow up. figure 1: epsilon wave at v1, t wave inversion from v1-v3, prolonged s wave upstroke (55ms), localised qrs widening (110ms) in v1-v3, rsr pattern at precordial leads. figure 2: : ecg of epsilon wave, a reproducible low amplitude signal between end of qrs complex to onset of t wave in right precordial leads particularly v1. international journal of human and health sciences vol. 06 no. 01 january’22 138 figure 3: apical 4 chamber view shows dilated ra/rv on focused cardiac ultrasound (focus). rv was bigger than lv and loss normal triangular shape. discussion diagnosing arvc in ed is difficult and there is  no single diagnostic tool for arvc. the diagnosis is a combination of clinical, electrocardiographic and radiological features, as defined by 2010 task  force criteria.2,3 rv dilation based on echo, endomyocardial biopsy confirmation of fibro-fatty  changes of right myocardium, presence of epsilon waves in v1-v3, t wave inversion in precordial leads, arrhythmias are all major criteria.2 in emergency department (ed), ecg and ultrasound are two modalities that widely available, low cost and easy to use. approximately 50-90% of arvc patient will have ecg characteristics finding such as t-wave inversion in the anterior  precordial leads (v1 through v6), epsilon waves, or vt with a left bundle branch block pattern, although polymorphic and right bundle branch block patterns also have been reported.4,7 the epsilon wave is described as slurring tiny signals at the end of right precordial qrs complex ecg and was found 30% in arvc patients.5 it represents delayed activation of right ventricular myofibres4. although ecg has higher false positive results, the role of ecg screening as a tool to rule out cardiac syncope is worthwhile in all kinds of emergency setting. over the years, point-of-care ultrasound (pocus) has been extensively used by em fraternity and become part of the mandatory training.8 it is useful as an extension of physical examination. pocus could help the physician in detecting potential arvc cases by looking at ra/rv dilatation and regional hypokinetic rv wall.3,4 even though mri still the goal standard in diagnosis arvc6 previous studies have shown that pocus is a one of the major tools for diagnosis of arvc.3,9 however, pocus especially cardiac ultrasound have some limitations such as patient habitus especially in obese patient that led to inadequate images. it also unable to localised regional abnormal findings on  rv wall in certain condition like minor ventricular bulge and focal aneurysms10. despite limitations, we believed that abnormal rv on pocus aided with epsilon wave on ecg could help clinician in early detection of this rare condition especially in resource-limited setting whereby other advanced imaging techniques such as transoesophageal echo (tee) and ct scan/ mri are not available. thus, urgent referral to appropriate team can be done in timely manner. 139 international journal of human and health sciences vol. 06 no. 01 january’22 conclusion all young and healthy adult patients present with syncope should consider arvc in their differential  diagnoses. usage of pocus and ecg as bedside investigation could help in early identification and  fasten the management source of fund (if any) : this case report did not receive any special funding conflict of interest: the authors declared no conflict of interest.  ethical clearance: no ethical approval needed for this case report authors’ contribution: conception: wck, mhf, ar,mfms; collection and assembly of data: wck,mhf,mnag; writing manuscript: wck,mhf,mnag; editing and approval of final  draft: wck,mhf,ar,mfms,thtk,mnag references 1. mcnally e, macleod h, dellefave-castillo l. arrhythmogenic right ventricular cardiomyopathy. 2005 apr 18 [updated 2017 may 25]. in: adam mp, ardinger hh, pagon ra, et al., editors. genereviews® [internet]. seattle (wa): university of washington, seattle; 1993-2021. 2. mckenna wj, thiene g, nava a, fontaliran f, blomstrom-lundqvist c, fontaine g, camerini f. diagnosis of arrhythmogenic right ventricular dysplasia/cardiomyopathy: task force of the working group myocardial and pericardial disease of the european society of cardiology and of the scientific  council on cardiomyopathies of the international society and federation of cardiology. br heart j. 1994; 71: 215–218. 3. cox mg, van der smagt jj, wilde aa, wiesfeld ac, atsma de, nelen mr, rodriguez lm, loh p, cramer mj, doevendans pa, van tintelen jp, de bakker jm, hauer rn. new ecg criteria in arrhythmogenic right ventricular dysplasia/cardiomyopathy. circ arrhythm electrophysiol. 2009 oct;2(5):524-30. 4. kayser hw, van der wall ee, sivananthan mu, plein s, bloomer tn, de roos a. diagnosis of arrhythmogenic right ventricular dysplasia: a review. radiographics. 2002;22:639–50. 5. hurst jw. naming of the waves in the ecg, with a brief account of their genesis. circulation. 1998 nov 3;98(18):1937-42. 6. liu,  t.,  pursnani,  a.,  sharma,  u.c.  et  al.  effect  of  the  2010  task  force  criteria  on  reclassification  of cardiovascular magnetic resonance criteria for arrhythmogenic right ventricular cardiomyopathy. j cardiovasc magn reson 16, 47 (2014). 7. garcía-niebla j, baranchuk a, bayés de luna a. epsilon wave in the 12-lead electrocardiogram: is its frequency underestimated? rev esp cardiol (engl ed). 2016 apr;69(4):438. 8. whitson, m.r., mayo, p.h. ultrasonography in the emergency department. crit care 20, 227 (2016). 9. marcus fi, fontaine gh, guiraudon g, frank r, laurenceau jl, malergue c, grosgogeat y circulation. 1982 feb; 65(2):384-98. 10. cismaru g, grosu a, istratoaie s, et al. transoesophageal and intracardiac ultrasound in arrhythmogenic right ventricular dysplasia/ cardiomyopathy: two case reports. medicine (baltimore). 2020;99(15):e19817. international journal of human and health sciences vol. 07 no. 02 april’23 122 original article: moringa oleifera extract decreases interleukin 6 levels and disease activity in rheumatoid arthritis patients nurhasan agung prabowo1, arief nurudhin2, yulyani werdiningsih,3, dikha dwi putra4, desy puspa putri5, retno widyastuti6 abstract moringa oleifera (mo) has anti-inflammatory, anti-arthritis, and immunosuppressant effects in rheumatoid arthritis (ra). this study aims to determine the effect of moringa oleifera extract on interleukin 6 levels and disease activity in ra. this research, with 30 patients, was divided into two groups: the intervention and the placebo. the intervention group received 40.50 mg/kg bw/day of moringa oleifera extract for one month. il-6 levels and sdai scores were measured before and after the treatment. paired t-test showed that il-6 levels (p=0.070) and sdai scores (p=0.142) before and after mo administration for the control group were not significantly different (p> 0.05). paired t-test il-6 (p=0.001) and sdai scores (p=0.001) before and after giving mo to the treatment group decreased significantly (p <0.05). independent t-test shows that the two changes, delta-il6 (p=0,008) and delta-sdai (p=0,017), are significantly different (p<0.05). moringa oleifera extract decreases il-6 levels and sdai scores in ra patients keywords: moringa oleifera, interleukin 6, sdai score, rheumatoid arthritis correspondence to: nurhasan agung prabowo, internal medicine department, faculty of medicine, universitas sebelas maret, ir sutami street no 36, kentingan, jebres, surakarta, indonesia, 57126, email: dr.nurhasan21@staff.uns.ac.id 1. nurhasan agung prabowo, faculty of medicine, universitas sebelas maret, ir sutami street no 36, kentingan, jebres, surakarta, indonesia, 57126 2. arief nurudhin, faculty of medicine, universitas sebelas maret, ir sutami street no 36, kentingan, jebres, surakarta, indonesia, 57126 3. yulyani werdiningsih, faculty of medicine, universitas sebelas maret, ir sutami street no 36, kentingan, jebres, surakarta, indonesia, 57126 4. dikha dwi putra, faculty of medicine, universitas sebelas maret, ir sutami street no 36, kentingan, jebres, surakarta, indonesia, 57126 5. desy puspa putri, faculty of medicine, universitas sebelas maret, ir sutami street no 36, kentingan, jebres, surakarta, indonesia, 57126 6. retno widyastuti, faculty of medicine, universitas islam sultan agung, kaligawe raya street, terboyo kulon, genuk, semarang, jawa tengah 50112 introduction rheumatoid arthritis (ra) is an autoimmune disease characterized by chronic and progressive systemic inflammation, in which the small joints of the hands and feet are the primary target. ra can also affect organs outside the joints, such as the skin, heart, lungs, and eyes. complications such as cardiovascular, infection, kidney disease, malignancy, and comorbidities can increase mortality in cases of ra (1). in indonesia, the prevalence and incidence of ra cases vary between populations. the epidemiological survey results in bandungan, central java, showed an ar prevalence of 0.3%. in malang, ar prevalence for people over 40 years of age was 0.5% in municipalities and 0.6% in regencies. in the rheumatology clinic of cipto mangunkusumo hospital, jakarta, in 2000, new cases of ar constituted 4.1% of all international journal of human and health sciences vol. 07 no. 02 april’23 doi: http://dx.doi.org/10.31344/ijhhs.v7i2.561 123 international journal of human and health sciences vol. 07 no. 02 april’23 new cases. in the rheumatology clinic of hasan sadikin hospital, 9% of all new rheumatism cases were found in 20002002 (2). the target for ra treatment is remission or a low degree of disease activity. research in indonesia showed ra remission using the sdai score reached 16.7% of patients. it is, therefore, urgent to find new therapies for ra (3,4). the simplified disease activity index (sdai) is a more straightforward tool than the disease activity score (das) to assess the degree of ar activity. das28 is not possible for every patient in outpatient rheumatology because it takes time and requires tools to calculate it. das28 is a tool primarily used for patients with clinical trial purposes only. compared with das28, which has a complex formula and requires a calculator for evaluation, sdai is much simpler and easier to evaluate without a calculator (5,6). the inflammatory process plays a significant role in the pathogenesis of ra. proinflammatory markers such as creactive protein (crp), interleukin-6 (il 6)(7) , tumor necrosis factor (tnf-α), and il-10 (8) were very high in synovial fluid and serum of ra patients. studies have shown that inflammatory markers such as hs-crp, il6, il10, and tnf-α were significantly increased in ra patients compared to controls and correlated with disease activity (9) . moringa oleifera (mo) is native to asia and africa. it has been known to have many bioactive components (10,11) . the most widely used bioactive components are the leaves, which are rich in vitamins, phenols, flavonoids, and isothiocyanates (11) . its leaves have higher bioactive components than its seeds or flowers. moreover, it leaves is easy to find and has been researched for so many times. mo leaves extract has been shown to inhibit the production of cytokines such as tumor necrosis factor alpha (tnf-α), interleukin-6 (il6), and interleukin-8 (il-8)(12) . moringa has immunosuppressant properties by reducing the number of cd4 t-lymphocytes (t-helper lymphocytes) by cell apoptotic pathways due to excessive calcium entry into cells. in addition, moringa oleifera will have an antiinflammatory effect by inhibiting nf. inhibition of nf will cause a decrease in proinflammatory cytokines il 6, il 1, and tnf, so tissue inflammation decreases (13) . moringa oleifera leaf extract has shown anti-inflammatory, antiarthritis, and immunosuppressant effects in mice with ra(14–16) . mo can suppress the production of proinflammatory cytokines such as tnf-α, il-1, and il-6 to relieve the inflammatory process(15,16) . this study aims to determine the effect of moringa oleifera extract on interleukin 6 levels and disease activity in rheumatoid arthritis patients. methods this study used a randomized controlled trial (rct) design with a total sample of 30 people divided into two groups: the treatment group and the control group. each group contains 15 research objects. this research was conducted in the outpatient clinic of dr. moewardi hospital in surakarta, indonesia. the inclusion criteria used were female patients aged 18-60 who met the ar criteria according to the acr / eular 2010 and vas> 3. while the exclusion criteria used were pregnant patients, or using methylprednisolone> 8 mg daily or using nsaids, or having comorbidities such as tuberculosis infection, diabetes mellitus, liver cirrhosis, malignancy, and chronic kidney disease. moringa leaves extract was obtained from dried and macerated leaves in distilled water (100 g in 2l), then evaporated to dryness in an oven for four days at 40oc. in previous studies on mice, it was found that moringa oleifera extract had an immunosuppressive effect at doses >200 mg/kg. researchers used a dose of 500 mg/kg in mice which were then converted to a dose for humans of 40.50 mg/kg bb/day for the treatment group, while the control group was given a placebo 12. the treatment group was given intervention in moringa oleifera extract, while the control group was given a placebo for one month. each research object will be measured to know the il-6 levels and sdai scores before and after the intervention. the prerequisite test used the normality test (shapiro-wilk) and the homogeneity test (levene’s test of homogeneity of variances), then continued with analysis using the paired t-test and independent t-test. if the normality test shows that the data distribution is not normal, then the data analysis test uses the wilcoxon and mannwhitney tests. result the number of samples was 30 people divided into two groups: the treatment group and the control international journal of human and health sciences vol. 07 no. 02 april’23 124 group. the results of the shapiro-wilk normality test showed that the research variables that had normal data distribution in both the control and mo treatment samples were delta_il6 and delta_sdai. table 1. description and normality testing of il_6 variable data and sdai score according to sample group and measurement period. control group treatment group variable description normality test description normality test mean sd s-w prob mean sd s-w prob. il-6_pre 182,09 51,89 0,797 0,003* 198,30 72,23 0,898 0,089 il-6_post 147,99 52,23 0,963 0,751 79,87 54,68 0,834 0,011* delta_il6 -34,09 67,23 0,913 0,152 118,43 92.11 0,943 0,426 skor sdai_pre 27,12 14,04 0,921 0,199 24,55 11,72 0,840 0,013 skor sdai_post 22,37 11,83 0,964 0,762 9,89 10,06 0,836 0,011* delta_sdai -4,75 11,82 0,890 0,068 -14,65 9,40 0,951 0,547 note: * data distribution is not normal; after the sample is combined, it becomes normal. the il-6_pre variable has an abnormal data distribution in the control sample group, but the data distribution in the mo treatment sample group is normal. while the il-6_post variable, sdai_pre score, and sdai_post score had normal data distribution in the control sample group, the mo treatment sample group had an abnormal distribution. after testing with all data or a combination of the control sample group and the mo treatment sample group, it turns out that the three variables are normally distributed. therefore, the independent t-test and paired t-test were used in this study. from table 2, it is found that the independent t-test results show the il-6 variable and sdai score for the control group and the mo treatment group in the conditions before given mo leaves extracts were not significantly different (p> 0.05). this means that this analysis begins with a homogeneous il-6 and sdai score in the two sample groups, namely the control group and the mo treatment group. table 2. comparison of il-6 and sdai scores in the control group and the mo treatment group in the conditions before given treatment. control mo treatment independent t test variable mean deviation std mean deviation std statistic score p value il-6 182,09 51,89 198,30 72,23 t = -0,706 0,486 skor sdai 27,12 14,04 24,55 11,72 t = 0,545 0,590 note: ** significant at the 1 percent degree of significance. * significant at the 5 percent level of significance. table 3. comparison of il-6 and sdai scores in the control group and the mo treatment group in conditions after given treatment. control mo treatment independent t test variable mean deviation std mean deviation std statistic score p value il-6 147,99 62,23 79,87 54,69 t = 3,185 0,004** skor sdai 22,37 11,83 9,89 10,06 t = 3,111 0,004** note: ** significant at the 1 percent degree of significance. * significant at the 5 percent level of significance. 125 international journal of human and health sciences vol. 07 no. 02 april’23 in addition, table 3 shows that the independent t-test results show the il-6 variable and sdai score for the control group and the mo treatment group in the conditions after giving mo leaves extract significantly different (p <0.05). this means that the il-6 and sdai scores were significantly different after the treatment period in the two sample groups, namely the control group and the mo treatment group. after the paired t-test, the results showed that the il-6 variable and sdai score were not significantly different before and after giving mo leaf extract to the control group (p> 0.05). this means that il-6 in the control group did not change before and after given mo leaves extract treatment. in addition, the paired t-test results showed that the il-6 variable and sdai score before and after giving mo leaf extract to the mo treatment group differed significantly (p> 0.05). this means that the iil-6 and sdai scores in the mo treatment group experienced changes before and after the mo leaves extract treatment or experienced a significant decrease after treatment was given. the results of the paired t-test on the delta-il6 and delta-sdai variables show that it was found that the two change variables (delta-il6 and delta-sdai) differed conclusively at the 5 percent significance degree (p <0.05). this condition indicates that the provision of mo leaves extract can impact reducing the il-6 variable and sdai score. discussion several previous studies have shown that moringa oleifera extract has anti-inflammatory, antiarthritis, and immunosuppressant effects in trials with mice(14–16). these effects are expected to suppress the inflammatory process and reduce the degree of disease activity in ra patients (14). in ra patients, there will be an increase in il-6 levels. this increase in il-6 levels indicates an increase in the severity of ra disease and vice versa(9,17). excessive ros production will cause oxidative stress, stimulating the active transcription factor nf-ĸb (nuclear factor kappa b)(18) as a marker of acute inflammation, increasing levels of oxidants expressing proinflammatory agents, including tnf-α. acute inflammation that is not appropriately handled, prolonged, and repeated will cause tissue necrosis (19). in this study, m. oleifera, known to have antiinflammatory, antioxidant, and immunomodulatory effects, was shown to lower il 6 levels and sdai scores in ra patients. this is in line with previous studies containing glucosinolates and isothiocyanates, has a strong effect on the international journal of human and health sciences vol. 07 no. 02 april’23 126 production of no (nitric oxide), can lower insulin, leptin, resistin, cholesterol, interleukin1ß (il-1ß), tumor necrosis factor-alpha (tnf), and glucose-6-phosphatase in diabetic rats, and based on the results of this study, it was concluded that isothiocyanate compounds might be the main bioactive ingredients that have anti-diabetic and anti-inflammatory effects. flavonoids, like quercetin, kaempferol glucoside, and flavonoid malfat, have anti-inflammatory effects by stopping lps macrophages from making no. many studies have shown that m. oleifera stops no, vegf, tnf, il-2, il-1ß, il6, glucose-6-phosphatase, insulin, leptin, resistin, and cholesterol from doing their jobs. the most common pathway, which is thought to be the prototypical proinflammatory signaling pathway, and the parent transcription factor(13) . studies have shown that the dose of moringa oleifera has two effects on cd4 t lymphocytes/t helper cells: low doses stimulate the immune system, while high doses slow down the immune system. the active ingredient in moringa leaf extract acts as an immunostimulant in the immune system, which is why the number of cd4+ t cells increases. saponins and flavonoids are two active substances that might work as immunostimulants. saponins and flavonoids may be able to make more of the cytokines that are needed for cd4+ t cell activity to come out. saponins and flavonoids help regulate helper t cells by causing them to make more of the cytokine interleukin 2 (il-2). cd4+ cells need the il-2 cytokine to change into the helper 2 (th2) and th1 t cell subsets. moringa leaf extract can also work as an immunosuppressant in addition to being an immunostimulant. this is shown by the fact that when high doses of moringa leaf extract were given, the number of cd4+ t cells went up less than when low doses were given. the most important effect of high doses of sle is that they cause immunosuppression by killing lymphocytes (13) . the results of data analysis in this study indicate that the treatment group given moringa oleifera extract showed a significant reduction in il-6. so, it can be concluded that moringa oleifera extract reduces or suppresses the inflammatory process. in addition, the treatment group that was given moringa oleifera extract also showed a significant decrease in sdai score, so it can be concluded that the administration of moringa oleifera extract has an effect in reducing the degree of activity of ra disease. the limitation of this study is that we did not record the drug patient. conclusions moringa oleifera extracts decrease il-6 levels and sdai scores in ra patients. further research is needed regarding using moringa oleifera extract in ra patients using different variables. it is necessary to monitor the risk of acute infection and the physical activity of the research subjects. conflicts of interest there are no conflicts to declare. ethical clearance this study received ethical approval from the health research ethics committee of moewardi hospital with ethical approval number 1278/xi/ hrec/2020. acknowledgments we acknowledge research assistants, laboratory staff at the faculty of medicine, and also research and community service institutes from universitas sebelas maret for their help and support for this research. authors’ contribution nurhasan agung prabowo, arief nurudhin, yulyani werdiningsi, dikha dwi putra, and desy puspa putri are the researcher and data analysts and all of us prepare the manuscript 127 international journal of human and health sciences vol. 07 no. 02 april’23 references 1. i nyoman suarjana. artritis reumatoid. in: buku ajar ilmu penyakit dalam. 6th ed. jakarta: interna publishing; 2014. p. 3130-40. 2. indonesia reumatologi association. rekomendasi perhimpunan reumatologi indonesia untuk diagnosis dan pengelolaan artritis reumatoid. jakarta: ira; 2021. 3. sun x, li r, cai y, al-herz a, lahiri m, choudhury mr, et al. clinical remission of rheumatoid arthritis in a multicenter real-world study in asia-pacific region. the lancet regional health western pacific. 2021 oct;15:100240. 4. prabowo na, adnan za, nurudhin a, werdiningsih y, prasetyo k. mesenchymal stem cell conditioned medium as good as methyl prednisolone in decreasing levels of interleukin 10 and the degree of pulmonary vasculitis in lupus mice. bangladesh j med sci. 2021 feb 1;20(2):426–30. 5. salafi f, ciapetti a. clinical disease activity assessments in rheumatoid arthritis. international journal of clinical rheumatology. 2013 jun;8(3):347– 60. 6. sharma r, thakare m, thomas j, agrawal s, rajasekhar l, narsimulu g. simplified disease activity index as an index of disease activity in patients with rheumatoid arthritis: a comparison with das28. indian journal of rheumatology. 2009 mar;4(1):11–4. 7. prabowo na, setyaningrum rh, apriningsih h. interleukin 6 associated with adrenal insufficiency in covid-19 patient. 2022;4. 8. prabowo na, apriningsih h. colchicine reduces inflammation in covid-19 patients. iop conf ser: earth environ sci. 2021 jul 1;824(1):012087. 9. shrivastava ak, singh hv, raizada a, singh sk, pandey a, singh n, et al. inflammatory markers in patients with rheumatoid arthritis. allergologia et immunopathologia. 2015 jan;43(1):81–7. 10. padayachee b, baijnath h. an overview of the medicinal importance of moringaceae. :9. 11. saini rk, manoj p, shetty np, srinivasan k, giridhar p. relative bioavailability of folate from the traditional food plant moringa oleifera l. as evaluated in a rat model. j food sci technol. 2016 jan;53(1):511–20. 12. kooltheat n, sranujit r, chumark p, potup p, laytragoon-lewin n, usuwanthim k. an ethyl acetate fraction of moringa oleifera lam. inhibits human macrophage cytokine production induced by cigarette smoke. nutrients. 2014 feb 18;6(2):697– 710. 13. nurudhin a, widyastuti r, prabowo na, adnan za, werdiningsih y. the effect of mmoringaoleifera leaf extract on mean platelet volume and neutrophil to lymphocyte ratio in lupus. bangladesh j med sci. 2021 jan 1;20(1):68–73. 14. fatima n, fatima sj. pharmacological screening for anti-arthritic activity of moringa oleifera. 2016;9(3):6. 15. mahajan sg, mali rg, mehta aa. protective effect of ethanolic extract of seeds of moringa oleifera lam. against inflammation associated with development of arthritis in rats. journal of immunotoxicology. 2007 jan;4(1):39–47. 16. fard m, arulselvan p, karthivashan g, adam s, fakurazi s. bioactive extract from moringa oleifera inhibits the proinflammatory mediators in lipopolysaccharide-stimulated macrophages. phcog mag. 2015;11(44):556. 17. orr ck, najm a, young f, mcgarry t, biniecka m, fearon u, et al. the utility and limitations of crp, esr and das28-crp in appraising disease activity in rheumatoid arthritis. front med. 2018 aug 3;5:185. 18. prabowo na, myrtha r, apriningsih h. lupus flares in covid-19 patients: a case report. 2022;3. 19. widi wardani at, purwanto b, donoindarto -, wasita b, cilmiaty ar r. effect of moringa leaf ethanol extract on reduced levels of mda, tnf-α and description of inflammatory cells in rat sinus mucosa model of acute rhinosinusitis. bangladesh j med sci. 2022 feb 25;21(2):311–7. 351 international journal of human and health sciences vol. 06 no. 04 october’22 editorial: students’ elective in undergraduate medical education and reflective writing as method of assessment salam a1, zainol j2 keywords: elective course, medical education, reflective skills, assessment method. correspondence to: dr abdus salam, associate professor and head of medical education unit and community medicine unit, faculty of medicine, widad university college, bandar indera mahkota, 25200 kuantan, pahang, malaysia. email: abdussalam.dr@gmail.com orcid id: https://orcid. org/0000-0003-0266-9747 1. abdus salam, medical education unit and community medicine unit, faculty of medicine, widad university college, kuantan, malaysia. 2. jamaludin zainol, surgery unit and dean faculty of medicine, and deputy vice-chancellor (academic and internationalisation), widad university college, malaysia. in modern medical education, there is growing importance to include the elective program in the undergraduate medical curriculum1. electives are the curricular contents that students choose freely as apart of their training2. these courses are designed to prepare the students for their future careers by increasing professional opportunities3. elective courses allow students to have varied learning experiences outside the fixed curriculum. it permits inter-professional education, enhances students’ interest and motivation in the program as they can choose according to their choice, feel more responsible and build personal skills. also, electives complement the core curriculum as students can select according to their interests and need1,2. this paper briefly describes the kind of activities offered for students’electives, how to plan and implement them successfully and how to assess, especially by reflective writing skills, as method of assessment aimed at conducting a sustainable, effective elective program in undergraduate medical education. the kinds of educational activity offered for electives range from meeting individual educational needs to the exploration of likely career pathways, with many factors influencing choice4. in the united states, electives range from courses like ethics, leadership, health policy, and foreign language to speciality-specific electives5. short elective courses generally cover the fields of education, research, community postings, or other speciality-specific courses like laboratory electives, palliative care, neurology, emergency medicine, surgery, radiology, primary care, etc.3,5. in designing an elective, based on situation analysis and considering the available resources, the organizer should clearly spell out the specific learning outcomes of the electives. students should have a clear understanding of the name of coordinating faculty, supervising faculty, mentoring faculty, details of students allowed to join the course, the duration of course, time tabling of the sessions, assessment procedures, resource materials or support services available and prerequisites for joining the elective3,6,7. the time assigned for electives should not be utilized to cover any shortage in their other courses3. all students should know about the content areas covered, including those which might require partnership from neighbouring or international institutions or agencies,3,4,6,8,9. practicalities such as travel, accommodation, as well as risk management of the student and their elective supervisors also need to be addressed where necessary4. the elective course lays down the foundation for the students to become self-directed learners, as these courses are opted by the students on their own3,4. assessment method teaching and assessment are the two sides of the same coin10. students’ electives need to be assessed toward the end of the course aimed to judge international journal of human and health sciences vol. 06 no. 04 october’22 page : 351-354 doi: http://dx.doi.org/10.31344/ijhhs.v6i4.472 international journal of human and health sciences vol. 06 no. 04 october’22 352 whether they have met their intended learning outcomes. assessment of elective scan be done either by measuring the percentage of attendance or completion of a logbook or the submission of a project work or evidence for learning or any assignment -namely presentation in a seminar or in a conference, or recording the reflections on learning3,4,9.the reflections on learning or reflective writing make the learning deeper and predicts critical thinking3. reflective writing reflective writing is considered an essential component for the assessment of elective courses in modern medical education11 as reflection promotes critical thinking of the students.there are various formats or tools for writing reflection. one such format comprised of three parts: (1) descriptive reflection, (2) dialogic/analytic reflection and (3) critical reflection. descriptive reflection is characterized by a description of actions or events. dialogic/analytic reflection demonstrates a “stepping back’ from the actions or events, leading to discourse with self and exploring the possible alternative and possible hypothesis. critical reflection demonstrates the analysis of actions or events as well as explores the various perspectives about the events influenced by various socio-political and historical contexts11. another format of reflective writing comprised of six parts12, which are writing of: (1) description of the event about what happened, (2) feelings about the event, (3) evaluation, -what was good and bad about the event/experience (4) analysis of what sense make about the event /situation (5) conclusion drawn in general and specifically, (6) action plan about what will be done if it rose again in future.12 another format is the 4rs model of reflective writing skills13, which are: (1) reporting and responding, (2) relating, (3) reasoning, and (4) reconstructing13. the organiser needs to decide on one format. implementation of elective the key areas for sustaining a successful implementation of an elective program, the organiser should ensure that the following things have been considered before during and after elective placement4,14. before elective choose personal learning outcomes before going to elective placement, students need to set their own personal learning outcomes, which will be included in their elective plan. learning outcomes should be smart, an acronym of s=specific, m=measurable, a=attainable, r=relevant and t=timely. an example of a smart personal learning outcome is: “while on my elective placement, i will participate in the postpartum nursing care of a mother who has given birth naturally and a mother who has had a caesarean, in order to better understand their contrasting needs14. choose group learning outcomes if students work with a group, they need to select group learning outcomes together, which arerelated to cultural competency. this will empower them to expand their cultural competencies, such as supporting one another as peers, developing group management, teamwork and public speaking skills etc. choose an elective placement that is best suited to achieve learning outcomes when choosing an elective placement, students need to think judiciously about what type of placement would best suit the learning outcomes that they have set. learning outcomes should dictate where they choose to go for their elective placement. students need to decide how to organise and prepare for their elective placement, how to achieve their learning outcomes, how their outcomes will be assessed, and what support services available. during elective while on placement, students must need to create and collect evidence of their activities to show how they meet their learning outcomes. the evidences may be: (i) written reflections (ii) photographs (iii) videos (iv) audio recordings etc. students must ensure that they follow the guidelines on confidentiality, consent and copyright etc.while collecting evidence. after elective teaching without ‘testing’ is somewhat cooking without ‘tasting’15.students’ electives need to be tested, and students need to show evidence of how they have achieved their learning outcomes. reflective writing is the most commonly used tool as evidence because it makes the learning deeper and predicts critical thinking3. there is no word limit of reflective writing, but the amount of time they spend on creating their evidence should be equivalent to the amount of time they would spend on a 2000-word essay14. this will be part of their 353 international journal of human and health sciences vol. 06 no. 04 october’22 assessment and will be graded by their mentor / facilitator. support study showed that monitoring the elective course is a crucial element for its success which is opposed to the tendency to keep electives untouched1.students have to be supported by a member of staff –a mentor to facilitate electives throughout the process. medical teachers play the role of mentoring, one of the twelve important roles described by harden 16. mentors can guide the students or mentees under them during their elective posting17. this is extra work for the mentors’/course coordinators to handle the elective course, including the assessment2. during mentoring it is important to assess the knowledge or how much students or mentees grasped from what has been told and explained about activities on elective by the mentor18. mentors play a great role in helping their mentees to reflect on their experiences and learning from elective placement, considering a standard format of reflective writing agreed upon by the faculty or organiser. effective communication between mentor and mentee is important to guide the students17, 19. there is space for faculty development, as faculty need to pay more attention to improving student competency20. conclusion an elective is an outstandingopportunity to take responsibility for students’ own learning and prepare themselves for their future careers by increasing professional opportunities through experiencing things in a different kind of environment. before starting an elective, students need to identify their (i) personal learning outcomes that they would like to achieve from their undertaking elective opportunity (ii) elective placement which would be the best place for them to achieve the personal learning outcome (iii) evidence of their experiences to show the mentor for assessment purpose. the implementation of an effective elective course in an institution principally requires faculty development, and thus they should be briefed about the different aspects of the elective course and the need for the same in the current era. this paper offers medical schools, faculty and elective students a window or a guide to implement and assess a sustainable, effective elective program in undergraduate medical education. funding no funding was received for this paper. conflict of interest the author declared no conflicts of interest. authors’ contribution both authors participated well in preparing this paper and approved the final version for submission to the journal for publication. international journal of human and health sciences vol. 06 no. 04 october’22 354 references: 1. ramalho ar, vieira-marques pm, magalhaes-alves c, severo m, ferreira ma, falcao-pires i. electives in the medical curriculuman opportunity to achieve students’ satisfaction? bmc med educ. 2020; 20:440. https://doi.org/10.1186/s12909-020-02269-0 2. mahajan r, singh t. electives in undergraduate health professions training: opportunities and utility. medical journal armed forces india 2021; 77:s12-s15. 3. shrivastava sr, shrivastava ps. introducing electives in the undergraduate medical training period: points to ponder. j sci soc 2021;48(1):52-53. 4. lumb a, murdoch-eaton d. electives in undergraduate medical education: amee guide no. 88. med teach2014;36:557-72. 5. agarwal a, wong s, sarfaty s, devaiah a, hirsch ae. elective courses for medical students during the preclinical curriculum: a systematic review and evaluation. med educ online 2015; 11;20:26615. doi: 10.3402/meo.v20.26615. 6. suzuki t, nishigori h. national survey of international electives for global health in undergraduate medical education in japan, 2011-2014. nagoya j med sci2018;80:79-90. 7. nordhues hc, bashir mu, merry sp, sawatsky ap. graduate medical education competencies for international health electives: a qualitative study. med teach2017;39:1128-37. 8. ehn s, agardh a, holmer h, krantz g, hagander l. global health education in swedish medical schools. scand j public health2015;43:687-93 9. comeaux z. international health electives: strengthening graduate medical education. j am osteopath assoc2013;113:446-7. 10. salam a, yousuf r, allhiani rf, zainol j. continuous assessment in undergraduate medical education towards objectivity and standardization. international journal of human and health sciences 2022;06(03):233-236. doi: http://dx.doi. org/10.31344/ijhhs.v6i3.453 11. donohoe a, guerandel a, o’neill gm, malone k, campion dm. reflective writing in undergraduate medical education: a qualitative review from the field of psychiatry. cogent education 2022; 9:1, 2107293. doi: 10.1080/2331186x.2022.2107293 12. reflective writing structure (westernsydney.edu.au). adapted from western sydney university school of nursing and midwifery (2016, pp. 70-72. retrieved from: https://www.westernsydney.edu.au/__data/ assets/pdf_file/0007/1082779/reflective_writing_ structure.pdf accessed date: 1st september 2022. 13. ryan m, and ryan m. altc project: developing a systematic, cross-faculty approach to teaching and assessing reflection in higher education: final report. 2012. retrieved from:https://www.westernsydney. e du.a u/__da ta /a sse ts/pdf_file /0007/1082779/ reflective_writing_structure.pdf accessed date: 1st september 2022. 14. elective placements, school of health sciences www.nottingham.ac.uk/healthsciences electiveplacementsnotingham.pdf retrieved from: file:///d:/electives%20in%20ug%20med%20 e d / e l e c t i v e p l a c e m e n t s % 2 0 n o t i n g h a m . p d f accessed date: 1st september 2022. 15. zainol j, salam a. an audit on mentor-mentee program: mentees perceptions on mentors. bangladesh journal of medical science 2021; 20(04): 840-847. doi: https://doi.org/10.3329/bjms. v20i4.54143 16. harden rm, crosby rmhj. amee guide no 20: the good teacher is more than a lecturer the twelve roles of the teacher. med teach. 2009;22:334–347. doi: 10.1080/014215900409429. 17. salam a, begum h, zakaria h, allaw baq, han t, algantri kr, mofta ag, elmahi meb, mohamed eme, elkhalifa maa, zainol j. core values of professionalism among fresh medical graduates in a malaysian private university. international journal of human and health sciences 2021; 05(04):463472 doi. http://dx.doi.org/10.31344/ijhhs.v5i4.358 18. salam a. tea to entertain outcome based education for 21st century educators to produce safe human capitals for a sustainable global development. international journal of human and health sciences 2022; 06(02):153-154 doi.http:// dx.doi.org/10.31344/ijhhs.v6i2.437 19. salam a, zakaria h, abdelhalim at, choon lc, alsharkawy a, taibi mkbm, satwi s, hassan km, zainol j. communication skills of fresh medical graduates in a malaysian private university. bangladesh journal of medical science 2022; 21(02):404-412. doi: http://doi.org/10.3329/bjms. v21i2.58074 20. salam a, allaw baq, begum h, abdelhalim at, alsharkawy a, hassan km, satwi s, zainol j. audit on clinical competency of fresh medical graduates in a malaysian private university using kirkpatrick level-1 evaluation model. education in medicine journal 2021;13(4): 57–70. https://doi.org/10.21315/ eimj2021.13.4.5 international journal of human and health sciences vol. 06 no. 03 july’22 280 original article foot self-care behaviours and the level of perceived risk of amputation in type 2 diabetes havva sert1, feride taşkın yılmaz2, azime karakoc kumsar3, fatma can öztürk4 abstract background: diabetic foot which is one of the complications of diabetes may develop in parallel with the frequency of diabetes. objective: to determine the factors affecting foot self-care behaviours and amputation risk perception levels in individuals with type 2 diabetes. methods: the descriptive and correlational study included 157 individuals who had been diagnosed with type 2 diabetes for at least six months and had no previous diabetic foot and previous amputation history. the data were obtained by using patient diagnosis form, foot self-care behaviour scale and perceived risk of amputation evaluation form. results: the total score of the participants from the foot self-care behaviour scale was found to be below the mean value (37.95±8.93). it was determined that individuals, who had the disease for more than ten years and were informed on the disease, foot health and care by physician or nurse, had better foot care behaviours (p<0.05). the average amputation risk perception evaluation score was found to be very low (4.87±10.08) and 61.8% stated that they had no risk for amputation. in addition, no significant difference was found between the glycemic control parameters and the amputation risk perception levels of the individuals (p>0.05). conclusion: it was determined that the individuals did not have good foot self-care behaviours, that disease duration and being informed on foot self-care affected foot self-care behaviours and that their amputation risk perception level was very low. keywords: amputation, diabetic foot, type 2 diabetes, risk perception, self-care correspondence to: feride taşkın yılmaz, associate professor, faculty of health sciences, sakarya university of applied sciences, sakarya, turkey. tel: +902646160530, email: feride_taskin@hotmail.com 1. assistant professor, faculty of health sciences, department of internal diseases nursing, sakarya university, sakarya, turkey 2. associate professor, faculty of health sciences, sakarya university of applied sciences, sakarya, turkey 3. assistant professor, faculty of health sciences, department of internal disease nursing, biruni university, istanbul, turkey 4. diabetes nurse, sakarya toyotasa emergency aid hospital, sakarya, turkey international journal of human and health sciences vol. 06 no. 03 july’22 page : 280-288 doi: http://dx.doi.org/10.31344/ijhhs.v6i3.459 introduction diabetes is a chronic metabolic disorder requiring constant medical care in which the organism cannot make sufficient use of carbohydrates, fats and proteins due to insulin deficiency or defects in insulin action.1 according to 2019 data, there are 463 million diabetics around the world between the ages of 20-79 and it is predicted that this number will increase to 700 million in 2045. it is also estimated that about half (49.7%) of all people living with diabetes are undiagnosed.2,3 in turkey, it is stated that the prevalence of diabetes ranges between 17.3 and 12.3%.4 increasing in parallel with the incidence of diabetes, diabetic foot, as one of the leading complications of diabetes, is characterized by peripheral neuropathy, by peripheral vascular disease that leads to the loss of protective sensation as a result of long-term high blood glucose levels, or by the combination of both that results in deterioration of skin functions.5-7 it is a clinical condition that can cause ulceration in further stages. diabetic foot development in diabetic individuals not only prolongs hospitalization and recovery process, but also causes high rate lower extremity amputations, an important increase 281 international journal of human and health sciences vol. 06 no. 03 july’22 in treatment cost, deterioration in quality of life and an increase in mortality rate.1,5-12 moreover, diabetic foot may have negative effects on daily activities of the individuals and cause difficulties in work environment due to walking problems, loss of labour force, restriction in social activities and psychosocial trauma.13 despite the treatment methods and educational programs developed in the literature, it is reported that approximately 15-25% of all diabetic individuals have a risk of developing diabetic foot during their lifetime5,9-11 and 60-70% of the individuals with diabetic foot are exposed to lower extremity amputation;14 an amputation due to a diabetic foot complication is performed in the world every 30 seconds15 and the risk of death increases approximately 2.5 times in people with diabetes who have new ulcer in the foot.1 the presence of peripheral vascular disease, peripheral neuropathy, previous ulceration, long duration of diabetes, poor glycaemic control, fungal infections of the foot and the inability to self-examine the feet are among the important risk factors in diabetic foot development.16 the essential purpose of the prevention of diabetic foot development is to provide primary protection. for this, it is necessary to identify individuals under risk, to teach how to examine the foot from the moment the patient is diagnosed, and to develop and evaluate preventive health behaviours.15 in addition to regular diabetic foot risk assessment performed with patient and healthcare worker training; diabetic foot problems and amputations can be significantly reduced and prevented by applying protective foot self-care behaviours such as daily self-examination and protection of the feet from injuries.5-7,9,10,17,18 however, in literature, it is observed that the behaviours of diabetic individuals regarding foot self-care are insufficient.14,15,19 in order to prevent the development of diabetic foot, which is a preventable complication, the nurse has an important role inhelping patients gain preventive foot self-carebehaviours through regular monitoring and training as from the diagnosis of diabetes.20 risk perception is important in preventing the development of complications in people with diabetes.21,22 in literature, risk perception is defined as the subjective judgementthat people make about the characteristics and severity of a risk.23 high level and accurate risk perception can affect individuals’ willingness to take protective behaviours,24 and promote a healthy lifestyle such as healthy nutrition and adequate physical activity.25 motivation in foot self-care behaviour in individuals with diabetes can also be affected by risk perception.26 in this context, it is necessary to measure the perceived risk in order to detect false perceptions that will adversely affect treatment or self-care practices.6,27 when the literature is examined, it is seen that in turkey, there are studies to determine the general situation related to diabetic foot care,11,12,15,28 but there are limited number of studies searching the risk perception of individuals towards diabetic foot development. evaluation of foot self-care behaviours and perceived risk of amputation in diabetic individuals will contribute significantly to creating awareness about diabetic foot and to guide health professionals in preventing it. methods this descriptive research carried out to determine foot self-care behaviours, affecting factors, and the level of perceived risk of amputation in type 2 diabetes. the population of the study consisted of patients diagnosed with type 2 diabetes who applied to toyotasa emergency hospital diabetes policlinic in turkey between february and may of 2019. in this regard, 157 individuals diagnosed with type 2 diabetes for at least 6 months whowere 18 or older, had no diabetic foot development, hadno previous diabetic foot history, did not have an amputation due to diabetes, did not have a verbal communication barrier andagreed to participate in the research were included in the study. the data were obtained by using patient diagnosis form, foot self-care behaviour scale and perceived risk of amputation evaluation form. patient diagnosis form consists of three sections. in the first part of the form, there are 10 questions that assess the socio-demographic characteristics of individuals and the habit of smoking and drinking alcohol. in the second part of the form, there are 12 statements including individuals’ disease information the third part of the form consists of two questions that assess individuals’ glycaemic indicators. the glycaemic control parameters of the individuals were obtained from the laboratory results requested by the physician during the application to the outpatient clinic. foot self-care behaviour scale was first created by borges as foot care observation guide in 2007 in order to improve foot self-care behaviours international journal of human and health sciences vol. 06 no. 03 july’22 282 in diabetes.29 the validity and reliability study of the turkish version of the scale was conducted by biçer and enç.30 the 5-point likert scale is scored according to the agree-disagree status and consists of 15 items. the lowest score that can be obtained from the scale evaluating foot self-care behaviour as a single dimension is 15 while the highest score is 75. the increase in the scale score indicates that the individual’s foot self-care behaviours are better.30 in the study, cronbach’s alpha of the scale was found as 0.83. perceived risk of amputation evaluation form consists of two items. the first item assesses individuals’ risk of diabetes-related amputation. the evaluation was made with visual analogue scale and it ranges between “0 = no risk” and “100 = very high risk”. individuals were asked to mark in the 0-100 range for the perceived risk of amputation. the second question of the form assesses the level of fear individuals experience against diabetes-related amputation risk. before collecting the data, the form was evaluated for clarity by three faculty members including a diabetes specialist and two nurses. after the arrangement of the form in line with expert opinions, a pilot study was conducted with 20 diabetes patient. as a result of this study, the data collection tool was given its final form in line with the feedback received and evaluated for clarity. the data are interpreted in spss 22.0 package program. socio-demographic and disease-related characteristics of individuals with diabetes and foot self-care behaviour scale mean score were assessed with percentage and average test; the relationship between socio-demographic and disease characteristics and foot self-care behaviour scale mean score was determined by student’s t-test, one-way anova, mann-whitney u test and kruskal-wallis h test; the relationship between hba1c and levels of perceived risk of amputation was evaluated by chi square test. in statistical evaluation, significance was accepted as p<0.05. results the mean age of the individuals included in the study was 59.06±9.11 years (min = 37, max = 77), 64.3% were women, 82.2% were married and 65.6% were primary school graduates. 80.3% of the participants did not have an occupation and 85.4% considered their economic status as at medium level. 11.5% of the participants of whom almost all benefit from social security (98.7%), lived alone, 19.7% were still smoking and 1.2% used alcohol. disease-related characteristics of individuals are presented in table 1. it was determined that only 8.9% of individuals with type 2 diabetes received training on foot health and care from a physician or nurse, 93.6% applied to the physician for a foot ulcer and 6.4% self-managed the wound. it was stated that the fasting blood glucose and hba1c values of individuals with type 2 diabetes were above the target value (80-130 mg/dl and hba1c <7%) accepted by the international diabetes consensus group (3); especially 64.8% of them were found to be under risk in terms of developing complications related to diabetes (table 2). when the distribution of the foot self-care behaviour scale score averages of individuals with type 2 diabetes were examined, it was determined that the mean score was 37.95±8.93.in addition, individuals had the highest mean score (3.69±0.85) for the expression “i wear socks that are not too tight or not too wide but fit my feet,”, yet the lowest mean score for the expression “i do not use sharp tools (razor, scissors etc.) for foot care” (1.42±0.93) (table 3). when some sociodemographic and disease characteristics of the individuals and the foot selfcare behaviour scale mean score were compared in the study, it was identified that there was no statistically significant difference between age, gender, education, employment status, presence of other chronic diseases and foot self-care behaviour level (p>0.05). however, in the study, it was found that individuals with a disease duration of more than 10 years and those who received information about the disease, foot health and care from a physician or a nurse, had better foot selfcare behaviours (p<0.05) (table 4). it was found that diabetic individuals’ risk assessment mean score for amputation was quite low (4.87±10.08). although 61.8% of the individuals stated that they did not have any risk of amputation, 45.2% of them were found to have a moderate level of fear and 19.1% had a high level of fear of amputation (table 5). when the glycaemic control parameters and the levels of perceived risk of amputation of individuals with type 2 diabetes were compared 283 international journal of human and health sciences vol. 06 no. 03 july’22 in the study, no statistically significant difference was obtained (p>0.05) (table 6). table 1. disease-related characteristics of individuals with diabetes characteristics n % disease duration (year) (m±sd) 8.40±7.17 (min=1, max=35) type of the treatment oral antidiabetic therapy 95 60.5 oral antidiabetic and insulin therapy 48 30.6 insulin therapy 14 8.9 regular use of medications yes 42 26.8 partially 90 57.3 no 25 15.9 following the diet yes 12 7.6 partially 61 38.9 no 84 53.5 regular exercise (walking etc. for at least 20 minutes every day) yes 10 6.4 partially 32 20.4 no 115 73.2 presence of diabetes-related chronic complications *yes 108 68.7 retinopathy 14 8.9 nephropathy 10 6.4 neuropathy 97 61.8 hypertension 84 53.5 no 49 31.3 the frequency of hospitalization due to diabetes or its complications in the past year never 126 80.3 once 26 16.6 two or three times 5 3.1 education received from a physician or a nurse about the disease yes 39 24.8 no 118 75.2 education received about foot health yes 14 8.9 no 143 91.1 presence of other chronic diseases yes 98 62.4 no 59 37.6 general health assessment good 46 29.3 average 92 58.6 bad 19 12.1 *the number n varies. table 2. distribution of glycaemic control parameters of individuals with type 2 diabetes glycaemic control parameters min-max m ± sd n % fasting blood glucose (mg/dl) 89-564 200.71±81.88 hba1c 5.20-15.90 9.14±2.43 ≤7 35 22.3 7-9 48 30.6 >9 74 47.1 table 3. distribution of foot self-care behaviour scale mean score of individuals with type 2 diabetes foot self-care behaviour scale m±sd 1. i check the temperature of the water i wash my foot. 1.66±1.05 2.i dry between my toes after washing my foot. 1.90±1.35 3. i use moisturizing cream for my feet. 1.80±0.98 4. i do not apply cream between the toes. 1.43±0.96 5. i cut my toenails straight. 2.32±1.44 6. i check my nails for thickening, ingrown toenail and length. 2.81±1.04 7. i check if there are peeling, fungus and claw toes due to the moist between the fingers. 2.59±0.97 8. i check under my feet for calluses, redness, blister or open wounds. 2.57±1.02 9. i check the inside of the shoes for foreign objects such as nails, dust, stones. 2.73±1.46 10. i don’t walk anywhere barefoot (for example: at home, on the street, at the beach). 2.59±1.10 11. i wear shoes that fully grasp my feet, suitable for width, length and height. 3.37±1.00 12. i wear soft leather shoes with smooth inner surface. 3.31±1.00 13. i wear clean, cotton and soft socks. 3.68±0.84 14. i wear socks that are not too tight or not too wide but fit my feet. 3.69±0.85 15. i do not use sharp tools for foot care (razor, scissors etc.). 1.42±0.93 total score 37.95±8.93 international journal of human and health sciences vol. 06 no. 03 july’22 284 table 4. the comparison of some sociodemographic and disease characteristics of the individuals with type 2 diabetes and foot self-care behaviour scale mean score characteristics n % foot self-care behaviour scale test, significance age 36-64 years 107 68.2 38.30±9.43 t=0.723 p=0.470 65 years and above 50 50 37.20±7.76 gender female 101 64.3 38.45±9.07 t=0.942 =0.348 male 56 35.7 37.05±8.67 education illiterate 15 9.6 39.26±7.06 kw=4.926 p=0.085 elementary 103 65.6 36.93±8.56 secondary and higher 39 24.8 40.15±10.10 employment status works 31 19.7 36.93±7.99 t=-0.709 p=0.480does not work 126 80.3 38.20±9.15 presence of other chronic diseases yes 98 62.4 37.34±8.64 t=-1.101 p=0.273no 59 37.6 38.96±9.37 disease duration 6 months5 years 70 44.6 36.75±7.59 f=6.042 p=0.003** 6-10 years 44 28.0 36.06±7.41 11 years and above 43 27.4 41.83±11.11 education received from a physician or a nurse about the disease yes 39 24.8 42.58±10.84 t=3.905 p=0.000**no 118 75.2 36.42±7.65 training received from a physician or a nurse on foot health and care yes 14 8.9 43.85±11.75 z=-2.040 p=0.049*no 143 91.1 37.37±8.43 *p<0.05; **p<0.01 table 5. distribution of the level of perceived risk of amputation in individuals with type 2 diabetes parameters n % min-max m ± sd level of perceived risk of amputation 0-95 4.87±10.08 no risk (0 points) 97 61.8 risk at 1-10 points level 44 28.0 risk at 11-95 points level 16 10.2 level of fear of amputation i am not afraid 3 1.9 i am slightly afraid 53 33.8 i am moderately afraid 71 45.2 i am extremely afraid 30 19.1 285 international journal of human and health sciences vol. 06 no. 03 july’22 table 6. the relationship between the glycaemic control parameters and levels of perceived risk of amputation of individuals with type 2 diabetes hba1c value level of perceived risk of amputation test, significance0 points n (97) 1-10 points n (44) 11-95 points n (16) ≤%7 26 (74.3) 7 (20.0) 2 (5.7) x2=3.502 p=0.478 %7.1-9 29 (60.4) 8 (10.8) 6 (12.5) >%9 42 (56.8) 24 (32.4) 8 (10.8) discussion due to the increase in the number of individuals with diabetes, studies on preventing and reducing other complications, especially diabetic foot, are gaining importance. the findings of the study conducted to determine the foot self-care behaviours, the factors affecting these behaviours and the level of perceived risk of amputation in individuals with type 2 diabetes, were compared and discussed in line with the literature. as with other diabetic complications, it is very important to maintain glycaemic control in the prevention of diabetic foot, that is, to keep the hba1c value at the desired level. because, with strict glycaemic control (hba1c <7%), the risk of amputation can be reduced by 35%.3 in the study, it was determined that the hba1c values of individuals were above the target value and approximately two-thirds of them were under risk in terms of developing complications related to diabetes. in other studies examining foot self-care behaviours in individuals with diabetes, the rate of individuals whose hba1c value was above the target value was found to be 47.3-100%.5,10,11 in a comparative study carried out with amputated and non-amputated individuals, the hba1c value of the amputated individuals was found to be significantly higher.31 the study finding shows that individuals with diabetes do not have good glycaemic control and it draw attention to the risk of amputation increasing along with poor glycaemic control. patient education, which is an important element of effective diabetes management in diabetic individuals, provides a significant improvement in knowledge, skills and self-care behaviours. foot self-care training is also part of general diabetes management.32 in the study, it was determined that only 8.9% of the individuals received training on foot health and care from a physician or a nurse. in other studies, the rate of diabetic individuals who received training on foot health and care was found to be quite low (8.5-18.4%).12,15 the findings of the study suggest that the educational step towards preventing diabetic foot development may have been omitted or may have been underestimated by the sick individual. poor foot self-care practices in individuals with diabetes are the most important risk factor for diabetic foot development.10 in the study, it was clear that the total score of the individuals obtained from the foot self-care behaviour scale was lower than the average value, and the individuals’ foot self-care behaviours were not good. although the study finding is lower than the work of biçer and enç (51.67±10.51),20 it is in parallel with other studies.14 in other studies, it was found that only 6-17% of the individuals have good foot self-care behaviours.8,10,15,17,19 in studies conducted in south india and malaysia, it was stated that more than one third of the participants had good foot selfcare behaviours.18,33 foot self-care behaviours, including daily foot examination, observation of the changes in skin integrity, hygiene and appropriate footwear selection, help minimize foot complications.28,34 in the study, it was determined that individuals mostly comply with the behaviour of wearing socks that are not too tight or not too wide but fit the feet, and they comply with the behaviour of not using sharp tools for foot care least.in addition, individuals’ control level of under feet in terms of calluses, redness, blister or open wounds was found to be moderate. the findings of the study are in line with the literature.11,12,28 in the study of lamchahab et al, it was found that 29% of individuals use sharp tools while cutting the toenail, 50% never dry their feet, 58% wear tight socks and 35.5% wear unsuitable shoes.35 khamseh et al, stated that culture plays an important role in complying with foot care advice, and in this study, it was determined that muslim individuals do not control international journal of human and health sciences vol. 06 no. 03 july’22 286 their feet carefully although they wash their feet on average three to five times a day.36 in a study conducted in pakistan, individuals’ foot self-care behaviour was found to be quite low; the rate of those who dried their feet after washing was 28%, the rate of those wearing suitable shoes was 21.3% and the rate of those who examined their feet once a day was 35.3%.17 the study finding shows that individuals need training in foot selfcare. however, we know that one of the steps of diabetes education is foot health. nevertheless, the lack of foot self-care behaviours at the desired level supports the fact that there is not enough attitude towards this direction. for this reason, it is recommended to try new training methods to develop attitudes towards foot self-care and turn them into behaviours. in the study it was found that individuals with a disease duration of more than 10 years and those who received information about the disease, foot health and care from a physician or a nurse, were better in foot self-care behaviours; however, it was determined that age, gender, education, employment status and presence of other chronic diseases did not affect foot self-care behaviour. in some studies, it was found that sociodemographic characteristics were not related to foot self-care behaviours.12,17-19 however, in similar studies it was identified that, individuals under the age of 60,10 individuals with higher education,8.10,15,19,35,36 individuals with diabetes duration of 1-5 years and 16 years and more,15 and individuals who received information about diabetic foot care from healthcare professionals previously had better foot self-care behaviours.8,15,17,19,33 it can be stated that individuals become more sensitive to the disease and preventive measures as the duration of the disease increases. it is important to evaluate risk perceptions and correct biased information in order to encourage individuals with diabetes to adapt to the treatment and diabetes-related self-care behaviours.37 in the study, it was determined that individuals’ risk assessment means score for amputation was quite low, about two-thirds stated that they did not have any risk of amputation. in a study conducted with african americans, it was found that the perceived risk of amputation in 12.6% of individuals with type 2 diabetes was high while 40.5% stated that they did not consider themselves under risk, and overall risk perception towards amputation was low.38 in a qualitative study, it was reported that the participants’ risk perceptions of diabetic foot were quite low and they considered diabetic foot ulcers as a normal wound.27 in another qualitative study, it was found that lower extremity amputation was more common in individuals with diabetes, but it was perceived as mainly caused by poor blood circulation in the feet and not related to foot ulcer.6 in a qualitative study with diabetic individuals who had no amputation but had lower extremity injuries, it was found that individuals responded to the question assessing their feelings about amputation by using the terms anxiety, fear, and end of the world.39 the study finding shows that, despite the high glycaemic parameters in terms of diabetic foot and thus the risk of developing amputation, awareness among individuals is low. it has long been argued that diabetic foot development can be prevented by providing foot care with the education of the diabetic individual, determining risk factors for diabetic foot, taking necessary measures and ensuring glycaemic control.11 in a study, 79.3% of the participants stated that it is important to receive antidiabetic therapy to prevent foot complications.17 in the current study, no difference was found between the glycaemic control parameters and levels of perceived risk of amputation of individuals. it is thought that this situation may be due to the insufficient awareness of patients about the effects of glycaemic control on complications, especially on amputation. naturally, our study had some limitations. since the research was conducted with diabetic individuals who applied to a single hospital in a certain time period and who agreed to participate in the study, it is an important limitation of the research that its results can be generalized to its own universe. information about foot self-care behaviours and perceived risk of amputation is based on self-report of individuals. besides, neurological examination of the foot was not performed in the study. conclusion in line with the findings obtained in the study, it was determined that the individuals with type 2 diabetes did not have good foot care behaviours, the duration of the disease and the information obtained about foot care affects the foot self-care behaviour, and the perceived risk of amputation were quite low. in this context, beginning from the diagnosis of the especially health professionals providing home care services and diabetes 287 international journal of human and health sciences vol. 06 no. 03 july’22 nurses, it is recommended to provide information about foot self-care behaviours in addition to the disease information, to raise awareness about the amputation that may occur as a result of insufficient foot self-care behaviours, to ensure the regular participation of the individuals in health checks and to evaluate their compliance with foot self-care behaviours, to provide visual training materials and reminder information to individuals with low level of education, to repeat foot care training regularly and to conduct studies examining the reasons why individuals with diabetes do not apply foot self-care behaviours. conflict of interest: none declared. ethical approval issue: the study was approved by the ethical comity of sakarya university noninvasive ethics committee presidency, sakarya, turkey. funding statement: no funding. authors’ contribution: conception and design of the study: hs, fty; data collection and compilation: hs, fcö; data analysis: fty, akk; critical writing, revision and finalizing the manuscript: hs, fty, akk. references 1. turkey endocrinology and metabolism society. diagnosis, treatment and follow-up guide of diabetes mellitus and complications. 2019. available from: url: http://temd.org.tr/admin/ uploads/tbl_kilavuz/20191107144832-2019tbl_ kilavuz7c65cb4e70.pdf 2. cho n, shaw j, karuranga s, et al. idf diabetes atlas: global estimates of diabetes prevalence for 2017 and projections for 2045. diabetes research clinical practice. 2018;138:271-281. 3. international diabetes federation. diabetes atlas 9th edition. 2019. available from: url: https:// www.diabetesatlas.org/upload/resources/2019/idf_ atlas_9th_edition_2019.pdf 4. yılmaz mb, kılıçkap m, abacı a, et al. temporal changes in the epidemiology of diabetes mellitus in turkey: a systematic review and meta-analysis. turk kardiyoloji dernegi arsivi. 2018;46(7):546-555. 5. biçer ek, çelik s. comprehensive foot examination for diabetes patients and risk assestment. turkey clinics journal of nursing sciences. 2016;8(1):6270. 6. gale l, vedhara k, searle a, et al. patients’ perspectives on foot complications in type 2 diabetes: a qualitative study. journal of general practice. 2008;58(553):555-563. 7. bus s, van netten j, lavery l, et al. iwgdf guidance on the prevention of foot ulcers in at‐risk patients with diabetes. diabetes/metabolism research reviews. 2016;32:16-24. 8. desalu o, salawu f, jimoh a, et al. diabetic foot care: self reported knowledge and practice among patients attending three tertiary hospital in nigeria. ghana medical journal. 2011;45(2). 9. dorresteijn ja, kriegsman dm, assendelft wj, valk gd. patient education for preventing diabetic foot ulceration. cochrane database of systematic reviews. 2012;10. 10. lakshmi n, patel n, parmar p, et al. study the foot care practice among diabetic patients in ahmedabad city, gujarat. international journal of medical science public health. 2018;7(5):333-338. 11. nural n, hindistan s. investigating the knowledge and attitude related to foot care of diabetic patients. journal of anatolia nursing and health sciences. 2015;18(2):116-124. 12. yücel f, sunay d. assessment of knowledge, attitudes and behaviours of diabetic patients about diabetic foot and foot care. ankara medical journal. 2016;6(3):270-284. 13. saltoğlu n, kılıçoğlu ö, baktıroğlu s, et al. diagnosis, treatment and prevention of diabetic foot wounds and ınfections: turkish consensus report. klimik journal. 2015;28(suppl 1):2-34. 14. sözen e, kızılcı s. examinatıon and comparison of foot care behaviors of individuals who have type 2 diabetes. journal of ege university nursing faculty. 2012;28(2):41-53. 15. aypak c, koç a, yıkılkan h, et al. diabetic foot care: self reported practice among patients attending family medicine outpatient clinics. cumhuriyet medical journal. 2012;34(4):423-428. international journal of human and health sciences vol. 06 no. 03 july’22 288 16. bortoletto mss, de andrade sm, matsuo t, et al. risk factors for foot ulcers a cross sectional survey from a primary care setting in brazil. journal of primary care diabetes. 2014;8(1):71-76. 17. hasnain s, sheikh nh. knowledge and practices regarding foot care in diabetic patients visiting diabetic clinic in jinnah hospital, lahore. the journal of the pakistan medical association. 2009;59(10):687. 18. muhammad-lutfi a, zaraihah m, anuar-ramdhan i. knowledge and practice of diabetic foot care in an inpatient setting at a tertiary medical center. malaysian orthopaedic journal. 2014;8(3):22. 19. abu-qamar m. knowledge and practice of foot selfcare among jordanians with diabetes: an interviewbased survey study. journal of wound care. 2014; 23(5):247-254. 20. biçer ek, enç n. evaluation of foot care and selfefficacy in patients with diabetes in turkey: an interventional study. international journal of diabetes in developing countries. 2016;36(3):334-344. 21. soltanipour s, heidarzadeh a, jafarinezhad a. reliability and validity of the persian (farsi) version of the risk perception survey-diabetes mellitus. eastern mediterranean health journal. 2014;20(3):190-195. 22. walker ea, caban a, schechter cb, et al. measuring comparative risk perceptions in an urban minority population. the diabetes educator. 2007;33(1):103110. 23. sachs ml, sporrong sk, colding-jørgensen m, et al. risk perceptions in diabetic patients who have experienced adverse events: implications for patient involvement in regulatory decisions. pharmaceutical medicine. 2017;31(4):245-255. 24. pinelli nr, herman wh, brown mb, et al. perceived risk and the willingness to enroll in a diabetes prevention lifestyle intervention in arabamericans. diabetes research clinical practice. 2010;90(2):e27-e29. 25. kim c, mcewen ln, piette jd, et al. risk perception for diabetes among women with histories of gestational diabetes mellitus. diabetes care. 2007;30(9):2281-2286. 26. scollan-koliopoulos m, walker ea, bleich d. perceived risk of amputation, emotions, and foot selfcare among adults with type 2 diabetes. the diabetes educator. 2010;36(3):473-482. 27. godoy-coronao a, illesca-pretty m, cabezasgonzález m, et al. foot ulcers: perception of patients with type 2 diabetes. revista de la facultad de medicina. 2018;66(2):187-194. 28. erkoç a, yürügen b, mehtap t, et al. foot care behaviors among nursing home residents with diabetes. gümüşhane university journal of health sciences. 2015;4(2):194-203. 29. borges wj, ostwald sk. improving foot self-care behaviors with pies sanos. western journal of nursing research. 2008;30(3):325-341. 30. biçer ek, enç n. validity and reliability of the turkish adaptation of the foot self care behavior scale. nursing forum in diabetes obesity and hypertension. 2014;6(2):35-39. 31. i̇çer m, durgun hm. factors affecting amputations in patients with diabetic foot ulcer referring to the emergency units. dicle med j. 2017;44(1):91-98. 32. baba m, duff j, foley l, et al. a comparison of two methods of foot health education: the fremantle diabetes study phase ii. journal of primary care diabetes. 2015;9(2):155-162. 33. george h, rakesh p, krishna m, et.al. foot care knowledge and practices and the prevalence of peripheral neuropathy among people with diabetes attending a secondary care rural hospital in southern india. journal of family medicine primary care. 2013;2(1):27. 34. bonner t, foster m, spears-lanoix e. type 2 diabetes–related foot care knowledge and foot selfcare practice interventions in the united states: a systematic review of the literature. diabetic foot ankle. 2016;7(1):29758. 35. lamchahab f, el kihal n, khoudri i, et al. factors influencing the awareness of diabetic foot risks. annals of physical rehabilitation medicine. 2011;54(6):359-365. 36. khamseh m.e, vatankhah n, baradaran hr. knowledge and practice of foot care in iranian people with type 2 diabetes. international wound journal. 2007;4(4):298-302. 37. rouyard t, kent s, baskerville r, et al. perceptions of risks for diabetes‐related complications in type 2 diabetes populations: a systematic review. diabetic medicine. 2017;34(4):467-477. 38. calvin d, quinn l, dancy b, et al. african americans’ perception of risk for diabetes complications. the diabetes educator. 2011;37(5):689-698. 39. cornell rs, meyr a. perceived concerns of patients at risk for lower extremity amputation. wounds: a compendium of clinical research practice. 2018;30(2):45-48. 139 international journal of human and health sciences vol. 07 no. 02 april’23 original article: association between neck circumference and preeclampsia in pregnant women dwi apriyanti1*, uki retno budihastuti2, dan kusnandar3 abstract the nutritional status of a person can be measured by neck circumference. this measurement uses a tape measure that is looped around the neck just below the larynx and perpendicular to the length of the neck. the parameters of neck circumference used to assess nutritional status are > 34 cm in women with bmi > 25 kg/m2 and > 36.5 cm in women with bmi > 30 kg/m2 with an accuracy rate of 99%. being overweight and obese during pregnancy and childbirth will increase the risk of chronic disease in both mother and child. pregnant women with obesity are at risk for pregnancy complications such as gestational hypertension, preeclampsia, gestational diabetes mellitus, and more often undergo cesarean delivery due to a baby born prematurely. an observational study with a case-control design using a cross-sectional approach was carried out by measuring neck circumference in 130 pregnant women with gestational age above 20 weeks which was divided into 65 respondents of pregnant women with preeclampsia and 65 respondents of pregnant women without complications. this research was conducted on pregnant women in tangerang regency. the chi-square test is used to analyze the data with a significant value of 0.05. the results of the chi-square test obtained a p-value of 0.000 (p<0.05), indicating a relationship between neck circumference and the occurrence of preeclampsia in pregnant women. the contingency coefficient value of 0.493 indicates the impact of obesity on the occurrence of preeclampsia by 49.3%, while other factors that influence preeclampsia are 50.7%. neck circumference can be used as a method to assess nutritional status in pregnant women to prevent preeclampsia. keywords: neck circumference, preeclampsia, obesity correspondence to: dwiapriyanti, the study program oh nutrition science, master’s degree program, sebelasmaret university, surakarta, e-mail : dwiapriyanti@student.uns.ac.id 1. the study program of nutrition science, master’s degree program, sebelasmaret university, surakarta, indonesia. 2. the study program of obstetric and gynecology, faculty of medical science, sebelasmaret university, surakarta, indonesia (rsud dr. moewardi) 3. the study program of agribusiness, faculty of agriculture, sebelasmaret university, surakarta, indonesia introduction based on indonesia’s health profile in 2020, it can be seen that the increase in mmr cases in indonesia from 4,221 deaths in 2019 increased to 4,726 in 2020. the main factors causing the high mortality include 25% bleeding in as many as 1,330 cases, 24% hypertension in pregnancy including preeclampsia, eclampsia, peb in as many as 1,110 cases, 8% disorders of the blood circulation system in as many as 230 cases (ministry of health of the republic of indonesia, 2021), (nur &adhar, 2017). preeclampsia is one of several health problems that exist during pregnancy and has the potential for complications in 2-3% of pregnancies (sukmariah et al., 2019). preeclampsia is a serious medical condition that can affect 3-5% of pregnancies and is a contributing factor to more than 35,000 maternal deaths in the international journal of human and health sciences vol. 07 no. 02 april’23 doi: http://dx.doi.org/10.31344/ijhhs.v7i2.564 mailto:dwiapriyanti@student.uns.ac.id international journal of human and health sciences vol. 07 no. 02 april’23 140 world every year. preeclampsia can affect the work of other organs causing an increased risk of complications in pregnancy (wen et al., 2018). the world health organization (who) stated that the incidence of preeclampsia is 7 times higher in developing countries compared to developed countries. the prevalence of the incidence of preeclampsia in developed countries is 1.3% 6% while in developing countries it is about 1.8% 18%. the latest who report states that preeclampsia accounts for 70,000 maternal deaths every year in the world (arikah, rahardjo& widodo, 2021). the risk factors for preeclampsia are primigravida pregnancy risk 4,654 times greater than that of multigravida pregnant women, age, gestational age, obesity, history of hypertension, pregnancy visits or antenatal care, family income, and the use of hormonal contraceptives (nur and arifuddin, 2017). the prevalence of overweight and obesity is becoming a global health problem today. obesity is significantly associated with the development of chronic disorders such as cardiovascular disease (cvd), type ii diabetes mellitus, insulin resistance, hypertension, and cholesterol. early detection is indispensable to prevent long-term effects that can be detrimental, especially for those with an unhealthy lifestyle (ferrari et al., 2019). as many as a quarter to one-third of pregnant women are obese and have a bmi of > 30 kg/m2 in developed countries. obesity can significantly increase the risk of non-emergency and emergency cesarean delivery (you-ten et al., 2015). based on the description above, it can be seen that being overweight and obese greatly affects the condition of pregnant women and risks causing preeclampsia and other chronic diseases during pregnancy. therefore, efforts are needed to prevent obesity in pregnant women, one of which is by measuring neck circumference to monitor the nutritional status of pregnant women in addition to seeing weight gain during pregnancy. neck circumference measurements can be used as an early screening for obesity. this can be early intervention in preventing preeclampsia and hypertension in pregnancy so that it does not become a condition of severe preeclampsia to cause conditions that can harm the health of the mother and fetus. the aims this study aims to see if there is a relationship between neck circumference and the incidence of preeclampsia in pregnant women. methods this study is an observational study with a casecontrol research design using a cross-sectional approach. this performance grouped samples into cases and controls carried out at the same time(probandari et al., 2020). this research wasconducted in july 2022 in tangerang regency. sel was taken using a multistage sampling technique and obtained a study sample of 130 pregnant women respondents which was divided into 65 respondents of normal pregnant women and 65 respondents of pregnant women with preeclampsia. data collection used primary data obtained by measuring the neck circumference of respondents and looking at data on pregnant women through the mch book. data analysis was performed to see the relationship between the research variables.the measurement of neck circumference is carried out by measuring at a point just below the larynx (thyroid cartilage) and perpendicular to the axis the length of the neck (with a band line in front of the neck at the same height as the band line of the back of the neck). the tool used is an inelastic tape measure in centimeter units. measurements are carried out twice to ensure accuracy and use the average value for analysis. if two readings are far different from the predetermined point (0.5 cm) then a third measurement is taken (ferrari et al., 2019). the hypothesis in this study is the assumption that the neck circumference can be used as one of the screenings for determining nutritional status and its relationship with the incidence of preeclampsia during pregnancy. result and discussion this study aims to find out whether there is a relationship between neck circumference and the incidence of preeclampsia in pregnant women. the data used in this study were primary data taken on pregnant women with a gestational age of more than 20 weeks in tangerang regency. the following are the results of the research obtaine. characteristics of respondents 141 international journal of human and health sciences vol. 07 no. 02 april’23 table 1. characteristics of respondents (n=130) characteristics amount(n) percentage (%) age of respondents (year) 15 – 19 4 3.1 20 – 35 100 76.9 >35 26 20 gestational age (sunday) 22 28 61 49.9 29 42 69 50.1 parity 1-3 104 80 ≥ 3 26 20 neck circumference (cm) ≤ 34 45 34.6 > 34 85 65.4 source: primary data,2022 table 1 explained the characteristics of the study respondents, where respondents with risky pregnancies at the age of 15-19 years as many as 4 people with a percentage of 3.1% and aged over 35 years as many as 26 people with a percentage of 20%. respondents with a productive gestational age of 100 people at the age of 20-35 years with a percentage of 76.9%. the gestational age of the respondents in this study was a pregnancy of more than 20 weeks. respondents with a gestational age of2 2 – 28 weeks were 61 people with a percentage of 61% and a gestational age of > 28 weeks as many as 69 people with a percentage of 69%. the lowest gestational age is 20 weeks and the highest is 40 weeks. respondents with a parity of more than 3 children were 26 people with a percentage of 20%, while respondents who had children 1 to 3 children were 104 people with a percentage of 60.8%. pregnant women with a parity of more than 3 children are at risk of pregnancy complications in the next pregnancy compared to pregnant women with a parity of fewer than 3 neck circumference characteristics are used to see the nutritional status of pregnant women, where the neck circumference is ≤ 34 cm as many as 45 people with a percentage of 34. 6% and > 34 cm as many as 85 people with a percentage of 65.4%. neck circumference data shows that at 20 weeks of gestation and above pregnant women begin to increase weight where the nutritional status of obesity is more than the normal nutritional status. children. neck circumference with preeclampsia source: primary data, 2022 table 2 shows the relationship of neck circumference with the incidence of preeclampsia in pregnant women. pregnant women who experienced preeclampsia with obesity as many as 60 people or 70.6% and pregnant women with normal conditions were obese as many as 25 people with a percentage of 29.4%. these results show that mothers with preeclampsia have an obese nutritional status compared to pregnant women without complications. a study on the relationship of excess weight gain to the risk of preeclampsia showed that women who had preeclampsia experienced more weight gain than women who did not experience preeclampsia with a difference of 3.5 kg in total body fluids observed at week 36 but were inversely proportional between fat mass and the possibility of preeclampsia (hillesund et al., 2018). in this study, the results of the p-value of 0.000 with a significant 0.05 which means that the p<0.05 value shows a relationship between measuring nutritional status using neck circumference and the occurrence of preeclampsia in pregnant women. the numerical parameters used on a woman’s neck circumference are that a person with a bmi > of 25 kg/m2 has a cut of point> 34 cm and a bmi of > 30 kg/m2 with a cut of point> 36.5 cm. from the validation results that have been carried out, neck circumference can be used as one of the obesity table 2. relationship of neck circumference withpreeclampsia in pregnant women variable neck circumference sum x2 p value normal obesity n % n % n % pregnancy status normal 40 88.9 25 29.4 65 50 39.3 0.000 preeclampsia 5 11.1 60 70.6 65 50 sum 45 100 85 100 130 100 international journal of human and health sciences vol. 07 no. 02 april’23 142 screening methods with a sensitivity of 98%, specificity of 89%, the accuracy of 94% for men, and 99% for women (par’iet al., 2017). obesity is one of the risk factors for the occurrence of preeclampsia 2 times every increase in body weight by 5-7 kg and an increase in bmi which is associated with the risk of preeclampsia and severe preeclampsia by 64%. this risk can increase two to three times due to an increase in bmi from 20 kg/m2 to 30 kg/m2 (david et al., 2016),(zahra and rodiani, 2016). the contingency coefficient value of 0.493 in this study showed the effect of obesity on the occurrence of preeclampsia by 49.3%, while other factors that affect preeclampsia but are not explained in this study were 50.7%. some of the risk factors associated with the development of preeclampsia include extreme age (too young / too old), parity, previous history of preeclampsia, a distance of pregnancy, ivf, family history of preeclampsia, obesity, having a comorbid medical history including gestational diabetes, previous chronic hypertension, kidney disease as well as autoimmune diseases such as systemic lupus erythematosus and antiphospholipid syndrome (poon et al., 2019). a study showed that pregnant women with obesity have a risk factor for preeclampsia 5,632 times greater than pregnant women without obesity (nur and arifuddin, 2017). in the human body whether pregnant or not, endothelial dysfunction occurs due to obesity. this leads to endothelial damage and further provokes the occurrence of preeclampsia in pregnant women. a woman who has preeclampsia has a lesion of the uteroplasent artery. these lesions have the characteristic presence of parts that undergo fibrinoid necrosis including macrophage cells that are lipid phagotiated. lesions that occur in the glomerulus are related to the occurrence of proteinuria. changes in fat metabolism play a role in the destruction of endothelial lesions in people with preeclampsia. the severity of hypertension and proteinuria describes the severity of endothelial damage (poon et al., 2019),(wafiyatunisa zahra and rodiani, 2016). overweight and obese before and during pregnancy have a negative impact on fertility, during pregnancy and childbirth and increase the risk of developing chronic diseases for the mother and child. women with overweight and obese increase the risk of developing complications such as gestational hypertension, preeclampsia, gestational diabetes mellitus and more often having cesarean delivery (timmermans et al., 2019). conclusion from the results of this study, there is a relationship between neck circumference and the occurrence of preeclampsia in pregnant women based on the cutoff point of nutritional status of obesity at gestational age above 20 weeks. this research was carried out in tangerang regency in june 2022 with a total sample of 130 people. of the total number of respondents with a neck circumference of > 34 cm as many as 85 people (64.5%), preeclampsia pregnant women with obesity as many as 60 people (70.6%), and normal pregnant women with obesity as many as 25 people (29.4%). the p-value of 0.000 and contingency coefficient of 0.493 indicated the relationship between obesity and preeclampsia, where the effect of obesity on the occurrence of preeclampsia was 49.3%, while other factors affecting preeclampsia but not explained in this study were 50.7%. suggestions for further research on the effect of neck circumference on lipid profiles with different characteristics of respondents. conflict of interest the authors stated there was no conflict of interest in the study. ethical clearance this study has been approved by the research ethics committee of the faculty of medicine sebelasmaret universitynumber 35/un27.06.11/ kep/ec/2022. authors’ contribution dwiapriyanti conceptualized and designed the study, prepared the draft of the manuscript and reviewed of the manuscript. ukiretnobudihastuti assisted in drafting of the manuscript, reviewed of manuscript. kusnandar conducted the study, data analysis and interpretation and reviewed of the manuscript. 143 international journal of human and health sciences vol. 07 no. 02 april’23 references 1. arikah, t., rahardjo, t.b.w., widodo, s. incidence of hypertension in pregnant women. jurnal research and development of indonesian community health 2021;(1) : 115–124.https://doi.org/10.15294/jppkmi. v1i2.40329 2. david, h., han, a., hanson, claudia, helewa, michael, hoodbhoy, zahra, hutcheon, jenn, jaime, j., katageri, g., kintu, a., oladapo a. ladipo, andré lalonde, laura a. magee, a.m., mathai, m., miller, s., jean-marie m, j.w. the figo textbook of pregnancy hypertension an evidence-based guide to monitoring, prevention and management, medicine, biomedical sciences, health and social care science cranmer. the global library of women’s medicine, london (uk), 2016. https://www.researchgate.net/publication/312916347_ the_figo_textbook_of_pregnancy_hypertension 3. ferrari, l.d.m., gerson, kovalskys, i., fisberg, m., gomez, g., rigotti, a., sanabria, l.y.c., garcía, m.c.y., torres, r.g.p., herrera-cuenca, m., zimberg, i.z., guajardo, v., pratt, m., pires, c., solé, d., moreno, l.a., lloyd, b., lynch, b., jauregui, m., guidi, a., costa, l., fisberg, r.m., koletzko, b., tucker, k.l., amigo, m.p., janezic, x., cardini, f., echeverry, m., de frança, n.a.g., echeverría, g., landaeta, l., castillo, ó., vargas, l.n., tobar, l.f., castillo, y.m., rojas, r.m., chinnock, a., fontana, m.e.h., cáceres, m.v., ocampo, m.b., torres, r.p., liria, m.r., meza, k., abad, m., penny, m., landaeta, m., méndez, b., vasquez, m., rivas, o., meza, c., ruiz, s., ramirez, g., hernández, p., chiavegatto filho, a.d.p., gonçalves, p.b., alberico, c., de moraes ferrari, g.l. association of moderate-to-vigorous physical activity with neck circumference in eight latin american countries. bmc public health 2019; (19):1–8.doihttps://doi. org/10.1186/s12889-019-7153-y 4. hillesund, e.r., seland, s., bere, e., sagedal, l.r., torstveit, m.k., lohne-seiler, h., vistad, i., øverby, n.c. preeclampsia and gestational weight gain in the norwegian fit for delivery trial nct0100168 nct. bmc 2018; (11) : 1–6. doi https://doi.org/10.1186/ s13104-018-3396-4 5. holil m. par’i, sugengwiyono, titus priyoharjatmo. nutritional status assessment. in: widyasari, nofaldo, d.a., supriyadi (eds.), nutritional teaching materials. ppsdm ministry of health of the republic of indonesia, jakarta, 2017: 315. 6. ministry of health of the republic of indonesia, 2021. indonesia health profile jakarta, 2020 7. nur fahira. a, arifuddin, a.. risk factors for the incidence of preeclampsia in pregnant women at anutapura hospital, palu city. tadulakojournal of health 2017;(3): 69–75.https://123dok.com/ d o c u m e n t / y e r p 2 3 4 q f a k t o r r i s i k o k e j a d i a n preeklampsia-hamil-anutapura-fahira-arifuddin.html 8. poon, l.c., shennan, a., hyett, j.a., kapur, a., hadar, e., divakar, h., mcauliffe, f., da silva costa, f., von dadelszen, p., mcintyre, h.d., kihara, a.b., di renzo, g.c., romero, r., d’alton, m., berghella, v., nicolaides, k.h., hod, m. the international federation of gynecology and obstetrics (figo) initiative on pre-eclampsia: a pragmatic guide for first-trimester screening and prevention. international journal gynecology obstetric 2019. https://doi. org/10.1002/ijgo.12892 9. probandari, a.n., pamungkasari, e. poncorini, febrinasari, r.p., sumardiyono, widyaningsih, v. quantitative research methods, 1st ed. uns press, surakarta, 2020 10. sukmariah, h., nisrina, agustina, t.a., ismiyati. efforts to prevent hypertension in pregnancy (hdk) with nonpharmacological methods (nutrition and stress factors). in: prevention of non-communicable diseases. puipk poltekkeskemenkes banten, banten, 2019 11. timmermans, y.e.g., van de kant, k.d.g., reijnders, d., kleijkers, l.m.p., dompeling, e., kramer, b.w., zimmermann, l.j.i., steegers-theunissen, r.p.m., spaanderman, m.e.a., vreugdenhil, a.c.e., 2019. towards prepared mums (top-mums) for a healthy start, a lifestyle intervention for women with overweight and a child wish study protocol for a randomized controlled trial in the netherlands. bmj open,2019; (9):1–14.https://doi.org/10.1136/ bmjopen-2019-030236 12. wafiyatunisa zahra, rodiani. obesity relationship with the occurrence of preeclampsia. majority2019 ; (5) : 184–190. 13. wen, s.w., white, r.r., rybak, n., gaudet, l.m., robson, s., hague, w., simms-stewart, d., carroli, g., smith, g., fraser, w.d., wells, g., davidge, s.t., kingdom, j., coyle, d., fergusson, d., corsi, d.j., champagne, j., sabri, e., ramsay, t., mol, b.w.j., oudijk, m.a., walker, m.c. effect of high dose folic acid supplementation in pregnancy on pre-eclampsia (fact): double-blind, phase iii, randomized controlled, international, multicentre trial. bmj, 2018 ; (362):1–8.https://doi.org/10.1136/bmj.k3478 14. you-ten, k.e., desai, d., postonogova, t., siddiqui, n. accuracy of conventional digital palpation and ultrasound of the cricothyroid membrane in obese women in labor. anaesthesia, 2015; (70):1230–1234. doi: 10.1111/anae.13167 https://doi.org/10.15294/jppkmi.v1i2.40329 https://doi.org/10.15294/jppkmi.v1i2.40329 https://www.researchgate.net/publication/312916347_the_figo_textbook_of_pregnancy_hypertension https://www.researchgate.net/publication/312916347_the_figo_textbook_of_pregnancy_hypertension https://doi.org/10.1186/s12889-019-7153-y https://doi.org/10.1186/s12889-019-7153-y https://doi.org/10.1186/s13104-018-3396-4 https://doi.org/10.1186/s13104-018-3396-4 https://123dok.com/document/yerp234q-faktor-risiko-kejadian-preeklampsia-hamil-anutapura-fahira-arifuddin.html https://123dok.com/document/yerp234q-faktor-risiko-kejadian-preeklampsia-hamil-anutapura-fahira-arifuddin.html https://123dok.com/document/yerp234q-faktor-risiko-kejadian-preeklampsia-hamil-anutapura-fahira-arifuddin.html https://doi.org/10.1002/ijgo.12892 https://doi.org/10.1002/ijgo.12892 https://doi.org/10.1136/bmjopen-2019-030236 https://doi.org/10.1136/bmjopen-2019-030236 https://doi.org/10.1136/bmj.k3478 s14 oral presentation eagle syndrome: the forgotten entity muhamad ariff sobani1, noor shairah mat barhan1, abdul azim al-abrar ahmad kailani1,2, norazila abdul rahim1, masaany mansor1 elongated styloid process or eagle syndrome is a rare condition presenting with a wide range of symptoms including throat pain, foreign body sensation, neck pain and ear pain. establishing a diagnosis requires a high index of suspicion and understanding of this entity by the physician. computed tomography (ct) is the gold standard to diagnose eagle syndrome. conservative medical treatment with analgesics, oral steroids and anticonvulsants are offered in patients who refused surgery. the mainstay of treatment is surgical resection via intraoral or cervical approaches. we describe a rare case of bilateral eagle syndrome in a 46-year-old female who was presented with chronic foreign body sensation in the throat but aggravated following fish bone ingestion. flexible nasopharyngolaryngoscopy (fnpls) and cervical x-ray did not reveal any foreign body and the patient was treated conservatively. incidentally, a cervical x-ray also revealed an elongated styloid process bilaterally. upon follow-up, the patient was still symptomatic. thus, a ct scan with contrast of the neck was requested, which reported no foreign body, but the presence of bilateral elongated styloid process suggesting eagle syndrome. the patient was subjected to transoral endoscopic assisted bilateral styloidectomy following tonsillectomy. there was a complete resolution of the symptoms postoperatively. this approach is recommended to avoid external scarring and minimize postoperative pain. eagle syndrome is diagnosed based on a combination of physical examination and radiological findings. the treatment options may vary based on the severity of symptoms. keywords: eagle syndrome, elongated styloid process, transoral, endoscopic, styloidectomy ___________________________________________________________________________ 1department of otorhinolaryngology-head and neck surgery, faculty of medicine, universiti teknologi mara (uitm), sungai buloh campus, 47000 sungai buloh, selangor, malaysia. 2department of otorhinolaryngology-head and neck surgery, school of medical sciences, health campus, universiti sains malaysia, 16150 kota bharu, kelantan, malaysia correspondence to: muhamad ariff sobani1, department of otorhinolaryngology-head and neck surgery, faculty of medicine, universiti teknologi mara, sungai buloh campus, 47000 sungai buloh, selangor, malaysia. email: ariffsobani@gmail.com __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v6i0.404 mailto:ariffsobani@gmail.com international journal of human and health sciences vol. 07 no. 02 april’23 128 original article: relationship between premature rupture of membranes and caesarean section delivery analytical observational study at sultan agung islamic hospital semarang yulice soraya nur intan 1, mohammad akbarrudin sholeh 2, mutiara delia subiyanto3 abstract background: premature rupture of membranes (prom) is a rupture of the membranes before delivery which poses a serious threat in the form of an increased risk of cesarean delivery. the risk of greater morbidity and mortality needs to be considered in cesarean delivery compared to vaginal delivery. objective: this study aims to determine the relationship between premature rupture of membranes and delivery by cesarean section at sultan agung islamic hospital, semarang. methods: this research is an analytic observational study with a cross sectional research design. the population of this study was pregnant women with inpatient deliveries at the sultan agung islamic hospital, semarang in 2018-2020. the study sample size was 50 patients. the research instrument used medical records from the obstetrics and gynecology section at sultan agung islamic hospital, semarang. the sampling technique of this study is a non-probability sampling technique with purposive sampling method and meets the inclusion and exclusion criteria. data were analyzed by chi square test (x2). results: the results of the study from a total of 50 samples obtained were 19 patients (38%) with prom, of which 10 were delivered by cesarean section (52.6%) and 9 patients had vaginal delivery (47.4%). patients who did not experience prom were 31 patients (62%) of which 26 were delivered by cesarean section (83.9%) and 5 patients delivered vaginally (16.1%). the results of the chi square test (x2) obtained a significance value or asymptotic significance (2-sided) of 0.039. conclusion: the conslusion of this study is that there is a relationship between premature rupture of membranes and delivery by cesarean section. keywords: premature rupture of membranes, sectiocaesarea delivery correspondence to: yulice soraya nur intan, department of obstetrics and gynecology, faculty of medicine, sultan agung islamic university, semarang, indonesia, e-mail: yulicesoraya@gmail.com 1. department of obstetrics and gynecology, faculty of medicine, sultan agung islamic university semarang, indonesia 2. department of microbiology, faculty of medicine, sultan agung islamic university, semarang, indonesia 3. faculty of medicine, sultan agung islamic university, semarang, indonesia introduction premature rupture of membranes (prom) is an obstetric problem due to rupture of the membranes that can occur before 37 weeks of gestation which is called preterm prom. the membranes that rupture at or more than 37 weeks of gestation are called term prom.10 prom is a condition that poses a serious threat in the form of an increased risk of cesarean delivery. oligohydramnios and fetal distress conditions to intrauterine infection in preterm and term prom affect the well-being of the mother and fetus if not managed properly so it is necessary to terminate pregnancy, one of which is by caesarean section delivery.1sectiocaesarea delivery needs attention because of the greater risk of postoperative morbidity and longer hospitalization recovery time than vaginal delivery.5 international journal of human and health sciences vol. 07 no. 02 april’23 doi: http://dx.doi.org/10.31344/ijhhs.v7i2.562 129 international journal of human and health sciences vol. 07 no. 02 april’23 the problem of premature rupture of membranes requires great attention because the incidence is quite high. according to in 2013 the incidence of prom in the world was 50-60% while in indonesia it was 35% of 17,665 births.15 the incidence of prom at term occurs around 6.4615.6% of term pregnancies. the incidence of preterm prom occurs in the range of 2-3% of all singleton pregnancies. these data show that the incidence of term prom is higher than that of preterm prom.10 the incidence of prom is associated with adverse maternal and perinatal outcomes. the immediate risks of prom include correspondence to: umbilical cord prolapse, placental abruption, and cord compression. further risks are in the form of neonatal and maternal infections and delivery by cesarean section.14 the incidence of prom without risk depends on the way of management and complications that occur. the greater the complications, the smaller the incidence of prom without risk.8 the incidence of potentially severe infections occurs in about 1/3 of pregnant women who experience preterm prom.10 increased cases of prom can result in an increase in the number of caesarean sections.3 from the background above, the author wants to examine the relationship between premature rupture of membranes and delivery by cesarean section so that maternal care with prom can be managed properly and minimize sectiocaesarea delivery.16 the author wants to examine this with the consideration that there has been no similar research in semarang, especially at the sultan agung islamic hospital, semarang. the purpose of this study was to determine the relationship between prom and sectiocaesarea delivery. the benefits of this study are expected to increase knowledge about the relationship between prom and sectiocaesarea delivery and as an evaluation of delivery management and the basis for policy making in order to improve hospital services, especially at sultan agung islamic hospital, semarang. the hypothesis of this study is that there is a relationship between prom and delivery by cesarean section. material and methods this type of research is an observational analytic study with a cross sectional research design. the statistical test used is the chi square test (x2). this research was conducted at the islamic hospital sultan agung semarang from june to july 2021. the population in this study were pregnant women with inpatient deliveries at the islamic hospital sultan agung semarang in 2018-2020. the population was determined by non-probability sampling with purposive sampling method and met the inclusion and exclusion criteria and then included in the research sample until the number was met. the number of samples taken was 50 patients. the research instrument was the medical record of the obstetrics and gynecology section at the sultan agung islamic hospital, semarang. the inclusion criteria for this study were mothers who gave birth by sectiocaesarea because the primary diagnosis of premature rupture of membranes at term was with the head position and mothers who gave birth through vaginal delivery due to the primary diagnosis of premature rupture of membranes at term with the head position.exclusion criteria for this study included pregnant women with a primary diagnosis of malpresentation, pregnant women with multiple or multiple pregnancies, and incomplete medical record data.the sample data was processed using the statistical package for the social sciences (spss) application. data analysis used univariate analysis and bivariate analysis. result 1. univariate analysis univariate analysis is a description of the research sample that presents the frequency distribution of the number of cases of prom and cesarean delivery. the distribution of the frequency of prom events at sultan agung islamic hospital semarang can be seen in table 1.based on the results of the study on the frequency distribution of prom, 50 samples were obtained with the number of cases of prom 19 patients and 31 patients without prom. the results of this study indicate that the incidence of prom is 38% of the total research sample. this figure is much larger than the figure estimated which is around 6.46-15.6%.10 the incidence of prom at 38% is also higher than the incidence of prom in indonesia which is 35% of 17,665 births. the difference in the proportion of the incidence of prom can be caused by differences in the number of patients experiencing prom and differences in the number of populations studied. table 1. distribution of the frequency of premature rupture of membranes at sultan agung hospital semarang in 2018-2020 incident premature rupture of membrane amount percentage premature rupture of membrane 19 38% no premature rupture of membrane 31 62% total 50 100% international journal of human and health sciences vol. 07 no. 02 april’23 130 the characteristics of the sample in this study were seen from the age of pregnant women and gravida status. the distribution of the frequency of prom events based on gravida status at sultan agung islamic hospital semarang can be seen in table 2. table 2. frequency distribution of premature rupture of membranes based on gravida status at sultan agung hospital semarang in 2018-2020 incident premature rupture of membrane gravida status total %primi gravida % multi gravida % premature rupture of membrane 11 22 8 16 19 38 no premature rupture of membrane 11 22 20 40 31 62 total 22 44 28 56 50 100 table 2 shows that mothers who experience prom are more common in primigravida mothers. this study is in line with previous research that primigravida mothers have a 5.4 times risk of experiencing prom compared to multigravida mothers.13 however, this study is different from other theoriesthat the cause of prom is multiparous because the cervical opening process is faster than primiparas so that infection is easy to occur. the results that are not in line with this theory can be caused by various factors, including regular antenatal care, a healthy lifestyle, how to clean the genitals properly (from front to back), and immediately see a doctor if there are things that are not normal in the pubic area.7 the distribution of the frequency of prom events based on maternal age at sultan agung islamic hospital semarang can be seen in table3. based on table 3, mothers who experience prom often occur in mothers of age who are not at risk (20-35 years). this study is in line with other studiesthat mothers giving birth with prom are more than 20-35 years old. this is because the age of 20-35 years is a productive age for pregnancy.11 however, this is not in line with the theory which states that age < 20 years or > 35 years is at risk of prom.9 these different results can be caused by good antenatal care management. the distribution of the frequency of delivery types at the sultan agung islamic hospital in semarang is shown in table 4. table 4. frequency distribution of types of delivery at rsi sultan agung semarang in 2018-2020 type of delivery amount percentage sectiocaesarea 36 72% no caesarean section (vaginal) 14 28% total 50 100% based on table 4, it shows that from a total sample of 50 patients, 36 were delivered by cesarean section and 14 were delivered vaginally. these data indicate that the total incidence of cesarean section deliveries is 72%, which exceeds the national incidence of cesarean section deliveries. according to the ministry of health of the republic of indonesia in 2018, the incidence of sectiocaesarea in indonesia is 17.6% of the total number of deliveries.6 the high rate of cesarean section deliveries at the sultan agung hospital, semarang as a type b hospital is due to being an obstetrical referral from various health facilities such as clinics and health centers in the local area as well as referrals from district hospitals. efforts to minimize sectiocaesarea can be done by providing education to pregnant women for routine antenatal care as an early detection of risk factors for sectiocaesarea. sectiocaesarea delivery is carried out based on certain indications. indications for cesarean section delivery in 36 patients with cesarean section are shown in table5. table 3. distribution of the frequency of premature rupture of membranes based on maternal age at sultan agung hospital semarang in 2018-2020 incident premature rupture of membrane mother’s age total % at risk (<20 or >35 years) % no risk (20-35 years old) % premature rupture of membrane 2 4 17 34 19 38 no premature rupture of membrane 6 12 25 50 31 62 total 8 16 42 84 50 100 131 international journal of human and health sciences vol. 07 no. 02 april’23 table 5. indications for sectio caesarea delivery at sultan agung hospital semarang in 2018-2020 indication amount percentage premature rupture of membranes 10 27,77% former sc 8 22,22% severe preeclampsia 6 16,66% cpd 5 13,88% labor does not progress 5 13,88% plasenta previa 2 5,55% total 36 100% 2. bivariate analysis bivariate analysis to determine the relationship between the independent variable and the dependent variable with the chi square test (x2). pr (prevalence ratio) with the risk estimate statistical test to determine the risk. than 18 hours can increase the risk of infection in the fetus. previous research showed that prolonged prom (more than 18 hours) had 10 times the risk of neonatal infection.1 infection in the fetus causes fetal distress until it progresses to asphyxia due to insufficient oxygen and nutrients for the fetus. another condition for choosing cesarean delivery in prom patients is when oligohydramnios or induction failure is found.2prom causes oligohydramnios which can trigger compression of the umbilical cord to occur fetal hypoxia. the presence of oligohydramnios should be suspected of fetal distress. the more amniotic fluid that comes out will result in a smaller amount and if there are no signs of labor, the risk of fetal distress is even greater.12 this study is in line with previous research that the majority of prom patients who experienced asphyxia and were not asphyxia gave birth by sectio caesarea.4 the results of the continuity correction test obtained a p value of 0.039 (<0.05), which means that there is a significant (mean) relationship between the prom variable and caesarean section delivery. the results of the risk estimate statistical test obtained a pr value of 0.628 indicating that prom is a risk factor (pr>1) for sectiocaesarea which has a 0.628 greater risk for the occurrence of cesarean delivery. discussion premature rupture of membranes (prom) is the rupture of the membranes before the start of labor. the condition of oligohydramnios or fetal distress to intrauterine infection in term or preterm prom requires termination. termination can be done through induction of labor with bishop score evaluation before induction. if the induction of labor is successful, a vaginal delivery can be performed, but if the induction of labor fails or if there are obstetric abnormalities, a caesarean section is required.1,3 this study shows that there are 10 patients with prom who experienced cesarean section delivery (52.6%). the prom cases taken in this data are prom without other delivery complications and then a cesarean section is delivered. prom without complications of cesarean section delivery can be related to the duration of prom. the duration of prom more the study showed that 9 people with prom experienced vaginal delivery (47.4%). vaginal delivery is performed in prom patients due to success in labor induction. induction of labor is done in an effort to stimulate the onset of his. prom patients who had vaginal delivery were also caused by the absence of other complications, so there was no indication for sectio caesarea.12this study showed that there were 26 patients without table 6. chi square test(x2) premature rupture of membrane labor total p value pr sectiocaesarea no sectiocaesarea(vaginal) f % f % f % premature rupture of membrane 10 52.6 9 47.4 19 100 0.039 0.628 no premature rupture of membrane 26 83.9 5 16.1 31 100 total 36 72 14 28 50 100 international journal of human and health sciences vol. 07 no. 02 april’23 132 prom who underwent cesarean section delivery (83.9%). this shows that sectiocaesarea is not only performed in prom conditions. delivery by cesarean section is carried out on maternal and fetal indications. there were 5 patients without prom who experienced vaginal delivery (16.1%). this shows that the patient is a spontaneous parturition without other complications so that there is no indication for caesarean section. sectiocaesarea delivery is performed when the mother or fetus is at high risk and vaginal delivery is not possible.3 conclusion the results showed that there was a relationship between prom and delivery by cesarean section (p = 0.039). conflict ofinterest the authors state no conflict of interest. ethical clearance ethical clearance has been approved by the research ethics commission of the facultyof medicine, sultan agung islamicuniversity semarangwith the number 158/ec/kepk/2021. authors’ contribution study design: all authors. data gathering: mutiara delia subiyanto writing and submitting manuscript: yulice soraya nur intan editing and approval of final draft: all authors. references 1. boskabadi, h. & zakerihamidi, m. (2018) ‘evaluation of maternal risk factors, delivery, and neonatal outcomes of premature rupture of membrane: a systematic review study’, journal of pediatrics review, 7(2), pp. 77–88. doi: 10.32598/jpr.7.2.77. 2. byonanuwe, s. et al. (2020) ‘predictors of premature rupture of membranes among pregnant women in rural uganda: a cross-sectional study at a tertiary teaching hospital’, international journal of reproductive medicine, 2020, pp. 1–6. doi: 10.1155/2020/1862786. 3. cunningham, leveno, bloom, hauth, rouse, s. (2014) obstetri williams. 24th edn. new york: mcgraw-hill education. 4. febriani, s. r., garna, h., &mansyur, f. a. f. (2017) ‘perbandinganasfiksia neonatorum pada kejadianketubanpecah dini dan tidakketubanpecah dini serta hasil luaran bayi di rsud al – ihsan periodejanuari 2016–31 mei 2017’, prosiding pendidikan dokter, (3(2)), pp. 550–560. 5. ibishi, v. a., &isjanovska, r. d. (2015) ‘prelabour rupture of membranes: mode of delivery and outcome’, open access macedonian journal of medical sciences, 3(2), pp. 237–240. doi: https://doi. org/10.3889/oamjms.2015.037. 6. kementerian kesehatan republik indonesia (2018) laporan nasional riskesdas. jakarta: badan penelitian dan pengembangan kesehatan. 7. manuaba (2012) ilmukebidanan, penyakitkandungan, dan kb. jakarta: egc. 8. mochtar, r. (2012) sinopsisobstetri. 3rd edn. jakarta: egc. 9. nugroho, t. (2012) obsgynobstetri dan ginekologi :untukkebidanan dan keperawatan. yogyakarta: nuhamedika. 10. pogi (perkumpulanobstetri dan ginekologi indonesia himpunankedokteranfeto maternal) (2016) ‘pedoman nasional pelayanankedokteranketubanpecah dini’, in. 11. pradana, t. a. & surya, i. g. n. h. w. (2020) ‘karakteristik ibu bersalindenganketubanpecah dini (aterm& preterm) di rumahsakitumum pusat sanglah denpasar periodejuli 2015-juni 2016’, jurnalmedikaudayana, 9(1), pp. 92–97. 12. prawirohardjo, s. (2016) ilmukebidanan. 4th edn. jakarta: pt. bina pustaka sarwonoprawirohardjo. 13. rifiana, a. &hasanah (2018) ‘faktor-faktor yang berhubungandenganketubanpecah dini pada ibu bersalin di puskesmastanggeungciannjur’, ilmu dan budaya, 41(60), pp. 7001–7018. available at: http:// journal.unas.ac.id/ilmu-budaya/article/view/461. 14. weekes, c. r. & mahomed, k. (2017) ‘term prelabour rupture of membranes ( term prom )’, the royal australian and new zealand college of obstetrics and gynecologists, (july 2010), pp. 8–11. 15. who (2014) levels and trend maternal mortality. geneva: who press. 16. yoan putri praditia susanto (2019) ‘faktor-faktor yang berhubungan dengan penatalaksanakan persalinan sectio caesarea di rs tk. ii pelamonia makassar’, jurnal kesehatan delimapelamonia, 3(1), p. issn : 2597-7989. doi: https://doi.org/10.37337/ jkdp.v3i1.119. https://doi.org/10.3889/oamjms.2015.037 https://doi.org/10.3889/oamjms.2015.037 http://journal.unas.ac.id/ilmu-budaya/article/view/461 http://journal.unas.ac.id/ilmu-budaya/article/view/461 international journal of human and health sciences vol. 06 no. 03 july’22 298 original article evaluation of oral health status among pregnant women using oral hygiene indexsimplified (ohi-s) score sabrina farida chowdhury1, md. nazrul islam2, sadia akther sony3 abstract background:oral health of women is often neglected during pregnancy. we need to address this issue in a developing country’s perspective,as oral healthcare is not an integral part of antenatal protocols. objective: to evaluate the oral health status of pregnant women using oral hygiene index-simplified (ohi-s) score as well as explore oral hygiene practice by them and conduct a mini-assessment of their knowledge of oral health. methods: this cross-sectional, descriptive study was conducted using data by using a semi-structured questionnaire among 170 pregnant women attending an antenatal center in dhaka city, bangladesh,from march to august of 2018. a pre-tested semi structured questionnaire containing ohi-s indexwas used for data collection. dental mirror and probe were used for oral hygiene assessment. results: the mean age of the participants was 24.22±5.07 years. 140(82.4%) were found to use toothbrushes as a tooth-cleaning aid and 146(85.9%) used toothpaste as a tooth cleaning material. among them, 132(94.3%) were found to brush at least once a day. the predominant health problems identified by clinical examination among those pregnant women were gum bleeding, mild to severe periodontitis, halitosis (bad breath) and loose teeth. the majority didnot know the safe period of dental treatment and the consequences of having poor oral health during pregnancy. the overall oral hygiene status of the maximum pregnant women was ‘fair’ (50.6%) (ohi-s score 0-1.2), while 39.4% had ‘poor’ oral hygiene status (ohi-s score 1.3-3.0) and only 10% had ‘good’ oral hygiene status (ohi-s score 3.1-6.9). conclusion: pregnant women in bangladesh suffer from various oral health issues during pregnancy; however, they exhibit that they do not address this issue due to lack of awareness and other factors. hence, it is crucial to plan and implement effective oral health programmes for pregnant women all over the country. keywords: oral health status, oral hygiene index-simplified (ohi-s) score, pregnant women correspondence to: dr. sabrina farida chowdhury, lecturer, department of public health, faculty of modern science, leading university,ragib nagar, south surma, sylhet-3112, bangladesh. email: dr.sabrinachowdhury@lus.ac.bd 1. department of public health, leading university, ragib nagar, south surma, sylhet-3112, bangladesh. 2. department of public health,american international university-bangladesh (aiub), dhaka-1229, bangladesh. 3. department of public health and informatics, bangabandhu sheikh mujib medical university, dhaka-1000, bangladesh. international journal of human and health sciences vol. 06 no. 03 july’22 page : 298-303 doi: http://dx.doi.org/10.31344/ijhhs.v6i3.462 introduction pregnancy affects nearly every aspect of a woman’s life including her oral health. a good health of a pregnant woman is required for the wellness of herself and for her future child. hence, it is very important to practice and maintain healthy lifestyles during pregnancy. there are number of factors that may negatively influence wellbeing of a pregnant woman. hormonal changes, being unaware about necessity of oral health maintenance, negative oral health experience, and often improper oral 299 international journal of human and health sciences vol. 06 no. 03 july’22 health practices during pregnancy particularly can worsen oral health conditions and may lead to oral health problems in pregnant mothers.1-3 oral health problems in pregnant women come in different pattern and varying intensity. the milder and earlier form of periodontal disease can be simply gingivitis which can later progress to gingival enlargement, severe periodontitis, tooth mobility and even tooth loss.4report suggests that the prevalence of gingivitis in pregnant women ranges from 30% to 100%.1,4often, preexisting gingivitis in women may become severe in the first two months of pregnancy.5women with pregnancy gingivitis may sometimes develop localized gingival enlargements. the pregnancy induced vomiting canresult in dental erosion in pregnant women.6,7dental caries are also common during pregnancy.4the occurrence of dental caries may results from cravings for dietary items that are rich in sugar, increased acidity in the oral cavity, and limited attention to oral health during pregnancy.8untreated carious lesions may increase the incidence of abscess and lead to cellulitis in pregnant women.9prevalence of pregnancy tumour is 5% of all pregnancies and usually benign in nature. the favourable site for pregnancy tumor is gingiva and usually starts to appear after first trimester. it is harmless and resolves after delivery; however, sometimes, it requires excision.10another common problem is loose tooth,which is commonly associated with progressive periodontal disease at advanced stage among pregnant women. in absence of any gum problem, the increased levels of progesterone and estrogen can affect the periodontal structure and lead to loose teeth.11the significance of good oral health of pregnant mother lies in its impact on herself and her baby. poor oral health comes with negative consequences there are evidence from various studies that suggests that poor maternal oral health is associated with adverse pregnancy outcome and poor oral health of the offspring. this includes adverse outcomes like prematurity, low-birth weightinfants, and early dental caries in the infant.12-14 as poor maternal oral health brings negative outcome for both mother and child, special attention should be given on increasing oral health awareness among pregnant women.american college of obstetricians and gynecologists recognizes oral health is an integral part of preventive healthcare for pregnant women and their newborns.15unfortunately, in our country, oral healthcare is not an integral part of antenatal protocols. we lack guidelines, proper infrastructure at both rural and urban level hospitals as well as in private practice, and awareness among people. hence, we proposed to assess pregnant women’s oral health status and knowledge related to oral health and look at oral hygiene practices of the pregnant women as well. the findings of the present study are expected to create awareness and address the issues related to oral healthcare during pregnancy. methods this cross-sectional, descriptive study was conducted between march and august of 2018 in randomly selected healthcare centers situated in dhaka city, bangladesh, where pregnant women have access to anc services. the study population involved pregnant women aged between 16 and 45 years, who were interested to participate and able to understand the nature and purpose of the study. thus, informed consent was obtained from participants. privacy, anonymity, and confidentiality were strictly maintained. a total of 170 women were selected using convenience sampling technique.a pre-tested semi structured questionnaire containing ohi-s index16was used for data collection. dental mirror and probe were used for oral hygiene assessment.oral hygiene index-simplified (ohi-s) was calculated using debris index and calculus index; then ohi-s score was assigned to sum up oral hygiene status of the respondents. three levels of oral hygiene have been obtained; these are: good (ohi-s score 0-1.2), fair (ohi-s score 1.3-3.0) and poor (ohi-s score 3.1-6.9).16collected data were analyzed by spss (statistical package for social sciences)version 16.0. after data collection data entry was done. data analysis was summarized in form of proportion and frequency tables for categorical variables. continuous variables were summarized using means and standard deviation. results the mean age of the participants was 24.22±5.07 years. the majority (36.5%) of the pregnant mothers were in between 26 and 30 years. among the respondents, 77.6 percent were literate and has obtained at least primary level (36.5%), secondary level (25.9%), higher secondary level (14.7%) or graduate level education (0.6%) (table 1).regarding oral hygiene practice, the international journal of human and health sciences vol. 06 no. 03 july’22 300 tooth cleaning aids were found toothbrush, finger, and tree twig (miswak) among the respondents. 82.4% of the pregnant women reported to use toothbrush, whereas 11.8% cleaned their teeth by their finger and 5.9% of the respondents used tree twig (miswak) as a tooth cleaning aid (table-1). regarding tooth cleaning material, 85.9% of the respondents used tooth paste to clean their teeth, where 2.4% used tooth powder and 11.7% used charcoal powder (manjan/coal ash) to clean their teeth.in response to query about pregnant women’s frequency of teeth brushing practice among those who brushed their teeth with toothbrush (n=140), 94.3% respondents were found to brush at least once in a day (once-18.6%, twice or more 75.7%) (table-1). several oral health problems were found among the pregnant women. among the respondents, 64.1% reported halitosis (bad breath), 71.2% had gum bleeding, 43% had mild to severe periodontitis (shallow periodontal pocket in 35.9% and deep periodontal pocket in 7.1%) and 2.9% had one or more loose tooth (table-2).oral hygiene status of the respondents was categorized as ‘good’, ‘fair’ and ‘poor’ using simplified oral hygiene index (ohi-s index). the oral hygiene status of most of the respondents (50.6%) was ‘fair’ (ohi-s score 0-1.2), while 39.4% had ‘poor’ oral hygiene status (ohi-s score 1.3-3.0) and only 10% had ‘good’ oral hygiene status (ohi-s score 3.1-6.9) (table-2). pregnant women were asked three basic knowledge questions about oral health maintenance. among them, 61.2% knew fluoridebased toothpaste can prevent tooth decay. majority of the respondent did not know which trimester is safe for dental treatment during pregnancy (93.5%) and that poor oral health may negatively influence pregnancy outcome(97.1%) (table 3). table1: sociodemographic and behavioural characteristicsof pregnant women variables frequency (%) total number of respondents age group (in years) 16 -20 21-25 26-30 31-36 51(30.0) 44(25.9) 62(36.5) 13(7.6) n=170 mean±sd = 24.22±5.07 educational qualification illiterate literatea 38 (22.4) 132(77.6) n= 170 variables frequency (%) total number of respondents tooth cleaning aid tooth brush finger tree twig (miswak) 140(82.4%) 20(11.8%) 10 (5.9%) n=170 material used in tooth cleaning tooth paste tooth powder charcoal powder (manjan/ ash) 146(85.9) 4(2.4) 20(11.7) n=170 frequency of tooth brushing (in a day) not regular once twice or more 8(5.7) 26(18.6) 106 (75.7) n=140b a = literate: respondents who have attained at least primary level/secondary level/higher secondary level/equivalent/ graduate/equivalent level study. b = respondents who do not use toothbrush (n=30) as tooth cleaning aid were excluded. table2: pattern of oral health problems and oral hygiene status of pregnant women (n=170) variables frequency (%) oral health problems halitosis (bad breath) gum bleeding periodontitis (mild to severe) periodontal pocket 4-5mm periodontal pocket ≥6mm dental caries mobility of one or more teeth 109(64.1) 121(71.2) 73(43) 61(35.9) 12 (7.1) 53(31.2) 5(2.9) oral hygiene status* good fair poor 17 (10.0) 86 (50.6) 67 (39.4) *ohi-s score: good (0-1.2), fair (1.3-3.0) and poor (3.1-6.9) table3: knowledge related to oral hygiene status and oral hygiene practice among pregnant women (n=170) knowledge questions correct response frequency (%) incorrect response frequency (%) fluoride based toothpaste can prevent tooth decay. 105 (61.2) 65(38.8) the safe period of dental treatment during pregnancy is second trimester. 11 (6.5) 159 (93.5) poor oral health can negatively affect pregnant mother’s child. 5(2.9) 165(97.1) 301 international journal of human and health sciences vol. 06 no. 03 july’22 discussion oral health is an important determinant for the quality of life. acknowledging the fact, the world health organization (who)’s global oral health policy also emphasizes the importance of oral healthcare.17oral health problem is noticeably high among pregnant women across the globe, specifically in developing countries. if left untreated, oral health problems like gum disease and tooth decay of pregnant women may lead to adverse pregnancy outcomes and negatively influence her child.15,17 the findings related to teeth cleaning by pregnant women with toothbrush and fluoride-based toothpaste is also consistent with the findings of other studies done in bangladesh, india and uae.2,18-21majority of the respondents either were found with irregular in teeth cleaning or cleaning once a day. this finding is consistent with the studies reported previously.20-22 oral health changes during pregnancy are subject to physiological alterations and fluctuations in levels of oestrogen and progesterone due to pregnancy itself leads to increase sensitivity and irritation of gingiva.15,23also, oral acidic condition, low literacy, low income, negligence and unawareness about oral health, poor oral hygiene practices, not visiting dentist etc. affects negatively oral health conditions of pregnant women.10,23,24 with varying degree of occurrence, the oral changes during pregnancy includes gingivitis, periodontitis, loose tooth, pregnancy gingivitis, tooth erosion, dental caries, gingival hyperplasia, pyogenic granuloma etc.18-25major problems that were found among the pregnant women in the current study were halitosis (bad breath) (64.1%), gum bleeding (71.2%), mild to severe periodontitis (43%), dental caries(31.2%) and loose tooth (2.9%). the burden of periodontal disease among pregnant women is comparatively high than other oral health problems.the present study reported dental caries among 31.2%pregnant women which is lower than thatof previous findingsin bangladesh.18,19we also found 71.2% of the pregnant mothers had bleeding gum,which is much higher than study findings in india.21,22the overall oral hygiene status of the majority respondents (50.6%) was ‘fair’ (ohi-s score 0-1.2). this is consistent with the findings of kashetty et al., as they found that 55% of the pregnant women had “fair” oral hygiene status in karnataka, india.20 adequate oral health knowledge is essential to develop appropriate oral health practices that prevent oral diseases.15,17various literatures have reported positive association between oral health knowledge scores and oral health status.26-28 majority of the respondent did not know which trimester is safe for dental treatment during pregnancy (93.5%) and that poor oral health may negatively influence pregnancy outcome(97.1%). however, a relatively higher number of pregnant females (19.38%) of central india were aware of the fact that poor oral health can negatively affect their baby.22we felt that health education programmes need to be designed to familiarize pregnant women with appropriate oral hygiene practices to preserve their oral health and prevent possible negative consequences of poor oral hygiene during pregnancy, which is also supported by the literature.10,17,18-25 limitation of the study this was a survey with a limited sample. hence,the findings cannot be generalized. hence, further large-scale study needs to be carried out. however, the study provides insights into the oral health status and oral health knowledge and practice among pregnant women in dhaka city, which may contribute to literature and helps policy makers in formulating policy to promote oral healthcarefor the pregnant mothers. conclusion ensuring good oral healthcare during pregnancy not only improves the health of the pregnant mother, but also potentially the health of her future child. most of the pregnant women remain unaware of the potential consequences of neglecting oral hygiene and often defer oralhealth consultation during pregnancy. we do hereby address the need of various oral health education and health promotional interventions during pregnancy period. oral health assessment should be included in the prenatal checkup list at the antenatal clinics. besides, the findings of this study will provide international journal of human and health sciences vol. 06 no. 03 july’22 302 an idea to formulate evidence based oral health reinforcement programmes to minimize the gap in knowledge and practices related to oral hygiene and oral health among general population, too. acknowledgements: we would like to express our sincere appreciation to all the pregnant women who participated in the study and to the authority of the selected healthcare center for allowing and accommodating us to conduct the study. conflict of interest:the authors have no conflict to declare. ethical approval:the study was approved by the ethical review board (erb) of american international university-bangladesh (aiub), dhaka, bangladesh funding statement:this research did not receive any specific grant from any public, non-profit or commercial funding agencies. authors’ contribution: conceptualization and design of the study: sfc, mni; data collection, compilation and analysis: sfc, sas; manuscript writing, editing, revision and finalizing: sfc, mni, sas. references 1. onigbinde o, sorunke m, braimoh m, adeniyi a. periodontal status and some variables among pregnant women in a nigeria tertiary institution. ann med health sci res. 2014;4(6):852-7. 2. john s, almesmar hs. oral health status, oral hygiene practices, and factors affecting dental treatment utilization among pregnant women in dubai. dubai med j. 2021;4(4):320-8. 3. michalowicz bs, diangelis aj, novak mj, buchanan w, papapanou pn, mitchell da, et al. examining the safety of dental treatment in pregnant women. j am dent assoc. 2008;139(6):685-95. 4. centers for disease control and prevention (cdc). pregnancy and oral health. cdc. 2019. available from: https://www.cdc.gov/oralhealth/publications/ features/pregnancy-and-oral-health.html (accessed december 11, 2019). 5. srinivas sk, parry s. periodontal disease and pregnancy outcomes: time to move on? j women’s health. 2012;21:121-5. 6. laine ma. effect of pregnancy on periodontal and 303 international journal of human and health sciences vol. 06 no. 03 july’22 dental health. acta odontol scand. 2002;60(5):25764. 7. schroeder pl, filler sj, ramirez b, lazarchik da, vaezi mf, richter je. dental erosion and acid reflux disease. ann intern med. 1995;122(11):809-15. 8. hey-hadavi jh. women’s oral health issues: sex differences and clinical implications. women’s heal prim care. 2002;5(3):189-99. 9. giglio ja, lanni sm, laskin dm, giglio nw. oral health care for the pregnant patient. j can dent assoc. 2009;75(1):43-8. 10. silk h, douglass ab, douglass jm, silk l. oral health during pregnancy. am fam physician. 2008;77(8):1139-44. 11. scheutz f, baelum v, matee mim, mwangosi i. motherhood and dental disease. community dent health. 2002;19(2):67-72. 12. ide m, papapanou pn. epidemiology of association between maternal periodontal disease and adverse pregnancy outcomes – systematicreview. j periodontol. 2013;84(4 suppl):s181-94. 13. azarpazhooh a, tenenbaum hc. separating fact from fiction: use of high-level evidence from research syntheses to identify diseases and disorders associated with periodontal disease. j can dent assoc. 2012;78:c25. 14. lydon-rochelle mt, krakowiak p, hujoel pp, peters rm. dental care use and self-reported dental problems in relation to pregnancy. am j public health. 2004;94(5):765-71. 15. acog committee opinion no. 569: oral health care during pregnancy and through the lifespan. obstet gynecol. 2013;122(2 pt 1):417-22. 16. greene jc, vermillion jr. the simplified oral hygiene index. j am dent assoc. 1964;68:7-13. 17. petersen pe. global policy for improvement of oral health in the 21st century – implicationstooral health research of world health assembly 2007, world health organization. community dent oral epidemiol. 2009;37(1):1-8. 18. nabi m, karim ammn, rashid smmu. pattern of oral diseases and associated contributing factors in pregnant women attending a maternity center in dhaka city, bangladesh. jopsom.2020;39(1):50-9. 19. rahman mm, hassan mr, islam mz, ahmad ms, alam mm, islam kmm. oral health status of pregnant women attended the mothers and children welfare center (mcwc) in bangladesh. city dent coll j. 2013;10(2):1-4. 20. kashetty m, kumbhar s, patil s, patil p. oral hygiene status, gingival status, periodontal status, and treatmentneeds among pregnant and nonpregnant women: a comparative study. j indian soc periodontol. 2018;22(2):164-70. 21. gupta s, jain a, mohan s, bhaskar n, walia pk. comparative evaluation of oral health knowledge, practices and attitude of pregnant and nonpregnant women, and their awareness regarding adverse pregnancy outcomes. j clin diagn res. 2015;9(11):zc26-32. 22. payal s, kumar gs, sumitra y, sandhya j, deshraj j, shivam k, et al. oral health of pregnant females in central india: knowledge, awareness, and present status. j educ health promot. 2017;6:102. 23. yenen z, ataçağ t. oral care in pregnancy. j turk ger gynecol assoc. 2019;20(4):264-8. 24. gil-montoya ja, leon-rios x, rivero t, expósitoruiz m, perez-castillo i, aguilar-cordero mj. factors associated with oral health-related quality of life during pregnancy: a prospective observational study. qual life res. 2021;30(12):3475-3484. 25. naseem m, khurshid z, khan ha, niazi f, zohaib s, zafar ms. oral health challenges in pregnant women: recommendations for dental care professionals. saudi j dent res. 2016;7(2):138-46. 26. parker ej, jamieson lm. associations between indigenous australian oral health literacy and selfreported oral health outcomes. bmc oral health. 2010;10:3. 27. deinzer r, micheelis w, granrath n, hoffmann t. more to learn about: periodontitis-related knowledge and its relationship with periodontal health behaviour. j clin periodontol. 2009;36(9):756-64. 28. sony sa, haseen f, islam ss, chowdhury sf. knowledge and practice of oral health and hygiene and oral health status among school going adolescents in a rural area of sylhet district, bangladesh. community based med j. 2021;10(1):30-6. s31 case report: eclampsia in a post covid-19 patient ehsan rosdi1 covid-19 infection has attracted many clinicians and researchers to study its disease process and complications, as it is not only causing respiratory problems, but also affecting pregnant mothers and their babies. many recent studies have shown that covid-19 infection increases the risk of developing preeclampsia via its effect on the placenta. this case highlights covid-19 infection as one of the emerging risk factors for the development of preeclampsia and eclampsia. a 26 years old patient, primigravida at 28 weeks of pregnancy with no known underlying condition, was presented with oneday history of visual disturbance, and two-week history of epigastric pain and vomiting. she had an uncomplicated covid-19 infection category 2 at 20 weeks of pregnancy. during the assessment, she was alert but lethargic looking. vital signs showed a blood pressure of 176/98 mmhg, a pulse rate of 98 per minute, spo2 of 97% and a capillary sugar level of 5.8 mmol/l. she then developed an eclamptic episode which prompted immediate delivery of the baby via emergency caesarean section. postdelivery, magnesium sulphate infusion was started, and her blood pressure was controlled with labetalol. subsequently, she was discharged well after one week of admission. the baby with a weight of 800g was admitted to the neonatal icu for further care. there have been studies that showed covid19 infection affecting the placenta via its effect on angiotensin-converting enzyme 2 (ace2). this enzyme is responsible for the haemostasis of maternal circulation and its downregulation will lead to a cascade of events that is similar to the pathogenesis of preeclampsia. further research and evidence are needed to study this enzyme with the hopes to prevent the development of preeclampsia and eclampsia. keywords: preeclampsia, eclampsia, covid-19, angiotensin-converting enzyme 2 ___________________________________________________________________________ 1 hospital kuala lumpur, malaysia. correspondence to: mohamad ehsan bin mohamad rosdi, medical officer, hospital kuala lumpur (malaysia). email: sca0610@gmail.com _______________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v6i0.421 mailto:sca0610@gmail.com international journal of human and health sciences vol. 06 no. 01 january’22 108 original article three-jaw chuck pinch strength and its correlation with hand breadth in electronic technicians shahnawaz akter1, moushumi taher asha2, shamim ara3, segupta kishwara4, sunjida shahriah5 abstract context: the three jaw chuck pinch refers to an act where placing the object between the pad of the distal phalanx of the thumb opposing the pads of the distal phalanges of both the index finger and the middle finger. pinch strength is generally influenced by the  health status and level of physical activity of a person. objectives: the present study was planned to measure the correlation of three-jaw chuck pinch strength with hand breadth in electronics technicians working in dhaka metropolitan city. the data obtained from the study used as a base line for other professions as well as for research in our country. methods: a cross-sectional, analytical study was carried out in the department of anatomy, dhaka medical college, dhaka during the period of july’ 2015 to june’ 2016 with 100 adult male electronics technicians and 100 adult sedentary workers. collection was done by convenient purposive sampling technique. hand breadth was measured by digital slide calipers and pinch gauge was used to measure the three-jaw chuck pinch strength. results: the mean three-jaw chuck pinch strength was significantly higher (p<0.05) in case group  than in the control group. significant difference also observed between case group and  control group in the mean hand breadth (p<0.05). mean hand breadth was greater in case  group  than  that  of  control  group.  three-jaw  chuck  pinch  strength  showed  significant  positive correlation with hand breadth in case group. case group was further subdivided according to their working experiences, the mean three-jaw chuck pinch strength and hand breadth was significantly higher (p<0.05) in more working experience group than  in less working experience group. conclusion: three-jaw chuck pinch strength showed significant positive correlation with hand breadth. keywords: three-jaw chuck pinch, pinch, pinch gauge, hand breadth correspondence to: dr shahnawaz akter, assistant professor, department of anatomy, marks medical college & hospital, mirpur-14, dhaka, bangladesh. email: himupoly2005@gmail.com 1.  assistant  professor,  department  of anatomy,  marks  medical  college  &  hospital,  mirpur-14,  dhaka, bangladesh. 2. assistant professor, department of anatomy, bashundhara ad-din medical college, dhaka, bangladesh. 3. professor and head, department of anatomy, holy family red crescent medical college, dhaka, bangladesh. 4. professor and head, department of anatomy, dhaka medical college, dhaka, bangladesh. 5.  professor  and  head,  department  of anatomy,  marks  medical  college&  hospital,  mirpur-14,  dhaka, bangladesh. international journal of human and health sciences vol. 06 no. 01 january’22 page : 108-112 doi: http://dx.doi.org/10.31344/ijhhs.v6i1.385 introduction the human hand is a prehensile part of upper limb endowed with grasping and precision movements for skill works. prehensile movements of the hand have been described as three basic forms of grip, namely precision, power and hook grips. in precision grip, an object is held by the pulp surface of the thumb and the fingers which  place themselves opposite to each other and small movements of the digits are carried out skillfully. pinch grip is an example of precision 109 international journal of human and health sciences vol. 06 no. 01 january’22 grip.1 despite the technological advancements in many manufacturing industries, hands and fingers are still primary tools for high precision  manufacturing work.2 the human hand is one of the most sophisticated and complex anatomical structures in the body.3 it  is  not  a  fixed,  static  structure but a dynamic sensory motor organ.4to perform such sophisticated functions the human hand has been equipped with both mechanical and sensory capabilities.3 non powered hand tool operation and manual assembly are the typical activities, in which pinching is usually applied.5 the human hand is capable of pinching, moving and placing objects without rough impact because of  the  softness  of  human  finger  tips.6 pinch strength is categorized as isometric strength. 7 pinch strength is the backbone of pinch grip. the majority of the inward force is generated by the long flexor tendon of forearm. this force is  balanced by one or more fingers of the same hand  applying a force back towards the thumb. strength of the fingers is greatly influenced by the flexion  and extension of the wrist. 8 pinch strength depends on factors such as occupation, grip span, position of the thumb, position of the elbow and position of the arm, torque directions, contact surface orientations, object shape and size. manual labourers exert stronger three-jaw chuck pinch compared to sedentary and skill labourers.9 there are four types of pinch techniques such as three-jaw chuck pinch, pulp pinch, tip pinch and lateral pinch.6 in threejaw chuck pinch the palm faced down, force was exerted between the pad of the index and middle fingers together and the pad of the thumb, through  the centre of the opposing pads .10 the muscles that contribute to pinch grips include both the intrinsic and extrinsic musculatures of hand and forearm. 11 activities of daily living tasks require constant pinch strength. workers in various occupations such as electronics technicians, rock climbers, musicians, dentists, carpenters use pinch techniques for their daily work.12according to ager, cited by ertem, et al, pinch strength increases from early childhood towards adolescence and with increasing age pinch strength decreases.13 pinch strength exertions by males on dominant hand was found to be significantly higher.3 electronics service technicians are responsible for installing and repairing home electronics equipment. they use pinch grip for high precision tasks, such as connecting or disconnecting wires, assembling small electronics parts. the present study aims to see the correlation of pinch strength and hand breadth between the electronics technicians of dhaka metropolitan city and sedentary workers of the same region. materials and methods a cross-sectional, analytical study, was carried out in the department of anatomy, dhaka medical college, dhaka during the period of july’ 2015 to june’ 2016 with 100 adult male electronics technicians (case group) and 100 adult male sedentary workers (control group), age ranging from 25-45 years both the groups residing in dhaka metropolitan city. 100 participants of case group was further divided into two subgroups according to their working experience. among them 53 were in less working experience (5-10 years) group and 47 were in more working experience (1115 years) group. electronics technicians should have minimum 5 years working experience were selected  from  different  electronics  repair  shops  of dhaka, and they used tools like screwdrivers, impact drivers, tweezers etc for their work handling them using three-jaw chuck pinch. sedentary worker had no prior experience in jobs which involve the use of tools requiring the use of three-jaw chuck pinch. after obtaining informed written consent from all the study subjects data were documented in a pre-designed data sheet. prior to consent they were explained the aim and purpose of the research. the subjects were assured of the confidentiality of the study.  exclusion criteria: 1. congenital deformity of hand such as syndactyly, polydactyly etc. 2. acquired hand deformity due to burn contracture, fracture or any surgical procedure of hand. after collection of data, statistical analysis was done by the software, spss (statistical package for social sciences) for windows, version 22.0. all data were expressed as mean ± sd (standard deviation) as appropriate. mean values of different  parameters were compared to see the differences  between two groups by using student’s unpaired ‘t’ test. correlation was done by pearson’s correlation coefficient test. the pinch strength measurements were recorded by a pinch gauge, which is inexpensive, easy to administer, and are considered to provide international journal of human and health sciences vol. 06 no. 01 january’22 110 repeatable measurements, with the subject sitting on a chair with the elbow flexed at 90o and wrist in neutral position. subjects were asked to exert his maximal voluntary contraction (mvc) on the pinch gauge and to hold that force for three second. to overcome the fatigue, subject was given one minute resting period between each exertion (figure: 1). mean value of three exertion was taken  into account. hand breadth was measured by slide calipers as a straight distance from the radial side of the second metacarpophalangeal joint to the ulnar side of the fifth metacarpophalangeal joint  (figure:2).  fig: 1 photograph showing measurement of three jaw chuck pinch strength by using pinch gauge fig. 2. photograph showing measurement of hand breadth results mean three-jaw chuck pinch strength was 7.80±0.77 kg and 13.96±1.46 kg and mean hand breadth was 80.01±1.55 mm and 86.38±2.32 mm in control group and case group respectively (table  1).  significant  difference  was  observed  between control group and case group in the mean three-jaw chuck pinch strength and hand breadth (p<0.001) where mean three-jaw chuck pinch strength and hand breadth was greater in case group than that of control group. mean three-jaw chuck pinch strength of less working experience group (5-10 years) and more working experience group (11-15 years) was 12.75±0.85kg and 15.32±0.47kg and mean hand breadth was 85.07±1.72mm and 87.86±2.01mm respectively  (table  2).  statistically  significant  difference  was  observed  between  less  working  experience group and more working experience group in the mean three-jaw chuck pinch strength and in hand breadth (p<0.001), where mean threejaw chuck pinch strength and hand breadth was lower in less working experience group than that of more working experience group (table 3). table 1: comparison of threejaw chuck pinch strength and hand breadth between control group and case group variable control group (n=100) (mean ± sd) case group (n=100) (mean ± sd) p value threejaw chuck pinch strength in kg 7.80 ± 0.77 (5.90 – 9.20) 13.96 ± 1.46 (11.10 – 16.50) 0.001* hand breadth in mm 80.01 ± 1.55 (74.23 – 84.10) 86.38 ± 2.32 (80.00 – 90.75) 0.001* figure in parentheses indicate range.sd=standard deviation, comparison between control and case was done by unpaired student’s ‘t’ test, ns= not significant,  *=significant, control group = sedentary worker, case  group = electronics technicians table: 2 comparison of threejaw chuck pinch strength and hand breadth between different sub  group of case group variable less working experience group (n=53) (mean ± sd) more working experience group (n=47) (mean ± sd) p value threejaw chuck pinch strength in kg 12.75 ± 0.85 (11.10 – 14.30) 15.32 ± 0.47 (14.50 – 16.50) 0.001* hand breadth in mm 85.07 ± 1.72 (80.00 – 88.20) 87.86 ± 2.01 (81.50 – 90.75) 0.001* figure in parentheses indicate range, sd=standard deviation, comparison between different subgroup  of cases was done by unpaired student’s ‘t’ test, 111 international journal of human and health sciences vol. 06 no. 01 january’22 ns=not significant, *=significant, sub group of case  group was done depending on working experience in year, less working experience group = 5 – 10 years, more working experience group = 11 – 15 years. table 3: correlation of three –jaw chuck pinch strength with hand breadth in control group and case group variable control group case group r value p value r value p value hand breadth +0.122 p=0.226 ns +0.629 p<0.001* statistical analysis done by pearson’s correlation coefficient (r) test, * = significant, ns = not significant. discussion pinch  has  been  identified  as  a  basic  yet  crucial  skill for daily task performance, and is used to assess general strength in order to determine work capacity. pinch strength is one of the most important parameters of hand function. regular exercise improves pinch strength. any deterioration in pinching ability can impair activities of daily living. in this study, correlation of three-jaw chuck pinch strength with hand breadth was discussed. electronics technicians were selected for the present study on the basis of the observation that they regularly and repeatedly use pinch grip hundreds and thousands of times a day to get firm  hold  of  the  instrument  to  disassemble  and  reassemble equipment parts. sedentary workers do not use the three-jaw-chuck pinch in their work. the results of the present study were compared with the studies carried out by imrhan and rahman, didomenico and nussbaum, dempsey and ayoub, mohammadian et al., and kaushik and patra,p., in the present study, the mean three-jaw chuck pinch strength of control group and case group was 7.80±0.78 kg and 13.96±1.47 kg respectively. the mean three-jaw chuck pinch strength was significantly higher (p<0.0001) in case group than  in control group. dempsey and ayoub found 6.6±2.19 kg mean three-jaw chuck pinch strength.14 mohammadian, et al. found 10.3±2.7 kg mean three-jaw chuck pinch strength.15 the mean three-jaw chuck pinch strength of case group in this study was significantly higher (p<0.0001) than the findings  of dempsey and ayoub and mohammadian et al. in the present study, the mean three-jaw chuck pinch strength was recorded 12.75±0.85 kg in less working experience group (5-10 years) and 15.32±0.47 kg in more working experience (1115 years)group. the mean three-jaw chuck pinch strength was significantly higher (p<0.0001) in the  more working experience group than in the less working experience group. kaushik and patra reported 16.23±2.10 kg mean three-jaw chuck pinch strength in the group with 6-9 years working experience, 16 which was significantly higher (p<0.0001) than that for less  working experience group of the present study, and the researcher also recorded 13.42±2.43 kg mean three-jaw chuck pinch strength in the group with 10-14 years working experience which was significantly  lower  (p<0.0001)  than  that  of  the  more working experience group of the present study. the mean hand breadth was 80.01±1.55 mm and 86.38±2.32 mm in control group and case group respectively.  there  was  significant  difference  observed between control group and case group in the mean hand breadth (p<0.001). mean hand  breadth was greater in case group than that of control group. in the present study three-jaw chuck pinch strength showed significant positive  correlation with hand breadth in case group (r=+0.629, p<0.001).  in contrary, imrhan and rahman recorded 80.0±4.0 mm and didomenico and nussbaum reported 88.0±5.0 mm mean hand breadth.17,10 the mean hand breadth of didomenico and nussbaum was significantly  higher  (p<0.0001)  and  mean  hand  breadth of imrhan and rahman was significantly  lower(p<000.1)  than  the  findings  of  the  present  study. dempsey and ayoub found 83.7±6.4 mm and mohammadian, et al. recorded 89.9±4.4 mm mean hand breadth.14,15 the mean hand breadth of mohammadian, et al. was significantly higher  (p<0.0001) and the mean hand breadth of dempsey  and ayoub was significantly lower (p<000.1) than  the findings of the present study. the researchers  also  found  nonsignificant  positive  correlation  between the three-jaw chuck pinch strength and hand breadth (r= +0.493, p<0.05) and significant  positive correlation between the three-jaw chuck international journal of human and health sciences vol. 06 no. 01 january’22 112 pinch strength and hand breadth (r= +0.16, p<0.05) respectively.  conclusion in this study, the three-jaw chuck pinch strength was significantly higher in electronics technicians.  significant  positive  correlation  between  three-  jaw chuck pinch strength and hand breadth in electronics technicians was found. in case group, the more experienced subgroup had significantly  higher three-jaw chuck pinch strength than the less  experienced  subgroup.  besides,  significant  difference in hand breadth was observed between  the  sub-group.  the  study  findings  suggest  the  repetitive work increases three-jaw chuck pinch strength. the cause of increase hand breadth needed to be evaluated by further study. conflict of interest: none declared. funding statement: no funding. ethical approval issue: ethical clearance has been taken from the ethical review committee (erc) of dhaka medical college, dhaka, bangladesh. author contributions: conception and study design: sa, sa; data collection, compilation and analysis: sa, mta; manuscript writing, literature review, revision and finalizing: sa,mta, sa, sk, ss.  references: 1. salmons s. muscles. in: williams lp. ed. gray’s anatomy, 38th ed, london: churchill livings stone, 1995; 733-889. 2. ng  kp,  et  al.  the  effects  of  size  on  pinch  force.  international postgraduate conference on aerospace, manufacturing and mechanical engineering. 2015;1(1):1-10. 3. dianat i, feizi h, hasan-khali k. pinch strength in healthy iranian children and young adult population. health promotion perspectives, 2015;5(1):52-8. 4. shim hj, et al. normative measurements of grip and pinch strength of 21st century korean popution. arch plast surg. 2012;40(1):52-6. 5. shih c, chen l, huang s. the effect of splints on  peak strength, sustaining time, and total force generation  at  different  pinching  types.  journal  of the chinese institute of industrial engineers. 2005;22(2):134-42. 6. ng kp, et al. a review of different   pinch techniques.  theoretical issues in ergonomics science. 2014;15(5):517-33. 7. chandra ma, et al. a comparative assessment of the  impact  of  different  occupations  on  worker’s  static musculoskeletal fitness. international journal of occupational safety and ergonomics (jose). 2007;13(3):271-8. 8. de s, et al. age and sex related variation of pinch strength among adult bengalee population. developments in agricultural and industrial ergonomics. 2005;1(1):1-11. 9. ng kp, et al. pinch effort variations with torques,  shape, size, sensation and technique. j. applied science. 2014;14(5):401-14. 10. didomenico, a. and nussbaum, a.m. measurement and  prediction  of  single  and  multi-digit  finger  strength. ergonomics. 2003;46(15):1531-48. 11. ng kp, saptari a. a review of shape and size consideration in pinch grips. theoretical issues in ergonomics science. 2014;15(3):305-17. 12. jansen swc, et al. measurement of maximum voluntary    pinch    strength:  effects    of    forearm   position and outcome score. j hand ther, 2003; 16(4): 326-36. 13. ertem k, et al.   effects of dominance, body mass,  index and age on grip and pinch strength. isokinetics and exercise science. 2003;11(4):219-23. 14. dempsey gp, ayoub mm. the influence of gender,  grasp type, pinch width, and wrist position on sustained pinch strength. international journal of industrial ergonomics. 1994;17(3):259-73. 15. mohammadian m, et al. investigation of grip and pinch strengths in iranian adults and their correlated anthropometric and demographic factors . work. 2015;53(2):1-9. 16. kaushik a, patra p. upper extremity and neck disability in male hairdressers with concurrent changes in pinch strength: an observational study. healthline. 2014;5(2):46-52. 17. imhran ns, rahman r. the effect of pinch width on  pinch strengths of adult males using realistic pinchhandle coupling. international journal of industrial ergonomics. 1994;16(2):123-34. s27 quadriceps femoris ultrasonography: a tool to assess nutritional status and prognosticate mortality outcome in adult mechanically ventilated patients zulaikha zahir1, ariffin marzuki1, saedah ali1, ahmad tarmizi2, kamarul azmanie kamaruzaman3 objective: intensive care unit (icu) patients possess higher nutritional risk due to their heterogeneity of demographic factors and disease trajectories upon hospitalization. mnutric score was used to classify them into high nutritional risk; hnr (score ≥5) or low nutritional risk; lnr. these hnr patients have been shown to have significant muscle loss during icu stay which led to significant adverse outcomes. thus, skeletal muscle ultrasonography was introduced as a tool to assess the nutritional status thus predicting their disease outcome. methods: a prospective cohort study involving 60 patients was conducted in hospital universiti sains malaysia, whereby blood parameters, skeletal muscle thickness, and nutritional intake measurement of the patients were recorded during their icu stay. the adverse outcome such as duration of mechanically ventilated days, hospitalisation days and mortality events were recorded. the serial percentage decline of quadriceps femoris thickness is then used to prognosticate mortality. results: overall, the recruited patients had a mean apache ii score of 13, sofa score of 8, charlson comorbidity index score of 3.3, and the average score for mnutric score is 3.6. this study revealed that 85% of our patients received optimal nutritional delivery by an average of 2.6 days. the hnr patients had a significant percentage of skeletal muscle thickness decline by day 5, with ≥7.80% decline that can predict mortality. however, there were no statistically significant changes in mechanical ventilated days and hospitalisation days. conclusion: ultrasonography of quadriceps femoris was perceived as a new emerging utility as a surrogate tool to assess nutritional status and predict mortality. serial scanning of quadriceps femoris was seen as a more dynamic approach to evaluate the degree of muscle wasting, thus alarming for an earlier method for nutritional optimisation, early muscle rehabilitation and patient mobility which may reduce morbidity and mortality of these patients. keywords: mnutric score, critical ill nutrition, ultrasonography, quadriceps femoris, mortality ___________________________________________________________________________ 1department of anaesthesiology and intensive care unit, hospital universiti sains malaysia. 2department of radiology, hospital universiti sains malaysia. 3department of dietetic and nutrition, hospital universiti sains malaysia correspondence to: zulaikha zahir, dr. , hospital universiti sains malaysia, malaysia, zulaikha88zahir@gmail.com __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v6i0.417 mailto:zulaikha88zahir@gmail.com microsoft word ijhhs imam 23rd asc 2022 s30 case series: palliative care challenges in head and neck cancer patients mohamad zulfadhli abdullah1, nor amalina abd latif1 , siti khairizan rahim2  head and neck cancer cases are increasing and there were 4870 new cases reported by malaysian national cancer registry in the year 2020. most of the cases are aggressive and diagnosed in the advanced stage. in pusat perubatan universiti sains malaysia, bertam (ppusmb), the commonest head and neck cancer cases referred to the palliative care team are lip and oral cavity cancer, followed by maxillary squamous cell carcinoma. we reviewed 10 cases of head and neck cancer and analysed the challenges in managing pain, wound and nutrition. we have selected 10 cases of head and neck cancer referred to the palliative care team between the year 2019 to 2022. the patients were aged between 38 to 77 years old and in the advanced stage of cancer. the cases selected consist of six cases of tongue cancer, two cases of maxillary squamous cell cancer and two cases of lip cancer.  the most challenging pain symptom was during brachytherapy, radiotherapy session and pain from the wound. the highest cumulative dose of opioids (oral morphine milligram equivalent) required was 660 mg morphine in 24 hours for a patient with tongue cancer. most of the wounds developed were due to the cancer progression and after radiotherapy. caretakers and nurses handling the wounds faced challenges to find suitable types of dressings as most of the cases have non-healing wounds with excessive discharge and tendencies to bleed. most of the patients had difficulties feeding orally and percutaneous gastrostomy tube feeding was the best option to maintain nutritional support in this population. palliative care is an approach to improve the quality of life of these patients and their caretakers. they manifest a diverse range of physical symptoms but pain control, wound care and nutritional support are the most challenging parts encountered by both caretakers and the palliative care team. keywords: head and neck cancer, palliative care, pain, wound care, nutrition. 1. pusat perubatan universiti sains malaysia, bertam, pulau pinang 2. internal medicine, pusat perubatan universiti sains malaysia, bertam, pulau pinang __________________________________________________________________________________ correspondence to: mohamad zulfadhli abdullah, medical officer, pusat perubatan universiti sains malaysia bertam, pulau pinang, malaysia, zulab2994@usm.my __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v7i70.532 editorial review article review article review article original article original article original article original article original article original article original article original article original article original article original article case report case report international journal of human and health sciences vol. 07 no. 01 january’23 table of contents faculty development in medical education: what, why and how. salam a1, abdelhalim at2, begum h3, pasha ma4. effect of physical activityon insulin resistance in diabetes mellitus aiesha mohammed almutawa1, noorah saleh al-sowayan1 dogs, mental stress and the human heart: role of cortisol and neuropeptide y devarajan rathish1-2, rajapakse peramune vedikkarage jayanthe rajapakse2, kosala gayan abeysundara dissanayake weerakoon3 prevalence and trends of overweight and obesity among children and adolescents in turkey: ameta-analysis cansev meşe yavuz morphometric study of the asterion in adult dry human skulls of nigerian origin okoro ogheneyebrorue godswill1, wilson josiah iju2, o. a. udi1, ahama endurance efe2, igben vincent-junior onoriode3, enaohwotaniyohwo mamerhi2, inikoro charity4, owhefere great owhefere2 antenatal risk factors of children with cerebral palsy: an experience of center for the rehabilitation of the paralysed (crp) in bangladesh md. anwar hossain1, saida sharmin2, atia afrin3, tunazzina shahrin4, mahabub hossain5 quality of life and activity of daily living of ischaemic stroke patients in northeastern of peninsular malaysia: the effect of bal-ex stroke home rehabilitation nurzaitil aswani zainuddin1,2, juwita shaaban1, rosediani muhamad1, zuraida zainun3, azzyati muhamad nor4, najib majdi yaacob5, siti suhaila mohd yusoff1, rosnani zakaria1 and nani draman1. characterization of the sociodemographic and reproductive profiles of patients with cervical intraepithelial neoplasia and cervical cancer from rajshahi medical college hospital, bangladesh saifeen parvin1, kajol akter2 histopathological and biochemical effects of aqueous fruit extract of balaniteaegyptiaca on selected organs of mice solomon matthias gamde1, usman wali2, aminu garba3, daniel dansy agom4, haruna mallah ayuba5 combating the covid-19 pandemic: experience of a tertiary care children hospital in dhaka, bangladesh nobo krishna ghosh1, sharmin afroze2, erfan ahmed3 high dietary consumption of iodine induced thyroid cytotoxicity in diabetic intoxicated rats via oxido-nitrergic mechanism queen eiza bisi ozegbe1, gideon nimedia aitokhuehi2, oyovwi mega obukohwo3, adesoji adedipe fasanmade2, lawrence dayo adedayo4, onome bright oghenetega5 effect of comorbidities on antibody status following covid-19 vaccination – a comparison between sars-cov-2 infected and non-infected healthcare professionalsin dhaka, bangladesh rimpi romana1, forhadul hoque mollah1, miliva mozaffor2, shohana akter3, tanusri chakraborty4, fahmida sharmin5 a comparative study of suicide cases in pre-covid and covid phases anamika nath1, pradip kumar thakuria1, aditya madhab baruah1 the utility of antibiogram in prevention of hearing impairment caused by chronic suppurative otitis media (csom): a prospective study from rural area of maharashtra, india sabiha saleem tamboli1, saleem b tamboli2 smoking turnover intentionamong active tobacco smokers during the covid-19 pandemic in kathmandu, nepal bhuvan saud1, saroj adhikari2, neetu amatya1, harish singh thapa3, govinda paudel1, shankar shahi4, pravin kumar yadav2 epstein-barr virus-negative associated with sinonasal lymphoepithelial carcinoma –a rare case report mohamad najib salleh1,2, nurul syuhadah hasny1, ramiza ramza ramli1, sakinah mohamad1, norasnieda md shukri1, nusaibah azman3, faezahtul arbaeyah hussain3 lethal complicationin a newly diagnosed patient with hypertension najwan mustafa alsulaimi 03 09 15 20 31 35 40 48 54 60 67 75 81 86 91 97 103 microsoft word ijhhs imam 23rd asc 2022 s28 sinonasal lymphoma: a rare pathology presenting with common post-influenza symptoms muhamad ariff sobani1, noor shahira mohamad fuzi1, intan kartika kamarudin1,2, norazila abdul rahim1,2, nik mohd hazleigh nik hussin1,2  sinonasal malignancies are uncommon and only account for 3% of head and neck cancers. despite diffuse large b-cell lymphomas (dlbcl) being the most common type of non-hodgkins lymphoma occurring at various extranodal sites, its occurrence as a sinonasal tumor is exceedingly rare. early detection and treatment of sinonasal lymphoma, have favourable outcomes with improvements in the 2-year and 5-year survival rates. we are reporting a case of primary sinonasal dlbcl in a 63-year-old lady who initially presented with nasal obstruction and epistaxis, both common symptoms in patients who have had a recent influenza a infection. however, due to the unilaterality and progressive nature of her nasal obstruction, she warranted a specialist otorhinolaryngology assessment. naso endoscopy revealed a unilateral nasal mass extending from the right middle meatus to the nasal floor and was friable with contact bleeding. these clinical findings are similarly seen in most of the various types of sinonasal malignancies, and diagnosis can be challenging. pathologists rely upon immunohistochemical staining profiles to differentiate this highly heterogeneous group of malignancies. histopathological examination confirmed the diagnosis of sinonasal lymphoma. the treatment of this rare pathological entity is discussed. keywords: sinonasal lymphoma, epistaxis, unilateral nasal mass, diffuse large b-cell lymphoma 1. department of otorhinolaryngology, head and neck surgery, hospital al-sultan abdullah uitm, universiti teknologi mara, selangor, malaysia 2. department of otorhinolaryngology, head and neck surgery, faculty of medicine, universiti teknologi mara, selangor, malaysia ___________________________________________________________________________ correspondence to: intan kartika kamarudin, senior lecturer and otorhinolaryngology head and neck surgeon, department of otorhinolaryngology head and neck surgery, universiti teknologi mara, malaysia, kartika@uitm.edu.my __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v7i70.530 international journal of human and health sciences vol. 06 no. 02 april’22 200 original article: the relationship between food myths and the incidence of anaemia among pregnant women in the third trimester of pregnancy aghnia ilma izzati1, didik gunawan tamtomo2 , setyo sri rahardjo3 abstract background: nutrition in pregnant women is an important factor affecting maternal and fetal health. anaemia is one of the problems in pregnancy. lack of protein and iron intake is one of the factors causing anaemia. cultural beliefs and knowledge such as food myths and taboos can give bad impacts on maternal and child health. objective: to determine the relationship between food myths and the incidence of anaemia among pregnant women in the third trimester of pregnancy. materials and methods: this observational research used a cross-sectional design. the determination of the subject used a simple random sampling and the obtained samples were puskesmas margasari, puskesmas kesambi, and puskesmas lebaksiu. the population was pregnant women in the third trimester of pregnancy in tegal district with the subject of 120 pregnant women. the data were collected using a food myth questionnaire. data were analysed using chi-square. result: there was a relationship between belief in food myths and the incidence of anaemia among pregnant women in the third trimester of pregnancy in tegal district (p-value: 0.002). keywords: food myths, anemia, pregnant women correspondence to: aghnia ilma izzati, postgraduate program of nutrition science, sebelas maret university, indonesia, e-mail : aghniaizzati13@gmail.com 1. postgraduate program of nutrition science, sebelas maret university, indonesia. 2. faculty of public health, sebelas maret university, indonesia 3. faculty of medicine, sebelas maret university, indonesia international journal of human and health sciences vol. 06 no. 02 april’22 page : 200-203 doi: http://dx.doi.org/10.31344/ijhhs.v6i2.446 introduction anaemia in pregnant women is a global problem and is a serious health problem as it can affect fetal development, premature birth, infectious diseases, and maternal and fetal death1. a total of 40% of maternal deaths in the world are associated with anaemia2. anaemia in pregnant women is caused by a lack of iron intake3. the recommended iron needs in the first trimester of pregnancy are 18 mg/day and increase to 27 mg/day4 in the third trimester. thus, if the increased need for iron is not balanced with the consumption of sufficient iron sources can cause anemia5. the global prevalence of pregnant women with anaemia reaches 38% (32.4 million)2. in indonesia in 2013 pregnant women with anemia reached 37.1% and increased to 48.9% in 20186. however, the prevalence of anemia in pregnant women in central java in 2015 was 50%6 while in tegal district it reached 3416 pregnant with anaemia (12.7%) in 2018 with an increase to 3909 pregnant with anaemia (13.6%) in 20197. food intake is related to a person’s belief in consuming food, resulting in a habit and the emergence of a food myth culture3. food myths are assumptions in a culture that are believed to have the truth for recommended and prohibited foods to be consumed during pregnancy8. cultural beliefs and knowledge such as myths about food restrictions can have a negative impact on maternal and child health8. the socio-culture of each region also contributes 201 international journal of human and health sciences vol. 06 no. 02 april’22 to dietary behavior, especially for pregnant women and usually, there is a belief in food myths that limits the consumption of certain foods. in java, myth related to pregnancy is passed down from one generation to the next to maintain the advice of the ancestors even though the truth has not been proven. therefore, there are myths or beliefs during pregnancy that affect dietary habits or behavior8. the food myth in bojonegoro is that pregnant women have taboos on eating pineapple and fishy foods. belief in pineapple society can cause hot uterus and cause miscarriage. food myths like do not consume food that are fishy, such as fish, because they are believed to cause the baby and amniotic fluid to smell fishy and cause bleeding during childbirth8. in central java, there is a food myth for pregnant women not to eat eggs and meat because they are believed to complicate childbirth and cause bleeding9. food myth in india that pregnant women are prohibited from eating papaya, fish, peanuts, acidic foods, and green vegetables. papaya is believed to cause miscarriage, fish causes itching in babies, vegetables are believed to cause reduced movement of babies in the womb10. materials and method this observational study used a cross-sectional design. the target population were third trimester pregnant women in tegal district. the total of 115 pregnant women were included in this study. reserve is added 10% in anticipation of the subject dropping out so that the subject becomes 120. the sample was determined using the simple random sampling technique obtained puskesmas margasari, puskesmas kesambi, and puskesmas lebaksiu. inclusion criteria were the third trimester of pregnancy, antenatal care at puskesmas margasari, puskesmas kesambi, or puskesmas lebaksiu. the exclusion criteria were pregnant women with mental disorders. the independent variable was the food myths. the dependent variable was anemia among pregnant women in the third trimester of pregnancy. data collected through interviews include the identity of the subject and data about food myths. food myth data were collected using a questionnaire containing some of the food restrictions and the reasons is available in the questinare. data were analyzed using chisquare. result the characteristics of the respondents are presented in table 3. a total of 56 pregnant women (46.7%) experienced anaemia, while 64 pregnant women (53.3%) did not experience it. a total of 44 pregnant women (36.7%) believed in food myths and 76 pregnant women (63.3%) did not believe them. table 1. characteristics of respondents characteristics total % incidence of anaemia anaemia 56 46,7 not anaemia 64 53,3 food myths believe 44 36.7 not believe 76 63.3 table 2 shows that 35 anaemic pregnant women (47.3%) believe in food myths and 39 pregnant women (52.7%) do not believe in food myths. in the group of non-anaemic pregnant women, 9 pregnant women (19.6%) believed in food myths and 37 pregnant women (80.4%) did not believe them. the bivariate test obtained a p-value of 0.002 which means that there is a relationship between believing in food myths and the incidence of anaemia in pregnant women. pregnant women who believe in food myths are at risk of developing anaemia even though the or effect is only 0.271. table 2. the relationship between belief in food myths and the incidence of anaemia among pregnant women in tegal district variable incidence of anemia p value or anemia not anemia n % n % myths 0.002believe 35 47.3 9 19.6 0.271 not believe 39 52.7 37 80.4 total 74 100 46 100 discussion based on the results of the study, 44 pregnant women still believe in food myths during pregnancy. the bivariate analysis indicated that food myths were related to the incidence of anaemia in pregnant women with a p-value of 0.002 although the risk was very small as seen by international journal of human and health sciences vol. 06 no. 02 april’22 202 the or value of only 0.271. the results of this study are supported by martini and haryanti (2015) who found that food myths have an effect on the incidence of anaemia in pregnant women11 . a study by mohammed et al (2019) revealed that believing in food myths during pregnancy had a 2.21% risk of developing anaemia than mothers who don’t believe them12 . belief in food myths can be influenced by cultural perceptions. cultural perception is thought through the stages of selection, organization and interpretation including values, beliefs, strategy, expectations that take place comprehensively that determine actions, attitudes and habits. one of the problems resulting from cultural perceptions is the food myths in pregnant women13 . the food myth believed by pregnant women in this study is that pregnant women are prohibited from eating fish as it is believed to cause the baby and amniotic fluid to smell fishy. pregnant women are also prohibited from consuming seafood such as shrimp because they are believed to complicate the delivery process. furthermore, eating eggs is also believed to complicate the delivery process. the restriction to consume certain foods of animal protein is in contrast with science. protein needs during pregnancy increase especially in the third trimester14 . protein needs in the first trimester reach 61 g/day, 70 g/day in the second trimester, and 90 g/day in the third trimester4. pregnant women need nutritious food intake with high bioavailability, such as foods from animals and their refined products. pregnant women need more protein nutrition during pregnancy for physical changes, blood plasma composition, changes in metabolism, and the growth of the fetus. consumption of protein as a macronutrient is important as the main component of haemoglobin which is an indicator of anaemia is protein15 . restriction in consuming high nutrients foods that are recommended during pregnancy becomes a problem for pregnant women. therefore, it limits the type of food consumed by pregnant women and causes a lower intake of nutrients. limitations of this study researchers did not analyze food intake in pregnant women and other influences related to anaemia. suggestions for further studies the researcher hopes that further studies will analyze food intake so that it can be seen the relationship between food myths and food intake and its relation to the incidence of anaemia. conclusion there is a relationship between belief in the food myths during pregnancy and the incidence of anaemia among pregnant women in the third trimester of pregnancy in tegal district with a p-value of 0.002. conflict of interest the authors state no conflict of interest ethical clearance this research has been declared ethically feasible by the research ethics committee of the faculty of medicine, sebelas maret university no:43/ un27.06.6.1/kep/ec/2021. acknowledgement the authors highly appreciate nutritionists and midwives at puskesmas margasari, puskesmas kesambi, and puskesmas lebaksiu as well as village cadres who have assisted in this study. authors’ contribution study design: all authors data gathering: aghnia writing and submitting manuscript: aghnia editing and approval of final draft: all authors 203 international journal of human and health sciences vol. 06 no. 02 april’22 references 1. soh, k. l. et al. anemia among antenatal mother. j. biosci. med. 03, 6–11 (2015). 2. who. anaemia policy brief. world health organization 1–7 www.who.int (2014). 3. nuraeni, r., sari, p., martini, n., astuti, s. & rahmiati, l. peningkatan kadar hemoglobin melalui pemeriksaan dan pemberian tablet zat besi pada program ‘gerakan jumat pintar’. j. pengabdi. kpd. masy. (indonesian j. community engag. 5, 200 (2019). 4. kemenkes. angka kecukupan gizi untuk masyarakat indonesia. kementrian kesehatan ri hukor.kemkes. go.id (2019). 5. astuti, d. & kulsum, u. pola makan dan umur kehamilan trimester iii pada kejadian anemia pada ibu hamil. indones. j. kebidanan 2, 26–28 (2018). 6. kemenkes. laporan nasional riset kesehatan dasar 2018. kementrian kesehatan ri 1–582 www.kemkes. go.id (2018). 7. dinkes kabupaten tegal. laporan bumil kek dan anemia kabupaten tegal. dinas kesehatan kabupaten tegal bidang kesehatan keluarga dan gizi dinkes.tegalkab.co.id (2019). 8. muthoharoh, h. pandangan ibu hamil tentang budaya dan mitos kehamilan. j. promosi kesehat. 7, 55–65 (2015). 9. praditama, a. d. pola makan pada ibu hamil dan pasca melahirkan di desa tiripan kecamatan berbek kabupaten nganjuk. j. e-biomedik 4, 2–6 (2016). 10. jaiswal, s., singh, s., yadav, a. & shankar, r. food taboos and social beliefs among pregnant women in the rural population of varanasi district. indian j. prev. soc. med 49, 36–40 (2018). 11. martini, s. & haryanti, t. tabu makanan terhadap kejadian anemia pada ibu hamil trimester ii. j. kesehat. ibu dan anak akad. kebidanan an-nur 1, 1–8 (2015). 12. mohammed, s. h., taye, h., larijani, b. & esmaillzadeh, a. food taboo among pregnant ethiopian women. nutr. j. 18, 1–9 (2019). 13. alifka, d. s. hubungan pantangan makanan terhadap risiko kekurangan energi kronik pada ibu hamil. j. med. hutama 02, 278–286 (2020). 14. kocyłowski, r. et al. assessment of dietary intake and mineral status in pregnant women. arch. gynecol. obstet. 297, 1433–1440 (2018). 15. friday, l. c., hakimi, m. & kandarina, b. i. efektivitas makanan tambahan olahan ikan untuk ibu hamil trimester iii di kota yogyakarta. ilmu gizi indones. 4, 59 (2020). microsoft word ijhhs imam 23rd asc 2022 s26 covid-19 and spectrum of vestibular dysfunctions: a case report intan kartika kamarudin1 covid-19 infection had shown to affect multiple systems. a positive covid-19 case with multiple vestibular problems, its management and a review of the literature were reported. a 63-year-old lady who was a category 5 covid-19 infection patient, complicated by mild frontal stroke, left isolated mononeuropathy causing foot drop, had persistent dizziness lasting hours to days in the first month after being extubated. she underwent vestibular rehabilitation which did not resolve her vertigo. upon presentation to the vestibular clinic at 3-months post-extubation, she complained of vertigo on changing positions lasting a few seconds with dizziness in between. her dizziness handicap inventory (dhi) was severe, with severe abnormal depression anxiety stress scale 21 (dass 21). vestibular assessments showed oculomotor abnormalities with positive left posterior benign paroxysmal positional vertigo (bppv) on dixhallpike test. during epley maneuver, there was canal conversion to the anterior canal which was resolved with a deep head hanging maneuver. the canal repositioning maneuver was done in serial, and her vertigo reduced tremendously. her video head impulse test showed abnormalities in all semicircular canals bilaterally, rotatory chair showed lateral vestibular weakness and videonystagmography showed abnormal smooth pursuit, saccade and optokinetic suggesting central lesion. her cervical and ocular vestibular evoked myogenic potential were normal reflecting normal saccular and utricular function. tympanometry showed type a bilaterally with right mild and left mild to moderate sensorineural hearing loss. magnetic resonance imaging of the internal acoustic meatus showed bilateral vascular loop with no cerebellopontine angle tumour. upon review three months later, the patient was asymptomatic of vestibular complaint with normal dhi and dass21 score. her foot drop had also resolved.  evidence in the literature showed up to 16.8% of covid-19 patients reported vestibular symptoms. the mechanism of this vestibular neuritis is unclear but may be similar to the pathogenesis causing anosmia or vasculopathy. keywords: covid-19, vestibular dysfunction, multicanal bppv, vestibular neuritis, vertigo 1. department of otorhinolaryngology head and neck surgery, universiti teknologi mara, malaysia.  ___________________________________________________________________________ correspondence to: intan kartika kamarudin, senior lecturer and otorhinolaryngology head and neck surgeon, department of otorhinolaryngology head and neck surgery, universiti teknologi mara, malaysia, kartika@uitm.edu.my _______________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v7i70.528 161 international journal of human and health sciences vol. 02 no. 03 july’18 case report: preservation of lingual nerve in excision of bilateral submandibular sialolith via intraoral approach: a case report nasir msnm1, ibrahim r2, abdullah b3 abstract salivary gland stone (sialolithiasis) is most common disease of the salivary gland and mainly occur at the submandibular gland. traditionally, sialolithiasis is removed via an extra-oral approach but the major disadvantages of this treatment include a risk of injuring the lingul nerve, marginal mandibular nerve and scar formation. in this case report, we revealed an even less invasive intraoral surgical technique for the removal of sialolith that does not affect the submandibular gland function with the preservation of lingual nerve. this report describes a patient who had unusual bilateral submandibular gland sialolith that posteriorly located,which successfully removed via intraoral approach without any postoperative complications. keywords: sialolithiasis, submandibular gland, lingual nerve. correspondence to: mohd shaiful nizam bin mamat nasir, department of otorhinolaryngology-head & neck surgery, school of medical sciences, universiti sains malaysia health campus, 16150 kota bharu, kelantan, malaysia & department of otorhinolaryngology, hospital tengku ampuan afzan, 25100 kuantan, pahang, malaysia.email: drshaiful10@gmail.com 1. mohd shaiful nizam mamat, department of otorhinolaryngology, hospital tengku ampuan afzan, 25100 kuantan, pahang, malaysia 2. rohaida ibrahim, department of otorhinolaryngology, hospital tengku ampuan afzan, 25100 kuantan, pahang, malaysia 3. baharudin abdullah, department of otorhinolaryngology-head & neck surgery, school of medical sciences, universiti sains malaysia health campus, 16150 kota bharu, kelantan, malaysia introduction sialolithiasis is a disease characterised by the development of salivary stones, known as calculi or sialoliths, in the salivary ducts or in the salivary gland themselves. more than 80% of salivary sialoliths occur in the submandibular gland or in its duct, 6–15% in the parotid gland and about 2% in the sublingual and minor salivary gland1-2. its estimated frequency is 1.2% in the adult population, with a slight male predominance3. flow of saliva against gravity, longer secretory duct, its more alkaline ph and the high mucin and calcium content could explain the preferential stone formation in the submandibular gland5. one of the important nerve that closely related with submandibular gland and its duct is lingual nerve. it supplies the general sensation to the mucosa of the anterior two-thirds of the tongue, the sublingual mucosa, the mandibular lingual gingiva and the floor of the mouth6-7. in the excision of submandibular gland cases, problems arise due to formation of scar, alteration of dermal sensation, taste formation, also functional problems such as the reduction of salivation. because of such problems, recently, in the treatment of submandibular duct stones, efforts have been made to preserve the submandibular gland (9-10). case summary a 24 year old male presented to our department for the chief complaint of the postprandial swelling at the left submandibular area of neck. this symptom was initiated one years ago and getting increase in size. it was associated with increase in severity of pain and swelling before and during meal followed by gradual relief by itself. international journal of human and health sciences vol. 02 no. 03 july’18 page : 161-163 doi: http://dx.doi.org/10.31344/ijhhs.v2i3.47 international journal of human and health sciences vol. 02 no. 03 july’18 162 in physical examination, a diffuse swelling was seen on the left submandibular area about 3cm x 3cm, slight tenderness but firm in consistency. surprisingly, in intraoral examination, 2 firm swelling can be felt over both right and left floor of the mouth. considering the history and physical examination, a provisional diagnosis of submandibular duct stones was made hencecomputed tomography of the neck was performed. the result showed two rounded opacity likely suggestive of the calculus located at the superomedial to the submandibular gland measuring 1.2cm x 0.9cm on the right side and 0.8cm x 0.9cm on the left side (figure 1). other laboratory investigations were within normal limits figure 1: ct showed calculus seen at the superomedial to the bilateral submandibular gland (arrow). figure. 2: lingual nerve identified and preserved. (arrow) in view of patient was young and avoidance of external scar, so we planned to remove the stones by intraoral approach to preserve the submandibular gland in general anaesthesia. intra-operatively two calculi were removed by taking incision at the floor of mouth opposite third lower molar tooth bilaterally. we manage to located and preserved lingual nerve intraoperatively (figure 2). post operatively patient made an eventful recovery and was put on our regular outpatient follow up. discussion choice of treatment for sialolithiasis is depend on the location and size of calculus. ideally, intraoral approach is preserved when the sialolith is easily palpable and located in the distal third of the gland. but, in patient with intraglandular calculus and associated with recurrent infection may require submandibular sialoadenectomy13. the intraoral access for the removal of calculus is quite efficient and less harmful in relation to sialoadenectomy, as gland function is maintained. advantages of the intraoral approach include, less risk of iatrogenic injury to the marginal mandibular nerve, avoidance of an external scar, minimal risk of postoperative mucocele formation, or inflammation of wharton’s duct11. preuss et al retrospectively analyzed 258 patients treated with excision of the submandibular gland through intraoral access and found a low percentage of complications12. preservation of gland function with low risk of surgery for the patient should be primary objective in the treatment of sialolithiasis, furthermore in young and healthy patient like in our case. conclusion in summary, intraoral technique is an excellent treatment of choice for removal of submandibular sialolithwith preservation of the submandibular gland. as in this present case described here, our young patient showed complete resolution of the symptoms, which there were no injury to the lingual nerves as well as in the duct apparatus of the submandibular gland. 163 international journal of human and health sciences vol. 02 no. 03 july’18 references: 1. g. seifert, diseases of salivary glands, springer, berlin, germany, 2000. 2. iro h, zenk j, escudier mp, nahlieli o, capaccio p, katz p, brown j, mcgurk m. outcome of minimally invasive management of salivary calculi in 4,691 patients. the laryngoscope. 2009 feb 1; 119(2):2638. 3. mcgurk m, escudier mp, brown je. modern management of salivary calculi. british journal of surgery. 2005 jan 1; 92(1):107-12. 4. nahlieli o, eliav e, hasson o, zagury a, baruchin am. pediatric sialolithiasis. oral surgery, oral medicine, oral pathology and oral radiology. 2000 dec 1; 90(6):709-12. 5. mathew cherian n, vichattu sv, thomas n, varghese a. wharton’s duct sialolith of unusual size: a case report with a review of the literature. case reports in dentistry. 2014; 2014. 6. chung kw, chung hm. gross anatomy. 6th ed. lippincott williams & wilkins; 2008. 7. erdogmus s, govsa f, celik s. anatomic position of the lingual nerve in the mandibular third molar region as potential risk factors for nerve palsy. journal of craniofacial surgery. 2008 jan 1; 19(1):264-70. 8. hald j, andreassen uk. submandibular gland excision: short-and long-term complications. orl. 1994; 56(2):87-91. 9. novotny gm. submandibular sialolithiasis: transoral excision. the journal of otolaryngology. 1989 dec; 18(7):354-6. 10. gross bd. sialolithiasis: diagnosis and treatment. lda journal. 1979; 37(2):9-13. 11. hong kh, kim yk. intraoral removal of the submandibular gland: a new surgical approach. otolaryngology—head and neck surgery. 2000 jun; 122(6):798-802. 12. preuss sf, klussmann jp, wittekindt c, drebber u, beutner d, guntinas-lichius o. submandibular gland excision: 15 years of experience. journal of oral and maxillofacial surgery. 2007 may 1; 65(5):953-7. 13. lee lt, wong yk. pathogenesis and diverse histologic findings of sialolithiasis in minor salivary glands. journal of oral and maxillofacial surgery. 2010 feb 1; 68(2):465-70. microsoft word ijhhs imam 23rd asc 2022 s32 an adolescent with hodgkin lymphoma health seeking behaviour and the primary health care response noor faridzatul ain mohd noor1 and aneesa abdul rashid1 hodgkin lymphoma (hl) accounts for approximately 10 percent of all lymphomas. hl is a type of lymphoma that accounts for around 7% of childhood cancers. lymphoma is a rare form of cancer that must be diagnosed and treated immediately for a better outcome. this case study illustrates how a 17-year-old adolescent and his family battled a sickness that they had never heard of before. he presented with severe cough and systemic symptoms including night sweats, weight loss or fever. on his physical examination, there was no palpable peripheral lymphadenopathy. the biochemical results showed increased c-reactive protein and a neutrophilic leukocytosis of approximately 15,500 leukocytes per microliter. chest radiograph revealed a significant left-sided pleural effusion and a large mediastinal mass measuring 10 cm. he was screened for tuberculosis at the health clinic and found to be normal findings. to accelerate diagnostic procedures, the patient was admitted to the internal medicine department. chest computed tomography showed a large anterior mediastinal mass, causing effect and compression onto adjacent great vessels and left the main bronchus, associated with moderate left pleural effusion, as confirmed by histopathology findings. although hl is mainly managed in a hospital setting, primary care plays a vital role in this study; the importance of recognizing patients with social-related problems, such as financial constraints or logistic issues to avoid this becoming a barrier to seeking treatment in health care facilities. this case commentary discusses the delay in identifying such a high-risk patient at the primary care level, who was later diagnosed with hl. essential role through effective education, supportive care, and symptom management, can play an important role to help them make the right decision in obtaining healthcare services and further treatment for a better outcome. keywords: hodgkin lymphoma, adolescents, psychosocial impact, delayed treatment 1. department of family medicine, faculty of medicine and health sciences, universiti putra malaysia, 43400 serdang, malaysia ___________________________________________________________________________ correspondence to: aneesa abdul rashid, associate professor and medical lecturer, department of family medicine, faculty of medicine and health sciences, universiti putra malaysia, 43400 serdang, malaysia, aneesa@upm.edu.my   __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v7i70.534 209 international journal of human and health sciences vol. 07 no. 03 july’23 editorial: team based learning: sponsoring small group benefits in large group setting. abdelhalim at1, salam a2. keywords: team based learning, collaborative interactive learning, small group benefits in large group teaching. correspondence to: dr abdus salam, consultant medical educationalist and public health specialist, associate professor and head of medical education unit, faculty of medicine, widad university college, bandar indera mahkota, 25200 kuantan, pahang, malaysia. email: abdussalam.dr@gmail.com. orcid id: https://orcid. org/0000-0003-0266-9747. 1. abdelbaset taher abdelhalim, faculty of medicine, paediatric and pharmacology unit, widad university college, malaysia. 2. abdus salam, faculty of medicine, medical education unit, widad university college, malaysia. team based learning: sponsoring small group benefits in large group setting. team-based learning (tbl) is an innovative small group teaching–learning method in a large group class1,2. tbl initiates with the students’ homework, during which they study an advance task or assignment allocated by the lecturer and then take part in the readiness assurance test (rat) to determine their knowledge on the assigned task. the rat comprises of an individual readiness assurance test (irat), followed by the same test among multiple groups as group readiness assurance test (grat), with immediate feedback and the opportunity to change answer options of individual test questions. after the rat, discussions are done on the difficult materials and also on the rest of the subject by the lecturer. tbl implies active learning process that promote students’ higher-level cognitive skills in addition to learning of factual material3,4,5. this paper briefly determines the students’ expression on tbl following the attendance of a tbl session in a malaysian private university. the paper may be of help to get thought to initiate tbl in educational institutions. a tbl session was conducted as a preliminary transformative process from traditional lecture to innovative tbl at widad university college (wuc), malaysia in june 2023. a cross-sectional study was conducted among all 21 first year, semester-2 undergraduate medical students who attended the tbl session. it was a class of pharmacology on the topic titled ‘antibiotic’. the relevant teaching materials were sent few days before the scheduled lecture class by the assigned lecturer to all students for an understanding of the topic. on the scheduled class-day at the beginning of class, an individual readiness assurance test (irat) was carried out utilising one-best answer questions (oba) on different aspects of the topic ‘antibiotic’. after completion of irat, all the 21 students were divided into five groups comprising four to five students in each group. the same irat was then used as group readiness assurance test (grat) among the groups and students appealed and changed the answer options of the same test after discussion with team members. after grat, clarification was given on difficult materials that were poorly understand by the students and immediate feedback to the students was provided by the assigned lecturer. at the end, the tbl session was evaluated by administering a simple questionnaire containing different aspects of tbl, rated by a 5-point likert scale ranging 1 as poor and 5 as very good, along with open ended questions about their liking, disliking and suggestion for improvement. among 21 participants, 20 students responded, giving a response rate of 95%; where all the participants rated good to very good on different aspects of tbl ranging 5-15% as good and 85100% as very good (section-a, table-1). analysis of the results of irat and grat revealed that there were some corrections made by some of the international journal of human and health sciences vol. 07 no. 03 july’23 page : 209-211 doi: http://dx.doi.org/10.31344/ijhhs.v7i3.576 mailto:abdussalam.dr@gmail.com international journal of human and health sciences vol. 07 no. 03 july’23 210 students after discussion in grat and there were improvements of students’ performance. this finding has similarity with previous studies1,6,7, where weaker students benefited more from the tbl. in response to open ended questions such as their liking, disliking and suggestion for future improvement, it is revealed that students like the tbl session very much, as the session was interesting to them and help them to have a great understanding on the subject. students perceived that they learn from mistake with the help of the team mates. learning from mistake is one of the principles of learning. students like the team work in discussing and solving questions and they suggested to add more questions, so that the team members can share their ideas on how to solve the questions. table-1: perspectives of students about tbl at wuc, n=20 section-a: aspects of tbl poor-1 satisfactory-2 unsure-3 good-4 very good-5 n (%) n (%) n (%) n (%) n (%) general aspect introductory session 3 (15) 17 (85) individual readiness assurance test 2 (10) 18 (90) group readiness assurance test 1 (5) 19 (95) team activities 20 (100) teaching materials 20 (100) attitudinal aspect desire to have more tbl session 2 (10) 18 (90) usefulness aspect overall usefulness of the tbl class 2 (10) 18 (90) section-b: open ended questions and responses what did you like on the tbl session you attended? giving space by sitting in group helps us to share our ideas about the topic. team working between members helps in fixing misunderstanding and solving questions. moving to be more interested in subject; boosting understanding; learning from mistake. helping to understand the topic much better; realising how deep i understand the topic. an eye-opener and a good way to learn new stuffs or re-learn some topics. what did you dislike on the tbl session you attended? if we don’t continue this tbl as soon as feasible, it would be unfortunate. discomfort regarding late notice for tbl grouping. working in team, its normal that some feels not good in the subject and tend to stay quiet. nothing to be dislike, so far. any suggestion for improvement of tbl in future? to increase the number of questions and by that we can discuss more about it among us and increase our knowledge together. questions format must not only be in one best answer. it should be nice if we are able to have this program in longer period of time. -to further promote ongoing comfortability with one another, groups can be formed and broken by the students themselves and it would be great if we can shuffle it for next tbl. tbl should be conducted for all of the subject. the tbl is an educational tool to be practiced in making the teaching more interactive, collaborative and interesting aimed to increase learners’ efficiency. tbl differs from problembased learning (pbl) where there is no need of multiple faculty and multiple rooms for tbl3. the four crucial principles in tbl are: (i) teams/groups must be rightly formed, (ii) students must be made liable for their individual and group activities, (iii) group works must promote both learning and team development, and (iv) students must have immediate feedback3. tbl is a new way to teach students in general, and medical students in particular to make it more collaborative, interactive and interesting and more learners directed with lecturers’ guidance aimed to develop higher order cognitive skills among future human capital3. 21st century is a time of rapid development in science and technology which leads people striving to continuously improve upon themselves and gain more knowledge and skills8. teaching is an interaction between a teacher and learners in order to provide opportunities for learning9. the roles of teachers are now changing from deliverer of materials to a more creative, designer and facilitator of learning10. this paper offers 211 international journal of human and health sciences vol. 07 no. 03 july’23 a window to the teachers’ family around the globe in developing a transformative progression from traditional lecture to innovative tbl skills and thereby sponsoring benefits of small group teaching in a large group setting. the ultimate aim is to produce competent and confident future leader or human capital. educational manager should implement tbl in medical schools in order to produce competent and confident human capital. acknowledgement the authors would like to thank the first-year semester-2 medical students of academic session 2023 at widad university college for their participation in this study. funding no funding was received for this paper. conflict of interest the authors declared no conflicts of interest. authors’ contribution both the authors conceptualised, designed, analysed, drafted and finalised this paper and approved for submission to the journal for publication. references: 1. salam a, mohamad n, siraj hh, kamarudin ma, yaman mn, bujang sm. team-based learning in a medical centre in malaysia: perspectives of the faculty. the national medical journal of india 2014; 27(6):350. 2. parmelee d, michaelsen lk, cook s, hudes pd. team-based learning: a practical guide: amee guide no. 65. med teach 2012; 34:e275–e287. doi:10.310 9/0142159x.2012.651179. 3. salam a, bujang sm, kamarudin ma, yaman mn, siraj hh, mohamad n. preparedness of the teachers for team-based learning: liking, disliking and suggestions of faculty. j app pharm sci, 2016; 6(03):077-080. available online at http://www. japsonline.com doi: 10.7324/japs.2016.60313 issn 2231-3354. 4. thompson bm, schneider vf, haidet p, levine re, mcmahon kk, perkowski lc, richards bf. teambased learning at ten medical schools: two years later. medical education 2007; 41:250-257. doi:10.1111/ j.1365-2929.2006.02684.x 5. nieder gl, parmelee dx, stolfi a, hudes pd. teambased learning in a medical gross anatomy and embryology course. clin anat 2005; 18:56-63. doi: 10.1002/ca.20040. 6. koles pg, stolfi a, borges nj, nelson s, parmelee dx. the impact of team-based learning on medical students’ academic performance. acad med 2010; 85:1739-1745. 7. levine re, o’boyle m, haidet p, lynn dj, stone mm, wolf dv, et al. transforming a clinical clerkship with team learning. teach learn med 2004; 16:270275. 8. salam a. best teaching method used, very good in teaching, the best lecturer ever: secrets of teaching online during covid-19 pandemic. int j of human and health sci 2021; 05(04):377-380. doi: http:// dx.doi.org/10.31344/ijhhs.v5i4.346. 9. salam a. tea to entertain outcome based education for 21st century educators to produce safe human capitals for a sustainable global development. int j of human and health sci 2022; 06(02): 153-154. doi: http://dx.doi.org/10.31344/ijhhs.v6i2.437 10. salam a, yousuf r, allhiani rf, zainol j. continuous assessment in undergraduate medical education towards objectivity and standardization. int j of human and health sci 2022; 06(03):233-236. doi: http://dx.doi.org/10.31344/ijhhs.v6i3.453 http://dx.doi.org/10.31344/ijhhs.v5i4.346 http://dx.doi.org/10.31344/ijhhs.v5i4.346 http://dx.doi.org/10.31344/ijhhs.v6i2.437 http://dx.doi.org/10.31344/ijhhs.v6i3.453 233 international journal of human and health sciences vol. 06 no. 03 july’22 editorial: continuous assessment in undergraduate medical educationtowards objectivity and standardization salam a1, yousuf r2, allhiani rf3, zainol j4 keywords: continuous assessment, medical education, objectivity, standardization correspondence to: dr. abdus salam, associate professor and head of medical education unit and community medicine unit, faculty of medicine, widad university college, bandar indera mahkota, 25200 kuantan, pahang, malaysia. email: abdussalam.dr@gmail.com orcid id: https://orcid. org/0000-0003-0266-9747 1. abdus salam, medical education unit and community medicine unit, faculty of medicine, widad university college, malaysia. 2. rabeya yousuf, blood bank unit, department of diagnostic laboratory services, hospital canselor tuanku muhriz, universiti kebangsaan malaysia (ukm) medical centre, malaysia. 3. rajaa fahad allhiani, medical education department, faculty of medicine, king abdulaziz university, saudi arabia. 4. jamaludin zainol, surgery unit and dean faculty of medicine, and deputy vice-chancellor (academic and internationalisation), widad university college, malaysia. international journal of human and health sciences vol. 06 no. 03 july’22 page : 233-236 doi: http://dx.doi.org/10.31344/ijhhs.v6i3.453 assessment is an essential component of teachinglearning in higher education. it determines the extent of students’ learning or achievements over the course of study1. teaching and assessment are the two sides of the same coin2. teaching without testing is similar to cooking without tasting3. educational testing or assessment thus drives learning, and learning ultimately drives practices4. learning results in a change in learners’ behaviours5. undergraduate medical education aims to produce doctors in the region who are safe, competent and confident and able to meet the health needs of the community while also being able to continuing medical education6. the medical curriculum is designed with specific content to meet societies’ demands by having competent medical doctors to offer quality medical care to their communities and clients worldwide7. in an effectively designed curriculum, course objectives reflect the assessment content8. the objectives fall into three domains: knowledge, skills, and attitudes. knowledge objectives address cognitive measures ranging from being able to recall factual events to integrating processes for problem-solving and creation. skills objectives involve psychomotor aspects needed to be an efficient clinician. attitude objectives relate to the personal qualities of the learner and their approach to medicine, patients and their peers8. knowledge is assessed by written examinations such as multiple-choice questions (mcq), modified essay questions (meq), short answer questions (saq), and key feature questions (kfq). the mcqs can be multiple true-false (mtf), single best answer (sba) and extended matching questions (emq)9. the mcqs are the most widely used objective test items and can test any higher level of the cognitive domain if they are constructed well10. the practical skills are assessed by objective structured practical examination (ospe). clinical skills are assessed by clinical examination using the long case, short case and objective structured clinical examination (osce)9. attitudinal aspects are assessed through the personal qualities and behavioural approach of the learners.this paper describes methods of continuous assessment used in undergraduate medical education aimed to ensure the objectivity and standardization of the assessment. it has been found that lack of objectivity and varying standards of assessment methods in higher education is a big problem11. traditionally, the assessment system of students in educational institutions is one-shot, i.e., at the end of the international journal of human and health sciences vol. 06 no. 03 july’22 234 course or semester or programme, which has strong criticism that it may not give much reliable information about students’outcomes. as a result, continuous assessment is introduced to harvest more reliable outcomes on students’ grades or learning12. continuous assessments are a series of tests on students conducted during a course of study rather than a one-shot examination at the end of the term or semester. there is a continuous record of all academic achievements and activities in the various folders. the final mark or score of continuous assessment is the average of the scores achieved by the student and used to grade the students’ ability in that particular course.the marks are carried to the summative assessment, making summative assessments cumulative9. continuous assessment guides the students and allows the teachers and counsellors in an educational institution to know the easiest way of assessing students without waiting for a oneshot assessment of traditional examination12.the continuous assessment appears to be an essential tool to monitor, guide and strengthen the course or the programme13. continuous assessment worked for both formative and summative purposes14. it is formative, or “assessment for learning”, when used to diagnose students’ understanding and learning problems, provide appropriate feedback, and enable students to attain and improve meaningful learning. it is summative, or “assessment of learning”, when a mark is given that contributes to the complete results of the course /semester /programme to facilitate progression or certification15,16. thus, the formative function facilitates students’ learning development, and the summative function enables progression and certification17. however, in supporting “assessment for learning,” the practice of formative feedback often faces challenges and seems to fail17. the reasons are widespread uses of continuous assessment with summative purpose18, the move towards modularization of curricula leading to an increase use of summative with a decreased use of formative assessment19, inadequate staff, growing student diversity, plagiarism17, lack of feedback, large class size, shortage of time, lack of facilities13 and inefficient staff. feedback dialogue between student and faculty is an essential condition for students to have meaningful and constructive learning experiences17,20 and thereby improve the in-depthlearning and future studying as well21. however, it is evidenced that, the feedback given is not enough (quantity), is very brief, which may not be very helpful, or feedback does not provide advice on how to improve (quality), and feedback comes too late in regards to timing17. more feedback conversation between faculties and students is required so that students become aware of how the feedback can positively guide their learning17. widespread use of continuous assessment with a summative function may cause the faculties to experience a heavy workload, especially in a large class with a lack of adequate teaching materials and institutional resources14. students also may feel overloaded and will get less time for preparation for the subsequent assessment, which may them lead to cheating and plagiarism14. moreover, faculties in medical schools in many cases traditionally are not trained to teaching and assessment3,22,23. right now, the roles of faculties are changing from deliverer of material to a more creative, designer and facilitator of learning3. it is essential to train the faculty to develop their teaching skills and abilities in continuous assessment, giving constructive and effective feedback on pedagogical approaches and their effectiveness in delivering subject content within programmes14,24. institutional support is mandatory to provide a conducive environment for its implementation, for faculty development and also to appreciate their contribution through rewards and incentives. the continuous assessment may include assessment of daily classwork, seminars, case presentation, course-related research project preparation, presentations and report writings, field visits with reporting, practical work etc. mini clinical evaluation exercises (minicex), direct observation of procedural skills (dops), objective structured long case examination records (osler), logbook and portfolio assessments are formative assessments often carried out for the clinical students9,25. a portfolio assessment system is an efficient tool for the students to concentrate their efforts. the portfolio also includes evidence of work, a logbook, personal reflections and certificates from the tutor on the students’ work26. multi-source feedback (msf) is another evaluation method for clinical students, consists of evaluation completed by peers, other clinical team members such as nurses, pharmacists, psychologists or even by patients on the trainees’ work habits, teamwork 235 international journal of human and health sciences vol. 06 no. 03 july’22 capability, interpersonal sensitivity, etc. examples of msf tools include: physician achievement review (par), 360-degree assessments or minipat (peer assessment tool)27. it is essential that the assessment methods should be aligned to teaching and intended learning outcomes as well as valid, reliable and implemented for maximal effects14. therefore, harmony between the assessment weightage and the curriculum towards objectivity and standardization is essential28. assessment that aligns with the curriculum signifies its reliability and validity. reliability is how an assessment gives a consistent outcome on a students’ progress across multiple measures. validity is the extent to which an assessment measures what it is intended to measure29. faculty development activity should be an integral part of educational institution for a sustainable educational and organizational development30. in conclusion, continuous assessments are a series of tests of students’ learning activities recorded continuously during the course period, which helps in students’ guidance by the teachers and the counsellors for educational development. continuous assessment worked both for formative and summative purposes. but, formative purposes i.e., feedback delivery is failed due to inadequate staff, widespread uses of continuous assessment for summative purposes experiencing heavy faculty workload with lack of teaching materials, growing student diversity with plagiarism. careful planning and well coordination between teaching delivery and assessment in terms of reliability and validity is recommended. the educational planners need to pay attention on the methods of continuous assessment towards objectivity and standardization through a harmony between weightage in the assessment system and the curricular content.regular faculty development programmes should be implemented by welltrained trainer across all levels of faculty aimed to produce competent and confident human capitals for a sustainable educational and organizational development. institutional management support with adequate resources is mandatory to provide a conducive environment for its implementation and also to appreciate the contribution through rewards and incentives. this paper offers a window for educators around the world to ensure the methods of continuous assessment toward objectivity and standardization in medical education. funding no funding was received for this paper. conflict of interest the author declared no conflicts of interest. authors’ contribution all authors participated well in the preparation of this paper and approved the final version for submission to the journal for publication. references: 1. ferris h, flynn do. assessment in medical education; what are we trying to achieve? international journal of higher education 2015; 4(2): 139-144. 2. salam a. best teaching method used, very good in teaching, the best lecturer ever: secrets of teaching online during covid-19 pandemic. international journal of human and health sciences october 2021; 05(04): 377-380 doi: http://dx.doi.org/10.31344/ ijhhs.v5i4.346 3. zainol j and salam a. an audit on mentormentee program: mentees perceptions on mentors. bangladesh journal of medical science october 2021; 20(04): 840-847 doi: https://doi.org/10.3329/ bjms.v20i4.54143 4. yousuf r, salam a. teaching medical education during the era of covid-19 pandemic: challenges and probable solutions. bangladesh journal of medical science 2021; 20(special issue): s3-s6. doi: https://doi.org/10.3329/bjms.v20i5.55394 5. salam a. tea to entertain outcome based education for 21st century educators to produce safe human capitals for a sustainable global development. international journal of human and health sciences 2022a; 06(02): 153-154 doi:http://dx.doi. org/10.31344/ijhhs.v6i2.437 6. salam a, zainuddin z, latiff aa, ng sp, soelaiman in, mohamad n, moktar n.assessment of medical graduates competencies. annals academy of medicine 2008;37(9):814-816. 7. asani m. assessment methods in undergraduate medical schools. nigerian journal of basic and international journal of human and health sciences vol. 06 no. 03 july’22 236 clinical sciences 2012; 9(2); 53-60 8. vergis a, hardy k. principles of assessment: a primer for medical educators in the clinical years. the internet journal of medical education 2009; 1 (1): 1-9. 9. ahmed ss, reddy sc. assessment tools preferred by the undergraduate clinical medical students: a study in national défense university of malaysia. european journal of clinical medicine 2021;2(4): 14-19. 10. salam a, yousuf r, bakar sma. multiple choice questions in medical education: how to construct high quality questions. international journal of human and health sciences april 2020; 04(02):7988 doi: http://dx.doi.org/10.31344/ijhhs.v4i2.180 11. salam a, y. surahaya mohd yusof, zainol j. management of teaching-learning in classroom setting. journal of science and management research 2022b; 9(1): 126-136. 12. joy sc obi, susana u. obineli. continuous assessment in counselling. hugotez publications 2019. 13. kugamoorthy s, weerakoon wms. continuous assessment methods: critical review for quality improvement of the post graduate diploma in education programme of the open university of sri lanka. international research journal of human resources and social sciences 2018; 5(10): 55-71. 14. vahed a, walters mm, ross aha. continuous assessment fit for purpose? analysing the experiences of academics from a south african university of technology, education inquiry 2021; doi: 10.1080/20004508.2021.1994687 15. heywood j. assessment in higher education. 2000. london: jessica kingsley 16. knight pt and yorke m. assessment, learning and employability. 2003. maidenhead: srhe and open university press. 17. herna´ndez r. does continuous assessment in higher education support student learning? high education 2012; 64:489-502. doi: 10.1007/s10734-012-95067. 18. mcdowell l, sambell k, bazin v, penlington r, wakelin d, wickes h, et al. assessment for learning: current practice exemplars from the centre for excellence in teaching and learning, guides for staff. 2005. newcastle: university of northumbria at newcastle. 19. yorke m. formative assessment in higher education: moves towards theory and the enhancement of pedagogic practice. higher education 2003;45:477501. 20. reimann n, and sadler i.personal understanding of assessment and the link to assessment practice: the perspectives of higher education staff. assessment and evaluation in higher education 2017; 42(5): 724-736. 21. turner j, and briggs g.to see or not to see? comparing the effectiveness of examinations and end of module assessments in online distance learning. assessment and evaluation in higher education 2018; 43(7): 1048-1060. 22. salam a, mohamad m. teachers perception on what makes teaching excellence: impact of faculty development programme. international medical journal 2020;27(1):1-4. 23. cater ot, mann k, mccrorie, ponzer s, snell l, steinert y. faculty development through international exchange: the imex initiative. medical teacher 2014; 36(7): 591-595.https://doi.org/10.3109/01421 59x.2014.899685 24. amador f, martinho ap, bacelar-nicolau p, caeiro s, oliveira cp. education for sustainable development in higher education: evaluating coherence between theory and praxis. assessment and evaluation in higher education 2015; 40(6):867–882. 25. campbell c, crebbin w, hickey k, stokes ml, watters d. work-based assessment: a practical guide. building an assessment system around work. the tripartite alliance (racp; racs; rcpsc) 2014; p 1-31. 26. haldane t. “portfolios” as a method of assessment in medical education. gastroenterol hepatol bed bench 2014;7(2):89-93. 27. sood r, singh t. assessment in medical education: evolving perspectives and contemporary trends. the national medical journal of india 2012;25 (6): 357364. 28. thomé g, hovenberg h, edgren g. portfolio as a method for continuous assessment in an undergraduate health education programme.medical teacher 2006;28(6):e171-6. 29. harris a.editorial: fit for purpose: lessons in assessment and learning. english in education 2017; 51(1): 5–11. 30. salam a, mohamad n, siraj hh, kamarudin mr, yaman mn, bujang sm. team-based learning in a medical centre in malaysia: perspectives of the faculty. the national medical journal of india2014; 27(6): 350. international journal of human and health sciences vol. 02 no. 03 july’18 158 case report: left-sided gallbladder without situs inversus : report of a case mehmet sait ozsoy1, fatih buyuker, aman gapbarov, nuray colapkulu, cem ilgin erol, ozgur ekıncı,tunc eren, orhan alimoglu abstract a gallbladder that is placed on the left side of the liver without situs inversus is a very rare situation. this anatomical position makes harder to define with ultrasonography (us) before operation. a 41-years-old woman admitted with complaints of indigestion, bloating and stomach pain which started one year ago. multiple millimetric gall stones were detected at ultrasonography, and there wasn’t any information about the anatomic position of the gallbladder. a laparoscopic cholecystectomy was scheduled for the patient. it was visualized that the gallbladder was embedded in the segment iii of the liver intraoperatively. in such cases, the fact that vascular and biliary anomalies may accompany should be kept in mind as this condition may hinder the clear visualization of the cystic artery and duct which may bring the risk of iatrogenic injury. correspondence to: : orhan alimoglu, md, professor, istanbul medeniyet university, school of medicine, department of general surgery, istanbul,turkey, email:orhanalimoglu@gmail.com 1. istanbul medeniyet university, medical faculty, goztepe training & research hospital, general surgery department, istanbul, turkey. introduction left-sided gallbladder without situs inversus is a very rare situation. this entity was first reported by hochstetter in 18861. a left-sided gall bladder is defined as a gall bladder attached to the lower surface of the left lateral segment iii of the liver (i.e. to the left of the interlobar fissure and round ligament). this rare anatomic position of the gallbladder is hard to define with ultrasonography preoperatively1. in this case report, we present a patient with a left-sided gallbladder that was defined during the exploration of her laparoscopic cholecystectomy which was electively performed for chronic cholecystitis. case report a 41-years old woman presented with the complaints of indigestion, bloating and stomach pain that she experienced along the last year. she had no history of any chronic diseases, or any surgical history except having undergone a cesarean section three years ago. multiple millimetric gall stones were detected at ultrasonography, and there wasn’t any information about the anatomic position of the gallbladder. her preoperatively tested routine biochemical and hematologic parameters were in normal ranges. the operation started laparoscopically, and at exploration, it was visualized that the gallbladder was placed at the left lateral segment iii of the liver. other intraabdominal organs were normally localized. meticilous dissection was carried out for the creation of a safety zone in order to avoid any possible bile duct or vascular injuries due to the left-sided gallbladder. the cystic duct was located on the left side of the gall bladder whereas the cystic artery was located on the right side of the organ. both structures were safely dissected, international journal of human and health sciences vol. 02 no. 03 july’18 page : 158-160 doi: http://dx.doi.org/10.31344/ijhhs.v2i3.46 159 international journal of human and health sciences vol. 02 no. 03 july’18 clipped and cut. the gallbladder was released from liver and cholecystectomy was accomplished laparoscopically. one surgical drain was placed in the subhepatic area and the operation was finalized. the surgical drain was removed on the first postoperative day as no drainage was observed. the patient was discharged on the postoperative second day uneventfully. discussion the gallbladder is placed on the right side of the falciform ligament, at the same level with the middle hepatic vein, between the right anterior sector and the left medial sector of the liver when it completes its normal embirological development2. left-sided gallbladder is a very rare anomaly, and it rarely can be defined preoperatively. a left-sided gallbladder may take place due to the pathological right-sided development of the intraabdominal viscera or the gallbladder may directly take its origin from the left hepatic channel2,3. hsu et al reported the only one case that is present in the literature in concern of a left-sided gallbladder which orginated from the left hepatic channel3. embryologically, a left-sided gallbladder may develop in 3 possible ways. firstly, the gallbladder develops from the normal hepatic diverticulum. however, it becomes attached to the developing left lobe of the liver and is carried across to the left side of the round ligament. secondly, as another possibility for such development is that a second gallbladder develops directly from the left hepatic duct as an accessory gallbladder. the main gallbladder either regresses or fails to develop. thirdly, as the last pattern of this type of development is that it may result from the failure of the quadrate lobe of the liver to develop as shown in operative findings4. a left-sided gallbladder may open to the left hepatic duct directly or to the left side of the common hepatic duct4. in the study by hsu et al, they could find only nine leftsided gallbladders according to the examinations of 1482 comuterized tomography (ct) scans3. in another study by strong et al, among 19 patients with the diagnosis of a left-sided gall bladder who were scheduled for an elective cholecystectomy for gallbladder stones, there was only one patient detected with ct and the other 18 patients were detected by ultrasonography1. in our case, there weren’t any signs bringing the suspicion of a left-sided gallbladder at us of the patient who had admitted with symotoms & signs of chronic cholecystitis. despite the gallbladder being left-sided, cholecystitis in this condition almost always causes right-sided symptoms when encountered. it is believed that the the pain being right-sided is the consequence of the visceral nerve fibers that do no transpose with the gallbladder 5,6. safe surgery may not always be achieved with the trocars inserted conventionally in the left-sided gallbladder operations. some studies mention that trocar sites must replaced. in the study by koksal et al, operations were performd via access through conventional trocar insertion sites2,7. in this same study, the cystic duct was ligated at its nearest site to the gallbladder2. in our case, we used conventional trocar insertion sites throughout the operation. it is not so important to define the location of the gallbladder before operations such as cholecystectomy, but it’s important to clearly demonstrate the vessels and biliary anomalies in operations those involving large vessels such as hepatectomies7,8. in a case of a left-sided gallbladder which couldn’t be preoperatively defined via magnetic resonance imaging– cholangiopancreaticography (mrcp), us, endous (eus) and ct reported by iskandar and dhulkotia, it was seen that the cystic arter was located on the right side of the gall bladder during the operation5,9. in our case, cystic artery was located on the right side and the cystic duct was located on the left side of the organ. conclusion left-sided gallbladder is a very rare situation in which vascular and biliary anomalies can accompany. us, which is one of he the most important preoperative definitive imaging methods prior to laparoscopic cholecystectomy cases is not enough to define the possible presence of a left-sided gallbladder. in cases of a left-sided gallbladder having been defined intraoperatively, it should always be kept in mind that vascular and biliary anomalies may accompany. for safe dissection of the cystic duct and artery, new trocars may be inserted during the operation. after revealing all anatomical structures, the cystic artery and duct may safely be ligated. international journal of human and health sciences vol. 02 no. 03 july’18 160 references 1. strong rw, fawcett j, hatzifotis m, hodgkinson p, lynch s, o’rourke t, slater k, yeung s. surgical implications of a leftsided gallbladder. am j surg. 2013;206(1):5963. 2. koksal hm, celayir mf, vartanesyan zc, baykan a. left-sided gallbladder: a case report. turkish j surg 2010; 26(4): 220-222. 3. hsu sl, chen ty, huang tl, sun ck, concejero am, tsang ll, cheng yf. leftsided gallbladder: its clinical significance and imaging presentations. world j gastroenterol. 2007;13(47):6404-6409. 4. bender ea, springhetti s, shemisa k, wittenauer j. left-sided gallbladder (sinistroposition) with duplication of the common bile duct. jsls. 2007;11(1):148-150. 5. iskandar me, radzio a, krikhely m, leitman im. laparoscopic cholecystectomy for a left-sided gallbladder. world j gastroenterol. 2013;19(35):5925-5928. 6. zoulamoglou m, flessas i, zarokosta m, piperos t, papapanagiotou i, birbas k, konstantinou e, mariolis-sapsakos t. left-sided gallbladder (sinistroposition) encountered during laparoscopic cholecystectomy: a rare case report and review of the literature. int j surg case rep. 2017;31:65-67. 7. zografos gc, lagoudianakis ee, grosomanidis d, koronakis n, tsekouras d, chrysikos j, filis k, manouras a. management of incidental left-sided gallbladder. jsls. 2009;13(2):273-275. 8. nagai m, kubota k, kawasaki s, takayama t, bandaiy, makuuchi m. are left-sided gallbladders really located on the left side? ann surg. 1997;225(3):274-280. 9. dhulkotia a, kumar s, kabra v, shukla hs. aberrant gallbladder situated beneath the left lobe of liver. hpb (oxford). 2002;4(1):39-42. international journal of human and health sciences vol. 03 no. 03 july’19 172 case report: aggressive angiomyxoma: a rare perineal mass mehmet sait ozsoy1, nuray colapkulu1, aman gapbarov1, ozgur ekinci1, nesrin gunduz2, ayse nur toksoz3, orhan alimoglu1 abstract aggressive angiomyxoma (aam) is a rare tumour that usually occurs in females at reproductive ages and affects pelvic region. we herein report a case of perineal aam to conribute to the literature about pathological features and clinical outcomes of this tumour. a 36 year old female with no history of chronic diseases presented to our hospital with a nontender perineal mass. the mass was present for two years and it first appeared during pregnancy. she underwent surgery for local resection. the histology of the mass was consistent with aam and multifocal extention into surgical margins was observed. with immunohistochemical staining the tumor was positive for desmin, cd31, cd34, er and pr; poorly focal positive for sma and negative for s-100. ki67 was less than 1%. due to surgical margin positivity she had a second operation. after the resection with clear margins, patient showed no signs of reccurence for 7 months. resections with positive surgical margins were mostly concluded as reccurent with wide time range and reccurence rates, extended surgical resection is gold standard for management of this tumour. keywords: perineal tumour, vulvar mass, soft tissue lesions, mesenchymal tumour correspondence to: orhan alimoglu, md, prof. department of general surgery, faculty of medicine, istanbul medeniyet university. istanbul medeniyet university goztepe training and research hospital, department of general surgery, dr. erkin street, goztepe, 34722, kadikoy, istanbul.turkey. e-mail: orhanalimoglu@gmail.com” 1. istanbul medeniyet university, goztepe training and research hospital, general surgery department, istanbul 2. istanbul medeniyet university, goztepe training and research hospital, radiology department, istanbul 3. istanbul medeniyet university, goztepe training and research hospital, pathology department, istanbul introduction aggressive angiomyxoma (aam) is a locally infiltrative soft tissuelesion which is discribed as a tumour with uncretain differentiation by world health organization in classification of bone and soft tissue. female/male incidence ratio is 6:11. generally, this tumour is found in the pelvic and perineal region of female but there are cases with intrabdominal aam located in liver and pelvic ureter2,3. patients with perineal aam usually present with a nontender, edematous lesion which is found as a reducible mass in physical examination4,5,6. as a rare entity aam is often misdiagnosed with bartholin cyst, vulvar lesions, condylama acuminatum, lipoma or pelvic floor hernia. the lesions are usually much more bigger than they seem on inspection and palpation due to their tendency to grow towards the deeper soft tissues7. the main treatment approach is surgical resection with negative margins since there is only a few data about reccurance rates6,7 we herein report a case of perineal aam to conribute to the literature about pathological features and clinical outcomes of this tumour. case report a 36-years old female with no history of chronic diseases presented to our hospital with a nontender perineal mass. the mass was present for two years and it first appeared during pregnancy. in lithotomy position on right gluteal region, 8 cm from the anus; soft, nontender mass with fluctation was palpated. laboratuary tests were within normal limits. ultrasound showed a mass measuring 73 x 68 x 48 mm and consistent with abscess contaning air-dense fluid level. with magnetic resonance imaging (mri), the mass was isointense on t1-weighted and hyperintense on t2-weighted images, starting from adjacent of right vaginal wall to intergluteal cleft (figure 1,2). international journal of human and health sciences vol. 03 no. 03 july’19 page : 172-174 doi: http://dx.doi.org/10.31344/ijhhs.v3i3.98 173 international journal of human and health sciences vol. 03 no. 03 july’19 no diffusion restriction on diffusion-weighted imaging was noted. she underwent surgery for local resection. macroscopic examination showed a solid tumour that was homogeneous, dark grey colored and glistening on the surface (figure 3). the histology of the mass was consistent with aam and multifocal extention into surgical margins was observed. with immunohistochemical staning the tumor was positive for desmin, cd31, cd34, er and pr; poorly focal positive for sma and negative for s-100. ki67 was less than %1. due to surgical margin positivity she had a second operation. after the resection with clear margins, patient showed no signs of reccurence for 7 months. discussion aam is first described by steeper and rosai in 1983 as an infiltrative and reccurent neoplastic tumour of the blood vessels8. the etiology remains unclear, but significantly increased female dominancy, incidence peak at reproductive ages and reported cases during pregnancy suggest an hormonal involvement to pathogenesis4,9. most cases locates in pelvic and perineal region but in a review study, sato et. al have reported a patient which was an aam, arising from the liver and other cases from the literature located in larynx, oral floor, spraclavicular fossa and lungs were encountered2. clinical characteristics are similar to perineal lesions, therefore there is no specific findings on physical examination. most cases are misdiagnosed with other vulvar pathology or levator hernia6. ultrasonografic examination aam appear as homogeneous and hypoechoic lesions and on colored doppler blood flow is usually observed6,10. on mri, due to increased water content and loose matrix of these lesions, they appear hyperintense on t2-weighted imaging and masses demonstrate a ‘swirled’ pattern3,9,10. gilardi et al. reported modorate fdg uptake of an aam with 3.75 suv max11. the tumor cells are bounded by fibrofatty tissues without a well shaped border and surfaces are myxedematous or gelatinous, and gray reddishbrown. they appear as spindle-shaped cells with lightly stained or eosinophilic cytoplasm6,13. the nuclei are oval-shaped, bland, and lightly stained with a single, small, centrally located international journal of human and health sciences vol. 03 no. 03 july’19 174 nucleolus. mitotic figures are usually absent. by immunohistochemistry, tumour cells show strong expression of vimentin, desmin, er, and pr. on the other hand, partial or weak expression was observed for sma, actin,cd34, and s-100, whereas the ki-67 index was 1% to 3%4,6. most of the patients were treated surgically but there are studies that invastigated pharmocological approaches. in a case series with 7 patients, magtibay et al reported a patient that was administered tamoxifen and during treatment tumour progression was observed. another patient in this series, a 59 year old woman, recieved preoperative radiation and angiographic embolization (after an unsuccessful resection), fallowed by intraoperative radiotherapy and definitive surgery. tumour margins were clear, yet after 42 months patient had evidence of recurrence on ct12. im et. al. reported a case treated with both surgery and gonadotropinrelasing hormone agonist. the tumor showed reduction after the treatment but reccured after 10 months14. conclusion aggressive angiomyxoma is a rare entity, but with increased number of reported cases diagnostic and pathological features of this tumor was enlightened. resections with positive surgical margins were mostly concluded with recurrence in varied time intervals. in summary due to high reccurence rates, extended surgical resection is gold standard for management of this tumor. conflict of interest no conflict of interest has been disclosed by the authors. funds this study did not receive any special funding. authors’ contributions: data gathering and idea owner of this study: mehmet sait ozsoy, nuray colapkulu, ozgur ekinci, orhan alimoglu study design: mehmet sait ozsoy, nuray colapkulu, ozgur ekinci, orhan alimoglu data gathering: mehmet sait ozsoy, nuray colapkulu, aman gapbarov, ozgur ekinci, nesrin gunduz, ayse nur toksoz, orhan alimoglu writing and submitting manuscript: mehmet sait ozsoy, nuray colapkulu, aman gapbarov editing and approval of final draft: orhan alimoglu references: 1. fletcher c, bridge j, hogendoorn p, et al. world health organization classification of tumours of soft tissue and bone. 4th ed. iarc press, lyon:2013. 2. sato k, ohira m, shimizu m, et al. aggressive angiomixoma of the liver: a case report and literature review. surg case rep. 2017;3(1):92. 3. zugail as, boawaiden f, comperat em, et al. angiomyxoma of the ureter imitating an upper tract urothelial carcinoma: a case report. int j surg case rep. 2018;53:39-42. 4. theofano o, kim cs, vites sf, et al. a case report of aggressive angiomyxoma in pregnancy: do hormones play a role? case rep obstet gynecol. 2016; 2016:6810368. 5. al-umairi rs, kamona a, al-busaidi fm. aggressive angiomyxoma of the pelvis and perineum: a case report and literature review. oman med j. 2016;31(16):456-458. 6. chen h, zhao h, xie y, jin m. clinicopathological features and differential diagnosis of aggressive angiomyxoma of the female pelvis: 5 case reports and literature review. medicine (baltimore). 2017;96(20):e6820. 7. sutton b.j., laudadio j. aggressive angiomyxoma. arch pathol lab med. 2012;136(2):217–221. 8. steeper ta, rosai j. aggressive angiomyxoma of the female pelvis and perineum. report of nine cases of a distinctive type of gynecologic soft-tissue neoplasm. am j surg pathol. 1983;7(5):463-475. 9. malukani k, varma av, choudhary d, dosi s. aggressive angiomyxoma in pregnancy: a rare and commonly misdiagnosed entity. j lab physicians. 2018;10(2):245–247. 10. benson jc, gilles s, sanghvi t, et al. aggressive angiomyxoma: case report and review of the literature. radiol case rep. 216;11(4):332-335. 11. gilardi l, vadrucci m, pittaro a, et al. 18f-fdg pet/ ct in aggressive angiomyxoma of the pelvis. rev esp med nucl imagen mol. 2017;36(6):403-405. 12. magtibay pm, salmon z, keeney gl, podratz kc. aggressive angiomyxoma of the female pelvis and perineum: a case series. int j gynecol cancer. 2006;16(1):396-401. 13. brezezinska bn, clements ae, rath ks, reid gc. a persistent mass: a case of aggressive angiomyxoma of the vulva. gynecol oncol rep. 2018;9(24):15-17. 14. im sw, han ss. treatment of aggressive angiomyxoma of the female perineum: combined operative and hormone therapy. j obstet gynaecol. 2016;36(6):819-821. international journal of human and health sciences vol. 07 no. 02 april’23 106 review article a comparative review on iron deficiency anemia among children and long-term strategy seyida afreen seyid mohamed moulana1, muhamed muneeb muahmed musthafa1, rajavarthani sanjeev2, seyida himaya seyid mohamed moulana1, faiz mohideen mohamed thassim marikar3 abstract background:one of the most prevalent dietary disorders in the world is iron deficiency anemia (ida) which impacts people of all ages, genders, and physiological categories. in the current situation, iron fortification in food is seen as a long-term, cost-effective, and sustainable technique. scope and approach: the ideal mix of iron form and food carrier, as wellas the food circumstances in which it is consumed, are critical.combining iron with a bioavailability booster and avoiding interactions with iron inhibitors are suggested. as a result, this paper provides a thorough examination of the high prevalence of ida, its various causes, absorption of haem and non-haem iron, and bioavailability,in addition to iron fortification strategies. results: ascorbic acid and meat components in animal tissue are the most prominent enhancers of iron absorption in diets. polyphenols, phytates, and calcium are the utmost potentinhibitors of iron absorption. additional approaches to minimize iron uptake from diets may include changes in diet that lower iron consumption and reduce iron bioavailability. conclusion: food fortification is a viable technique for lowering anemia prevalence. the combination of iron fortificants and food vehicles should be harmless, agreeable, and ingested by the target population for an effective fortification program.it should also have no negative impact on the ultimate product’s acceptance and stability. novel food fortification techniques may lead to the development of new approaches to treating iron deficiency and anemia. keywords:iron deficiency anemia, children, bioavailability, iron fortification correspondence to: dr. faiz mohideen mohamed thassim marikar, staff development centre, general sir john kotelawala defense university, ratmalana, sri lanka. email: faiz@kdu.ac.lk and muhamed muneeb muahmed mustafa, department of biosystems technology, faculty of technology, south eastern university of sri lanka, sri lanka. email: muneeb@seu.ac.lk 1. department of biosystems technology, faculty of technology, south eastern university of sri lanka, sri lanka. 2. department of human biology, faculty of health care, eastern university of sri lanka, sri lanka. 3. staff development centre, general sir john kotelawala defense university, ratmalana, sri lanka. introduction the utmostcommunal nutritional problem in the world is iron deficiency anemia. the incidence varies across the globe, with greater rates in developing nations.1 anemia affects above 30% of the global population.2except for china, where the frequency of ida is lower, ida is also an issue across latin america, the middle east, the caribbean, east asia, and the pacific, where the prevalence of ida ranges from 22 to 66 %.3 anemia continues to be a major global health issue, impacting 43% of children underthe age of five, 38% of pregnant women, and 29% of non-pregnant women globally.4southern asian and african childrenare especially vulnerable, with ida affecting more than 50% of children of preschool age in most nations.4 anemia is a condition in which there isn’t enough iron in the body to maintain normal red cell production.5 it develops when the body’s international journal of human and health sciences vol. 07 no. 02 april’23 doi: http://dx.doi.org/10.31344/ijhhs.v7i2.559 mailto:?subject= mailto:muneeb%40seu.ac.lk%20?subject= 107 international journal of human and health sciences vol. 07 no. 02 april’23 physiologic requirements for red blood cells (andas a result, theircarrying capacity for oxygen) are not met. globally, iron deficiency is thought to be the most significant reason for anemia.6 when bodily stocks of iron are depleted, such as when there is an increased need for iron or when iron intake and absorption are reduced, iron deficiency (id) occurs.7 id mainly affects newborns and young children in most parts of the world, due to their greater iron requirements associated withgrowth, and females of the childbearing stage, as a result of menstruation loss and pregnancy.8,9 young kids are particularly susceptible to the effects of ida since their body systems are working to develop, particularly their brains, which are the quickest developing organs during infancy and early childhood.2 it can cause major public health problems, such as increased disease and mortality in children, as well as impaired growth, immune system, and cognitive development, decreased physical activity, low endurance capacity, and poor learning ability.2,10,11 anemia is caused by a variety of factors in developing countries, including nutritional deficiencies (iron, folate, and vitamin b12), infectious disease, for example,malaria and intestinal parasite infection, and chronic disease.5 iron deficiency anemia arisesresulting from a shortage of iron-rich meals and the availability of iron absorption barriers in the diet.12 childhood anemia is a multi-factorial environmental condition.poverty, ignorance, improper cooking, a shattered family structure, reducedconsumption and storage patterns, and, of course, a lack of educational knowledge all have various impacts on childhood anemia.13 mother’s anemia during pregnancy, and a lack of breastfeeding also contribute to an increased occurrence of the disease in children.14 in this context, communityhealth measures to prevent and control anemia include a variety of iron-supply alternatives now available, although iron dietary fortification appears to offer the greatest risk-benefit ratio.15 in the long run, this remains anauspicious and moneymaking method of focusing on a certain set of people. since they have an impact on nutrient bioavailability, the chosen food carrier, and the aimed micronutrient must be synergistic. therefore, understanding the destiny of iron and its bioavailability is critical for the creation of plannedmethodologies to alleviate anemia through iron supplementation. prevalence of ida iron deficiency is the most common and widespread nutritional disorder in the world, impacting a lot of children in developing countries as well as many in developed countries. the prevalence of ida is depicted in table 1. table 1. nutritional disorder in selected countries in the world year country age prevalence of anemia (%) prevalence of ida (%) reference 2020 indonesia 5 -14 years 26.4 5.8 andriastuti et al., 202016 libya <5 years 50.4 49.5 el-mansoury, 202010 brazil <59 months 20.9 ethiopia 6-59 months 44 central statistical agency ethiopia & measure dhs icf macro, 201117 bangladesh 6-23 months 24-59 months 64 42 rashid et al., 201018 angola 6-23 months 52 23.92 fançony et al., 202019 myanmar 6 – 36 months 72.6 zhao et al., 201220 malaysia 1-6 years 7-12 years 36.7 25.6 26.7 16.3 ngui et al., 201221 international journal of human and health sciences vol. 07 no. 02 april’23 108 determinants of ida id is multifactorial in the world, and ida arises from a bigger framework of biological, cultural, and socioeconomic factors, with both direct and indirect causes and components. table 2.determinants of iron deficiency anemia factors iron deficiency anemia (%) in different countries kenya sri lanka angola lebanon brazil india ethiopia japan age < 6 months 33 16.4 25 6 – 8 months 76.5 83 39.9 75.3 43.8 9 – 11 months 64.8 54.9 78.9 12 -23 months 68.9 72 71.4 78.7 57.8 2435 months 40 28.8 68.2 56.2 37.4 36-47 months 58.2 34.6 48 – 59 months 26 48.3 29.2 sex male 75.5 53 51.6 38.9 41.7 64.6 48 44.9 female 74.4 51 41.4 34.8 27.7 64.9 52 41.0 mother’s educational level none 71.7 22.7 47.2 primary 25.6 59 36.3 39 65.9 54.4 42.2 secondary 74.4 42 50.4 23.1 59.6 23 45.1 higher 13.3 49.7 44.4 income per month low 34.4 59.1 43.5 67.8 59.2 medium 25.1 40.9 31.5 67.3 35.3 high 30.8 58.3 5.4 wealth index poor 75.6 38.1 41.8 middle 65.2 24.8 44 rich 52.7 37.2 42.7 residence area urban 33.3 67.4 42.5 rural 39.3 60 44.0 size of family < 5 35.3 67.1 45.2 >5 27.6 32.9 43.4 109 international journal of human and health sciences vol. 07 no. 02 april’23 factors iron deficiency anemia (%) in different countries kenya sri lanka angola lebanon brazil india ethiopia japan duration of breast feeding <180days 49.3 28.2 180 – 360 days 52.5 41.9 >360 days 35.8 treated drinking water (boiled for children) yes 58 73.5 42.7 no 50 49.6 44.7 consumption of meat and fish yes (nonheme) 35.3 32.4 18.7 no (heme) 75.8 70 68.6 consumption of fruits (previous day) yes 60 no 48 consumption of dark leafy vegetables yes 30.7 14.8 no 43.1 30.5 cow milk intake yes 42.9 no references wangusi et al., 201622 malkanthi et al., 20108 fançony et al., 202019 mhanna et al., 201623 nambiema et al., 201924 bharati et al., 201525 orsango et al., 202126 keokenchanh et al., 202127 dietary iron absorption 1. iron absorption: food contains two types of iron: non-haem iron and haem iron. non-haem iron is found in both plant and animal’s foods, whereas haem iron is only derived from animal products.although iron is absorbed mostly in the duodenum, the methods of absorption for these types differ.iron absorption across the enterocyte is commonly regarded in terms of three processes. they are iron utilization from the food across the brushborder and then into the enterocyte, an intracellular process in which iron is aimed directly to the basolateral membrane for delivery to the circulation, storage, or utilization within the enterocyte, and iron transfer across the basolateral membrane, also known as the transfer step. non-haem iron invegetables and grains is absorbed more slowly than dietary haem iron. the proximal intestine absorbs the majority of haem, with absorption capacity diminishing as you move farther away. hcp1 (haem carrier protein 1), an intestinal haem transporter, has been recognized and found to be significantly expressed in the duodenum. hypoxia and iron shortage enhance its activity. bcrp (breast cancer resistant protein) and flvcr are two exporter proteins (feline leukaemia virus subtype c),that allow some haem iron to be reabsorbed intact into the cell’s circulation. the duodenum would be the primary site for non-haem iron absorption. a brush border ferrireductase converts non-haem iron from ferric to ferrous form and the low ph of the stomach dissolves non-haem iron. cells in the duodenal international journal of human and health sciences vol. 07 no. 02 april’23 110 crypts can recognize the iron requirements of the body and store this data as they develop into the cell’s capacity to absorb iron at the villi’s tips. iron is transported across the apical (luminal) exterior of small intestinal mucosal cells by the protein called divalent metal transporter 1 (dmt1) or natural resistance-associated macrophage protein (nramp2).irons are carried crosswiseto the apical (luminal) surface of the mucosal cells in the small intestine by a protein called divalent metal transporter 1 (dmt1) or natural resistanceassociated macrophage protein (nramp2). iron might be transported through the cell to enter the plasma or kept as ferritin once within the mucosal cell;the iron condition of the body system at the time the crypt cell originates adsorbing cell is certainly the determining factor. when mucosal cells are shed, iron is misplaced in the intestinal lumen after being stored as ferritin., regulating iron equilibrium. theirontransportationthrough the basolateral surface of mucosal cells is regulated by ferroportin 1 (fpn 1), a transporter protein including an iron-responsive element (ire). hephaestin, a multicopper protein, is needed by this transporter protein.iron absorptionregulates the body’s iron level, however there is no physiological process for removing unnecessary iron. the main molecule that controls iron absorption is hepcidin, a 25-amino-acid peptide produced in the liver. hepcidin regulates the function of the iron-transferring protein ferroportin by binding to it and causing it to be internalized and destroyed, resulting in a reduction in iron efflux from iron-exporting tissue into plasma. as a result, inflammatory cytokines such as il-6, which produce high levels of hepcidin (which occurs in inflammatory situations), degrade ferroportin and impede iron absorption.28 2. nutritional enhancers a) ascorbic acid (aa) adding enhancers of iron absorption to fortified foods mightprogress the efficacy of fortification schemes, particularly in foods containing inhibitors including phytate and tannins.29 the most efficient booster of iron absorption is vitamin c. with a molecular weight of 176.13 and the empirical formula c6h8o6, it is a chemically defined compound.30 vitamin c helps convert fe3+ (ferric) iron to fe2+ (ferrous) iron, which is the most easily absorbed form. vegetarians frequently consume a significant amount of vitamin c, which is found in a variety of fruits and vegetables.31adding vitamin c to a test food with a molarity of 1.6:1augmented iron absorption considerably32, whereas adding vitamin c to a test food with a molarity of 4:1 augmented nonheme iron intake by 185 percent.33the beneficial effect of aa on iron absorption from a complete diet is less pronounced than in single-test-diet studies.29 in the overall diet research, however, the consumption of ascorbic acid is related to iron absorption.29between 2010 and 2014, the european food safety authority investigated the relationship between ascorbic acid and iron absorption and concluded that “vitamin c contributed significantly to increaseabsorption of non-heme iron.34 according to research, vitamin c from maize and wheat improved iron absorption in these cereals by up to 84 percent and 48 percent, respectively.35it should be remembered that temperature and air exposure are both important factors for aa. and that oxidation to dehydroascorbic acid during preparing food can diminish aa content.30 several ascorbic acid compounds are less heat and oxygen susceptible. a study recently presented that after being baked into iron-fortified bread, ascorbyl palmitate conserves its boosting result on the absorption of iron.30,36 b) animal tissue muscle tissue, whether it’s from meat, fish, or chicken, enhances non-heme iron absorption, particularly in cereal and legume-based diets. meat enhances iron absorption in a variety of ways, involving chelation and stomach acidity impacts. initially, by boosting gastric acid production and, as a result, improving iron solubilization in the stomach. after that, in the stomach’s acidic (lower ph) environment, a meat component may chelate the solubilized iron, retaining iron solubility during intestinal digestion and absorption. absorption of non-heme iron was increased 2–3-fold when chicken, beef, or fisheries were added to a maize meal, comparedto no effect when the same quantity of protein was delivered as ovalbumin.37 in young women, incorporating pork meat (50 g or 75 g) into food with 220 mg of phytate and 7.4 mg of vitamin c, which was thought to have low iron bioavailability, dramatically enhanced iron absorption.38 when salmon fish was added to a high-phytate meal, it was found that such sum of salmon consumed could significantly increase iron absorption from bean meal.39 the enhancing impact of animal tissue is unaffected by cooking 111 international journal of human and health sciences vol. 07 no. 02 april’23 temperature.40 however, by converting haem iron to non-haem iron,41 reduces the amount of haem iron in the body, potentially counteracting iron absorption. 3. inhibitors a) phytate phytate (myo-inositol phosphate),themajor blocker of absorption of non-haemiron is a biologically active molecule abundant in plant-based foods.42 legumes, nuts, whole grain cereals, and unprocessed bran are examples. dependent on the numberof phosphates related to the inositol ring, inhibit the absorption of non-haem iron. the most powerful iron inhibitors are inositol hexaphosphate and inositol pentaphosphate, which have a dosedependent impact.43 highermolarratios of phytate: iron (>1) diminish iron absorption.39 the usage of marketable phytases for phytate dephosphorylation has been stimulatedsubsequently the collaboration is due to the complexion of positively charged metal iron with phytate’s negatively charged phosphate groups.44long-term regular consumption of wheat bread containing a high proportion of whole-grain reduced the body’s natural iron levels (serum ferritin)among vegetarians45 and in young women.46lactic acid fermentation reduces the phytate concentration of cereal flours47 more effectively than yeast fermentation.48 b) polyphenols polyphenols are a heterogeneous set of complexes present in fruits, berries, vegetables, spices, pulses, and whole grains, with a high concentration in tea, coffee, chocolate, red wine, and some herbal teas.49the phenolic combinations from the meal or drink are released during digestion and could form a bond with fe in the intestinal lumen, rendering it inaccessible for absorption.50according to a study, beverages usually contains 20–50 mg of total polyphenolic compounds per serving reduced iron absorption from a bread diet by 50–70%, while beverages possessing 100–400 mg of total polyphenolic compounds per serving reduced uptake by 60–90%.51when compared to water as a control drink, tea restricts non-heme iron absorption by at least 37%, according to research. it also found that a one-hour time delay between tea drinking and a meal neutralizes these inhibitory activities by at least 1.6-fold. black tea is a good example of an iron inhibitor, as are green tea, coffee, chocolate, wine, herbs and spices, and seeds to a lesser extent. the percentage of people affected by black tea ranged from 79 to 94 percent.52,53iron absorption was reduced by 59 percent (p <0.001) and 49 percent (p< 0.05) in iron deficiency anemia and control personscorrespondingly, when a cup of tea drink was added to the reference meal.54 c) calcium calcium is also thought to limit the absorption of iron, respectively haem and non-haem. however,a new study reveals that calcium has only a minor impact on the absorption of iron over time (potentially as a result of a physiological adaptation).55 bovine milk and milk-based products seem to be the most calcium-rich foods. spinach, broccoli, cabbage, and okra are examples of green vegetables,56as well as some legumes like soya beans, which contain significant levels of calcium. in single-test-meal research, dairy items and calcium complement reduced iron uptake;the effect was contingent upon thesimultaneous accessibility of iron and calcium inside the colon, and it was also demonstrated when calcium and iron were provided together while fasting.29dosedependent inhibiting results were noted when calcium was delivered to bread rolls at dosages of 75–300 mg and calcium via dairy items at levels of 165 mg.calcium appears to have a negative impact on the absorption of iron in single-diet studies, so although calcium appears to have only a minor impact on iron absorption in numerousfood researches that used a variety of ingredients and varying amounts of other inhibitors and stimulants.43 however, it’s probably better to evade taking high calcium supplements with food. iron fortification the most cost-effective and long-term plan is to lower the occurrence of idis to fortify foods with iron.it’s a well-received public-health initiative. the purposeful increased amount of a vital trace element within diet is known as fortification, including minerals and vitamins (includingtrace elements), to improve the nutrient quality of the food supply while posing minimal health risks.57the effectiveness of iron fortification in enhancing iron status is dependent on a number of parameters, including the vehicle chosen,the iron complicatesutilized, as well as the iron level of the population under consideration.the selection of food that will serve as a carrier for the trace elementis the most important step in a fortification program and must be a regular part of the overall population’s diet, should be inexpensive to the international journal of human and health sciences vol. 07 no. 02 april’23 112 target group, consumed on a regular basis, and available in predictable quantities.58 solubility is a key characteristic of fortificants, and it has been classified into three types: i) dissolvable in water, ii) dissolves in dilute acids but weakly soluble in water, and iii) insoluble in water but, it is low soluble in dilute acids. i) iron compounds that are water soluble. ferrous sulfate is generally the first choice for iron fortification due to its excellent relative bioavailability and low cost. however,its major drawback isthat it is highly unstable and that its oxidation is temperature and air-exposure reliant., and that it might cause undesirable sensory attributes changes.59 the adding of ferrous sulfate to various cereal flours, particularly those kept in warm, moist environments, could cause lipid rancidity.60 ii) poorly water-soluble compounds with well soluble in gastric juice. although ferrous fumarate seems to have the same bioactivity and solubility as ferrous sulfate, it has a far lower organoleptic impact. it’s commonly used to boost the nutritional value of cereal-based supplemental foods.60 iii) water-insoluble and low solubility in dilute acids the chosen iron compounds for diets are ferric orthophosphate and ferric pyrophosphate (fpp), which are primarily utilized in the fortification of various infant cereals, rice, and chocolatecontained food.61they have reduced bio accessibility compared to the others, which is a vital factor for bioavailability60, but they are also more susceptible to undesirable color and flavor alterations, as these molecules tempt minimal if any sensory changes. it is essential to choose the optimum blend of fortificant and vehicle when designing ironfortified food,considering the people who will gain from its consumption. powder infant formulae are an excellent example of this approach. they usually have ferrous sulfate, which is 100 percent soluble when re-formed, and ascorbic acid, which ensures adequate iron bioavailability.62cereal meals, whether for weaning or adulthood, are attractive contenders for fortification since they are the maindiets in many cultures everywhere in the entire globe andit could be processed into a solid form that makes iron-fortified grain foods.ferric pyrophosphate,electrolytic iron ferrous sulfate, and ferrous fumarate are the iron complexes suggested by the who for the fortification of cereals.63seasonings including fish sauce, soy sauce, table salt,and curry powder were tested as food carriers with iron supplements, in addition to infant formula and main meals, due to their widespread usage in severalaim groups.64 iron bioavailability while iron insufficiency remains one of the most prevalent dietary problems globally, justifying long-lasting worldwide attempts to rise iron consumption in high-risk populations, little nutritional bioavailability of iron remains the primary cause of anemia in both industrialized and developing countries.65iron bioavailability refers to the percentage of iron consumed which is digested by the intestine and used throughout regular metabolic processes or retained.59even when an acceptable amount of nutritional/ supplemental iron is supplied, normal persons are predicted to have a wide range of iron absorption efficiency.66the inverse link between absorption of iron and the size of bodily iron status, as well as the kinds of food, mixtures of foods, and timing of food intake, all influence the mineral’s maximum removal capability from the meal.67 although ferrous iron is thought to be better absorbed than ferric iron, both ions could be effectively absorbed as long asthey are soluble when they approach the mucosa. because ferric salts could precipitate as ph increases from the stomach to the duodenum, solubility is the limiting factor.the precipitation of iron can be avoided by combining it with chemicals that create absorbable chelates that stay soluble when the non ph rises.59 in general, haem iron is absorbed more quickly (15–40%) than -haem iron (1–15%). pigs were utilized in a study to see how the bioavailability of four different iron compounds affected the fortification of cereals. the inquiry makes use of micronized dispersible ferric pyrophosphate (mdfp), ferrous fumarate (ff), electrolytic iron (ei), and ferrous sulphate heptahydrate (fsh).the data show that ei is less effective in replacing stored iron than other compounds. because the iron bioavailability of ff and mdfp was equal, the iron reserves of the weaned piglets increased significantly. as a result, dietary patterns have a massive influence on dietary iron distribution and absorption.68as a result, a well-balanced combination of foods can aid in boosting iron status and bioavailability. 113 international journal of human and health sciences vol. 07 no. 02 april’23 viewpoint on the future the results suggest that more research into many aspects of ida in children and other demographic groups is recommended. the issue of anemia should be examined from a regional standpoint. this has the potential to result in enormous national and international transformations. the problem could be better addressed by identifying region-specific diets that could serve as potential food vehicles, conducting studiesand developing maintainable food fortification methods, developing innovative food formulations that take into account enhancers and inhibitors of iron absorption, and, most significantly, raising public awareness about the importance of healthy diets and food micronutrients.iron fortification studies must take into account the cost-benefit ratio because it is an issue of worldwide interest. the barriers to implementing the boosting measures, on the other hand, must be removed. additionally, the price of some fortification methods might put the cost of food out of reach for people who require the most nutrients. this constraint could be overcome by employing less expensive alternatives, such as food-to-food fortification using local resources. nevertheless, there is a lack of understanding of the procedures and benefits of food-to-food fortification. conclusion as iron deficiency seems to be the most common dietary deficiency, there is clearly a social necessity, andthe number of consumers is huge. in this framework, precision nutrition-based advice developed for specific populations isbecoming more common. as a result, fortification remains the harmless way to report the problem of iron deficiency. iron fortification would be more in line with the human body’s functioning and physiology.it’s critical to understand the major components of iron-fortified foods. relationships between iron supplement, a food carrier, and customer demand for a multi-disciplinary strategy method. it’s also worth noting that the solubility of iron complexes in the gastrointestinal tract influences the relationship between the absorption of iron and iron status. there is a need for a better knowledge of nutrient bioavailability as well as solutions to the fortificant’s sensory attributes and degrading issues. most attempts to prevent iron deficiency through fortification schemes have focused on overcoming technical issues such as discoloration, off-flavor formation, and fatty acid oxidation, often ignoring other practical issues that are critical for effective implementation.the involvement of iron fortification in bioavailability causes is hard to assess because the intake of ironfortified food products and the bioavailability of iron-fortification constituents differ greatly. conflict of interest:none declared. funding statement:no funding. ethical approval: not applicable. author`s contribution:all authors were equally involved in searching and reviewing literature, writing, editing, and approval of the final version of the manuscript. international journal of human and health sciences vol. 07 no. 02 april’23 114 references 1. achouri i, aboussaleh y, sbaibi r, ahami a, el hioui m. prevalence of iron deficiency anaemia among school children in kenitra, northwest of morocco. pak j biol sci. 2015;18(4):191. 2. singh s, parihar s. prevalence of anemia in under five-year-old children: a hospital-based study, 2019. 3. lozoff b, corapci f, burden mj, kaciroti n, angulobarroso r, sazawal s, black m. preschool-aged children with iron deficiency anemia show altered affect and behavior. j nutr. 2007;137(3):683-9. 4. pasricha sr, drakesmith h. iron deficiency anemia: problems in diagnosis and prevention at the population level. hematology/oncology clinics. 2016;30(2):309-25. 5. gedefaw l, tesfaye m, yemane t, adisu w, asres y. anemia and iron deficiency among school adolescents: burden, severity, and determinant factors in southwest ethiopia. adolesc health med ther. 2015; 6:189. 6. who c, chan m. haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. geneva, switzerland: world health organization, 2011;1–6. 7. wong c. iron deficiency anaemia. paediatrics and child health. 2017;27(11):527-9. 8. malkanthi rldk, silva kdrr, jayasinghemudalige uk. risk factors associated with high prevalence of anemia among children under 5 years of age in paddy-farming households in sri lanka. food nutr bull. 2010;31(4):475-82. 9. uddin mm, zakeel mc, zavahir js, marikar fm, jahan i. heavy metal accumulation in rice and aquatic plants used as human food: a general review. toxics. 2021 ;9(12):360. 10. el-mansoury a. prevalence of iron deficiency anaemia among children under the age of 5 years in paediatric hospitals-benghazi, libya, 2020. 11. world health organization. global accelerated action for the health of adolescents (‎aa-ha!)‎: guidance to support country implementation, 2017. 12. alam mj, mobarak r, alam hk, haque ms, tayab ma. meeting micronutrient requirements for health and development: an update. bangladesh j child health. 2012;36(1):36-45. 13. ramesh s. assess the knowledge and practice of prevention and management of childhood anemia among mothers of preschool children in selected anganwadi centres of thrissur, kerala, south india. wnc, 2017;231–6. 14. musthafa mm, nastaran ad, marikar fm, rajandram d, ahmed ab. phytochemical, pharmaceutical and biochemical activites of selected climber plants: a review. annu res rev biol. 2017;8:1-22. 15. prentice am, mendoza ya, pereira d, cerami c, wegmuller r, constable a, spieldenner j. dietary strategies for improving iron status: balancing safety and efficacy. nutri rev. 2017;75(1):49-60. 16. andriastuti m, ilmana g, nawangwulan sa, kosasih ka. prevalence of anemia and iron profile among children and adolescent with low socio-economic status. int j pediatr adolesc med. 2020;7(2):88-92. 17. central statistical agency ethiopia, & measure dhs icf macro. ethiopia demographic and health survey 2011: preliminary report. edhs, 2011;1–29. 18. rashid m, flora ms, moni ma, akhter a, mahmud z. reviewing anemia and iron folic acid supplementation program in bangladesh-a special article. bangladesh med j. 2010;39(3). 19. fançony c, soares â, lavinha j, barros h, brito m. iron deficiency anaemia among 6-to-36-month children from northern angola. bmc pediatr. 2020;20(1):1-3. 20. zhao a, zhang y, peng y, li j, yang t, liu z, lv y, wang p. prevalence of anemia and its risk factors among children 6–36 months old in burma. am j trop med hyg. 2012;87(2):306. 21. ngui r, lim ya, chong kin l, sek chuen c, jaffar s. association between anaemia, iron deficiency anaemia, neglected parasitic infections and socioeconomic factors in rural children of west malaysia. plos negl trop dis. 2012;6(3): e1550. 22. wangusi nl, waudo jn, mugendi bj. prevalence and determinants of iron-deficiency anaemia among children 6-23 months attending thika level-5 hospital, kiambu county, kenya. 23. mhanna rg, rahal m, iskandarani m, hammoudi d. incidence and risk factors associated with iron deficiency anaemia among hospitalised lebanese infants. int j pharm pract. 2016;24(3):203-8. 24. nambiema a, robert a, yaya i. prevalence and risk factors of anemia in children aged from 6 to 59 months in togo: analysis from togo demographic and health survey data, 2013–2014. bmc public health. 2019;19(1):1-9. 25. bharati s, pal m, chakrabarty s, bharati p. socioeconomic determinants of iron-deficiency anemia among children aged 6 to 59 months in india. 115 international journal of human and health sciences vol. 07 no. 02 april’23 asia pac j public health. 2015;27(2):np1432-43. 26. orsango az, habtu w, lejisa t, loha e, lindtjørn b, engebretsen im. iron deficiency anemia among children aged 2–5 years in southern ethiopia: a community-based cross-sectional study. peerj. 2021;9:e11649. 27. keokenchanh s, kounnavong s, midorikawa k, ikeda w, morita a, kitajima t, sokejima s. prevalence of anemia and its associated factors among children aged 6–59 months in the lao people’s democratic republic: a multilevel analysis. plos one. 2021;16(3):e0248969. 28. kuma pj, clark ml. kumar and clark’s clinical medicine 10th edition. elsevier, 2020;10, 407-10. 29. lynch s. food iron absorption and its importance for the design of food fortification strategies/ discussion. nutr rev. 2002;60(7): s3. 30. teucher, olivares, cori. enhancers of iron absorption: ascorbic acid and other organic acids. int j vitam nutr res 2004;74(6):403-19. 31. hunt jr. high-, but not low-bioavailability diets enable substantial control of women’s iron absorption in relation to body iron stores, with minimal adaptation within several weeks. am j clin nutr. 2003;78(6):1168-77. 32. davidsson l, walczyk t, zavaleta n, hurrell rf. improving iron absorption from a peruvian school breakfast meal by adding ascorbic acid or na2edta. am j clin nutr. 2001;73(2):283-7. 33. fidler mc, davidsson l, zeder c, hurrell rf. erythorbic acid is a potent enhancer of nonhemeiron absorption. am j clin nutr. 2004;79(1):99-102. 34. panel e, nda a. scientific opinion on the substantiation of a health claim related to vitamin c and increasing non haem iron absorption pursuant to article 14 of regulation (ec) no 1924/2006. efsa journal, 2014;12(1):1-9. 35. serna-saldivar so, carrillo ep. food uses of whole corn and dry-milled fractions. in corn: chemistry and technology, 3rd ed. elsevier inc., 2019. 36. pizarro f, olivares m, hertrampf e, nunez s, tapia m, cori h, de romana dl. ascorbyl palmitate enhances iron bioavailability in iron-fortified bread. am j clin nutr. 2006;84(4):830-4. 37. hurrell rf, reddy mb, juillerat m, cook jd. meat protein fractions enhance nonheme iron absorption in humans. j nutr. 2006;136(11):2808-12. 38. bæch sb, hansen m, bukhave k, kristensen l, jensen m, sørensen ss, purslow pp, skibsted lh, sandström b. increasing the cooking temperature of meat does not affect nonheme iron absorption from a phytate-rich meal in women. j nutr. 2003;133(1):94-7. 39. navas-carretero s, pérez-granados am, sarriá b, carbajal a, pedrosa mm, roe ma, fairweathertait sj, vaquero mp. oily fish increases iron bioavailability of a phytate rich meal in young iron deficient women. j am coll nutr. 2008;27(1):96101. 40. bæch sb, hansen m, bukhave k, jensen m, sørensen ss, kristensen l, purslow pp, skibsted lh, sandström b. nonheme-iron absorption from a phytate-rich meal is increased by the addition of small amounts of pork meat. am j clin nutr. 2003;77(1):173-9. 41. cross aj, harnly jm, ferrucci lm, risch a, mayne st, sinha r. developing a heme iron database for meats according to meat type, cooking method and doneness level. food sci nutr. (print). 2012;3(7):905. 42. schlemmer u, frølich w, prieto rm, grases f. phytate in foods and significance for humans: food sources, intake, processing, bioavailability, protective role and analysis. mol nutr food res. 2009;53(s2): s330-75. 43. hurrell r, egli i. iron bioavailability and dietary reference values. am j clin nutr. 2010;91(5):s14617. 44. nielsen av, tetens i, meyer as. potential of phytasemediated iron release from cereal-based foods: a quantitative view. nutrients. 2013;5(8):3074-98. 45. tetens i, bendtsen km, henriksen m, ersbøll ak, milman n. the impact of a meat-versus a vegetable-based diet on iron status in women of childbearing age with small iron stores. eur j nutr. 2007;46(8):439-45. 46. layrisse m, garcía-casal mn, solano l, barón ma, arguello f, llovera d, ramírez j, leets i, tropper e. iron bioavailability in humans from breakfasts enriched with iron bis-glycine chelate, phytates and polyphenols. j nutr. 2000;130(9):2195-9. 47. reale a, konietzny u, coppola r, sorrentino e, greiner r. the importance of lactic acid bacteria for phytate degradation during cereal dough fermentation. j agric food chem. 2007;55(8):29937. 48. lopez hw, krespine v, guy c, messager a, demigne c, remesy c. prolonged fermentation of whole wheat sourdough reduces phytate level and increases soluble magnesium. j agric food chem. 2001;49(5):2657-62. international journal of human and health sciences vol. 07 no. 02 april’23 116 49. williamson g. the role of polyphenols in modern nutrition. nutr bull. 2017;42(3):226-35. 50. dueik v, chen bk, diosady ll. iron-polyphenol interaction reduces iron bioavailability in fortified tea: competing complexation to ensure iron bioavailability. j food qual. 2017;2017. 51. villaño d, vilaplana c, medina s, algaba-chueca f, cejuela-anta r, martínez-sanz jm, ferreres f, gil-izquierdo a. relationship between the ingestion of a polyphenol-rich drink, hepcidin hormone, and long-term training. molecules. 2016;21(10):1333. 52. ahmad fuzi sf, koller d, bruggraber s, pereira di, dainty jr, mushtaq s. a 1-h time interval between a meal containing iron and consumption of tea attenuates the inhibitory effects on iron absorption: a controlled trial in a cohort of healthy uk women using a stable iron isotope. am j clin nutr. 2017;106(6):1413-21. 53. hurrell r. use of ferrous fumarate to fortify foods for infants and young children. nutr rev. 2010;68(9):522-30. 54. thankachan p, walczyk t, muthayya s, kurpad av, hurrell rf. iron absorption in young indian women: the interaction of iron status with the influence of tea and ascorbic acid. am j clin nutr. 2008;87(4):881-6. 55. mølgaard c, kæstel p, michaelsen kf. longterm calcium supplementation does not affect the iron status of 12–14-y-old girls–. am j clin nutr. 2005;82(1):98-102. 56. milman nt. a review of nutrients and compounds, which promote or inhibit intestinal iron absorption: making a platform for dietary measures that can reduce iron uptake in patients with genetic haemochromatosis. j nutr metab. 2020;2020. 57. martins jm. universal iron fortification of foods: the view of a hematologist. rev bras hematol hemoter.2012;34:459-63. 58. huma n, salim-ur-rehman, anjum fm, murtaza ma, sheikh ma. food fortification strategy— preventing iron deficiency anemia: a review. crit rev food sci nutr. 2007;47(3):259-65. 59. blanco-rojo r, vaquero mp. iron bioavailability from food fortification to precision nutrition. a review. innov food sci emerg technol 2019;51:126-38. 60. hurrell rf. iron fortification practices and implications for iron addition to salt. j nutr. 2021;151(suppl1):3-14. 61. hertrampf e, olivares m. iron amino acid chelates. international journal for vitamin and nutrition research. internationale zeitschrift fur vitaminund ernahrungsforschung. journal international de vitaminologie et de nutrition. 2004;74(6):435-43. 62. shamah-levy t, villalpando s, rivera-dommarco ja, mundo-rosas v, cuevas-nasu l, jiménezaguilar a. ferrous gluconate and ferrous sulfate added to a complementary food distributed by the mexican nutrition program oportunidades have a comparable efficacy to reduce iron deficiency in toddlers. j pediatr gastroenterol nutr. 2008;47(5):660-6. 63. diego quintaes k, barberá r, cilla a. iron bioavailability in iron-fortified cereal foods: the contribution of in vitro studies. crit rev food sci nutr. 2017; 57(10):2028-41. 64. degerud em, manger ms, strand ta, dierkes j. bioavailability of iron, vitamin a, zinc, and folic acid when added to condiments and seasonings. ann ny acad sci. 2015;1357(1):29-42. 65. de carli e, dias gc, morimoto jm, marchioni dm, colli c. dietary iron bioavailability: agreement between estimation methods and association with serum ferritin concentrations in women of childbearing age. nutrients. 2018;10(5):650. 66. hoppe m, hulthén l, hallberg l. the importance of bioavailability of dietary iron in relation to the expected effect from iron fortification. eur j clin nutr. 2008;62(6):761-9. 67. hallberg l, hulthén l. prediction of dietary iron absorption: an algorithm for calculating absorption and bioavailability of dietary iron. am j clin nutr. 2000;71(5):1147-60. 68. caballero valcárcel am, martínez graciá c, martínez miró s, madrid sánchez j, gonzález bermúdez ca, domenech asensi g, lópez nicolás r, santaella pascual m. iron bioavailability of four iron sources used to fortify infant cereals, using anemic weaning pigs as a model. eur j nutr 2019;58(5):1911-22. international journal of human and health sciences vol. 06 no. 02 april’22 168 original article factors associated with covid-19 mortality at setiu district, terengganu state of malaysia in 2021 erwan ershad ahmad khan1, mohd hanief ahmad2, kamarul azhar mohamed2,muhammad hanif shaari2, kasemani embong3 abstract: background: covid-19 infections caused a range of morbidities and mortalities especially in the high-risk group patients. objective:to determine the factors associated with covid-19 related mortality in a population of malaysia. materials and methods: a case-control study was conducted that utilized secondary data from line listing of covid-19 patients at setiu district in terengganu state of malaysia, from january to september of 2021. for both case and control groups, only samples aged 18 years old and above were included. patients under home surveillance orders and were not admitted to hospitals or treatment centres, brought in dead cases and incomplete data of 20% or more were excluded from this study.a total of 126 samples that fulfilled the study criteria were selected for this study. simple random sampling was done. multiple logistic regression analysis was done to determine factors associated with covid-19 mortality using spss version 26.0. results: among the mortality cases, majority were aged ≥60 years old (66.7%), female (61.1%), having comorbidities (83.3%), with incomplete vaccination (83.3%) and were admitted at tertiary hospital (55.6%). factors associated with covid-19 mortality were presence of comorbidity (adjor: 14.40, 95% ci:2.26, 91.79) and incomplete vaccination (adjor: 4.51, 95% ci:1.01, 20.16). conclusion: covid-19 patients with comorbidities and incomplete vaccination must be more closely monitored as they are more likely to succumb to death. explicit preventive measures against covid-19 mortality and its determinants must be implemented by the stakeholders so that patients’ survival can be improved. keywords: covid-19, mortality, morbidity, covid-19 vaccination, malaysia correspondence to: dr. erwan ershad ahmad khan, department of community medicine, school of medical sciences, health campus, universiti sains malaysia, 16150 kubang kerian, kelantan, malaysia.tel: +60179247673, email: erwanershad@gmail.com 1. department of community medicine, school of medical sciences, health campus, universiti sains malaysia, 16150 kubang kerian, kelantan, malaysia. 2. setiu district health office, ministry of health malaysia, lot 11916 – 11918, kampung tok majid, 22100 bandar permaisuri, setiu, terengganu, malaysia. 3. terengganu state health department, ministry of health malaysia, wisma persekutuan, jalan sultan ismail, 20920 kuala terengganu, terengganu, malaysia. international journal of human and health sciences vol. 06 no. 02 april’22 page : 168-172 doi: http://dx.doi.org/10.31344/ijhhs.v6i2.440 introduction covid-19 infection was declared as a global pandemic by the world health organization (who) in march 2020.1 as of september 21, 2021, the who has received reports of 228,807,631 confirmed cases of covid-19, with 4,697,099 fatalities.2rapid mutation and emergence of new variants of concern such as delta increase the infectivity and pathogenicity of the virus due to immune evasion.3 the disease is primarily spread by droplets through coughing and sneezing and could result in acute respiratory illness.4many efforts have been implemented worldwide to contain the disease from spreading and to reduce the associated mortality and morbidity such as initiation of lockdown, mass screening, quarantine and vaccination. the first covid-19 case was reported in malaysia back on january 25, 2020, and was tracked back to three individuals who 169 international journal of human and health sciences vol. 06 no. 02 april’22 had close contact with an infected individual in singapore.5 as of 22nd september 2021, a total of 2,123,165 cases with 24,078 deaths were reported in malaysia.6on the country’s way forward out of the covid-19 pandemic, the government had introduced a recovery plan that consists of four phases. progression to the next recovery phase will be determined by the number of covid-19 cases reported each day, the capacity of the healthcare system, including the number of beds available in intensive care units (icu), and the percentage of the population vaccinated against covid-19.7a reducing trend in the number of daily cases and icu beds occupation had been seen lately as more than 80% of the adult population in the country had already completed vaccination.6 setiu is a district in terengganu with a population of around 60,000. most of the population are malays.8 they are mainly involved in agriculture as farmers and fishermen. as of 22nd september 2021, a total of 3395 covid-19 cases were recorded in the district. this contributed to around 7% of covid-19 cases in terengganu.9around 80.3% of the adult population in terengganu had already completed vaccination against covid-19 as of 23rd september 2021.6 there are limited published studies that discussed factors associated with covid-19 mortality in malaysia, let alone at the district level. therefore, sufficient data need to be obtained for further improvement of preventive measures. every covid-19 case needs to be properly evaluated and stratified accordingly so that, complications including death can be minimalized. findings from this study can be presented to the stakeholders so that effective strategies can be implemented to reduce the burden of the problems. this study aims to determine the factors associated with covid-19 mortality at setiu district, terengganu state of malaysia. methods this case-control study was conducted using secondary data from the line listing of covid-19 cases recorded at setiu distrcit from january to september of 2021. the sampling frame was all covid-19 cases at setiu for the year 2021 (january 2021 – september 2021) and fulfilled the study criteria. only samples aged 18 years old and above were included in the study. cases under home surveillance orders and were not admitted to hospitals or treatment centres, brought in dead cases and incomplete data of 20% or more were excluded from this study. the sample size was calculated for each variable of factors associated with covid-19 mortality using power and sample size calculation software (dichotomous – two proportions formula).10 the largest estimated sample for each group was 58 using the proportion of covid-19 mortality status by the factor of age ≥ 60 years old (0.44) (11), an estimated proportion of 0.20, 5%type 1 error, and 80% power. therefore, the total sample size required is 116 patients with covid-19 infection.as only 18 mortality cases were recorded at setiu from january 2021 – september 2021, a 1:6 ratio of cases to controls was applied and 108 controls were selected to be included in this study. a total of 3569 covid-19 cases were recorded at setiu from january 2021 – september 2021 as of 27th september 2021. of these 3569 cases, 2043 cases were eligible for this study. due to limited data, for cases, no sampling method was applied. all 18 mortality cases were included in the study. 108 controls were selected among patients that survived, matched to the gender of cases. simple random sampling was done using an excel spreadsheet to select all the controls. data were extracted into an excel spreadsheet and then into the spss database. the variables required were age, gender, comorbidity, vaccination status and type of treatment centre. data were collected from the covid-19 cases line listing for setiu district which was also in excel spreadsheet. for operational definition, covid-19 mortality case was defined as any certified case that succumbs to death due to covid-19 infection. presence of comorbidity was defined as the presence of any medical illness prior to diagnosis of covid-19 infection. complete vaccination was defined as completed at least 14 days after the second dose vaccine for pfizer-biontech (comirnaty), sinovac and astra zeneca (azd1222) or at least after 21 days from the single-dose vaccine such as cansino. data were entered and analysed using spss statistics version 26.0. descriptive statistics were used to summarize all factors. categorical data were presented as frequency (percentage). age was categorized into less than 60 years old (reference group) and 60 years old and above. gender was categorized into female (reference group) and male. presence of comorbidity was categorized into absent (reference group) or presence of any of pre-existing illness.vaccination international journal of human and health sciences vol. 06 no. 02 april’22 170 status was categorized into complete (reference group) and incomplete. type of treating centre was divided into tertiary hospitals (reference group) and others that include district hospitals and covid-19 quarantine and treatment centres (pkrc).to determine the factors associated with covid-19 mortality, simple logistic and multiple logistic regression analyses were performed. simple logistic regression was done to all variables and presented as crude odds ratio. only variables with p-value less than 0.25 or any clinically important factors were selected for multiple logistic regression via enter method. the variables selected for multivariate analysis were age, comorbidity, vaccination status and type of treatment centre.multicollinearity and interaction between significance variables were checked. goodness of fit model was checked. the test was presented as adjusted odds ratio and p-value of < 0.05 was considered significant. results among the mortality cases, the majority were aged ≥ 60 years old (66.7%), female (61.1%), having comorbidities (83.3%),with incomplete vaccination (83.3%) and were admitted at the tertiary hospital (55.6%). table 1 illustrates the characteristics of covid-19 patients of the present study.the odds of death among patients with comorbidity were greater than the odds of death among patients without comorbidity by a factor of 14.40 (95% ci: 2.26, 91.79). on the other hand, the odds of death among patients with incomplete vaccination were greater than the odds of death among patients with complete vaccination by a factor of 4.51 (95% ci: 1.01, 20.16). table 2 illustrates the factors associated with covid-19 mortality. table 1. characteristics of selected covid-19 patients at setiudistrict, terengganu sate in 2021 (n=126) variables overall n (%) mortality no n (%) yes n (%) age group < 60 87 (69.0) 81(75.0) 6 (33.3) ≥ 60 39 (31.0) 27 (25.0) 12 (66.7) gender female 78 (61.9) 67 (62.0) 11 (61.1) variables overall n (%) mortality no n (%) yes n (%) male 48 (38.1) 41 (38.0) 7 (38.9) comorbidity no 92 (73.0) 89 (82.4) 3 (16.7) yes 34 (27.0) 19 (17.6) 15 (83.3) vaccination complete 50 (39.7) 47 (43.5) 3 (16.7) incomplete 76 (60.3) 61 (56.5) 15 (83.3) treatment centre tertiary hospital 22 (17.5) 12 (11.1) 10 (55.6) others 104 (82.5) 96 (88.9) 8 (44.4) table 2. factors associated with covid-19 mortality at setiu district, terengganu sate in 2021 (n=126) variables crude or (95% ci) p-valuea adjusted or (95% ci) p-valueb age group < 60 1.00 ≥ 60 6.00 (2.05, 17.54) 0.001 1.36 (0.32, 5.77) 0.677 gender female 1.00 male 1.04 (0.37, 2.90) 0.940 comorbidity no 1.00 yes 23.42 (6.16, 88.99) < 0.001 14.40 (2.26, 91.79) 0.005* vaccination complete 1.00 incomplete 3.85 (1.05, 14.09) 0.041 4.51 (1.01, 20.16) 0.049* treatment centre tertiary hospital 1.00 others 0.10 (0.03, 0.30) < 0.001 0.59 (0.13, 2.72) 0.500 asimple logistic regression bmultiple logistic regression 171 international journal of human and health sciences vol. 06 no. 02 april’22 no multicollinearity and no interaction were found.hosmer lemeshow test, p-value=0.083. classification table 88.1% correctly classified.the area under receiver operating characteristics (roc) curve was 88.0%. *p-value < 0.05. discussion a total of 2 factors had been identified to be associated with covid-19 mortality in this study. the odds of death among patients with comorbidity were greater than the odds of death among patients without comorbidity. this finding is in line with another published study that highlighted the presence of comorbidities such as chronic respiratory diseases, diabetes mellitus, hypertension and cardiovascular disease to have an increased risk of death from covid-19.12 such conditions were found to be related to derangement of inflammatory markers resulting in the more severe form of infection, leading to mortality.13 the presence of comorbidities also increased the risk for coagulopathy as part of the systemic inflammatory response syndrome of severe covid-19 infection.14 in the present study, data showed that the odds of death among patients with incomplete vaccination were greater than the odds of death among patients with complete vaccination. this finding is in line with another published study that reported unvaccinated persons as two times more likely to die due to covid-19 compared to those with completed vaccinations.15 vaccination against covid-19 had been shown to be effective in clinical and community trials. the efficacy of two doses of the bnt162b2 vaccine was 93.7% in people with the alpha variant and 88.0% in people with the delta variant while the efficacy of two doses of the chadox1 ncov-19 vaccine was 74.5% in people with the alpha variant and 67.0% in people with the delta variant.16 the covid-19 vaccines provide disease protection by eliciting an immune response to the sars-cov-2 virus. acquiring immunity by vaccination reduces the likelihood of developing the illness and its effects.17 other variables in this study were found not to be significant predictors for covid-19 mortality. this could be due to the small sample size of the study. age and type of treatment centre were significant at the univariate level but became not significant at the multivariate level. this could also be contributed by the high number of patients with comorbidity that were less than 60 years old of age due to a wider definition for the presence of comorbidity by the data manager. another logical explanation would be patients with well-controlled comorbidity were managed at district hospitals and covid-19 quarantine and treatment centres (pkrc) rather than tertiary hospitals.18 on the other hand, gender was not significant possibly due to matching criteria applied. there were some limitations of this study. as the study utilized secondary data, variables such as smoking, and laboratory profiles were not included as they were not recorded in the original database. these variables had been shown of importance in the literatures. apart from that, although data on symptoms and patients’ category were available in the line listing, the data entry for those variables were done prior to clinical assessment at covid-19 assessment centre, thus was not accurate. on top of that, a small sample size due to the limited number of mortality cases at setiu district in 2021 is another limitation. therefore, future studies could be done by merging data from other districts or states as well with more variables from primary data collection so that, more detailed analysis can be done. conclusion explicit preventive measures against covid-19 mortality and its determinants must be implemented by the stakeholders. covid-19 patients with comorbidity must be monitored at proper institutions such as hospitals or covid-19 quarantine and treatment centre (pkrc) as currently being practised in malaysia (18). continuous surveillance on close contact with comorbidity despite being asymptomatic is also essential. other than that, efforts for vaccination against covid-19 must be hastened so that more people can be protected. health promotion strategies and correcting the misconception about covid-19 vaccines will then be deemed to be beneficial in achieving universal coverage, hence reducing the burden of disease. acknowledgement: the authors would like to thank the director-general of health malaysia for his permission to publish this paper. international journal of human and health sciences vol. 06 no. 02 april’22 172 conflict of interest: all the investigators declared no conflict of interest in this study. ethical approval: research was registered with national medical research register (nmrr id21-01982-viz) and conducted after approval from the medical research ethics committee (mrec), ministry of health malaysia (reference number: 21-01982-viz). funding statement: this study was supported by self-funding. author contribution: concept and design: eeak, data collection, analysis, manuscript writing, revision and final approval:eeak, mha, kam, mhs, ke. references: 1. who. coronavirus disease (covid-19) outbreak – who announces covid-19 outbreak a pandemic [internet]. 2020 [cited 2021 sep 22]. available from: https://www.euro.who.int/en/health-topics/ health-emergencies/coronavirus-covid-19/news/ news/2020/3/who-announces-covid-19-outbreak-apandemic 2. who. who coronavirus (covid-19) dashboard with vaccination data [internet]. 2021 [cited 2021 sep 22]. available from: https://covid19.who.int/ 3. mlcochova p, kemp s, dhar ms, papa g, meng b, ferreira iatm, et al. delta variant replication and immune evasion. nature. 2021;599(7883):114-9. 4. riou j, althaus cl. pattern of early human-to-human transmission of wuhan 2019 novel coronavirus (2019-ncov), december 2019 to january 2020. euro surveill. 2020;25(4):2000058. 5. new straits times. 3 coronavirus cases confirmed in johor baru [internet]. 2020 [cited 2021 sep 22]. available from: https://www.nst.com.my/news/ nation/2020/01/559563/breaking-3-coronaviruscases-confirmed-johor-baru 6. ministry of health malaysia. covidnow in malaysia covidnow [internet]. 2021 [cited 2021 sep 22]. available from: https://covidnow.moh.gov. my/ 7. the malaysian insight. muhyiddin outlines malaysia’s 4-phase covid-19 exit plan today [internet]. 2021 [cited 2021 sep 22]. available from: https://www.todayonline.com/world/muhyiddinoutlines-malaysias-4-phase-covid-19-exit-plan 8. setiu district and land office. latar belakang daerah setiu [internet]. 2014 [cited 2021 sep 23]. available from: http://pdtsetiu. t e r e n g g a n u . g o v. m y / i n d e x . p h p ? o p t i o n = c o m _ content&view=article&id=101&itemid=97 9. terengganu state health department. situasiterkini covid-19 negeri terengganu sehingga 22 september 2021 [internet]. 2021 [cited 2021 sep 23]. available from: https://www.facebook.com/jkntrg/photos/pcb.4 659664210751326/4659664020751345/ 10. dupont wd, plummer wdj. power and sample size calculations. a review and computer program. control clin trials. 1990;11(2):116-28. 11. grasselli g, greco m, zanella a, albano g, antonelli m, bellani g, et al. risk factors associated with mortality among patients with covid-19 in intensive care units in lombardy, italy. jama intern med. 2020;180(10):1345-55. 12. sanyaolu a, okorie c, marinkovic a, patidar r, younis k, desai p, et al. comorbidity and its impact on patients with covid-19. sn compr clin med. 2020;2(8):1069-76. 13. wolff d, nee s, hickey ns, marschollek m. risk factors for covid-19 severity and fatality: a structured literature review. infection. 2021;49(1):15-28. 14. gómez-mesa je, galindo-coral s, montes mc, muñoz martin aj. thrombosis and coagulopathy in covid-19. currprobl cardiol. 2021;46(3):100742. 15. muthukrishnan j, vardhan v, mangalesh s, koley m, shankar s, yadav ak, et al. vaccination status and covid-19 related mortality: a hospital based cross sectional study. med j armed forces india. 2021;77(suppl 2):s278-s282. 16. lopez bernal j, andrews n, gower c, gallagher e, simmons r, thelwall s, et al. effectiveness of covid-19 vaccines against the b.1.617.2 (delta) variant. n engl j med. 2021;385(7):585-94. 17. who. coronavirus disease (covid-19): vaccines [internet]. 2021 [cited 2021 sep 26]. available from: https://www.who.int/news-room/q-a-detail/ coronavirus-disease-(covid-19)-vaccines 18. ministry of health malaysia. annex 2: management of suspected, probable and confirmed covid-19 case [internet]. 2021 [cited 2021 dec 21]. available from: https:// covid-19.moh.gov.my/garis-panduan/garis-panduankkm/annex_2_management_of_suspected_ probable_and_confirmed_covid19_26112021.pdf international journal of human and health sciences vol. 01 no. 01 january’17 22 review article the concept of successful aging misha’l aa1 abstract aging is characterized by progressive and predictable changes that include gradual, unrepaired accumulations of biochemical tissue alterations that compromise cell and tissue systems, rendering individuals to become less fit to reproduce, and survive. the complex processes of aging are not homogenious among individuals and in various tissue systems, and are influenced by genetic, lifestyle and environmental factors. aging can be healthy or pathological. the concept of successful aging is related to opportunities for continued activity and productivity that should represent an essential strategy from both social and medical perspectives. the heterogenous deterioration of functions are initially detectable as loss of reserve capacity to restore homeostasis under stress, followed by altered functions at rest. this article will present contemporary knowledge related to health and psychosocial parameters and undertakings that aim at achieving continued healthy lifestyle, generatively and making significant contribution by the elderly. keywords: aging; lifestyle; retirement; successful aging correspondence to: aly a. misha’l, ex-executive director, islamic hospital, amman, jordan. email:fimainfo@islamic-hospital.org international journal of human and health sciences vol. 01 no. 01 january’17. page : 22-25 introduction aging is characterized by a progressive loss of coordinated cell and tissue function, a process that is manifested, at variable extents, across body organs and systems that renders individuals to become gradually less fit to reproduce and survive. deterioration of function is heterogeneous among systems and individuals. it is initially observed as a gradual loss of reserve capacity, and the ability to restore homeostasis under stress, followed, later in life, by altered function even at rest1,2. biological age, in contrast to chronological age, is synonymous with functional and physiological age, and it is an indicator of the general health status of individuals, their remaining healthy life span and active life expectancy. biological age may help in identifying individuals at risk for age-related disorders, serve as a measure of relative fitness, and predict disability in later life and mortality, independent of chronological age2. people who function poorly are looked upon as being “biologically older” than their chronological age. conversely, people who function well are deemed as “biologically younger”. this concept may be best represented by construction of an index derived from biological markers (called biomarkers of aging)1. different researchers have developed several types of biomarkers. but because different tissues and organs age at different rates, there is a need to obtain different biomarkers for different body systems. some of the newly developed biomarkers include:  changes in telomere length  cross-linking of collagen  glycosylation and glycoxidation  pulse wave velocity  sarcopenia (changes in muscles)  inflammatory markers  clotting markers  immune function markers such biomarkers may be looked upon as only predictors of more relevant regulatory mechanisms and systems, which need time and effort to elucidate1. moreover, most biomarkers are under substantial genetic influence, which strengthens the concept that longevity is heritable. this concept does not negate the importance of environmental influences. the development of biological age estimates, using a combination of reliable biomarkers, together with the search for genes which contribute to aging, will benefit in extending a healthy life span, and maintaining well-being, both physical 23 the concept of successful aging and psychological. although the basic mechanisms under-lying aging processes are unknown, available evidence is consistent with accumulation of a variety of biochemical alterations that impair functions of nucleic acids, proteins and lipid membranes. these alterations probably include, but are not limited to:  oxidation by free radicals3.  non-enzymatic glycosylation4.  epigenetic changes, such as dna methylation and histone acetylation5. the extent to which differentiated cells are affected by aging determines physiologic function, while the extent to which stem and precursor cells (the reserve cells) are affected determines the capacity to replace and repair damaged cells and tissues6. in studying of changes in older people, it is important to distinguish between effects of aging per se, and those caused by age-related illnesses. a twin study found that genetics accounted for about 25% of the variation in longevity among twins, and environ-mental factors accounted for about 50%7. however, with greater longevity (to age 90 or 100 years), genetic influences become more important. age-associated body system changes age impacts widespread changes, involve various body tissues and systems, at variable rates8-13. despite all these changes, elderly individuals may significantly expand their productive life at home, in society and the workplace, by engaging in social, physical and cognitive activities. in healthy older volunteers, cognitive training can lead to increases in brain grey matter volume in the “exercised” areas14. lifestyle and behavioral measures, with specific carefully designed, age oriented medical care and specific devices wherever needed, are instrumental to achieve successful aging. remaining active physically, cognitively, and socially, with continued generativity and making a contribution, are the main parameters of successful aging2,15. remaining active has specific health benefits, both in the physical and cognitive domains. there is evidence to support the old saying “use it or lose it”: to live longer and also healthier. there is abundance of evidence suggesting that mental health diverges from physical health, in that coping, adaptation and resilience functions are surprisingly well preserved throughout most of the human life span16. this important aspect of aging has very significant implications in the various roles that older people can perform in various aspects of their societies. their input could be extremely fruitful in many areas that need cognitive capability. the physical aging should not bar them from providing this crucial input. this may add to the various shortcomings and fallacies of the arbitrary retirement age of 65 years. being able to make a contribution has been described as an essential element of “successful aging”. it has been reported that women who participated in voluntary work or activity had greater longevity than those who did not. moreover, this voluntary work is essential to psychological well-being in late life. physical and cognitive activity, along with social engagement, are related to improved health and function with aging. in addition to the generativity and contributions, elderly individuals can ensure their legacy through defining one’s life contributions and achievements. staying cognitively active helps to protect memory in older people. regular physical activity, both of moderate and high intensity, are associated with lower frequency of heart disease, diabetes mellitus, maintenance of proper weight, more beneficial levels of cardiovascular disease risk factors, and lower likelihood of disability and dependence. much has been learned recently regarding the adaptability of various biological systems by exercise17. regular exercise is effective to reduce or prevent a number of functional declines associated with aging, and contributes to an increase in healthy life expectancy. additional benefits include:  improved bone health with reduction in risk of fractures.  improved postural stability, with reduction in falls.  increased coordination, flexibility and range of motion.  psychological benefits: related to preserved cognitive function and alleviation of depression.  improved concept of personal control and self-efficacy, in-dependent lifestyle, functional capacity and quality of life. a good number of clinical studies showed significant benefits of exercise and community involvement18,19. those who live longer lives, and are vibrant until shortly before death, may provide the best possible example of successful aging. from the psychological domain, aging is seen as a life-long misha’l aa 24 adaptive process, an ongoing dynamic of selective optimization with compensation, involving the following three elements, which provide a general framework for understanding the developmental changes and resilience across the life span17. 1. selection: as a result of physical and cognitive limitations, individuals select, or optimize, their efforts into areas of high priority. 2. optimization: individuals continue to engage in behaviors that enrich and augment their physical and mental reserves. 3. compensation: individuals compensate by using psychological and techno-logical strategies. psychological strategies may involve using external memory aids. technological strategies may include a hearing aid. the three elements interplay with one another so that a person may suffer from a reduction in general capacity and losses in specific functions, but creates a transformed and effective life, and thereby the older person maximizes and attains positive or desired outcomes, and minimizes or avoids negative or undesired ones. the role of society/state it may be very difficult for old individuals to get involved in activities that produce successful aging. it is hard to accomplish in a retirement setting or in isolation. in most countries, very few efforts are made to open organized avenues for old people to play meaningful roles as they age2. the experiences, abilities and time of older adults are largely not harnessed, and most efforts are limited to the variable needs of the elderly, without making use of their contributions to their societies. some workers in this area describe the older generations as the only increasing natural resource, but the least used one!2. in the post retirement years, more than half of people aged 65 and older are without significant disabilities, although 80% of them have one or more chronic disease2. such chronic diseases are usually managed successfully, and most affected people lead near normal life. most of them are, however, marginalized from productivity, while having plenty of time and experience. the family, society and the state need to develop modalities, policies, strategies and legislations to achieve this, in active efforts towards maximizing productive and healthy years of life, side by side with minimizing the number of years of late life lived sick and disabled. such modalities also help to decrease costs. it is the duty of society to create widely accessible opportunities for older adults to remain active and productive. positive social support, and social activity of the older adults have been related to improving their health, functioning and happiness. a prominent example of opportunities for older people to accomplish is the field of children education2. in most societies there is a two way deficiency of time and attention provided by working parents, as well as by the school systems to provide various types of care to the young generation. this deficiency includes teaching and education, as well as areas of culture and general knowledge. with their wide knowledge and experiences, together with their valuable support, advice and helping hand, both at home and school levels, the older generation can provide valuable contributions and role models. in addition, it provides them with the joy of giving and happiness of more achievements. programs must be designed that are attractive and convenient to old people, to maximize their effectiveness and contributions, as long as possible. this educational model could be conveniently and actively extended to include other areas of health, environment, social and charitable work to serve and support their communities. concluding remarks in the post retirement years, more than half of subjects aged 65 and older, lead healthy lives, with no significant disabilities, although the majority have one or more successfully managed chronic illnesses. however, most of them are marginalized from productivity. the prevailing approach, by society and medical professionals, is limited to addressing only some of the variable needs of the elderly, without making proper use of their contributions in their post-retirement years. the family, society and medical professionals have an obligation to develop modalities to achieve the concept of “successful aging” towards maximizing productive and healthy years of the older subjects, with minimizing the years of illness and disability. healthy and competent older people, with their knowledge experiences and wisdom, may have significant and constructive roles to play in their societies. 25 the concept of successful aging references 1. karasik d, demissic s, cupples a, et al. disentangling the genetic determinants of human aging: biological age as an alternative to the use of survival measures. j gerontal a biol sci med sci. 2005; 60 (5):574-587. https://doi.org/10.1093/gerona/60.5.574 2. fried lp, freedman m, endres te, et al. building communities that promote successful aging. west j med 1997;167:216-219. 3. cowdry ev. problems of ageing: biological and medical aspects, 2nd ed, williams & wilkins, baltimore 1942. 4. bokov a, chaudhuri a, richardson a. the role of oxidative damage and stress in aging. mech ageing dev 2004;125:811. https://doi.org/10.1016/j. mad.2004.07.009 5. suji g, sivakami s. glucose, glycation and aging. biogerontology 2004;5:365. https://doi.org/10.1007/ s10522-004-3189-0 6. egger g, liang g, aparicio a, jones pa. epigenetics in human disease and prospects for epigenetic therapy. nature 2004; 429:457. https://doi.org/10.1038/ nature02625 7. conboy im, conboy mj, wagers aj, et al. rejuvenation of aged progenitor cells by exposure to a young systemic environment. nature 2005; 433:760. https://doi.org/10.1038/nature03260 8. walston j, hardley ec, ferrunic: l et al. research agenda for frailty in older adults: toward a better understanding of physiology and etiology: summary from the american geriatric society / national institute on aging research conference on frailty in older adults. j am geriatr soc 2006;54:991-1001. https://doi.org/10.1111/j.1532-5415.2006.00745.x 9. veldhuis jd. altered pulsatile and coordinate secretion of pituitary hormones in aging: evidence of feedback disruption. aging (milano) 1997;9:19. https://doi.org/10.1007/bf03339688 10. hofman ma, swaab df. living by the clock: the circadian pacemaker in older people. ageing res rev 2006;5:33. https://doi.org/10.1016/j.arr.2005.07.001 11. lipsitz la, goldberger al. loss of ‘complexity’ and aging. potential applications of fractals and chaos theory to senescence. jama 1992;267:1806. https:// doi.org/10.1001/jama.1992.03480130122036 12. romero-ortuno r, wallis s, biram r, keevil v. clinical frailty adds to acute illness severity in predicting mortality in hospitalized older adults: an observational study. eur j intern med 2016;35:24. https://doi.org/10.1016/j.ejim.2016.08.033 13. sherman ss, hollis bw, tobin jd. vitamin d status and related parameters in a healthy population: the effects of age, sex, and season. j clin endocrinol metab 1990; 71:405. https://doi.org/10.1210/jcem71-2-405 14. maclaughlin j, holick mf. aging decreases the capacity of human skin to produce vitamin d3. j clin invest 1985;76:1536. https://doi.org/10.1172/ jci112134 15. pattanaungkul s, riggs bl, yergey al, et al. relationship of intestinal calcium absorption to 1.25-dihydroxyvitamin d [1,25 (oh)2d] levels in young versus elderly women: evidence for agerelated intestinal resistance to 1.25 (oh)2d] action. j clin endocrinol metab 2000;85:4023. 16. mattson m, chan s, duan w. modification of brain ageing and neurodegenerative disorders by genes, diet and behaviour. physiol rev 2002;82:637– 72. https://doi.org/10.1152/physrev.00004.2002 pmid:12087131 17. foster jr. successful coping, adaptation and resilience in the elderly: an interpretation of epidemiologic data. psychiatr q 1997;68(30):189-219. 18. american college of sports medicine position stand. exercise and physical activity for older adults. med sci sports exerc 1998;30(6)992-1008. https://doi. org/10.1249/00005768-199806000-00033,https:// doi.org/10.1097/00005768-199806000-00033. pmid:9624662 19. depp ca, jestc dv. definitions and predictors of successful aging: a comprehensive review of larger quantitative studies-am j geriatr psychiatry 2006;14(1):2-5. https://doi.org/10.1097/01. jgp.0000192501.03069.bc, pmid:16407577 20. tate rb, lah l, and cuddy te, definition of successfully aging by elderly canadian males: the manitoba followup study. the gerontologist 2003; 43,5:736-744. https://doi.org/10.1093/geront/43.5.735 195 international journal of human and health sciences vol. 07 no. 02 april’23 case report ruku’s position might improve scoliosis curve angles of 18-years old female with mild thoracic adolescents idiopathic scoliosis: a case report olympia zahradewi1, eko ari setijono2, trianggoro budisulistyo3, yuyun yueniwati4 abstract adolescent idiopathic scoliosis with an incidence of around 2%, commonly affects thoracic regions. the functional curves or structural treatment cannot be managed by the muscle’s active force and the ruku’ movement on moslem prayer led paravertebral muscles to gently bend with consistent forces and improve mild thoracic ais in 4-week. an 18-yearold female diagnosed with mild thoracic ais carried out treatment by improving ruku movements regularly for 4-5 minutes from august 12 to september 12, 2022. the formed angle by an imaginary line of th 4 and th 9 spinal processes, showed improvement (2.42% to 4.24%). another study that used core stabilization training can also resolve ais for 12 weeks, 3 sessions/week, and with 60 minutes/session.thus, consistent ruku’s movement in the proper position promotes the spinal column remaining in the midline, so might correct the mild thoracic ais’s misaligned, support ergonomic position, and make the patients not easily tired. keywords: cobb angle, ruku’s position, thoracic scoliosis correspondence to: olympia zahradewi, student, faculty of medicine brawijaya university, malang indonesia, e-mail: olymp.zahra2004@gmail.com 1. faculty of medicine brawijaya university, malang indonesia 2. neurology department, faculty of medicine, brawijaya university, malang indonesia 3. neurology department, faculty of medicine, diponegoro university, semarang indonesia 4. radiology department, faculty of medicine, brawijaya university, malang indonesia introduction scoliosis is an example of an abnormality in the spine. scoliosis is categorized into several types, namely idiopathic, congenital, neuromuscular, and syndromic. of those many types, idiopathic scoliosis has become the most common type of scoliosis suffered by adolescents and can also be referred to as adolescent idiopathic scoliosis (ais).[1] it is the one type of scoliosis that often affects adolescents around the world and globally has impacted 2.5% of the total adolescent population in the world in 2015. the cause of this disease is unknown among 80-85% of patients with ais, but generally, an incidence of about 2% can affect the thoracic region of adolescents and cause cns (central neuron system) abnormalities in various study series.[1,2] it is divided based on the stages, namely mild (early stages), moderate, and severe (late stages). the treatment of ais which is still categorized as early stages (cobb angle 10-25º) is said to be more cost-effective than the treatment after the occurrence of an acute stage in other studies. several hypotheses have also been put forward to find appropriate, fast, inexpensive, and not tiring treatment that can be carried out by sufferers of this disorder, but to no avail. treatment in the early stages, which is said to be cheaper than acute treatment, still takes a long time to see changes in the cobb angle. therefore, new solutions that can solve the early-stage ais problem need to be investigated. with the criteria, it does not require a lot of money, can be done anywhere, and can only take a short time.[3] ruku’ is one of the movements carried out by adherents of islam. ruku’ is done before prostration and after reading a short prayer in the qur’an. the movements achieved during ruku’ are conducted by facing the thorax and head to look at the floor which forms a 90º angle while making both palms clasp the feet and cover the patella area (thumb international journal of human and health sciences vol. 07 no. 02 april’23 doi: http://dx.doi.org/10.31344/ijhhs.v7i2.574 international journal of human and health sciences vol. 07 no. 02 april’23 196 and index finger cupping the patella area). the bowing motion in this study was first hypothesized in the world to slowly bend the paravertebral bones of sufferers with consistent strength. this might reflect of spinal muscles pull maximally has the possibility to cause the spine to slowly return to its normal position or to the midline. so can lead to better vertebra column alignment which muscles and supportive tissues are in the proper position.[3] scoliosis cannot be justified by the dysfunction or wrong movement of active muscles, as some cases might cause by the sitting bent habit or compromise to the comfort side due to musculoskeletal or disc problems.ruku’ makes the spinal muscles pull maximally has the possibility to cause the spine to slowly return to its normal position or to the midline, so we thought that it could be improved for managing ais problems. materials and method the subject that’s being used in this study was an indonesian woman aged 18 years old and suffering from mild thoracic ais without mechanical or sport traumatic injuries before. she also did not have any severe disease in the thoracic area during the study.she was observed having mild thoracic ais beforehand, which an initial cobb angle of 20º on its right thorax and with spinous processes of 165º. the most frequently reported complaint during this mild thoracic ais is that she always gets tired faster than her friends in carrying out activities while she has difficulty breathing or hyperventilation. the thoracic x-ray was taken at dr. kariadi hospital in semarang, then followed for 1-month observation as ordered by one radiologic weekly examinationat radiology department in malang. the study was conducted over the range of a month or four weeks. starting on august 12th and ending on september 12th, 2022. the implementation of the ruku’ movement or bowing by 90º and looking at the floor is shown in figure 1. this ruku’ movement is carried out in every prayer each session takes 4-5 minutes. within a day, normally the bowing movement is performed 17 times (2 bowing in one-morning prayer, 4 bowing in 3 times in the afternoon-evening-night prayers, and 3 times bowing in one maghrib prayer). considering this, the study was mobilized to be carried out with a total of 17 bowing timesand carried out consistently within the implementation period. the implementation of the research was carried out by the subjects in private boarding rooms and at the campus mosque; in malang. the radiological results obtained will be used as a measure of this study. radiological results were calculated using the cobb angleformula.[4,5,6,7] if the angle that’s being made is <10º, then the bones of the subject are normal. mild is in the 1025º angle range, moderate is 25-45º, and severe is >45º. in addition to using the cobb angle, the measurement also measures the spinous process or tissue sticking out of the plate of the spinal organ. the spinous process is measured using the degree of measurement on the curved part only in the midline of the spine. in this study, the results of the cobb angle and the spinous process will be measured using a certain formula using angles and then divided by the correlation per week and per day. the cobb angle in this innovation will be referred to as ca and the spinous process will be referred to as ps. both things will be measured using a structure like this: the above method formula is used with the aim of being able to see the degree of spinal changes of the patient every day or every week. this formula is used with the aim that the x-ray results passed in the second week can still be able to be calculated validly. this study also will show how long do the subject’s vertebrae doing their job per day. those jobs included sitting down and walking or standing up. in addition to that information, the result of this study will also show how many times ruku’ has been done by the subject per week to show whether the intensity of doing the ruku’ movement in everyday life can really straighten the paravertebral curve in scoliosis sufferers and maintain the good posture in everyday life. 197 international journal of human and health sciences vol. 07 no. 02 april’23 furthermore, in this study, the authors declared that the method that’s being used does not violate any points in the wma declaration of helsinki about ethical principles for medical research involving human subject 2000 such as the respecting subject’s safeness and rights. results from the study that’s being carried out, it was found that the study of the cobb angle of the spine which had an initial tilt angle of 20º to the right could drop to 9º and the initial spinous process (165º) on 18 years old could be corrected to 172º within 4 weeks.using the chronological movement of muslim prayer, starting from raising the hand to sitting down, the paravertebral or the vertebrae of the sufferer can deform to their original normal shape which is shaped straight to the midline of the body or linear to the cranial bone of the body. even though a few important points that have been done need to be reconsidered in the future experiment and this study. those points are provided below along with the following head-ups about what’s going to be discussed in the next chapter. the radiological examination with concerned about a health matter, as the continuous x-ray exposure was not more than 4 times with 1-week intervals. so, the study was started 2 weeks after the initial exposure. this action was being taken to be dismissed due to the health matter of the subject when being exposed to the x-ray light. other than figure 2:the specific formula for the result’s discussion figure 3: variable control; right cobb angle20º and with processus spinosusof 165º that, in the execution of the study that’s being held, the subject has skipped a few times of the daily prayer in the following week (week-2) which is being converted into days will interpret as 2 days without 17 times movement of ruku’ per day. other additional information for this result is that in the period time of the experiment, the subject always sat down and walk or stood up in less than eight hours. the duration of these activities has a certain relationship with the change in the vertebrae’s shape. without specific measurement or being looked up closely and with the objective measurement, the changes that occur in the vertebrae of the subject can be seen vividly.[8]the changes in vertebrae angle in the data seem to be international journal of human and health sciences vol. 07 no. 02 april’23 198 starting from the upper vertebrae near the cranial and then slowly changing the vertebrae area near the lumbar bones. this can happen because thoracic bones are much evolutivethan lumbar bones and can increases through disc wedging during the rapid growth spurt later.[9] discussion the results above show that the movement of ruku’ can make changes in the curvature of the spine with corresponding changes. to simplify understanding, two figures below: cobb angle and processus spinous’s statistics, will show a shifting line in showing the angle degree of vertebrae. the statistics that are showed a declining angle degree or descending line (figure 5), and an inclined angle degree known as the ascending line (figure 6). those lines with similarities meant, that observing the improvements in scoliosis alignments might give positive feedback. using figure 4:the result table of ruku’ movement 199 international journal of human and health sciences vol. 07 no. 02 april’23 the formula that’s present in the method and material chapter above, the degree changes from variable result a to the prior variable result, and the percentage of the effectiveness of the utility of the conducted movement can be seen. the resulting degree that will be shown in two measurements is divided into classifications: per week degree or days degree. formula per week for shifting tilt started from week-1. it was seen that in the named week there were no changes in the cobb angle (0,0º) according to the variable control as the prior variable result while the processus spinous of this variable result shows about 4º changes for one week and 119 ruku’ movement in the week. skipping the variable result in week-2, and week3 shows that there are 5º ca changes and 1º ps changes from week-1 for 119 ruku’ movement. if the division of the existing degree of ca and ps in week-2 is merged with the degree changes in week-3, then in each week there will be 2.5º ca and 0.5º ps degree changes with a total of 204 ruku’ movement. for week-4, the changes degree of ca and ps from the prior variable is 6º for 153 ruku’ movement. the formula per day for shifting tilt starting from week-1 shows about 0.0º ca changes and 0.57º ps changes. skipping week-2, and week-3 have 0,71º ca changes per day and 0.14º ps changes. if the degree changes between week-2 and week-3 are being merged, then the final output of its number is 0.35º ca and 0.07º ps angle degree. lastly, the week-4 of this experiment showed that from the prior experiment, the ca of the sufferers is 0.66º while the pschanges to 0.22º. the percentage of the existing data in each week will be shown using formula b and formula c (figure 2). figure 5:the decreasing degree of cobb angle figure 6:the increasing angle degree of processus spinous the measurement above observed ca and ps changes (26.6% and 3.23%) (figure 7), wherein priorly the core stabilization treatment might improve 15.5% of the cobb angle.[10] otherwise, in this study, the proper ergonomic posture could play role in the improvements, but the movement needs to be done correctly and regularly especially for early ais patients (10-14 years old) due to the body growth spurt so that their vertebrae can grow normally and stay in the midline.[11] regarding muscle mechanics, most practice uses muscle tractionto simulate thecurved muscles onspinal loading such asmuscle traction forces between origin andcurved muscle insertion that are typically transmitted to the vertebral bodies or other body parts via “passing points” making contact forces between muscles and vertebral bodies to simulate proper action that wraps around the muscle. therefore, future research about muscle can be pursue. for example, the examination of soft tissue deformation during changes in posture or movement to understand the realistic physiological properties of muscles during exercise, the information about the complexity of asymmetric loads that combine motion in threedimensional space to see significantly increase the risk of spinal injury, and to seewhether it can be personalized for one person and applied to many people.[12] conclusion in this study, it was found that doing daily prayer in everyday life and performing the movement of ruku’ properly can improve vertebral column position. when the position of the backbone is correct and the paravertebral muscles can support an ergonomic position, our body will unable to easily feel tired. with the correlation of the data above that shows the consistency and lots international journal of human and health sciences vol. 07 no. 02 april’23 200 of amount, it will deform scoliosis back to the normal shape faster than the ones that didn’t. we realize that the long-term duration of the study, subject participants, and early moderate stages of scoliosis could describe the effectiveness of the treatment. limitations the limitation or lack of this research is that the participant is limited and more subjects needs to be involved. the variables that are being analyzed also should be more varied, such as length of activity sitting, standing, exercise, body mass index, age groups, etc. acknowledgement the study proceeds are conducted at the faculty of medicine brawijaya university and the radiology examinations are done at dr. kariadi hospital semarang and sima laboratory malang in indonesia. author contributions oz designed the study, performed the experiment, and study’s subject. together with ea, tb and yn to analyzed the data and wrote whole the publication article. yn advices for x-ray observation and cobb angle measurements during the study. ea and tb monitored the execution and how it can cause the nervous system. funding this research received no external funding. conflicts of interest the authors declare no conflicts of interest. figure 7: raising percentage of the changes in degree from variable control to week-4 201 international journal of human and health sciences vol. 07 no. 02 april’23 references 1. berdishevsky h, lebel va, bettany-saltikov j, rigo m, lebel a, hennes a, et al. physiotherapy scoliosisspecific exercises –a comprehensive review of seven major schools. scoliosis and spinal disorders. 2016; 11:20. https://doi.org/10.1186/s13013-016-0076-9 2. elattar ea, saber nz, farrag da. predictive factors for progression of adolescent idiopathic scoliosis: a 1-year study. egyptian rheumatology and rehabilitation. 2015; 42(3): 111–9. https://doi. org/10.4103/1110-161x.163943 3. hefti f. pathogenesis and biomechanics of adolescent idiopathic scoliosis (ais). j child orthop. 2013; 7: 17–24. https://doi.org/10.1007/s11832-012-0460-9 4. al-zubaer imran a, huang c, tang h, fan w, cheungkmc, to m. analysis of scoliosis from spinal x-ray images. electrical engineering and systematic science. cornell university, april 2020. https://doi.org/10.48550/arxiv.2004.06887 5. keenan be, adam cj, pearcy mj, pettet gj. medical imaging and biomechanical analysis of scoliosis progression in the growing.queensland univeristy of technology. https://eprints.qut.edu.au/84532/1/ bethany%20elin_keenan_thesis.pdf 6. malfair d, flemming ak, dvorak mf, munk pl, vertinsky at, et al. radiographic evaluation of scoliosis. american journal of roentgenology. 2010; 194: s8-22.https://doi.org/10.2214/ajr.07.7145 7. jeb mcaviney j, roberts c, sullivanb, alevrasaj, petra l grahampl, brown bt. the prevalence of adult de novo scoliosis: a systematic review and meta analysis. eur spine j. 2020; 29(12): 2960-9.https://doi.org/10.1007/s00586-020-06453-0 8. wang j, zhang j, xu r, chen tg, zhou ks, zhang hh. measurement of scoliosis cobb angle by end vertebra tilt angle method. j orthop surg res. 2018; 13(1): 223. https://doi.org/10.1186/s13018-0180928-5 9. will re, stokes ia, qiu x, walker mr, sanders jo. cobb angle progression in adolescent scoliosis begins at the intervertebral disc. spine (phila pa 1976). 2009 dec 1;34(25):2782-6.https://doi. org/10.1097/brs.0b013e3181c11853 10. qi k, fu h, yang z, bao l, shao y. effects of core stabilization training on the cobb angle and pulmonary function in adolescent patients with idiopathic scoliosis. j environ public health. 2022: 4263393.https://doi.org/10.1155/2022/4263393 11. sung s, chae hw, lee hs, kim s, kwon jw, lee sb, et al. incidence and surgery rate of idiopathic scoliosis: a nationwide database study. int. j. environ. res. public health. 2021; 18: 8152. https:// doi.org/10.3390/ijerph18158152 12. jaejin hwang, gregory g. knapik, jonathan s. dufour & william s. marrascurved muscles in biomechanical models of the spine: a systematic literature review, ergonomics, 2017; 60:4, 577-588, https://doi.org/10.1080/00140139.2016.1190410 https://doi.org/10.1186/s13013-016-0076-9 https://doi.org/10.4103/1110-161x.163943 https://doi.org/10.4103/1110-161x.163943 https://doi.org/10.1007/s11832-012-0460-9 https://doi.org/10.48550/arxiv.2004.06887 https://www.google.com/url?sa=i&source=web&cd=&ved=0caqqw7ajahckewjw29voqjj7ahuaaaaahqaaaaaqba&url=https%3a%2f%2feprints.qut.edu.au%2f84532%2f1%2fbethany%2520elin_keenan_thesis.pdf&psig=aovvaw1iba502dbra3z2wn6btbbb&ust=1667781364294912 https://www.google.com/url?sa=i&source=web&cd=&ved=0caqqw7ajahckewjw29voqjj7ahuaaaaahqaaaaaqba&url=https%3a%2f%2feprints.qut.edu.au%2f84532%2f1%2fbethany%2520elin_keenan_thesis.pdf&psig=aovvaw1iba502dbra3z2wn6btbbb&ust=1667781364294912 https://doi.org/10.2214/ajr.07.7145 https://doi.org/10.1007/s00586-020-06453-0 https://doi.org/10.1186/s13018-018-0928-5 https://doi.org/10.1186/s13018-018-0928-5 https://doi.org/10.1097/brs.0b013e3181c11853 https://doi.org/10.1097/brs.0b013e3181c11853 https://doi.org/10.1155/2022/4263393 https://doi.org/10.3390/ijerph18158152 https://doi.org/10.3390/ijerph18158152 https://doi.org/10.1080/00140139.2016.1190410 73 international journal of human and health sciences vol. 07 no. 01 january’23 original article a comparative study of suicide cases in pre-covid and covid phases anamika nath1, pradip kumar thakuria1, aditya madhab baruah1 abstract background: india’s first case of covid-19 was in january 2020. national lockdown brought along mental ailments like depression, anxiety, stress, phobias, etc. objective: to find the number of suicidal deaths during the covid pandemic and to compare the pre-covid phase, and the factors affecting them. methods: this was a cross-sectional, retrospective study conducted at a tertiary care medical centre from 2018-2021. suicide cases coming for autopsy in 2018-2019 and 2020-2021, excluding those where the manner of death was not documented, were analyzed. age, sex, residence, occupation, and cause of death from autopsy reports and inquest papers were noted. results: out of 362 suicide cases, 43.64% were in pre-covid and56.35% in the covid phase with 42.93% males in pre-covid and 57.70% in the covid phase. females were 52.06% in pre-covid and44% in the covid phase. the majority of cases in the study period were in the 21-30 years and 31-40 years groups. housewives were the majority in the pre-covid phase (32.91%), and daily-wage labourers in the covid phase (49.26%). the number of hanging and burn cases were similar and the majority during the pre-covid phase, while in the covid phase hanging cases were a majority. conclusion: covid-19 pandemic showed a rise in suicide cases and a shift towards male preponderance that was daily-wage labourers and hanging cases, which might be due to loss of pay during the phase. keywords: covid-19, suicide, daily-wage labourers, hanging correspondence to: anamika nath, deptt. of forensic medicine, tezpur medical college & hospital, tumuki, assam. pin: 784010, tezpur medical college & hospital. email: arachneliya@gmail.com, orcid:0000-0002-2697-5020 1. deptt.of forensic medicine, tezpur medical college & hospital, tumuki, assam. pin: 784010, tezpur medical college & hospital. introduction death due to suicide is a entirely preventable occurence. it affects families, communities, and nations. over 700,000 individuals worldwide die from suicide each year, making it a serious public health issue. among people aged 15 to 29, suicide ranks as the fourth most common cause of death. lowand middle-income nations account for 77% of all suicides worldwide. among the most popular suicide techniques used worldwide is pesticide ingestion, hanging, and using a gun.1 the corona virus disease 2019 (covid-19), also known as the severe acute respiratory syndrome coronavirus 2 (sars-cov-2), initially surfaced in wuhan, china, in november 2019.2 since then, covid-19 has expanded to every continent in the world, prompting the world health organization to formally classify the epidemic as a pandemic.3 as a result, the covid-19 pandemic is thought to be the worst of the century and is expected to result in an increasing number of international journal of human and health sciences vol. 07 no. 01 january’23 page : 73-77 doi: http://dx.doi.org/10.31344/ijhhs.v7i1.501 mailto:arachneliya@gmail.com http://baruaditya@gmail.com international journal of human and health sciences vol. 07 no. 01 january’23 74 fatalities. covid-19 may also result in direct and indirect mortality through suicide in addition to respiratory discomfort and distress that ultimately result in death.4 india’s first case of covid-19 was reported on 30th january 2020 from kerala.5 the national lockdown was implemented in four different phases.6 the pandemic profoundly impacted mental health. 1,53,052 suicides were reported in 2020, an 8.7% increase during 2020 over 2019.7 hence this research was taken up to find the number of suicidal deaths during the covid pandemic and to compare between precovid phase, and factors affecting them. methods this cross-sectional retrospective study was taken up in a tertiary care medical centre among the suicide cases brought for medicolegal autopsy. the study period was from the year 2018 to 2021. the cases from 2018 and 2019 have been marked as the pre-covid phase and from 2020 and 2021 as covidphase for the study. inclusion criteria: all suicide cases during the study period have been included in the study except those where the manner of death was not documented or was doubtful and in severely decomposed bodies. data has been collected from the accessible records of police inquest and autopsy reports using a data collection proforma, which was pretested and validated through a pilot study. data has been collected in the variables of age, sex, residence, occupation, and cause of death. all the data has been encoded in non-identifiable serial numbers and tabulated in an excel sheet.statistical analysis ofdata was done and expressed in numbers and percentages using microsoft excel. results during the study period of 4 years, a total of 1155 numbers of autopsies were performed out of which 362 cases were opined to be of suicide. in the precovid phase, 158 cases (43.64%) of suicide were noted which is significantly lower than that in the post covid phase with 204 cases. the highest number of suicide cases was recorded in 2020 with 117 cases of suicide. in the pre covid phase, a higher number of females were involved which reversed in the covid phase with a higher number of male cases recorded as shown in figure 1.age distribution of cases did not show any major difference in both the phase. 21-30 years followed by 31-40 years were the most commonly affected group as shown in figure 2.housewives were most commonly involved in the pre covid phase while daily wage labourers were the most involved occupational group as shown in figure 3. while self-inflicted burn deaths were high in pre covid phase hanging deaths were much more common in the covid period as shown in figure 4. the residents of all the cases were of rural background. figure 1: distribution of cases based on the sex of the individual figure 2: distribution of cases based on the age of the individual figure 3: distribution of cases based on the occupation of the individual 75 international journal of human and health sciences vol. 07 no. 01 january’23 figure 4: distribution of cases based on the cause of death of the individual discussion in contrast to other pandemics, covid-19 has complicated processes that have aided in its swift and disastrous global spread.8 the pandemic is regarded as the worst of the twenty-first century. the unexpected rise and spread of the covid-19 virus have caused a rise in community unrest, which has resulted in a pandemic status and may have ultimately contributed to the rising trend of suicidal attempts reported during the covid-19 pandemic compared to other pandemics the world has previously experienced.9 anxiety and depression, financial loss/job loss, domestic abuse, and pre-existing mental health condition(s) were among the characteristics that one systematic review identified as risk factors for suicidal attempts and deaths during the covid-19 pandemic.10 in our study we found 56.36% of suicide deaths during the covid phase as compared to 43.64% during the pre-covid phase. this clearly shows an increase in suicidal trends during the covid phase which is similar to the findings of calati et al.7 a similar pattern in suicide rates among those afflicted by war and natural calamities, is a common occurrence. in vulnerable populations, such as those with pre-existing psychiatric disorders and people who live in areas with a high covid-19 prevalence, social isolation, anxiety, fear of contracting an infection, uncertainty, chronic stress, and financial difficulties, these factors may contribute to the development or exacerbation of depressive, anxiety, substance use, and other psychiatric disorders, ultimately leading to suicidal ideation.11 during the precovid phase, there was female preponderance. according to a study that compared different risk factors for suicide attempts by sex, familial support had the biggest sex difference. young women were much more likely to attempt suicide when their family’s support was inadequate; young men were not affected by this relationship.12 there is male preponderance in our study during the covid phase. this is in accordance with pathare et al.13 and acharya et al.14. there is no difference in affected age groups in pre-covid and covid phases. in both phases, ages between 21-40 years are majorly affected. this is similar to pathare et al who found 30-50 years as a majorly affected age group.13 during the precovid phase, housewives were majorly affected while in the covid phase, daily wage labourers were the majority. pathere et al in their study did not find any difference in occupation affecting suicide deaths. however, rajkumar et al found migrant workers to be the majority.15another researcher pointed out the helplessness of migrant workers and their joblessness leading to suicidal ideation.16 burn injuries were the major cause of death in pre-covid, while hanging was the major cause of death during the covid phase. this is similar to the findings of previous researchers who found hanging as the cause of death in the majority of suicides during the covid phase.13,15 sher et al.17 found that those who had previous psychiatric disorders tended to commit suicide during the covid pandemic. goto et al.18 found family disputes to be a major predisposing factor to suicidal ideation during the covid phase. the lockdown may have increased young people’s exposure to trauma from family members, raising their likelihood of developing a variety of psychopathologies, including anxiety, sadness, and disruptive conduct. the importance of social connections during pandemics to prevent suicides can be a public health strategy to minimize loneliness brought on by quarantine. notably, brief contact interventions— through phone calls or social media seem to be a promising method for lowering the risk of suicide by fostering social support and encouraging access to mental health care from a distance as suggested by some researchers.19 early detection and prompt care for people exhibiting suicidal behaviours are essential, especially in light of the significance of reducing suicide attempts and fatalities brought on by the covid-19 pandemic.20 the increased suicide rates we discovered during the pandemic may have several political repercussions. international journal of human and health sciences vol. 07 no. 01 january’23 76 governments and policymakers need to be aware of potential ways that the pandemic and the ensuing public health responses to it could increase the psychological and socioeconomic factors that contribute to suicide. economic safety nets and methods for delivering mental health services tailored to local socioeconomic disparities and needs should be included in public health interventions against the pandemic, especially the more drastic ones like lockdowns and business shutdowns. to comprehend the causes of suicide and how covid-19 affects suicide in various subpopulations, more epidemiological studies are required. conclusion the covid-19 pandemic showed a rise in suicide cases. there has been an appreciable shift towards male preponderance. daily-wage labourers were the majority of victims. there has been a rise in the number of hanging victims. any further covid pandemic spread must keep the economic aspect of the affected population in mind and the society as a whole has to come up with a better and executable plan of action to prevent such deaths. also, the mental aspect of losing one’s income source is a major contributory factor to the rise of suicide cases in the covid phase. conflict of interest: none declared. ethical approval:ethical clearance has been obtained from the institutional ethical committee vide tmch/25/2022 dated 10/08/22. source of fund: nil. authors’ contribution: all authors were equally involved in data collection, analysis, manuscript preparation, revision and finalization. 77 international journal of human and health sciences vol. 07 no. 01 january’23 references 1. world health organization. suicide [internet]. available from: suicide [https://www.who.int/newsroom/fact-sheets/detail/suicide][cited 2022 oct 16]. 2. spiteri g, fielding j, diercke m, campese c, enouf v, gaymard a, et al. first cases of coronavirus disease 2019 (covid-19) in the who european region, 24 january to 21 february 2020. eurosurveillance [internet]. 2020 mar 5 [cited 2022 oct 16];25(9). available from: https://www.eurosurveillance.org/ content/10.2807/1560-7917.es.2020.25.9.2000178 3. world health organization. coronavirus disease (covid-19) weekly epidemiological update and weekly operational update.[cited 2022 oct 16]. 4. leaune e, samuel m, oh h, poulet e, brunelin j. suicidal behaviors and ideation during emerging viral disease outbreaks before the covid-19 pandemic: a systematic rapid review. prev med. 2020;141:106264. 5. siddiqui af, wiederkehr m, rozanova l, flahault a. situation of india in the covid-19 pandemic: india’s initial pandemic experience. int j environ res public health. 2020;17(23):e8994. 6. salvatore m, basu d, ray d, kleinsasser m, purkayastha s, bhattacharyya r, et al. comprehensive public health evaluation of lockdown as a nonpharmaceutical intervention on covid-19 spread in india: national trends masking state-level variations. bmj open. 2020;10(12):e041778. 7. alati r, gentile g, fornaro m, tambuzzi s, zoja r. preliminary suicide trends during the covid-19 pandemic in milan, italy. j psychiatr res. 2021;143:21-2. 8. pitlik sd. covid-19 compared to other pandemic diseases. rambam maimonides med j. 2020;11(3):e0027. 9. yamamoto v, bolanos jf, fiallos j, strand se, morris k, shahrokhinia s, et al. covid-19: review of a 21st century pandemic from etiology to neuro-psychiatric implications. j alzheimers dis. 2020;77(2):459-504. 10. pathirathna ml, nandasena hmrk, atapattu ammp, weerasekara i. impact of the covid-19 pandemic on suicidal attempts and death rates: a systematic review. bmc psychiatry. 2022;22(1):506. 11. kõlves k, kõlves ke, de leo d. natural disasters and suicidal behaviours: a systematic literature review. j affect disord. 2013;146(1):1-14. 12. lewinsohn pm, rohde p, seeley jr, baldwin cl. gender differences in suicide attempts from adolescence to young adulthood. j am acad child adolesc psychiatry. 2001;40(4):427-34. 13. pathare s, vijayakumar l, fernandes tn, shastri m, kapoor a, pandit d, et al. analysis of news media reports of suicides and attempted suicides during the covid-19 lockdown in india. int j ment health syst. 2020;14(1):88. 14. acharya b, subedi k, acharya p, ghimire s. association between covid-19 pandemic and the suicide rates in nepal. leong c, editor. plos one. 2022;17(1):e0262958. 15. rajkumar rp. suicides related to the covid-19 outbreak in india: a pilot study of media reports. asian j psychiatry. 2020;53:102196. 16. k. nayar p. the long walk. j extreme anthropol. 2020;4(1):e1–6. 17. sher l. the impact of the covid-19 pandemic on suicide rates. qjm int j med. 2020;113(10):707–12. 18. goto r, okubo y, skokauskas n. reasons and trends in youth’s suicide rates during the covid-19 pandemic. lancet reg health west pac. 2022;27:100567. 19. milner a, spittal mj, kapur n, witt k, pirkis j, carter g. mechanisms of brief contact interventions in clinical populations: a systematic review. bmc psychiatry. 2016;16(1):194. 20. mcintyre rs, lee y. preventing suicide in the context of the covid 19 pandemic. world psychiatry. 2020;19(2):250-1. 89 international journal of human and health sciences vol. 07 no. 01 january’23 case report epstein-barr virus-negative associated with sinonasal lymphoepithelial carcinoma –a rare case report mohamad najib salleh1,2, nurul syuhadah hasny1, ramiza ramza ramli1, sakinah mohamad1, norasnieda md shukri1, nusaibah azman3, faezahtul arbaeyah hussain3 abstract lymphoepithelial carcinoma (lec), also known as lymphoepithelioma-like carcinoma, is a rare type of cancer. lec can affect any organ, but it is most common in the head and neck region. sinonasal lymphoepithelial carcinoma (snlec) is an example of lec that can occur in our body and it is very rare. lec has usually associated with epstein-barr virus (ebv) infection and gives a picture of undifferentiated carcinoma with an intermixed reactive lymphoplasmacytic infiltrate on histology. it is pretty difficult to commit to a diagnosis, therefore histological examination and immunohistochemical investigations are used to determine the ultimate definite diagnosis. most cases present with locally aggressive illness, which may or may not include regional lymph node metastases. general treatment depends on the patient’s condition, including surgical resection, radiation therapy, and chemotherapy. herein, we present a case of a young, previously healthy gentleman with sudden onset of anosmia with left eye blurred vision whose final diagnosis was ebv negative snlec subsequently managed by radiotherapy. keywords: lymphoepithelial carcinoma; anosmia; sinonasal; radiotherapy; histology correspondence to: dr. ramiza ramza ramli, department of otorhinolaryngology-head & neck surgery, school of medical sciences, universiti sains malaysia health campus, kota bharu, kelantan, malaysia. email: ramizaramza@usm.my 1. department of otorhinolaryngology-head & neck surgery, school of medical sciences, universiti sains malaysia health campus, kota bharu, kelantan, malaysia. 2. department of otorhinolaryngology-head and neck surgery, hospital tuanku fauziah, kangar, perlis, malaysia. 3. department of pathology, school of medical sciences, universiti sains malaysia health campus, kota bharu, kelantan, malaysia. introduction schminke and regaud first described lec in 1921 [1]. lec is commonly found in the nasopharynx, salivary glands, and larynx in the head and neck region. however, it is relatively uncommon in the sinonasal area compared to other malignant lesions. snlec is rare cancer with only about 40 occurrences reported, and over 90% of lesions positive for the epstein-barr virus (ebv). slec is found throughout the world; however, it is more prevalent in southeast asia.1 nests, sheets, or individual undifferentiated or poorly differentiated malignant epithelial cells surrounded and penetrated by substantial components of small, mature lymphocytes and plasma cells are microscopic descriptions of lec.2 patients are usually asymptomatic but may present as nonspecific symptoms depending on the location of the lesion, and sometimes the lesion is discovered by coincidence during imaging. in our case, the patient initially complained of anosmia only and later on developed eye symptoms after disease progression. clinicoradiological tests, in general, do not help identify the ultimate diagnosis. the conclusive diagnosis of lec is made using histology and immunohistochemistry tests.2 thus, in this case report, we present a case of snlec and the management experience of our patient international journal of human and health sciences vol. 07 no. 01 january’23 page : 89-94 doi: http://dx.doi.org/10.31344/ijhhs.v7i1.504 http://ramizaramza@usm.my international journal of human and health sciences vol. 07 no. 01 january’23 90 case report a 39-year-old malay man with no previous medical illness presented with a loss of smell that had been present for the past three months, which was sudden onset and persistently associated with intermittent loss of taste. besides that, he also had rhinitis symptoms since young, like occasional rhinorrhea, sneezing, nasal itchiness and bilateral nasal blockage, which were aggravated by dust and seafood. otherwise, he never experienced epistaxis, foul smelly nasal discharge, posterior nasal drip, facial pain, headache, limb weakness, eye or ear pain, or diplopia. there was no history of trauma, no loss of weight or appetite, no night sweat or tuberculosis bacilli contact or symptoms like night sweat, chronic cough or hemoptysis. he works as a medical assistant at a governmental hospital and has no exposure to wood dust, fume or inhalation injury. for the initial presentation, the patient sought treatment at otorhinolaryngology (orl) clinic; that clinical examination showed no facial deformities, no mass on anterior rhinoscopy, and a normal cold spatula test nasoendoscopy showed left deviated septum with no apparent mass seen. the doctor treated it for allergic rhinitis with the deviated nasal septum. rapid test kit antigen (rtk-ag) for coronavirus was also done twice shown negative results. then patient complained of the painless left lower eyelid swelling that was present for one month that extended into the medial canthus and superolateral to the eye globe associated with decreased vision over the left eye for one week; thus, he then sought treatment at the ophthalmology clinic. otherwise, patient had no nasal swelling or deformity, no headache, no vomiting altered level of consciousness.due to anosmia and suddenly associated with eye swelling, the ophthalmology team proceeded with an urgent computed tomography scan (ct) of the brain, orbit and paranasal sinus to look for any relevant findings to suggest the cause of the manifestation.from the ct scan, the image showed the presence of heterogeneously enhancing soft tissue mass occupying the ethmoid air cells measuring approximately 5.6 x 3.4 x 4.6cm (apxwxcc), destruction of the frontal bone, posterior wall of the frontal sinus and cribriform plate with the extension of the mass to the frontal sinus. the mass extends into the anterior cranial fossa, causing the frontal lobe’s mass effect and causing bony destruction of the bilateral lamina papyracea and left optic canal (figure 1a & 1b). the working diagnosis was aggressive paranasal soft tissue mass with extensive bony destruction, and intracranial extension may represent esthesioneuroblastoma or sinonasal carcinoma that need tissue biopsy to establish the diagnosis. the case then was referred to our centre for further assessment. upon initial inspection, we did a thorough clinical examination. examination showed left periorbital swelling and proptosis with impaired cranial nerve i, ii, vi of the left side (figure 2).nasoendoscopy showed left septal spur touching the inferior turbinate, high left deviated nasal septum touching the middle turbinate, congested left lateral nasal wall, mucoid discharge seen at the left middle meatus, olfactory cleft and bilateral fossa of rosenmuller was clearwith no noticeable nasal mass or polyp seen. otherwise, no other abnormalities were detected in the ear, intraoral, and neck examination. we proceeded with examination under anaesthesia because of no noticeable nasal mass seen via nasoendocopy in our clinic as a ct scan has shown aggressive soft tissue mass with extensive bony destruction. during intra-operation, after done uncinectomy,we noted a fleshy mass occupying the middle meatus and a biopsy was taken and sent for a histopathology examination (figure 3). after a thorough histopathology examination, the result came back as lec ebv negative (figure 4). histopathology examination showed tumour cells arranged in sheets and nests separated by hyalinised stroma and minimal intervening lymphocytic infiltrates. the nuclei were enlarged, round to oval with vesicular chromatin and occasional prominent nucleoli. mitoses are hardly seen. immunohistochemical study showed tumour cells were positive for high molecular weight cytokeratin marker, ck5/6 and p63, while low molecular weight cytokeratin marker ck7 was negative. this biopsy showed sparse lymphocytic infiltrates as shown by cd3 (t cell marker) and cd20 (b cell marker). tumour cells are also negative for p16 and synaptophysin. we have outsourced for eber in-situ hybridization, which was reported as negative. after a multidisciplinary team discussion, we decided for the patient to undergo chemotherapy followed by radiotherapy, as the patient’s staging prior to treatment was t4bn0mx. currently, patients under the oncology team follow up for completion of treatment. 91 international journal of human and health sciences vol. 07 no. 01 january’23 figure 1a: ct scan bone setting axial and sagittal view shown mass over ethmoid sinus caused the destruction of the frontal bone, posterior wall of the frontal sinus and cribriform plate with the extension of the mass to the frontal sinus and also causes bony destruction of the bilateral lamina papyracea and left optic canal; figure 1b: ct scan soft tissue setting was shown to be of heterogeneously enhancing soft tissue mass occupying the ethmoid air cells extend to the frontal sinus and had intracranial extension into the anterior cranial fossa, causing a mass effect to the frontal lobe. figure 2. the noted patient had obvious left periorbital swelling and left eye proptosis during the examination. international journal of human and health sciences vol. 07 no. 01 january’23 92 figure 3: a) nasal endoscopy showed no apparent mass seen before we proceeded with examinaton under anaesthesia. biopsy was taken and sent for a histopathology examination;b) shows fleshy mass seen after the uncinectomy over the lateral wall of the nasal cavity. figure 4:(a) tissue from the middle meatus lesion (h&e, ×400)showing tumour cells arranged in clusters (green arrow) with minimal lymphocyte infiltrates (yellow arrow). adjacent normal glands are seen (yellow circles). the tumour cells are strongly positive for ck5/6 (b, ×100), negative for ck7 (c, ×40) both are carcinoma markers, and cd3 (d, ×40) & cd20 (e,×40) are markers for t and b lymphoid cells are minimally seen scattered in between the tumour cells. discussion lec is defined by the world health organization (who) as “a poorly differentiated squamous cell carcinoma or histologically undifferentiated carcinoma with a prominent reactive lymphoplasmacytic infiltrate, morphologically similar to nasopharyngeal carcinoma and there is no keratinization, necrosis, or mucus production.3the nasopharynx, salivary glands, and larynx are all common sites for lec. the lungs, oesophagus, stomach, pancreas, skin, cervix, endometrial, vulva, kidney, bladder, and central nervous system are rarely affected.3 lec is most usually diagnosed in people between the ages of 40 to 70,4 like in our case; the patient was 39 years old. the ebv was found in 87.5 % of all lec cases, while the remainder is ebv negative. 93 international journal of human and health sciences vol. 07 no. 01 january’23 ebv appears to play a function in the aetiology of lec depending on the anatomical site [1,4]. the absence of ebv does not exclude the diagnosis. oral and oropharyngeal lecs are more likely to metastasize (70%) and spread locally (16.6%), whereas nasal and paranasal lecs are less likely to metastasize (60%) and disseminate locally.1,4the patient is usually asymptomatic in most cases, but the patient can present depending on the lesion’s location. for example, if it occurs in the sinonasal area, it may present with nasal symptoms such as nose block, nasal discharge, altered smell, and rarely cause bleeding.2 sometimes the lesion is discovered accidentally during imaging. the sinonasal lec, as well as specific other sites, have shown a solid link with ebv. ebv has been highly related to nasopharyngeal carcinoma (npc) in numerous serologic, immunofluorescence, and nucleic acid hybridisation studies. ebv is significantly linked to the aetiology of lec of the sinonasal tract, similar to npc, but some instances are ebv negative. in such circumstances, tumour cells express high levels of ebv rna, which can be detected in the eber in-situ hybridisation test. eber in-situ hybridisation test helps differentiate between lec and sinonasal undifferentiated carcinoma (snuc), in which snuc is consistently eber-negative. there are very few reported lec cases with ebv negative.1 differentials of lec include lymphoma, melanoma, olfactory neuroblastomaand sinonasal undifferentiated carcinoma (snuc). the latter lack syncytial growth pattern and has more profound necrosis and mitoses.immunohistochemically, it lacks ck5/6 and is limited to absent p63.1,5 all sinonasal tumours are equally detectable on ct and mri. mri performed better than ct in detecting tumour margin and extension of the tumour, thus can help in making a diagnosis and preparation for planning surgery and providing an operative road map for subsequent functional endoscopic sinus surgery. still, it cannot give a definitive diagnosis compared to histological examination and immunohistochemical investigations.6 patients with lec of head and neck with regional invasion have a high chance for distal metastases. in dubey et al.7, the 5-year actuarial rate of distant metastasis in patients who presented with lymphadenopathywas 36%, and the incidence of regional adenopathy at the time of diagnosis was 76%. previous studies have shown that nasopharyngeal lec is a radiosensitive condition for which radiation can achieve excellent local control rates.7-9 radiotherapy should be the primary treatment modality even for cases with lymph node metastasis.9 locoregional treatment strategy for patients with non-nasopharyngeal lec will be to irradiate all the primary tumours. excellent local control rates can be achieved using widely differing fractionation schemes.7the 5-year overall survival and progression-free survival rates were 78.04% and 68.74%, respectively.10 conclusion snlec is a very rare malignant tumourwith limited discussion in the literature and has features of rapid disease progressiveness. the symptoms of lec might vary depending on the location of the lesion. making a diagnosis is highly complex and time-consuming. however, ct or mri is an essential tool for assessing lesions to look for extension, depth, and structure related, thus can narrow the differential diagnosis. histopathological examination and immunohistochemistry studies are used to make the final diagnosis.early diagnosis and treatment are mandatory because lec is highly radiosensitive and has a good outcome if treated early. conflict of interest: the authors declare that they have no conflict of interest. ethical issue: informed consent was obtained from the patient for publication of this case report and any accompanying images. authors’ contribution: study conception and design, acquisition of data: mns, nsh; analysis and interpretation of data,drafting of the manuscript, critical revision: mns, nsh, rrr, sm, nms, na, fah. international journal of human and health sciences vol. 07 no. 01 january’23 94 references: 1. bonnerup s, gitau m, shafique k. a rare case of sinonasal lymphoepithelial carcinoma presented with clinically stage iv disease. ear nose throat j. 2022;101(6):386-91. 2. mohammed d, jaber a, philippe m, kishore s. lymphoepithelial carcinoma in the maxillary sinus: a case report. j med case rep. 2012;6:416. 3. rytkönen ae, hirvikoski pp, salo ta. lymphoepithelial carcinoma: two case reports and a systematic review of oral and sinonasal cases. head neck pathol. 2011;5(4):327-34. 4. almeida ly, silveira ha, silva ev, barbeiro co, de paula ja, bufalino a, ribeiro-silva a, león je. ebv-negative lymphoepithelial-like carcinoma of the lower lip. autops case rep. 2019;10(1):e2020138. 5. wenig bm. lymphoepithelial-like carcinomas of the head and neck. semin diagnpathol. 2015;32(1):7486. 6. gomaa ma, hammad ms, abdelmoghny a, elsherif am, tawfik hm. magnetic resonance imaging versus computed tomography and different imaging modalities in evaluation of sinonasal neoplasms diagnosed by histopathology. clin med insights ear nose throat. 2013;6:9-15. 7. dubey p, ha cs, ang kk, el-naggar ak, knapp c, byers rm, morrison wh. nonnasopharyngeal lymphoepithelioma of the head and neck. cancer. 1998;82(8):1556-62. 8. sanguineti g, geara fb, garden as, tucker sl, ang kk, morrison wh, peters lj. carcinoma of the nasopharynx treated by radiotherapy alone: determinants of local and regional control. int j radiat oncol biol phys. 1997;37(5):985-96. 9. allen mw, schwartz dl, rana v, adapala p, morrison wh, hanna ey, weber rs, garden as, ang kk. long-term radiotherapy outcomes for nasal cavity and septal cancers. int j radiat oncol biol phys. 2008;71(2):401-6. 10. takakura h, tachino h, fujisaka m, nakajima t, yamagishi k, ishida m, shojaku h. lymphoepithelial carcinoma of the maxillary sinus: a case report and review of the literature. medicine (baltimore). 2018;97(28):e11371. 131 international journal of human and health sciences vol. 02 no. 03 july’18 original article: kaifiyāt-i-arba‘a as a prime cause of physical changes of matter ansari abdul waqas1*, momin shahzad1, naziya aejaz rasool2 keywords: matter; physical changes; destructions; kaifiyat-i-arba; unani medicine. correspondence to: ansari abdul waqas, dept of kulliyat, national institute of unani medicine, bangalore, india. e-mail: waqas.ayesha16@gmail.com 1. dept of kulliyat, national institute of unani medicine, bangalore 2. dept of preventive and social medicine, national institute of unani medicine, bangalore introduction: unani system of medicine is based on philosophy and it is holistic in approach. it is different compared to other system of medicine because of its fundamentals, principles and crucial concepts, for instance; concept of arkān-i-arba‘a, akhlāṭ, mizāj etc. kaifiyāt-i-arba‘a is one of the most important and primary concept in the system of unani medicine. kaifiyāt-i-arba‘a refers to the four primary qualities of matter which are perceived by ḥiss-i-lamisa (touch and tactile sensation), that is heat (ḥarārat), cold (burūdat), moisture (ruṭūat), and dryness (yubūsat). for the origin of life and genesis of the cosmos, the primary forms of matter are fire, air, water, and soil. since, kaifiyāt-i-arba‘a are associated with these primary forms of matter, thus they become the prime cause of all the physical change and variation in matter. for example; water and air can adopt and be easily dispersed into different forms due to their moist quality, because in any object moisture is easily formed and dryness is formed with difficulty. amongst the kaifiyāt-iarba‘a two are active (heat and cold) and two are passive (moist and dry). all the natural changes are always the work of these kaifiyāt-i-arba‘a. in arabic and unani medicine i.e. heat, cold, moisture, and dryness are mandatory for each reaction, and are responsible for genesis, destruction, putrefaction, changes and variations of all the things. for example; the lower temperature of the scrotum is necessary for the production of semen in the testicles. we cannot make ice without maintaining the appropriate cold temperature. similarly the evaporation of water cannot take place unless the water is warmed up by the appropriate heat. the aim of this study is to evaluate the role of four primary qualities regarding the physical changes and variations in all the things. methods: literature related to four primary qualities of the matter (kaifiyāt-i-arba‘a) was surveyed from various classical unani books, journals, periodicals, manuscripts, and online citations from the subject specific websites. collected material was then analyzed and systematized in comprehensive manner. conclusion: kaifiyāt-i-arba‘a are four primary qualities of the each matter i.e. heat, cold, moisture, and dryness. these are perceived by touch and tactile sensations only. these four qualities are responsible for destruction and putrefaction, build-up and break-down processes of each physical body. background and objectives: the study of the physical universe, its structure, dynamics, origin and evolution, and fate are still having the ground for further research. cosmology is the biggest challenge from the ancient time till today for philosophers and thinkers. the aristotle and other philosophers have given the fundamentals about the genesis of all living and non-living things. their observations were based on naked eye examinations. they believe that the four primary qualities which are known as kaifiyāt-i-arba‘a international journal of human and health sciences vol. 02 no. 03 july’18 page : 131-135 doi: http://dx.doi.org/10.31344/ijhhs.v2i3.40 international journal of human and health sciences vol. 02 no. 03 july’18 132 when the heat and cold are masters into the matter then they generate a thing. the natural changes are introduced by these powers into the matter underlying a given thing when they are in a certain ratio to that matter which is the passive qualities that is moist and dry. therefore, all the physical change and variation that took place in the body are the manifestation of kaifiyāt-i-arba‘a. according to raban tabri (810-859ad): kaifiyāt are the qualities which are associated to the body; like, colour, odour, taste, heat, cold, dryness, moistness etc.1 kaifiyāt are those qualities which are perceived by five external senses (ḥawās-ikhamsa ẓāhira). these are sense of vision (ḥissi-bāṣira), auditory sense (ḥiss-i-sāmi‘a), sense of taste (ḥiss-i-dhāiqa), olfactory sense (ḥissi-shāmmah), sense of touch and tactile (ḥissi-lāmisa). for example, the taste of things is perceived by sense of taste and different smell or odour perceived by sense of olfaction but kaifiyāti-arba‘a are the qualities which perceived by touch and tactile sensation (ḥiss-i-lāmisa). ibn-i-sina (980-1037ad) says that since the prime qualities of arkān-i-arba‘a are four, so in all the things mizāj (temperament) are produced by these power, however the physical change and variations in all the bodies are accomplished by kaifiyāt-i-arba‘a.2, 3 amongst the arkān-i-arba‘a , water and soil are heavier (saqīl).4 these two are responsible for genesis and stability of the organs. the organs have a more watery and earthy content which are heavy and cold in their quality. air and fire are lighter and responsible for the motion and genesis of arwāḥ (sprit, pneuma).4 amongst the kaifiyāt-i-arba‘a, two qualities i.e. the heat and the cold are active; and the other two i.e. the dry and moist are passive5. we can appreciate this better by looking at an example. in every case heat and cold determine, conjoin and change things of the same kind and things of different kind, moistening, drying, hardening and softening them. while the things which are either dry or moist are the subjects of the determination and of the other affection enumerated. heat and cold are active because congregating is essentially a species being active. moist and dry are passive because it is in virtue of its being acted upon in a certain way that a thing is said to be easy to determine or difficult to determine. perception of the active and pasive quality: hakim akbar arzani mentions that the active quality heat and cold are perceived directly through the touch and tactile sensation, but passive qualities dry and moist are not perceived directly.6 majusi (930-994ad) says that perception of both active and passive qualities are felt by touch and tactile sensation, but passive qualities are perceived by applying pressure and gripping additionally.7 characteristics of active qualities: active qualities are heat and cold and some of their specific characteristics are mentioned below.  heat causes laṭāfat and khiffat in any moist or dry object.5, 6 the word laṭīf means the subtle in which contents have a thin consistency. khafīf means anything that has the natural tendency to the periphery. fire and air are hot in quality.3,4,6 that’s why both fire and air have the tendency to move away from the centre and both are laṭīf and khafīf.  it increases dryness in any moist object by evaporating their moisture.  it becomes a cause of motion, hence every moved thing has a mover and quality of heat, if it is lost completely then their nature becomes at rest.  it causes concoction of every matter and concoction is a sort of perfecting, hence due to lack of heat concoction is not completed. the cold quality has some specific characteristics:  cold causes kathāfat and thaqālat in any moist or dry objects.6 kathīf means density in which the object has a thick consistency and strong bonding. thaqīl refers to anything having tendency to move towards the centre. water and soil are kathīf and thaqīl due to their cold quality, hence both have the tendency towards the centre or towards gravity.  the act of condensation is enhanced in any moist object due to cold quality.  coldness becomes a cause of rest for natural bodies due to lack or absence of heat. so anything become at rest due to its cold nature. it may also cause inconcoction which is always associated with cold quality or lack of heat. characteristics of passive qualities:  the qualities of any of the passive matter are moist (ruṭūbat) and dry (yubūsat).5, 8 all bodies are composed of themselves and whichever predominates determine the nature of the body; thus some bodies partake more of the dry, others of the moist. 133 international journal of human and health sciences vol. 02 no. 03 july’18  different forms are to be adopted and dispersed easily due to the moist and with difficulty due to dry quality of the objects. hence, the moist is easily determined and the dry quality is determined with difficulty.  for the moist quality, it is easy to separate and get unite but for the dry it is difficult to separate and unite. hence, moist become a cause of continuity (itteṣāl or to conjoin) and dry causes of discontinuity (tafarruq-iitteṣāl) in matter.  moist and dry qualities are affected by heat and cold. moist objects are evaporated by heat and condensed through the cold while dry objects are burnt by heat and solidify through the cold.  majusi says that the moist quality makes the body soft while dryness makes the body hard.7 anything which is made up of the dry and moist is necessarily either hard or soft. a hard thing is that whose surface does not yield into it and a soft thing is that whose does yields but not by interchange of place, like water. effects of kaifiyāt-i-arba‘a in destruction and putrefaction: all the natural and physical change is carried out through the kaifiyāt-i-arba‘a. destruction and putrefaction are the natural phenomena and are found not only in animals but also plants and in their parts. according to aristotle putrefaction is the destruction of the peculiar and natural heat in any moist subject by external heat [heat of environment].9 putrefaction cannot take place until the objects have fluid content and whenever the external heat is higher than the heat of the moist object putrefaction takes place e.g. the milk is degraded easily in summer than the winter season; because in summer season, the heat of environment is greater than the heat of milk and that’s why there is a need to boil the milk for their preservation. for everything that putrefy, their destruction ends in putrefaction, it begins by being moist and ends by being dry, e.g. putrefaction of dead body begins by being moist and ends by being dry. things that do not putrefy are those that which are frozen and also those which are boiling. the mechanism of a refrigerator is an example of preservation of the foods by freezing. in boiling the heat in the air is less than that in the object so it does not putrefy. in addition, things which are moving or flowing or having circulation are less capable to putrefy than things at rest because heat produced by motion in the air is weaker than that is pre existing in the moving object. e.g. the water of sea, river and lakes which are flowing or in motion does not putrefy but the water in ponds may be degraded easily. kaifiyāt-i-arba‘a and isteḥāla: isteḥāla is the manifestation of kaifiyāt-i-arba‘a and actually it is the change of the active into the passive quality.1 build up and breakdown process (koun and fasād) are the kind of isteḥāla. both processes take place in the atom (jawhr) of matter but isteḥāla and change are always accompanied in the qualities of the object, e.g. isteḥāla and change of heat into cold, sweetness become changed into bitterness. isteḥāla of a build up process is always done from the low to the high quality of things, e.g. seeds of the dates give rise to a tree. isteḥāla of breakdown process always happen from higher to the lower thing, e.g. destruction and putrefaction of the body into the smaller things. things having difference in only one quality either active or passive ones, their isteḥāla becomes easy, e.g. isteḥāla of water into air become easy. since water is cold and moist in its quality and air is hot and moist, both have the same passive quality but have a difference in their active quality that is cold and hot, so it is easy for the water to be converted into the air and vice versa. things that have difference in both the active and passive quality, their isteḥāla take place with more difficulty, for example; isteḥāla of water into the fire is difficult because both are different in active and passive quality that are cold and moist and hot and dry respectively. so isteḥāla of the water into the fire is a more difficult process. according to ibn-i-sina, all things which are affected by each other are similar with respect to matter but different in their qualities.2, 3 a body does not get affected by another body until both are having similar quality. the capability of the body to accept different form is depends on their kaifiyāt-i-arba‘a. thus, the forms of the body changed after the changes in their qualities. role of kaifiyāt-i-arba‘a in concoction and inconcoction: concoct means made by combining or mixing various ingredients. it also means boiled together or mature and fully developed.10 concoction is a sort of perfecting. proper heat and moisture international journal of human and health sciences vol. 02 no. 03 july’18 134 are necessary for concoction but inconcoction is an imperfect state due to lack of proper heat and this imperfect state is in the corresponding passive qualities i.e. moist and dry. according to aristotle, concoction is a process in which the natural and proper heat of an object perfects the corresponding passive qualities.9 concoction ensues whenever matter is having moisture and as long as the ratio between heat and moist exists in an object a thing maintain its nature. things that undergo a process of concoction necessarily become thicker and hotter because the action of the heat is to make things more compact, thicker and drier. concoction is due to proper heat and it has different kinds: ripening, boiling, and broiling while inconcoction is due to coldness and its kinds are rawness, imperfect boiling and imperfect broiling. ripening is a sort of concoction; we used the word ripening when there is a concoction of the nutrients in the fruit. the seeds in fruit are able to reproduce the fruit in which they are found when the process of ripening is perfected by proper heat. that’s why the word ripening is mostly applied to the fruit. however, many other thing that have undergone concoction are said to be ‘ripe’ the general character of the process being the same, though the word applied by an extension of meaning. when we noticed about the ripening of boils, they are ripe by the action of proper heat into their moisture. hence, everything which undergoes the process of ripening they must be condensed from a spirituous into a watery state and from watery into an earthy state. rawness is an imperfect concoction of the nutrients in the fruit, namely of the undetermined moisture. everything which is raw contains water or spirit or both. rawness will be an imperfect state and this state is due to lack of natural heat and its disproportion to the moisture that is undergoing the process of ripening. water alone as liquid does not thicken without the admixture of some dry matter, so this proportion may be either due to defect of heat or to excess of the matter to be determined; hence the juice of the raw thing is thin, cold rather than hot and unfit for food or drink. boiling is a nuḍj or concoction by moist heat of the indeterminate matter which is present as the moisture of the thing boiled. the indeterminate matter will be either spirituous or watery. the cause of concoction is the fire contained in the moisture because what is cooked in a frying-pan is broiled. for a thing that is being boiled, the moisture contained in it is drawn out of it by the heat in the liquid outside. hence boiled meats are drier than broiled meat. not every body admits of the process of boiling, if there is no moisture in it, it does not (for instance; stone), nor does it if there is moisture in it but the density of the body is too great for it to be mastered as in case of wood. it is true that the gold and wood and many other things are said to be boiled but the only bodies that can be boiled are those that contain moisture which can be acted on by the heat contained in the liquid outside. imperfect boiling is an inconcoction of the undetermined matter in a body due to lack of heat in the surrounding liquid. the lack of heat implies the presence of the cold is either due to the lack of heat in the liquid or to the quantity of moisture in the object undergoing the process of boiling. in the process of boiling the inside becomes drier than the outside of an object and it is easy to heat the object uniformly. broiling is a concoction by dry foreign heat. in the case of broiling, the outer parts of the thing are the first to get dry through the affect of fire or heat and consequently get more intensely dry. in this way the outer pores contract due to dryness and the moisture in the thing cannot be secreted out but remains in the thing due to the closing of the pores, hence the outer portion becomes drier than the inner and it is difficult to heat the object uniformly. now boiling and broiling are the artificial processes but the same general kind of thing is found in nature too. for instance; the concoction of the food in the body is like boiling because it takes place in a hot and moist medium and the agent is the heat of the body. so certain forms of indigestion are like imperfect boiling due to deficiency in the proper heat or to the quantity of water in the thing undergoing the process. 135 international journal of human and health sciences vol. 02 no. 03 july’18 references: 1. tabri ahais. firdaws al-hikmat fi’l tibb (urdu translation by hkm awwal shah sambahli). new delhi: faisal brothers, 2002. 2. gruner oc. the canon of medicine of avicenna. new york: ams press, 1973. 3. ibn sina. al qanoon fit tibb (urdu translation by ghulam hasnayn kinturi). part.1. new delhi: idara kitabul shifa, ynm. 4. baghdadi maib. kitab al-mukhtarat fi’l tibb (urdu translation by ccrum). vol-1. new delhi: ccrum ministry of h&fw, 2008. 5. kabiruddin hm. kulliyat-e-nafisi. new delhi: idara kitabul shifa; 1954. 6. arzani a. mufarreh qulub (urdu translation by sayyed afzal husain). new delhi: idara kitabul shifa, 2002. 7. majusi aia. kamil al-sana‘a al-tibbiyya (urdu translation by ghulam hasnayn kinturi). vol.1. new delhi: idara kitabul shifa, 2010. 8. jalinus. kitab fil mizaj (urdu translation by hkm syed zillur rahman). aligarh: ibn sina academy, 2008. 9. aristotle. meteorology (english translation by e w webster). in: ross wd, editor. aristotle organon and other works [internet]. cited on 2017 oct 05. available from: http//archive.org/details/ aristotleorganon. 10. kabiruddin hm. ifada-ikabir. new delhi: ccrum, ynm. international journal of human and health sciences vol. 06 no. 04 october’22 372 original article injectable iron and blood transfusion for correction of anemia in pregnancy in a peripheral tertiary hospital in bangladesh: a quasi-experimental study syed muhammad baqui billah1, fatema kamrun naher2 abstract background: anemia in pregnancy is one of the most commonly encountered medical disorders. objective: to compare the effects of injectable iron and blood transfusion for correction of anemia in pregnancy. methods: this quasi-experimental study was conducted in the obstetrics & gynaecology outpatient department (opd) of shaheed ziaur rahman medical college hospital, bogura, bangladesh, between april and december of 2020on 100 expecting mothers through interviews, investigation of hemoglobin (hb) level at 16 weeks, 24-28 weeks and 36 weeks. the injectable iron and blood transfusion were the experiments given to the pregnant women around 24-28 weeks.the effect of the experiment along with other factors were assessed over the change of hb level from 24-28 weeks to 36 weeks. results: only iron injection singly significantly improved hb level (1.4 mg/ dl, p<0.001) though it improved a little in combination with blood transfusion (0.472 mg/ dl, p=0.15) too, but blood alone was associated with decreased hb level (-0.414 mg/dl, p=0.07). other factors were not related to the change. conclusion: iron injection improves hemoglobin status and should be given to all anemic women irrespective of presence or absence or other risk factors. keywords: anemia, pregnancy, injectable iron, blood transfusion, anemia correction correspondence to: dr. syed muhammad baqui billah, department of community medicine, sher-e-bangla medical college, barishal, bangladesh. email: sbbillah@gmail.com 1. department of community medicine, sher-e-bangla medical college, barishal, bangladesh 2. department of obstetrics & gynaecology, naogaon medical college, naogaon, bangladesh introduction anemia in pregnancy is one of the most commonly encountered medical disorders with an overall global prevalence of around 56%1. females are usually found to be anemic2, which becomes obvious during pregnancy, contributing to 20-40% of maternal deaths3. in this situation, the risk of death is double in developing countries4. albeit the intervention options are limited to oral iron therapy, injectable iron and blood transfusion5 or a combination of any or all of these, the prevalence of anemia during pregnancy in bangladesh remains over 25%6,7. the treatment options include dietary sources, oral, intravenous or intramuscular iron therapy, blood transfusion of the combination of any of the above8. study shows that anemia is more prevalent in second trimester hence focus the importance of intervention during this period of time3,9. with a high prevalence of anemia in pregnancy6,7,10, the need to assess the effective intervention has become a necessity in a recourse-compromised country like bangladesh. world health organization (who)11 targeted a 50% reduction of anemia in women of reproductive age. oral iron therapy has been a common treatment option during pregnancy, though non-adherence, infection, coexisting morbidity or incorrect diagnoses have led to treatment failure8. besides oral iron, researchers have tried intravenous, intramuscular, blood transfusion or other intervention options8,12-17 to correct anemia in pregnancy. we find information of post-partum anemia correction18, but there is a knowledge gap comparing blood transfusion and intravenous iron therapy, or a combination of these two to the patients, the effectiveness of these two interventions for improvement of anemia needs to be examined. we aimed to compare the effect international journal of human and health sciences vol. 06 no. 04 october’22 page : 372-376 doi: http://dx.doi.org/10.31344/ijhhs.v6i4.475 373 international journal of human and health sciences vol. 06 no. 04 october’22 of injectable iron and blood transfusion to correct anemia in pregnancy in a peripheral tertiary health care facility, to refute the null hypothesis that the intervention is not effective. methods this quasi-experimental study was conducted in the obstetrics & gynaecology outpatient department (opd) of shaheed ziaur rahman medical college hospital, bogura, bangladesh, between april and december of 2020 on 100 willing pregnant women who completed a minimum of three antenatal visits. expecting mothers who declined to participate, or who had severe co-morbidities were excluded. we recorded age (completed years), education level, address, religion, gravida, blood group, rh typingand serum hemoglobin at 16, 24-28 and 36 weeks. history of iron intake, sun exposure, progesterone therapy, eggs and fruits consumed per week, thalassemia, iron injection, blood transfusion were among the suspected factors. the questionnaire was developed based on the important factors from different studies and reviewed afterwards by an expert panel of clinicians and epidemiologists.the experiments consisted of iron supplementation and/or blood transfusion, after first trimester as indicated by their hb concentration, so we took 24-28 weeks as baseline and checked whether iron supplement and/or blood transfusion could improve their blood hb at 36 weeks of pregnancy or not. we recorded the data in excel after collection and cleaned to remove any stroke or data error. after data management in excel, the product was exported to spss where the final analysis was done, the figures were constructed in excel though. we operationalized hb category taking ≥11 mg/dl as normal, 10.1-10.9 mg/dl as mild, 7.0 to 10.0 mg/dl as moderate, and <7 mg/dl as severe anemia respectively. we assessed numeric and categorical anemia variable with the demographic and other related variables using mann whitney u and kruskal-wallis test. we deducted hb level of 24-28 weeks from 36 weeks to compute the change as outcome variable. because the interventions were mixed up as some patients got only iron injection, some only blood transfusion and some both, we computed a new variable of intervention classifying those who took only iron injection, those who took only blood transfusion and those who took both the intervention. we applied non-parametric test to assess the variables as the sample size was small and also continuous variables showed skewed distribution. finally, we conducted generalized linear model analysis taking the significant factors from the univariate and bivariate analysis. we also included some clinically important though non-significant variables like iron intake, thalassemia, assumed to be confounding with the hb concentration. because almost invariably we advise for oral iron to all patients, as happened here too, added with the clinical experience and practice, we did not assess the oral iron with injectable one in the model. the quantitative variables are presented as mean±standard deviation (sd), minimum (min) and maximum (max), while the qualitative variables are presented as frequency and percentage. we considered a p value of ≤0.05 to be significant in our study. results table 1 shows the baseline information of the respondents. the respondents were 25.04±4.27 years of age, almost 50% of them had secondary education. there was a nearly homogeneous distribution of their address. a half of them were primigravida. around 90% of them were muslims; a+ve, b +ve and o +ve blood group were almost equally distributed around 30% each. figure 1 depicts the anemia status before and after intervention that the intervention significantly (p<0.001) shifted the severe and moderate anemia to mild and normal anemia. there were only 2 severe anemia which turned to moderate anemia after intervention. while looking at the hemoglobin status, we observed that the hemoglobin level decreased from first to second trimester, which again increased in third trimester. the minimum and maximum hb level in third trimester roamed around the level of first trimester, though the mean hb was a little higher than that of first trimester. looking at the category of anemia in table 2, we detected that the hb level improved from second to third trimester indicating the effectiveness of the intervention. we constructed a general linear model to assess the change of hb status by the intervention and other significant factors keeping age as covariate (table 4). the model showed that only iron injection was significantly associated with improvement of hb level by 1.4 mg/dl adjusting for other variables. only blood transfusion was associated with a reduction of hb level by 0.414 mg/dl. other variables could not show any significant relation with the change. international journal of human and health sciences vol. 06 no. 04 october’22 374 table 1.basic demographic information of the respondents variables mean ± sd / n min-max / % age 25.01 ± 4.26 18-36 education illiterate 2 2.0 primary 29 28.7 secondary 48 47.5 graduate and above 22 21.8 address rural 58 57.4 urban 43 42.6 gravida 1 52 51.5 2 25 24.7 >2 24 24.8 religion muslim 88 87.1 non-muslim 13 12.9 blood group o +ve 32 31.7 a -ve 3 3.0 a +ve 28 27.7 b -ve 1 1.0 b +ve 30 29.7 ab +ve 7 6.9 fig. 1.status of anemia before and after intervention table 2.hemoglobin status at first, second and third trimester including change from second to third trimester after the intervention (n=100) weeks of pregnancy mean sd min max 16 weeks 9.80 1.10 7 12.7 24-28 weeks 9.50 1.09 6.4 7.1 36 weeks 9.92 0.99 7.1 12.4 weeks of pregnancy normal mild moderate severe 16 weeks 14 23 63 0 24-28 weeks 11 21 66 2 36 weeks 15 30 55 0 we evaluated several factors with hb change, but none of those were associated with the hb change except for the intervention variable (p<0.001) and thalassemia (p=0.03). table 3 showed that only iron injection significantly improved the hb level by 1.5 mg/dl. strikingly, only blood transfusion could not improve the hb, rather the hb decreased from 24-28 weeks to 36 weeks by 0.24 mg/dl even after blood transfusion. similarly, oral iron intake couldn’t improve the hb level rather it was almost significantly higher in those who didn’t take iron therapy. the significance was being contributed by iron injection only as appeared in post hoc test (data not shown). table 3.second to third trimester change of hemoglobin with the factors variables n mean sd p value religion muslim 88 0.38 0.92 0.25non-muslim 13 0.70 1.23 address rural 58 0.51 1.01 0.26urban 43 0.29 0.88 education illiterate 2 -0.35 0.49497 0.64primary 29 0.52 1.11secondary 48 0.37 0.93 graduate and above 22 0.45 0.85 gravida 1 52 0.39 0.93 0.622 25 0.57 1.21 >2 24 0.31 0.71 blood group o +ve 32 0.365 0.91 0.86 a -ve 3 0.97 0.45 a +ve 28 0.45 1.20 b -ve 1 0.50 . b +ve 30 0.47 0.88 ab +ve 7 0.11 0.67 sun exposure no 54 0.47 1.07 0.52yes 47 0.35 0.82 egg/week 0 9 0.27 0.57 0.50 3 7 0.00 0.79 4 4 0.98 0.75 5 1 -0.20 . 7 80 0.45 1.01 fruits/week 0 10 0.39 0.67 0.59 2 1 0.80 . 3 8 -0.05 0.74 4 3 1.03 0.91 5 1 -0.20 . 7 78 0.45 1.01 oral iron intake no 17 0.81 0.92 0.06yes 84 0.34 0.95 progesterone therapy no 54 0.38 0.96 0.67yes 47 0.46 0.96 thalassemia no 95 0.45 0.98 0.03yes 6 -0.02 0.35 intervention no intervention 51 0.08 0.69 <0.001 iron injection 27 1.47 0.89 blood transfusion 18 -0.24 0.43 both 5 0.54 0.52 375 international journal of human and health sciences vol. 06 no. 04 october’22 table 4.general linear model to predict hemoglobin change parameter coefficient p value α (intercept) 0.541 0.28 blood + iron* 0.472 0.15 only blood -0.414 0.07 only iron* 1.400 <0.001 thalassemia 0.314 0.37 age -0.006 0.72 * iron = injectable iron discussion our study excavated that fact that injectable iron can be a key management option to correct anemia in pregnancy. other interventions like blood transfusion only and mixed intervention (blood transfusion and iron injection) cannot be regarded as treatment of choice to manage anemia in pregnancy, though we adopt these intervention preferences in our clinical setting. the present study is unique as we compared injectable iron and blood transfusion with and without combination, while other researchers compared oral iron with injectable iron, intravascular iron with intramuscular iron and other different combinations12,13,17,19-21. though oral iron has been the first line of management choice in pregnancy22, the clinical experts experienced that intravenous iron works better than oral iron. even researchers found that oral therapy throughout the pregnancy failed to meet the purpose of iron therapy12. they advocated to assess the factors related to anemia so that proper treatment decision can be made23. of the different interventions tried by different researchers, intravenous iron therapy proved to improve the hb better than other intervention options16. our study and other study findings bring about a question on rationality of the decision for blood transfusion. if the blood transfusion has got a small or no role as evidenced in our study, we should be more cautious about the cause of anemia before deciding for transfusion. out of different determinants of anemia, iron deficiency has been common in developing world so far research has been explored1,9,23-25 with adverse pre, intra and post-natal outcomes4,26. as the pregnant women commonly suffer from this problem3,7,12,23, researchers recommended for iron therapy to prevent the adverse outcome during and after pregnancy. though age has been identified a risk factor related with anemia in pregnancy1, we didn’t find any relation with the improvement of hb in our study. antenatal care (anc) and gestation age at first anc were related to anemia24. researchers in ghana showed that regular anc visit can significantly improve the hb level. this brings us an addressable limitation in our study which we learned after the collection of data and analysis. researchers recommended different prevention strategies to prevent anemia in pregnancy. of the options, women education especially nutrition education, deworming, diagnosing and treating chronic diseases in early pregnancy, government and non-government initiative through long term policy have been the key steps suggested by them27. though our study significantly established the iron therapy to improve the hb status of the pregnant women, we can’t claim the strength of this study as it was not a randomized controlled trial (rct). being a quasi-experimental study, we should have adjusted other confounding factors such as anc history, helminthic infestation and comorbidities. conclusion our study finding emphasized the fact to investigate the cause of anemia before initiating any treatment to correct anemia. as different study suggested that iron deficiency is the main cause of anemia in pregnancy in our population, we should keep in mind to prefer injectable iron over blood transfusion during pregnancy. conflict of interest:the authors declare no conflict of interest. ethical approval:ethical approval was obtained from ethical review committee of shaheed ziaur rahman medical college, bogura, bangladesh. funding statement:self-funded. authors’contribution:smbb and fkn designed the study; fkn collected data and entered in excel; smbb analyzed data in spss;smbb and fkn wrote the manuscript, reviewed, and finalized the draft. international journal of human and health sciences vol. 06 no. 04 october’22 376 references 1. ababiya t, gabriel t. prevalence of anemia among pregnant women in ethiopia and its management: a review. int res j pharmacy. 2014;5(10):737-750. 2. chathuranga g, balasuriya t, perera r. anaemia among female undergraduates residing in the hostels of university of sri jayewardenepura, sri lanka. anemia. 2014;2014:526308. 3. prakash s, yadav k. maternal anemia in pregnancy: an overview. int j pharmacy pharmaceutical res. 2015;4(3):174-179. 4. daru j, zamora j, fernández-félix bm, et al. risk of maternal mortality in women with severe anaemia during pregnancy and post partum: a multilevel analysis. the lancet global health. 2018;6(5):e548-e554. 5. munoz m, pena-rosas jp, robinson s, et al. patient blood management in obstetrics: management of anaemia and haematinic deficiencies in pregnancy and in the post-partum period: nata consensus statement. transfus med. 2018;28(1):22-39. 6. lindstrom e, hossain mb, lonnerdal b, raqib r, el arifeen s, ekstrom ec. prevalence of anemia and micronutrient deficiencies in early pregnancy in rural bangladesh, the minimat trial. acta obstet gynecol scand. 2011;90(1):47-56. 7. ahmed f, khan mr, shaheen n, et al. anemia and iron deficiency in rural bangladeshi pregnant women living in areas of high and low iron in groundwater. nutrition. 2018;51-52:46-52. 8. baird-gunning j, bromley j. correcting iron deficiency. aust prescr. 2016;39(6):193-199. 9. mortaz r, ahmed m, sultana a, et al. pattern of anemia during pregnancy among patients in selected hospital in bangladesh. moj public health. 2015;2(4). 10. merrill r, shamim a, ali h, et al. high prevalence of anemia with lack of iron deficiency among women in rural bangladesh: a role for thalassemia and iron in groundwater. asia pac j clin nutr. 2012;21(3):416424. 11. world health organization (who). wha global nutrition targets: 2025: anaemia policy brief. geneva. 2014. 12. wali a, mushtaq a, nilofer. comparative stydy efficacy, safety and compliance of intravenous iron sucrose and intramuscular iron sorbitol in iron deficiency anemia of pregnancy. j pak med assoc. 2002;52(9):392-395. 13. krafft a, breymann c. iron sucrose with and without recombinant erythropoietin for the treatment of severe postpartum anemia: a prospective, randomized, openlabel study. j obstet gynaecol res. 2011;37(2):119124. 14. bhavi sb, jaju pb. intravenous iron sucrose v/s oral ferrous fumarate for treatment of anemia in pregnancy. a randomized controlled trial. bmc pregnancy childbirth. 2017;17(1):137. 15. naqash a, ara r, bader gn. effectiveness and safety of ferric carboxymaltose compared to iron sucrose in women with iron deficiency anemia: phase iv clinical trials. bmc womens health. 2018;18(1):6. 16. qassim a, mol bw, grivell rm, grzeskowiak le. safety and efficacy of intravenous iron polymaltose, iron sucrose and ferric carboxymaltose in pregnancy: a systematic review. aust nz j obstet gynaecol. 2018;58(1):22-39. 17. das sn, devi a, mohanta bb, choudhury a, swain a, thatoi pk. oral versus intravenous iron therapy in iron deficiency anemia: an observational study. j family med prim care. 2020;9(7):3619-3622. 18. chua s, gupta s, curnow j, gidaszewski b, khajehei m, diplock h. intravenous iron vs blood for acute post-partum anaemia (iibappa): a prospective randomised trial. bmc pregnancy childbirth. 2017;17(1):424. 19. darwish am, khalifa ee, rashad e, farghally e. total dose iron dextran infusion versus oral iron for treating iron deficiency anemia in pregnant women: a randomized controlled trial. j matern fetal neonatal med. 2019;32(3):398-403. 20. darwish am, fouly ha, saied wh, farah e. lactoferrin plus health education versus total dose infusion (tdi) of low-molecular weight (lmw) iron dextran for treating iron deficiency anemia (ida) in pregnancy: a randomized controlled trial. j matern fetal neonatal med. 2019;32(13):2214-2220. 21. chughtai f, syed h, shams m, akhter a, munir a, rana s. intravenous iron treatment in pregnancy: comparison of high dose carboxymaltose vs iron sucrose. pak armed forces med j. 2020;70(5):14691473. 22. garzon s, cacciato pm, certelli c, salvaggio c, magliarditi m, rizzo g. iron deficiency anemia in pregnancy: novel approaches for an old problem. oman med j. 2020;35(5):e166. 23. richards t, breymann c, brookes mj, et al. questions and answers on iron deficiency treatment selection and the use of intravenous iron in routine clinical practice. ann med. 2021;53(1):274-285. 24. anlaakuu p, anto f. anaemia in pregnancy and associated factors: a cross sectional study of antenatal attendants at the sunyani municipal hospital, ghana. bmc res notes. 2017;10(1):402. 25. rahman mm, abe sk, rahman ms, et al. maternal anemia and risk of adverse birth and health outcomes in lowand middle-income countries: systematic review and meta-analysis. am j clin nutr. 2016;103(2):495-504. 26. stephen g, mgongo m, hussein hashim t, katanga j, stray-pedersen b, msuya se. anaemia in pregnancy: prevalence, risk factors, and adverse perinatal outcomes in northern tanzania. anemia. 2018;2018:1846280. 27. sifakis s, pharmakides g. anemia in pregnancy. ann ny acad sci. 2000;900:125-36. 101 international journal of human and health sciences vol. 07 no. 02 april’23 editorial: leadership development and emotional competence in undergraduate medical education yousuf r1, yusoof mba2, hassan km3, zainol j4, salam a5. keywords: leadership development, emotional competence, medical education. correspondence to: dr abdus salam, medical educationalist and public health specialist, associate professor and head of medical education unit, faculty of medicine, widad university college, bandar indera mahkota, 25200 kuantan, pahang, malaysia. email: abdussalam.dr@gmail.com orcid id: https://orcid.org/0000-0003-0266-9747 1. rabeyayousuf, blood bank unit, department of diagnostic laboratory services, hospital canselor tuanku muhriz, universiti kebangsaan malaysia (ukm) medical centre, malaysia. 2. mahmood bin abu yusoof, orthopaedics unit, faculty of medicine, widad university college (wuc), kuantan, malaysia 3. khaled mat hassan, obstetrics & gynaecology unit, faculty of medicine and deputy dean (quality and faculty assessment),wuc, kuantan, malaysia 4. jamaludin zainol, surgery unit and dean, faculty of medicine and deputy vice chancellor (academic) wuc, kuantan, malaysia. 5. abdus salam, medical education unit, faculty of medicine, wuc, kuantan, malaysia introduction medicine is a profession that requires high standards of behaviour and leadership skills in addition to a large body of knowledge and clinical skills1,2. leadership is increasingly recognized as an important contributor in modern health care system in delivering the high-quality patient care and performance in the organization3. leadership is defined by the oxford dictionary as ‘the action of leading a group of people or an organization’. a good leader is able to influence and guide the followers or members of an organization4. the educational environment of ‘teaching and evaluation by intimidation’ needs to end if educators expect students to form their own identities, and form ethical and leadership development1,5. good leadership depends on the interaction of the leaders with other members of the team. to develop a good leadership behavior, the factors such as intentions, motivations and emotional intelligence (ei) are considered important6. emotional intelligence is the characteristic of an individual that reveals the ‘ability to monitor ones’ own and others’ emotions, to discriminate among them, and to use this information to guide ones’ thinking and actions7. it involves the perception, processing, regulation and management of own emotion and other peoples’ emotions as well8. emotional competence goleman et al. (2002) describes four dimensions of a leaders’ emotional competencies that impacts on individuals’ leadership skill and on an organization bottom line. the four dimensions are: (a) self-awareness, (b) self-management, (c) social awareness, and (d) relationship management. these four domains were further divided into 18 different personal and social competences. for example, (a) self-awareness domain includes (i) emotional self-awareness, (ii) accurate selfassessment and (iii) self-confidence; (b) selfmanagement domain includes the competencies of (i) self-control, (ii) transparency, (iii) adaptability, (iv) achievement, (v) initiative and (vi) optimism; (c) social awareness includes the competencies of (i) empathy, (ii) organizational awareness and service; (d) relationship management includes the competencies of (i) inspiration, (ii) influence, (iii) developing others, (iv) change catalyst, (v) international journal of human and health sciences vol. 07 no. 02 april’23 doi: http://dx.doi.org/10.31344/ijhhs.v7i2.558 international journal of human and health sciences vol. 07 no. 02 april’23 102 conflict management, (vi) team work and (vii) collaboration9. physicians’ role only as a clinical expert is no longer acceptable in current health care system, it demands the physicians having high quality leadership skills3. the changing health care system with more complexity and increased cost demands a change in the clinical leadership. in addition to the excellent clinical skills in managing the patient, the new clinical leader is expected to transform the health care system by giving priority to the needs of the patient from the patients’ point of view as well as the clinicians10. physicians play a leading role in delivering high quality care to the patient and responsible for patient outcome11. they need to pay first priority to the patient care to achieve the good consequences for all patients as efficiently as possible and also to avoid duplication, reduce error, and ensure coordinated services according to the patients’ needs10. thus, physicians play a role in addition to their clinical skills, for the team work, mentoring, patients’ safety, clear communication, reduction in waste and inefficiency making a better financial outcome12. emotional intelligence is thought to be related to the modern medical core competencies required for graduate medical education which are patient care; professionalism; systems-based practice; interpersonal and communication skills; medical knowledge, and practice-based learning and improvement8. emotional intelligence can be nurtured and refined through proper training; therefore, it is useful to include it in leadership development initiatives within the medical education system of medical school6. important tasks for the clinical leaders oates (2012) has described seven task important for the clinical leaders. these are: i. lead reform in putting the patient first, ii. create a culture of safety, iii. motivator, mentor and facilitator, iv. communicator, v. team leader and team player, vi. demonstrate high level clinical skills and research, vii. manage finances. in addition to these seven tasks, the mentioned personal qualities such as ability to think critically; to monitor his or her own performance; to behave in an honest, open and ethical manner; to display integrity; to see the big picture; to be able to learn from experience; and most importantly to put the patient, rather than himself or herself at centre stage10. it is necessary to develop the skills of leadership and management by all qualified doctors as in their future careers they will need to lead in the interdisciplinary medical team13. the involvement of clinicians in leadership and management has a beneficial effect on healthcare services, along with the quality of patient care. undergraduate and post-graduate medical education are the platform to lay the foundation for these leadership competencies. the institute of medicine (iom) recommends that academic health centers ‘‘develop leaders at all levels who can manage the organizational and system changes necessary to improve health through innovation in health professional education, patient care, and research’’. the general medical council (gmc) recommends “leadership and team working” as a core competency for all newly qualified doctors so that they can contribute to the management and leadership of the health service14. the association of american medical colleges (aamc) has included leadership as anessential competency for medical students15. leadership model known as medical leadership competency framework (mlcf) developed by the national health service, consists of five domains with four sub-competencies in each domain which are (1) demonstrating personal qualities, (2) working with others, (3) managing services, (4) improving services, and (5) setting direction11,15. qualities for emotional intelligence9 including self-awareness, empathy, cultural sensitivity, professionalism, drive, inspirational, commitment, confidence, and creativity are the key qualities critical for leader16. although there is no doubt about the necessity of the leadership training in medical education, but there is lack of consensus about the curricular content, and teaching and evaluation modalities13. a well-planned leadership curriculum is essential to engage tomorrows’ doctors in the leadership in an interdisciplinary medical team including management in the organization. leadership-development methodologies for leadership-development different methodologies can be approached ranging from one-to-one coaching, mentoring, action learning that consists six to eight people, setting common goals under experienced counsellors, networking with peer and senior leaders, experiential learning in real field and self-directed learning using books and audio recordings13. awareness about self with clear understanding about strength and weakness enables the student to identify the areas for 103 international journal of human and health sciences vol. 07 no. 02 april’23 improvement. in this regard, swot analysis and reflective writing can help to explore the strength and weakness and thus improve their self-confidence and emotional intelligence and resilience17. a team-work-skill is necessary to develop leadership. student-lead-team-work includes arranged seminar or a competition, participating in inter-professional teams in hospitals or community settings, in comprehensive effective patient care in multi-disciplinary settings17. study showed that in an undergraduate leadership curriculum, the key skills necessary are communication, time management, conflict resolution, negotiation, delegation, teamwork, and community service16. skills in communication is an art18, and communication can be best presented for easy remembrance by connecting a nutritious drink tea: the acronym of tell, explain and assess19,20. based on assessment result, after telling and even after explaining, if it is found that the message has not been transmitted accurately, then the need to re-transmit the message using simple language and assessing again to ensure that the message has been transmitted as required. the use of tea is aimed at ensuring that the message of the team-leader has been transmitted to all team member correctly. for a sustainable organizational development faculty development activity should be an integral part of any educational institution21,22. a major challenge for educators is to become a role model while delivering high standards of professionalism during their clinical teachings23,24. students frequently receive contradictory messages between what they learn in the class room and what they see in real settings23,25. role model played by the faculty has an important impact on the development of leadership by the students. therefore, the institution needs to arrange appropriate faculty development training as well as take necessary steps to develop a supportive conducive atmosphere for the students and for faculty through administrative and financial support with allocation of necessary resources, incentives and motivations for faculty17. environment plays a great role in development, and the role of leaders cannot be ignored to ensure a productive environment aimed at sustainable organisational development1. educational environment involves all teaching-learning activities between teacher and students including corporal facilities providing by an organisation26,27. it is mostly affected by the curriculum which is outlined as everything that is happening in the class room, department/ unit, faculty, medical school or the university as a whole26,28. the role of faculty is multifaceted, the authoritarian or dictatorial manner of leadershipis not conducive for a supportive environment26. lack of objective, selection of irrelevant and overloaded content, unsuitable methods of content delivery and inappropriate ways of assessment are common issues in medical education29,30. the most difficult problem facing medical education is deciding how the course is adapted and customised30. the faculty must know what to include in the course/curriculum, what to leave out; how to select and organise the contents of the course that relate with course-title and courseoutcomes, how to deliver the course-content, how to assess; and how to orient new students and new lecturer when joined in a department/unit and how to engage them in class room with teaching excellence and research excellence. the planned curriculum, the taught curriculum and the learned curriculum should overlap each other. there is trustworthy correlation between the educational environment and the students’ outcome achievements26,28,31,32. continuous changing is happening in teachers and students’ compositions in medical schools globally33. so, understanding of educational environment and meeting the needs of multicultural society is very important for an effective leadership and effective curriculum26. educators in a multicultural-environment must work to circumvent any monocultural instructional methodologies to lead and promote a sustainable organisational development26. with the necessity of medical faculties to be socially accountable, there is increasing pressure for teaching-research excellence and professionalization of teaching practices34,35. there will be no curriculum and leadership development without faculty development36. leaders in higher education should give due importance on regular faculty development program by well-trained trainer across all levels of faculty aimed at producing high-quality future leaders36. conclusion leadership is defined as the action of leading a group of people or an organization. in medical professional scenario, doctors as clinicians play a leading role in delivering high quality care to the patient. the changing health care system with more complexity and increased cost, demands a change in the clinical-leadership. medical international journal of human and health sciences vol. 07 no. 02 april’23 104 professionals’ role, only as a clinical expert is no longer acceptable in current health care system, it demands the clinicians having high quality leadership skill. self-awareness, self-management, social-awareness, and relationship-management are key dimensions of emotional competencies. unprofessional language and educational environment of ‘teaching and evaluation by intimidation’ needs to be end to frame students’ own professional identities and ethical-leadership development. emotional self-awareness, accurate self-assessment, self-confidence; self-control, transparency, adaptability, achievement, initiative, optimism; empathy, organizational awareness and services; inspiration, influence, developing others, change catalyst, conflict management, teamwork and collaboration are the important dimensions of a leaders’ emotional competencies to be related to modern core medical care competencies. it is necessary to develop the skills of leadership management with emotional intelligence by all qualified doctors as in future in their careers they will need to lead in the interdisciplinary medical team. emotional intelligence can be developed and refined through appropriate training. medical schools should include leadership and emotional intelligence development initiatives within their medical curriculum in order to meet the needs of the society through ensuring the production of high quality future leaders. funding: no funding was received for this paper. conflict of interest: nil. authors’ contribution: all authors participated well in the preparation of this paper and approved the final version for submission to the journal for publication. references: 1. salam a, begum h, zakaria h, allaw baq, han t, algantri kr, mofta ag, elmahi meb, mohamed eme, elkhalifa maa, zainol j. core values of professionalism among fresh medical graduates in a malaysian private university. international journal of human and health sciences 2021; 05(04): 463472. doi: http://dx.doi.org/10.31344/ijhhs.v5i4.358 2. litzclman dk, cottingham ah. the new formal competency-based curriculum and informal curriculum at indiana university school of medicine: overview and five-year analysis. acad med. 2007; 82: 410-421. doi: 10.1097/acm.0b013e31803327f3. 3. clark j.clinical leadership and engagement: no longer an optional extra. in: patole s. (eds) management and leadership – a guide for clinical professionals.springer, cham. 2015.https://doi. org/10.1007/978-3-319-11526-9_2 4. pratt mk. leadership.tech target network. 2017. retrieve on 10 july 2022from:https://www.techtarget. com/searchcio/definition/leadership. 5. yamey g, roach j. witnessing unethical conduct: the effects. west j med. 2001;174(5):355-356. doi: 10.1136/ewjm.174.5.355-a. 6. saxena a, desanghere l, stobart k, and walker k. goleman’s leadership styles at different hierarchical levels in medical education. bmc medical education 2017; 17:169. doi: 10.1186/s12909-017-0995-z. 7. mayer jd, salovey p. what is emotional intelligence? in: salovey p, sluyter dj, eds. emotional development and emotional intelligence: educational implications. new york, ny: basic books 1997;3–31. 8. arora s, ashrafian h, davis r, athanasiou t, darzi a, sevdalis n. emotional intelligence in medicine: a systematic review through the context of the acgme competencies. medical education 2010; 44: 749– 764. doi:10.1111/j.1365-2923.2010.03709.x. 9. goleman d, boyatzis r, mckee a. primal leadership: learning to lead with emotional intelligence. boston, ma: harvard business school press. 2002. 10. oates k. the new clinical leader. journal of paediatrics and child health 2012; 48: 472–475. 11. chen ty. medical leadership: an important and required competency for medical students. tzu chi medical journal 2018; 30(2): 66-70. 12. van diggele c, burgess a, roberts c, mellis c. leadership in healthcare education. bmc med educ 2020; 20(suppl 2):456. https://doi.org/10.1186/ s12909-020-02288-x 13. james e, evans m, mi m. leadership training and undergraduate medical education: a scoping http://dx.doi.org/10.31344/ijhhs.v5i4.358 https://doi.org/10.1007/978-3-319-11526-9_2 https://doi.org/10.1007/978-3-319-11526-9_2 https://www.techtarget.com/searchcio/definition/leadership https://www.techtarget.com/searchcio/definition/leadership https://doi.org/10.1186/s12909-020-02288-x https://doi.org/10.1186/s12909-020-02288-x 105 international journal of human and health sciences vol. 07 no. 02 april’23 review. medical science educator 2021; 31:15011509. https://doi.org/10.1007/s40670-021-01308-9. 14. general medical council. outcomes for graduates. manchester: general medical council; 2012. 15. clyne b, rapoza b, george p. leadership in undergraduate medical education: training future physician leaders. r i med j 2015; 98:36-40. 16. varkey p, peloquin j, reed d, lindor k, harris i. leadership curriculum in undergraduate medical education: a study of student and faculty perspectives. medical teacher 2009; 31: 244-250. doi:10.1080/01421590802144278. 17. sethi s, shah h, supe a. framework to incorporate leadership training in competency-based undergraduate curriculum for the indian medical graduate. indian pediatr 2021; 58:675-681. 18. salam a, zakaria h, abdelhalim at, choon lc, alsharkawy a, taibi mkbm, satwi s, hassan km, zainol j. communication skills of fresh medical graduates in a malaysian private university. bangladesh journal of medical science 2022; 21(02): 404-412. doi: http://doi.org/10.3329/bjms. v21i2.58074 19. salam a, wahab mkba, ahamad a, aziz nba. faculty perspectives on “foundations in teaching and learning” training workshop. australasian medical journal 2017; 10(7): 645-646. 20. salam a. tea to entertain outcome based education for 21st century educators to produce safe human capitals for a sustainable global development. international journal of human and health sciences 2022; 06(02):153-154. doi: http://dx.doi. org/10.31344/ijhhs.v6i2.437 21. salam a, yousuf r, allhiani rf, zainol j. continuous assessment in undergraduate medical educationtowards objectivity and standardization. international journal of human and health sciences 2022; 06(03): 233-236.doi: http://dx.doi. org/10.31344/ijhhs.v6i3.453 22. salam a, mohamad n, siraj hh, kamarudin mr, yaman mn, bujang sm. team-based learning in a medical centre in malaysia: perspectives of the faculty. the national medical journal of india 2014; 27(6): 350. 23. yousuf r, salam a. role modeling in clinical educators: an important issue in medical education. south east asia journal of public health 2015;5(1):49-50. doi: http://dx.doi.org/10.3329/ seajph.v5i1.2485 24. lombarts kmjmh, heineman mj, arah oa. good clinical teachers likely to be specialist role models: results from a multicentercross-sectional survey. plos one 2010; 5(12): e15202. 0015202. 25. salam a, song co, mazlan nf, lee ls, abdullah mh, hassin h. professionalism of future medical professionals in universitikebangsaan malaysia (ukm) medical centre. international medical journal(int med j) 2012;19(3):224-8. 26. salam a, akram a, mohamad n, siraj hh. measures of educational environment in a higher educational institution using dundee ready educational environment measure -dreem. intmedj2015; 22(2): 98-102. 27. harden rm. the learning environment and the curriculum. medical teacher 2001; 23: 335-336. 28. bassaw b, roff s, mcaleer s, roopnarinesingh s, de lisle j, teelucksingh s, gopaul s. students’ perspectives of the educational environment, faculty of medical sciences, trinidad. med teach 2003; 5:522-526. 29. salam a. input, process and output: system approach in education to assure the quality and excellence in performance. bangladesh journal of medical science 2015; 14(01):1-2. http://dx.doi.org/10.3329/bjms. v14i1.21553 30. salam a. issues of objectives, content, methods and assessment in the development of relevant curriculum in medical schools. malaysian medical association (mma) april 2010;22-24. 31. genn jm. amee medical education guide no. 23 (part 1).; curriculum, environment, climate, quality and change in medical education -a unifying perspective. med teach 2001; 23:337-344. 32. jamaiah i. rreview of research in learning environment. journal of the university of malaya medical centre (jummec) 2008; 11:7-11. 33. salam a, akram a, bujang sm, yaman mn, kamarudin mr, siraj hh, mohamad n. educational environment in a multicultural society to meet the challenges of diversity. journal of applied pharmaceutical science 2014; 4(09): 110-113. doi: 10.7324/japs.2014.40919. 34. mclean m, cilliers f, van wyk jm. faculty development: yesterday, today and tomorrow. med teach. 2008;30(6):555-84. doi: 10.1080/01421590802109834 35. salam a, abdelhalim at, begum h, pasha ma. faculty development in medical education: what, why and how. international journal of human and health sciences 2023; 07(01): 3-8. doi: http:// dx.doi.org/10.31344/ijhhs.v7i1.489 36. 36. salam a, mohamad mb. teachers perception on what makes teaching excellence: impact of faculty development programme. intmedj2020; 27(1):1-4. https://doi.org/10.1007/s40670-021-01308-9 http://doi.org/10.3329/bjms.v21i2.58074 http://doi.org/10.3329/bjms.v21i2.58074 http://dx.doi.org/10.31344/ijhhs.v6i2.437 http://dx.doi.org/10.31344/ijhhs.v6i2.437 http://dx.doi.org/10.31344/ijhhs.v6i3.453 http://dx.doi.org/10.31344/ijhhs.v6i3.453 http://dx.doi.org/10.3329/seajph.v5i1.2485 http://dx.doi.org/10.3329/seajph.v5i1.2485 http://dx.doi.org/10.3329/bjms.v14i1.21553 http://dx.doi.org/10.3329/bjms.v14i1.21553 http://dx.doi.org/10.31344/ijhhs.v7i1.489 http://dx.doi.org/10.31344/ijhhs.v7i1.489 international journal of human and health sciences vol. 07 no. 02 april’23 148 original article: intention of nutrition students in implementing general guidelines for balanced nutrition deri andika putra1, suminah2, eti poncorini pamungkasari3 abstract general guidelines for balanced nutrition is a daily food composition based on the type and amount of nutrients, all of which have been adapted to the body’s daily needs. nutrition students have practical experience in educating balanced nutrition, which they have learned during their learning. even so, they still experience nutritional problems and still need to comply: general guidelines for balanced nutrition in their daily lives. the purpose of this study was to determine the intention of nutrition students in implementing general guidelines for balanced nutrition. this study uses a combination of quantitative and qualitative methods. the population of this study is nutrition students, instagram application users, and the subject nutrition instagram account followers who have the content of the general guidelines for balanced nutrition. study 1 was quantitative from a survey of 114 respondents who got the results of good intentions in the 82% and behaviour 83%. the results of the pearson statistical test between the relationship between intention and behavior in the application of general guidelines for balanced nutrition with a p-value of 0.000, this result can be concluded that the value is smaller than 0.05 with a correlation coefficient value or r table 0.424. study 2 conducted in-depth interviews with 6 respondents selected by purposive sampling from 114 respondents with the results of the interviews showed that these six have a strong intention to implement and educate the general guidelines for balanced nutrition. the author’s observations visited respondents to see diving activities a day, and the respondents found that they carried out two messages from the ten messages of balanced nutrition contained in the general guidelines for balanced nutrition. nutrition students need real action in implementing the general guidelines for balanced nutrition in their daily lives. however, nutrition students have a good intention category in writing and verbally but not with what they practice daily. keywords: education, balanced nutrition, nutrition students, instagram correspondence to: deri andika putra, department of nutrition, specialising in human nutrition, postgraduate school, sebelas maret university, surakarta, indonesia. e-mail:deriandika@student.uns.ac.id 1. department of nutrition, specialising in human nutrition, postgraduate school, sebelas maret university, surakarta, indonesia 2. department of agricultural extension and communication, faculty of agriculture, sebelas maret university, surakarta, indonesia 3. department of public health, faculty of medicine, sebelas maret university, surakarta, indonesia introduction the nutrition guidelines with balanced diet have been practiced in many countries since 1992 as a follow-up to the recommendations of the world food conference (fao)/who in rome. and the old guidelines that follow the basic four guidelines from the usa, such as 4 healthy 5 perfect, have been updated into the balanced diet pyramid. whereas in indonesia, it is better known as the general guidelines for balanced nutrition. it is a daily food composition based on the type and amount of nutrients, all of which have been international journal of human and health sciences vol. 07 no. 02 april’23 doi: http://dx.doi.org/10.31344/ijhhs.v7i2.566 mailto:deriandika@student.uns.ac.id 149 international journal of human and health sciences vol. 07 no. 02 april’23 adapted to the body’s daily needs 1 ,2 . students have several important roles, one of which is as a driver who invites the community to make changes for the better by considering various sciences and ideas according to the focus of their studies. this is usually done through training and counseling activities 3 . nutrition students are individuals who are studying nutrition at the university level, both public and private, or other institutions that are at the same level as universities. nutrition science is one of the focuses of study in the health sector, which aims to increase awareness, willingness, and ability to live healthily for everyone to realize the highest degree of public health. as prospective nutritionists, nutrition students are required to master various competencies. nutrition students have practical experience in educating balanced nutrition, which they have learned during their learning. the difference between vocational and undergraduate can be seen clearly through the composition of the curriculum. vocational education generally has an academic curriculum comprising 60% practice and 40% theory. at the same time, undergraduate education consists of 60% theory and 40% practice5 . according to ajzen (2005), the intention is a person’s position on the subjective probability dimension that involves a relationship between himself and several actions. then intention is a motivational factor that affects behavior and describes a person’s willingness to try a behavior until there is the right opportunity to do it. balanced nutrition behavior is a state of a person’s self in doing something such as acting, behaving, thinking, and providing feedback or response to something in maintaining and improving the composition of daily food intake based on the type and amount of nutrients adapted to the daily needs of the body. early nutritional needs are met by considering the principles of food diversity, physical activity, clean living behavior, and maintaining normal body weight. these responses can be in the form of active and passive responses6,7. nutrition students must understand and apply the general guidelines for balanced nutrition, and this is because they will become nutritionists in the future whose task is to provide advice and information to patients related to the implementation of nutrition and nutrition related to diagnosis or health problems. before nutrition students educate the public regarding the general guidelines for balanced nutrition, they must first understand knowledge and act. students with a deeper analytical mindset than their peers need to have the opportunity to hold the title of student8. therefore, even if they do not take a study program related to nutrition, students will tend to gain nutrition knowledge through seminars, books, magazines, or internet media. this allows students to have good nutritional knowledge. in addition, life pattern also affects students’ consumption patterns. for example, a student who follows a strict diet maintains a thin body. they will skip one or more meals each day, not eat fatty foods, and limit the types of food they eat9. to prevent nutrition students from experiencing nutritional problems, it is necessary to apply the principles of balanced nutrition, which can be used as guidelines for nutrition, physical activity, healthy lifestyles, and normal weight control. this is in line with research showing the tendency of nutritional problems that occur by students, such as research in malaysia, which is 6.1% of the sample of undergraduate students are underweight, 53.4% in the normal range of 23.0% are overweight, and 17.6% are obese (radzi et al., 2019 ). while in indonesia alone, nutritional problems can still be found in university areas, especially students with nutritional status results during the pandemic underweight 17.0%, normal 48.2%, overweight 17.9%, obesity level i 13.4%, obesity level ii 3.6%10. furthermore, masitah’s research (2018) shows that social media can increase nutritional knowledge because health education using instagram application media can contain visual formats such as pictures or videos online11,12. the selection of instagram social media does not escape its popularity as a medium of education and information among nutritionists and nutrition students as one of the breakthroughs in technological progress. instagram provides an excellent opportunity for educating the general guidelines for balanced nutrition for nutritionists and nutrition students13,14. instagram provides a new way for nutrition students to learn to apply the general guidelines for balanced nutrition critically before they also educate when they become nutritionists while helping nutrition students reflect on meaningful learning processes15. this study aims to determine the intention of nutritional vocational students in implementing general guidelines for balanced nutrition. in the international journal of human and health sciences vol. 07 no. 02 april’23 150 end, to find out what positive impact was obtained by nutrition students in improving the behavior of implementing the general guidelines for balanced nutrition in daily life. material and method this research is mixed method research with a sequential model combination method. in the first stage, the research uses a quantitative method with a lower weight than the qualitative method carried out in february-april on three gizi instagram accounts. the first study quantitatively by conducting a questionnaire survey that will be measured here is the variable of intention and behavior. meanwhile, for the second study, after the survey selected informants from the respondents in the first study, six informants were taken with two methods of in-depth interviews and observation to determine intentions and behavior16 e research subjects were nutrition students, active instagram users, and followers of nutrition instagram accounts. the subjects in this study were 114 respondents in the first study, and 6 informants were selected using the purposive sampling method from the 114 respondents in the initial study in the second study. based on the regulation of the minister of health of the republic of indonesia number 28 of 2019, the age of students is in the 19-29 year range. the independent research variable is balanced nutrition intention, while the dependent variable is the healthy behavior of nutrition students who follow nutrition instagram accounts. the questions in the knowledge questionnaire of students majoring in nutrition will be assessed using a multiple-choice scale consisting of 15 questions. the total score is categorized into 1: less if the correct answer is <60%, 2: enough if the answer is 60-80% correct, and 3: good if the correct answer is >80%. this research is mixed method research with a sequential model combination method. in the first stage, the research uses a quantitative method with a lower weight than the qualitative method carried out in february-april on three gizi instagram accounts. the first study quantitatively by conducting a questionnaire survey that will be measured here is the variable of intention and behavior. meanwhile, for the second study, after the survey selected informants from the respondents in the first study, six informants were taken with two methods of in-depth interviews and observation to determine intentions and behavior16. the research subjects were nutrition students, active instagram users, and followers of nutrition instagram accounts. the subjects in this study were 114 respondents in the first study, and 6 informants were selected using the purposive sampling method from the 114 respondents in the initial study in the second study. based on the regulation of the minister of health of the republic of indonesia number 28 of 2019, the age of students is in the 19-29 year range. the independent research variable is balanced nutrition intention, while the dependent variable is the healthy behavior of nutrition students who follow nutrition instagram accounts. the questions in the knowledge questionnaire of students majoring in nutrition will be assessed using a multiple-choice scale consisting of 15 questions. the total score is categorized into 1: less if the correct answer is <60%, 2: enough if the answer is 60-80% correct, and 3: good if the correct answer is >80%. the first study data in this study consisted of variables of intention and behavior. intention and behavior data were collected by filling out questionnaires distributed by three instagram nutrition accounts with followers of more than ten thousand followers. this is done because data collection during the covid-19 pandemic is not allowed to meet in person according to indonesian government regulations. the second study was conducted by collecting data online through the zoom meeting application by asking open questions about the intentions and behavior of balanced nutrition. then indirect observations were made with informants providing activities related to the general guidelines for balanced nutrition17. the study used an online survey using a website from google forms. research question questionnaires were taken from journals that have been published and have been modified by researchers. the authors assisted and compiled the in-depth interview and observation guidelines using openended questions and indonesian spelling to make it easy to understand when conducting interviews and giving instructions. data analysis using spss 16.0 computer application in knowing the relationship between the two variables of intention and behavior with correlation test and using nvivo computer application to help code interview and observation data. result first study with the survey results in detail, the data can 151 international journal of human and health sciences vol. 07 no. 02 april’23 be seen in the following tables by analyzing the characteristics and the description of anthropometric measurements. description of the basic characteristics of instagram users, description of knowledge, attitudes, and behavior of research respondents about balanced nutrition. it is hoped that it can describe the basic characteristics of research respondents. table 1. distribution of basic characteristics of research respondents variable variable amount frequency (n) percentage (%) gender man 4 3.5 woman 110 96.5 age 18 9 7.9 19 27 23.7 20 37 32.5 21 41 36.0 lecture semester 1 1 0.9 2 15 13.2 3 5 4.4 4 23 20.2 5 8 7.0 6 35 30.7 7 4 3.5 8 22 19.3 10 1 0.9 study program diploma iii 13 11.4 diploma iv 31 27.2 bachelor 70 61.4 based on the distribution of the characteristics of the research respondents is shown in table 1. based on gender, the highest number is in the female group, namely 96.5%, the age category of 14 years is 50.0%, the semester of college is in the 6th semester with 30.7%, and the study program consists of undergraduate nutritionists 61.4%. table 2. distribution of basic characteristics of instagram users variable amount frequency (n) percentage (%) instagram account @ig1 10 8.8 @ig2 14 12.3 @ig3 7 6.1 following all three 83 72.8 knowing instagram account family 1 0.9 friend 14 12.3 own 67 58.8 instagram recommendations 32 28.1 long following instagram account > 5 months 26 22.8 > 8 months 26 22.8 > 1 year 62 54.4 based on the distribution of the number of instagram followers on nutrition and duration of use of instagram is shown in table 2. as many as 72.8% of nutrition students follow the three instagram accounts about nutrition, 58.8% know instagram accounts from searching for themselves with their interest in nutrition, and 54.4% of nutrition students have followed instagram account for more than 1 year. table 3. distribution of intentions and behaviors implementation of the general guidelines for balanced nutrition variable amount frequency (n) percentage (%) intention not enough 1 0.8 enough 31 27.1 well 82 71.9 behavior not enough 1 0.9 enough 30 26.3 well 83 72.8 based on table 3. results of intentions and behavior of research respondents regarding international journal of human and health sciences vol. 07 no. 02 april’23 152 general guidelines for balanced nutrition. respondents have intentions with good category 71.9% and less category 0.8% while for behavior to get behavior results with good category 72.8% and less category 0.9%. based on table 4. above, it can be concluded that the results of the pearson statistical test between the relationship between intention and behavior in the application of general guidelines for balanced nutrition with a p-value of 0.000, this result can be concluded that the value is smaller than 0.05 with a correlation coefficient value or r table 0.424. thus h0 is rejected, and h1 is accepted, which means that there is a significant relationship between intention and behavior in applying general guidelines for balanced nutrition. second study after the first study, the author continued the second study with data that there was a relationship between good intentions and good behavior in applying general guidelines for balanced nutrition. therefore, in the second study, 6 informants were taken from 114 respondents who participated in purposive sampling with the help of a wheel of names computer application to choose the informant’s name after being selected. the informants would be coded i1 to 16. the interview results in the intention or intention session produced an overview of the informants’ desire to apply balanced nutrition; their desire arose to educate and motivate the community to implement balanced nutrition. intentions or intentions produce a picture of the informant’s desire to carry out or apply balanced nutrition. the informants’ intentions to carry out balanced nutrition are very strong even though they are difficult to do in practice. i1 a lack of awareness causes it: “humans tend to underestimate the future, meaning that the things we have now are more valuable to us than the things we will have in a few years”. for example, most informants are very strong in implementing balanced nutrition: i1 that he intends to carry out general guidelines for balanced nutrition in daily life. “...yes, actually table 4. test the relationship between intentions and behavior of the implementation of the general guidelines for balanced nutrition variable amount frequency (n) r xy table r xy calculate p<value intention with implementation behavior general guidelines for balanced nutrition 112 0.424 0.184 0.000 my intention is because to maintain our own body condition and also keep away from disease...”. i3 intends to carry out general guidelines for balanced nutrition because they want to be healthy and not easily fatigued in physical activities. “... yes, i intend... yes, i want to be healthy, firstly, i don’t get sick easily, i don’t get tired easily because we often feel like that, then secondly, we provide education to the public so that people believe that by giving good feedback...” in the in-depth interview, the author’s behavioral session focuses more on discussions based on the informants’ experiences applying balanced nutrition. behavior is a set of actions or actions of a person responding to something. therefore, questions in the behavioral session will focus on the informants’ experiences regarding balanced nutrition. implementing balanced nutrition, i3 admit that more is needed when doing balanced nutrition. “... it’s not good enough, it’s not good enough, right, even though i’ve reduced the consumption of snacks that have a lot of fried food, but in one meal, it’s not complete, you know, i’ve arranged it but sometimes it’s not complete because of the availability of food at home, right? there is no such thing, no vegetables or complete animal and vegetable side dishes, sometimes there is no fruit but as much as possible if it is complete i also apply ..”. i4 also tells about the obstacles in implementing balanced nutrition. “... the obstacles that i experienced... that’s what was mentioned a lot earlier. like the availability of side dishes or diversity in the kitchen at home, it becomes an 153 international journal of human and health sciences vol. 07 no. 02 april’23 obstacle. ..”. i5 explains the factors of implementing balanced nutrition. “...there is a problem, usually it’s actually time, only if the obstacle is usually a regular breakfast, if we want to study offline, it’s rarely breakfast because there are people who drive from home to campus it’s far ...”. discussion in this study, there were more women than men because most of the respondents in the health faculty were female18,19. students here have an age of 18-21 years, with a maximum age of 21 years 36.0% and a minimum age of 18 years 7.9%. this is by the theory that students enter adulthood which is generally in the age range of 18-25 years or young adults. in research, the age group is only 18-21 years old. it is feared that those aged > 21 years are no longer active or are busy writing a thesis20.respondents here are nutrition students with undergraduate study programs 61.4%, diploma iv 27.2% and diploma iii 11.4% and with various semesters from at least semester 10.9% and at most semester 6 30.7%, it is expected that respondents with high education can understand the knowledge questionnaire, attitude, and behavior. respondents with academic education influence a person’s nutritional knowledge. the higher their educational level of education, the higher their information ability can increase their knowledge21. from the results obtained in the survey, it was found that most of the nutrition students following instagram accounts such as @ ig1, @ ig2, and @ ig3 have sufficient knowledge about balanced nutrition. this is different from the education level of the respondents, especially nutrition students, so it is hoped that the level of understanding of balanced nutrition can be even better. this is because informants are more informed and know more about developing @ ig1, @ ig2, and @ ig3 accounts. the selection of educational information materials is currently very necessary. social media users play an active role in the selection and use of media. usually, media users choose media because of their individual psychological and social needs. like respondents, they chose instagram as an educational news media because of its ease of application22. based on the theory of planned behavior, intentions can accurately predict various behavioral tendencies 23. according to schiffman (2007), intention is a person’s tendency to perform a certain action or behavior24. in the research of dhauvadel et al. (2022), it was found that the nutrition education program was found to be significantly effective in changing students’ intention to consume healthy food and attitudes, perceived behavioral control, and intentions toward healthy eating behavior. however, there was no significant change in social media on healthy eating behavior25. therefore, school-based nutrition education programs will change healthy eating intentions. likewise the research conducted by handarbeny (2017), explaining the change in intention in the treatment group is the result of education in the form of discussion, by discussing the respondents feel motivated so that the intention to increase taking balanced nutrition actions26. according to the general guidelines for balanced nutrition, in the science of nutrition, a variety of foods (i.e., foods that contain nutrients the body needs in both quality and quantity) are often called triguna foods which contain energy, structure, and regulation food27. ministry of health according to research from plotnikoff (2015), the analysis results showed that many students had followed the first pillar regarding eating a variety of foods, which is a message that has been quite well implemented28. this has the same results as research (mozaffarian et al., 2018), which shows that half of all students have bad eating habits. diverse foods are needed because in every food ingredient, and there is no single type that contains complete nutrients. besides the amount and type of nutrients in each type of food ingredient are also different. so the more diverse the pattern of food dishes, the easier it is to meet the needs for various nutrients29. guidelines for balanced nutrition are a daily diet containing nutrients in the right type and amount according to the body’s needs, accompanied by 4 principles. balanced nutrition guidelines are made to replace the slogan “4 healthy 5 perfect”, which is considered irrelevant to today’s society. however, general guidelines for balanced nutrition is not quite familiar in the community because the scientific description is quite high compared to the slogan “4 healthy 5 perfect”30. this is in line with fauzi’s (2012) research, which was conducted on 11 informants and found that none of the students knew the general guidelines for balanced nutrition and was more familiar with the slogan “4 healthy 5 perfect”31,32. in addition, previous research found that respondents international journal of human and health sciences vol. 07 no. 02 april’23 154 chose food regardless of whether the food was nutritionally balanced or not, and the general guidelines for balanced nutrition values were not known by most of the respondents. in line with that, the results of mcmanus’s research (2017) on informants stated that information related to general guidelines for balanced nutrition was still not widespread in the community. hence, students’ knowledge about general guidelines for balanced nutrition still needed to be higher33. the results of the research that nutrition students received from two exposures to social media instagram nutrition and nutrition lectures had a strong intention in implementing balanced nutrition. however, in practice, students only explained a few general guidelines for balanced nutrition, with most grateful for and enjoying various foods34,35. food and the least that is done is consuming various staple foods. meanwhile, why do nutritionists use instagram as a medium for education and promotion of balanced nutrition by departing from the reason that many untrue nutritional myths must be overcome, one of which is through the provision of education and information, there are still many people, families and nutrition students who do not understand correctly what is balanced nutrition and there are still many who know “4 healthy 5 perfect”36. with the development of technology, the use of social media instagram as a medium of information is used by informants who are nutritionists as an educational medium because instagram can be accessed anywhere and anytime, especially instagram has the advantage of audio-visual that is easy and understandable for followers of the informants’ instagram account. thus, the results cannot be generalized to the entire population37. the limitation of this study is that the distribution of online questionnaires with 3 nutrition instagram accounts is not 100% accurate and efficient. however, at least it can describe the knowledge, attitudes, intentions, behavior, and subjective norms of nutrition students about balanced nutrition that they get from the instagram account. sampling can only be represented by some groups of students in indonesia who have implemented balanced nutrition through balanced nutrition education using instagram social media. this certainly has many shortcomings, including the data obtained being less accurate and precise. conclusion nutrition students need real action in implementing the general guidelines for balanced nutritionin their daily lives. however, nutrition students have a good intention category in writing and verbally but not with what they practice daily. source of fund (if any) this study had no financial support or sponsorship from any partypure research usingfinance from researchers. conflict of interest noneoftheauthorshaveanyconflictofinterest. wealso would like to declare that we do not have anycompeting interests. ethical clearance it has been approved by the research ethics committee of the faculty of medicine, sebelas maret university, surakarta, indonesia authors’ contribution datagatheringandideaowner:deri andika putra,suminah,eti poncorini pamungkasari writing,editingfinal draftandsubmittingof themanuscript:deri andika putra approvaloffinaldraft:suminah, eti poncorini pamungkasari 155 international journal of human and health sciences vol. 07 no. 02 april’23 references 1. food and agriculture organization. sustainable healthy diets. sustainable healthy diets. 2020. https:// doi.org/10.4060/ca6640en. 2. ministry of health of the republic of indonesia. regulation of the minister of health of the republic of indonesia number 41 of 2014 concerning guidelines for balanced nutrition. 2014;55: 3909. 3. zaki i, sari hp. social media-based nutrition education increases knowledge and energy-protein intake of young women with chronic energy deficiency. gizi indonesia.2019;42:111–122.https:// doi.org/10.36457/gizindo.v42i2.469. 4. green bn, johnson cd. interprofessional collaboration in research, education, and clinical practice: working together for a better future. journal of chiropractic education.2015;29: 1–10.https://doi. org/10.7899/jce-14-36. 5. ministry of education and culture of the republic of indonesia. decree of the director general of vocational education of the ministry of education and culture. 2020. 6. ajzen i. attitudes, personality, and behavior. new york: open university press. vol. 2. 2005. 7. kaenong km, dachlan dm. salam a. description of macro nutrient intake, nutritional status, and level of satisfaction of students organizing systems of food served in ummul mukminin boarding school makassar gizi. 2014. 8. dimaria-ghalili ra. challenges and opportunities for nutrition education and training in the health care professions : intraprofessional and interprofessional. 2 0 1 4 ; 9 9 : 11 8 4 – 11 9 3 . h t t p s : / / d o i . o rg / 1 0 . 3 9 4 5 / ajcn.113.073536.introduction. 9. scalvedi ml, gennaro l, saba a, rossi l. relationship between nutrition knowledge and dietary intake: an assessment among a sample of italian adults. frontiers in nutrition.2021;8:1–13. https://doi.org/10.3389/fnut.2021.714493. 10. bolang cr, kawengian ses, mayulu n, bolang asl. student nutritional status before and during the pandemic covid-19. jurnal biomedik : j b m .2 0 2 1 ; 1 3 : 7 6 – 8 3 . h t t p s : / / d o i . o rg / 1 0 . 3 5 7 9 0 / jbm.13.1.2021.31746. 11. masitah, r., pamungkasari, e. p. & suminah. instagram, facebook and adolescent nutrition knowledge. sintesa.2018;0:573–578. 12. dwi w, zebua a, syifa, utari a. virtual ethnography study on the use of social media for education on prevention of stunting in children. proceeding international conference on social sciences.2019;229–239.available at: https://www. boc.web.id. 13. jefrydin n, sedik fsm, kamaruzaman na, nor nm, shapi’i a, talib ra. use of instagram® to educate adolescents on nutrition labelling: a feasibility study in selangor, malaysia. jurnal gizi dan pangan.2020;15:149–158.https://doi.org/10.25182/ jgp.2020.15.3.149-158. 14. adamski m, truby h, klassen km, cowan s. gibson, s. using the internet : nutrition information-seeking behaviours of lay people enrolled in a massive online nutrition course. 2020. 15. united nations international children’s emergency fund. social and behaviour change communication strategy: improving adolescent nutrition in indonesia. unicef.2021;1–83.available at: https:// w w w. u n i c e f . o r g / i n d o n e s i a / m e d i a / 9 2 2 1 / f i l e / executive summary of social behavioural change communication strategy.pdf. 16. creswell j. educational research planning: planning, conducting, and evaluating quantitative and qualitative research. 2011. 17. lim xj, mohd ra, cheah jh, wong mw.the impact of social media influencers on purchase intention and the mediation effect of customer attitude. asian journal of business research.2017;7.https://doi. org/10.14707/ajbr.170035. 18. risberg g, johansson ee, westman g,hamberg k. gender in medicine an issue for women only? a survey of physician teachers’ gender attitudes. international journal for equity in health.2003;2:1–8. https://doi.org/10.1186/1475-9276-2-1. 19. carr pl, raj a, kaplan se, terrin n, breeze jl, freund km.. gender differences in academic medicine. academic medecine.2018;93:1694–1699. https://doi.org/10.1097/acm.0000000000002146. 20. nelson lj, badger s, wu b. the influence of culture in emerging adulthood : perspectives of chinese college students. int. j. behav. dev.2015;28, 26–36. 21. jeruszka-bielak m. are nutrition-related knowledge and attitudes reflected in lifestyle and health among elderly people? a study across five european countries. front. physiol.2018;9:1–13. 22. haslam sa. a social identity approach to leadership development; the 5r program. j. pers. psychol.2017;16:113–124. 23. ajzen i. the theory of planned behavior. organ. behav. hum. decis. process. 1991;179–211. 24. schiffman, leon, kanuk & leslie, l. consumer international journal of human and health sciences vol. 07 no. 02 april’23 156 behavior second edition. paper knowledge . toward a media history of documents. 2007. 25. dhauvadel as, wagle s. bhandari tr. effects of nutrition education program in intention change for consuming healthy food among adolescents: a school-based study abstract. j. sci. soc.2022;46, 41–45. 26. handarbeny wr. mahmudiono t. pengaruh pendidikan gizi berbasis theory of planned behavior untuk mempromosikan pembatasan konsumsi fast food pada siswi. amerta nutr.2017;1, 351. 27. cena h, calder pc. defining a healthy diet: evidence for the role of contemporary dietary patterns in health and disease. nutrients. 2020; 27:12(2):334. https://doi.org/10.3390/nu12020334. 28. plotnikoff rc. effectiveness of interventions targeting physical activity, nutrition and healthy weight for university and college students: a systematic review and meta-analysis. int. j. behav. nutr. phys. act.2015;12, 1–10. 29. mozaffarian d, angell sy, lang t, river ja. role of government policy in nutrition-barriers to and opportunities for healthier eating. bmj2018;361, 1–11. 30. maliati n, sumarti t, agusta i,tanziha i. national policy on food and nutrition in the family food fulfillment practices in aceh : foucauldian analysis on the discourses of the power of human body kebijakan pangan dan gizi nasional dalam praktik pemenuhan pangan keluarga di aceh : analisis foucauldian tentang diskursus kuasa tubuh manusia. 2022;10, 77–90. 31. fauzi ca. analysis of the knowledge and behaviour of adolescents based on the general guidelines of balanced nutrition (pugs) point 6 , 10 , 11 , and 12. kesehat. reproduksi.2012;3, 91–105. 32. vina rizky putri, dudung angkasa, r. n. indonesian journal of human nutrition. indones. j. hum. nutr.2017;5, 48–58. 33. mcmanus ke, bertrand a, snelling am, cotter ew. in their own words: parents and key informants’ views on nutrition education and family health behaviors. int. j. environ. res. public health2018;18. 34. adiba c, pradigdo sf, kartasurya mi. association between social media exposure to food and beverages with nutrient intake of female adolescents. kesmas2020;15, 191–198. 35. rounsefell, k. social media, body image and food choices in healthy young adults: a mixed methods systematic review. nutr. diet.2020;77, 19–40. 36. lensoni. pelatihan pencegahan penularan penyakit scabies dan peningkatan hidup bersih dan sehat bagi santriwan. din. j. pengabdi. kpd. masy.2020;4, 470–475. 37. januraga pp. qualitative evaluation of a social media campaign to improve healthy food habits among urban adolescent females in indonesia. public health nutr.2020;24, 98–107. microsoft word ijhhs imam 23rd asc 2022 s31 do medical students like pre-recorded lectures? an insight from pharmacology teaching elsa haniffah mejia mohamed1 and nur lisa zaharan1 objective: the covid-19 pandemic has forced academic institutions to move many of their face-toface teaching and learning activities online. the medical education research and development unit (merdu), universiti malaya had instructed that all lectures to be prepared beforehand as pre-recorded voiced-over lecture slides to allow for more flexibility for students. this study aimed to see if stage 1 and stage 2 medical students appreciated the changes made for online learning and if the changes could be maintained after the movement control order (mco) is over.   methods: longitudinal comparison of feedback obtained from traditional face-to-face pharmacology teaching to pre-clinical stage 1 and stage 2 students from the 2018/2019 cohort with the 2020/2021 cohort was carried out.  student feedback scores on the effectiveness of having pre-recorded lectures in assisting them to achieve learning objectives were collected. open-ended students’ feedback including preferences and suggestions for changes was also noted.  a two-tailed student’s t-test was used to compare the scores, and p<0.05 was taken as significant.  results: the total number of respondents was 790 and 774, for the 2018/2019 and 2020/2021 cohorts, respectively. a total of 45 teaching sessions were included for each cohort.  the average score comparison between the 2018/2019 and 2020/2021 cohorts was statistically very significant (p<0.00005, mean 4.44±0.25 and 4.700.16, respectively). 40 out of 45 sessions had either quizzes or case-based learning during their synchronous sessions. these helped students understand the topics better, while the lecturers noted positive interactions with the students.  conclusion: changes made to accommodate online teachings had resulted in a positive learning experience for pre-clinical pharmacology students. with these results, it is likely that pre-recorded lectures to support flexible learning as well as interactive discussion/quiz approach during face-to-face sessions, may be adopted as the mainstay of pharmacology teaching in the future.   keywords: covid-19 learning, asynchronous, pre-recorded lectures, active learning 1. department of pharmacology, faculty of medicine, universiti malaya, 50603, kuala lumpur ___________________________________________________________________________ correspondence to: elsa haniffah mejia mohamed, medical lecturer, pharmacology department, faculty of medicine, universiti malaya, kuala lumpur. elsa@ummc.edu.my __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v7i70.533 microsoft word ijhhs imam 23rd asc 2022 s29 a novel bedside diagnostic technique for acquired tracheoesophageal fistula nesha rajendram1,2, muhammad ariff sobani2, masaany mansor1,2, intan kartika kamarudin1,2,, norazila abdul rahim1,2  acquired tracheoesophageal fistula is a rare and challenging medical dilemma. in general, tracheoesophageal fistula (tof) is diagnosed by subjecting a patient to imaging such as barium swallow or computed tomography of the neck and thorax. the patient may need a diagnostic bronchoscopy under general anaesthesia and flexible oesophagoscopy. we report three cases of suspected tof diagnosed utilising a new, novel, minimally invasive, an office-based procedure in a bedside setting. tof is difficult to diagnose. our technique is practical, utilizes instruments in the clinic itself, is comfortable for the patient, and is inexpensive. the cases include a post tracheostomised patient who was suspected to be complicated with tof, a patient who underwent ogds for investigation of dysphagia and odynophagia with an incidental finding of oesophageal fistula, and a patient who underwent anterior cervical corpectomy and fusion with an open tracheostomy, who was suspected to have an oesophageal fistula post neck surgery. the technique used a flexible nasopharyngolaryngoscope (fnpls), and a nasogastric tube instilled with methylene blue and local anaesthesia into the larynx and trachea in an awake patient. the detailed step-by-step procedure was described. this technique is simple and safe. it eliminates the need to subject patients to general anaesthesia or contrasted imaging in diagnosing tof. keywords: tracheoesophageal fistula, oesophageal fistula; methylene blue; office-based procedure 1. department of otorhinolaryngology, head and neck surgery, faculty of medicine, universiti teknologi mara, sungai buloh campus, selangor, malaysia 2. department of otorhinolaryngology, head and neck surgery, hospital al sultan abdullah uitm, puncak alam, malaysia ___________________________________________________________________________ correspondence to: intan kartika kamarudin, senior lecturer and otorhinolaryngology head and neck surgeon, department of otorhinolaryngology head and neck surgery, universiti teknologi mara, malaysia, kartika@uitm.edu.my __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v7i70.531 microsoft word ijhhs imam 23rd asc 2022 s33 challenges in managing early dementia with multimorbidities in primary care choong siaw-mei1, lee ping yein2, aneesa abdul rashid3 dementia is one of the most common disabling illnesses associated with aging. about 6.1% of the worldwide population aged 65 years old and above suffers from dementia. early-onset dementia (eod) refers to dementia becoming clinically manifested before the age of 65. the prevalence rate of early dementia is 40-100/100,000 in developed countries. primary causes such as alzheimer's disease, is the most common cause (50-75%), followed by vascular dementia (20-30%). this case illustrates a 57-year-old lady with underlying diabetes mellitus, hypertension and dyslipidaemia who came for follow-up in the primary care clinic. her husband complained that she had been having forgetfulness for the past 3 years. this included difficulty in remembering specific routes and she even got lost while driving home. otherwise, she was still able to manage her basic daily activities including bathing, eating, dressing, grooming and toileting, hence the husband thought that this was common in aging and did not need any intervention or treatment. her physical examination was unremarkable apart from her mmse score was 22 out of 30 points, suggestive of mild dementia. the patient was subsequently referred to geriatrics and psychiatry. her ct scan of the brain showed the presence of a multifocal infarct. the diagnosis of vascular dementia based on the multiple vascular risks and radiological findings was made even though there were physical neurological deficits. this case highlights the challenges in the diagnosis and screening of dementia in primary care. a multidisciplinary approach, an essential role of the family medicine specialist in providing holistic, continuous, coordinated, and comprehensive care to the patient is the cornerstone in managing patients with this diagnosis. keywords: dementia, cognitive impairment, vascular dementia, silent stroke, multimorbidity 1. klinik kesihatan pasir panjang, taman pasir panjang, 71250 port dickson, negeri sembilan 2. e-health unit, faculty of medicine, university of malaya, 50603 kuala lumpur 3. department of family medicine, faculty of medicine & health sciences, universiti putra malaysia, 43400 serdang, ___________________________________________________________________________ correspondence to: aneesa abdul rashid, associate professor and medical lecturer, department of family medicine, faculty of medicine and health sciences, universiti putra malaysia, 43400 serdang, malaysia, aneesa@upm.edu.my _________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v7i70.535 s26 huge renal angiomyolipoma in a child with tuberous sclerosis complex: a diagnostic and therapeutic dilemma sharifah nurdurrah binti syed mudzhar1, mohd yusran othman1 abstract tuberous sclerosis complex (tsc) is a rare neuro-cutaneous disorder that is associated with the development of benign hamartomas including renal angiomyolipoma (raml). tsc associated raml are usually asymptomatic, but it carries a life-threatening bleeding risk. we are sharing a case of a 5-year-old girl who was diagnosed to have tsc with associated subependymal giant cell astrocytoma, cardiac rhabdomyoma and autism. she presented with a history of worsening abdominal distension over 3 weeks duration and clinically noted to be pale with a ballotable left flank mass. ultrasound and ct scan found to have multiple raml in both kidneys with a huge mass on the left side. the mass represented a huge raml (8cm) with aneurysmal formation with suspicion of intratumoral bleeding. the option of conservative management with mammalian target of rapamycin inhibitor followed with partial nephrectomy has been questioned with its life-threatening risk of bleeding and inability to do biopsy to rule out the possibility of renal cell carcinoma. decision for nephrectomy was then made clearer following a mag-3 scan which revealed only 11% differential function of the left kidney. she underwent a total left nephrectomy uneventfully and intraoperatively noted to have an enlarging lesion as compared to the previous imaging; 15cm in largest diameter. histopathological finding was consistent with multifocal angiomyolipoma with intratumoral haematoma. decision for nephrectomy in tsc-associated raml need to be justified carefully in view of its risk of losing the contralateral kidney following the disease progression which may end up with life-long renal replacement therapy. keywords: tuberous sclerosis complex (tsc), renal angiomyolipoma (raml), rapamycin inhibitor, partial nephrectomy 1. paediatric surgery, hospital tunku azizah, malaysia doi: http://dx.doi.org/10.31344/ijhhs.v5i0-2.344 http://dx.doi.org/10.31344/ijhhs.v5i0-2.344 s22 leptospirosis: a rare cause of acute hepatitis jo ann wong1 abstract leptospirosis is a zoonotic infection caused by the pathogenic leptospira interrogans. humans acquire the infection either through direct contact with the urine of infected animals, commonly rats or indirect contact of contaminated water or soil. it is a rare cause of acute hepatitis in the uk with fewer than 100 reported cases a year and hence diagnosis is commonly delayed. a 51-year-old fit caucasian gentleman was admitted with a one-week history of painless jaundice, dark urine and pale-coloured stools. this was associated with feeling unwell, anorexia, nausea and intermittent epigastric discomfort. he binges on alcohol on a weekend. he works as a telephone engineer which occasionally exposes him to sewage water. on clinical examination, he was icteric with mild right hypochondriac tenderness. liver biopsy was performed and histologically it was suggestive of leptospirosis. he was started on a five-day course of intravenous ceftriaxone followed by two days course of oral doxycycline. his igm leptospirosis result finally came back as positive. due to the rarity of leptospirosis in the uk, the serological testing of leptospirosis is only performed in the rare and imported pathogens laboratory in porton down, salisbury leading to a delay in getting the result. the patient underwent an invasive procedure which can be avoided if the leptospirosis serology was ordered early and result available quickly. fortunately, the patient made a full recovery after two months. leptospirosis should be considered in an individual with acute hepatitis and a history of exposure to sewage. keywords: leptospirosis, hepatitis, liver biopsy 1. st james' university hospital, united kingdom doi: http://dx.doi.org/10.31344/ijhhs.v5i0-2.340 http://dx.doi.org/10.31344/ijhhs.v5i0-2.340 microsoft word ijhhs imam 23rd asc 2022 s27 most daunting aspect of being a house officer: a survey among medical graduates in a malaysian public university aneesa abdul rashid1, sazlina shariff ghazali1, norhafizah mohtaruddin2, wan zul haikal hafiz bin wan zukiman3, farina mustaffa kamal4, nurul amelina nasharuddin5 objectives: medical graduates often express their unreadiness to work due to several factors. it is important for medical educators to take steps toward assisting house officers (ho) to become work ready. this study assessed the most daunting aspects of being a ho as perceived by medical graduates in a public malaysian university. methods: this was part of a larger study entitled “development of an online module for medical graduates’ readiness to work”. the first part of this study involves an online survey on medical graduates from universiti putra malaysia (upm) from november 2020 to january 2022. the survey used was the “confidence and readiness to work as a house officer questionnaire” that consists of 75 questions altogether. two of the questions were on readiness to work, of which one asked “in my opinion, the most daunting aspect of being a ho is?” there were 8 choices: (i) physical demand: difficulty in maintaining patience; (ii) physical demand: difficulty in maintaining clinical judgement; (iii) confronting the seniors; (iv) handling patients with responsibilities (including communication) (v) competence required in knowledge and judgement; (vi) competence required in practical skills; (vii) time management; (viii) having to adjust to different routines in work and life. ethics was granted from the ethics committee for research involving human subjects upm (jkeupm-2020-341).   results: one hundred and fifty-nine medical graduates completed the questionnaire. they were mostly female (69.2%), single (99.4%), muslim (56.6%) and malay (54.7%). the most daunting aspects were “competence required in knowledge and judgement” (36.5%), followed by “handling patients with responsibilities (including communication) (17.6%) and “physical demand: difficulty in maintaining clinical judgement” (15.7%).  conclusion: more than one third of the respondents selected “competence in knowledge and judgement” as the most daunting aspect of becoming ho. future research should further investigate these factors.  keywords: house officer, work readiness, medical graduates, media education 1. department of family medicine, faculty of medicine and health sciences, universiti putra malaysia, 43400 serdang, malaysia 2. department of pathology, faculty of medicine and health sciences, universiti putra malaysia, 43400 serdang, malaysia 3. department of medicine, faculty of medicine and health sciences, universiti putra malaysia, 43400 serdang, malaysia 4. department of pathology & veterinary microbiology, faculty of veterinary medicine, universiti putra malaysia, 43400 serdang, malaysia 5. department of multimedia, faculty of computer science and information technology, universiti putra malaysia, 43400 serdang, malaysia ___________________________________________________________________________ correspondence to: aneesa abdul rashid, associate professor and medical lecturer, department of family medicine, faculty of medicine and health sciences, universiti putra malaysia, 43400 serdang, malaysia, aneesa@upm.edu.my __________________________________________________________________________________ doi: http://dx.doi.org/10.31344/ijhhs.v7i70.529 355 international journal of human and health sciences vol. 06 no. 04 october’22 review article association of vitamin d with crp as a diagnostic marker of cytokine storm in covid-19 patients samina gul1, muhammad ajmal khan2 abstract the novel corona virus disease (covid-19) outbreak imposed the catastrophic impact on the communities worldwide. recentevidence suggests that vitamin d is one of the important factors that affects the covid-19 disease severity and the mortality increased in the vitamin d deficient covid-19 patients. since creactive protein (crp)is an indicator of inflammation, an increase in levels of vitamin d hence leads to the decrease in cytokines which ultimately affects the degree of c reactive proteins in the patients. in this review, we have focusedhere on the association between vitamin d and surrogate marker creactive protein (crp)in cytokine storms in covid-19 patients. keywords:covid-19, cytokine storm, creactive protein, vitamin d correspondence to: samina gul, faculty of medicine, lab of molecular genetics of aging and tumor, kunming university of science and technology, chenggong campus, kunming, yunnan province 650500, china. email: minna_gul@hotmail.com, samina.gul@cecos.edu.pk 1. faculty of medicine, lab of molecular genetics of aging and tumor, kunming universityof science and technology, chenggong campus, kunming,yunnan province 650500, china. 2. division of life science, center for cancer research, hong kong university of science and technology, kowloon. hong kong. introduction the respiratory tract infection is less frequent in summer than in winter, cold temperature the virus spread and transmitted easily. several pneumonia cases reported in wuhan hubei province of china in 20191 and the disease spread at light speed to the other provinces of china and 6 continents within 3 months,2 which imposed catastrophic effect on every society but the mortality rate and severity are higher in elderly population, the world health organization (who) subsequently named as ‘corona virus disease 2019’ (covid-19) in february 2020.3this disease shows high variability in clinical severity, in which 30-40% develop mild symptoms, 40-50% remain asymptomatic and 15% develop severe cases with subsequent systematic inflammation, multi organ failure and fatal outcome.4in elderly population, the weak immune system response to high lead of sars-cov2 and subsequently lead to increased level of cytokine production by the overreaction of adaptive immune system.5in china, the clinical data obtained from the covid 19 patients to better understand theimmune system defense mechanism against covid 19, indicate the presence of high concentration of cytokine storm such as ilk 6, tnfalpha, mcp1, mip1a, ip10, and gcsf in covid 19 patients samples.6 how vitamin d impact on immune system have been supported widely by multiple studies.7 the level of vitamin d in winter might lead to the susceptibility of some respiratory tract virus such as rsv respiratory syncytial virus, influenza virus infection has been suggested by many studies.8 during 1918-1919 viral influenza virus pandemic vitamin d suppressed the cytokine storms suggested by some researcher.9here we focus on the deficiency of vitamin d, covid 19 and unregulated inflammation crp which is nonspecific marker of the cytokine storm severity measurement in covid 19 case. sources and roles of vitamin d vitamin d is responsible for wide spectrum of immune modulatory, anti-inflammatory, antifibrotic and antioxidant actionsas a fat soluble secosteriod. in humans, the most abundant type of vitamin d are d2 and d3 i.e., ergocalciferol and cholecalciferol respectively. our liver converts d2 into 25-hydroxyergocalciferol and d3 into 25-hydroxycholecalciferol. 25-hydrooxyvitamin d25(oh)d is principal metabolite of vitamin d, which is measured to find out the vitamin d level international journal of human and health sciences vol. 06 no. 04 october’22 page : 355-361 doi: http://dx.doi.org/10.31344/ijhhs.v6i4.473 international journal of human and health sciences vol. 06 no. 04 october’22 356 of an individual. 1-α hydroxylase enzyme present in kidney generates[1, 25-(oh)2d], which is the active form of vitamin d.10the calcitriolcirculates as hormone in blood, which encourage the healthy remodeling of bone and play major role in calcium and phosphate homeostasis. vitamin daffects gene expressions –bothgenomic and non-genomic.11the genomic impact of vitamin d includesligand activated transcription factors known as vdr vitamin d receptor, calcitriol binds to vdr and heterodimerizes are form in some cases with active metabolites of vitamin a retinoid x receptor rxxr. this interaction regulates the gene expression positively or negatively.11non genomics effect includes the interaction of dependent genes in promoter region of vitamin d with responsive element vdre.12 besides, these also play major role in neuro muscular function, cellular growth, immune function includes antiinflammatory action, its insufficiency associated with overexpression of th1 cytokines, and inhibit the expression of inflammatory cytokines e.g tumor necrosis factor tnf alpha, il-1b, ilk6, il-1d.13,14food source of vitamin d are fat fish, cod fish oil, daily recommended allowance (15-20microgram) for adult, with exception of mushroom no plant source of vitamin d. sundried mushroom contain 7 and 25 microgram/100g of vitamin d.15 immune system and vitamin d vitamin d play major role in defense mechanism of immune system16 and have impact on immune system cells such as dendritic cells, neutrophils, macrophages, t and b lymphocytes.17vitamin d inhibits the pro-inflammatory cytokines storms production.18 in disease pathogenesis, the innate immune cell including neutrophil, macrophages, mast cells, cytokines storms (g-csf, mcp-1a, il-6, il-2, il-7, and tnf alpha), lymphopenia, reduced functional state of t cell play important roles.19 vitamin d minimize the pro-inflammatory response in patient through different mechanism including interaction with immune cell such as neutrophil, macrophages and mast cells, reducing leukocytes infiltration into inflammatory sites and selective suppression of inflammatory cytokines.20 vitamin d also plays important roles in regulation of thrombotic pathway. in covid-19 patients, the thrombotic complications are common,21and deficiency of vitamin d associated with increase thrombotic episodes. tregulatory lymphocytes t(reg) defense against viral uncontrolled inflammation has been reported to be low in severe covd 19 patients.22 vitamin d supplementation increases the t(reg) level.23 covid-19 and c-reactive protein(crp) c-reactive protein-related with elevated response of ongoing inflammation and much higher in bacterial infection than in viral infection, is produced in liver.22-25it is used as a diagnostic biomarker in infection. it is key protein of acute phase response in normal healthy individual andin any tissue damaging event; it appears in blood within 6-10 hours. crp baseline reported in blood is less than 10microgram/ ml.26 in disease or tissue trauma crp blood level increase 10-100 folds within 10-72 hours, level above 100 microgram/ml associated with poor disease prognosis, crp differentiate viral from bacterial infection, crp level in viral infection ~ 20microgram/ml and in uncomplicated bacteria level increase >40microgram/ml, in covid 19 the crp level varied from 28.7microgram/ml in non-severe disease and 47.6microgram/ml in severe disease.26significantly elevated crp level in covid 19 patient >100microgram/ml reflected coagulation abnormalities, multiple organ failure, tissue damaging, and pathologies associated with cytokine storms. vitamin d and crp crp is non-specific marker, in covid 19 it is more specific to cytokine storm and il-6 bioactivity.27 in covid 19 severe patient dendritic cells, il-6 production by monocytes, macrophages lead to crp production and systematic pro-inflammatory cytokines.27 the anti-inflammatory cytokines absence leads to high grade inflammation and cytokine storms.28 a recent study shown that vitamin d lead to reduction of crp by alter the bioactivity of il-6 to induce more antiinflammatory cytokines, such as il-10 instead of il-7 as pro-inflammatory cytokines,29 as shown in figure 1. renin-angiotensin system renin-angiotensin system regulate blood pressure, systematic vascular resistance, fluid and electrolyte balance by conversion of angiotensinogen to angiotensin i and angiotensin ii which is catalyzed by ace,30 the rate limiting enzyme of ras, kidney synthesis and secrete renin and its main source is juxtaglomerular cells, which release the renin from storage granules. this secretion is inhibited by via ang ii via vt1r. the endothelial cells surface has two receptor 357 international journal of human and health sciences vol. 06 no. 04 october’22 of ace are at1r and at2r. ang ii release cotecholamines and vasoconstriction. ang ii via at1r induce the release aldosterone and sodium reabsorption.31 a novel homologue of ace, ace2 expressed in kidney, lung, cardiovascular system, vascular smooth muscles, and endothelial cell. ace2 cleave ang1 to ang 1-9, ang ii to ang 17. ang 1-9 via at2r exert cardiovascular protection effect and counterbalance the effect of ang ii and ang 1-7 via at1r and mas oncogene. ras produce inflammation,vasoconstriction, hypertrophy and fibrosis and ace2 counteract those effects,32 as shown in figure 2. c-reactive protein mechanism c-reactive protein (crp)mechanism consist of three isoform, mind isoform, monomeric isoform and native isoform. isoform-n is synthesized in liver,33andalso synthesized by other cells, e.g., macrophages, adipocytes, muscles and lymphocytes.34native crp dissociate and give rise mcrp, have different inflammation properties, on partially dissociation another mcrp give rise. in crp biology the important stage is complement activation.35 the complement activated via c1q classical pathway, c1q activate the chain of c4, c2,c3 and c3 activated induce, cell lysis, opsonization and inflammation,36as shown in figure 3. crp caused cell cycle arrest and dna damage by induction of gadd153 gene expression. crp main function iscontributed to inflammatory process attached locally at dna damage tissue and inflammation, activate complement binding to fc receptors which induce the production of proinflammatory cytokine.37 ras, crp and sars-cov2 infection sars-cov2 is virus which is spherical in shape and covered by lipid envelope, chain of rna in positive sense covered by nucleocapsid make its genome. this virus has important externally s protein, m protein and e protein for its pathogenesis. s protein is important for binding its ace2 receptor, e protein is important for haemagglutinin esterase and assembly of virus and m protein for structural support. during infection the sars-cov2 virus bound to ras member ace2 and transported molecule into cell.38ace2 initially play protective role against ang ii harmful effect by transferring ang ii to ang 1-7. this internalization of ace2/virus complex increased the expression of adam17 (adisintegrin metalloprotease 17), the proteolytic effect of adm17 decrease the ace2 on the surface of cell.39 the ang ii induced the pro-inflammatory cytokines production, fibrosis, vasoconstriction, and crp production through its at1r receptor and nuclear translocation of nf-kb. the drastic effect of ace2 on cell surface reduction lead to deterioration of conversion of ang ii into ang1-7 and produce inflammation, under this mechanism the sars-cov2 mechanism effect the ras and increase production of crp,40as shown in figure 3. effect of vitamin d on crp, ras and sarscov2: low level of vitamin d increase ang ii, ras activity anddecrease the (pra) plasma renin activity shown by many researchers.41vitamin d act as negative regulator of ras, prevent overaction of vdr knock out mice.42 and suppress the transcriptional activity in renin gene promoter act as renin expression negative regulator as shown in figure 4. the cellular internalization of ace2/virus complex increased ang-ii activity which induced the pro-inflammatory cytokines and crp production. sars-cov2 binding with ace2 down-regulate its activity, expression andincreased the risk of acute lung failure.43vitamin d potentially disrupt the impact of sars-cov2 via increased the expression of ace2.44vitamin d inhibit the nuclear receptor corepressor 1 (ncor1) renin protein expression enhancer and cyclic adenosine monophosphate camp has been shown by many studies. therefore, vitamin d blocked the angiotensinogen conversion to ang i and ace ang ii and down-regulate the renin transcript which suppress the ras activity [46]. the relation between vitamin d and crp concluded that risk factor predicated reduce to 16.6% following vitamin d status normalization (>75nmol) by low vitamin d and high crp.46 conclusion in summary, vitamin d deficiency have both skeletal and non-skeletal effects. vitamin d deficiency was frequently found in severe covid-19 patients. safely and significantly raised serum concentration of vitamin d leads to alter the bioactivity of crp,which ultimately leads to more anti-inflammatory cytokines production and reduce disease severity risk. conflict of interest: the authors declare that they have no conflicts of interest. ethical approval:not applicable. funding statement: this review work was supported by none. international journal of human and health sciences vol. 06 no. 04 october’22 358 authors’ contribution: sg was involved inconception and design of the paper, while sg andmak both were involved in literature search, review, compilation, manuscript writing, revision and final drafting. figure 1: vitamin d leads to the reduction of crp level induce anti-inflammatory cytokines and reducethe covid 19 severity. figure 2: a) raas (renin-angiotensin-aldosterone system) controlling regulation of blood flow and blood volume. b)renin gene induces cleavage of angiotensinogen to angiotensin i via angiotensin converting enzyme (ace)converted to angiotensin ii; ang ii activates the angiotensin 1 receptor which results in an increase of blood pressure, inflammation, hypertrophy and catecholamines and further effects on the vascular system. ang ii suppresses renin synthesis via at1r. c)renin counter regulatory pathway is activated through cleavage of ang i to ang1–9 via ace2 and activate at2r, ang ii to ang1–7 which activate mas receptor which decrease blood pressure, inflammation, hypertrophy and catecholamines. 359 international journal of human and health sciences vol. 06 no. 04 october’22 figure 3: sars-cov2 disrupts the counter regulatory pathway of renin when attached to ace2 which un-control the classical renin pathway and leads to hypertrophy, vasoconstriction, cancer, inflammation, and the ang ii and at1r hyperactivity leads to higher expression of adam17 which cause lungs damage, heart, and vessels injury in covid 19 patients and crp, crp activate complement and fcr receptor which cause cell lysis and inflammation. figure 4: vitamin d suppresses the ras activity by inhibition of renin, which lead to reduction of ace, ang-ii and increase in level of ace2, which leads ang-ii to ang-1-7 to produce anti-inflammatory cytokines, decrease blood pressure and vasodilation. international journal of human and health sciences vol. 06 no. 04 october’22 360 references: 1. jain a, chaurasia r, sengar ns, singh m, mahor s, narain s. analysis of vitamin d level among asymptomatic and critically ill covid-19 patients and its correlation with inflammatory markers. sci rep. 2020;10(1):20191. 2. chakhtoura m, napoli n, el hajj fuleihan g. commentary: myths and facts on vitamin d amidst the covid-19 pandemic. metabolism. 2020;109:154276. 3. world health organization (who).clinical management of severe acute respiratory infection when novel coronavirus (ncov) infection is suspected: interim guidance. 2020. 4. wu z, mcgoogan jm. characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72 314 cases from the chinese center for disease control and prevention. jama. 2020;323(13):1239-42. 5. daneshkhah a, agrawal v, eshein a, subramanian h, roy hk, backman v. the possible role of vitamin d in suppressing cytokine storm and associated mortality in covid-19 patients. medrxiv. 2020. https://doi.org/10.1101/2020.04.08.20058578. 6. goncalves-mendes n, talvas j, dualé c, guttmann a, corbin v, marceau g, et al. impact of vitamin d supplementation on influenza vaccine response and immune functions in deficient elderly persons: a randomized placebo-controlled trial. front immunol. 2019;10:65. 7. aranow c. vitamin d and the immune system. j investig med. 2011;59(6):881-6. 8. khare d, godbole nm, pawar sd, mohan v, pandey g, gupta s, et al. calcitriol [1, 25[oh]2 d3] preand post-treatment suppresses inflammatory response to influenza a (h1n1) infection in human lung a549 epithelial cells. eur j nutr. 2013;52(4):1405-15. 9. grant wb, giovannucci e. the possible roles of solar ultraviolet-b radiation and vitamin d in reducing case-fatality rates from the 1918-1919 influenza pandemic in the united states. dermatoendocrinol. 2009;1(4):215-9. 10. cardoso mp, pereira lal. native vitamin d in predialysis chronic kidney disease. nefrologia (engl ed). 2019;39(1):18-28. 11. biesalski hk. vitamin d deficiency and comorbidities in covid-19 patients – a fatal relationship? nfs journal. 2020;20:10-21. 12. pike jw, meyer mb. fundamentals of vitamin d hormone-regulated gene expression. j steroid biochem mol biol. 2014;144(pt a):5-11. 13. hii cs, ferrante a. the non-genomic actions of vitamin d. nutrients. 2016;8(3):135. 14. hughes da, norton r. vitamin d and respiratory health. clin exp immunol. 2009;158(1):20-5. 15. huang g, cai w, xu b. vitamin d2, ergosterol, and vitamin b2 content in commercially dried mushrooms marketed in china and increased vitamin d2 content following uv-c irradiation. int j vitam nutr res. 2017;87(5-6):1-10. 16. di rosa m, malaguarnera m, nicoletti f, malaguarnera l. vitamin d3: a helpful immunomodulator. immunology. 2011;134(2):123-39. 17. adams js, ren s, liu pt, chun rf, lagishetty v, gombart af, et al. vitamin d-directed rheostatic regulation of monocyte antibacterial responses. j immunol. 2009;182(7):4289-95. 18. gombart af, pierre a, maggini s. a review of micronutrients and the immune system-working in harmony to reduce the risk of infection. nutrients. 2020;12(1):236. 19. teymoori-rad m, marashi sm. vitamin d and covid-19: from potential therapeutic effects to unanswered questions. rev med virol. 2021;31(2):e2159. 20. xu y, baylink dj, chen cs, reeves me, xiao j, lacy c, et al. the importance of vitamin d metabolism as a potential prophylactic, immunoregulatory and neuroprotective treatment for covid-19. j transl med. 2020;18(1):322. 21. weir ek, thenappan t, bhargava m, chen y. does vitamin d deficiency increase the severity of covid-19? clin med (lond). 2020;20(4):e107-8. 22. giannis d, ziogas ia, gianni p. coagulation disorders in coronavirus infected patients: covid-19, sarscov-1, mers-cov and lessons from the past. j clin virol 2020;127:104362. 23. mohammad s, mishra a, ashraf mz. emerging role of vitamin d and its associated molecules in pathways related to pathogenesis of thrombosis. biomolecules 2019;9:649. 24. nehring sm, goyal a, patel bc. c reactive protein (crp). treasure island, fl: statpearls; 2020. 25. marnell l, mold c, du clos tw. c-reactive protein: ligands, receptors and role in inflammation. clin immunol 2005;117:104-11. 26. potempa la, rajab im, hart pc, bordon j, fernandez-botran r. insights into the use of c-reactive protein as a diagnostic index of disease severity in covid-19 infections. am j trop med hyg. 2020;103(2):561-563. 27. daneshkhah a, agrawal v, eshein a, subramanian h, roy hk, backman v. evidence for possible association of vitamin d status with cytokine storm and unregulated inflammation in covid-19 patients. aging clin exp res. 2020;32(10):2141-58. 28. pepys mb, hirschfield gm. c-reactive protein: a critical update. j clin invest. 2003;111(12):1805-12. 29. mcgregor r, chauss d, freiwald t, yan b, 361 international journal of human and health sciences vol. 06 no. 04 october’22 wang l, nova-lamperti e, et al. an autocrine vitamin d-driven th1 shutdown program can be exploited for covid-19. biorxiv [preprint]. 2020:2020.07.18.210161. 30. honardoost m, ghavideldarestani m, khamseh me. role of vitamin d in pathogenesis and severity of covid-19 infection. arch physiol biochem. 2020:1-7 31. mosquera-sulbaran ja, pedreañez a, carrero y, callejas d. c-reactive protein as an effector molecule in covid-19 pathogenesis. rev med virol. 2021;31(6):e2221. 32. li yc, qiao g, uskokovic m, xiang w, zheng w, kong j. vitamin d: a negative endocrine regulator of the renin-angiotensin system and blood pressure. j steroid biochem mol biol. 2004;89-90(1-5):387-92. 33. eisenhardt su, thiele jr, bannasch h, stark gb, peter k. c-reactive protein: how conformational changes influence inflammatory properties. cell cycle. 2009;8(23):3885-92. 34. calabró p, willerson jt, yeh et. inflammatory cytokines stimulated c‐reactive protein production by human coronary artery smooth muscle cells. circulation. 2003;108:1930‐2. 35. smilowitz nr, kunichoff d, garshick m, shah b, pillinger m, hochman js, berger js. c-reactive protein and clinical outcomes in patients with covid-19. eur heart j. 2021;42(23):2270-9. 36. reis es, mastellos dc, hajishengallis g, lambris jd. new insights into the immune functions of complement. nat rev immunol. 2019;19(8):503-16. 37. guyton kz, xu q, holbrook nj. induction of the mammalian stress response gene gadd153 by oxidative stress: role of ap-1 element. biochem j. 1996;314(pt 2):547-54. 38. de groot rj. structure, function and evolution of the hemagglutinin-esterase proteins of coronaand toroviruses. glycoconj j. 2006;23(1-2):59-72. 39. santos ra, simoes e silva ac, maric c, silva dm, machado rp, de buhr i, et al. angiotensin-(1-7) is an endogenous ligand for the g protein-coupled receptor mas. proc natl acad sci usa. 2003;100(14):825863. 40. scott aj, o’dea kp, o’callaghan d, williams l, dokpesi jo, tatton l, et al. reactive oxygen species and p38 mitogen-activated protein kinase mediate tumor necrosis factor α-converting enzyme (tace/ adam-17) activation in primary human monocytes. j biol chem. 2011;286(41):35466-76. 41. kumar r, rathi h, haq a, wimalawansa sj, sharma a. putative roles of vitamin d in modulating immune response and immunopathology associated with covid-19. virus res. 2021;292:198235. 42. peng my, liu wc, zheng jq, lu cl, hou yc, zheng cm, et al. immunological aspects of sarscov-2 infection and the putative beneficial role of vitamin-d. int j mol sci. 2021;22(10):5251. 43. machado cds, ferro aissa a, ribeiro dl, antunes lmg. vitamin d supplementation alters the expression of genes associated with hypertension and did not induce dna damage in rats. j toxicol environ health a. 2019;82(4):299-313. 44. gracia-ramos, ae. is the ace2 overexpression a risk factor for covid-19 infection? arch med res. 2020;51:345-6 45. andersen lb, przybyl l, haase n, von versenhöynck f, qadri f, jørgensen js, et al. vitamin d depletion aggravates hypertension and target-organ damage. j am heart assoc. 2015;4(2):e001417. 46. malek mahdavi a. a brief review of interplay between vitamin d and angiotensin-converting enzyme 2: implications for a potential treatment for covid-19. rev med virol. 2020;30(5):e2119. international journal of human and health sciences vol. 06 no. 03 july’22 292 original article association of admission glucose level with arrythmia and heart failure in hyperglycemic patients with non-st-segment elevation myocardial infarction md. tariqul islam khan1, mahmood hasan khan2, mariya tabassum3, mahadi hassan4, s. m. tarique mahmud1, farhana naznen5 abstract background: observetion of admission blood glucose level in non-st elevation myocardial infarction is crucial to predict its outcome. objective: to find out correlation of plasma glucose level with adverse events like arrythmia and heart failure in hyperglycemic patients with non-stsegment elevation myocardial infarction (nstemi). methods: this prospective analytical study was conducted in the department of cardiology, mymensingh medical college hospital, mymensingh, bangladesh, between june 2016 and may 2017. a total of 130 (95 males and 35 females) patients having nstemi participated in the study. detail history was taken and physical examination was done. venous blood samples were obtained from all patients to determine their cardiac troponins, plasma blood glucose, hba1c, lipid profile, serum creatinine, and other cardiac enzymes. then, the study participants were categorized into two groups. a total of 67 included (44 males and 23 females) in group i, as having nstemi with plasma glucose level 7.8-9.3 mmol/l. in group ii, 63 were included (51 males and 12 females) having nstemi with plasma glucose level ≥9.4 mmol/l. follow up was done according to the standard protocol,i.e. serial ecg, echocardiography, monitoring pulse, blood pressure, and auscultation of the lungs’ base. results: the mean age of the patients was 49.68±3.12 years. incidence of arrhythmia was observed in 4(5.97%) and 20(31.75%) cases in group i and group ii respectively, while heart failure was found in 6(8.96%) and 48(76.19%) cases respectively (p<0.001). a statistically significant moderate negative correlation with medium strength of association (r = -0.056) was observed between heart failure (as measured by lvef and clinical status) and admission plasma glucose levels of the study participants suggesting that the higher was admission plasma glucose level (8.27±1.03 vs. 13.34±3.65; p<0.001),the lower was the lvef (54.19±7.13 vs. 44.21±7.36; p<0.001), i.e. higher risks of heart failure. conclusion: a higher admission plasma glucose level relates to a lower lvef,i.e. higher incidence of arrythmia and heart failure in non st-elevation mi patients. keywords: plasma glucose, arrythmia, heart failure, left ventricular ejection fraction, myocardial infarction correspondence to: dr. md. tariqul islam khan, medical officer, department of cardiology, mymensingh medical college hospital, mymensingh-2206. email: drwasimbd.khan@gmail.com 1. department of cardiology, mymensingh medical college hospital, mymensingh-2206, bangladesh. 2. department of clinical & interventional cardiology, evercare hospital dhaka, dhaka-1229, bangladesh. 3. department of biochemistry, abdul malek ukil medical college, begumganj, noakhali-3823, bangladesh. 4. department of cardiology, 250 bed district sadar hospital, bhola-8300, bangladesh. 5. department of physiology, community based medical college, bangladesh (cbmc,b), winnerpar, mymensingh-2200, bangladesh. international journal of human and health sciences vol. 06 no. 03 july’22 page : 292-297 doi: http://dx.doi.org/10.31344/ijhhs.v6i3.461 introduction acute coronary syndrome encompasses different clinical presentations resulting from myocardial ischemia and includes silent angina, stable and unstable angina (ua), acute myocardial infarction [both non-st segment elevation myocardial infarction (nstemi) and st-elevation myocardial infarction (stemi)].1among the non-st segment elevation acute coronary syndromes,unstable angina (ua) and non-st segment elevation 293 international journal of human and health sciences vol. 06 no. 03 july’22 myocardial infarction (nstemi) are common.2 non-st segment elevation coronary syndrome usually results from instability of an atherosclerotic plaque, with subsequent activation of platelets and several coagulation factors.2non-st elevation myocardial infarction (nstemi) is a recognized diagnostic entity that has an unacceptable mortality rate when it goes unrecognized.1research revealed that south asian populations have high cardiovascular disease (cvd) burden in the world.3 however, recent advances in diagnostic tools have led to utilization of different biomarkers to detect and treat myocardial infarction (mi) at an early stage. these biomarkers have tremendous diagnostic and prognostic values, e.g.cardiac troponins, ck-mb,natriuretic peptide, lipoproteins, and other inflammatory acute phase proteins.4-6 the role of hyperglycemia in the development of cardiovascular complications in mi patients is often overlooked, and thus, remains unclear. surprisingly, hyperglycemia, as determined by using a simple, low-cost laboratory test, has been associated with a worse prognosis in mi patients, even in the absence of diabetes.7,8patients either with or without a prior history of diabetes mellitus may present with hyperglycemia during acute myocardial infarction. among patients with no prior history of diabetes, hyperglycemia may reflect previously undiagnosed diabetes, preexisting carbohydrate intolerance, stressrelated carbohydrate intolerance, or a combination of these.9,10several studies have reported an association between elevated blood glucose upon admission and subsequent increased adverse events, including congestive heart failure, cardiogenic shock, and death.7-11hence, observationof admission blood glucose level in non-st elevation myocardial infarction is also crucial. recording of plasma glucose level at admissionis a cheap and easily available test, which has a significant valueto predict outcome of nstemi. the value suggests which of thepatients need to be managed urgently with pharmacological or interventional therapy to achieve a better outcome.12many studies were conducted to see the impact of admission blood glucose level in patients with first attack of non-st segment elevation myocardial infarction in many countries across the globe. however, no report has been found in our country to date. hence, we proposed the present study to see the association of admission glucose level with adverse events like arrythmia and heart failure in a tertiary level healthcare facility in the country where patients hailing from both urban and rural communities are admitted and treated. methods this prospective, analytical study was conducted in the department of cardiology, mymensingh medical college hospital, mymensingh, bangladesh, between june 2016 and may 2017. a total of 130 patients were included in this study. inclusion criteria: i) patients with first attack of non-st elevation myocardial infarction (the diagnosis of acute non-st-elevation myocardial infarction was done according to the ‘third universal definition of myocardial infarction’)13with no history of diabetes mellitus; and ii) patients provided consent to be enrolled in the study. exclusion criteria: i) patients having previous history of myocardial infarction; ii) patient having latent diabetes (previously undiagnosed), as excluded by determining hba1clevel; iii) patients with valvular heart disease, congenital heart disease and cardiomyopathy; and iv) patients having major non cardiovascular disorder which causes st elevation. after taking detailed medical history and complete physical examination, data were recorded for the major cardiovascular risk factors such as age, sex, smoking, diabetes mellitus, hypertension, and family history of coronary artery disease. in addition, body mass index (bmi), pulse, systolic and diastolic blood pressure were recorded. venous blood samples were obtained from all patients to determine their cardiac troponins, plasma blood glucose, hba1c, lipid profile, serum creatinine, and other cardiac enzymes.then, the study participants were categorized into two groups. a total of 67 included (44 males and 23 females) in group i, as having nstemi with plasma glucose level 7.8-9.3 mmol/l. in group ii 63 were included (51 males and 12 females), as having nstemi with plasma glucose level ≥9.4 mmol/l.follow up was done according to the standard protocol,14 as international journal of human and health sciences vol. 06 no. 03 july’22 294 we adopted serial ecg, echocardiography, and clinical examinations like monitoring pulse, blood pressure, and auscultation of the lungs’ base.heart failure was determined by left ventricular ejection fraction (lvef) and clinical status of the patient as per standard guideline.14the sequence of the study procedure is shown below in figure 1. patients admitted into department of cardiology with chest pain (study population) history taking, targeted physical examination, ecg, troponin-i level (at admission and after 6 hours, if initial result comes negative), plasma glucose level, hba1c level + applying inclusion and exclusion criteria (sample population) outcome variables (serial ecg, echocardiography, and clinical examinations, e.g. pulse, blood pressure, auscultation of lung base) data collection and analysis data were collected and recorded in the structured case record form. statistical analyses were done using the spss version 20.0 for windows (spss inc., chicago, illinois, usa). the mean±sd values were calculated for continuous variables. the qualitative observations were expressed by frequencies and percentages. chi-square test was used to analyze the categorical variables, while student t-test was used for continuous variables. p value <0.05 was considered as statistically significant.correlation between admission plasma glucose levels and subsequent development of heart failure was determined using pearson’s correlation test. results the mean age of study participants was 49.68±3.12 years. no statistically significant difference was found in age, sex, bmi, living and risk factors (p>0.05) (table 1).mean plasma glucose level at admission was 8.27±1.03 and 13.34±3.65 in group i and group ii respectively, while cardiac troponin i was found 9.39±1.04 and 11.58±2.86 respectively (p<0.001). however, no difference was observed in lipid profile and serum creatinine levels (p>0.05)(table 2). incidence of arrhythmia figure 1. flow chart of study design. table 1. demographic profile of the study participants (n=130) variables group i(n=67) group ii (n=63) p value age group 21-30 4 3 >0.05 31-40 11 9 41-50 28 31 51-60 12 9 61-70 7 6 71-80 2 3 81-90 3 2 mean±sd 49.68±3.12 sex male 44 53 >0.05 female 23 12 bmi 24.53±4.03 24.50±4.09 >0.05 living area rural 38 40 >0.05 urban 29 25 risk factors smoking 38 46 >0.05 hypertension 53 59 family history 31 37 was observed in 4(5.97%) and 20(31.75%) cases in group i and group ii respectively, while heart failure was found in 6(8.96%) and 48(76.19%) cases respectively (p<0.001). heart failure was 295 international journal of human and health sciences vol. 06 no. 03 july’22 measured based on lvef, which was found 54.19±7.13% and 44.21±7.36% in group i and group ii respectively (p<0.001) (table 3). pearson’s correlation test revealed a statistically significant moderate negative correlation with medium strength of association (r = -0.056) between heart failure (as measured by lvef and clinical status) and admission plasma glucose levels of the study participants suggesting that the higher was admission plasma glucose level the lower was the lvef in echocardiography i.e. higher chance of heart failure (figure2). table 2. biochemical markers of the patients during admission variables group i(n=67) group ii (n=63) p value plasma glucose 8.27±1.03 13.34±3.65 <0.001 troponin i 9.39±1.04 11.58±2.86 <0.001 lipid profile tc 183.04±49.72 184.58±50.80 >0.05tg 189.09±119.18 194.82±124.82 hdl-c 34.88±7.64 34.72±7.59 ldl-c 114.83±39.95 115.53±41.55 serum creatinine 1.06±0.08 1.09±0.09 >0.05 table 3. incidence of arrythmia and heart failure in patients (n=130) variables group i(n=67) group ii (n=63) p value arrhythmia 4 (5.97%) 20 (31.75%) <0.001 heart failure 6 (8.96%) 48 (76.19%) <0.001 lvef 54.19±7.13 44.21±7.36 <0.001 figure 2. correlation between heart failure (lower lvef) and admission plasma glucose levels of the study population (n=130) discussion bangladesh has been experiencing epidemiological transition from communicable disease to noncommunicable disease (ncd) over decades. the exact prevalence of coronary artery diseases in our country is not known. only a limited number of small-scale epidemiological studies are available.15-18a prospective study at tertiary centre of the country showed the mean age of the patients 50.15±8.8 years,17 which is very similar to our study. most important risk factors identified by different research groups are smoking, hypertension, diabetes and dyslipidemia,16-18 which arealso in congruence with our results. our study revealed that higher level of admission plasma glucose level in first attack of nstemi patients subsequently gives rise to lower lv ejection fraction (lvef), which ultimately leads to arrythmia and heart failure. hyperglycemia in those non-diabetic patients is more often a marker of stress response due to more extensive myocardial damage; in such cases a greater degree of stress is necessary to achieve the hyperglycemic state because their metabolic control is usually normal.11there is also a graded relationship between both elevated fasting glycemia and admission glycemia and 30-day mortality in nondiabetic patients with acute myocardial infarction, which suggests that fasting glycemia is a more important predictor of 30-day mortality than admission glucose alone.19 patients with both elevated admission glucose and elevated fasting glucosehavemultiple times increasedrisks of mortality.19-21there is also an important association between magnitude of glycemia variation and both post-discharge endpoints and mortality, unlike with in-hospital prognosis.11,20,21 another study suggests that patients presenting with an acute mi, who are hyperglycemic upon admission represent a high-risk population. the worst outcomes occurred among those without a prior history of diabetes. this may relate to hyperglycemia being associated with several high-risk features, including older age, female gender, and a prior history of heart failure.22if stress hyperglycemia indeed reflects an underlying dysglycemic state, then this would be expected to correlate with a higher overall risk for more extensive coronary artery disease and would international journal of human and health sciences vol. 06 no. 03 july’22 296 explain a worse prognosis after acute mi.23thus, elevated plasma glucose would both reflect the acute stress and predict an increased propensity for long-term cardiovascular events.10 several studies showed that an elevated admission blood glucose in myocardial infarction correlates with an increased incidence of congestive heart failure, cardiogenic shock, and inhospital mortality,7-11,19-22 which support our findings. the limitations of the study include smaller sample size as the study subjects were selected purposively, limited follow up of the patients due to time constraint, and unavailability of coronary angiogram to all the patients due to their financial problem. hence, it is difficult to generalize our findings to the reference population. conclusion to summarize, a higher admission plasma glucose level relates to a lower lvef i.e. higher chance of arrythmia and heart failure in non st-elevation mi patients. however, we propose that the result of this study needs further confirmation in a randomized large scale, multicentre prospective cohort study. conflict of interest:the authors declare no competing financial or personal interest. ethical approval issue:the study was approved by the ethical review committee ofmymensingh medical college, mymensingh, bangladesh. funding statement:no funding. authors’ contribution:conception and design of the study: mtik; patient selection, data collection and compilation: mtik, mhk, mh, smtm, fn; data analysis: mtik, mt; critical writing, revision and finalizing the manuscript: mtik, mhk, mt, mh, smtm, fn. references 1. anantharaman v, lim sh. treatment of nstemi (non-st elevation myocardial infarction). curr emerg hosp med rep. 2013;1:18-28. 2. silva fm, pesaro ae, franken m, wajngarten m. acute management of unstable angina and non-st segment elevation myocardial infarction. einstein (sao paulo). 2015;13(3):454-61. 3. hussain sm, oldenburg b, wang y, zoungas s, tonkin am. assessment of cardiovascular disease risk in south asian populations. int j vasc med. 2013;2013:786801. 4. chan d, ng ll. biomarkers in acute myocardial infarction. bmc med. 2010;8:34. 5. mueller c. biomarkers and acute coronary syndromes: an update. eur heart j. 2014;35(9):5526. 6. vafaie m. state-of-the-art diagnosis of myocardial infarction. diagnosis (berl). 2016;3(4):137-42. 7. karetnikova v, gruzdeva o, uchasova e, osokina a, 297 international journal of human and health sciences vol. 06 no. 03 july’22 barbarash o. glucose levels as a prognostic marker in patients with st-segment elevation myocardial infarction: a case-control study. bmc endocrdisord. 2016;16(1):31. 8. timmer jr, ottervanger jp, bilo hj, dambrink jh, miedema k, hoorntje jc, zijlstra f. prognostic value of admission glucose and glycosylated haemoglobin levels in acute coronary syndromes. qjmed. 2006;99(4):237-43. 9. oswald ga, corcoran s, yudkin js. prevalence and risks of hyperglycaemia and undiagnosed diabetes in patients with acute myocardial infarction. lancet. 1984;1(8389):1264-7. 10. capes se, hunt d, malmberg k, gerstein hc. stress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview. lancet. 2000;355(9206):773-8. 11. monteiro s, gonçalves f, monteiro p, freitas m, providência la. the magnitude of the variation in glycemia: a new parameter for risk assessment in acute coronary syndrome? rev espcardiol. 2009;62(10):1099-108. 12. hao y, lu q, li t, yang g, hu p, ma a. admission hyperglycemia and adverse outcomes in diabetic and non-diabetic patients with non-st-elevation myocardial infarction undergoing percutaneous coronary intervention. bmc cardiovasc disord. 2017;17(1):6. 13. thygesen k, alpert js, jaffe as, simoons ml, chaitman br, white hd, et al. third universal definition of myocardial infarction. eur heart j. 2012;33(20):2551-67. 14. wright rs, anderson jl, adams cd, bridges cr, casey de jr, ettinger sm, et al. 2011 accf/aha focused update of the guidelines for the management of patients with unstable angina/non-st-elevation myocardial infarction (updating the 2007 guideline): a report of the american college of cardiology foundation/american heart association task force on practice guidelines developed in collaboration with the american college of emergency physicians, society for cardiovascular angiography and interventions, and society of thoracic surgeons. j am coll cardiol. 2011;57(19):1920-59. 15. islam akmm, majumder aas. coronary artery disease in bangladesh: a review. indian heart j. 2013;65(4):424-35. 16. fatema k, zwar na, milton ah, ali l, rahman b. prevalence of risk factors for cardiovascular diseases in bangladesh: a systematic review and meta-analysis. plos one. 2016;11(8):e0160180. 17. akanda mak, ali sy, islam aemm, rahman mm, parveen a, kabir mk, et al. demographic profile, clinical presentation & angiographic findings in 637 patients with coronary heart disease. faridpur med coll j. 2011;6(2):82-5. 18. huda rm. mozaffor m, alam ma, hossain md. metabolic syndrome: its association with acute st-elevation myocardial infarction and its clinical outcome – a study done in the tertiary level hospital in bangladesh. int j hum health sci (ijhhs). 2020;4(3):215-21. 19. suleiman m, hammerman h, boulos m, kapeliovich mr, suleiman a, agmon y, et al. fasting glucose is an important independent risk factor for 30-day mortality in patients with acute myocardial infarction: a prospective study. circulation. 2005;111(6):754-60. 20. zhou z, sun b, huang s, zhu c, bian m. glycemic variability: adverse clinical outcomes and how to improve it? cardiovasc diabetol. 2020;19(1):102. 21. anand ss, dagenais gr, mohan v, diaz r, probstfield j, freeman r, et al. glucose levels are associated with cardiovascular disease and death in an international cohort of normal glycaemic and dysglycaemic men and women: the epidream cohort study. eur j prev cardiol. 2012;19(4):755-64. 22. wahab nn, cowden ea, pearce nj, gardner mj, merry h, cox jl, et al. is blood glucose an independent predictor of mortality in acute myocardial infarction in the thrombolytic era? j am coll cardiol. 2002;40(10):1748-54. 23. coutinho m, gerstein hc, wang y, yusuf s. the relationship between glucose and incident cardiovascular events. a metaregression analysis of published data from 20 studies of 95,783 individuals followed for 12.4 years. diabetes care. 1999;22(2):233-40. international journal of human and health sciences vol. 01 no. 01 january’17 18 review article artificial nutrition and hydration albar ma1, chamsi-pasha h2 abstract hydration and nutrition are essential for the maintenance of life. discontinuation of artificial support can result in distress for patients, family members, and healthcare providers. proponents of maintaining hydration argue that hydration is a basic human need and can reduce and prevent dehydration-induced delirium, opioid neurotoxicity, and/or fatigue in terminally ill patients. opponents have argued that parenteral hydration is burdensome and prolongs the dying process. islamic law does not allow the withholding or withdrawal of basic nutrition because this would result in death by starvation. terminal patients should continue receiving nutrition, hydration, and general supportive care without discrimination. key words: nutrition, hydration, end-of-life, ethics, islam correspondence to: albar mohammed ali, department of medical ethics, international medical center, saudi arabia; e-mail:malbar@imc.med.sa 1. albar mohammed ali, department of medical ethics, international medical center, saudi arabia. 2. chamsi-pasha hassan, department of cardiology, king fahd armed forces hospital, saudi arabia. international journal of human and health sciences vol. 01 no. 01 january’17. page : 18-21 introduction in patients at the end of life (survival days or weeks), artificial hydration and nutrition pose clinical, ethical, and logistical dilemmas in the western culture resulting in debates for and against such interventions.1 currently, there are differences in perceived benefits of artificial nutrition/hydration between healthcare providers and the general public.2 wide variations in practice patterns exist depending on the setting (inpatient versus hospice); culture. a qualitative study examining the attitudes of healthcare providers regarding artificial nutrition and hydration at the end of life, compared the different attitudes of physicians from australia with dutch doctors. the dutch physicians often take primary responsibility for providing artificial nutrition and hydration while the australian doctors are more likely to let the patient’s family make the decision.3 consequently, communication provided by healthcare providers about artificial nutrition/hydration is inconsistent which may cause confusion for patients and family members. patients and family members are often not involved in the decision-making; and when involved, their decisions are influenced by their physicians’ recommendations.4 although discussions about withholding or withdrawing of life-sustaining treatments often include decisions about stopping or never starting artificial nutrition and hydration (anh), feeding issues continue to be among the most emotional and value laden for patients and families. the decisions are often considered separately from decisions around the use of ‘machines’. the ethical decision-making process is difficult when considering the risks and benefits of feeding tubes in patients with advanced dementia.5 the majority of terminally ill patients will derive no clinical benefit from parenteral nutrition, with some exceptions that include patients with a good functional status and a nonfunctional gastrointestinal tract or a slow growing tumor.1 dehydration in turn can cause or aggravate preexisting symptoms such as fatigue, sedation, and delirium. withdrawal of nutrition and hydration, on the other hand, causes physiological responses which are, at the very least, unpleasant for those caring for the patient to witness.6,7 a 2016 study out of taiwan suggests caregivers often prefer life-sustaining treatments more so than patients; it is suspected that caregivers tend to feel guilt over ‘not having done enough’ for their parents.8 arguments for hydration state that hydration provides a basic human need,provides comfort and prevents uncomfortable symptoms: confusion, agitation, and neuromuscular irritability, prevents complications (e.g. neurotoxicity with high-dose 19 artificial nutrition and hydration narcotics),relieves thirst, and provides minimum standards of care; not doing so would break a bond with the patient. those arguing against hydration state that intravenous therapy is painful and intrusive , it interferes with acceptance of the terminal condition,prolongs suffering and the dying process, and lead to less fluid in the gastrointestinal tract with less vomiting, and less pulmonary secretions and less cough, choking, and congestion.1 there is scarcity of scientific evidence to support either approach, with only a few prospective or randomized controlled trials conducted in patients at the end of life. controlled clinical trials addressing the potential symptomatic and survival benefits of artificial hydration are difficult to conduct because of methodological and ethical reasons. consensus statements from both the american geriatric society and the american academy of hospice and palliative medicine (aahpm) do not recommend feeding tubes in advanced dementia, and instead recommend oral assisted feeding. however, both professional societies stressed the importance of respecting cultural beliefs and having high-quality patient-centered meetings. they recognize families will consider anh as basic sustenance for faith-based, cultural, and personal reasons, and these views should be explored, understood, and respected.9,10 the american society for parenteral and enteral nutrition’s (aspen) position paper emphasize that, although from scientific, ethical, and legal perspectives there should be no differentiation between withholding and withdrawing of anh, withdrawing is more emotionally laden than withholding, especially within specific cultures. it recommends learning relevant religious positions and cultural attitudes one will encounter in the regional population.5 the decision about withholding and withdrawing artificial nutrition and hydration include the clinical course of the disease, religious beliefs, cultural identity of the patient, family, and healthcare provider, the cost of treatment, legal, ethical and moral issues.11,12 case #1: mrs f 82 years old, is in a nursing home, where she exists in a near-vegetative state. she had previously worked as a nurse for many years, caring for patients with alzheimer’s disease. before being diagnosed with the disease herself, she had stipulated in a written advance directive that she be allowed to die if she was ever in a state of advanced dementia. in spiteof this, the facility’s nurses and care aides were instructed to continue to give her food and fluids, as doing otherwise would constitute neglect. when challenged by her daughter, the facility argued that mrsf opened her mouth when being fed, which they saw as a sign that she wanted food. they rejected the notion that this could be a reflex action. mrs. f’s daughter filed a lawsuit arguing that this continued feeding constituted battery.13 case # 2 an 89-year-old woman with vascular dementialives in a nursing home. she is able to walk, talk, andfeed herself, but needs assistance with dressing andtoileting. she is transferred to the hospital for a largeischemic stroke; mri confirms diffuse hypoxic braininjury. four days later, she withdraws to pain, hasunintelligible speech, does not respond to commands,but has corneal and gag reflexes. being unable to swallow, a nasogastric tube is placed fornourishment in her. her son, the healthcare proxy,is hopeful she will return to her previous state, wantsaggressive resuscitative efforts, and is adamant thata percutaneous endoscopic gastrostomy (peg) tubebe placed; otherwise, his mother will starve. herprimary team is concerned that a peg will notachieve the son’s goals for the patient.5 in both cases an ethical conflict between the patient’s proxy and the primary team exists. in the first case, the patient’s daughter is refusing feeding while in the second case the son is demanding the tube feeding. islamic view a recent position paper of the american society for parenteral and enteral nutrition advises respect for the religious, ethnic, and cultural background of patients and families ‘to the extent it is consistent with other ethical principles and duties’. however, little data is found in the english literature about religious and cultural attitudes regarding the ethics of withholding and withdrawing artificial nutrition and hydration, apart from jewish and catholic perspectives.14,15 the prophet muhammad (pbuh) discouraged forcing the sick to take food or drink. however, muslim families tend to express great concern when the nutritional intake of a patient is jeopardized. some muslim families may demand for a medical intervention to compensate for this decreased nutritional intake. reference to the teachings of the prophet (pbuh) on this albar ma, chamsi-pasha h 20 matter may alleviate the concerns of families and facilitate their understanding of the anorexia/ cachexia syndrome associated with malignancy, for example. however, in patients who are slowly deteriorating, one should maintain the required amount of nutrition and hydration until the last moment of life.16,17 in islam, nutritional support is considered a basic care and not a medical treatment, and it is a duty to feed people who are no longer capable of feeding themselves.15 islamic law therefore does not allow the withholding or withdrawal of basic nutrition because this would result in death by starvation, which is a crime according to islamic law and contrary to both the fundamental importance of the sanctity of life and the duty to provide nutrition to a fellow muslim. 16 if hydration and feeding is stopped, the patient will suffer from dehydration and hunger for 1014 days, and it would be more humane to inject him with a medicine that will let him die in seconds rather than torturing him for 2 weeks. however, this is considered euthanasia which is emphatically prohibited by islamic jurists.17 the islamic medical association of north america (imana) states that: “when death becomes inevitable, the patient should be allowed to die without unnecessary procedures. however, no attempt should be made to withhold nutrition and hydration.18 the saudi council for health specialties has advised that “intravenous fluids and nutrition should not be withheld from a patient who cannot otherwise be fed normally, regardless of the nature of his disease or its duration.”19in aprolonged terminal phase, active disease treatment may be determined to bemedically futile and patients are transferred to palliative care where theyreceive nutrition, hydration, and pain control, as well as social andpsychological support.20 conclusion discontinuation of artificial nutrition or hydration result in distress for patients, family members, and healthcare providers.research showed no clear benefits of parenteral hydration on symptom burden or survival for terminally ill patients. however, dehydration can cause or aggravate pre-existing symptoms such as fatigue, sedation, hunger and delirium. the islamic view on this subject is that nutrition and fluids should not be withheld from a patient who cannot be fed normally, regardless of the nature of the disease or its duration. 21 artificial nutrition and hydration references 1. dev r, dalal s, bruera e. is there a role for parenteral nutrition or hydration at the end of life? curr opin support palliat care 2012;6(3):365-70. 2. raijmakers nj, fradsham s, van zuylen l, mayland c, ellershaw je, van der heide a et al.variation in attitudes towards artificial hydration at the end of life: a systematic literature review. curr opin support palliat care 2011;5:265–272. 3. buiting hm, clayton jm, butow pn, van delden jj, van der heide a. artificial nutrition and hydration for patients with advanced dementia: perspectives from medical practitioners in the netherlands and australia. palliat med 2011;25:83–91. 4. morita t, tsunoda j, inoue s, chihara s. perceptions and decision-making on rehydration of terminally ill cancer patients and family members. am j hosppalliat care 1999;16:509–516. 5. somers e, grey c, satkoske v.withholding versus withdrawing treatment: artificial nutrition and hydration as a model. curropin support palliat care. 2016;10(3):208-213. 6. tuner-stokes l, wade d, playford d, et al. prolonged disorders of consciousness national clinical guidelines. london, 2014. https://www.rcplondon. ac.uk/resources/ prolonged-disorders-consciousnessnational-clinical-guidelines 7. fritz z. can ‘best interests’ derail the trolley? examining withdrawal of clinically assisted nutrition and hydration in patients in the permanent vegetative state. j med ethics 2017;43:450-454. 8. tang st, wen fh, liu ln, et al. a decade of changes in family caregivers’ preferences for life-sustaining treatments for terminally ill cancer patients at the end of life in the context of a family-oriented society. j pain symptom manage 2016;51:907–915. 9. american academy of hospice and palliative medicine. do not recommend percutaneous feeding tubes in patients with advanced dementia; instead, offer oral assisted feeding, 2013. 10. american geriatric society ethics committee and clinical practice and models of care committee. feeding tubes in advanced dementia position statement. j am geriatr soc 2014;62:1590–1593. 11. monturo c. the artificial nutrition debate: still an issue... after all these years. nutr clin pract 2009;24(2):206-213. 12. geppert cm, andrews mr, druyan me. ethical issues in artificial nutrition and hydration: a review. jpen j parenter enteral nutr 2010;34(1):79-88. 13. storch j. ethics in practice: at end of life-part 2. can nurse. 2015;111(7):20-22. 14. barrocas a, geppert c, durfee sm, maillet jo, monturo c, mueller c, stratton k, valentine c; a.s.p.e.n. board of directors; american society for parenteral and enteral nutrition. nutr clin pract 2010;25(6):672-679. 15. alsolamy s. islamic views on artificial nutrition and hydration in terminally ill patients. bioethics 2014;28(2):96-99. 16. albar ma, chamsi-pasha h, albar a. mawsouatakhlakhiatmehnataltib. jeddah (ksa): king abdul aziz university; 2013.http://saaid.net/ book/20/14541.pdf 17. al-bar ma, chamsi-pasha h. contemporary bioethics: islamic perspective. new york (ny): springer; 2015.http://link.springer.com/ book/10.1007/978-3-319-18428-9. 18. the islamic medical association of north america (imana):islamic medical ethics: the imana perspective. file:///c:/users/owner/ downloads/5528-19440-1-pb.pdf 19. al-freihj hm. saudi council for health specialties: ethics of the medical profession: 33–42. available at: http://english.scfhs.org.sa/ book/en-scfhs_2007_ p1.pdf. 20. wolenberg km, yoon jd, rasinski ka, curlin fa. religion and united states physicians’ opinions and self-predicted practices concerning artificial nutrition and hydration. j relig health 2013;52(4):1051-1065. international journal of human and health sciences vol. 07 no. 02 april’23 144 original article: relationship between nutritional knowledge, physical activity, carbohydrates intake and fat intake on nutritional status of overweight adolescents in banjarmasin amelia rn1, suminah2, and budiastuti vi3 abstract in indonesia, the prevalence of overweight in adolescents has increased during the past ten years. being overweight at a young age can lower the quality of life and cause early death at any age, affecting both men and women equally. this study analyzed the relationship between nutritional knowledge, physical activity, carbohydrate intake and fat intake in overweight adolescents in banjarmasin. it used an observational study with the crosssectional approach. purposive sampling was used to determine its samples, consisting of 64 respondents. the data on nutritional knowledge, physical activity, carbohydrate intake and fat intake were collected through structured questionnaires. data of intake was collected by 3x24 hours food recall method on weekend and class days. they were analyzed by using the pearson product moment statistical test. the results indicated that there is no relationship between nutritional knowledge (p=0,529) physical activity (p=0,218), carbohydrates intake (p=0,776) with nutritional status and there is relationship between fat intake with nutritional status (p=0.045) in overweight adolescents in banjarmasin. keywords: carbohydrate intake, fat intake, physical activity, nutritional knowledge, overweight correspondence to: reri noor amelia, the study program of nutrition science, master’s degree program, universitas sebelas maret, surakarta, e-mail: rerinooramelia@gmail.com 1. the study program of nutrition science, master’s degree program, universitas sebelas maret, surakarta, indonesia. 2. the study program of agricultural extension and communication, faculty of agriculture, universitas sebelas maret, surakarta, indonesia. 3. the study program of general medicine, faculty of medicine, universitas sebelas maret, surakarta, indonesia. introduction adolescence is a period of psychological and social transition from childhood to adulthood that will last and end in their teens or early twenties. adolescent nutritional problems that are a threat in indonesia today include iron deficiency anemia, stunting, chronic energy deficiency, overweight and obesity.1 the prevalence of overweight adolescents in indonesia in 2018 with an age range of 16-18 years was 9.5%, while in the province of south kalimantan it was 8.9%.1 banjarmasin city has a fairly high overweight prevalence, reaching 12.3%.2 the main cause of being overweight is a long-term energy imbalance between calories consumed and calories expended.3in addition, there are various factors that can cause overweight, including gender, age, socioeconomic conditions, environmental factors, psychological factors, genetic factors, eating habits and physical activity.4 changes in eating habits in adolescents are caused by low nutritional knowledge. adolescents who have good nutritional knowledge will prefer food according to their needs.5the diet that is run by teenagers today is a high-energy diet that mostly consists of carbohydrates and fats.6on the other international journal of human and health sciences vol. 07 no. 02 april’23 doi: http://dx.doi.org/10.31344/ijhhs.v7i2.565 mailto:rerinooramelia@gmail.com 145 international journal of human and health sciences vol. 07 no. 02 april’23 hand, the proportion of physical activity in most adolescents in banjarmasin is in the less category.2 to support metabolic processes, a teenager should receive food according to their needs, because food intake and physical activity affect a person’s nutritional status.7overweight at a young age if it continues to be obese can increase the risk of experiencing hypertension, hyperlipidemia, coronary heart disease and type 2 diabetes mellitus and can reduce the quality of life and is associated with premature death at all ages, both for men and women.6 adolescents are said to be overweight if the bmi z-score is from 1 to 1.99.8 the purpose of this study was to determine the relationship between nutritional knowledge, physical activity, carbohydrate intake and fat intake to the nutritional status of overweight adolescents in banjarmasin. methods this study used a cross-sectional design. the sample size is 64 students of sman 4 and sman 7 banjarmasin aged 15-17 years. sample selection was done through screening. the inclusion criteria in this study were adolescent girls and boys with bmi z-score is from 1 to 1.99 (overweight) and willing to fill out informed consent. this research has been approved by the research ethics committee of the faculty of medicine, universitas sebelas maret. this study begins with the measurement of the weight and height of the sample population based on gender and age. overweight nutritional status was determined by calculating the bmi z-score. data on nutrition knowledge, physical activity and food intake were obtained by filling out a nutritional knowledge questionnaire, a pal (physical activity level) questionnaire and a 24-hour food recall form. the data on the nutritional status of adolescents was processed using the who anthro plus software, the bmi z-score. data analysis was carried out using the nutrisurvey application to determine carbohydrate and fat intake compared to the rda. the statistical test to see the relationship between nutritional knowledge and physical activity on carbohydrate intake and fat intake for overweight adolescents is the pearson product moment correlation test. results characteristics of respondents including gender, knowledge of nutrition, physical activity, carbohydrate intake, and fat intake are presented in the following table. table 1. respondent’s characteristics characteristics amount (n) percentage % gender male female age 15 years 16 years 17 years nutritional knowledge moderate poor physical activity moderate light carbohydrates intake excessive sufficient insufficient fat intake excessive sufficient insufficient 29 35 12 31 21 25 39 4 60 3 19 42 27 26 11 45.3 54.7 18.8 48.4 32.8 30.1 60.9 6.3 93.8 4.7 29.7 65.6 42.2 40.6 17.2 respondents who are female as much as 54.7% while men as much as 35.3%. respondents aged 15-17 years, respondents aged 15 years by 18.8%, aged 16 years by 48.4% and aged 15 years 32.8%. most of the respondents’ knowledge of nutrition is included in the less category (60.9%). the majority of respondents have physical activity in the light category (93.8%). the level of carbohydrate intake in the insufficient category is high enough, namely 65.6% while the level of excessive fat intake is 42.2%, sufficient fat intake is 40.6% and insufficient is 17.2%. table 2. relationship between nutritional knowledge, physical activity, carbohydrates intake and fat intake on nutritional status variable min max mean ± sd p value bmi-for-age nutritional knowledge physical activity carbohydrates intake fat intake 1.00 13.00 0.56 91.00 29.00 2.00 77.00 1.57 423.00 213.00 1.58 ± 0.27 53.96 ± 12.74 1.00 ± 0.22 214.34 ± 66.18 78.73 ± 31.455 0.529* 0.218* 0.776* 0.045* *pearson product moment discussion in this study, statistically, there was no significant relationship between nutritional knowledge and nutritional status with a p-value of 0.529 (p>0.05). this is in line with mali’s research in 2022, which means that nutritional knowledge is not directly a factor related to nutritional status in overweight adolescents.9 the cause of the absence of a relationship between nutritional knowledge international journal of human and health sciences vol. 07 no. 02 april’23 146 and nutritional status is that nutritional knowledge has an indirect influence on nutritional status, but nutritional knowledge is the main problem of nutritional problems. meanwhile, the direct causes of nutritional problems are nutritional intake and infectious diseases.10 knowledge of nutrition is an indirect factor that affects nutrition. people who already know about the amount, frequency, content, type, method of administration and benefits of nutrients will try to obtain foods that contain appropriate nutrients as needed by their bodies.11another study states that a person’s nutritional knowledge can affect attitudes and behavior in choosing food and will later affect the nutritional state of the individual.12 several previous studies have shown that being overweight and obese are also associated with lifestyle factors such as a sedentary lifestyle, physical activity etc. even so, not all studies can prove it significantly.13 the results of this study indicate that there is no relationship between physical activity and nutritional status of overweight adolescents with a p-value of 0.218 (p>0.05). this is in line with school-based survey research from 146 countries, and regions including 1.6 million students aged 11-17 years which states that globally students at that age are not physically active enough for both male and female groups. regions with the highest prevalence of underactivity are asia pacific countries. the level of physical activity and the incidence of obesity can be said to be very weakly correlated.14 most of the respondents have a light physical activity level, it is recommended to increase physical activity such as walking or jogging. the more active a person is in doing physical activity, the more energy he or she expends, if the nutritional intake is more with light physical activity, the person is prone to overweight and even obese nutritional status.15physical activity if done regularly according to age and ability will reduce risk and prevent fat accumulation that will cause obesity or overweight in the body. this is because physical activity can increase fat-free tissue mass and decrease fat-tissue mass.15 carbohydrate intake in this study did not have a relationship with the nutritional status of overweight adolescents as indicated by the p-value of 0.076 (p>0.05). this is in line with the research of wulandari (2017) in surakarta, that there is no relationship between carbohydrate intake and the nutritional status of overweight adolescents. in another study, a very weak relationship strength was found between all carbohydrate intakes and the nutritional status of overweight adolescents. however, an interesting finding was the direction of the correlation between simple carbohydrate intake and body mass index, in contrast, the opposite direction between saturated fat intake and physical activity with body mass index. these results indicate that the higher the body mass index of adolescents, the higher the intake of simple carbohydrates and the lower the physical activity. on the other hand, the positive result is an indication that the higher the body mass index, the lower the saturated fat intake of adolescents.16 the results showed that there was a relationship between fat intake and nutritional status of overweight adolescents with a p-value of 0.045 (p <0.05). this explains that a good level of intake will affect good nutritional status and if the level of intake is excessive, it can result in overweight status.17 epidemiological studies show that high fat intake is a risk factor for excess body weight which will lead to fat accumulation in adipose tissue.18 this study is in line with the theory that states that excess fat intake will lead to being overweight. fatty foods that have a delicious taste can increase appetite which eventually consumes excessive food. fat is also the largest energy reserve in the body. regarding the contribution of slightly excess fat, special attention needs to be given to improving the diet in adolescents to prevent non-communicable diseases as early as possible.19adolescents who have an excessive intake of macronutrients (energy, protein, fat and carbohydrates), frequent fast food consumption and light physical activity are at greater risk of obesity.20 conclusion there is a relationship between fat intake and nutritional status and there is no relationship between nutritional knowledge, physical activity and carbohydrate intake on nutritional status in overweight adolescents in banjarmasin. further identification of other more influential factors and the use of more diverse research locations are needed for further research. it is necessary to know other factors such as genetic predisposition and more specific characteristics of food intake that may have a greater influence on the occurrence of overweight to support this study. 147 international journal of human and health sciences vol. 07 no. 02 april’23 conflict of interests: there is no conflict of interest regarding the publication of this paper. ethical clearance this study has been approved by the research ethics committee of the faculty of medicine, universitas sebelas maret number 108/ un27.06.11/kep/ec/2022. authors’ contribution reri noor amelia conceptualized and designed the study, prepared the draft of the manuscript and reviewed the manuscript.suminah conducted the study, data analysis and interpretation, assisted in drafting of the manuscript, reviewed the manuscript. veronika ika budiastutiassisted in drafting of the manuscript, reviewed the manuscript. references 1. ministry of health of the republic of indonesia. national report on basic health research 2018. agency for health research and development. jakarta; 2018. pp. 221–222. 2. lpb. report of south kalimantan province riskesdas 2018. publishing institute for health research and development agency lpb: 2019. 3. world health organization. obesity and overweight. 2018. [cited 1 october 2022] available from http:// www.who.int/en/news-room/fact-sheets/detail/ obesityand-overweight 4. febriani rt. analysis of factors that influence the nutritional status of adolescents in the city of malang. 2018;1–135. 5. permaesih. nutritional status of adolescents and factors affecting it. ministry of health research and development; 2003. 6. lung, t., jan, s., tan, e. j., killedar, a., & hayes, a. impact of overweight, obesity and severe obesity on the life expectancy of australian adults. international journal of obesity. 2018;43:4, 43(4), 782–9. https:// doi.org/10.1038/s41366-018-0210-2 7. suhartini, ahmad. analysis of factors related to the nutritional status of young women in class vii students of smpn 2 tambak baya village, cibadak district, lebak regency, 2017. j med (health info media). 2018;5(1):72–82 8. who. physical status : the use and interpretation of anthropometry. report of a who expert committee. who genewa. 1995. 9. mali am, setia a, boleng pm. relationship of nutritional knowledge and intake with nutritional status of students of sman 12 kupang city. kupang journal of food and nutrition research. 2022;30;3(2):1-1. 10. pantaleon mg. the relationship between nutritional knowledge and eating habits with the nutritional status of adolescent girls in sma negeri ii kupang city. chmk health journal. 2019;4;3(3):69-76. 11. notoatmodjo, soekidjo. education and health behavior. reneka. create. jakarta. 2003 12. fitriani, r. the relationship between knowledge of balanced nutrition, body image, adequacy level of energy and macro nutrients with nutritional status in students of sma negeri 86 jakarta. journal of health & science: gorontalo journal of health and science community. 2020;2(2),29–38. https://doi. org/10.35971/gojhes.v4i1.5041 13. ansokowati, astaripuruhita. percentage of macronutrient intake to total energy based on overweight and obesity status in adolescent sma negeri city of yogyakarta. avicenna: scientific journal, 2022, 17.1:30-40. 14. guthold, r. et al. global trends in insufficient physical activity among adolescents: a pooled analysis of 298 population-based surveys with 1·6 million participants, the lancet child and adolescent health. 2020;4(1), pp. 23–35. doi: 10.1016/s23524642(19)30323-2 15. harahap, n. l., lestari, w., manggabarani, s. relationship of diversity of food, snack food and physical activity with nutritional status of adolescents in labuhan batu district. nutrdiaita. 2020; 12(2), 45-51. 16. anggraeny, olivia, dwiaridhanti, and fajar ari nugroho. there is no correlation between intake of simple carbohydrates, saturated fat, and levels of physical activity with nutritional status in overweight and obese adolescents. action: aceh nutrition journal. 2018;3.1: 1-8. 17. noviyanti, r. d., &marfuah, d. the relationship of knowledge of nutrition, physical activity, and diet to the nutritional status of adolescents in purwosarilaweyan, surakarta. urecol. 2017;421426. 18. kamulasari, d.a. relationship between fat intake, diet, physical activity and obesity in adolescents at sma angkasa lanud husein sastranegara bandung. scientific papers. health polytechnic ministry of health bandung. bandung; 2016. 19. ansokowati, astaripuruhita. percentage of macronutrient intake to total energy based on overweight and obesity status in adolescent sma negeri city of yogyakarta. avicenna: scientific journal. 2022;17.1:30-40. 20. telisa i, hartati y, haripamilu ad. risk factors for obesity in high school adolescents. faculty of health journal. 2020;2;7(03):124-31. http://www.who.int/en/news-room/fact-sheets/detail/obesityand-overweight http://www.who.int/en/news-room/fact-sheets/detail/obesityand-overweight http://www.who.int/en/news-room/fact-sheets/detail/obesityand-overweight https://doi.org/10.1038/s41366-018-0210-2 https://doi.org/10.1038/s41366-018-0210-2 https://doi.org/10.35971/gojhes.v4i1.5041 https://doi.org/10.35971/gojhes.v4i1.5041 supplementary issue:02 37 molecular characterization, antifungal susceptibility to fluconazole and analysis of risk factors in patients with candida auris blood stream infection from tertiary care hospital in north india dr. chitra bhartiya1, dr. rungmei s k marak1, dr. r s singh2, dr. pratima rawat1, dr. chinmoy sahu1, dr. ajai kumar dixit1 and ms. shikha tripathi1 1. departments of microbiology sanjay gandhi postgraduate institute of medical sciences, lucknow, up 2. emergency medicine, sanjay gandhi postgraduate institute of medical sciences, lucknow, up correspondence: dr. rungmei s k marak professor, department of microbiology sanjay gandhi post graduate institute of medical sciences, lucknow, u.p. – 226014 email id: rungmei@gmail.com abstract aim and objectives: to analyse the risk factors, molecular characterization and detection of drug resistance to fluconazole in candida auris candidemia. material and methods: bactec blood culture positive for candida on gram stain from january 2017-december 2020 were inoculated on sda plate and incubated for at 37ºc for the isolation of yeast colonies. the isolates were subjected to phenotypic identification, pcr and maldi-tof ms and antifungal susceptibility testing to fluconazole by etest method. demographic details of the patients were recorded and significant associated risk factors were analysed. results: a total of 59689 blood cultures were received during the study period from admitted patients. there was 623 episodes of candidemia during the study and 111 episodes was due to c. auris. incidence of candidemia due to c. auris was 17%. the associated risk factors were diabetes mellitus (p <0.024), underlying respiratory illness (p <0.013), mechanical ventilation (p <0.009), dialysis (p <0.034), prolonged icu stay (p <0.009), hypertension (p <0.035) and others included use of broad-spectrum antibiotics (94.5%) and steroids (23.4%). only 9% (n=10) isolates were sensitive to fluconazole; 85.6% (n=95) were resistant and 5.4% (n=6) were sensitive dosedependent. study showed mortality in 36%. supplementary issue:02 38 conclusions: emergence of candida auris infection has caused a significant threat in patients admitted to the icus and is known to cause outbreaks in healthcare facilities. strict precautions like barrier nursing, hand hygiene and proper infection control practices must be followed as well as use of appropriate antifungal therapy to prevent and control the spread of c. auris. keywords: fungemia, etest, drug resistance, pcr introduction candidemia is the most frequent infection among invasive fungal infections. the prevalence of candidaemia has risen over time as a result of improvements in medical and surgical procedures, the use of broad-spectrum antibiotics, a growing pool of people who are at the extremes of age and a susceptible population with transplant recipients and haematological malignancies1-3. globally, the epidemiology of invasive candida infection has changed in the last ten years, with a clear shift in the species that cause candidemia from candida albicans to a predominance of non-albicans candida (nac)4,5. in industrialised countries, candida glabrata, candida tropicalis, and candida parapsilosis are prevalent. candida tropicalis, candida parapsilosis, and the recently reported development of candida auris are all considered to be multidrug resistant (mdr) species6,7. candida auris is becoming an important cause of nosocomial blood stream infections (bsis) in asia, africa, america and europe. (7-13) a multidrug-resistant, healthcare-associated fungal pathogen, c. auris was initially discovered in the external ear canal of a person in japan in 2009 and has since been identified from every continent except antarctica14-17. c. auris has been linked to outbreaks in a variety of hospital settings18,19 and has been identified as the pathogen responsible for several invasive fungal infections, including bloodstream infections20-22. intensive care unit (icu) admission, use of central venous and urinary catheters, immunocompromising diseases, chronic renal disease, and exposure to broad-spectrum antifungal and antibiotic drugs are risk factors for c. auris infection that are comparable to other candida infections23-25. fluconazole resistance is common in c. auris isolates, while the susceptibility to other antifungal medications varies24,26. in this study, the aim was to successfully identify all the isolates by phenotypic method later confirmed by maldi-tof ms and colony pcr. herein, we analyse the risk factors and the supplementary issue:02 39 outcome associated with candida auris candidaemia and the antifungal susceptibility testing was performed by concentration gradient strip method (e-test). material and methods the study analyzed 623 yeast isolates from cases of fungemia cultured during the period of 04 years from 2017 and 2020. out of 623 isolates, 111 cases were of candida auris candidemia. all samples were seeded on sabouraud dextrose agar. the plates were incubated at 37°c for 24 to 48 hrs and the conventional phenotypic identification was done. identification of yeast yeast isolated from blood was first initially identified by phenotypic method then confirmed by maldi tof ms and molecular method i.e., pcr. on phenotypic method, the isolates were mainly gram-positive budding yeasts without pseudohyphae and on germ tube test isolates were only budding yeasts and no pseudohyphae. the isolates were subcultured on chromogenic agar in which white coloured colonies were observed on hi-chrome agar and mauve coloured colonies were on tetrazolium reduction medium (trm). chlamydospore production test and carbohydrate assimilation test was also performed 27. maldi-tof ms and colony pcr: all preserved candida auris isolates were subcultured sabouraud’s dextrose agar (sda) and checked for purity. these isolates were subjected to maldi-tof ms and colony pcr for confirmation of the candida species. matrix assisted laser desorption ionization time of flight mass spectrometry (malditof ms) sample preparation: identification of candida species by maldi-tof ms: the pure subcultured candida blood isolates were uniformly spotted on the maldi target plate, after drying 1.0 ul of formic acid was added and on complete drying 1ul of chca matrix solution (α-cyno-4 hydroxy cinnamic acid) was added to the spot on the maldi plate. escherichia coli (atcc 8937) was spotted as a positive control and processed by maldi tof ms. the data was collected and interpreted and the candida isolates were identified after matching with the reference profiles in the maldi data base. supplementary issue:02 40 protocol for identification of candida auris by colony polymerase chain reaction (pcr) assay: the pcr was performed after extraction of the dna using manual phenol-chloroform isoamyl alcohol method and amplification was carried out using primers its 1 (5’tcc-gta ggt gaa cct gcg g -3’) and its 4 (5’tcc tcc gct tat tga tat gc -3’)28. the electrophoresis of the pcr result was done in 1.5% agarose gel in tris-acetate-edta (tae) buffer at 50 volts for 45 minutes. ethidium bromide (0.1 ul/ml) was used to stain the gel, which was visualized under an ultraviolet light. the size of pcr products was immediately assessed by directly comparison with 100 bp molecular size marker (invitrogen). antifungal susceptibility testing for azoles (fluconazole) by concentration gradient strip method (e-test) on rpmi 1640 medium the minimal inhibitory concentration (mic) of fluconazole was performed by concentration gradient strip method (e-test, biomerieux) on rpmi 1640 medium. on sabouraud agar, each isolate was cultured for 24 hours at 37°c. using an inoculation culture and a cell suspension calibrated to a 0.5 mcfarland standard, the e-test strip was placed on the inoculated plates and incubated for 24 hours at 37°c. the drug concentration at which the inhibition ellipse intercepted the scale on the antifungal strip read after 24 hours was the mic of that particular antifungal agent. the clsi recommended quality control stains candida parapsilosis (atcc 22019) and candida krusei (atcc 6258) were also put up along with the blood isolates. the isolates are categorized as susceptible (s), susceptible-dose dependent (sdd) or resistant (r). results fungal isolates and identification a total of 59689 blood cultures were received during the study period from 2017 to 2020. there were 623 episodes of candidemia during the study period; of which111 episodes of candidemia was due to c. auris. yeasts other than candida auris like candida albicans, candida glabrata, candida parapsilosis, candida tropicalis etc, cryptococcus spp., trichosporon spp., etc was excluded from the study. case patient description supplementary issue:02 41 an overall higher prevalence was observed in male patients (59.45%; n= 66) than in females (40.55%; 45). mostly the patients were residents from urban population (96.3%; n=107) and few were from rural areas (3.7%; n=4). higher prevalence of c auris candidemia was seen in patients between the age group of 61-70 years (23.4%; n=26) followed by the age group of 51-60 years (18%; n=20), 41-50 years (12.6%; n=14), 21-30 years (10.8%; n=12) and 15.3% of the patients were from the paediatric age group (9%; < 10 yrs.; n=10) and 6. 3% in the age group of 11-20 yrs. (n=7). we studied the cases of c. auris candidemia from different departments and found that majority of the cases were admitted to emergency department (33.3 %; n=37), followed by critical care medicine (ccm) (19.81%; n=22), nephrology (9.0%; n=10), gastroenterology (7.2%; n=8). 5.4% (n=6) was seen in pulmonary medicine and neonatology. fewer cases (n=3; n=2, n=1) was seen from other departments also table 1. distribution of candida auris in various departments sl. no. department patients (n=111) 1. emergency department 37 2. critical care medicine (ccm) 22 3. nephrology 10 4. gastroenterology 8 5. pulmonary medicine 6 6. neonatology 6 7. neurosurgery 5 8. hematology 3 9. cardiology 3 10. endocrinology 2 11. apex trauma center 2 12. anaesthesia 1 supplementary issue:02 42 13. endocrine surgery 1 14. neurology 1 15. paediatric gastroenterology 1 16. surgical gastroenterology 1 17. transplant unit 1 18. urology 1 risk factors associated with candidemia during the study period, it was observed that the majority of the patients with c. auris candidemia had many underlying risk factors use of broad-spectrum antibiotics, mechanical ventilation, respiratory illness, diabetes mellitus, patient on dialysis, etc. majority group of patients had received broad-spectrum antibiotics (94.5%; 105) before the onset of candidemia, some patients had respiratory illness (75.6%; 84), patients were on mechanical ventilation (73%; 81), some had comorbidities like diabetes mellitus (32.4%; 36), some suffered from chronic kidney disease (34.3%; 38) table 2. associated risk factors in patients with candid auris candidemia sr. no. associated risk factors patients (n=111) 1. use of broad-spectrum antibiotics 105 (94.5%) 2. respiratory illness 84 (75.60 3. mechanical ventilation 81 (73%) 4. hypertension 50 (45.1%) 5. chronic kidney disease 38 (34.3%) 6. diabetes mellitus 36 (32.4%) 7. dialysis 30 (27%) 8. use of steroids 26 (23.4%) supplementary issue:02 43 9. neurological disorder 20 (18%) 10. pancreatitis 14 (12.6) 11. malignancy (solid organ/hematology) 13 (11.7%) 12. chronic liver disease 11 (9.9%) 13. renal transplant recipients 3 (2.8%) a univariate analysis of risk factors using logistic regression showed that diabetes mellitus (p <0.024), respiratory illness (p <0.013), icu stay (p <0.009), mechanical ventilation (p <0.009), dialysis (p <0.034) and hypertension (p < 0.035) had significant correlation in those with mortality. out of the 111 patients with candida auris candidemia; 81.9% (n=91) were admitted in the icu and 18.1% (n= 20) were admitted to different wards of the hospital. acquisition of candidemia during the study, it was observed that the acquisition of candidemia (c. auris) occurred early after admission; as early as 3rd day. it was seen that infection occurred as early as 1st and 2nd week in 28 cases; however maximum cases (44.7%) were blood culture positive by the 3rd week and 4th week. blood culture positivity with c. auris was seen in 15.3% (n=17) prior to 48 hrs. of admission indicating that these were non-hai and these patients may have acquired the infection from other healthcare facilities. however, 84% (n=94) of the patients acquired the infection after 48 hrs of admission to the hospital and out of this 44.7% (n=42) acquired the infection on the 3rd and 4th week of admission suggesting poor infection control practices. molecular identification of clinical isolates of candida spp. by pcr universal primers it s1 (5’tcc-gta ggt gaa cct gcg g -3’) and its4 (5’tcc tcc gct tat tga tat gc -3’) were able to successfully amplify the its1-5.8s rrna region of c. auris. all 111 candida auris isolates were successfully amplified by the standardized pcr supplementary issue:02 44 protocol and the pcr products were of approximately 400 bp; which was seen as a clear band parallel to the dna ladder of the desired size. fig. 1: pcr products from blood isolates of candida species on agarose gel electrophoresis. lanes 1, 2, 3,4 and 5 are the pcr products of c. auris. lane 6 negative control. lanes 7: 100 bp dna ladder. antifungal susceptibility testing antifungal drug susceptibility testing was carried out on all 111 isolates by the concentration gradient strip method (e-test) on rpmi 1640 medium. out of 111 isolates tested, 9.0% (n=10) were sensitive to fluconazole with mic range from 0.25 to 3 µg/ml, 5.4% (n=6) of the isolates were sensitive dose -dependent (sdd) with mic range from 16 to 32 µg/ml and 85.6 % (n=95) isolates were resistant to fluconazole with mic of > 64-256 µg/ml. most of isolates of candida auris were found to be resistant to fluconazole during the study period. patient outcome we studied the outcome of the patients and found that out of 111 patients with candidemia; 63.9 % (n=71) were resolved and were discharged and attended opd for follow up. mortality was supplementary issue:02 45 seen in 36% (n=40) of the patients; maximum mortality was seen in the 61-70 yrs. age group (30% (n=7) followed by 81-90 yrs. age group (17.5% (n-7); 15% (n=6) in 41-50 yrs. and 12.5% was in seen 31-40 yrs. no mortality was seen below 10 years of age. discussions: the study highlights the identification and differentiating c. auris from other candida species through conventional phenotypic methods as well as their rapid identification by malditof ms and colony pcr from archived isolates. a total of 111 c. auris isolates were correctly identified by maldi-tof ms with an accuracy of 100%. the demographic profile of patients showed higher prevalence of candidemia among males (59.45%; n= 66) than in females (40.55%; n=45). in a study previously conducted in oman by mohsin et al (29) from 2016-2019 also showed a male (60%) preponderance. in hu et al (30) in 2021 showed that out of 827 patients studied, 508 (61.4%) were male and 319 (38.6%) were female. these studies showed similar results as our study. during the study, the age group ranged from 3 months to 83 years of age. the highest prevalence (23.4%) was seen in the age ranging from 6170 years irrespective of gender. the median age in the present study was 52 years (iqr 30-65.5 year). a study by shastri et al (31), showed the median age of the patients with c. auris candidemia was 56.5 year (iqr 43.3-70.5 year). majority of the cases with c auris candidemia was seen in patients admitted to emergency department (33.3 %; n=37), followed by critical care medicine (ccm) (19.81%; n=22), nephrology (9.0%; n=10), gastroenterology (7.2%; n=8). 5.4% (n=6) was seen in pulmonary medicine and neonatology. fewer cases (n=3; n=2, n=1) was seen from other departments also. in another study done by rudramurthy sm et al (32) in 2017, he studied candidemia (n=1400) in 27 icu setting and showed that 5.3% c auris candidemia was seen in 19/27 icus and there was also male predominance (62.2%). major associated risk factors seen in our patients was the use of broad-spectrum antibiotics (94.5%), icu stay (81.9%), respiratory illness (75.6%), patients on mechanical ventilation (73%), chronic kidney disease (34.3), diabetes mellitus (32.4%), patient on dialysis (27%), steroid use (23.4%) and neurological disorder (18%). 12.6 % patients were suffering from pancreatitis, 11.7% supplementary issue:02 46 patients were of malignancy and eleven percent (11%) of our patient was having chronic liver disease. al-rashdi et al (33) studied 108 patients, he also found similar associated risk factors i. e., the use of broad-spectrum antibiotics (84.25%), mechanical ventilation (78.70%) and icu stay (78.7%). rudramurthy sm et al (32) conducted a subgroup analysis and comparison of the clinical manifestations of c. auris and non-auris cases in 27 indian icus where he found that the major risk factor was pulmonary illness (40.5%) followed by renal disease (21.6%) and liver disease (6.8%). a study by hu et al (30) in 2021 showed that use of broad-spectrum antibiotics was seen in 55.9% followed by patients on mechanical ventilation in 26.4%, diabetes mellitus (19.9%), renal disease in 18.4% and use of steroid in 10.5%. the variation of these associated risk factors between studies depends on the patient profile and nature of treatment practise and therapeutic interventions observed in that institutions. knowledge of these risk factors is helpful in adopting centre specific strategies for selective administration of antifungal drugs. it was observed that the acquisition of c. auris candidemia occurred early after admission; as early as 3rd day. maximum (44.7%) blood culture positivity was seen by the 3rd week and 4th week followed by 29.78% in the 1st and 2nd week. blood culture positivity with c. auris was seen in 15.3% (n=17) prior to 48 hrs. of admission indicating that these were non-hai and these patients may have acquired the infection from other healthcare facilities. 84% of the patients acquired the infection after 48 hrs of admission and 44.7% acquired by the 3rd and 4th week. most of the cases were from emergency department followed by critical care medicine. therefore, hand hygiene as well as infection control practices should be strictly implemented and reinforced in these departments to prevent the acquisition of healthcare associated infections. the antifungal susceptibility testing was performed in all 111 candida auris isolates and found that only 9% were sensitive to fluconazole (mic range 0.25 to 3 µg/ml). this suggests that antifungal susceptibility must be performed in all suspected c. auris blood stream isolates and fluconazole should not be used as empirical drug of choice for the treatment of invasive c auris infection. as evidenced in certain reports c. auris, is usually resistant to fluconazole and shastri et al (31) found 97% of his c. auris isolates were resistant and, in our study, too we also found that 86.6% of our c. auris isolates were resistant to fluconazole. a multicentric study is done by chakrabarti a et al (6) in icu setting in which they found 58.1% resistant to fluconazole in their isolates. a study conducted by lockhart et al (34) in 3 continents found 93% of their isolates were fluconazole resistant. these studies were in concordance with our study. supplementary issue:02 47 in this study the overall mortality rate for c. auris candidemia was 36% (n=40). maximum mortality was seen in the 61-70 yrs. age group (30% (n=7) followed by 81-90 yrs. age group (17.5% (n-7); 15% (n=6) in 41-50 yrs. and 12.5% mortality was in seen 31-40 yrs. no mortality was seen below the age10 years. the mortality in males (55%; n=22) was slightly higher than females (45%; n=18)). the 30-day crude mortality was 60%. in a multicentric study, done by chakrabarti et al (6) in icu setting, the crude mortality was 44.7%. the result of the current study indicates that patient with c. auris candidemia had a greater chance for mortality if the patient suffered from diabetes mellitus (or=2.6, p=0.024), had respiratory illness (or=3.8, p= 0.013), undergoing dialysis (or=2.99, p< 0.034), on mechanical ventilation (or= 4.0, p< 0.009) and if patients were admitted in the icu (or=15.3, p< 0.009). conclusion due to the widespread use of antifungals in contemporary medicine, resistant to fungal infections brought on by candida species, have been on the rise. candida auris candidemia continues to be a threat in hospitalized patients. the incidence of candidemia due to candida auris was 17.8% during our study. all the isolates were identified accurately by maldi-tof ms and all isolates were successfully amplified by using conventional colony pcr protocol. c. auris is continuously reported from different departments in our institute especially from emergency, critical care medicine and intensive care units. underlying risk factors seen in c. auris candidemia were mainly the use of broad-spectrum antibiotics, mechanical ventilation, respiratory illness, diabetes mellitus, and patient on dialysis. the comorbidities found in the patients were diabetes mellitus, chronic kidney disease, pancreatitis, chronic liver disease, malignancy either solid organ or hematological. in our study, only few isolates were sensitive to fluconazole; most of the isolates (85.6 %; n=95) showed resistance to fluconazole with mic of ≥ 64. 36% mortality was seen during the study. the rapid candida species identification, antifungal susceptibility testing along with the medical staff's attentiveness, awareness and infection control procedures will aid in an early diagnosis, appropriate antifungal therapy and control of the spread of candida auris. empirical therapy must be avoided much as possible in order to reduce the selection of resistant candida strains. supplementary issue:02 48 references 1. mccarty tp, pappas pg. invasive candidiasis. infect dis clin north am. 2016 mar;30(1):103-24. 2. pappas pg. invasive candidiasis. infect dis clin north am. 2006 sep;20(3):485-506 3. barchiesi f, orsetti e, gesuita r, skrami e, manso e; candidemia study group. epidemiology, clinical characteristics, and outcome of candidemia in a tertiary referral center in italy from 2010 to 2014. infection. 2016 apr; 44 (2): 205-13 4. pfaller ma, diekema dj. epidemiology of invasive candidiasis: a persistent public health problem. clin microbiol rev. 2007 jan;20 (1):133-63. 5. kullberg bj, arendrup mc. invasive candidiasis. n engl j med. 2015 oct 8;373 (15):1445-56 6. chakrabarti a et al. incidence, characteristics and outcome of icu-acquired candidemia in india. intensive care med 2015; 41:285-95. 7. chowdhary a, sharma c, meis jf. candida auris: a rapidly emerging cause of hospital-acquired multidrug-resistant fungal infections globally. plos pathog 2017;13: e1006290 8. khan z, ahmad s, al-sweih n, joseph l, alfouzan w, asadzadeh m. increasing prevalence, molecular characterization and antifungal drug susceptibility of serial candida auris isolates in kuwait. plos one. 2018 apr 9;13(4): e0195743 9. girard v, mailler s, chetry m, vidal c, durand g, van belkum a, colombo al, hagen f, meis jf, chowdhary a. identification and typing of the emerging pathogen candida auris by matrix-assisted laser desorption ionisation time of flight mass spectrometry. mycoses. 2016 aug;59 (8): 535-538 10. walia k, chowdhary a, ohri vc, chakrabarti a. multidrug-resistant candida auris: need for alert among microbiologists. indian j med microbiol. 2017 jul-sep; 35 (3):436. 11. mohsin j et al. the first cases of candida auris candidaemia in oman. mycoses. 2017 sep;60 (9):569-575. supplementary issue:02 49 12. schelenz s et al. first hospital outbreak of the globally emerging candida auris in a european hospital. antimicrob resist infect control. 2016 oct 19;5: 35. 13. ruiz-gaitan a, moret am, tasias-pitarch m, et al. an outbreak due to candida auris with prolonged colonization and candidemia in a tertiary care european hospital. mycoses. 2018. jul; 61(7): 498-505. 14. chakrabarti a. fungal infections in asia: eastern frontier of mycology. india: 1st edtn, elsevier; 2013. 15. chakrabarti a, mohan b, shrivastava sk, marak rs, ghosh a, ray p. change in distribution & antifungal susceptibility of candida species isolated from candidaemia cases in a tertiary care centre during 1996-2000. indian j med res. 2002 jul; 116:5-12. 16. johanna rhodes, matthew c fisher. global epidemiology of emerging candida auris. cur opinion microbiol 2019; 52:84-89. 17. satoh k et al. candida auris sp. nov., a novel ascomycetous yeast isolated from the external ear canal of an inpatient in a japanese hospital. microbiol immunol 2009; 53(1): 41-44. 18. lee wg et al. first three reported cases of nosocomial fungemia caused by candida auris. j clin microbiol 2011;49 (9):3139-42. 19. magobo re, corcoran c, seetharam s, govender np. candida auris–associated candidemia, south africa. emerg infect dis 2014; 20:1250-1. 20. schelenz s, et al. first hospital outbreak of the globally emerging candida auris in a european hospital. antimicrob resist infect control 2016; 5:35. 21. adams e et al.; candida auris investigation workgroup. candida auris in healthcare facilities, new york, usa, 2013–2017. emerg infect dis 2018; 24:1816-24. 22. sarma s, upadhyay s. current perspective on emergence, diagnosis and drug resistance in candida auris. infect drug resist 2017; 10:155-65. 23. lone sa, ahmad a. candida auris-the growing menace to global health. mycoses 2019; 62:620-37. 24. osei sekyere j. candida auris: a systematic review and meta-analysis of current updates on an emerging multidrug-resistant pathogen. microbiology open. 2018 aug;7(4): e00578. supplementary issue:02 50 25. kerins jl et al. rapid emergence of candida auris in the chicago region. open forum infect dis. 2018 nov 26;5(suppl 1): s28. 26. lockhart sr, etienne ka, vallabhaneni s, farooqi j, chowdhary a, govender np, et al. simultaneous emergence of multidrug-resistant candida auris on 3 continents confirmed by whole-genome sequencing and epidemiological analyses. clin infect dis 2017; 64:13440. 27. marinho sa, teixeira ab, santos os, cazanova rf, ferreira ca, cherubini k, de oliveira sd. identification of candida spp. by phenotypic tests and pcr. braz j microbiol. 2010 apr;41(2):286-94. 28. vijayakumar r, giri s, kindo aj. molecular species identification of candida from blood samples of intensive care unit patients by polymerase chain reaction restricted fragment length polymorphism. j lab physicians. 2012 jan;4(1):1-4 29. mohsin j, hagen f, al-balushi zam, de hoog gs, chowdhary a, meis jf, al-hatmi ams. the first cases of candida auris candidaemia in oman. mycoses 2017; 60:569-575. 30. hu s, zhu f, jiang w, wang y, quan y, zhang g, gu f and yang y (2021) retrospective analysis of the clinical characteristics of candida auris infection worldwide from 2009 to 2020. front. microbiol. 12:658329 31. shastri p. s., shankarnarayan, s. a., oberoi, j., rudramurthy, s. m., wattal, c., & chakrabarti, a. (2020). candida auris candidaemia in an intensive care unit – prospective observational study to evaluate epidemiology, risk factors, and outcome. j crit care. 2020 jun;57: 42-48 32. rudramurthy sm et al. candida auris candidaemia in indian icus: analysis of risk factors. j antimicrob chemother 2017; 72:1794-801. 33. al-rashdi, a.; al-maani, a.; al-wahaibi, a.; alqayoudhi, a.; al-jardani, a.; al-abri, s. characteristics, risk factors, and survival analysis of candida auris cases: results of one-year national surveillance data from oman. j. fungi 2021, 7, 31. 34. lockhart sr, etienne ka, vallabhaneni s, farooqi j, chowdhary a, govender np, et al. simultaneous emergence of multidrug-resistant candida auris on 3 continents confirmed supplementary issue:02 51 by whole-genome sequencing and epidemiological analyses. clin infect dis 2017; 64:13440. supplementary issue:02 182 a case series of three cases of japanese encephalitis in aligarh region: has the disease taken its tour from east to west up hiba sami1, sadia hassaan1 syed ghazanfar ali1, adil raza1, islam ahmad1, zeeshan mustafa1, mohd kashif ali2, zeeba zaka-ur-rab2, nazish fatima1, haris m khan1 1viral research and diagnostic laboratory, department of microbiology, 2 department of paediatrics, jawaharlal nehru medical college, aligarh correspondence: dr. syed ghazanfar ali, microbiologist, vrdl lab, jnmch, amu syedmicro72@gmail.com abstract objective: japanese encephalitis (je) virus is a flavivirus that is widespread in asia and is spread via culex mosquitoes. it is a member of the flaviviridae family and is one of the most common viral causes of acute encephalitis syndrome (aes) among known etiological viral encephalitis agents, and it has been linked to significant morbidity, death, and disability. we present three cases of acute encephalitis syndrome brought on by the japanese encephalitis virus from an area of india that is typically underreported. material and methods: three infants presenting with symptoms of aes were included in the study. diagnosis of japanese encephalitis was made using commercial igm elisa kit for je. hsv i & ii was also tested by commercial elisa kits (calbiotech). results: all the three cases presented with abnormal movements and seizures and they all belonged to paediatric age group. they did not have any recent travel history to endemic areas. they were started with empirical and supportive treatment. all the three cases had a unfortunate outcome with mortality on 7th and 9th day of admission. conclusion: given the diverse clinical symptoms of the japanese encephalitis virus, significant effort should be made to pinpoint the specific causal agent that initiates aes. despite having little effect on management, vector control and vaccination can stop the spread of the disease to healthy contacts and the general public. keywords: je, acute encephalitis syndrome, flavivirus. supplementary issue:02 183 introduction japanese encephalitis (je) is an arbovirus and belong to a family flaviviridae (1). it is most common cause of epidemic encephalitis in india (2). the vector for this virus is culex tritaeniorhynchus and culex vishnui and there are various animal host as well. pigs act as amplifier host, cattle act as mosquito attractants, birds and pigs are reservoir and horse are the only animal which shows the symptoms (3). je virus was so named because, it was first seen in japan in 1871 as summer encephalitis epidemics. man is the dead-end host as there is no man-to-man transmission. it mainly affects children in the age group of less than 15 years and is mostly asymptomatic. it usually resolves within weeks if symptomatic and support for ventilator is not generally needed. hospitalization is primarily due to neurological symptoms. in india, je is endemic in 15 states and gorakhpur district of uttar pradesh accounts for largest burden of the disease in the past (4). between 2010 to 2019, a total of 14,933 cases and 2,230 deaths have been reported (4). the incubation period of the disease is between 5-15 days. no trials on japanese encephalitis have led to advancements in treatment as of yet though numerous trials on its treatment research are going on (5). we report three je cases that occurred in 2022 among paediatric patients presenting with abnormal movements and seizures. case report 1 a 9-year-old boy presented with fever for 2 days accompanied by altered sensorium and uncoordinated movement in form of tonic-clonic seizure of all four limbs for which he was brought to the hospital. he did not have any recent travel history. on admission he was febrile with a temperature of 98.9 0c, pulse 100/min, bp 116/74 mmhg and respiratory rate of 20/min. the patient was started on empirical antibiotics and routine blood culture was sent to the bacteriology lab which came out to be negative. the patient did not show any signs of improvement on empirical therapy after 4 days of admission. on 4th day of admission, the patient had 2 episodes of tonicclonic seizure. his gcs was e1v3m6 (10/15) with bilateral pupil reacting to light. the patient also showed features of raised intra-cranial tension and bilateral papilledema. cect head was done which was normal. eeg showed evidence of focal epileptiform discharge. his blood sample was sent for hsv and je elisa. hsv i & ii by elisa were negative. serum sample for igm antibody to je virus was positive. the patient expired on day 9 of admission. supplementary issue:02 184 case report 2 a 7-year-old girl presented with complaints of pain abdomen and fever for 8 days. after 6 days she also developed abnormal movement and altered sensorium for which she was brought to the emergency department of our hospital. there was no recent travel history. patient showed abnormal movements which were tonic-clonic involving all the 4 limbs associated with frothing from mouth, up rolling of eyeballs. on admission she was febrile with a temperature of 1010c, pulse 167/min, bp 98/58, rr 30/min. her gcs was e4v1m4 (9/15), pupil mid dilated, sluggishly reactive to light. the patient was shifted to picu and empirical antibiotics were started. routine blood culture was sent to the bacteriology laboratory which came out to be negative. blood samples were also sent for hsv and je-elisa. hsv i & ii by elisa on serum sample were negative. serum sample for igm antibody to je virus came out to be positive. the patient did not show any sign of improvement on empirical therapy after 3 days of admission. on 4th day her gcs dropped to e1v1m4 and bilateral pupils were sluggishly reactive to light. patient developed altered breathing pattern and had to be intubated. the patient showed signs of increased intracranial tension. cect head was done which showed the following findings: 1. diffuse effacement of cortical sulci of bilateral cerebral hemisphere, bilateral lateral ventricle and third ventricle shows diffuse cerebral edema. 2. acute to subacute infarct involving left occipital lobe. 3. mild leptomeningeal enhancement with mild fuzziness noted along bilateral mca. the patient expired after 9 days of admission. figure 1: ctct of case 2 revealed diffuse effacement of cortical sulci of b/l cerebral hemisphere, b/l lateral ventricle and third ventricle shows diffuse cerebral edema. mild leptomeningeal enhancement with mild fuzziness noted along b/l mca supplementary issue:02 185 case report 3 a 9 months old boy presented to the emergency department with fever, irritability and altered sensorium for last 5 days associated with new onset tonic clonic seizure from last 2 days. there is no recent travel history. on admission he was febrile. the temperature was 102.90f, pr:170/min, bp 105/58 mmhg. patient was started on empirical antibiotics and routine blood culture was sent to bacteriology lab, which turned out to be negative. the patient did not show any signs of improvement after two days of empirical therapy. on second day of admission, patient has one episode of tonic clonic seizure with respiratory distress. his gcs was e1v3m5 (09/15) and bilateral pupils were reactive to light. therefore, patient was intubated and shifted to icu. serum samples for herpes simplex virus i & ii, dengue igm antibody and japanese encephalitis igm antibody were sent to vrdl laboratory for analysis and igm antibody to je virus came out to be positive. the patient was treated conservatively with iv fluid, anti-convulsant and supportive care. on day 7 of admission, the patient expired. discussion je is a viral zoonotic disease caused by flavivirus, which is an enveloped virus containing ssrna. culex mosquito act as vector. five genotype of the virus have been identified which mainly affect the cns (6). the transmission cycle is: ardied bird/pigs → culex → ardied bird/pigs → culex and man is the dead-end host. there is no man → mosquito cycle (7). about 85% of cases occur in child below 15 years and above 10% cases are seen in elderly population. infection is more common in rainy season. this may be due to greater breeding of the vectors. living near paddy fields is also a risk factor for disease transmission (8). in this study we report three cases of japanese encephalitis. all our three cases belong to the pediatric age group and they presented in between august to november which is rainy and post rainy season. je although a big public health burden in eastern uttar pradesh has not made any in roads into our western up area until 2020 when two cases were reported from the same area (9). majority of cases are asymptomatic in je and these 3 cases may represent only the tip of the iceberg. the criteria for lab evidence of je are supplementary issue:02 186 positive igm antibody in a single sample of serum or csf according to who (7). all 3 of our cases had positive igm antibody in serum for je. in one of the patients cect head shows lesions involving cortical sulci, lateral ventricle and occipital lobe. all the three cases presented with fever and seizure which is a common manifestation of the disease (10). as there is no specific antiviral medicine available against je virus so prevention is best option for the patients (2). preventive measures include vaccination against je virus and strict vector control measures. vaccine for je started in 2006 in india for age group of 1 – 15 years. three types of vaccines are available: cell culture derived inactivated vaccine; mouse brain derived vaccine; cell culture live attenuated vaccine (11). the most common strain of je virus vaccine is formalin inactivated je strain sa1414-2 adsorbed to an aluminum hydroxide (0.1%) adjuvant. two doses of je vaccine are recommended on day 0 and day 28, with dose: 6 mcg (in 0.5ml), intramuscular route at deltoid region. adverse complications of je infection include permanent neurological damage due to the neuro-tropical nature of the virus. mortality rate is high in case of je infection, according to global estimates, the mortality burden of je was 20 thousand deaths in 2011 and 25 thousand in 2015 (12–14). we also report a high mortality rate as all three patients expired in spite of the best efforts from physicians. conclusion given the diverse clinical symptoms of the japanese encephalitis virus, significant effort should be made to pinpoint the specific causal agent that initiates aes. despite having little effect on management, vector control and vaccination can stop the spread of the disease to healthy contacts and the general public. acknowledgement we acknowledge the support of dhr, icmr in funding our vrdl. we acknowledge the support of our staff mrs shibli javed, mr sanaullah, mr samran and mr rizwan. references 1. lindenbach bd, rice cm. molecular biology of flaviviruses. adv virus res. 2003;59:23– 61. 2. kulkarni r, sapkal gn, kaushal h, mourya dt. japanese encephalitis: a brief review on indian perspectives. open virol j. 2018 aug 31;12:121–30. supplementary issue:02 187 3. walsh mg, pattanaik a, vyas n, saxena d, webb c, sawleshwarkar s, et al. high-risk landscapes of japanese encephalitis virus outbreaks in india converge on wetlands, rain-fed agriculture, wild ardeidae, and domestic pigs and chickens. int j epidemiol. 2022 oct 1;51(5):1408–18. 4. singh ak, kharya p, agarwal v, singh s, singh np, jain pk, et al. japanese encephalitis in uttar pradesh, india: a situational analysis. j fam med prim care. 2020 jul;9(7):3716. 5. ajibowo ao, ortiz jf, alli a, halan t, kolawole oa. management of japanese encephalitis: a current update. cureus. 13(4):e14579. 6. mackenzie js, williams dt, van den hurk af, smith dw, currie bj. japanese encephalitis virus: the emergence of genotype iv in australia and its potential endemicity. viruses. 2022 nov;14(11):2480. 7. japanese encephalitis [internet]. [cited 2022 dec 27]. available from: https://www.who.int/news-room/fact-sheets/detail/japanese-encephalitis 8. solomon t, dung nm, kneen r, gainsborough m, vaughn dw, khanh vt. japanese encephalitis. j neurol neurosurg psychiatry. 2000 apr 1;68(4):405–15. 9. sami h, khan s, hassan f, mustafa z, ahmad i, afzal k., et al. case reports of japanese encephalitis: an underdiagnosed entity in an endemic region of uttar pradesh, india. int j adv res. 2021 jan 31;9(01):533–6. 10. turtle l, solomon t. japanese encephalitis — the prospects for new treatments. nat rev neurol. 2018 may;14(5):298–313. 11. satchidanandam v. japanese encephalitis vaccines. curr treat options infect dis. 2020;12(4):375–86. 12. cheng y, tran minh n, tran minh q, khandelwal s, clapham he. estimates of japanese encephalitis mortality and morbidity: a systematic review and modeling analysis. plos negl trop dis. 2022 may 25;16(5):e0010361. 13. campbell gl, hills sl, fischer m, jacobson ja, hoke ch, hombach jm, et al. estimated global incidence of japanese encephalitis: a systematic review. bull world health organ. 2011 oct 1;89(10):766–74, 774a-774e. 14. quan tm, thao ttn, duy nm, nhat tm, clapham h. estimates of the global burden of japanese encephalitis and the impact of vaccination from 2000-2015. elife. 2020 may 26;9:e51027. 133 international journal of human and health sciences vol. 07 no. 02 april’23 original article: validity and reliability of knowledge and behavioral questionnaire about weight loss diet in teenage girls diva amalia1, tri rejeki andayani2, and sapja anantanyu3 abstract background: the choice of diet method by teenage girl can be influenced by the knowledge. methods: this study aimsto determining the validity and reliability of the knowledge and diet behavior questionnaire. the subject of this research is 30 female students. data analysis of the validity using analysis of difficulty levels, differentiating power, distractor analysis, discrimination test and lawshe’s content validity ratio (cvr) analysis. the reliability test using cronbach’s alpha coefficient test. results: the results showed that 24 items of knowledge questions were declaired valid and 15 items in the diet behavior questionnaire were declared valid.the reliability test of the questionnaire for knowledge and diet behavior was declared reliable with result 0,877 and 0,858. conclusions: the validity and reliability test of the instrument have proven that the instrument of diet knowledge and behavior has good validity and reliability values. keywords: knowledge, behavior, diet, validity, reliability correspondence to: diva amalia, department of human nutrition, postgraduate school, sebelas maret university, surakarta, indonesia, e-mail: divaamalia@student.uns.ac.id 1. department of human nutrition, postgraduate school, sebelas maret university 2. departement of social psychology, faculty of medicine, sebelas maret university 3. departement of community extension and empowerment. faculty of agriculture, sebelas maret university introduction the capability of teenagers in behaving related to the physical changes that occur in the teenage’s phase is that teenagers are able to accept physical states and make effective use of their body conditions.howeverin this phase of development, it often causes its own problems so that teenagers are actually unable to accept the physical state due to the physical changes that occur. weight problem is one of the main problems faced by teenagers, especially teenage girls. paying attention to changes in body shape to look ideal is a form of teenagers response caused by changes in body shape due to weight problem1. the efforts made by teenagers to control weight are by doing a diet2. diet behavior is an individual activity in the regulation of dietary habit, drinking, and physical activity based on stimuli from the surrounding environment to lose weight. healthy dietbehaviors are carried out appropriately, while unhealthy diet behaviors are carried out excessively3. unhealthy diet behaviors in teenagers such as eating very few portions, skipping meals or taking diet pills are the starting point for eating disorders that cause concern for teenagers health4. nutritional status is one way to determine the health status of teenagers5. riskesdas data (2018) shows the prevalence of nutritional status of teenage girls aged 16-18 years in indonesia, including very thin (0.5%), thin (3.8%), normal (79.8%), obese (11.4%), and obese (4.5%). the selection of diet methods carried out by teenage girls can be influenced by the teenage girl’s knowledge of the diet6. knowledge is an important component in the formation of one’s attitudes and behaviors7. international journal of human and health sciences vol. 07 no. 02 april’23 doi: http://dx.doi.org/10.31344/ijhhs.v7i2.563 mailto:divaamalia@student.uns.ac.id international journal of human and health sciences vol. 07 no. 02 april’23 134 nutritional knowledge is the result of a person knowing and understanding about things related to nutrition8. the level of knowledge and behavior of a person can be known by taking measurements using standardized measuring instruments to ensure the accuracy of the data and the consistency of the measurements collected. standardized measuring instrumentsmust meet therequirements of validity and reliability9. a questionnaire is a set of structured lists of questions or statements that are used as a measuring tool to obtain information from respondents regarding perceptions, aspirations, behaviors, attitudes, circumstances, personal opinions, or other things according to the research or survey conducted10. a good questionnaire instrument will produce valid and reliable research data.so it is necessary to test the validity and reliability of the questionnaire first before the questionnaire is given to respondents. invalid and reliable instruments will produce invalid and unreliable data when used to collect data11. based on this description, this study aims to assess the validity and reliability of the questionnaire of knowledge and diet behavior in teenage girls. materials and methods this study is a descriptive examiner by examining the validity and reliability of the weight loss diet knowledge and behavior questionnaire in teenage girls that condected at sma negeri 1 candimulyo. this research is quantitative, because the interpretation of research results is based on the results of statistical processing usingsoftware on a computer.the samples needed in this study were teenage girls aged 16-18 years who had been or were on a weight loss diet. the number of samples in this study was 30 teenage girls based on the minimum requirements for parametic statistical tests. sample selection is carried out bypurposive sampling method. data analysis analysis of difficulty levels difficulty level analysis is an analysis carried out to find out whether the question is included in the category of easy or difficult questions. the level of difficulty is a number that indicates the difficulty or ease of a question12. here is the equation used to calculate the difficulty level of an item: description: p = difficulty level index nb= the number of students who answered the item correctly n = the number of students who answer items the criteria for the difficulty level index according to arikunto (1999) are as follows13: table 1. difficulty level criteria p-value criteria 0,00 – 0,29 0,30 – 0,69 0,70 – 1,00 difficult medium easy differentiating power analysis the differentiating power of the question is the ability of the question item in distinguishing students who have high abilities from students who have low abilities13. here is the equation used to calculate the differentiating power of the problem item: description : dp= differentiating power index ba= the number of upper group test takers who answered the correct questions bb= the number of lower group test takers who answered the correct questions ja= the number of upper group test takers ja= the number of lower group test takers the limits of the distinguishing power index criteria are as follows: table 2. differentiating power index criteria dp value criterion 0,00 – 0,19 0,20 – 0,39 0,40 – 0,69 0,70 – 1,00 negative ugly enough good very well not good, it must be thrown away distractor analysis an instrument used to measure learning achievement with multiplechoice question 135 international journal of human and health sciences vol. 07 no. 02 april’23 itemswith several alternative answers. the question item can be said to be good if the deceiver can function properly, which is at least chosen by 5% of respondents13. validity test validation is a test to show how well the data collected from the research instrument14. reliability is testing on research instruments that are carried out to find out how well the instrument provides stable and consistent results. the validity test of the diet behavior questionnaire was carried out usinglawshe’s content validity ratio (cvr) analysis. cvr analysis is a test performed to measure the validity of the contents. the cvr value is considered to be the higher the validity of its contents if the > 015. discrimination item test the power of item discrimination is a test carried out to measure the ability of items to distinguish between individuals or groups of individuals who have attributes and do not have attributes that are measured. items that reach a correlation coefficient of ≥ 0.30 are included in the criteria for high discrimination power, while items with a correlation coefficient of < 0.3 are included in the criteria of low discrimination power16. the item discrimination power test was performed using the pearson product moment correlation coefficient which was analyzed using spss version 25 software. reliability test reliability tests are important because they refer to the consistency of all instruments14. the reliability test used in this study was the cronbach’s alpha coefficient. the reliability test results are considered good if they have acronbach’s alphavalue ≥ 0.6 or ralpha>rcritical. the instrument is reliable when the value of cronbach’s alphawhich is < 0.5 means low, 0.5-0.7 means medium, 0.70.9 means high, and > 0.9 means very good17. results and discussion the research was conducted by preparing a list of questions and questionnaire statements to be used. the questionnaire used in this study consisted of 25 questions regarding knowledge about the nutritional needs of teenagerswith multiple choice answer and 15 statements regarding teenagers dietbehavior in losing weight body with the answer using skala likert.furthermore, testing was carried out on 30 girl students at smanegeri 1 candimulyomagelang. the validity of knowledge questionnaire using analysis of difficulty levels, differentiating power, and distractor analysis. the behavioral questionnaire validity test uses an item discrimination test and lawshe’s content validity ratio (cvr) analysis. while reliability testing using cronbach’s alpha coefficient test. the following are the results and discussions on eachquestionnaire test conducted: table 3. difficulty level of question items on the knowledge questionnaire item difficulty index kategory 1. 0.43 medium 2. 0.70 easy 3. 0.53 medium 4. 0.37 medium 5. 0.60 medium 6. 0.23 difficult 7. 0.40 medium 8. 0.60 medium 9. 0.47 medium 10. 0.87 easy 11. 0.93 easy 12. 0.73 easy 13. 0.67 medium 14. 0.33 medium 15. 0.50 medium 16. 0,30 medium 17. 0.40 medium 18. 0.77 easy 19. 0.40 medium 20. 0.53 medium 21. 0.43 medium 22. 0.90 easy 23. 0.47 medium 24. 0.47 medium 25. 0.37 medium source: microsoft excel calculation result (2022) table 3 shows the results of the calculation of the difficulty level in each question, it can be seen that as many as 1 question item (4%) belongs to the category of easy questions, 18 question items (72%) belong to the medium question category, international journal of human and health sciences vol. 07 no. 02 april’23 136 and 6 question items (24%) belong to the difficult question category. table 4. knowledge questionnaire differentiating power index item differentiating power index criteria 1 0,73 very well 2 0,60 good 3 0,67 good 4 0,20 enough 5 0,67 good 6 0,33 enough 7 0,47 good 8 0,13 bad 9 0,27 enough 10 0,13 bad 11 0,13 bad 12 0,27 enough 13 0,53 good 14 0,40 good 15 0,60 good 16 -0,07 not good 17 0,67 good 18 0,47 good 19 0,27 enough 20 0,53 good 21 0,27 enough 22 0,20 enough 23 0,27 enough 24 0,53 good 25 0,33 enough source: microsoft excel calculation result (2022) table 4 shows an analysis of the differentiating power of items on knowledge questionnaires as many as 1 item (3.3%) including criteria to be eliminated, 3 items (10%) including bad criteria, 9 items (30%) including the criteria are enough, 11 items (36.7%) include good criteria, and 1 item (3.3%) includes criteria for very well. table 5. distractor analysis on knowledge questionnaire no. criterion amount 1. 2. good not good enough 68 32 total 100 source: microsoft excel calculation result (2022) table 5 shows the calculation of the distractor analysis on the knowledgequestionnairewhich is carried out based onnumber of answer choices which are then multiplied by the number of question items, but the key answer is notincluded in the calculation so that the total number ofdistractor is100 distractors.a total of 68 distractor are included in the good criteria, while 32distractor are included in the bad criteria. table 6. lawshe’s content validity ratio (cvr) analysis on dietary behavior questionnaire items cvr value matrix value 1 1,00 0 2 0,45 0 3 0,45 0 4 0,45 0 5 0,82 0 6 0,64 0 7 0,82 0 8 1,00 0 9 0,82 0 10 0,27 0 11 0,82 0 12 0,82 0 13 1,00 0 14 0,82 0 15 0,64 0 source: microsoft excel calculation result (2022) table 6 shows the results of the validity test of the contents of the diet behavior questionnaire usinglawshe’s content validity ratio(cvr) analysis showing that 15 itemson the dietbehavior questionnaire were declared valid because they had a cvr value of > 0. after testing the validity of the contents, a trial 137 international journal of human and health sciences vol. 07 no. 02 april’23 was continued on 30 respondents to determine the power of item discriminationand reliability in the diet behavior questionnaire. the results ofthe itemdiscrimination power test with the pearson product momenttest resulted in a coefficient ranging from 0.279 to 0.776 (table 7). table 7. discrimination power test items on the diet behaviour questionnaire items value of the correlation coefficient criteria 1 0,527 high 2 0,639 high 3 0,776 high 4 0,379 high 5 0,440 high 6 0,726 high 7 0,279 low 8 0,333 high 9 0,453 high 10 0,300 high 11 0,518 high 12 0,623 high 13 0,366 high 14 0,741 high 15 0,347 high source: spss 25 results (2022) table 7 shows the results of the item discrimination test on the diet behavior questionnaire of 15question items, as many as 14 items (93.3%) were declared to have a high degree of discrimination because of the coefficient correlation value greater than 0.30 and 1 item (6.7) questions were stated to have low discrimination power because of the coefficient correlation value less than 0.30. table 8. questionnairereliability test results no. variable cronbach’s alpha n of items 1. knowledge 0.877 24 2. dietary behavior 0.858 15 source: spss 25 results (2022) table 8 shows that thereliability test on the questionnaire of knowledge and dietbehaviorwas declared reliable withanralpha (cronbach’s alpha count) >rcritical (cronbach’s alpha standard). the ralpha value of the knowledge questionnaire with 24 question itemswas 0,877. and the ralpha value of the dietary behavior questionnaire was 0,858. so that the two questionnaires can be said to be reliable or reliable as research instruments. conclusion the validity test of the teenager nutritional needs knowledge questionnairethere were 24 items of questions declared valid. on the validity test of the dietbehavior questionnaire, all items of statements with a total of 15 statements were declared valid.meanwhile in the reliability test,the two questionnaires were declared reliable or consistent with the value ofcronbach’s alphaknowledge questionnaire, which was 0.877 and the value of cronbach’s alphaquestionnaire on dietbehavior was 0.858. the results of the trial of the validity and reliability of the instrument have proven that the research instrument on knowledge and diet behavior has a validity and reliability value that meets the criteria for used as a measuring tool for the level of knowledge ofteenagersnutritional needs and diet behavior in teenage girls. conflict of interest there is no conflict of interest regarding the publication of this paper. ethical clearance this article has been derived from a research projectapproved by sebelas maret university of medical sciences,with protocol number 01/02/09/2022/114 authors’ contribution diva amalia conceptualized and designed the study, prepared the draft of the manuscript and reviewed the manuscript. tri rejekiandayani conducted the study, data analysis and interpretation, assisted in drafting of the manuscript, reviewed the manuscript. sapjaanantanyuasisted in drafting of the manuscript and reviewed the manuscript. international journal of human and health sciences vol. 07 no. 02 april’23 138 references 1. safitri, a. o., novrianto, r., &marettih, a. k. e. body dissatisfaction dan perilaku dietpada remaja perempuan. psibernetika. 2020; 12(2), 100–105. https://doi.org/10.30813/psibernetika.v12i2.1673 2. lintang, a., ismanto, y., &onibala, f. diet pada remaja putri di sma negeri 9 manado. keperawatan. 2015; 3(2), 1–8. 3. meiliana,m.,valentina,v., retnaningsih,c., putri, d. a., indryawati, r., prima, e., sari, p., rahayu, m. s. et al. body dissatisfaction and diet behavior of female adolescents. empati. 2019; 1(1), 88-97. http://ejournal.uinsuka.ac.id/isoshum/pi/article/ view/260/241 4. leal, g. v. d. s., philippi, s. t., & alvarenga, m. dos s.unhealthy weight control behaviors, disordered eating, and body image dissatisfaction in adolescents from são paulo, brazil. brazilian journal of psychiatry. 2020; 42(3), 264–270. https://doi. org/10.1590/1516-4446-2019-0437 5. yunita, f. a., eka, a., yuneta, n., &sutisna, e.the correlation between adolescence’s dietary pattern with nutritional status. 2020; 8(2), 27–32. 6. jeki, a. g., & septinora, r. pengetahuan dan persepsi remaja putri tentang perilaku diet sehat di sma negeri 1 kota jambi. universitas adiwangsa jambi. 2016 7. nusa, a. f. a., & adi, a. c. hubunganfaktorperilaku, frekuensikonsumsi fast food, diet dan genetikdengantingkatkelebihanberat badan. media gizi indonesia. 2013; 9(1), 20–27. 8. bening, s., &margawati, a. perbedaanpengetahuan gizi, body image, asupanenergi dan status gizi pada mahasiswi gizi dan non gizi universitas diponegoro. 2014. 9. dewi, s. k., &sudaryanto, a. validitas dan reliabilitaskuesionerpengetahuan, sikap dan perilakupencegahan demam berdarah. seminar nasional keperawatan universitas muhammadiyah surakarta (semnaskep) 2020, 73–79. 10. nugroho, e.prinsip-prinsip menyusun kuesioner. malang; ub press. 2018. 11. herlina, v.panduan praktismengolah data kuesionermenggunakan spss. jakarta; pt elex media komputindo. 2019 12. ismail, i. assesmen dan evaluasipembelajaran. cendekia publisher. 2020 13. arikunto, s. dasar-dasarevaluasi pendidikan. bumi aksara. 1999 14. sukmawati, n. m. h., & putra, i. g. s. w.reliabilitaskusioner pittsburgh sleep quality index (psqi) versi bahasa indonesia dalam mengukur. jurnallngkungan dan pembangunan. 2019; 3(2), 30–38. 15. hendryadi, h. validasi isi: tahap awal pengembangankuesioner. jurnal riset manajemen dan bisnis (jrmb) fakultas ekonomi uniat. 2017: 2(2), 169–178. https://doi.org/10.36226/jrmb.v2i2.47 16. azwar, s. penyusunan skala psikologiedisi 2. pustaka belajar. 2015 17. taherdoost, h. validity and reliability of the research instrument; how to test the validation of a questionnaire/survey in a research. ssrn electronic journal. 2018;september.https://doi.org/10.2139/ ssrn.3205040 https://doi.org/10.30813/psibernetika.v12i2.1673 http://ejournal.uinsuka.ac.id/isoshum/pi/article/view/260/241 http://ejournal.uinsuka.ac.id/isoshum/pi/article/view/260/241 https://doi.org/10.1590/1516-4446-2019-0437 https://doi.org/10.1590/1516-4446-2019-0437 https://doi.org/10.36226/jrmb.v2i2.47 https://doi.org/10.2139/ssrn.3205040 https://doi.org/10.2139/ssrn.3205040 167 international journal of human and health sciences vol. 02 no. 03 july’18 case report: outer table frontal bone fracture: when need surgical intervention? adam mohamad1, irfan mohamad1, khairulzaman adnan2, syed yusoff alzawawi syed abdul fattah2 abstract frontal bone fracture is a common facial bone fracture which commonly involved the outer table part. most of the time outer table fracture is treated conservatively. however, when there is involvement of orbital wall fracture, as well as entrapment of extraocular muscle, surgical intervention via open reduction and internal fixation is needed. we described a case of outer table frontal bone fracture with left orbital roof fracture complicated with superior rectus muscle entrapment which was successfully treated via open reduction and internal fixation. keywords: frontal bone, fracture, open reduction internal fixation, orbital roof correspondence to: adam mohamad, department of otorhinolaryngology-head & neck surgery, school of medical sciences, universiti sains malaysia health campus, 16150 kota bharu and department of otorhinolaryngology, hospital tengkuampuanafzan, 25100 kuantan, pahang,malaysia. email: persona522115@gmail.com 1. department of otorhinolaryngology-head & neck surgery, school of medical sciences, universiti sains malaysia health campus, 16150 kota bharu, kelantan, malaysia 2. department of oral maxillofacial surgery, hospital sultan haji ahmad shah,jalanmaran, 28000 temerloh, pahang. introduction frontal sinus fracture consists of 5-15% of all facial trauma1. it is a common encounter in emergency setting2. out of all craniocerebral trauma, comminuted fracture involving both inner and outer table of frontal sinus occurrence is 0.72.1% of the cases1. in general, any postponement in the treatment of frontal sinus fracture can leads to various sequelae such as acute and chronic sinusitis, mucocele, mucopyelocele, osteomyelitis, meningitis as well as brain abscess3. orbital rim is the least common injury associated with frontal bone fracture4. it is thought that the frontal bone is the strongest of the craniofacial skeleton, thus disruption in this region indicates that the force of injury is likely due to high velocity5. should management of fracture delayed or inadequate, it will result in serious complication such as enophthalmos, restriction in ocular motility, cosmetic and functional problem that will complicate the future treatment later6. case report a 30-year-old malay gentleman was referred by ophthalmology department at day 22 after a motor vehicle accident (mva). he presented with swelling at left upper eyelid and eyebrow with restriction movement of upward gaze direction. he was a motorbike rider where he collided with a car. he claimed to wear helmet at the time of injury. post trauma, he sustained loss of consciousness and regained consciousness few hours later. he also presented with retrograde amnesia, swelling over the left eye and laceration wound over the left parietal bone region. he had no history of shortness of breath, vomiting, chest and neck pain neither even post trauma abdominal pain. he was initially diagnosed as left orbital roof fracture with laceration wound over the left eyebrow and lateral part of canthus which not involving the lid margin. during his follow up at ophthalmology clinic, patient complaining of worsening blurred vision on the left, associated with persistent swelling of the left eyebrow. vision test revealed reduction of left visual acuity which is 6/12, while the right visual acuity was normal 6/6. on examination, patient was alert and conscious. his vital signs were stable. healed wound visible clinically at the left parietal region (figure 1). apart from that, there was mechanical ptosis on the left upper eyelid and restriction eye movement international journal of human and health sciences vol. 02 no. 03 july’18 page : 167-169 doi: http://dx.doi.org/10.31344/ijhhs.v2i3.49 international journal of human and health sciences vol. 02 no. 03 july’18 168 upon upward gaze. otherwise, no abnormality detected at the right eye. intraoral examination revealed poor oral hygiene. computed tomography (ct) scan of orbit revealed comminuted fractures involving anterior wall of left frontal sinus extending to the roof and lateral wall of left orbital wall (figure 2 & 3). the fractures also showing entrapment of the superior rectus muscle and impingement of the left eye globe (figure 4). apart from that, air pocket was seen at the right sclera of left orbit. he underwent reduction and reconstruction of left orbital roof via existing healed wound under general anaesthesia (figure 5). upon follow up two weeks later, his condition improved with no more restriction of eye movement. figure 1: mechanical ptosis on the left upper eyelid and restriction of eye movement upon upward gaze (day 22 post injury). figure 2: comminuted fractures involving anterior wall of left frontal sinus extending to the roof and lateral wall of left orbital wall (arrow). figure 3: 3-d reconstruction image of the fractured site (arrow). figure 4: sagittal view showing the fractures causing entrapment of the superior rectus muscle and impingement of the left eye globe (arrow). figure 5: bony segments immobilized and fixed with plates, screws and mesh (arrow). 169 international journal of human and health sciences vol. 02 no. 03 july’18 discussion: there has been a controversy associated with the diagnosis and repair of frontal sinus fractures7. rohrich and hollier in 1992 had created graduated anatomic algorithm for the treatment of frontal sinus fracture based on the fracture displacement, frontal recess involvement as well as presence cerebrospinal fluid (csf)8. they recommended non-displaced fracture should be left untreated, non-complicated anterior table displacement together with aesthetic deformity should be treated by fragment reduction and stabilization, sinus obliteration when fractures involved damage to the frontal recess and lastly cranialization should be used to treat comminuted, displaced outer and inner table fractures, especially the one with persistent csf leak and associated frontal recess involvement8. in our case, the patient successfully underwent fragment reduction and stabilization, as well as sinus obliteration as the fracture involves the frontal recess. historically, the evolution of treatment involved the orbital wall has undergone significant change in the past century, varies from closed reduction, external fixation and kirshner wires were all used until open reduction with internal wire fixation introduced in 1940s and soon became widely applied by the year 1950s8. later, rigid fixation to craniofacial fracture management was adopted into treatment of orbital injuries. it is recommended that, frontal bone injuries involving the orbit are best approached using coronal incision for limited injury or the laceration if present. apart from that, the decision to use bicoronal approach is decided not only by the severity/ degree of frontal region injury, but also by degree of injury to naso orbitoethmoid and zygomatic complex regions6. in this case, the incision was made at the pre-existing healed laceration wound. in cases of more complex injuries involving inner table frontal sinus exploration is required, however there has been different opinion regarding either cranialization or obliteration6. cranialization of the sinus is recommended for extensive injuries such as dural tears, brain parenchymal injuries and csf leakage6. involvement of orbital roof fracture on the other hand, is associated with higher rate of ocular injury including globe rupture and optic nerve injury4. in our patient, he had some degree of restriction of eye movement on upward gaze preoperatively due to impingement of the fractures causing entrapment of the superior rectus muscle, which successfully released intraoperatively. forced duction test after the operation done shown no more restriction of the movement. conclusion: management of frontal sinus fracture depends on the severity of injury and involvement of frontal recess. surgical intervention rather than conservative management is the best treatment option when there is associated orbital wall fracture especially when present of extraocular muscle entrapment, as early treatment might prevent early and late sequelaes such as ophthalmoplegia, acute and chronic sinusitis, mucocele, mucopyelocele, osteomyelitis, meningitis as well as brain abscess. reference: 1. kalavrezos n. current trends in the management of frontal sinus fractures. injury. 2004;35(4):340-6. 2. ioannides c, freihofer hp, friens j. fractures of the frontal sinus: a rationale of treatment. british journal of plastic surgery. 1993;46(3):208-14. 3. gonty aa, marciani rd, adornato dc. management of frontal sinus fractures: a review of 33 cases. journal of oral and maxillofacial surgery. 1999;57(4):372-9. 4. antonyshyn o, gruss j, galbraith d, hurwitz j. complex orbital fractures: a critical analysis of immediate bone graft reconstruction. annals of plastic surgery. 1989;22(3):220-35. 5. wallis a, donald pj. frontal sinus fractures: a review of 72 cases. the laryngoscope. 1988;98(6):593-8. 6. manolidis s, weeks b, kirby m, scarlett m, hollier l. classification and surgical management of orbital fractures: experience with 111 orbital reconstructions. journal of craniofacial surgery. 2002;13(6):726-37. 7. disa jj, robertson bc, metzinger se, manson pn. transverse glabellar flap for obliteration/isolation of the nasofrontal duct from the anterior cranial base. annals of plastic surgery. 1996;36(5):453-7. 8. rohrich r, hollier l. management of frontal sinus fractures. changing concepts. clinics in plastic surgery. 1992;19(1):219-32. 9. gerbino g, roccia f, benech a, caldarelli c. analysis of 158 frontal sinus fractures: current surgical management and complications. journal of cranio-maxillofacial surgery. 2000;28(3):133-9. supplementary issue:02 138 prevalence of enterobacteriaceae in blood stream infections and their resistance profile: a brief study at a tertiary care hospital nosheen neyazi1, fatima khan1, asfia sultan1, anees akhtar1 1department of microbiology, jawaharlal nehru medical college, aligarh muslim university, aligarh, up, india *correspondence: nosheen neyazi, mbbs proff. phase 3, jnmc, amu aligarh 202002 neyazi.nosheen@gmail. abstract: introduction: blood stream infections are the leading complications among the critically ill patients in any hospital setting. enterobacteriaceae are notoriously involved in the majority of these cases. also, most of these isolates happen to show resistance to the common drugs available. objective: this study aims to review the drug resistance among enterobacteriaceae family. materials and methods: observational analysis of blood culture reports obtained from the microbiology lab archives was done for a period of 1 year (jan 2022dec 2022). blood culture was performed by bact/alert automated system and anti microbial susceptibility testing was done by kirby bauer disc diffusion method as well as vitek system.results:out of the 3441 blood culture samples, 505 were positive. there were 155 cases of gram-positive bacteria, 114 cases of candida species and 236 cases of gram-negative bacteria. out of 236, 151 (64%) were members of enterobacteriaceae.99 isolates of klebsiella were reviewed. 92% were resistant to aminoglycosides, 85% were resistant to one or more cephalosporins, 84% were resistant to amoxicillin-clavulanic acid, 82% were resistant to carbapenems, 82% were resistant to tetracyclines, 80% were resistant to cotrimoxazole, 41% were resistant to colistin, and 24% were pan drug resistant. conclusion: the choice of antibiotic regimen has become increasingly challenging due to the emergence of multi drug resistant organisms especially enterobacteriaceae (klebsiella, e. coli, salmonella). keywords: enterobacteriaceae, carbapenems,multi drug resistance introduction: bloodstream infections (bsi) are one of the most destructive but also preventable complications in any critical health care set-up. it has dramatic consequences ranging from mailto:neyazi.nosheen@gmail supplementary issue:02 139 prolonged hospital stay, additional costs to the patient and the hospital economy as well and nevertheless substantial morbidity as well as mortality. blood stream infections could be community acquired (ca-bsi) or hospital acquired (ha-bsi) [1]even though the prevalence of ca-bsi is more, patients with ha-bsi are relatively older, are more likely to have co-morbid illnesses and a polymicrobial etiology [2] the problem of bsi’s can be attributed to advancement of medical sciences in terms of increased invasive interventions, and therefore they account for 15% of all nosocomial infections and affect approximately 1% of all hospitalized patients[3].about 8.75% cases in indian icu’s are documented for bsis.[4] the organisms involved in a bloodstream infection vary in terms of type of healthcare facility involved, type of catheter use, duration of catheterization, prevalent organisms, immune status of the host, underlying comorbidities of the patient and most importantly the precautions taken for maintaining aseptic conditions while inserting the catheter itself.[5] the current trends point out that among the causative bacteria, staphylococcus aureus, coagulase negative staphylococcus and enterococcus faecalis are the most common gram-positive organisms. the figure is however dominated by gram negative organisms mainly of enterobacteriaceae family, and non-fermenters like pseudomonas and acinetobacter baumanii.[6] among fungi, it is nonalbicans candida species are more common than candida albicans.[7] because enterobacteriaceae are a common cause of both community acquired and hospital acquired infections, they need to be watched closely [8]. the members of enterobacteriaceae family have evolved through time and have an innate ability to proliferate by developing resistance to several antimicrobials via molecular mechanisms, such as enzyme production, efflux pump overexpression, porin modification, facilitated by plasmid mediated genetic exchanges. [9] carbapenems were the effective against esbl and ampc producing enterobacteriaceae, but there has been emerging resistant to carbapenem, the last-line antibiotic.[10] according to centers for disease control (cdc) description of the antimicrobialresistant pathogens, carbapenem resistant enterobacteriaceae such as klebsiella species, escherichia coli (e. coli) and enterobacter species pose a substantial threat at the global level.[11].with this in mind, our study aims for a thorough review of resistance profiles of enterobacteriaceae isolates from blood stream infections in a tertiary healthcare center of western uttar pradesh. materials and methods: the study was conducted at jawaharlal nehru medical college and hospital, aligarh, a tertiary care institute in western uttar pradesh. analysis of blood culture supplementary issue:02 140 isolates was done for their antimicrobial susceptibility, over a period of one year that is january 2022-december 2022. sample grouping: blood culture was performed by bact/alert automated system and positive isolates were first grouped into gram positive, gram negative and fungal. among the gram negative, members of the enterobacteriaceae were reviewed for their resistance profile. antimicrobial susceptibility testing: ast was done kirby bauer disc diffusion method as well as vitek automated system wherein the isolates were exposed to several antibiotics as per the clsi guidelines [12] results out of the 3441 blood culture samples, 505 (14.67%) were positive. there were 155/505 (30.69%) cases of gram positive,114/505 (22.57%) cases of candida species and 236/505(46.73%) species of gram-negative bacteria. fig 1. positive blood cultures supplementary issue:02 141 fig 2. distribution of isolates out of the 236 gram negative isolates,151(63.98%) were enterobacteriaceae and the rest were non-fermenters like pseudomonas, acinetobacter and burkholderia. fig 3. gram negative isolates overall among the enterobacteriaceae, 99/151(65.56%) were klebsiella isolates, 33/151 (21.85%) were e. coli isolates, 15/151(9.93%) were salmonella isolates and 4/151(2.65%) were enterobacter cloacae isolates supplementary issue:02 142 fig 4. enterobacteriaceae isolates overall among 99 klebsiella isolates, 91/99 (90.09%) were resistant to aminoglycosides like amikacin or gentamicin; 85/99(84.15%) were resistant to one or several 2nd and 3rd generation cephalosporins; 84/99(83.16%) were resistant to the combination of amoxicillin and clavulanic acid;81/99(80.19%) were resistant to tetracyclines; 81/99(80.19%) were resistant to carbapenems;79/99(78.21%)were resistant to cotrimoxazole, 41/99(40.59%) were resistant supplementary issue:02 143 colistin and a whopping 24/99(23.76%)were pan-drug resistant. fig 5. resistance profile in klebsiella among the 33 e. coli isolates, 27/33 (81.81%) were resistant to aminoglycosides, 25/33(75.75%) are resistant to carbapenems, 24/33(72.72%) were resistant to cephalosporins, 17/33(51.51%) were resistant to amoxicillin clavulanic acid combinations,15/33(45.45%) were resistant to tetracyclines, 12/33(36.36%) were resistant to cotrimoxazole and 6/33(18.18%) were resistant to colistin. supplementary issue:02 144 fig 6. resistance profile of e. coli among the 15 salmonella isolates, 11/15(73.33%) were resistant to combinations of piperacillin and tazobactam,10/15(66.67%) were resistant to 3rd generation cephalosporins, 10/15(66.67%) were resistant to carbapenems, 9/15(60%) were resistant to tetracyclines, 7/15(46.67%) were resistant to cotrimoxazole,6/15(40%) were resistant to aminoglycosides mostly amikacin and 3/15 (20%) were colistin resistant. supplementary issue:02 145 fig. 7 resistance profile of salmonella carbapenem resistant enterobacteriaceae (cre) has been prevalent worldwide and our data happens to reflect the same, where in 25/33(67%) of salmonella isolates,25/33 (76%) of e. coli isolates and 81/99 (82%) of klebsiella pneumoniae isolates were found to be resistant to carbapenems. fig. 8. resistance to carbapenems supplementary issue:02 146 discussion: there is a high propensity of blood stream infections progressing to septic shock and multi-organ failure, increasing the risk of mortality by 40%, especially when gram negative organisms are implicated.[13] therefore the need of a prompt and aggressive therapy regimen is emphasized by microbiologists' time and again. the appropriate “time window” for administration of medication is <6hrs, some even arguing that the first hour is most critical.[14] the management of bsis associated with enterobacteriaceae family emerges as a challenge as this group is known for producing esbls. extended spectrum beta lactamases are enzymes that hydrolyze most beta lactams rendering penicillins, most cephalosporins and monobactams ineffective. since the plasmid that encodes esbl’s is frequently known to carry genes conveying resistances towards other antibiotic groups, these enterobacteriaceae are often found to be resistant towards aminoglycosides and tetracyclines as well.[15]. carbapenems are therefore considered the centerpiece in case of bsi’s caused by esbl producing enterobacteriaceae.[16] however studies have pointed out that increased production of ampc-mediated β-lactamases or extended-spectrum β-lactamases (esbls) in organisms, porin mutations [17,18]as well as synthesis of carbapenemases itself has conferred resistance against carbapenems as well. resistance among enterobacteriaceae is an issue demanding great concern considering the frequency by which they cause infections.[19] these organisms, especially carbapenem resistant enterobacteriaceae result in prolonged hospitalization, higher costs incurred, and also higher mortality as compared to their susceptible counterparts.[20]presence of these microbes possess a threat of emergence of other resistant organisms via mobile genetic elements like plasmids being shared.[21] the resistance profiles of our sample isolates aptly reflect the fact there are virtually no drugs left. therefore, the development of new drugs is a global need. conclusion: given the therapeutic complications of blood stream infections, it is implied that better health strategies be developed to prevent them in the first place. use of sterile barrier precautions for all patients, appropriate skin antiseptics, especially while inserting central line catheters and frequent handwashing are to name a few. antimicrobial stewardship programmes too, are imperative. references: supplementary issue:02 147 1. garner, j. s., jarvis, w. r., emori, t. g., horan, t. c., & hughes, j. m. (1991). cdc definitions for nosocomial infections 1988. zeitschrift fur arztliche fortbildung, 85(17), 818-827. 2. lenz r, leal jr, church dl, gregson db, ross t, laupland kb. the distinct category of healthcare associated bloodstream infections. bmc infectious diseases. 2012 dec;12(1):16. 3. exline, m. c., ali, n. a., zikri, n., mangino, j. e., torrence, k., vermillion, b., ... & sopirala, m. m. (2013). beyond the bundle-journey of a tertiary care medical intensive care unit to zerocentral line-associated bloodstream infections. critical care, 17, 1-13. 4. parameswaran, r., sherchan, j. b., mukhopadhyay, c., & vidyasagar, s. (2011). intravascular catheter-related infections in an indian tertiary care hospital. the journal of infection in developing countries, 5(06), 452-458. 5. bharadwaj, r., bal, a., kapila, k., mave, v., & gupta, a. (2014). blood stream infections. biomed research international, 2014. 6. datta, s., wattal, c., goel, n., oberoi, j. k., raveendran, r., & prasad, k. (2012). a ten year analysis of multi-drug resistant blood stream infections caused by escherichia coli & klebsiella pneumoniae in a tertiary care hospital. the indian journal of medical research, 135(6), 907. 7. kaur, r., goyal, r., dhakad, m. s., bhalla, p., & kumar, r. (2014). epidemiology and virulence determinants including biofilm profile of candida infections in an icu in a tertiary hospital in india. journal of mycology, 2014. 8. centers for disease control and prevention. (2019). antibiotic resistance threats in the united states, 2019. atlanta, ga: us department of health and human services, cdc; 2019. 9. de angelis, g., del giacomo, p., posteraro, b., sanguinetti, m., & tumbarello, m. (2020). molecular mechanisms, epidemiology, and clinical importance of β-lactam resistance in enterobacteriaceae. international journal of molecular sciences, 21(14), 5090. 10. van duin, d., & paterson, d. l. (2016). multidrug-resistant bacteria in the community: trends and lessons learned. infectious disease clinics, 30(2), 377-390. 11. tilahun, m., kassa, y., gedefie, a., & ashagire, m. (2021). emerging carbapenemresistant enterobacteriaceae infection, its epidemiology and novel treatment options: a review. infection and drug resistance, 4363-4374. 12. hsueh, p. r., ko, w. c., wu, j. j., lu, j. j., wang, f. d., wu, h. y., ... & teng, l. j. (2010). consensus statement on the adherence to clinical and laboratory standards institute (clsi) antimicrobial susceptibility testing guidelines (clsi-2010 and clsi-2010update) for enterobacteriaceae in clinical microbiology laboratories in taiwan. journal of microbiology, immunology and infection, 43(5), 452-455. 13. conn, j. r., catchpoole, e. m., runnegar, n., mapp, s. j., & markey, k. a. (2017). low rates of antibiotic resistance and infectious mortality in a cohort of high-risk hematology supplementary issue:02 148 patients: a single center, retrospective analysis of blood stream infection. plos one, 12(5), e0178059. 14. kang, c. i., kim, s. h., park, w. b., lee, k. d., kim, h. b., kim, e. c., ... & choe, k. w. (2005). bloodstream infections caused by antibiotic-resistant gram-negative bacilli: risk factors for mortality and impact of inappropriate initial antimicrobial therapy on outcome. antimicrobial agents and chemotherapy, 49(2), 760-766. 15. conn, j. r., catchpoole, e. m., runnegar, n., mapp, s. j., & markey, k. a. (2017). low rates of antibiotic resistance and infectious mortality in a cohort of high-risk hematology patients: a single center, retrospective analysis of blood stream infection. plos one, 12(5), e0178059. 16. paterson, d. l. (2000). recommendation for treatment of severe infections caused by enterobacteriaceae producing extended-spectrum β-lactamases (esbls). clinical microbiology and infection, 6(9), 460-463. 17. bradford, p. a., urban, c., mariano, n., projan, s. j., rahal, j. j., & bush, k. (1997). imipenem resistance in klebsiella pneumoniae is associated with the combination of act1, a plasmid-mediated ampc beta-lactamase, and the foss of an outer membrane protein. antimicrobial agents and chemotherapy, 41(3), 563-569. 18. chow, j. w., & shlaes, d. m. (1991). imipenem resistance associated with the loss of a 40 kda outer membrane protein in enterobacter aerogenes. journal of antimicrobial chemotherapy, 28(4), 499-504. 19. gupta, n., limbago, b. m., patel, j. b., & kallen, a. j. (2011). carbapenem-resistant enterobacteriaceae: epidemiology and prevention. clinical infectious diseases, 53(1), 6067. 20. patel, g., huprikar, s., factor, s. h., jenkins, s. g., & calfee, d. p. (2008). outcomes of carbapenem-resistant klebsiella pneumoniae infection and the impact of antimicrobial and adjunctive therapies. infection control & hospital epidemiology, 29(12), 1099-1106. 21. watanabe, m., iyobe, s., inoue, m., & mitsuhashi, s. (1991). transferable imipenem resistance in pseudomonas aeruginosa. antimicrobial agents and chemotherapy, 35(1), 147-151. supplementary issue:02 96 chronic port site discharging sinus following laparoscopic cholecystectomy: an experience of 5 years at a tertiary health care centre shahbaz habib faridi1, bushra siddiqui2, hasan harris1, danish hussain1, saurabh mittal2 1. department of surgery, jnmch, amu, aligarh, uttar pradesh, india. 2. department of pathology, jnmch, amu, aligarh, uttar pradesh, india. correspondence: dr shahbaz habib faridi assistant professor, department of surgery, jn medical college, amu aligarh, up, india email id drshahbazfaridi@gmail.com abstract background: laparoscopy has replaced the open technique in the majority of cholecystectomy surgeries. however laparoscopic surgeries are associated with some of its own set of complications amongst which one of the most bothersome is chronic port site infection. it adds to the morbidity of the patient and also undermines the benefit of laparoscopic surgery. infection with rapidly growing atypical mycobacteria having multidrug resistance is frequently encountered in many of these patients. this study focuses on the clinical diagnosis, management, and prevention of this problem at a tertiary centre. material and methods: this study has been done in 40 patients who suffered from chronic port site infection over a period of 5 years in a tertiary care centre. result: majority of the patients presented 4 weeks after laparoscopic surgery with a discharging sinus. altogether 19 patients (48%) completely responded with prolonged fluoroquinolone for 68 weeks without any surgical intervention. anti-tubercular therapy was given in 15 patients (37%) and surgical debridement followed by fluoroquinolone and antitubercular therapy for 6-9 months was given in 6 patients (15%). conclusion: chronic port site infection is a rare preventable complication if appropriate measures are taken preoperatively, intraoperatively and postoperatively. it can often be treated nonsurgically, with early identification and appropriate management. it can be best avoided by proper sterilization techniques of the laparoscopic instruments with appropriate sterilizing agent for appropriate time. supplementary issue:02 97 keywords: laparoscopic cholecystectomy; atypical mycobacterial infection, discharging sinus, anti-tubercular therapy. introduction laparoscopic cholecystectomy has replaced the open cholecystectomy as the “gold standard” procedure for symptomatic gallstone disease due to its several advantages which include less pain, early return to work, better cosmesis and less chances of incisional hernia.1 this technique is not free of complications and surgeons are now facing quite different set of complications which were not there in the conventional open technique. traumatic injuries due to veress needle, trocar and laparoscopic instruments, heat injury by diathermy due to coupling or inadvertent contact with viscera and port related complications like infection need a substantial training especially from young surgeons.2 port site infection is of two types. the first type occurs immediately within 1 week of laparoscopic surgery due to gram negative or positive bacteria. it usually subsides in few days with dressing and antibiotics. the second type of infection i.e chronic port site infection (psi) usually occurs 34 weeks after the surgery when wound healing has occurred. it is usually caused by atypical mycobacteria which includes the group of mycobacterial species that is not part of the m. tuberculosis complex having an incubation period of 3 to 4 weeks which do not respond to common antibiotics.3 chronic port site infection (psi) is one the most worrisome complication for patients after laparoscopic surgeries. the incidence of chronic psi as reported in literature is around 1.4-6.7%.4 in the recent years, atypical mycobacteria (atm) has emerged as an important opportunistic pathogen. atm has been known to colonize tap water, natural waters, and soil and hence can easily contaminate solutions used in hospital settings.5 these microorganisms do not respond to first-line anti-tuberculosis drugs. thus, the standard treatment consists of combinations of secondline anti-tubercular drugs including macrolides such as clarithromycin, fluoroquinolones such as levofloxacin or moxifloxacin, tetracyclines such as doxycycline, and aminoglycosides.6 improper sterilization of laparoscopic instruments is responsible for such infections and makes it a problem mainly affecting developing countries, such as india. thus, proper sterilization of such instruments supplementary issue:02 98 is essential to prevent the occurrence of post-laparoscopic wound infections with atypical mycobacteria. there are five clinical stages of chronic port site infections (psi)7 first stage: a tender nodule appears in the vicinity of the port site, and its usual timing of appearance is around four weeks following the surgery. second stage: increase in the size of the nodule, and increased tenderness of the site along with other signs of inflammation with eventual formation of an abscess. third stage: reduced pain sensation following discharge of the purulent material and necrosis of the skin surrounding the port site. fourth stage: chronic sinus discharging white or serous fluid. fifth stage: hyper-pigmentation of the skin surrounding the sinus and the appearance of multiple nodules at different places. materials and methods 40 patients (female =32 and male =08) who had all undergone standard four port laparoscopic cholecystectomy and presented with symptoms of port site infection in the form of abscess at port site or chronic discharging sinus 3-4 weeks after the surgery were included in the study. laparoscopic cholecystectomy was done at some other hospital in 34 patients and 6 patients who developed chronic psi were operated at our centre. at the time of discharge and suture removal, none of the 6 patients who were operated at our centre showed any signs of local wound infection or any systemic signs of sepsis. ultrasound scans showed no evidence of intra-abdominal collection or bile leak. the blood test of these patients showed normal white blood cell and differential count thus confirming the absence of systemic infection. the culture of the pus collected from the wound site was found to be negative for gram-positive and gram-negative bacteria. results supplementary issue:02 99 among the 40 patients, 32 were female (80%) and 8 were male (20%). mean age of presentation was 28 years with youngest patient of 22 years and oldest was 56 years of age. out of 40 patients, 3 patients were known case of type 2 diabetes mellitus (7.5%). total 6 patients out of 40 were operated at our centre and 34 were operated in private hospitals. chronic psi infection occurred at epigastric port in all of the 40 patients. 3 patients had involvement of umbilical port besides epigastric port. in 2 patients all the four port sites developed chronic psi. table 1: ports affected by chronic psi port affected number of patients epigastric port alone 35 epigstric port with umbilical port 3 all four ports 2 we analyzed the results and found that all the patients had more or less similar clinical presentation: delayed onset of wound infection (3-4 weeks after surgery), erythematous and thickened skin, discharging sinus and absence of systemic illness (fig 1). the cultures were negative for gram positive and gram negative bacteria as well as fungi. all the patients were treated initially with oral moxifloxacin 400mg once daily. out of 40, 19 (48%) patients responded well and they were kept on same treatment for 8 weeks. in 15 patients (37%) who didn’t improve with oral moxifloxacin alone att was given for 6 months. in 6 patients (15%) in whom debridement with excision of sinus tract was done, we started combination of att and moxifloxacin for 6-9 months. the histopathology of the sinus tract showed presence of granulomas (fig 1,2,3). patients were followed up for 3 months after completion of treatment and none of the patient showed any sign of recurrence. table 2: treatment given to the patients of chronic psi treatment given number of patients (total=40) oral moxifloxacin 400 mg (6-8 weeks) 19 supplementary issue:02 100 anti tubercular therapy (att) with oral moxifloxacin 15 surgical debridement followed by oral moxifloxacin and att 06 • fig 1: o fig 1a : chronic discharging sinus at the epigastric port site (blue arrow) o fig 1b : excised sinus tract (white arrow) supplementary issue:02 101 o fig 1c :granuloma composed of epitheliod cells, lymphocytes and langhans giant cells.(h&e,10x) (black arrow) • fig 2: o fig 2a :discharging sinus at epigastric port (black arrow) o fig 2b :opened up cavity after the excision of sinus tract supplementary issue:02 102 o fig2c:epitheliod cells, lymphocytes and langhans giant cells.(h&e,40x) (orange arrow) • fig 3 : o fig 3a :chronic sinus at epigastric port (black arrow) o fig 3b: cavity of excised tract (white arrow) o fig 3c: well-formed granuloma (black line) supplementary issue:02 103 discussion infection at the port site can present with two types. the first type appears within a week of surgery and is usually caused by gram-positive or gram-negative bacteria. it is acquired from the infected gallbladder or the surgical procedure and can be treated with usual antibiotics and wound dressing. the second type present 3-4 weeks after surgery which is caused by atypical mycobacteria and does not respond to commonly used antibiotics.3 infections with atypical mycobacteria usually occur after laparoscopic procedures and are rarely associated with open procedures. this is because of the fact that instruments used in open surgery are usually autoclaved; unlike the instruments used for laparoscopic surgery that have a layer of insulation that restricts the use of the autoclave in the sterilization process.8 these instruments are usually washed with tap water which is a good source of atypical mycobacteria and then disinfected by 2.0 2.5% glutaraldehyde for atleast 20 minutes.9 also, if these instruments are not properly cleaned before putting them in glutaraldehyde solution the, blood and charred tissue deposits are left. these endospores in the contaminated instrument get deposited in the subcutaneous tissue, which germinates in three to four weeks to produce clinical signs and symptoms.3 in our study, all 40 cases presented atleast 3-4 weeks after the surgery in different stages of chronic port site infection. boiled tap water used to clean/wash the instruments after surgery is also considered to be the source of infection. clarithromycin, moxifloxacin and a combination of amikacin and doxycycline have been observed to be effective against atypical mycobacterial infections.6 in our study, we used oral moxifloxacin in the dosage of 400mg once daily for a minimum of 4 weeks initially. out of the 40 patients 19 patients (48%) who presented in early stages of infection, responded to oral moxifloxacin which was continued for 8 weeks. in 21 patients who were not responding to moxifloxacin, antitubercular therapy was also started. 6 patients who presented in late stages of infection with multiple discharging sinus required surgical debridement in addition to att and oral moxifloxacin. the hospital must follow certain guidelines to ensure proper sterilization of laparoscopic instruments and other invasive surgical devices. after the surgery, all the parts of the instruments should be dismantled and cleaned with warm normal saline. higher concentration of glutaraldehyde (3.4%) with an exposure time of at least 8-12 hours achieve the desired level of sporicidal activity. use of ethylene oxide and plasma sterilizer have shown to be effective in killing supplementary issue:02 104 spores.10 besides aseptic precautions and proper sterilization of instruments, spillage of bile or gut content in the port site shall be avoided. use of non-porous specimen retrieval bags for retrieving the specimen and thorough irrigation and cleaning of the port site before wound closure should be done.11 conclusion chronic port site infection in laparoscopy is a problem faced by laparoscopic surgeons in developing countries. wound infection 3-4 weeks after the surgery, poor response to antibiotics and persistent pus discharge from port site should raise the suspicion for atypical mycobacterial infections. proper sterilization techniques and optimum treatment significantly reduce morbidity. conflict of interest: none of the authors have any conflict of interest to disclose. patient consent: informed and written consent was taken from the patients for publication of manuscript and photographs. references 1. bittner r. laparoscopic surgery: 15 years after clinical introduction. world j surg. 2006; 30:1190-203, doi: 10.1007/s00268-005-0644-2. 2. perugini ra, callery mp. complications of laparoscopic surgery. in: holzheimer rg, mannick ja, editors. surgical treatment: evidence-based and problem-oriented. munich: zuckschwerdt; 2001. 3. sasmal pk, mishra ts, rath s, meher s, mohapatra d. port site infection in laparoscopic surgery: a review of its management. world j clin cases. 2015 oct 16;3(10):864-71. doi: 10.12998/wjcc.v3.i10.864. 4. shindholimath vv, seenu v, parsad r, chaudhry r, kumar a. factors influencing wound infection following laparoscopic cholecystectomy. trop gastr. 2003; 24:90-2. 5. yadav rp, baskota b, ranjitkar rr, dahal s. surgical site infections due to nontuberculous mycobacteria. jnma j nepal med assoc. 2018 mar-apr;56(211):696-700. pmid: 30381768; pmcid: pmc8997279. 6. choi ge, min kn, won cj, jeon k, shin sj, koh wj. activities of moxifloxacin in combination with macrolides against clinical isolates of mycobacterium abscessus and supplementary issue:02 105 mycobacterium massiliense. antimicrob agents chemother. 2012 jul;56(7):3549-55. doi: 10.1128/aac.00685-12. 7. chaudhuri s, sarkar d, mukerji r. diagnosis and management of atypical mycobacterial infection after laparoscopic surgery. indian j surg. 2010;72:438–442. 8. chauhan a, gupta ak, satyanarayan s, jena j. a case of nosocomical atypical mycobacterial infection. mjfai. 2007;63:201–202. 9. petersen bt, chennat j, cohen j. multisociety guideline on reprocessing flexible gi endoscopes: 2011. infect control hosp epidemiol. 2011;32:527–537. 10. rutala wa, weber dj. disinfection and sterilization in health care facilities: what clinicians need to know. clin infect dis. 2004;39:702–709. 11. sasmal pk, mishra ts, rath s, meher s, mohapatra d. port site infection in laparoscopic surgery: a review of its management. world journal of clinical cases : wjcc. 2015;3(10):864-871. doi:10.12998/wjcc.v3.i10.864. supplementary issue:02 159 socio-demographic characteristics of patients with ocular infection in northern india shariq wadood khan1, adil raza1, shaik mohammed zakir2, *mohd. yasir zubair3, haris manzoor khan1, mohammad shahid4 1. department of microbiology j. n. medical college, amu, aligarh, india 2. institute of ophthalmology j. n. medical college, amu, aligarh, india 3. department of community medicine j. n. medical college, amu, aligarh, india 4. department of microbiology, immunology & infectious diseases, college of medicine & medical sciences, kingdom of bahrain * correspondence: dr. mohd. yasir zubair senior resident, department of community medicine j. n. medical college, amu, aligarh, india email id: yasmuhsin@gmail.com abstract background: the microbiological and epidemiological patterns seem to vary with the patient population, site of infection, geographic location and it may also change over time. hence, an understanding of the epidemiological features, risk factors and etiological agents that occur in a specific region are important in rapid recognition, timely institution of empirical therapy, optimal management and prevention of these infections. objective: to study association of various socio-demographic factors with ocular infections and microbiological positivity rates of collected samples at our tertiary care centre. methods: this study was conducted in the department of microbiology & institute of ophthalmology, jawaharlal nehru medical college, aligarh muslim university (a.m.u.), aligarh from july 2018 to february 2021. results: out of 350 patients diagnosed with ocular infections in the study, 207(59.14%) were male patients, and 143 (40.8%) were female. similar number of patients presented in each group. the clinical diagnosis of the infective conditions of the eye ranged from mostly innocuous conjunctivitis to sight threatening corneal ulcers and endophthalmitis. the overall culture-positivity rate for bacterial isolation was 54.57% (191/350). conclusion: there is slight gender preponderance towards males for infective ocular conditions. in this study, the most prevalent clinical condition was ocular adnexal bacterial infections, followed by corneal ulcers. from 350 patients with ocular infections, 54.57% supplementary issue:02 160 were culture-positive. our study provides pattern of different ocular infections in opd and ipd settings which may be may be of use to clinicians in their day to day practice. keywords: ocular infections, culture, sociodemographic demographic characteristics introduction the eye is largely immune to external agents. the numerous mechanical, anatomical, immunologic, and microbiological elements work together to prevent ocular infections and prevent pathogenic micro-organisms from surviving in the eye.1-2 however, under certain conditions, micro-organisms manage to get past all the defenses and enter the eye, where they can then cause a variety of infections, from minor eye irritation to serious sight threatening infections like endophthalmitis. the bacteria that colonize the eye differ from those that do so in other areas of the body.3 there is a risk of bacterial, fungal, viral, and parasite infections in the outer layer of the eye. additionally, bacteria can get inside the eye and harm its interior structures, which frequently causes varying degrees of vision loss. both exogenous or endogenous factors may be the cause of an eye infection.4 external bacterial infections of the eye are usually localized but may frequently spread to adjacent tissue, from the conjunctiva to the cornea, the inner eye, the orbit and the brain. the conjunctival sac and lid margins of the eye harbor a variety of micro-organisms and the bacteria present in the conjunctival sac form a constant source of infection to other parts of the eye. conjunctivitis, keratitis, blepharitis, canaliculitis, dacryocystitis, external hordeolum, and cellulitis are all clinical manifestations of external eye infections.5 bacteria frequently produce the clinical signs and symptoms of ocular inflammation. globally, gram-positive bacteria are the predominant cause of these purulent infections. organisms frequently isolated are haemophilus influenzae, streptococcus pneumoniae, staphylococcus aureus, and staphylococcus epidermidis.6 however, the margins of the lids and conjunctival sacs of healthy individuals can also contain gram-negative pathogens. the microbiological and epidemiological patterns seem to vary with the patient population, site of infection, geographic location and it may also change over time. hence, an understanding of the epidemiological features, risk factors and etiological agents that occur in a specific region are important in rapid recognition, timely institution of empirical therapy, optimal management and prevention of these infections. the present study was conducted with the objective of studying the supplementary issue:02 161 association of various socio-demographic factors with ocular infections and microbiological positivity rates of collected samples at our tertiary care centre. materials & methods this study was conducted in the department of microbiology & institute of ophthalmology, jawaharlal nehru medical college, aligarh muslim university (a.m.u.), aligarh from july 2018 to february 2021. a total of 350 patients presented during the study period to the outpatient and inpatient departments of the institute of ophthalmology, jnmch, amu. all the patients were examined under diffused torch light, followed by slit-lamp biomicroscopy by ophthalmologists. diagnosis was made clinically and appropriate specimen was collected for microbiological examination. the clinical specimens were processed in the laboratory. direct microscopy of gram-stained smear was performed for all the collected specimens, which were inoculated onto 5% sheep blood agar (sba), chocolate agar (ca), macconkey agar (mca), robertson cooked meat broth (rcm), thioglycolate medium, and brain-heart infusion broth (bhi). these were incubated at 37°c for 18-24 hours. the organism was identified based on morphology, culture characteristics, and biochemical tests. the clinical findings, microbiological profile and sociodemographic information was documented on a pre-designed semi-structured questionnaire. data management the data so collected was entered in ibm spss version 20.0 software for analysis. ethics ethical clearance was obtained from the institutional ethics committee, jawaharlal nehru medical college, amu, aligarh. informed consent was obtained from patients/guardians for their participation. . results out of 350 patients diagnosed with ocular infections in the study, 207(59.14%) were male patients, and 143 (40.8%) were female. the male-to-female ratio was 1.4:1 (table 1). the distribution of supplementary issue:02 162 patients with respect to different age groups is presented in table 2. similar number of patients presented in each group. table 1. distribution of patients according to sex (n=350) gender frequency (%) percentage (95% ci) male 207 59.2 (53.9-64.2) female 143 40.8 (35.7-46.0) table 2 distribution of ocular infections according to age (n=350) age group (years) patients percentage (95% ci) 0-10 53 15.14% (11.5-19.3) 11-20 32 9.14% (6.3-12.6) 21-30 48 13.71% (10.2-17.7) 31-40 58 16.57% (12.8-20.8) 41-50 40 11.42% (8.2-15.2) 51-60 66 18.86% (14.8-23.3) 61-70 38 10.85% (7.8-14.6) >70 15 4.28% (2.4-6.9) the clinical diagnosis of these infective conditions ranged from mostly innocuous conjunctivitis to sight threatening corneal ulcers and endophthalmitis. conjunctivitis, dacryocystitis, endophthalmitis and corneal ulcers were found to be the most common ocular infections in our study. conjunctivitis was more commonly seen in patients less than 20 years of age, and endophthalmitis and corneal ulcer were more common in elderly patients. dacryocystitis cases mostly belonged to the middle age group of 21-50 years accounting for 45.2% of cases. no age predominance was observed for pre-septal and orbital cellulitis. around half of patients with supplementary issue:02 163 endophthalmitis (51.9%) and panophthalmitis (50%) belonged to older age group of >50 years (table 3). table 4 shows the bacterial culture positivity rate in different ocular infective conditions. the overall culture-positivity rate was 54.57% (191/350). the maximum culture positivity rate was found in panophthalmitis, 04 (4/4; 100%) and post-surgical infection, 04(4/4; 100%), followed by dacryocystitis, 50 (50/62; 80.64%) and internal hordeolum, 13 (13/21; 61.90%). more than half of conjunctivitis (56.6%), preseptal cellulitis (60.0%) and external hordeolum (52.8%) were also culture positive. in endophthalmitis, 23 of 81 patients (28.3%) were found to be culture positive. table 3: pattern of various bacterial ocular infections in relation to age age groups 0-20 years n, % (ci) 21-50 years n, % (ci) >50 years n, % (ci) total n, % (ci) conjunctivitis 27, 50.9% (36.8-64.9) 16, 30.2% (18.3-44.3) 10, 18.9% (9.4-32.0) 53 (15.1%) corneal ulcer 04, 6.2% (1.7-15.2) 25, 39.1% (27.1-52.1) 35, 54.7% (41.7-67.2) 64 (18.3%) external hordeolum 02, 5.5% (0.6-18.7) 32, 88.9% (73.9-96.9) 02, 5.5% (0.6-18.7) 36 (10.3%) internal hordeolum 03, 14.3% (3.1-36.3) 13, 61.9% (38.4-81.9) 05, 23.8% (8.2-47.2) 21 (6.0%) dacryocystitis 17, 27.4% (16.9-40.2) 28, 45.2% (32.5-58.3) 17, 27.4% (16.9-40.2) 62 (17.7%) preseptal cellulitis 05, 33.3% (11.8-61.6) 05, 33.3% (11.8-61.6) 05, 33.3% (11.8-61.6) 15 (4.2%) orbital cellulitis 04, 40% (12.2-73.8) 02, 20% (2.5-55.6) 04, 40% (12.2-73.8) 10 (2.8%) endophthalmitis 21, 25.9% (16.8-36.9) 18, 22.2% (13.7-32.8) 42, 51.9% (40.5-63.1) 81 (23.1%) supplementary issue:02 164 panophthalmiitis 01, 25% (0.6-80.6) 01, 25% (0.6-80.6) 02, 50% (6.7-93.2) 04 (1.1%) post-surgical infection 01, 25% (0.6-80.6) 01, 25% (0.6-80.6) 02, 50% (6.7-93.2) 04 (1.1%) total (n) 85, 24.3% (19.9-29.1) 141, 40.3% (35.1-45.4) 124, 35.4% (30.4-40.7) 350 table 4. bacterial culture positivity rate of different ocular infections ocular infections patients bacterial isolates percentage (95% ci) conjunctivitis 53 30 56.6 (43.269.9) corneal ulcer 64 31 48.4 (36.1-60.6) external hordeolum 36 19 52.8 (36.4-69.0) internal hordeolum 21 13 61.9 (41.1-82.6) dacryocystitis 62 50 80.6 (70.8-90.4) preseptal cellulitis 15 09 60.0 (35.2-84.7) orbital cellulitis 10 08 80.0 (44.3-97.4) endophthalmitis 81 23 28.4 (18.33-37.7) panophthalmiitis 04 04 100 post-surgical infection 04 04 100 total 350 191 54.57 (49.3-59.7) supplementary issue:02 165 discussion: in the present study, a total of 350 patients with clinically diagnosed ocular infections were studiedf. in our study 59.2% patients were males and 40.8% were females. tilahun aweke et al7 (2014) in their study amongst 281 patients with external ocular infections reported that 59.4% patients were males and 40.6% were females. amongst the various ocular infective conditions in our study, 34% (119/350) patients had ocular adnexal bacterial infections (external hordeolum, internal hordeolum, dacryocystitis), 15.14% (53/350) had conjunctivitis, 18.28% (64/350) had corneal infections, 1.1% (4/350) had a post-surgical infection. the remaining 24.28% (85/350) had an infection of the intraocular tissues (endophthalmiitis + panophthalmitis). belyhun yeshambel et al8 (2018) in their study among 210 patients of external ocular infections reported conjunctivitis in 32.9% (69), blepharitis in 26.7% (56), dacryocystitis in 14.8% (51), blepharoconjunctivitis in 11.9% (25), and trauma in 10.0% (21) of their patients. tilahun aweke et al7 (2014) found 49.8% cases of conjunctivitis, 19.6% blepharitis, 11.03% cornral infections, 5.4% dacryocystitis and 12.8% others. most of the endophthalmitis cases in our study were subsequent to cataract surgery, and cataract is the disease of the elderly population; this provides an explanation for more endophthalmitis cases in elderly people. in our study, the overall culture-positive rate was 54.57 percent (191 out of 350). bharathi jm et al.9(2010) and tilahun aweke et al.7 (2014) found a similar culture positivity rate of 58.8% and 48.8% respectively . mohammed et al10 also reported a similar rate of 60% (198/332) in 2020. hemavathi et al. (2014)11 conducted their study in bangalore, india and it yielded 34.5% (81/235) of bacterial growth. the probability of isolating a causal organism is dependent on a number of variables, including the volume of inoculum12, the site from which it is collected, the types of media utilised for culture (enriched or basic media)13, and the empirical treatment received before the sample collection.14 this can partially explain culture-positivity rate across centres. the difference can also be attributed to geographic location, study period, study population, socioeconomic condition of the study population, and laboratory method used to isolate microorganisms. in our study, we found the highest culture positivity rate among the samples collected from panophthalmitis (100%; 4/4), post-surgical infections (100%; 4/4), and lacrimal apparatus supplementary issue:02 166 infections (dacryocystis, 80.64%; 50/62). the possible reason might be that blockage of the nasolacrimal duct harbors a significant number of microorganisms resulting in significant recovery of bacteria in culture. we found positive culture in 56.6% cases of conjunctivitis and 48.4% cases of keratitis. belyhun yeshambel et al8 (2018) reported that 32.8% (43), 23.7% (31), and 16.0% (21) of the isolates could be detected in conjunctivitis, dacryocystitis, and blepharitis, respectively and 27.5% (36) of bacteria were detected in other infections of the eye. conclusion: there is slight gender preponderance towards males for infective ocular conditions. in this study, the most prevalent clinical condition was ocular adnexal bacterial infections, followed by corneal ulcers. from 350 patients with ocular infections, 54.57% were culturepositive. our study provides pattern of different ocular infections in opd and ipd settings which may be may be of use to clinicians in their day to day practice. limitations this was a hospital-based study at a tertiary care center and therefore it is subject to selection bias. the sample size of the study was small. reference 1. mcclellan ka. mucosal defense of the outer eye. surv ophthalmol. 1997; 42:233–46. 2. nassif kf. ocular surface defense mechanisms. in: tabbara kf, hyndiuk ra, editors. infections of the eye. boston: little brown and company; 1996. 35–41 3. hemavathi sp, shenoy p. profile of microbial isolates in ophthalmic infections and antibiotic susceptibility of the bacterial isolates: a study in an eye care hospital, bangalore. j clin diagn res. 2014; 8(1):23–5. 4. muluye d, wondimeneh y, moges f, nega t, ferede g. types and drug susceptibility patterns of bacterial isolates from eye discharge samples at gondar university hospital, northwest ethiopia. bmc res notes. 2014;7(1): 292. 5. schaefer f, bruttin o, zografos l, guex-crosier y. bacterial keratitis: a prospective clinical and microbiological study. brit j ophthalmol. 2001;85(7): 842–7. 6. bremond-gignac d, chiambaretta f, milazzo s. a european perspective on topical ophthalmic antibiotics: current and evolving options. ophthalmol eye dis. 2011; 3:29. supplementary issue:02 167 7. tilahun aweke, gelila dibaba, kenenisa ashenafi, mengist, kebede. bacterial pathogens of exterior ocular infections and their antibiotic vulnerability pattern in southern ethiopia. african journal of immunology research vol. 1 (2) pp. 019-025 8. belyhun, y., moges, f., endris, m. et al. ocular bacterial infections and antibiotic resistance patterns in patients attending gondar teaching hospital, northwest ethiopia. bmc res notes 11, 597 (2018) 9. bharathi mj, ramakrishnan r, meenakshi r, mittal s, shivakumar c, srinivasan m. microbial diagnosis of infective keratitis: comparative evaluation of direct microscopy and culture results. br j ophthalmol. 2006; 90:1271–6. 10. mohammed et al. bacterial etiology of ocular and periocular infections, antimicrobial susceptibility profile and associated factors among patients attending eye unit of shashemene comprehensive specialized hospital, shashemene. ethiopia bmc ophthalmology (2020) 20:124 11. hemavathi et al., profile of microbial isolates in ophthalmic infections and antibiotic susceptibility of the bacterial isolates. journal of clinical and diagnostic research. 2014 jan, 8(1): 23-25 12. moeller ct, branco bc, yu mc, farah me, santos ma, hofling-lima al. evaluation of normal ocular bacterial flora with two different culture media. can j ophthalmol. 2005; 40:448–53. 13. gaynor bd, chidambaram jd, cevallos v, miao y, miller k, jha hc, et al. topical ocular antibiotics induce bacterial resistance at extraocular sites. br j ophthalmol. 2005;89:1097– 9 14. bharathi jm, ramakrishnan r, shivakumar c, meenakshi r, lionalraj d. etiology and antibacterial susceptibility pattern of community-acquired bacterial .ocular infections in a tertiary eye care hospital in south india.indian j ophthalmol. 2010 nov-dec; 58(6): 497– 507. international journal of human and health sciences vol. 07 no. 01 january’23 54 original article histopathological and biochemical effects of aqueous fruit extract of balanite aegyptiaca on selected organs of mice solomon matthias gamde1, usman wali2, aminu garba3, daniel dansy agom4, haruna mallah ayuba5 abstract background: balanites aegyptiaca is a medicinal plant for diabetes, leukemia, and breast cancer. unfortunately, it is hard to assume whether the plantis safe because substantial data are lacking. objective: to determine the biochemical effects of aqueous fruit extract of balanite aegyptiaca in selected organs of mice. methods: the acute toxicity study was performed using the up and down method at an oral limit dose of 5000 mg/kg in mice while subacute oral doses of 200, 400, and 800 mg/kg were administered for 28 days.animals were weighed on those days to assess possible weight changes. after exposure, animals were euthanized and blood samples were collected via cardiac puncture for biochemical analysis. results:the acute toxicity studyshowed no major toxic effect and indicated an ld50 greater than 5000 mg/kg. subacute doses of 200, 400, and 800 mg/kg extract did not produce significant changes inthe body weights of animals for 28 days.there were no pathological changes in animals at 200 mg/kg. however, the extract significantly raised liver transaminases ast, alp, asp, and potassium ions at 400 and 800 mg/kg. conclusion: balanite aegyptiaca fruit had an ld50 greater than 5000 mg/kg, indicating its safety at the acute level. in the subacute assessment,extract at 200 mg/kg was not toxic. however, 400 and 800 mg/kg extract was toxic to the liver and lungs. the toxicological effects suggest that balanite aegyptiaca fruit would be safe when controlled. keywords: balanites aegyptiaca, medicinal plant, biochemical effects, liver function test, kidney function test correspondence to: solomon matthias gamde, department of medical laboratory science, bingham university, karu, nasarawa state, nigeria. email: solomonmatthias85@gmail.com 1. department of medical laboratory science, bingham university, karu, nasarawa state, nigeria 2. department of chemical pathology, school of medical laboratory sciences, usmanu danfodiyo university sokoto, nigeria 3. department of haematological, school of medical laboratory science, usmanu danfodiyo university sokoto, nigeria. 4. national health insurance scheme authority, sokoto state office, nigeria 5. department of medical laboratory technician, nigeria air force school of medical sciences and aviation medicine, kaduna, nigeria introduction medicinal plants have a distinct therapeutic window on biological systems used all over the world as functional food and medicines for many diseases. unfortunately, in attempts to improve health, plants are misused with no substantial information on their safety1,2. besides, most herbal practitioners who engaged in prescription do so with no empirical data for their safe dose3. medicinal plants could cause damage to vital organs of the body even when considered safe4 balanites aegyptiaca del. (family balantiaceae) is one of the most substantial herbal medicineformany diseases including diabetes, leukemia, colon, and breast cancersin nigeria folklore similar to south asia 5,6. pharmacological studies reported all parts of b. aegyptiaca to be medicinal and opens new opportunities for treating several diseases that are international journal of human and health sciences vol. 07 no. 01 january’23 page : 54-59 doi: http://dx.doi.org/10.31344/ijhhs.v7i1.497 55 international journal of human and health sciences vol. 07 no. 01 january’23 hard to cure.thefruitsare used for hyperglycemia and hyperlipidemia which are risk factors for developing cardiovascular diseases such as atherosclerosis, hypertension, and coronary heart diseases7,8. the fruits are also used in the treatment of intestinal worms9, jaundice9, leukemia10, colon11, and breast cancers12. besides, cancer and its treatments are known risk factors for other malignant disorders8,13. b. aegyptiaca contains glycosides, coumarins, flavonoids, 6-methyldiosgenin, and saponins14. saponins are a large family of both steroids and triterpenes with wide-ranging pharmacological properties such as anti-inflammatory, antibacterial, and anti-viral activities15,16. although b. aegyptiaca fruit provides therapeutic options for treating diseases for which current therapies are minimal, there is no guaranteed safety on its use. the plants could cause damage to consumerseven when considered safe.we aimed to determine the histopathological and biochemical effects of aqueous fruit extract of balanite aegyptiaca in selected organs of mice. materials and methods reagents: standard assay rat kits for ast, alt, ap, and e/u/cr were purchased from ali shuaibu diagnostics, sokoto nigeria plant material: the plant was collected from the garden of medicinal plants at the department of pharmacognosy, faculty of pharmaceutical sciences, usmanudanfodiyo university, and airdried in shade at room temperature, pulverized into a fine powder by using a pestle and mortar. extraction of the plant: a hundred grams of powdered plant materialwas macerated in 2000 ml of distilled water for 24 hours.the mixture was filtered with whatman paper and evaporated to dryness under reduced pressure by using a rotary evaporator. preparation of the extract dose: extract 5.0 g was dissolved in 20 ml distilled water as a vehicle to get extract solution, then administeredvia oral gavage according to the animal’s body weight. animals used: twenty white albino mice of both sexes weighing 20-30 g bred in animal house, faculty of pharmaceutical sciences, usmanu danfodiyo university, sokoto, nigeria were used for the study. experimental procedures followed the national institute of health guide for the care and use of laboratory animals17 as reported in the guidelines written by the national committee for research ethics in science and technology (nent), norway. acute toxicity study: an oral acute toxicity study was carried out using the ‘up-anddown’ method of testing mice and a dose of 5000 mg/ kg was administered via oral gavage following the organization for economic development (oecd) guideline18. animals were observed for 30 min for signs of toxicity and mortality. the same procedure was repeated for the remaining animalsand observed for 14 days. subacute toxicity study: a subacute toxicity study was carried out according to the organization for economic development (oecd) guideline18. twenty animals were randomly divided into four groups of five animals, group’s i-iii received 200, 400, and 800 mg/kg extract dissolved in distilled water while group iv received distilled water (ml/ kg). animals were dosed daily via oral gavage using a curved, ball-tipped stainless steel feeding needle for 28 days18. animals were weighed on those days to assess possible weight changes. on day 29, animals were anesthetized in chloroform after an overnight fast, and blood was drawn by cardiac puncture into plain sample bottles for biochemical analysis while the liver, kidney, lung, heart, and testis were excised for histological study. tissue sampling: withdrawn blood was allowed to clot and centrifuged for serum biochemical analysis whilethe liver, kidney, lung, heart, and testis were preserved in 10% formalin until the histopathological study was done. biochemical analysis: the spun serum was analyzed for liver transaminases alkaline phosphatase (alp), aspartate aminotransferase (ast), alanine aminotransferase (alt), as well as total protein (tp), albumin (alb), total bilirubin (tb), direct bilirubin (db), urea, creatinine (cr) and electrolytes; potassium (k+), sodium (na+), chloride (cl-), and bicarbonate (hco3) were analyzed using diagnostic kits from randox laboratory. histopathological analysis: the liver, kidney, lung, heart, and testis werefixed in 10% buffered formalin for 24 h. fixed tissues were dehydrated in three changes ofethanol, dealcoholized in international journal of human and health sciences vol. 07 no. 01 january’23 56 xylene, and embedded in molten paraffin wax. tissue sections were cut using a rotary microtome (surgcare microtome, model 335a usa), and stained with hematoxylin and eosin (h&e). data analysis: statistical values obtained were presented as mean ±standard deviation (sd) and analyzed using way analysis of variance (anova) (spss version 25.0 software usa) followed by the bonferroni post hoc test. p<0.05 were considered significant. results acute toxicity assessment: oral acute toxicity (ld50) ofthe aqueous fruit extract of b. aegyptiaca del in mice was greater than 5000 mg/kg. no acute toxicity or mortality was recorded. subacute toxicity assessment: there were no significant changes in the weights of animals treated withextract at 200, 400, and 800 mg/kg for 28 days compared to the control. however, the body weights of animals at 400 and 800 mg/ kg significantly (p>0.05, p=0.016) increased at the 14th day of treatment (table 1, figure 1).the biochemical effect of b. aegyptiaca fruit extract at oral doses of 200, 400, and 800 mg/kg for 28 days are presented in table 2. there was a significant (p<0.05) raised transaminase ast, ast, alt, and potassium ions at 400 and 800 mg/kg. the conjugated and unconjugated bilirubin at all tested doses were also increased when compared with the control. however, the differences were not statistically significant. furthermore, there were no significant differences in total protein and albumin in extract-treated animals compared with the control (table 2, figure 2 & 3). table 1: effect of the extracton body weights group weight day 1 mean ±sd weight (g) weight day 14 weight day 28 control 20.50 ± 1.66 21.75 ± 1.55 22.75 ± 1.10 ba 200 mg 34.75 ± 2.18 31.00 ± 3.54 18.50 ± 6.46 ba 400 mg 24.75 ± 1.11 25.75 ± 1.49* 22.00 ± 1.58 ba 800 mg 18.00 ± 0.71* 20.00 ± 1.08* 21.00 ± 1.78 p-value ˂ 0.001 0.016 0.874 data were expressed as mean ± sd. the statistical analyses were performed using anova and bonferroni post hoc analysis. significant at *p<0.05 compared with the control. figure 1: effect of the extract on body weight figure 2: effects of the extract on liver function parameters figure 3: effects of the extract on kidney function parameters discussion the oral acute toxicity test of aqueous fruit extract of b. aegyptiaca in mice at 5000 mg/kg body weight indicated no major toxic effect. according to the organization for economic development harmonized classification system for chemical substances and mixtures, substances with ld50> 2000 5000 mg/kg are relatively safe18,19. this suggests that the extract may be relatively safe 57 international journal of human and health sciences vol. 07 no. 01 january’23 table 2: effect of the extract on biochemical parameters parameter control 200 mg/kg ba 400 mg/kg ba 800mg/kg ba alt (iu/l) 9.25 ± 2.69 9.25 ± 0.95 14.00 ± 4.76* 16.00 ± 4.83* ast (iu/l) 8.25 ± 1.65 8.25 ± 1.03 11.25 ± 2.75* 11.75 ± 3.34* alp (iu/l) 67.75 ± 5.23 72.25 ± 5.12 82.50± 10.62* 84.00 ± 8.43* albumin (mg/l) 39.25 ± 1.11 38.00 ± 0.71 36.50 ± 2.36 38.00 ± 0.58 total protein (mg/l) 64.25 ± 1.65 69.25 ± 1.89 62.50 ± 0.87 67.25 ± 2.56 total bilirubin (umol/l) 0.85 ± 0.07 0.98 ± 0.10 1.65 ± 0.82* 1.83 ± 0.70* direct bilirubin (umol/l) 0.25 ± 0.03 0.28 ± 0.03 0.65 ± 0.45* 0.75 ± 0.42* urea (μmol/l) 4.55 ± 0.55 4.30 ± 0.38 5.35 ± 0.27 5.00 ± 0.28 creatinine(μmol/l) 0.63 ± 0.17 0.53 ± 0.09 0.80 ± 0.09 0.53 ± 0.13 chloride (cl-) (mmol/l) 89.25 ± 0.63 97.50 ± 4.44 95.50 ± 3.66 98.50 ± 3.07 sodium (na+) (mmol/l) 133.75 ± 4.72 140.75 ± 1.93* 139.90± 4.66* 143.50± 2.84* potassium (k+) (mmol/l) 2.75 ± 0.12 4.27 ± 0.22* 4.10 ± 0.49* 3.90 ± 0.40* bicarbonate (hco3-) (mmol/l) 26.50 ± 1.71 25.00 ±2.12 26.75 ± 2.29 23.25 ± 1.80 data were expressed as mean ± sd.statistical analyses were performed using anova followed by bonferroni post hoc analysis. significant at *p<0.05 compared with the control. with an ld50 greater than 5000 mg/kg. besides, pharmaceutical compounds with ld50 greater than 1000 mg/kg are considered to be of very low toxicity or safe20. subacute doses of b. aegyptiaca extract at 200, 400, and 800 mg/kg did not cause significant changes in the body weights of animals for 28 days when compared to the control.body weight changes are a sensitive indicator of toxicity. an increased body weight suggests an episode of hypertrophy while a decrease suggests necrosis in the target organ21,22. nonetheless, organ weight data must be interpreted in an integrated approach with the biochemical and histopathology assessments23. at 200 mg/kg, aqueous fruit extract of b. aegyptiaca did not cause any significant biochemical and histopathological changes in animals for 28 days. but, estimation of the serum biochemical parameters at 400 and 800 mg/kg extract indicated significantly raised liver transaminases ast, alp, asp, and potassium ions. raised liver transaminases are classical laboratory findings in liver cell injury which measure the intracellular enzymes that have escaped into the blood circulation due to the changes in the cell membrane integrity increased liver enzyme activities24. the raised liver transaminases are in tandem with the histopathological changes which confirmed the presence of inflammatory cells in the liver and lung at 400 and 800 mg/kg extract.the findings were resembling those of jane et al.19 who reported increased liver enzymes following the administration of the stem bark extract of b. aegyptiaca. toxicological studies25,26,27 reported that medicinal plants induced toxicities in the heart, kidney, and testis and as such could be an important tool in toxicological assessments. however, b. aegyptiaca did not cause any observable histopathological changesin the heart, kidney,and testis of animals. the maintenance of normal histological features of animals exposed to b.aegyptiaca may result from the extract metabolism before reaching distant tissues to the liver27. the toxicities observed in the liver and lung could be due to some phytochemical constituents that are present in b.aegyptiaca. conclusion balanite aegyptiaca had an ld50 greater than 5000 international journal of human and health sciences vol. 07 no. 01 january’23 58 mg/kg, indicating its safety at the acute level. in the subacute assessment, extract at 200 mg/kg was not toxic. however, higher extract dosesof 400 and 800 mg/kg were toxic to the liver and lungs with raised liver transaminases and potassium ions. the toxicological effects suggest balanite aegyptiaca would be safe when controlled. acknowledgment: we acknowledged the technical support of abdulrahman in the animal’s house, faculty of pharmaceutical sciences, usmanu danfodiyo university, sokoto, nigeria. conflict of interest: none declared. funding: nothing to declare authors’ contribution: all authors were equally involved in data collection, analysis, manuscript preparation, revision and finalization. references: 1. islam m, sikder a, rashid ma, hossain k. phytopharmacological investigations of leaves of cissus trifoliata (l.).dhaka univ jpharm sci. 2022;21(1): 69-75. 2. chowdhury v, shristy nt, rahman h, chowdhury ta. qualitative phytochemical screening, fatty acid composition analysis and biological studies of trianthemaportulacastrum l. leaves. dhaka univ j pharm sci. 2022;21(1):33-43. 3. emon nu, rudra s, alam s, haidar a, paul s, richi ft, et al. chemical, biological and proteinreceptor binding profiling of bauhinia scandens l. stems provide new insights into the management of pain, inflammation, pyrexia, and thrombosis. biomed pharmacother. 2021;143:112185. 4. ukoha uu, mbagwu si, ndukwe gu, obiagbo c. histological and biochemical evaluation of the kidney following chronic consumption of hibiscus sabdariffa. hindawi publishing corporation. adv biol. 2015;1-5. 5. sagna mb, niang ks, guisse a,goffner d. 59 international journal of human and health sciences vol. 07 no. 01 january’23 balanites aegyptiaca (l.) delile: geographical distribution and ethnobotanical knowledge by local populations in the ferlo (north senegal)/balanites aegyptiaca (l.) delile: distribution géographique et connaissancesethnobotaniques des populations locales du ferlo (nordsénégal). biotechnologie, agronomie, société et environnement. 2014;18(4):503. 6. ibrahim ee. phytochemical, antioxidant activity, and cytotoxicity of methanolic extract of balanites aegyptiaca (l.) delile. pharmacieglobale. 2016;7(1):1. 7. hassan md, abdulkarim zi, mary m. effects of balanites aegyptiaca fruit pericarp on fructoseinduced hyperglycemia and hyperlipidemia in rats. asian jbiotech. 2020;12:87-96. 8. al-ashaal has. antidiabetic, cytotoxic, antioxidant and antitrematodal medicinal efficacy of polar and non-polar phytochemicals of balanites aegyptiaca del. asian pacj trop dis. 2017;7(12):797-805. 9. raushanara a, raquibul hsm, mokarram hm, mariam j, sultana sc, mazumder meh, et al. antidiarrhoeal and antioxidant properties of curcuma alismatifolia leaves. aust j basic appl sci. 2010;4(3):450-6. 10. putul m, sunit c, pritha b. neovascularisation offers a new perspective to glutamine-related therapy. ind. j. exp. biol. 2000;38:88-90. 11. elie by, shimon bs, noa g, bishnu pc, rui h. anti-proliferative activity of steroidal saponins from balanites aegyptiaca–anin vitro study. phytol. 2010;180. 12. gnoula c, megaliz zv, neve nd, sauvage s, ribaucour f, guissou p, et al. balanitin-6 and -7: diosgenyl saponins isolated from balanites aegyptiaca del. display significant anti-tumor activity in vitro and in vivo. int j oncol. 2008;32:515. 13. nelson ka, walsh d, abdullah o, mcdonnell f, homsi j, komurcu s, et al. common complications of advanced cancer. semin oncol. 2000;27(1):34-44. 14. raju j, mehta r. chemo-preventive and therapeutic effects of diosgenin, a food saponin. nutr. cancer. 2009;61(1):27–35. 15. salzman r, pácal l, tomandl j, kanková k,tóthováe, gál b,kostrica r, et al. elevated malondialdehyde correlates with the extent of the primary tumor and predicts poor prognosis of oropharyngeal cancer. anticancer res. 2009;29(10):4227-31. 16. ramos-vara, ja. technical aspects of immunohistochemistry. vet pathol. 2005;42(4):40526. 17. national institute of health (nih). guide for the use of laboratory animals dhhs, phs nih. 1985;8523. 18. organization for economic development. guideline for testing of chemicals. guidance no. 425. up and down procedure, adopted: 17th december 2001. 19. ugwah-oguejiofor cj, okoli co, ugwah mo, umaru ml, ogbulie cs, mshelia he, et al. acute and sub-acute toxicity of aqueous extract of aerial parts of carallumadalzielii n. e. brown in mice and rats. heliyon. 2018;5:e01179. 20. ibrahim h, williams fe, salawu km, usman am. phytochemical screening and acute toxicity studies of crude ethanolic extract and flavonoid fraction of carissa edulis leaves. biokemistri.2016;27(1):39-43. 21. arthur fkn, woode e, terlabi eo, larbie c.evaluation of acute and subchronic toxicity of annona muricata (linn.) aqueous extract in animals. eur j expbiol. 2011;1(4):115-24. 22. teo s, stirling d, thomass, hoberman a, kiorpes a, khetani v. a 90-day oral gavage toxicity study of d-methylphenidate and d, l-methylphenidate in spraguedawley rats. toxicol.2002;179(3):183e196. 23. sellers rs, morgan d, michaelb, roome n, johnson jk, yano bl, et al. society of toxicologic pathology position paper: organ weight recommendations for toxicology studies. toxicol. pathol. 2007;35(5):751e755. 24. gamde sm, kabiru h, abubakar a, abubakar k, musa a, perede a. histopathological and biochemical effects of aqueous leaf extract of cadabafarinosa on liver of adult wistar rats. int j res medsci. 2019;7(3):3716-21. 25. yakubu mt, akanji, ma,oladiyi at. hematological evaluation in male albino rats following chronic administration of aqueous extract of fadogiaagrestis stem. pharmacognosy magazine. 2007;3:34-38. 26. osigwe cc, akah pa,nworu cs. biochemical and hematological effects of the leaf extract of newbouldialaevis in alloxan-induced diabetic rats. j biosci medi. 2017;5:18-36. 27. hassaan ef, kadhim dj, younus mm. safety profile of biological drugs in clinical practice: a retrospective pharmacovigilance study. iraqi j. pharm. sci. 2022;31(1):32-42. 313 international journal of human and health sciences vol. 06 no. 03 july’22 original article effect of movement control order to emergency department visit in a teaching university hospital in malaysia during covid-19 wong chui king1, mohd. johar jaafar1,mohd. rizal haji manaf2, mohd. hisham isa1, ismail mohd. saiboon1 abstract background: implementation of lockdown was identified as a factor that affects the utilization of emergency department (ed) globally during covid-19 pandemic. objective: to compare the ed utilization rate based on different triage acuity during movement control order (mco) of covid-19 pandemic at a teaching university hospital in the capital of malaysia, kuala lumpur. methods: this retrospective study included patients presented to ed during mco i.e. march 18 to june 9 of 2020) and a similar period of pre-pandemic for comparison. patients were randomized and segregated to different triage categories. other outcomes determined include demographics, comorbidities, type of cases, mode of arrival and disposition. the data were analysed using chi-square test. results: distribution of cases based on triage acuity were consistent between mco and pre-pandemic period (p=0.063). lowest triage acuity (tg), had the highest utilization, followed by second triage acuity (ty) and finally highest triage acuity (tr). for tg, adult and elderly (p<0.001), married (p<0.001) and presence of comorbidities groups (p<0.001) were the main presenters and were more likely to require admission during mco (p=0.01). the ty categories were higher amongst adult and elderly (p<0.001) and married individuals (p=0.003) during mco. paediatric age-group was significantly low in both lower triage acuity categories. in term of ambulance arrival, majority of patients belongs to the ty acuity category (p=0.005). tr category patients did not demonstrate significant changes. conclusion: mco implementation during covid-19 pandemic did not change the rate of patient presentation based on triage acuity. however, pattern of cases in the lower triage acuity showed some differences. keywords: acuity utilization, covid-19 pandemic, emergency department, movement control order, triage correspondence to: dr.mohd johar jaafar, department of emergency medicine, faculty of medicine, universiti kebangsaan malaysia medical centre, jalan yaacob latif, 56000 kuala lumpur, malaysia. email: mdjoharjaafar@gmail.com 1. department of emergency medicine, faculty of medicine, universiti kebangsaan malaysia medical centre, jalan yaacob latif, 56000 kuala lumpur, malaysia. 2. department of community health, faculty of medicine, universiti kebangsaan malaysia medical centre, jalan yaacob latif, 56000 kuala lumpur, malaysia. international journal of human and health sciences vol. 06 no. 03 july’22 page :313-319 doi: http://dx.doi.org/10.31344/ijhhs.v6i3.465 introduction covid-19 which is caused by the ‘severe acute respiratory distress syndrome coronavirus 2’ (sars-cov-2) was first identified in the city of wuhan, china in december 2019 and since then it has been spreading rapidly across the globe.12world health organization (who) declared covid-19 as a pandemic on march 11, 2020. in order to reduce community spread of the disease, most of the countries have implemented measures such as lockdowns, stay-at-home orders or similar restrictions to slow down the spread of the disease. this serves as a temporary measures to reorganize, relocate healthcare resources and to prevent healthcare workers from burnout. malaysia responded to the covid-19 pandemic by implementing movement control order (mco) or international journal of human and health sciences vol. 06 no. 03 july’22 314 also known as ‘perintah kawalan pergerakan’ on 18th of march to 3rd of may, 2020. during mco, there were travel restrictions, large gatherings and religious activities were prohibited, all industries were ordered to close except essential services and all nurseries, schools, institute of higher learning were closed. the mco was successful in bringing down the total number of infected cases, thus, malaysia went into conditional movement control order (cmco) from may 4, 2020 whereby there was relaxation of regulations with the aim of reviving the economy in a controlled manner. cmco ended on june 9, 2020, with the country entering recovery movement control order subsequently.3 during the covid-19 pandemic, the emergency department (ed) which serves as a front-liner plays an important role in controlling the spread of the disease as well as managing non-covid conditions. few studies have shown that there was a reduction in ed patients’ volume during the pandemic.4-6however, there are scarce data regarding implementation of lockdown on the acuity of the ed visits globally. one study in australia concluded that state of emergency restriction was associated with a decreased in ed visits across all ed triages except the most urgent triage category.7 in malaysia, the triage service divides patients into three clinical zones based on patients’ acuity according to the malaysia triage system. it has three categories which consists of critical care service, triage red (tr); semi-critical service, triage yellow (ty) and non-critical care service, triage green (tg). critical care (tr) zone managed patients who are hemodynamically unstable and treatment should be immediately given. in ty, patients are hemodynamically stable and their lives are not in immediate danger. care should be provided within 15-20 minutes upon arrival. in tg category, patients are stable and do not require immediate care however should be seen within 90 minutes.8the aim of this study is to study the effect of mco during covid-19 pandemic on utilization of ed in terms of patient’s acuity in the emergency department in teaching university hospital in malaysia. methods this is a case-control retrospective study, which has been approved by the ethics committee of our institution. this hospital is a teaching university hospital which is located in the capital of malaysia, kuala lumpur. the ed is a mixed adult and paediatric ed which receives an average of 70,000 patients per annum. this study included patients that arrived to the ed from march 18 to june 9 of 2020 (mco during covid-19 pandemic) and from a similar period in 2019 (prepandemic). based on the number of sample size, seven days in each month of march 18 until june 9, 2020 and seven days in each month of march 18 until june 09, 2020 were randomly selected. therefore, a total of 21 days were chosen from the selected period from 2019 and 21 days from 2020 in order to get the required number of samples for each comparative period of before and during covid-19 pandemic. the dates were chosen randomly using computer generated random numbers where there were representative of all days in a week (including weekends). forty-three patients were randomly selected from the chosen day using computer generated numbers from the list of patients on the particular day which was arranged based on time of registration. a total of 903 patients were initially chosen from year 2019 (pre-pandemic) and 903 patients from a similar period in year 2020 (mco of covid-19 pandemic) as comparison. primary outcome measured were comparison between utilization rate of patients with different triage acuity that presented to the ed during mco of covid-19 pandemic and pre-pandemic. secondary outcome were association between patients’ characteristics and rate of different triage acuity utilization. all the patients’ details were extracted from hospital computerized record log (chets system) after randomization. patients’ triage category, characteristics of patients which consist of age, gender and marital status, mode of arrival, presence of comorbidities, types of cases and disposition were determined, entered, cleaned and coded accordingly. all categorical data were compared using chi-square test. statistical analyses wasdone using spss version 24.0. results a total of 871 from pre-pandemic and 880 patients during mco were collected (response rate of 96.5% and 97.5% respectively). this study showed that triage utilization of different acuity did not defer significantly during mco of covid-19 pandemic period as compared to pre-pandemic 315 international journal of human and health sciences vol. 06 no. 03 july’22 period with the utilization of lowest acuity triage, the non-critical tg remained the highest, followed by semi-critical ty and triage of highest acuity which is the critically ill tr (p=0.056) (figure 1). there were significantly more adult (age 15 to 64) and elderly (>65) patients that visited our ed during mco in both tg (p<0.001) and ty (p<0.001) whereas utilization amongst paediatric age groups were significantly lesser (table 1). no association was found between age group and mco implementation in tr (p = 0.524). analysis on gender did not find significant association between gender and utilization across all triage acuity during mco. tg (p=0.290), ty (p=0.368) and tr (p=0.194). on the other hand, analysis on marital status found association between marital status and mco implementation in tg (p<0.001) and ty (p=0.003)with non-married more likely to visit ed during pre-pandemic period and married more likely to visit ed during mco. there was no significant association found in patients in tr (p=0.522). patients in tg with presence of comorbidities were associated with higher ed utilization during mco (p<0.001). patients in ty and tr with presence of comorbidities had similar findings but did not reach statistical significance. ty (p=0.080), tr (p=0.811) (table 2). ambulance arrival was significantly more during mco compared to prepandemic period amongst ty patients (p=0.005). figure 1. utilization of triage acuity during pre-pandemic and during mco of covid-19 pandemic however, in tr, ambulance arrival was more during mco but it was not statistically significant (p=0.259). there were no significant association between type of cases (trauma and non-trauma) and mco implementation across all triage acuity. tg (p=0.333), ty (p=0.828) and tr (p=0.736). however, we found higher non-trauma cases in tg and ty and more trauma cases in tr during mco period. in term of patient disposition, tg had significantly more patients who were being managed and required in-patient care during mco (p=0.01). no significant difference was observed in between those two periods in term of disposition amongst patients in tr (p=0.952) and ty (p=0.257). table 1.comparison for utilization according to patients’ demographics between mco of covid-19 pandemic vs pre-pandemic using chi-square test for all triage categories variables triage utilization rate of periods studied number of patients (n), percentage (%) p value 2019 2020 age green <14 150(32.1%) 74(14.2%) <0.001 15 to 64 242(51.8%) 359(68.9%) >65 75(16.1%) 88(16.9%) total 467 521 yellow <14 68(20.4%) 21(7.3%) <0.001 15 to 64 177(53.2%) 175(60.6%) >65 88(26.4%) 93(32.2%) total 333 289 red <14 9(13.6%) 5(7.7%) 0.524 15 to 64 27(40.9%) 30(46.2%) >65 30(45.5%) 30(46.2%) total 66 65 international journal of human and health sciences vol. 06 no. 03 july’22 316 variables triage utilization rate of periods studied number of patients (n), percentage (%) p value 2019 2020 gender green male 265(56.5%) 278(53.2%) 0.290 female 204(43.5%) 245(46.8%) total 469 523 yellow male 187(56%) 153(52.4%) 0.368 female 147(44%) 139(47.6%) total 334 292 red male 38(56.7%) 44(67.7%) 0.194 female 29(43.4%) 21(32.3%) total 667 65 marital status green married 190(40.7%) 312(60.2%) <0.001 non-married 277(59.3%) 206(39.8%) total 467 518 yellow married 195(59.6%) 199(71.1%) 0.003 non-married 132(40.4%) 81(28.9%) total 327 280 red married 46(70.8%) 47(75.8%) 0.522 non-married 19(29.2%) 15(24.2%) total 65 62 table 2. comparison for utilization according to patients’ presence of comorbidities, mode of arrival, type of cases and disposition between mco of covid-19 pandemic vs pre-pandemic using chisquare test for all triage categories variables triage presence of comorbidities utilization rate number of patients (n), percentage (%) p value 2019 2020 presence of comorbidities green present 177(38.1%) 266(51.1%) <0.001not present 288(61.9%) 255(48.9%) total 465 521 yellow present 232(69.7%) 221(75.9%) 0.080not present 101(30.3%) 70(24.1%) total 333 291 red present 53(82.8%) 54(84.4%) 0.811not present 11(17.2%) 10(15.6%) total 64 64 mode of arrival yellow non-ambulance 309(92.5%) 250(85.6%) 0.005ambulance 25(7.5%) 42(14.4%) total 334 292 red non-ambulance 52(76.5%) 44(67.7%) 0.259ambulance 16(23.5%) 21(32.3%) total 68 65 317 international journal of human and health sciences vol. 06 no. 03 july’22 variables triage presence of comorbidities utilization rate number of patients (n), percentage (%) p value 2019 2020 type of cases green trauma 71(15.1%) 68(13%) 0.333non-trauma 398(84.9%) 455(87%) total 469 523 yellow trauma 36(10.8%) 30(10.3%) 0.828non-trauma 297(89.2%) 262(89.7%) total 333 292 red trauma 7(10.4%) 8(12.3%) 0.736non-trauma 60(89.6%) 57(87.7%) total 67 65 disposition green assessed and requiring in-patient care 45(9.7%) 79(15.1%) 0.010 assessed and can be discharged 421(90.3%) 444(84.9%) total 466 523 yellow assessed and requiring in-patient care 191(57.2%) 180(61.6%) 0.257 assessed and can be discharged 143(42.8%) 112(38.4%) total 334 292 red assessed and requiring in-patient care 60(89.6%) 58(89.2%) 0.952assessed and can be discharged 7(10.4%) 7(10.8%) total 67 65 discussion the emergence of the unprecedented covid-19 pandemic has changed pattern of utilization of the ed in various ways in different countries with most countries reported a decrease in utilization across all triage categories.4,9-10this study demonstrated that triage utilization of different acuity did not defer significantly during mco of covid-19 pandemic period as compared to pre-pandemic period. however, we found that utilization of tg was higher amongst patients with presence of comorbidities group and tg patients were also more likely to be admitted for in-patient care during mco compared to pre-pandemic period. with these findings, it is postulated that patients that visited the ed during mco had higher acuity compared to pre-pandemic period although they present to the lowest acuity triage category. these patients had acute conditions which required emergency care and hospitalization. in addition, the study found that ambulance arrival was significantly more during mco for ty patients which support the postulation that patients that arrive during mco had higher diagnoses acuity. previous study had shown that patients who arrived by ambulance had higher acuity level and they suffered more severe illness.11 the covid-19 pandemic has brought multiple negative impacts to both physical and mental health. the implementation of mco had jeopardized jobs and incomes of individuals especially in those with lower income group.12-13with loss of income especially to the breadwinner of the family, the food security of the family is under threat. thus, it is expected that more populations will have poor nutrition and poor health.14 in addition, losing job disrupts one’s mental health. it heightened the feeling of anxiety and insecurity leading to more depression. certain individuals may even resort to illicit drug use or alcohol abuse as a coping mechanism which lead to more health problems. besides, the order for social distancing itself international journal of human and health sciences vol. 06 no. 03 july’22 318 may put individual’s mental health at stake by disrupting their social rhythm which may be the only way for them to cope with stress.15 patients with presence of comorbidities such as hypertension, chronic lung disease, cardiovascular disease and obesity who contracted covid-19 were reported to have poorer outcome compared to patients without comorbidities.16thus, there have been warnings by public health professionals to these groups of patients to prevent themselves from getting infected. with this knowledge, patients with comorbidities may have heightened anxiety and may seek treatment at the ed when they develop any symptoms. this may explain the higher attendance amongst patients with comorbidities to tg during mco. besides, there was a significant reduction of paediatric age groups in both lower acuity categories during mco. similar findings were recorded such as studies in argentina and canada which found significant reduction in ed visits amongst children and young people especially during the lockdown period.5,17with the implementation of mco, children and younger people’s activities were more restricted due to school, colleges, and universities closure and on top of that, sports activities were not allowed as well. physical distancing with school closures may play a role in reducing spread of covid-19 cases as well as other transmissible diseases, thus reducing the number of sick children. another possible explanation for the observed reduction in paediatric visits may be parental fear of contracting covid-19 disease in the hospital. the reduction in attendance amongst the younger age group may reflect a possible delay in seeking appropriate medical treatment. when comparing general ed and paediatric ed, goldman et al.17 reported that parents had greater preference for paediatric ed and they avoided ed in a general hospital due to the perception of general ed potentially attend more adult covid-19 patients. in the analysis of patients from triage of highest acuity, the tr showed that there was no significant association between age group and mco implementation during covid-19 pandemic. it may be due to the urgent nature of the disease which requires immediate attention that present to the category. this study found that married individuals in lower triage acuity to have higher ed utilization during mco. evidence has shown that marital status is associated with individual’s health status with married individuals have better mental health compared to non-married individuals.18 the exact reason for higher utilization of lower acuity triage amongst married individuals was unclear. earlier report noted a decrease in number of cases of motor vehicle collision during covid-19 pandemic.4 a decline in numbers of trauma due to motor vehicle collision is expected due to the movement restriction, remote work, stay at home orders and closure of businesses. however, this study did not find any association between type of cases (trauma or non-trauma) and implementation of mco during covid-19 pandemic across all triage categories. one possible explanation is that this study included all type of trauma patients that also include any traumas that occurs at home. therefore, further study is required to study association between trauma due to motor vehicle collision and mco implementation. limitationsof the study this study was conducted in an ed of a teaching university hospital and may not be representative of other hospitals in malaysia. in addition, we only included ambulance arrival through our hospital’s ambulance. lack of reporting regarding arrival through other ambulance services is one of the limitations. conclusion in summary, this study found that implementation of mco during covid-19 pandemic did not change the rate of patient presentation based on triage acuity. however, there were some differences in pattern of cases in lower triage acuity. although the exact reason for these changes requires further investigation, it is crucial for physicians and public health professionals to emphasize on the importance for seeking medical treatment for urgent medical problem during mco of covid-19 pandemic. conflict of interest: the authors declare no competing interest. ethical approval:the study was approved by the ethics review committee of the faculty of medicine, universiti kebangsaan malaysia, kuala lumpur, malaysia. funding statement: nil. authors’ contribution: all authors were involved equally in subject selection, data collection, analysis, manuscript writing, revision and finalizing. 319 international journal of human and health sciences vol. 06 no. 03 july’22 references 1. li q, guan x, wu p, wang x, zhou l, tong y. early transmission dynamics in wuhan, china, of novel coronavirus–infected pneumonia. n engl j med.2020;382:1199-1207. 2. who. naming the coronavirus disease (covid-19) and the virus that causes it. world health organization. web site. available athttps://www.who. int/emergencies/diseases/novel-coronavirus-2019/ technical-guidance/naming-the-coronavirus-disease(covid-2019)-and-the-virus-that-causes-it. [accessed november 24, 2020]. 3. koya z. conditional movement control order extended for another four weeks to june 9. the star.https://www.thestar.com.my/news/ nation/2020/05/10/conditional-mco-extended-foranother-four-weeks-to-june-9#:~:text=%22on%20 the%20advice%20of%20the,be%20enforced%20 until%20june%209. published 2020.[accessed november 24, 2020]. 4. boserup b, mckenney m, elkbuli a. the impact of the covid-19 pandemic on emergency department visits and patient safety in the united states. am j emerg med.2020;38(9):1732-1736. 5. ferrero f, ossorio mf, torres fa, debaisi g. impact of the covid-19 pandemic in the paediatric emergency department attendances in argentina. arch dis child. 2021;106:e5. 6. jeffery mm, d’onofrio g, paek h, platts-mills tf, soares we, hoppe ja, et al. trends in emergency department visits and hospital admissions in health care systems in 5 states in the first months of the covid-19 pandemic in the us. jama intern med.2020;180(10):1328-1333. 7. mitchell rd, o’reilly gm, mitra b, smit dv, miller jp, cameron pa. impact of covid‐19 state of emergency restrictions on presentations to two victorian emergency departments. emerg med australas.2020;32(6):1027-33. 8. medical development division. emergency medicine and trauma services policy. malaysia: ministry of health malaysia,2012.available at https://www.moh. gov.my/moh/images/gallery/polisi/emts_book.pdf. [accessed november 24, 2020]. 9. hartnett kp, kite-powell a, devies j, coletta ma, boehmer tk, adjemian j, et al. national syndromic surveillance program community of practice. impact of the covid-19 pandemic on emergency department visits—united states, january 1, 2019– may 30, 2020. mmwr morb mortal wkly rep. 2020;69(23):699-704. 10. kam aw, chaudhry sg, gunasekaran n, white aj, vukasovic m, fung at. fewer presentations to metropolitan emergency departments during the covid‐19 pandemic. med j. aust2020;213(8):370-1. 11. mould-millman cnk, rominski s, oteng r. ambulance or taxi? high acuity prehospital transports in the ashanti region of ghana. afr j emerg med.2014;4(1):8-13. 12. lim ll. the socioeconomic impacts of covid-19 in malaysia: policy review and guidance for protecting the most vulnerable and supporting enterprises. malaysia: international labour organization, 2020. available at http://ilo.org/wcmsp5/groups/ public/---asia/---ro-bangkok/documents/publication/ wcms_751600.pdf. [accessed november 24, 2020]. 13. teo d. 1 in 5 malaysians out of job due to covid-19. hrmasia. https://hrmasia.com/1-in-5-malaysians-outof-job-due-to-covid-19/. published 2020.[accessed november 26, 2020]. 14. who. impact of covid-19 on people’s livelihoods, their health and our food systems. web site. available at:https://www.who.int/news/item/13-10-2020impact-of-covid-19-on-people’s-livelihoods-theirhealth-and-our-food-systems. [accessed december 14, 2020]. 15. shanmugam h, juhari ja, nair p, ken cs, guan nc. impacts of covid-19 pandemic on mental health in malaysia: a single thread of hope. malaysian j psychiatr.2020;29(1):78-84. 16. sanyaolu a, okorie c, marinkovic a, patidar r, younis k, desai p, et al. comorbidity and its impact on patients with covid-19. sn compr. clin. med. 2020;1069-76. 17. goldman rd, grafstein e, barclay n, irvine ma, portales-casamar e. paediatric patients seen in 18 emergency departments during the covid-19 pandemic. emerg med j.2020;37(12):773-7. 18. uecker je. marriage and mental health among young adults. j health soc behav.2012;53(1):67-83. 117 international journal of human and health sciences vol. 07 no. 02 april’23 original article relationship between burnout syndrome symptoms and demographic characteristics among long-term covid-19 hospital healthcare workers in south sumatra, indonesia ardi artanto1, dientyah nuranggina1 , ahmad ghiffari2, dimas farizul huda3, ridha ilma4 abstract background: during the covid-19 pandemic, the workload of health professionals grew significantly, particularly in the service sector. such heavy workload, particularly for those working on the front lines, can result to burnout syndrome. objective: to find the correlation between long-term covid-19 service personnel characteristics and burnout syndrome symptoms at hospitals. methods: this cross-sectional, analytic study was done on health workers that managed covid-19 at palembang muhammadiyah hospital and palembang bari hospital in south sumatra, indonesia. purposive sampling was used to sample, with 88 samples total that satisfied the inclusion and exclusion criteria. a questionnaire was filled out to collect the data. results: based on the research results of data sets, there was a correlation between age and burnout syndrome (p=0.000), sex and burnout syndrome (p=0.006), covid-19 service period and burnout syndrome (p=0.002), working hours per day and burnout syndrome (p=0.014), and marital status and burnout syndrome (p=0.013). conclusion: long-term covid-19 service personnel and burnout syndrome symptoms in those hospitals are directly interrelated. keywords: health professionals, covid-19 hospital, work overload, burnout syndrome, covid-19 pandemic correspondence to: ardi artanto, department of community and family medicine, faculty of medicine, universitas muhammadiyah palembang, south sumatra, indonesia, e-mail: ardi.artanto.spok@gmail.com 1. dept. of community and family medicine, faculty of medicine, universitas muhammadiyah palembang, south sumatra indonesia 2. dept. of parasitology, faculty of medicine, universitas muhammadiyah palembang, south sumatra indonesia 3. undergraduate program, faculty of medicine, universitas muhammadiyah palembang, south sumatra indonesia 4. english education study program, faculty of education and teaching, universitas islam negeri raden fatah, south sumatera indonesia introduction coronavirus disease 2019 (covid-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (sarscov-2).1 covid-19 cases are increasing in number from time to time. in the world, the number of cases of covid-19 was recorded at 198,547,026 cases with a death rate of 4,232,892 cases as of august 1, 2021. as of august 1, 2021, in indonesia, there were 3,440,396 cases of covid-19 with a total number of 95,723 deaths.2 in south sumatra province, the number of positive cases of covid-19 increased by 48.7% in the last week. there were 47,757 cases of covid-19 with a death rate of 2,137 cases. in the city of palembang, there were 25,216 covid-19 cases and 887 deaths.3 the covid-19 epidemic has increased the load on the health-care system, notably on health-care personnel. health professionals, particularly those on the front lines, are very susceptible to catching covid-19, putting their lives and safety at danger. aspects of mental health, such as the possibility of mental exhaustion or burnout syndrome, can also be impacted by personal safety, infection prevention, and productivity of health worker international journal of human and health sciences vol. 07 no. 02 april’23 doi: http://dx.doi.org/10.31344/ijhhs.v7i2.560 international journal of human and health sciences vol. 07 no. 02 april’23 118 services. 4 risks to health professionals arise, and in this era of pandemics it is undoubtedly necessary to develop a policy framework for surveillance.4 a high rate of burnout was observed among doctors during the covid-19 pandemic, resulted of the burnout syndrome subscale were significantly predicted by age, job title, length of employment, and hours worked per day.5 the purpose of this research is to analyze the relationship between the characteristics of long-term covid-19 service workers and the symptoms of burnout syndrome in hospitals in palembang. methods between december 2021 and january 2022, this cross-sectional, analytic study was done among healthcare workers dedicated to covid-19 related services in palembang muhammadiyah hospital and palembang bari hospital in south sumatra, indonesia. all healthcare practitioners who work with covid-19 are required to fill out a questionnaire regarding their qualities and burnout risk. the study’s sample consisted of 88 respondents who were chosen by purposeful sampling. the inclusion criteria for the study required participants to be willing research participants and to have worked in the covid-19 ward for at least three months. respondents who were unwell or absent throughout the study and who did not fill out the questionnaire in its entirety were omitted from the analysis. on the basis of the research done, 88 respondents were sampled: 50 from palembang muhammadiyah hospital and 38 from palembang hospital bari. the statistical analysis was done using the statistical package for social sciences (spss) version 22.0 for windows (spss inc., chicago, illinois, usa). data analysis was univariate and bivariate. chi-square test, and alternative kolmogorov-smirnov test yielded p values. a p-value <0.05 was considered as statistically significant. results table 1 displays that the majority of respondents (35.2%) are between the ages of 18-35 and 36-45. table 2 reveals that the majority of respondents are female, with 63 female respondents (71.6%), and 25 male respondents (28.4%). according to table 3, 69 respondents are married (78.4%), whereas 19 respondents are single (21.6%). table 4 indicates that 58.0% of respondents have a three-month working period. this equates to 51 individuals. table 5 reveals that the greatest number of respondents with work duration >7 hours is 53 (60.2%). 18 respondents (20.5%) were diagnosed with mild burnout syndrome, 44 respondents (50%) were diagnosed with moderate burnout syndrome, and 26 respondents (29.5%) were diagnosed with severe burnout syndrome (table 6). table 7 shows a significant correlation between the age of covid-19 service personnel and symptoms of burnout syndrome in palembang hospitals. moreover, there is a significant link between the gender and symptoms of burnout syndrome (table 8). there is a significant link between the marital status of covid-19 service personnel and symptoms of burnout syndrome in palembang hospitals (table 9). we also found a strong correlation between the service duration of covid-19 service personnel and symptoms of burnout syndrome (table 10). there is a significant link between covid-19 service workers’ daily working hours and symptoms of burnout syndrome (table 11). table 1: age frequency distribution of health workers (n=88) age years old amount percentage 18-35 (early adult) 31 35.2 36-45 (late adulthood) 31 35.2 46-60 (elderly) 26 29.5 total 88 100 table 2: gender frequency distribution of health workers (n=88) gender amount percentage man 25 28.4 woman 63 71.6 total 88 100 table 3: marital status frequency distribution of health workers (n=88) marital status amount percentage marry 69 78.4 not married yet 19 21.6 total 88 100 table 4: service period frequency distribution (n=88) covid-19 service period amount percentage < 3 months 37 42.0 > 3 months 51 58.0 total 88 100 119 international journal of human and health sciences vol. 07 no. 02 april’23 table 5: working hours per day frequency distribution (n=88) working hours per day amount percentage 7 hours 35 39.8 > 7 hours 53 60.2 total 88 100 table 6: burnout syndrome levels frequency distribution (n=88) burnout syndrome rate amount percentage light 18 20.5 currently 44 50.0 heavy 26 29.5 total 88 100 table 7. age relationship with burnout syndrome age (years old) burnout syndrome p valuelight moderate heavy n % n % n % 18-35 4 12.9 23 74.2 4 12.9 0.000 36-45 8 25.8 16 51.6 7 22.6 46-60 6 23.1 5 19.2 15 57.7 total 18 14.8 44 50.0 26 29.5 table 8: gender relationship with burnout syndrome gender burnout syndrome p valuelight moderate heavy n % n % n % man 9 36.0 6 24.0 10 40.0 0.006woman 9 14.3 38 60.3 16 25.4 total 18 20.5 44 50.0 26 29.5 table 9: marital status relationship with burnout syndrome marital status burnout syndrome p valuelight moderate heavy n % n % n % marry 8 11.6 36 52.6 25 36.2 0.013not married 10 52.6 8 42.1 1 5.3 total 18 20.5 44 55.0 26 29.5 table 10: covid-19 service period relationship with burnout syndrome covid-19 service period burnout syndrome p valuelight moderate heavy n % n % n % < 3 months 14 37.8 16 43.2 7 18.9 0.002> 3 months 4 7.8 28 54.9 19 37.3 total 18 20.5 44 55.0 26 29.5 table 11: working hour per day relationship with burnout syndrome working hours per day burnout syndrome p valuelight moderate heavy n % n % n % 7 hours 12 34.3 17 48.6 6 17.1 0.014>7 hours 6 11.3 27 50.9 20 37.7 total 18 20.5 44 50.7 26 29.5 discussion 18 respondents (20.5%) had mild burnout syndrome, 44 had moderate, and 26 had severe. the service sector has a higher risk of burnout, which explains its high occurrence. during the epidemic in china, health care workers had to adapt to a new work environment, a heavier workload, a lack of personal protective equipment, and the fear of getting the disease and infecting others. burnout syndrome is caused by feeling powerless to help a patient and managing difficult relationships.6 burnout syndrome (bos) causes psychological, emotional, and physical stress. 82% of health professionals in indonesia have had moderate burnout syndrome, and 1% with severe psychological degrees are at danger of negatively damaging their quality of life and labor efficiency in the health services.7 late adults to the elderly (ages 46 to 60) exhibited a more worse form of burnout syndrome, according to the study. this may be due to the epidemic, which demands nurses to remain in constant contact with patients, causing fatigue. senior nurses have more influence over their work and are more motivated to perform well.8 senior nurses’ tasks are physically, emotionally, and mentally draining. 16 female responders experienced severe burnout syndrome, according to the study. using chiinternational journal of human and health sciences vol. 07 no. 02 april’23 120 square testing, a significant correlation was found between the sex of covid-19 service employees and burnout syndrome symptoms in palembang hospitals. sari (2015) found a 0.000 p-value between nurse gender and exhaustion.9 women are more sensitive to depression, which is influenced by their environments, including coworker arguments, challenging patients, and the family situation. the epidemic raises nurses’ stress, which affects this outcome. working with ppe is stressful, especially when mixed with the fear of contracting a sickness and infecting family members.10 men who treat patients are more apathetic, thus male nurses experience less burnout.11 25 married respondents had significant burnout, according to observations. married health practitioners may have more financial and social responsibilities. the kolmogorov-smirnov test found a p-value of 0.013 between covid-19 service members’ marital status and burnout symptoms in palembang hospitals. sari (2015) at sanglah hospital showed a significant association between marital status characteristics and burnout syndrome with a p-value of 0.015.9 in a pandemic, health care workers with a high risk of contracting the disease may worry about infecting their family, causing stress. a married person must also support their family and attend social events. this overburdens married women with responsibilities, causing stress. more than three months of covid-19 service was related with significant burnout, according to the study. the statistical test found a 0.002 p-value between covid-19 service length and burnout syndrome symptoms in palembang hospitals. this is congruent with sari’s (2015) research, which shows a substantial connection between tenure and burnout syndrome.9 during the covid-19 pandemic, nurses play a critical role as the first line in conducting evaluations, decreasing difficulties with close monitoring, performing emergency actions, and addressing crisis circumstances that may result in high pressure and burnout syndrome. physical (workload) stress causes poorer muscular performance and slower movement.12 this scenario is caused by a combination of factors, such as a heavy workload and daily pressures. according to the study, severe burnout was more common among those who worked more than seven hours a day. the statistical test showed a p-value of 0.014, indicating a connection between covid-19 service professionals’ daily working hours and burnout symptoms in palembang hospitals. sari’s (2015) research on nurses at sanglah hospital discovered a p-value of 0.006 between workload and burnout syndrome (p-value 0.05).9 this may be due to the long hours nurses work, which can lead to fatigue or boredom, stress, and lower job satisfaction. the absence of proven medicines and the vast number of patients contribute to the established work shifts during the covid-19 epidemic. extreme work stress can cause nurse burnout.12,13 limitations of the study during the data collection process, not all types of work were accounted for. the on-duty laboratory workers, radiology technicians, and physicians did not adequately reflect all sorts of healthcare workers who deal with the covid-19 pandemics in those hospitals. conclusion the findings revealed a substantial association between the characteristics of long-term covid-19 service staff and symptoms of burnout syndrome in palembang hospitals. it is suggested that additional research be conducted on additional aspects, such as individual effort factors, organizational effort factors, and work environment, which may lead to burnout syndrome among covid-19 service professionals. conflict of interest: none declared. funding statement: no funding. ethical approval: this research has been approved by research ethics committee faculty of medicine universitas muhammadiyah palembang, south sumatra, indonesia. no. 029/ec/kbhki/ fk-ump/xi/2021 authors’ contribution: concept and design: aa; data collection: aa, dfh, ag; data compilation and statistical analysis: dna; manuscript writing, revision and finalizing: aa, dfh, ag, dna. 121 international journal of human and health sciences vol. 07 no. 02 april’23 references 1. ghiffari a, hasyim h, iskandar i, kamaluddin mt, anwar c. sars-cov-2 variants of concern increased transmission and decrease vaccine efficacy in the covid-19 pandemic in palembang indonesia. acta biomed. 2022;93(8):1-11. 2. worldometers. coronavirus update [internet]. https://www.worldometers.info/coronavirus/. 2021 [cited 2021 aug 1]. available from: https://www. worldometers.info 3. ghiffari a, purwoko m, fitriani y, hotlan m. vaccination coverage and transmission of covid-19 in palembang. 2022;(5):90-4. 4. nisa aa, rahayu t, wijayanti y, azam m, budiono i, fauzi l. strategi dalam tindakan pencegahan covid19 melalui surveilans dan promosi kesehatan. higeia j public heal res dev. 2021;5(2):283-91. 5. elghazally sa, alkarn af, elkhayat h, ibrahim ak, elkhayat mr. burnout impact of covid-19 pandemic on health-care professionals at assiut university hospitals, 2020. int j environ res public health. 2021;18(10):5368. 6. fumis rrl, costa elv, dal’col svc, azevedo lcp, pastore junior l. burnout syndrome in intensive care physicians in time of the covid-19: a cross-sectional study. bmj open. 2022;12(4):e057272. 7. fkui. 83% tenaga kesehatan indonesia mengalami burnout syndrome derajat sedang dan berat selama masa pandemi covid-19 fkui. humas fkui. 2020. p.1. 8. hartono b, hidayati a, kurniati t, basir n. the effect of heads’ leadership and nurses’ job motivation on nursing performance in the hospital inpatient room. j adm kesehat indones. 2020;8(2):175. 9. sari dy. hubungan beban kerja, faktor demografi, locus of control dan harga diri terhadap burnout syndrome pada perawat pelaksana ird rsup sanglah. coping ners j. 2015;3(5):51-60. 10. eliyana e. factors related to the executive nurse’s burnout in patient wards at rsj west kalimantan province in 2015. j adm rumah sakit indones. 2016;2(3):172–82. 11. ayudytha au, putri da. faktor-faktor yang mempengaruhi burnout pada perawat diruang rawat inap rs pmc. real nurs j. 2019;2(3):144. 12. stults-kolehmainen ma, sinha r. the effects of stress on physical activity and exercise. sports med. 2014;44(1):81-121. 13. said r, sjattar el. factors related to burnout in nurses in ward of wajo regency general hospital. j empower community educ. 2021;1(2):47-53. s25 a healthy young lady with ‘unprovoked’ persistent bilateral pulmonary embolism why? dr muhammad farid bin mohd fauad1, dr hazlyna baharuddin1, dr mohd arif mohd zim1, dr bushra johari1 abstract pulmonary embolism (pe) was reported in about 9% patients with antiphospholipid syndrome (aps). seronegative aps is an entity which demonstrates clinical manifestations highly suggestive of aps but persistently negative aps antibodies. a 31-year-old lady presented with a two-month history of exertional dyspnoea. she had two consecutive miscarriages at 12 and 14 weeks, previously. physical examination revealed a thin lady who was tachycardic, tachypneic, hypoxic but normotensive. there was a loud p2 without signs of heart failure. investigations revealed a type 1 respiratory failure, sinus tachycardia with right ventricular strain pattern, cardiomegaly with normal lung fields, and dilated right atrium and right ventricle with increased in pulmonary arterial pressure of 70mmhg from echocardiography. ct pulmonary angiography (ctpa) confirmed the presence of pe over bilateral pulmonary arteries. she continued to have exertional dyspnoea and was readmitted 9 months later with worsening dyspnoea. aps antibodies performed during both admissions were negative. seronegative aps was diagnosed. interestingly, two ctpas performed at 6 months and 9 months after initial presentation revealed persistent bilateral pulmonary embolism. the provoking factors for pe should be sought because ‘unprovoked’ pe especially in young individuals need further attention. aps, including seronegative aps, should be considered. persistence of symptoms of pe also warrants further attention as chronic thromboembolic pulmonary hypertension (cteph) may be the cause. currently, there are available medical and surgical treatment of cteph, therefore establishing its diagnosis is important and it is best performed in pulmonary hypertension expert centre. keywords: pulmonary embolism; seronegative anti-phospholipid antibodies, chronic thromboembolic pulmonary hypertension (cteph) 1. department of internal medicine, faculty of medicine, universiti teknologi mara doi: http://dx.doi.org/10.31344/ijhhs.v5i0-2.343 http://dx.doi.org/10.31344/ijhhs.v5i0-2.343 international journal of human and health sciences vol. 07 no. 02 april’23 202 case report the effect of “seiza” sitting position during dzikr after moslem prayer on stomach circumference changes: a case report rakhazidane muhammad1*, amiroh kurniati1$, trianggoro budisulistyo2†, nirmala safitri3% abstract introduction.the japanese floor-sitting seiza is reflected of femoral artery pinched, which improved of tissues oxygenation and circulation. it might play role on body metabolism, also the nerves system. methods: study was conducted on a 20-year-old obese man performed routinely dzikr with seiza sitting, so the time duration counted. stomach circumference and body weight was monitoring twice weekly until 1 month. results: the stomach circumference measurements of 114 cm observed improvement, as at week 1 (1.75%), week 2 (0.88%), week 3 (63%), and week 4 (3.51%) underwent 316 to 334 seconds weekly of seiza sittings. a 100,4 kg of body weight showed gradually improvement: 0.55%, 0.35%, 0.25%, and 1.89% in each weeks. discussion: the seiza sitting might be relate to st36 meridian points. it stimulated of parasympathetic system, digest and absorption, aliementary glands activated, also fat metabolism. conclusions: the seiza sitting during dzikr after prayer might improve of body metabolism. keywords: stomach, circumference, metabolism, seiza, sitting, dzikr, moslem prayer correspondence to: email: zidanetennyson944@gmail.com 1. faculty of medicine sebelas maret university, surakartaindonesia 2. faculty of medicine diponegoro university, semarangindonesia 3. central java provincial health office 4. department of clinical pathology 5. department of neurology, pain and minimally invasive %: division of nutritional and family health introduction seiza is a sitting position popularized in japanese culture. this is done by bending the knees and extending the ankle joints. this sitting position is commonly used in formal occasions, religious rituals, and accepting guests.1 former research studies suggested, that seiza sitting position may help with digestive system function, food absorption, and defecation.2 obesity is a condition marked by the high amount of fat deposits inside the body. this high body fat might affect physical activities and induce underlying diseases. obesity can be measured by using a bmi scale, where we compare body weight to body height ( in meters) squared. the results then can be classified as lean, overweight, and obese. we recommend the seiza sitting position for obese patients to help improve digestive functions, ease the process of defecation, and increase peristaltic activity. obese patients in indonesia increase as time goes by, with the prevalence of obese patients over 18 years old at 11,7% in 2010, 15,4% in 2013, and 21,8% in 2018. the risk factors for obesity in indonesia are over-eating above the recommended daily intake coupled with a sedentary lifestyle. this is further proven by an independent survey conducted by the ministry of health in 2014, where 40,7% of participants consumed fatty foods; 53,1% of participants consumed sweets, and; 26,1% of participants lived a sedentary international journal of human and health sciences vol. 07 no. 02 april’23 doi: http://dx.doi.org/10.31344/ijhhs.v7i2.575 mailto:zidanetennyson944@gmail.com 203 international journal of human and health sciences vol. 07 no. 02 april’23 lifestyle. commonly body weight or fat deposit treatment is difficult, as it needs self-commitment and discipline. managing obesity is also difficult on older patients as they may need more attention and they may have developed degenerative conditions that limits physical ability. in regards to this issue, we proposed the idea of seiza sitting as it is possible to be done on a wide range of patients, provided they didn’t suffer from muscle atrophy or neuropathy. methods this is a case report on a single subject, which was conducted by training the subject to sit in a seiza sitting position for the duration of their dzikr. the subject did this for 4 weeks and was asked to record the duration with a stopwatch. the results were rounded up/down accordingly. then, body weight and stomach circumference were measured twice a week –at the beginning of the week and the end of the week. 5.1 5.2 5.3 5.4 5.5 dzikr duration average dzikr duration in each week week 1 week 2 week 3 week 4 80.1 90.1 100.1 110.1 120.1 week 1 week 2 week 3 week 4 physical changes after applying seiza body weight stomach circumference the seiza sitting posture as practiced by the subject. note the plantar-flexion followed by knee-flexion and straight back results dzikr duration varies between 316 to 334 seconds during the observation. weekly dzikr duration averaged 337 seconds on week 1, 327 on week 2, 346 on week 3, and 336 on week 4. stomach circumference started at 114 cm, then goes as low as 112 cm at the end of the first week. then, week 2 stayed at 112 cm, and weeks 3 and 4 showed a reduction of up to -1cm in stomach circumference. body weight starts at 100,4kg, then goes down and stayed between 99,4 to 99,6kg for the rest of the week. from these results, we conclude that there is a correlation between the habituation of the seiza sitting position to stomach circumference and body weight. the subject also reported less effort in defecating followed by an increase in frequency. charts showing a. average dzikr duration per week of observation and; b. physical changes after applying seiza by measuring body weight and stomach circumference of the subject discussion body position may affect the digestion process and defecation. in anatomic relations, the rectum and anus are facing towards the dorso-posterior of the body. this causes a folding in the recto-anal junction, effectively creating a hard corner which affects an increasing effort to defecate. while squatting, intraabdominal pressure drops, but the recto-anal lumen opens. this also affects the gutbrain circuit which controls the normal microbiota in the gut and affects physiologic functions in digestion.3seiza sitting can be an alternative or supplementary therapy for patients with obesity. despite the lack of evidence on weight loss, we saw an improvement in digestive functions. the acupuncture meridian points sit near peripheral nerve receptors and pathways, nerve plexus, capillary beds, and lymphatic vessels (figure 1). it international journal of human and health sciences vol. 07 no. 02 april’23 204 was also found that stimulating these acupuncture points, may also induce nerve activity. these signals may be carried to the cns and affect the nervous system, visceral organs, and muscle tone.4,5 st37 meridian points may be stimulated to affect the autonomic nervous system and inhibit gastric peristalsis between 6.67% to 13.3%. whereas st36 meridian points may stimulate the vagus nerve and inhibit non-adrenergic non-cholinergic pathways in neurotransmitters.6seiza’s sitting posture may stimulate lower extremity acupressure points and align the recto-anal junction. it was also found in mice, that inducing hypoxia through femoral artery ligation has the effect of increased lower limb muscle exercise and the joining between main and collateral circulation. seiza sitting induces hypoxia in the same way an artery ligation would, where this may induce hypoxia-inducible factor-1 and vascular-endothelial growth factor to join the collateral vessels with main arteries, thus increasing oxygenation and load capacity.7-9 a b illustrations. (a) meridian points diagram with acupuncture points near peripheral nerve receptors and somatic sensory pathways on skin surface. p: pericardial; l = lung; li = large intestine; s: stomach; g = gallbladder.3 (b) the mechanisms of acupuncture on the enteric nervous system; st37 and st25 points may be stimulated and excite or inhibit respectively. a: sympathetic pathway; b: parasympathetic pathway; 1: inhibitory pathway; 2: excitatory pathway; 3: intrinsic myenteric afferent fibres; 4:primary intrinsic sub-mucosal afferent fibres; 5: vasodilator/secretomotor nerves; lm: longitudinal muscle; mp: myenteric plexus; cm: circular muscle; (+): effective, (−): ineffective[72]; ens: enteric nervous system.6 st36 meridian points (zu san li) (figure 1a) have been proven to improve abdominal and gastric functions in digestion and food absorption. lab rats were tested with st36 meridian stimulation in cv4 (guan yuan), which stimulates nerve receptors in intestines, and k11 (yon quan) for maintaining vascular tone; showed improved metabolism. bowel movements and intestinal glands are more active, and lab rats saw a reduction in weight up to 19,57%, with abdominal fats being the biggest contributor ( 72,7% fat lost ). lab rats also showed a reduction in fat absorption and low blood fat levels.12 in the beginning, the subject’s stomach circumference starts at 114 cm, then saw a reduction after seiza sitting habituation by 1,75% in week 1; 0,88% in week 2; 2,63% in week 3, and; 3,51% in week 4. body weight starts at 100,4 kg, then saw a reduction up to 0,55% in week 1; 0,35% in week 2; 0,25% in week 3, and; 1,89% in week 4. this may be affected by the duration of seiza’s sitting posture during dzikr. the seiza sitting also pressurizes meridian points and affects the intestinal lumen size.13 therefore, 205 international journal of human and health sciences vol. 07 no. 02 april’23 we found that the longer duration of seiza sitting is, the more it affects digestion, metabolism, and fat accumulation in the abdomen. despite our findings, we’re still short on clinical trials and long-term habituation. conclusion seiza sitting may trigger acupressure effects on the st36 meridian points in the lower extremities. this stimulates the digestive system which aids in peristalsis and muscle contraction to help digestion and defecation. we found that there are correlations between weight loss and seiza in aiding the digestive and excretion of food. so in the end, we can recommend the seiza sitting posture be practiced daily during dzikr followed by a diet program to enhance its effects.14-15 limitations our results were based from a single case report, and observation was only done for four weeks. we should also consider adding more variables such as age groups, gender, and physical activities. acknowledgement the study is conducted in sebelasmaret university, and all measurements are done by rzm after consulting tb, ns, and ak for methods and interpretations. author contributions rzm performed the experiment and became the study’s object. observations were done by rzm with consulting towards tb, ns, and ak so as to measure physical changes and rzm noted some changes i.e. less effort in defecating etc. ns provided prevalence data and survey results for obesity, while tb and ak concerns more on data collecting and formatting of the article. funding this article did not reveive external fundings. conflicts of interest the authors declare no conflicts of interest. international journal of human and health sciences vol. 07 no. 02 april’23 206 references 1. fukuichi a, sugamura g. (2022). sitting posture and moral impression formation: a focus on traditional japanese sitting posture (seiza). journal of physical education and sport; vol. 22 (issue 2): 503 – 11. https://doi.org/10.7752/jpes.2022.02063 2. sakakibara r, tsunoyama k, hosoi h, takahashi o, sugiyama m, kishi m, et al. (2010) influence of body position on defecation in humans. luts; 2: 16–21. https://doi.org/10.1111/j.1757-5672.2009.00057.x 3. de vadder f, kovatcheva-datchary p, goncalves d, vinera j, zitoun c, duchampt a, et al. (2014) microbiota-generated metabolites promote metabolic benefits via gut-brain neural circuits. cell; 156, 1–13. http://dx.doi.org/10.1016/j. cell.2013.12.016 4. quiroz-gonza ́lez s, castillo st, lo ́pez-go ́mez rs, estrada ij. (2017) acupuncture points and their relationship with multireceptive fields of neurons. journal of acupuncture and meridian studies; 10(2): 81-9. http://dx.doi.org/10.1016/j.jams.2017.01.006 5. longhurst j. c. (2010). defining meridians: a modern basis of understanding. journal of acupuncture and meridian studies, 3(2), 67–74. https://doi. org/10.1016/s2005-2901(10)60014-3 6. yu z. (2020)neuromechanism of acupuncture regulating gastrointestinal motility. world j gastroenterol; 26(23): 3182-200.https://dx.doi. org/10.3748/wjg.v26.i23.3182 7. arrarteterreros n, van willigen bg, niekolaas ws, et al. (2022) occult blood flow patterns distal to an occluded artery in acute ischemic stroke. journal of cerebral blood flow & metabolism; 42(2): 292-302. doi:10.1177/0271678x211044941 8. schaper w. collateral circulation: past and present. (2009) basic res cardiol;104(1):5-21. doi: 10.1007/ s00395-008-0760-x 9. chilian wm, pung yf vascular endothelial growth factor and the collateral circulation: the story continues. (2008) circulationresearch; 103(9): 905–6.https:// doi.org/10.1161/01.res.0000338258.90706.2c 10. zimna a, kurpisz m.hypoxia-inducible factor-1 in physiological and pathophysiological angiogenesis: applications and therapies. biomed research international. 2015; 549412.https://doi. org/10.1155/2015/549412 11. han h, guo x, meng xj, zhang j, yamaguchi r, motoo y, yamada s.acupuncture improved lipid metabolism by regulating intestinal absorption in mice. world j gastroenterol. 2020; 26(34): 5118-29. https://doi.org/10.3748/wjg.v26.i34.5118 12. mourad fh, saadé ne.neural regulation of intestinal nutrient absorption. progneurobiol. 2011; 95: 149 162. https://doi.org/10.1016/j.pneurobio.2011.07.010 13. li h, he t, xu q, li z, liu y, li f, yang bf, liu cz.acupuncture and regulation of gastrointestinal function. world j gastroenterol. 2015; 21: 83048313. https://doi.org/10.3748/wjg.v21.i27.8304 14. paley, c.a. and johnson, m.i. abdominal obesity and metabolic syndrome: exercise as medicine?,bmc sports science, medicine and rehabilitation. 2018;10(1). available at: https://doi.org/10.1186/ s13102-018-0097-1 15. sajoux i, bellona,vidal j. challenges in treatment of obesity in the elderly. endocrinolmetabint j. 2017;5(5):291‒297. doi: 10.15406/emij.2017.05.0013 https://doi.org/10.7752/jpes.2022.02063 https://doi.org/10.1111/j.1757-5672.2009.00057.x http://dx.doi.org/10.1016/j.cell.2013.12.016 http://dx.doi.org/10.1016/j.cell.2013.12.016 http://dx.doi.org/10.1016/j.jams.2017.01.006 https://doi.org/10.1016/s2005-2901(10)60014-3 https://doi.org/10.1016/s2005-2901(10)60014-3 https://dx.doi.org/10.3748/wjg.v26.i23.3182 https://dx.doi.org/10.3748/wjg.v26.i23.3182 https://doi.org/10.1161/01.res.0000338258.90706.2c https://doi.org/10.1161/01.res.0000338258.90706.2c https://doi.org/10.1155/2015/549412 https://doi.org/10.1155/2015/549412 https://doi.org/10.3748/wjg.v26.i34.5118 https://doi.org/10.1016/j.pneurobio.2011.07.010 https://doi.org/10.3748/wjg.v21.i27.8304 https://doi.org/10.1186/s13102-018-0097-1 https://doi.org/10.1186/s13102-018-0097-1 393 international journal of human and health sciences vol. 06 no. 04 october’22 original article time domain measures of heart rate variability to assess cardiac autonomic nerve function in adult bangladeshi male and female qazi farzana akhter1, qazi shamima akhter2, masuma akhtar banu3,matia ahmed1, farhana naznen4 abstract background: heart rate variability (hrv) has been considered as an indicator of autonomic nerve function status. objective:to find out the reference values of heart rate variability by time domain measures of hrv inadult bangladeshi population of both sexes. methods:this cross-sectional, analytical study was conducted between july 2012 and june 2013. a total of 180 subjects were selected through the department of physiology, dhaka medical college dhaka, bangladesh, with the age ranging from 18 to 60 years. all the study subjects were divided into 3 different groups: group a (18-30 years), group b (31-45 years) and group c (46-60 years). each group had 60 subjects: 30 males and 30 females. the experimentation of hrv parameters and recording of data were done using rms polyrite d (version 2.4) in autonomic nerve function test laboratory of the department of physiology, bangabandhu sheikh mujib medical university (bsmmu), dhaka, bangladesh. mean systolic and diastolic blood pressure, heart rate along with r-r interval between successive qrs complexes, standard deviation of nn interval (sdnn), rmssd (square root of mean squared differences between adjacent nn intervals) were observed and analyzed. results: systolic and diastolic blood pressure and rmssd were significantly higher in males than that of females in all three groups (p<0.001). however, no differences were observed in mean heart rate, r-r interval, and sdnn between males and females in any group. conclusion: our data suggest that males have higher cardiac sympathetic activities, while females show higher cardiac parasympathetic activities in different age groups in terms of heart rate and blood pressure regulation. the difference of blood pressure is statistically significant; however, the difference of mean heart rate is not statistically significant. keywords: heart rate, autonomic nerve function, male, female, bangladeshi population correspondence to: dr. qazi farzana akhter, associate professor, department of physiology, uttara adhunik medical college, uttara, dhaka-1230. bangladesh. email: qfarzanaakhter@gmail.com 1. department ofphysiology, uttara adhunik medical college, uttara, dhaka-1230, bangladesh. 2. department of physiology, dhaka medical college, dhaka-1000, bangladesh. 3. department of anatomy, uttara adhunik medical college, uttara, dhaka-1230, bangladesh. 4. department of physiology, community based medical college, bangladesh (cbmc,b), winnerpar, mymensingh-2200, bangladesh. introduction both sympathetic and parasympathetic divisions of the autonomic nervous system (ans) in humans regulate and modulate the cardiovascular function.1 sympathetic part of it increases the heart rate and blood pressure (bp) on the other hand parasympathetic part decreases heart rate and bp.1,2 heart rate variability (hrv) refers to the beat to beat variation in the heart rate generated by the interplay of the sympathetic and parasympathetic nerve activity at the sinus node of the heart.3 it is well recognized that cardiovascular functions vary both in male and females.1,4-7 there are evidences of sex difference in the autonomic control of international journal of human and health sciences vol. 06 no. 04 october’22 page : 393-397 doi: http://dx.doi.org/10.31344/ijhhs.v6i4.478 international journal of human and health sciences vol. 06 no. 04 october’22 394 heart due to effect of sex hormones and there is higher sympathetic response in males and higher parasympathetic response in females.4-7 gender is also an important predictor of baroreceptor sensitivity (brs).7,8research revealed that brs is significantly higher in older men in comparison to itscounterpart. the mechanism responsible for this lower brs in women may be due to sex hormone.8,9moreover, parasympathetic tone is more than sympathetic tone in younger women and sympathetic neural outflow is less in women as compared with men.9-12the reverse is true for men, which may be due to testosterones and muscular built of males that cause higher vagal tone.912however, the difference diminishes after the 5th decade of life.9 some other studies have shown that vagal function is not significantly different between males and females, but sympathetic activity is significantly higher in maleswhen compared to females.10,11heart rate variability (hrv) reflects autonomic nerve function status.3,12 normallyvariation in heart rate is related to the balance between sympathetic and parasympathetic nervous system which provides early better qualitative and quantitative interpretation of sympatho-vagal activity and can detect autonomic impairment.3moreover, hrv represents a non-invasive, pain free, economic and simple measurement which help us understand a range of information provided by the numerous hrv parameters.13high hrv reflects good adaptability and well-functioning autonomic control.3,12,13 on the other hand, reduced hrv acts as a strong predictor of many cardiac diseases.3,12,13hence, this study was proposed to assess the autonomic nerve function status through heart rate variability in males and femalesin a bangladeshi adult population to explore its role in health and disease and to an information pool toraisemore awareness among clinicians for better management of the cardiac diseases in clinical practice. methods this cross-sectional, analytical study was carried out to observe the autonomic nerve function by power spectral analysis of hrv in 180 healthy adult bangladeshi people with age ranging from 18 to 60 years, between july 2012 and june 2013. for this, total study subjects were first divided into 3 age-groups: group a: (18-30 years), group b (31-45 years), and group c (46-60 years). each group was again divided into two subgroups, i.e. a1 & a2, b1 & b2, and c1 & c2 containing equal number (30) of males and females respectively. all the subjects were volunteers and selected from different areas of dhaka city through the department of physiology, dhaka medical college, dhaka, bangladesh. they were free from any known heart disease, hypertension, diabetes mellitus, kidney disease, neurological and psychiatric disorders, and smoking. the subjects were thoroughly informed about the procedure of the study. they were allowed to withdraw themselves from the study wheneverthey liked. informed written consent was taken. we adopted the standard recommended procedure suggested by the task force of the european society of cardiology and the north american society of pacing and electrophysiology.14the recommendations were very useful and provided information on which hrv parameters to take into account and what their significance is at the physiological level. accordingly, the subjects were advised to have their meal by 9:00 pm, to remain free from any physical or mental stress and not to take sedatives or any drugs affecting central nervous system at the night before the day of examination. the subjects were also asked to take light breakfast and to avoid tea or coffee at the time of breakfast. on the day of the examination, the subjects were advised to attend the autonomic nerve function test laboratory in the department of physiology, bangabandhu sheikh mujib medical university (bsmmu), dhaka, bangladesh, between 9:00 and 11:00 am. whenever the subject appeared in the department, he/she was interviewed and detail history regarding personal history, drug history, past medical history were taken. then thorough physical examinations and anthropometric measurement, e.g.,height and weight were recorded. then bmi was calculated. all information were recorded in a prefixed questionnaire. then he/she was kept in complete bed rest in supine position for 15-20 minutes in a cool and calm environment. during this period subject was advised not to talk, eat or drink and also not to perform any physical or mental activity, even sleep. then all preparations for recording of the heart rate variability parameters were made by connecting the channels to a transducer for ecg to a computerized polygraph and 5 minutes recording was taken in resting supine position. the experimentation and recording of data were done usingrms polyrite d (version 2.4). data were obtained by software analysis of the power spectral band of the hrv. data were expressed 395 international journal of human and health sciences vol. 06 no. 04 october’22 as mean±sd. for statistical analysis, unpaired student’s ‘t’-test was performed. p value <0.05 was considered as statistically significant.all the analyses were done using the spss version17.0for windows (spss inc., chicago, illinois, usa). results the mean height, weight, systolic and diastolic blood pressure andrmssd were significantly higher in group a1 than that of group a2(p<0.001). again,the mean r-r interval was higher in group a1 than that of group a2, while heart rate and sdnn were higher in group a2 than that of group a1. however, the differences were notstatistically significant (p>0.05)(table 1). similarly,the mean height, weight, systolic and diastolic blood pressure, and rmssdwere significantly higher in group b1 than that of group b2(p<0.001). however,no significant differences were observed in mean rr interval, heart rate and sdnnbetween males and females(p>0.05)(table 2) the mean height, weight, systolic and diastolic blood pressure, and rmssdwere significantly higher in group c1 than that of group c2 (p<0.001). the mean r-r interval was higher in group c1 than that of group c2, and heart rate and sdnn were higher in group c2 than that of group c1,the differences were statistically not significant though(p>0.05) (table 3). table 1.study parameters in group a (n=60) parameters a1(n=30) a2(n=30) p value age (years) 24.40±3.66 25.97±3.56 >0.05 weight (kg) 56.97±6.32 50.73±4.46 <0.001 height (cm) 165.67±6.25 157.37±3.69 <0.001 bmi (kg/m2) 20.67±1.30 20.43±1.13 >0.05 pulse (beats/m) 73.70±6.90 72.73±3.97 >0.05 sbp (mm of hg) 116.17±4.86 108.33±5.31 <0.001 dbp (mm of hg) 76.50±4.39 70.67±4.50 <0.001 mean rr (sec) 0.80±0.11 0.76±0.12 >0.05 mean heart rate (beats/m) 76.30±10.01 79.87±11.42 >0.05 sdnn (ms) 74.88±20.65 77.35±16.68 >0.05 rmssd (ms) 101.67±14.45 80.62±21.62 <0.001 results are expressed as mean±sd; p value reached from unpaired student’s ‘t’ test sbp = systolic blood pressure, dbp = diastolic blood pressure r-r = interval between successive qrs complex (sec), sdnn = standard deviation of nn interval rmssd =square root of mean squared differences between adjacent nn intervals group a1 = male; group a2= female table 2.study parameters in group b (n=60) parameters b1(n=30) b2(n=30) p value age (years) 35.53±3.73 34.97±3.24 >0.05 weight (kg) 59.80±4.85 54.73±2.69 <0.001 height (cm) 166.00±5.43 160.00±2.60 <0.001 bmi (kg/m2) 21.67±0.99 21.35±0.65 >0.05 pulse (beats/m) 72.53±5.22 73.80±5.80 >0.05 sbp (mm of hg) 116.67±4.79 110.83±6.96 <0.001 dbp (mm of hg) 76.00±5.32 72.50±4.31 <0.001 mean rr (sec) 0.80±0.11 0.78±0.09 >0.05 mean heart rate (beats/m) 76.43±8.82 77.93±7.5 >0.05 sdnn (ms) 76.10±15.94 78.20±19.03 >0.05 rmssd (ms) 97.55±16.64 72.03±14.68 <0.001 results are expressed as mean±sd; p value reached from unpaired student’s ‘t’ test sbp = systolic blood pressure, dbp = diastolic blood pressure r-r = interval between successive qrs complex (sec), sdnn = standard deviation of nn interval rmssd =square root of mean squared differences between adjacent nn intervals group b1 = male; group b2= female table 3.study parameters in group c (n=60) parameters c1(n=30) c2(n=30) p value age (years) 51.00±3.97 48.63±3.09 >0.05 weight (kg) 61.23±4.39 54.10±4.04 <0.001 height (cm) 167.50±3.77 159.30±3.71 <0.001 bmi (kg/m2) 21.74±0.98 21.18±1.04 >0.05 pulse (beats/m) 74.80±6.65 75.60±6.66 >0.05 sbp (mm of hg) 121.67±6.21 114.50±8.34 <0.001 dbp (mm of hg) 79.83±6.50 73.00±5.87 <0.001 mean rr (sec) 0.78±0.10 0.79±0.10 >0.05 mean heart rate (beats/m) 80.43±7.76 81.87±8.97 >0.05 sdnn (ms) 67.97±19.51 74.62±16.69 >0.05 rmssd (ms) 83.84±14.98 60.98±13.40 <0.001 results are expressed as mean±sd; p value reached from unpaired student’s ‘t’ test sbp = systolic blood pressure, dbp = diastolic blood pressure international journal of human and health sciences vol. 06 no. 04 october’22 396 r-r = interval between successive qrs complex (sec), sdnn = standard deviation of nn interval rmssd =square root of mean squared differences between adjacent nn intervals group c1 = male; group c2= female discussion the importance of heart rate variability (hrv) as a tool for assessing the autonomic nervous system activity in many different diseases and conditions has steadily increased in recent times.2,13in the present study, hrv parameters in healthy male and female of different age group were almost within normal range; differences were observedwith a higher blood pressure in males in comparison to its female counterpart. our results arevery similar to those reported by the various investigators in the western countries.47,10,12researchers from south asia region also published similar reports on heart rate variability in respect of age and sex.9,11,15-17similarobservations were reported by the researchers in our country.1822different timedomain components of hrv has been used as marker of cardiac autonomic activity.13 the task force guideline for hrv analysis have demonstrated the interpretation of these parameters to understand the status, behaviour and the balance between sympathetic and parasympathetic due to their continuous interaction.13 the total power represents the variability of r-r interval and is the result of the total cardiac autonomic nervous activities and hormonal activities on heart. therefore, its lower value indicates lower modulation of cardiac autonomic nervous activities on heart.14 in the present study, the mean heart rate and sdnn were higher in females than males in all age groups, but the differences were statistically not significant. many explanations are suggested by different investigators for this involvement of cardiac autonomic nerve function in sex differences.4-10 though the exact mechanisms are not clear to date, gender differences in the autonomic nervous functions may be due to developmental differences or due to the effects of prevailing levels of male and/or female sex hormones.7 such prevailing hormone levels may also produce differences between preand postmenopausal women and amongst pre-menopausal women at different phases of the menstrual cycle.1,7,23however,in our study, the exact endocrine mechanisms is not elucidated as the serum and urinary catecholamines, oestrogen and testosterone hormone levels were not assessed due to time and budget constraint. conclusion to summarize, variation of cardiac autonomic nerve function may occur between sexes, which is characterized by the higher cardiac sympathetic activity in malesand the higher cardiac parasympathetic activities in females. the difference of blood pressure is statistically significant in between sexes; however, the difference of mean heart rate is not statistically significant. acknowledgement:the authors of this study are thankful to the authority of department of physiology, bangabandhu sheikh mujib medical university (bsmmu), dhaka, bangladesh, for the technical support in experimentation and recording of data usingrms polyrite d (version 2.4) in its autonomic nerve function test laboratory. conflict of interest: the authors declare no conflict of interest. ethical approval: the study was approved by the ethical review committee of dhaka medical college, dhaka, bangladesh. funding statement:nil. authors’ contribution: concept and design of the study: qfa, qsa; subject selection and data collection: qfa, mab, ma, fn; data analysis: qfa, mab; manuscript writing, revision and finalizing: qfa, qsa, mab, ma, fn. 397 international journal of human and health sciences vol. 06 no. 04 october’22 references 1. barrett ke, barman sm, boitano s, brooks hl.ganong’s review of medical physiology, 24th ed.new york, usa: mcgraw-hill;2012. 2. gibbons ch. basics of autonomic nervous system function. handb clin neurol. 2019;160:407-18. 3. schwab jo, eichner g, schmitt h, weber s, coch m, waldecker b. the relative contribution of the sinus and av node to heart rate variability. heart. 2003;89(3):337-8. 4. barnett sr, morin rj, kiely dk, gagnon m, azhar g, knight el, et al. effects of age and gender on autonomic control of blood pressure dynamics. hypertension. 1999;33(5):1195-200. 5. sevre k, lefrandt jd, nordby g, os i, mulder m, gans ro, et al. autonomic function in hypertensive and normotensive subjects: the importance of gender. hypertension. 2001;37(6):1351-6. 6. joyner mj, wallin bg, charkoudian n. sex differences and blood pressure regulation in humans. exp physiol. 2016;101(3):349-55. 7. dart am, du xj, kingwell ba. gender, sex hormones and autonomic nervous control of the cardiovascular system. cardiovasc res. 2002;53(3):678-87. 8. jones pp, christou dd, jordan j, seals dr. baroreflex buffering is reduced with age in healthy men. circulation. 2003;107(13):1770-4. 9. moodithaya s, avadhany st. gender differences in age-related changes in cardiac autonomic nervous function. j aging res. 2012;2012:679345. 10. voss a, schroeder r, heitmann a, peters a, perz s. short-term heart rate variability – influenceof gender and age in healthy subjects. plos one. 2015;10(3):e0118308. 11. choi jb, hong s, nelesen r, bardwell wa, natarajan l, schubert c, et al. age and ethnicity differences in short-term heart-rate variability. psychosom med. 2006;68(3):421-6. 12. gellish rl, goslin br, olson re, mcdonald a, russi gd, moudgil vk. longitudinal modeling of the relationship between age and maximal heart rate. med sci sports exerc. 2007;39(5):822-9. 13. laborde s, mosley e, thayer jf. heart rate variability and cardiac vagal tone in psychophysiological research –recommendationsfor experiment planning, data analysis, and data reporting. front psychol. 2017;8:213. 14. heart rate variability: standards of measurement, physiological interpretation and clinical use. task force of the european society of cardiology and the north american society of pacing and electrophysiology. circulation. 1996;93(5):1043-65. 15. kiran td, patil vv, latti rg, sandip gh. genderselective interaction between aging andcardiovascular sympathetic activity. pravara med rev. 2010;2(2):106. 16. saleem s, hussain mm, majeed sm, khan ma. gender differences of heart rate variability in healthy volunteers. j pak med assoc. 2012;62(5):422-5. 17. deo sk, agrawal k, bhattarai p. heart rate variability as a marker of changes in mood state in daily life by photoplethysmography technique. nepalese med j. 2018;1(2):100-3. 18. islam t, begum n, begum s, ferdousi s, ali t. evaluation of parasympathetic nerve function status in healthy elderly subjects. j bangladesh soc physiol. 2008;3:23-8. 19. jahan k, begum n, ferdousi s. power spectral analysis of heart rate variability in femalerheumatoid arthritis patients.j bangladesh soc physiol. 2012;7(1):8-12. 20. ahmed m, begum n, ferdousi s. assessment of autonomic nerve function in hypothyroids by time domain method of heart rate variability. j bangladesh soc physiol. 2012;791):48-52. 21. nayem m, begum n, ferdousi s. assessment of autonomic nerve function in patients with irritable bowel syndrome.j bangladesh soc physiol. 2012;7(1):53-9. 22. akhter qf, akhter qs, rohman f, sinha s, ferdousi s. effect of aging on short term heart rate variability. j bangladesh soc physiol. 2014;9(2):78-82. 23. hart ec, charkoudian n, miller vm. sex, hormones and neuroeffector mechanisms. acta physiol. 2011;203(1):155-65. supplementary issue:02 119 analysis of two different outbreaks in picu of a tertiary care centre in two different time zones fatima khan1, uzma tayyaba1, asfia sultan1, anees akhtar1, shariq ahmed1 1department of microbiology, jn medical college, amu, aligarh correspondence: dr. asfia sultan assistant professor, department of microbiology, jn medical college, faculty of medicine, aligarh muslim university, aligarh-202002, u.p., india orcid id: 0000-0003-0343-9513 e-mail id: drasfia@gmail.com abstract klebsiella pneumoniae is one of the common cause of nosocomial outbreak. with the emergence of multi-drug resistance, clinical management has become a serious challenge. the present study is a comparative analysis of changing trends of antimicrobial resistance (amr) between two outbreaks of klebsiella pneumoniae in picu occurring over a gap of 8 years. materials & methods: 1054 blood culture samples received from paediatric patients over a period of 6 months were tested by bact/alert-3d & vitek-2 system. survey of environmental samples was also conducted in paediatric icu. all the findings were then analysed with the data from another outbreak of mdr klebsiella pneumoniae in picu reported from the same institute in the year 2015. result: from 154 (14.6%) positive paediatric blood samples, gram-negative bacilli was most commonly isolated (75/154, 48.7%), followed by gram-positive cocci (53, 34.4%). amongst gram-negative isolates klebsiella pneumoniae was commonest (40/75, 53.3%), followed by pseudomonas speices (17.3%), escherichia coli (16%), burkholderia cepacia-complex (6.7%), and acinetobacter baumanii-complex (4%). out of 40 klebsiella pneumoniae, 90% were extensively-drug resistant (xdr), i.e resistant to cephalosporins, carbapenems, aminoglycosides, fluoroquinolone, co-trimaxazole as well as tigecyclin. 45% of these patients were admitted in the picu. however, previous outbreak reported 90 klebsiella pneumoniae (43.3% of all isolates) over a period of 4 month, out of which 45.5% were mdr & 18.8% were esbl producers. however, mailto:drasfia@gmail.com supplementary issue:02 120 carbapenems were effective in majority of them (98.9%), which is a contrast to our present finding (97.5% resistance). moreover, multiple mdr strains of klebsiella species (7/16 isolates, 43.7%) were obtained from picu samples in previous outbreak, with antibiogram similar to that of patient samples. similarly picu sampling in the current outbreak also yielded xdr klebsiella pneumoniae from medicine table, with similar profile that is seen in patients sample. conclusion: on analysis of two outbreaks from same hospital in two different time zones, we observed changing trend in resistance pattern, as carbapenems were effective in previously isolated mdr strains, but now xdr stains are isolated which are resistant to carbapenems as well. urgent and effective measures are needed to restrain emergence and transmission of xdr strains within the hospital. stringent infection control practices should be advocated and strictly followed. keywords: outbreak, klebsiella pneumoniae, picu, mdr, xdr introduction bloodstream infections (bsi) are common cause of febrile illness and is associated with high morbidity and mortality worldwide. the bacterial pathogen klebsiella pneumoniae is a major cause of nosocomial infections, especially in immunocompromised individuals (1). increasing antimicrobial resistance among these notorious bacteria, particularly with emergence of carbapenem resistance seen in recent years (2), and their worldwide dissemination (3), possess serious threat to public health worldwide. because infections caused by these carbapenemresistant klebsiella pneumoniae (crkp) are difficult to treat (4), and are associated with high mortality (5). crkp strains produces a variety of cabapenamases enzymes and/or extendedspectrum beta-lactamases (esbls) along with porin loss and efflux pump overexpression, leading to emergence of multi-drug resistant (mdr), extensively-drug resistant (xdr) and pan-drug resistant (pdr) bacteria. (6) another aggravating factor is the tendency of klebsiella pneumoniae to cause outbreaks in healthcare facilities, particularly in icus (7–9). moreover, klebsiella pneumoniae has propensity to silently colonize patients and hospital personnel, without causing any sign of infections. these carriers function as reservoirs and help in its dissemination, making control of outbreak a difficult challenge (9). furthermore, because of extensive use of antibiotics in hospital setting, multiple supplementary issue:02 121 drug resistance have selective advantage in perseverance of such nosocomial bacteria in hospitalised patients as well as in hospital environment (7). to apply productive infection control measures, it is crucial to know relevant environmental contamination and in-hospital transmission routes. therefore the present study was done to describe changing pattern of antimicrobial resistance (amr) between two outbreaks of klebsiella pneumoniae associated with bacteriemia in paediatric patients reported from the same institute occurring over a gap of 8 years (10). materials & methods: the study was conducted in a tertiary care centre in two different time zone. present data was taken from july 2022 to december 2022. blood samples for culture were collected from paediatric patients taking all sterile precautions. blood culture positive samples identified by bact/alert 3d (biomérieux) automated system were plated on 5% sheep blood agar, macconkey agar and chocolate agar. bacterial identification as well as antimicrobial sensitivity of positive growth was done by vitek-2 (biomérieux) automated system. survey of environmental samples was also conducted in paediatric icu. environmental samples were taken from various sites including patient bed, door handle, medicine table, medicine basket, ventilator knob, suction pipe, warmer and disinfectant bottle. air culture was done by settle plate method. samples were inoculated on brain heart infusion broth, from which subculture was done next day on 5% sheep blood agar and macconkey agar. bacterial identification was done by conventional methods and confirmed by vitek-2. all the findings of present outbreak was then compared & analysed with another outbreak of mdr klebsiella pneumoniae reported in paediatric blood culture isolates from the same institute 8 years back in the year 2015. (10) result & discussion: a total of 1834 blood samples were received in the enteric lab over the period of 6 months, out of which 1054 (57.5%) were from paediatric patients. out of these 1054 paediatric blood samples, supplementary issue:02 122 154 (14.6%) were identified positive. gram negative bacilli was most commonly isolated (75/154, 48.7%), followed by gram positive cocci (53, 34.4%), then yeast like fungi (24, 16.9%). amongst gram negative bacilli, maximum isolates were of klebsiella pneumoniae (40/75, 53.3%), followed by pseudomonas speices (13/75, 17.3%), escherichia coli (12, 16%), burkholderia cepacian complex (5, 6.7%), acinetobacter baumanii complex (3, 4%), citrobacter species (1, 1.3%), and enterobacter cloacae complex (1, 1.3%) as depicted in figure1. figure1 out of 40 paediatric samples from which klebsiella was isolated 27 (67.5%) were of infants, which includes 17 neonates (42.5%). 45% of these patients were admitted in the picu, and 36.8% of patients were intubated and were on mechanical ventilation. antimicrobial susceptibility profile by vitek-2 system showed 97.5% (n=39) of total 40 klebsiella pneumoniae were resistant to beta lactams antibiotics (namely ampicillin, amoxicillin/clavulanic acid, piperacillin/tazobactum, cefuroxime, ceftriaxone, supplementary issue:02 123 cefoperazone/sulbactum, cefepime, ertapenem, imipenem, meropenem), tigecyclin, as well as aminoglycosides (amikacin & gentamicin). ciprofloxacin resistance was seen in 95% (n=38), and co-trimaxazole resistance in 90% (n=36). thus, 90% of the strains were extensively drug resistant (xdr), which is defined as non-susceptible to at least one agent in all but two or fewer antimicrobial categories (6). another outbreak of mdr klebsiella pneumoniae was reported 8 years back in the year 2015 in paediatric blood culture isolates from the same institute (10). in the previous outbreak 90 klebsiella pneumoniae (43.3% of all isolates) were isolated over a period of 4 month. out of which 71.1% were from picu. antimicrobial susceptibility testing showed resistance rates of 62.3% to amikacin, 84.5% to gentamycin, 83.4% to ceftriaxone, 85.6% to cefoperazone, 66.7% to cefoperazone+sulbactum, 68.9% to piperacillin+tazobactum and 53.4% to levofloxacin (10). 45.5% were reported as mdr. fortunately, imipinem was resistant in only 1.1% isolates, which is contrast to our present study, where carbapenems are resistant in 97.5% of klebsiella isolates. figure 2 depicts increasing trend of resistance pattern from 2015 outbreak to the present outbreak, especially to carbapenems. alarming rise in resistance rates of carbapenems seen over 8 years, is a cause of concern as this leaves us with only few available treatment options (11). supplementary issue:02 124 figure2 for successful containment of an outbreak it is very important to understand how transmission is occurring. to identify the source of contamination within the picu environmental samples were taken. air culture by settle plate method grew bacillus and coagulase negative staphylococcus species. no growth was seen in sample from patient bed side and disinfectant bottle. different bacteria isolated from different samples were bacillus, coagulase negative staphylococcus species (cons), acinetobacter baumanii complex, klebsiella pneumoniae, pseudomonas stutzeri, and enterococcus species (table). apart from variety of different bacteria isolated from different sites, xdr klebsiella pneumoniae was isolated from medicine table, with similar antimicrobial resistance profile that is seen with patients samples, which could be source of contamination. strict infection control practices were advocated to stop any further cross contamination to the patients. table 1 s.no. site organism isolated susceptibility profile a m ik a c in a z tr e o n a m g e n ta m ic in c e ft ri a x o n e c e fo p e ra z o n e + s u lb a c tu m c e fe p im e im ip e n e m m e ro p e n e m c ip ro fl o x a c in c o tr im a x a z o l e t ig e c y c li n m in o c y c li n 1. air bacillus cons 2. medicine table pseudomonas stutzeri s r s r s s s klebsiella pneumoniae r r r r r r r r r r 3. medicine basket pseudomonas species s s r s r r r bacillus 4. syringe tray cons enterococcus species 5. ventilator knob acinetobacter baumanii complex r r r r r r r r r 6. suction pipe klebsiella pneumoniae s s r s r s s r s r 7. warmer acinetobacter baumanii complex s r r r r r r r i 8. door handle pseudomonas species s s r r s s s supplementary issue:02 125 bacillus similarly in the previous outbreak of 2015, multiple mdr strains of klebsiella species (7/16 isolates, 43.7%) were obtained from environmental sampling, with antibiogram similar to that of patient samples (10). most of the environmental mdr strains were still susceptible to imipenem, which is contradictory to our present study where carbapenems are ineffective. presence of such xdr strains in healthcare environment is unsettling, since cross contamination of these organisms may cause grave danger to patients. it warrants the need to create improved cleaning protocols and ensuring strict adherence to infection control practices within the picu. our hospital is a tertiary referral centre as well as a teaching hospital. environment such as ours, with enormous burden of patients, unrestrained movement of medical as well as paramedical students inside wards for teachings and rounds and duty exchange within nursing staff, lead to reduced compliance with infection prevention practices and facilitate transmission of multidrug resistant organisms (mdro), from either hospital environment or hands of healthcare staff to the patients (12). poor hand hygiene practices among staff is the most plausible reason. strict infection prevention practices among healthcare staff have been described as an effective tool to combat mdro transmission within the healthcare system (13). in recent years klebsiella pneumoniae have been identified as major cause of nosocomial outbreaks in the icu (8,9). patients admitted in the intensive critical units of hospitals are always at a risk of acquiring nosocomial infections, because of their critical condition, low immunity and prolonged hospitalisation (14). furthermore, infants and newborns admitted in picu are at greater risk due to their immature immune system, low birth-weight and regular usage of antimicrobials and invasive devices (15). numerous studies have described klebsiella pneumoniae as most common etiological agent of outbreak within icu (16,17) and neonatal icus (nicu) (18,19). similar to our report, nosocomial outbreak of xdr klebsiella pneumoniae have been reported worldwide, like report of nosocomial bsi by xdr klebsiella pneumoniae in a teaching hospital in china by wenzi b et al (20), and by gasper et al in brazil in 2022 (21) and so on. xdr isolates show high resistance to beta-lactams antibiotics (including carbapenems and beta-lactam/ beta-lactamase inhibitors combination), supplementary issue:02 126 aminoglycosides, fluoroquinolones, tigecycline and/or polymyxins, and may lead to emergence of pan drug-resistant (pdr) isolates. (22,23). the rising prevalence and worldwide dissemination of these xdr isolates, especially in healthcare system, is a major public health threat, as there are very few effective therapeutic options left (24) and are associated with high mortality (25). conclusions our study describes an outbreak of xdr klebsiella pneumoniae associated with bacteriemia in paediatric patients. on comparative analysis of two outbreaks from same hospital in two different time zones, we observed changing trend in resistance pattern seen in nosocomial pathogen. in the present outbreak xdr stains are isolated which are resistant to carbapenems as well, which were effective in previously isolated mdr strains. this makes us wonder, from here, where do we go next? urgent and effective measures are needed to restrain emergence and transmission of xdr strains within the hospital. vigorous infection control practices should be advocated and strictly followed. also, high mortality associated with bsis caused by xdr klebsiella pneumoniae should alert clinicians to institute effective and rational antibiotic policy. references: 1. wyres kl, holt ke. klebsiella pneumoniae population genomics and antimicrobialresistant clones. trends microbiol. 2016 dec;24(12):944–56. 2. campos ac, albiero j, ecker ab, kuroda cm, meirelles lef, polato a, et al. outbreak of klebsiella pneumoniae carbapenemase–producing k pneumoniae: a systematic review. american journal of infection control. 2016 nov 1;44(11):1374–80. 3. lee cr, lee jh, park ks, kim yb, jeong bc, lee sh. global dissemination of carbapenemase-producing klebsiella pneumoniae: epidemiology, genetic context, treatment options, and detection methods. front microbiol. 2016 jun 13;7:895. 4. paczosa mk, mecsas j. klebsiella pneumoniae: going on the offense with a strong defense. microbiol mol biol rev. 2016 sep;80(3):629–61. supplementary issue:02 127 5. munoz-price ls, poirel l, bonomo ra, schwaber mj, daikos gl, cormican m, et al. clinical epidemiology of the global expansion of klebsiella pneumoniae carbapenemases. lancet infect dis. 2013 sep;13(9):785–96. 6. magiorakos ap, srinivasan a, carey rb, carmeli y, falagas me, giske cg, et al. multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. clinical microbiology and infection. 2012 mar 1;18(3):268–81. 7. peña c, pujol m, ardanuy c, ricart a, pallares r, liñares j, et al. epidemiology and successful control of a large outbreak due to klebsiella pneumoniae producing extendedspectrum β-lactamases. antimicrob agents chemother. 1998 jan;42(1):53–8. 8. jarvis wr, munn vp, highsmith ak, culver dh, hughes jm. the epidemiology of nosocomial infections caused by klebsiella pneumoniae. infect control. 1985 feb;6(2):68–74. 9. asensio a, oliver a, gonzález-diego p, baquero f, pérez-díaz jc, ros p, et al. outbreak of a multiresistant klebsiella pneumoniae strain in an intensive care unit: antibiotic use as risk factor for colonization and infection. clin infect dis. 2000 jan;30(1):55–60. 10. khan f, siddiqui n, sultan a, rizvi m, aqbari s, shukla i, et al. klebsiella pneumoniae outbreak in paediatric ward: detection and prevention. intjcurrmicrobiolappsci. 2015;(special issue-1):81–7. 11. logan lk, weinstein ra. the epidemiology of carbapenem-resistant enterobacteriaceae: the impact and evolution of a global menace. the journal of infectious diseases. 2017 feb 15;215(suppl_1):s28–36. 12. casewell m, phillips i. hands as route of transmission for klebsiella species. br med j. 1977 nov 19;2(6098):1315–7. 13. kim nh, han wd, song kh, seo hk, shin m jin, kim ts, et al. successful containment of carbapenem-resistant enterobacteriaceae by strict contact precautions without active surveillance. am j infect control. 2014 dec;42(12):1270–3. 14. giviti steering committee, bertolini g, nattino g, tascini c, poole d, viaggi b, et al. mortality attributable to different klebsiella susceptibility patterns and to the coverage of supplementary issue:02 128 empirical antibiotic therapy: a cohort study on patients admitted to the icu with infection. intensive care med. 2018 oct;44(10):1709–19. 15. ruiz e, rojo-bezares b, sáenz y, olarte i, esteban i, rocha-gracia r, et al. outbreak caused by a multi-resistant klebsiella pneumoniae strain of new sequence type st341 carrying new genetic environments of aac(6′)-ib-cr and qnrs1 genes in a neonatal intensive care unit in spain. international journal of medical microbiology. 2010 nov 1;300(7):464–9. 16. snitkin es, zelazny am, thomas pj, stock f, nisc comparative sequencing program group, henderson dk, et al. tracking a hospital outbreak of carbapenem-resistant klebsiella pneumoniae with whole-genome sequencing. sci transl med. 2012 aug 22;4(148):148ra116. 17. xu l, sun x, ma x. systematic review and meta-analysis of mortality of patients infected with carbapenem-resistant klebsiella pneumoniae. ann clin microbiol antimicrob. 2017 mar 29;16(1):18. 18. gastmeier p, groneberg k, weist k, rüden h. a cluster of nosocomial klebsiella pneumoniae bloodstream infections in a neonatal intensive care department: identification of transmission and intervention. american journal of infection control. 2003 nov 1;31(7):424–30. 19. rastogi v, nirwan ps, jain s, kapil a. nosocomial outbreak of septicaemia in neonatal intensive care unit due to extended spectrum β-lactamase producing klebsiella pneumoniae showing multiple mechanisms of drug resistance. indian j med microbiol. 2010;28(4):380–4. 20. bi w, liu h, dunstan ra, li b, torres vvl, cao j, et al. extensively drug-resistant klebsiella pneumoniae causing nosocomial bloodstream infections in china: molecular investigation of antibiotic resistance determinants, informing therapy, and clinical outcomes. front microbiol. 2017 jun 30;8:1230. 21. gaspar gg, tamasco g, abichabki n, scaranello aft, auxiliadora-martins m, pocente r, et al. nosocomial outbreak of extensively drug-resistant (polymyxin b and carbapenem) klebsiella pneumoniae in a collapsed university hospital due to covid-19 pandemic. antibiotics (basel). 2022 jun 17;11(6):814. 22. andrade ln, vitali l, gaspar gg, bellissimo-rodrigues f, martinez r, darini alc. expansion and evolution of a virulent, extensively drug-resistant (polymyxin b-resistant), qnrs1supplementary issue:02 129 , ctx-m-2-, and kpc-2-producing klebsiella pneumoniae st11 international high-risk clone. j clin microbiol. 2014 jul;52(7):2530–5. 23. gaspar gg, bellissimo-rodrigues f, andrade ln de, darini al, martinez r. induction and nosocomial dissemination of carbapenem and polymyxin-resistant klebsiella pneumoniae. rev soc bras med trop. 2015;48(4):483–7. 24. lim tp, cai y, hong y, chan ecy, suranthran s, teo jqm, et al. in vitro pharmacodynamics of various antibiotics in combination against extensively drug-resistant klebsiella pneumoniae. antimicrob agents chemother. 2015 may;59(5):2515–24. 25. falagas me, tansarli gs, karageorgopoulos de, vardakas kz. deaths attributable to carbapenem-resistant enterobacteriaceae infections volume 20, number 7—july 2014 emerging infectious diseases journal cdc. [cited 2023 feb 24]; available from: https://wwwnc.cdc.gov/eid/article/20/7/12-1004_article 83 international journal of human and health sciences vol. 07 no. 01 january’23 original article smoking turnover intentionamong active tobacco smokers during the covid-19 pandemic in kathmandu, nepal bhuvan saud1, saroj adhikari2, neetu amatya1, harish singh thapa3, govinda paudel1, shankar shahi4, pravin kumar yadav2 abstract background: sars-cov-2 mainly causes respiratory tract infection in humans. objective: this study was aimed to access active smokers’ knowledge of health consequences caused by smoking, perception, and turnover intention during the covid-19 pandemic. methods: a cross-sectional descriptive, questionnaires-based, face-to-face interview was conducted with 350 participants inside kathmandu valley, nepal. the questionnaire consisted of socio-demographic characteristics, knowledge of health consequences, and perception and turnover intention. the association of smokers’ perception towards harmful health effects of smoking and turnover intention during the pandemic measured by chi-square test and p-value <0.05 was considered significant. results: overall, 93.7% of participants were male, more than 63.0% were from age group 31 to 50 years, 41.4% had intermediate level education, 76.3% were employed, 76.3% followed hindu religion, 67.7% were married and 64.2% were daily wage workers. 94.8 % smoked cigarettes and nearly 50.0% smoked 11-20 sticks/day. the majority of the participants had knowledge about lung cancer and copd. significant association of perception with turnover intention was seen in smoking damages health severely with covid-19 infection, quitting smoking was beneficial for health, smoking could damage health in the future and smokers may show severe complication. conclusion: this study showed that even though majority participants were familiar about the health hazards caused by smoking, some of them had no turnover intention. the respondents did not have perceptionof health consequences resulted from smoking to second-hand users and that smoking could reduce lung and immunity function. public awareness programs, imposing heavy taxes on tobacco products and active advertisements can be done to promote turnover intention in smokers. keywords: smoking, health, covid-19, quit intension, perception correspondence to: bhuvan saud, associate professor, department of medical laboratory technology, janamaitri foundation institute of health sciences, lalitpur, nepal. email: bhuvan.saud@lajf.edu.np 1. department of medical laboratory technology, janamaitri foundation institute of health sciences, lalitpur, nepal. 2. national trauma center, ministry of health and population, kathmandu, nepal. 3. department of development studies, kathmandu university school of education, lalitpur, nepal. 4. public health laboratory, bagmati province, dhulikhel, kavrepalanchok, nepal. introduction severe acute respiratory syndrome coronavirus 2 (sars-cov-2) has severely affected human health and the economy globally. sars-cov-2 is transmitted via contact of infected respiratory droplets with nasal, conjunctivaor oral mucosa. sars-cov-2 spike has a receptor-binding domain that binds to an angiotensin-converting enzyme 2 receptor present in the host cells1.the virus primarily attacks the respiratory tract and then can affect a variety of organs ofthe human body2. symptoms induced by infection can be mild to fetal such as fever, cough, tiredness, loss of taste or smell, lung injury and other organ damage 3. the morbidity and mortality of the disease are higher in individuals with underlying clinical conditions like diabetes, cardiovascular diseases, pulmonary diseases, cancer, etc. international journal of human and health sciences vol. 07 no. 01 january’23 page : 83-88 doi: http://dx.doi.org/10.31344/ijhhs.v7i1.503 mailto:bhuvan.saud%40lajf.edu.np?subject= international journal of human and health sciences vol. 07 no. 01 january’23 84 globally, about one-third of the adult population consumes tobacco daily 4. tobacco is associated with several life-threatening non-communicable diseases which cause significant morbidity and mortality. death associated with smoking is higher in low and middle-income countries 5. nepal is a low-income country and has insufficient health infrastructures 6. demographic and health survey (dhs)7and world health organization step-wise surveillance (who step) surveys8 are used to estimate the national prevalence of tobacco consumption in nepal. in nepal, 27 thousand people die from tobacco-related diseases annually accounting to 14.9% of all deaths9. in 2015, 21.6% of the people were tobacco users in nepal.mostly males, older aged, socioeconomically poor, hilly and rural areas individuals were more likely to smoke. according to who10, in 2019, 28.9% aged between 15-69 years use either smoked or smokeless tobacco products. also, tobacco is mainly popular among males, 50.0% of men aged 15-69 years use tobacco. in addition, exposure to secondhand smoke accounted to one–third of household population and two-fifth people at the workplace 10. smoking is associated with lung disease, chronic obstructive pulmonary disease, chronic bronchitis, heart disease, stroke, cancer, problems of the immune system etc.11. research suggests that smokers are at higher risk of developing severe covid-19 outcomes and death. tobacco smokers are more vulnerable to contracting covid-19 via virus transmission from hand to mouth. in community and social setting sharing cigarettes, mouth-pieces and hoses facilitate virus transmission12. smoking increases the risk and severity of pulmonary infection by damaging the upper airway, increasing inflammation and reducing immune function. a study has evidenced that smokers have 1.91 times the odds of progression in covid-19 severity than nonsmokers13. thus, the present study was designed to know about the knowledge of tobacco associate health hazards, perception and intention to quit smoking among active smokers of kathmandu valley during the sars-cov-2 pandemic. methods a cross-sectional, descriptive study was conducted between january and march of 2021 in kathmandu valley, nepal. all adult tobacco smokers (18 years and above) of both genders were enrolled in this study from the community. adult smokers who reported active smoking every day and agree to participate were eligible for this study and those who were not willing to participate, had cognitive impairment and could not complete the study were excluded. a convenience sampling method was used to recruit the participants.a total of 350 participants’ data were collected.in this study, questionnaires were used to obtain data from the participants. questionnaires were developed into two languages; english and nepali. the questionnaire consisted of the following parts: 1) questions on socio-demographic characteristics, 2) knowledge of health consequences of smoking and turnover intention 3) smokers’ perception and turnover intention. questionnaires were developed with the help of studies previously published and indexing in pubmed, scopus, hinari and medline. the translated version was pretested in 20 smokers and two health care professionals who are an expert in this field to get feedback about thevalidity of questions. a face-to-face interview of around 1012 minutes was conducted to obtain data from each participant. confidentiality of participants was ensured. all participants were consented before obtaining the data. the results were analyzed using the statistical package for social sciences (spss)version 20.0 (spss inc., chicago, il). the data were described using frequency distribution. a chi-square test was used to measure the association between the perception of health effects of smoking and intentions to quit. results in this study number of male participants was much higher than females. the number of participants of age groups between 31 to 40 and 41 to 50 were 115 (32.8%) and 109 (31.4%) respectively. majority of participants had intermediate level of education followed by school-level education. more than three-fourth participants had employment. more than half of the participants were hindus religion followed by buddhist and more than half were daily wage workers. majority of participants (97.9%) smoked cigarette and 48.8 % of them 85 international journal of human and health sciences vol. 07 no. 01 january’23 smoked 11-20 sticks/day. 28.5% of participants had less than 10 sticks/day dependency as shown in table 1.majority of the participants had knowledge about the health risks of smoking; about lungs cancer (289) followed by copd (101) and high blood pressure (72). on the other hand, respondents had little knowledge regarding smoking as a cause of cancer at sites other than the lungs (11). very few respondents knew that smoking affects the immune system (14) and the reproductive system (25) as shown in figure 1.table 2 shows that the majority of participants responded that smoking severely damages health with covid-19 infection, quitting smoking will benefit them and the current outbreak was the right time to quit smoking. furthermore, there were significant associations (p<0.05) noted for turnover intention with different perception questions like smoking severely damages health, health benefitted if quit smoking, smoking damages health in the future and there can be severe complications among smokers. however, there were no significant relations of perception with the turnover intention in the respondents in this pandemic for the following: smoking makes more susceptible to covid-19 infection, smoking reduces lung (oxygen saturation) function, cigarettes reduce immunity and make more susceptible to covid-19, the current outbreak was the right time to quit smoking and smoking is dangerous to second-hand smokers.moreover, 32.3% of respondents had turnover intention within one month, 21.0% had within three months, 46.1% had turnover intention within six months and interestingly 0.6% had no intention to quit. table 1: socio-demographic characteristics of the respondents variables frequency(n) percentage (%) gender male 328 93.7 female 22 6.2 age <20 18 5.1 21-30 94 26.8 31-40 115 32.8 41-50 109 31.4 >50 14 4.0 education level uneducated 19 5.4 school 128 36.5 intermediated 145 41.4 bachelor 41 11.7 master 17 4.8 current employment status yes 267 76.3 no 83 23.7 religion hindu 181 51.7 muslim 19 5.4 buddhist 142 40.5 other 8 2.2 marital status married 237 67.7 unmarried 113 32.3 profession student 5 1.4 government 9 2.5 private employee 31 8.8 self business 80 22.8 daily wage worker 225 64.2 type of smoke cigarettes 332 94.8 bedi (rolled tobacco) 11 3.1 others (hookah, sulfa, chillum) 7 2.0 smoke dependency low (<10 sticks/ day) 100 28.5 moderate (11-20 sticks/day) 171 48.8 high (>20 sticks/day) 42 12.0 occasional (<7 sticks/week) 23 6.5 figure 1: respondents who had knowledge about various diseases caused by smoking variables related to health knowledge international journal of human and health sciences vol. 07 no. 01 january’23 86 table 2: smokers’ perception towards harmful health effects and turnover intention perception variables categories frequency intention to quit χ2 & p-valueyes no how much do you think smoking damages your health more severely with covid-19 infection? very much somewhat not at all 224 99 27 128 67 21 96 32 6 χ2 (2)=6.41 p<0.04* how much do you think you would benefit from health if you quit smoking during covid-19? very much somewhat not at all 251 66 33 133 38 25 118 28 8 χ2 (2)=6.21 p<0.04* how worried are you that smoking will damage your health in the future? very much somewhat not at all 70 230 50 41 147 48 29 83 2 χ2 (2)=22.37 p<0.001* how much do you think smoking makes you more susceptible to covid-19 infection? very much somewhat not at all 37 228 95 16 144 72 11 84 23 χ2 (2)=5.43 p=0.66 how much do you think smokers may show severe complications in covid-19? very much somewhat not at all 101 186 63 72 112 52 29 74 11 χ2 (2)=11.64 p<0.002* how much do you think smoking reduces lung (oxygen saturation) function? very much somewhat not at all 42 227 81 23 137 52 19 90 29 χ2 (2)=1.04 p=0.59 how much do you think that cigarette reduces immunity and makes you more susceptible to covid-19? very much somewhat not at all 10 31 309 4 15 134 6 16 175 χ2 (2)=0.3464 p= 0.840 how much do you think the current outbreak is the right time to quit smoking habit? very much somewhat not at all 261 65 47 158 45 36 82 20 9 χ2 (2)=3.54 p=0.169 how much do you think smoking is dangerous to second-hand smokers in this pandemic? very much somewhat not at all 23 201 125 16 127 80 9 74 44 χ2 (2)=0.05 p=0.97 discussion globally, smoking is the most common form of tobacco use and over 80.0% of the world`s tobacco consumershave been living in low and middle-income countries14. generally, tobaccos are highly addictive due to nicotine and causes cardiovascular, respiratory diseases and more than 20 different types of cancer. it is estimated that over 8 million people die from tobacco use annually15. the finding of this study indicated that majority of the respondents had knowledge about lung cancer (80.2%) followed by copd (28.8%), increased blood pressure (20.5%) and stroke (10.0%). lesser knowledge was observed in response to the following: smoking could cause cancer at sites other than lungs (3.1%), smoking affects immune system (4.0%) and smoking could cause heart attack (4.5%). a similar study from iraq has found that 80.6% had knowledge about lung cancer, 66.33% had knowledge about stroke16. in this study, majority of participants responded that smoking severely damages health with covid-19 infection, quitting smoking will benefit them and the current outbreak was the right time to quit smoking. smoking is a known risk factor for respiratory infections.smokers have several folds increased risk of pneumococcal disease, influenza and tuberculosis compared to non-smokers17. in case of covid-19, smokers are more likely to develop serious disease than non-smokers18. a recent study has noted that due to covid-19 active smokers had higher risks of hospitalization (or 1.80, 95% ci 1.26-2.29) and mortality (smoking 1–9/day: or 2.14, 95% ci 0.87-5.24; 10–19/day: or 5.91, 95% ci 3.66-9.54; 20+/day: or 6.11, 95% ci 3.5910.42)19. we have found there were significant associations (p<0.05) noted with the turnover intention with different perception questions like smoking severely damages health, benefitted if 87 international journal of human and health sciences vol. 07 no. 01 january’23 quitting smoking, smoking damages health in future, and may show severe complications among smokers. in addition, 35.7% (125) respondents responded that smoking is not dangerous to second hand smokers in this pandemic and there was no significance with intension to quit (p<0.97). according to who, annually second hand exposure causes 1.2 million deaths in which 65,000 were children15. in the usa alone, every year 7,300 deaths are reported due to lung cancer caused by second hand smoke20. significant proportion of participants being unaware of the harmful effects of second hand smoke indicates the reluctance to avoid smoking in public places, workplace or home. this has raised the vulnerability of secondhand smokers to smoking related diseases. in a study conducted in iraqi smokers about intension to quit, it was revealed that 6.5% had intension to quit next month, 14.5% in the next six months16. in our study 32.3% of respondents had turnover intention within one month and 21.0% had intension to quit within three months and 46.1% had within six months. a survey conducted in china had revealed that 31.9% of active smokers intended to turnover at some point in the future21.36.0 % had an intention to quit smoking in the future among bangladeshi smokers22.also similar study from india also recorded 10.0% of active smokers had intension to quit in next month23, 54.8% smokers of kenyan and zambian had smoking turnover intensions within the next 6 months 24. in our study 0.6% had no intension to quit in the near feature. a study conducted among adolescent smokers in eastern nepal had revealed that nearly 8.0% active smokers were unwilling to turnover in the future25. a study concluded that the prevalence of turnover intension is high in developed countries smokers26. the tobacco product (control and regulation) act, 2010 is the primary law governing tobacco control in nepal. in 2015 government had increased the health warnings graphics from 75.0% to 90.0% on both sides of the packet27. along with this awareness campaign, counseling to reduce nicotine dependency, publicizing of anti-tobacco message and family, society and healthcare providers support could play vital role to reduce the smoking habits and quit earlier. the fact that 14.9% of all deaths in nepal are due to tobacco related diseases28 is an alarming sign and a scale up of awareness programs are necessary to reduce the burden of tobacco related diseases. health policy makers and health care workers should actively work on curbing smoking habit starting from adolescents as they are the most vulnerable group. this study was limited only to adult smokers over 18 years of age residing in kathmandu valley during the semi-lockdown period. a convenience sampling (non-probability) may contribute biases into study. close-ended questions were used to obtained data thus, the results may not reflect the situation for all active smokers. conclusion this study reflects that even though maximum participants were familiar about the health hazards caused by smoking, some of them still wanted to continue smoking. also it was found that there was no significant relation in the participants’ perception that smoking is dangerous to secondhand smokers, reduces pulmonary function and affects immunity system with quitting smoking. conflict of interest: none declared. funding statement: this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. author`s contribution: bs: conceptualized the study. bs, na, gp and ss: data collection and statisticalanalysis. bs, sa, and hst:writing the first draft and reviewed the literature. hst and pky: critical feedback to the draft. all authors read and approved the final version of the manuscript. references 1. harrison ag, lin t wp. mechanisms of sars-cov-2 transmission and pathogenesis. trends immunol. 2020;41(12):1100-15. 2. cucinotta d vm. who declares covid-19 a pandemic. acta biomed. 2020;91(1):157-60. 3. rando hm, maclean al, lee aj, lordan r, ray s, bansal v, et al. pathogenesis, symptomatology, and transmission of sars-cov-2 through analysis of viral genomics and structure. asm journal. 2021;6(5). 4. reitsma mb, fullman n, ng m, salama js, abajobir a ak et al. smoking prevalence and attributable disease burden in 195 countries and territories, 1990-2015: a systematic analysis from the global burden of disease study 2015. lancet. 2017;389(10082):1885-906. 5. shrestha n, mehata s, man p, pradhan s, joshi d. a international journal of human and health sciences vol. 07 no. 01 january’23 88 nationally representative study on socio-demographic and geographic correlates , and trends in tobacco use in nepal sci rep. 2019;9:2682. 6. saud b, paudel g. the threat of ambient air pollution in kathmandu. nepal j environ public health. 2018;2018:1-7. 7. ministry of health and population (mohp) [nepal]. new era, icf international inc: nepal demographic and health survey 2006. kathmandu, nepal: ministry of health and population, nepal;2007. 8. dhimal m, bista b, bhattarai s, dixit lp, hyder mka, agrawal n, et al.2020. report of non communicable disease risk factors: steps survey nepal 2019. kathmandu, nepal: nepal health research council; 2009. 9. world health organization. the fatal link between tobacco and cardiovascular diseases in the who south-east asia region-may 2018. 10. world health organization. a brilliant reason to quit tobacco covid-19may 2020. doi:https://www. who.int/nepal/news/detail/31-05-2020-a-brilliantreason-to-quit-tobacco--covid-19. 11. cdc. national center for chronic disease prevention and health promotion (nccdphp): tobacco use. 2021. doi: https://www.cdc.gov/chronicdisease/ r e s o u r c e s / p u b l i c a t i o n s / f a c t s h e e t s / t o b a c c o . htm#:~:text=as of 2018%2c about 34,41%2c000 deaths from secondhand smoke. 12. cdc.national center for chronic disease prevention and health promotion. tobacco use. 2018. doi: https://www.cdc.gov/chronicdisease/resources/ publications/factsheets/tobacco.htm#:~:text=as of 2018%2c about 34,41%2c000 deaths from secondhand smoke. 13. marquez p v. tobacco use and coronavirus (covid-19): a deadly but preventable association. voices 2020. 14. world health organization. tobacco; 2021. available from: https://www.who.int/news-room/fact-sheets/ detail/tobacco. 15. world health organization. tobacco. available from: https://www.who.int/health-topics/ tobacco#tab=tab_1. 16. dawood ot, rashan ma, hassali ma sf. knowledge and perception about health risks of cigarette smoking among iraqi smokers. j pharm bioallied sci. 2016;8(2):146-51. 17. arcavi l bn. cigarette smoking and infection. arch intern med 2004;164(20):2206-16. 18. who statement: tobacco use and covid-19-may 2020. available from: https://www.who.int/news/ item/11-05-2020-who-statement-tobacco-use-andcovid-19. 19. clift ak, ende a von, tan ps, sallis hm, lindson n, coupland cac, et al. smoking and covid 19 outcomes : an observational and mendelian randomisation study using the uk biobank cohort. thorax 2021;65-73. 20. cdc. health effects of secondhand smoke; 2020. available from: https://www.cdc.gov/tobacco/data_ statistics/fact_sheets/secondhand_smoke/health_ effects/index.htm#:~:text=secondhand smoke causes lung cancer in adults who have never smoked.&text=4,nonsmokers who are exposed to secondhand smoke at home or,cancer by 20–30%25.&text=secondhand smoke causes more than,among u.s. nonsmokers each year. 21. yang j, hammond d, driezen p, fong gt, jiang y. health knowledge and perception of risks among chinese smokers and non-smokers : findings from the wave 1 itc china survey. tob control 2010;19(suppl 2). published october 2010. 22. driezen p, abdullah as, quah ack, nargis n fg. determinants of intentions to quit smoking among adult smokers in bangladesh: findings from the international tobacco control (itc) bangladesh wave 2 survey. glob heal res policy. 2016;1:11. 23. sansone gc, raute lj, fong gt, pednekar ms, quah ac, bansal-travers m, gupta pc sd. knowledge of health effects and intentions to quit among smokers in india: findings from the tobacco control policy (tcp) india pilot survey. int j env res public health. 2012;9(2):564-78. 24. kaai sc, fong gt, goma f, et al. identifying factors associated with quit intentions among smokers from two nationally representative samples in africa: findings from the itc kenya and zambia surveys. prev med rep. 2019;15:100951. 25. man p, pradhan s, marahatta k. cross-sectional survey on quitting attempts among adolescent smokers in dharan, eastern nepal. j addiction. 2016:1-5. 26. khan za, goel r, mukherjee ak, khan t. prevalence and predictors of intention to quit tobacco smoking in smokers of rural area of north india ( haryana ). intj community med public health. 2018;5(4):1617-22. 27. legislation by country nepal. tobacco control laws. 2021; available from: https://www. tobaccocontrollaws.org/legislation/country/nepal/ summary. 28. shrestha g, phuyal p, gautam r, mulmi r, pradhan pms. burden of tobacco in nepal: a systematic analysis from the global burden of disease study 1990-2017. bmj open. 2021;11(8):e047847. https://www.who.int/news-room/fact-sheets/detail/tobacco https://www.who.int/news-room/fact-sheets/detail/tobacco https://www.who.int/health-topics/tobacco#tab=tab_1 https://www.who.int/health-topics/tobacco#tab=tab_1 https://www.who.int/news/item/11-05-2020-who-statement-tobacco-use-and-covid-19 https://www.who.int/news/item/11-05-2020-who-statement-tobacco-use-and-covid-19 https://www.who.int/news/item/11-05-2020-who-statement-tobacco-use-and-covid-19 https://www.tobaccocontrollaws.org/legislation/country/nepal/summary https://www.tobaccocontrollaws.org/legislation/country/nepal/summary https://www.tobaccocontrollaws.org/legislation/country/nepal/summary 157 international journal of human and health sciences vol. 07 no. 02 april’23 original article: maternal dissatisfaction about toddler’s body size and its relationship to children’s eating behaviours wulandari e1, wiboworini b1, widyaningsih v1 abstract the fulfilment of toddlers’ nutritional needs is very dependent on their parents. parental dissatisfaction can affect feeding practices and food choices for her children that are related to eating behaviour. this study aimed to analyzed the relationship between maternal satisfaction of children’s body size and their children’s eating behaviour. this cross-sectional study involved 126 pairs of mother-toddler ages 24-59 months. mother’s satisfaction was assessed using toddler silhouette questionnaire, while their children’s eating behaviour was assessed using the children’s eating behaviour questionnaire (cebq). the result shows that 77.6% of mothers who have well-nourished children desire a heavier child. there is a positive relationship between maternal satisfaction with food avoidance behaviour (p<0.01) at subscale slowness in eating (p<0.01), food fussiness (p<0.05) and emotional eating (p<005). mother who wants their children to be heavier tends to have children who are food avoidance, slow to eat, picky eaters and emotional eating. keywords: maternal dissatisfaction, children’s eating behaviour, toddler correspondence to: eka wulandari, student of postgraduate nutrition science program, sebelas maret university, indonesia, email: ekawulan.w3@gmail.com 1. postgraduate nutrition science program, sebelas maret university, surakarta, indonesia introduction body satisfaction was psychological sign that compare self-image with desire body size or body size considered ideal, in negatif or possitive ways1. body satisfaction can occur in all age groups, but toddler and preschooler had difficulty to perceiving their bodies correctly2. the role of dissatisfaction of body size in eating behaviour was mainly focused on tendency to diet3. the fulfillment of nutritional needs at this age also still depends on what is given by their parents, so that the opinion of parents regarding toddler nutritional status or body size is very important. parental satisfaction determines parent’s decisions of food choices for their children and how parents fed them. there are no studies in indonesia that look at maternal satisfaction about their toddler body size, but other studies have seen that mothers think a fat toddler is a good thing4,5. maternal concern about their children weight linked to maternal pressuring of restricting of food6. mothers who want their children to be heavier tend to give more food and tent to push their children to eat that can affects to child’s eating behavior7. children’s eating behaviour is tendency of eating behaviour in children which is extracted from the information of the mother as a caregiver. it devided into food approach type and food avoidance type. food approach type consist of indicator food responsiveness, emotional over-eating, enjoyment international journal of human and health sciences vol. 07 no. 02 april’23 doi: http://dx.doi.org/10.31344/ijhhs.v7i2.567 international journal of human and health sciences vol. 07 no. 02 april’23 158 of food, and desire to drink; while food avoidance type consist of indicator satiety responsiveness, slowness in eating, emotional under-eating, and food fussiness8. food responsiveness describe desire to consume food. enjoyment of food and desire to drink describe children’s interest in food and drink. food fussiness describe picky eating in children. slowness in eating assesses child’s speed to finish their meal. satiety responsiveness assess child sensitivity of satiety or respon full. emotional eating which includes over-eating and under-eating examines the influence of emotions on children’ food consumtion. eating behaviour in children can continue become an eating disorder when the child reaches adolescence9. it is normal for toddlers to have eating problems because there are certain phases, but there are eating disorders that must be anticipated because it can affect the current growth process and children’s future health. study shows that infantile anorexia, which usually occurs in children aged 6-36 months, is assosiated with impaired cognitive development and abnormal sleep patterns10. this study aimed to analyzed the relationship between maternal satisfaction with children’s body size and their children’s eating behaviour. materials and methods this cross-sectional study was conduct in kramat jati, east jakarta from july to august 2022 involved 126 pairs of mother-toddler ages 24-59 months were selected by using multistage cluster random sampling. subject’s weight and height meassured and nutritional status viewed by w/h (weight per height) indicators and clasified as “underweight” (zscore <-2sd), “healthy weight” (zscore >-2sd – 2sd), and “overweight” (zscore >2sd). mother as a respondent interviewed about their toddler eating behaviour with children’s eating behaviour questionnnaire (cebq) includes 30 questions using likert scale11. each item of the question will be given a score of 5 (always), 4 (often), 3 (sometimes), 2 (rarely), 1 (never). mean score from each indicator were measured. mother’s satisfaction was assessed using toddler silhouette questionnaire, which consists of 2 sets of 7 children’s picture with number 1 (thinnest) to 7 (fattest)12. mother asked to choose picture’s number that describe (1) the body size that most closely resembled their child, and (2) the body size that she want their child to be, and score is obtained from the difference set (1) minus set (2). score result categorized into “want to be thinner” (negative score), “satisfied” (score= 0), and “want to be heavier” (positif score). toddler’s nutritional status and maternal satisfaction’ category analyzed using chi-square test, while cebq score and maternal satisfaction score analyzed using the rank spearman test. results general characteristics of the data table 1. shows distribution of age, gender, and nutritional status of the subject. in this study most subject has a healthy weight (84.9%). table 1. characteristics of respondents variables n % age 23-35 months 53 42.1 36-47 months 34 27.0 48-59 months 39 31.0 gender male 56 44.4 female 70 55.6 nutritional status underweight 7 5.6 healthy weight 107 84.9 overweight 12 9.5 the significant chi-square analysis suggested that there were differences in maternal satisfaction with their children’s body size by the weight status of the children. table 2. shows that 77.6% of mothers who have children with healthy weight want their children to be heavier, and only 18.7% of them are satisfied with their child’s body. as for mothers with overweight children, 16.7% of them still want their children heavier even though they are already overweight 159 international journal of human and health sciences vol. 07 no. 02 april’23 table 3. relationships between maternal satisfaction and children eating behaviour fr eo ef dd food approach sr se eu ff food avoidance maternal satisfaction ρ 0.093 0.178* -0.174 0.064 0.059 0.027 0.331** 0.177* 0.182* 0.256** p 0.298 0.046 0.051 0.457 0.512 0.766 0.000 0.047 0.041 0.004 *significant at the 0.05 level (spearman rank) **significant at the 0.01 level table 2. relationship between maternal satisfaction and nutritional status nutritional status underweight healthy weight overweight χ2 p n % n % n % maternal satisfaction wants thinner 0 0 4 3.7 5 41.7 32.822 0.000satisfied 0 0 20 18.7 5 41.7 wants heavier 7 100 83 77.6 2 16.7 total 7 100 107 100 12 100 fr (food responsiveness), eo (emotional overeating), ef (enjoyment of food), dd (desire to drink), sr (satiety responsiveness), se (slowness in eating), eu (emotional undereating), ff (food fussiness) statistical results show a positive relationship (ρ) between mother’s satisfaction with children’s body size and children’s eating behaviour on the food avoidance type behavior especially in indicator slowness in eating, food fussiness, emotional undereating, and the food approach type behavior in indicator emotional overeating. discussion toddlers are one of the nutritionally vulnerable groups whose nutritional needs still depend on what their parents give them. this study found that most mothers were dissatisfied with their child’s current body size and wanted to gain weight. most of the mothers who have children with healthy weight want their children heavier, and there are still mothers who have overweight children want that too. this is line with similar research13,14,15,16 and proves that mother’s perception of obese children is a good thing in society was true. maternal dissatisfaction of children’s body size can make mother tend to give more food to their children, choose high-calorie foods or increase their children’s portion and snack in effort to increase weight13. this can increase the potential for children obesity. maternal dissatisfaction is related to children’s eating behaviour with food avoidance type, one of which indicator is food fussiness or called picky eating in several studies17,18,19. mothers who want to increase their child’s weight but their children are picky eaters, will be more permissive so that they give whatever food their children want, as long as they willing to eat20,21. food fussiness and slowness in eating indicator in eating behaviour has negative relationship with children’s weight22, which makes it more difficult for mothers who want to gain weight. research shows that mothers who have value conflict about giving healthy-unhealthy snacks and tend to give their children what they like, even though they know it’s unhealthy23. children naturally like sweet food3. in indonesia, this age group rank first for consuming most sugary foods and drinks in a day24. excessive sugary foods and drinks increase the risk of healthy problems both now and in the future. eating behaviour is formed in toddler and tends to carry over into their adolesence and adult9,25. emotional eating may not have an significant effect to current nutritional status22 because the mother will try to meet the nutritional needs of her child. but, emotional eating in early life can lead to eating dissorder if not treated early. the age at which they can determine their own diet, eating disorders can cause various nutritional problems. international journal of human and health sciences vol. 07 no. 02 april’23 160 children’s overeating is also assosiated with the incidence of hyperlipidemia, hypercholesterolemia and hyperlipoprotein wherease undereating is lack of micronutrients in adolescence. it is necessary to provide knowledge to mothers about healthy child’s body size, good feeding practice and healthy food choices. conclusion mother who dissatisfied and wants their children to be heavier tends to have children who are food avoidance, slow to eat, picky eaters and emotional eating both undereating and overeating. health providers should give education about healthy body size and healthy food for children with difficulty eating so as not to increase the risk of obesity. conflict of interest none declared ethical clearance this study has been approved by research ethics committee faculty of medicine universitas sebelas maret no. 93/un27.06.11/kep/ec/2022 authors’ contribution eka wulandari conceptualized and designed the study, conducted the study, data analysis, interpretation and drafting manuscript. budiyanti wiboworini assissted in conceptualized and designed the study, and review the manuscript. vitri widyaningsih assisted in designed the stud, analysis data and review the manuscript. 161 international journal of human and health sciences vol. 07 no. 02 april’23 reference 1. navarro-patón r, mecías-calvo m, pueyo villa s, anaya v, martí-gonzález m, and lago-ballesteros j. perceptions of the body and body dissatisfaction in primary education children according to gender and age. a cross-sectional study. int. j. environ. res. public health 2021; 18, 12460 2. león m, gonzález-martí i, fernández-bustos j, and contreras o. perception of body size and dissatisfaction in children aged 3 to 6: a systematic review. anales de psicología, 2018; 34(1): 173-183 3. dovey t, eating behaviour, london: open university press, 2010 4. sari r, gambaran persepsi ibu terhadap obesitas pada anak usia prasekolah di kelurahan grogol selatan kebayoran lama jakarta selatan, 2015 5. wijayanti hs and syahidah za. perbedaan aktivitas fisik, screen time, dan persepsi ibu terhadap kegemukan antara balita gemuk dan non-gemuk di kota semarang. journal of nutrition college, 2017; 6(1): 11-18 6. scaglioni s, cosmi vd, ciappolino v, parazzini f, brambilla p, and agostoni c. factors influencing children’s eating behaviours. nutrients, 2018; 10, 706 7. costa a, hetherington m, and oliveira a. maternal perception, concern and dissatisfaction with child weight and their association with feeding practices in the generation xxi birth cohort. the british journal of nutrition, 2022; 127(7): 1106-1116 8. wardle j, guthrie ca, sanderson s, rapoport l. development of the children’s eating behavior questionnaire. j child psychol psychiatry, 2001; 42(7): 963-70 9. herle m, stavola bd, hübel c, abdulkadir m, ferreira ds, loos rjf, et all. a longitudinal study of eating behaviours in childhood and later eating disorder behaviours and diagnoses. br j psychiatry, 2020; 216(2): 113-119 10. agustina nn, santosa q, munaya na and dwijayanti gc. association of infantile anorexia with sleep pattern and cognitive development of children at southern region of central java, indonesia. j compr ped, 2021; 12(2): e99766 11. purwaningrum dn, arcot j, hadi h, hasnawati ra, rahmita rs and jayasuriya r. a cultural adaptation and validation of a child eating behavior measure in a lowand middle-income country. public health nutrition, 2020; 23(11): 1931-1938 12. adeniyi of, ekure e, olatona fa, ajayi eo and nworgu n. nutritional assessment and maternal perception of toddler body size using toddler silhouette scale in nigeria a developing country. international journal of mch and aids, 2018; 7(1): 9-16 13. flax vl, thakwalakwa c, phuka jc and jaacks lm. body size preferences and food choice among mothers and children in malawi. matern child nutr, 2020; 16:e13024 14. allen j and prkachin gc. parental awareness and perception of their children’s body size. open journal of medical psychology, 2013; 2: 77-80 15. hager er, candelaria m, latta lw, hurley km, wang y, caulfield le, and black mm. maternal perceptions of toddler body size: accuracy and satisfaction differ by toddler weight status. arch pediatr adolesc med, 2012; 166(5): 417–422 16. killion l, hughes so, wendt jc, pease d and nicklas ta. minority mothers’ perceptions of children’s body size. international journal of pediatric obesity, 2006; 1(2): 96-102 17. cerdasari c, helmyati s, and julia m. pressure to eat with picky eater in 2-3 years old children. jurnal gizi klinik indonesia, 2017; 13(4): 170-178 18. hardianti r, dieny ff and wijayanti hs. picky eating dan status gizi pada anak prasekolah. jurnal gizi indonesia (the indonesian journal of nutrition), 2018; 6(2): 123-130 19. putri an and muniroh l. correlation of picky eater with intake adequacy and nutritional status in preschool-aged children in gayungsari. amerta nutr, 2019; 232-238 20. idai. rekomendasi ikatan dokter anak indonesia: pendekatan diagnosis dan tata laksana masalah makan pada batita di indonesia, 2014 21. lestari rf, sari ab and daniati m. pengalaman ibu yang memiliki anak usia prasekolah kesulitan makan di paud imanuel pekanbaru; studi fenomenologi. jurnal photon, 2017; 7(2): 21-27 22. webber l, hill c, saxton j, jaarsveld cv, and wardle j. eating behaviour and weight in children. int j obes (lond), 2009; 33(1): 21–28 23. damen fw, luning pa, hofstede gj, fogliano v, steenbekkers bl. value conflicts in mothers’ snack choice for their 2to 7-year old children. matern child nutr, 2020; 16:e12860 24. ministry of health, riskesdas 2018 25. lewer m, bauer a, hartmann as and vocks s. different facets of body image disturbance in binge. eating disorder: a review. nutrients, 2017; 9:1294 26. hübel c, herle m, ferreira dls, abdulkadir m, bryant-waugh r, loos rjf, et all. childhood overeating is associated with adverse cardiometabolic and inflammatory profiles in adolescence. scientific reports, 2021; 11:12478 international journal of human and health sciences vol. 07 no. 01 january’23 78 original article the utility of antibiogram in prevention of hearing impairment caused by chronic suppurative otitis media (csom): a prospective study from rural area of maharashtra, india sabiha saleem tamboli1, saleem b tamboli2 abstract background: chronic suppurative otitis media (csom) is a common cause of hearing impairment, especially in rural population. objective: to determine the bacteria associated with csom and their antibiotic sensitivity pattern for better management of the disease and to reduce morbidity due to csom. methods: patients with clinical diagnosis of csom were included in the study. ear swabs were collected from the discharging ear. culture and sensitivity studies were done as per conventional methods.patients with hearing impairment were tested using the tuning fork examination to determine whether the impairment was conductive or sensorineural. results: the present study consists of 789 clinically diagnosed patients of csom. mostof the patients (62.73%) were in pediatric age group. otorrhea was a constant presentation among all patients, followed by hearing loss. majority of the patients were having conductive hearing loss (87%) followed by sensorineural hearing loss (9%) and mixed hearing loss (4%). analysis of isolated organisms showed preponderance of gram-negative bacilli. the most commonly isolated organism was pseudomonas aeruginosa (40 %) followed by staphylococcus aureus (33%) and klebsiella species (10%). gentamicin and ciprofloxacin commonly used topical agents showed good activity against most of the isolates.conclusion: with the development and widespread use of antibiotics, the type of pathogenic microorganism and their resistance to antibiotics have changed. continuous and periodic evaluation of microbiological patterns and antibiotic sensitivity of isolates is necessary to decrease the potential risk of complications by early institutions of appropriate treatment. keywords: chronic suppurative otitis media, hearing impairment, antibiogram correspondence to: dr. sabiha saleem tamboli, associate professor, department of microbiology, indian institute of medical science & research jalna (iimsr jalna), maharashtra, india-431202. email: microbiopharma@yahoo.com introduction chronic suppurative otitis media (csom) is defined as chronic inflammation of middle ear and mastoid cavity that may present with recurrent ear discharges through a tympanic perforation.1it is a persistent disease with irreversible sequelae and can proceed to serious intra extracranial complications.2 common causative microorganisms are bacteria, fungi and virus resulting in inflammation of mucosal lining of middle ear. if not treated it leads to partial or total loss of tympanic membrane and ossicles resulting in acquired hearing loss.3 as per national sample survey office (nsso) data, the estimated prevalence of adult onset deafness in india was found to be 7.6 % and childhood onset deafness to be 2%. currently there are 291 persons per one lakh population who are suffering from mild to severe hearing loss. of these a large percentage of children are between the age group of 0 to 14 years. with such a large number of hearing impaired young indians, it amounts to a severe loss of productivity, both physically and economically. it has been noted by who that half of the causes of deafness are preventable and about 30% though not preventable, are treatable or they 1. dr. sabiha saleem tamboli, associate professor, department of microbiology, indian institute of medical science & research jalna (iimsr jalna), maharashtra, india-431202. 2. dr. saleem b tamboli, professor, dept of pharmacology, grant government medical college & sir j j hospital, byculla, mumbai, india international journal of human and health sciences vol. 07 no. 01 january’23 page : 78-82 doi: http://dx.doi.org/10.31344/ijhhs.v7i1.502 79 international journal of human and health sciences vol. 07 no. 01 january’23 can be managed with assistive devices. csom is an important cause of hearing loss that can be treated before it causes deafness.4 inadequate and inappropriate treatment of csom can result in a wide range of complications. these may be due to the spread of organisms to structures adjacent to ear or local damage in the middle ear itself.5 various organisms are responsible for csom; therefore, the microbial culture and sensitivity will help in appropriate management and thus preventing the emergence of resistant bacterial strain. with this the present study was carried out to know the organisms that cause csom and their antibiotic sensitivity pattern among the patients who attended ent opd in a rural hospital in maharashtra, india. methods this is a prospective study conducted in the rural medical college and hospital of maharashtra. the study was conducted for a period of 6 months. ethical committee clearance was obtained before the study. a written consent was obtained from all patients. a total of 789 patients with csom were selected based on inclusion and exclusion criteria. patients coming with chronic ear discharge, perforation of tympanic membrane of all age groups and both genders were included in the study. patients on antibiotic treatment for 5 or more days, children who are not cooperative and cases of otitis externa and acute otitis media were excluded from the study. on otoscopy conditions of tympanic membrane perforation, condition of middle ear mucosa and ossicles were also noted. pure tone audiometry, impedence audiometry and tuning fork test were performed in every case for confirmation of deafness. according to the who guidelines(1980), patients were categorized on the basis of degree of hearing loss into five groups mild (26 to 40 db), moderate(41 to 55 db), moderately severe (56 to 70 db), severe (71 to 90 db) and profound (>90 db) respectively. patients with hearing impairment were tested using the tuning fork examination to determine whether the impairment was conductive or sensorineural. a tuning fork with a frequency of 512 hz was considered to be an ideal test of air conduction (ac) and bone conduction (bc) in conjunction with the rinne test and weber test.using the microscope excess discharge is sucked out of the external acoustic canal.6,7 then specimen is collected through the perforation with small, sterile cotton swab and sent for microbiological analysis. two swabs were collected. in the laboratory, the first swab was used for gram staining and second swab was inoculated on nutrient agar, mac conkey agar, blood agar for bacterial isolation.8,9the plates were incubated overnight at 37 degree centigrade. the bacteria were identified with standard biochemical tests. antibiotic sensitivity testing was done by kirby bauer disc diffusion methods.10 results the present study consists of 789 clinically diagnosed patients of csom (430 males and 359 females). the majority of patients (62.73%) were in pediatric age group (table 1). otorrhea was a constant presentation among all patients, followed by diminished hearing. unilateral ear discharge was found in 78% patients and bilateral in 22% patients (table 2).the most common site of perforation was anteroinferior quadrant 32% followed by posterioinferior quadrant 26%. (table 3). majority of the patients were having conductive hearing loss 87% followed by sensorineural hearing loss 9% and mixed hearing loss in 4% (table 4). majority of the patients were having mild to moderate hearing loss (82%) and moderately severe to severe hearing loss (9%) (table 5). in a total of 789 ear swab culture, 640 (81.11%) organisms were isolated. among them 538 were monomicrobial and 102 were polymicrobial whereas in 149 (18.88%) cultures no organism was grown even after 48 hours of incubation. analysis of isolated organisms showed preponderance of gram-negative bacilli. the most isolated organism was pseudomonas aeruginosa 40% followed by staphylococcus aureus33%, and klebsiella species 10% (table 6). in vitro gentamicin showed sensitivity to klebsiella and proteus 100% , e.coli 80%, and pseudomonas aeruginosa 80% (table 7). table 1:age and sex distribution (n= 789) age/ sex pediatric age group adult age group total no. of cases male 280 150 430 emale 215 144 359 total 495 294 789 international journal of human and health sciences vol. 07 no. 01 january’23 80 table 2:symptoms of patients (n= 789) symptoms no. of patients (%) otorrhea 100% diminished hearing 98% upper respiratory infection 22% pain in the ear 15% itching 10% table 3: site of perforation site of perforation no. of patients (%) anteroinferior 32% posteroinferior 26% inferior 13% anterior 10% posterosuperior marginal 6% posterior 5% attic 5% total perforation 3% total 100% table 4:type of hearing loss type of hearing loss no. of patients (%) conductive 687(87%) sensorineural 71 (9%) mixed 31 (4%) table 5: pure tone audiometry in csom type percentage mild hearing loss 26 40 db 53% moderate hearing loss 41 – 55 db 29% moderately severe 56-70 db 7% severe 71-90 db 2% couldn’t assess 9% discussion csom is a condition of the middle ear that is characterized by persistent or recurrent discharge through a chronic perforation of tympanic membrane. due to perforation of tympanic membrane, microorganism gain entry to the middle ear via the external ear.11 the sex wise distribution in the present study showed 54.49 % of total cases of csom were males and 45.50 % were females. similar results of male preponderance were reported by previous studies,12-14 whereas a study by mansoor et al reported higher female preponderance.15 in the present study, highest prevalence 62.73% was reported in the pediatric age group. this finding was in congruencewith previous authors.2,16 the incidence of csom in pediatric age group is because of increased risk of respiratory infections, short and straight eustachian tube in infant and young children allows ready access of bacteria to middle ear. hot and humid climate is one of the risk factor along with ear picking with different objects, putting oil drops in ear and swimming. otorrhoea was a commonest clinical presentation in our study followed by diminution of hearing. similar finding have been observed in the study done by mugliston etal.17 it is observed from our study that 640 patients with csom were tested by pure tone audiometry, degree of hearing loss in decibels had mild 53%, moderate 29%, moderately severe 7% and severe hearing loss is 2%. our findings were similar to handi etal.18 and deviana et al.19. hearing loss depends on the size of the perforation which results in increase hearing loss. we found mild to moderate hearing loss in 82% of the patients. only 9% had moderately severe to severe hearing loss. this is similar to the observations by priyadarshani etal.20 in our study, 87% of patients had conductive type hearing loss and 9% sensorineural and 4 % mixed hearing loss which is similar to other study done by alabbasi et al.21 knowledge of the local microorganism pattern table 6:percentile of bacterial isolates (no. of isolates = 640) bacterial isolates percentage (%) gramm negative bacteria 61% pseudomonas aeruginosa 40% klebsiella species 10% escherichia coli 7% proteus species 4% gram positive bacteria 39% staphylococcus aureus 33% coagulase negative staphyloccocci 6% 81 international journal of human and health sciences vol. 07 no. 01 january’23 table 7: antibiogram of bacterial isolates in csom (inpercentages) isolates e amp amc gen amk cip ctx cfx pip pseudomonas aeruginosa 80 100 90 81 90 89 staph.aureus 75 74 80 65 98 85 78 72 50 klebsiella 83 60 100 50 70 76 70 40 e.coli 82 65 80 65 65 80 75 50 cons 60 82 60 60 80 50 80 74 50 proteus 60 50 100 60 80 70 60 65 [e-erythromycin, amp-ampicillin, amcamoxicillin clavulanic acid, gengentamicin amkamikacin, cipciprofloxacin, ctxceftriaxone, cfxcefuroxime, pippiperacillin] and their antibiotic sensitivity is essential to allow effective and cost saving treatment.5 in the present study, pseudomonas aeruginosa (40%) was the predominant organism followed by staphylococcus aureus (33%). it is observed that both gram negative and gram positive organisms were responsible for csom. gram negative bacilli were more as compared to gram positive cocci. these findings were consistent to the finding of other studies.22,23 in contrast,someof the studies reported staph.aureus as predominant organisms followed by pseudomonas aeruginosa.11,24 in the present study, coliforms including klebsiella and e.coli were isolated from 10% and 7% cases respectively, these findings were similar to the studies by mansoor etal.15 who reported the same to be 8% and 4% respectively.more frequent isolation of fecal bacteria like e.coli, klebsiella and water bacteria like pseudomonas indicates that individual are at high risk of infection due to poor hygiene conditions. among the various antibiotics tested amikacin, ciprofloxacin, cefuroxime, piperacillin were found to be most effective. gentamicin and ciprofloxacin commonly used topical agents showed good activity against most of the isolates. in the present study both pseudomonas aeruginosa and staph. aureus showed good sensitivity to amikacin and gentamicin and the finding is supported by previous study.25 although very few cases are documented, but risk of ototoxicity due to aminoglycoside overuse should also be kept in mind.26 the present study showed that 80% of all isolates sensitive to ciprofloxacin indicating that it is very effective drug.thus knowing the etiological agents of csom and their antimicrobial susceptibility is of essential importance for an efficient treatment, prevention of both complications and development of antibiotic resistance and finally, the reduction of the treatment cost, changes in the microbial flora , introduction of more sophisticated antibiotics and the changing ast pattern increases the relevance of culture and sensitivity which serves as an important tool for the clinician to plan the treatment of a chronically discharging ear. conclusion from this study it can be concluded that the site and size of tympanic membrane perforation affect hearing loss. to limit hearing loss due to csom, proper diagnosis and treatment must be started as early as possible. so awareness should be developed among the general population about csom and its sequelae.with the development and widespread use of antibiotics, the type of pathogenic microorganism and their resistance to antibiotics have changed. continuous and periodic evaluation of microbiological patterns and antibiotic sensitivity of isolates is necessary to decrease the potential risk of complications by early institutions of appropriate treatment. conflict of interest: none declared. funding: nothing to declare ethical approval: the study was approved by the reb ofindian institute of medical science & research jalna (iimsr jalna), maharashtra, india. author’s contribution: the author is solely responsible fordesign of the study, patient selection, data collection, analysis, manuscript preparation, revision and finalization. references: international journal of human and health sciences vol. 07 no. 01 january’23 82 1. acuin j. global burden of disease due to chronic suppurative otitis media: disease, deafness, death delays chronic suppurative otitis mediaburden of illness and management option.geneva: world health organisation;2004.p.9-23. 2. poorey vk, iyer a.study of bacterial flora in csom and its clinical significance.indian j otolaryngol head neck surg 2002;54(2):91-5. 3. kumar r, srivastava p, sharma m, etal.isolation and antimicrobial sensitivity profile of bacterial agent in csom at nims hospital. international journal of pharmacy and biological sciences 2013;3(4):265-9. 4. vengala rr, suraneni vr, osuri s, etal. prevalence and etiological factors causing hearing loss in school going children of vizianagaram district.int jsci stud.2014;2(9):41-3. 5. loy ahc, tan al, lu pks. microbiology of chronic suppurative otitis media in singapore. singapore med j. 2002;43(6):296-9. 6. menichetti f. current and emerging serious gram positive infections.clin microbiol infect. 2005;11(suppl.3):22-8. 7. mohammed shafiqul islam, md. rafiqul islam, mohammed ashequrahmanbhaiyan. pattern and degree of hearing loss of chronic suppurative otitis media. bangladesh j otorhinolaryngol. 2010;16(2):96-105. 8. gupta v, gupta a, sivarajan k. chronic suppurative otitis media: anaerobic microbiological study. indian j otol.1998;4:79-82. 9. winn ws .allen sd, janda wm, koneman ew, procop gw, schreckenberger pc, charts. in: darcy p, pterson n, montalbano j, editors. koneman’s color atlas and textbook of diagnostic microbiology .6th ed. philadelphia: lippincott; 1997. p.1442-1535. 10. collee jg, miles rs.tests for identification of bacteria. in:collee jg, fraser ag, marmion bp, simmons a, eds. mackie and mc cartney practical medical microbiology.14th ed. new york: churchil livingstone;1996. p.131-49. 11. ettehad g, refahi s, nemmati a, piradeh a. microbial and antimicrobial susceptibility patterns from patients with chronic otitis media in ardebil. int. j trop med.2006;1:62-5. 12. hiremath sl, kanta rc, yeshwanthrao m, vasantha kumar cm. aerobic bacterial isolates of csom and their antibiotic sensitivity pattern. the indian practitioner.2001;54:486-9. 13. saranya sk, vazhavandal g, vallab ganesh b et al. bacteriological and mycological profile of chronic suppurative otitis media in a tertiary teaching hospital, trichy, tamilnadu . intj pharma sci invention. 2015;4(1):13-9. 14. wadile rg, bhate vm, kalshetti vt. bacteriological profile of chronic suppurative otitis media. intj current microbiol appl sci. 2015;4(6):41-7. 15. mansoor t, musani m, khalid g, kamal m. pseudomonas aeruginosa in chronic suppurative otitis media: sensitivity spectrum against various antibiotics in karachi. j ayub med coll abbottabad. 2009;21(2):120-3. 16. iqbal k, khan m, satti l. microbiology of chronic suppurative otitis media. experience at dera ismail khan, gomal jmed sci. 2012;9(2):189-93. 17. mugliston t, o’ donoghue g. otomycosis: a continuing problem. j laryngol otol.1985;99:32733. 18. handi ps, mallikarjun pn, presenkumar kr. evaluation of hearing loss by pure tone audiometry in chronic suppurative otitis media. int j otorhinolaryngol head neck surg.2018;4:1173-6. 19. deviana, indrasworo d. pattern and degree of hearing loss in chronic suppurative otitis media. j med dent sci. 2016;15:73-80. 20. priyadarshini g, sowmiya m, febin j. clinical and audiological study of chronic suppurative otitis media tubotympanic type. int j otorhinolaryngol head neck surg.2017;3:671-5. 21. ahmed m alabbasi, ihsan e alsaimary, jassim m najim. prevalence and pattern of chronic suppurative otitis media and hearing impairment in basrah city. j med med sci. 2010;1(4):129-33. 22. osazuwa f, osazuwa e, osime c, igharo ea, imade pe, lofor p, et al. etiologic agents of otitis media in benin city, nigeria. n am j med sci.2011;3:95-8. 23. shyamla r, reddy sp. the study of bacteriological agents of chronic suppurative otitis media – aerobic culture and evaluation. j microbiolbiotechnol res.2012;2:152-62. 24. singh ah, basu r, venkatesh a. aerobic bacteriology of chronic suppurative otitis media in rajahmundry. biol med.2012;4:73-9. 25. vishvanath s, mukhopadhyay c, prakash r, pillai s, pujary p. chronic suppurative otitis media: optimising initial antibiotic therapy in a tertiary care setup. indian j otolaryngol head neck surg.2012;64:285-9. 26. haynes ds, rutka j, hawke m, ronald ps. ototoxicity of ototropical drops-an update. otolaryngol clin north am. 2007;40(3):669-83. international journal of human and health sciences vol. 05 no. 04 october’21 418 original article assessment of knowledge, attitude, handwashing practices and its associated factors among mothers of children presenting in paediatric department of a tertiary care hospital of a developing country. shahzaib maqbool1, maryam haider1, ather iqbal, arham ihtesham1, waleed inayat mohamed1, muhammad nadeem langove2, laraib arsh1, omaima sundus1, syed turab haider3, hassam omer1. abstract objective: despite remarkable progress in scientific methods and measures against infectious disease transmission, the prevalence of infectious diseases is still on the rise in resource-poor countries. hand hygiene is considered an effective way of fighting against deadly infectious diseases. our study aimed to assess knowledge, attitude, and hand hygiene practices among mothers of children presenting for routine paediatric check-up in the department of paediatrics in a tertiary care hospital of rawalpindi. materials and methods: it’s a descriptive cross-sectional study involving 400 mothers from the paediatric department of the holy family hospital (hfh), rawalpindi. a convenient sampling technique was used to select the study participants. a semi-structured, pre-tested questionnaire that included demographic details, knowledge, attitude, and practice levels were assessed through validated questionnaires used in previously published studies. descriptive statistics were used for demographic details and chi-square analysis was used to find an association between handwashing practice with knowledge and attitude. a p<0.05 was taken as significant. data analysis was done through spss.v.23. results and discussion: in total, 400 females participated in the study and the mean age (±sd) was 32.4±10.2 years. the mean age of children was 31.2±12.2 months. the level of good handwashing knowledge and attitude was 93% and 60% respectively. however, the level of good handwashing practice was just 40%. the age of mothers, residential area, occupation, socioeconomic status, and the level of knowledge regarding handwashing, showed significant association with handwashing practices. conclusion: in our study handwashing practice among mothers was relatively low. age of mothers, residential area, occupation, socioeconomic status, and the level of knowledge regarding handwashing, were significantly associated with handwashing practices. keywords: attitude, handwashing, knowledge, practice, paediatric department, mothers of children. correspondence to: shahzaib maqbool, final year mbbs, rawalpindi medical university, rawalpindi, pakistan. e-mail: hasanshahzaib299@gmail.com international journal of human and health sciences vol. 05 no. 04 october’21 page : 418-423 doi: http://dx.doi.org/10.31344/ijhhs.v5i4.351 1. final year mbbs, rawalpindi medical university, rawalpindi, pakistan. 2. house officer, rawalpindi medical university, rawalpindi, pakistan. 3. final year mbbs, nishtar medical university, multan, pakistan. introduction despite remarkable progress in scientific methods and measures against infectious disease transmission, the prevalence of infectious diseases is still on the rise in resource-poor countries as evident from a study that infectious diseases are responsible for 1.6 million deaths among children of under-five age group [1,2]. hand hygiene is considered an effective way of fighting against deadly infectious diseases such as respiratory tract infections and most importantly diarrheal diseases that are posing a significant disease burden among children [3]. there are several effective ways of maintaining hand hygiene that could vary among different communities depending upon their customs and practices, but handwashing with soap is taken as the most cost-effective method of preventing infectious diseases [4]. the evidence-based benefits of practicing regular hand washing and maintaining overall hygiene could effectively reduce the increasing burden of infectious diseases among children. this is supported by a study that shows the number of deaths could be reduced 419 international journal of human and health sciences vol. 05 no. 04 october’21 to 2.4 million by practicing safe and effective handwashing practices [5]. the role of the mother in maintaining the hygiene of herself and her child is pivotal as the mother is considered a continuous source of contact with her child and plays a paramount role in her child’s health and well-being [6,7]. hand washing is termed as a mechanical barrier in the transmission of infectious diseases like respiratory tract infections, skin diseases, trachoma, and finally diarrhoea [8]. the dual duty of mothers of rearing their child, maintaining a healthy environment, and housekeeping in terms of cooking and house cleanliness all are potent factors for infectious diseases transmission to children that need to be addressed in an effective way [9]. despite knowing the importance of hand hygiene and overall sanitary lifestyle, still children’s caregivers show insignificant attitude towards hand hygiene practice and show poor performance in maintaining a good healthy environment for their children’s wellbeing [10]. in the light of the above-given scenario, our study aimed to assess knowledge, attitude, and hand hygiene practices among mothers of children presenting for routine paediatric checkup in the department of paediatrics in a tertiary care hospital of rawalpindi. materials and methods study design, period, and setting: hospital-based descriptive cross-sectional study was carried out from 15th september 2019 to 15th november 2020 to assess the knowledge, attitude, and hand hygiene practices among mothers of children presenting in the paediatric department of holy family hospital rawalpindi, punjab which is tertiary care hospital affiliated with the rawalpindi medical university, rawalpindi. sample size determination: the sample size calculation was done through a single population proportion formula with population proportion of approximately 50% (p=0.5) as obtained with 95% confidence level having the corresponding z-score of 1.96 with 5% margin of error (d). the total sample size was calculated out to be 384.16 or approximately 385, but we intentionally took 400 sample size, the reason for this oversampling was to account for non-eligibility and non-responder rates. sampling technique: convenient sampling technique was used to select the study participants. all those children with age of less than 5 years were selected and their mothers were interviewed directly. the language barriers were nullified by explaining each and every question of the used questionnaire to mothers. all those mothers who were willing to participate were included in our study and those who were non-cooperative due to some social and cultural barriers were excluded from study population. the participants who were elected from the department of paediatrics and data was collected from mothers presenting in the out-patient department (opd), paediatric emergency, paediatric ward, and high dependency unit (hdu). the purpose of the study was clearly described to every participant and verbal consent was taken before the collection of data. ethical values were considered with full capacity and confidentiality of each participant was maintained. data collection tool: a semi-structured, pretested questionnaire with excellent validity and reliability having cronbach alpha value of 0.78, was adapted from various published literature was used to assess the variables of our interest [11,12]. the score of ≥65% was considered as good knowledge, attitude and practice. those who failed to answer at least 65% of the asked responses were categorized as negative or poor knowledge, attitude and practice. the questionnaire included socio-demographic details of mothers in terms of age, education, residential area, and source of water either protected or unprotected. the socio-economic status was assessed through the family affluence scale with eight-points score form (0-7) that was further divided into three categories low (0-3), middle (4-5) and high (6-7) [13]. the knowledge and attitude of handwashing among mothers was assessed through 8 and 10 objectively designed questions respectively. there were 21 questions for assessment of handwashing practices. mothers who scored ≥65% (positive) overall on knowledge indicator items were considered to have good knowledge and those who failed to answer at least 65% of the asked responses were considered to have poor (negative) knowledge about handwashing. the same scoring scale was used for good and poor handwashing attitude and practices. statistical analysis: the collected data was carefully evaluated and the datasheet was constructed with full accuracy. data analysis was done through the social package for statistical analysis (spss.v.23). sociodemographic details were described in terms of frequencies and percentages. finally, chisquare analysis was done to find the association between handwashing practices among mothers with desired demographic features and with their knowledge and attitude. a value of <0.05 was considered as significant. international journal of human and health sciences vol. 05 no. 04 october’21 420 results in total 400 females participated in the study and the mean age (±sd) was 32.4±10.2 years. the mean age of children was 31.2±12.2 months. most of the children were suffering from diarrheal diseases followed by upper respiratory tract infections, meningitis, malnutrition, and other childhood illnesses as shown in (figure 1). the demographic characteristics were quantified in terms of frequencies and percentages as shown in (table 1). most of the females were housewives 235 (58.75%) while 165 (41.25%) females were employed. the majority of females were literate and were living in urban areas. however, the most common handwashing facility was through water and soap combined. the majority of patient burden was from middleclass families forming 61.25% of the total sample population. the study results that the levels of good handwashing knowledge and attitude was 93% and 60%. however, only 40% of mothers were showing good hand hygiene practices. by using chi-square analysis, the age of mothers, residential area, occupation, socioeconomic status, and handwashing knowledge were showing statistically significant results with mother’s handwashing practice. the age of mother (p-value=0.003), occupational status (p-value=0.000) and handwashing knowledge (p-value=0.000), socioeconomic status (p-value=0.045), residential area (p-value=0.001) were significant at p<0.05 as shown in (table 2). discussion and conclusion discussion: this study sought to assess the level of knowledge, attitude, and hand hygiene practices among mothers of children presenting in the paediatric department of a tertiary care hospital. it also assessed the associated factors with good handwashing practices among the mothers maintaining good hand hygiene is considered an essential way of preventing transmissible diseases. as evident from various literature that poor hand washing is associated with the transmission of several infectious diseases like diarrhoea, respiratory tract infections, and children are more prone to get these infections because they are in continuous contact with their parents, relatives, and friends [14]. this is now considered the sole responsibility of the parents to protect their children from getting exposed to these infectious diseases. in our study findings, the prevalence of poor handwashing practices was high among mothers. as per our study findings, the level of knowledge regarding handwashing was high among 93% of females but only 40% of the mothers were practicing recommended handwashing practices and these findings are consistent with a similar study conducted in ethiopia with only 39% of the mother’s population showing good hand hygiene practices [15]. however, similar studies from nigeria [16], hosanna [17], and india [18] were showing a higher prevalence rate of 73.8%, 71.97%, and 43.6% respectively. the variation table 1: demographic characteristics variables frequency (n) percent (%) age of mothers in years 16-27 28-33 34-42 43-48 102 103 101 94 36.25 25.75 28.75 9.25 residential area urban rural 250 150 62.5 37.5 educational status literate illiterate 280 120 70 30 occupation housewife employed 235 165 58.75 41.25 socioeconomic status upper class middle class lower class 35 245 120 8.75 61.25 30 type of hand washing facility water only water and soap hand sanitizer 120 220 60 30 55 15 source of water protected unprotected 298 102 74.50 25.50 fig 1: the percentages of children presenting with various diseases. 421 international journal of human and health sciences vol. 05 no. 04 october’21 table 2: showing the descriptive statistics between handwashing practice and demographic details by using chi-square analysis. characteristics mothers handwashing practice p-value good (%) poor (%) age of mother 16-27 28-33 34-42 43-48 45 (28.15) 41 (25.62) 34 (21.25) 40 (25.00) 57 (23.75) 62 (25.83) 67 (27.91) 54 (22.50) 0.003 * residential status rural urban 40 (25.00) 120 (75.00) 110 (45.83) 130 (54.16) 0.001 * occupation employed housewife 88 (55.00) 72 (45.00) 77 (32.76) 158 (67.23) 0.000 * educational status illiterate literate 45 (28.12) 115 (71.87) 85 (35.41) 155 (64.58) 0.281 socioeconomic status lower class middle class upper class 50 (31.25) 85 (53.12) 25 (15.62) 70 (29.16) 160 (66.66) 10 (4.16) 0.045 * mothers handwashing knowledge poor good 3 (1.87) 157 (98.12) 24 (10.00) 216 (90.00) 0.000 * mothers handwashing attitude poor good 53 (33.12) 107 (66.87) 110 (45.83) 130 (42.91) 0.401 note: * p-value<0.05 is taken as significant. between these studies and our study findings could be explained due to differences in the socio-demographic nature of the study areas, the difference in measuring tools and health services. many factors can influence knowledge, attitude, and handwashing practices and the most important factors are socio-demographical features like education level, occupational status, residential areas, and socio-economic status. in our study, we found a significant association between the age of the mother and handwashing practice with p<0.003. our study findings are showing that with the increasing age of the mothers the handwashing practices become poor that could due to careless attitude with the increasing number of pregnancies [15]. in our study, the handwashing knowledge among mothers was also significantly associated with handwashing practices but still, mothers were not performing recommended handwashing practices. the possible reason could be that the knowledge alone is not enough for practicing good handwashing practices, multiple factors can fig 2: showing the levels of handwashing knowledge, attitude and practice. international journal of human and health sciences vol. 05 no. 04 october’21 422 help in improving and maintaining the desired level of handwashing practices as evident from a published study [19]. similarly, lack of education and sense of negligence in maintaining the good handwashing practices could be the reason, that despite of having good handwashing knowledge and attitude, still the level of handwashing practices was poor. socioeconomic status is also considered an important factor towards good and recommended handwashing practices. different kinds of literature are showing clearly that higher socioeconomic status is a paved road map towards good handwashing practices. in our study, we found a significant association between handwashing practice with socioeconomic status p<0.045 that is in concordance with a study showing the socioeconomic status as a good predictor of handwashing practices [20], showing that the level of good hand hygiene practice is high among mothers of higher socioeconomic status. similarly, we found a significant association between handwashing practices and a residential area showing that those who are living in urban areas were having higher levels of good handwashing practices as in line with a similar study from ethiopia [15]. the possible reason could be the availability of hand hygiene products and high quality of life among the urban population. the interesting finding of our study was a non-significant association between mother’s handwashing attitude and handwashing practices with a p>0.05 that is contrary to other studies, showing that desirable attitude is associated significantly with good handwashing practices [21]. however, some studies are validating our study findings in terms of showing a nonsignificance association between handwashing practices and handwashing attitude [22]. this study was conducted among mothers of the children presenting in the paediatric department however, there are still chances of infection transmission from fathers and other relatives that need further research to explore these associations. in the light of above-mentioned study results it is need of time to make the mothers of aware of handwashing benefits in terms of their children good health and wellness. arranging seminars and through mass media awareness campaigns the level of levels of good handwashing practices among mothers can be improved effectively. conclusion: handwashing practice is considered an important barrier against disease transmission. in our study handwashing practice among mothers was relatively low, and only 40% of the mothers were performing good and recommended handwashing practices. however, the level of knowledge was good among 93% of the population. similarly, the level of attitude was good among 60% of the population. the age of mothers, residential area, occupation, socioeconomic status, and mother’s level of knowledge regarding handwashing, were significantly associated with handwashing practices with p-values of (0.003, 0.001, 0.000, 0.045, 0.000). recommendations: we would like to recommend that awareness sessions and seminars should be arranged either at national or international levels for making our society aware of health benefits related to handwashing practices. we do believe that this effort will prove fruitful in eradication of number of diseases. source of fund: no funding was granted by any source for accomplishment of this study. conflict of interest: authors have declared that they have no conflict of interest to disclose. ethical clearance: our study is approved by ethical review board and ethical considerations were given full priority during data collection as well. authors’ contribution: shahzaib maqbool and maryam haider: conception and design. ather iqbal and arham ihtesham: data acquisition and analysis. waleed inayat mohamed and muhammad nadeem langove: critical analysis and manuscript writing. laraib arsh and omaima sundus: manuscript design and critical review of article. syed turab haider and hassam omer: final approval and data maintenance. 423 international journal of human and health sciences vol. 05 no. 04 october’21 1. gbd 2016 causes of death collaborators. global, regional, and national age-sex specific mortality for 264 causes of death, 1980-2016: a systematic analysis for the global burden of disease study 2016. lancet. 2017 sep 16;390(10100):1151-1210. 2. kosek m, bern c, guerrant rl. policy and practice the global burden of diarrhoeal disease, as estimated from studies published between 1992 and 2000. bull world health organ. 2003;81(485):197-204. 3. curtis v, cairncross s. effect of washing hands with soap on diarrhea risk in the community: a systematic review. lancet infect dis. 2003 may;3(5):275-81. 4. cairncross s, valdmanis v, et al: water supply, sanitation, and hygiene promotion. in disease control priorities in developing countries. new york: oxford university press; 2006:771-792. 5. prüss-üstün a, bos r, gore f, bartram j. safer water, better health: costs, benefits, and sustainability of intervention to protect and promote health. geneva: world health organization; 2008. 6. al-zahrani am, al-mushayt as, otaibi mf, wyne ah. knowledge and attitude of saudi mothers towards their preschool children’s oral health. pak j med sci. 2014 jul;30(4):720-4. 7. chen cc, chiou sj, ting cc, lin yc, hsu cc, chen fl, lee ch, chen t, chang cs, lin yy, huang hl. immigrant-native differences in caries-related knowledge, attitude, and oral health behaviors: a cross-sectional study in taiwan. bmc oral health. 2014 jan 14;14: 3. 8. odu oo, emmanuel ee, amu eo, deji s, dada sa, marcus o. practice of effective hand washing and associated factors among caregivers of infants attending infant welfare clinics in ado-ekiti, ekiti state, nigeria. j adv med res. 2017:1-8. 9. bertrand we, walmus bf. maternal knowledge, attitudes and practice as predictors of diarrhoeal disease in young children. int j epidemiol. 1983 jun;12(2):205-10. 10. curtis va, danquah lo, aunger rv. planned, motivated and habitual hygiene behaviour: an eleven-country review. health educ res. 2009 aug;24(4):655-73. 11. uner s, sevencan f, basaran e, balci c, bilaloglu b. determining of persons knowledge and attitudes on social hand washing who were admitted to a primary health care center. taf prev med bull. 2009;8(3):207-16. 12. odu oo, emmanuel ee, amu eo, deji s, dada sa, marcus o. practice of effective hand washing and associated factors among caregivers of infants attending infant welfare clinics in ado-ekiti, ekiti state, nigeria. j adv med res. 2017:1-8. 13. currie ce, elton ra, todd j, platt s. indicators of socioeconomic status for adolescents: the who health behaviour in school-aged children survey. health educ res. 1997 sep;12(3):385-97. 14. bartram j, cairncross s. hygiene, sanitation, and water: forgotten foundations of health. plos med. 2010 nov 9;7(11): e1000367. 15. taddese aa, dagnew b, dagne h, andualem z. mother’s handwashing practices and health outcomes of under-five children in northwest ethiopia. pediatric health med ther. 2020 mar 11;11: 101-108. 16. ogwezzy-ndisika ao, solomon t. knowledge, attitude and practice of hand washing among mothers of children 0-59 months of age in lagos nigeria. univ j public health. 2019;7(2):52-58. 17. buda as, mekengo de, lodebo tm, sadore aa, mekonnen b. knowledge, attitude and practice on hand washing and associated factors among public primary school’s children in hosanna town, southern ethiopia. j public health epidemiol. 2018;10(6):205-214. 18. sangra s, nowreen n. knowledge, attitude, and practice of mothers regarding nutrition of under-five children: a cross-sectional study in rural settings. int j med sci public health. 2019;8(5):392-394. 19. pati s, kadam ss, chauhan as. hand hygiene behavior among urban slum children and their care takers in odisha, india. j prev med hyg. 2014 jun;55(2):65-8. 20. kumar s, loughnan l, luyendijk r, hernandez o, weinger m, arnold f, ram pk. handwashing in 51 countries: analysis of proxy measures of handwashing behavior in multiple indicator cluster surveys and demographic and health surveys, 20102013. am j trop med hyg. 2017 aug;97(2):447-459. 21. mekonnen m, aga f, kinati t, shifera d. assessment of hand washing practice and associated factors among primary school children in sebeta town oromia regional state, ethiopia. health sci j. 2018;12(6):1-6. 22. pang j, chua sw, hsu l. current knowledge, attitude and behaviour of hand and food hygiene in a developed residential community of singapore: a cross-sectional survey. bmc public health. 2015 jun 21;15: 577. references supplementary issue:02 198 invitro antimicrobial synergy of carbapenem with tigecycline and colistin in gram negative isolates from icu lubna parveen 1, fatima khan1, salman shah1, abu nadeem1, asfia sultan1, asad u khan1 1microbiology, jawaharlal nehru medical college & hospital, amu, india correspondence: dr. fatima khan, associate professor, department of microbiology, jnmch, amu fatimasalmanshah@gmail.com abstract the worldwide increase in the emergence of carbapenem resistant gram-negative (crgn) pathogens calls for the investigation into alternative approaches for treatment. the aim of this study is to evaluate the in vitro effect of the colistin–carbapenem (including meropenem, doripenem, ertapenem and imipenem) combination and tigecycline-carbapenem combination against carbapenem resistant enterobacterales (cre) using two different techniques viz. chequerboard and time-kill synergy method. methods a total of 118 cre isolates were included to the study. the minimum inhibitory concentrations of colistin, tigecycline and carbapenem (including meropenem, doripenem, ertapenem and imipenem) were determined with broth dilution method. in addition, pcr amplifications of the most common beta lactamases contributing to carbapenem resistance were performed. synergistic effects of tigecycline-carbapenem and colistin-carbapenem were investigated by checkerboard technique and time kill assay. results all of the isolates were resistant to carbapenems whereas none of the isolates were resistant to colistin and tigecycline. synergistic effect for the colistin-carbapenem and tigecycline-carbapenem combination was observed using both methods. additive effects were also detected in both combinations where the ∑fici of carbapenem combined with colistin was 1.167 ± 0.354 and that of carbapenem with tigecycline was 1.106 ± 0.337. the combination of colistin-carbapenem showed better effects as compared to tigecycline-carbapenem (p < 0.05). the colistin-carbapenem and tigecycline-carbapenem combinations also showed a decrease of 2.6 and 2.8-fold, respectively. time-kill assays additionally showed synergistic effects, and no bacterial re-growth was detected following a 24 h incubation. synergistic effect was variable and strain-depended supplementary issue:02 199 against cre isolates that have been tested. conclusion our study showed that the combination of carbapenems with colistin and tigecycline could be a promising antimicrobial strategy in treating cre infections and holds great importance for management of patients who cannot afford expensive drugs for treatment. key words: multidrug resistance, synergy, time kill assay, chequerboard technique background infections caused by carbapenem-resistant gram-negative (crgn) pathogens are increasing globally and are associated with poor patient outcomes [1]. the emergence of carbapenem resistant gram-negative (crgn) pathogens and their detection in several regions across the world makes their treatment increasingly challenging [2] .they have emerged as one of the most important nosocomial pathogens, especially in patients admitted to an intensive care unit (icu). they can colonize multiple body sites of hospitalized patients and survive for a long time on inanimate surfaces [3]. both these aforementioned characteristics may have contributed to the prominent role of crgn in nosocomial infections. a wide range of broad-spectrum antimicrobial agents have been used in the treatment of infections caused by carbapenem resistant enterobacterales (cre). of these agents, carbapenems are often resorted to due to their low toxicity and high efficacy. nonetheless, the overuse and misuse of carbapenems led to an increase in resistance rates against this potent class of antimicrobial agents [4]. the high carbapenem resistance rates pose serious therapeutic and infection control challenges, especially since they are associated with high mortality rates and an increase in hospital stay [5]. moreover, the lack of effective antibiotics against cre isolates led to the re-use of colistin [6] . colistin, which was abandoned since the 1960s due to nephrotoxicity, gained new interest for its activity against these infections. tigecycline also showed good in vitro bacteriostatic activity against carbapenem resistant strains that showed different susceptibilities to carbapenems. [6] supplementary issue:02 200 therefore, it is important to look for combination of drugs that might be synergistic. combination treatment with a colistin and a carbapenem has been suggested to improve effectiveness, supported by in vitro models showing synergism between the two antibiotics and this combination therapy has been adopted widely by clinicians. the aim of this study is to evaluate the in vitro effect of the colistin–carbapenem (including meropenem, doripenem, ertapenem and imipenem) combination and tigecycline-carbapenem combination against carbapenem resistant enterobacterales (cre) using two different techniques viz. chequerboard and time-kill synergy method. [6] method study design and clinical isolates the prospective study was carried out in the department of microbiology of jn medical college and hospital, amu, aligarh. a total of 118, non-duplicate consecutive isolates were collected from various clinical specimens from december 2020 to december 2022. minimum inhibitory concentration (mic) was estimated for 60 representative isolates of differing levels of drug resistance. no written consent from the patients was taken since no interventions were performed. identification and antimicrobial susceptibility testing the clinical samples received in the laboratory were inoculated on 5% sheep blood agar (ba), macconkey agar (mca), nutrient broth and brain heart infusion (bhi) broth. these were incubated at 35°c for 18-24 hours. isolates obtained were further subjected to various biochemical reactions. the organisms were identified on the basis of morphology, cultural characteristics and biochemical tests. susceptibility to different classes of antimicrobial agents was determined by the disc diffusion method [7]. antimicrobial susceptibility of organisms was also performed by automated method using vitek-2 (biomeuriux). in addition, minimum inhibitory concentrations (mics) of colistin, tigecycline, meropenem, imipenem, doripenem and ertapenem were performed by broth dilution methods [7]. cutoff values were ≤ 2 μg/ ml≥ 4 μg/ ml for colistin and ≤ 1μg/ ml≥ 4 μg/ ml for meropenem, imipenem, doripenem and ≤ 1μg/ ml≥ 2 μg/ ml for ertapenem [7]. the fda tigecycline breakpoints for enterobacterales were applied to due to lack of breakpoint criteria in the clsi guidelines [8] . supplementary issue:02 201 polymerase chain reactions dna extraction was performed for all the isolates as described by [9]. the dna extracts were preserved at −20°c until used. blavim, blandm and blaoxa were tested for by pcr using the primers listed in table 1 [10,11,12,13]. positive and negative controls for the tested genes were provided from previous studies performed in the laboratory [10,14]. table 1: primers used for pcr amplification with their different amplicon size. betalactamases bla gene primer direction sequence (5'–3') size (bp) class b vim vim f attccggtcgg(a=g) gaggtccg 601 vim r tgtgctkgagcaaktcyagaccg ndm ndm f gggccgtatgagtgattgc 825 ndm r gaagctgagcaccgcattag class d oxa48 oxa48 f gcttgatcgccctcgatt 281 oxa48 r gatttgctccgtggccgaaa r, reverse primer; f, forward primer. the checkerboard technique the checkerboard technique was performed in using the combinations of colistin-carbapenem (including meropenem, imipenem, doripenem and ertapenem) and tigecycline-carbapenem combination. concentration ranges of 16xmic to 1/16xmic for colistin and tigecycline and 256xmic to 1/256xmic for carbapenems were prepared. the bacterial inoculum was adjusted to 5 × 105cfu/ml and distributed in all the tubes. two wells were reserved for positive and negative controls. after incubation at 37°c for 24 h, the fractional inhibitory concentration index (fici) was calculated using the formula “fica + ficb = fici” where “fica” is the mic of the drug a supplementary issue:02 202 in combination/ mic of the drug a alone; and “ficb” is the mic of the drug b in combination/ mic of the drug b alone (daoud et al., 2013). the sum of fici was then interpreted as follows: synergy if ∑fici ≤ 0.5, additive effect if 0.5 < ∑fic ≤ 2, indifference if 2 < ∑fic ≤ 4, and antagonism if ∑fic > 4 (pillaii et al., 2005). time-kill curve assay briefly, concentration ranges of 16, 8, 4, 2, 1, 0.5, 0.25, and 0.125xmic were prepared in mueller hinton broth for colistin and tigecycline and carbapenems (including imipenem, meropenem, ertapenem and doripenem alone, and in combination (colistin-carbapenem and tigecyclinecarbapenem). a 5 x × 105cfu/ml inoculum of the tested organism was also prepared. the suspensions were then incubated at 37°c for 4 h. an antibiotic-free growth control was also included. at predetermined time points (4 h and 24 h), subcultures were done from each tube next day onto muellerhinton agar plates. time kill curves were then constructed as a function of time and the results were represented as a difference in log10 between the cfu/ml at 4 h and 24 h. synergistic effects were determined by a decrease of 3 log10 in colony count at 24 h by the combination compared to most active single agent. additivity/indifference were interpreted as <3 log10 increase or decrease in colony count at 24 h by the combination compared with that by the most active drug alone. antagonism was interpreted as 3 log10 increase in colony count at 24 h by the combination with that by the most active drug alone. results bacterial isolates and susceptibility testing in this study, majority of isolates constituted escherichia coli (n=57;52.7%), klebsiella pneumoniae (n=22; 20.3%), klebsiella oxytoca (n=10;9.2%) followed by enterobacter cloacae (n=10; 9.2%) and citrobacter freundii (n=9; 8.3%). the antibiotic resistance profile of enterobacterales to different antibiotics is depicted in figure 1. of the various groups tested, enterobacterales showed maximum sensitivity to colistin: 100%, ceftazidime: 70.3%, followed by ceftriaxone 66.6%. enterobacterales showed a moderate degree of sensitivity to ceftriaxone sulbactum: 62%, piperacillin tazobactum: 60.1% and cefepime: 52.7%. the prevalence of antimicrobial resistance was considerably high in enterobacterales. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5442352/#b13 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5442352/#b33 supplementary issue:02 203 carbapenem resistance genes pcr amplification of the common carbapenemase genes detected three blaoxa (n=3;10%) genes to be positive out of 29 carbapenemase producing isolates. the rest of the genes tested for were not detected in any of the isolates. in vitro combination effects synergistic effects were detected while combining carbapenem with colistin (10 isolates) and tigecycline (10 isolates) using the checkerboard and time kill assay. additive effects were also detected in both combinations where the ∑fici of carbapenem combined with colistin was 1.167 ± 0.354 and that of carbapenem with tigecycline was 1.106 ± 0.337. the combination of colistin with carbapenem showed a better additive effect than the tigecycline with carbapenem combination (p < 0.05). the combinations of carbapenem-colistin and carbapenem-tigecycline resulted in a decrease of 2.8and 2.6-folds in the mic of carbapenems, respectively. 0 20 40 60 80 100 120 antimicrobial susceptibility pattern of enterobacterales enterobacterales supplementary issue:02 204 time-kill curves showed that there was bactericidal activity detected for all three antibiotics (colistin, tigecycline and carbapenem), where all the isolates showed a decrease in colony counts from 4 hours to 24 hours. a significant bactericidal effect of colistin-imipenem when compared to colistin-meropenem (p < 0.05) was determined at 0.5xmic. moreover, no bacterial re-growth was detected at the different concentrations of colistin and colistin-carbapenem combinations. it is important to note that, due to limitations that were faced during the experiment, only 10 out of the 60 isolates were tested for at 16xmic, which could have resulted in obtaining rather high values at this concentration as compared to the other concentrations. table 2: log 10 values of the cfu/ml of the enterobacterales isolates obtained by the time kill curve assays after incubation, as compared to the initial inoculum. antibiotics bactericidal effect of colistin and carbapenems alone and in combination (time kill curve) 16xmic 8xmi c 4xmi c 2xmi c 1xmi c 0.5xmi c 0.25xmi c 0.125xmi c δlog10 col 0.429 0.155 0.214 0.441 1.18 1.368 1.621 1.826 imp 0.325 0.139 0.137 0.121 0.218 1.12 1.914 2.174 mer 0.413 0.131 0.116 0.282 1.12 1.922 2.054 2.194 erta 0.403 0.178 0.098 0.195 0.106 0.815 1.06 1.802 dori 0.325 0.139 0.137 0.121 0.218 1.12 1.914 2.174 col-imp 0.437 0.196 0.115 0.066 0.096 0.349 0.915 1.828 col-mer 0.403 0.178 0.098 0.195 0.106 0.815 1.06 1.802 col-erta 0.001 0.031 −0.11 −0.404 −1.077 −1.059 −0.732 −0.024 col-dori −0.006 0.05 −0.119 −0.274 −0.937 −0.553 −0.554 −0.014 p-value 0.528 0.698 0.679 0.103 0.831 0.018 0.112 0.731 col, colistin; imp, imipenem; mer, meropenem; erta, ertapenem; dori, doripenem; col-imp, colistin imipenem combination, col-mer, colistin meropenem col-erta, colistin ertapenem, coldori, colistin doripenem combination supplementary issue:02 205 table 3: log 10 values of the cfu/ml of the enterobacterales isolates obtained by the time kill curve assays after incubation, as compared to the initial inoculum. antibiotics bactericidal effect of tigecycline and carbapenems alone and in combination (time kill curve) 16xmic 8xmi c 4xmi c 2xmi c 1xmi c 0.5xmi c 0.25xmi c 0.125xmi c δlog10 tgc 0.413 0.131 0.116 0.282 1.12 1.922 2.054 2.194 imp 0.403 0.178 0.098 0.195 0.106 0.815 1.06 1.802 mer 0.325 0.139 0.137 0.121 0.218 1.12 1.914 2.174 erta 0.001 0.031 −0.11 −0.404 −1.077 −1.059 −0.732 −0.024 dori −0.006 0.05 −0.119 −0.274 −0.937 −0.553 −0.554 −0.014 tgc-imp 0.437 0.196 0.115 0.066 0.096 0.349 0.915 1.828 tgc-mer 0.403 0.178 0.098 0.195 0.106 0.815 1.06 1.802 tgc-erta 0.001 0.031 −0.11 −0.404 −1.077 −1.059 −0.732 −0.024 tgc-dori −0.006 0.05 −0.119 −0.274 −0.937 −0.553 −0.554 −0.014 p-value 0.528 0.698 0.679 0.103 0.831 0.018 0.112 0.731 tgc, tigecycline; imp, imipenem; mer, meropenem; erta, ertapenem; dori, doripenem; tgcimp, tigecycline imipenem combination, tgc-mer, tigecycline meropenem tgc-erta, tigecycline ertapenem, tgc-dori, tigecycline doripenem combination discussion the possibility and the probability of acquiring infections in icu has increased in the past two decades. such infections constitute a significant problem for the patients with substantial morbidity and mortality [15]. these infections represent a leading cause of death and represent important health care cost [16]. treatment of icu infections is increasingly hampered by the emergence of antibiotic resistance. rapid and accurate diagnosis of icu infections is an important aspects of intensive care medicine [17]. mic values of six drugs namely colistin, tigecycline, meropenem, ertapenem, doripenem and imipenem were determined by the broth dilution method. for colistin the mic range was 0.51µg/ml. most of the isolates showed the mic value of less than 0.5 µg/ml. the mic range of supplementary issue:02 206 tigecycline came out to be 1-4 µg/ml. most of the isolates showed the mic value of 2 µg/ml. for carbapenems the mic range was 32-512 µg/ml. most of the isolates showed mic values of 32 µg/ml. the prevalence of antimicrobial resistance was considerably high in enterobacterales. multidrug-resistant enterobacterales and nil fermenters with combined decreased susceptibility to imipenem, meropenem, ertapenem and doripenem is increasingly being found as a cause of nosocomial infections. it is important to look for combination of drugs that might be synergistic. the putative benefits are to increase efficacy by achieving synergistic killing and preventing the emergence of antibiotic resistance, but data are sparse [18]. combinations of carbapenems/colistin and carbapenems/tigecycline have synergistic effects against gram negative isolates. combinations of carbapenems and colistin and combination of carbapenems with tigecycline have found to be synergistic. this supported an in vivo synergistic or additive effect of the carbapenem plus colistin combination. resistance is becoming increasingly common among gram negative bacteria. therefore, making empirical therapy decisions more difficult. infections caused by carbapenem-resistant gramnegative (crgn) pathogens are increasing globally and are associated with poor patient outcomes. the most serious resistance patterns now emerging among gram-negative organisms include resistance to extended-spectrum cephalosporins and penicillins [19]. this resistance is commonly mediated by esbls in escherichia coli and klebsiella species, or by the hyper production of chromosomally mediated cephalosporinases (bush group i ampc enzymes) in serratia and citrobacter species [20]. the esbl genes generally result from point mutations in the genes of broad-spectrum ß-lactamase ambler class a enzymes, such as ctx-m, tem or shv. they are usually located in conjugative megaplasmids, which often carry genes responsible for resistance to other antibacterial drugs, making it extremely difficult to treat infections caused by bacteria that produce these enzymes [20]. the role of antibiotic combinations in the treatment of cre infections is a matter of long-standing debate. the potential advantages of combination treatment are improved effectiveness due to synergism and prevention of resistance development. the potential disadvantages are increased side effects and increased selection pressure (because of increased antibiotic use), which favours the spread of antibiotic-resistant organisms. while some observational studies reported greater survival in patients treated with colistin combination regimens. the rationale behind synergy supplementary issue:02 207 testing as a basis for choosing combination treatment is attractive: it could improve clinical outcomes in patients for whom the combination is synergistic and reduce antibiotic use compared with giving combination treatment to everyone.[20] however, there is a paucity of clinical data regarding the effectiveness of synergy-guided treatment for crgn infections, and most data come from case reports. with synergy-guided treatment, it is important to select the synergy testing method that best correlates with clinical outcome. various in vitro testing methods have been used, including checkerboard, e-test and time-kill assays. the checkerboard assay has the advantage of testing a wide range of drug concentration combinations simultaneously. time-kill assay provides data on the rapidity of synergistic killing compared to each drug alone, but it is impractical when testing a large number of isolates or in the routine clinical microbiology laboratory, as it is complicated and time consuming. multidrug-resistant enterobacterales and nil fermenters with combined decreased susceptibility to imipenem, meropenem, ertapenem and doripenem is increasingly being found as a cause of nosocomial infections. it is important to look for combination of drugs that might be synergistic. the putative benefits are to increase efficacy by achieving synergistic killing and preventing the emergence of antibiotic resistance, but data are sparse [vladimir chachanidze et al]. combinations of carbapenems/colistin and carbapenems/tigecycline have synergistic effects against gram negative isolates. combinations of carbapenems and colistin and combination of carbapenems with tigecycline have found to be synergistic. this supported an in vivo synergistic or additive effect of the carbapenem plus colistin combination conclusion nowadays, the rate of carbapenem resistance among nosocomial isolates is high, particularly in icus. increasing rates of carbapenem resistance have led to widespread use of combination treatment for the treatment of diverse infectious disease. although the isolates tested were resistant to one or both antibiotics, synergy was observed which suggests that treatment with combination of antibiotics is a good option in multidrug resistant isolates and should be tried. this finding holds great importance for management of patients infected with multidrug resistant gram-negative organisms and in poor patients who cannot afford expensive drugs for treatment. supplementary issue:02 208 these results suggest that even if enterobacterales isolates are resistant to carbapenems drugs by disc diffusion method or even if they have high mic values, they can be used with combination of colistin and tigecycline. this protocol can help in overcoming increasing resistance in carbapenems. we suggest that synergy testing should be performed at various centres to assess which combination of antibiotics is most synergistic references 1. vardakas kz, athanassaki f, pitiriga v, falagas me. clinical relevance of in vitro synergistic activity of antibiotics for multidrug-resistant gramnegative infections: a systematic review. j glob antimicrob resist 2019;17:250e9 2. towner k. acinetobacter: an old friend, but a new enemy. j. hosp. infect. (2009). 73, 355– 363. 10.1016/j.jhin. 2009.03.032 3. ayats j, corbella x wissenschaftliche verlagsgesellschaft, clinical relevance of in vitro synergistic activity of antibiotics for multidrug-resistant gramnegative infections: a systematic review. j glob antimicrob resist 2019;17:250e9 2007:199-211. 4. el-herte r. i., kanj s. s., matar g. m., araj g. f. the threat of carbapenem-resistant enterobacteriaceae in lebanon: an update on the regional and local epidemiology. j. infect. public health 2012; 5, 233–243. 10.1016/j.jiph.2012.02.003. 5. zilberberg m. d., nathanson b. h., sulham k., fan w., shorr a. f. multidrug resistance, inappropriate empiric therapy, and hospital mortality in acinetobacter baumannii pneumonia and sepsis. (2016) crit. care 20, 221 10.1186/s13054-016-1392-4 6. neonakis i. k., spandidos d. a., petinaki e. confronting multidrug-resistant acinetobacter baumannii: a review. int. j. antimicrob. agents (2011) 37, 102–109. 10.1016/j.ijantimicag.2010.10.014 7. clinical laboratory and standards institute. performance standards for antimicrobial susceptibility. twenty-five informational supplement m100–s25. wayne, pa: clsi. 2015 8. stein g. e., babinchak t. tigecycline: an update. diagn. microbiol. infect. dis. 2013; 75, 331–336. 10.1016/j.diagmicrobio.2012.12.004 9. zhu h., qu f., zhu l.-h. isolation of genomic dnas from plants, fungi and bacteria using benzyl chloride. nucleic acids res. 1993; 21, 5279 10.1093/nar/21.22. supplementary issue:02 209 10. moubareck c., brémont s., conroy m.-c., courvalin p., lambert t. ges-11, a novel integron-associated ges variant in acinetobacter baumannii. antimicrob. agents chemother. 2009; 53, 3579–3581. 10.1128/aac.00072-09 11. dallenne c., da costa a., decré d., favier c., arlet g. development of a set of multiplex pcr assays for the detection of genes encoding important β-lactamases in enterobacteriaceae. j. antimicrob. chemother. 2010;65, 490–495. 10.1093/jac/dkp498 12. ardebili a., talebi m., azimi l., lari a. r. effect of efflux pump inhibitor carbonyl cyanide 3-chlorophenylhydrazone on the minimum inhibitory concentration of ciprofloxacin in acinetobacter baumannii clinical isolates. jundishapur j. microbiol. 2014; 7:e8691. 10.5812/jjm.8691 13. rafei r., dabboussi f., hamze m., eveillard m., lemarié c., mallat h., et al. first report of bla ndm-1-producing acinetobacter baumannii isolated in lebanon from civilians wounded during the syrian war. int. j. infect. dis. 2014;21, 21–23. 10.1016/j.ijid.2014.01.004 14. hammoudi d., moubareck c. a., hakime n., houmani m., barakat a., najjar z., et al. spread of imipenem-resistant acinetobacter baumannii co-expressing oxa-23 and ges-11 carbapenemases in lebanon. int. j. infect. dis. 2015;36, 56–61. 10.1016/j.ijid.2015.05.015 15. pittet, diaz, rosenthal, ramirez. effect of efflux pump inhibitor carbonyl cyanide 3chlorophenylhydrazone on the minimum inhibitory concentration of ciprofloxacin in acinetobacter baumannii clinical isolates. jundishapur j. microbiol. 2006;7:e8691. 10.5812/jjm.8691 16. speller, humphreys, tambyah, higuera, first report of bla ndm-1producing acinetobacter baumannii isolated in lebanon from civilians wounded during the syrian war. int. j. infect. dis. 2007; 21, 21–23. 10.1016/j.ijid.2014.01.004 17. koeman et al. confronting multidrug-resistant acinetobacter baumannii: a review. int. j. antimicrob. agents 2010;37, 102–109. 10.1016/j.ijantimicag.2010.10.014 18. vladimir chachanidze et al clinical relevance of in vitro synergistic activity of antibiotics for multidrug-resistant gramnegative infections: a systematic review. j glob antimicrob resist 2019;17:250e9 supplementary issue:02 210 19. diekema dj, pfaller ma, jones rn, doern gv, winokur pl, gales ac, sader hs, kugler k, beach m: survey of bloodstream infections due to gramnegative bacilli: frequency of occurrence and antimicrobial susceptibility of isolates collected in the united states, canada and latin america for the sentry antimicrobial surveillance program, 1997. clin infect dis 1999;29:595-607 20. carlet j. ben ali a, tabah a, willems v, philippart f. chafine a, garrouste-orgeas m, misset b: multidrug resistant infections in the icu:mechanisms, prevention and treatment. in 25 years of progress and innovation in intensive care medicine. edited by: kuhlen r, moreno r, ranieri vm, rhodes a. berlin, germany: medizinisch international journal of human and health sciences vol. 07 no. 03 july’23 212 review article a narrative review of the strategy for covid-19 vaccination sani rachman soleman1, ahmed m refaat2 abstract background: covid-19 vaccination is a health intervention to halt the escalation of the pandemic. several countries have succeeded in rolling out vaccination policy for the population. objective: this paper aims to provide strategies for implementing covid-19 vaccination. methods: a narrative review was proposed to gather published papers about strategies for vaccination rollout from the pubmed search engine using the boolean method. all types of paper, including experiment, cohort study, mathematical model, and other observational studies, were included in the analysis. comments, perspectives, letters to the editor, and opinions were included as long as they provided accurate descriptions of the implementation of covid-19 vaccination. the papers were extracted, synthesised, and analysed, and 461 were found eligible. after extraction, the synthesis found 24 eligible papers for further analysis. results: from the analysis of these papers, several categories were found and classified as the role of local and regional governments, partnership, intergovernmental networking, role of public figures, role of pharmacists, role of religious leaders, developing vaccine manufacture, developing digital infrastructure, developing vaccine centres, public preferences, priority groups, free of charge, strengthening family physician, communication, and reward and punishment. hence, the four major components of vaccination strategy are system, networking, stakeholders, and infrastructure. conclusion: the covid-19 pandemic requires a comprehensive system to terminate the spread of infection by vaccination. however, a successful vaccination program needs a strategy consisting of a system, networking, stakeholders, and infrastructure. keywords: covid-19 pandemic, vaccination, strategy implementation correspondence to: sani rachman soleman, department of public health, faculty of medicine, universitas islam indonesia, yogyakarta, indonesia.email: sanirachman@gmail.com, sani.rachman@uii.ac.id 1. department of public health, faculty of medicine, universitas islam indonesia, yogyakarta, indonesia. sleman, yogyakarta, indonesia. 2. department of zoology, faculty of science, minia university. menia governorate, egypt. introduction the current coronavirus disease-19 (covid-19) is the seventh member of the reported human coronaviruses triggered by severe acute respiratory syndrome coronavirus-2 (sarscov-2). compared to previously identified respiratory corona viruses such as severe acute respiratory syndrome coronavirus (sarscov) and middle east respiratory syndrome coronavirus (mers-cov) in 2003 and 2012, respectively.1,2 the current covid-19 produces a further extreme pandemic due to its rapid spread and the population affected. although countries around the world have taken various mitigation efforts since the first instance of new coronavirus infections was discovered in december 2019 in wuhan, china, countries are still fighting the waves of covid-19 infections, which have been devastating. by the end of 2021, over 300 million cases and over 5 million deaths because of covid-19 were recorded. yet, understanding and forecasting the wave pattern of covid-19 international journal of human and health sciences vol. 07 no. 03 july’23 page : 212-219 doi: http://dx.doi.org/10.31344/ijhhs.v7i3.577 mailto:sani.rachman%40gmail.com?subject= mailto:sani.rachman%40gmail.com?subject= 213 international journal of human and health sciences vol. 07 no. 03 july’23 remains difficult. although many trials and efforts were undertaken to control this pandemic, including social distancing, stay-at-home orders, and lockdown measures, covid-19 vaccination is still the most effective way to bring the pandemic under control.3 vaccination is the primary tool and considered an essential public health measure to reduce infectious disease burden in populations where most people are vaccinated. the covid-19 vaccines are supposed to offer similar health benefits worldwide. the world health organization (who) has identified 333 vaccine candidates, 139 of which are currently in the clinical development stage. among those diverse vaccine platforms, many techniques have been used and developed, including traditional live attenuated and inactivated pathogens as well as modern alternatives using viral vectors, mrna, dna, single proteins, and virus-like particles as carriers.4,5 to reduce the impact of covid-19 on daily life, some analysis results suggest that around 80-90 per cent of the population should acquire sars-cov-2 protection through either vaccination or prior infection.6 furthermore, the vaccination coverage around the world is expected to reach 60% by january 2022. therefore, regulations will be required to achieve 90 per cent vaccination coverage in the population. several countries run to reach herd immunity by vaccination with various strategies. india, for example, has a policy to vaccinate 300 million people by the end of august 2021. the government has launched some indigenous vaccines, such as covaxin and covishield, to support the program. in addition, vaccination policy and networking have undergone modification and amendment since the earlier vaccination policy.7 currently, 49.4% or 581 million of the population of india have been fully vaccinated, the second highest vaccination rate in the world.8 another country is china. since the beginning of the pandemic, china has positioned five home vaccines in a completely full clinical trial to support the policy. the government inoculated 100 million doses to 200 million doses in 25 days, and this was continued by 200 million doses to more than 300 million doses in 16 days. it took 9 days for 300 million doses to 400 million doses and 5 days for 600 million doses to 700 million doses. hence, the total population fully vaccinated was more than 900 million, while the first inoculation reached over 1 billion people or approximately 77.6% of the total population as reported in september 2021.9 the current situation in china shows that 1.22 billion people have been fully vaccinated and 2.96 doses have been distributed across the country.8 in addition to the two aforementioned countries, the big five countries with vaccination rollout also include brazil, united states of america (usa), and indonesia,8 each having different strategies to increase the uptake of vaccination. learning from those countries that successfully roll out vaccination in home countries has left a question behind. what is the successful strategy to implement vaccination in developed countries? hence, this paper aims to examine some strategies for the implementation of vaccination rollout policy as a lesson to learn by other governments. methods data sources: this study aims to analyse the strategies for covid-19 vaccination. these strategies are fundamental to the provision of information about a country’s implementation of vaccination rollout in the population as well as assessment of the challenges and constraints. the data were taken from the pubmed database through a boolean method without any restrictions on the language and date of publication. in addition, the references in the published papers were reviewed. finally, the search terms and strategies are table 1: criteria of eligible papers criterion description problem covid-19 vaccination concept the strategies for covid-19 vaccination to reduce cases, improve intention of vaccination, remove refusal or hesitancy about vaccination, and others; the data were based on not only statistical findings but also statements or reports in the papers context ● implementation of vaccination strategies in any developed or developing countries. ● the vaccination target was not only general population but also healthcare workers, essential workers, elderly, and vulnerable population. search strategy (((vaccination [title/abstract]) and (strategy [title/abstract])) and (covid 19 [title/abstract])) and (policy [title/abstract]) international journal of human and health sciences vol. 07 no. 03 july’23 214 presented in table 1. eligibility criteria: original papers about strategies for covid-19 vaccination in any countries were eligible in this study, including several research designs such as observational study, experiment, quasi-experiment, and mathematical model. in addition, editorial letters, opinions, and perspectives were also eligible as long as they provided an accurate explanation of vaccination strategies and vaccination impact. the impact of vaccination includes decreasing case number and increasing vaccination intention, removing vaccination hesitancy or refusal in the population, and others. the detailed criteria of eligibility are presented in table 1. management of literature: the published paper results were imported to microsoft excel for extraction and synthesis, and the mendeley software was used as the reference management. both authors (srs and amr) screened the eligible papers based on the title and abstract. if the title and abstract screening results were agreed, the process would continue to a full-text screening. coding: the coding was performed according to authors’ information, year of publication, country’s name, characteristics of population, summary of results, strategies for covid-19 vaccination, category of strategy, component of strategy, and outcome of vaccination. summary: the conclusion of the strategies for covid-19 vaccination was drawn narratively based on the various implementations in each country, and a diagram was prepared for the final summary. results literature screening: there were 23 studies included in this review and presented in figure 1. four studies were descriptive (10–13), six studies were modelling (14–19), three studies were editorial letters (7,20,21), and two studies were experiments, commentaries, and perspectives (9,22–26). meanwhile, the remaining studies were rct (27), cross-sectional (28), case-control (29), and correspondences (30). there were ten countries in those papers, including usa (eight), china (five), india (three), and serbia, thailand, records identified from pubmed (n=461) duplicate records removed (n = 1) reports assessed for eligibility (n =119) reports excluded (n=96) because of no actual data about vaccination identification of studies via pubmed id en tifi ca tio n sc re en in g studies included in review (n =23) in cl ud ed records screened after removing duplication (n=460) eli gi bil ity reports excluded (n=341) because of irrelevant topics figure 1. flowchart for selection of the literature 215 international journal of human and health sciences vol. 07 no. 03 july’23 south korea, canada, and the united kingdom (uk), european union (eu) as well as united emirates arab (uea) each with one published paper. the populations in the included papers were adults, elderly, healthcare workers, comorbidities, pharmacists, and nursing homes. components of the vaccination strategy networking: the component of networking was categorised into the role of governments, either local, regional, or national (9,26,30), and partnership involvement (7,21,24). stakeholders: the element of stakeholders was grouped into the role of public figures (27), the role of religious leaders (24), and the role of pharmacists and other healthcare workers (hcws) (25,26). infrastructure: the section of infrastructure was assembled into developing vaccine manufacturers (7,9,26), developing vaccine centres (21), and developing digital infrastructure (24,26). system: the part of system was gathered into priority groups (7,10,21,12–19), public preferences (11,22,23), strengthening family physician (21), giving reward and punishment (9,29), and communication (28). outcome of vaccination strategy: the outcome of vaccination strategy consisted of some aspects, such as increasing intention (27), reducing mortality and morbidity (10,12–18), reducing community transmission (13), raising the scope • role of local, regional government • involving partnership with ngo • intergovernmental networking • developing vaccine manufacture • developing digital infrastructure • developing vaccine center • role of public figures • role of pharmacists • role of religious figures stakeholders • raising intention • maintaining essential working functions • reducing mortality and morbidity • increasing scope of vaccination • increasing rate of vaccination • reducing community transmission • reaching herd immunity • increasing vaccination production • reducing covid-19 cases system • public preferences • priority group • free of charge • strengthening family doctors • communication • reward and punishment infrastructure networking figure 2. summary of the vaccination strategy international journal of human and health sciences vol. 07 no. 03 july’23 216 of vaccination (7,21–23,25,28–30), increasing the rate of vaccination (9,11,20,26), increasing vaccination production (24), and reaching herd immunity (19). summary of the components of vaccination strategy and outcome: a summary of the vaccination strategy entailing the components, categories, and outcomes of the policy is presented in figure 2. discussion networking: networking highlights how vaccination is under government control by coordinating national to district levels or national to national government levels. inter-collaboration among departments and ministries is employed to reach the initial vaccination scope (26), and all resources and methods are mobilised and concentrated to carry out vaccination works (9). the government has set up a national board to provide vaccination guidance administration called the national expert group on vaccine administration for covid-19 (negvac) (9). in addition, application suitability and emergency use of vaccination are conducted by the central drugs standard control organization (cdsco) in india (7,26), the national health commission (nhc) in china (9), and the joint committee on vaccination and immunization (jcvi) and uk medicine and healthcare products regulatory agency (mhra) in uk (21). these boards comprise various experts who determine some conditions and requirements for vaccination priority. in addition, an inter-governmental partnership by the serbian government employs a thousand vaccines for the neighbouring countries to strengthen diplomacy in the balkan regions (30). the government has a role not only to establish national boards but also to ensure that public communication works well by providing accurate message services in printed, online, or social media platforms (24). dealing with a pandemic is challenging. since the escalation of the pandemic is getting wider, networking is a significant action to face it. the government plays a critical role to mobilise financial resources and human power; however, coordination among governments and the lowerlevel governments is more crucial to deploy vaccination policy. the national government establishes many different bodies to review, assess, monitor, and evaluate vaccination requirements, emergency use, and scope. lastly, the role of the government is not only to focus on those aspects but also to guarantee accurate information and avoid untrusted news to encourage the community in the vaccination program. stakeholders: stakeholders focus on the community and the role of public figures to escalate the scope of vaccination. healthcare workers (hcw) are the primary stakeholder of vaccination; however, they require the skills to inoculate and manage adverse effects by training and workshop. the training concerns the capacity building of hcw such as medical doctors, nurses, midwives, and pharmacists as vaccinators. after completing vaccination training, all hcw are deployed across the country in remote, rural, and even mountainous areas (26). as a secondary frontline hcw, pharmacists can maintain the cold chain, keep vaccines intact, and be deployed as vaccinators after training, accreditation, certification, and amendment of regulation to cover the role of pharmacists in vaccination strategy (25,26). on the other hand, a religious leader’s role includes delivering a message that vaccination is permissible in islam (24). an islamic fatwa has declared that covid-19 vaccine is halal and allowable to inoculate in the community (31). a study about stakeholders’ roles reported that political figures also have a role in raising the scope of vaccination (27). the presidential election in the united states of america (usa) has increased the uptake of vaccination and belief in the safety of vaccination. in this regard, human resources such as religious or political figures have an essential role in vaccination rollout programs because they can influence constituents. therefore, the increasing scope of vaccination nowadays concerns hcw, and public figures can encourage more public intention to covid-19 vaccination. infrastructure: infrastructure highlights physical and digital systems. vaccine manufacture is established to produce an indigenous vaccine to cover the entire population in home countries. since the demand for vaccination is high, making own vaccines can be a solution to cover millions of people in the countries. building manufacture requires a large number of funding resources and supporting clinical research phases. in addition, physical infrastructure alone is less effective without digital resources which provide applications for registering, detecting, monitoring, and evaluating inoculation in the population. thus, 217 international journal of human and health sciences vol. 07 no. 03 july’23 digital infrastructure can become a useful strategy to deliver message and information as well as to track vaccinated or unvaccinated individuals. manufacturing indigenous vaccines is one crucial step to fulfil vaccine allocation in home countries. some countries have launched and registered vaccines that work 24 hours to accomplish domestic necessities (7,9,24,26). developing a mass vaccination centre has also been implemented, supervised by trained vaccinators, armed forces, and hcw, and vaccination centres have been deployed in local pharmacies, local communities, private hospitals, and religious buildings (21). digital infrastructure has been developed in uea (24) and india (26) since the first time of vaccination launch. al hosn app is used for contact tracing, national registration of vaccination, and tracking vaccination history, while malaffi platform is used to collect and share information with many healthcare facilities connected to electronic medical records (24). meanwhile, covid vaccine intelligence network (co-win) is a digital platform to register people in the vaccination program and monitor immunised individuals for any adverse effects. the co-win system sends appropriate schedule, place, and vaccination supervisor data (26). system: studies about priority groups have found that healthcare workers and frontline workers are the most critical priority since they essentially function in daily activities, deploy vaccination, and guarantee daily life during the pandemic. protecting hcw and essential workers can mean handling the transmission of infection in the community. meanwhile, older people are the most vulnerable; however, several studies are arguable regarding the cut-off age of elderly, whether it is more than 50 y.o. (16), more than 65 y.o. (19), or more than 80 y.o. (12). one consensus about comorbidities agreed in most studies is that underlying diseases in age-stratified groups are included in the priority. older people and underlying diseases are prioritised because they have morbidity and mortality in the population. in addition, after prioritizing hcw, essential workers, elderly, and comorbidity, the last priority is young adults and children, and one priority that might be overlooked is pregnancy. however, the published papers have limited data on the precedence given to pregnant women for vaccination. regarding public preferences for covid-19 vaccination, studies have reported that one vaccination episode with low adverse effects is preferred in health facilities. immediate service performed voluntarily is intended, and people prefer vaccines if the community in their place is already vaccinated. the general preference is challenging to implement since every vaccine has side effects that depend on individual responses. immediate vaccination depends on each government’s capability to manage the people, including human resources in inoculation. public preferences are essential, but to entirely rely on them is problematic. a fruitful action is a communication about the procedure, side effects, and preand post-vaccination occasion that must be delivered comprehensively. communication plays an important role in delivering information about the side effects and symptoms, which is preferable to respondents who do not obtain such information (28). free vaccination increases willingness rate (11). even though vaccination is free of charge, the government should provide paid vaccination, particularly for low-income residents. since vaccination must be delivered equally in low, middle-, and high-income residents, vaccine stocking in paid or free schemes is obligatory. in addition, medical insurance also offers a protection scheme to vaccination policy; however, there is minimal data regarding the medical insurance scheme in relation to the rate of vaccination. the role of medical insurance funds to cover vaccination is limited (9). further study is warranted to observe the role of medical insurance in the willingness of vaccination policy. the primary care strengthening establishes vaccination centre programs beside hospitalbased ones by employing human resources such as medical doctors, laboratory staff, and nurses. the uk deployed a million doses of influenza vaccine years ago, a success story from previous experience for implementing covid-19 vaccination based on primary care resources (21). finally, another strategy to escalate vaccination is by providing reward and punishment. a reward, either monetary or non-monetary, can stimulate people’s response to come for vaccination (9). as the pandemic is unprecedented, massive vaccination ensures protection of the community from the infection. for people who refuse vaccination, such punishment as being banned in public office may encourage willingness and remove hesitancy. this study has several limitations. first, a narrative international journal of human and health sciences vol. 07 no. 03 july’23 218 review is the author’s subjective intuition that potentially show a bias; second, the narrative review does not have any protocols to employ the methodology. further study is warranted by employing a qualitative method to collect more accurate and in-depth data regarding health policy of covid-19 vaccination. conclusion vaccination is one of the most effective measures during the pandemic. all countries have launched several policies to roll out vaccination. our findings suggest strengthening networking, empowering stakeholders, implementing an appropriate system, and building infrastructure in every country to succeed in covid-19 vaccination strategy. the strategy of vaccination can strengthen the resilience of the health system during the pandemic. conflict of interest: the authors declare no conflict of interest. funding statement: no funding ethical approval: not applicable author’s contribution: srs contributed to searching for the included papers, data extraction and synthesis, writing and analysing the manuscript. amr contributed to writing, analysing and reviewing the manuscript. references 1. stadler k, masignani v, eickmann m, becker s. sars-beginning to understand a new virus. nat rev. 2003;1:209-18. 2. zaki a, boheemen s, bestebroer t, osterhaus a, fouchier r (2012) isolation of a novel coronavirus from a man with pneumonia in saudi arabia. n engl j med. 367:1814–20. 3. vignesh r, shankar em, velu v (2020) is herd immunity against sars-cov-2 a silver lining? front immunol. 11:1–6. 4. le tt, cramer jp, chen r, mayhew s (2020) evolution of the covid-19 vaccine development landscape. nat rev drug discov. 19:19–20. 5. rawat k, kumari p, saha l (2020) covid-19 vaccine: a recent update in pipeline vaccines, their design and development strategies. eur j pharmacol. 89:173751. 6. mcdermott a, writer s (2021) herd immunity is an important — and often misunderstood — public health phenomenon. pnas.118(21):1–4. 7. nurunnabi asm, ashique ss, jahan a, sweety aa, sharmin s. children and covid-19 vaccine: a 219 international journal of human and health sciences vol. 07 no. 03 july’23 public health ethics perspective. bangladesh med j. 2021;50(3):44-8. 8. rackimuthu s, hasan m, bardhan m, essar m (2021) covid-19 vaccination strategies and policies in india : the need for further re-evaluation is a pressing priority. int j heal plann mgmt.;1–4. 9. data in our world.[https://ourworldindata.org/covidvaccinations]. accessed january 24, 2022. 10. meng z (2021) china’s covid-19 vaccination strategy and its impact on the global pandemic. risk manag healthc policy.14:4649–55. 11. an z, wang f, pan a, yin z, rodewald l, feng z (2021) vaccination strategy and challenges for consolidating successful containment of covid-19 with population immunity in china. bmj. 12. liu r, zhang y, nicholas s, leng a, maitland e (2021) covid-19 vaccination willingness among chinese adults under the free vaccination policy. vaccine.9:292. 13. roghani a (2021)the influence of covid-19 vaccination on daily cases , hospitalization , and death rate in tennessee , united states : case study corresponding author : related articles : jmirx med.2(3):e29324. 14. yang j, zheng w, shi h, yan x, dong k, you q (2021). who should be prioritized for covid-19 vaccination in china ? a descriptive study. bmc med. 19(45):1–13. 15. ko y, lee j, kim y, kwon d (2021) covid-19 vaccine priority strategy using a heterogenous transmission model based on maximum likelihood estimation in the republic of korea. j environ res public heal.18:6469. 16. islam r, oraby t, audrey m (2021) evaluation of the united states covid-19 vaccine allocation strategy. plos one.16(11):1–22. 17. mandal s, arinaminpathy n, bhargava b (2021) india ’ s pragmatic vaccination strategy against covid-19 : a mathematical modelling based analysis. bmj open.11:1–8. 18. ferranna m, cadarette d, bloom de (2020) covid-19 vaccine allocation: modeling health outcomes and equity implications of alternative strategies. engineering.7:924–35. 19. suphanchaimat r, tuangratananon t, rajatanavin n (2021) prioritization of the target population for coronavirus disease 2019 ( covid-19 ) vaccination program in thailand. int j environ res public heal 2021. 18:10803. 20. macintyre cr, costantino v, trent m (2020) modelling of covid-19 vaccination strategies and herd immunity, in scenarios of limited and full vaccine supply in nsw, australia. vaccine. 21. tuite a, fisman d, lana d, zhu l, salomon j (2021) alternative dose allocation strategies to increase bene fi ts. ann intern med. 18–20. 22. harnden a, earnshaw a (2021) lessons from the united kingdom’s covid19 vaccination strategy. 23. wilson i, mody a, hoan k, id t, bradley c, sheve a (2021) preferences for covid-19 vaccine distribution strategies in the us : a discrete choice survey. plos one. 16(8):1–15. 24. dong d, xu rh, wong el, mbbs ch, feng d, feng z (2020) public preference for covid-19 vaccines in china : a discrete choice experiment. heal expect.23:1543–78. 25. suliman d, nawaz fa, mohanan p, abdul m, adam k, yasir m (2020) uae efforts in promoting covid-19 vaccination and building vaccine confidenc. vaccine.3:6341–5. 26. paudyal v, fialová d, henman mc, hazen a, okuyan b, lutters m (2021) pharmacists ’ involvement in covid 19 vaccination across europe : a situational analysis of current practice and policy. int j clin pharm. 43(4):1139–48. 27. kumar v, perumal s, trakht i, thyagarajan s (2021) strategy for covid-19 vaccination in india : the country with the second highest population and number of cases. npj vaccines.6(60). 28. bokemper se, huber ga, gerber as, james ek (2020) timing of covid-19 vaccine approval and endorsement by public figures. vaccine.39:825–9. 29. merkley e, loewen p (2021) assessment of communication strategies for mitigating covid-19 vaccine-specific hesitancy in canada. jama network open 30. berry sd, mph rrb, link-gelles r, gifford dr (2021) strategies associated with covid-19 vaccine coverage among nursing home staff. j am geriatr soc.1–10. 31. barovic a, cardenas n (2021) covid-19 diplomacy : analysis of serbia covid-19 vaccine strategy in the western balkans. j public health (bangkok).1:1–2. 32. mardian y, shaw-shaliba k, karyana m, lau c (2021) sharia ( islamic law ) perspectives of covid-19 vaccines. front trop dis.2:1–8. 67 international journal of human and health sciences vol. 07 no. 01 january’23 original article effect of comorbidities on antibody status following covid-19 vaccination – a comparison between sars-cov-2 infected and non-infected healthcare professionalsin dhaka, bangladesh rimpi romana1, forhadul hoque mollah1, miliva mozaffor2, shohana akter3, tanusri chakraborty4, fahmida sharmin5 abstract background: vaccination with the oxford-astra zeneca covid-19 vaccine was initially started in the uk and quickly implemented across the globe including bangladesh. objective: to observe the difference in antibody status between infected and non-infected individuals as well as between relatively healthy individuals and individuals having comorbidities. methods: this cross-sectional, analytical study was conducted in the department of biochemistry and molecular biology, bangabandhu sheikh mujib medical university (bsmmu), dhaka, bangladesh, between march 2021 and february 2022. a total of 70 adult participants (healthcare professionals) were included in this study who were working in different departments of bsmmu hospital. study participants were categorized into two groups: healthcare professionals who were infected by sars cov-2 and later vaccinated by two doses of astrazeneca covid-19 vaccine were included in group a, while group b included those who were not infected by sars cov-2 but took two doses of astrazeneca covid-19 vaccine. each group had 35 participants.demographic profile, detailed history was recorded in data collection sheet. then blood pressurewas measured and recorded. random blood sugar was estimated by glucose oxidasemethod, while serum igg was assessed by chemiluminescent microparticle immunoassay method. results:participants with hypertension in group a had igg levels as median 2183.20 au/ml, and iqr (inter quartile range)of 0 au/ml, and in group b, as median 624.70 au/ ml, and iqr of 0 au/ml. (p>0.05). in contrast, among participants with no hypertension showed significant differences in igg levels (group a median 2242.65 au/ml, and iqr 3758.88 au/ml; group b median 619.60 au/ml, and iqr 672.23 au/ml) (p<0.001). participants having both diabetes mellitus and hypertension in group a had igg levels as median 1949.70 au/ml, and iqr of 4294.43 au/ml, and in group b, as median 739.00 au/ml, and iqr of 423.75 au/ml. (p<0.001). among participants with no such comorbidities also showed significant differences in igg levels (group a median 2183.20 au/ml, and iqr 3547.50 au/ml; group b median 592.40 au/ml, and iqr 740.98 au/ml) (p<0.001). after summation, participants having all types of comorbidities in group a had igg levels as median 2183.20 au/ml, and iqr of 4095.70 au/ml, and in group b, as median 624.70 au/ml, and iqr of 558.80 au/ml. (p<0.001). in contrast, among participants with no comorbidities showed similar differences in igg levels (group a median 2394.45 au/ml, and iqr 3450.73 au/ ml; group b median 653.10 au/ml, and iqr 990.13 au/ml) (p<0.001).conclusion:antibody status (serum igg levels) was significantly higher in previously infected vaccinated group (both with comorbidities and without comorbidities)than that of non-infected vaccinated group. keywords: covid-19 vaccination, antibody status, sars cov-2 infection, comorbidities, healthcare professionals correspondence to: dr. rimpi romana, resident, department of biochemistry and molecular biology, bangabandhu sheikh mujib medical university (bsmmu), dhaka-1000, bangladesh. email: rimpiromana.dr@gmail.com 1. department of biochemistry and molecular biology, bangabandhu sheikh mujib medical university (bsmmu), dhaka-1000, bangladesh. 2. department of biochemistry, medical college for women & hospital, uttara, dhaka-1230, bangladesh. 3. department of biochemistry, sher-e-bangla medical college, barishal-8200, bangladesh. 4. department of biochemistry, pabna medical college, pabna-6602, bangladesh. 5. department of biochemistry,colonel malek medical college, manikganj-1800, bangladesh. international journal of human and health sciences vol. 07 no. 01 january’23 page : 67-7 2 doi: http://dx.doi.org/10.31344/ijhhs.v7i1.500 international journal of human and health sciences vol. 07 no. 01 january’23 68 introduction the sars-cov-2 pandemic has caused an unprecedented worldwidepublic health challenge.1 in bangladesh, coronavirus case was first reported on march 8, 2020, while the first death announced on march 18, 2020.2igg antibody is associated with reduced risk of sars-cov-2 reinfection in the ensuring almost 6 months.3 scientists are trying their best to invent effective drug against covid-19; however,none has come to the effect to date.under the circumstances, the only way to protect the human being from the curse of covid-19 by producing antibody either by low level passive exposure or active exposure to sars-cov-2 infection or vaccination or both.4bangladesh started its nationwide administration of covid-19 vaccine on february 7, 2021 with oxford astrazeneca produced and distributed by the serum institute of india.5evidence showed a strong relationship between previous sars-cov-2 infection and higher antibody responses; individuals with previous sars-cov-2 infection generate strong humoral and cellular responses to one dose/two doses of covid-19 vaccine, with evidence of high titres of in-vitro live virus neutralisation.3 however, to date, no reports are available in our countryon the antibody status with or without previous sars-cov-2 infection and following as well as the antibody status of patients suffering with comorbidities like diabetes and hypertension. moreover, it is unknown how much antibody level raised after sars-cov-2 infection and following vaccination, and whether that level is enough to protect the human being from reinfection or hospitalization.6evidence showed that patients with type 2 and type 1 diabetes or cardiovascular diseases (cvd) have an increased vulnerability to severe sufferings from sars-cov-2.1,4 therefore, vaccination should be prioritized in diabetes, hypertensive,and cvd patients.moreover, we also felt the necessity to know the diversity in immunity status ofpeople in different healthcare settings, as they remain most vulnerable in this pandemic situation. hence, we proposed this cross-sectional, analytical study to evaluate and compare the antibody status between sarscov-2 infected vaccinated and sars-cov-2 non-infected vaccinated healthcare professionals, as well as observe the difference in antibody status between subjects having comorbidities and without any comorbidity. methods this cross-sectional, analytical study was conducted in the department of biochemistry and molecular biology, bangabandhu sheikh mujib medical university (bsmmu), dhaka, bangladesh, between march 2021 and february 2022. inclusion criteria: 1) aged between 25 and 65 years; 2) healthcare professionals who were sarscov-2 infected last 8-12 months ago (rtpcr positive report) and received two doses of astrazeneca covid-19 vaccine 4 to 6 months back; and 3) healthcare professionals who were sarscov-2 non infected but received two doses ofastrazeneca vaccine last 4 to 6 months ago. exclusion criteria: 1) subject with acute infection; 2) pregnant women; 3) lactating mother; 4) history of heart failure; 5) chronic systemic diseases,e.g., chronic liver disease, chronic kidney disease; and 6) subject who are suffering from any immunosuppressive disorderse.g., cancer, sle, etc. based on inclusion and exclusion criteria, a total of 70 healthcare professionals were included in this study from different departments of bsmmu hospital. study participants were categorized into two groups: group a consisted of healthcare professionals who were previously infected by sars cov-2 and later vaccinated (two doses of astrazeneca covid-19 vaccine) and group b by who were not infected by sars cov2 but received the same doses of astrazeneca covid-19 vaccine. there were 35 participants in each group. a data collection sheet formatted both in english and bengali was used as a data collection tool. the sheet included three sections: section-i contained general information, while section-ii contained information related to sarscov-2 infection and section-iii included further test reports related to this study. demographic profile, detailed history was recorded 69 international journal of human and health sciences vol. 07 no. 01 january’23 in data collection sheet.then bloodpressure of each individualwas measured and recorded. after that, with all aseptic precaution, 5ml blood sample was collected from the anti-cubital vein, using a disposable plastic syringe. 2ml of blood was delivered immediately into sodium-fluoride tube (grey top tube) and 3ml into a plain tube (red top tube). all the test tubes were centrifuged properly at 3000 rpm for 10 minutes to separate plasma and serum within one hour of collection. then the serum (about 500µml) was separated from each of the plain tube by micropipette, collected in eppendorf tube, properly labeled, and stored at minus 65-degreecelsius temperature. separated plasma was used for estimation of random blood sugar (rbs) by using by glucose oxidase method. estimation of serum igg levels wasdoneusing chemiluminescent microparticle immunoassay in abbott alinityiautoanalyzer (made by abbott inc.,usa). all the biochemical and immunological assays were performedin the department of biochemistry and molecular biology ofbangabandhu sheikh mujib medical university (bsmmu).autoanalyzer used in this study was calibrated before starting the tests as per test manual. before starting daily investigations, control run was done. quality control and quality assurance in all areas were maintained as per respective laboratory rules. pre-analytic, analytic, and post-analytic errors were carefully minimized as per laboratory standard operating procedure (sop). after multiple checking, data were recorded in a predesigned data collection sheet. continuous variables were expressed as mean±sd and compared between groups by unpaired student’s t-test. categorical variables were expressed as frequency and percentage and compared using chi-square test. mann-whitney u test was done to compare serum igg levels in between sarscov-2 infected vaccinated group and sarscov-2 non-infected vaccinated group.level of significance was defined as p value <0.05 at 95% confidence interval. statistical analysis was done using statistical package for the social sciences (spss) version 20.0 for windows. results the mean age of previously infected and vaccinated individuals (group a) was 41.14±12.51 years, while 38.43±9.18 years for non-infected but vaccinated individuals (group b). however, there was no significant difference in age between the groups (p>0.05). a male predominance was observed in group a; in contrast, female predominance was found in group b. the difference in gender between the groups was statistically significant (p<0.05). in group a, there were 57.1% doctors, 20% nurses, 8.6% phlebotomists, and 14.3% other staff. similarly, in group b, there were 48.6% doctors, 17.1% nurses, 11.4% phlebotomists, and 22.9% other staff. no significant difference was observed between the groups (p>0.05) (table 1).mean systolic blood pressurein group a was 121.00±7.05mm of hg, while in group b 119.37±7.92 mm of hg. observed mean diastolic blood pressure were 80.14±6.36 mm of hg and 79.43±5.53 mm of hg respectively. random blood sugar was found 6.05±1.97 mmol/l in group a, whereas 5.91±1.88 mmol/l in group b. however, the differencesbetween the groups were not statistically significant in any of those parameters (p>0.05) (table 2). participants withhypertension had following igg levels: in group a as median 2183.20 au/ml, and iqr of 0 au/ml, and in group b, as median 624.70 au/ml, and iqr of 0 au/ ml. (p>0.05). in contrast, among participants with no hypertension showed significant differences in igg levels (group a median 2242.65au/ ml, and iqr 3758.88au/ml; group b median 619.60au/ml, and iqr 672.23au/ml) (p<0.001) (table 3). participants having both diabetes mellitus and hypertension had following igg levels: in group a as median 1949.70au/ml, and iqr of 4294.43 au/ml, and in group b, as median 739.00au/ml, and iqr of 423.75au/ ml. (p<0.001). among participants with no such comorbidities also showed significant differences in igg levels (group a median 2183.20au/ml, and iqr 3547.50au/ml; group b median 592.40au/ ml, and iqr 740.98au/ml) (p<0.001) (table 4). after summation, participants having all types of comorbidities had following igg levels: in group a as median 2183.20 au/ml, and iqr of 4095.70 au/ml, and in group b, as median 624.70 au/ml, and iqr of 558.80 au/ml. (p<0.001). incontrast, among participants with no comorbidities showed similar differences in igg levels (group a median 2394.45 au/ml, and iqr 3450.73 au/ml; group b median 653.10 au/ml, and iqr 990.13 au/ml) (p<0.001) (table 5). international journal of human and health sciences vol. 07 no. 01 january’23 70 table 1. demographic characteristics of the study participants (n=70) variables group a(n=35) group b (n=35) p value age in years mean±sd 41.14±12.51 38.43±9.18 >0.05ns gender male 24 (68.6) 14 (40.0) <0.05s female 11 (31.4) 21 (60.0) occupation doctor 20 (57.1) 17 (48.6) >0.05ns nurse 7 (20.0) 6 (17.1) phlebotomist 3 (8.6) 4 (11.4) other staff 5 (14.3) 8 (22.9) continuous variables were expressed as mean±sd, while categorical variables were expressed as frequency and percentage. unpaired students t-test was used to compare differences in age, while chi-square test was used to compare gender and occupation. s=significant, ns=not significant. table 2. clinical characteristics of the study participants (n=70) variables group a (n=35) group b (n=35) p value systolic blood pressure mm of hg 121.00±7.05 119.37±7.92 >0.05ns diastolic blood pressure mm of hg 80.14±6.36 79.43±5.53 >0.05ns random blood sugar mmol/l 6.05±1.97 5.91±1.88 >0.05ns data were expressed as mean±sd. p value reached from chi-square test; ns=not significant. table 3. antibody status of the study subjects with or without hypertension (n=70) hypertension antibody status (au/ml) group a (n=35) group b (n=35) p value present median 2183.20 624.70 >0.05ns iqr 0.00 0.00 min-max 1036.20 -5131.90 259.80 -764.50 absent median 2242.65 619.60 <0.001s iqr 3758.88 672.23 min-max 861.70 -12884.10 96.10 -2330.00 data were expressed as median and iqr (interquartilerange).p value reached from mannwhitney u test; ns=not significant, s=significant. table 4. antibody status of the study subjects with or without diabetes mellitus and hypertension (n=70) both diabetes mellitus &hypertension antibody status (au/ml) infected vaccinated non infected vaccinated p value present median 1949.70 739.00 <0.05s iqr 4294.43 423.75 min max 897.3-8797.6 232.3-918.2 absent median 2183.20 592.40 <0.001s iqr 3547.50 740.98 min max 861.7-12884.1 96.1-2330.0 data were expressed as median and iqr (interquartile range).p value reached from mannwhitney u test; s=significant. table5. antibody status of the study subjects with and without comorbidities (n=70) variables antibody status (au/ml) group a group b p value with comorbidity (n=26) median 2183.20 624.70 <0.001siqr 4095.70 558.80 min max 897.30-8797.60 99.401393.90 without comorbidity (n=44) median 2394.45 653.10 <0.001siqr 3450.73 990.13 min max 861.70-12884.10 96.102330.00 data were expressed as median and iqr (interquartile range). p value reached from mannwhitney u test; s=significant. discussion antibody plays a vital role in suppressing the pathogenesis of sars-cov-2 by disrupting the binding of viral spike protein to angiotensinconveting-enzyme2 receptor on the target cell.6a longitudinal study in china showed that igm levels increased first week after sars-cov-2 infection peaked 2 weeks after that decline whereas igg was detectable after 1 week and maintained at a high level for a long period.7the peripheral t and b cell from the sars-cov-2 patients revealed a positive correlation of humoral immune response and the t cell immune memory with disease severity.8 evidence showed a strong relationship between previous sars-cov-2 infection and higher 71 international journal of human and health sciences vol. 07 no. 01 january’23 antibody responses. several research reported that individuals with previous sars-cov-2 infection generate strong humoral and cellular responses to one dose/two doses of covid-19 vaccine, with evidence of high titres of in-vitro live virus neutralisation. in contrast, most individuals who are infection-naive generate both weak t-cell responses and low titres of neutralising antibodies.9-14 our results are in congruence with those research fundings. in our study, it was observed that in both group a considerable number of study subjects were suffering from hypertension, or diabetes or both. we found that 22.9% infected participants had some types of comorbidities. yang et al.15reported that prevalence of sars-cov-2 was higher with hypertension 21.1% and diabetes 9.7%. similarly, sanyaolu et al.16found that most common comorbidities of sars-cov-2 patients were hypertension (15.8%) and diabetes (9.4%).studies also found that the relative risk of developing severe covid-19 or death is higher in patients with risk factors for cvd (hypertension, diabetes) and much higher in patients with cvd.1,4,17,18 similarly, a study conducted in bangladesh found that covid-19 patients with cvd had almost five times higher odds of death, and covid-19 patients with cvd and diabetes had almost seven times higher odds of death.19 we evaluated the antibody level between hypertensive and non-hypertensive individuals in between infected vaccinated group and non-infected vaccinated group; we found a higher antibody level in infected vaccinated group than that of noninfected vaccinated group. simultaneously, wealso evaluated the antibody level with or without both diabetic and hypertensive individuals in infected vaccinated and non-infected vaccinated group; higher antibody levels in infected vaccinated group compared to non-infected vaccinated group was also observed. ali et al.20stated that diabetic and hypertensive individuals had a robust antibodyresponse to vaccination as demonstrated by their high antibody titer which was statistically significant. in their study, done in kuwait, three weeks after second dose of vaccine they observed that serum igg level was 138 bau/ml in diabetic participants and without diabetic participants was 154 bau/ml, while in hypertensive individuals 144 bau/ml and non-hypertensive individuals 151 bau/ml, which were relatively lower.20 another study done in austria bysourij et al.21 reported that after the first vaccination only 52.7% type-1diabetes group and 48.0% in the type2 diabetes group showed antibody level above the cut-off value but the antibody level after the second vaccination were similar in type-1, type2 and healthy controls. another study done by iacobucci et al.22suggested that after a single dose of vaccination there was significant difference in antibody level in between diabetes, cardiovascular disease and normal individuals; however, in other study done by uysal et al.23 observed that the inequalities in antibody levels amongst those groups did not persist after the second dose, as high antibody titers>250 u/ml were observed nearly all participants. our findings are more or less similar to those studies. conclusion to summarize, antibody status (serum igg levels) was significantly higher in previously infected vaccinated group (both with comorbidities and without comorbidities) than that of non-infected vaccinated group. however, further studies are recommended involving larger samples from different age groups and multicentre across the country. acknowledgement:the authors of this study are thankful to the healthcare professionals who voluntarily participated in this study. conflict of interest: the authors declare no conflict of interest. ethical approval: the study was approved by the institutional review board ofbangabandhu sheikh mujib medical university (bsmmu), dhaka, bangladesh. funding statement:this research was funded by the university research grant of bangabandhu sheikh mujib medical university (bsmmu), dhaka, bangladesh. authors’ contribution: concept and design of the study: rr, fhm; subject selection and collection of samples: rr, fhm, mm, sa, tc, fs; data collection and compilation: rr, fhm; data analysis: rr, mm; manuscript writing, revision and finalizing: rr, fhm, mm, sa, tc, fs. international journal of human and health sciences vol. 07 no. 01 january’23 72 references: 1. pal r, bhadada sk, misra a. covid-19 vaccination in patients with diabetes mellitus: current concepts, uncertainties and challenges. diabetes metab syndr. 2021;15(2):505-8. 2. directorate general of health services (dghs). covid-19 dynamic dashboard for bangladesh. ministry of health and family welfare, govt. of the people’s republic of bangladesh. 2022. retrieved from: https://dghs-dashboard.com/pages/covid19. php (accessed on march 26, 2021). 3. jeyanathan m, afkhami s, smaill f, miller ms, lichty bd, xing z. immunological considerations for covid-19 vaccine strategies. nat rev immunol. 2020;20(10):615-32. 4. fang l, karakiulakis g, roth m. are patients with hypertension and diabetes mellitus at increased risk for covid-19 infection? lancet respir med. 2020;8(4):e21. 5. hasan k. nationwide covid-19 vaccination drive begins. dhaka tribune. february 7, 2021. retrieved from: https://archive.dhakatribune.com/ bangladesh/2021/02/07/nationwide-vaccinationprogram-starts (accessed march 26, 2021). 6. fiedler s, piziorska ma, denninger v, morgunov as, ilsley a, malik ay, et al. antibody affinity governs the inhibition of sars-cov-2 spike/ace2 binding in patient serum. acs infect dis. 2021;7(8):2362-9. 7. hou h, wang t, zhang b, luo y, mao l, wang f, et al. detection of igm and igg antibodies in patients with coronavirus disease 2019. clin transl immunology. 2020;9(5):e01136. 8. zhang f, gan r, zhen z, hu x, li x, zhou f, et al. adaptive immune responses to sars-cov-2 infection in severe versus mild individuals. signal transduct target ther. 2020;5(1):156. 9. eyre dw, lumley sf, o’donnell d, stoesser ne, matthews pc, howarth a, et al. stringent thresholds in sars-cov-2 igg assays lead to under-detection of mild infections. bmc infect dis. 2021;21(1):187. 10. prendecki m, clarke c, brown j, cox a, gleeson s, guckian m, et al. effect of previous sarscov-2 infection on humoral and t-cell responses to single-dose bnt162b2 vaccine. lancet. 2021;397(10280):1178-81. 11. zollner a, watschinger c, rössler a, farcet mr, penner a, böhm v, et al. b and t cell response to sars-cov-2 vaccination in health care professionals with and without previous covid-19. ebiomedicine. 2021;70:103539. 12. wei j, stoesser n, matthews pc, ayoubkhani d, studley r, bell i, et al. antibody responses to sarscov-2 vaccines in 45,965 adults from the general population of the united kingdom. nat microbiol. 2021;6(9):1140-9. 13. tut g, lancaster t, krutikov m, sylla p, bone d, kaur n, et al. profile of humoral and cellular immune responses to single doses of bnt162b2 or chadox1 ncov-19 vaccines in residents and staff within residential care homes (vivaldi): an observational study. lancet healthy longev. 2021;2(9):e544-53. 14. jamiruddin r, haq a, khondoker mu, ali t, ahmed f m, khandker ss, et al. antibody response to the first dose of azd1222 vaccine in covid-19 convalescent and uninfected individuals in bangladesh. expert rev vaccines. 2021;20(12):1651-60. 15. yang j, zheng y, gou x, pu k, chen z, guo q, et al. prevalence of comorbidities and its effects in patients infected with sars-cov-2: a systematic review and meta-analysis. int j infect dis. 2020;94:91-5. 16. sanyaolu a, okorie c, marinkovic a, patidar r, younis k, desai p, et al. comorbidity and its impact on patients with covid-19. sn compr clin med. 2020;2(8):1069-76. 17. bae s, kim sr, kim mn, shim wj, park sm. impact of cardiovascular disease and risk factors on fatal outcomes in patients with covid-19 according to age: a systematic review and meta-analysis. heart. 2021;107(5):373-80. 18. dessie zg, zewotir t. mortality-related risk factors of covid-19: a systematic review and meta-analysis of 42 studies and 423,117 patients. bmc infect dis. 2021;21(1):855. 19. sharif n, ahmed sn, opu rr, tani mr, dewan d, daullah mu, et al. prevalence and impact of diabetes and cardiovascular disease on clinical outcome among patients with covid-19 in bangladesh. diabetes metab syndr. 2021;15(3):1009-16. 20. ali h, alahmad b, al-shammari aa, alterki a, hammad m, cherian p, et al. previous covid-19 infection and antibody levels after vaccination. front public health. 2021;9:778243. 21. sourij c, tripolt nj, aziz f, aberer f, forstner p, obermayer am, et al. humoral immune response to covid-19 vaccination in diabetes is age-dependent but independent of type of diabetes and glycaemic control: the prospective covac-dm cohort study. diabetes obesmetab. 2022;24(5):849-58. 22. iacobucci g. covid-19: most uk adults had antibodies after one dose of astrazeneca or pfizer vaccine, data suggest. bmj. 2021;373:n1274. 23. uysal eb, gümüş s, bektöre b, bozkurt h, gözalan a. evaluation of antibody response after covid-19 vaccination of healthcare workers. j med virol. 2022;94(3):1060-6. supplementary issue:02 149 susceptibility to ceftriaxone-sulbactam-edta in gram negative mdr & non-mdr isolates at tertiary care centre jnmch aligarh, uttar pradesh syed hilal husain1, fatima khan1, asfia sultan1, anees akhtar1 1department of microbiology, jawaharlal nehru medical college, aligarh muslim university, aligarh, up, india *correspondence: dr. syed hilal husain mbbs proff. 3, jnmc, amu aligarh 202002 syedhilalhusain@gmail.com abstract: introduction: a rapid increase in multidrug-resistant (mdr) is being reported across india. ceftriaxone-sulbactam-edta (cse) is a promising therapeutic option available in cases of infections caused by esbl and mbl producing pathogens proving to be a carbapenem-sparing antibiotic. however, cse effectiveness needs to be evaluated due to rapidly increasing antimicrobial resistance. objectives: following prospective observational study was directed to generate data on in-vitro susceptibility of mdr and non-mdr to ceftriaxone-sulbactam-edta (cse). materials and methods: gram negative bacterial isolates cultured from various nonrepetitive clinical samples of indoor and outdoor patients of a tertiary care centre of up for a period of 9 months (1 april 2022 to 31 december 2022) were included in the study. antimicrobial susceptibility testing to antibiotics was done using kirby-bauer disk diffusion and vitek methods. results: during study period, 82.3% (229/278) and 17.6% (49/278) of mdr and nonmdr gram negative isolates respectively. among the isolates 51% of mdr and 95% of nonmdr were found to be susceptible to cse. conclusions: present study shows that in-vitro susceptibility to cse varies from 51% to 95% depending on the organism. a trend of increasing resistance in multidrug-resistant (mdr) organisms is being reported across all isolates. ceftriaxone-sulbactam-edta fixed dose combination is a promising therapeutic option in cases of infections caused by mdr (especially esbl and mbl producing pathogens) acting as carbapenem-sparing antibiotics. keywords: ceftriaxone-sulbactam-edta, susceptibility, multi-drug resistant. supplementary issue:02 150 introduction: the rapid increase of antimicrobial resistance with emergence of multidrug resistant (mdr) organism producing extended spectrum beta lactamases (esbl) and metallo-beta lactamases (mbl) conferring sufficient protection from antibiotics action, poses a therapeutic challenge to treating physicians. a vast majority of healthcare-associated infections in india are caused by mdr gram-negative bacteria [1]. apart from being associated with increased morbidity and mortality among hospitalized patients, these infections are associated with increased health care costs burdening and an overall negative impact on the economy. [2,3]. carbapenems and colistin form the mainstay of treatment against gram-negative pathogens, especially esbl and mbl producing isolates. in view of the increasing failure rate of β-lactams [4] and increased resistance to carbapenems with toxicity of colistin, especially in intensive care units (icus), there is a need for a new antibiotic/combination of antibiotics which can work more efficiently against esbls and mbls. [5,6,7}. a new approach to improve the existing antimicrobial agents is the use of antibiotic adjuvant therapy (aae). prompt use of aae (ceftriaxone, sulbactam with adjuvant edta) has been reported to have proven efficacy in a wide range of infections [8,9]. the in vitro, preclinical, microbiological and molecular studies have demonstrated it to be more effective than penicillins, cephalosporins, beta-lactam and beta-lactamase inhibitor combinations including piperacillin + tazobactam,cefoperazone + sulbactam, amoxicillin + clavulanate [6,7,8,9] proving to be a carbapenem-sparing antibiotic which requires further susceptibility testing and required evaluation. to the best of our knowledge, there is no data available from this tertiary care center on in‐vitro susceptibility profile of clinical mdr and non-mdr gram-negative bacterial isolates to this aae. keeping this void in mind, the following study has been conducted with the aim of generating preliminary laboratory data on this subject. material and methods: the following study was conducted at tertiary care centre jnmch, amu in department of microbiology. bacterial isolates of both in-patients and icus were studied for a period of nine months from april 2022-december 2022. sample collection: during the study period, a total of 278 gram negative bacterial isolates were obtained from tracheal, urinary and blood samples collected from in-patients and icus. sample grouping: gram negative bacterial isolates were further classified as mdr (being nonsusceptible to at least one agent in three or more antimicrobial categories [10]) and non-mdr after screening them as per the clinical laboratory standards institute (clsi) guidelines [11]. supplementary issue:02 151 antimicrobial susceptibility testing: antimicrobial susceptibility testing was performed by subjecting the isolates to kirby-bauer disk diffusion and vitek methods with antibiotic panel of ceftriaxone-sulbactam-edta (cse). results: with a total of n=278 isolates, 74 were obtained from tracheal and the remaining 204 being blood and urine, collected from both inpatients and outpatients during the study period of 9 months from april 2022 to december 2022. out of total clinical isolates, 82.3% (229/278) were gram-negative mdr, while remaining 17.6 % (49/278) were found to be non-mdr gram negative ones. a major contribution 57.55% (160/278) of mdr species came from blood and urinary samples. acinetobacter spp. and escherichia coli were the most predominant gram-negative pathogens comprising 43.2% and 74.4% of tracheal and blood urinary isolates respectively cse susceptibility results: among tracheal isolates most of them were multidrug resistant (mdr) species, acinetobacter 43.24 % (32/74) was most commonly detected, followed by klebsiella 29.74 % (22/74), e. coli 16.21% (12/74), pseudomonas 5.40 (4/74) and others 5.40% (4/74). fig.1 tracheal isolates susceptiblity organism wise isolated bacteria (mdr & nonmdr) total isolates (tracheal) susceptible to cse, n/n (%) acinetobacter spp. 32 20/32 (62) klebsiella spp. 22 9/22 (40) e.coli 4 1/4 (25) supplementary issue:02 152 table. 1 susceptibility of tracheal isolates to cse only 52.6 % (38/74) isolates including both mdr and non-mdr were susceptible to cse. however, there is a high degree of resistance in half of isolates. fig.2 tracheal isolates overall e.coli 78.43% (160/204) is the most common isolate among urinary samples, followed by klebsiella 17.15% (35/204) and proteus 3.43% (7/204). a total 78.43% (160/204) of isolates came out to be mdr with 67.5% (108/160) of them were susceptible to cse. pseudomonas spp. 4 1/4 (25) others 4 2/4 (50) supplementary issue:02 153 fig.3 blood urinary isolates susceptibility organism wise isolated bacteria ( mdr & non-mdr ) total isolates (blood & urine) susceptible to cse, n/n (%) e.coli 160 27/160 (16.8) klebsiella spp. 35 15/35 (42.8) proteus spp. 7 0/7 (0) table. 2 susceptibility of blood and urinary isolates to cse a peculiar finding showed that all non-mdr 20% (44/204) isolated from blood and urinary samples were cse susceptible. fig.5 blood urinary isolates supplementary issue:02 154 during the study period, 82.3% (229/278) and 17.6% (49/278) of mdr and non-mdr gram negative isolates were detected respectively. fig.6 total clinical isolates (both tracheal and urinary among the total isolates 51% of mdr and 95% of non-mdr were found to be susceptible to ceftriaxone-sulbactam-edta. (a) mdr (b) non-mdr fig.7 total bacterial isolates discussion: extended-spectrum beta-lactamase and mbl producers have rendered most of the beta-lactam antibiotics [12], which are the most widely prescribed ones in both community and nosocomial infections. use of these agents for a long duration has however resulted in a dramatic increase in the rates of resistance that now threatens the utility of most of the large drug family [13]. meropenem, tigecycline and colistin are the last remaining resorts and there are chances they may become ineffective in near time as increasing carbapenem resistance among gram-negative bacteria has been documented greatly in recent year [14]. the need of hour is to combat increased antimicrobial resistance by using proper combination of including beta-lactam and beta lactamase inhibitors (bl+bli). this study retrospectically documents clinical isolate’s susceptiblity to aae supplementary issue:02 155 of ceftriaxone-sulbactum-edta which has given some promising results as depicted in study by chaudhary et al., which shows ceftriaxone + sulbactam in the ratio of 2:1 along with edta disodium (3 mg/ml) (cse1034) lowered mic to >8 fold and possessed synergy against the most esbl-producing microorganisms. cse is an effective against mdr pathogen producing esbls, mbls like ndm-01 and prevents “transfer of resistant plasmid” and hence the spread of resistance is controlled [15]. furthermore, studies have shown that ceftriaxone-sulbactam-edta combination is a promising therapeutic option as carbapenem sparer in cases of infections caused by esbl and mbl producing pathogens, respectively [16,17,18,19]. conclusion. present study shows that in-vitro susceptibility to cse varies from 51% to 95% depending on the gram-negative organism. preliminary data suggest mdr being more susceptible to cse as compared to non-mdr. a trend of increasing resistance in multidrug-resistant (mdr) organisms is being reported across all isolates thus judicious use with antibiotic stewardship is required while prescribing cse. ceftriaxone-sulbactam-edta fixed dose combination may be a promising therapeutic option in cases of infections caused by mdr (especially esbl and mbl producing pathogens) acting as carbapenem-sparing antibiotics further evaluation and more study is required. supplementary issue:02 156 references 1. chaudhry d, prajapat b. intensive care unit bugs in india: how do they differ from the western world? j assoc chest phys 2017;5:10-7 2. gandra s, barter dm, laxminarayan r. economic burden of antibiotic resistance: how much do we really know? clin microbiol infect 2014;20:973-80. 3. zimlichman e, henderson d, tamir o, franz c, song p, yamin ck, et al. health careassociated infections: a meta-analysis of costs and financial impact on the us health care system. jama intern med 2013;173:2039-46. 4. chaudhary m, payasi a (2013) rising antimicrobial resistance of pseudomonas aeruginosa isolated from clinical specimens in india. j proteomics bioinform 6:005-009. 5. manu c, anurag p (2012) prospective study for antimicrobial susceptibility of escherichia coli isolated from various clinical specimens in india. j microb biochem technol 4: 157-160. doi:10.4172/1948-5948.1000088 6. chaudhary m, payasi a (2012) molecular characterization and antimicrobial susceptibility study of acinetobacter baumannii clinical isolates from middle east, african and indian patients j proteomics bioinform 5: 265-269. 7. singh, s., sahu, c., patel, s. s., singh, a., & yaduvanshi, n. (2020). a comparative in vitro sensitivity study of "ceftriaxone-sulbactam-edta" and various antibiotics against gram-negative bacterial isolates from intensive care unit. indian journal of critical care medicine : peer-reviewed, official publication of indian society of critical care medicine, 24(12), 1213–1217. https://doi.org/10.5005/jp-journals-10071-23573 8. chaudhary m, payasi a. a randomidez, open label prospective, multicenter phase-iii clinical trial of elores in lower respiratory tract and urinary tract infections. j pharm res. 2013a;6:409–14. 9. chaudhary m, payasi a. clinical, microbial efficacy and tolerability of elores, a novel antibiotic adjuvant entity in esbl producing pathogens: prospective randomized controlled clinical trial. j pharm res. 2013b;6:275–80. 10. magiorakos ap, srinivasan a, carey rb, carmeli y, falagas me, giske cg, harbarth s, hindler jf, kahlmeter g, olsson-liljequist b, paterson dl, rice lb, stelling j, struelens mj, vatopoulos a, weber jt, monnet dl. multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard supplementary issue:02 157 definitions for acquired resistance. clin microbiol infect. 2012 mar;18(3):268-81. doi: 10.1111/j.1469-0691.2011.03570.x. epub 2011 jul 27. pmid: 21793988. 11. clinical and laboratory standards institute. performance standards for antimicrobial susceptibility testing; clsi document m100-s23. 12. singh, s., sahu, c., patel, s. s., singh, a., & yaduvanshi, n. (2020). a comparative in vitro sensitivity study of "ceftriaxone-sulbactam-edta" and various antibiotics against gram-negative bacterial isolates from intensive care unit. indian journal of critical care medicine : peer-reviewed, official publication of indian society of critical care medicine, 24(12), 1213–1217. https://doi.org/10.5005/jp-journals-10071-23573 13. shameem, m., & mir, m. a. (2016). management of pneumonia and blood stream infections with new antibiotic adjuvant entity (ceftriaxone + sulbactam + disodium edetate)a novel way to spare carbapenems. journal of clinical and diagnostic research : jcdr, 10(12), lc23–lc27. https://doi.org/10.7860/jcdr/2016/20904.9014 14. singh, s., sahu, c., patel, s. s., singh, a., & yaduvanshi, n. (2020). a comparative in vitro sensitivity study of "ceftriaxone-sulbactam-edta" and various antibiotics against gram-negative bacterial isolates from intensive care unit. indian journal of critical care medicine : peer-reviewed, official publication of indian society of critical care medicine, 24(12), 1213–1217. https://doi.org/10.5005/jp-journals-10071-23573 15. chaudhary m, sudaroli m, kumar s, krishnaraju v. catering esbl resistance challenge through strategic combination of ceftriaxone, sulbactam and ethylene diamine tetraacetic acid. int j drug dev res. 2012;4(1):72–81. 16. attili vs, chaudhary m. pharmacokinetics and pharmacodynamics of elores in complicated urinary tract infections caused by extended spectrum beta-lacatamase strains. int j pharm sci res 2014;6:2569-78. 17. patil un, jambulingappa kl. a combination strategy of ceftriaxone, sulbactam and disodium edetate for the treatment of multi-drug resistant (mdr) septicaemia: a retrospective, observational study in indian tertiary care hospital. j clin diagn res 2015;9:fc29-32. 18. bhatia p. alternative empiric therapy to carbapenems in management of drug resistant gram negative pathogens: a new way to spare carbapenems. res j infect dis 2015;3:2. supplementary issue:02 158 19. bhatia p. alternative empiric therapy to carbapenems in management of drug resistant gram negative pathogens: a new way to spare carbapenems. res j infect dis 2015;3:2. international journal of human and health sciences vol. 05 no. 04 october’21 412 original article improving the safety of hospital complexes in modern conditions vaulin vladimir ivanovich1, singeev sergey aleksandrovich1 abstract background: the article presents the results of a study of ensuring fire safety in medical and preventive institutions (lpi) on the example of the central city hospital. objectives: research is aimed at improving the fire safety of hospital complexes and hospitals in modern conditions. materials and methods: the study used the methods of system analysis of scientific research and statistical data on ensuring fire safety, methods of structural analysis of the practice of ensuring fire safety of hospital complexes, mathematical methods for calculating the evacuation of people from a building and the spread of a fire in a building, methods for calculating the economic efficiency of means of support fire safety. results and discussion: based on the analysis of fire statistics in healthcare facilities in russia, it is concluded that it is advisable to improve the fire safety of hospitals and hospital complexes in modern conditions. the point of view is expressed that along with the fact that fire safety in hospitals is observed, the analysis indicates the existing problems in the practice of implementation. conclusion: in order to increase the level of fire safety, it is possible to introduce: a modern fire alarm system; video of control systems and monitoring of safety of objects on the territory of the medical facility; installation of automatic fire extinguishing systems in fire-hazardous premises; installation of additional emergency lighting and reflectors indicating the direction of evacuation in case of fire and smoke; carrying out organizational and practical measures to ensure the safety of patients in a medical institution in an emergency situation (es), namely, it is proposed to develop a memo of actions for patients in the hospital complex on inpatient treatment in case of an emergency with a list in the instruction log; provision of medical facilities with individual rescue equipment and provision of hospitals and hospital complexes with highrise buildings with modern evacuation means. keywords: fire safety system, improving the fire safety of hospitals and hospital complexes in modern conditions, fire alarm system, video control and monitoring system for the safety of facilities, automatic fire extinguishing system in fire-hazardous premises, individual rescue equipment, modern means evacuation. correspondence to: vaulin vladimir ivanovich, department of “engineering disciplines”, branch of fsbei he “samara state technical university” in syzran, russia. international journal of human and health sciences vol. 05 no. 04 october’21 page : 412-417 doi: http://dx.doi.org/10.31344/ijhhs.v5i4.350 introduction. according to the statistics of the ministry of civil defense, emergencies and elimination of consequences of natural disasters of the russian federation for 2012-2016, an average of 140 fires occurred in medical and preventive institutions per year 1. data analysis shows that every 2nd fire in a health facility occurs in stationary facilities. the first cause of fires is the “human factor”. on average, about 3 million people are treated in hospital every day in 8400 hospitals, 1502 polyclinics, 106 clinics of research institutes and universities and other medical institutions in our country, and about 130 thousand patients are treated in day hospitals. up to 250 thousand patients a day in the country are being treated in hospitals in a helpless state for health reasons, add to this figure patients in nursing homes and 1. vaulin vladimir ivanovich 2. singeev sergey aleksandrovich department of “engineering disciplines”, branch of fsbei he “samara state technical university” in syzran, russia. 413 international journal of human and health sciences vol. 05 no. 04 october’21 boarding schools. the main share of fires (58%) falls on medical and preventive institutions (lpu). at the same time, characteristic conditions that contribute to the death of people in fires are: a state of alcoholic intoxication (53%), a state of sleep (18%) and non-transportability of victims (14%). the most common causes of fires at these facilities were: careless handling of fire (30%), violation of the rules for the installation and operation of electrical equipment and household appliances (24%) and carelessness when smoking (16%) 2. these facts are evidence of the relevance of considering the issue of improving fire safety in health care facilities in modern conditions. modern medical facilities are equipped with a large number of complex diagnostic equipment, which increases the risk of fire and fire load on the premises. in operating rooms, in addition to a large amount of electronic equipment, oxygen is also provided, which will accelerate the development of a fire and may lead to an explosion. thus, in all the above cases, a fire can occur in almost any room of the health care facility where people can be located-from wards to utility rooms. therefore, any medical facility is an object of increased fire danger – and this danger is combined with the constant presence of a large number of people. the combination of dangerous factors and fire conditions requires improvement of the fire safety system 3. this approach is the basis for searching for solutions to a scientific problem. materials and methods. experimental method. the study used methods of system analysis research and statistics on fire safety, methods of structural analysis practices ensuring fire safety of hospital complexes, mathematical methods of calculation of evacuation of people from buildings and spread of fire in the building, methods of calculation of economic efficiency of means of maintenance of fire security. results theoretical foundations (theory and calculations). it should be noted that from the point of view of the law, fire safety of medical institutions ensures their work, but there are a number of features that require detailed consideration from the point of view of practice. the analysis of fire safety on the example of the medical institution of the sbu “syzranskaya tsgb” shows that as shown by the calculations, the main building structures meet the requirements of regulatory documents on fire resistance indicators. however, the examination of the internal layout of the hospital buildings has significant drawbacks. since the building of the sbu “syzranskaya tsgb” was designed and built in 1977, it is necessary to improve the fire extinguishing system, evacuation signs, fire evacuation signs, doors with expanded passageways, alarm systems and video surveillance systems that meet modern requirements. the modern fire protection system should no longer be focused on the elimination of the intended focus and should become adaptive. the implementation of this approach is the use of a modular wireless fire extinguishing system that interacts with the heat field of the fire 4. in the domestic industry, several types of wireless fire extinguishing systems are produced: “garant-r” and “trvgarant-r” 5 . it is possible to note the advantages of this alarm system: extinguishing a fire in the initial period is much easier and cheaper; the problem of extinguishing spills of liquids is eliminated; the reliability of the automated fire protection system is significantly increased; the effectiveness of the automatic extinguishing system is monitored. analysis of fire statistics at such facilities indicates that the rapid spread of fire over the area of the building, the average annual damage is quite large. therefore, the possibility of introducing a wireless fire extinguishing system can reduce damage and is economically feasible. we will justify the approach by calculating two options for protecting premises: the first, without bspt, when the object is protected by outdated fire protection equipment; the second option, when there is a bspt to the existing protection. the main performance indicators are: capital investment k1 and к2, rub.; operating expenses c1 and c2, rub. / year; fire damage у1 and у2, rub. / year. analysis of fire statistics for 5 years on 40 existing similar institutions (n=40) that are not equipped with bspt (table 1). table 1: distribution of the number of fires and damage by year 6 years тi number of fires ni damage yi,, thousand rubles 2013 223 (14885340) 3920283 2014 192 (18246565) 347419 2015 171 (22461847) 294012 2016 153 (13418423) 510372 2017 164 (13767378) 513751 2018 211 (15517156) 89231 international journal of human and health sciences vol. 05 no. 04 october’21 414 based on the method of calculating the damage assessment7, the calculation of direct fire damage over six years is: 5675068 тыс.руб./ 1114= 5094 thousand rubles / year (1) calculations also show8 that the average fire damage for building structures is 17.5 thousand rubles., and for equipment 82.5 thousand rubles. thus, y п.э = 0,12 ∙ 17,5 + 0,15 ∙ 82,5 = 14,47 thousand rubles (2) the total average annual damage for the first option will be yi = 5094 + 14.47 = 425,73 thousand rubles / year. (3) calculations of indicators for the second option indicate that the capital investment for the bspt device is approximately k2 = 25 thousand rubles. we will determine the economic effect of the options, in accordance with the standard methodology. we determine the listed costs by options: i var. p1 = y i/cр = yi =19 thousand rubles / year, (4) ii var. p2=k2en+c2+ y2 = 25•0,15+2,825+6,24=12,815 thousand rubles / year. (5) the annual economic effect of using a wireless fire extinguishing system at one facility will be 412.9 thousand rubles, which indicates the feasibility of implementing a new fire extinguishing system. the evacuation system also needs to be improved. for example, “sbuz so syzranskaya tsgb” has 736 round-the-clock beds in 34 profiles, 2 polyclinic therapeutic departments with a capacity of 375 visits per shift, a women’s consultation for 200 visits per shift, a trauma center and oncological department of the clinic, diagnostic, paraclinical and auxiliary units. the hospital staff consists of 1,172 employees, including: 160 doctors, 549 average medical workers, 258 junior doctors, and 205 others. more than 25,000 patients are treated in our hospital’s inpatient beds every year. 85% of them are emergency patients. the obstetric observational department and the neonatal department are equipped with modern equipment purchased after reconstruction and received within the framework of the prp “health”. every year, the maternity hospital accepts about 2500 deliveries9. in the event of a fire, fire extinguishing actions are organized simultaneously with the evacuation of people and the protection of escape routes. calculations indicate that 10 minutes after the fire occurred, the fire reached the walls of the room, will take a rectangular shape: s p2 = a · l 2 = 4 ·10 = 40 m 2 (6) 1. perimeter of a fire in a semicircular development: p p2 = 2( a + l 2) = 2(4+10) = 28 m (7) 1. the growth rate of square fire: v s2 = s p2/ t svr2 = 40/10 = 4 m 2 / min (8) calculations show a high level of danger to the medical facility in the event of a fire. various variants of calculations of smoke in the event of a fire indicate that, depending on the size of the premises and combustible materials, the room can be filled with smoke in the event of a fire from 30 seconds to 4-5 minutes in the corridors. in the event of an evacuation, the emergency exit lights located at a height of more than 2 meters may not be visible. signs located at a height of 1.5 m in a poorly lit corridor may not be visible. at objects with a mass stay of people, the head of the organization ensures the availability of serviceable electric lights at the rate of 1 lamp for 50 people. since patients act independently in case of fire, we suggest using photoluminescent evacuation plans. schemes of this type have the characteristics of the material due to their physical and mechanical properties, allowing you to solve the problem of orientation as effectively as possible, even in complete darkness. they make it easier to evacuate the building at night, as well as in the presence of a dense wall of smoke. every year, more than 25,000 patients are treated in inpatient beds at the syzran central hospital. analysis of training plans for emergency signal with evacuation of patients from the premises of the hospital complex indicates that they are held once a half-year. quantitative analysis of the number of annual treatment of patients in hospitals of medical institutions shows that their number significantly exceeds by 6-8 times the number of hospital beds in the hospital, therefore 2-3% of the contingent of patients undergoing instruction on actions in case of emergency are not included. therefore, it is necessary to organize the development of memos for patients and instructions on fire safety in accordance with current legal acts with a signature about familiarization in the instruction log. the presence of a large number of patients who are not able to leave the hospital complex on their 595,4 405 168175192184200 1 1 = ⋅ ++++ =       = ∑ ∑ = = nt y ó n i i n i i in 415 international journal of human and health sciences vol. 05 no. 04 october’21 own requires improving the means of evacuation of patients (new fire escape systems, external evacuation devices for bedridden patients, training incoming patients). we will calculate the time of evacuation10 from the hospital, provided that the fire occurred in the afternoon and the fire is located on the third floor in one of the wards. the building has 1 (a) main exit and 2 evacuation (b, c). the hospital building is a three-story building of ii degree of fire resistance and has dimensions in terms of 100x50m. the calculations are summarized in table 2. analyzing the results obtained during the calculation, it is possible to formulate a final conclusion that the estimated time of evacuation from exits a, b, and c corresponds to fire safety standards. however, a big problem is providing fire safety for people who are not mobile (people who are unable to move independently – nontransportable), unable to evacuate themselves, the number of which in hospitals reaches dozens of people. these people include weakened elderly citizens, bedridden patients admitted to a hospital ward after surgery, as well as disabled people with musculoskeletal disorders. it is extremely difficult to carry non-mobile people on stretchers (and based on the number of medical staff and their physical capabilities), it is advisable to suggest the use of an individual means of rescue – a travois, an evacuation mattress, an evacuation pad, an evacuation chair. travois-used for evacuation and rescue of disabled people in hospitals and nursing homes by medical staff. they are suitable for rooms and passages with limited dimensions and hard-to-reach places. evacuation travois are stored in a collapsed state and in the event of a fire or other emergency (emergency), they are quickly deployed11. the evacuation mattress is used for emergency evacuation of bedridden patients, including those with a large weight, in case of fire and emergency by medical personnel. movement is performed by sliding on the floor and stairs. the mattress is flexible and not wide, which allows you to evacuate patients through standard doorways, corridors and fire escapes. evacuation substrate – safety, simplicity, economy and efficiency. it is used for emergency evacuation of bedridden patients in case of fire and emergency by medical staff. in case of increased fire, it will be a means of rapid and simple movement of bedridden patients. movement is performed by sliding on the floor and stairs. the mattress does not require lifting the patient, and the nylon material supports have a low degree of resistance, which allows a physically untrained person to transport the patient. the evacuation substrate consists of a single cross-shaped web, has four slings that form two transverse belts for fixing and two slings that form longitudinal traction loops to ensure movement. in the corners diagonally located elastic straps for attaching the substrate to the mattress. on the sides there are four pockets for storing cross belts, with which the patient is fixed on the mattress. the cross belts are connected by buckles with a length adjustment function. evacuation chair-provides easy access to the stairs for people with limited mobility in case of fire and emergency12. the evacuation chair can be easily moved up the stairs. this is important for children with disabilities and people with limited mobility, who can quickly move from their strollers to a chair. it is advisable to provide high-rise hospital complexes with modern means of evacuation. inclined rescue sleeve13. this system can quickly and reliably provide a safe mass evacuation of people from buildings. a special feature is the ease of bringing the device into working condition, which allows you to use it to rescue children, women, the elderly and people with disabilities before the arrival of the rescue service or firefighters. discussion and conclusion scientists have studied various aspects of fire safety: in the works legasov v. a., topol’s’ke n. g., h. h. brushlinskii, a. k. mikeev discusses the creation of a doctrine or concept of fire safety, improve the legal framework for the activities of the fire service; andresearch scientists borodin, d. a., yershova, k., vasiliev v., titkova, v., etc. – are considered fire safety as a specific firetechnical work. rudakov p. g., smirnova o. ya., khartofilakas a. c., kamlet kh. y., krundyshev b. l., stepanov v. k., molotkova e. g. investigated the design of a comfortable and safe living table 2: evacuation time 250 people number of people exit the evacuation time 170 а 5 min 21 sec 40 в 1 min 33 sec 40 с 48 seconds international journal of human and health sciences vol. 05 no. 04 october’21 416 environment for the disabled and elderly. authors: koshmarov yu. a., ryzhov yu. a., dekterev a. a. and others devoted their works to modeling the spread of fire hazards. these developments were used in calculating the spread of the hospital fire model. the works of v.v. kholshchevnikov14, r.n. istratov, v. m. predtechenskiy, d. a. samoshin, e. e. kiriukhantsev, e. t. shurin, a. b. apakov, and others were devoted to modeling the processes of evacuation of people, including the study of evacuation of people with disabilities. the achievements were used in calculations and search for solutions to evacuate patients from a hospital building in the event of an emergency. foreign scientists d. dreidel15 and othersstudied modeling of the spread of fire hazards; a. schadschneider [16], w. klingsch, h. kluepfel, t. kretz, c. rogsch, a. seyfried, e. kuligowsky, d. peacock r. and others – studied modeling of evacuation processes. serebrennikov e. a., chupriyan a. p., kopylov n.p. and others investigated fire safety and modern directions of its improvement17; ivanova l.p., sukhonina m.a., tikhonova n.v.18 considered the issues of fire safety in buildings of medical institutions. these aspects contributed to the definition of measures to improve fire safety in modern conditions. scientists khairil idham ismail, haniza mohd yusof, ahmad faidi mz, basri i. have considered the importance of fatigue management for healthcare workers19. scientific achievements of scientists allowed us to complete the research tasks. conclusion. thus, the analysis of the security system of the gbuz with “tsgb” indicates that the existing system ensures compliance with the requirements of documents. however, practical activities require improvement. in order to improve the level of fire safety possible implementation: advanced alarm systems for fire, video monitoring system and security monitoring facilities on the territory of sbme; the installation of automatic fire suppression systems in fire areas (warehouse, laboratory, canteen, etc.); setup of external devices and evacuation of the sick; the installation of additional emergency lighting and reflectors indicating the direction of evacuation in case of fire and smoke; set individual elements of pointers on the floor covering with reflectors or lyuminestsentnym coating, which will allow you to specify the path of evacuation; conducting organizational and practical measures to ensure the safety of patients of medical institutions in emergency situations, namely, it is proposed to develop a memo of action patients located in a hospital complex for inpatient treatment in case of emergency with the painting in the journal of instruction; provision of health facilities by individual means of salvation (scrapers of various types, evacuation mattresses, evacuation of the substrate, evacuation chairs) and provision of hospitals and hospital complexes, high-rise modern means of evacuation (rescue sloping arms). funding the study was carried out in the absence of funding. conflicts of interest “the authors state that there is no conflict of interest.” ethical purity: during the development of the article, copyright is not violated. the article in this version has not been published in magazines. authors’ contribution: in the course of work on the article, the author vaulin vladimir ivanovich prepared the idea of the study, reviewed the statistical materials, clarified the calculations, made conclusions, and completed the design of the article. the author of the article singeev sergey aleksandrovich checked the calculations, clarified the authors of the discourse, and detailed the conclusions. in general, the authors jointly checked the quality of the article. 417 international journal of human and health sciences vol. 05 no. 04 october’21 1. distribution of the number of fires in cities of the russian federation for 2012-2016 by main types of fire objects. fires and fire safety in 2016: statistical compendium. under the general editorship of d.m. gordienko. moscow: vniipo, 2017, 124 p.: il. 40 (in russian) 2. available at: wiki-fire.org statistics-fires-rf-2017. ashx. (in russian) 3. article 3. the system of fire safety. on fire safety (as amended on october 30, 2018) russian federation federal law on fire safety of december 21, 1994 n 69-fz (as amended on october 30, 2018). adopted by the state duma on november 18, 1994. (in russian) 4. fire safety in healthcare institutions. type of work: diploma (wrc). available at: published: 201205-10 source: https://www.bibliofond.ru/view. aspx?id=563773 © bibliofond appeal 11.02.20 (in russian) 5. the matsuk a. m., wireless fire extinguishing systems. published: journal “security systems” no. 4, 2010. available at: source: https://os-info. ru/pojarotuschenie/besprovodnye-sisntemy -pozha rotuschenya. appeal 11.02.20 (in russian) 6. fires and fire safety in 2018: statistical compendium. under the general editorship of d. m. gordienko. m.: vniipo, 2019, 125 p.: ill. 42. (in russian) 7. unified interdepartmental methodology for assessing damage from man-made, natural and terrorist emergencies, as well as classification and accounting of emergencies. moscow: federal state research institute of state emergency situations (fcs), 2004. (in russian) 8. calculation and graphic task for the discipline: “economics of fire protection”. belgorod: belgorod state technological university named after v.g. shukhov, 2018. available at: source: http://kit.bstu. ru/research_activities appeal 11.02.20 (in russian) 9. kuzina e.v. fire safety system of the medical center //final qualifying work. syzran: samstu sf, 2018; 34. (in russian) 10. morozov r.v. model and methods of intellectual support for management decisions on fire safety of buildings in the sphere of education// diss. cand. tech. sci. krasnoyarsk, federal state budgetary institution of science institute of computational modeling of the siberian branch of the russian academy of sciences, 2015; 157. (in russian) 11. evacuation mattresses and evacuation of the substrate (scraper). available at: posted: http:// www.spiderrescue.ru/evakuacionnye-matrasy-ievakuacionnye-podlozhki-volokushi.html appeal: 11.04.2020 (in russian) 12. evacuation of people with disabilities in case of fire and emergency. available at: posted: https:// www.secuteck.ru/articles/ehvakuaciya-lyudej-sogranichennymi-vozmozhnostyami-pri-pozhare-i-chs . appeal: 11.04.2020 (in russian) 13. inclined rescue sleeve (ladder, chute, ramp) euroace-r. available at: posted: http://www. spiderrescue.ru/naklonnyj-spasatelnyj-rukav-trapzhelob-skat-euroace-r.html appeal: 11.04.2020 (in russian) 14. kholshchevnikov in.in., evacuation of people with physical disabilities. / kholshchevnikov in in.,the samoshin, etc.a.,istratov p.n. // the internet-the magazine “technosphere safety technologies”, 2012; 3: 1-9. (in russian) 15. drayedel, d. introduction to the dynamics of fires [text] / d. drayedel, translated from the english by k.g. bromstein, edited by yu. a. koshmarov, v. e. makarova. moscow: stroizdat, 1990; 424. (in russian) 16. schadschneider, a evacuation dynamics: empirical results, modeling and applications / a. schadschneider, w. klingsch, h. kluepfel, t. kretz, c. rogsch, a. seyfried // encyclopedia of complexity and systems science, 2009; 3142-3176. (in russian) 17. fire safety and modern directions of its improvement [text ] / e.a. pieces of silver, and. p. chupriyan, n.p. kopylov et al.; ed . yu .l . vorobyova / / vniipo. moscow, 2004. 187 p. 18. ivanova l.p., sukhonina m.a., tikhonova n.v. some questions of fire safety in buildings of medical institutions. security algorithm №3, 2017; 52-55. (in russian) 19. khairil idham ismail, hanizah mohd yusof, ahmad faidhi m.z., basri, i. the importance of fatigue management for healthcare workers from islamic perspective/ international journal of human and health sciences. supplementary issue: 2019. № 2523692х. doi: http://dx.doi.org/10.31344/ijhhs.v0i0.155 references: supplementary issue:02 188 a six-year ictc based study on the sociodemographic profile of the hiv infected individuals in north-west region of india. nusrat perween1, hiba sami2, meher rizvi3, parvez a khan2, adil raza2, nazish fatima2, haris m khan2 1department of microbiology, gmch, bettiah 2 department of microbiology, jnmch, amu, aligarh, 3 department of microbiology and immunology, college of medicine and health sciences, sultan qaboos university hospital, muscat, oman correspondence: dr. nusrat perween, senior resident, department of microbiology, jnmch, amu emailnusratzafar60@gmail.com abstract introductionit is well recognized that, if left untreated hiv progresses through several stages due to the progression in immunosuppression. the level of immunosuppression is linked directly to the cd4+ t-lymphocyte count as well as to acquisition of opportunistic infections. the data generated in the integrated counselling and testing centre (ictc) provides a valuable information pertaining to the demographic epidemiology and clinical profile of the hiv positive patients of that particular region. in this study, we analysed the sociodemographic and clinical profiles of the attendees at the ictc of a tertiary care hospital over a period of 6 years. material and methodsthis study included 1205 hiv positive patients who attended ictc either voluntarily or after being referred by various departments and being tested for their hiv serostatus since january 2014 to december 2019 in the ictc, jnmch, aligarh, u.p. resultsout of the 32680 attendees, the total hiv positives were 1205 (3.68%), out of which 61.3% were males and 38.4% were females. majority of the patients (755/1205), belonged to the age group of 20-39 yrs. the pattern of risk behaviour showed that a large percentage (59.9%) of hiv positive patients had a sexual mode of transmission. most of the hiv positive patients presented with fever (47.4%), weight loss (46.5%), cough (15.4%), diarrhoea and oral ulcer (8.8%), coinfection of tb (6.8%) whereas 14.4% were asymptomatic. in the pre art monitoring, most of the patients (498; 41.3%) had a cd4 count <200 whereas after 6 months of art the number of hiv positive patient with cd< 200 decreased to 324; 26.8%. 128 (10.6%) patients died while on art treatment. majority (72%) of the patients with unfavourable outcome belonged to who stage 3 and 4. conclusionmost of the patients were young and in the sexually active age group. this disease not only results in financial loss to the family but also adds an extra burden of taking the treatment lifelong. the ictc programme is playing an important role in early diagnosis of hiv and connecting the patients to art facilities. keywords: hiv, ictc, socio-demographic profile, aids, art. mailto:email-%20nusratzafar60@gmail.com supplementary issue:02 189 introduction aids is a chronic immune system disease caused by the human immunodeficiency virus (hiv). hiv targets the immune system and impairs the function of immune cells. infected individuals, if left untreated or are non-compliant, are lost to follow up gradually become immunodeficient and succumb to various opportunistic infections such as tuberculosis, fungal infections, severe bacterial infections and some cancers. according to the recommendations of world health organisation (who), every person who may be at risk should seek comprehensive and effective hiv prevention, testing and treatment services (1). people who are diagnosed with hiv should be offered art (antiretroviral treatment) and referred to art centres as soon as possible and should be monitored periodically using clinical and laboratory parameters, including tests to measure the viral load and cd4 count (before and after the start of art) (2). according to the who 2021 report, there were approximately 38.4 million people living with hiv/ acquired immunodeficiency syndrome (aids) worldwide and 6,50,000 people even died from hiv related causes (1). about 28.7 million people living with hiv/aids were receiving antiretroviral therapy (art) globally till 2021. in india, the number of people living with hiv (plhiv) is estimated at around 24 lakhs and the aids-related deaths (ard) are estimated as 41,970 in 2021 (1). annual new infections (ani) are estimated as 62,970 in 2021. there is an estimated 46.3% decline in ani at the national level from 2010-2021 (3). the northeast region states have the highest adult hiv prevalence (2.70% in mizoram, 1.36% in nagaland, and 1.05% in manipur) followed by southern states (0.67% in andhra pradesh, 0.47% in telangana, and 0.46% in karnataka) (3,4). it is cause for concern that that only 10 to 20% of those infected with hiv know that they are infected, which considerably impedes treatment and prevention efforts (5). to cope up with these challenges, new models of care and cost-effective health care delivery systems are needed with a better understanding of hiv/aids epidemiology in a particular region especially with regards to various sociodemographic factors, level of awareness as well as pattern of risk behaviours of the population. the most effective approaches available are generating awareness and modifying lifestyles. the integrated counselling and testing centre (ictc) is an excellent programme where people are offered an opportunity to be confidentially imparted with appropriate knowledge and awareness about hiv and to come to terms with their sero-status in a mature manner and proceed to responsible management of the disease (6). the data generated in the integrated counselling https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/hiv/treatment https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/hiv/strategic-information/person-centered-hiv-patient-monitoring supplementary issue:02 190 and testing centre (ictc) provides valuable information pertaining to the demographic epidemiology and clinical profile of the hiv positive patients of that particular region. in this study, we analysed the sociodemographic and clinical profiles of the attendees at the ictc of a tertiary care hospital over a period of 6 years. material and methods the present study was focused the attendees of ictc, in the department of microbiology, jawaharlal nehru medical college and hospital, amu, aligarh (u.p.) to develop an insight of the trends in this group of patients over the last six years. ethical approval was obtained prior to the study. this study included 1205 hiv positive patients who attended either voluntarily or after being referred by various departments and being tested for their hiv serostatus from january 2014 to december 2019 in the ictc centre of jnmch, aligarh, u.p. anonymous information about all the attendees of the ictc was available from the records which were maintained at the ictc. information pertaining to age, sex, occupation, the pattern of risky behavioural pattern, the place of residence and the hiv serostatus of the attendees was collected while maintaining confidentiality. the guidelines of naco were followed strictly. the counsellor of the ictc interviewed the attendees under strict confidentiality. all the attendees were tested after obtaining their consent following the standard naco guidelines (7). relevant data of all the hiv positive individuals during the study period was compiled and analysed by using standard statistical methods. results out of the 32680 attendees, the total hiv positives were 1205 (3.68%) during the six-year period. a declining trend in hiv positivity was observed over the last six years. in 2014, it was 4.54% while by 2019, it had declined 2.16%, with peaks in 2015, 5.48 and 4.4 in 2017) as can be seen in figure 1. among the hiv positive patients, 61.3% were males, and 38.4% were females and 0.24% were transgenders. overall, male predominance was found with male, female and transgender ratio of 1.59: 0.62: 0.002. gender-wise distribution of hiv positive individuals is shown in figure 2. majority of the hiv positive patients, 62.6% (755/1205), belonged to the age group of 20-39 years and least (2.4%) belonged to the age group of >60yrs. (table 1). among the seropositive patients, the pattern of risk behaviour (table 2) showed that a large percentage of 59.9% (722) had a heterosupplementary issue:02 191 sexual mode of transmission. among the other mode of transmission were blood transfusion; 118 (9.79%), vertical transmission; 68 (5.64%), intravenous drug abusers; 60 (4.97%), homosexuals 7 (0.58%) and needle stick injury; 3 (0.24%). most of the hiv positive patients presented with fever (47.3%), weight loss (46.5%), cough (15.4%), diarrhoea and oral ulcer (8.8%), coinfection of tb (6.8%) whereas 14.4% were asymptomatic (figure 3). during the pre art monitoring, most of the patients (41.3%) had cd4 count <200; 20.7% had counts ranging between 200-349; 12.3% had a count range of 350-500 and only 9% of hiv positive patients had a count > 500 (table 3) while during post art monitoring, it was found that 26.9% had a cd4 count of <200; 22.5% patients had count in the range of 200-349; 17.1% patients had count ranging between 350-500 and 16.9% had cd4 count >500. 128 (10.6%) patients died while on art treatment. majority (72%) of the patients with unfavourable outcome belonged to who stage 3 and 4. figure 1: year wise trends of hiv prevalence at ictc centre during the study period (2014-2019) 4.54 5.48 4.08 4.4 2.67 2.6 0 1 2 3 4 5 6 2013 2014 2015 2016 2017 2018 2019 2020 hiv positivity (%) supplementary issue:02 192 fig 2: gender distribution of hiv positive patients (n=1205) table 1: distribution of hiv positive patients according to their age group age groups no. of patients (%) 0-19 108 (8.9) 20-39 755 (62.6) 40-59 313 (25.9) >60 29 (2.4) table 2: routes of transmission of hiv among the study population males, 739 females, 463 transgender, 3 total, 1205 males females transgender total route of transmission no. of patients (%) sexual intercourse 722(59.9) blood transfusion 118(9.79) parent to child transmission 68(5.64) intravenous drug abuse 60(4.97) homosexuality 7(0.58) needle stick injury 3(0.24) supplementary issue:02 193 figure 3: clinical features in hiv positive patients (n=1205) table 3: pre and post art cd4 count of hiv positive patients cd4 range pre art cd4 count post 6 months art cd4 count <200 498 324 200-349 250 271 350-500 148 206 >500 109 204 discussion with no vaccine available till date, early detection and counselling are the mainstay for the control of hiv. this study describes the socio-epidemiologic profile, risk factors, trends in hiv and pre and post art cd4 count. the estimated prevalence of hiv in 2019 was 2.6% while overall it was 3.68% which is lower compared to the current national hiv prevalence in india (8). male patients outnumbered the female patients, a finding which is similar to other studies (9). majority of the hiv positive patients in this study were within the age-group of 20-39 years (63%). the prevalence of hiv in 0-19 years age group was 8.9% which is comparable to the national prevalence of hiv in children and young adults (3% and 7% respectively) according to naco technical report (8). trends of hiv prevalence at our ictc centre during 2014 to 2019 showed an initial increase in hiv proportion from 4.54% (2014) to 5.48% (2015) followed by a decline in proportion from 4571 561 186 174 106 106 82 36 0 100 200 300 400 500 600 supplementary issue:02 194 4.4% (2016-2017) to 2.6% (2018-2019). other studies analysing the trend of hiv prevalence in north india have also reported a decline in hiv prevalence from the year 2010 to 2014 (2) and year 2011 to 2015 (3) respectively. such steadily falling seropositivity rates is an encouraging sign. ictcs play an important role in prevention and care as they increase awareness about hiv and help in decreasing associated stigma. moreover, the well-functioning national aids control programme is also playing an important role by increasing awareness about the disease aetiology and preventive measures. in the present study, male patients (61.3%) far outnumbered the female (38.4%) patients. similar gender prevalence has also been reported from south india (10) and punjab (11). the male-tofemale ratio of hiv patients in a given population may be associated with the medical seeking habits (negligence in females), gender bias, and the level of stigma of hiv among women. though in this study males outnumbered females, it’s a cause of concern as females are at high risk because of the high-risk behaviour of their male partners. in the present study, the most common mode of transmission of hiv was through the heterosexual route (59.9%), followed by blood transfusion (9.79%) and third was parent to child transmission (5.64%.). intravenous drug abuse, homosexual and needle stick injuries were among the other mode of transmission. heterosexual mode has been reported as the commonest mode of transmission of hiv not only in india (9,12,13) but also throughout south asia (14). it may be considered a tragic systems failure that as high as 9.79% transmission is by blood transfusion and 5.64% from parent to child. both these are avoidable and greater stress should be placed on accurate testing of blood prior to transfusion and mandatory testing of pregnant women and optimal treatment of mother and child. in the present study, fever (47.3%), weight loss (46.5%) and cough (15.4%) were the three predominant complaints. our findings are comparable with earlier studies from maharashtra, mangalore and ethiopia (15–17). the second most frequent presenting symptom was weight loss (35.1%), which is consistent with other studies (16,18,19). 14.4% of hiv positive patients in this study were asymptomatic. in studies conducted by umesh et al (20), (7.0%) and kaiser ahmed wani et al (18) in kashmir (18.0%), asymptomatic individuals were found in the same proportions as in the present study. co-infection of tb was found in 6.8% of hiv positive individuals. pulmonary tuberculosis is the most prevalent opportunistic infection among hiv-positive supplementary issue:02 195 individuals in india (15,21). plhiv are more vulnerable to developing new tb or experience a reactivation of latent infection d due to low level of immunity. different parts of india have reportedly varying rates of co-infection with hiv and tb. it is reported to range from 0.4 to 20.1% in north india (22,23). the prevalence of coinfection in this study was in the range as reported by others in north india. most of the patients in this study had cd4 count < 200 cells/mm3 at the time of diagnosis. very few patients had cd4 count of more than 500 cells/mm3 at the time of diagnosis but this number increased significantly after 6 months of art treatment. the reason for this low cd4 count at presentation may be attributed to late seeking of medical care which allowed the disease to advance. according to a study conducted in ethiopia, the main obstacles to early presentation for hiv/aids care included low awareness, nondisclosure, perceived art side effects, and hiv stigma (24). patients with a decline in cd4 count even after art treatment should get tested for viral loads and antiviral resistance. low cd4 count even on art may be caused by non-adherence to treatment, lack of family support, medicine shortage, or drug toxicity. 10.6% patients in this study died while on art treatment. majority (72%) of these patients belonged to who stage 3 and 4. who (1) states that even after beginning art, people with advanced hiv disease (who stage 3 and 4) are at significant risk of death and this risk rises as their cd4 cell counts drop. conclusion most of the patients in this study were young and in the sexually active age group. this disease not only results in financial loss to the family but also adds an extra burden of lifelong treatment. low baseline cd4 count at the beginning of an art regimen was linked to higher mortality. the ictc programme is playing an important role in early diagnosis of hiv and connecting the patients to art facilities. acknowledgement: we acknowledge the support of mr. syed masood ali in data compilation. references 1. hiv [internet]. [cited 2023 jan 8]. available from: https://www.who.int/news-room/factsheets/detail/hiv-aids 2. national aids control organisation: antiretroviral therapy guidelines for hiv-infected adults and adolescents may 2013. supplementary issue:02 196 [http://www.naco.gov.in/upload/policies%20&amp;%20guidelines/antiretroviral%20therapy% 20guidelines%20for%20hiv-infected%20adults%20and%20adolescents.pdf]. 3. practitioner ti. 24 lakh hiv positive people in india: 2022 [internet]. the indian practitioner. 2022 [cited 2023 jan 8]. available from: https://theindianpractitioner.com/24-lakhhiv-positive-people-in-india-2022/ 4. kesri m. india on its way to end aids epidemic [internet]. the daily guardian. 2022 [cited 2023 jan 8]. available from: https://thedailyguardian.com/india-on-its-way-to-end-aidsepidemic/ 5. steinbrook r. hiv in india--a complex epidemic. n engl j med. 2007 mar 15;356(11):1089–93. 6. patra g, chakrabarti s. avian diversity in and around digha, district—east midnapore (west bengal, india). adv biosci biotechnol. 2014;05(07):596–602. 7. documents | national aids control organization | mohfw | goi [internet]. [cited 2023 jan 8]. available from: http://naco.gov.in/documents 8. national aids control organization & icmr-national institute of medical statistics (2022). india hiv estimates 2021:fact sheet. new delhi: naco, ministry of health and family welfare, government of india. 9. kumawat s, kochar a, sirohi p, garhwal j. socio-demographic and clinical profile of hiv/aids patients in haart era at a tertiary care hospital in north-west rajasthan, india. int j community med public health. 2017 jan 5;3(8):2088–93. 10. balasundaram a, sarkar s, hamide a, lakshminarayanan s. socioepidemiologic profile and treatment-seeking behaviour of hiv/aids patients in a tertiary-care hospital in south india. j health popul nutr. 2014 dec;32(4):587–94. 11. singh a, mahajan s, singh t, deepti ss. socio-demographic and clinical profile of hiv/aids patients attending the art centre of amritsar, punjab. int j community med public health. 2018 apr 24;5(5):2059–65. 12. uma t, srijayanth p, valarmathi s, sekar s, kabilan n, natarajan m. socio-demographic profile of hiv/aids patients at art centres in chennai. bmc infect dis. 2012 may 4;12(1):p53. 13. dandona r, rewari bb, kumar ga, tanwar s, kumar sgp, vishnumolakala vs, et al. survival outcomes for first-line antiretroviral therapy in india’s art program. bmc infect dis. 2016 oct 11;16(1):555. 14. rodrigo c, rajapakse s. current status of hiv/aids in south asia. j glob infect dis. 2009;1(2):93–101. 15. deshpande jd, giri pa, phalke db. clinico-epidemiological profile of hiv patients attending art centre in rural western maharashtra, india. south east asia j public health. 2012;2(2):16–21. supplementary issue:02 197 16. nayak ub, lenka s, achappa b. clinical and socio demographic profile of attendees at art centre in a tertiary care hospital in mangalore, india. asian j med sci. 2015 mar 18;6(5):61– 5. 17. tsega e. the demographic, social and clinical presentations of one hundred ethiopian patients with human immunodeficiency virus (hiv) infection. ethiop med j. 1990 apr;28(2):81– 8. 18. wani ka. clinical profile of hiv/aids patients in srinagar, kashmir, india. public health. 2012;4(9). 19. chakravarty j, mehta h, parekh a, attili svs, agrawal nr, singh sp, et al. study on clinico-epidemiological profile of hiv patients in eastern india. j assoc physicians india. 2006 nov;54:854–7. 20. joge u, deo d, lakde r, choudhari s, malkar v, ughade hh. sociodemographic and clinical profile of hiv/aids patients visiting to art centre at a rural tertiary care hospital in maharashtra state of india. in 2012 [cited 2023 jan 7]. available from: https://www.semanticscholar.org/paper/sociodemographic-and-clinical-profile-of-hiv%2faids-ajoge-deo/12e6b420af0108c057ce17d64a7a1948879bf5cf 21. kumarasamy n, solomon s, flanigan tp, hemalatha r, thyagarajan sp, mayer kh. natural history of human immunodeficiency virus disease in southern india. clin infect dis off publ infect dis soc am. 2003 jan 1;36(1):79–85. 22. journal of the association of physicians of india japi [internet]. [cited 2023 jan 7]. available from: https://www.japi.org/q2948484/prevalence-of-hivtb-co-infection-among-hivpatients-hospital-based-study-from-northern-part-of-india 23. sharma sk, aggarwal g, seth p, saha pk. increasing hiv seropositivity among adult tuberculosis patients in delhi. indian j med res. 2003 jun;117:239–42. 24. abaynew y, deribew a, deribe k. factors associated with late presentation to hiv/aids care in south wollo zoneethiopia: a case-control study. aids res ther. 2011 feb 28;8:8. supplementary issue:02 130 awareness to clinical antimicrobial sensitivity reporting: a questionnaire-based study. anees akhtar1*, asfia sultan1, fatima khan1, shariq wadood khan1, uzma tayyaba1, bhaswati bhattacharya1 1 department of microbiology, jnmch, amu aligarh. *correspondence: dr. anees akhtar, assistant professor, department pf microbiology, jnmch amu draneesakhtaralig@gmail.com abstract: antimicrobial resistance (amr) has emerged as one of the leading public health threats of the 21st century. the clinical microbiology reporting of culture and antimicrobial susceptibility test, if communicated and understood correctly, may lead to effective treatment without increasing the amr burden. this questionnaire-based study was conducted to access the awareness of microbiology reporting and resistance related comments among clinicians. a questionnaire consisting of 10 questions was prepared and circulated among clinicians of different departments to assess the level of awareness to microbiology reporting maintaining their confidentiality, and their responses were recorded manually. 62 (91%) out of 69 clinicians were aware of the remarks written on the microbiology report, and 35 (51%) clinicians were agreed that these remarks were relevant to guide them for antimicrobial prescriptions. when asked about remarks like “mrsa and high content gentamycin and streptomycin sensitivity interpretation”, 34(50%) and 24(35%) responded correctly, respectively. on asking about their action to remarks like “contaminated” and “commensal flora”, 51(73%) clinicians provided the right answer. some direct questions related to avoidance of particular antibiotics as for example use of tigecycline in bacteremia and nitrofurantoin (intrinsic resistance) in cases of proteus spp. 20 (29%) and 42(62%) participants were aware of the standard guidelines respectively, while 29(42%) clinicians responded correctly that in case of ventilator associated pneumonia (vap), intermediate sensitivity colistin should be given inhalationally. there is an urgent need for the microbiology laboratory to incorporate various comments, advices and additional messages. also, there should be a clear communication and case based discussion between clinician and microbiologist. key words: antimicrobial resistance, antimicrobial susceptibility testing, awareness. supplementary issue:02 131 introduction: bacterial antimicrobial resistance (amr)—which occurs when changes in bacteria cause the drugs used to treat infections to become less effective—has emerged as one of the leading public health threats of the 21st century. the review on antimicrobial resistance, commissioned by the uk government, argued that amr could kill 10 million people per year by 2050, and this leads to higher medical costs, prolonged hospital stays, and increased mortality [1]. healthcare providers play an essential role in preventing infections and stopping the spread of drug resistant organism. in most developed countries, one of the most pressing concerns is how to prevent the transmission of infectious diseases within hospitals, either between patients or to medical staff and visitors [2-4]. patients might visit our practice with an infection or can get infections when receiving health care in a facility, so it’s our responsibility to curb the bug before creating disaster. if we are not aware of the standard protocols, guidelines, then of course, we are taking part in worsening the situation either intentionally or unintentionally. the clinical microbiology reporting for culture and antimicrobial susceptibility test is the most important investigation reported from a microbiology laboratory. furthermore there is a wide communication gap between clinicians and microbiologists making the situation more serious. [5] so this study is conducted in the form of questionnaire to increase the awareness to microbiology reporting among clinicians, so that the gaps either communication or ignorance can be filled up with necessary actions that will help to reduce the burden of amr in our set up. materials and methods: a questionnaire of 9 multiple choice questions were prepared and circulated among clinicians of different departments particularly surgery, orthopaedic surgery, gynaecology, oto-rhinolaryngology, medicine and pediatric, tuberculosis and respiratory diseases and intensive care units (icu) from where we received our bulk of samples, to access the level of awareness to microbiology reporting and their understanding related to our comments, maintaining their confidentiality, and their responses were recorded manually. questionnaire attached in annexure ⅰ. results: 62(91%) out of 69 clinicians were aware of the remarks written on the microbiology report while 7(9%) were not though we were not expecting even this much of unawareness. 35 (51%) clinicians were agreed that these remarks were very relevant to guide them for antimicrobial supplementary issue:02 132 prescriptions and they often get benefit from our remarks. when asked about remarks like “mrsa and high content gentamycin and streptomycin sensitivity interpretation”, 34(50%) and 16(23%) responded correctly respectively but 31(46%) response were disappointing they said they will not use vancomycin in cases of mrsa. on asking about their action to remarks like “contaminated”, 51(73%) clinicians provided the right answer that resends the samples, while 6(9%) clinicians said that they usually ignore the report, and 6(9%) clinicians reported that they prescribed other antibiotics from there side without consulting from microbiologists. some direct questions related to avoidance of particular antibiotics as for example use of tigecycline in bacteremia and nitrofurantoin (intrinsic resistance) in cases of proteus spp. 20 (29%) and 42(62%) participants were aware of the standard guidelines respectively, and rest of the clinicians stated about incorrect antibiotics and 5(7%) were given no any answer it was really disappointing to mention that 25(36%) clinicians said that they will repeat the culture or wait for 3 days to see the responses if uti is not responding in case of proteus spp. infection. 29(42%) clinicians responded rightly that in case of ventilator associated pneumonia (vap), intermediate sensitivity colistin should be given inhalationally and 34 (49%) response were wrong they said either intravenous colistin should be given or any other combination can be used along with colistin. do you consider microbiology remark relevant to guide you for prescription? very often 16 (23%) often 35 (51%) sometimes 16 (23%) never 1 (1.5%) for mrsa which of the antimicrobials cannot be prescribed cotrimoxazole 13 (19%) cefepime 34 (51%) vancomycin 18 (26%) didn’t mark 3 (4%) which of the following treatment option has no benefit for high content gentamycin and streptomycin ampicillin+ vancomycin 16 (23%) ampicillin+ gentamycin 24 (35%) vancomycin+ gentamycin 17 (25%) vancomycin+ amikacin 3 (4%) antimicrobials should not be given in bacteremia meropenem 4 (5%) tigecycline 20 (29%) colistin 36 (52%) piperacillin+ tazobactum 3 (4%) uti patient culture positive for proteus spp. not responding to nitrofuratoin your action wait for three days 7 (10%) change the antibiotics 42 (62%) repeat the culture 18 (26%) no answer 1(2%) supplementary issue:02 133 in vap patients with intermediate colistin sensitive, your choice would be iv colistin 15 (22%) inhalational colistin 29 (43%) colistin+ polymyxin-b 18 (26%) colistin+ minocycline 1 (1%) your action when you receive a “contaminated” or “commensal” on reporting. resend sample 51 (73%) & 36 (52%) ignore the report 6 (8%) & 2 (3%) prescribe from their side 6 (9%) & 7 (10%) discuss with microbiologists 6 (9%) & 23 (33%) discussion: in our study, we found the relevance of comments on the microbiology report. about 98.5% of clinicians agreed that they benefited from the comments. so there is an urgent need for the microbiology lab to raise the standards of their clinical microbiology report by adding different comments, suggestions, and added messages. there are different kinds of comments, such as report categories, in-progress reports, filling out a requisition form, collecting a sample, footnotes in the ast table, infection control recommendations, suggestions about antimicrobial agents, comments about predicted susceptibility, and comments about intrinsic resistance. the usage of comments will substantially assist physicians in rationalizing their antimicrobial practice, improvising specimen collection and requisition form-filling procedures, and finally implementing the proper infection control procedures. in this study, we also found a wide communication gap between clinicians and microbiologists. for the interpretation of comments like “cefoxitin is a surrogate marker for mrsa”, [6] the response of 46% of the clinicians was wrong. the probable reason for this could be not giving importance to the comment, and this may lead to the further spread of mrsa as many studies show that mrsa prevalence is increasing and has become a serious concern worldwide, including in india. [7-9] likewise, in another comment, “susceptibility to high content gentamycin and streptomycin”, [6] responses were not very promising, only 23 % of the clinician responded correctly. in indian medical colleges, the majority of medical employees in microbiology departments are engaged in laboratory result reporting, educating medical students, and in certain instances, research. they have limited interaction with clinicians. for addressing these types of problems, regular communications and discussions of clinicians and microbiologists on a case basis are the need of the hour. the microbiology team must do clinical rounds, talk to the clinicians, and give supplementary issue:02 134 advice and suggestions as needed. it will help better clinical training for microbiologists, and better microbiological training for clinicians, in addition to enhancing patient outcomes. it will also support, complement, and augment the role of clinicians by providing improved diagnostics. conclusions: there is an immediate requirement for the microbiology laboratory to incorporate numerous suggestions, recommendations, and additional messages. also, there must be clear communication and case-based discussion between the clinician and the microbiologist. limitation of study: single-centric study and less no of participants. annexure i q1. have you noticed the remarks written on microbiology report, if yes then where is it written on the report? a. upper part of the report b. lower part of the report c. right side of the report d. left side of the report. q2.do you consider these remarks relevant to guide you for antibiotic prescription? a. very often b. often c. sometimes d. never q3. cefoxitin is a surrogate marker for mrsa? for cefoxitin screen positive strains which of the following antimicrobials cannot be prescribed. a. cotrimoxazole b. cefepime c. vancomycin d. linezolid supplementary issue:02 135 q4. susceptibility to high content gentamycin and streptomycin implies existence of synergy between aminoglycosides, penicillin and vancomycin. which of the following treatment option has no benefit for hs and /or hg susceptible isolates? a) ampicillin + vancomycin b) ampicillin + gentamycin c) vancomycin + gentamycin d) vancomycin + amikacin q5. what is your action when you receive a report mentioning “contaminated”. a. resend sample b. ignore the report c. prescribe from your side d. discuss with microbiologist q6.what is your action when we report with a remark that “may be a commensal flora kindly correlate clinically”. a. resend sample b. ignore the report c. prescribe from your side d. discuss with microbiologist q7.which of the given antimicrobial agents should not be given in bacteremia? a. meropenem b. tigecycline c. colistin d. piperacillin –tazobactum q8. what will you do when a uti patient not responding to nitrofurantoin and you get a culture positive for proteus spp? a. wait for 3 days to see response b. change the antibiotics supplementary issue:02 136 c. repeat the culture d. ignore the report. q9. in a ventilator acquired pneumonia patients with intermediate sensitivity to colistin which of the following drugs is preferably given. a. iv colistin b. inhalational colistin c. colistin with polymixin b d. colistin with minocycline references 1. o’neill j. tackling drug-resistant infections globally: final report and recommendations. london: review on antimicrobial resistance, 2016. 2. calfee dp, salgado cd, classen d, arias km, podgorny k, anderson dj, et al. strategies to prevent transmission of methicillin-resistant staphylococcus aureus in acute care hospitals. infect control hosp epidemiol 2008; 29:s62-80. 3. marschall j, mermel la, classen d, arias km, podgorny k, anderson dj, et al. strategies to prevent central line-associated bloodstream infections in acute care hospitals. infect control hosp epidemiol 2008; 29 suppl 1:s22-30. 4. dubberke er, gerding dn, classen d, arias km, podgorny k, anderson dj, et al. strategies to prevent clostridium difficile infections in acute care hospitals. infect control hosp epidemiol 2008; 29:s81-92. 5. brita skodvin, karina aase, anita løvås brekken, esmita charani, paul christoffer lindemann, ingrid smith, addressing the key communication barriers between microbiology laboratories and clinical units: a qualitative study, journal of antimicrobial chemotherapy, volume 72, issue 9, september 2017, pages 2666–2672, https://doi.org/10.1093/jac/dkx163 6. clsi. performance standards for antimicrobial susceptibility testing. 32th ed. clsi standard m100-s29. wayne pa: clinical and laboratory standards institute; 2022. supplementary issue:02 137 7. petersen a, larssen kw, gran fw, enger h, hæggman s, mäkitalo b, haraldsson g, lindholm l, vuopio j, henius ae, nielsen j and larsen ar (2021) increasing incidences and clonal diversity of methicillin-resistant staphylococcus aureus in the nordic countries results from the nordic mrsa surveillance. front. microbiol. 12:668900. doi: 10.3389/fmicb.2021.668900 8. lohan, kirti1; sangwan, jyoti1,; mane, pratibha1; lathwal, sumit2. prevalence pattern of mrsa from a rural medical college of north india: a cause of concern. journal of family medicine and primary care 10(2):p 752-757, february 2021. | doi: 10.4103/jfmpc.jfmpc_1527_20 9. indian network for surveillance of antimicrobial resistance (insar) group, india. methicillin resistant staphylococcus aureus (mrsa) in india: prevalence & susceptibility pattern. indian j med res. 2013;137(2):363-369. supplementary issue:02 106 microbiological profile and antibacterial resistance pattern of gram-negative blood isolates in a tertiary care centre in northern india uzma tayyaba1, isna rafat khan2, zainab yusufali motiwala2, fatima khan1, asfia sultan1*, sadia hassaan1 1. department of microbiology, jn medical college, amu, aligarh 2. jn medical college, amu, aligarh correspondence: dr. asfia sultan assistant professor, department of microbiology, jnmch, amu, aligarh e-mail id: drasfia@gmail.com abstract bloodstream infections (bsis) are one of the most frequent infections and a potentially lethal condition with a case fatality rate of 20–50%. the present study was done to determine the prevalence and antimicrobial resistance pattern of gram-negative bacteria in blood stream infections (bsi) in a tertiary care center in northern india. methodsthis was an observational study of antibiotic susceptibility data of gram-negative bacilli causing blood stream infections. 1939 blood cultures were received in the department of microbiology over a period of 1 year. automated blood culture method was used (bact/alert3d). bacterial identification as well as antibiotic-sensitivity was done using vitek-2 automated systems. resultsout of the 1939 blood cultures received in the microbiology lab, 283 (14.6%) showed positive culture growth, 1136 (58.6%) were sterile and 520 (26.8%) were found to be contaminated. 140 (49.5%) cultures were found positive for gram-negative rods (gnr), 90 (31.8%) for gram-positive cocci and 53 (18.7%) for yeast-like candida. among gnr, klebsiella pneumoniae was the most common (20.1%), followed by escherichia coli (7.7%), actinobacter baumanii (7.4%), salmonella species (5.3%), enterobacter cloacae complex (3.1%), and pseudomonas species (3.1%). most of the klebsiella species were found to be multi-drug resistant mailto:drasfia@gmail.com supplementary issue:02 107 (mdr), with resistance rates observed against ampicillin, ceftriaxone, cefepime, piperacillin+tazobactum, meropenem, ciprofloxacin, amikacin & cotrimaxazole as 57.8%, 57.8%, 42%, 50.8%, 54.3%, 52.6%, 47.3%, & 45.6% respectively. similarly, resistance rates observed for e. coli against same antibiotics were 63.6%, 41%, 50%, 32%, 36%, 59%, 18%, & 50% respectively. conclusionklebsiella pneumoniae was found to be the leading cause of bsi among gnr in our set-up. report of mdr organisms causing bsi is a cause for concern. moreover, 26.8% of the samples were found to be contaminated, which is a high number, demonstrating the need for improved sampling and handling methods. keywords: blood stream infection (bsi), gram-negative bacteria, gnr, klebsiella pneumoniae, multi-drug resistant (mdr) introduction worldwide, infectious diseases continue to rank first in terms of death, morbidity, and disability and extended hospital stays. high infection rates pose a risk to the public's health. gram-negative bacteria are more prevalent in bacteremia and are responsible for 45% of community-acquired infections and 25% of nosocomial infections (1). escherichia coli, pseudomonas, klebsiella, serratia, salmonella, enterobacter, and other common gram-negative bacteria are to blame for bacteremia (2). whereas the three main gram-positive bacterial species that can enter the circulation after an infection are staphylococcus, streptococcus, and enterococcus (3). bloodstream infections (bsis), which are one of the most frequent infections, are a potentially lethal condition with a case fatality rate of 20–50% (4). bsi can be a self-limiting infection or it could be as fatal as sepsis. these are a major global contributor to sepsis-related morbidity and mortality (5). the majority of the antibiotics regularly used to prevent and cure bacterial infections are in danger of losing their effectiveness due to the evolving epidemiology and susceptibility patterns of microorganisms (6). supplementary issue:02 108 multidrug-resistant (mdr) infections have become more prevalent over time in both community and hospital settings in india. globally, antibiotic resistance is a serious issue. bacteria that are resistant to antibiotics result in 23,000 deaths annually. while europeans and americans use 1st or 2nd generation antibiotics, the indian subcontinent uses 3rd or 4th generation antibiotics (7). india is a developing country and it is a hub for emerging infections and the problem of increasing resistance and its changing patterns is serious because it is one of the causes of failure of treatment. the present study was done to evaluate the microbiological profile and antimicrobial resistance pattern of pathogens isolated from the blood samples of the patients from a tertiary care center in north india. methodology this was a retrospective cross-sectional study of antibiotic susceptibility data of gram-negative bacilli causing bloodstream infections. a total of 1939 blood cultures were received in the department of microbiology of jawaharlal nehru medical college and hospital, amu over a period of 1 year. blood samples were collected under strict aseptic precaution before starting antimicrobial therapy and immediately inoculated into bact/alert3d blood culture bottle. for up to 5 days, bottles were incubated in the bact/alert3d (biomérieux) automated system. positive samples identified by the machine were immediately inoculated into 5% sheep blood, macconkey agar, and chocolate agar. standard bacteriological techniques were used to identify bacterial pathogens, and were confirmed by vitek-2 (biomérieux) automated systems. antibioticsensitivity was done using vitek-2 automated system and results were interpretated as per clsi 2022 guidelines (8). the definition of multi-drug resistant (mdr) by cdc is an isolate that is resistant to at least one antibiotic in three or more drug classes (9). as a result, the need for nonsusceptibility to at least three types of antibiotics were chosen as the definition of mdr. results a total of 1939 blood culture samples were received in the enteric lab over a period of 1 year. out of which 283 (14.6%) showed positive culture growth, 1136 (58.6%) were sterile and 520 (26.8%) were found to be contaminated. out of 283 positive cultures 140 (49.5%) were gram-negative rods (gnr), 90 (31.8%) showed growth for gram-positive cocci (gpc) and 53 (18.7%) yeast-like supplementary issue:02 109 candida respectively. among gnr, klebsiella pneumoniae was the most common (57, 20.1%), followed by escherichia coli (22, 7.7%), acinetobacter baumanii (21, 7.4%), salmonella species (15, 5.3%), enterobacter cloacae complex (9, 3.1%), pseudomonas species (9, 3.1%), burkholderia cepacia (4, 1.4%), citrobacter (2, 0.7%) and morganella morgani (1, 0.3%) (figure1). figure 1 depicting the positive culture growths seen in blood cultures samples table1: antibiotic resistant rates of the isolated organisms resistant rates amc n (%) pit n (%) amp n (%) cfz n (%) ctr n (%) cfs n (%) cpm n (%) ipm n (%) mrp n (%) ak n (%) gen n (%) cip n (%) cot n (%) klebsiella species (n=57) 28 (49.1) 29 (50.8) 33 (57.8) 30 (52.6) 33 (57.8) 27 (47.3) 24 (42) 25 (43.8) 31 (54.3) 27 (47.3) 28 (49) 30 (52.6) 26 (45.6) e. coli (n=22) 9 (41) 7 (32) 14 (63.6) 12 (54.5) 9 (41) 5 (22.7) 11 (50) 5 (22.7) 8 (36) 4 (18) 9 (41) 13 (59) 11 (50) acinetobacter baumanii (n=21) 1 (4.7) 11 (52.3) 0 10 (47.6) 11 (52.3) 9 (43) 11 (52.3) 10 (47.6) 12 (57) 10 (47.6) 10 (47.6) 10 (47.6) salmonella species (n=15) 1 (6.6) 1 (6.6) 2 (13.3) 1 (6.6) 3 (20) 1 (6.6) 1 (6.6) 0 3 (20) 6 (40) 7 (46.6) 6 (40) 1 (6.6) pseudomonas species (n=9) 1 1 1 2 0 2 3 3 0 0 gpc 32% yeast like candida 19% klebsiella species 20% acitinobacter 8% salmonella 5% enterobacter 3% pseudomonas 3% e coli 8% gnr 50% gpc yeast like candida klebsiella species acitinobacter salmonella enterobacter pseudomonas burkholderia citrobacter morganella e coli supplementary issue:02 110 enterobacter cloacae (n=9) 5 3 0 4 3 3 4 3 3 3 3 4 3 table abbreviations: amc : amoxicillin + clavulanic acid; pit : piperacillin + tazobactam; amp : ampicillin; cfz : cefoperazone; ctr : ceftriaxone; cfs : cefoperazone + sulbactam; cpm : cefepime; ipm : imipenem; mrp : meropenem; ak: amikacin; gen : gentamicin; cip : ciprofloxacin; cot : co-trimaxazole on antimicrobial susceptibility testing, most of the klebsiella species were found to be multi-drug resistant (mdr), with resistance rates observed against ampicillin, ceftriaxone, cefepime, piperacillin+tazobactum, meropenem, ciprofloxacin, amikacin & cotrimaxazole as 57.8%, 57.8%, 42%, 50.8%, 54.3%, 52.6%, 47.3%, & 45.6% respectively. similarly, resistance rates observed for e. coli against same antibiotics were found to be 63.6%, 41%, 50%, 32%, 36%, 59%, 18%, & 50% respectively. (table) collectively enterobacterales were the dominant group of gnr isolated from blood samples, most of which were found to be mdr. maximum resistance was seen with ciprofloxacin 51.4%. among beta-lactams, maximum resistance was seen with ampicillin 47.5%, followed by ceftriaxone 46.6% and cefpodoxime 45.6%. 40% of them were found to be esbl producers. carbapenems were found to be resistant in 32% (imipenem) and 43.6% (meropenem) of isolates. among aminoglycosides, amikacin was found to be resistant in 39% and gentamicin in 45.6%. fortunately, none of the isolate was found to be resistant with colistin. (figure2) supplementary issue:02 111 figure2: resistance rates in enterobacterales generally, the highest resistance to antimicrobials for gram-negative pathogens were seen towards: ampicillin, ceftriaxone, meropenem, cefuroxime axetil, cefotaxime and ciprofloxacin by klebsiella species with 57.8%, 57.8%, 54.3%, 52.6%, 52.6% and 52.6%, respectively; ampicillin, ciprofloxacin, cefuroxime axetil and cefotaxime by escherichia coli, 63.6%, 59.0%, 54.5% and 54.5%, respectively; meropenem, ceftriaxone, cefepime, piperacillin+tazobactum by acinetobacter species, 57.0%, 52.3%, 52.3% and 52.3% respectively; gentamicin, amikacin, ciprofloxacin and cefuroxime axetil by salmonella species, 46.6%, 40.0%, 40.0% and 26.6% respectively; gentamicin and amikacin by pseudomonas species, 33.33% and 33.33%, respectively; and amoxicillin/ clavulanic acid and cefuroxime axetil by enterobacter species, 55.5% and 55.5%, respectively. moreover, klebsiella species was found to be highly resistant to piperacillin + tazobactum (50.8%), gentamicin (49%), amikacin and cefoperazone (47.3% each); e. coli demonstrated 50.0% resistance against cefepime and trimethoprim each; 47.6% acinetobacter species were resistant to cefotaxime, gentamicin, ciprofloxacin and trimethoprim each; salmonella species to ceftriaxone 41 39 47.5 45.6 46.6 35 39 32 43.6 39 45.6 51.4 40 0 10 20 30 40 50 60 resistant rates in enterobacterales amoxicillin and clavulanic acid piperacillin and tazobactam ampicillin cefpodoxime ceftriaxone ceftazidime cefepime imipenem meropenem amikacin gentamicin ciprofloxacin co-trimaxazole supplementary issue:02 112 and meropenem (20.0% each); and enterobacter species to cefotaxime, cefipime and ciprofloxacin (44.4% each). fortunately, none of the gnr isolated was found to be resistant with colistin, except burkholderia cepacia, where it is intrinsically resistant. discussion the culture positivity rate for the present study was 283 (12.5%) which was higher as compared to the previous studies done in india by rani n et al 8.3% & gohel k et al 9.9% (10,11). although it is quite similar to the positivity rates in nigeria 13.1% (12), and also quite similar to our previous report of 13.6% positivity rate from the same institute in the year 2015 (13). this rate was higher as compared to other studies conducted in countries like jimma & cambodia 8.8% (14), and tanzania 5.6% (15). it was lower than those reported in lebanon 18.6% (16), turkey 21.3% (17), india 22.3% (18), ethiopia 18.2% (19) and 28% (20), zambia 24% (21), dhaka 14.38% (22), zanzibar 14% (23) and pakistan 16% (24). these differences in result could probably be due to variation in sample size, study design, location of study, epidemiological factors, causative agents, number and methods used for blood culture, volume of blood drawn and lack of clinical indication of bsi. total 140/283 (49.5%) cultures were found positive for gram-negative rods (gnr), 90/283 (31.8%) for gram-positive cocci (gpc) and 53/283 (18.7%) for yeast-like candida. similar trend of gnr predominance is depicted by studies from cambodia, cote d’ ivoire, ethiopia and afghanistan (14,25–27). in contrast, gpc predominance was observed in various studies from ethiopia, zambia and usa (19–21,28). the fluctuation in results can be attributed to diversity of causative agents and epidemiological factors. the predominant bacterial isolate among gnr was found to be klebsiella pneumoniae 57 (20.1%). this finding was in agreement with numerous studies previously done in other countries(12,15,23,27,29). similarly in the previous study from our institute klebsiella pneumoniae was the most common isolate (13). this was followed by escherichia coli 22 (7.7%) and acinetobacter baumanii 21 (7.4%). a similar trend of prevalence was observed in ethiopia and usa (26,28). in contrast to this study, a larger proportion of pseudomonas species were supplementary issue:02 113 isolated among other gram negative bacteria in various studies from india and ethiopia (11,18,19). furthermore, different studies from numerous countries had reported salmonella species among the top 3 most isolated gram-negative bacteria in blood isolates (10,14,17,20,21,23). acinetobacter was the most common pathogen isolated causing bsi in a study by khurana s et al., in india (30) and e. coli was found to be the most prevalent organism in a study done by oyekale et al., in a tertiary hospital in nigeria (31), whereas in our scenario e.coli is the second most prevalent organism isolated but klebsiella species was isolated as second most common in the study by khurana s et al. (30). these variations can be attributed to differences in geographic location and infection control policies practiced in various countries. in our study klebsiella species showed the highest resistance towards ampicillin and ceftriaxone (57.8% each), whereas e. coli demonstrated it towards ampicillin (63.6%) and ceftriaxone (41%). study done in india by rani v et al. demonstrated maximum resistance to cefotaxime by klebsiella species and ampicillin by e. coli which is comparable to our study (10). klebsiella species showed least resistance to ticarcillin and ceftriaxone-sulbactam and e. coli to ticarcillin, ceftazdime and levofloxacin. a study conducted by gohel k. et al. highlighted that carbapenems were the most effective agent against klebsiella, while carbapenems and aminoglycosides were most effective agents against e. coli (11). a study done in ethiopia reported that the majority of klebsiella species were resistant to ampicillin, ceftriaxone and amoxicillinclavulanate which is quite close to results of our study (32). the highest resistance shown towards e. coli by the study done in ethiopia and nepal (32,33) is identical to our study. likewise to our study, others also found that most of the gnr causing bsi were multi-drug resistant (mdr) (4,20), with as high as 74.3% of gnr reported as mdr by eshetu et al in 2018 (26). such increasing trend in mdr bacteria causing bsi is a cause of concern as they are associated with poor outcomes, high cost and prolonged hospital stay if not properly and timely treated. some of the limitations of this study include short duration, uni-centric, small sample size and its study design. poor sample collection technique and non-adherance of hospital staff to infection control practices while handling patient’s samples is proven by a lot of contaminated samples and commensals detected, therefore hindering the accuracy of the results. regional surveillance and supplementary issue:02 114 studies, such as ours, should be done from time to time in order to address the looming problem of changing epidemiology of bsi and changing trends in antibiotic resistance patterns. these regional trends and resistance pattern from such localized studies may be extrapolated to study the general population of india. further multi-centric studies for longer duration are needed to study microbiological profile and drug resistance pattern of all blood isolates. this will help in implementing infection prevention and control strategies targeted to reduce blood stream infections. conclusion klebsiella pneumoniae was found to be the leading cause of bsi among gnr in our set-up. report of mdr organisms causing bsi is a cause for concern. the knowledge of microbial profile is crucial for management of bloodstream infections. the antibiotic resistance pattern changes from hospital to hospital in the same country and continuously changes over time therefore antimicrobial resistance patterns will help us better in choosing appropriate drugs for treatment. moreover, 23.0% of the samples were found to be contaminated, which is a high number, demonstrating the need for improved sampling and handling methods. references 1. gaynes r, edwards jr, national nosocomial infections surveillance system. overview of nosocomial infections caused by gram-negative bacilli. clin infect dis. 2005 sep 15;41(6):848– 54. 2. mia ar, zerin t. antibiogram of blood culture isolates of patients from a hospital in dhaka, bangladesh. matrix science medica. 2020 jan 1;4(1):1. 3. rolston kvi, yadegarynia d, kontoyiannis dp, raad ii, ho dh. the spectrum of grampositive bloodstream infections in patients with hematologic malignancies, and the in vitro activity of various quinolones against gram-positive bacteria isolated from cancer patients. int j infect dis. 2006 may;10(3):223–30. supplementary issue:02 115 4. gupta a, sharma s, arora a, gupta a. changing trends of in vitro antimicrobial resistance patterns in blood isolates in a tertiary care hospital over a period of 4 years. indian j med sci. 2010 nov;64(11):485–92. 5. global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the global burden of disease study 2013. the lancet. 2015 jan 10;385(9963):117–71. 6. deasy j. antibiotic resistance: the ongoing challenge for effective drug therapy. jaapa. 2009 mar;22(3):18–22. 7. farooqui hh, selvaraj s, mehta a, heymann dl. community level antibiotic utilization in india and its comparison vis-à-vis european countries: evidence from pharmaceutical sales data. plos one. 2018;13(10):e0204805. 8. m100ed33 | performance standards for antimicrobial susceptibility testing, 33rd edition [internet]. clinical & laboratory standards institute. [cited 2023 mar 27]. available from: https://clsi.org/standards/products/microbiology/documents/m100/ 9. magiorakos ap, srinivasan a, carey rb, carmeli y, falagas me, giske cg, et al. multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. clinical microbiology and infection. 2012 mar 1;18(3):268–81. 10. rani n, gopal k, narendra m, vishwakanth d, nagesh vrd, yogitha m, et al. a retrospective study on blood stream infections and antibiotic susceptibility patterns in a tertiary care teaching hospital. international journal of pharmacy and pharmaceutical sciences. 2012 jan 1;4:543–8. 11. gohel k, jojera a, soni s, gang s, sabnis r, desai m. bacteriological profile and drug resistance patterns of blood culture isolates in a tertiary care nephrourology teaching institute. biomed res int. 2014;2014:153747. 12. nwadioha i, odimayo ms, omotayo j, taiwo ao, olabiyi e. a retrospective cross sectional study of blood culture results in a tertiary hospital, ekiti, nigeria. open journal of medical microbiology. 2015 nov 25;5(4):202–8. supplementary issue:02 116 13. khan f, kirmani s, siddiqui n, sultan a, sami h, rizvi m, et al. cons in blood culture: contaminants or pathogens? 2015;(1). 14. vlieghe er, phe t, smet bd, veng hc, kham c, lim k, et al. bloodstream infection among adults in phnom penh, cambodia: key pathogens and resistance patterns. plos one. 2013 mar 29;8(3):e59775. 15. mahende c, ngasala b, lusingu j, butichi a, lushino p, lemnge m, et al. bloodstream bacterial infection among outpatient children with acute febrile illness in north-eastern tanzania. bmc research notes. 2015 jul 3;8(1):289. 16. kanafani za, dakdouki gk, el-chammas ki, eid s, araj gf, kanj ss. bloodstream infections in febrile neutropenic patients at a tertiary care center in lebanon: a view of the past decade. international journal of infectious diseases. 2007 sep;11(5):450–3. 17. kurtoğlu m, bozkurt h, tuncer o, kesli r, berktas m. distribution, optimum detection time and antimicrobial susceptibility rates of the microorganisms isolated from blood cultures over a 4-year time period in a turkish university hospital and a review of the international literature. j int med res. 2008 dec 1;36(6):1261–72. 18. pal n. microbiological profile and antimicrobial resistant pattern of blood culture isolates, among septicaemia suspected patients. njlm [internet]. 2016 [cited 2023 mar 9]; available from: http://njlm.net/article_fulltext.asp?issn=0973709x&year=2016&month=january&volume=5&issue=1&page=17-21&id=2090 19. dagnew m, yismaw g, gizachew m, gadisa a, abebe t, tadesse t, et al. bacterial profile and antimicrobial susceptibility pattern in septicemia suspected patients attending gondar university hospital, northwest ethiopia. bmc research notes. 2013 jul 22;6(1):283. 20. wasihun ag, wlekidan ln, gebremariam sa, dejene ta, welderufael al, haile td, et al. bacteriological profile and antimicrobial susceptibility patterns of blood culture isolates among febrile patients in mekelle hospital, northern ethiopia. springerplus. 2015 jul 3;4:314. 21. chimese sm, andrews b, lakhi s. the etiology and outcome of adult patients presenting with sepsis to the university teaching hospital, lusaka, zambia. med j zambia. 2012;39(3):19–22. supplementary issue:02 117 22. wahud a, khalil mi, shamsuzzaman akm, islam kms, mondal bb, banda mz, et al. bacteriological profiles of blood culture isolates by bact/alert 3d automated system. journal of shaheed suhrawardy medical college. 2009;1(2):21–6. 23. onken a, said ak, jørstad m, jenum pa, blomberg b. prevalence and antimicrobial resistance of microbes causing bloodstream infections in unguja, zanzibar. plos one. 2015 dec 23;10(12):e0145632. 24. fayyaz m, mirza i, abbasi s, ikram a, hussain a, khan i. pattern of bacterial pathogens and their antimicrobial susceptibility from blood culture specimens in a tertiary care setting. in 2013. 25. akoua-koffi c, tia h, plo jk, monemo p, cissé a, yao c, et al. epidemiology of community-onset bloodstream infections in bouaké, central côte d’ivoire. new microbes new infect. 2015 jul 16;7:100–4. 26. eshetu s, bitew a, tadesse t, abera d, gizaw s. multi-drug resistance profile of bacteria isolated from blood stream infection at tikur anbessa specialized hospital, addis ababa, ethiopia. ec micro. 2018 feb 21;14:119–26. 27. tariq tm. bacteriologic profile and antibiogram of blood culture isolates from a children’s hospital in kabul. j coll physicians surg pak. 2014 jun;24(6):396–9. 28. orsini j, mainardi c, muzylo e, karki n, cohen n, sakoulas g. microbiological profile of organisms causing bloodstream infection in critically ill patients. j clin med res. 2012 dec;4(6):371–7. 29. ballot de, nana t, sriruttan c, cooper pa. bacterial bloodstream infections in neonates in a developing country. international scholarly research notices. 2012 aug 5;2012:e508512. 30. khurana s, bhardwaj n, kumari m, malhotra r, mathur p. prevalence, etiology, and antibiotic resistance profiles of bacterial bloodstream infections in a tertiary care hospital in northern india: a 4-year study. j lab physicians. 2018;10(4):426–31. 31. oyekale ot, ojo bo, olajide at, oyekale oi. bacteriological profile and antibiogram of blood culture isolates from bloodstream infections in a rural tertiary hospital in nigeria. afr j lab med. 2022 aug 24;11(1):1807. supplementary issue:02 118 32. birru m, woldemariam m, manilal a, aklilu a, tsalla t, mitiku a, et al. bacterial profile, antimicrobial susceptibility patterns, and associated factors among bloodstream infection suspected patients attending arba minch general hospital, ethiopia. sci rep. 2021 aug 5;11(1):15882. 33. global. bacteriological profile and antibiotic susceptibility pattern of blood culture isolates from patients visiting janamaitri hospital, balaju, kathmandu, nepal [internet]. [cited 2023 mar 9]. available from: https://globaljournals.org/item/5903-bacteriological-profile-andantibiotic-susceptibility-pattern-of-blood-culture-isolates-from-patients-visiting-janamaitrihospital-balaju-kathmandu-nepal supplementary issue:02 52 etiology of viral hepatitis among acute hepatitis patients at a tertiary care hospital in north india zeeshan mustafa, islam ahmad, hiba sami, syed ghazanfar ali, safiya firoze, adil raza, nazish fatima, haris m khan, department of microbiology, jawaharlal nehru medical college, aligarh correspondence: dr hiba sami assistant professor, department of microbiology, jnmch, amu, aligarh hibasamizafar@gmail.com abstract introduction: viral hepatitis, a significant public health burden, affects millions of individuals worldwide. hav, hbv, hcv, and hcv are primary causative agent for viral hepatitis. large number of outbreaks of hav and hev occurs every year. hbv and hcv are primary cause of chronic liver disease. exploring the etiology and clinic-epidemiological profile of acute viral hepatitis (avh) becomes crucial for planning the preventive measures to control the diseases. methods: this study was conducted at vrdl, department of microbiology, jnmc, amu, aligarh, uttar pradesh, india from january 2018 to october 2022. patients showing symptoms of hepatitis such as jaundice, fever, malaise, headache, nausea, vomiting, anorexia, diarrhoea, and abdominal pain were included in the study. results: out of 1798 patients presenting with acute viral disease, 21.02% (378/1798) had hav, 20.96% (377/1798) had hbv, 9.78% (176/1798) had hcv, and 5.45% (98/1798) had hev. there were 0.5% (09/1798) samples which were positive for both hbv surface antigen and anti-hcv antibodies and 0.3% (06/1798) samples were positive for both anti-hav igm and anti-hev igm. with the exception of hepatitis a, which was more common in children, other viral hepatitis were more common in adults with a male preponderance. conclusions: vaccination, better cleanliness, and appropriate blood screening before blood transfusion are all safety measures that can help to lower the incidence rate of viral hepatitis and stop its spread. regularly identifying the cause of avh and keeping track of cases would aid in patient management and help disease control programs make policy decisions. keywords: avh, viral hepatitis, hav, hbv. supplementary issue:02 53 introduction viral hepatitis is a global public health problem and a serious health issue in developing countries like india. due lack of awareness among people, viral hepatitis is spreading at an alarming rate affecting a large population and causing a large number of deaths are every year. viral hepatitis is caused by any of the four major hepatitis viruses hav, hbv, hcv and hev. as per who 2017 global hepatitis report there are around 1.34 million deaths occurred due to viral hepatitis. india has a high incidence of hav-associated hepatitis (10-30%) and acute liver failure (5-15%). furthermore, hev is responsible for 10-40% of acute hepatitis and 15-45% of acute liver failure [1]. infection with either hepatitis b or hepatitis c can last a lifetime, in 2019, the world health organization estimates that 1.1 million people died from chronic viral hepatitis and its effects, such as liver cancer and cirrhosis [2]. hepatitis-a is a rna virus belongs to family picornaviridae and genus hepatovirus. the majority of children infected with hav are asymptomatic or mildly symptomatic [3]. a person with hepatitis a often experiences sudden onset and characteristic symptoms that include yellowish discoloration of the eyes, fever, nausea, vomiting, dark urine, and jaundice within a few days to a week [4]. hepatitis-b virus (hbv) is a dna virus that belongs to the family hepadnaviridae; it can cause immune-mediated liver diseases of varied severity and duration and is transmitted by contact with infected blood or body fluids [5]. hepatitis c virus is a rna virus of family flaviviridae and genus hepacivirus; it is commonly transmitted through parental routes and by contact with an infected person through blood or body fluids [6]. most individuals with hcv infection present with a silent, insidious onset of disease that persists for a long period. this virus has a high risk of worsening chronic liver disease, which may result in chronic hepatitis, cirrhosis, and occasionally hepatocellular carcinoma [7]. hepatitis-e virus hev is positive stranded rna virus belongs to family hepeviridae of genus hepevirus, hev is transmitted mainly through faeco-oral route [8]. there have been several outbreaks of hev infection in india over the past fifty years. in india, hev infection is a significant contributor to acute and sub-acute liver failure, compared to women who had other kinds of hepatitis, pregnant women with jaundice and acute viral hepatitis of hev genesis had greater death rates and worse obstetric and fetal outcomes [7]. in the present study we investigate the prevalence and pattern of acute viral hepatitis in aligarh region of western uttar pradesh, north india. supplementary issue:02 54 materials and methods study population and sample collection this study was conducted at viral research and diagnostic laboratory (dhr/icmr), department of microbiology, jawaharlal nehru medical college, amu, aligarh, uttar pradesh, india from january 2018 to october 2022. patients showing symptoms of hepatitis such as jaundice, fever, malaise, headache, nausea, vomiting, anorexia, diarrhea, and abdominal pain treated at jawaharlal nehru medical college hospital were included in the study. clinical samples venous blood samples about 5 ml in a sterile clot activator vacutainer along with clinical and demographic information were collected from symptomatic patients referred to this laboratory. a total of 1798 patients from all ages and gender were included in the study. the serum was separated by centrifugation and stored at -20°c till further testing. ethics statement informed consent was taken from all patients or their attendants. serological assays for detection of hepatitis a, b, c, and e virus detection of hepatitis a & e virus: hepatitis-a and e igm elisa kit by diapro usa, was used for diagnosis of hepatitis a virus as per manufactures instruction. detection of hepatitis b virus: hepatitis-b virus surface antigen (hbsag) elisa kit by tulip diagnostic was used for diagnosis of hepatitis-b virus. detection of hepatitis c virus: hepatitis-c virus anti igg elisa kit by tulip diagnostic was used for diagnosis of hepatitis-c virus. all test were performed as per manufacturer’s instructions. detection of routine clinical indices in blood and serum routine blood serum tests, including sgot or aspartate transaminase (ast), sgpt or alanine aminotransferase (alt), alkaline phosphatase (alp), bilirubin total, and bilirubin direct were determined from the blood samples of all patients showing symptoms of viral hepatitis. results supplementary issue:02 55 1798 suspected patients of viral hepatitis with deranged levels of lft from all gender and age group were included in the present study. among them 21.02% (378/1798) were found positive anti-hav igm, 20.96% (377/1798) were positive for hbv surface antigen, 9.78% (176/1798) were positive for anti-hcv igg and 5.45% (98/1798) were positive for anti-hev igm. there were 0.5% (09/1798) samples which were positive for both hbv surface antigen and anti-hcv antibodies and 0.3% (06/1798) samples were positive for both anti-hav igm and anti-hev igm. in the present study we found that males are more prone to viral hepatitis than females (fig 1). figure 1: gender distribution of acute viral hepatitis patients out of total positive cases, we found that, hav infection is found to be highest in the age group of 0-10 years (74.64%), on the other hand hbv infection is more common in the group 21-30 years (34.21%) followed 31-40 years (17.54%), hcv infection is more prevalent in the age group 21-30 years (23.76%) followed 31-40 years (22.77%), and the hev infection is highest in the age group 11-20 years (38.96%) followed by 21-30 years (31.17%). (figure 2). supplementary issue:02 56 figure 2: age distribution of acute viral hepatitis patients mean concentration of ast, alt and alp was highest in patients suffering from hepatitis a virus followed by hepatitis e, on the other hand the mean concentration of total bilirubin was highest in patients suffering from hepatitis e virus followed by patients suffering from hepatitis b virus (table 1). mean concentration of different liver enzymes in patients suffering different viral hepatitis from 2018 to 2022 ast alt alp tbi d ind hepatitis a 1013.5 1209.9 433.6 5.5 4.1 2.1 hepatitis b 359.60 368.59 188.75 6.98 5.15 2.75 hepatitis c 229.05 178.03 206.39 2.63 1.73 3.00 hepatitis e 624.24 643.03 297.40 9.73 5.09 1.97 table 1: mean concentration of liver enzymes in acute viral hepatitis patients from the study we also found that a higher ast and alt levels (>1000u/l) were found in 34% and 41.8% of hav infected patients respectively and only 2.94% and 1.29% of hav infected patients have normal level (0-50 u/l) of ast and alt, on the other hand only 5.91% patients have raised level (>1000u/l) of alp, instead about 46.36% of hav infected patients have a alp level in the range of 201-500 u/l, and about 14.09% of hav infected patients have normal alp level (fig 3). a raised level of total bilirubin index (5.1 – 10 mg/dl) is found in about 42.73 % of hav infected patients. supplementary issue:02 57 figure 3: liver enzymes level in hav infected individuals in case of hbv infection only 9.93% and 10.98% of infected patients have a higher level (>1000u/l) of ast and alt respectively, instead 42.55%, 43.29%, and 46.67% of hbv infected patients have ast, alt and alp level in the range of 51-200u/l (fig 4). the total bilirubin index in hbv infected patients was >10 mg/dl in about 22.05% and in the range of 5.110 mg/dl in about 26.77% of hbv infected patients. figure 4: liver enzymes level in hbv infected individuals in case of hcv infection only 5.56% and 4.44% of infected patients have a higher level (>1000u/l) of ast and alt respectively, instead about 61.11%, 42.22% and 51.72% infected patients have ast, alt, and alp level in the range of 51-200 u/l, 33.33%, 44.44%, and 10.34% of infected patients have normal level (0-50u/l) of ast, alt, and alp respectively (fig 5), on supplementary issue:02 58 the other hand only 3.45% of hcv infected patients have higher level (>10 mg/dl) of total bilirubin index, and about 44.83% infected patients have total bilirubin index in the range of 1.12 mg/dl. figure 5: liver enzymes level in hcv infected individuals in case of hev infection about 20.34%, 20.63 and 3.92% of infected patients have a higher level (>1000u/l) of ast, alt and alp respectively, about 42.37% and 47.62% of infected patients have ast and alt level in the range of 51-200 u/l (fig 5). a higher level of total bilirubin index (>10 mg/dl) was found in about 14.29% of infected individuals, majority of infected patients (38.10%) have total bilirubin index in the range of 5.1-10 mg/dl. discussion viral hepatitis is one of the major health problems in india. still, due to a lack of awareness among people in the country, viral hepatitis is spreading at a faster rate. four major viruses are responsible for causing viral hepatitis in indiahav, hbv, hcv, and hev [9]. hav is the primary causative agent of acute viral hepatitis among children. hav and hev are waterborne diseases, easily spread through contaminated food and water at unhygienic places like street food [10]. hbv is responsible for causing chronic viral hepatitis, mainly among adults. hbv and hcv are transmitted primarily by an infected individual through the exchange of body fluids like blood; it supplementary issue:02 59 is also transmitted through unsafe sexual contact with infected people [11, 12]. a study on the prevalence of hbv and hcv infection is needed to understand its epidemiology and to create strategies to improve public health, which may help in disease prevention and control. in the present study in the aligarh region of western uttar pradesh, we describe the investigation of viral hepatitis and demonstrate the presence of all major hepatitis viruses in patients with deranged lft from january 2018 to october 2022. we found that a significant number of individuals have viral hepatitis either by hav, hbv, hcv, or hev. hav was a predominant etiological agent of viral hepatitis, followed by hbv, hcv, and hev. this is in concordance with the previous study by jain et al., 2013 [9], while some other studies by chandra ns et al., 2014 [13] and pv barde et al., 2019 [14] reported hev as the predominant cause of viral hepatitis in india. hepatitis a infection, a common infection in children but relatively rare in adults, follows the same trend in this study. there were 21.02% of patients had hav infection; among them, 74.64% hav infected persons were from the age group of 0-10 years. these results are in support by our previous findings [4], and several other studies by rajani m. et al., 2016 [15] also reported the same results for hav prevalence in children. the significant prevalence of hav in youngsters demonstrates the importance of appropriate sanitation, especially sanitary dietary habits. parental health education is also required to control these diseases in youngsters. to guard against hepatitis-a, the who, cdc, and indian academy of pediatrics urge regular immunization of all children and susceptible groups. the hbv surface antigen and anti-hcv antibodies were found among 20.96% and 9.78% of individuals, respectively, with the highest share among individuals of age group 21-30 years, 34.21% for hbv and 23.76% for hcv. similar findings were reported by jain p. et al. 2013 and singh, k et al. 2022 [9, 16]. chronic hbv infection poses a serious public health concern for our nation since it can cause liver cirrhosis and hepatocellular carcinoma [17]. the higher number of cases of hbv and hcv among adults may be due to unawareness about the infection, e.g., unsafe practices like unsafe sexual contact with a stranger, drug abuse by unsterile syringes, using unsterile blades by barbers, dental treatment by non-qualified persons using unsterile instruments or by blood transfusion at unauthorized places [18, 19, 20]. hence running awareness programs among people may help in controlling the spread of infection. on the other hand, in our study, we found that only 5.45% of individuals were infected by hev, with the highest share among individuals of age group 11-20 years (38.96%) followed by 21-30 supplementary issue:02 60 years (31.17%) this is in support by the study by jain p et al. 2013 who also found that the hev infection is prevalent in adults [9]. over the past five and a half decades, several epidemics of hev infection have occurred in india. hev infection is also an important cause of acute and sub-acute liver failure in the country [21]. pregnant women with jaundice and acute viral hepatitis of hev etiology showed higher mortality rates and poorer obstetric and fetal outcomes than those with other types of hepatitis [22]. one of the primary reasons for the large number of cases of viral hepatitis is the lack of awareness among people of india about available vaccines for hav, and hbv, due to which most of the people are not vaccinated against hav, and hbv [26, 27]. therefore, to control the spread of viral hepatitis caused by hav, especially in children and hbv in adults, the health care and government agencies must make some policies like running awareness programs in the community and free immunization to everyone. unlike hav and hbv, there is no approved vaccine for hcv and hev [28, 29], so preventive measures are the only way to survive from getting the infection [23]. as we know, in viral hepatitis liver is the organ that is highly affected laid to an increase in the concentration of different liver enzymes and pigments like ast, alt, alp, and bilirubin [24]. in the present study, we found that the mean concentration of ast and alt was very high (>1000u/l) and alp (>400u/l) in individuals suffering from hav infection, followed by hev, hbv, and hcv infection. similar findings were reported in previous studies by ahmad i et al, 2020, and mittal a et al. 2016 [4, 25]. in our study, we also reported co-infection of hav with hev, which is only 0.3%, and about 0.5% of individuals are co-infected with hbv and hcv. regarding hav and hev, general hygiene, particularly sanitation, water supply, and food preparation, reflects socioeconomic class and living conditions and significantly impacts its endemicity [4]. interestingly, we found hbv to be the second most common cause of viral hepatitis in contrast to another study by irshad m. et al, 2010 [30] in which hbv is the leading cause of viral hepatitis. there were some limitations of our study, we do not have data for the year 2021 due to covid-19 pandemic, and all data provided here is from 2018, 2019, 2020, and 2022. also, we did not investigate our samples for hdv and hgv. conclusion from the present study, we conclude that all four viruses (hav, hbv, hcv, and hev) actively circulate in the study area, infecting all genders and ages. however, male individuals are more https://www.mdcan-uath.org/searchresult.asp?search=&author=anshu+mittal&journal=y&but_search=search&entries=10&pg=1&s=0 supplementary issue:02 61 prone to infection. hav is prevalent among children and very rare in adults, while hbv, hcv, and hev are more prevalent among adults. biochemical analysis shows that liver enzymes were highly elevated during hav infection, followed by hbv and hev. however, liver pigment bilirubin was highly elevated in hev infection, followed by hbv and hav. proper sanitation, maintaining good personal hygiene and consuming hygienic food and water, and proper immunization is the only effective way of preventing and controlling the spread of hav and hev. the preventive strategy for hbv and hcv infection should include a vigilant screening of blood and blood products and safe practices like using sterile instruments at a barber’s shop, dental treatment by a qualified professional, avoiding the reuse of syringes, etc., and safe sex practices and proper immunization against hbv. list of abbreviations vrdl: viral research & diagnostic laboratory elisa: enzyme linked immunosorbent assay hav: hepatitis-a virus hbv: hepatitis-b virus hcv: hepatitis-c virus hev: hepatitis-e virus acknowledgement this study was performed in viral research and diagnostic laboratory, funded by dhr/icmr govt. of india. the authors are thankful to mrs shibli javed, mr sanaullah, mr. samran and mr rizwan for providing technical support. conflict of interest: nil references 1. who, global hepatitis report, 2017 available at: https://www.who.int/publications/i/item/9789241565455 2. world health organization. global progress report on hiv, viral hepatitis and sexually transmitted infections, 2021. available at: https://www.who.int/publications/i/item/9789240027077external icon. https://www.who.int/publications/i/item/9789241565455 https://www.who.int/publications/i/item/9789240027077 supplementary issue:02 62 3. iorio, n., & john, s. (2022). hepatitis a. in statpearls [internet]. statpearls publishing. 4. ahmad, i., sami, h., & mustafa, z. (2020). investigation of hepatitis a virus outbreak in aligarh and its peripheral areas, uttar pradesh, india. j microbiol exp, 8(4), 156-161. 5. iannacone, m., & guidotti, l. g. (2022). immunobiology and pathogenesis of hepatitis b virus infection. nature reviews immunology, 22(1), 19-32. 6. gupta, e., bajpai, m., & choudhary, a. (2014). hepatitis c virus: screening, diagnosis, and interpretation of laboratory assays. asian journal of transfusion science, 8(1), 19. 7. abraham, p. (2012). viral hepatitis in india. clinics in laboratory medicine, 32(2), 159174. 8. khuroo, m. s., & khuroo, m. s. (2016). hepatitis e: an emerging global disease–from discovery towards control and cure. journal of viral hepatitis, 23(2), 68-79. 9. jain, p., prakash, s., gupta, s., singh, k. p., shrivastava, s., singh, d. d., ... & jain, a. (2013). prevalence of hepatitis a virus, hepatitis b virus, hepatitis c virus, hepatitis d virus and hepatitis e virus as causes of acute viral hepatitis in north india: a hospital based study. indian journal of medical microbiology, 31(3), 261-265. 10. sinha, a., & dutta, s. (2019). waterborne & foodborne viral hepatitis: a public health perspective. the indian journal of medical research, 150(5), 432. 11. https://www.cdc.gov/hepatitis/abc/index.htm 12. lemoine, m., nayagam, s., & thursz, m. (2013). viral hepatitis in resource-limited countries and access to antiviral therapies: current and future challenges. future virology, 8(4), 371-380. 13. chandra, n. s., ojha, d., chatterjee, s., & chattopadhyay, d. (2014). prevalence of hepatitis e virus infection in west bengal, india: a hospital-based study. journal of medical microbiology, 63(7), 975-980. 14. barde, p. v., chouksey, v. k., shivlata, l., sahare, l. k., & thakur, a. k. (2019). viral hepatitis among acute hepatitis patients attending tertiary care hospital in central india. virusdisease, 30, 367-372. 15. rajani, m. (2016). age wise seroprevalence of hepatitis viral markers in acute infectious hepatitis patients at a tertiary care centre in india. indian j microbiol res, 3(3), 224-229. https://www.cdc.gov/hepatitis/abc/index.htm supplementary issue:02 63 16. singh, k., sidhu, s. k., & oberoi, l. (2022). prevalence of acute viral hepatitis in symptomatic patients in a tertiary care hospital of north india. journal of advances in microbiology, 22(11), 67-71. 17. world health organization. (2016). combating hepatitis b and c to reach elimination by 2030: advocacy brief (no. who/hiv/2016.04). world health organization. 18. baha, w., foullous, a., dersi, n., they-they, t. p., el alaoui, k., nourichafi, n., oukkache, b., lazar, f., benjelloun, s., ennaji, m. m., elmalki, a., mifdal, h., & bennani, a. (2013). prevalence and risk factors of hepatitis b and c virus infections among the general population and blood donors in morocco. bmc public health, 13, 50. https://doi.org/10.1186/1471-2458-13-50 19. puga, m. a. m., bandeira, l. m., weis, s. m. dos s., fernandes, f. r. p., castro, l. s., tanaka, t. s. o., rezende, g. r. de ., teles, s. a., castro, v. de o. l. de ., murat, p. g., capelin, g. j. m., & motta-castro, a. r. c.. (2018). high-risk behaviors for hepatitis b and c infections among female sex workers. revista da sociedade brasileira de medicina tropical, 51(rev. soc. bras. med. trop., 2018 51(2)). https://doi.org/10.1590/0037-86820231-2017 20. kundu, a., mehta, s., agrawal, b. k., & singh, v. a. (2016). assessment of associated risk factors in hepatitis b virus and hepatitis c virus infections. jk science, 18(4), 229232. 21. sarin, s. k., choudhury, a., sharma, m. k., maiwall, r., al mahtab, m., rahman, s., ... & apasl aclf research consortium (aarc) for apasl aclf working party. (2019). acute-on-chronic liver failure: consensus recommendations of the asian pacific association for the study of the liver (apasl): an update. hepatology international, 13, 353-390. 22. chilaka, v. n., & konje, j. c. (2021). viral hepatitis in pregnancy. european journal of obstetrics & gynecology and reproductive biology, 256, 287-296. 23. roger, s., ducancelle, a., le guillou-guillemette, h., gaudy, c., & lunel, f. (2021). hcv virology and diagnosis. clinics and research in hepatology and gastroenterology, 45(3), 101626. https://doi.org/10.1186/1471-2458-13-50 supplementary issue:02 64 24. kochar, d. k., kaswan, k., kochar, s. k., sirohi, p., pal, m., kochar, a., ... & das, a. (2006). a comparative study of regression of jaundice in patients of malaria and acute viral hepatitis. journal of vector borne diseases, 43(3), 123. 25. mittal, a., bithu, r., vyas, n., & maheshwari, r. k. (2016). prevalence of hepatitis a virus and hepatitis e virus in the patients presenting with acute viral hepatitis at a tertiary care hospital jaipur rajasthan. new nigerian journal of clinical research, 5(8), 47. 26. yasobant, s., trivedi, p., saxena, d., puwar, t., vora, k., & patel, m. (2017). knowledge of hepatitis b among healthy population: a community-based survey from two districts of gujarat, india. journal of family medicine and primary care, 6(3), 589. 27. lavanchy, d. (2012). viral hepatitis: global goals for vaccination. journal of clinical virology, 55(4), 296-302. 28. https://www.cdc.gov/hepatitis/hev/index.htm 29. https://www.cdc.gov/hepatitis/hcv/index.htm 30. irshad, m., singh, s., ansari, m. a., & joshi, y. k. (2010). viral hepatitis in india: a report from delhi. global journal of health science, 2(2), 96. https://www.cdc.gov/hepatitis/hev/index.htm https://www.cdc.gov/hepatitis/hcv/index.htm international journal of human and health sciences vol. 02 no. 02 april’18 94 case report: herpes zoster infection of maxillary nerve in a healthy lady mohamad a1, wan mohamad we2 , soleh mn3, mohamad i4 abstract herpes zoster infection (hzi) occurs as a result from previous exposure to varicella zoster virus and the disease recurred at later onset of life when patient are in immunocompromised state. the manifestation can be varies and in fact can involve all parts of dermatome distribution. we present a case of hzi involving the second division of trigeminal nerve which involved danger triangle of face that resolved after one week of intravenous acyclovir. keywords: herpes zoster infection, maxillary nerve, acyclovir correspondence to: adam mohamad, department of otorhinolaryngology-head & neck surgery, school of medical sciences, universiti sains malaysia health campus, 16150 kota bharu, kelantan, malaysia, email: persona522115@gmail.com 1. adam mohamad, department of otorhinolaryngology-head & neck surgery, school of medical sciences, universitisains malaysia health campus, 16150 kota bharu and department of otorhinolaryngology, hospital tengkuampuanafzan, 25100 kuantan, pahang, malaysia 2. wan emelda wan mohamad, department of otorhinolaryngology, hospital tengkuampuanafzan, 25100 kuantan, pahang, malaysia 3. mohd najeb soleh, department of otorhinolaryngology, hospital tengkuampuanafzan, 25100 kuantan, pahang, malaysia 4. irfan mohamad, department of otorhinolaryngology-head & neck surgery, school of medical sciences, universitisains malaysia health campus, 16150 kota bharu, malaysia international journal of human and health sciences vol. 02 no. 02 april’18 page : 94-97 introduction herpes zoster infection (hzi) involving the maxillary division of trigeminal nerve is a rare condition.1 it is an acute infection viral disease that characterized by inflammation of dorsal root ganglion or extra medullary cranial nerve ganglia that associated with vesicular eruptions of the skin or mucous membrane in an area supplied by the affected nerve.2 it occurs due to reactivation of varicella zoster virus (vzv) which lies dormant in the sensory ganglia after previous episode of chicken pox.3 it usually affects the middle-aged and elderly who is in immunocompromised state especially the one with underlying diseases such as human immunodeficiency virus (hiv), leukemia, diabetes mellitus, malignancy as well as patient who had physical trauma, surgical stress, immunosuppressive therapy or radiation therapy.4 pathognomonic features of the disease are painful unilateral vesicular rash, usually confined to distribution of sensory nerve. thoracolumbar trunk is the most commonly affected5, especially t3 to l3. with regards to maxillofacial regions, trigeminal nerve is the most commonly involved, followed by glossopharyngeal and hypoglossal nerve. ophthalmic dermatome is the most commonly affected, while the maxillary and mandibular dermatome involvements are less common.6 case report a 21-year-old healthy malay lady, presented with rashes at right side of face 4 days prior to admission. it was preceded with pain over right eye and right upper gum one day prior. the rash started with papules (figure 1) which then become vesicles and later on erupted into pustules. she denied of otalgia or facial asymmetry. apart from that, she also had dysphagia to solid but still able to tolerate soft diet. there was no rash elsewhere. she sought treatment at clinic nearby at day 2 of illness whereby she was prescribed with tablet acyclovir 200 mg 5 times daily together with acyclovir cream for local application, painkiller and antihistamine, unfortunately the lesions was 95 international journal of human and health sciences vol. 02 no. 02 april’18 getting worse. due to worsening condition, she went to emergency department. on examination, she was alert and conscious. her vital signs were stable. there were erythematous patches involving right side of face along the right maxillary nerve distribution. there were few vesicles (figure 2) and pustules involving mainly the right upper lip, right nose particularly the dorsum and right vestibules with crusting within (figure 3). the right upper lip was swollen. besides that, there was eye redness; however there was no mucopurulent discharge or blurring of vision. oropharyngeal examination revealed whitish lesion over right hard palate and soft palate. her facial nerve was intact. otoscopic examinations were unremarkable. the diagnosis of herpes zoster of right maxillary branch was established and she was started with intravenous acyclovir 500 mg thrice daily, vaseline as emollient, tablet diclofenac 50 mg thrice daily and tablet loratadine once daily. her condition gradually improving and the lesion responded figure 1: lesion at right side of face on day 2 of illness figure 2: patient condition during admission figure 3: crusting and swelling of the right vestibule (danger triangle of face). figure 4: after 4 days of treatment figure 5: patient’s condition 3 weeks later; the lesion had completely resolved with only minimal scarring remained. well to treatment and started to dry up (figure 4). she was discharged home at day 7 of admission. upon follow up 3 weeks later, the lesion and pain had completely resolved, however only minimal scarring remained (figure 5) together with mild itchiness. international journal of human and health sciences vol. 02 no. 02 april’18 96 discussion: vzv is the virus responsible for chicken pox in childhood.7 upon resolution of the primary varicella infection, the remaining provirus segments travelled from the sensory nerve endings up and finally lodged in the cranial or dorsal root ganglia. those viral fragments will then reside in neuronal or satellite cell nuclei, whereby they are protected from antibody that persist in circulation as a result of primary infection. this theory explained why herpes zoster usually affects the sensory ganglia and its dermatomal distribution.1 the virus remain latent inside the neuronal nucleus and does not multiply, however it can revert to an infectious state at any time especially when cellmediated immunity dropped.7 the risk factor such as stressful condition is likely the cause of vzv reactivation as at that time, she was sitting for her final exam. generally, other potential risk factors for vzv reactivation includes prior vzv exposure (chicken pox), elderly, immunocompromised condition, immunosuppressive drugs, hiv/ acquired immune deficiency syndrome (aids), bone marrow or organ transplantation, cancer, chronic steroid therapy and trauma.8 the diagnosis of herpes zoster is made clinically based on presence of prodromal pain, itching and typical zoster rashes.8 the prodromal pain usually begin 4 days to 2 weeks before the lesion appeared, which at times associated with paraesthesia at the region that will become zoster-affected dermatome. the pain could be either intermittent, throbbing, burning or shooting pain.9 some of them experienced abnormal skin sensations such as tingling, dysesthesia and itching as well.10 typical zoster rashes usually appeared proximally and then only spread to the affected dermatome. initially, the lesions appear as erythematous papules, and then gradually turn to vesicles within 12 to 24 hours.8 the vesicles later become pustules in about 3 days and forming scabs 7 to 10 days later10, which is demonstrated in our case. the most significant complication of hzi is post herpetic neuralgia. others include motor nerve palsy, optic neuropathy, blindness, encephalitis and facial scarring.5 besides that, complications such as alveolar bone necrosis and rapid tooth exfoliation has been reported when there is involvement of either maxillary or mandibular division of trigeminal nerve.5 in this case, she only had minimal facial scarring. generally, hzi related pain resolves after about 90 days for many patients suffering it, unfortunately approximately 20% of them will have post herpetic neuralgia, which defined as pain persist for more than 3 months after rash had healed which requiring long term pain management.11 given the incidence rate, all patients post hzi should be followed up for at least 3 months onwards after the rash settled. the treatment of hzi includes prompt initiation of antiviral treatment and adequate analgesic agents. antivirals of choice are acyclovir, famciclovir or valacyclovir.12 this patient had been started with oral and topical acyclovir two days earlier, however the lesion get worsening. this could be due to high viral load at that time and oral acyclovir not that effective as compared to intravenous acyclovir. this could have been true as after the usage of intravenous acyclovir, the lesion started to dry up. a study was done by bean at el, showing the effectiveness of intravenous acyclovir in treating acute herpes zoster13, however so far there is no study comparing effectiveness oral versus intravenous acyclovir in treating hzi in the literature. apart from that, with the involvement of the lesion at the danger triangle of face in this case, more aggressive treatment with intravenous antiviral agent was given to prevent life-threatening cavernous sinus thrombosis.14 there has been reported case of hzi which causes orbital abscess and superior orbital fissure syndrome as well as cavernous sinus thrombosis.15 these antiviral agents can reduce the duration of viral shedding, fastening rash healing, reducing severity and duration of acute pain, as well as reduce risk of progression to post herpetic neuralgia when taken early in the course of infection.16 aggressive treatment of hzi with antiviral drugs, glucocorticoid, opioid and non-opioid analgesics is recommended to prevent post herpetic neuralgia as these can reduce viral replications, inflammation and pain elimination respectively17, thus conservative management is not advisable though it is known to be non-contagious and selflimiting. conclusion: herpes zoster infection is a potential life threatening infection if there is delayed treatment such as when it involve danger triangle of face. clinician has to recognize the early features of herpes zoster infection and provide prompt antiviral therapy to prevent the complications. 97 international journal of human and health sciences vol. 02 no. 02 april’18 reference: 1. paquin r, susin lf, welch g, barnes jb, stevens mr, tay fr. herpes zoster involving the second division of the trigeminal nerve: case report and literature review. journal of endodontics. 2017;43:1569-1573. 2. arduino pg, porter sr. herpes simplex virus type 1 infection: overview on relevant clinico‐pathological features. journal of oral pathology & medicine. 2008;37(2):107-121. 3. barrett ap. herpes zoster virus infection: a clinicopathologic review and case reports. australian dental journal. 1990;35(4):328332. 4. jain mk, manjunath k, jagadish s. unusual oral complications of herpes zoster infection: report of a case and review of literature. oral surgery, oral medicine, oral pathology, oral radiology, and endodontology. 2010;110(5):e37-e41. 5. owotade fj, ugboko vi, kolude b. herpes zoster infection of the maxilla: case report. journal of oral and maxillofacial surgery. 1999;57(10):1249-1251. 6. carbone v, leonardi a, pavese m, raviola e, giordano m. herpes zoster of the trigeminal nerve: a case report and review of the literature. minerva stomatologica. 2004;53(1-2):49-59. 7. arvin a. aging, immunity, and the varicella– zoster virus. new england journal of medicine. 2005;352(22):2266-2267. 8. weinberg jm. herpes zoster: epidemiology, natural history, and common complications. journal of the american academy of dermatology. 2007;57(6):s130-s5. 9. wood m, easterbrook p. shingles, scourge of the elderly: the acute illness. clinical management of herpes zoster: ios press, washington (dc); 1995. p. 193-209. 10. johnson rw, whitton tl. management of herpes zoster (shingles) and postherpetic neuralgia. expert opinion on pharmacotherapy. 2004;5(3):551-9. 11. takao y, miyazaki y, okeda m, onishi f, yano s, gomi y, et al. incidences of herpes zoster and postherpetic neuralgia in japanese adults aged 50 years and older from a community-based prospective cohort study: the shez study. journal of epidemiology. 2015;25(10):617-625. 12. siwamogstham p, kuansuwan c, reichart p. herpes zoster in hiv infection with osteonecrosis of the jaw and tooth exfoliation. oral diseases. 2006;12(5):500-5. 13. bean b, braun c, balfour h. acyclovir therapy for acute herpes zoster. the lancet. 1982;320(8290):118-121. 14. zhang j, stringer md. ophthalmic and facial veins are not valveless. clinical & experimental ophthalmology. 2010;38(5):502-510. 15. lavaju p, badhu bp, shah s. herpes zoster ophthalmicus presenting as orbital abscess along with superior orbital fissure syndrome: a case report. indian journal of ophthalmology. 2015;63(9):733. 16. sampathkumar p, drage la, martin dp, editors. herpes zoster (shingles) and postherpetic neuralgia. mayo clinic proceedings; 2009: elsevier. 17. schmidt sa, rowbotham mc. aggressive noninvasive treatment of acute herpes zoster for the prevention of postherpetic neuralgia. in herpes zoster: postherpetic neuralgia and other complications 2017 (pp. 341-364). springer international publishing. supplementary issue:02 168 antimicrobial stewardship: how much do the nurses realize their role? fatima khan1, bhanu chaudhary2, fatima mohtashim3, arsalan4, asfia sultan1, ritik garg2, yasir alvi5, haris m khan1 department of microbiology1, mbbs intern2, department of business administration3, mbbs phase 34, jnmch, amu; department of community medicine, himsr, new delhi5 *corresponding author dr. fatima khan, associate professor, department of microbiology, jnmch, amu fatimasalmanshah@gmail.com abstract: background: antimicrobial stewardship is a team work and nurses can especially play an essential role in optimizing diagnostic tests or diagnostic stewardship and patient education. however, there is little focus on antimicrobial stewardship training amongst healthcare professionals. even more neglected is the concept of the role of nursing and their training on antimicrobial stewardship. this study was conducted in a tertiary care centre of aligarh city of india to 1) evaluate the nurses’ knowledge about antibiotic resistance and antimicrobial stewardship 2) to assess the willingness of nurses to participate in antibiotic stewardship programs. methods: a multi-hospital exploratory, collective, mixed method approach (qualitative and quantitative) was used to assess the knowledge and attitude on antimicrobial stewardship amongst the nursing officers. three-fifty (350) nurses from three hospitals of aligarh, jawaharlal nehru medical college hospital (jnmch), mohanlal gautam rajkiya mahila chikitsalaya (mgrmc) and pt deen dayal upadhyay hospital were interviewed. their awareness, knowledge and willingness to participate in hospital antimicrobial stewardship program were assessed using a predesigned questionnaire. results: we observed most of the nurses had a poor knowledge (40.2%) while 29.8% had average and 30.0% had good knowledge. however, three-fourth (74.3%) of the participants agreed to participate in amsp teaching learning and implementation, while 25.7% did not. conclusion: tailored interventions to improve awareness and create a favourable attitude among nurses towards the prevention of antibiotic resistance. key words: antimicrobial resistance, antimicrobial stewardship, nursing. supplementary issue:02 169 introduction: antimicrobial resistance kills around 7 lac people every year worldwide1. it can lead to around 10 million deaths by 2050. world health organisation (who) has announced antimicrobial stewardship as urgent priority area and several nations including india have formed national action (nap) plans for containment of antimicrobial resistance (amr) 2. india formulated its national action plan on amr for five years in april 2017-20213. in a consensus meeting between the cdc, infectious diseases society of america (idsa) and the society for healthcare epidemiology of america (shea) antibiotic stewardship has been defined as “coordinated interventions designed to improve and measure the appropriate use of [antibiotic] agents by promoting the selection of the optimal [antibiotic] drug regimen including dosing, duration of therapy, and route of administration” 4,5,6. the benefits of antibiotic stewardship include improved patient outcomes, reduced adverse events including clostridium difficile infection (cdi), improvement in rates of antibiotic susceptibilities to targeted antibiotics, and optimization of resource utilization across the continuum of care. antimicrobial stewardship is a team work and nurses can especially play an essential role in optimizing diagnostic tests or diagnostic stewardship and patient education. examples include triaging patients for isolation, a timely collection of culture samples before antimicrobial use, educating patients on how to take antimicrobials at discharge from the hospital7. with the cbme model of medical education infection control has been made a part of undergraduate curriculum for mbbs students8, however there is little focus on antimicrobial stewardship training in the same. even more neglected is the concept of the role of nursing and their training on antimicrobial stewardship. this study was conducted in a tertiary care centre of aligarh city of india to 1) evaluate the nurses’ knowledge about antibiotic resistance and antimicrobial stewardship 2) to assess the willingness of nurses to participate in antibiotic stewardship programs. methods: a multi-hospital exploratory, collective, mixed method approach (qualitative and quantitative) was used to assess the knowledge and attitude on antimicrobial stewardship amongst the nursing officers. three-fifty (350) nurses from three hospitals of aligarh, jawaharlal nehru medical college hospital (jnmch), mohanlal gautam rajkiya mahila chikitsalaya (mgrmc) and pt deen dayal upadhyay hospital were interviewed. their awareness, knowledge and willingness to participate in hospital antimicrobial stewardship supplementary issue:02 170 program were assessed using a predesigned questionnaire. the questionnaire was formulated on antimicrobial prophylaxis with six closed-ended questions. evidenced based guidelines on antimicrobial stewardship established by the cdc4 were used as a reference in our study. the questionnaire was validated by face validity and a pilot study on 10% of the sample size. challenges were identified and listed after every question and suggestions were given to overcome these challenges. a questionnaire was prepared and nurses were interviewed at three government hospitals of aligarh, uttar pradesh with major focus on jawaharlal nehru medical college and hospital. nurses from all the departments and working in all specialities were interviewed about their knowledge and involvement in antibiotic stewardship. their willingness to participate in asp was also analysed. the descriptive analysis of the questionnaire was performed using spss version 20.0 (ibm corp, armonk, ny) to characterize the population parameters and study variables. the collected data were checked regularly for clarity, completeness, consistency, accuracy, and validity. ethical consideration permission was obtained from jawaharlal medical college hospital infection control committee and administrators for conducting the study. the process of data collection was started after the objectives of the study were explained to the nursing officers and verbal informed consent was obtained from all participants. participants were also informed that participation was voluntary and that they could withdraw from the study at any stage if they desired and that information was kept confidential. results: we enrolled 350 nurses working in three different government tertiary level hospital in aligarh. majority of the participants had 1-5 years (35.1%) and 5-10 years (36.0%) of experience (graph 1). majority (63.4%) of the nurses we enrolled worked in a multi-speciality teaching hospital, while 19.1% and 17.5% were working at a non-teaching hospitals. we also measured their knowledge regarding the antimicrobial resistance. we observed most of the nurses had a poor knowledge (40.2%) while 29.8% had average and 30.0% had good knowledge. figure 1: knowledge and willingness of nursing officers on amsp based on their experience in years supplementary issue:02 171 we measured the participants’ willingness to participate in amsp. three-fourth (74.3%) of the participants agreed to participate, while 25.7% did not. we observed that nurses with higher experience do not want to participate in amsp in comparison to those with less years of experiences. this relationship was found to be statistically significant in chi-square test (p < 0.0001). we also observed that the nurses working in teaching hospital were more willing to participate in amsp (92.8%) in comparison to those working in non-teaching hospital (43.3% and 42.6%) and relationship was found to be statistically significant in chi-square test (p < 0.0001) (table 1). table 1: comparison of knowledge and willingness amongst the three hospitals experience (in years) hospital number of participants knowledge (out of 10 ) willingness to participate in amsp good (>7) average (5-7) poor (<5) 1-5 jnmch 80 (22.8) 32 (40.0) 20 (25.0) 28 (35.0) 80 (100) mgmrc 21 (6.0) 4 (19.0) 6 (28.5) 11 (52.4) 11 (52.4) ddu 22 (6.2) 4 (18.2) 7 (31.8) 11 (50) 11 (50) 6-10 jnmch 81 (23.1) 32 (39.5) 25 (30.7) 24 (29.6) 81 (100) mgmrc 24 (6.8) 6 (25.0) 8 (30.3) 10 (41.7) 11 (45.8) 35.1 36 7.1 12 3.2 6.6 32.6 33.3 28 23.8 18.1 17.3 26.8 31.6 40 30.9 27.2 21.7 40.6 34.9 32 45.2 54.5 60.8 82.9 79.3 60 78.5 36.3 26 0 10 20 30 40 50 60 70 80 90 1-5 6-10 11-15 16-20 21-25 >25 knowledge and willingness of nursing officers on amsp based on their experience in years no. of particpants good average poor poor willingness to particpate in amsp supplementary issue:02 172 ddu 21 (6.0) 4 (19.0) 7 (33.3) 10 (47.6) 9 (42.9) 11-15 jnmch 10 (2.8) 4 (40.0) 4 (40.0) 2 (20.0) 9 (90.0) mgmrc 8 (2.2) 1 (12.5) 3 (37.5) 4 (50.0) 3 (37.5) ddu 7 (2.0) 2 (28.6) 3 (42.8) 2 (28.6) 3 (42.9) 16-20 jnmch 30 (8.5) 8 (26.7) 8 (26.7) 14 (46.6) 30 (100) mgmrc 8 (2.2) 1 (12.5) 3 937.5) 4 (50.0) 2 (25.0) ddu 4 (1.1) 1 (25.0) 2 (50.0) 1 (25.0) 1 (25.0) 21-25 jnmch 6 (1.7) 2 (33.3) 3 (50.0) 1 916.7) 2 (33.33) mgmrc 2 (0.5) 0 0 2 1 (50.0) ddu 3 (0.8) 0 0 3 1 (33.3) >25 jnmch 15 (4.2) 3 (20.0) 5 (33.3) 7 (46.7) 4 (26.7) mgmrc 4 (1.1) 1 0 3 1 (25.0) ddu 4 (1.1) 0 0 4 1 (25.0) total 350 105 (30.0) 104 (29.8) 141(40.2) on qualitative analysis during focussed group discussions, we found that the main challenge was that the majority of nurses were not aware of the term “antimicrobial stewardship”, so we reframed the questions based on antimicrobial resistance. on after explaining the term “antimicrobial stewardship” to them, when asked about their role in it, 224 (64%) majority of them were unaware that they could play any role in antimicrobial stewardship, because they were not trained or told to do so. 165 (47.1) nurses said that they know which antibiotic is to be given at what timings, but they [159(74%)] were not aware how this impacts amsp. on asking about the importance of specimen collection, they didn’t knew its significance in preventing antimicrobial resistance and they considered themselves overburdened to communicate to the patients for they specimens the patients have to collect themselves. table 2: challenges and solutions to amsp in nursing components of amsp & roles of number of nursing challenge solution supplementary issue:02 173 nursing officers in it agreeing to the role (%) nurses have a role in antimicrobial stewardship programme (amsp)/antibiotic resistance? 126 (36) most nurses were not aware about the term antibiotic stewardship, so we included the term antibiotic resistance in questionnaire after a pilot survey. it is neither taught in nursing curriculum nor any training provided to them regarding amsp. amsp should be made a component of the routine monthly infection control training program for nurses run by the hospitals. has anyone ever discussed of antimicrobial stewardship with you before? 31 (8.8) nobody discussed this term with them ever in jnmch, malkan singh and deendayaal hospital. few exceptions were the nursing staff who had previous work experience in hospitals like aiims, hospitals in saudi arabia, and corporate hospitals there is an urgent need to advance the monthly trainings and include antimicrobial stewardship to it. are you aware which patient is given which antibiotic and its timings? 165 (47.1) yes, since this is the responsibility of the nurses to give medication to the patients, particularly the iv medications. do you think correct timing and dosages can play a role in amsp? 91 (26) although most of the nurses said they know which antibiotic is to be given and and what timing, an overview of pharmacokinetics and dynamics of the drugs should also be given to supplementary issue:02 174 but they were not aware how the dose and timings affects the patients’ outcome through the pharmacokinetics and pharmacodynamics of the drug. them so that they can understand the significance of correct dosage and timings. do you review the reports of the patients and suggest change of treatment? 98 (28) although the nurses take rounds with the consultants, but they are not a part of any decision making and do not review the reports of the patients neither they can suggest any treatment changes. since the nurses are the most assessable healthcare workers in wards and various units, they should be at least trained to recognise the critical investigations and raise red flags by communicating to the doctors when necessary. do you think nurses should raise alert to review the antimicrobials at 48-72 hours of prescription? 87 (24.8) same as above it should be made a routine practice for the nurses to remind the doctors to review the antimicrobial therapy at 72 hours or as soon as the culture reports are available. do you think specimen collection has any role in amsp? 86 (24.6) they were sure that specimen collection is significant for correct diagnosis and treatment but were not aware how it can play a role in amsp. introducing them to diagnostic stewardship along with amsp is necessary and should be done during amsp trainings, once they are introduced. supplementary issue:02 175 do you ensure to collect timely cultures before starting the antibiotics? 35 (10.0) since decision to go for culture is taken by consultants, nurses take timely culture only when consultants recommend it. once they would be sensitized about the terms amsp & diagnostic stewardship, they would realise the significance of timely cultures. do you communicate with the patients regarding proper specimen which they collect on their own? 66 (18.8) they considered themselves overburdened and do not have time most of the times for communication. communicating with the patients for proper specimen collection, would ease in correct diagnosis and treatment, better and early patient recovery and discharge, thus saving their own time. do you think amsp should be a part of nursing practice? 260 (74.3) majority agreed but few were hesitant, considering it to be an extra work load on themselves. the hicc should include and empower nurses and assign them roles and responsibilities for amsp. do you think nurses should be trained for amsp? 288(82..3) the eagerness to learn new concepts was clearly visible and should be exploited to the benefit of the patients. discussion: the alarming rise in amr rates is a worldwide problem, but it is perhaps most severe in india. the rising amr rates in india can be attributed to a number of different causes9. these include insufficient infection prevention and control guidelines, an abundance of infectious diseases, and the excessive and inappropriate use of antibiotics. hcps particularly doctors and nurses are often at the forefront of efforts to reduce antimicrobial resistance (amr). everyone has supplementary issue:02 176 a part to play in the collective effort to avert antimicrobial resistance. being the frontline workers, nurses' knowledge and outlook affect the quality of care provided and the learnings imparted hence it is crucial to ascertain their knowledge and attitude with respect to antimicrobial resistance 10. there was a major lacunae amongst the knowledge of nurses on the antimicrobial stewardship and thus majority of them 224 (64%) were unaware of their role in it, since they were not sensitised for it earlier. amsp should be made a component of the routine monthly infection control training program for nurses run by the hospitals. similarly despite knowing the timing and duration of antibiotics to be given, they were unaware of its significance and also of the importance of specimen collection before starting the antimicrobials. an overview of pharmacokinetics and dynamics of the drugs should also be given to them so that they can understand the significance of correct dosage and timings. since the nurses are the most assessable healthcare workers in wards and various units, they should be at least trained to recognise the critical investigations and raise red flags by communicating to the doctors when necessary. introducing them to diagnostic stewardship along with amsp is necessary and should be done during amsp trainings, once they are introduced. once they would be sensitized about the terms amsp & diagnostic stewardship, they would realise the significance of timely cultures. majority 284 (81.2%) considered themselves overburdened to communicate to the patients for the specimens the patients have to collect themselves. they were sensitized during the fgds that communicating with the patients for proper specimen collection, would ease in correct diagnosis and treatment, better and early patient recovery and discharge, thus saving their own time. the silver lining is that the nurses in this study were generally supportive of stewardship programmes and their associated antimicrobial activities. although they didn’t score high, but most of them were eager to learn and participate in antimicrobial stewardship program. results from this study are consistent with those from a study conducted in pakistan, which found that despite low levels of knowledge about asps, the majority of healthcare professionals (hcps), including nurses, had a favourable attitude towards implementing them in hospitals 11. training on asps was recognised as a necessity by a strong majority of respondents (82.2 percent). abera et al12 found that the majority of nurses wanted asps, so this finding is in line with their conclusions. alex et al13 reports that survey data from a medical school show that 87% of students supplementary issue:02 177 want to learn more about antimicrobial resistance a s a result of these results, it is clear that hcps require more education and training to raise their level of awareness14. there is an increasing consensus that nurses need more education on the topic before they can be given the competence to hold meaningful contributions, such as feeling confident enough to voice concerns about antibiotic management practises15-16 . the argument that education will help overcome some of the barriers identified in this study is endorsed by studies showing a positive correlation between nurses' anti-microbial stewardship education, their contribution to successful antibiotic management, and their competence in discussing antibiotic administration with prescribers 17,18 . in this study, nurses were aware of their place in antimicrobial stewardship and eager to contribute to the worldwide effort to address this issue. this finding is encouraging because it shows that nurses want to collaborate for this goal. however, nurses will only be able to effectively voice their concerns if they have the self-assurance to do so. it is generally agreed that nurses need to speak up to ensure the safety of their patients and to fulfil their role as advocates for their patients 19. according to studies, nurses may be reluctant to speak up because they worry they won't be taken seriously 20,21 or because they want to fit in with the rest of the ward team by avoiding conflict 22,23. more specifically, nurses are hesitant to doubt antibiotic prescribers due to concerns that doing so would be met with resistance from doctors24,25; and because challenging prescribing decisions is seen as one of the most difficult aspects of ward work12. as a result, nurses may have to prioritise their own psychological and social well-being over that of their patients 21. education on the significance of speaking up as a whole, and of anti-microbial stewardship in particular, may be more effective when given on an inter-professional basis13 because, in addition to facilitating learning, it would contribute to efforts to breakdown customary hierarchies, promote collaboration and coordination12, and allow for an understanding from various perspectives13 . strengths and limitations: in this article, we discuss the critical issue of antibiotic resistance and antimicrobial stewardship and the critical role that nurses can play in developing and implementing strategies to combat this growing global threat. it also reveals that the nurses who took part in the study had a positive outlook on the need to take measures to reduce antibiotic resistance. our supplementary issue:02 178 research also highlights the importance of involving clinical nurses in the fight against antibiotic resistance by providing them with education and tools to improve antimicrobial stewardship. however, the present study is restricted to nurses working in three different government hospitals in aligarh, uttar pradesh. nurses working in corporate or private hospitals may have a different view and may have different knowledge and attitude towards amsp. variation in recall abilities and the propensity to provide a socially acceptable answer rather than one's genuine belief about antibiotic use and prevention of antibiotic resistance both increase the likelihood that the response is inaccurate. regardless of these caveats, the study still sheds light on how frontline nurses perceive their role in preventing antibiotic resistance and its stewardship and what they know about the topic. implication for practice: antimicrobial stewardship programmes and the prevention of antibiotic resistance require knowledge of the problem and a positive, proactive outlook. based on the results of this research, nurses need to acquire more information and adopt a more positive mindset before they can make meaningful contributions to antimicrobial resistance prevention strategies and antimicrobial stewardship initiatives. researchers can use the study's context-specific baseline data to shape a curriculum that educates and inspires nurses. conclusion: the present study showed that nurses themselves are not fully aware of the basics of antibiotics antibiotic resistance and the methods to be employed in its prevention. as such, this study highlights the importance of tailored interventions to improve awareness and create a favourable attitude among nurses towards the prevention of antibiotic resistance. references: 1. neill jo’. ―tackling drug-resistant infections globally: final report and recommendations, ‖ 2016, accessed: oct. 14, 2022. [online]. available: https://apo.org.au/node/63983. 2. who world health organization, regional office for south-east asia. jaipur declaration on antimicrobial resistance. 2011.,‖ 2011. [online]. available: http://www.who.int/iris/handle/10665/205397 . 3. government of india. national action plan on antimicrobial resistance (nap-amr) 2017 2021. 2017 4. dellit th, owens rc, mcgowan je, et al. infectious diseases society of america and the society for health care epidemiology of america guidelines for developing an supplementary issue:02 179 institutional program to enhance antimicrobial stewardship. clin infect dis. 2007; 44:159– 177. 5. centers for disease control and prevention. antibiotic resistance threats in the united states 2019. https://www.cdc.gov/drugresistance/pdf/threats-report/2019-arthreats-report-508.pdf. 6. cosgrove s, hermsen e, rybak m, file t, parker s, & balram t. guidance for the knowledge and skills required for antimicrobial stewardship leaders. infection control & hospital epidemiology 2014, 35 (12), 1444-1451. 7. american nurses association & centers for disease control and prevention. redefining the antibiotic stewardship team: recommendations from the american nurses association/centers for disease control and prevention workgroup on the role of registered nurses in hospital antibiotic stewardship practices. 2017. accessed july 19, 2021. https://www.cdc.gov/antibiotic-use/healthcare/pdfs/anacdcwhitepaper.pdf. 8. https://www.nmc.org.in/information-desk/for-colleges/ug-curriculum/ 9. rajni e, rathi p, malik m, sonali m, ved prakash m. impact of hospital-acquired infection and antibiotic resistance awareness campaign on knowledge attitude and practices of medical undergraduates in a tertiary care teaching hospital, india. j clin diagn res. 2020;14(9):dc23-27. 10. nair m, tripathi s, mazumdar s, maharajan r, harshana a, pereira a, et al. knowledge, attitudes, and practices related to antibiotic use in paschim bardhaman district: a survey of healthcare providers in west bengal, india. plos one. 2019;14(5):e0217818. doi: 10.1371/journal.pone.0217818. ecollection 2019. 11. jones‐berry, s. (2018). antimicrobial resistance: nurses’ role in fighting a global health threat. nursing standard, 33(1); 36–38. 10.7748/ns.33.1.36.s14 12. merrill k , forsyth hanson s , sumner s , vento t , veillette j , & webb b. antimicrobial stewardship: staff nurse knowledge and attitudes. american journal of infection control 2019, 47(10); 1219–1224. 10.1016/j.ajic.2019.03.022 13. broom a, broom j , kirby e , gibson a , & post j. how do hospital respiratory clinicians perceive antimicrobial stewardship (ams)? a qualitative study highlighting barriers to ams in respiratory medicine. journal of hospital infection 2017, 96(4); 316–322. 10.1016/j.jhin.2017.05.001 https://www.cdc.gov/drugresistance/pdf/threats-report/2019-ar-threats-report-508.pdf https://www.cdc.gov/drugresistance/pdf/threats-report/2019-ar-threats-report-508.pdf https://www.cdc.gov/antibiotic-use/healthcare/pdfs/anacdchttps://www.nmc.org.in/information-desk/for-colleges/ug-curriculum/ supplementary issue:02 180 14. monsees e, tamma p , cosgrove s, miller m , fabre v. integrating bedside nurses into antibiotic stewardship: a practical approach. infection control & hospital epidemiology 2019, 40(5); 579–584. 10.1017/ice.2018.362 15. tarrant c , leslie m , bion j , & dixon‐woods m. a qualitative study of speaking out about patient safety concerns in intensive care units. social science & medicine 2017, 193; 8–15. 10.1016/j.socscimed.2017.09.036 16. churchman j, doherty, c. nurses’ views on challenging doctors’ practice in an acute hospital. nursing standard 2010, 24(40): 42–47. 10.7748/ns.24.40.42.s50 17. okuyama a , wagner c, bijnen b. speaking up for patient safety by hospital‐based health care professionals: a literature review. bmc health services research 2014, 14: 61. 18. mansour m, & mattukoyya, r. development of assertive communication skills in nursing preceptorship programmes: a qualitative insight from newly qualified nurses. nursing management 2019, 26(4), 29–35. 10.7748/nm.2019.e1857 19. sumner s , forsyth s , collette‐merrill k , taylor c, vento t, veillette j, & webb, b. antibiotic stewardship: the role of clinical nurses and nurse educators. nurse education today 2018, 60; 157–160. 10.1016/j.nedt.2017.10.011 20. nes . (2014). exploring the role of nurses and midwives in antimicrobial stewardship. retrieved from https://www.nes.scot.nhs.uk/media/3065663/exploring_role_of_nurses_and_midwi ves_in_antimicrobial_stewardship_report.doc+&cd=2&hl=en&ct=clnk&gl=uk 21. broom a , broom j, kirby e , & scambler g. nurses as antibiotic brokers: institutionalized praxis in the hospital. qualitative health research 2017, 27(13); 1924–1935. 10.1177/1049732316679953 22. hayat k, rosenthal m, gillani ah, chang j, ji w, yang c, & fang y. perspective of key healthcare professionals on antimicrobial resistance and stewardship programs: a multicenter cross-sectional study from pakistan. frontiers in pharmacology 2020, 10; 1520. 10.3389/fphar.2019 23. abera b, kibret m, mulu w. knowledge and beliefs on antimicrobial resistance among physicians and nurses in hospitals in amhara region. ethiopia. bmc pharmacology and toxicology 2014, 15(1); 26. 10.1186/2050-6511-15-26 https://www.nes.scot.nhs.uk/media/3065663/exploring_role_of_nurses_and_midwives_in_antimicrobial_stewardship_report.doc%2b%26cd=2%26hl=en%26ct=clnk%26gl=uk https://www.nes.scot.nhs.uk/media/3065663/exploring_role_of_nurses_and_midwives_in_antimicrobial_stewardship_report.doc%2b%26cd=2%26hl=en%26ct=clnk%26gl=uk supplementary issue:02 181 24. alex i o. knowledge of antibiotic use and resistance among students of a medical school in nigeria. malawi medical journal 2019, 31(2); 133– 137. https://doi.org/10.4314%2fmmj.v31i2.5 25. ahmad a, khan mu, patel i, maharaj s, pandey s, dhingra s. knowledge, attitude and practice of b. sc. pharmacy students about antibiotics in trinidad and tobago. journal of research in pharmacy practice 2015, 4(1); 37. https://doi.org/10.4103%2f2279042x.150057 https://doi.org/10.4314%2fmmj.v31i2.5 https://doi.org/10.4103%2f2279-042x.150057 https://doi.org/10.4103%2f2279-042x.150057