international journal of integrated health sciences. 2018;6(2) 97 case cervical stump fibroidpost supra-cervical hysterectomy correspondence: sherman david mathew, department of radiology, apollo hospital, muscat 7/368c, mavelipuram, kakkanad, kerala, india e-mail: sher_mat@yahoo.com sherman david mathew,1 betsy abraham2 1department of radiology, apollo hospital, muscat, india 2department of critical care, royal hospital, muscat, india abstract objective: to describe of a rare case of cervical stump fibroid presenting as a late complication of supra-cervical hysterectomy. methods: a 68-year old-female with a history of lower abdominal pain and distention for six months with increasing intensity was referred from a local clinic to the department of radio-diagnosis for evaluation. she had a history of subtotal hysterectomy previously. on ultrasonography and computerized tomography imaging studies, a large adnexal lesion was noted suggesting the possibility of a cervical stump leiomyoma. the patient underwent an elective surgery and the diagnosis was confirmed in the context of histological findings. results: patient was operated for the radiologically diagnosed large cervical stump leiomyoma which was laterhistologically confirmed with an uneventful recovery. conclusions: imaging investigations like computerized tomography and magnetic resonance imaging are valuable in the diagnosis of rare adnexal masses from cervical stump arising as late delayed complications of supracervical hysterectomy. keywords: cervical stump leiomyoma, computerized tomography, magnetic resonance imaging, supra-cervical hysterectomy pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v6n2.1257 ijihs. 2018;6(2):97–9 introduction after supracervical hysterectomy procedure, cervical leiomyomas can occur as a rare and delayed complication these leiomymas are unusually found as mesenchymal tumours comprising 0.5–2% of all uterine leiomyomas presented dominantly with lower abdominal pain, vaginal bleeding, distension, as well as obstructive symptoms like urinary retention and constipation.1–3 cervical myomas are generally solitary in contrast to uterine myomas and are usually encountered in the reproductive age group.2 cervical fibroid depending on the position can clinically mimic many conditions.4–6 excision of cervical fibroids can be risky due to close proximity to important structures in a limited space and has escalated the need for precise preoperative diagnosis. in subtotal (supracervical) hysterectomy, only the upper part of uterus is removed while the cervix is left in place. on the other hand, in total hysterectomy, the entire uterus and cervix are removed. after the development of laparoscopy, supracervical hysterectomy has become a common-place, as it is shown to have significantly reduced intraoperative complications and morbidity compared to other types of hysterectomy. despite its rare occurence, there have been cases reported cervical stump fibroids and malignancies. other complications including, among other, prolapse, endometriosis and adhesions with the bowel have also been reported as other long term complications of cervical stump. current advanced imaging techniques such as ultrasonography (usg), contrast enhanced computerized tomography (ct) and magnetic resonance imaging (mri) have valuably aided in the precise diagnosis of characterization received: july 3, 2018 revised: august 8, 2018 accepted: september 10, 2018 :97–9 98 international journal of integrated health sciences. 2018;6(2) of adnexal lesions especially in rare lesions arising from the cervical stump post supra cervical hysterectomy.7 case a 68-year-old female was referred for pelvic and abdominal evaluation by ultrasonography. patient presented with complaints of lower abdominal pain and distention for more or less six months which was gradually increasing in severity. patient then delivered a history of appendectomy and hysterectomy due to uterine fibroids. she was on regular medication for hypertension and diabetes mellitus. ultrasound image showed a well-defined pelvic mass of myometrial echogenicity with no internal calcifications or cystic spaces was found. no significant ascites was encountered while the other abdominal organs were mostly normal. from the imaging findings and clinical history, a benign entity was suggested, which was thought to be possible gastrointestinal stromal tumour. the history of hysterectomy, and initially leiomyoma was not considered in the top differential diagnosis. further imaging was advised to further define the character and extent of the lesion and a contrast enhanced computer tomography was carried out. the patient was claustrophobic and, hence, refused magnetic resonance imaging study. contrast enhanced computer tomography demonstrated the presense of a large pelvic mass. the mass appeared to be in continuity with cervical stump on axial images. it is seen to demonstrate mass effect with displacement of the adjacent structures (fig. 1). on contrast the lesion was seen to show heterogeneous enhancement, with no specific evidence to indicate extension into urinary bladder (fig. 2). the possibility of a cervical leiomyoma arose from the finding of cervical stump. patient then underwent an elective excision and diagnosis was later confirmed histopathologically. discussion cervical leiomyomas are sparsely encountered mesenchymal tumours that comprise 0.5–2% of all uterine leiomyomas and may occur atypically as a delayed complication of supra cervical hysterectomy.1–4 extensive literature search revealed no data on the incidence of such a recurrence. the most frequently seen benign cervical mesenchymal tumours, reported with almost similar incidences, are haemangioma and leiomyoma.6 embryonal rhabdomyosarcoma, leiomyosarcoma, undifferentiated endocervical sarcoma, alveolar soft part sarcoma, ewing sarcoma, malignant peripheral nerve sheath tumour and liposarcoma are most constantly reported mesenchymal malignancies, in a decreasing order.6 leiomyomas can originate from the supra-vaginal or vaginal sections of the cervix and can be categorized as anterior, posterior, lateral and central depending on their location of genesis.3,4 patients present predominantly with lower abdominal pain, distention, vaginal bleeding and obstructive symptoms such as urinary retention and constipation depending on the site of origin. the complications of cervical leiomyomas include pressure effects on the bladder or urethra, degenerative phenomena cect abdomen, axial view showing continuity of pelvic mass with cervical stump fig. 1 :97–9 cervical stump fibroidpost supra-cervical hysterectomy cect abdomen, coronal view showing a large pelvic mass of heterogeneous enhancement fig. 2 international journal of integrated health sciences. 2018;6(2) 99 sherman david mathew, betsy abraham such as ulceration, inter-menstrual bleeding, pelvic cramping, prolapse with infection and torsion. several conditions like uterine leiomyoma, leiomyosarcoma, chronic uterine inversion, adenomyosis, tumors of ovarium, cystocoele, cervical polyps, uterine prolapse, transient myometrial contractions, lipoleiomyoma, and diffuse leiomyomatosis can clinically imitate cervical leiomyoma emphasizing the need for imaging techniques for accurate preoperative diagnosis.4–8 though ultrasonography is highly operator dependent, it is usually used as the preliminary investigation for evaluating the female pelvis. transvaginal scans are more sensitive than the transabdominal views for the diagnosis of small fibroids. the transabdominal views can often be challenging in obese patients. ultrasonography findings are that of welldefined lesions appearing hypo/isoehcoic to the normal myometrium. the computerized tomography scan is not the investigation of choice for the evaluation of pelvic masses but can be beneficial for patients with claustrophobia. findings from computerized tomography usually present a soft tissue density lesion causing distortion of uterine contour. some may exhibit internal calcification. magnetic resonance imaging is the desired imaging modality for identification of cervical fibroids and localizing their exact anatomical relations. the magnetic resonance imaging is highly sensitive in detecting various types of degeneration like hyaline, myxoid, cystic and red degeneration; calcification and malignant transformations.7–10 they appear as low to intermediate signal intensities compared to the uterine myometrium on t1 weighted and hypointense on t2 weighted imaging while on contrast imaging, variable enhancement is seen. in conclusion, cervical leiomyoma, though rare should always be considered in cases of adnexal lesions arising in patients post supra cervical hysterectomy and advanced imaging modalities are indicated in these cases for accurate preoperative diagnosis. :97–9 references 1. katke rj, thakre, mourya, acharya s. cervical fibroids with its management and review of literature: an original article. southeast asian j case report rev. 2017;6(1):5–9. 2. el-agwan as. lipoleiomyoma of the uterine cervix: an unusual variant of uterine leiomyoma. egypt j radiol nuclear med. 2015;46(1):211–3. 3. taingson mc, adze ja, bature sb, amina dm, caleb m, amina a. vaginal myomectomy of a huge prolapsed cervical leiomyoma. arch intsurg. 2016;6(2):127–9. 4. singh s, chaudhary p . central cervical fibroid mimicking as chronic uterine inversion: a case report. int j reprod contracept obstet gynecol. 2013;2(4):687–8. 5. jaouad k, youssef b, hanane r, driss m, mohamed d. huge prolapsed cervical myoma mimicking cystocele. saudi j health sci. 2015;4(2):135–7. 6. fadare o, ghofrani m, stamatakos md, tavassoli fa. mesenchymal lesions of the uterine cervix. ajsp. 2006;11(3):140–52. 7. sue w, sarah s-b. radiological appearances of uterine fibroids. the indian j radiol imaging. 2009;19(3):222–31. 8. teimoori b, esmailzadeh a. a large uterine leiomyoma leading to non-puerperal uterine inversion: a case report. int j reprod biomed (yazd). 2017;15(1):55–6. 9. khan at, shehmar m, gupta jk. uterine fibroids: current perspectives. int j womens health. 2014;6(1):95–114. 10. alharbi sr. uterine leiomyoma with spontaneous intraleiomyoma hemorrhage, perforation, and hemoperitoneum in postmenopausal woman: computed tomography diagnosis. avicenna j med. 2013;3(3):81–3. 26 international journal of integrated health sciences. 2017;5(1) original article sapodilla (manilkara zapota) broth as an alternative media for candida albicans abstract objective: to determine whether sapodilla can be used to grow candida albicans. among all the high galactose and arabinose content fruits, the sapodilla was chosen because it is available year round and can get easily in market. other than that, it also contains vitamins, calcium and phosphorus which are very useful for fungi growth. methods: this study used an experimental study as a method of research. the researcher culture candida albicans on the experimental sapodilla media and identifies the morphology of the fungi by using gram staining method. the experiment will be replicated two times to get accurate result. the procedure of this experiment constitute of sapodilla media preparation, sapodilla media observation, organism preparation, planting and incubation, observation of fungal colonies and identification of the fungi. results: in 0%, there was no fungal growth at all. in 5%, there was mild density of fungal colonies. in 10%, there was moderate density of fungal colonies and in 15% the fungal grew with very dense colonies. conclusions: sapodilla (manilkara zapota) broth can be used as an alternative media for candida albicans. keywords: alternative media, candida albicans, sapodilla broth pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v5n1.965 ijihs. 2017;5(1):26–9 introduction fungi, like all other living organisms, require certain nutrients for growth. these nutrients must contain chemical elements that are constituents of the cellular materials and that are necessary for the activity of enzyme and transport systems. the main constituents of organic compounds are carbon, oxygen, hydrogen, nitrogen, sulphur and phosphorus. the remaining bioelements are metal ions such as potassium, magnesium, calcium and iron. they are required as cofactors for enzyme activity.1 candida albicans is a normal component of the mammalian gastrointestinal flora and one of the most opportunistic pathogens in humans. infection by this pathogen is usually found in the gastrointestinal tract because it produces an anaerobic growth condition environment. it can also be found on skin, mouth and vagina.2,3 sabouraud dextrose agar is commonly used to support growth of fungi due to its’ high glucose content. sabouraud’s dextrose agar is a selective medium which is formulated to allow growth of fungi and inhibit the growth of bacteria. therefore, this study was initiated to offer an alternative media to support growth of fungi. the available means of inhibiting bacterial growth in sabouraud’s pre-antibiotic era was an acidic medium (ph 5.6). another objective of the study was to discover what is the minimal concentration of sapodilla is chen chui ying,1 ine kuswardinah,2 elsa pudji setiawati3 1faculty of medicine, universitas padjadjaran 2department of microbiology, faculty of medicine, universitas padjadjaran 3department of public health, faculty of medicine, universitas padjadjaran correspondence: chen chui ying, faculty of medicine, universitas padjadjaran jalan raya bandung-sumedang km.21 jatinangor, sumedang, west java, indonesia e-mail:chuiying_91@hotmail.com received: january 10, 2017 revised: february 15, 2017 accepted: march 6, 2017 :26–9 international journal of integrated health sciences. 2017;5(1) 27 needed for the growth of candida albicans. fruit naturally enriched of nutrient to support the growth of fungi. among all the high galactose and arabinose content fruits, an examination relating to sapodilla was performed. sapodilla is regarded as a material available year round and can be obtained easily in market.6 sapodilla, also known as manilkara zapota, is considered as a medium-sized tree native to central america, origin from mexico. sapodilla is introduced to indonesia in the 1700s. seeds are dark brown to black, 3/4 inch long, have a smooth and shiny surface.7 sapodilla is a main composition in making chewing gum.9 sapodilla consist nutrients that are needed by candida albicans for growing, such as carbohydrate and proteins. in addition, it also contains vitamins, calcium and phosphorus which are very useful for fungi growth.10 microorganisms often grow and reproduce when minerals and sources such as energy, carbon, nitrogen, phosphorus, and sulphur are supplied. the most important environmental factors affect microbial growth are solutes and water activity, ph, temperature,oxygen level, pressure, and radiation.11 methods this study used an experimental study as a research method. culturing candida albicans on the experimental sapodilla media and identifying the morphology of the fungi by using gram staining method were performed. the experiment was repeated two times to get accurate result. material used in this experiment is sapodilla media. microbial agent used in the experiment was candida albicans obtained from microbiology laboratory of faculty of medicine, universitas padjadjaran. reagent used for gram staining were crystal violet as a primary stain, iodine solution as a mordant, ethanol 95% as decolourizer, safranin as a counter stain, physiological saline, oil emersion and sterile water. controlled media used in the experiment was sabouraud’s dextrose agar. instrument that were needed in the experiment are as following: weighing scale, test tubes, test tube rack, petri dishes, bunsen burner, cotton swap, microscope, glass slide, ph indicator, inoculating loop, marking pen, toothpick and incubator. the procedure of this experiment constitute of sapodilla media preparation, sapodilla media observation, organism preparation, planting and incubation, observation of fungal colonies and identification of the fungi. the preparation of sapodilla extract done by peeling the skin of sapodilla and it was cut into 4 pieces. the sapodilla was put into a beaker and crushed into small particles. therefore, the extract was diluted into 4 different concentrations which were 5%, 10%, 15% and aquadest which contained 0% of sapodilla extract. to get 5% concentration, 5 g of sapodilla extract was prepared and diluted in 100 ml warm water. for 10% concentration, 10 g of sapodilla extract was prepared and diluted in 100 ml of warm water, and for 15%, 15 g of sapodilla extract was prepared and diluted in 100 ml of warm water. the ph of sapodilla media was adjusted by adding koh 40% into the media. two gram of bacteriological agar was added into each concentration and then it was inserted into water bath. all the flask was placed into autoclave machine due to make the media sterile. the media was put into petri dish and incubated for 24 hours in 37 0c. moreover, 0.1ml of 0.5mf contains around 300 x 105 cfu/ml of candida albicans was placed to petri dish. the petri dish was incubated for 48 hours in 37 0c. results based on the experiment performed in the study, the result showed that in 0%, there was no fungal growth (table). in 5% concentration, there was mild density of fungal colonies. in 10% concentration, there was moderate density of fungal colonies. however, in 15% concentration indicated that the fungal grew with very dense colonies. all the plates showed present of fungal growth except for the 0% which contains only aquadest act as the negative control. discussion a number of studies have been carried out to discover another alternative culture media to replace nutrient agar. a previous study using similar method showed that sterilized juices of vegetables and fruits can support adequate growth of cryptococcus neoformans as well as candida albicans.11 in addition, a study which was conducted by deivanayaki and iruthayaraj reported that an alternative media produced from raw vegetables can be used to cultivate microbes.12 in this study, the infusion of a hundred :26–9 chen chui ying, ine kuswardinah, et al. 28 international journal of integrated health sciences. 2017;5(1) sapodilla (manilkara zapota) broth as an alternative media for candida albicans percent concentration of manilkara zapota was diluted with distilled water to get the remaining three concentrations, which were 5%, 10% and 15% to determine whether similar results could be obtained. the results showed that sapodilla broth can be an alternative media for candida albicans. different concentration has different fungal growth density. the higher the concentration of sapodilla extract, the greater the fungal grow. the previous study showed that alternative media by using raw vegetables supply need nutrients.12 both solid and liquid media of different formulations were then designed to discover the ability to grow the test organisms and compared to the growth on conventional media. both media illustrate a good growth of fungal and bacteria.12 however, this study has several limitations due to narrow time frame to complete the whole study. the results should be further analyzed to determine the effectiveness of manilkara zapota. besides, limited access to a good facility such as in determining the actual concentration of extract, making the sapodilla extract in big amount and have to be fresh was among the problems. other extraction method should be identified to validate the results by comparing whether similar results are obtained. in conclusion, sapodilla (manilkara zapota) broth has been proven in this study can be an alternative media for candida albicans. a further study can be performed to compare the reliability for this media to be an alternative media compared to the media that used now which is sabouraud’s dextrose agar. therefore, this study also recommends other researchers to do the same experiment but with other fungi to discover the limitation of sapodilla to be a media. :26–9 references 1. chanda sv, nagani kv. antioxidant capacity of manilkara zapota l. leaves extracts evaluated by four in vitro methods. nat sci. 2010;8(10):260‒6. 2. annous ba, fratamico pm, smith jl. quorum sensing in biofilms: why bacteria behave the way they do. j food sci. 2009;74(1):24‒37. 3. janelle mh. sabouraud agar for fungal growth. in: gupta vk, tuohy mg, ayyachamy m, turner km, o’donovan a, editors. laboratory protocols in fungal biology. 2nd ed. new york: springer; 2013. p. 211–6. 4. shi j, chinn ms, sharma-shivappa rr. interactions between fungal growth, substrate utilization, and enzyme production during solid substrate cultivation of phanerochaete chrysosporium on cotton stalks. bioproc biosyst eng. 2014;37(12):2463‒73. 5. ahn m, yoon kc, ryu sk, cho nc, you ic. clinical aspects and prognosis of mixed microbial (bacterial and fungal) keratitis. cornea. 2011;30(4):409‒13 6. mason kl, downward jre, mason kd, falkowski nr, eaton ka, kao jy, et al. candida albicans and bacterial microbiota interactions in the cecum during recolonization following broad-spectrum antibiotic therapy. infect immunol. 2012;80(10):3371‒80. 7. pandiyan p, conti hr, zheng l, peterson ac, mathern dr, hernández-santos n, et al. cd4+ cd25+ foxp3+ regulatory t cells promote th17 cells in vitro and enhance host resistance in mouse candida albicans th17 cell infection model. immunity. 2011;34(3);422–34. concentration 0% 5% 10% 15% replication 1 ++ +++ ++++ replication 2 + +++ ++++ replication 3 ++ ++ +++ note: = no colony; + = grew with small density; ++ = grew with mild density; +++ = grew with moderate density; ++++ = grew with very dense colonies table fungal growth on sapodilla media after 48 hours incubation international journal of integrated health sciences. 2017;5(1) 29:26–9 8. woo pf, yim hs, khoo he, sia cm, ang yk. effects of extraction conditions on antioxidant properties of sapodilla fruit (manilkara zapota). food res int. 2013;20(5);2065–72. 9. patel cj, asija s, patel p, dhruv m, tyagi s. medicated chewing gum: a modern era of novel drug delivery system. rjpdft. 2012;4(6):293‒9. 10. willey j, sherwood l, woolverton c. prescott’s microbiology. 9th ed. new york: mcgraw-hill companies inc; 2014. 11. misra vc, randhawa hs. occurrence and significance of cryptococcus neoformans in vegetables and fruits. indian j chest dis allied sci. 2000;16;42(4):317–22. 12. deivanayaki m, iruthayaraj a. alternative vegetable nutrient source for microbial growth. int j bio sci. 2012;2(5):47–51. chen chui ying, ine kuswardinah, et al. 80 international journal of integrated health sciences. 2018;6(2) original article association of ki-67 expression and response of neoadjuvant chemotherapy in invasive breast cancer patients in bandung abstract objective: to analyze the association of ki-67 expression and response of neoadjuvant chemotherapy in patients with invasive breast cancer. methods: a retrospective observational study on the association of ki-67 expression and response of neoadjuvant chemotherapy in patients with invasive breast cancer was conducted. this study included twenty-five female patients with invasive breast cancer who met the inclusion criteria. parameters analyzed were age, tumor size, and immunohistochemical expression of ki-67. size of the tumor at preand post-neoadjuvant chemotherapy were obtained in cm3 and compared between 3 groups of ki-67 expression levels. one way anova was used to perform the statistical analysis. results: a significant difference in changes of tumor size for ki-67 level >20% compared to <14% and 14–20% was seen. based on the result, neoadjuvant chemotherapy was proven to have similar effects in patients with ki-67 expression of <14% and 14–20% but less effective in patients with ki-67 expression of >20%. conclusions: low to modest expression of ki-67 was a better biomarker to predict the response of neoadjuvant chemotherapy in patients with invasive breast cancer compared to high expression of ki-67. however, the cut-off value of 20% could be ideal to predict the outcome of neoadjuvant chemotherapy in patients with invasive breast cancer. keywords: breast cancer, ki-67, neoadjuvant chemotherapy, invasive breast cancer, tumor pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v6n2.1374 ijihs. 2018;6(2):80–3 introduction breast cancer is the leading cancer in women both in developed and developing countries.1 incidences of breast cancer are increasing in the developing countries because of increasing life expectancy, urbanization, and adoption of western lifestyles. in indonesia, breast cancer is the number one cancer for women in 2014.2 according to this condition, more attention should be given to breast cancer to be able to benefit more patients. neoadjuvant chemotherapy is defined as the administration of systemic drugs before doing surgical intervention that is also the standard treatment to treat locally advanced breast cancer as well as a standard option for primary operable disease.3 ki-67 is a protein strictly associated with proliferation of the cell. since the discovery of this protein, it has been widely introduced to be a proliferation marker for tumor cells.4 many cancers are associated with an increased level of ki-67 expression in cancer cells that they are used as a biomarkers for cancer cells.5,6,7 furthermore, it would be andri rezano,1,2 chen en pan,3 afrida aizzatun istiqomah,2 almira zada4 1division of cell biology, department of biomedical sciences, faculty of medicine, universitas padjadjaran 2graduate school of biomedical sciences master program, faculty of medicine, universitas padjadjaran 3undergraduate medical school, faculty of medicine, universitas padjadjaran 4division of biochemistry and molecular biology, department of biomedical sciences, faculty of medicine, universitas padjadjaran correspondence: andri rezano, division of cell biology, department of biomedical sciences, faculty of medicine, universitas padjadjaran jl. raya bandung-sumedang km 21 jatinangor, indonesia e-mail: andri.rezano@unpad.ac.id received: august 3, 2018 revised: september 6, 2018 accepted: september 10, 2018 :80–3 international journal of integrated health sciences. 2018;6(2) 81 interesting to find out the interaction between ki-67 expression and the effect of neoadjuvant chemotherapy. as neoadjuvant chemotherapy is such effective choice of therapy and ki-67 being and uprising biomarkers in the breast cancer field, this study aimed to analyze the association between ki-67 expression level and response of neoadjuvant chemotherapy in patients with invasive breast cancer. methods this study was a retrospective observational study on the association of ki-67 expression and response to neoadjuvant chemotherapy in patients with invasive breast cancer. the ethical clearance was sought from the health research ethics committee of faculty of medicine universitas padjadjaran under the registration no. 0116080891. total sampling approach was applied for this study. the inclusion criteria used included twenty five female patients with a diagnostic code of c50, underwent one cycle of chemotherapy prior to surgical intervention, and had tissue sample immunohistochemically stained for ki-67. exclusion criteria were patients whose primary diagnosis was not c50. the tumor size was used as an indicator to measure the neoadjuvant chemotherapy response because of the limited choice available in the medical record. cpr and ppr were not recorded for the patients. one-way anova were used to determine association of ki-67 expression and the response of neoadjuvant chemotherapy. ki-67 expressions were then categorized into three groups, i.e. low (expression of <14%), modest (expression between, 14–20%), and high (expression of >20%). one way anova test followed by lsd test for post hoc analysis was used to analyze the mean difference of tumor size (before and after chemotherapy) towards ki-67 expression category. results twenty five patients participated in this study with all patients received the fac regimen consisting of 5-fluorouracil, doxorubicin and cyclophosphamide as the standard choice of neoadjuvant chemotherapy for invasive breast cancer in dr. hasan sadikin general hospital, bandung. the mean age of patients was 50.28 years (table 1). patients with a ki-67 expression of 14–20% contributed approximately half of the subjects (n=13), which was double of the subjects with ki-67 expression of <14% (n=6) and >20% (n=6). the majority of the tumor sizes before chemotherapy were found between 101–300 cm3 which is the medium category for tumor size and about one-third of the subjects had a tumor size of more than 300 cm3. the changes of the tumor size were shown in cm3 (table 2). the overall distribution of the tumor size looks similar between the low and modest category while the patient of the high category has a higher average tumor size. these finding suggest tumor size reduction in the low and modest category post-neoadjuvant chemotherapy. in contrast, those patients with high ki-67 expression showed insignificant reduction of tumor size after their treatment. the posthoc test result showed a specific significance value when each category of ki-67 expression was compared against each other. there was no significant difference when low ki-67 expression and modest ki-67 expression were compared (p=0.516), which suggest that the neoadjuvant chemotherapy has a similar effect among patients within these 2 groups of population. however, when those 2 categories were compared to patients with high ki-67 expression, both groups showed a significant difference and suggested a significant decrease of effectiveness (p<0.05). discussion after analyzing the data, the significance of changes in tumor size for the ki-67 expression :80–3 andri rezano, chen en pan, et al. table 1 characteristics of patients characteristics mean or frequency age (yrs) 50.28 tumor size, prechemotherapy (cm3) small (<100) 3 medium (100–300) 14 large (>300) 8 ki-67 expression low (<14%) 6 modest (14–20%) 13 high (>20%) 6 82 international journal of integrated health sciences. 2018;6(2) association of ki-67 expression and response of neoadjuvant chemotherapy in invasive breast cancer patients in bandung >20 is still difficult to explain due to insufficient evidence to reach the conclusion. however, data supports the conclusion of several other results that ki-67 could be used as a good predictive marker for assessing neoadjuvant chemotherapy outcome. low to modest expression of ki-67 was a better biomarker to predict the response to neoadjuvant chemotherapy in patients with invasive breast cancer compared to the high expression of ki-67. a previous study determined that ki-67 can be used to predict neoadjuvant chemotherapy response, but the cut-off value for the ki-67 expression is 25%. hence, value higher than 25% for ki-67 expression can be used as a predictor of response towards neoadjuvant chemotherapy.7 in comparison to this study, the data collected was unable to reach such precision of ki-67 expression. in addition, 76% of the patient in this data has ki-67 expression that is <20% which is much lower than the suggested cut-off value of ki-67 expression as a predictor to assess the response to neoadjuvant chemotherapy. to a certain extent, this study also supports the result of the previous study from the perspective of ki-67 expression that is below 25% which is not within the range to suitably predict the response of neoadjuvant chemotherapy. another previous studies also stated that ki67 has the potential to be used as a predictive and prognostic marker. however, the studies did not specify the exact cut-off value for ki67 expression for its predictive and prognostic value to be more evident as well as prominent after using the standard ki-67 cut off value suggested by the st. gallen’s international expert consesus.8,9 these results are similar to previous studies where it is stated that the idea of a relatively high ki-67 expression value to be valid. in addition, another study investigated the optimal cut-off point for ki-67 as a prognostic factor concluded that the ideal point is at 20% as the hazard ratio of that cut off point is the highest compared to the others.10 pathologic response is also a very common and useful way to determine the effectiveness of cancer treatments, they are used in both of the research that is being compared above. but due to the retrospective nature of this study with no data available about the pathologic responses after the treatment, it is unable to include into this study which compromises its validity. furthermore, the suggested cut-off point by st. gallen consensus of 14% is slowly being proven to be not the ideal cut-off point by many study. this study which uses the suggested value of 14% also was not able to discover anything significant at that value. the limitation of this study is that ihc test is not routinely done in dr. hasan sadikin general hospital, bandung for all invasive breast cancer patients which leads to a very small sample size for this study, thereby limiting the credibility of this study. :80–3 table 2 changes of tumor size by ki-67 expression ki-67 expression tumor size p valuepre-chemo (mean ± sd) post-chemo (mean ± sd) δ(delta) preand post-chemo (mean ± sd) low (<14%)a 556.83±641.11 329±375.17 229.17±266.20 a vs b : 0.516 modest (14–20%)b 362.54±330.97 216.04±242.00 145±101.92 b vs c : 0.011 high (>20%)c 2,161.67±5,065.42 2,152.33±5,069.70 17.33±56.34 a vs c : 0.018 references 1. siegel r, naishadham d, jemal a. cancer statistics. ca cancer j clin. 2012;62(1):10–29. 2. world health organization. cancer country profiles 2013. [cited 2016 apr 1]. available from: http://www.who.int/cancer/countryprofiles/en/. 3. lotsch j, sipila r, tasmuth t, kringel d, estlander am, meretoja t, et al. machinelearning-derived classifier predicts absence of persistent pain after breast cancer surgery international journal of integrated health sciences. 2018;6(2) 83:80–3 andri rezano, chen en pan, et al. with high accuracy. breast cancer res treat. 2018;72(12):399–411. 4. burcombe rj, makris a, richman pi, daley fm, noble s, pittam m, et al. evaluation of er, pgr, her-2 and ki-67 as predictors of response to neoadjuvant anthracycline chemotherapy for operable breast cancer. br j cancer. 2005;92(1):147–55. 5. ingolf jb, russalina m, simona m, julia r, gilda s, bohle rm, et al. can ki-67 play a role in prediction of breast cancer patients’ response to neoadjuvant chemotherapy? biomed res int [serial on the internet]. 2014 mar [cited 2017 aug 7];2014(1):[about 8p.]. available from: https://www.hindawi.com/journals/ bmri/2014/628217/. 6. inwald ec, klinkhammer-schalke m, hofstädter f, zeman f, koller m, gerstenhauer m, et al. ki67 is a prognostic parameter in breast cancer patients: results of a large population-based cohort of a cancer registry. breast cancer res treat. 2013;139(2):539–52. 7. kim ki, lee kh, kim tr, chun ys, lee th, park hk. ki-67 as a predictor of response to neoadjuvant chemotherapy in breast cancer patients. j breast cancer. 2014;17(1):40–6. 8. fasching pa, heusinger k, haeberle l, niklos m, hein a, bayer cm, et al. ki67, chemotherapy response, and prognosis in breast cancer patients receiving neoadjuvant treatment. bmc cancer [serial on the internet]. 2011 nov [cited 2018 jan 17];11(486):[about 13p.]. available from: https://www.ncbi.nlm.nih.gov/pmc/ articles/pmc3262864/. 9. gnant m, thomssen c, harbeck n. st. gallen/ vienna 2015: a brief summary of the consensus discussion. breast care (basel). 2015;10(2):124–30. 10. tashima r, nishimura r, osako t, nishiyama y, okumura y, nakano m, et al. evaluation of an optimal cut-off point for the ki-67 index as a prognostic factor in primary breast cancer: a retrospective study. plos one [serial on the internet]. 2015 jul [cited 2017 dec 12];10(7):[about 10p.]. available from: https://journals.plos.org/plosone/ article?id=10.1371/journal.pone.0119565. 52 international journal of integrated health sciences. 2017;5(2) original article maternal mortality risk factors in dr. hasan sadikin general hospital, bandung in 2009−2013 correspondence: shely karma astuti, faculty of medicine, universitas padjadjaran jl. raya bandung-sumedang km 21 jatinangor, indonesia e-mail: shelykarma@gmail.com abstract objective: to discover the factors affecting the occurrence of maternal deaths. the high maternal mortality rate (mmr) in indonesia is still a common problem which needs urgent solution. methods: this is an analytic observational, cross-sectional study using a case control approach fifty two cases were selected as cases, another 52 were selected as control. the sampling was performed by simple random sampling. the instruments used in this study were the medical records of mothers who gave birth in dr. hasan sadikin general hospital bandung from 1 january 2009–31 december 2013. data analysis was performed using chi-square test. results: in this study, the results showed that the risk factors contributing to maternal deaths were pregnancy complication (p<0.001), delivery complication (p<0.001), puerpural complication (p=0.022), age (p=0.030), parity (p=0.427), prior medical history (p<0.001), antenatal care (p=0.007), maternal education (p=0.527), and area of residence (p=0.049). conclusions: the risk factors that contribute to maternal deaths include pregnancy complication, delivery complication, puerpural complication, maternal age, prior medical history, antenatal care, and area of residence. keywords: complication, maternal deaths, risk factors pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v5n2.992 ijihs. 2017;5(2):52–6 shely karma astuti,1 muhammad alamsyah aziz,2 insi farisa desy arya3 1faculty of medicine, universitas padjadjaran 2department of obstetrics and gynecology, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital, bandung 3department of public health, faculty of medicine, universitas padjadjaran introduction maternal mortality rate (mmr) is an important component of the human development index (hdi), a measure of a nation’s development.1 indonesia is one of the southeast asian countryies that have failed to reach the target of lowering mmr. in 2012, mmr in indonesia was 359 per 100,000 live births, increasing increased from the rate in 2007 (228 deaths per 100,000 live births).2 the definition of maternal death according to the tenth revision of the international classification of diseases (icd–10) is “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes”.3 according to mccarthy and maine, there are 3 determinant factors affecting maternal death. these three factors are divided into close, intermediate, and distant determinants. close determinants include the immediate processes after maternal death such as complications in pregnancy, childbirth, or postnatal periods. intermediate determinants are those which influence close determinants such as maternal health, reproductive status, access to health care, health care behavior or utilization of health care, and other unknown or unexpected factors. distant determinants are those which influence the intermediate determinants such as sociocultural and economic factors.4 this study aimed to discover factors affecting the occurrence of maternal deaths. received: january 10, 2017 revised: july 25, 2017 accepted: august 24, 2017 :52–6 international journal of integrated health sciences. 2017;5(2) 53 methods this study was an analytic observational, casecontrol study conducted in dr. hasan sadikin general hospital bandung. data were collected from the medical records of women giving birth in dr. hasan sadikin general hospital during the period from 1 january 2009–31 december 2013. this study had been approved by health research ethics committee dr. hasan sadikin general hospital, bandung. the minimum sample size was calculated using the unpaired analytic comparative study formula which set 52 case subjects and 52 control subjects. the inclusion criterion in this study was medical records that include variables collected in this study. medical records with incomplete or missing data were excluded. out of 104 maternal death cases identified, 52 fulfilled the inclusion criterion. samples were selected using simple random sampling method and were assigned into the case group. shely karma astuti, muhammad alamsyah aziz, et al. :52–6 table 1 characteristics of case and control risk factors result (n=52) p value death (%) death (%) pregnancy complication yes 21 (40%) 5 (9%) <0.001 no 31 (60%) 47 (90%) delivery complications yes 41 (79%) 22 (42%) <0.001 no 11 (21%) 30 (58%) puerpural complications yes 11 (21%) 3 (6%) 0.022 no 41 (79%) 49 (94%) maternal age <20 years or >35 years 20 (38%) 10 (19%) 0.030 20–35 years 32 (61%) 42 (81%) parity <1 or >4 24 (46%) 20 (38%) 0.427 1–4 28 (53%) 32 (61%) prior medical history yes 23 (44%) 2 (4%) <0.001 no 29 (56%) 50 (96%) antenatal care <4 times 13 (25%) 3 (6%) 0.007 ≥4 times 39 (75%) 49 (94%) maternal education <9 years 37 (71%) 34 (65%) 0.527 ≥9 years 15 (29%) 18 (34%) area of residence urban 28 (63%) 23 (44%) 0.049 rural 24 (36%) 29 (56%) 54 international journal of integrated health sciences. 2017;5(2) data collection was done on the control group which also had 52 subjects (case-control ratio =1:1). after data collection, data tabulated using microsoft excel, and bivariate analysis was performed using chi-square test through the use of statistics software. complications in pregnancy, delivery, and the puerpural period were analyzed. analysis was also performed on maternal age, parity, maternal medical history, antenatal care, maternal education, and area of residence. results the number of maternal patients giving birth in dr. hasan sadikin general hospital from 2009 to 2013 was 13,453 people, with 104 (0.77%) death cases. both groups characteristics (case and control) presented in table 1 show correlations were found between pregnancy complication (p<0.001), delivery complication (p<0.001), puerpural complication (p<0.022), maternal age (p<0.001), antenatal care (p=0.007), and area of residence (p=0.049) and the incidence of maternal deaths. meanwhile, parity and education variables did not show significant correlations to maternal deaths (p>0.05). or analysis with 95% confidence interval (ci) was performed to measure the effects of significant variables on the incidence of maternal deaths (table 2). discussion this was a case-control study involving 104 samples comprising of 52 cases and 52 controls. maternal death risk factors were classified into three determinants: close, intermediate, and distant.4 the study variables included as close determinants were complications during pregnancy, complications during birth, and also neonatal complications. all close determinants included in this study had a significant correlation with the incidence of maternal deaths (table 1). mothers with complications during pregnancy had a 6.368 times larger risk to suffer maternal death compared to those without them. mothers with complications during birth were 5.083 times more vulnerable to maternal deaths compared to those without them. mothers with neonatal complications had a maternal death risk that was 4.382 times larger than those without them. this findings supported previous studies which discover that obstetric complications, i.e. pregnancy complications, delivery complications, as well as puerpural complications, are risk factors for maternal deaths.4,5 obstetric complications that directly result in maternal deaths contribute to 75% of all maternal deaths. such deaths can actually be prevented through medical interventions.6 age, prior medical history, and antenatal care, which are intermediate determinants, showed significant results (table 1). mother who were under 20 or over 35 had 2.625 times larger risk than mothers age 20−35. age that is too young or too old had an effect on the condition of the uterus. mothers that are too young are not physically ready yet to conceive and give birth.7,8 comparing the two highrisk age groups, more maternal deaths came from the young age mothers.8 mothers with a history of diseases had 19.828 times larger risk compared to those without any history. prior medical history included diseases that had been suffered by the mothers before maternal mortality risk factors in dr. hasan sadikin general hospital, bandung in 2009−2013 :52–6 table 2 maternal death risk factors risk factors results p value or 95% ci pregnancy complication <0.001 6.368 2.172 – 18.668 delivery complication <0.001 5.083 2.143 – 12.053 puerpural complication 0.022 4.382 1.145 – 4.382 maternal age 0.030 2.625 1.081 – 6.377 prior medical history <0.001 19.828 4.356 – 90.258 antenatal care 0.007 5.444 1.449 – 20.462 area of residence 0.049 2.190 0.998 – 48.07 international journal of integrated health sciences. 2017;5(2) 55 shely karma astuti, muhammad alamsyah aziz, et al. conceiving/giving birth and would give the pregnancy an effect or greater burden. mothers with poor antenatal care were more prone to maternal deaths by 5.444 times than those without it. antenatal care functions to screen mother for other diseases or disorders that the mother has. in india (2013), 7 out of 10 mothers passed away because they did not receive antenatal care. government’s intervention in the form of family planning is needed to address this issue.9 in this study, the factor that was included as distant determinants was mother’s area of residence. mothers that stayed far from health care facility had a 2.190 times larger risk compared to those who stayed close to one (urban). this finding supported a previous study in gambia.6 as the referral hospital in west java, the cases handled in dr. hasan sadikin general hospital were all referred cases. the distant location is one of the 3 “too late” causes of maternal deaths.10 this was because patients needed more time to reach dr. hasan sadikin general hospital, causing them to arrive late and receive late treatments.6,11 for this reason, maternal deaths are 11 times more likely to happen in referral hospitals if the patients do not arrive in two hours.5 the problem of maternal deaths demands serious attention because it affects not only the mothers, but also their families. when its occur, other family members will have a decrease in their productivity which will eventually affect the family’s economy and social status.12,13 multi-sector governmental intervention is needed to solve this problem.11 policies need to be made according to the principle of decentralization so as to achieve effectiveness and efficiency in each region.2 one of the limitations of this study was that the unsuitability of the definition of maternal death with the conditions in dr. hasan sadikin general hospital. maternal deaths include the deaths that occur during pregnancy up to 42 days after birth; however, the medical records only had information about pregnancy up to a few days of hospital care. there was no data of maternal condition up to the 42nd day after birth. besides that, another limitation was the limited number of samples. the number of missing medical records was not a little. complete medical records and systematic, careful filing of medical records should be done. if possible, they can be done through a computerized system to prevent missing or incomplete data and expedite data searching. further studies should apply different method so that other factors that affect maternal deaths can also be observed. hence, it is concluded that the risk factors that affect maternal deaths in dr. hasan sadikin general hospital from 2009 to 2013 comprise of pregnancy, delivery, and puerpural complications, maternal age, prior medical history, antenatal care, and area of residence. :52–6 references 1. helmizar. evaluasi kebijakan jaminan persalinan dalam penurunan angka kematian ibu. kemas. 2014;9(2):197−205. 2. prakarsa welfare initiative for better societies. angka kematian ibu melonjak, indonesia mundur 15 tahun. [cited 2013 dec 6]. available from: http://theprakarsa.org/new/in/papers/ detail/19/angka-kematian-ibu-aki-melonjakindonesia-mundur-15-tahun. 3. shirin s, nahar s. maternal mortality-a public health problem. ibrahim med coll j. 2012;6(2):64−9. 4. khaskheli ms, baloch s, sheeba a. risk factors and complications of puerperal sepsis at a tertiary healthcare centre. pak j med sci. 2013;29(4):972–6. 5. abi bazar, theodurus, zaimursyaf aziz, azhari. maternal mortality and contributing factors. inajog. 2012;36(1):8−13. 6. cham m, sundby j, vangen s. maternal mortality in the rural gambia, a qualitative study on access to emergency obstetric care. reproductive health. 2005;2(3):1−8. 7. suwal jv. maternal mortality in nepal: unraveling the complexity. canadian studies in population. 2008;35(i):1−26. 8. datta d, datta pp. maternal mortality in india: problems and challenges. asian j med res. 2013;2(1):33−5. 9. nove a, matthews z, neal s, camacho av. maternal mortality in adolescents compared with women of other ages: evidence from 144 countries. the lancet global health. 2014;2(3):e155−64. 10. nour nm. an introduction to maternal mortality. rev obstet gynecol. 2008;1(2):77−81. 11. khan n, pradhan mr. identifying factors associated with maternal deaths in jharkhand, 56 international journal of integrated health sciences. 2017;5(2) maternal mortality risk factors in dr. hasan sadikin general hospital, bandung in 2009−2013 :52–6 india: a verbal autopsy study. j health popul nutr. 2013;31(2):262−71. 12. hernandez jc, moser cm. community level risk factors for maternal mortality in madagascar. afr reprod health. 2013;17(4):118−29. 13. gurnadi ji, mose jc, handono b, fauziah pn, pramatirta ay. correlation between fms-like tyrosine kinase-1 (sflt-1) cell-free messenger rna expression and fms-like tyrosine kinase-1 (sflt-1) protein level in severe preeclampsia and normal pregnancy. ijihs. 2015;3(2):66–71. volume 9 no 2 2021 fix.indd 84 international journal of integrated health sciences (iijhs) introduction cardio-cerebral infarction (cci) is an rare case and used to describe the simultaneous of acute myocardial infarction (ami) and acute ischemic stroke (ais). the risk of stroke in patients after acute myocardial infarction (ami) is significantly higher in comparison with the general population. the incidence of an ischemic stroke within a month after a review on acute cardio-cerebral infarction: a case report abstract objective: to describe a case of a cardio-cerebral infarction (cci) male patient presented with a history of chest pain recognized using electrocardiography, brain computed tomography, and percutaneous coronary intervention (pci). methods: a 69 years old man came with history of chest pain since 13 hours before to the emergency room. electrocardiography, brain computed tomography, and pci were performed, leading to the diagnosis of cci. results: the electrocardiography showed st elevation in antero-lateral, atrial fibrillation and left-sided hemipharesis, which occurred on the second day. brain computed tomography demonstrated acute infarct stroke, while the percutaneous coronary intervention (pci) showed one vessel disease with severe stenosis in lad and implanted stent in proximal-mid lad. therapy prescribed was providing antiplatelet and anticoagulation. discussion: acute myocardial infarction (ami) and acute infarct stroke (ais) have a narrow therapeutic time-window and a delayed intervention may results in morbidity and death. antiplatelet and anticoagulant used in pci for ami increase the risk for hemorrhagic, and ais with thrombolytic increase the risk of cardiac wall rupture in ami. direct oral anticoagulant (doac) treatment should reduce ischaemia and lower bleeding. the optimal time point to start anticoagulant treatment might be between 4-14 days after the onset of stroke. duration of post-pci triple therapy should be minimized depending on bleeding and risks of ischemia. keywords: acute infarct stroke, acute myocardial infarction, cardio cerebral infarction received: october 18, 2020 accepted: march 30, 2021 case report teddy arnold sihite, michi astuti rehmenda mario sitepu, cut azlina effendi department of cardiology and vascular medicine, faculty of medicine universitas padjajaran/dr. hasan sadikin general hospital bandung, indonesia pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ ijihs.v9n2.2178 ijihs. 2021;9(2):84–88 correspondence: teddy arnold sihite, department of cardiology and vascular medicine, faculty of medicine universitas padjajaran/dr. hasan sadikin general hospital bandung, indonesia e-mail: teddysyhyte@yahoo.com st elevation myocardial infarction (stemi) has found to be 2 % and up to 1 % within 90 days after non st-elevation acute coronary syndrome (nste-acs). 1,2 stroke occurs in the early postinfarction compared with occur late higher mortality. a delayed intervention, may result in permanent irreversible morbidity and mortality. deciding when to initiate oral anticoagulant (oac) in patients with non-valvular atrial fibrillation is a longstanding, common, and unresolved clinical challenge. although the risk of early recurrent ischaemic stroke is high in this population, early oral anticoagulation is suspected to increase the risk of potentially harmful intracranial haemorrhage, including international journal of integrated health sciences (iijhs) 85 haemorrhagic transformation of the infarct.3,4 this condition remains a challenge even today and can lead to potentially devastating complications. case a 69 years old man came to the hospital with history of typical angina chest pain at rest since 13 hours before admission. patient had history of dyspnoe on effort since 1 year, paroxysmal nocturnal dyspnoe since 6 month, and leg edema since 6 month before admission. patient had risk factors of smoking, hypertension and stroke known since 4 years ago. previous electrocardiography (ecg) onset 5 hours before admission showed stemi anterolateral. physical examination showed he was compos mentis with blood pressure 100/60 mmhg, heart rate 102 beats per minute, respiratory rate 22 times per minute, temperature 36.70 c, oxygen saturation 98 % with canule nasal 3 liter per minute. jugular vein pressure was 5+2 cmh20. heart examination showed cardiomegaly without murmur. he had focal neurological deficits with left hemipharesis. national institues of health stroke scale (nihss) was 25. electrocardiography showed sinus tachycardia, old myocardial infarction anterolateral, st elevation anterolateral, without evolution. laboratory examination showed haemoglobin 12.5 g/dl, hematocrite 47.8 g/dl, leukocyte 18.060 g/dl, thrombocyte 387.000 g/dl, ureum 40 mg/ dl, and creatinine 0.98 mg/dl. troponin 1.35 mg/dl on the first day of treatment the monitor showed paroxysmal atrial fibrillation (af) and the second day of treatment the patient complained sinistra hemiplegia. brain computed tomography scan showed infarct in cortical, subcortical lobus temporo-occipital dextra, multiple infarct lacunar in basal ganglia bilateral and cerebri senillis atrophy. patient underwent percutaneous coronary intervention (pci) after being approved by the neurology department on sixth day of treatment and the examination showed right coronary system dominance with severe stenosis in left anterior descending (lad) at proximal-mid portion and total occlusion in mid portion. left circumflex (lcx) artery has mild stenosis at proximal portion and severe stenosis in obtuse marginal 1. right coronary artery (rca) shows mild stenosis in mid portion. patient underwent coronary stenting in lad with 2 drug eluting stents (des) are 3.0 x 26mm and 2.75 x 38 mm deployed overlappingly. during procedure the patient is asymptomatic with stable vital signs. observation during this period shows normal vital sign. our evaluation using ecg doesn’t show any changes in anterolateral leads. the patient was discharged after 8 days of treatment in hospital without any symptoms. during hospitalization patient gets therapy was aspirin 81 mg once daily (od), clopidogrel 75 mg (od), warfarin 2 mg od, carvedilol 6.25 mg twice daily, ramipril 2.5 od, furosemide 40 mg od, spironolactone 25 mg od , nitrat 2.5 mg twice daily, atorvastatin 40 mg od. this case report presents a 69-yearold patient presenting with typical angina chest pain who is later diagnosed with recent fig. 1 electrocardiography showed sinus tachycardia, old myocardial infarction anterolateral, st elevation anterolateral teddy arnold sihite, michi astuti rehmenda mario sitepu, et al 86 international journal of integrated health sciences (iijhs) stemi anterolateral and in hospital treatment the patient complains of left hemiparesis who is later diagnosed with ischemic stroke. discussion a 69 years old man came with typical angina chest pain and history of left hemipharesis on second day treatment was diagnosed as stemi anterolateral and infarct stroke. patient has electrocardiography showed sinus tachycardia, old myocardial infarction, st elevation anterolateral. brain ct demonstrated acute infarct stroke. angiography showed showed right coronary system dominance with severe stenosis in left anterior descending (lad) at proximal-mid portion and total occlusion in mid portion. fig. 2 electrocardiography showed sinus tachycardia, old myocardial infarction anterolateral, evolution (-) fig. 3 angiography showed severe stenosis in left anterior descending (lad) at proximal-mid portion and total occlusion in mid portion left circumflex (lcx) artery has mild stenosis at proximal portion and severe stenosis in obtuse marginal 1. right coronary artery (rca) shows mild stenosis in mid portion. patient underwent coronary stenting in lad with 2 drug eluting stents (des) are 3.0x26 mm and 2.75x 38 mm deployed overlappingly. cardio-cerebral infarction (cci) is used to describe the simultaneous occurrence of acute ischemic stroke (ais) and acute myocardial infarction (ami). ais and ais that coincidence usually referred cci type 1. the risk of stroke in patients after ami is significantly higher in comparison with the general population. the incidence of stroke among ami survivors can approach 1.2% during a 1-month observation, whereas longterm observational data show that more than 2% have stroke within 1 year. one of the cardiac condition coincidence ais and ami in this patient is paroxysmal atrial fibrillation suggested caused dislodged lv thrombus. although the result of echocardiography was no found thrombus, but there’s decrease lv systolic function (biplane’s 35%). stroke following a myocardial infarction remains a challenge even today and can lead to potentially devastating complications. furthermore, strokes occurring in the early postinfarction period are associated with excessive mortality compared with those that occur late.1,2 the management of a simultaneous presentation of both stroke and ami is unclear. a delayed intervention of one infarcted territory for the other may result in permanent irreversible morbidity or disability, and even death. both conditions have a narrow therapeutic time-window, such that acute management of one at the expense of the other may result in permanent irreversible disability from the infarcted area that received review on acute cardio-cerebral infarction: a case report international journal of integrated health sciences (iijhs) 87 delayed intervention. in addition, the use of antiplatelet and anticoagulants that are inherently part of a percutaneous coronary intervention (pci) for ami may increase the risk for hemorrhagic conversion associated with intravenous thrombolysis and the use of a thrombolytic in ais increases the risk of cardiac wall rupture in the setting of ami.3,4 there are no clinical trials that have addressed this dilemma likely due to its rarity, and there are also no evidenced-based societal guidelines on the sequence of approach to management. the ideal management of simultaneous cci is a treatment strategy that benefits both vascular territories. an important deciding factor in approach to management is the presentation of ami. simultaneous cci with stemi poses the greatest management challenge, and the management options suggested in present article will be more beneficial for simultaneous presentation of ais and stemi. intravenous thrombolysis, approved for the acute management of both conditions has been suggested as the best approach to the treatment of simultaneous cci if there is no contraindication, and both presentations are within the time. a combined endovascular approach with the use of percutaneus transluminal coronary angiplasty for ami and thrombectomy devices for ais have been suggested.the statement from the american heart association/ american stroke association on the scientific rationale for the inclusion and exclusion criteria for iv-tpa in ais recommended treatment with iv-tpa at the dose appropriate for ais, followed by ptca and stenting if indicated (class iia, level of evidence c), based on the fact that pretreatment with iv-tpa does not decrease the coronary benefit of ptca and stenting.5,7 in patients with atrial fibrillation and a recent ischaemic stroke (who are at high risk for both recurrent ischaemia, doac treatment which should reduce ischaemia and has a lower bleeding risk than vkas is a promising strategy. however, individual net clinical benefit will vary according to the absolute risk of these events occurring in such patients, since the risk might depending on the timing of treatment (with early treatment being likely to reduce the risk of ischaemic stroke but potentially increasing the risk of intracranial haemorrhage). the aha/asa guidelines recommend that starting oral anticoagulation within 4–14 days after ischaemic stroke onset is reasonable for most patients. moreover, early (2–3 days after stroke onset) initiation of vka administration was associated with fewer recurrent ischaemic strokes than late (>3 days after stroke onset) initiation of vka treatment in the vista prospective cohort study of 1644 patients with ischaemic stroke and atrial fibrillation.8,9 precise-dapt score for predicting bleeding events in patients with acute coronary syndrome undergoing percutaneous coronary intervention (pc) was 3 (low criteria) patients with an indication for oral anticoagulation undergoing pci should concern about ischaemic risk and bleeding risk prevailing. follow-up this patient was triple therapy with oac, clopidogrel, and aspirin 80 were continued for 1 month after bms placement and for 1 year after des placement. duration of triple therapy should be minimized depending on bleeding and ischaemic risks.10,11 1. podolecki ts, lenarczyk rk, kowalczyk jp. mazurek mh, swiątkowski am, chodór pk, et al. the risk of stroke in patients with acute myocardial infarction treated invasively. coron artery dis. 2012;23(1):9–15. 2. dutta m, hanna e, das p, steinhubl sr. incidence and prevention of ischemic stroke following myocardial infarction: review of current literature. cerebrovasc dis. 2006;22(56):331–9. 3. sseiffge dj, werring dj, paciaroni m, dawson j, warach s, milling tj, et al. timing of anticoagulation after recent ischaemic stroke in patients with atrial fibrillation. lancet neurol. 2019;18(1):117-126. 4. altavilla r, caso v, bandini f. anticoagulation after stroke in patients with atrial fibrillation to bridge or not with low-molecular-weight heparin?. stroke. 2019;50:2093–100. 5. akinseye oa, shahreyar m, heckle mr, khouzam rn. simultaneous acute cardiocerebral infarction: is there a consensus for management?. ann transl med. 2018;6(1):7. 6. omar hr, fathy a, rashad r, helal e. concomitant acute right ventricular infarction and ischemic cerebrovascular stroke; possible references teddy arnold sihite, michi astuti rehmenda mario sitepu, et al 88 international journal of integrated health sciences (iijhs) explanations. int arch med. 2010;3:25. 7. demaerschalk bm, kleindorfer do, adeoye om, demchuk am, fugate je, grotta jc, et al. scientific rationale for the inclusion and exclusion criteria for intravenous alteplase in acute ischemic stroke: a statement for healthcare professionals from the american heart association/american stroke association [published correction appears in stroke. 2016 nov;47(11):e262]. stroke. 2016;47(2):581–641. 8. paciaroni m, agnelli g, falocci n, caso v, becattini c, marcheselli s, et al. early recurrence and cerebral bleeding in patients with acute ischemic stroke and atrial fibrillation effect of anticoagulation and its timing: the raf study. stroke. 2015;46(8):2175–82. 9. abdul-rahim ah, fulton rl, frank b, tatlisumak t, paciaroni m, caso v, et al. association of improved outcome in acute ischaemic stroke patients with atrial fibrillation who receive early antithrombotic therapy: analysis from vista. eur j neurol. 2015;22(7):1048–55. 10. valgimigli m, bueno h, byrne ra, collet jp, costa f, jeppsson a, et al. 2017 esc focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with eacts. eur j cardiothorac surg. 2018;53(1):34–78. 11. lamberts m, gislason gh, olesen jb, kristensen sl, schjerning olsen am, mikkelsen a, et al. oral anticoagulation and antiplatelets in atrial fibrillation patients after myocardial infarction and coronary intervention. j am coll cardiol. 2013;62(11):981–9. review on acute cardio-cerebral infarction: a case report 36 international journal of integrated health sciences. 2017;5(1) triamcinolone acetonide and 5-fluorouracil intralesional combination injection in keloid treatment introduction keloid is resulted from an abnormal wound healing process of injured skin that is marked by uncontrolled dermal as well as subcutaneous collagen synthesis and also deposition beyond the original site of injury. keloid does not regress spontaneously and has the tendency to recur after excision.1–5 the exact etiology is not understood but genetic predisposition to keloids has long been suggested due to the fact that patients with keloids often report a positive family history.4–8 until recently, keloid has been a challenge for dermatologists because of its recurrency and inadequate responses to the treatment modalities including drugs, silicon gel sheet dressing, compression therapy, excision, and cryoteraphy.1,3 until currently, intralesional injection of corticosteroid has always been the first line treatment for keloids, with triamcinolone acetonide (ta) as the most common agent.4,6 unfortunately, old keloids do not respond well to steroids. there are reports documenting a successful use of steroid and 5-fluorouracil (5-fu) injection combination for keloid that have been published.7 this article will describe a case report of a 22-yearold woman with keloid who was treated with intralesional ta and 5-fu combination. case a 22-year-old woman who complained about the presence of red purple and pruritic tumors on her neck, shoulder, and chest visited tumor and dermatosurgery outpatient clinic of dr. hasan sadikin general hospital, bandung, indonesia. the first complaint emerged about 10 years ago as lenticular tumors on neck, shoulder, and chest started as acne scars. abstract objective: to evaluate the effectiveness of steroid and 5-fluorouracil (5-fu) injection combination for keloid management. methods: a 22-year-old female patient was presented with recurrent skin lesions. the skin lesions first appeared 10 years prior to consultation, had been surgically excised, and were given triamcinolone acetonide injection. however, no improvement was observed. a decision was made to use and evaluate treatment using an intralesional 4 mg (0.1 ml of 40 mg/ml) triamcinolone acetonide and 45 mg (0.9 ml of 50 mg/ml ) 5-fu injection combination for 5 weeks. results: clinical improvements were observed in the third week as the lesions softened and pruritic sensation dinimished. at the end of the fifth week, improvements in the form of keloid lesion flattening and size reduction were observed. conclusions: intralesional injection using a combination of triamcinolone acetonide and 5-fluorouracil is effective for keloid lesion treatment. keywords: 5-fluorouracil, intralesional injection, keloid, triamcinolone acetonide pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v5n1.959 ijihs. 2017;5(1):36–41 received: may 31, 2016 revised: october 25, 2016 accepted: february 27, 2017 jono hadi agusni, eva krishna sutedja, franky chandra department of dermatology and venereology, faculty of medicine, universitas padjdajaran-dr. hasan sadikin general hospital case correspondence: franky chandra, department of dermatology and venereology, faculty of medicine, universitas padjdajaran-dr. hasan sadikin general hospital jl. pasteur no. 38, bandung, indonesia e-mail: franky_chandra_87@yahoo.co.id :36–41 international journal of integrated health sciences. 2017;5(1) 37 patient’s original keloid lesions. a) 13 x 2.5 x 0.7 cm, irregular keloid lesion with hyperpigmentation. b) 3.3 x 2.5 x 0.1 cm, irregular purplish red keloid lesion with telangiectasia. c) 4.2 x 2.2 x 0.2 cm, irregular hyperpigmented purplish red keloid fig. 1 :36–41 two years later, the lesions extended over the original border and the patient underwent excision by a surgeon. three months later, the tumor relapsed on the operation scar site, but patient did not seek any treatment. howover, the lesions enlarged and became itchy, that the patient decided to visit our clinic and was given ta 0.1 ml/cm2 (10 mg/ml) injections every 2 weeks. due to the lack of improvement after 3 months, the patient was suggested to go on surgery, but she refused. on physical examination, a 13 x 2.5 x 0.7 cm, solitary, irregular form, clear border, bulging, and dry hyperpigmented tumor lesion was found on the anterior surface of neck. on the left shoulder, a 4.2 x 2.2 x 0.2 cm, solitary, irregular form, clear border, bulging, and dry hyperpigmented purplish red tumor was observed. on the chest, a 3.3 x 2.5 x 0.1 cm, solitary, irregular form, clear border, bulging, and dry purplish red tumor was discovered with telangiectasia (fig. 1). patient’s final diagnosis was keloid on neck, chest and left shoulder. in this case, lesions were treated with intralesional combination of 4 mg (0.1 ml of 40 mg/ml) ta and 45 mg (0.9 ml of 50 mg/ml) 5-fu injection for 5 weeks. the procedure was started with the provision of local anesthesia using lidocain 1%. four miligrams ta and 45 mg 5-fu combination injections were given within 1 cm distance until the tissue bleached. after two weeks, clinical improvements were seen in the form of decreased pruritus, softened and flattened keloid on her neck, and reduced keloid size on the shoulder. after five injection series, lesion on the neck looked flatter and lesion on chest was minimized. in this case, ulceration at the injection sites developed after the first injection and could be managed with topical application of gentamycin 0.1% cream, twice a day. discussion keloid may appear as pink to purple-colour tumor, with glistening surface, accompanied by hyperpigmentation or telangiectasia and, occassionally, subjective symptoms of pain or pruritus.7,9 in this case, patient’s history and physical examination supported keloid diagnosis because the lesssion showed a purplish-pink, shiny, and clear margin keloid lesion. the ultimate goal of hypertrophic scar and keloid management is to prevent function impairment and maintain an appearance thati is cosmetically acceptable.10 for this specific patient, the treatment was sought because the keloid was enlarging, cosmetically iritating, and itchy. intralesional corticosteroid injection softens and flattens keloids by decreasing fibroblast proliferation, collagen synthesis, glycosaminoglycan synthesis, and suppressing pro-inflammatory mediators.1,5 the most commonly used corticosteroid for keloid is 10–40 mg/ml triamcinolone acetonide injection that is administered intralesionally at 2–3-week intervals.1 response to therapy should be observed within three months, and injections should be discontinued when jono hadi agusni, eva krishna sutedja, et al. 38 international journal of integrated health sciences. 2017;5(1) keloid lesions on the fourth intralesional injection. a) 13 x 2.5 x 0.4 cm. b) 3.3 x 2.5 x 0.1 cm. c) 4 x 2.2 x 0.2 cm fig. 3 :36–41 keloid lesions on the third intralesional injection. a) 13 x 2.5 x 0.5 cm b) 3.3 x 2.5 x 0.1 cm. c) 4 x 2.2 x 0.2 cm. note the hemorrhagic crusts on keloid lesions on neck and left shoulder after injection. patient admitted some improvements such as diminishing itch and softening of lesions fig. 2 the scar is stable, surgical intervention is indispensable, or if side effects such as tissue atrophy, hypopigmentation, or telangiectasia develop.5 the patient in the study had been given a 3 month intralesional ta before deciding to discontinue the treatment due to the lack of improvement. furthermore, keloid lesion on her neck was highly risk for contracture, thus she was consulted to be operated. the most common indications for keloids surgery are large lesions that are unlikely to be completely managed by medical therapy in a reasonable time frame and keloid scar contractures that triamcinolone acetonide and 5-fluorouracil intralesional combination injection in keloid treatment international journal of integrated health sciences. 2017;5(1) 39 jono hadi agusni, eva krishna sutedja, et al. keloid lesions on the fifth intralesional injection. a) 13 x 2.5 x 0.4 cm. b) 3 x 2.5 x 0.1 cm. c) 4 x 2.2 x 0.2 cm. patient admitted improvements as flattening and size reduction of the lesions fig. 4 :36–41 hamper musculoskeletal function.10,11 in this case, patient had been advised by plastic surgery department to have excision, but she had refused. patient agreed to get intralesional ta and 5-fu injection combination after informed consent was given. the biological basis of keloid formation lies on the substantial proliferation, apoptosis inhibition of fibroblasts and imbalance between collagen synthesis and degradation.12,13 keloid fibroblasts are considered to proliferate more rapidly, with oversecretion of type i collagen fibers and high expression levels of vascular endothelial growth factor, transforming growth factorβ1̸β2 and platelet-derived growth factor-α.12 tgf-β has been implicated in the collagen synthesis1 by increasing the effect of epidermal growth factor (egf) in fibroblast population, which stimulates epithel differentiation and initiates dna and rna synthesis.8 intralesional 5-fu works by inhibiting fibroblast proliferation, interrupting both dna and rna synthesis as well as inhibiting tgfβ-induced expression of the type i collagen gene in human fibroblasts.3,5,14 5-fluorouracil acts as an alternative therapeutic agent for patients who have not responded well to corticosteroids.1 5-fluorouracil is administered once every one or two weeks, up to thrice a week, adjusted according to the extent of the lesions, but the dosage given should not exceed 100 mg/ session (2 ml). the solution is injected into the central aspect of scar tissue, until slight blanching is clinically visible, usually 0.05 cc or less/injection site, approximately 1 cm apart.1 5-fu dosage should be adjusted in patients with liver dysfunction.14 contraindications to 5-fu include pregnancy, breastfeeding allergy, bone marrow depression, and severe intercurrent infection.1,15 the most common side effects of 5-fu injection include pain or discomfort, ulceration, burning sensations, and hyperpigmentation at the injection site.1,7,15 addition of 0.1 ml of ta (40 mg/ml) to 0.9 ml of 5-fu (50 mg/ml) helps to reduce the pain and also the inflammation.3 khan et al.6 has compared the use of ta injection as a monotherapy to ta and 5-fu injection combination for 150 patients with keloid and hypertrophic scars, who were divided into two experimental groups. in this study, eight injections were given in weekly 40 international journal of integrated health sciences. 2017;5(1):36–41 1. pratchyapruit w, vashrangsi n. a new therapeutic modality intralesional 5-fluorouracil in the treatment of keloids and hypertrophic scar. inst dermatol ass. 2012;13(9):157–63. 2. kelly ap. update on the management of keloids. semin cutan med surg. 2009;28(2):71–6. 3. sharma s, bassi r, gupta a. treatment of small keloids with intralesional 5-fluorouracil alone vs intralesional triamcinolone acetonide with 5-fluorouracil. j pak assoc dermatol. 2012;22(1):35–40. 4. guimarães co, parada mb, bagatin e. keloid treatment:comparative intralesional injections of 5-fluorouracil, corticosteroid and 5-fluorouracil combined with corticosteroid. surg cosmet dermatol. 2011;3(1):60–2. 5. wolfram d, tzankov a, pulzi p, piza-katzer h. hypertrophic scars and keloids-a review of their pathophysiology, risk factors, and therapeutic management. dermatol surg. 2009;35(2):171–81. 6. khan ma, bashir mm, khan fa. intralesional triamcinolone alone and in combination with 5-fluorouracil for the treatment of keloid and hypertrophic scars. j pak med assoc. 2014;64(9):1003–7. 7. gauglitz gg, korting hc, pavicic t, ruzicka t, jeschke mg. hypertrophic scarring and keloids: pathomechanisms and current and emerging treatment strategies. mol med. 2011;17(1):113–25. 8. gauglitz gg. management of keloids and hypertrophic scars:current and emerging options. clin cosmet investig dermatol. 2013;6(1):103-14. 9. chike-obi cj, cole pd, brissett ae. keloids: pathogenesis, clinical features, and management. semin plast surg. 2009;23(3):178–84. 10. vivas ac, tang jc, maderal ad, viera mh. hypertrophic scars and keloids, part 1:conventional treatments. cosmet dermatol. 2012;25(3):309–16. 11. edriss as, smrcka v. therapy of keloid and hypertrophic scars:a review. eur j plast surg. 2011;34(5):425–36. 12. dong x, mao s, wen h. upregulation of proinfammatory genes in skin lesions may be the cause of keloid formation. biomed rep. 2013;1(6):833–6. 13. gupta s, sharma vk. standard guidelines of care: keloids and hypertrophic scars. indian j dermatol venereol leprol. 2011;77(1):94-100. 14. darougheh a, asilian a, shariati f. intralesional triamcinolone alone or in combination with 5-fluorouracil for the treatment of keloid and hypertrophic scars. clin exp dermatol. 2009;34(1):219–23. 15. kranendonk s, obagi s. an algorithmic approach references triamcinolone acetonide and 5-fluorouracil intralesional combination injection in keloid treatment interval. the group receiving combination of 4 mg ta and 45 mg 5-fu, demonstrated good results (lesion height reduction: 50–75%) and excellent results (lesion height reduction: 75– 100%) in 63 patients (84%) while in the group receiving 10 mg ta injection as monotherapy, good and excellent results were seen in 51 patients (68%). according to this patient’s history, physical, and laboratory examination, she had no contraindication towards 5-fu administration and did not need any dosage adjustment. patient was given 4 mg ta and 45 mg 5-fu injection combination therapy once a week. lidocaine injection was given before therapy administration to minimize the pain. every injection was separated by 1 cm distance. gentamycin 0.1% cream was applied after the procedure and patient was requested to apply it twice a day if ulceration developed. the superficial ulcerations at the injection sites may be observed soon after the first 2–3 injection sessions and may heal with the use of topical antibiotics.2 the hyperpigmentation typically resolves spontaneously after three months.15 in this case, ulceration developed after the first injection and could be managed with topical application of gentamycin 0.1 % cream, twice a day. response of therapy commonly needs five to ten injection sessions. the first subjective symptoms of response are decreased pain and pruritus followed by softened and flattened scar and decreased erythema.4 in this case, the patient felt symptom improvements as decreased pruritus and softened keloid lesion after two injections. on examination, keloid on her neck become flattened and the other on shoulder reduced in size. after five injection series, lesion on the neck looked more flat and lesion on chest was minimized (fig. 2–6). international journal of integrated health sciences. 2017;5(1) 41:36–41 to hypertrophic scars and keloids:maximizing nonsurgical options. j cosmet dermatol. 2011;24(1):28–39. 16. indrayati h, agusni jh, soedarwoto a, kartamihardja ahs. comparison of the effectiveness of phosphorus 32 application and 10 mg/cc triamcinolone acetonide intralesional injection on keloid. ijihs. 2016;4(1):26–31. jono hadi agusni, eva krishna sutedja, et al. 56 international journal of integrated health sciences. 2019;7(1) case amyotrophic lateral sclerosis: first case report in department of neurosurgery, faculty of medicine, universitas padjadjaran, bandung correspondence: ahmad faried, department of neurosurgery, faculty of medicine, universitas padjadjaran-dr. hasan sadikin hospital, bandung jl. pasteur no. 38, bandung, indonesia e-mail: faried.fkup@gmail.com ahmad faried, priandana adya eka saputra, alief dhuha, muhammad zafrullah arifin department of neurosurgery, faculty of medicine, universitas padjadjaran-dr. hasan sadikin hospital, bandung abstract objective: amyotrophic lateral sclerosis (als) is a neurodegenerative disease that is incurable and results in paralysis of the muscles. electromyography (emg) is used to diagnosis amyotrophic lateral sclerosis. although recently there is no cure for als, knowledge has increased significantly in the past several years and is helping those who are newly diagnosed. methods: this study reported for the first time in department of neurosurgery, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital, bandung a 58-year old man who was presented in the institution with a history of weakness of both lower extremities for four months preceded by weakness of both upper extremities since the previous month. there was no history of any medical illness or any chronic medication. the patient then underwent emg studies, followed by muscle biopsy. results: electromyography and histopathological results confirmed a diagnosis of als. conclusions: this case was so exceptional, since als occurrence in neurosurgery centre is extremely rare, and the diagnosis can only be established through emg and histopathological of muscle biopsy studies. keywords: the fist reported of als in neurosurgery bandung, electromyography studies pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v7n1.1237 ijihs. 2019;7(1):56–60 introduction amyotrophic lateral sclerosis (als) is a neurodegenerative disease characterized by progressive muscular paralysis reflecting degeneration of motor neurons (mns) in the primary motor cortex, brainstem and spinal cord. amyotrophy refers to the atrophy of muscle fibers, leading to weakness of affected muscles and fasciculations. lateral sclerosis refers to hardening of the anterior and lateral corticospinal tracts as mns in these areas degenerate and are replaced by gliosis; hence the electromyography (emg) and the histopathological examination should be performed in order to confirm the diagnosis.1 the etiology of als has not been well understood; but it seems that various mechanisms leading to als been propose, such as (i) gene mutation, various genetic mutations can lead to inherited als which appears nearly identical to the noninherited form, (ii) chemical imbalance people with als generally have higher than normal levels of glutamate, a chemical messenger in the brain, around the nerve cells in their spinal fluid. high concentration of glutamate is known to be toxic to some nerve cells, (iii) disorganized immune response, sometimes a person’s immune system begins attacking some of his or her body’s own normal cells, which may lead to the death of nerve cells.2–4 international data showed the incidence of als is 1.9 patients per 100,000 people in the population and als prevalence is 6 per 100,000 people in the population; the highest incidence of als found in the population aged over 50 years. received: april 24, 2018 revised: december 20, 2018 accepted: march 19, 2019 :56–60 international journal of integrated health sciences. 2019;7(1) 57 assuming that 15 % of indonesia’s population aged over 50 years (total population in 2015 are 260 million people); the prevalence of als in indonesia in 2015 is estimated at 2,500 people.5 however, the incidence nor observation never been reported from indonesia, except one report from 2001–2012 survey results regarding als and parkinson in papua, indonesia.6 herewith, the study reported for the first time at department of neurosurgery, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital, bandung, a case of 58-years old man with weakness on his four extremities, thus diagnosed as als according to the histopathological and emg findings. although, the study might not represent the general population in indonesia and requires further investigation. case a 58-year old man came to our center with weakness of both lower extremities for 4 months as the chief complaint; this was also accompanied with weakness of both upper extremities since the previous month (fig. 1a–c). the complaint was initially felt four months prior to consultation; at the moment the patient was unable to stand on his toes and tiptoed. the complaint further progressed, with the right side is weaker than the left one. at the time of consultation, the patient was already unable to stand and walk properly. there were no histories of any medical illness or any chronic medication. the patient had already undergone hospitalization by our fellow neurologist who further consulted the patient to our department. at presentation, the patient was fully conscious and in moderate-ill condition. vital signs were within normal limit. on both lower extremities there were atrophies with decreased power (3/5). there were no sensory, proprioceptive or autonomic deficits. any other physical examination was within normal limit. neuroimaging modalities such as head and complete spinal mri had failed to show any pathology lesion. nerve conduction study shows decreased compound muscle action potential (cmap) on bilateral peroneal and tibial nerve with intact sensory function. needle electromyography shows increased insertion activities, complex repetitive discharges, fibrillation, positive sharp waves, polyphasic, decreased recruitment on bilateral gastrocnemius muscles suggestive for myogenic lesion. an initial diagnosis of motor neuropathy disease (mnd) was made (table1 and 2). muscle biopsy was then performed to this table 1 muscles spontaneous activity muap’s recruitment pattern ipfibs psw fasc ltc amp(mv) dur. (min) poly.p right muscle m. gastrocnemius ↑ + + − − 0.1–0.3 2–6 + ↓ ↓ m. tibialis anterior ↑ + + − − 0.1–1.0 2–10 + ↓ ↓ m. vastus lateralis ↑ + + − − 0.1–1.0 2–14 + ↓ ↓ m. gluteus maximus ↑ + + − − 0.1–2.0 2–18 + ↓ ↓ m. deltoid n − − − − 0.1–1.6 2–8 − n n left muscle m. gastrocnemius ↑ + + − − 0.1–2.0 2–14 + ↓ n notes: amp=amplitude, dur.=duration, fasc=fasciculatiouns, fib=fibrillation potentials, ia=insertional activity, ip=interference pattern, ltc=latency, muap=motor unit action potential, psw: positive sharp wave, poly.p=polyphasic potential, :56–60 ahmad faried, priandana adya eka saputra, et al. needle emg result that supported final diagnosis of amyotrophic lateral sclerosis 58 international journal of integrated health sciences. 2019;7(1) clinical inspection reveals symmetrical atrophies on both hands and legs. muscle atrophy at right hand (a); muscle atrophy at left leg (b); muscle atrophy at right leg (c) fig. 1 a b c patient. muscle biopsy is needed only rarely but may be considered if the presentation of als is atypical. the results will confirm the presence of signs of denervation and re-innervation or may lead to an alternative diagnosis. the presence of small, angular fibers is consistent with neurogenic atrophy (denervation). fiber-type grouping is consistent with reinnervation. the biopsy was performed at the right gastrocnemius muscle under local anesthesia. a muscle tissue sample, sized about 1 cm3 was sent to a pathologist at dr. hasan sadikin general hospital, bandung. this muscle biopsy shows neurogenic atrophic changes, with clumps of pyknotic nuclei, large group (fascicular) atrophy, hypertrophic fibers, and scattered angulated atrophic fibers (hematoxylin and eosin or he stain, ×100). markedly atrophic muscle obtained at biopsy shows end-stage myopathic changes with diffuse fatty infiltration (he stain, ×200). the final diagnosis for our patient was als. the patient was discharged, on his own will, with slight balance disturbance and no post-biopsy complication was observed. the patient died one month later of cardiorespiratory failure, seven months after symptom onset. discussion amyotrophic lateral sclerosis is a neurodegenerative disease that paralyzes the muscles because of the loss of functioning motor neurons. amyotrophy refers to the atrophy of the muscle fibers, which then produces spasms and muscle weakness. lateral sclerosis refers to the hardening of the anterior and lateral horn of the corticospinal tract.7 there are many forms of als which include: a) progressive bulbar palsy; b) progressive muscular atrophy; c) primary lateral sclerosis; d) flail arm syndrome; e) flail leg syndrome.7 each form of als has its own set of symptoms but all somehow will lead to the same degenerative and eventually the :56–60 amyotrophic lateral sclerosis: first case report in department of neurosurgery, faculty of medicine, universitas padjadjaran, bandung international journal of integrated health sciences. 2019;7(1) 59 worst outcome. amyotrophic lateral sclerosis is terminal and eventually leads to death caused by respiratory distress. the aim was to explain the different types of als, how imaging is currently being used, sometimes it failed, to diagnose the disease and a few palliative care methods used to care for als patients. the progressive muscular atrophy (pma) is one of the type of als; it is characterized by degeneration of the lower motor neurons without any or less symptoms of upper motor neuron degeneration. these patients lose control of their limbs and trunk. the pma progresses slowly with bulbar and respiratory problems appearing later.8 the pma eventually leads to mainstream als which will slow the patient down and lead to respiratory problems. magnetic resonance imaging (mri) is the only imaging modality that is currently used to diagnose als. the majority of the time mri is used to rule out other als mimicking diseases. in the effort to gain knowledge about the als disease new mri techniques have been developed to image the brain differently. somehow not in all case it would be useful. other modalities to diagnose als are emg. often used to rule out other muscular disorders, emg measures the amount of muscle movement over a particular area, then it is shown in wave form.9 general feature of mnd histopathology: a) decreased of large motor neuron with focal astroglyosis; b) senescent changes; c) intra cytoplasmic inclusion; d) proximal and distal axonopathies distal with axonal spheroid; e) tractus degeneration; f ) motoric fibers degeneration, motor end-plates and muscle atrophies.10 even though als has been around since the 1800s it was not a very well known disease until lou gehrig was diagnosed in the 1940s.3 there is a lot that is unknown about als and what causes it. although there is no cure for als, knowledge has increased significantly in the past several years and is helping those who are newly diagnosed. by keeping the patient nourished and slowing down the progression of the disease, the efforts could help to sustain life. the cellular therapy table 2 muscles ia spontaneous activity muap’s fibs psw fasc amp(mv) poly.p config. recruitment first dorsal interrosei (r) normal none none none 0.2–1.0 none normal normal brachioradialis (r) normal none 1+ none 0.2–1.0 none normal normal bicep brachii (r) normal none none none 0.2–1.0 none normal normal deltoid (r) normal none none none 0.2–1.0 none normal normal tricep brachii (l) normal none none none 0.2–1.0 none normal normal tibialis anterior (r) increased 1+ 1+ none 0.2–1.0 none normal reduced peroneus longus (r) crd 2+ 2+ none 0.2–1.0 none normal reduced gastrocnemius (r) increased 1+ none none 0.1–0.3 few normal reduced vastus medialis (r) normal 1+ none none 0.2–1.0 none normal reduced tibialis anterior (l) normal 1+ 1+ none 0.2–1.0 few normal reduced gastrocnemius (l) normal 1+ 1+ none 0.1–0.3 few normal reduced first dorsal interrosei (l) normal none none none 0.2–1.0 none normal normal deltoid (l) normal none none none 0.2–1.0 none normal normal notes: amp=amplitude, dur.=duration, fasc=fasciculatiouns, fib=fibrillation potentials, ia=insertional activity, ip=interference pattern, ltc=latency, muap=motor unit action potential, psw: positive sharp wave, poly.p=polyphasic potential, ip: interference pattern :56–60 ahmad faried, priandana adya eka saputra, et al. needle emg result that supported final diagnosis of amyotrophic lateral sclerosis (continued from table 1) 60 international journal of integrated health sciences. 2019;7(1) references 1. silani v, messina s, poletti b, morelli c, doretti a, ticozzi n, ma l. the diagnosis of amyotrophic lateral sclerosis. arch italiennes de biologie 2011;149(1):5-27 2. andersen pm, al-chalabi a. clinical genetics of amyotrophic lateral sclerosis: what do we really know? nat rev neurol. 2011;7(11):603– 15. 3. zarei s, carr k, reiley l, diaz k, guerra o, altamirano pf, et al. a comprehensive review of amyotrophic lateral sclerosis. surg neurol int [serial on the internet]. 2015 nov [cited 2017 sep 20];6(171):[about 30p.]. available from: https://www.ncbi.nlm.nih.gov/pmc/ articles/pmc4653353/. 4. mccombe pa, henderson rd. the role of immune and inflammatory mechanisms in als. curr mol med. 2011;11(3):246–54. 5. chiò a, logroscino g, traynor bj, collins j, simeone jc, goldstein la, whitef la. global epidemiology of amyotrophic lateral sclerosis: a systematic review of the published literature. neuroepidemiology. 2013;41(2):118–30. 6. okumiya k, wada t, fujisawa m, ishine m, garcia del saz e, hirata y, et al. amyotrophic lateral sclerosis and parkinsonism in papua, indonesia: 2001–2012 survey results. bmj open [serial on the internet]. 2014 march [cited 2017 oct 3];4(2014):[about 14p.]. available from: https://www.ncbi.nlm.nih.gov/pmc/ articles/pmc3996815/. 7. wijesekera lc, leigh pn. amyotrophic lateral sclerosis. orphanet j rare dis [serial on the internet]. 2009 feb [cited 2017 dec 7];4(3):[about 22p.]. available from: https://ojrd.biomedcentral.com/ articles/10.1186/1750-1172-4-3. 8. de carvalho m, scotto m, swash m. clinical patterns in progressive muscular atrophy (pma): a prospective study. amyotroph lateral scler. 2007;8(5):296–9. 9. mills kr. detecting fasciculations in amyotrophic lateral sclerosis: duration of observation required. j neurol neurosurg psychiatr. 2011;82(5):549–51 10. chou sm. pathology of motor system disorder. in: leigh pn and swash m editors. motor neuron disease biology and management. london: springer-verlag; 1995. pp.53-92 with stem cells or induced pluripotent stem cells (ipscs), surrounded by a deal of great technical challenge, is presented with a future perspective of neuro-regeneration as well as of neuro-protection of motor-neurons in als. in conclusion, als is particularly rare at neurosurgery centre and the diagnosis along with the treatment is difficult to be established. the imaging modalities alone could be challenging the diagnosis of als. in this study, the diagnosis of als can only be confirmed by means of emg and histopathological studies. :56–60 amyotrophic lateral sclerosis: first case report in department of neurosurgery, faculty of medicine, universitas padjadjaran, bandung international journal of integrated health sciences. 2018;6(2) 63 original article pregnancy rate after intrauterine insemination with the presence or absence of leukocytospermia in sperms prepared using density gradient method correspondence: rini widyastuti, departement of animal production, animal husbandry faculty, universitas padjadjaran jl. raya bandung-sumedang km 21 jatinangor, indonesia e-mail: r.widyastuti@unpad.ac.id abstract objective: to examine the association between different concentrations of leukocyte and sperm recovery rate after sperms are prepared using density gradient method and pregnancy rate after intrauterine insemination (iui). increased leukocytes in semen have been associated with increased reactive oxygen species (ros) that reduces sperm quality. methods: semen samples that were collected from 31 male partners of couples undergoing infertility investigation were analyzed for sperm concentration, motility, and leucocytes concentration. semen samples were then divided in two groups based on their leucocytes concentrations (category a: >0 to <1 × 106/ml; category b: >1 x 106/ml. semen samples were processed using density-gradient centrifugation technique. results: there was a significant difference in the number of sperms harvested and sperm motility after preparation. interestingly, pregnancy rate after iui was higher (p<0.05) in non-leukocytospermia semen (39%) when compared to leukocytospermia semen (30%). conclusions: seminal leukocytes (pmnl) concentration affects pregnancy rate after intrauterine insemination. keywords: density gradient method, sperm recovery rate, intrauterine insemination, pregnancy rate pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v6n2.1318 ijihs. 2018;6(2):63–6 introduction urogenital tract infection (uti) that increases the number and concentration of leucocytes up to more than 1 x 106 per ml, or known as leucocytospermia, is one of the most common causes of male infertility because it is associated with increased number of the reactive oxygen species (ros) that eventually reduces sperm quality.1 a previous study has reported that a high ros level triggers oxidative stress that impairs sperm motility, fertilization, and leads to deoxyribonucleic acid (dna) damage.2 the techniques of sperm preparation prior to intrauterine insemination (iui) play an important role in removing the leucocytes, seminal plasma, and also debris from the sperm as well as increasing the concentrations received: july 17, 2018 revised: august 15, 2018 accepted: september 5, 2018 :63–6 rini widyastuti,1,2,3 julius pangayoman,4 aida riyanti,5 alkaustariyah lubis,6 mas rizky anggun adipurna syamsunarno2,7,8,9 1laboratory of animal reproduction and artificial insemination, departement of animal production, animal husbandry faculty, universitas padjadjaran 2central laboratory, universitas padjadjaran 3study program of veterinary medicine, faculty of medicine, universitas padjadjaran 4melinda hospital 5indonesia reproductive medicine research and training center-indonesia medical research and education institute 6faculty of medicine, universitas padjadjaran 7departement of biomedicine sciences, faculty of medicine, universitas padjadjaran 8biotechnology study program postgraduate school 9department of biochemistry and molecular biology, faculty of medicine, universitas padjadjaran 64 international journal of integrated health sciences. 2018;6(2) of motile sperm prior to introduction into uterine cavity which will eventually increase the chances of conception. the techniques applied vary from laboratory to laboratory and even from patient to patient. in addition, these techniques are also very useful to treat infertility in male individuals by improving sperm motility and the pregnancy rates after iui. in artificial reproductive technology (art) there are 4 techniques for sperm preparation i.e. simple washing, swim-up, density gradient, and mini gradient.3 compared to the swim-up method, better sperm preparations using pure sperm density gradient method is able to better improve the quality of the sperms.4 when using density gradient method, it is showed that immotile or abnormal sperm cells, leucocytes, and cell debris are thoroughly cleared from the final solution, decreases ros leak and eventually decreases the dna damage.5 furthermmore, this method is more effective because it is easy to perform and has fewer critical points that are sensitive to errors during preparation. the link between leukocytospermia, semen quality, and pregnancy rate after intrauterine insemination using specific sperm preparation method is inconsistent. the study presented here was designed to evaluate the effects of leukoscytospermia on the sperm recovery rate after sperm preparation using density gradient method and pregnancy rate outcomes after iui. methods the study involved 36 couples who underwent iui because of male infertility factor including oligo, astheno, and also terratozoospermia in melinda hospital, bandung, indonesia. semen specimens were collected by masturbation after 2–7 days of sexual abstinence. semen specimens collected were divided into two groups according to the amount of leucocytes present in the semen. specimen in group 1 had who-defined leukeocytospermia of > 1 x 106/ml (n=23) and non-leukocytospermia in group 2 had seminal leucocytes less than 1 x 106/ml (n=23). semen analysis was conducted during the period of 30–60 minutes after liquefaction based on a guideline published by the world health organization (2010) through the use of a phase contrast microscope (nikon e-400, japan). semen liquefaction time, appearance, volume, ph, and viscosity were determined. these specimens were analyzed for sperm concentration as well as progressive motilities before and after sperm preparation. all samples underwent density gradient and prepared spermatozoa were processed using discontinuous density gradient centrifugation. one milliliter of a 90% density lower layer, 1 ml of a 45% density upper layer, and 1 ml of semen (1/1/1) were pipetted and put into a 15ml conical falcon tube. the mixture was then centrifuged at 1,500 rpm for 10 minutes. after centrifugation, the supernatant was removed and the spermatozoa (pellet) was placed into another 15-ml falcon tube containing 5 ml of modified-earle’s buffer salt solution (mebss) supplemented with 3% human albumin serum (has, vitrolife). the solution of spermatozoa pellet was then centrifuged at 1500 rpm for 10 minutes. the final pellet was re-suspended in the same medium solution to obtain a final volume of 0.5 ml. a 10-μl aliquot was used to perform the analysis of post-processing seminal parameters. the harvested quality sperms were suspended in the final volume of 0.3 ml of sperm preparation medium to be used for iui. all semen samples were analyzed for sperm motility and sperm concentration in the same person, in the same laboratory, and in the same condition. recombinant fsh was used for stimulating ovarium. female patients were scheduled for the iui procedure when at least one follicle that was 20 mm in size was detected through ultrasound scanning. insemination using the prepared sperms was performed with a sterile catheter and 1 ml syringe. here, the catheter was gently passed through the cervical canal and 0.3 ml of the sperm suspension was expelled slowly into the uterine cavity close to the tubal junction. the female patients were asked to rest in lithotomy position for 30 minutes after iui. the pregnancy test was performed 14 days after insemination. statistical analysis was conducted using spss software version 16 (spss inc, chicago, il, usa). all data were analyzed using student’s t-test. the level of significance different was p<0.05. results sperm washing must be performed to prepare the sample for insemination in iui cycle. the baseline data of sperm characteristic before preparation was used to choose the method of preparation and predict sperm recovery rate after the process. the baseline data of sperm characteristic in this study consisted :63–6 pregnancy rate after intra uterine insemination with the presence or absence of leukocytospermia sperms prepared using density gradient method international journal of integrated health sciences. 2018;6(2) 65 rini widyastuti, julius pangayoman, et al. of the number and motility of the sperms. the average number of sperms from sample without leukocytospermia was significantly lower when compared to sperm samples that presented with leucocytospermia (p<0.05) (69.60±5.92 versus 84.78±5.75). interestingly, the sperm motilities in both groups were not significantly different (p>0.05) (35.39±10.54 vs 38.69±2.60). the number of sperms harvested as well as the total number of motile sperms in the samples with and without leukocytospermia are shown in this study (table). the results showed that the presence of leukocytes in the semen significantly increased the number of sperm harvested and a total number of motile sperms (p<0.05). however, the sperm motility after performing density gradient method was not significantly different in both groups (p<0.05). interestingly, pregnancy rate after iui, in female inseminated with semen without leukocytospermia yielded the higher pregnancy rate 39%) (p<0.05) compared to semen with leukocytospermia (30%). discussion the success rate of iui depends on factors such as drugs used for stimulation, triggering time, number of cycles and the total number of motile sperms after washing. a previous study suggested that the number of sperms inserted into uterus will decrease when the number of washed motile sperm is insufficient.6 sperm motility is an important factor in iui because it is an indicator of sperm ability to reach and fertilize the ovulated oocyte. it is reported that the association between leukocyte and sperm quality will depend on concentration with motility percentage increases when the leukocyte concentration is 0 to <1.0 x106/ml and decreases when leukocyte concentration is >1.0x106.7 this fact is contrary to the results of a previous study reported that there was no significant difference between no leukocytes, low-level leukocytes, and leukocytospermia groups in baseline clinical characteristics and conventional parameters that includes semen concentration, motility, and morphology).8 leukocyte, bacteria, and dead spermatozoa produce reactive oxygen species or ros that negatively influence the ability of sperms to fertilize the egg.9 it was reported that patient with low seminal leukocytes concentration (<1.0x106/ml) had significantly higher level of ros and sperm dna damage and there was no significant difference in ros level between low leukocytes level and leukocytospermia.10 a significant positive correlation between leukocytospermia and the oxidative stress has been reported, suggesting that the leukocytes are the primary source of ros in semen.11,12 although the primary source of ros is wbcs, a portion of these ros is produced by sperms. the hydroxyl radical formed through haberweiss reaction will attack unsaturated fatty acids in sperm membrane and initiate lipid peroxidation.12,13 catalase as well as superoxide dismutase are antioxidant enzymes. it is also reported that a positive correlation is found between sperm concentration and superoxide dismutase and a negative correlation is seen with leukocytospermia.14 group with leukocytospermia in this study presented a lower pregnancy rate due to pnml concentration was higher than physiological condition which triggers a higher level of ros production. ros has a correlation with the ability of sperms to fertilize mature oocytes; including two primary factors, a slow rate of forwarding progression of sperm and the presence of excess numbers of white cells in the semen.15 the recent study showed the same result as the result of a previous study by aldujaily reported that the pregnancy rate after :63–6 table parameter pmnl concentration >0 <1 x 106/ml pmnl concentration >1 x 106/ml total harvested sperm (millions) 2.22±0.80a 2.52±0.98b total motile sperms (millions) 1.95±0.67a 2.23±0.84b sperm motility (%) 88.61±6.48a 89.04±5.77a pregnancy rate (%) 39.50±0.50a 30.43±4.70b note: different superscripts in the same row indicate a statistically significant difference (p<0.05). comparison of sperm parameter after performed density gradient method and pregnancy rate after iui on semen with and without leukocytospermia 66 international journal of integrated health sciences. 2018;6(2) iui in leukocytospermic couples was lower compared to normozoospermic couples. the percentage was 20% in normozoospermic and 13.3% in leukocytospermia.16 these findings indicate that leukocytic infiltration into male reproductive tract is only harmful when the contamination level of leucocyte is high enough (>1×106/ml) to overwhelm the antioxidants present in human seminal plasma. the high levels of leucocyte contamination will disrupt the fertility in vivo. the results indicate that leukocytospermia may not have a negative effect on the sperm preparation outcome though it might affect pregnancy rate after intrauterine insemination procedure. the absense of sperm morphology analysis as well as the retrospective nature of the study create limitations in this study. a future prospective study on more patients with sperm morphology assessment is needed. :63–6 references 1. cooper tg, noonan e, von eckardstein s, auger j, baker hw, behre hm, et al. world health organization reference values for human semen characteristics. hum reprod update. 2010;16(3):231–45. 2. aitken rj, koppers aj. apoptosis and dna damage in human spermatozoa. asian j androl. 2011;13(1):36–42. 3. henkel r. sperm preparation: state-of-theart—physiological aspects and application of advanced sperm preparation methods. asian j androl. 2012;14(2):260–9. 4. amiri i, ghorbani m, heshmati s. comparison of the dna fragmentation and the sperm parameters after processing by the density gradient and the swim up methods. j clin diagn res. 2012;6(9):1451–3. 5. shamsi mb, kumar r, dada r. evaluation of nuclear dna damage in human spermatozoa in men opting for assisted reproduction. indian j med res. 2008;127(2):115–23. 6. dorjpurev u, kuwahara a, yano y, taniguchi t, yamamoto y, suto a, et al. effect of semen characteristics on pregnancy rate following intrauterine insemination. j med investigation. 2011;58(1):127–33. 7. lackner je, agarwal a, mahfouz r, du plessis ss, schatzl g. the association between leukocytes and sperm quality is concentration dependent. reprod biol endocrinol. 2010;8(1):12. 8. agarwal a, mulgund a, alshahrani s, assidi m, abuzenadah am, sharma r, et al. reactive oxygen species and sperm dna damage in infertile men presenting with low levekl leukocytospermia. reprod biol endocrinol [serial on the internet]. 2014 dec [cited 2018 jan 8];12(126):[about 8p.]. available f r o m : h t t p s : / / r b e j . b i o m e d c e n t r a l . c o m / articles/10.1186/1477-7827-12-126. 9. domes t, lo kc, grober ed, mullen jb, mazzulli t, jarvi k. the incidence and effect of bacteriospermia and elevated seminal leukocytes on semen parameters. fertil steril. 2012:97(5):1050–5. 10. alshahrani s, agarwal a, assidi m, abuzenadah am, ayaz a, sharma r. the effect of low level leukocytospermia on oxidative stress markers in infertile men. bmc genomics. [serial on the internet]. 2014 apr [cited 2018 jan 8];15(suppl 2):[about 2p.]. available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ pmc4075643/. 11. aggarwal r, puri m, dada r, saurabh g. correlation between leukocytospermia and pxidative stress in male partners of infertile couples with leukocytospermia. int j reprod contracept obstet gynecol. 2017;4(1):168–72 12. sandoval js, raburn d, muasher s. leukocytospermia: overview of diagnosis, implications, and management of a controversial finding. middle east fertil soc j. 2013;18(3):129–34 13. aitken rj, curry bj. redox regulation of human sperm function: from the physiological control of sperm capacitation to the etiology of infertility and dna damage in the germ line. antioxid. redox signal. 2011;14(3):367–81. 14. pasqualotto ff, umezu fm, salvador m, borges e, sobreiro p, pasqualotto b. effect of cigarette smoking on antioxidant levels and presence of leukocytospermia in infertile men: a prospective study. fertil steril. 2008;90(2):278–83. 15. barraud-lange v., pont jc, pocate k, kunstmann jm, chalas-boissonas c, ducot b, wolf jp. seminal leukocytes and clinical outcomes with donor sperm insemination. fertil. steril. 2011;96(6):1320–4 16. al-dujaily ss, al-jnabi mh, jasim sn. the influence of leukocytospermia and teratozoospermia in iui outcome. ijar. 2015;3(11):255–65. pregnancy rate after intra uterine insemination with the presence or absence of leukocytospermia sperms prepared using density gradient method international journal of integrated health sciences. 2017;5(1) 21 original article correspondence: dila larasati, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital jl. raya bandung-sumedang km 21 jatinangor, indonesia e-mail: larasati.dila@gmail.com cognitive function profile of post-stroke patients abstract objective: to discover cognitive function profile of post-stroke patients undergoing rehabilitation to inform rehabilitation professionals in planning for a program and provide services that meet the patient’s need. methods: this study was a descriptive cross-sectional study involving 32 post-stroke patients undergoing rehabilitation at the physical medicine and rehabilitation clinic of dr. hasan sadikin general hospital bandung in august–september 2014. an examination was conducted using the mini mental state examination (mmse) to obtain the cognitive function profile of post-stroke patients. results: the results showed that almost all post-stroke patients undergoing rehabilitation had normal cognitive functions (93.8%), only few patients had probable cognitive impairment (6.2%). probable cognitive impairment were found in male and female patients who were in the age range of 50–60 years who were elementary school graduates and in the sub acute phase of stroke. conclusions: almost all post-stroke patients undergoing rehabilitation have normal cognitive functions, only minority of patients have probable cognitive impairment, and there are no patients with definite cognitive impairment. keywords: cognitive function, education, rehabilitation, stroke pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v5n1.962 ijihs. 2017;5(1):21–5 dila larasati,1 irma ruslina defi,2 henny anggraini sadeli3 1faculty of medicine, universitas padjadjaran 2department of physical medicine and rehabilitation, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital, bandung 3department of neurology, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital, bandung introduction stroke is known as one of the cerebral function abnormalities marked by a sudden decrease in neurological function due to cerebral blood circulation disturbance. globally, stroke has become one of the main causes of disability in adults. statistical data of the american heart association show that around 795.000 people experience stroke every year, with 610.000 cases of them are the first attack of stroke and 185.000 cases are recurrent attacks.1 based on the global burden of diseases, injuries, and risk factors study 2010, stroke is the third leading cause of disability adjusted life years (dalys) lost in the world.2 impaired blood circulation to the brain may lead to tissue damage or death which then interrupts neurological functions, including the cognitive function which is regulated by the tissue. it is estimated that approximately 50% of patients have cognitive impairment in the early phase after stroke and 32% of patients showed persistent cognitive impairment up to three years after the first attack of stroke.3 typically, domains of cognitive function that are interrupted are attention, concentration, memory, and executive functions.4 impaired cognitive functions may affect the ability of post-stroke patients to perform daily activities and also influence the recovery process. the patients with cognitive impairment require specific rehabilitation that is more difficult and time consuming.5 hence, the assessment received: january 10, 2017 revised: february 15, 2017 accepted: march 6, 2017 :21–5 22 international journal of integrated health sciences. 2017;5(1) of cognitive function and the determination of cognitive status in post-stroke patients may provide information for rehabilitation professionals to plan the optimal rehabilitation program and provide services that meet the patient’s needs.6,7 methods this study used a descriptive cross-sectional design and was performed at the physical medicine and rehabilitation clinic of dr. hasan sadikin general hospital bandung during the period of august–september 2014 and was approved by the hospital’s ethical clearance committee with the ethical clearance number lb.04.01/a05/ec/307/vii/2014. the total sampling approach was applied for data collection with a minimum sample size of 82 patients based on the result of the calculation based on the sample size formula for descriptive study for categorical variables. it involved previously-diagnosed post-stroke patients who underwent rehabilitation for the first time in the clinic. there were only 32 posts-stroke patients who met the inclusion criteria, consisting of 20–60 years old poststroke patients who were in a conscious state and cooperative. the exclusion criteria were patients who probably have any cognitive impairment that was not caused by a stroke and aphasia patients. the cognitive status of the subjects was decided based on an interview and observation of post-stroke patients using the mini mental state examination (mmse).8,9 it included the assessment of orientation of place and time, short and long-term memory, registration, recall, constructional ability, language, and the ability to understand and follow commands. the cognitive function was divided into three categories based on the mmse score: normal (24–30), probable cognitive impairment (17–23), and definite cognitive impairment (0–16). the cognitive function profile was obtained from a cross tabulation between the cognitive status and general characteristics of post-stroke patients (gender, age, level of education, and phase of stroke). the phase of stroke was divided into three categories based on the onset of stroke, which were categorized into acute phase (<2 weeks), sub acute phase (2 weeks–6 months), and chronic phase (>6 months). this study used descriptive statistics to analyzed data. the data was then processed using statistical computerized software. results general characteristics of the post-stroke patients in the rehabilitation clinic are shown (table 1). the number of male patients was higher than the female patients. most of patients were in the age range of 50–60 years old. based on the level of education, no patient did not attend school and most patients have graduated from elementary school. cognitive function profile of post-stroke patients in the rehabilitation clinic is portrayed (table 2). in general, the post-stroke patients in this study had normal cognitive functions. only few patients had probable cognitive impairments and no patient had definite cognitive impairment. the number of patients who had normal cognitive function was almost the same, while the number of patients with probable cognitive impairment consisted of 1 male and 1 female patients. patients with probable cognitive impairment were in the age range of 50–60 years old, graduated from elementary school and were in the sub acute phase of stroke. more than a half of the patients were in the sub acute phase and there was no patientg in the acute phase. the number of patients who were in the sub acute phase was higher than patients in the chronic phase. gender totalmale (n=18) female (n=14) age (year) 20–29 0 0 0 30–39 0 0 0 40–49 4 4 8 50–60 14 10 24 level of education not attend school 0 0 0 elementary school 7 4 11 middle school 1 6 7 high school 5 4 9 university 5 0 5 phase of stroke acute 0 0 0 sub acute 15 9 24 chronic 3 5 8 cognitive function profile of post-stroke patients :21–5 table 1 general profile of post-stroke patients based on gender international journal of integrated health sciences. 2017;5(1) 23 dila larasati, irma ruslina defi, et al. discussion impaired cognitive function may affect the ability of post-stroke patients to perform their daily activities as well as influencing the recovery process. this study aimed to discover the cognitive function profile of post-stroke patients undergoing rehabilitation to provide information for rehabilitation professionals in order to plan the program and provide services including tools or human resources that can be involved in rehabilitation of post-stroke patients with or without cognitive impairment based on patient’s characteristics. the post-stroke patients in rehabilitation were mostly in the age range of 40–60 years old. this result was in accordance with data from the centers for disease control and prevention that showed that the prevalence of stroke increases with age.10 according to the centers for disease control and prevention, cognitive impairment did not occur only on one type of disease and was not limited to a specific age group.11 however, in this sudy, patients with probable cognitive impairment were in the age range of 50–60 years old. the number of male patients was higher than female patients. this was in accordance with data from the framingham heart study which stated that women aged 45–84 years had a lower risk of having a stroke compared to men, but this relationship reversed at older ages, with an increased risk of stroke in women aged over 85 years, making it higher that the risk for men. a study in sweden also noted that the incidence of stroke in women is less than men at the age of 55–64 years, but at the age of 75–85 years, the incidence of stroke in women is higher than men.1 according to the stroke association, one of the cognitive impairments that can be caused :21–5 table 2 cognitive function profile of post-stroke patients cognitive function totalnormal (n=30) probable cognitive impairment (n=2) definite cognitive impairment (n=0) age (year) 20–29 0 0 0 0 30–39 0 0 0 0 40–49 8 0 0 8 50–60 12 2 0 14 gender male 17 1 0 18 female 13 1 0 14 level of education not attend school 0 0 0 0 elementary school 9 2 0 11 middle school 7 0 0 7 high school 9 0 0 9 university 5 0 0 5 phase of stroke acute 0 0 0 0 sub acute 22 2 0 24 chronic 8 0 0 8 24 international journal of integrated health sciences. 2017;5(1) by a stroke is vascular dementia, which is about 20% of all cases of dementia.12 more than a quarter of those who experienced a stroke suffered vascular dementia in three months.12 cognitive impairment was more common in men because of the factors associated with a higher risk of stroke in men. based on the level of education, the results of this study indicated that patients with probable cognitive impairment were graduated from elementary school. although there was no large number when compared with patients with normal cognitive function, this result was in accordance with research centers for disease control and prevention which stated that the prevalence of stroke is higher in adults with lower levels of education.10 patients with higher level of education have a life style and risk factor profile that can prevent cognitive decline.13 the frequency of cognitive impairment in the acute phase of stroke is estimated to be more than 70% but, in the first week and a few months after stroke, recovery of cognitive function occurs through the re-canalization followed by reperfusion or brain plasticity.14 the process of functional recovery in poststroke patients can still continue to occur up to a certain extent, especially in the first 3–6 months after a stroke or is in the sub acute phase of stroke rehabilitation.5 according to the results, most of the patients who come for rehabilitation were in the sub acute phase. patients with probable cognitive impairment were also in the sub acute phase of stroke so cognitive impairment may turn to normal either during the rehabilitation or after it. this study used mmse as the instrument to obtain the cognitive profile for the reason that its administration is short and that it is was easy to use. the mmse is as brief assessment tools particularly used in primary care and probably the most common way to do routine screening compared to other instruments.15 the mmse is moderately sensitive (0.66) to cognitive impairment but has a very good specificity (0.97).16 limitation in this study is the number of samples did not meet the minimum number of samples required because the number of new patients in the clinic of physical medicine and rehabilitation dr. hasan sadikin general hospital bandung is relatively less compared with patients who have undergone treatment. this study was also limited by the minimum amount of time so that the required sample size could not be fulfilled. the results of this study cannot be generalied because this study only took post-stroke patients population undergoing rehabilitation at dr. hasan sadikin general hospital bandung, so it cannot represent the whole population of indonesia or the global population. based on these limitations, it is suggested that further research is carried out in a longer time to obtain a sufficient sample size to represent the general population. in addition, further research needs to be done regarding the location of the lesion in the brain so the appropriate rehabilitation program can be provided. rehabilitation professionals is expected to provide services in accordance with the needs of patients, especially patients with probable cognitive impairment and patients who are in the sub acute phase of stroke. appropriate rehabilitation programs like brain games are needed for patients with impaired cognitive function. participation of patients and their families are also needed in the process of cognitive function and overall functional recovery. it is concluded that the majority of the poststroke patients undergoing rehabilitation have normal cognitive functions (93.8%) and only a small number of patients have probable cognitive impairment (6.2%). no patient has been shown as having a definite cognitive impairment. patients with probable cognitive impairment may associate with older age, lower educational level, and earlier phase of stroke. :21–5 references cognitive function profile of post-stroke patients 1. go as, mozaffarian d, roger vl, benjamin ej, berry jd, blaha mj, et al. heart disease and stroke statistics—2014 update: a report from the american heart association. circulation. 2014;129(3):e28–292. 2. murray cjl, vos t, lozano r, naghavi m, flaxman ad, michaud c, et al. disability-adjusted life years (dalys) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the global burden of disease study 2010. lancet. 2012;380(9859):2197–223. 3. pinter mm, brainin m. rehabilitation after stroke in older people. maturitas. 2012;71(2):104–8. international journal of integrated health sciences. 2017;5(1) 25:21–5 4. hoffmann t, bennett s, koh c, mckenna k. a systematic review of cognitive interventions to improve functional ability in people who have cognitive impairment following stroke. topics stroke rehabilitation. 2010;17(2):99–107. 5. wirawan rp. stroke rehabilitation in primary health care. maj kedokt indon. 2009;59(2):61– 71. 6. korner-bitensky n, barrett-bernstein s, bibas g, poulin v. national survey of canadian occupational therapists’ assessment and treatment of cognitive impairment post-stroke. aust occup ther j. 2011;58(4):241–50. 7. gurr b, ibbitson j. how does cognitive ability affect stroke rehabilitation outcomes? int j ther rehabil. 2012;19(8):458–62. 8. folstein mf, folstein se, mchugh pr. “minimental state”: a practical method for grading the cognitive state of patients for the clinician. j psychiatric res. 1975;12(3):189–98. 9. folstein mf, robins ln, helzer je. the minimental state examination. arch general psychiatry. 1983;40(7):812. 10. centers for disease control and prevention. prevalence of stroke--united states, 20062010. mmwr. 2012;61(20):379–82. 11. centers for disease control and prevention. cognitive impairment: a call for action, now! 2011. [cited 2015 jan 6]. available from: https://www.cdc.gov/aging/pdf/cognitive_ impairment/cogimp_poilicy_final. 12. the stroke association. cognitive impairment after stroke. 2010. 13. khedr em, hamed sa, el-shereef hk, shawky oa, mohamed ka, awad em, et al. cognitive impairment after cerebrovascular stroke: relationship to vascular risk factors. neuropsychiatr dis treatment. 2009;5:(1):103–16. 14. danovska m, peychinska d. post-stroke cognitive impairment–phenomenology and prognostic factors. journal of imab–annual proceeding scientific papers. 2012;18(3):290– 7. 15. cullen b, o’neill b, evans jj, coen rf, lawlor ba. a review of screening tests for cognitive impairment. j neurol neurosurg psychiatry. 2007;78(8):790–9. 16. 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(6):1712–6. 17. cumming tb, churilov l, linden t, bernhardt j. montreal cognitive assessment and minimental state examination are both valid cognitive tools in stroke. acta neurol scand. 2013;128(2):122–9. 18. pendlebury st, mariz j, bull l, mehta z, rothwell pm. impact of different operational definitions on mild cognitive impairment rate and mmse and moca performance in transient ischaemic attack and stroke. cerebrovasc dis. 2013;36(56):355–62. 19. oudman e, postma a, van der stigchel s, appelhof b, wijnia jw, nijboer tc. the montreal cognitive assessment (moca) is superior to the mini mental state examination (mmse) in detection of korsakoff ’s syndrome. clin neuropsychol. 2014;28(7):1123–32. 20. olazarán j, hoyos-alonso mc, del ser t, garrido barral a, conde-sala jl, bermejo-pareja f, et al. practical application of brief cognitive tests. neurologia. 2016;31(3):183–94. dila larasati, irma ruslina defi, et al. international journal of integrated health sciences. 2018;6(2) 91 ethanol extract of stylissa carteri induces cell death in parental and paclitaxel-resistant cervical cancer cells introduction despite the availability of advanced treatment options, cancers remain one of the major causes of mortality in the world after cardiovascular diseases. data from world health organization (who), cancer was responsible for 8.8 million deaths in 2015. one of the deadliest cancers is cervical cancer.1 in indonesia, cervical and breast cancers are cancers with the highest prevalence among women. between 2005 and 2007, jakarta cancer registry has reported that the prevalence of cervical cancer in jakarta is 9.25/100,000 population.2 people’s lifestyle, environmental changes, and possible genetic factors increase the risk for cervical cancer, creating a serious threat for women. several treatment options are available for cervical cancer including surgery, radiotherapy, chemotherapy, as well as their combination.3 the standard chemotherapy regimens used are the combination of cisplatin or paclitaxel therapy.3 chemotherapy, as adjuvant therapy, plays an important role in preventing the recurrence and metastasis, thus increasing the life sustainability of cervical cancer patients. unfortunately, some patients become abstract objective: to evaluate the cytotoxic effects of ethanol extract from marine sponge stylissa carteri in both parental and paclitaxel-resistant hela cervical cancer cells. methods: this was an experimental in-vitro study subjected ethanol extract from stylissa carteri obtained from pramuka island, kepulauan seribu national park, jakarta. both parental and paclitaxel-resistant hela cells were treated with ethanol extract followed by microscopic observation and mtt assay. the ic50 and drug curves were analyzed using four-parametric logistic regression by sigmaplot for windows version 12.0 from systat software inc., usa. results: ethanol extract from stylissa carteri triggered cell death-associated morphological changes in parental hela cells. it demonstrated cytotoxic activities with an ic50 value of 1 ppm. importantly, this extract also triggered cell death in paclitaxel-resistant hela cells. the ic50 of ethanol extract of stylissa carteri was 4 ppm in paclitaxel-resistant hela cells. conclusions: there is a potential cytotoxic activity of stylissa carteri that is not only confirmed in parental hela cells but also in paclitaxel-resistant hela cells. keywords: cervical cancer, paclitaxel resistance, hela cells, cytotoxicity assay, stylissa carteri pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v6n2.1378 ijihs. 2018;6(2):91–6 received: august 2, 2018 revised: september 18, 2018 accepted: september 19, 2018 isna nisrina hardani,1 fachreza aryo damara,1 annisa dewi nugrahani,1 muhammad hasan bashari2,3 1undergraduate medical program, faculty of medicine, universitas padjadjaran 2division of pharmacology and therapy, department of biomedical sciences, faculty of medicine, universitas padjadjaran 3oncology and stem cell research group, faculty of medicine, universitas padjadjaran correspondence: muhammad hasan bashari, division of pharmacology and therapy, department of biomedical sciences, faculty of medicine, universitas padjadjaran jl. eyckman no.38 bandung 40161, indonesia e-mail: bashari@unpad.ac.id :91–6 original article 92 international journal of integrated health sciences. 2018;6(2) resistant to chemotherapy drugs including to paclitaxel. in advanced cervical cancer, the overall response rate and the median overall survival are 29.1–67% and 12.87 months, respectively.4,5 therefore, discovering a novel anticancer agent is very crucial. stylissa carteri, a marine sponge which is widely distributed in the indonesian exclusive economic zone (eez), has been recognized for its therapeutic potentials, especially for its anticancer properties.6 based on our previous studies, ethanol extract of stylissa carteri has been proven to induce cell death and to inhibit the cell proliferation of colon cancer cell lines as well as breast cancer cell lines (unpublished data). hence, stylissa carteri is thought to have a potential to target cervical cancer cells. the anticancer property potential of marine sponge stylissa carteri needs to be unravelled. therefore, the analysis of cytotoxic activity of marine sponge extract and its potential toward paclitaxel resistance was conducted through the evaluation of cell death using mtt assay method in parental as well paclitaxel-resistant hela cervical cancer cells. methods subjects of this study were ethanol extract from stylissa carteri gained from fresh sample collected in pramuka island, kepulauan seribu national park, jakarta, indonesia. stylissa carteri was collected and identified by beginner subhan, m.sc. from bogor agricultural university then extracted by harold atmaja. this study was conducted on cervical cancer cell lines that included parental hela cells obtained from ahmad faried, dr., sp.bs., ph.d. (dr. hasan sadikin general hospital, bandung, indonesia) and paclitaxelresistant hela cells. the paclitaxel-resistant hela cells were generated by culturing parental hela cells with stepwise escalating concentration of paclitaxel (gifted by pratiwi, apt. from pharmacy dr. hasan sadikin general hospital, bandung, indonesia) to have 3.5fold resistance which already represented clinically-relevant resistance.7 both parental and paclitaxel-resistant hela cells were cultured in rpmi medium (cat no. 11875093, gibco, usa) that was supplemented with 10% fetal bovine serum (fbs) (cat no. 10270106, gibco, usa) and 1% penicillin-streptomycin. cells were incubated in an incubator with a controlled temperature at 37 oc containing 5% co2. the cells were sub-cultured until reaching 80–90% confluence. cytotoxic effects of the ethanol extract of stylissa carteri in both hela cells was evaluated by using the mtt assay (3-[4.5-dimethylthiazol2-yl]-2.5 diphenyl tetrazolium bromide, cat no. m2128, sigma-aldrich, usa), with a procedure as described in a previous study.8 the cells were seeded on 96-well plate then untreated or treated with sponge extract based on the indicated concentrations and then followed :91–6 ethanol extract of stylissa carteri induces cell death in parental and paclitaxel-resistant cervical cancer cells microscopic appearance of parental hela cells of untreated (control) (a) and treated with ethanol extract of stylissa carteri with the following concentrations: 5 ppm (b), 50 ppm (c), and 100 ppm (d) (magnification 100x) fig. 1 international journal of integrated health sciences. 2018;6(2) 93 isna nisrina hardani, fachreza aryo damara, et al. :91–6 fig. 2 cell death curve showing the percentage of parental hela cell death upon a serial concentration of ethanol extract of stylissa carteri table ic parent paclitaxel-resistant fold of resistance concentration (nm) 50 0.015 0.052 3.5 75 0.061 2.011 33.0 90 0.327 10.337 31.6 note: ic=inhibitory concentration fig. 3 cell death curve of paclitaxel comparing the parental and paclitaxel-resistant hela cells fold of resistance of paclitaxel in paclitaxel-resistant hela cells by incubation for 72 hours. subsequently, cells were exposed to mtt reagent followed by stop reaction using dimethyl sulfoxide (dmso, cat no. d8418, sigma-aldrich, usa). then, the absorbance was measured using plate reader with 550 nm of wavelength. cell death percentage was calculated by using sample’s absorbance, control’s absorbance, and also blank absorbance. the experiments had been triplicated. all procedures were conducted in the laboratory of cell culture and cytogenetic, faculty of medicine, universitas padjadjaran, indonesia. the data was analyzed using fourparametric logistic regression by sigmaplot for windows version 12.0 software from systat software inc., usa. this study was supported by program kreativitas mahasiswa (no. 141/ spk/km/iv/2018) from kemenristekdikti for inh and competence research grant from universitas padjadjaran for mhb (no.2476/ un6.c/lt/2018). results to evaluate the cytotoxic effects of the ethanol extract from stylissa carteri, mtt assay was applied on parental and paclitaxel-resistant hela cells. the evaluation using mtt assay was started in the parental hela cells. prior to the exposure to mtt reagent, we observed morphologic appearance of parental hela cells that were untreated and treated with ethanol extract of stylissa carteri under microscope. data showed that an increasing of cell death-associated morphological changes along with the raising of concentration of the sponge extract (fig. 1). quantification of the cytotoxic effect was performed through measuring well absorbance and calculating the percentage of cell death after incubating the parental hela cells with mtt reagent for about 4 hours. data showed that the ethanol extract of stylissa carteri induced cell death in parental hela cell line in a dose-dependent manner (fig. 2). the ic50 of the ethanol extract from stylissa carteri was achieved at 1 ppm in the parental hela cells. the ic50 as well as the cell death curve were predicted and analyzed using four-parametric logistic regression with r square of 0.9942. then, the cytotoxic effect of ethanol extract of stylissa carteri in paclitaxel-resistant hela cells was evaluated. at first, the paclitaxel resistant hela cells were less sensitive to 94 international journal of integrated health sciences. 2018;6(2):91–6 microscopic appearance of paclitaxel-resistant hela cells of untreated (control) (a) and treated with ethanol extract of stylissa carteri with the following concentrations: 5 ppm (b), 50 ppm (c), and 100 ppm (d). (magnification 100x) fig. 4 fig. 5 cell death curve showing the percentage of paclitaxel-resistant hela cell death against a serial concentration of ethanol extract of stylissa carteri ethanol extract of stylissa carteri induces cell death in parental and paclitaxel-resistant cervical cancer cells paclitaxel-induced cell death (fig. 3) with 3.5fold resistance against paclitaxel compared to parental hela cells (table). evaluation was continued with evaluating cell morphology of paclitaxel-resistant hela cells by inverted microscope upon treatment of ethanol extract of stylissa carteri. similar to the parental hela cells, the observation of paclitaxel-resistant hela cells also indicated the increasing of cell death along with the raising of concentration of the extract (fig.4). the cytotoxic activity of the ethanol extract of stylissa carteri was then evaluated using mtt assay. interestingly, this extract was also triggered cell death in paclitaxel-resistant hela cells in a dose-dependent manner which r square was valued at 0.9793 (fig. 5). the ic50 of ethanol extract of stylissa carteri was 4 ppm in paclitaxel-resistant hela cells. discussion stylissa carteri has become one of the well distributed sponges in indonesian maritime. moreover, it has known that stylissa carteri was also found in pacific’s ocean overspread to australia. previous study had been conducted to evaluate the anticancer effects from stylissa carteri collected from indonesian marine sea.9 the study showed that the crude methanol extract of stylissa carteri has cytotoxic effect in hela cervical cancer cell line with ic50 value 30 ppm.9 on the other hand, this study has proven that the ic50 value of ethanol extract of stylissa carteri on parental hela cell was 1 ppm. a remarkable difference of ic50 value between the previous study and our study can be discovered. this different value is possibly resulted from different places of sponge collection. a previous study collected the sponges from latondu island, sulawesi while this study collected the sponges from pramuka island, kepulauan seribu national international journal of integrated health sciences. 2018;6(2) 95 references 1. stewart bw, wild cp. world cancer report 2014. geneva: world health organization; 2014. 2. wahidin m, noviani r, hermawan s, andriani v, ardian a, djarir h. population-based cancer registration in indonesia. asian pacific j cancer prev. 2012;13(4):1709–10. 3. marth c, landoni f, mahner s, mccormack m, gonzalez-martin a, colombo n, et al. cervical cancer: esmo clinical practice guidelines for diagnosis, treatment and follow-up. ann oncol. 2017;28(suppl 4):iv72–83. 4. zhu h, luo h, zhang w, shen z, hu x, zhu x. molecular mechanisms of cisplatin resistance in cervical cancer. drug des devel ther [serial on the internet]. 2016 jun [cited 2018 apr 9];2016(10):[about 11p.]. available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ pmc4907638/. 5. peng x, gong f, chen y, jiang y, liu j, yu m, et al. autophagy promotes paclitaxel resistance of cervical cancer cells: involvement of warburg effect activated hypoxia-induced factor 1-α-mediated signaling. cell death dis. [serial on the internet]. 2014 aug [cited 2018 apr 7];5(8):[about 11p.]. available from: https:// www.nature.com/articles/cddis2014297. 6. o’rourke a, kremb s, bader tm, helfer m, schmitt-kopplin p, gerwick wh, et al. alkaloids :91–6 isna nisrina hardani, fachreza aryo damara, et al. park, jakarta. the different characteristics of water inhabits the sponge is causing chemical substantial difference due to the physiology of stylissa carteri sponge that they are dependent on characteristic of water which constantly flow through their pores. hence, the character of sponge’s environment is very determining the quality of chemical compounds within stylissa carteri extract.10 this study evaluated potential anti-cancer effects of stylissa carteri on hela paclitaxelresistant cancer cell line. the results showed that the ic50 value in hela paclitaxel-resistant cancer cell line was 4 ppm. therefore, stylissa carteri sponge extract can significantly kill the paclitaxel-resistant hela cells. stylissa carteri extract has very potential anticancer compounds that need to be furtherly evaluated. moreover, data in this study showed the ic50 of ethanol extract of stylissa carteri in both parental hela cells and paclitaxel-resistant hela cell lines were very low, indicating a strong cytotoxic activity. chemical screening and isolated compound evaluation of stylissa carteri has shown that sponge extract contains a group of chemical compounds of cyclic peptides, alkaloid, and triterpenoid. the latest data from prior study has also shown towards the use of ethanol extract of stylissa carteri also proved that is causing cell death and inhibition of cells proliferation and migration in both breast cancer and caco-2 colon cancer cells (unpublished data). among of those three groups of compound, cyclic peptides and alkaloid had proven that have anticancer effects and triterpenoid has anti-inflammation effects.9 the cyclic peptide compounds of stylissa carteri have direct cytotoxic effect toward cancer cells as well as inhibiting angiogenesis. the cytotoxic effects of cyclic peptide was associated with pro-apoptotic proteins such as bax, bak, and bh3-only protein.11 moreover, the inhibition of angiogenesis is resulted from cyclic peptide compounds through inhibition vegf expression in cancer cells.12 in addition, alkaloid contained in sponge extract has significant role as the inhibitor of ubiquitin enzyme complex formation with proteasome that will p53 activity to lower the excessive cell proliferation activity in cancer cells and also cause apoptosis induction for proliferated cells.6,12 an evaluation of stylissa carteri extract as their potential as anticancer agent has been conducted. stylissa carteri ethanol extracts were treated toward parental hela cells and also paclitaxel-resistant hela cells. the study results revealed that stylissa carteri extract induces cell death significantly among both of cell lines. however, this study was limited due to only using simple in vitro functional assay for cytotoxicity. moreover, we also only used a crude ethanol extract of stylissa carteri. a follow up study is conducting to further analyze the anticancer activity of stylissa carteri not only by determining the molecular mechanism of stylissa carteri against cancer cells but also isolating the bioactive compounds. in conclusions, this study indicates the potential of bioactive compounds from ethanol extract of stylissa carteri to overcome cervical cancer, particularly in chemotherapy resistance. 96 international journal of integrated health sciences. 2018;6(2) from the sponge stylissa carteri present prospective scaffolds for the inhibition of human immunodeficiency virus 1 (hiv-1). mar drugs. [serial on the internet]. 2016 feb [cited 2018 apr 9];102(6):[about 10p.]. available from: http://www.mdpi.com/16603397/14/2/28. 7. mcdermott m, eustace aj, busschots s, breen l, crown j, clynes m, et al. in vitro development of chemotherapy and targeted therapy drug-resistant cancer cell lines: a practical guide with case studies. front oncol [serial on the internet]. 2014 mar [cited 2018 apr 9];4(40):[about 16p.]. available from: 2https:// w w w. f r o n t i e r s i n . o r g / a r t i c l e s / 1 0 . 3 3 8 9 / fonc.2014.00040/full. 8. bashari mh, fan f, vallet s, sattler m, arn m, luckner-minden c, et al. mcl-1 confers protection of her2-positive breast cancer cells to hypoxia: therapeutic implications. breast cancer res [serial on the internet]. 2016 mar [cited 2018 apr 9];18(1):[about 15p.]. available from: http://www.ncbi.nlm. n i h . g ov / p u b m e d / 2 6 9 2 1 1 7 5 % 5 c n h t t p : / / www.pubmedcentral.nih.gov/articlerender. fcgi?artid=pmc4769490. 9. dewi as, suhita a. when east meets west: the chemistry of indonesian sponges and australian nudibranchs. [dissertation]. queensland; the university of queensland; 2017. 10. lin y-c, tan f, marra kg, jan s-s, liu d-c. synthesis and characterization of collagen/ hyaluronan/chitosan composite sponges for potential biomedical applications. acta biomater. 2009;5(7):2591–600. 11. boohaker rj, lee mw, vishnubhotla p, perez jm, khaled ar. the use of therapeutic peptides to target and to kill cancer cells. curr med chem. 2012;19(22):3794–804. 12. afifi ah, el-desoky ah, kato h, mangindaan rep, de voogd nj, ammar nm, et al. carteritins a and b, cyclic heptapeptides from the marine sponge stylissa carteri. tetrahedron lett. 2016;57(11):1285–8. :91–6 ethanol extract of stylissa carteri induces cell death in parental and paclitaxel-resistant cervical cancer cells 30 international journal of integrated health sciences. 2018;6(1) original article relationship between gymnastics exercise and insomnia in elderly abstract objective: to analyze the relationship between gymnastics exercise and insomnia in elderly. methods: this study involved 60 elderly as the respondents. the respondents were divided into two groups: group 1 consisting of elderly who practiced gynmastics exercise and group 2 consisting of elderly who did not practice gymnastics exercise. the members of group 1 were enrolled from 3 gymnastic groups in 3 villages in jatinangor, west java, indonesia and the members of group 2 were elderly who lived in the same villages as the elderly in group 1. the inclusion criteria were elderly women who could communicate effectively and with a mini mental state examination (mmse) score of >23. particularly for group 1, additional criteria were applied, i.e. elderly who did gynmastics exercise minimal once a month and each exercise lasted for at least one hour. insomnia level was determined using the insomnia severity index (isi). this study was carried out in june 2017. homogeneity of the groups was examined using proportion difference test and data were analyzed using chi-square test and one way anova. results: insomnia prevalence was 56.6% but insomnia prevalence in group 2 was higher (43.3%) than that of group 1 (13.3%). this study discovered that there was significant relationship between gymnastics exercise and insomnia in elderly (p=0.000). referring to the frequency of the gymnastics exercise, significant relationship between gymnastics exercise and insomnia in elderly was also found (p=0.040). conclusions: gymnastics exercise is a promising nonpharmacologic therapy to treat insomnia in elderly. keywords: elderly, insomnia, gymnastics exercise pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v6n1.1132 ijihs. 2018;6(1):30–5 introduction indonesia is currently facing increased number of elderly (>60 years old) due to rise in life expectancy and reduction of total fertility. during the past 10 years, the life expectancy has increased from 70.9 years in 2015–2020 to 72 years in 2025–2030.1 additionally, the percentage of elderly is increasing persistently. in 2015, the percentage of elderly was 8.5% but this percentage is estimated to approximately 11.8% in 2025.1 physical or psychological health problems may occur during aging, including problems related to sleep-wake cycle. the sleep-wake cycle problem that is most commonly found in elderly is insomnia.2 insomnia is known as a condition of difficulty to fall asleep, maintain sleep, wake up very early in the morning, or lower quality of sleep that relates to daytime activity interferences, such as tiredness and memory disturbance.3 insomnia prevalence in elderly may vary in various countries. a previous study conducted by kim et al.2 in south korea found that 29.2% of citizen >65 years had insomnia. another study in egypt stated that the percentage of elderly who had insomnia was 33.6% while in taiwan the insomnia prevalence among elderly was fauziah nurillah nasa,1 sharon gondodiputro,2 lina rahmiati2 1diploma iv of midwifery program, faculty of medicine, universitas padjadjaran 2department of public health, faculty of medicine, universitas padjadjaran correspondence: fauziah nurillah nasa, diploma iv of midwifery program, faculty of medicine, universitas padjadjaran jl. raya bandung-sumedang km 21 jatinangor, indonesia e-mail: fnurillahnasa@gmail.com received: november 10, 2017 revised: december 12, 2017 accepted: february 22, 2017 :30–5 international journal of integrated health sciences. 2018;6(1) 31 41%.4,5 studies on insomnia among indonesian elderly are limited; however, a study which was conducted in bali, indonesia has discovered a high insomnia prevalence (40%).6 many factors may cause insomnia. a study by jaussent et al.7 reported that age, female, sleeping pill consumption, nightmare, chronic diseases, and depression are among factors that cause insomnia in elderly. furthermore, previous studies revealed that lower education background and smoking may also becaome factors that lead to insomnia.8,9 insomnia in elderly can be treated by using treatments that are pharmacological and nonpharmacological in nature. good sleep hygiene, sleep restriction, cognitive behavioral method, relaxation, stimulus control therapy, as well as physical activities/exercise are among the known non-pharmacological approaches10 in elderly, physical activities do not only treat sleeping problems but also makes elderly to be more healthy.10–13 the type and intensity of exercise for elderly should be adapted to their specific condition.14,15 one of the types of exercise that is easy for elderly is gymnastics exercise. this study aimed to understand the relationship between gymnastics exercise and insomnia in elderly. methods this was a cross-sectional analytical study comparing two groups, elderly group who did exercise and elderly group who did not do any exercise. the study was performed on elderly people who, at the time of the study, lived in jatinangor sub-district, sumedang, west java province, indonesia. the study was conducted in june 2017 and has been approved by the health ethics committee, faculty of medicine, universitas padjadjaran through the issuance of ethical clearance number 577/un6.c10/ pn/2017. a sampling calculation method was used to determine the total number of respondents. thirty respondents were recruited for each group. the inclusion criteria were elderly women whose age was 60 years or above, able to communicate effectively with comprehensive language, did not have dementia proven by a mini mental state examination (mmse) score of >23. an additional inclusion criterion were applied for the first group, i.e. elderly who joined gymnastics exercise class for the last month and attended exercise class for elderly minimum once a month. the exclusion criteria in this study were elderly who had chronic diseases and those who did not want to participate in the study. in jatinangor sub district, 3 out of 7 villages had elderly gymnastics exercise groups with a total number of members of 35. the number of elderly who did not join gymnastics exercise group was 34. the respondents’ names and addresses were recorded through interviews done by cadres. before the study was started, the respondents were given information on the aim of this study. the respondents who understood and agreed to participate filled and signed the informed consent. the mmse test was then performed. if the score was >23, insomnia measurement were then carried out by using the insomnia severity index (isi). :30–5 fauziah nurillah nasa, sharon gondodiputro, et al. table 1 respondents’ age and educational background distribution characteristics gymnastics exercise group non-gymnastics exercise group total (n) (n) (n) age (yrs.) 60–69 27 26 53 >70 3 4 7 educational background primary school 13 15 28 junior high school 10 9 19 senior high school 4 3 7 college graduate 3 3 6 total 30 30 60 32 international journal of integrated health sciences. 2018;6(1) relationship between gymnastics exercise and insomnia in elderly gymnastics exercise frequency (n) 1x in a month 6 2x in a month 7 3x in a month 10 4x in a month 7 total 30 insomnia severity index is one of the most widely used distinctive test to measure sleep problems. the american thoracic society or ats stated that this test contains 7 items with questions on the severity of sleep onset, sleep maintenance, and early morning awakening problems, sleep dissatisfaction, interference of sleep, difficulties with daytime functioning, noticeability of sleep problems by others, and distress caused by the sleep difficulties.16, the recall period is the “last week”. a 5-point likert scale is used to rate each item (0=no problem; 4=very severe problem), yielding a total score that ranges from 0 to 28. the level of insomnia is classified into the following 4 categories: absent of insomnia (0–7), sub-threshold of insomnia (8–14), moderate insomnia (15–21), and severe insomnia (22–28). the appropriate frequency of gymnastics exercise for elderly is stated as once a week or four times a month. in this current study, the gymnastics exercise frequency was divided into the following 4 categories, once a month, twice a month, three times a month, and four times a month. the typical gymnastics exercise lasted 60 minutes: 15 minutes warming up, 30 minutes main course, and 15 minutes cooling down. the respondents’ characteristics documented were age and educational background. two age groups were used: 60–69 years old and ≥70 years old age group. four categories were applied for educational background: primary school, junior high school, senior high school, and college graduate. data homogeneity for respondents’ age data in both groups was analyzed by using proportion difference test. data were then examined statistically by using chi-square test for comparative analysis of two unpaired groups and one way anova for comparative analysis of more than two groups. results this study included sixty respondents and discovered that the age distribution in both groups was homogeneous based on the results of two groups’ proportion difference test. the majority of the respondents were in the 60– 69 years old age group with lower educational background (table 1). in the gymnastics exercise group, most of the respondents exercised three times a month with only 7 respondents exercised four times a month (table 2). the absent of insomnia was found in 22 respondents who did gymnastics exercise (table 3) although 4 respondents in the nongymnastics exercise group also did not have insomnia. total number of respondents in gymnastics exercise and non-gymnastics exercise groups who had insomnia were 34 (table 4). the p value significance for the chi-square test awas 0.000 (<0.05). this showed that a relationship between gymnastics exercise and insomnia in elderly was found. most respondents who did exercises more than once a month presented a lower insomnia level (table 5). higher risk of severe insomnia was frequently found in elderly who exercised once a month. based on the results using one way anova, the p value significance for this was 0.040 (<0.05). discussion elderly may experience various health-related problems, including insomnia, which disturb daily activities.2 insomnia prevalence in many :30–5 score gymnastics exercise group non gymnastics exercise group (n) (n) absent insomnia 22 4 sub threshold insomnia 6 15 moderate insomnia 2 9 severe insomnia 0 2 total 30 30 table 2 gymnastics exercise frequency per month insomnia level based on insomnia severity index table 3 international journal of integrated health sciences. 2018;6(1) 33:30–5 fauziah nurillah nasa, sharon gondodiputro, et al. countries varied between 20–40%.2,4–6 in this study, insomnia prevalence is quite high when compared to the previous studies. this higher percentage was caused by higher percentage of elderly who did not exercise while insomnia prevalence of elderly who exercised was lower. based on the statement made by widianti and proverawati in yurintika, the exercise for elderly is typically light and easy to perform.16 atikah and suarti as quoted by manangkot added that the exercise for elderly contains a sequence of easy rhythmic motions involving all muscles and joints.17 this exercise also has recreational elements and flexible, so that it can be done both indoor and outdoor. this study discovered that there was a relationship between gymnastics exercise and insomnia. a theory that elaborates relationship between physical activities, including exercise, and sleep is the thermoregulation effect theory.10,11 this theory stated that physical activity/exercise can increase human body temperatur and stimulate body to decrease the temperature mechanically by releasing heat. hence, blood flow to the skin increases, which can stimulate process of sleeping.10,11 glotzbach and heller, as stated in varrasse and passos, revealed that insomnia may occur due to the failure in temperature downregulation at night.10,11 another theory which explains the effect of physical activity/exercise on sleep is the anxiolytic and antidepressant effect theory.10,11 anxiety is suggested to play a major role in insomnia10,11 because one of several symptoms frequently found in insomnia is anxiety.10 a previous study has revealed that patients with chronic insomnia can decrease their anxiety before sleeping by practicing aerobic exercise with a moderate intensity.10 another study found that there are several positive effects between aerobic exercise and sleep quality, as well as reduction of depression symptoms.11 it is believed that physical activity/exercise can improve immune functions.10 in healthy elderly men, some evidence were found to support this notion, including a decrease in awakening time, rapid eye movement (rem) latency, interleukin-6 (il-6), tumor necrosis factor-α (tnf-α), tnf-α/interleukin-10 (il10) ratio, and increased il-10 level.10 different insomnia levels were found to be affected by the exercise frequency in a table 4 relationship between exercise and insomnia in elderly exercise insomnia total (n) p value yes (+) no (-) (n) (n) yes (+) 8 22 30 0.000 no (-) 26 4 30 total 34 26 60 exercise for elderly insomnia total (n) p value yes (+) no (-) (n) (n) 1x in a month 4 2 6 0.040 2x in a month 1 6 7 3x in a month 3 7 10 4x in a month 0 7 7 total 8 22 30 table 5 relationship between gymnastics exercise for elderly and insomnia based on exercise frequency 34 international journal of integrated health sciences. 2018;6(1) month. in elderly who exercised four times a month, significant insomnia level was not found. this condition is different for elderly who did exercises less than 3 times in a month where moderate insomnia was found. several studies on exercise duration to maintain sleep quality reported different results. allessi in passos et al.11 did not found any effect of exercising for 8 weeks but ferris in passoss et al.11 found improvements after exercising for 3 months. these findings shows the possibility of the involvement of other factors in causing insomnia. the findings in this study should also be carefully interpreted as the sleep quality assessment conducted was considered to be subjective because data were collected using a questionnaire that only relies on respondents’ ability to recall the facts. other limitation in the study was that other risk factors contributed to insomnia are not identified. some elderly who were in non-gymnastics exercise group actually performed another form of exercise such as walking in the morning twice to three times a week and this can create a bias in the analysis of this study because this study only focused on “gymnastics exercise” only. hence, a relationship between gymnastics exercise, gymnastics exercise frequency, and insomnia prevalence in elderly is found. it is expected that exercise can be applied as one non-pharmacological treatment alternative in order to improve the quality of life for elderly. references 1. bappenas, bps, and unfpa. proyeksi penduduk indonesia 2010-2035. bps. 2013;1(1):1–3. 2. kim wh, kim bs, kim sk, chang sm, lee dw, choet mj, et al. prevalence of insomnia and associated factors in a community sample of elderly individuals in south korea int psychogeriatrics. 2013;25(10):1729–37. 3. american academy of sleep medicine. international classification of sleep disorders: diagnostic and coding manual, 2nd ed. american academy of sleep medicine westchester: il; 2005. 4. allah esa, abdel-aziz hr, el-seoud ara. insomnia: prevalence, risk factors, and its effect on quality of life among elderly in zagazig city, egypt. j nursing education practice. 2014;4(2):52–69. 5. tsou mt. prevalence and risk factors for insomnia in community-dwelling elderly in northern taiwan. j clin gerontol geriatr. 2013;4(3):75–9. 6. dewi pa, ardani igai. angka kejadian serta faktor-faktor yang mempengaruhi gangguan tidur (insomnia) pada lansia di panti sosial tresna werda wana seraya denpasar bali tahun 2013. e j medika udayana. 2014;3(10):1–13. 7. jaussent i, dauvilliers y, ancelin ml, dartigues jf, tavernier b, touchon j, et al. insomnia symptoms in older adults: associated factors and gender differences. am j geriatr psychiatry. 2011;19(1):88–97. 8. kim wj, joo w, baek j, sohn sy, namkoong k, youm y, et al. factors associated with insomnia among the elderly in a korean rural community. psychiatry investig 2017;14(4):400–6. 9. ogunbode am, adebusoye la, olowookere oo, owolabi m, ogunniyi a. factors associated with insomnia among elderly patientsattending a geriatric centre in nigeria. curr gerontol geriatr res. 2014;2014(2014):1–10. 10. varrasse m, li j, gooneratne n. exercise and sleep in community-dwelling older adults. curr sleep med rep. 2015;1(4):232–40. 11. passos gs, poyares dlr, santana mg, tufik s, mello mt. is exercise an alternative treatment for chronic insomnia? clinics. 2012;67(6):653– 9. 12. wang x, shawn d. youngstedt. sleep quality improved following a single session of moderate-intensity aerobic exercise in older women: results from a pilot study. j sport health sci. 2014;3(4):338–42. 13. sumedi t, wahyudi, kuswati a. pengaruh senam lansia terhadap penurunan skala insomnia pada lansia di panti wredha dewanata cilacap. soedirman j nurs. 2010;5(1):13–20. 14. rahmi u, somantri b, alifah nyn. gambaran pengetahuan lansia mengenai senam lansia di panti sosial tresna werdha budi pertiwi kota bandung 2015. j pendidikan keperawatan indonesia. 2016;2(1):38–43. 15. yurintika f, sabrian f, dewi yi. pengaruh senam lansia terhadap kualitas tidur pada lansia yang insomnia. jom. 2015;2(2):111–22. 16. suastari nmp, tirtayasa pnb, aryana igps, kusumawardhani rt. hubungan antara sikap sleep hygiene dengan derajat insomnia pada lansia di poliklinik geriatri rsup sanglah, relationship between gymnastics exercise and insomnia in elderly :30–5 international journal of integrated health sciences. 2018;6(1) 35 fauziah nurillah nasa, sharon gondodiputro, et al. denpasar. e j medika udayana. 2014;3(9):1–18. 17. manangkot mv, sukawana iw, wita ims. pengaruh senam lansia terhadap keseimbangan tubuh pada lansia di lingkungan dajan bingin sading. j keperawatan community publishing nursing. 2016;4(1):24–7. :30–5 42 international journal of integrated health sciences. 2017;5(1) incidence of cavum septum pellucidum and cavum vergae in dr. hasan sadikin general hospital, bandung, indonesia introduction cavum septum pellucidum (csp) is an anterior separation of two leaflets of the septum pellucidum resulting the cerebrospinal fluid (csf)-filled space and usually isolated. it is not a part of the ventricular system and does not communicate with the subarachnoid space; although in some cases communicate with third ventricle.1–3 cavum vergae (cv) is a space that is located as an extention posteriorly of the csp. the csp mistakenly referred as the fifth ventricle. the cv does not contain csf, therefore, it is incorrect to mark cv as the sixth ventricle.4,5 besides, both csp and cv are not eqquipped by choroid plexus. the csp and cv represent normal anatomical variants of ventricle and usually asymptomatic which were commonly found incidentally.2 the csp and cv are developed in utero at 3 months of gestation and begin to fuse from posterior to the anterior or rostral with age, and usually disappear in the first few weeks after birth. therefore, csp and cv are present in all premature infants, 97% at term infants, about 85% of one month old infants and 12–15% of six months infant. meanwhile, the incidence of csp in full term infants is 36%.4 the csp may incidentally found alone or together with cv, if both exist then the passage between those two cavities are known as verga’s aqueduct.6 the incidence of csp from various study is ranging from 0.7% and 37%.4 however, the incidence nor observation has never been reported from indonesia. cases this study reported several observations of the patients that incidentally seen in their abstract objective: to describe the cavum septum pellucidum (csp) and cavum vergae (cv) findings. methods: thirteen samples were recruited in the study. the study was conducted at the department of neurosurgery, dr. hasan sadikin hospital, bandung, indonesia in the period of 2015–2016. thirteen samples were recruited for the study. cavum septum pellucidum and cv spaces are relatively rare. during neurology and neurosurgery examination of patients with head computed tomography (ct) scan and magnetic resonance imaging (mri), csp and cv were discovered accidentally. the incidence of these unique spaces reported from many countries, but have never been reported from indonesia. results: this is the first-time reported incidental finding of csp and cv from indonesia, 13 cases in one-year period. since the presence of csp and cv is usually asymptomatic, clinician seem don’t really care to put it in their report. conclusions: the presence of csp and cv as a common incidental finding can be more revealed in our country in years to come and hopefully can be more studied in term of anatomical landmark on neurosurgical field. keywords: cavum septum pellucidum, cavum vergae, incidental finding pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v5n1.964 ijihs. 2017;5(1):42–6 received: december 14, 2016 revised: march 7, 2017 accepted: march 9, 2017 ahmad faried, adolf setiabudi soeprajogo, regina melia, muhammad zafrullah arifin department of neurosurgery, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital case correspondence: ahmad faried, department of neurosurgery, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital jl. pasteur no. 38, bandung, indonesia e-mail: faried.fkup@gmail.com :42–6 international journal of integrated health sciences. 2017;5(1) 43 imaging (csp and cv) found in the department of neurosurgery, dr. hasan sadikin general hospital, bandung, indonesia. in the case no 1, a 66 year-old male came to complain of migrane. the head magnetic resonance imaging (mri) was performed then csp and cv spaces were accidentally found. in the case no 2, a 68 year-old female came with chief complaint of decreased level of conciousness. the symptom was preceded by severe headache and vomiting. the patient was then diagnosed with hypertension five years before admission but did not control blood pressure regularly. the blood pressure was 240/110 mmhg, pulse rate was 108 beat per minute (bpm), glasgow comma scale (gcs) of e1m4v2, nuchal rigidity was found. the head computed tomography (ct) scan was performed and then csp and cv were found with hemmorhage. she was diagnosed spontaneous subarachnoid hemorrhage due to suspect aneurysm rupture with intraventricula, -csp and -cv hemmorhage with emergency hypertension. in the case no 3, a 11 year-old boy was complaining of headache since three months prior to admission. vomitting (+) and gait disturbance was found. glasgow comma scale was 15. romberg test (+), the patients tended to fall to the back. head ct scan with contrast was performed, csp and cv were found. the patient was diagnosed non-communicating hydrocephalus due to infratentorial space occupying lession (sol) ec medulloblastoma. in the case number 4, a 10 year-old girl was complaining of headache since one month prior to admission. the patient vomitted (+) and had double vision. ten days before admission, the patient got seizures at which 3–5 minutes duration each seizure, whole body, before and after seizure patients was concious and gcs was 15. there were paralysis of left cranial nerve vi and vii central. head ct scan was performed then csp and cv spaces were found. the patient was diagnosed with non-communicating hydrocephalus due to colloid cyst at third ventricle. in the case no 5, a 58 year-old female came with chief complaint decrease of conciousness. she had history of uncontrolled hypertension. blood pressure was 170/110 mmhg, gcs was e3m6v4, and nuchal rigidity was not found. physiological reflex was normal and there was no pathological reflex. head ct scan was performed then csp and cv spaces were found. the patient was diagnosed with spontaneous intracerebellar hemorrhage due to hypertension grade ii. in the case no 6, a 19 year-old male came with chief complaint blindness of both eyes. gcs was 15, pupil round equal with diameter right/left occuli 5/5 mm, light reflex right/ left occuli +/+, visus right/left occuli 0, fundoscopy: papil papil atrophy bilateral. a 66 year-old male with migrane and coexistent of cavum septum pellucidum (csp; white filled arrow) and cavum vergae (cv; black filled arrow) observed by magnetic resonance imaging (a). three days old baby boy with ventriculomegaly and cv observed using ultrasonography (b) fig. 1 (a) (b) :42–6 ahmad faried, adolf setiabudi soeprajogo, et al. 44 international journal of integrated health sciences. 2017;5(1) head ct scan was performed then csp and cv spaces were found. the patient was diagnosed with supratentorial sol at sellar region due to hypophysis macroadenoma. in the case no 7, a 40 year-old female came with chief complaint blindness of both eyes. glasgow comma scale was 15, pupil round equal with diameter right/left occuli 5/5 mm, light reflex right/left occuli +/+, visus right/left occuli 0, fundoscopy papil atrophy bilateral. head ct scan was performed, csp and cv spaces were found. the patient was diagnosed with supratentorial sol at sellar region due to tuberculum sellae meningioma. in the case no 8, a 19 year-old female came with chief complaint headache; 4 hours before admission. the patient was riding a motorcycle without helmet suddenly lost her balance and fell down with head hitting the asphalt. vomiting (+) with gcs was 15. head ct scan was performed and csp and cv spaces were found. the patient was dignosed as mild head injury with closed linier fracture at midfrontal and intracerebellar hemorrhage (ich) at midfrontal at left parietal. in the case no 9, a 3 day-old baby boy came with ventriculomegaly from ultra sonography (usg). since ninth month of pregnancy, the neonate was diagnosed with intrauterine ventriculomegaly. as the consequence, the mother was hospitalized and cesarian secton was perfomed, head circumference 34 cm (n: 34–38cm), anterior fontanella open, flat, not tense, 5 x 4 cm, children comma scale (ccs 11). ultra sonography transcranial was performed and cv space was found. age gender diagnosis imaging modality csp cv 66 yrs. male migrane mri x x 68 yrs. female spontaneous subarachnoid hemorage due to rupture aneurysm ct-scan x x 11 yrs. male non-communicating hydrocephalus et causa infratentorial tumor due to meduloblastoma ct-scan x x 10 yrs. female non-communicating hydrocephalus due to colloid cyst at 3rd ventricle ct-scan x x 58 yrs. female spontaneous intracerebral hemorage due to hypertention grade ii ct-scan x x 19 yrs. male supratentorial tumor at sella region due to macroadenoma hipofise ct-scan x x 40 yrs. female supratentorial tumor at sella region due to tuberculum sellae meningioma ct-scan x x 19 yrs. female mild head injury with closed linear fracture at midfrontal and intracerebral hemorage at left parietal ct-scan x x 3 days old male intrauterine ventriculomegaly usg − x 16 yrs. female supratentorial tumor at left retroorbita due to meningioma ct-scan x x 42 yrs. male moderate head injury with intraventricle hemorage and contusio cerebri at frontal bilateral et ganglia basal ct-scan x x 26 yrs. female supratentorial cyst at left temporal due to arachnoid cyst mri x x 1 yrs. female communicating hydrocephalus ct-scan − x note: yrs. = years old; csp = cavum septum pellucidum; ct-scan = computed tomography scan; cv = cavum vergae; mri = magnetic resonance imaging; usg = ultrasonography table summary of thirteen patients that incidentally found during one year period in dr. hasan sadikin general hospital, bandung, indonesia :42–6 incidence of cavum septum pellucidum and cavum vergae in dr. hasan sadikin general hospital, bandung, indonesia international journal of integrated health sciences. 2017;5(1) 45 ahmad faried, adolf setiabudi soeprajogo, et al. :42–6 in the case no 10, a 16 year-old female came with chief complaint protruded eye. glasgow comma scale was 15, pupil round unequal with diameter right/left occuli: 3/4 mm, light reflex right/left occuli +/-, visus right/left occuli +/-, fundoscopy left papil atrophy. head ct scan was performed then csp and cv spaces were found. the patient was diagnosed with supratentorial sol at left retroorbital due to meningioma. in the case no 11, a 42 year-old male came with decreased consciousness, 3 hours before admission, the patient was riding a motorcycle with helmet, lost balance, and fell down with head hitting asphalt. unconsciousness (+), gcs was e3m5v4. head ct scan was performed and csp and cv spaces were found. the patient was diagnosed as moderate head injury with ivh and contusio cerebri at frontal bilateral et basal ganglia dextra. in the case no 12, a 26 year-old female came with chief complaint vertigo. glasgow comma scale was 15, head mri was performed then csp and cv spaces were found. the patient was diagnosed with supratentorial sol at left temporal due to arachnoid cyst. in the case no 13, a 1 year-old baby girl came with head enlargement. head circumference 58 cm (n: 44–49 cm), anterior fontanella open, flat, not tense, 7 x 5 cm, ccs 11, sunset eye (+), frontal boozing (+). head ct scan was performed and cv space was found. the patient was diagnosed with communicating hydrocephalus. in this study, the informed consent was obtained from the patients for publication of this case report and any accompanying images. the patient’s family was present at the time. discussion septum pellucidum is not simply an anatomical structure having thinned-out translucent membranous that extends from the anterior part or the body, the genu, bridge between the the rostrum of the corpus callosum and the superior surface of the fornix. the septum pellucidum is important relay station linked with the main hippocampus−hypothalamus; part of the limbic system. therefore, it is septum pellucidum as a correlative center relaying visceral information through hypothalamic autonomic system to hippocampus, amygdala, habenula and brainstem reticular formation, partake in consciousness, sleep and in emotional response to the environment. in this regard, it is a part of the circuit which subserves mental self-maintenance processes, food finding, sexuality, autonomicvegetative adaptation modes for homeostasis, fight and flight, also species maintenance. the csp had been explained in 1851 by an italian anatomist andrea verga and walter dandy in 1931 described further regarding the csp and cv nomenclature. the csp is a space between the two septum pellucidum anterior to the foramina of monro, when they at least 1 mm apart. in the anterior, it is bounded by genu and rostrum of corpus callosum (cc), in the posterior it is bound by the fornix, in the superior it is bounded by the body of the cc, and in the inferior by anterior commisure and rostrum of the cc.7,8 posterior space of foramina of monroe is called a cv. the width of csp varies from 2–5 mm or more. according to schwidde, average of transverse, vertical and longitudinal dimensions of csp is 3, 6, and 7.5 mm.4 in the period 10–12 weeks’ of gestation, cc starts to develop from the lamina terminalis as a bundel of fiber that connects right and left hemisphere, and cavitation of medial inferior commisural plate of this lamina terminalis will form the leaves of septum pellucidum. closure of csp happens at 6–8 months of gestation for rostral to caudal, so it’s incidence will decrease as age progress.4,7 the prevalence of csp and cv observed by ct scan is 5.5% in great britain; 1.24% in china; 0,93% in taiwan, but unknown in indonesia. cavum septum pellucidum reported might be associated with schizophrenia, post-traumatic stress disorder, chronic brain trauma and boxer. this study did not find such background in the history of the patients. from anatomy point of view, these two cavities are not separated.8–11 however, csp may exist without cv or in opposite manner. most of our cases (11 out of 13), had both csp and cv; only two case had only cv; this is an agreement with the previous study by chen et al.8 that found most of their cases had coexistent of csp and cv (95.5%) and cv alone only 1.7%. theoritically, the prevalence of csp and cv should decresed as age progresses; in study by chen et al.8 the highest prevalence of csp and cv are among young adults (20–39 years old).12 however, this study shows that the highest prevalence is among adults (>40 years old; 5 cases) and the lowest is in infants (3 days old; one case). this study might not represent the general population in indonesia and this requires further investigation. in conclusion, this study is the first reported incidental finding of csp and cv found in indonesia which were 13 cases in 46 international journal of integrated health sciences. 2017;5(1) references 1. bikmaz k, dinc c, cakabay m, iplikcioglu ac. epidermoid cyst of the cavum septum pellucidum. acta neurochir (wien). 2007;149(1):1271–2. 2. al-tubaikh ja, reiser mf. congenital diseases and syndrome: an illustrated radiological guide. berlin heidelberg: springer–verlag; 2009. 3. greenberg ms. handbook of neurosurgery. 7th ed. new york: thieme; 2010. 4. pearce jms. some observations on the septum pellucidum. eur neurol j. 2008;59(1):332–4. 5. ciołkowski mk. cavum velum interpositum, cavum septum pellucidum and cavum vergae: a review. childs nerv syst. 2011;27(1):2027– 28. 6. tubbs rs, krishnamurthy s, verma k, shoja mm, loukas m, mortazavi mm, et al. cavum velum interpositum, cavum septum pellucidum, and cavum vergae: a review. childs nerv syst. 2011;27(1):1927–30. 7. winter tc, kennedy am, byrne j, woodward pj. the cavum septi pellucidi: why is it important? j ultrasound med. 2010;29(1):427–44. 8. chen jj, chen cj, chang hf, chen dl, hsu yc, chang tp. prevalence of cavum septum pellucidum and/or cavum vergae in brain computed tomographies of taiwanese. acta neurol taiwan. 2014;23(1):49–54. 9. filipovic b, ilankovic n, starcevic a, filipovic b, stijak l, puskas l, et al. cavum septi pellucidi as a marker of the neuropsychiatric diseases: a pointer or mislead? a cadaveric-clinical observation. j forensic res. 2013;5(1):208–12. 10. aviv ri, tomlinson g, kendall b, thakkar c, valentine a. cavum septi pellucidi in boxers. can assoc radiol j. 2010;61(1):29–32. 11. griffiths pd, batty r, reeves mj, connolly dj. imaging the corpus callosum, septum pellucidum and fornix in children: normal anatomy and variations of normality. neuroradiology. 2009;51(1):337–45. 12. gur re, kaltman d, melhem er, ruparel k, prabhakaran k, riley m, et al. incidental findings in youths volunteering for brain mri research. ajnr am j neuroradiol. 2013;34(10):2021–5. :42–6 incidence of cavum septum pellucidum and cavum vergae in dr. hasan sadikin general hospital, bandung, indonesia one year period. since the existance of csp and cv usually asymptomatic, clinicians seem oblivious relating to this finding. this study discover that the presence of csp and cv as a common incidental finding can be more revealed in indonesia in these years to come and hopefully can be more studied in term of anatomical landmark on neurosurgical field. vol 9 no 1 2021 (2).indd international journal of integrated health sciences (iijhs) 25 introduction cardiovascular disease is the leading cause of death worldwide.1, 2 there were 422,7 million cardiovascular cases and 17.92 million deaths in 2015.2 cardiovascular events in patients with hypertension are influenced by modifiable and non-modifiable risk factors.3, 4 the global prevalence of hypertension is 1,13 billion in 2015.5 the overall prevalence of hypertension in adults is estimated to be 3045%, with higher proportion in males (24%) than females (20%).5 data from basic health research in 2018 showed the prevalence cardiovascular-related death risk factors in hypertensive patients: indonesia family life survey 2000–2014 abstract objective: to determine the characteristics of the risk factors of cardiovascular death in hypertensive patients in indonesia based on the indonesian family life survey (ifls) longitudinal data. methods: this was a retrospective descriptive study on secondary data from the ifls population starting from2000 and was followed up in 2007 and 2014. the inclusion criteria for participation were15 years old or older, had hypertension, had cardiovascular events as thecause of death, and had complete data in both ifls 3 (2000) and ifls 4 (2007). results: the ifls 5 (2014) reported 918 deaths among eligible subjects with complete data, both in ifls 3 (2000) and ifls 4 (2007). of those, a total of 608 subjects experienced hypertension started from 2000 and/or 2007. of these deaths, 112 were due to cardiovascular events. cardiovascular death was more common in males (58.9%), age of >65 years old when died (47.3%), had poor socioeconomic status (24.1%), and with normal body mass index (54.9%). conclusion: male, late adulthood, low level of education, normal bmi, and poor socioeconomic status represented the greater risks of cardiovascular death among hypertensive patients in indonesia. keywords: cardiovascular death, hypertension, ifls, risk factor received: october 27, 2020 accepted: march 30, 2021 correspondence: rudi supriyadi, department of internal medicine, faculty of medicine universitas padjadjaran-dr. hasan sadikin general hospital bandung, indonesia e-mail: rudisdoc@gmail.com original article rudi supriyadi,1 david paranoan,1 yulia sofiatin2 1department of internal medicine, faculty of medicine universitas padjadjaran-dr. hasan sadikin general hospital, bandung, indonesia, 2department of public health faculty of medicine universitas padjadjaran, indonesia pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ ijihs.v9n1.2185 ijihs. 2021;9(1):25–29 of hypertension in indonesia was 34.1% (increased from 25.8% in 2013).6 indonesia family life survey is a large-scale series of cross-sectional study conducted by rand corporation in indonesia.7, 8 it has been conducted five times (1993, 1997, 2000, 2007, 2014) with re-contact rates higher compared to the similar survey in the united states and europe.7,8 the ifls represented of 83% of the indonesia population, provinces in west and central part of indonesia were included. individual and household factors such as age, gender, education, income, household composition, subjective and objective health measurements and biomarkers, health risk behaviors, healthcare utilisation, cognitive health, and subjective wellbeing were included in the ifls. thus, it can provide an opportunity to obtain secondary data on risk factors of cardiovascular death from hypertensive 26 international journal of integrated health sciences (iijhs) patients in indonesia.7, 8 this study aimed to determine the risk factors of cardiovascular death in hypertensive patients in indonesia based on ifls longitudinal data.7, 8 methods this was a retrospective descriptive study based on secondary data from ifls 3 (2000), ifls 4 (2007) and ifls 5 (2014). the study population was all subjects who were reported died in ifls 5. the inclusion criteria were age over 15 years old, had hypertension in 2000 and/or 2014 data, and death due to cardiovascular events. subjects with type 2 diabetes mellitus (t2dm) and chronic kidney disease (ckd) were excluded from this study. t2dm and ckd were diagnosed through self reported. data were extracted using statacause of death were taken from ifls 5 exit form file, blood pressure measurement report on ifls 3 (hh00_all_dta, table bus1_1. dta) and ifls 4 (hh07_all_dta, table bus1_1. dta) was calculated as average for systolic and diastolic blood pressure and defined as hypertension if systolic ≥140 and/or diastolic ≥90 mmhg were taken from (hh00_all_dta table us07,hh07_all_dta table us07 and hh14_ all_dta table us07), age of death were taken from (hh14_all_dta table fe1_1.dta), gender were taken from (hh00_all_dta table ar07, hh07_all_dta table ar07 and hh14_all_dta table ar07), education were taken from b3a_dl1.dta file, body mass index were taken from (hh00_ all_dta table bus_us.dta, hh07_all_dta table bus_us.dta, hh14_all_dta table bus_us.dta), assessment of socioeconomic status based on the quintile of asset ownership using the principal component analysis (pca) method were taken from table hrtype, measurement body mass index is calculating weight and height, were taken from bus_us.dta, cigarette smoking were taken from table b3b_km. blood pressure and bmi calculation of ifls participants were measured by trained nurses. blood pressure were measured using an omron meter, hem-7203, three times on alternate arms in a seated position.8 the bmi was classified according to asian criteria: normal (18.5 to <23.0 kg/m2), overweight (23.0 to <25.0 kg/m2), and obese (25+ kg/m2). the smoking status was determined on the questionnaire response to ‘do you still have the habit or have you totally quit?’. the complete details of ifls study design and methods have been described elsewhere.7, 8 this study had received approval from the research ethics committee dr. hasan sadikin general hospital bandung no. lb.02.01/x.6.5/77/2020. results there are 918 subjects reported as died in ifls 5 (2014) which can be tracked back to data in ifls 3 (2000) and ifls 4 (2007), leaving a total of 608 subjects with hypertension in the data of year 2000 and 2007, and only 112 died. among 112 subjects who died due to cardiovascular events with the history of hypertension, most of them were males (58.9%) aged >65 years old (47.3%), elementary school graduates (49,1%), poor socioeconomic status (24.1%), non-smoker (67%), and normal bmi (54.9%; table) cardiovascular death in both gender was more common in primary school graduates. in males (31.3%) and females (17.9%; fig. 1). cardiovascular death in both gender was more common in the age of >65 years old (fig. 2). table subjects characteristic variables n (%) sex male 66 (58,9) level of education no school elementary school junior high school senior high school university 30 (26,8) 55 (49,1) 9 (8,0) 16 (14,3) 2 (1,8) age of death 25 to 45 46 to 55 56 to 65 >65 5 (4,5) 23 (20,5) 31 (27,7) 53 (47,3) socioeconomic status very poor poor middle high very high 24 (21,4) 27 (24,1) 25 (22,3) 21 (18,8) 15 (13,4) cigarette smoking yes no 37 (33,0) 75 (67,0) bmi* underweight normal overweight obese n=102 10 (9,8) 56 (54,9) 26 (25,5) 10 (9,8) *data not complete; bmi=body mass index cardiovascular-related death risk factors in hypertensive patients: indonesia family life survey 2000–2014 international journal of integrated health sciences (iijhs) 27 cardiovascular death in males was more common in poor income (16.1%). in females, cardiovascular death was more common in high income (13.4%; fig. 3). cardiovascular death in both gender was more common in normal bmi, in males 34,8% and females 15,2%. the distribution of bmi status amongst gender were shown in fig. 4. discussion this study found that males had a higher distribution of cardiovascular death compared to females. these results are consistent with data from the european society of cardiology (esc), and the american heart association (aha) that stated a male had a higher risk of cardiovascular disease compared to females.4,5 a study conducted based on indonesia basic health research 2013 by ghani et al 9 stated that women had 1.22 times greater risk of coronary heart disease.there is an increase in number of death in patients aged over 46 years old with the highest rate in subjects >65 years old. this result is similar to those obtained by ghani et al. in 2016, which found that the risk of stroke increased with age, and patients aged >55 years old had 10.23 times higher risk compared to those aged 15–44 years old.10 there is an increase in the cardiovascular fig 1. sex and level of education distribution fig 2. sex and age distribution fig 3. sex and socioeconomic status fig 4. sex and bmi distribution rudi supriyadi, david paranoan, et al. 28 international journal of integrated health sciences (iijhs) death profile and atherosclerotic process in males as age increases.11 while females of childbearing age have a high level of estrogen, which can protect against cardiovascular risk factors, the risk of cardiovascular disease increases two to fourfold after menopause.11, 12 men were more likely to have heavy plaques associated with impaired blood flow. this plaque has characteristics of thin and rich in fat or necrotic nuclei that are rich in lipids and have a high risk of cardiovascular death.13 in addition, endothelial dysfunction and arterial stiffness are more common in men than women in the age spectrum up to the sixth decade. before menopause, women are relatively protected from cardiovascular disease. in menopausal women, the risk of cardiovascular disease increases. this is related to a decrease in sex hormones that have been shown to play an important role in cardiovascular disease development at the onset of older age.12 this study showed that deaths due to cardiovascular events are more common in poor education level. in addition, poor education level subjects have limited access to health services. these results are consistent with a study conducted by ghani et al. that identified dominant risk factors for stroke based on indonesia basic health research 2013. ghani et al.9 found that stroke was more common in poor education. this is due to lack of knowledge related to the impact of bad lifestyle behavior such as high-fat diet which will lead to degenerative disease.10 another study based on ifls conducted by gumilang et. showed hypertension incidence was lower in subjects who attended school (17.3%) compared to subjects who didn’t attend school. there was a decrease in incidence as subjects had higher education.14 in addition, a study conducted by chiara et al. showed that level of education were independently associated with increased cardiovascular risk factors globally.15 cardiovascular death is more frequent in poor socioeconomic subjects. other study based on ifls 2007 and 2017 conducted by sudharsanan et al. showed that duration of socioeconomic status and cardiovascular risk factors (obesity, hypertension, and cigarette smoking) play an important role in the association between individual characteristics and mortality.16 cardiovascular death among hypertensive patients was more prevalent in non-smokers. while this finding seemed contrary with the current evidence, there were several concerns with the result. firstly, our data only showed current smoking status. we did not define the duration, quantity of cigarrete smoking, and history of previous smoking which could affected the result of our findings. secondly, we did not know whether the non-smokers had more comorbidities that we did not include in the studies, such as dyslipidemia, history of premature vascular disease, history of cerebrovascular disease. more subjects who died due to cardiovascular disease having normal body mass index (54,9%), while the lowest was underweight (9.8%). data from esc and aha showed that people with higher bmi are at risk of having cardiovascular disease.4, 5 a study based on ifls 5 conducted by kasyani et al. showed that there was a significant association between nutritional status with hypertension, higher bmi will increase the risk of developing hypertension.19 ghani et al. stated low body mass index has a risk of coronary heart disease 1.31 times for the incidence of coronary heart disease.4, 5, 13 until lately, metabolically healthy obesity (mho) has drawn increasing attention and has been reported to have better outcome than the obesity with metabolic abnormalities.20 the definition of mho is not uniform, but it is commonly described as obesity without or less than two of the five metabolic abnormalities (high plasma triglyceride concentration, high fasting blood glucose, low high-density lipoprotein cholesterol concentration, and large waist circumference, and high blood pressure).20 in this study, we did not include any other parameters of metabolic dysfunction other than hypertension, therefore we did not know whether the overweight and obesity group had any other metabolic abnormalities. furthermore, we did not know whether the hypertensive population were using any antihypertensive drugs and whether the blood pressure was under control. these factors might largely affected the result of the study. some limitations should be noted. the data collections were separated by 7 years, many subjects from previous survey were not contactable on the following surveys; smoking history, and passive smoking status were also limited. moreover, the descriptive nature of the study design without including numerous cardiovascular risk factors in the baseline characteristics sample should be taken into account as major limitations of this study. further analytical study with multivariate analysis might be necessary to confirm any findings from this study. it is concluded that cardiovascular death among hypertensive cardiovascular-related death risk factors in hypertensive patients: indonesia family life survey 2000–2014 international journal of integrated health sciences (iijhs) 29 patients in indonesia is more prevalent in male, late adulthood, low level of education, normal bmi, and poor socioeconomic status. 1. world health organization. cardiovascular disease. fact sheet [internet]. 2017 [cited 2019 jul 20]. available from: https://www. who.int/health-topics/cardiovasculardiseases/. 2. roth ga, johnson c, abajobir a, abd-allah f, abera sf, abyu g, et al. global, regional, and national burden of cardiovascular diseases for 10 causes, 1990 to 2015. journal of the american college of cardiology. 2017;70(1):1–25. 3. world health organization. a global brief on hypertension: silent killer, global public health crisis [internet]. 2013 [cited 2018 jun 23]. available from: https://ishworld.com/downloads/pdf/global_brief_ hypertension.pdf. 4. whelton pk, carey rm, aronow w, casey jr d, collins k, dennison himmelfarb c, et al. guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the american college of cardiology/american heart association task force on clinical practice guidelines. journal of the american college of cardiology. 2017;71(6):1269–324. 5. bryan w, giuseppe m, wilko s, enrico a, michel a, michel b. esc/esh guidelines for the management of arterial hypertension. eur heart j. 2018;39(33):3021–104. 6. kementrian kesehatan republik indonesia. laporan nasional riskesdas 2018. jakarta: kemenkes ri. 2018. 7. rand corporation. rand family life surveys (fls) 2018 [cited 2018 apr 29]. available from: https://www.rand.org/ well-being/social-and-behavioral-policy/ data/fls.html. 8. strauss j, witoelar f, sikoki b. the fifth wave of the indonesia family life survey: overview and field report. available from: https://www.rand.org/content/dam/ rand/pubs/working_papers/wr1100/ wr1143z1/rand_wr1143z1.pdf 9. ghani l, susilawati md, novriani h. faktor risiko dominan penyakit jantung koroner di indonesia. buletin penelitian kesehatan. 2016;44(3):153–64. 10. delima d, mihardja lk, ghani l. faktor risiko dominan penderita stroke di indonesia. indonesian bulletin of health research. 2016;44(1):20146. 11. gao z, chen z, sun a, deng x. gender differences in cardiovascular disease. medicine in novel technology and devices. 2019;4:100025. 12. rodgers jl, jones j, bolleddu si, vanthenapalli s, rodgers le, shah k, et al. cardiovascular risks associated with gender and aging. j cardiovasc dev dis. 2019;6(2):19. 13. merz aa, cheng s. sex differences in cardiovascular ageing. heart. 2016;102(11):825–31. 14. gumilang s. insidensi dan faktor risiko hipertensi di indonesia:suatu studi longitudinal dari indonesia family life survey [thesis]: fakultas kedokteran universitas padjadjaran; 2019. 15. di chiara t, scaglione a, corrao s, argano c, pinto a, scaglione r. education and hypertension: impact on global cardiovascular risk. acta cardiologica. 2017;72(5):507–13. 16. sudharsanan n. the association between socioeconomic status and adult mortality in a developing country: evidence from a nationally representative longitudinal survey of indonesian adults. the journals of gerontology: series b. 2019;74(3):484– 95. 17. sugiharti l, sukartini nm, handriana t. konsumsi rokok berdasarkan karakteristik individu di indonesia. jurnal ekonomi kuantitatif terapan. 2015;8(1):34–45. 18. suryawati c, kartikawulan lr, haryadi k. konsumsi rokok rumah tangga miskin di indonesia dan penyusunan agenda kebijakannya. jurnal kebijakan kesehatan indonesia: jkki. 2012;1(2):69–76. 19. kasyani, susetyowati, kandarina b. lingkar pinggang dan hipertensi pada orang indonesia usia 40 tahun ke atas. seminar nasional kesehatan masyarakat sriwijaya. 2017:299–312. 20. huang my, wang my, lin ys, et al. the association between metabolically healthy obesity, cardiovascular disease, and allcause mortality risk in asia: a systematic review and meta-analysis. int j environ res public health. 2020;17(4):1320. references rudi supriyadi, david paranoan, et al. volume 9 no 2 2021-2.indd international journal of integrated health sciences (iijhs) 55 therapeutic efficacies.1 many research also shows the importance of vitamin d in assisting the maximal function of muscle contraction and relaxation, its abundance benefit for dental health, renal functions, wound healing and repair, and also in reducing obesity which could lead to metabolic syndrome.2 lack of vitamin d may result in various defects and diseases such as rickets, osteoporosis, and osteomalacia.2 vitamin d also has other functions in the body, such as reducing inflammation and modulating cell formation, neuromuscular and immune function, and glucose metabolism.1,2,3. vitamin d influences several effectiveness of multimedia and education using lecturing method on role of vitamin d for health cadres abstract objective: to investigate the differences in the effectiveness of learning methods between multimedia and lecture methods on benefits of vitamin d for health from the perspective of health cadres’ knowledge. methods: this study was an experimental study with a pre-and posttest design. the knowledge of health cadres was assessed using a questionnaire. the questionnaire was distributed before and after the health cadres received vitamin d education by two different methods. data analysis was conducted using paired and independent t-test with a significance level of p<0.05. results: a total of 59 health cadres participated in this study. prior to education, the median test score for the multimedia group was 9.45, while the median test score for the lecture group was 82.70. after the education, the multimedia group and the lecture group got a median test score of 10.84. the multimedia method and lecture method significantly increased health cadres’ knowledge with p-values of <0.02 and 0.003, respectively. there was no difference in the multimedia method’s effectiveness compared to the lecture method in increasing the knowledge of health workers about vitamin d’s role in health (p=0.62). conclusion: the multimedia education method is as effective as the lecture method in increasing health cadres’ knowledge about the role of vitamin d in health. keywords: education, lectures, multimedia, vitamin d received: december 19, 2020 accepted: september 30, 2021 correspondence: indra wijaya, department of internal medicine, faculty of medicine universitas padjadjaran-dr. hasan sadikin general hospital bandung, indonesia, e-mail: indrawijayaipd@gmail.com original article sumartini dewi,1,2 adityana sulistyo,1 erwin sumardi,3 eka puji lestari,3, kevin sulay wijaya,3 paramitha kusuma,3 theresia wahyu,3 agraini,3 eldi sauma,3 winda kurniati,3 francisca nungki triandari,3 shelly iskandar,3 tuti kurnianingsih,3 veranita pandia3 1immunology central study, faculty of medicine, universitas padjadjaran, indonesia 2division of rheumatology, department of internal medicine, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia 3department of psychiatry, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ ijihs.v9n2.2243 ijihs. 2021;9(2):55–59 introduction vitamin d (also known as “calciferol”) is a fatsoluble vitamin found naturally in foods and provided as a dietary supplement.1 vitamin d can act both as a nutrient and a hormone and it is a quintessential element as a regulator of bodily functions and it has a wide range of 56 international journal of integrated health sciences (iijhs) genes that code for proteins that control cell proliferation, differentiation, and apoptosis. vitamin d receptors can be found in many tissues, and some of them transform 25(oh)d to 1,25(oh)2d. vitamin d comes in two forms: d2 (ergocalciferol) and d3 (cholecalciferol), which differ chemically only in their sidechain structures and are found in foods and dietary supplements. in the small intestine, both forms are well absorbed. simple passive diffusion and a mechanism involving intestinal membrane carrier proteins are used to absorb nutrients. vitamin d absorption is facilitated by the presence of fat in the gut, but some vitamin d is absorbed without it. vitamin d absorption from the gut is unaffected by age or obesity.4 indonesia, as a tropical country, is blessed with an abundance of sunlight, which is the primary source for the formation of vitamin d. unfortunately, many people in the community do not understand the role of vitamin d for health, so education is needed to increase public knowledge. there are various learning education methods. the lecture method is the most popular method of education. however, it requires trained personnel in a specific location and a certain schedule to gather the listener. therefore, practical, easy, and inexpensive educational methods are needed. another method that can be used as an alternative is through audio-visual. audio-visual methods tools can improve speaking skills several times over, more than other methods, which are needed for health cadres.5 the advantages of the audio visual method can be listed as follows: 1) the ability to ensure authentic language (what they are communicating effectively); 2) it can help learners to conceptualize ideas and get in-depth thought on the topic; 3) the motions that appeared in videos feature are always being motivational for the students; 4) it can provide the available information or substitute for books when they are not available on a particular topic, and 5) the dramatic reactions can bring historical events and personalities in life. however, audiovisual approaches have some disadvantages, such as the possibility of losing focus, the need for a well-designed presentation or content, and the fact that students could pay more attention to the visuals than the audio.6 this study aimed to compare the efficacy of a multimedia presentation versus a lecture on the role of vitamin d for health. methods this study was an experimental study with a pre-and post-test design. this study was a part of the community service program that is supported by universitas padjadjaran internal grant. this research was approved by the ethics committee of universitas padjadjaran with letter number 1506/un6.kep/ec/2019. the subjects were health cadres at puskesmas margahayu raya, margasari village, buah batu district, bandung city, west java, indonesia. the knowledge of health cadres was assessed using a questionnaire that was conducted before and after the health cadres received vitamin d education by two different methods. from 170 health cadres at puskesmas margahayu raya, the samples were selected using the simple random sampling method. the minimum total samples size is at least 30 people. health cadres who are 18 years old, speak indonesian, and have not undergone mental health training are eligible to participate. uncorrected vision impairment and uncorrected hearing difficulties were the exclusion criteria. health cadres who met the research criteria were given informed consent and randomly divided into two groups based on the hour of arrival until 09.00 am on the day of the intervention. before the intervention was carried out, the cadres of both groups were given the written form that they should fill completely for about 10 minutes. the cadres’ knowledge of vitamin d was measured using 15 multiple-choice questions. the questions asked include; the sources of vitamin d, the risk factors for vitamin d deficiency, the properties of vitamin d, the effects of vitamin d deficiency on health, and the benefits of consuming vitamin d. each of the correct answers gets a score of 1, and the wrong answer has no score. the final score is the total score for the 15 questions. then the first group was given the information on vitamin d by an internal medicine specialist using the lecture method. the second group was given the information by multimedia method, using educational video. the cadres’ knowledge of vitamin d after the education was measured using the same questions given before the education session. the presentation slides and the education video were developed by the researchers. a t-test with a significance level of 0.05 was used to analyze the data. effectiveness of multimedia and education using lecturing method on role of vitamin d for health cadres international journal of integrated health sciences (iijhs) 57 results the subject consisted of 59 health cadres, with 31 in the lecture method group and 28 in the multimedia group. the table shows the demographic data of the participants. data analysis showed no significant difference between the two groups in the respondent’s age (p=0.11) and education level (p=0.12). there was no comparison analysis between the subject’s gender because all subjects in the lecture method group were women. occupations were also not comparable because all respondents in the lecture method group do not have jobs. the normality test using the shapiro wilk showed that the scores of the lecture and multimedia groups were not normally distributed. at baseline, the lecture group subjects had a median of 10, a minimum of 4, and a maximum of 14, while the subjects in the multimedia group had a median of 8, a minimum of 2, and a maximum of 12. after education, the lecture group’s median was 11, minimum score 5, and maximum 14, and data analysis using the paired t-test showed that these scores increased significantly after education (p=0.00). after an education in the multimedia group, the median was 12, the minimum score was 2, and the maximum score was 14, and this value also increased significantly after education (p=0.00). an independent t-test comparing the increase in scores between the two treatment groups at baseline and post-education revealed no significant difference (p=0.62). discussion this study found that education using a multimedia method is as effective as the lecture method in increasing the knowledge of health cadres about the role of vitamin d in health. traditional lectures can reduce listening comprehension by causing listeners to lose focus because figures and words are only processed visually in lectures. another cause for reduced listening comprehension is alignment issues in conventional lectures, where there is a disjunction between figures and words due to the lecturers’ poor presentation skills, which is particularly apparent throughout slides. as a result, video clips with synchronized visual and auditory information may improve listening comprehension, especially during interventional procedures.7 in this study, there was no difference in the knowledge of the health cadres between multimedia group and lecture. this finding may be due to the slides used in the lecture method being the same as the slides used in the video of the multimedia method, so the health cadres of both groups receive similar visual information. the oral explanation in the video used a manuscript so that it was more table characteristic of health cadres demographic profiles lecture method (n=31) multimedia method (n=28) p-value n (%) median n (%) median gender male 3 (10.71) female 31 (100) 25 (89.29) age 50 49 0.195 education 0.296 below or equal to junior high school 11 (35.48) 9 (32.14) senior high school 13 (41.93) 14 (50.00) undergraduate 7 (22.58) 3 (10.71) post graduate 2 (7.14) employment employee 6 (21.43) unemployed 31 (100) 22 (78.57) sumartini dewi, adityana sulistyo, et al 58 international journal of integrated health sciences (iijhs) directed and organized. however, because the slides in the lecture are explained by an expert, the messages conveyed are also easier to catch by the audience. this study finding is in line with other previous studies. pandia et al.8 show that teaching materials using video is as effective as traditional lectures in lay health workers. kobra et al.9 show no significant difference between nursing students’ performance before and after training with the video and lecture methods. a study from brookfield et al. on medical students at the university of göttingen shows that video and live lectures are equally effective in preparing medical examinations. there are several differences in subjective evaluation; 48% of students prefer hands-on learning, 27% like video lessons, and 25% say they are ‘neutral’.10 a survey conducted by sarihan et al. in the department of emergency medicine’s residents shows no difference between traditional lectures to video-supported lectures’ efficiency within the training of the emergency medicine.11 ramezaninia et al. 7 showed that toothbrushing education’s effectiveness using lecture, video, and the pamphlet is almost the same; however, pamphlets are the most effective educational method. several other previous studies found that education using multimedia methods seems to have some advantages. the survey conducted by rajadell et al.12 on first-year students showed that students felt that learning through video was in line with their training needs and helped them have a clearer view. a study by ljubojevic et al.13 shows that the most efficient way is to insert educational video content in the middle of a lecture. mclean’s study shows that, on average, 74% of students said that video learning gave them comprehension about material that they missed while attending class.14 moazami et al.15 found that virtual learning is more effective than traditional learning. the subjects of this study were health cadres. health cadres can carry out education in the community. health cadres are volunteers selected by the community and have task to develop the community; in this case, health cadres are also known as health promoters or activists. according to minister of health regulations no. 25 of 2014, health cadres are elected by the community and trained to handle individual or community health problems and work in places related to providing health services in very close relationships with health service delivery places. the health cadres who have been elected are expected to care about health problems in the environment where they live, educate those in their environment about health, and disseminate health science information that they get from health officers or staff.16 education in the form of videos can be learned at any time, without being limited by place and time. educational videos are available 24 hours and can be viewed at any time according to a person’s schedule and activity. educational videos can also be quickly distributed widely through various social media, currently used by most indonesians from various backgrounds. park et al.17 show that emotion, motivation, and other affective variables are important not only in designing a multimedia learning environment but also in understanding and investigating learning, opening up new perspectives on the integrative nature of the cognitive learning process. the limitations of this study was that the people who provide education in lectures and videos are different, which causes different styles in the way the slides were explained. this difference can affect the results of the study. the other limitation is that lectures were not conducted by general practitioners but by an expert, so the results cannot reflect the quality of lectures held in the community. in conclusion, multimedia and lecture methods of education effectively increase health cadres’ knowledge, and multimedia education methods are just as effective as lecture methods in increasing health cadres’ knowledge about the role of vitamin d. we suggest that educational videos should be made under supervision of the experts in the field. references 1. brooks spj, sempos ct. the importance of 25-hydroxyvitamin d assay standardization and the vitamin d standardization program. j aoac int. 2017;100(5):1223–4. 2. sempos ct, heijboer ac, bikle dd, bollerslev j, bouillon r, brannon pm, et al. vitamin d assays and the definition of hypovitaminosis d. results from the first international conference on controversies in vitamin d. br j clin pharmacol. 2018;84(10):2194–207. 3. lefevre ml. screening for vitamin deficiency in adults: u.s. preventive services task force effectiveness of multimedia and education using lecturing method on role of vitamin d for health cadres international journal of integrated health sciences (iijhs) 59 recommendation statement. ann intern med. 2015;162(2):133–40. 4. silva mc, furlanetto tw. intestinal absorption of vitamin d: a systematic review. nutr rev. 2018;76(1):60–76. 5. kurniawan, f. the use of audiovisual media in teaching speaking. english education journal. 2016;7(2):180–93. 6. yousofi n, davoodi a, razmeh s. a comparative study of audio and video listening practices in a private language institute in iran. international j educational investigations. 2015;2(3):16–26. 7. ramezaninia j, naghibi sistani mm, ahangari z, gholinia h, jahanian i, gharekhani s. comparison of the effect of toothbrushing education via video, lecture and pamphlet on the dental plaque index of 12-year-old children. children (basel). 2018;5(4):50. 8. pandia v, kurnianingsih t, dewi s, iskandar s, kurniati w, triandari fn, et al. lecture and multimedia education methods are equally effective in increasing the knowledge of lay health workers about schizophrenia and other mental disorders. internet j academic physician assistants. 2020;11(1):1–5. 9. kobra p, sima l, fariborz r, rasouli as, neda k. the comparison of the effectiveness of two education methods video and lecture on knowledge, belief, and practice of hand hygiene in nursing students: clinical trial. int j med res heal sci. 2016;5(7):240–8. 10. brockfeld t, müller b, de laffolie j. video versus live lecture courses: a comparative evaluation of lecture types and results. med educ online. 2018;23(1). 11. sarıhan a, oray nc, güllüpınar b, yanturali s, atilla r, musal b. the comparison of the efficiency of traditional lectures to videosupported lectures within the training of the emergency medicine residents. turkish journal of emergency medicine. 2016;16(3):107–11. 12. rajadell m, garriga-garzón f. educational videos: after the why, the how. omniascience, intang cap. 2017;13(5):902–22. 13. ljubojevic m, vaskovic v, stankovic s, vaskovic j. using supplementary video in multimedia instruction as a teaching tool to increase efficiency of learning and quality of experience. int rev res open distance learn. 2014;15(3):275–91. 14. mclean jl, suchman el. video lecture capture technology helps students study without affecting attendance in large microbiology lecture courses. j microbiol biol educ. 2016;17(3):480–1. 15. moazami f, bahrampour e, azar mr, jahedi f, moattari m. comparing two methods of education (virtual versus traditional) on learning of iranian dental students: a posttest only design study. bmc med educ. 2014;14(1):1–5. 16. kementerian kesehatan ri. profil kesehatan indonesia 2014. jakarta: pusat data dan informasi kementerian kesehatan ri; 2014. 17. park b, plass jl, brünken r. cognitive and affective processes in multimedia learning. learn instr. 2014;29:125–7. sumartini dewi, adityana sulistyo, et al volume 9 no 2 2021 fixed.indd international journal of integrated health sciences (iijhs) 49 the incidence of cgl is unknown. in 2017, 301 patients went to the hemato-oncology polyclinic of internal medicine department in hasan sadikin, bandung.2 tyrosine kinase inhibitor (tki) is the standard treatment for cgl.3 currently, in indonesia, only imatinib and nilotinib are available. imatinib is given as the first choice, while nilotinib is given when there is resistance or intolerance to imatinib.4 the cardiotoxic effect on tki is one of the rarely reported events. according to some literature, the incidence of these effects varies from 0.5 to 2%.5–7 in this study, ten individuals who developed severe congestive heart failure global longitudinal strain of chronic granulocytic leukemia patients treated with imatinib and nilotinib abstract objective: to determine left ventricular function of patients with chronic granulocytic leukemia in chronic phase (cgl-cp) who received imatinib and nilotinib by using global longitudinal strain (gls) examination. methods: this was a descriptive study involving 46 cgl-cp patients who received imatinib and nilotinib therapy at the hemato-oncology clinic of the internal medicine departement of dr. hasan sadikin general hospital, bandung, indonesia. sampling was performed consecutively during the period of october to december 2019. variables assessed in this study were age, gender, bmi, length of treatment, hemoglobin level, left ventricular ejection fraction (lvef) value, and global longitudinal strain (gls). primary data were tested for normality using the saphirowilk test. statistical analysis was performed using spss software version 25.0. results: thirty-nine patients (seventeen males and twenty-two females with a mean age of 42±11) who had been in therapy for about 8 to 179 months at the time of the study were included as subjects. on average, the gls results for both treatment groups indicated a normal value based on the classification of the american society of echocardiography. the imatinib group gained a score of -22.4% (average range= -16.4% to (-28.1%)), while the nilotinib group gained a score of -21.6% (average range = -18.0% to (-25.9%)). conclusion: this study described the left ventricular function based on results of gls in cgl-cp patients receiving imatinib and nilotinib. keywords: chronic granulocytic leukemia, global longitudinal strain, imatinib, left ventricular ejection fraction, nilotinib received: november 23, 2020 accepted: september 30, 2021 correspondence: indra wijaya, department of internal medicine, faculty of medicine universitas padjadjaran-dr. hasan sadikin general hospital bandung, indonesia, e-mail: indrawijayaipd@gmail.com original article indra wijaya,1 arief sumarna,1 eliza nurazizah,2 evan susandi,3 erwan martanto1 1department of internal medicine, faculty of medicine universitas padjadjaran-dr. hasan sadikin general hospital bandung, indonesia 2faculty of medicine pasundan university bandung, indonesia 3faculty of medicine universitas padjadjaran, indonesia pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ ijihs.v9n2.2217 ijihs. 2021;9(2):49–54 introduction chronic granulocytic leukemia (cgl) is a myeloproliferative disorder caused by uncontrolled expansion of pluripotent hematopoietic cells, ranging between 10 and 15 cases/ 106/year without any significant geographic or ethnic differences.1 in indonesia, 50 international journal of integrated health sciences (iijhs) while on imatinib and this study show that imatinib-treated mice develop left ventricular contractile dysfunction. transmission electron micrographs from humans and mice treated with imatinib show mitochondrial abnormalities and accumulation of membrane whorls in both vacuoles and the sarco(endo the variations range from the asymptomatic lengthening of the qt interval, palpitations, arrhythmia, pericardial effusion, congestive heart failure, acute coronary syndrome and myocardial infarction.8,9 a previous study showed that the incidence of cardiovascular events is higher in nilotinib as compared to imatinib-related patients.10 experts currently advise against using nilotinib in patients with a high-risk cardiovascular profile whenever possible. among other tki, imatinib is the least associated drug with cardiac failure.11 cancer therapy–related cardiac dysfunction is commonly defined as a decrease in left ventricular ejection fraction (lvef) using twodimensional (2d) echocardiography.12 strain rate on lvef examination is a parameter that depends on the heart’s workload, and the diagnosis of cardiac dysfunction associated with cancer drug administration is often found at an advanced stage when the impairment of heart function has become irreversible. it is calculated using the modified biplane simpson method, depends on operator experience, and is not sufficiently sensitive to detect subclinical myocardial dysfunction.12,13 patients underwent complete echocardiography on four occasions: baseline (v1). global longitudinal strain (gls) is the best strain parameter for assessing left ventricular systolic function due to being more sensitive than lvef. it also can be used to identify subclinical left ventricular systolic dysfunction in cardiomyopathy.14 gls assessment is independent of cardiac workload; it is a sensitive method for detecting subclinical ventricular dysfunction before lvef is reduced in ejection fraction patients treated for various types of cancer.12 therefore, this study aimed to explore the left ventricular function by using gls in cglcp patients receiving imatinib and nilotinib. methods this study received approval from the health research ethics committee of hasan sadikin general hospital number lb.02.01/x.6.5/303/2019. this descriptive cross-sectional study involved 44 cgl-cp patients, selected based on the patient’s arrival from october to december 2019 at the hematooncology polyclinic of internal medicine department in hasan sadikin, bandung, who received imatinib and nilotinib. the study excluded patients with a past medical history such as hypertension, diabetes mellitus, and heart defects treated before receiving imatinib and nilotinib. the variables included in this study were age, gender, bmi, duration of treatment, hemoglobin value, lvef value, and gls value. subsequently, the subjects were examined by standard 2d transthoracic echocardiography followed by left ventricular gls. two consultant cardiologists assessed this examination with gls echocardiography competency. the gls examination on the left ventricular used the speckle tracking echocardiography (ste) technique, while the lvef measurement used the simpson biplane method obtained from 2 and 4-chamber apical views. the average gls % in normal healthy populations, according to the american society of echocardiography (ase), is -20%.15 the normality of primary data was analyzed using the shapiro-wilk test. statistical analysis was performed using spss software version 25.0. results there were 39 patients included in this study (table). seven of forty-six cgl-cp patients were excluded from the study due to the poor echocardiography window. the findings based on the normality test results using shapiro wilk analysis found that the distribution of the variables of age, hemoglobin level, gls%, and lvef% were normal (p>0.05). meanwhile, the length of therapy distribution was not normal (p <0.05). the average lvef was 66%, with a standard deviation of 5%. in the imatinib therapy group alone, it was 66%, with a standard deviation of 5%. in the nilotinib group it was 65%, with a standard deviation of 4%. the average gls% in 39 subjects showed -22.1%, with standard deviation of 2.9%. the average size in the group of patients treated with imatinib alone was -22.4%, with a standard deviation of 3.0%, while in the group of patients treated using nilotinib was -21.6%, with a standard deviation of 2.6%. the average gls %, according to american society of echocardiography (ase) guidelines, was within normal limits. there were two subjects with a decrease in the percentage of gls with global longitudinal strain of chronic granulocytic leukemia patients treated with imatinib and nilotinib international journal of integrated health sciences (iijhs) 51 a value of -16.4% and -16.6%. (fig.) discussion the age of cgl-cp patients in this study ranged from 26 to 61 years old, consisting of more women (56.4%) than men (43.6%). wing et al. mentioned in their journal that the average age of cgl patients in the united states is 65 years, in china is 45-50 years, thailand is 36-38 years, india is 38-40 years, and 37 years in south korea. reksodiputro et al.16 studied the epidemiological studies, and mutation profiles of cgl patients in indonesia mentioned that 100 patients were evaluated between january 1st, 2009, to december 31st, 2011, and found that the average age was 3435 years, and more patients were of productive age.the international randomized study of interferon and sti571 (iris) showed that cgl is more common in the elderly group and very different from the age group of cgl patients in indonesia. although the description looks different from caucasian, the age of cgl patients in indonesia is more similar to the data in asia.16 fig. boxplot difference in gls% between imatinib and nilotinib therapy groups table 1 subjects characteristics variable total n=39 therapy group imatinib n=28 nilotonib n= 11 age (y.o.). mean ±sd 42±11 42±11 41±12 gender. n (%) male female 17 43.6) 22 (56.4) 10 (35.7) 18 (64.3) 7 (63.6) 4 (36.4) bmi (kg/m2). median (range) 25.1 (19.6–35.9) 24.9 (20.7-35.9) 26.0 (19.6-35.9) bmi criteria. n (%) normal overweight obesity i obesity ii 10 (25.6) 8 (20.5) 18 (46.2) 3 (7.7) 6 (21.4) 8 (28.6) 12 (42.9) 2 (7.1) 4 (36.4) 0 (0.0) 6 (54.5) 1 (9.1) duration of therapy (month). median (range) 41 (8-179) 39 (8-179) 47 (14-143) hemoglobin. mean ±sd 12.1 ± 1.7 11.8 ± 1.5 13.9 ±1.9 therapy group arief sumarna, indra wijaya, et al 52 international journal of integrated health sciences (iijhs) the study’s average lvef and gls results of cgl patients receiving imatinib and nilotinib therapy were within normal limits. taher et al.17 previously reported no change in echocardiographic lv function after using imatinib for one year in 50 cgl patients. in addition, cirmi et al.18 also reported that among other tkis, it is the least likely to be associated with cardiac failure.fransisco et al.20 studied the cardiac function of patients with cgl receiving imatinib and nilotinib with a global longitudinal strain examination at the start of therapy. after one year of therapy, the results are normal; however, these results should be confirmed by a multicentre study. in this study, the average percentage of gls in cgl patients who received imatinib was within normal limits, but there were two subjects with a decrease in the percentage of gls with a value of -16.4% and -16.6%. the first subject with a decreasing gls percentage result was a 45-year -old man with a bmi of 23.4 who received imatinib for 74 months, no comorbid, hemoglobin level was 15.4, and lvef 69% with gls -16.6%. the duration of imatinib administration influenced the possibility of decreasing gls in this subject. he has received imatinib for 74 months, but it still needed to be evaluated for certainty cause of the decrease in the gls percentage. the researchers did not have a baseline of gls values before getting imatinib therapy. the second subject with a decreasing gls percentage result was a 32-year-old woman with a bmi of 27.3, and obese i. she has received imatinib for 29 months, no comorbid, hemoglobin level was 13.1, and lvef 58% with gls -16.4 the possibility of decreasing gls in this subject was influenced by the duration of giving imatinib, which was more than seven months, and increased bmi. obesity is associated with lower strain scores in children and adults without other comorbidities or decreased left ventricular ejection fraction.19 according to the food and drug administration (fda), the use of imatinib has an elimination time in the body of 7 days and its cardiotoxicity is reversible.21 in cgl patients receiving nilotinib with a history of previous use of imatinib, but no reduction in gls, the cardiotoxic effects of imatinib were lost due to the elimination time of imatinib. unfortunately, we did not have baseline ecg or echocardiography data before tki therapy. in this study, the group of cgl-cp patients using nilotinib were patients who had received imatinib treatment, so the effect of previous imatinib treatment might have a biased effect on the study results. however, the results did not find any cardiotoxic effects in the nilotinib group. more than 10% of the samples were excluded due to a poor echocardiography window. various factors can affect the gls measurement results. these various factors can be divided into technical factors and clinical factors. technical factors are usually related to the automation of tools, including image quality, image selection, segmentation model selection, selection of areas to be analyzed, timing in the cardiac cycle, poor tracking, and differences between software in performing data analysis. clinical factors include age, gender, systolic blood pressure, type 2 diabetes mellitus, and obesity.22 the limitation of this study is that there are no data on the causes of poor echocardiography windows in patients. in this study, 16 patients who received imatinib therapy were categorized as obese i and two patients categorized as obese ii. this study did not have the baseline bmi data before the initiation of tki; therefore, this study could not conclude whether the imatinib caused the weight gain in our samples. however, a previous study by aduwa et al.23 reported that imatinib induces significant weight gain and bmi modification after 24 months.the mechanism by which imatinib causes weight gain is still unknown. the hypothesis is that weight gain in patients treated with imatinib may be associated with a complex mechanism involving platelet-derived growth factor receptor kinase tyrosine phosphorylation.23 this study has determined the left ventricular function by using gls in cgl-cp patients receiving imatinib and nilotinib. references 1. 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2013;92(11):1581–2. global longitudinal strain of chronic granulocytic leukemia patients treated with imatinib and nilotinib international journal of integrated health sciences. 2018;6(2) 57 characteristics of cerebrospinal fluid in tuberculous meningitis patients with hydrocephalus abstract objective: to describe cerebrospinal fluid (csf) characteristics in tuberculous meningitis (tbm) with hydrocephalus patients as diagnostic criteria of tbm. methods: a cross-sectional using retrospective method was applied in this study by obtaining medical records of tbm with hydrocephalus patients that were treated at department of neurosurgery dr. hasan sadikin general hospital, bandung from january 2014–september 2016. results: sixty one records were included in the study. patient characteristics such as age, gender, and csf laboratory features such as color and clarity, cells and differential count, protein, and glucose were recorded and descriptively analyzed. the majority of csf macroscopic appearance was seen to be clear (88%) and colorless (88%). median for csf cell count was 25 cells/mm3 with lymphocyte predominance (median: 76%). increased protein from normal value range was seen in csf (median: 50 mg/dl) while the mean for csf glucose in this study remained in its normal value range (mean: 58.9±26.68 mg/dl) with lower csf to blood glucose ratio (mean: 0.41±0.27). conclusions: clear csf with colorless appearance, lymphocyte pleocytosis, high protein level, and low csf glucose as well as blood glucose ratio remain typical csf characteristics of tbm patients found at the department of neurosurgery, dr. hasan sadikin general hospital, bandung. keywords: cerebrospinal fluid, hydrocephalus, tuberculous meningitis pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v6n2.1129 ijihs. 2018;6(2):57–62 received: november 2, 2017 revised: may 15, 2018 accepted: september 5, 2018 correspondence: astrid tamara maajid budiman, faculty of medicine, universitas padjadjaran jl. raya bandung-sumedang km 21 jatinangor, indonesia e-mail: astridtamaramb@gmail.com introduction tuberculosis (tb) currently remains a major global health issue. indonesia is currently in the top three in terms of tb cases where 10% of the total tb population in the world is found in this country.1 one of extrapulmonary tb with high mortality and morbidity, esepcially in children, is tuberculosis meningitis (tbm).2 hydrocephalus is the most frequently found complication of tb and one of the predictors of mortality and morbidity.2 early diagnosis and proper management of tbm is an important factor that influences mortality and morbidity. cerebrospinal fluid (csf) examination is an important parameter in the diagnosis of tbm . this csf examinations includes macroscopic, microscopic, chemical, and microbiological examinations. bacterial culture or acid-fast bacilli (afb) observation in csf are used to establish tbm definitive diagnosis.2,3 a previous study has reported that the ratio of positive culture results were 13% among tbm patients.4 in several cases, low results of bacterial culture and afb on csf may be seen. hence it is important to observe the macroscopic, microscopic, and chemical characteristic as a reference for the laboratory-based diagnosis of tbm.4 original article :57–62 astrid tamara maajid budiman,1 nida suraya,2 ahmad faried,3 ida parwati2 1faculty of medicine, universitas padjadjaran 2department of clinical pathology, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital, bandung 3department of neurosurgery, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital, bandung 58 international journal of integrated health sciences. 2018;6(2) this study aimed to observe the chemical, macroscopic, and microscopic characteristics of csf in tbm patients with hydrocephalus at the department of neurosurgery dr. hasan sadikin general hospital, bandung. methods this design used in this study was retrospective cross-sectional descriptive study. tbm patients with hydrocephalus treated at the department of neurosurgery, dr. hasan sadikin general hospital, bandung who met the inclusion and exclusion criteria were included. the inclusion criteria in this study were inpatients during the period of january 2014–september 2016, with a computerized tomography (ct) scan results that suggested hydrocephalus who had undergo csf examination with specimens derived from ventricular drainage at the clinical pathology laboratory of dr. hasan sadikin general hospital, bandung, with macroscopic, microscopic, and chemical characteristic result, including protein and glucose levels. exclusion criteria included congenital hydrocephalus, meningitis caused by organisms other than mycobacterium tuberculosis, positive human immunodeficiency virus (hiv) status, and incomplete medical record. samples were selected using the total sampling method. approval from the ethics committee of the faculty of medicine, universitas padjadjaran under the ethical clearance no. 102/un6. c1.3.2/kepk/pn/2016 was gained. this study was conducted from august to december 2016 by collecting data from the medical records of tbm inpatients with hydrocephalus i who were treated at the department of neurosurgery, dr. hasan sadikin general hospital, bandung. csf of these patients were examined at the laboratory of clinical pathology of the same hospital. variables used in this study were age, csf color, clarity, leukocyte cell numbers, cell count percentage, protein level, and glucose level. data were then analyzed descriptively by counting the number and percentage for the results of macroscopic examination while for microscopic and chemical examination results, mean and standard deviations or median and range were used based on the distribution of the data. results there were 477 patients with tbm in dr. hasan sadikin general hospital bandung from 2014 to 2016. a total of 170 (35.6%) patients were treated at the department of neurosurgery dr. hasan sadikin general hospital, bandung with 149 cases (31.2%) were diagnosed as tbm with hydrocephalus. sixty six cases (44.3) met the inclusion criteria but five of them must be excluded, resulting a total of 61 (40.9%) cases. all were included in the study. all csf samples collected from these 61 patients were taken from ventricular drainage such as extra ventricular drainage (evd) or ventriculoperitoneal (vp) shunt. the number of male patients was higher than the number of female patients (table 1). age categorization of children and adults in this study referred to the existing consensus in dr. hasan sadikin general hospital, bandung with 0–14 years categorized as children, and >14 years classified as adults. the number of pediatric patients was higher when compared to adults patients. median age was 6 years old with a range of 6 months–58 years. examination of csf was performed on tbm patients with hydrocephalus and the results were compared to normal values and criteria from marais et al.3 (table 2). cerebrospinal fluid color in tbm patients with hydrocephalus characteristics of cerebrospinal fluid in tuberculous meningitis with hydrocephalus patients :57–62 gender children adults total (%) male 20 15 34 (56) female 19 7 27 (44) total 39 22 61 (100) table 1 distribution of tuberculous meningitis with hydrocephalus patients based on age and gender international journal of integrated health sciences. 2018;6(2) 59 astrid tamara maajid budiman, nida suraya, et al. :57–62 in this study was generally colorless. similarly, the clarity level of csf in this study generally showed a clear result. the median of the csf leukocyte cells was 25 cells/mm3 (range was 1-613 cells/mm3). the differential cell count of the cerebrospinal fluid was presented in the form of percentage of mononuclear (mn) and polymorphonuclear cells (pmn). mononuclear cells were shown to be the dominant cell in the csf. the scope of percentage for both pmn and mn was 0% to 100%. there were two cases which showed the percentage of pmn of 100%, with a csf leukocyte cell count of 1 cell/mm3 in both. the median csf protein was higher than the normal value but not as high as the one in marais et al.3 criteria. the mean csf glucose was 58.9±26.68 mg/dl which was still in the normal limit. the csf to blood glucose ratio could only be calculated in 11 patients (mean: 0.41±0.27). discussion this study reveals that the prevalence of tbm with hydrocephalus is predominated by males. this finding is in agreement with the results of previous studies.4–6 a study found that the prevalence of pediatric patient with tbm with hydrocephalus as complication is 71% while the same prevalence for adults is 12%.7 this study also shows that more children has tbm with hydrocephalus compared to adult. macroscopic examination on the color and clarity of csf was performed. the macroscopic appearance of csf in this study was generally clear and colorless. this is in line with the variable normal value marais et al. 3 criteria for tbm result macroscopic appearance csf color* colorless colorless, n(%) 54 (88 yellowish, n(%) 4 (7) yellow, n(%) 3 (5) clarity clear clear clear, n(%) 54 (88) cloudy, n(%) 6 (10) turbid, n(%) 1 (2) microscopic examination 25 (1–613) csf cells, median (range) <5 cells/mm3 10-500 cells/mm3 cells/mm3 differential count, median (range) pmn (%)** <50% 24 (0–100) mn (%)# >50% >50% 76 (0-100) chemistry protein, median (range) 10–40 mg/dl >100 mg/dl 50 (5–977) mg/dl absolute csf glucose, mean±std deviation 50–80 mg/dl <40 mg/dl 58.9±26.68 mg/dl csf to blood glucose ratio##, mean±std deviation 0.6 <0.5 0.41±0.27 note: *csf = cerebrospinal fluid; **pmn = polymorphonuclear; #mn = mononuclear; ##could only be done in 11 patients table 2 cerebrospinal fluid examination in tuberculous meningitis patients with hydrocephalus 60 international journal of integrated health sciences. 2018;6(2) diagnosis criteria of tbm according to marais et al.3 tuberculous meningitis is a chronic disease characterized by clear csf with not really high leukocyte count and is dominated by lymphocytes.3,8,9 the inflammation response of t cell as tbm pathogenesis is demonstrated through the predominance of lymphocytes in microscopic examination of csf, as seen in previous studies and this study.5,10–13 marais et al.3 stated that a diagnosis criteria of chemical examination of csf includes an increase in csf protein (>100 mg/dl). this study shows the amount of csf protein was not greater than 100 mg/dl as stated in the criteria diagnosis by marais et al.3 however, the median csf protein was in accordance with previous studies stating that the mean csf protein was not more than 100 mg/dl despite the increase of the csf protein value when compared to the normal value.6 as the top referral hospital in west java, dr. hasan sadikin general hospital, bandung, in particular the hospital’s clinical pathology laboratory, has their own normal csf protein range standard of 10–40 mg/dl. the csf protein in tbm which is supposed to be increased according to the pathogenesis of tbm is considered as the result from the increased permeability of blood brain barrier or decreased reabsorption in the arachnoidalis villi.8,13 the normal value of glucose in csf is 2/3 of the plasma glucose, or approximately 50 ti=o 80 mg/dl.8,13 as already explained in the criteria for tbm diagnosis, the csf glucose should be less than 40 mg/dl (2.2 mmol/l) or the ratio between csf glucose and plasma glucose is lower than 50%.3 this decrease in glucose is resulted from anaerobic glycolysis caused by bacteria or disturbance in glucose transport mechanism.8,13 the mean glucose level in this study was >40 mg/dl and wa still in the normal range of csf glucose. this is in contrast with the diagnostic criteria by marais et al.3 and some previous studies.6,9 a previous study presented that the number of patients with glucose level <40 mg/dl was 48% or less than a half of all patients and that the glucose level had a wide range between 12.1–156.7 mg/dl as also shown in this study (2–135 mg/dl).11 there are only 11 patients whose csf glucose to blood glucose ratio can be measured (median: 0.41±0.27). this result is in line with the diagnostic criteria by marais et al.3 which stated that csf glucose to blood glucose ratio is <50%. most previous studies that have discussed the csf characteristics in tbm use csf to blood glucose ratio <0.5 as one ofdiagnostic criteria for tbm.4,14 the previous studies showed that the sensivity of the low absolute csf glucose was low, that is 68% and 69,5%.12,15 on the other hand, previous studies also showed that the sensitivity of low csf to blood glucose ratio was 90%.15 this explains why the normal absolute csf glucose level cannot rule out the possibility of infection and it had also been suggested that considerations should be given to use csf to blood glucose ratio as additional information for diagnosis of tbm.15 the difference of csf content in this study compared to marais et al.3 criteria might be caused by the csf source itself.16 previous study had shown difference csf composition between ventricular and spinal csf that may be caused by the disease’s pathophysiology.16 the impaired blood-brain barrier leads to a higher protein composition which may slow down the circulation of csf and may impair csf absorption or obstruct the csf pathway that causes hydrocephalus after aggregation of csf protein and leukocytes caudally.16 the median of age in this study (median: 6 years) reflects a higher distribution among children below 6 years old. several previous studies have shown age-related variations in csf protein content.8,17 it is shown here that there is a lower protein csf value in children when compared to adults and this might result in lower protein csf in this study compared to the marais et al.3 criteria.8,17 furthermore, the use of antimicrobial agent before ventricular drainage may also affect csf protein and glucose content.18 time of interval median between the occurence of tuberculosis to hydrocephalus development was 21 days (range: 3–180 days). in between, patients consumed antituberculous drugs. a previous study has shown that csf glucose will increase and csf protein will decrease significantly after the use of antibiotic, especially in the period of >12 hours postantibiotics.18 there are several limitations in the study including the small sample size, i.e. 61 samples. this is due to the limited time and rejection from some tbm patients with hydrocephalus to undergo ventricular drainage that includes both evd and vp shunts. in addition, incomplete patient records and archives creates another limitation, especially when the result of csf in patient who underwent ventricular drainage is missing. another reason is that blood glucose measurement done 15–30 minutes prior to the ventricular drainage was not done in almost all samples. this makes the calculation of csf to glucose ratio cannot be performed in almost all patients. specimen was also taken from :57–62 characteristics of cerebrospinal fluid in tuberculous meningitis with hydrocephalus patients international journal of integrated health sciences. 2018;6(2) 61:57–62 references 1. world health organization. global tuberculosis report 2015. 20th ed. geneva: world health organization, 2015. 2. rock rb, olin m, baker ca, molitor tw, peterson pk. central nervous system tuberculosis: pathogenesis and clinical aspects. clin microbiol rev. 2008;21(2):243–61. 3. marais s, thwaites g, schoeman jf, torok me, misra uk, prasad k, et al. tuberculous meningitis: a uniform case definition for use in clinical research. lancet infect dis. 2010;10(11):803–12. 4. güneş a, uluca ü, aktar f, konca ç, şen v, ece a, et al. clinical, radiological and laboratory findings in 185 children with tuberculous meningitis at a single centre and relationship with the stage of the disease. ital j pediatr [serial on the internet]. 2015 oct [cited 2017 aug 12];41(75):[about 6p.]. available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ pmc4606503/. 5. pinto vl, lima ma, rolla vc, rebelo mc, boia mn. atypical cerebrospinal fluid profile in tuberculous meningitis. trop doct. 2009;39(2):76–8. 6. shaikh ma, shah m, channa f. criteria indicating morbidity in tuberculous meningitis. j pak med assoc. 2012;62(11):1137–9. 7. rajshekhar v. management of hydrocephalus in patients with tuberculous meningitis. neurol india. 2009;57(4):368–74. 8. karcher ds, mcpherson ra. cerebrospinal, synovial, serous body fluids, and alternative specimens. in: mcpherson ra, pincus mr, editors. henry’s clinical diagnosis and management by laboratory methods. 22nd ed. philadelphia: elsevier saunders; 2011. p. 480– 92. 9. qamar fn, rahman aj, iqbal s, humayun k. comparison of clinical and csf profiles in children with tuberculous and pyogenic meningitis; role of csf protein: glucose ratio as diagnostic marker of tuberculous meningitis. j pak med assoc. 2013;63(2):206–10. 10. salekeen s, mahmood k, naqvi ih, baig my, akhter st, abbasi a. clinical course, complications and predictors of mortality in patients with tuberculous meningitis-an experience of fifty two cases at civil hospital karachi, pakistan. j pak med assoc. 2013;63(5):563–7. 11. christensen a-sh, andersen åb, thomsen vø, andersen ph, johansen is. tuberculous meningitis in denmark: a review of 50 cases. bmc infect dis. 2011;11(1):1–6. 12. solari l, soto a, agapito jc, acurio v, vargas d, battaglioli t, et al. the validity of cerebrospinal fluid parameters for the diagnosis of tuberculous meningitis. int j infect dis [serial on the internet]. 2013 dec [cited 2016 nov 18];17(12):[about 5p.]. available from:https://www.ijidonline.com/article/ s1201-9712(13)00214-2/fulltext. 13. cerebrospinal fluid. in: strasinger sk, di lorenzo ms, editors. urinalysis and body fluids. 6th ed. philadelphia: f.a. davis company; 2008. p.177–95. 14. thwaites g, fisher m, hemingway c, scott g, solomon t, innes j. british infection society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children. j infect. 2009;59(3):167– 87. 15. solomons rs, visser dh, donald pr, marais bj, schoeman jf, van furth am. the diagnostic value of cerebrospinal fluid chemistry results in childhood tuberculous meningitis. childs nerv syst. 2015;31(8):1335–40. 16. alfayate-miguelez s, martinez-lage-azorin l, marin-vives l, garcia-martinez s, almagro mj, martinez-lage jf. normal ventricular-csf may comfound the diagnosis of tuberculous astrid tamara maajid budiman, nida suraya, et al. ventricular drainage that may also affect the results compared to those of previous studies that mostly used lumbar fluid as specimens. in conclusion, the diagnosis of tuberculous meningitis is still problematic, especially with the high number of the hydrocephalus seen. csf presentations such as clear and colorless csf, lymphocyte pleocytosis, increased protein level, and lower csf to blood glucose ratio are still the typical characteristics found in tbm with hydrocephalus in dr. hasan sadikin general hospital, bandung. examination of csf in tbm may be done in every level of health facilities as it is the easiest way to diagnose this disease. this study suggests the use of csf to blood glucose ratio as a routine examination to in tbm diagnosis. 62 international journal of integrated health sciences. 2018;6(2) meningitis hydrocephalus. neurocirugia (astur). 2011;22(2):157–61. 17. miftode eg, dorneanu os, leca da, juganariu g, teodor a, hurmuzache m, et al. tuberculous meningitis in children and adults: a 10-year retrospective comparative analysis. plos one. 2015 jul [cited 2016 nov 18];10(7):[about 10p.] available from: http://journals.plos. org/plosone/article/file?id=10.1371/journal. pone.0133477&type=printable. 18. nigrovic le, malley r, macias cg, kanegaye jt, moro-sutherland dm, schremmer rd, et al. effect of antibiotic pretreatment on cerebrospinal fluid profiles of children with bacterial meningitis. pediatr. 2008;122(4):72630. characteristics of cerebrospinal fluid in tuberculous meningitis with hydrocephalus patients :57–62 international journal of integrated health sciences. 2017;5(1) 1 prediction of jamar grip strength value using modified aneroid spyhgmomanometer cuff method lusia pujianita, tertianto prabowo, marietta shanti prananta department of physical medicine and rehabilitation, faculty of medicine, universitas padjajaran-dr. hasan sadikin general hospital abstract objective: to examine the prediction of jamar grip strength value by using aneroid sphygmomanometer cuff method in adults. methods: this study involved 120 subjects, aged 20–59 years old. the grip strength of subjects were measured using jamar dynamometer and aneroid sphygmomanometer cuff method. spearman analysis was used to evaluate the correlation between variables and grip strength. forward stepwise was used to analyze the regression of jamar dynamometer using aneroid sphygmomanometer cuff method. results: there was a weak correlation (r<0.4) between grip strength with age and bmi, moderate correlation (r = 0.4–0.6) for grip circumference, and also strong correlation r= (0.6–0.8) for sex, hand length, and hand width. jamar grip strength value can be predicted using spyghmomanometer with the formula of (0.1157 x sphygmomanometer grip strength value) – (5.696 x sex) + (0.0824 x age) (female =1, male= 0). conclusions: grip strength correlates with physiological variables. the variables to predict jamar grip strength using sphygmomanometer are sex and age. regression analysis shows that spyhgmomanometer can be used as an alternative to measure grip strength and has a valid value to predict the jamar grip strength value. keywords: adult, grip strength, jamar dynamometer, sphygmomanometer, prediction formula pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v5n1.958 ijihs. 2017;5(1):1–7 received: may 31, 2016 revised: october 18, 2016 accepted: february 27, 2017 correspondence: lusia pujianita, department of physical medicine and rehabilitation, faculty of medicine, universitas padjajaran-dr. hasan sadikin general hospital jl. pasteur no. 38, bandung, indonesia e-mail: lusia.pujianita@gmail.com introduction grip strength value is an important parameter to evaluate the management procedure of hand region, monitor the progression of hand disability, set up the realistic targets for a rehabilitation program, and also to evaluate the ability to return to work.1 grip strength is also used to predict the total muscle strength in healthy children, adolescents, and young adults.2 clinical and epidemiological studies have shown the potential use of grip strength as one of the predictors of mortality and morbidity of several systemic diseases. patients with grip strength disturbance have higher postoperative complications, longer duration of hospitalization, and also a higher rate of rehospitalization.3 grip strength is a physiological variable influenced by age, sex, and anthropometry.4 previous studies have proven that there is an association between the grip strength and various anthropometry dimensions.4–6 a study of anthropometry between indonesian and singaporean population showed significant mean differences. geographical origin affects variations of anthropometry. this has been confirmed by reports from another research in turkish population. geographical region has a significant effect on stature and weight of the turkish population. another factor influencing anthropometry variation is the original article :1–7 2 international journal of integrated health sciences. 2017;5(1) socioeconomic factor. higher socioeconomic status implies higher income and is associated with better education, resulting in better nutrition, better child care, and better medical and social services.7 the association between grip strength and anthropometry in some countries has shown variations in results. the normative value or prediction formula in one population should not be used in other population. a study on grip strength normative value in netherlands found that body weight and height have no significant association with grip strength, but sex has significant association.8 another study in australia presents a different result as it is able to discover the presence of association between grip strength and body mass index; however, their normative value is lower than that of the international literature.9 the standard instrument to measure grip strength worldwide is jamar dynamometer.10 however, jamar is rarely found in developing countries such as indonesia. this instrument may be unsuitable for some people due to its weight and rigidity. there is a need for an alternative instrument to measure the grip strength. the aneroid sphygmomanometer had the potential to be used as an alternative instrument to measure grip strength.4 this instrument is cheaper and readily available in prediction of jamar grip strength value using modified aneroid spyhgmomanometer cuff method modified sphygmomanometerfig. 1 :1–7 modified sphygmomanometerfig. 2 international journal of integrated health sciences. 2017;5(1) 3 lusia pujianita, tertianto prabowo, et al. :1–7 table 1 data characteristics variable male (n=48) female (n=72) mean (sd) median (range) mean (sd) median (range) age group 20–29 years old (n= 30) body weight (kg) 75 (58–89) 51.5 (39–75) body height (m) 1.70 (0.05) 1.57 (0.06) bmi (kg/m2) 24.2 (20.71–29.4) 21.36 (16.44–27.54) hand length (cm) 19 (17–21) 16.75 (15–19) hand width (cm) 8.5 (7.5–9) 7.5 (6.5–7.5) grip circumference (cm) 16.5 (14.5–18.5) 14.75 (13.5–17) jamar(kg) 30.66 (15.33–48.66) 16.5 (10.66–21) sphygmomanometer (mmhg) 251.66 (183.33–300) 173.33 (136.66–223.33) age group 30–39 years old (n=30) body weight (kg) 76.5 (52–95) 54.5 (41–84) body height (m) 1.71 (0.04) 1.58 (0.06) bmi (kg/m2) 26.22 (19.1–30.66) 21.95 (17.71–32.88) hand length (cm) 19 (17.5–21) 17.5 (16–19) hand width (cm) 8.75 (8–9) 7.5 (7–8.5) grip circumference (cm) 16.5 (15–18.5) 15 (14.5–17) jamar (kg) 30. 83 (24–52) 17.83 (10.66–26) sphygmomanometer (mmhg) 253.33 (190–300) 186.66 (110–226.66) age group 40–49 years old (n=30) body weight (kg) 65 (56–76) 62 (43–74) body height (m) 1.64 (0.03) 1.54 (0.04) bmi (kg/m2) 24.91 (19.84–27.91) 26.81 (18.13–31.11) hand length (cm) 18 (17–19.5) 17 (15.5–18.5) hand width (cm) 8.5 (8–9) 7.5 (7–8.5) grip circumference (cm) 15.5 (14–16) 14.5 (13–16.5) jamar (kg) 30.66 (22.66–41) 16.33 (12.66–23.33) sphygmomanometer (mmhg) 233.33 (166.66–276.66) 153.33 (106.66–200) age group 50–59 years old (n= 30) body weight (kg) 57 (46–70) 54 (41–113) body height (m) 1.63 (0.03) 1.55 (0.04) 4 international journal of integrated health sciences. 2017;5(1) prediction of jamar grip strength value using modified aneroid spyhgmomanometer cuff method :1–7 bmi (kg/m2) 20.76 (16.29–26.23) 22.89 (18.22–47.03) hand length (cm) 18.5 (17.5–20) 17 (15.5–18.5) hand width (cm) 8 (8–9) 7.5 (6.5–8) grip circumference (cm) 15.5 (14.5–17.5) 14.5 (13–16.5) jamar (kg) 26.33 (18.66–33.66) 14.66 (7.33–20.33) sphygmomanometer (mmhg) 213.33 (160–256.66) 136.66 (113.33–183.33) all health facilities. this instrument also has an accuracy that is equivalent with the mercury sphygmomanometer.11 sphygmomanometer has softer surface and it is lighter than jamar dynamometer. it is also more comfortable to be used by individuals with hand disability, such as rheumatoid arthritis, or those who are in the recovery phase of a post-hand injury. the grip measurement that is performed using sphygmomanometer will require some adaptation. unmodified sphygmomanometer can cause difficulties in grip stabilization and change in diameter during inflation. cuff method needs to be simple with quick preparation.12 this method is suitable for everyday use because it does not require a dedicated sphygmomanometer as it still can be used for blood pressure measurement. hamilton et al.13 discovered that the use of sphygmomanometer for measuring grip strength is valid. this study also produced a prediction formula of jamar grip strength value using sphygmomanoter in young women (25–39 years old). there is currently no study on jamar grip strength value using sphygmomanometer for all adult population (20–59 years old) yet. the prediction formula from hamilton study does not account the age, sex, and anthropometry. this study aimed to discover the predictability of jamar grip strength value using a modified sphygmomanometer cuff method in adults aged 20–59 years old. methods participants of this study were 120 healthy adults in dr. hasan sadikin general hospital, bandung. the consecutive sampling method was used until the required number of participants is met. participants gave consent before participating. the inclusion criteria were adults between the age 20–59 years old and independent in activity daily living. subjects were excluded if they had hand deformity (musculoskeletal or neuromuscular), hand pain, or history of heart disease, metabolic, and rheumatic disease. this study has been ethically approved by health research ethics committee of faculty of medicine universitas padjadjaran. hand grip median value graphicfig. 3 international journal of integrated health sciences. 2017;5(1) 5 variable r p value sex and jamar -0.794 0.000 sex and sphygmomanometer -0.724 0.000 age and jamar -0.152 0.097 age and sphygmomanometer -0.381 0.000 bmi and jamar 0.243 0.007 bmi and sphygmomanometer 0.189 0.039 hand length and jamar 0.658 0.000 hand length and sphygmomanometer 0.632 0.000 hand width and jamar 0.695 0.000 hand width and sphygmomanometer 0.681 0.000 grip circumference and jamar 0.523 0.000 grip circumference and sphygmomanometer 0.586 0.000 jamar and sphygmomanometer 0.835 0.000 the grip strength measurement used jamar dynamometer and sphygmomanometer aneroid. jamar dynamometer has 5 handle positions, and the second handle position was used for all subjects.14 the adaptation used for shygmomanometer aneroid is the cuff method. the inflatable part was folded into four equal parts and the remainder part of the cuff was wrapped around the inflatable part and fixed with a velcro cuff. the sphygmomanometer was inflated to 100 mm hg and its valve was kept closed to remove the folds from the inflatable portion. then, the pressure was reduced to 20 mm hg, and the valve was closed again to prevent leakage. subject’s identity, age, and sex data were collected. each participant was measured for body weight, body height, hand width, hand length, hand grip circumference, and hand grip strength. the hand width was measured from ulnar part of distal palmar crease to radial part. hand length was measured from distal wrist crease to the tip of middle finger. hand grip circumference was measured by gripping the cone where the tip of the thumb and middle finger met, then the cone circumference was measured. examination position during grip strength measurement was in accordance with the rules of the american society of hand therapists (asht). this testing position is described as sitting in a straight-backed chair with the feet flat on the floor, the shoulder adducted and neutrally rotated, elbow flexed at 900, forearm in a neutral position, and, in all cases, the arm should not be supported by the examiner or by an armrest. the grip strength measurement using dynamometer is presented vertically and in line with the forearm to maintain the standard forearm and wrist positions. participants were asked to grip up to 3 seconds using the dominant hand with 3 times repetition and a minute rest between the grips. all participants were measured using jamar dynamometer first, then sphygmomanometer aneroid cuff method. spearman’s correlation test was used to understand the relationship between the two instruments and between the hand grip with anthropometry factor. the analysis was continued with linear regression. results there were 120 participants (48 males and 72 females). the normality test using shapiro wilk shows that only body height that had normal distribution (table 1). adult’s hand grip reached the peak value in age group 30–39 years old, and decreased after 40 years old, both in males and females (fig. 3). correlations between the two instruments and others variables were tested using spearman correlation test and a confidence interval of 95% is listed (table 2) age and jamar do not show any significant correlation, whereas others variables had significant correlations with both jamar and sphygmomanometer. age and bmi had a weak correlation with the grip strength (r<0.4). the moderate correlation (r=0.4–0.599) was between grip circumference and grip strength. the strong correlation (r=0.6–0.799) was between sex, hand length, hand width and grip strength. the strongest correlation (r>0.8) was found between grip strength by jamar and sphygmomanometer. the regression analysis was performed using the forward stepwise method. the variables that are accounted into the regression were grip strength, sex, and age. the hand length, hand width, and grip circumference have had correlation with sex already. they are not accounted to regression analysis to lusia pujianita, tertianto prabowo, et al. :1–7 table 2 multivariables correlation toward hand grip strength 6 international journal of integrated health sciences. 2017;5(1) avoid the autocorrelation. during the analysis, there were 4 outliers found. after excluding the outliers from the regression analysis, the regression coefficient for jamar grip strength was calculated (table 3). the variables had a significant regression coefficient towards jamar grip strength with a prediction value of r = 0.986. this residue of prediction was tested, producing a mean of = 0.015 and sd 3.79 (table 3). t test for the residu presented a t count = 0.43 (p>0.05). this means that the mean of residu = 0. the normality test with shapiro wilk produced w = 0.977 (p=0.346), which presented a normal distribution of the residu. based on the residu testing, this prediction was valid to predict jamar grip strength of dominant hand using sphygmomanometer in west java adult population. the formula is jamar grip strength value using sphygmomanometer = (0.1157 x sphygmomanometer grip strength value) – (5.696 x sex) + (0.0824 x age). (constanta for sex : 1 for female, 0 for male). discussion grip strength reaches its peak value in the age group of 30–39 years old and decreases after 40 years old. this result corresponds with previous studies in australia, netherland, and england.8,915previous study involved participants aged 20–34 years old, making the description of association between grip strength and age does not represent all adult population. this study involves a wider range of age and found a weak correlation between grip strength and age. this weak correlation is caused by insignificant muscle mass reduction that happens with age. the muscle mass is started to reduce during the middle age and is significantly reduced after 60 years old.16,17 sex has a strong correlation with grip strength. males has a higher grip strength compared to females. male and female grip strength is almost equal before puberty. the increased testosterone level during puberty leads to hypertrophy that would cause the male strength quickly rise after puberty. this study also found that hand width, hand length, and grip circumference in males are larger than in females. the larger muscle mass will lead to larger muscle strength.9,15 the highest correlation was found between jamar grip strength and sphygmomanometer with a correlation coefficient of 0.835. this supports the prediction of jamar grip strength value using the sphygmomanometer. a modified sphygmomanometer can potentially be used in daily clinical practice, due to its portability, lower price, and softer surface, making it more comfortable to grip.12,13 this study has produced the a formula to predict the jamar grip strength value using sphygmomanometer in adult. based on the statistical analysis, this formula is valid to be used in adults in west java population. further research is needed to learn whether the prediction formula can be used in the population of people with disability and larger healty adult population. table 3 regression coefficient for jamar grip strength std. err. std. err. t(117) p value beta of beta beta of beta sphygmomanometer 0.9738 0.0375 0.1157 0.0045 25.9539 0.0000 sex -0.1953 0.0244 -5.6959 0.7129 -7.9900 0.0000 age 0.1480 0.0439 0.0824 0.0245 3.3692 0.0010 references 1. dhara pc, de s, pal a, sengupta p. assessment of hand grip strength of orthopedicaly chalenge persons affected with upper extremity. j life sci. 2009;1(2):121–7. 2. wind ae, tim, helders pj. is grip strength a predictor for total muscle strength in healthy children, adolescents, and young adults? eur j pediatr. 2010;169(3):281–7. prediction of jamar grip strength value using modified aneroid spyhgmomanometer cuff method :1–7 international journal of integrated health sciences. 2017;5(1) 7 lusia pujianita, tertianto prabowo, et al. :1–7 3. norman k, stobaus n, gonzalez c, schulzke j-d. hand grip strength: outcome predictor and marker of nutritional status. clin nutr j. 2010;30(2):135–42. 4. chandrasekaran b, ghosh a, prasad c, krishnan k, chandrasharma b. age and anthropometric traits predict hand grip strength in healthy normals. j hand microsurg. 2010;2(2):58–61. 5. koley s, yadav mk. an association of hand grip strength with some anthropometric variables in indian cricket players. physical education sport. 2009;7(2):113–23. 6. fallahi aa, jadidian aa. the effect of hand dimensions, hand shape and some anthropometric characteristics on handgrip strength in male grip athletes and non-athletes. j hum kinet. 2011;29(2):151–9. 7. chuan tk, hartono m, n k. anthropometry of the singaporean and indonesian population. int j industr ergonom. 2010;40(6):757–66. 8. peters mj, nes siv, vanhoutte ek, bakkers m, doorn pav, merkiers is, et al. revised normative value for grip strength with the jamar dynamometer. j peripher nerv syst. 2011;16(1):47–50. 9. massy-westropp nm, gill tk, taylor aw, bohannon rw, hill cl. hand grip strength: age and gender stratified normative data in a population based study. bmc res notes [serial on the internet]. 2011 apr [cited 2016 jun 12];4(127):[about 5p.]. available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ pmc3101655/. 10. roberts hc, denson hj, martin hj, patel hp, syddall h, cooper c, et al. a review of the measurement of grip strength in clinical and epidemiological studies towards a standardised approach. age ageing. 2011;40(4):1–7. 11. ma y, temprosa m, fowler s, prineas rj, montez mg, friday jb, et al. evaluating the accuracy of an aneroid sphygmomanometer in a clinical trial setting. am j hypertens. 2009;22(3):263– 6. 12. souza la, martins jc, moura jb, salmela lft, paula fvd, faria cd. assessment of muscular strength with the modified spyhgmomanometer test: what is the best method and source of outcome values? braz j phys ther. 2014;18(2):191–200. 13. hamilton gf, mcdonald c, chenier tc. measurement of grip strength: validity and reliability of the sphygmomanometer and jamar grip dynamometer. j orthop sports phys ther. 1992;16(5):215–9. 14. trampish, franke j, jedamzik n, hinrichs t, platen p. optimal jamar dynamometer handle position to assess maximal isometric hand grip strength in epidemiological studies. j hand surg am. 2012;37(11):2368–73. 15. dodds rm, syddall he, cooper r, benzeval m, deary ij, dennison em. grip strength across the life course: normative data from twelve british studies. plos one. 2014;9(12):1–15. 16. palmio j, udd b. borderlines between sarcopenia and mild late-onset muscle disease. frontiers aging neurosci. 2014;6(2):267–72. 17. yahin a, moeliono ma, prananta ms. handgrip strength prediction formula using aneroid sphygmomanometer in elderly. ijihs. 2016;4(2):47–55. international journal of integrated health sciences. 2018;6(2) 67 correspondence: eko fuji ariyanto, division of biochemistry and molecular biology, department of biomedical sciences, faculty of medicine, universitas padjadjaran jl. raya bandung-sumedang km 21 jatinangor, indonesia e-mail: fuji@unpad.ac.id infused oyster mushroom (pleurotus ostreatus) inhibits glucose absorption through intestinal mucosal membrane in wistar rats eko fuji ariyanto,1,2 muhammad nurhalim shahib,1 abdullah firmansah wargahadibrata3 1division of biochemistry and molecular biology, department of biomedical sciences, faculty of medicine, universitas padjadjaran 2research center for medical genetics, faculty of medicine, universitas padjadjaran 3division of nutrition, department of public health, faculty of medicine, universitas padjadjaran abstract objective: to observe the effects of infused oyster mushroom (latin name: pleurotus ostreatus) on glucose absorption through the intestinal mucosal membrane in wistar rats. methods: this study used experimental design. subjects of this study were six wistar rats which were randomly divided into two groups; three rats were used for the analysis of the most effective time for glucose absorption and the other three were used to evaluate the effect of infused oyster mushroom on glucose absorption. the intestine of subjects was connected to in situ perfusion machine. control glucose solution (ctr) or glucose solution containing 5% (oys 5%), 10% (oys 10%), and 20% (oys 20%) infused oyster mushroom was added into the perfusion machine and flowed back and forth in the lumen of intestine subsequently, accompanied by washing procedures using 0.9% nacl between treatments. the glucose concentration was determined using deproteinization method followed by absorbance measurement. student’s t test was performed to analyze the difference between groups. results: the level of glucose absorbed through intestinal mucosal membrane in control glucose solution and glucose solution with different concentrations of infused oyster mushroom, i.e. 5%, 10% or 20%, was 25.19+3.4 mg/dl, 16.27+0.86 mg/dl, 13.22+1.58 mg/dl and 10.03+1.25 mg/dl, respectively. student’s t test showed significant differences between groups; ctr and oys 5% (p=0.03), ctr and oys 10% (p=0.02), and ctr and oys 20% (p=0.007). conclusions: infused oyster mushroom inhibits glucose absorption through intestinal mucosal membrane in wistar rats. keywords: oyster mushroom (pleurotus ostreatus), glucose absorption, intestine pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v6n2.1354 ijihs. 2018;6(2):67–72 introduction glucose is one of the primary sources of energy for living organisms that is mostly obtained from outside the body and is absorbed through small intestines. this absorption is mediated by transporter proteins by which the glucose can be transported from the intestinal lumen into the intestinal mucosal cells and eventually into blood vessels. intestinal glucose transport was mediated by na+-d-glucose cotransporter sglt1 and also by glucose transporter type 2 (glut2).1–3 some studies have revealed several factors that may affect the glucose transport through intestinal mucosal membrane, such as glucose concentration, temperature, inhibitors and activators, and bile.4 diabetes mellitus is a metabolic disorder which is characterized by high blood glucose level. diabetes mellitus prevalence is increasing rapidly and has reached about 1 in 11 adults in the world have diabetes mellitus.5 one of original article received: july17, 2018 revised: august 29, 2018 accepted: september 10, 2018 :67–72 68 international journal of integrated health sciences. 2018;6(2) the strategis to lower blood glucose level in diabetic patients is through the inhibition of glucose absorption in intestine, an effect that can be achieved through the use of biguanide class of antidiabetic drugs.6 previous studies have reported that several mushroom species had effects on metabolism as wel as on glucose transporters. giant oyster mushroom (pleurotus giganteus) was found to accelerate adipocyte differentiation through activation of pparγ and glucose transporter type 1 and 4 (glut1 and glut4).7 oyster mushroom (pleurotus ostreatus) is one of the most famous edible mushrooms in indonesia. it contains valuable nutritional substances including the following substances; polysaccharides, lipopolysaccharides, lipids, proteins, peptides, lectins, and glycoproteins.8 moreover, oyster mushroom also has several benefits. a previous study has reported that oyster mushroom has an antidiabetic effect by increasing the translocation of glut4.9 oyster mushroom extract can also protect major organs from oxidative damage by increasing several antioxidant enzymes.10 another study revealed that oyster mushroom has the ability to inhibit the proliferation of breast and colon cancer cells.11 guanide, that is a known antihyperglycemic compound, has been reported to be associated with biguanide and it was also isolated from pleurotus species.12 hence, it is important to investigate whether oyster mushroom has any effect on glucose absorption in intestine. the objective of this study was to know the effect of infused oyster mushroom on glucose absorption through the intestinal mucosal membrane in rats. methods this study was conducted using experimental design and was carried out at laboratory of biochemistry, department of biochemistry, faculty of medicine, universitas padjadjaran. the subjects of this study were six wistar rats with age of 3–4 months and weight of 200–300 grams, which were divided into two groups. three rats were used for the analysis of the most effective time for glucose absorption, while the other three were used to evaluate the effect of infused oyster mushroom on glucose absorption through intestinal mucosal membrane. in order to identify the most effective time for glucose absorption in wistar rats’ intestinal mucosal membranes, the rats undergo fasting first for 18–24 hours (only plain water was available). after being anesthetized, surgery was performed to take the intestine out. a cannula was gently fixed at the distance of 10 cm after gastric pylorus and another cannula was fixed at the distance of 25 cm after the first cannula. the intestine was then washed three times using 0.9% nacl. both cannulas that were already fixed to intestine were then connected to perfusion machine designed by soedigdo and marsongkohadi (bandung institute of technology). this apparatus allowed the solution added into it to flow back and forth through the intestinal lumen six times per minute and the intestine was still functional for 6–8 hours. the glucose concentration of the solution was then measured every 15 minutes for one hour period through deproteinization method using the peridochrome glucose/god-pap reagent kit from st reagensia® and tca 8% according to the manufacturer’s instructions. glucose concentration was measured based on the absorbance difference determined by spectrophotometer. this experiment used old and fresh oyster mushroom with white body. the dried oyster mushroom was crushed to get very small pieces or powder form of mushroom. five gram, 10 gram, or 20 gram of crushed mushroom was added with 100 ml of water to make 5%, 10%, or 20% infused oyster mushroom, respectively, in pot i. pot i was then heated on hot water (90 °c)-containing pot ii for 15 minutes. the suspension was stirred only once during this heating process and, finally, infused oyster mushroom was filtered. three wistar rats were used to analyze the most effective time for glucose absorption through the intestinal mucosal membrane, while three other wistar rats were used to analyze the effect of infused oyster mushroom on glucose absorption through the mucosal membrane. solution used for measurement of absorbed glucose level in control condition was 24 ml of 3.0 x 10-3 m glucose solution (in 0.9% nacl) added with 1 ml of 0.9% nacl, while the solution used for analyzing the effect of infused oyster mushroom was 24 ml of 3.0 x 10-3 m glucose solution (in 0.9% nacl) added with 1 ml of 5%, 10% or 20% infused oyster mushroom, respectively. each of rat’s intestine was treated with glucose only solution (as control) and 5%, 10%, and 20% infused oyster mushroom-containing glucose solution, respectively, followed by washing using 0.9% nacl between treatments. furthermore, the glucose concentrations was infused oyster mushroom (pleurotus ostreatus) inhibits glucose absorption through intestinal mucosal membrane in wistar rats :67–72 international journal of integrated health sciences. 2018;6(2) 69 eko fuji ariyanto, muhammad nurhalim shahib, et al. :67–72 measured using the deproteinization method, followed by absorbance determination using spectrophotometer as described previously. data were presented in mean±sem and student’s t test was used to determine whether the difference between groups was significant. the experimental procedures used in this study followed the ethics regulation of animal research in faculty of medicine, universitas padjadjaran. results firstly, in order to know in which time point glucose solution is absorbed most effectively through rat intestinal mucosal membrane, the rate of glucose absorption through rat intestinal mucosal membrane in 1 hour were measured (fig. 1). by using in situ perfusion system, the level of glucose absorbed every 15 minutes was analyzed. the results showed that the absorbed glucose level at 15, 30, 45 and 60 minutes was 19.92±4.14 mg/dl, 30.25±6.19 mg/dl, 38.82±2.86 mg/dl and 41.99±4.01 mg/dl, respectively (figure 1). these data suggested that in wistar rats the most effective time for glucose absorption through the intestinal mucosal membrane was 15 minutes of exposure which was evident from the higher glucose absorption rate during the first 15 minutes that was higher when compared to the same rate during minute 15– 30, minute 30–45, and minute 45–60 (fig. 1). next, the effect of infused oyster mushroom on the glucose absorption through intestinal mucosal membrane was analyzed and, taking advantage of the in situ perfusion system, the glucose absorbed level after addition of control glucose solution and after addition of infused oyster mushroom-containing glucose solution into the lumen of intestine was compared. based on the previous data showing that the most effective time for glucose absorption in this model was 15 minutes, in this experiment we measured the absorbed glucose level after 15 minutes of solution addition (fig. 1). the levels of the glucose absorbed through the intestinal mucosal membrane in control glucose solution, 5% infused oyster mushroomcontaining glucose solution (oys 5%), 10% infused oyster mushroom-containing glucose solution (oys 10%) and 20% infused oyster mushroom-containing glucose solution (oys 20%) were 25.19±3.4 mg/dl, 16.27±0.86 mg/ dl, 13.22±1.58 mg/dl and 10.03±1.25 mg/ dl, respectively. student’s t test showed a significant difference between ctr and oys 5% (p=0.03), ctr and oys 10% (p=0.02), and ctr and oys 20% (p=0.007) (fig. 2). these data seemed to suggest that infused oyster mushroom can significantly inhibited glucose absorption through intestinal mucosal membrane in a dose-dependent manner. to evaluate whether washing the intestinal lumen using 0.9% nacl could recover the ability of intestinal mucosal membrane to absorb glucose, the absorbed glucose level between glucose-only solution treatment before and after washing procedures-following treatment of infused oyster mushroom was compared. the levels of glucose that is absorbed through intestinal mucosal membrane in the control glucose solution before treatment (ctr pre), 10% infused oyster mushroomcontaining glucose solution (oys 10%), and control glucose solution after the washing procedures-following treatment (ctr post) were 15.88±1.55 mg/dl, 2.65±1.19 mg/dl, and 23.11±1.16 mg/dl, respectively. student’s t test showed significant difference between ctr (pre) and oys 10% (p=0.01), and oys 10% and ctr (post) (p=0.003) (fig. 3). these data suggested that the inhibition of glucose transport through intestinal mucosal membrane by infused oyster mushroom in this system was reversible because washing the intestine several times using 0.9% nacl solution after infused oyster mushroom treatment could recover the ability of mucosal membrane to absorb glucose (fig. 3). rate of glucose absorption through intestinal mucosal membrane. the absorbed glucose level was measured at 15, 30, 45 and 60 minutes after addition of glucose solution. data were represented as mean±sem (n=3) fig. 1 70 international journal of integrated health sciences. 2018;6(2) infused oyster mushroom (pleurotus ostreatus) inhibits glucose absorption through intestinal mucosal membrane in wistar rats :67–72 discussion this study had revealed that infused oyster mushroom treatment had inhibition effect on glucose absorption through intestinal mucosal membrane in wistar rats. this finding gives us an opportunity to find new strategy to control glucose absorption in the intestine, which is important for diabetic patients. possible mechanism that can explain this finding was the one that makes use of guanide, which may be isolated from pleurotus species that might also exist in oyster mushroom and that functionally inhibits glucose transport in intestinal mucosal membrane. guanide is an antihyperglycemic compound associated with the biguanide class of antidiabetic drugs.12 several previous studies suggested that the infused oyster mushroom inhibited glucose absorption through intestinal mucosal membrane. the absorbed glucose level was measured after 15 minuteaddition of control glucose solution (24 ml of 3.0 x 10-3 m glucose solution (in 0.9% nacl) added with 1 ml of 0.9% nacl), or glucose solution containing infused oyster mushroom (24 ml of 3.0 x 10-3 m glucose solution (in 0.9% nacl) added with 1 ml of 5% (oys 5%), 10% (oys 10%) or 20% (oys 20%) infused oyster mushroom). data were represented as mean+sem (n=3). student’s t test was performed for indicated comparison. *p<0.05, ** p<0.01 fig. 2 washing the intestine using 0.9% nacl recovered the ability of intestinal mucosal membrane to absorb glucose. the absorbed glucose level was measured after 15 minute-addition of control glucose solution (24 ml of 3.0 x 10-3 m glucose solution (in 0.9% nacl) added with 1 ml of 0.9% nacl; ctr) before (pre) and after (post) treatment of glucose solution which contained infused oyster mushroom (24 ml of 3.0 x 10-3 m glucose solution (in 0.9% nacl) added with 1 ml of 10% infused oyster mushroom; oys 10%). data were represented as mean+sem (n=2). student’s t test was performed for indicated comparison. * p<0.05, ** p<0.01. fig. 3 international journal of integrated health sciences. 2018;6(2) 71 references 1. gorboulev v, schürmann a, vallon v, kipp h, jaschke a, klessen d, et al. na+-d-glucose cotransporter sglt1 is pivotal for intestinal glucose absorption and glucose-dependent incretin secretion. diabetes. 2012;61(1):187– 96. 2. thorens b. glut2, glucose sensing and glucose homeostasis. diabetologia. 2015;58(2):221– 32. 3. roder pv, geillinger ke, zietek ts, thorens b, koepsell h, daniel h. the role of sglt1 and glut2 in intestinal glucose transport and sensing. plos one [serial on the internet]. 2014 feb [cited 2018 mar 20];9(2):[about 10p.]. available from: https://journals.plos. org/plosone/article?id=10.1371/journal. pone.0089977. 4. bakke am, chikwati em, venold ff, sahlmann c, holm h, penn mh, et al. bile enhances glucose uptake, reduces permeability, and modulates effects of lectins, trypsin inhibitors and saponins on intestinal tissue. comp biochem physiol a mol integr physiol. 2014;168(1):96– 109. 5. zheng y, ley sh, hu fb. global aetiology and epidemiology of type 2 diabetes mellitus and its complications. nat rev endocrinol. 2018;14(2):88–98. 6. wu t, xie c, wu h, jones kl, horowitz m, rayner ck. metformin reduces the rate of small intestinal glucose absorption in type 2 diabetes. diabetes obes metab. 2017;19(2):290–3. 7. paravamsivam p, heng ck, malek sn, sabaratnam v, m rr, kuppusamy ur. giant oyster mushroom pleurotus giganteus (agaricomycetes) enhances adipocyte differentiation and glucose uptake via activation of pparγ and glucose transporters 1 and 4 in 3t3-l1 cells. int j med mushrooms. 2016;18(9):821–31. 8. patel y, naraian r, singh vk. medicinal properties of pleurotus species (oyster eko fuji ariyanto, muhammad nurhalim shahib, et al. :67–72 biguanide derivatives could inhibit intestinal glucose absorption.6,13,14 biguanide might have the ability to suppress the production of atp required for active absorption of glucose in the wall of small intestine.13 another possibility is that oyster mushroom might also contain other active compounds that act as the inhibitors for glucose transport in the intestine. the underlying mechanism might include the inhibition on na+-d-glucose cotransporter sglt1 or glucose transporter type 2, glut2. it is therefore very important to identify the active compound that might exhibit this effect through compound isolation techniques. in a previous study, several factors have been suggested to affect glucose absorption through the intestinal mucosal membrane, including, among others, glucose concentration, bile, and temperature.4 in this study, several strategies to control these possible confounding factors were applied. to avoid glucose concentration bias, a standardized glucose solution and measurement kit were used in the study. to prevent bile contamination, only intestine connected to cannulas at both ends at the same length (25 cm) were used. all procedures in the same room at the same time to control the temperature difference between experiments. subsequent treatments of glucose solution only (as control) and glucose solution added with different concentrations of infused oyster mushroom with washing procedure between treatments were performed. the experiments showed that after being exposed to infused oyster mushroom, which had an inhibition effect on glucose absorption, the ability of mucosal membrane to absorb glucose was recovered by washing the intestinal lumen using 0.9% nacl solution (fig. 3). taking these data into account, it is possible for us to give several treatments subsequently as long as washing procedures is done between the treatments. moreover, these data (fig. 3) could partially exclude possibility that lower absorbed glucose level in infused oyster mushroom-treated intestine was due to declined function of intestine by time. this study, however, did not evaluate whether our subsequent treatments to the intestines lead to cells exhaustion. limitations in this study include the lack of supporting data that explain the underlying mechanisms how intestinal glucose absorption is inhibited by infused oyster mushroom. it is therefore necessary to do further studies such as a study to elaborate whether infused and extract of oyster mushroom as well as the active compound decrease the protein expression of glucose transporter type 2, glut2, and na+-dglucose cotransporter sglt1, that primarily present in intestine. 72 international journal of integrated health sciences. 2018;6(2) mushroom): a review. world j fungal plant biol. 2012;3(1):1–12. 9. zhang y, hu t, zhou h, zhang y, jin g, yang y. antidiabetic effect of polysaccharides from pleurotus ostreatus in streptozotocininduced diabetic rats. int j biol macromol. 2016;83(1):126–32. 10. thomas pa, geraldine p, jayakumar t. pleurotus ostreatus, an edible mushroom, enhances glucose 6-phosphate dehydrogenase, ascorbate peroxidase and reduces xanthine dehydrogenase in major organs of aged rats. pharm biol. 2014;52(5):646–54. 11. gu yh, sivam g. cytotoxic effect of oyster mushroom pleurotus ostreatus on human androgen-independent prostate cancer pc-3 cells. j med food. 2006;9(2):196–204. 12. windholz m. the merck index: an encyclopedia of chemicals, drugs and biologicals, 10th ed. new jersey: merck and co; 1983. 13. wu t, horowitz m, rayner ck. new insights into the anti-diabetic actions of metformin: from the liver to the gut. expert rev gastroenterol hepatol. 2017;11(2):157–66. 14. rena g, pearson er, sakamoto k. molecular mechanism of action of metformin: old or new insights? diabetologia. 2013;56(9):1898–906. infused oyster mushroom (pleurotus ostreatus) inhibits glucose absorption through intestinal mucosal membrane in wistar rats :67–72 42 international journal of integrated health sciences. 2018;6(1) monocyte to lymphocyte ratio in peripheral blood of tuberculous meningitis with hiv patients in tertiary hospital in west java introduction human immunodeficiency virus (hiv) infection is one of the main global health problems and becomes a risk factor for tuberculosis.1,2 the characteristics of immunological effect of hiv is the cd4 cell count.2 people with hiv infection also have a higher risk to get all types of extra pulmonary tuberculosis, including tuberculous meningitis (tbm).3 tuberculous meningitis is the most common cause of meningitis in hiv-infected people along with cryptococcus meningitis.4,5 meningitis is considered as the worst manifestation of tuberculosis.6,7 their combined appearance makes diagnosis and treatment challenging due to the unspecific and similar clinical manifestations to other causes of chronic meningoencephalitis and also because it is necessary to provide treatment for both infections and their complication.8 knowledge on hematological manifestation of mycobacterium tuberculosis (mtb) infection is important to provide knowledge on the pathogenesis of the disease.9 myeloid-specific abstract objective: to describe peripheral blood monocyte to lymphocyte (ml) ratio in tuberculous meningitis (tbm) patients with human immunodeficiency virus (hiv) infection in dr. hasan sadikin general hospital bandung as a tertiary hospital in west java province, indonesia. methods: a cross-sectional study with retrospective data approach was done in dr. hasan sadikin general hospital, bandung. data were collected from tbm patients who were hospitalized in dr. hasan sadikin general hospital, bandung in the period of 2014–2016. the sample size was determined using total sampling method. general data, clinical manifestation data, and laboratory finding data were collected. the ml ratio was collected and presented into three groups of percentile (25th, 25–75th and 75th) based on the pre-defined cut-off. results: six subjects (40%) had an ml ratio of ≤0.47 and 3 subjects had an ml ratio of ≥1.22 in tbm with hiv population. among tbm with hiv-negative population, there were 16 subjects had ml ratio ≤0.47, and 19 subjects had ml ratio ≥1.22. conclusions: the ml ratio in tbm with hiv infection has become additional tool for detecting the development of tbm with hiv-infected, as well as tbm with non-hiv-infected. therefore, it could help directing the patients with clinical suspicious of tbm into the diagnosis algorithm and treatment of tbm, to have better outcome. keywords: human immunodeficiency virus infection, lymphocyte, monocyte, monocyte to lymphocyte ratio, tuberculous meningitis pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v6n1.1140 ijihs. 2018;6(1):42–7 received: december 6, 2017 revised: march 5, 2018 accepted: march 8, 2018 ridha amalia,1 dewi kartika turbawaty,2 adhi kristianto sugianli,2 siti aminah3 1faculty of medicine universitas padjadjaran, bandung, indonesia 2department of clinical pathology, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital, bandung 3department of neurology, faculty of medicine, universitaspadjadjaran-dr. hasan sadikin general hospital, bandung correspondence: ridha amalia, faculty of medicine, universitas padjadjaran jl. raya bandung-sumedang km 21 jatinangor, indonesia e-mail: ridhaamalia11@gmail.com :42–7 original article international journal of integrated health sciences. 2018;6(1) 43 cells have been known as the host cells for mtb growth and lymphoid cells are known as the main effector cells in tuberculosis immunity.9,10 the main role of monocytes and lymphocytes in inducing that immune response makes its level in monocytes to lymphocyte (ml) ratio is expected to be able to reflect the person’s immune condition toward the infection.9 study on patients with active tuberculosis showed that a higher median absolute number of monocytes and a lower median absolute number of lymphocytes were observed among these patients when compared to the healthy controls.9 hence, ml ratio could be used to differentiate patients with active tuberculosis from healthy people.9 a retrospective study on patients with active tuberculosis showed that higher or lower ml ratio based on a predefined cut-off could be a significant predictor for active tuberculosis.9 patients with extra pulmonary tuberculosis had an ml ratio as high as almost 2.5 times higher compared to the normal group.9 many studies showed that the ml ratio could be used to stratify tuberculosis risks and the involvement of hematopoietic stemcell in tuberculosis pathogenesis among hivinfected people.10 therefore, ml ratio could be used as an independent prognostic marker and a marker of a successful anti-tuberculosis therapy.11 screening and diagnostic testing of tbm in dr. hasan sadikin general hospital bandung still face several challenges: complicated tbm examination algorithm, expensive diagnostic tests, low economic status of the patients, lack of education, etc. due to these difficulties in diagnosing tbm with hiv co-infection, studies related to a simple detection or screening tool for tbm need to be done.5,7 the objectives of this study was to describe the ratio of monocytes to lymphocytes in peripheral blood as a predictor for tbm with hiv infection to seek the possibility to use the ratio as an additional tool for the clinician to perform the diagnostic algorithm of tbm. methods this was a cross-sectional study using tbm retrospective clinical-based data. population of this study consisted of tbm patients who were hospitalized in dr hasan sadikin general hospital bandung during the period of 2014– 2016. the inclusion criteria included patients aged 18 years old or above diagnosed with tbm based on the diagnostic criteria from marais et al.7 and had performed the first laboratory examination (hematology, immunology and cerebrospinal fluid (csf) examination) after being diagnosed tbm with complete data. patients with any missing data were excluded from this study. patients were divided into 4 groups based on the diagnostic criteria stated by marais et al.7 the criteria were definite tuberculous meningitis, probable tuberculous meningitis, possible tuberculous meningitis, and not tuberculous meningitis. the description on the components of these criteria and the scoring procedure is available elsewhere. this study used total sampling collection method, of which all members of the population were recruited in the study. all data regarding hospitalized tbm patients were collected from the medical record database of department of neurology, dr. hasan sadikin general hospital bandung during the period of 2014–2016. those who fulfilled the inclusion criteria were included in the analysis. the data collection process was performed in 2 places: department of neurology and medical record unit of dr. hasan sadikin general hospital bandung. data that were collected included data on patients’ general characteristics, clinical manifestations, and laboratory results. data collected were also double-checked for correctness with data on routine hematology with differential count and csf examination from the department of clinical pathology, dr. hasan sadikin general hospital, bandung. data collected were then merged in a prepared database for analysis. two hundred and eighty patients met the inclusion criteria of this study. of these, 195 were excluded due to incomplete data: absent of differential count test, no lumbar puncture was performed, or no hiv testing was done. the flowchart of this study was summarized in the diagram (fig. 1). this study was approved by the health research ethic committee of the faculty of medicine, universitas padjadjaran and from the research education unit of dr. hasan sadikin general hospital, bandung. patients’ data consisted of name, gender, age, diagnosis, hiv status, result of routine hematological tests and differential count, and results of csf examination were collected and entered into a pre-prepared database (excel software, microsoft corp.). all data were processed and presented using percentage in a table to describe the gender, age group, clinical manifestation, csf analysis, and ml ratio. the ml ratios were tabulated based on the hiv status and patient’s tbm diagnosis, :42–7 ridha amalia, dewi kartika turbawaty, et al. 44 international journal of integrated health sciences. 2018;6(1) which were divided into possible, probable, and definite tbm. the ml ratios were then classified and presented in percentiles: (1) ≤25th percentile ml ratio of all patients (ml ratio ≤0.47), (2) between 25th–75th percentile (0.47<ml ratio<1.22), (3) ≥75th percentile ml ratio of all patients (ml ratio ≥1.22).9 a bar chart was used to present the ml ratio in the population. all the data were analyzed using stata version 12.0 (stata corp., texas, usa). results in the population of this study, 15 patients (18%) were diagnosed as suffering from tbm with hivpositive and 70 patients (82%) with hiv negative. among the tbm with hiv positive population, male patients were more dominant (87%) as well as the 25–34 years old age group 47%). this finding is similar with the finding in a study performed by from afriandi et al.12 in 2009 that described the national aids cases were dominated by males (75%) with 42% were reported to be idu-related. heterosexual and homosexual transmission was 48% and 3.7%, respectively. most cases found in this study were classified as probable tbm (63.5%) in accordance with diagnostic criteria from marais et al.7 this number was followed by possible tbm (34.1%) and then definite tbm (2.4%) categories. the four most commonly identified clinical manifestations were headache, neck stiffness, fever, as well as decreased level of consciousness. results of csf examination showed that there was a process of meningeal irritation, which was proven by high number of leukocyte count (>5 cells/mm3), low csf-serum glucose ratio (<50%), and high level of protein (>50 mg/ dl) in most subjects. the median of ml ratio among hiv positive patients was 0.81 while the hiv negative patients had a ratio of 0.67 (table 1). in tbm with hiv positive population, there were 6 subjects who had an ml ratio of 0.47 and 3 with an ml ratio of 1.22. in tbm with hiv negative population, 16 subjects had an ml ratio of 0.47 and 19 had an ml ratio of 1.22. discussion hematological changes could be used as the first hallmark of a disease process as radiological changes and physical signs often appear later.13 monocyte is among the important components of innate immune response that act as a link to the adaptive immune system by presenting antigen to lymphocyte.9 hence, any factor that influences the function or relative number of both cells could potentially affect individual’s response toward infection.9 peripheral blood monocyte to lymphocyte ratio could reflects an individual’s capacity to mount effective immune responses.9 this ratio has been found to correlate with mycobacterial in vitro growth inhibition and is considered :42–7 monocyte to lymphocyte ratio in peripheral blood of tuberculous meningitis with hiv patients in tertiary hospital in west java fig. 1 screening and inclusion of study subject flowchart international journal of integrated health sciences. 2018;6(1) 45 ridha amalia, dewi kartika turbawaty, et al. :42–7 a risk if found in person with high or low ml ratio, based on the percentile cut-off.9,14 it has been reported that mtb infection could disturb hematopoietic stem cells or may directly infect the bone marrow mesenchymal stem cells.9,15 studies in mice and human have shown that hematopoietic stem cells present a different ratio of myeloid to lymphoid cells they will give rise to.9,16,17 different proportions of myeloid hematopoietic stem cells or lymphoid could lead to the difference of ml ratio in peripheral blood.9 hence, it is probable that mtb infection could affect hematopoietic stem cells as well as the ml ratio being affected.9 most subjects in this study were found to have lymphopenia. this is similar to a previous study by okamura et al.18 lymphopenia might occur due to the accumulation of lymphocytes in the infection sites, leading to a decrease in the number of lymphocites in the peripheral blood.11,19 for monocytes, most patients have normal or high monocyte count (monocytosis). table 1 characteristic, clinical manifestation, labolatory examination of study subjects variable hiv positive (n=15) hiv negative (n=70) gender female 2 (13%) 25 (36%) male 13 (87%) 45 (64%) age group, years 18–24 3 (20%) 22 (31%) 25–34 7 (47%) 25 (36%) 35–49 5 (33%) 15 (21%) >49 0 (0%) 8 (11%) tuberculous meningitis possible 5 (33%) 24 (34%) probable 9 (60%) 45 (64%) definite 1 (7%) 1 (1%) clinical presentation, n decrease of level of consciousness 13 (87%) 61 (87%) neck stiffness 12 (80%) 65 (93%) headache 13 (87%) 66 (94%) fever 12 (80%) 61 (87%) vomiting 5 (33%) 21 (30%) seizure 2 (13%) 5 (7%) csf analysis, n leukocyte count >5 cells/mm3 10 (67%) 66 (94%) glucose ratio <50% 13 (87%) 61 (87%) protein >50 mg/dl 11 (73%) 64 (91%) hematology cell-count, median (range) lymphocyte count, median (range), % 13 (4–56) 8 (2–47) monocyte count, median (range) % 8 (4–15) 6 (1–21) monocyte to lymphocyte ratio, median (range) 0.81 (0.13–2.80) 0.67 (0.03–1.62) data presented as n (%) unless there was another explanation mentioned. abbreviation: csf= cerebrospinal fluid; hiv= human immunodeficiency virus 46 international journal of integrated health sciences. 2018;6(1) monocytosis might occur because monocyte have a role in phagocytosis of microorganism.20 microorganisms which successfully escape the immune response cause infection and produce chemo attractant substances that will invite other leukocytes and resulting in unopposed production of monocytes.20 this creates a different ml ratio in patients when compared with healthy people. monocyte to lymphocyte ratio is a simple tools that is expected to reflect the person’s immune condition toward the infection. the normal average of ml ratio is 0.3.19 the tbm with hiv negative patients in this study had a higher ml ratio. the majority of the subjects have an ml ratio of more than 0.47 (>25th percentile). this is similar to the finding in a previous study by wang et al.9 with increased ml ratio among active tuberculosis and extra pulmonary tuberculosis patients and a lower or higher ml ratio can predict the presence of active tuberculosis. in tbm with hiv positive a higher ml ratio was also seen while some subjects had a lower ml ratio (less than or equals 0.47). this is similar to a previous study with hiv patients as the subjects by naranbhai et al.10 that showed tuberculosis is higher in hiv patients with lower or higher ml ratio. this situation might be explained by immune response toward mtb. myeloid-specific cells have been known to have role as host cells for mtb growth and lymphoid cells as the main effector in tb immunity.9,10 therefore, most of the tbm subjects in this study have higher ml ratio. within this study, any clear distinguish of ml ratio among each group was not found and further comprehensive study is needed to analyze. overall, the results of this current study gives evidence for supporting the correlation between immunity and tuberculosis as well as extra pulmonary tuberculosis, as described in previous study. hence, ml ratio could be used as a tool for detecting active tbm, either with or without hiv infection. this study has several limitations. this was retrospective study used data from medical record database. since the diagnosis was made using marais criteria, there might be a slight difference among clinicians when establishing the tbm diagnosis. despite the limitations, this study supports the notion that ml ratio is disrupted in tbm population with or without hiv infection as already mentioned in several previous studies. however, a prospective study using dedicated population and sample size need to be done to find the actual correlation between ml ratio and tbm. this study shows that the ml ratio in tbm patients with hiv infection at dr. hasan sadikin general hospital, bandung can be used as an additional tool for detecting the development of tbm in patients with hiv as well as in nonhiv-infected patients. therefore, it could help to direct the patients with clinical suspicion of tbm into tbm diagnosis algorithm and treatment and to a better disease outcome. the results of this study can also be used to create an evidence based-medicine approach in dr. hasan sadikin general hospital, bandung as a teaching hospital and tertiary hospital in west java, indonesia. references 1. world health organization | hiv/aids fact sheets. 2016.[cited 2017 aug 17]. available from: http://www.who.int/mediacentre/ factsheets/fs360/en/. 2. walker nf, meintjes g, wilkinson rj. hiv-1 and the immune response to tb. future virol. 2013;8(1):57–80. 3. vinnard c, macgregor rr. tuberculous meningitis in hiv-infected individuals. curr hiv/aids rep. 2009;6(3):139–45. 4. ghosh gc, sharma b, gupta bb. csf ada determination in early diagnosis of tuberculous monocyte to lymphocyte ratio in peripheral blood of tuberculous meningitis with hiv patients in tertiary hospital in west java :42–7 abbreviation: hiv= human immunodeficiency virus; tbm= tuberculous meningitis monocyte to lymphocyte ratio among tuberculous meningitis withor without human immunodeficiency virus patients fig. 2 international journal of integrated health sciences. 2018;6(1) 47 meningitis in hiv-infected patients. scientifica [serial on the internet]. 2016 apr [cited 2017 jun 10];2016(1):[about 4p.]. available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ pmc4837278/. 5. veltman ja, bristow cc, klausner jd. review article meningitis in hiv-positive patients in sub-saharan africa: a review. j int aids soc. 2014;17(1):1–10. 6. isabel be, rogelio hp. pathogenesis and immune response in tuberculous meningitis. malays j med sci. 2014;21(1):4–10. 7. marais s, thwaites g, schoeman jf, török me, misra uk, prasad k, et al. tuberculous meningitis: a uniform case definition for use in clinical research. lancet infect dis. 2010;10(11):803–12. 8. török me. tuberculous meningitis: advances in diagnosis and treatment. br med bull. 2015;113(1):117–31. 9. wang j, yin y, wang x, pei h, kuai s, gu l. ratio of monocytes to lymphocytes in peripheral blood in patients diagnosed with active tuberculosis. braz j infect dis. 2015;19(2):125–31. 10. naranbhai v, hill avs, abdool karim ss, naidoo k, abdool karim q, warimwe gm, et al. ratio of monocytes to lymphocytes in peripheral blood identifies adults at risk of incident tuberculosis among hiv-infected adults initiating antiretroviral therapy. j infect dis. 2014;209(4):500–9. 11. iqbal s, ahmed u, khan ma. haematological parameters altered in tuberculosis. pak j physiol. 2015;11(1):13–6. 12. afriandi i, aditama ty, mustikawati d, oktavia m, alisjahbana b, riono p. hiv and injecting drug use in indonesia: epidemiology and national response. acta med indones. 2009;41(1):75–8. 13. agarwal a, bhat ms, kumar a, shaharyar a, mishra m, yadav r. lymphocyte/monocyte ratio in osteoarticular tuberculosis in children: a haematological biomarker revisited. trop doct. 2016;46(2):73–7. 14. tobin dm, roca fj, oh sf, mcfarland r, vickery tw, ray jp, et al. host genotype-specific therapies can optimize the inflammatory response to mycobacterial infections. cell. 2012;148(3):434–46. 15. baldridge mt, king ky, boles nc, weksberg dc, goodell ma. quiescent haematopoietic stem cells are activated by ifn-γ in response to chronic infection. nature. 2010;465(7299):793–7. 16. schroeder t. hematopoietic stem cell heterogeneity: subtypes, not unpredictable behavior. cell stem cell. 2010;6(3):203–7. 17. muller-sieburg ce, sieburg hb, bernitz jm, cattarossi g. stem cell heterogeneity: implications for aging and regenerative medicine. blood. 2012;119(17):3900–7. 18. okamura k, nagata n, wakamatsu k, yonemoto k, ikegame s, kajiki a, et al. hypoalbuminemia and lymphocytopenia are predictive risk factors for in-hospital mortality in patients with tuberculosis. intern med. 2013;52(4):439–44. 19. muller gl, davidson dl. the monocytelymphocyte ratio as ameasurement of activity in pulmonary tuberculosis. n engl j med. 1934;211(6):248–52 20. iqbal s, ahmed u, badshah s, zaidi h. monocyte lymphocyte ratio as a possible prognostic marker in antituberculous therapy. jrawal med college. 2014;18(2):178–81. ridha amalia, dewi kartika turbawaty, et al. :42–7 volume 9 no 2 2021 fix.indd international journal of integrated health sciences (iijhs) 89 vessel. approximately 40% 65% patients who admit to hospital with stemi have multi-vessel disease. multi-vessel disease is a combination of culprit lesion and one or more significant stenosis (≥50% stenosis) non-culprit lesions on invasive coronary angiography.3 percutaneous coronary intervention (pci) has contributed in improving prognosis patients with stemi. therapy strategy of patients with stemi multi-vessel disease caused dilemma as there are vary strategies.3 culprit-only pci strategy has low contrast volume and complications, but associated with increased risk of repeated revascularization. complete revascularization strategy has improved prognosis and culprit-only versus complete revascularization in stemi multi-vessel disease: a case report abstract objective: to revisit data and highlight management of stemi multivessel disease and explore culprit-only versus multi-vessel pci and optimal timing to achieve complete revascularization. methods: a 67 years old male with chest pain at rest 2 hours before admission with a history of smoking one pack of cigarette everyday, was presented to the hospital. physical examination was within normal limit with normal hemodynamically; however, elevated cardiac troponin was identified. electrocardiogram showed stemi anteroseptal wall with ischemic inferior wall, leading tostemi anteroseptal wall, killip i diagnosis. primary pci was performed and multi-vessel disease was found. a complete revascularization single-staged procedure was performed due to his persistent chest pain. pci of these coronary stenoses is beneficial to reduce risk of cardiac death and recurrent infarction. however, some issues related to pci of non-culprit coronary arteries lesion and optimal timing to do complete revascularization is still a dilemma. results: related to data from some trials, e.g prami, cvlprit, danam3-primulti, compare-acute, complete, and some meta-analyses, showed benefit and safety of routine pci of non-culprit lesions as a preventive strategy to reduce morbidity and mortality. data showed reduce future morbidity and mortality in this setting. meanwhile, the optimal timing of complete revascularization is still a matter of debate, although some data showed benefit of index procedural pci. conclusion: pci of non-culprit lesions of myocardial infarction is consistently beneficial over culprit-only revascularization in patients with stemi multi-vessel disease, despite the debate on the optimum timing for complete revascularization in this setting. keywords: complete revascularization, multivessel disease, percutaneous coronary intervention, stemi received: december 25, 2020 accepted: september 27, 2021 case report mega amanda putri, achmad fauzi yahya, triwedya indra dewi department of cardiology and vascular medicine, faculty of medicine universitas padjajaran-dr. hasan sadikin general hospital bandung, indonesia pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ ijihs.v9n2.2249 ijihs. 2021;9(2):89–94 correspondence: triwedya indra dewi, department of cardiology and vascular medicine, faculty of medicine universitas padjajaran/dr. hasan sadikin general hospital bandung, indonesia e-mail: adeindradewi@gmail.com introduction st-segment elevation myocardial infarction is a myocardial cell death due to prolonged ischemia.1 incidence of stemi was 58 per 100.000 populations annually.2 in patients with stemi, sometimes atherosclerosis is not limited to single lesion, but involves multi90 international journal of integrated health sciences (iijhs) decreased risk of revascularization procedure and future morbidity.3 meanwhile, safety concerns including prolong procedure which results in contrast overload and radiation needed to be noticed.3 this case report and literature study will be interesting and informative to discuss a management perspective, especially in management of stemi multi-vessel disease in decision of culprit-only or complete revascularization and also timing in this particular patients. case a 67 years old male was admitted to hospital with chest pain at rest 2 hours before admission. patient had history of smoking one pack of cigarette per day. there was no history of dyspnoea, palpitation, syncope or near syncope. hemodynamic was within normal limit and with normal physical findings. laboratory results showed elevated cardiac troponin, others were within normal limits. electrocardiogram showed stemi anteroseptal wall with ischemic inferior wall (fig. 1). trans-thoracal echocardiography showed normal all chambers, reduced left ventricle systolic function (lvef 44% biplane), with severe hypokinetic anteroseptal wall to apical, hypokinetic anterior, and anteroseptal mid to apical. all these findings led to diagnosis of stemi anteroseptal wall, killip i. oct guided primary pci was performed through access right radial artery with diagnosed cathtere jr 3.5 6 fr and guide catheter bl 3.5 6 fr with contrast iohexol. coronary angiography showed normal left main (lm) coronary artery; acute total occlusion with haziness at proximal portion of left anterior descending (lad) coronary artery; diffuse stenosis at mid distal and critical stenosis at distal of left circumflex (lcx) coronary artery; and normal right coronary artery (rca). intervention was performed to lad lesion using wire runthrough intermediate (terumo, japan) conveyed to distal lad and wire runthough floppy (terumo, japan) was placed on diagonal 1 branch. thrombosuction was done at lad and showed timi flow 2. predilation from mid to osteal lad was performed using sprinter legend balloon 2.5 x 20 mm (medtronic, mexico) inflated to 8 atm and sprinter legend modified jailed balloon 2.5 x 15 mm (medtronic, mexico) inflated to 10 atm on osteal diagonal 1. provisional stenting was performed using des xience prime 3.0 x 38 mm (abbott, usa) placed on mid to osteal lad. oct post stenting showed distal reference diameter 3.0 mm and under expansion with white thrombus (fig. 2). proximal optimalization technique (pot) was carried out proximally with a sprinter legend balloon 3.5 x 15 mm (medtronic, mexico) inflated to 10 atm. oct post dilation showed good apposition and expansion with tissue protrusion at mid stent, msa 6.4 mm2 without stent edge dissection. during procedure patient experienced chest pain with normal hemodynamic and operator decided to perform another intervention at lcx non-culprit lesion using wire runthrough floppy (terumo, japan) placed at distal obtuse marginal and wire pilot 50 (abbott, usa) at table 1 randomized controlled trials comparing revascularization strategies in patients with multivessel stemi. 8-11 study sample strategy non-culprit lesions mace endpoints prami 465 culprit-only vs complete revascularization pci % diameter stenosis ≥ 50% 22.9% vs 9.0% (p<0.001) at 23 months cvlprit 296 culprit-only vs complete revascularization index or staged pci % diameter stenosis > 70% in 1 view or > 50% in 2 views 21.2% vs 10.0% (p=0.0009) at 12 months danami-3primulti 627 culprit-only vs complete revascularization with staged pci % diameter stenosis > 50% with ffr ≤ 0.80 22.0% vs 13.0% (p=0.004) at 27 months compareacute 885 culprit-only vs complete revascularization index or staged pci % diameter stenosis ≥ 50% with ffr ≤0.80 20.5% vs 7.8% (p<0.001) at 1 year ffr=fractional flow reserve culprit-only versus complete revascularization in stemi multi-vessel disease: a case report international journal of integrated health sciences (iijhs) 91 distal lcx. predilation was carried out using ryujin plus balloon 1.5 x 15 mm (terumo, japan), sprinter legend balloon 2.0 x 12 mm (medtronic, mexico), and sprinter legend balloon 2.5 x 20 mm (medtronic, mexico) at distal to proximal lcx. stenting was performed at proximal to distal lcx using xience prime 2.5 x 38 mm (abbott, usa). contrast injection showed timi flow 2 with thrombus (fig. 3). after pci, patient did not experience any chest pain and treated with eptifitabatide for 24 hours after procedure. operator decided to evaluate angiography on the 5th day. coronary angiography evaluation showed normal lm; lad showed stent patent in situ with 50% stenosis at distal lad; lcx showed stent patent in situ; normal rca. there was no thrombus, dissection, or residual stenosis, with timi flow 3. patient was discharged on the 9th day without any episode of chest pain or complication. informed consent was signed by patient himself allowing data publication. discussion current guidelines stemi recommends pci as a preference treatment strategy.4 pci was beneficial to reduce the risk of future morbidity and mortality.5 despite this benefits, there are some dilemmatic and controversial issues related to its benefit for non-culprit lesion and optimal timing.6 recent myocardial revascularization guideline recommends to achieve complete revascularization in cases with cardiogenic shock with presence of multiple critical stenosis, highly unstable lesions which angiographic signs of thrombi or rupture of the lesion, or evidence of persistent ischemia despite angioplasty of the affected table 2 risks and benefits of single-staged procedure vs multi-staged procedure18 single-staged procedure multi-staged procedure favorable preventing of recurrent ischemia / infarction better assessment of non-culprit lesion and the risks decreasing length of hospital stay using non-invasing testing to non-culprit lesion non favorable longer procedure and higher contrast volume and radiation additional cost to hospital stays and procedure poor assessment of benefit in nonculprit lesion late staged pci may not be beneficial table 3 factors affecting timing of non-culprit pci20 factors favoring index procedure factors favoring staged procedure ongoing chest pain infarct artery required short time and contrast unstable non-culprit lesion with large area of myocardium at risk simple pci of non-culprit lesion patient preference stable symptoms chronic kidney disease prolonged and complex procedure to open non culprit lesion complex lesion in non-culprit lesion patient preference fig. 1 electrocardiogram showed stemi anteroseptal wall, ischemic inferior wall mega amanda putri, achmad fauzi yahya, et al 92 international journal of integrated health sciences (iijhs) artery.7 trials and meta-analyses demonstrated conflicting results about beneficial of pci in non-culprit lesion. four multicenter randomized controlled clinical trials studied strategies in management of stemi multivessel disease, such as prami, cvlprit, danami-3-primulti, and compare-acute. these rcts showed a significant reduction in cardiovascular death, recurrent mi, and repeat revascularization associated with complete revascularization strategy (table 1).8,9,10,11 despite these supportive results, there were some limitations of these rcts as patients had low-risk features in inclusion criteria and sample sizes. therefore, statistical power to detect differences events of death or myocardial infarction was low. complete trial was conducted to resolve previous trials limitation, with total of 3,900 patients treated with des and optimal medical therapy. result showed primary outcome of cardiovascular death and myocardial infarction at 3 years was lower in complete revascularization group compared to culprit-only group. complete revascularization was associated with decreased need of repeated revascularization and in mortality and subsequent myocardial infarction in stemi multi-vessel disease.12,13 meta-analysis between 2002 to 2019 was performed with 10 rcts and 7030 patients. this meta-analysis showed benefit of routine fig. 2 oct post stenting showed distal reference diameter 3.0 mm and under expansion with white thrombus fig. 3 coronary angiography before and after stent deployment, (a) lcx before steting, (b) lad before stenting, (c) lcx after stenting, (d) lad after stenting culprit-only versus complete revascularization in stemi multi-vessel disease: a case report international journal of integrated health sciences (iijhs) 93 non culprit-lesion pci as a preventive strategy that reduce subsequent myocardial infarction and improve survival.14 in order to conclude results of these trials and metaanalyses, esc guidelines supports complete revascularization strategy as class iia recommendation, and acc/aha guidelines as class iib recommendation.15,16 these guidelines allow staged revascularization of non-culprit lesions. in our patient, operator found stemi multi-vessel disease and decided to do complete revascularization. dilemmatic strategy in patients with stemi multi-vessel disease was slightly resolved using previous data which showed complete revascularization was more superior than culprit-only revascularization in reducing future morbidity and mortality. meanwhile, optimal timing of this strategy remains debatable. potential options included performing complete revascularization index procedural/single-staged or elective procedural/multi-staged during in hospital stay or after discharge. large meta-analysis by zhenwei li et al. showed multi-staged revascularization had lower incidence of mace, all-cause death and/or myocardial infarction. it also stated that single-staged procedure complete revascularization was associated with greater mortality risk.17 cvlprit trial showed in hospital stay complete revascularization of non-culprit lesion, resulted in improvement of clinical outcomes compared to culprit-only lesion. potential risks and benefits of the two strategies are summarized in table 2.18 network metaanalysis by pieter et al.19 using 4 prospective and 14 retrospective studies between 1985 to 2010 and 40,280 patients successfully identified patients who underwent multistaged pci had lower rates of all-cause mortality, timi major bleeding, and also less mace. overall, mentioned meta-analyses and studies suggested multi-staged procedure as better option compared to single-staged procedure. another meta-analysis including 11 rcts stated that single-stage complete revascularization was safe. this strategy had significantly greater lvef compared to multistage complete revascularization and reduced hospitalization days and medical costs. despite its benefits, single-stage procedure associated with longer time and larger contrast volumes and radiation, and increased rates of contrastinduced nephropathy (cin) and procedural complication. there are some factors affecting operator in choosing whether complete revascularization index procedural or staging (table 3).20 in our patient, operator decided to do single-staged procedure due to patient’s complained ongoing chest pain. our case was comprehensively managed by using intracoronary imaging to help operator identify culprit and non-culprit lesion better. this study is lacking ability to identify non-culprit lesion using non-invasive stress imaging, particularly in stemi multi-vessel disease. ffr is necessary to identify which lesion is responsible for patient’s symptoms, meanwhile in this patient pci was not guided by ffr. complete revascularization in stemi multi-vessel disease should be considered when feasible and applicable. the decision of strategy using strategy index procedural or elective procedural is based on individually factors condition. best timing of non-culprit complete revascularization in this setting still remains dilemmatic and debatable, therefore further research is needed. it could understand better that complete revascularization is the best management in patient with stemi multivessel disease. 1. thygesen k, alpert j, jaffe a, chaitman b, bax j, morrow d, et al. fourth universal definition of myocardial infarction. circulation. 2018;138(20):237–69. 2. widimsky p, wijns w, fajadet j, de belder m, knot j, aaberge l, et al. european association for percutaneous cardiovascular interventions. reperfusion therapy for st elevation acute myocardial infarction in europe: description of the current situation in 30 countries. eur heart j. 2010;31(8):943–57. 3. paradies v, smits pc. culprit-only artery versus multivessel disease. in: watson tj, ong pjl, tcheng je, eds. primary angioplasty: a practical guide. singapore: springer; 2018. p. 167–78. 4. switaj tl, christensen sr, brewer dm. acute coronary syndrome: current treatment. am fam physician. 2017;95(4):232–40. 5. o’gara p, kushner f, ascheim d, casey d, chung m, de lemos j, et al. 2013 accf/aha guideline for the management of st-elevation myocardial infarction. circulation. 2013;127(4):362–425. references mega amanda putri, achmad fauzi yahya, et al 94 international journal of integrated health sciences (iijhs) 6. steg pg, james sk, atar d, badano lp, lundqvist cb, borger ma, et al. esc guidelines for the management of acute myocardial infarction in patients presenting with st-segment elevation: the task force on the management of stsegment elevation acute myocardial infarction of the european society of cardiology (esc). eur heart j. 2012;33(20):2569–619. 7. neumann fj, sousa-uva m, ahlsson a, alfonso f, banning ap, benedetto u, et al. 2018 esc/eacts guidelines on myocardial revascularization. eur heart j. 2019;40(2):87–165. 8. wald ds, morris jk, wald nj, chase aj, edwards rj, hughes lo, et al. randomized trial of preventive angioplasty in myocardial infarction. n engl j med. 2013;369(12):1115–23. 9. gershlick ah, khan jn, kelly dj, greenwood jp, sasikaran t, curzen n, et al. randomized trial of complete versus lesion-only revascularization in patients undergoing primary percutaneous coronary intervention for stemi and multivessel disease: the cvlprit trial. j am coll cardiol. 2015;65(10):963–72. 10. engstrøm t, kelbæk h, helqvist s, høfsten de, kløvgaard l, holmvang l, et al. complete revascularisation versus treatment of the culprit lesion only in patients with st-segment elevation myocardial infarction and multivessel disease (danami-3—primulti): an openlabel, randomised controlled trial. lancet. 2015;386(9994):665–71. 11. smits pc, abdel-wahab m, neumann f-j, boxma-de klerk bm, lunde k, schotborgh ce, et al. fractional flow reserve–guided multivessel angioplasty in myocardial infarction. new england journal of medicine. 2017;376(13):1234–44. 12. bainey k, mehta s, lai t, welsh r. complete vs culprit-only revascularization for patients with multivessel disease undergoing primary percutaneous coronary intervention for stsegment elevation myocardial infarction: a systematic review and meta-analysis. am heart j. 2014;167(1):1–14. 13. pavasini r, biscaglia s, barbato e, tebaldi m, dudek d, escaned j, et al. complete revascularization reduces cardiovascular death in patients with st-segment elevation myocardial infarction and multivessel disease: systematic review and meta-analysis of randomized clinical trials. eur heart j. 2019;41(42):4103–10. 14. pinilla-echeverri n, mehta s, wang j, lavi s, schampaert e, cantor w, et al. nonculprit lesion plaque morphology in patients with stsegment–elevation myocardial infarction. circ cardiovasc interv. 2020;13(7):e008768. 15. ibanez b, james s, agewall s, antunes mj, bucciarelli-ducci c, bueno h, et al. 2017 esc guidelines for the management of acute myocardial infarction in patients presenting with st-segment elevation: the task force for the management of acute myocardial infarction in patients presenting with st-segment elevation of the european society of cardiology (esc). eur heart j. 2018;39(2):119–77. 16. levine gn, bates er, blankenship jc, bailey sr, bittl ja, cercek b, et al. 2015 acc/aha/ scai focused update on primary percutaneous coronary intervention for patients with stelevation myocardial infarction: an update of the 2011 accf/aha/scai guideline for percutaneous coronary intervention and the 2013 accf/aha guideline for the management of st-elevation myocardial infarction. j am coll cardiol. 2016;67(10):1235–50. 17. li z, zhou y, xu q, chen x. staged versus one-time complete revascularization with percutaneous coronary intervention in stemi patients with multivessel disease: a systematic review and meta-analysis. plos one. 2017;12(1):e0169406. 18. khan jn, nazir sa, greenwood jp, dalby m, curzen n, hetherington s, et al. infarct size following complete revascularization in patients presenting with stemi: a comparison of immediate and staged in-hospital noninfarct related artery pci subgroups in the cvlprit study. j cardiovasc magn reson. 2016;18(1):85. 19. vlaar pj, mahmoud kd, holmes dr, jr., van valkenhoef g, hillege hl, van der horst ic, et al. culprit vessel only versus multivessel and staged percutaneous coronary intervention for multivessel disease in patients presenting with st-segment elevation myocardial infarction: a pairwise and network meta-analysis. j am coll cardiol. 2011;58(7):692–703. 20. gaffar r, habib b, filion kb, reynier p, eisenberg mj. optimal timing of complete revascularization in acute coronary syndrome: a systematic review and meta-analysis. j am heart assoc. 2017;6(4):e005381. culprit-only versus complete revascularization in stemi multi-vessel disease: a case report 36 international journal of integrated health sciences. 2018;6(1) original article :36–41 gender, age, marital status, and education as predictors to quality of life in elderly: whoqol-bref indonesian version indonesian basic health research, rosyada and trihandani suggested that the proportion of elderly with diabetes mellitus who also suffered from other diseases was 73.1%.2 the impacts of those diseases could influence their quality of life (qol). the world health organization (who) defined the qol as “individuals’ perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns”.3 this definition suggested that qol is an individual subjective evaluation or measurement on his/her life which does not only relate to disease symptoms or diseases but also the impact of those diseases or condition on qol, both holistically and multidimensially.3 instruments to measure qol (whoqol-100 and whoqol-bref) was developed by the whoqol group in 1995. skevington et al.4 reported that whoqol-bref self-assessment is a sound, cross-culturally valid assessment abstract objective: to analyze the quality of life in elderly with regards to gender, age, marital status, and education. methods: an analytical study involving 88 (eighty eight) elderly who lived in 6 villages in the suburb area of jatinangor sub-district, west java, indonesiawas performed in june 2017. the inclusion criteria were men and women, ≥60 years old, able to communicate in indonesian, and a mini mental state examination (mmse) score of ≥23. the variables in the study were gender, age, marital status, and education. quality of life (qol) was measured using translated whoqol-bref. collected data in the study were analyzed statistically using chi square, mann-whitney, friedman, post hoc using wilcoxon, and kruskal-wallis tests. results: the study discovered that all of the respondents had low qol score (≤60). the lowest score was the result of physical domain. there was no significant qol difference between men and women (p>0.05) but a significant qol difference regarding to age, marital status and education level was found in the study (p˂0.05). conclusions: elderly in suburb area has low qol and there is a difference in qol based on age, marital status, and educational level. keywords: education level, elderly, gender, marital status, quality of life pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v6n1.1201 ijihs. 2018;6(1):36–41 received: january 8, 2018 revised: february 13, 2018 accepted: february 23, 2018 sharon gondodiputro,1 aghnia rizki hidayati,2 lina rahmiati1 1department of public health, faculty of medicine, universitas padjadjaran 2diploma iv of midwifery program, faculty of medicine, universitas padjadjaran introduction indonesia has the 4th largest population in the world after china, india, and united states. in 2050, around 26% of indonesian population, or 72 million citizens, will be over 60 years old with 10 millions will be over 80 years old.1 the current health status reports in indonesia has reflected an apparent shift from communicable diseases to non-communicable or degenerative diseases such as hypertension, stroke, tumor/malignancy, diabetes mellitus, and coronary heart diseases.1 this may be worsened by the presence of multimorbidity. there are only a very limited number of studies on multimorbidity in elderly are available in indonesia. on reviewing data from the 2007 correspondence: sharon gondodiputro, department of public healh, faculty of medicine, universitas padjadjaran jl. dr. eyckman no. 38, bandung, indonesia e-mail: sharon_gondodiputro@yahoo.com international journal of integrated health sciences. 2018;6(1) 37 of qol. in 2004, the whoqol bref had been translated into indonesian by ratna mardiati, satya joewana, hartati kurniadi, isfandari, and riza sarasvita. additionally, the questionnaires had been revised twice (in 2014 and 2016) by fredrick dermawan purba. this questionnaire consists of 4 domains: physical, psychologycal, social relationship, and environment domains. the validity and reliability whoqol-bref for indonesian elderly was tested through a study conducted by salim et al.5 on 306 elderly. the result shows that whoqol-bref is a valid and reliable instrument to measure qol in elderly. quality of life measurement has not been widely performed in indonesia. therefore, this study aimed to analyze qol in elderly based on age, gender, marital status, and education. methods this was an analytical-comparative study on 88 out of 97 elderly (response rate was 90%). the study was conducted in jatinangor, one of the suburb areas in west java province, indonesia in june 2017. ethical clearance was obtained from the health research ethics committee, faculty of medicine, universitas padjadjaran number 779/un6.c.10/pn/2017. inclusion criteria in this study were elderly people aged >60 years old, able to communicate effectively, and not suffering from dementia, which was proven by a mini mental state exam (mmse) score of ≥23. exclusion criteria were elderly who was not present during the study. the sampling method used was multistage random sampling. in this current study, 6 out of 12 villages in jatinangor subdistrict were selected. the population size off each village varied that a proportional sampling method was applied to obtain a proporsional sample size. after the sample size for each village was determined, simple random sampling was applied to choose one rw (rukun warga, a neighborhood unit) from every village. respondents were then recruited according to the predetermined total sample size using consecutive sampling technique. prior to data collection, the objectives of the study were explained to the respondents. if the respondents understood and agreed to participate in the study, the respondents filled out and signed the informed consent provided. afterwards, the mmse test was performed and if the score was ≥23, the qol measurement was then performed by using the indonesian version of whoqol-bref. the questionnaire consists of 26 questions: 2 general questions related to respondents’ perception on their overall qol and health and 4 domains with the following details: physical domain with 7 questions, psychologycal domain with 6 questions, social relationship domain with 3 questions, and environment domain with 8 questions. a specific score of 1 to 5 was assigned to each question. after the total score of each domain was obtained, this total score was transformed using a transformation table into a scale of 0–100. the respondents’ characteristics included in the study were age, gender, marital status, and education. the age was divided into two categories, 60–69 years and ≥70 years. gender was classified as men and women; marital status was classified into married/still had a spouse and divorced/widower/widow while education was divided into 4 categories: no formal education, primary school graduate, junior school graduate, and senior high school graduate. a study by silva et al. to assess the diagnostic ability of different cut-off points for the world health organization quality of life-bref (whoqol-bref) as a predictor of quality of life in older adult using a receiveroperating characteristic curve (roc) has discovered a critical value of 60 as the optimal cut-off point for assessing perceived quality of life and satisfaction with health. the area under the curve was 0.758. the qol level was divided into 2 categories; good qol with a score of ≥60 and poor qol scored with a score of <60.6 the collected data underwent a normality test using the kosmogorov-smirnov test. the results showed that the data were not normally distributed (p<0.05). various statistical analysis were carried out in this study. to analyze the proportion differences of the respondents’ characteristics, a chi square test was performed. other statistical tests performed were unpaired test of 2 groups by using mann-whitney test, paired test of more than 2 groups by using friedman test, post hoc by using wilcoxon test, and unpaired test >2 groups by using kruskal-wallis test. results the study included 88 respondents with the majority of the respondents were 60–69 years and several respondents aged ≥70 years. the men and women proportion was equal. the results which were based on with or without spouse determined that those who had and did not have a spouse (divorced/widower/ widow) showed the same proportion. most :36–41 sharon gondodiputro, aghnia rizki hidayati, et al. 38 international journal of integrated health sciences. 2018;6(1) respondents had lower education and only several graduated from high school (table 1). this study revealed that most respondents’ qol based on several domains, including the physical, psychologycal, social relationship, and environment domains, seemed to be poor and scored less than 60 (table 2). eventhough the qol of each domain seemed to be equal, a statistical analysis using friedman test indicated a significantly different score in 3 domains (p=0.009). to discover which domain had a different score, a post hoc wilcoxon test was performed (table 3). the wilcoxon test result determined that qol based on physical domain was lower than the qol based on the social relationship domain (p=0028) while the qol that was based on psychologycal domain was higher when compared to the that of the social relationship domain (p=0.001). the qol that was based on social relationship domain was lower when compared to that of the environment domain (p=0.006) (table 2 and 3). a significant difference in the respondents’ perception on their overall qol and satisfaction to health based on age, marital status, and educational background was found in this study. the study also found that among the four whoqol-bref domains, the physical domain showed a significant different median score based on education level while psychologycal, social relationship, and environment domains indicated significant differences based on age, marital status, and educational level (table 4). discussion this study enrolled 88 elderly who lived in suburb of bandung, indonesia as respondents. data revealed that most respondents had lower education. in general, the qol in elderly based on all whoqol-bref domains was lower and scored less than 60. the lowest domain score found in the study was physical domain. the result in this study was lower when compared to those of other previous studies by campos et al.7 in brasil, bishak et al.8 in iran, and soósová et al.9 in slovakia. the differences of qol scores in many countries arose from the facts that aging process is a complex and very individualistic process and influenced by various factors showing relations from one to another.10 economical, cultural, and educational factors as well as health condition can contribute to the qol.8 another factor which can influence qol is elderly stereotyping.10 according to a study by diogini10, a stereotype can trigger different attitude and behavior among characteristics frequency (n=88) percentage (%) p value* age (yrs.) 60–69 64 73 <0.001 ≥70 24 27 gender men 39 44 0.286 women 49 556 marital status divorced/widowed 43 49 0.831 married/spouses 45 51 education level no education 22 25 <0.001 primary school 45 51 junior school 16 18 senior high school 5 6 note: chi-squared test :36–41 respondents’ characteristicts distribution based on age, gender, marital status, and education table 1 gender, age, marital status, and education as predictors to quality of life in elderly: whoqol-bref indonesian version international journal of integrated health sciences. 2018;6(1) 39 elderly. stereotype also determines the way elderly perceives themselves, other elderly (social comparison and thought to grow old), decision-making to join cognitive, social, and physical activities or to look for appropriate medical treatment. a study conducted by pei et al.11 described that participation in social activities become a key to successfully achieve good qol. this study discovered that there was no difference in qol between men and women based on the four qol domains. many studies in several countries showed different results. the study conducted by bishak et al.8 in iran explained the same results as revealed in this study that no qol difference between men and women. on a contrary, a study conducted by campos et al.7 in brazil revealed difference qol was found between men and women. the study also described that there were several factors which can contribute to qol. in women, the physical health and psychosocial factors contribute to achieving a better qol while in men, the socioeconomic, physical health, and psychosocial factors can contribute to gain better qol.7 a study conducted by lokare et al.12 stated that difference in qol between men and women was found in physical and environment domains while in psychological and social relationship domains, no significant difference was identified. a study conducted by nguyen et al.13 has reported that qol in elderly men was higher than in elderly women based on the four qol domains. in terms of the relationship with increase in age, increased age may decrease qol. this is based on the finding that the qol score in elderly aged ≥70 years was lower when compared to elderly whose age were 60–69 years. aging is regarded as a multidimensional process of physical, psychological and social changes.14 physical changes in aging include decreases in organ functions, progressive changes of body composition, decreases in body lean mass and excess fat, as well as changes in bone density.14 social and psychological factors can contribute to qol in elderly. fewer numbers of friends, minimum family encouragements, worthless feeling, lower financial condition, depression, and lonely feeling can cause higher risk to qol.14 with or without spouse condition seemed to have a relationship with qol. in this study, elderly without spouse presented a lower qol score when compared to elderly who still had a spouse, particularly based on the of psychology, social relationship, and environment domains. this finding is in line with the results from a table 3 post hoc test by using wilcoxon test whoqol bref domains post hoc test results by using wilcoxon test p value physical fitness psychology social relationship environment physical 0.266 0.028 0.319 psychologycal 0.266 0.001 0.931 social relationship 0.028 0.001 0.006 environment 0.319 0.931 0.006 table 2 total score quality of life based on domains whoqol bref domains total score ˂606 (%) median/mean minimum maximum physical 100 44 19 56 psychologycal 98.9 44 25 63 social relationship 96.6 44 19 75 environment 89.8 38 13 69 :36–41 sharon gondodiputro, aghnia rizki hidayati, et al. 40 international journal of integrated health sciences. 2018;6(1) previous study conducted by sherizadeh et al.15 in iran. the study explained that married elderly had a maximum score (53.56) when compared to divorced or widowed elderly (43.44).15 marital status significantly relates to mental health. persons who still have a spouse showed better mental health when compared to those without a spouse.15 repondents in this current study had low education background. most of the respondents graduated from junior school gaduates, or even lower level. this low educational background influences respondents’ perception to qol. a study by sherizadeh et al.15 discovered similar findings. a positive connection was revealed between literacy and qol, which may relate to sufficient information received by elderly regarding health and the way to improve qol.15 respondents with lower education create a limitation in this study due to the possibility that questions were not clearly comprehended by the respondent. although, this study only analyzed the connection between elderly demography to qol, the results also contain information which can be used by decision makers in developing distinctive programs for elderly. it is concluded that qol in elderly in suburb area is low. physical domain presented the lowest score when compared to psychologycal, social relationship, and environment domains. no difference in qol score was found between genders while age, with or without spouse, and education level contribute to qol. characteristics domain whoqol bref (median score) q1a q2b physical psychologycal social relationship environment age (yrs)* 60–69 4 3 41 44 44 44 ≥70 3 2 44 38 25 31 p value <0.001 <0.001 0.559 <0.001 <0.001 <0.001 gender* men 3 3 38 44 44 38 women 3 3 44 44 44 38 p value 0.554 0.847 0.171 0.124 0.668 0.959 marital status* devorced/widowed 3 3 44 38 31 38 married/spouses 4 3 38 50 44 44 p-value 0.001 <0.001 0.846 0.001 <0.001 <0.001 education level** no education 3 2 44 38 25 38 primary school 3 3 38 44 44 38 junior school 4 3 44 50 50 50 senior high school 4 4 38 50 44 56 p-value <0.001 <0.001 0.008 <0.001 <0.001 <0.001 note: q1a=questions regarding to “how would you rate your quality of life?” q2b= questions regarding to “how satisfied are you with your health?” *= statistical test of unpaired 2 groups test by using mann-whitney test **= statistical test of unpaired >2 groups test by using kruskal-wallis test :36–41 physical, psychologycal, social relationship, and environment domains based on age, gender, marital status, and education table 4 gender, age, marital status, and education as predictors to quality of life in elderly: whoqol-bref indonesian version international journal of integrated health sciences. 2018;6(1) 41 1. cao j, rammohan a. social capital and healthy ageing in indonesia. bmc public health. 2016;16(631):1–14. 2. rosyada a, trihandini i. determinan komplikasi kronik diabetes mellitus pada lanjut usia. j kes masy nas. 2013;9(7):395–401. 3. world health oranization. whoqol-bref, introduction, administration, scoring and generic version of the assessment. geneva: who; 1996. 4. skevington sm, lotfy m, o’connel ka, the world health organization’s whoqol-bref quality of life assessment: psychometric properties and results of the international field trialr from the whoqol group. qual life res. 2004;13(2):299–310. 5. salim oc, sudharma ni, kusumaratna rk, hidayat a. validitas dan reliabilitas world health organization quality of life-bref untuk mengukur qol lanjut usia. universa medicina. 2007;26(1):27–38. 6. silva pab, soares sm, santos jfg, silva lb. cutoff point for whoqol-bref as a measure of quality of life of older adults. rev saúde pública 2014;48(3):390–7. 7. campos acv, ferreira ef, vargas amd, albala c. aging, gender and quality of life (ageqol) study: factors associated with good quality of life in older brazilian community-dwelling adults. health qual life outcomes [serial on the internet]. 2014 nov [cited 2017 july 20];12(166):[about 11p.]. available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ pmc4261579/. 8. bishak yk, payahoo l, pourghasem b, jafarabadi ma. assessing the quality of life in elderly people and related factors in tabriz, iran. j caring sci. 2014;3(4):257–63. 9. soósová ms. determinants of quality of life in the elderly. cent eur j nurs midw. 2016;7(3):484– 93. 10. dionigi ra. stereotypes of aging: their effects on the health of older adults. j geriatr [serial on the internet]. 2015 oct [cited 2017 aug 10];2015(2015):[about 9p.]. available from: https://www.hindawi.com/journals/ jger/2015/954027/. 11. pei y, gunawan s, chich-je s. correlations between social engagement and quality of life of the elderly in china. revista internacional sociología. 2014;72(suppl 2):s105–18. 12. lokare po, karanjekar vd, deotale mk, jawarkar ak. assessment of quality of life among elderly population residing at old age homes. int j curr res. 2015;7(4):14552–5. 13. nguyen tv, nguyen hv, nguyen td, nguyen tv. difference in quality of life and associated factors among the elderly in rural vietnam. j prev med hyg. 2017;58(1):63–71. 14. amarya s, singh k, sabharwal m. changes during aging and their association with malnutrition. j clin gerontol geriatr. 2015;6(1):78–84. 15. sherizadeh y, sarkhoshi r, babazadeh t, moradi f, shariat f, mirzaeian k. the quality of life and its related factors in the elderly covered by health care centers in khoy city, iran. j anal res clin med. 2016;4(3):139–45. references :36–41 sharon gondodiputro, aghnia rizki hidayati, et al. 30 international journal of integrated health sciences. 2017;5(1) original article relationship between physical activity, anthropometry, and forced expiratory volume in one second with 6-minute walk distance in elderly correspondence: irna purnamasari sukarya, department of physical medicine and rehabilitation, faculty of medicine, universitas padjdajaran-dr. hasan sadikin general hospital jl. pasteur no. 38, bandung, indonesia e-mail: irna.purnamasari@yahoo.com irna purnamasari sukarya, vitriana, tertianto prabowo department of physical medicine and rehabilitation, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital abstract objective: to examine the correlation between physical activity using the global physical activity questionnaire (gpaq), anthropometry (body mass index/bmi), and forced expiratory volume in one second (fev1) value with six-minute walk distance in healthy community-dwelling elderly. methods: a cross-sectional design study with consecutive sampling was conducted. this study included sixty nine participants (30 males and 39 females), aged ≥60 years who lives at batununggal region in bandung, indonesia. the data was analyzed statistically by using normality, correlation, and multiple regresion tests. results: the results showed that there was a correlation between sixminute walk distance and bmi in females (p=0.006), and fev1 value in males (p=0.010). no significant correlation was found between gpaq value and sixminute walk distance in females (p=0.4074) and in males (p=0.0926). conclusions: there was a correlation between anthropometry and fev1 value with six-minute walk distance in healthy elderly. there was no significant correlation between physical activity and six-minute walk distance. keywords: anthropometric measurement, fev1, physical activity, six-minute walk distance pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v5n1.963 ijihs. 2017;5(1):30–5 introduction aging is a natural phase in humans results in some changes in the body compositions and skeletal muscles. muscle mass loss is associated with infiltration of fat and connective tissues into the muscle fibers. this leads to structural redistributions with the decrease of muscle strength and function which may affect some physical performances. muscle strength and function may decrease 1–2% per year at 50 years of age and above, results in significant decreases of some physical functions including cardiopulmonary functions, physical activity, and quality of life in elderly.1–3 cardiopulmonary system changes may occur in consort with significant decline of aerobic capacity in the elderly population. previous studies stated that cardiopulmonary fitness becomes a vital factor which influences the physical performance. cardiopulmonary fitness can decrease approximately 15% per decade after 30 years of age.1,3,4 there were several distinctive variables that significantly influence respiratory function such as age, sex, height, race, ethnic, smoking history, environment condition, measurement tools, and test methods. aging process causes several changes in body, including respiratory muscle mass, gas exchange, and control of ventilation. increased rigidity of the chest wall and decreased respiratory muscle strength in elderly can increase the closing capacity and decrease the forced expiration volume in one second (fev1) on pulmonary function tests. 5 functional fitness and physical activity received: december 14, 2016 revised: march 16, 2017 accepted: march 17, 2017 :30–5 international journal of integrated health sciences. 2017;5(1) 31 assessments are inevitably required as an implication to maintain flexibility of movement and quality of life in elderly. conceptually, functional fitness is the ability in performing daily activities normally and independently without early fatigue. routine physical activity becomes main factor to maintain flexibility of movement that prevent chronic diseases, and the physical activity assessment along with certain related factors are important for the authorities due to the population surveillance program.1,3,6,7 physical activity assessment can be done using objective and physiological methods, such as vo2 max indirect measurement by cardiopulmonary exercise testing. however, the most common conducted cardiopulmonary exercise testing is the six-minute walk test. the six-minute walk test is considered as an appropriate cardiopulmonary fitness test, inexpensive, and similar to daily activity.8–12 a study in west australia which involved caucasian participants aged 55–75 years revealed that six-minute walk distance in males was higher 59±13 than in females.11 a recent study in brazil which included females with average age 66 years reported that physical activity becomes an important independent predictor toward six-minute walk distance.10 some health conditions in elderly may disturb the ability of walking and become a limitation in performing six-minute walk test, so it is important to find another way to predict the six-minute walk distance for elderly with such condition. this study aimed to observe the correlation between physical activity using global physical activity questionnaire (gpaq), anthropometry (body mass index/bmi), and forced expiration volume in one second (fev1) value with sixminute walk distance in healthy communitydwelling elderly population. methods the participants involved in this study were the healthy elderly citizens at batununggal region, bandung, indonesia. the inclusion criterias in this study were elderly aged ≥60 years and able to comprehend the instruction with the mini mental status examination (mmse) score ≥24. the exclusion criterias were those who had uncontrolled cardiovascular and pulmonary diseases, stroke, uncontrolled hypertension, and those with deformities or lower extremity disorders which affect walking ability. the data of physical activity in this study were collected by conducting questionnaire distribution. the participants were asked several questions based on gpaq through guided interview to obtain the total score of physical activity level. the questionnaire is suitable to collect information relating to the participant physical activity in sedentary and three domains: (1) occupational activity, (2) traveling from and to another place, and (3) recreational activity.6,7 anthropometric measurements of bmi were performed using bioelectrical impedance :30–5 table 1 participant general data distribution respondent characteristics females (n=39) males (n=30) mean (sd) median mean (sd) median age (years) 66.69 (5.72)* 65 66.83 (6.71)* 64.5 education history (years) 11.12 (3.71)* 12 12.83 (3.87)* 12 body weight (kg) 59.79 (12.20) 59.7 61.83 (10.32) 64.5 body height (cm) 151.62 (5.80) 153 163.12 (4.64) 163 bmi (kg/m2) 25.94 (4.95)* 25.8 23.91 (2.64)* 24.3 6-minute walk distance (m) 391.84 (59.67) 390 444.96 (90.19) 440 fev1(l) 1.56 (0.30) 1.59 2.12 (0.43) 2.185 gpaq 4,169.74 (4,152.44)* 3480 2,520.66 (3,356.23)* 1680 notes: bmi=body mass index ; fev1=forced expiration volume in one second; gpaq=global physical activity questionnaire *non-normally distributed data using normality saphiro wilks test irna purnamasari sukarya, vitriana, et al. 32 international journal of integrated health sciences. 2017;5(1) analysis (bia/tanita bc601, tanita corp, tokyo, japan) in kilogram and kg/m2. forced expiration volume in one second was measured by using a spirometer (chestgraph hi-101, chest m.i.inc, tokyo, japan). a pulse oxymeter (cto fingertip pulse oxymeter) was applied on the thumb of left hand while performing spirometry and six-minute walk test. before and after the six-minute walk test, several assessments were performed such as measurement of blood pressure, heart rate, and rating of perceived exertion by borg scale. the participants were then instructed to walk on a 30-meter walking track. the distance of the six-minute walk test were recorded. the statistical test was used to determine the relationship between physical activity, anthropometry, and fev1 value with the distance of six-minute walk test. the statistical tests used in this study were normality data, descriptive statistic, pearson and spearman correlation based on data distribution, and multiple regression tests between the distance of six-minute walk test and physical activity, anthropometry, and fev1 value. this study was approved by the health research ethic committee, faculty of medicine, universitas padjadjaran, bandung, indonesia with ethical approval no 153/un6.c1.3.2/kepk/pn/2016. results eighty participants were invited to participate in this study. eleven participants did not meet the inclusion criteria and were not included in the study. therefore, sixty nine participants who met the inclusion criteria in this study were 30 males and 39 males (table 1). the relationship between physical activity, anthropometry, and fev1 value among the participants were discovered (table 2 and 3). no significant correlation was found between gpaq value and six-minute walk distance in females (p=0.4074) and in males (p=0.0926) (table 2). in females, the correlation between sixminute walk distance and fev1 (p=0.415) was not considered statistically significant but a correlation was found between six-minute walk distance and bmi (p=0.006) (table 3). however, in males, the correlation between six-minute walk distance and bmi (p=0.476) was not considered statistically significant but a correlation was found between six-minute walk distance with fev1 value (p=0.010). body mass index and fev1 were the main variables which influenced the results and showed significant correlation with six-minute walk distance. the correlation between gender and gpaq value with six-minute walk distance was not considered statistically significant which showed that gpaq was not included into the predictive equation. the regression analysis was repeatedly performed which included independent variables, such as bmi and fev1. residual descriptive statistical test was then performed by analyzing residual distribution (saphiro wilks test). the residual distribution was defined by the normal distribution with mean=0 (t test). in this study, the t value was 0.735328 with p>0.05 and mean=0. the residual distribution resulted w=0.966 with p=0.155. the results showed that the residual distribution was based on the normal distribution with mean=0. furthermore, the regression test resulted a predictive equation: six-minute walk distance = 133.583 x fev1 + 6.593 x bmi. discussion the six-minute walk distance average value was discovered in females (391.84±59.67 meter) and in males (444.96±90.19 meter). male participants show average 53,12 meter distance further than in females. in addition, a study reported similar results that males (690±62 meter) showed 59 meter distance further when compared to females (631±57 meter).11 several studies relating to physical activity stated that physical activity levels in males and females are distinguished. a previous study found that physical activity in male elderly were higher than females.13 using a self-reported physical activity method, the data determined that physical activity in males were about 0.8–21.4% higher than females. another study with different result revealed that the physical activity using selfreported method discovers that the physical activities in female elderly were higher.14 6-minute walk distance and gpaq spearman t (n-2) p value female (n=39) 0.1365 0.8381 0.4074 males (n=30) 0.3126 1.7412 0.0926 :30–5 relationship between physical activity, anthropometry, and forced expiratory volume in one second with 6-minute walk distance in elderly table 2 spearman correlation test between 6-minute walk distance and gpaq value international journal of integrated health sciences. 2017;5(1) 33 irna purnamasari sukarya, vitriana, et al. this study discovers that the gpaq value in females (4169.74±4152.44) was higher than in males (2520.66±3356.23). these results may be correlated with indonesian’s culture which still distinguishes between male and female based on biological difference and social participation. moreover, elderly females play an important role in the society, be able to socialize, and have insignificant decrease of activity level than in males. 15 there was no correlation found between the physical activity and six-minute walk distance in this study. based on the rank spearman test results, the correlation between physical activity assessed using gpaq and six-minute walk distance is not considered statistically significant in females and males (table 2). this can occur because the gpaq assessment is considered accurate only for assessing vigorous physical activity, compared to light and moderate physical activity. a review of gpaq validity data reported that there is higher discrepancy between physical activities assessment using self-report and objective method such as accelerometer for high intensity activities. different result may occur by other methods of physical activity assessment.7,16 body mass index becomes a common anthropometry parameter correlated with six-minute walk distance.18,19 walk distance can be predicted through several variables, including age, sex, body weight, body height, and bmi which influence 26–66% distance variability.9,18 this study also found that there was a correlation between six-minute walk distance with bmi in females. an alternative variable such as fev1 value can be used as a determinant but it potentially causes bias. the correlation strength between fev1 value and six-minute walk distance in subjects with minimal ventilation is different from the healthy subjects. however, there is a correlation between fev1 value and :30–5 6-minute walk distance (m) weight (kg) height (cm) bmi (kg/m2) fev1(l) females (n=39) correlation coefficient (r) -0.3159 0.265 -0.4306 -0.1342 p value 0.05 0.103 0.006* 0.415 males (n=30) correlation coefficient (r) 0.1143 0.4 0.1354 0.4644 p value 0.547 0.029* 0.476 0.010* notes: bmi: body mass index ; fev1: forced expiration volume in one second; *p value <0.05 table 3 pearson correlation test between 6-minute walk distance with anthropometries and forced expiration volume in one second beta st.err of beta b st.err. of b t(64) p value fev1 0.155203 0.109523 35.10641 24.773889 1.41707303 0.1613 weight -0.177682 0.11284 -1.215292 0.7717912 -1.5746377 0.1203 height 0.981931 0.139483 2.64373 0.3755422 7.03976838 1.58e-09* sex 0.013716 0.033823 8.78213 21.656821 0.40551354 0.6865 gpaq 0.026762 0.027719 0.0021817 0.0022598 0.96547134 0.3379 notes: fev1=forced expiration volume in one second; gpaq=global physical activity questionnaire *p value <0.05 table 4 forward stepwise regression analysis test with dependent 6-minute walk distance variable with adjusted r=0.97245103 34 international journal of integrated health sciences. 2017;5(1) six-minute walk distance found in chronic obstructive pulmonary disease subjects.18 this study discovers a correlation and a significant relationship between fev1value (r=-0.4644; p=0.010) and six-minute walk distance in male participants. these results are similar to the study in australia which included 70 elderly participants aged 55–75 years.11 the study reported that height and fev1 value are independent predictors which show significant correlation with six-minute walk distance, thus, combining the variables will result 33.9% variation of walk distance. a study conducted in singapore discovered 6-minute walk distance predictive equation without distinguishing sex.20 the predictive equation is (5.50 x % hr maks) + (6.94 x height) – (4.49 x age) – (3.51 x weight) – 473,27; with r = 0.78. another study in 2014 in indonesia revealed a predictive equation of 6-minute walk distance=586.254 + 0.622 weight (kg) – 0.265 height (cm) – 63.343 sex (0= male; 1= female) + 0.117 age, with r=0.606 and adjusted r2=0.345. the equation in this study meets the regression term to predict six-minute walk distance. residual test and residual equation distribution follow the normally probability distribution with significant value is >0.05 (p=0.155) that determines the equation is considered valid and can be used. based on the equation, the adjusted r was 95% with fev1 was 59% (beta=0.5906) and bmi was 39% (beta=0.3968) toward six-minute walk distance. the equation is properly used to predict six-minute walk distance in elderly females and males. the variables contribute 98% while another 2% is predicted by using other variables. in conclusion, there was a correlation between anthropometry and fev1 value with six-minute walk distance, therefore, there was no significant correlation between physical activity with six-minute walk distance in healthy elderly. there are several limitations in this study. the method used for assessing the physical activities was inproper to apply in elderly population due to the intensity of the activities. further study may use other methods which are sensitive for light and moderate physical activities, or by applying an objective assessment with accelerometer. this study also did not differentiate the healthy and minimal ventilation participants, that may become a consideration in the further study to homogenize lung function to decrease bias that might be appeared in the results. references 1. milanović z, pantelić s, trajković n, sporiš g, kostić r, james n. age-related decrease in physical activity and functional fitness among elderly men and women. clin interv aging. 2013;8:549–56. 2. bautmans i, lambert m, metst. the six-minute walk test in community dwelling elderly: influence of health status. bmc geriatrics [serial on the internet]. 2004 july [cited 2016 aug 12];4(6):[about 9p.]. available from: relationship between physical activity, anthropometry, and forced expiratory volume in one second with 6-minute walk distance in elderly :30–5 beta st.err of beta b st.err. of b t(64) p value fev1 0.0314 0.0475 20.1263 30.4160 0.6617 0.5105 weight 0.4100 0.1041 6.8118 1.7302 3.9370 0.0002* height 0.5265 0.1265 119.1030 28.6157 4.1622 0.0001* sex 0.0432 0.0361 0.0035 0.0029 1.1944 0.2367 gpaq 0.026762 0.027719 0.0021817 0.0022598 0.96547134 0.3379 notes: fev1=forced expiration volume in one second; gpaq=global physical activity questionnaire *p value <0.05 table 5 forward stepwise regression analysis test with dependent 6-minute walk distancevariable with adjusted r=0.95280530 international journal of integrated health sciences. 2017;5(1) 35 irna purnamasari sukarya, vitriana, et al. :30–5 h t t p s : / / b m c g e r i a t r. b i o m e d c e n t ra l . c o m / articles/10.1186/1471-2318-4-6. 3. leyk d, rüther t, wunderlich m, sievert a, essfeld d, witzki a, et al. physical performance in middle age and old age: good news for our sedentary and aging society. dtsch ärztbl int. 2010;107(46):809–16. 4. rick o, metz t, eberlein m, schirren j, bölükbas s. the six-minute-walk test in assessing respiratory function after tumor surgery of the lung: a cohort study. j thorac dis. 2014;6(5):421–8. 5. pruthi n, multanink. influence of age on lung function tests. j exercise sci physiother. 2012;8(1):1–6. 6. bull fc, maslin, ts, armstrong t. global physical activity questionnaire (gpaq): nine country reliability and validity study. j phys act health. 2009;6(6):790–804. 7. hoos t, espinoza n, marshall s, arredondo em. validity of the global physical activity questionnaire (gpaq) in adult latinas. j phys act health. 2012;9(5):698–705. 8. rao na, irfan m, haque as, zubairi abs, awan s. six-minute walk test performance in healthy adult pakistani volunteers. j coll physicians surg pak. 2013;23(10):720–5. 9. dourado vz. reference equations for the 6-minute walk test in healthy individuals. arq bras cardiol. 2010:25(1):1–11. 10. steffens d, beckenkamp pr, hancock m, paiva dn, alison ja, menna-barreto ss. activity level predicts 6-minute walk distance in healthy older females: an observational study. physiotherapy. 2012;99(1):21–6. 11. camarri b, eastwood pr, cecins nm, thompson pj, jenkins s. six minute walk distance in healthy subjects aged 55–75 years. respir med. 2006;100(4):658–65. 12. suwanachaiy s, kulaputana o, chaiwanichsirid. walk performance in thai men and women: physical activity dependence. asian biomed. 2010;4(1):87–93. 13. neto gam, de leon ap,lira va, farinatti ptv. assessment of cardiorespiratory fitness without exercise in elderly men with chronic cardiovascular and metabolic diseases. j aging res. 2012;2(8):1–6. 14. nusdwinuringtyas n, widjajalaksmi, yunus f, alwi i. reference equation for prediction of a total distance during six-minute walk test using indonesian anthropometrics. acta med indones. 2014;46(2):9–6. 15. sumirta in. implikasi gender terhadap kesehatan lansia. bunga rampai kesehatan lansia, http:/ramakrisnahareblogspotcoid. 2011. 16. cleland cl, hunter rf, kee f, cupples me, sallis jf, tully ma. validity of the global physical activity questionnaire (gpaq) in assessing levels and change in moderate-vigorous physical activity and sedentary behaviour. bmc public health. 2014;14(1):1–11. 17. santana p, cintra rm, rodrigues f. correlation study on the results from measures of function and functionality tests of portuguese copd patients. professional assignment project iii-2. 2009:1–5. 18. yusuff mr, hussain mr, norazizan s. anthropometry dimensions of older malaysians: comparison of age, gender and ethnicity. asian social sci. 2009;5(6):133–40. 19. albanese e, davis b, jonsson pv, chang m, aspelund t, garcia m, et al. overweight and obesity in midlife and brain structure and dementia 26 years later: the ages-reykjavik study. am j epidemiol. 2015;181(9):672–9. 20. poh h, eastwood pr, cecins nm, ho kt, jenkins sc. six-minute walk distance in healthy singaporean adults cannot be predicted using reference equations derived from caucasian populations. respirology. 2006;11(2):211–6. international journal of integrated health sciences. 2017;5(2) 47 correlation between body mass index, gender, and skeletal muscle mass cut off point in bandung richi hendrik wattimena, vitriana, irma ruslina defi department of physical medicine and rehabilitation, faculty of medicine, universitas padjajaran-dr. hasan sadikin general hospital, bandung abstract objective: to determine the average skeletal muscle mass (smm) value in young adults as a reference population; to analyze the correlation of gender, and body mass index to the cut off point; and to determine skeletal muscle mass cut off points of population in bandung, indonesia. methods: this was a cross-sectional study involving 199 participants, 122 females and 77 males. the sampling technique used was the multistage random sampling. the participants were those who lived in four major regions in bandung, indonesia: sukajadi, cicadas, buah batu, and cibaduyut. results: the average appendicular skeletal mass index (asmi) in females and males based on body mass index (bmi) were identified. the average asmi values for normal bmi in females was 5.982±0.462 kg/m2 while the average asmi values normal bmi for males was 7.581±0.744 kg/m2 conclusions: a correlation between bmi and asmi that was considered statistically significant was found in females (0.7712; p<0.05) and a very significant correlation was seen in males (0.870; p<0.05). the cut off points were defined by the normal bmi, which were 5.059 for females and 6.093 for males. keywords: appendicular skeletal muscle mass index, body mass index, cut off point, gender, skeletal muscle mass pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v5n2.990 ijihs. 2017;5(2):47–51 received: december 14, 2016 revised: april 11, 2017 accepted: august 24, 2017 correspondence: richi hendrik wattimena, department of physical medicine and rehabilitation, faculty of medicine, universitas padjajaran-dr. hasan sadikin general hospital jl. pasteur no. 38, bandung, indonesia e-mail: spartanrhw@gmail.com introduction skeletal muscle mass (smm) is considered as the biggest tissue in human body which covers approximately 40–50% of body mass.1 composition of smm may be stable during the age of 20–40 years old and begins to decrease significantly after the age of 45 years old. the decrease in smm occurs with aging process as a physiological change that is due to decreases in the amount and diameter of muscle fibers. in addition, there are also increases in noncontractile tissues in the muscle compartment, such as in the intramuscular fat and muscle connective tissues.2 these conditions trigger reduced physical ability, quality of life (qol), and cardiopulmonary metabolism function. increases in fall risks, physical disabilities, and even death are also seen.3,4 one of the distinctive ways to measure smm is by using bioelectrical impedance analysis (bia). the bioelectrical impedance analysis is commonly considered as a tool to measure body fat and lean body mass which has several advantages compared to other measurement tools. this analysis is also affordable, accurate, easy to use, fast, free from radiation, and can be used done in patients who are bed-ridden without having to mobilize the patients.3,5,6 the use of bia had been examined for more than 10 years and it has been proven to have correlations with magnetic resonance imaging (mri) examination results.4 the cut off point in bia is defined by the appendicular skeletal muscle mass index (asmi) which is obtained through the use of a formula that divides the total smm with height square.3,7,8 original article :47–51 48 international journal of integrated health sciences. 2017;5(2) recent studies reported that the cut off points of muscle mass can vary in different areas due to the fact that body composition as the main variable is influenced by ethnicity, age, physical activity, gender, and body mass index (bmi).7–11 the body mass index is also considered as a major parameter reflecting the population characteristics that correlate to physical activities and eating habit that will further influence the skeletal mucle mass. early studies have proposed bmi as one of the parameters in determining the cut off point of smm, and showed a correlation between bmi and the cut off point. 3,8,12 no smm cut off point has been used as a benchmark in bandung because of the lack of normative data related to the amount of muscle mass in adult population based on gender and bmi. therefore, this study aimed to analyze the correlation between bmi, gender, and muscle mass, as well as defining the smm average value which is important to determine a cut off point, and to determine the cut off point for decreased smm based on the skeletal muscle mass index (smi) in young adult population with normal bmi n bandung, indonesia. methods a cross-sectional study has been performed by involving 199 participants selected using the the multistage random sampling approach in 4 different areas, sukajadi, cicadas, buah batu and cibaduyut, in the period of january to february 2016. the participants who met the inclusion criteria were adults aged 20–40 years, bandung citizens, healthy (based on anamnesis and physical examination), and with no risk factors for congenital disease, including diabetes mellitus. the participant candidates who were excluded were those who had weight problems in the last 6 months, consumed medicines or supplements that influenced their body composition, used artificial pacemaker as well as athlete, dan pregnant women. muscle mass was measured using bia single variant type (tanita bc-601, tokyo, japan). this measurement was conducted in stand up position without footwear on the electrode with hand grasping the electrode handle in abduction position. average smm value was defined by the average asmi value in kg/m2. the smm cut off point was obtained using the asian working group for sarcopenia (awgs) reference which is 2 standard deviation (sd) below the average value of healthy young adult smm. the bmi value was obtained by using bia (kg/m2). body mass index was then classified into underweight (<18.5 kg/m2), normal (18.5–22.9 kg/m2), overweight (23– 24.9 kg/m2), grade i obesity (25–29.9 kg/m2), and grade ii obesity (≥30 kg/m2). informed consent was gained from the participants for their involvement in the study. data in this study were analyzed statistically using the normality test, descriptive statistics, t or mann whitney u tests based on the data distribution, and pearson or spearman correlation tests. the study was approved by the health research ethic committee, faculty of medicine, universitas padjadjaran, bandung, indonesia. results the participants included in this study were 199 subjects consisted of 122 females and 77 males. there was a significant differences in the characteristics between female and male participants except in the age and bmi (table 1). therefore, further analyses were performed based on gender. general increase in bmi leads to increase of asmi value (table 2 and 3). based on spearman correlation coefficient test, this study found a strong correlation between gender and asmi in both genders [males (r=0.71; p<0.05); females (r=0.65; p<0.05)] and between bmi and asmi [male (r=0.81; p<0.05); female (r=0.77; p<0.05)], respectively. the asian working group for sarcopenia (awgs) suggest using a 2 standard deviation (sd) below the average smm value in the young population as a reference of smm cut off point.5 the cut off point by using bia was defined by asmi. the result was obtained through a comparison between total smm and height squared. the total smm was measure as the appendicular skeletal muscle mass (asm) which value was obtained from the total muscle mass off both upper and lower extremities.2,4,10 the cut off points of smm found in this study were 5.059 kg/m2 in females and 6.093 kg/m2 in males for normal category of bmi. discussion the participants who were involved in this study were classified into adolescence and adult groups due to the fact that in adult the muscle mass does not change significantly as correlation between body mass index and gender with skeletal muscle mass cut off point in bandung :47–51 international journal of integrated health sciences. 2017;5(2) 49 richi hendrik wattimena, vitriana, et al. :47–51 table 1 participant characteristics characteristics females (n=122) males (n=77) p value mean (sd) mean (sd) age (years) 29.43 (8.09) 30.05 (8.44) 0.69 height (m) 154.36 (6.14) 166.67 (6.15) 0.00* weight (kg) 54.40 (10.53) 64.30 (14.32) 0.00* body fat 32.42 (13.03) 19.45 (7.14) 0.00* muscle mass (kg) 34.66 (3.92) 48.40 (7.24) 0.00* bone mass (kg) 2.29 (2.82) 2.99 (2.682) 0.00* bmi (kg/m2) 22.82 (4.15) 23.38 (4.54) 0.589 total body water (l) 48.38 (4.83) 54.67 (6.94) 0.00* body fat (%) 31.466 (7.7758) 19.509 (7.2249) 0.00* asm (kg) 15.19 (2.75) 22.52 (4.16) 0.00* asmi (kg/m2) 6.37 (1.02) 8.09 (1.37) 0.00* notes: * p value <0.05; sd= standar deviation; asm= appendicular skeletal muscle mass; asmi= appendicular skeletal muscle mass index; bmi= body mass index the consequence of aging process.3,7 in the age of 20–40 years bone stops growing so muscle do not have to adapt to this change anymore, which is characterized by decreasing hormon production, particularly the testosterone, after puberty.13–15 a correlation between gender and mm was found. a strong correlation was also found between bmi and asmi. these results were similar to a study that reported a different cut off point based on bmi.8 this study also revealed that the smm cut off points were divided into several types: (a) in females, underweight: 5.15 kg/m2, normal: 5.52 kg/ m2, overweight: 6.39 kg/m2, obesity: 6.77 kg/ m2, and (b) in males, underweight: 7.23 kg/m2, normal: 7.29 kg/m2, overweight: 8.00 kg/m2, obesity: 8.32 kg/m2. these are in line with a finding that the bmi can be used to measure muscle mass which may influence the cut off points.8,16 meanwhile, the height and weight are the bmi parameters to determine that the human body composition generally consists of water, body fats, proteins, and minerals. these are several underlying rationales that bmi can be used as a proper parameter to observe body changes which may be caused by lifestyles, eating habits, and physical activities.8,16 differences in muscle mass cut off points between gender were discovered. the result showed that the cut off point in females was lower than males. this result is similar to the previous studies which revealed a cut off point of 7.26 kg/m2 in males and 5.45 kg/m2 in females. kim reported a cut off point of 7.40 kg/m2 in males and 5.14 kg/m2 in females.10,11 the cut off points may vary, which is due to the differences in body compositions between males and females.3 women in general have lower height, lower weight, and shorter bone length, leading to a smaller smm and higher body fat than men.17 another study stated that bone length correlates with smm, the longer bone length, the bigger the smm is.18 this is in line with the condition that several body movements use smm and bone length balances. asmi n=122 mean (sd) (kg/m2) bmi category underweight 15 5.49 (0.31) normal 50 5.98 (0.46) overweight risk 22 6.77 (1.69) grade i obesity 25 6.85 (0.54) grade ii obesity 10 7.51 (0.72) notes: *sd= standard deviation; asmi= appendicular skeletal muscle mass; bmi= body mass index appendicular skeletal muscle mass index in females based on body mass index table 2 50 international journal of integrated health sciences. 2017;5(2) asmi n mean (sd) (kg/m2) bmi category underweight 9 6.39 (0.41) normal 33 7.58 (0.74) overweight risk 11 8.54 (0.56) grade i obesity 16 8.59 (2.99) grade ii obesity 8 10.69 (0.72) notes: *sd= standard deviation; asmi= appendicular skeletal muscle mass; bmi= body mass index the cut off points in normal bmi found in this study shows that the the results are lower than those of the previous studies. baumgartner et al.10 in united states reported a muscle mass cut off point of 7.26 kg/m2 and 5.45 kg/m2 for males and females, respectively. chien in taiwan stated cut off points of 8.87 kg/m2 in males and 6.42 kg/m2 in females while tanimoto in japan presented cut off points of 7.0 kg/m2 in males and 5.8 kg/m2 in females. kim in korea discovered cut off points of 6.75 kg/m2 in males and 5.07 kg/m2 in females.6,13,19 these diferences in asmi and muscle mass cut off points are influenced by gender, race, and physical activity. therefore, the body composition may differ between race characteristics and rural-urban areas. the influence of race characteristics toward muscle mass cut off pointwas examined by a study which reported that the mexicans have lower cut off points than the caucasians with a comparison of 5.86 to 7.26 in males and 4.72 to 5.45 in females.7 in addition, awgs discovered that the average asmi among chinese is 17% lower than the caucasians. a study found that different race may cause different body shape sand compositions.17 the northern chinese have bigger body with bigger smm than the southern chinese. chinese has smaller bone and smm than the caucasian.7,8,17 caucasian americans have lower body fat compared to caucasian europeans. also, africans and caucasians have longer legs and bigger smm than asians. the skeleton and skeletal muscle mass of asians are smaller than the caucasians. the chinese people have lower body fat than indians and malayans.17 a study reported that indonesians have higher body fat than caucasians but malay-indonesians have smaller skeleton and higher body fat than chinese-indonesians.18 lower skeletal muslce mass cut off point in indonesia found in this study may be caused by diferent ethnic groups which lead to higher body fat with smaller smm compared to other ethnics. therefore, different body shape, skeleton, and leg length are several factors of lower cut off points in indonesia. race characteristics can be included as a major data in a further study. a study has revealed that urbanization as well as progresses in transportation and economic development can change people’s physical activities.18 a sedentary lifestyle is one of the factors of higher level of body fat. according to the data in 2013, the physical activity proportions of indonesian people are ineffective.20 in addition, the indonesian people sedentary proportion is ≥6 hours per day or 24.1% of the total activities; thus, a further study should be conducted to analyze these incidences. however, this study does not include participant daily physical activities, such as occupation and leisure activities which may influence the results of the study. in conclusions, the average asmi in females with normal bmi is 5.98±0.46 kg/m2 and the average asmi values in males with normal bmi is 7.58±0.74 kg/m2. a strong correlation is found between sex and asmi and between bmi and asmi with moderate correlation in females and very strong in males. the cut off point based on normal bmi in females is 5.06 kg/m2 and in male was 6.09 kg/m2. a further study that also considers race characteristics and physical activities is also needed in order to determine the accurate respondent smm cut off point. the use of smm cut off point with bia can be performed to analyze the decrease of smm to be able to start early interventions. immediate intervensions may prevent the smm decrease and improve the functional capacity status and quality of life. correlation between body mass index and gender with skeletal muscle mass cut off point in bandung :47–51 references 1. sakuma k, aoi w, yamaguchi a. the intriguing regulators of muscle mass in sarcopenia and muscular dystrophy. front aging neurosci. 2014;6(1):1–17. appendicular skeletal muscle mass index in males based on body mass index table 3 international journal of integrated health sciences. 2017;5(2) 51 richi hendrik wattimena, vitriana, et al. :47–51 2. stenholm s, harris tb, rantanen t, visser m, kritchevsky sb, ferrucci l. sarcopenic obesity: definition, cause and consequences. curr opin clin nutr metab care. 2008;11(6):693–700. 3. chen lk, liu lk, woo j, assantachai p, auyeung tw, 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health sciences (iijhs) 13 introduction achilles tendon injuries are common in athletes, due to high stress with jumping and landing, or by overuse. the overall incidence of achilles tendon rupture is on the rise recently. nevertheless, controversy has surrounded the optimal treatment of acute achilles tendon rupture.1 nonoperative treatment as an alternative to operative treatment, is a effects of low-level laser therapy on fibroblast density in achilles tendon rupture healing abstract objective: to investigate the effect of low-level laser therapy (lllt) on fibroblast proliferation as a part of the tendon healing cascade. methods: this was an unpaired comparative experimental animal laboratory study with one control groups and two experimental groups, each consisted of 10 sprague dawley rats. the experimental groups 1 and 2 were given infrared irradiation for 15 minutes and 30 minutes per day, respectively, after having their achilles tendon partially cut. histological assessment was carried out to assess the fibroblast density in healing site after three weeks on intervention. results: the median values of fibroblast density in group 1, group 2, and control group were 1, 2, and 1, respectively, with a p-value of 0.014. no significant difference (p=0.123) was identified on mann-whitney test between the fibroblast density of group 1 and group 2. the same was also true forgroup 1 and control group (p=0.315). a significant difference was found between group 2 and control group (p=0.005). conclusions: a regime of lllt irradiation of 30 min/day for two weeks (1080 j cm-2) improves the fibroblast proliferation amidst tendon healing in a partially injured achilles tendon in a rat model, which is not seen in the regime with a 15 min/day duration. this emphasizes the significance of irradiation time to improve tendon healing, despite the deficient understanding of the mechanism. keywords: achilles, fibroblast, laser, rupture received: december 11, 2020 accepted: march 30, 2021 correspondence: raden andri primadhi department of orthopaedics and traumatology, faculty of medicine universitas padjadjaran-dr. hasan sadikin general hospital bandung, indonesia e-mail: randri@unpad.ac.id original article cakra andhika, raden andri primadhi, hermawan nagar rasyid department of orthopaedics and traumatology, faculty of medicine universitas padjadjaran-dr. hasan sadikin general hospital bandung, indonesia pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ ijihs.v9n1.2232 ijihs. 2021;9(1):13–18 cost-effective option and could be especially suitable for the general population that is not that active.2,3 in 2005, ingvar, tagil, and eneroth had reported 7% re-rupture rate of 198 consecutive achilles tendon rupture patients which treated nonoperatively.4 thus, surgical intervention as a primary treatment became questionable when taking cost and surgical complications into consideration, such as infection, pain, adhesion, and postoperative scarring. one of the therapeutic modalities that can be done to enhance the healing of musculoskeletal injuries including tendon rupture is low-level laser therapy (lllt) such as infrared therapy. lllt is a general 14 international journal of integrated health sciences (iijhs) term describing a treatment method based on photobiomodulation principles, that induce a biological effects on organisms, due to the interactions of photons with molecules in the cells or tissues. this process is referred to as “low-level” because its low energy compared to other form of laser therapy such as ablation, cutting, or coagulation. lllt triggers the release of nitric oxide (no), a small endogenous molecule with many physiological effects on the body systems.5 bokhari and murrell stated that in animal models, competitive inhibition of nitric oxide synthases (nos) resulted in reduced tendon healing, whereas the addition of no resulted in enhanced tendon healing.6 the results of research and clinical investigations into the effects of infrared, among others, show a potentially effective clinical outcome and a low risk.7, 8 joensen et al. had reported a significant differences in tendon thickness in rats which received lllt when compared to placebo group.9 in one study, low-level laser irradiation applied to a cell culture was also known to increase fibroblast cell proliferation and reduces cell death in a dose-dependent manner. in patients, lllt promotes tendon healing, alleviates the pain, and assists flexibility of soft tissue and joints, thus serves as a proper adjuvant therapy in tendon repair.11 the applications of lllt, in contrast with the past-well established terminology linked to the use of lasers, is now performed with a wide variety of different light sources, such as leds and lamps. although scientific data in relation to infrared application are increasing, the understanding of its effect to injured tendon healing in cellular level is still limited. lllt remains somewhat controversial for two principle reasons. first, there are uncertainties about the fundamental molecular and cellular mechanisms responsible for signals transduction. second, there are significant variations in terms of dosimetry parameters: wavelength, irradiance or power density, pulse structure, coherence, polarization, energy, fluence, irradiation time, contact vs noncontact application, and repetition regiment.12 it is important to assess the optimal dose of light for any specific use. the aim of this study was to investigate effects of infrared interaction in different dose to the tendon fibroblast proliferation shown histologically. methods this research was an experimental study with simple random sampling. we divided the animals into three groups, specifically one control group and two experimental animal groups, getting infrared irradiation for 15 minutes (group 1) and 30 minutes (group 2), respectively. the dependent variables in this research was histologically analyzed fibroblast density. this study was approved in advance by health research ethics committee of universitas padjadjaran no. 120/un6.kep/ ec/2020 (reg no. 0319121706). the study animals comprised of 30 male sprague dawley rats from animal laboratory of universitas padjadjaran medical school, weighing 250-300 g, which had their achilles tendon partially cut and divided into three groups. rats were kept at bioterium for one week, placed in a quiet room with adequate lighting and temperature maintained at 20o-25oc, with food and water ad libitum. the experimental procedure was carried out in four steps. first, all animals were anesthetized using 0.5 ml intramuscular ketamine, carried out cleaning and hair removal in the heel area. a longitudinal skin and subcutaneous incision was performed on the posteromedial side of the heel with attention to antiseptic procedure. deepened incision until the achilles tendon was done followed by a sharp hemisection to the achiles tendon with a scalpel blade size no. 15, at 0.5 cm above its insertion to the calcaneus bone (fig. 1a). the surgical wound was closed layer by layer using polypropylene thread size 4-0 and standard dressing. the limbs were not immobilized due its partial cut design. other consideration was to prevent inhibition of radiation by the enclosing cast or splint. second step, animals in experimental group were irradiated starting at 5th day after treatment using a philips infraphil 13379f/479, 150w lamp, ranging from 600 to 1500 nm, with a peak at 1000 nm, at a 30 cm distance from the animals. animals had their affected leg irradiated while fixed on a board. the other body areas were covered with a wet towel. the duration was differed between two experimental groups, specifically 15 min (540 j cm-2) and 30 minutes (1080 j cm-2) a day for fourteen days. to prevent infrared heating, the temperature was controlled by indoors air-conditioning with plenty of ventilation and routine temperature measurement using thermometer (fig. 1b). three weeks after initial treatment, the animals were killed by injection of 1 ml saturated potassium chloride solution to cause cardiac arrest. the tissue around the hemisected tendon were taken parallel to the joint ends en bloc, and then fixed in 10% effects of low-level laser therapy on fibroblast density in achilles tendon rupture healing international journal of integrated health sciences (iijhs) 15 formaldehyde solution. tendon specimens were taken and examined histologically under haematoxylin-eosin staining, particularly at hemisection site (fig. 2). fibroblast density was evaluated semi-quantitatively using three scales (0: absent, 1: mild appearance, and 2: marked appearance) and recorded for comparison between groups (fig. 3). histological analysis was conducted by an independent histopathological expert. data analysis was performed using statistics social service program (spss) ver. 25 for windows (spss inc. chicago, il, usa). descriptive analysis was carried out and data distribution and normality tests were performed to determine whether parametric or nonparametric analysis was used, and comparative hypothesis testing of numerical variables was carried out using one way anova for parametric testing or kruskal wallis test for nonparametric tests. results table 1 shows the distribution of fibroblast density among three groups. score maximum of 2 were found in both experimental groups, but not in control group. kruskal wallis statistical test followed by median test was used for analysis because the data were ordinal, abnormally distributed with a significance of 5%. calculated p value was 0.014, which means that there was a significant difference in the value median fibroblast density between the three groups. it can be seen that the fibroblast density has the highest median in the experimental group 2. considering there was a significant difference between groups, a further test was carried out with the median test to compare between the two groups (table 2). there was no significance difference between fibroblast density between experimental group 1 and group 2, as well as between experimental group 1 and control group (p>0.05). rather, the difference of medians between experimental group and control group was significant (p=0.005). table 1 fibroblast density according to groups groups n min. max. median mean sd p-value experimental group 1 10 0 2 1 1.00 0.816 0.014 experimental group 2 10 0 2 2 1.60 0.699 control group 10 0 1 1 0.60 0.516 table 2 median test results for fibroblast density variable group comparison p value experimental group 1 and group 2 0.355 experimental group 1 and control group 0.778 experimental group 2 and control group 0.005 discussion the results of this study were in a concordance with prior basic studies stating that infrared therapy in tissue healing can increase fibroblast proliferation.10,15 additional value of this study to the lllt application is the distinction made by dosage differences, specifically the irradiation time. this study showed histologically an increase of fibroblast cell density following a lllt. notable findings here was the different results among experimental groups, thus emphasizing the importance of the dosage setting, specifically different irradiation time of similar energy. in this study, irradiation of 540 j cm-2 for two weeks yielded insignificant result difference with control group. low-level laser therapy (lllt) refers to the use of photons at a non-thermal irradiance to alter biological activity. the main medical applications of lllt are reducing pain and inflammation, augmenting tissue repair, promoting regeneration of different tissues, and preventing tissue damage in situations where it is likely to occur.12,13 avci et al.12 has also mentioned that this procedure is referred to as ‘low-level’ because the energy or power densities employed are low compared to other forms of laser therapy such as ablation, cutting, and thermal tissue coagulation. it can be implied that the effects of irradiation are a response to the light and not due to heat.14 the increase in the number of fibroblasts mediates the production of collagen. infrared can also increase the activity of macrophages in the phagocytic process, secretion of growth cakra andhika, raden andri primadhi, et al. 16 international journal of integrated health sciences (iijhs) fig. 1 (a) partial achilles tendon cutting in the rat; (b) lllt irradiation set-up fig. 2 macroscopic finding of healed achilles tendon fig. 3 histological findings showing the different result of fibroblast density, speci�ically scored as 0 (absent), 1 (mild), and 2 (marked) effects of low-level laser therapy on fibroblast density in achilles tendon rupture healing international journal of integrated health sciences (iijhs) 17 factors, and stimulate collagen synthesis. in addition, it can also stimulate the formation of neovascularization, which will support increased perfusion and oxygenation, as well as regeneration of endothelial cells. fibroblasts are cells that have a significant role in the tendon healing process. fibroblasts secrete essential substances and collagen, which form scar tissue as a substitute for defects in wounds. the fibroblast proliferation process uses fibrin threads originating from the blood clotting process as a framework, and then the fibrin disappears according to collagen deposition.16 infrared therapy has been shown to stimulate nitric oxide production. nitric oxide is a small endogenous molecule with multiple effects on the body’s systems. nitric oxide is involved in a wide range of biological functions in the body, including vasodilation, immune response, and neurotransmission as reported by wink et al.17 the fact is that infrared can penetrate deep into wound tissue and allow non-invasive treatment of the wound healing process. the visible, infrared waves are easily absorbed by the surface components of the blood and muscle surfaces, limiting the penetration of the tissue to <10 mm. shortwave infrared (810 nm) is not easily absorbed and has a much greater depth of tissue penetration of 30-40 mm or more and thus provides more significant deposition of photons at the site of injury.18 the effect of providing heat to the body via infrared can also increase collagen fibers in the tendons and joint capsules, reduce the viscosity of the fluid tissue elements, reduce joint stiffness, reduce muscle spasm, vasodilate blood vessels, and increase metabolism. some of the positive clinical effects of infrared has been introduced, including those for reducing rheumatic knee pain, as well as its impact on wound healing.19 there are some limitations of this study. to date, no proper method for measuring the parameters of the biological effects of lllt, including the effective wavelength, irradiation time, and intensity has been developed. tsai and hamblin correctly noted that if certain parameters such as irradiation type, laser wavelength, continuous vs pulsed irradiation, pulse shape, and target area are changed, it may not be possible to compare between studies.14 thus, it is difficult to compare fairly between many lllt modalities for its efficacy as shown by many studies. however, hsu et al.20 had reported the effective irradiation time as an important factor for the biological application of lllt. among different irradiation times, specifically 15, 30, 45, and 60 minutes, the far-infrared biological index of 30 minutes irradiation was significantly higher than those of the other durations.there was a potential bias of this study as well, resulting of a single observer analysing the histological specimens. however, this study may provide the framework to define the guidelines for lllt therapy regarding achilles tendon rupture. other problematics included disadvantages of adjusting this study for clinical relevance in human, concerning the age and dosage adaptation. this short-term study was also unable to identify the side effects in rats, both locally and systemically. in conclusion, low-level laser irradiation at 1080 j cm-2 per day, administered for fourteen days appeared to increase the fibroblast density of injured achilles tendon in rat models, compared with control group and experimental group receiving 540 j cm2. this experiment is useful for investigating the positive effects of low-level laser therapy to enhance tendon healing and optimal duration of therapy. however, considering the healing cascade, we believe this results is only applicable for acute healing phase. further studies using this model should explore the maximum duration allowed to avoid harmful effects such as tissue damage. references 1. thevendran g, sarraf km, patel nk, sadri a, rosenfeld p. the ruptured achilles tendon: a current overview from biology of rupture to treatment. musculoskelet surg 2013;97(1):9–20. 2. su aw, bogunovic l, johnson j, klein s, matava mj, mccormick j, et al. operative versus nonoperative treatment of acute achilles tendon ruptures: a pilot economic decision analysis. orthop j sports med. 2020;8(3):2325967120909918. 3. park s-h, lee hs, young kw, seo sg. treatment of acute achilles tendon rupture 2020;12(1):1-8. 4. ingvar j, tagil m, eneroth m. nonoperative treatment of achilles tendon rupture: 196 consecutive patients with a 7% re-rupture cakra andhika, raden andri primadhi, et al. 18 international journal of integrated health sciences (iijhs) rate. acta orthop. 2005;76(4):597–601. 5. yuan z, lin c, he y, tao b, chen m, zhang j, et al. near-infrared light-triggered nitricoxide-enhanced photodynamic therapy and low-temperature photothermal therapy for biofilm elimination. acs nano. 2020;14(3):3546–62. 6. bokhari ar, murrell gac. the role of nitric oxide in tendon healing. j shoulder elbow surg. 2012;21(2):238–44. 7. cotler hb, chow rt, hamblin mr, carroll j. the use of low level laser therapy (lllt) for musculoskeletal pain. moj orthop rheumatol. 2015;2(5):00068. 8. frigo l, favero gm, lima hjc, maria da, bjordal jm, joensen j, et al. low-level laser irradiation (ingaalp-660 nm) increases fibroblast cell proliferation and reduces cell death in a dose-dependent manner. photomed laser surg. 2010;28(suppl 1):s151–6. 9. joensen j, gjerdet nr, hummelsund s, iversen v, lopes-martins rab, bjordal jm. an experimental study of low-level laser therapy in rat achilles tendon injury. lasers med sci. 2012;27(1):103–11. 10. frigo l, favero gm, lima hjc, maria da, bjordal jm, joensen j, et al. low-level laser irradiation (ingaalp-660 nm) increases fibroblast cell proliferation and reduces cell death in a dose-dependent manner. photomed laser surg. 2010;28:s151-6. 11. poorpezeshk n, ghoreishi sk, bayat m, pouriran r, yavari m. early low-level laser therapy improves the passive range of motion and decreases pain in patients with flexor tendon injury. photomed laser surg 2018;36(10):530–5. 12. avci p, gupta a, sadasivam m, vecchio d, pam z, pam n, et al. low-level laser (light) therapy (lllt) in skin: stimulating, healing, restoring. semin cutan med surg. 2014;32(1):41–52. 13. chung h, dai t, sharma sk, huang y-y, carroll jd, hamblin mr. the nuts and bolts of low-level laser (light) therapy. ann biomed eng. 2012;40(2):516–33. 14. tsai sr, hamblin mr. biological effects and medical applications of infrared radiation. j photochem photobiol b. 2017;170:197– 207. 15. wecksler s, mikhailovsky a, ford pc. photochemical production of nitric oxide via two-photon excitation with nir light. j am chem soc. 2004;126(42):13566–7. 16. najafbeygi a, fatemi mj, lebaschi ah, mousavi sj, husseini sa, niazi m. effect of basic fibroblast growth factor on achilles tendon healing in rabbit. world j plast surg. 2017;6(1):26–32. 17. wink da, hanbauer i, grisham mb, laval f, nims rw, laval j, et al. chemical biology of nitric oxide: regulation and protective and toxic mechanisms. curr top cell regul. 1996;34:159–87. 18. gupta a, dai t, hamblin mr. effect of red and near-infrared wavelengths on lowlevel laser (light) therapy-induced healing of partial-thickness dermal abrasion in mice. lasers med sci. 2014;29(1):257–65. 19. foley j, vasily db, bradle j, rudio c, calderhead rg. 830 nm light-emitting diode (led) phototherapy significantly reduced return-to-play in injured university athletes: a pilot study. laser ther. 2016;25(1):35–42. 20. hsu y-h, chen y-w, cheng c-y, lee s-l, chiu t-h, chen c-h. detecting the limits of the biological effects of far-infrared radiation on epithelial cells. sci rep. 2019;9(1):11586. effects of low-level laser therapy on fibroblast density in achilles tendon rupture healing international journal of integrated health sciences. 2017;5(1) 15 correspondence: cahyandari nurlaelatiningsih, dr. slamet garut hospital, garut, west java, indonesia jl. rumah sakit umum n0. 12 sukakarya, garut kota, garut 44151, west java, indonesia e-mail: cahyandariiwan@gmail.com correlation between neutrophil-lymphocyte ratio and cardiac autonomic neuropathy in diabetes mellitus type 2 patients cahyandari nurlaelatiningsih,1,2 sunaryo barki sastradimaja,2 irma ruslina defi2 1dr. slamet garut hospital, garut, west java, indonesia 2department of physical medicine and rehabilitation, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital, bandung, indonesia abstract objective: to analyze the correlation between cardiac autonomic neuropathy (can) and neutrophil-lymphocyte ratio (nlr) in dm type 2 patients. methods: this was a cross-sectional study which was conducted at the internal medicine clinic of dr. hasan sadikin general hospital, bandung and chronic disease management (cdm) club in garut district, west java, indonesia from october to december 2015. subjects were 57 dm type 2 patients who met the inclusion criteria. cardiac autonomic neuropathy examination and complete blood count (cbc) were performed to discover the subjects’ neutrophil-lymphocyte ratio. results: a strong correlation was found between can in dm type 2 patients and nlr (r=0.679; p=0.000) based on rank spearman correlation test. the nlr to can cut off point was 1.34. conclusions: nlr examination can be used as an indicator of can in dm type 2 patients with nlr cut off point. there was a correlation between can and dm type 2 diagnosis duration. keywords: cardiac autonomic neuropathy, diabetes mellitus type 2, ewing test, neutrophil-lymphocyte ratio pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v5n1.961 ijihs. 2017;5(1):15–20 introduction diabetes mellitus (dm) is a complication of metabolical diseases that is characterized by hyperglycemia due to insulin secretion and disorder or their combination.1,2 in this disease, hyperglycemia becomes the primary risk factor for microor macroangiopathy complications. it also augments the oxidative and nitrosative stress that leads to neuron dysfunctions. because endothelial dysfunction causes ischemic neuron, the condition may be worsened. axons, which contain many mitochondria, are easily exposed. both directly or indirectly, by oxidative and nitrosative stress. augmented oxidative stress stimulates poly (adp-ribose) polymerase (parp) activation which activates the polyol and hexonamine pathways and also produces glycation and protein kinase c. this problems cause oxidative stress exacerbation which induces gene expression changes. hence, the transcription factors can cause neuron disorders and deaths. activation of the pathways causes microvascular regulation disturbances and endothelial dysfunctions, leading to decreased neurovascular perfusion, and cell dysfunction and apoptosis, as well.3–5 cardiac autonomic neuropathy (can) is a dm complication that is rarely noticed by the patients. it is regarded as one of the major factors of a higher number of morbidity and mortality.4 a study stated that the prevalence of can in dm type 2 was 34.4% while can can be discovered after 1 year of dm type 2 diagnosis.6 in addition, it causes disorders in the nerve fibers that innervate the heart and blood vessels, leading to abnormal heart beat and blood vessel control. in the early stage of can, sub-clinical symptoms can be discovered. original article received: december 14, 2016 revised: february 5, 2017 accepted: february 27, 2017 :15–20 16 international journal of integrated health sciences. 2017;5(1) therefore, the patients’ condition may worsen because of this.4,7 diabetes mellitus influences the majority of the autonomic nervous systems. vagus nerve is autonomically considered as the longest nerve. it also physiologically maintains 75% of parasympathetic and sympathetic activities. in the early stage of can, parasympathetic nervous function may decrease and causes sympathetic nervous dominance. the gradual increase of sympathetic nervous dominance occurs until the later stage of can in apex to the lower part of of heart, namely symphatetic nervous denervation.4 ewing has already proposed a 5-simple noninvasive test to assess the cardiac autonomic functions based on heart rate and blood pressure to certain physiologic maneuvers.4 the test includes heart rate response to deep breathing, heart rate response to standing, heart rate response during valsalva maneuver, blood pressure response to standing, and blood pressure response to hand grip. the first two tests are able to describe parasympathetic activity disturbances while the last two tests are useful to describe changes in the sympathetic function. among the five tests, none is considered the best. however, heart rate response to deep breathing is the mostl frequently used because it shows high specificity and reproducibility as well as easy to use.4 neutrophil-lymphocyte ratio (nlr) is used as a marker of neutrophil and lymphocyte balance level in body. it is regarded as the recent indicator of systemic inflammation status. it is simple, inexpensive, and useful for sub-clinical inflammation diagnosis.6 chronic hyperglycemia in dm will increase the release of reactive oxygen species (ros) from the neutrophils and decrease lymphocyte levels. decreased lymphocyte proliferation is caused by lower levels of interleukin-2 (il-2) receptor expression in dm type 2. in addition, dm type 2 patients with uncontrolled glucose level may experience lower lymphocytes and higher neutrophils. several studies observed nlr with blood glucose level regulation (hba1c). the results showed that nlr will increase if the hba1c value is 7%. the higher levels of hba1c are associated with increased cardiovascular complications found in dm type 2 patients.8–11 another study examined the correlation between nlr and insulin resistance in newly diagnosed dm type 2 patients.12 the study stated that nlr can increse in patients with insulin resistance when compared to healthy patients. this finding determines that higher nlr can be used as an indicator to diagnose insulin resistance. this study was initiated to analyze the correlation between nlr and can in dm type 2 patients using ewing test. methods this was a cross-sectional study conducted at the internal medicine clinic of dr. hasan sadikin general hospital, bandung and chronic disease management (cdm) club in garut district, indonesia in the period of october to december 2015. the sampling method used to calculate the subjects was non-intervention consecutive sampling. the inclusion criteria in the study were dm type 2 patients aged 18–60 years without cognition disturbance and ability to stand up. the exclusion criteria were chronic diseases, hypertension, pulmonary tuberculosis, and acute exacerbation of chronic obstructive pulmonary disease. the subjects’ can and nlr in this study were assessed using simultant ewing tests. ewing tests performed were heart rate response to internal respiration, position change from sitting to standing, and blood pressure response to standing. meanwhile, the subject results were assessed based on ewing test standard assessment. the nlr score were described and examined to reveal the correlation between nlr and can through ewing tests. if the correlation between nlr and can was found, the nlr cut off point would be examined to detect the possibility of can incidence. the can examinations in this study were (1) heart rate response to internal respiration, (2) heart rate response while standing, and (3) blood pressure response to sitting. actually, can examination using ewing tests includes (1) heart rate response to internal respiration, (2) heart rate response while standing, (3) heart rate response on valsalva maneuver, (4) blood pressure to standing, and (5) blood pressure to grasping. the ewing test is considered as the most appropriate test when compared to other tests. the test frequently used is the heart rate response to internal respiration due to its higher specificity, reproducibility, as well as efficiency.6 in this study, the subjects were assessed by using the tests number 1, 2, and 4. the nlr examination was conducted by drawing 3 cc blood sample which was then correlation between neutrophil-lymphocyte ratio and cardiac autonomic neuropathy in diabetes mellitus type 2 patients :15–20 international journal of integrated health sciences. 2017;5(1) 17 cahyandari nurlaelatiningsih, sunaryo barki sastradimaja, et al. subjected to the differential count test. the differential blood counts were used to assess neutrophil and lymphocyte ratio. the data were statistically analyzed with p value <0.05. the normality test was performed using shapiro wilks and rank spearman correlation tests. the shapiro wilks test was used due to the small number of subjects and the data were measured on an interval scale. the rank spearman correlation test was used for an ordinal measurement scale and performed to analyze the correlation between the two variables without making distribution frequency assumption from the variables. the protocols in this study were approved by the health research ethich commitee, faculty of medicine, universitas padjadjaran. results the normality test result using shapiro wilk showed that the subject characteristic value related to body mass index (bmi) was normally distributed. for other variables that are not normally distributed, the rank spearman correlation test was performed. a significant correlation between can in dm type 2 patients and nlr was found statistically using the rank spearman correlation test with 95% confidence interval, (p=0.0000, r=0.679). a significant correlation was found between can and diagnosis duration of dm type 2 (p=0.0188, r=0.3188). the resulted scatter diagram showed a positive correlation pattern between the two variables, can and nrl (fig. 1). based on the receiver operator curve (roc), the best two cut-off points of nrl to can was 1.3400 with a sensitivity value 0.872 and 1-specificity 0.167 resulted area under the curve 92.2% (fig. 2). discussion fifty seven subjects were included in this study, consisting of 46 females and 11 males. a finding has been made showing that the prevalence of dm in females (11.2%) is higher than males (9.6%).13 this prevalence is associated with improper diet, high adipose tissue, genetic factors, and inactivity. the average age for this disease is fifty two years old and the median is 55 years with 35 years as the youngest age and 59 years as the oldest. based on the data from the ministry of health, the highest proportion of dm type 2 in indonesia was found in 55–64 years old group.11 table 1 subject characteristics subject characteristics median (min-max) n sex males 11 females 46 age (yrs.) 55 (35–59) 57 weight (kg) 62 (40–110) 57 height (cm) 156 (144–178) 57 diabetes mellitus diagnosis duration (month) 24 (1–144) 57 neutrophillymphocyte ratio 1.58 (0.47–4.44) 57 a similar study had reviewed many studies in the period of 1975–2013 to discover the prevalence of can in dm type 2.4 the results revealed that can in dm type 2 occurred in 27–59 years with median 44 and 55 years. median weight was represented by 65 kg and median height was represented by 156 cm. the average bmi was 24.9 with standard deviation (sd) 3.64 and median 25.2. the study included 117 dm type 2 patients with can and resulted in a bmi of 28.1+5.6.15 in this study, the average bmi is on the upper limit of normal bmi. higher bmi may become a risk factor which stimulates complications caused by dm. the duration of dm diagnoses reported were between 1–144 months with the average diagnosis duration of 37.4 months and median of 24 months. the duration varies with high blood glucose levels. high levels of blood glucose cause disorders to several organs. hyperglycemia persists in a very long time and causes changes in organs that leads to both microvascular and macrovascular complications. the most frequently found complication in dm type 2 is neuropathy which occurred in early and acute conditions.13 seven percents of the cardiac autonomic neuropathy can be diagnosed in the early diagnosis of dm type 1 and 2.4,16 based on the correlation between can and nrl, can (-) means lower nlr value and can (+) means higher nlr value. a previous study has examined the correlation between nlr and insulin resistance in newly diagnosis of dm type 2 patients and it is reported that nlr increases in subjects with insulin resistance when compared to healty subjects.12 in addition, high nlr levels become :15–20 18 international journal of integrated health sciences. 2017;5(1) a predictive sign of insulin resistance. this condition can occur because white blood cells have a positive association with acute or systemic inflammation process caused by hyperglycemia.17 the pathogenesis of cardiac autonomic neuropathy includes several mechanisms and factors which enhance ischemic neurons that may lead to direct cell dysfunctions or deaths. hyperglycemia can increase oxidative and nitrosative stress that lead to nerve disorders. acute and chronic inflammations as well as increased immunology cells can increase nlr in dm patients. hyperglycemic condition causes endothelial cell disorders leading to neutrophil adhesion. increased number of endothelial cells leads to higher neutrophil levels due to the release of reactive oxygen species (ros). higher neutrophil levels are associated with the process of thrombus shape and ischemic injury caused by hyperglycemia. lymphocyte levels in chronic inflammation should be increased. on the contrary, lower lymphocyte levels in dm type 2 patients occur due to decreased proliferation.3,18 it is stated in a previous study that lymphocyte proliferation insufficiency (lpi) occurs in dm patients.8 the study reported that lpi incidences are mostly found in uncontrolled dm type 2 patients compared to in controlled dm type 2 patients. another study revealed that the lymphocyte levels in uncontrolled dm type 2 patients are lower than in controlled dm type 2 patients.9 however, lymphocyte levels in dm type 1 patients are lower than in healty people.19 lower lymphocyte levels occur in dm type 2; thus, decreased lymphocyte proliferation is caused by lower levels of il-2 receptor expression. this leads to decreased lymphocyte levels and increased neutrophil levels. lower levels of il-2 receptor expression are caused by cd25 deficiency. cd25 plays a vital role which enhances il-2 receptor to produce t cells. stimulated by antigen, cd25 is important for t cells clonal expansion after antigen has been discovered. interleukin 2 expression is increased by the antigen stimulation because t cells are the main cells which proliferate in specific immune response. therefore, il-2 increase the proliferation and differentiation of lymphocyte.8 the correlation between can and dm type 2 diagnosis duration is considered statistically significant in this study. a study which has similar result to this study revealed that the average prevalence of can in dm type 2 increases 65% along with increased dm duration.20 however, another study stated different results that no correlation was found between dn duration and can incidences in dm type 2.4 it is reported in this study that dm duration becomes an independent factor of can incidences. cardiac autonomic neuropathy may be discovered 1 year after dm type 2 diagnosis or 2 year after dm type 1 diagnosis. however, can symptoms cannot be noticed in the early stage. a possible can symptom mostly found is heart beat variability.4,6 uncontrolled hyperglycemia becomes a major risk factor associated with incidences of can. fig. 1 a scatter diagram of cardiac autonomic neuropathy (can) and neutrophil-lymphocyte ratio (nlr) correlation pattern fig. 2 receiver-operating characteristic (roc) curve analysis of neutrophillymphocyte ratio (nlr) for predicting cardiac autonomic neuropathy (can) in diabetic patients correlation between neutrophil-lymphocyte ratio and cardiac autonomic neuropathy in diabetes mellitus type 2 patients :15–20 international journal of integrated health sciences. 2017;5(1) 19 references 1. perkumpulan endokrinologi indonesia. konsensus pengendalian dan pencegahan diabetes mellitus tipe 2 di indonesia 2012. 1st ed. jakarta: pb perkeni; 2012. 2. sacks db, arnold m, bakris gl, bruns de, horvath ar, kirkman ms, et al. guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus. diabetes care. 2011;34(6):61–99. 3. oakley i, emond l. diabetic cardiac autonomic neuropathy and anesthetic management: review of the literature. aana j. 2011;79(6):473–9. 4. dimitropoulos g, tahrani aa, stevens mj. the indonesian society for endocrinology described that 50% diabetic patients had not been diagnosed suffering from dm and only one-third of dm type 2 patients who was treated properly.1 uncontrolled hyperglycemic condition and dm type 2 duration are the major risk factors of can progresivity. this condition may be caused by longer duration of hyperglycemic exposure which will increase the oxidative stress and decrease the no levels. cell proteins are disrupted, while leukocyte adhesion in endothelium may increase due to parp activation. the activation will activate polyol and hexonamine pathways and produce glycations and kinase c proteins. activations of the pathways will cause oxidative stress exacerbation which induces gene expression changes and transcription factors leading to neuron disorders or deaths. the activation of the pathways causes various microvascular regulation disorders and also endothelial dysfunctions. a decrease in the level of neurovascular perfusion may be seen, which then leads to cell dysfunction and apoptosis.4 nitric oxide formation in the endothelium will be prohibited and worsen endothelial dysfunctions. acute endothelial dysfunctions exacerbate cell protein disorder and leukocyte adhesion in endhotelium. these changes can cause neuron, axon, and schwann cell metabolism abnormalites, which will then disturb axonal transport. increased vascular resistance and decreased neuronal blood flow can cause endoneurial hypoxia. hypoxia will induce advanced disorders of capillary such as axonal atrophy and can conduction that are caused by axonal transport disorders as well as decreased na,k-atpase activity. chronic inflammation will stimulate microangiopathy in dm patients, increasing the incidences of microangiopathy in dm patients.6 there are several possible mechanisms related to the correlation between can and nrl, which include hyperglycemia in dm type 2 that causes ischemic neuron and affects persistent inflammation process, leading to repeated antigen exposures.4,12 these underlie the process of chronic inflammation. the results in this study reveal that the relevant inflammations as well as nerve cell disorders in dm type 2 patients are mainly due to hyperglycemia. endothelial cell disorders cause neutrophil adhesion while a higher number of endothelial cells increase neutrophil levels. the presence of persistent and uncontrolled hyperglycemia will worsens inflammation since repeated antigen exposures may cause chronic inflammation. cytokines, derived from the t and macrophage cells, suppresses neutrophil and lymphocyte releases. however, t and macrophage cells are released in chronic inflammation. as persistent hyperglycemia, acute and chronic inflammations may continuously occur in dm patients.4 diabetes mellitus type 2 patients with uncontrolled hyperglycemia may experienced lower lymphocyte levels because lymphocyte proliferation is prohibited. this is caused by lower levels of il-2 receptor expression due to cd25 deficiency.15 in addition, higher neutrophil levels increase nlr. there were several limitations in this present study, such as the use of the crosssectional design which may not be suitable for discovering the cause and effect between can and nlr while hba1c examination was not performed to distinguish controlled and uncontrolled dm type 2 patients. in this study, there was no il-2 examination to observe lower lymphocyte levels caused by decreased il-2 levels. the exclusion criteria were pulmonary tuberculosis while non-pulmonary tuberculosis was not excluded because there is no advanced study which discovers the correlation between nlr and non-pulmonary tuberculosis in asia. in conclusion, a strong correlation is found between can and nlr creating a possibility to use nlr value as a predictor of can in dm type 2 patients with a cut off point of 1.34. cahyandari nurlaelatiningsih, sunaryo barki sastradimaja, et al. :15–20 20 international journal of integrated health sciences. 2017;5(1) cardiac autonomic neuropathy in patient with diabetes mellitus. world j diabetes. 2014;5(1):17–39. 5. tangvarasittichai s. oxidative stress, insulin resistance, dyslipidemia and type 2 diabetes mellitus. world j diabetes. 2015;6(3):456–80. 6. vinik ai, maser re, mitchell bd, freeman r. diabetic autonomic neuropathy. diabetes care. 2003;26(5):1553–79. 7. balcıoğlu as, müderrisoğlu h. diabetes and cardiac autonomic neuropathy: clinical manifestations, cardiovascular consequences, diagnosis and treatment. world j diabetes. 2015;6(1):80–91. 8. bratawidjaya kg, rengganis i. imunologi dasar. 11th ed. jakarta: badan penerbit fakultas kedokteran universitas indonesia; 2014. 9. sefil f, ulutas kt, dokuyucu r, sumbul at, yengil e, yagiz ae, et al. investigation of neutrophil lymphocyte ratio and blood glucose regulation in patients with type 2 diabetes mellitus. j int med res. 2014;42(2):581–8. 10. taşoğlu i̇, sert d, colak n, uzun a, songur m, ecevit a. neutrophil–lymphocyte ratio and the platelet–lymphocyte ratio predict the limb survival in critical limb ischemia. clin appl thromb hemost. 2014;20(6):645–50. 11. turkmen s, dogdu o, tekin k, kucukdurmaz z, cagliyan ce, sarikaya s, et al. the correlation between neutrophil/lymphocyte ratio and the timi flow grade in patients with stemi undergoing primary pci. eur rev med pharmacol sci. 2013;17(16):2185–9. 12. lou m, luo p, tang r, peng y, yu s, huang w, et al. correlation between neutrophil-lymphocyte ratio and insulin resistance in newly diagnosed type 2 diabetes mellitus patients. bmc endocr disord [serial on the internet]. 2015 mar 2 [cited 2016 april 30];15(9):[about 6 p.] available from: https://www.ncbi.nlm.nih. gov/pmc/articles/pmc4357061/#. 13. ekpenyong ce, akpan up, ibu jo, nyebuk de. gender and age specific prevalence and associated risk factors of type 2 diabetes mellitus in uyo metropolis, south eastern nigeria. diabetologia croatica. 2012;41(1):17– 28. 14. infodatin pusat data dan informasi kementrian kesehatan 2014. situasi dan analisis diabetes. [cited 2016 june 2]. available from: http:// www.depkes.go.id/folder/view/01/structurepublikasi-pusdatin-info-datin.html. 15. gulichsen e, fleischer j, ejskjaer n, eldrup e, tarnow l. screening for diabetic cardiac autonomic neuropathy using a new handle device. j diabetes sci technol. 2012;6(4):965– 72. 16. leon bm, maddox tm. diabetes and cardiovascular disease: epidemiology, biological mechanisms, treatment recommendations and future research. world j diabetes. 2015;6(13):1246–58. 17. huang w, huang j, liu q, lin f, he z, zeng z, et al. neutrophil-lymphocyte ratio is a reliable predictive marker for early-stage diabetic nephropathy. clin endocrinol (oxf ). 2015;82(2):229–33. 18. luo h, yuan d, yang h, yukui m, huang b, yang y, et al. post-treatment neutrophil-lymphocyte ratio independently predicts amputation in critical limb ischemia without operation. clinics (sao paulo). 2015;70(4):273–7. 19. raha o, chowdhury s, dasgupta s, raychaudhuri p, sarkar bn, raju pv, et al. approaches in type 1 diabetes research: a status report. int j diabetes dev ctries. 2009;29(2):85–101. 20. spallone v, ziegler d, freeman r, bernardi l, frontoni s, pop-busui r, et al. cardiovascular autonomic neuroathy in diabetes: clinical impact, assessment, diagnosis and management. diabetes metab res rev. 2011;27(7):639–53. correlation between neutrophil-lymphocyte ratio and cardiac autonomic neuropathy in diabetes mellitus type 2 patients :15–20 vol 10 no.1 2022 rev.2.indd international journal of integrated health sciences (iijhs) 39 introduction in some cases, fever can continue indefinitely, thus called as a fever of unknown origin (fuo). before etiologic cause is decided, administration of empiric therapy is not recommended although in selected cases administration of corticosteroid and broadspectrum antibiotics is allowed. in drug reaction with eosinophilia and systemic symptom (dress), fever is one of the possible differential diagnosis of fever of unknown origin in drug reaction with eosinophilia and systemic symptom (dress) abstract objective: to describe an unusual case of drug reaction with eosinophilia and systemic symptoms presenting as fever of unknown origin (fuo) and the diagnostic hurdles that come with the presence of differential diagnosis of fuo, which is tuberculous lymphadenitis. methods: a 34-year-old female with a chief complaint of fever that has lasted for 3 weeks accompanied with jaundice and skin rashes for 2 weeks was admitted with an indication of fuo. she had a history of carbamazepine consumption for trigerminal neuralgia 2 months prior. cervical lymphadenopathy was palpable bilaterally and hepatomegaly, elevated liver enzyme, as well as hyperbilirubinemia were observed. after excluding differentials for many causes of prolonged fever, patient was treated for drug reaction with eosinophilia and systemic symptom (dress) and was given intravenous steroid injections. fine needle aspiration biopsy was performed for her cervical lymphadenopathy. results: biopsy presented a mix of sialadenitis and tuberculous lymphadenopathy. clinical improvement was observed on the second day after steroid administration. patient was discharged on the seventh day after steroid administration. conclusion: fuo is one of the possible manifestations of dress; however, thorough investigation still needed to be done considering the possibility of more than one entity of disease that can cause fuo in patients, such as tuberculous lymphadenopathy seen in this case. keywords: case report, dress, drug reaction, fever of unknown origin, treatment received: november 8, 2020 accepted: march 23, 2022 case report kevin fachri muhammad, ferdy ferdian, andri reza rahmadi department of internal medicine, faculty of medicine universitas padjadjaran dr. hasan sadikin general hospital bandung, indonesia pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ ijihs.v10n1.2198 ijihs. 2022;10(1):39-45 correspondence: kevin fachri muhammad, department of internal medicine, faculty of medicine universitas padjadjaran-dr. hasan sadikin general hospital bandung, indonesia email: kevinfachri@gmail.com symptoms that can manifest. reports on fuo related to dress is scarce. here, this study present a case of fuo as a manifestation of dress in the presence of tuberculous lymphadenopathy which discovered much later. this study will unfold its clinical picture, disease history, workup, and treatment. cases a 34-year-old came female with a chief complaint of fever that lasted for 3 weeks before admission to the hospital. the patient experienced continuous fever, higher in the evening, gets better after consuming antipyretic but return after a few hours. there is no apparent symptom of infection such as 40 international journal of integrated health sciences (iijhs) cough, runny nose, dyspnea, earache, and dysuria. this complaint was accompanied by nausea, vomiting, and stomachache. patient had a history of drug consumption in the last 2 months, for her trigerminal neuralgia that was diagnosed by her neurologist and was treated with carbamazepine tablet 2x500 mg a day. there is no history of close contact with tuberculosis patient nor history of tuberculosis medication. there is no history of prolonged cough, night sweat, although there is a loss of 2 kilograms of bodyweight for 1 month. patient was married and have 2 children, there’s no history of miscarriage, hair loss, previous skin rash or photosensitivity. four days after the onset of her fever, she seeks treatment to a private hospital, and was told that her skin condition was caused by carbamazepine. however, after 2 weeks of hospital stay, her fever persists, and she was referred to the hospital. the patient was compos mentis and axilla measured temperature was 39°c. she was icteric, having multiple non-tender cervical lymph node enlargement, hepatomegaly, generalized confluent skin lesion with irregular border consisted of erythematous macule and desquamation that cover her entire skin. on laboratory examination this study found increased liver aspartate transferase (ast) 248 u/l, alanine transferase (alt) 492 u/l, total bilirubin 5.739 mg/dl, conjugated bilirubin 5.040 mg/dl, unconjugated bilirubin 0.699 mg/dl, with negative anti-hcv, antihiv, and hbsag. on blood smear microscopy, this study found atypical lymphocyte. two ziehl-neelsen-stained sputum samples result was negative. chest x-ray interpretation was bilateral bronchopneumonia. abdominal ultrasound from previous hospital revealed fig. 1 temperature curve fig. 2 (a, b) skin desquamation; (c) oral thrush with exfoliative cheilitis differential diagnosis of fever of unknown origin in drug reaction with eosinophilia and systemic symptom (dress) international journal of integrated health sciences (iijhs) 41 inhomogeneous liver parenchyma with resembling starry sky that suggests inflammatory process. she was given paracetamol 3x500 mg per oral, fluconazole 1x150 mg per oral, omeprazole 1x40 mg intravenous, curcuma 3x1 tablets per oral. from dermatology consult, this patient was suspected as having drug reaction with eosinophilia and systemic symptom (dress). patient was given dexamethasone 7,5 mg intravenous per day, cetirizine 10mg per day, vaseline for her skin. since steroid administration, liver function was measured regularly, and it was found that transaminase level improved along with her skin rash and jaundice. repeat blood smear examination was done and the atypical lymphocyte was not found. all her initial symptom has already diminished, from skin rashes, lymphadenopathy, liver enlargement, and jaundice. patients were discharged on the 13th day. her biopsy result came out at the same day, revealing necrotic mass with fibrin, lymphocyte, epithelioid cell, and langhans giant cell for her right cervical lymph. for her left cervical lymph shows necrotic mass, lymphocyte, polymorphonuclear cell, columnar cell, epithelioid, without langhans giant cell. pathology expertise concludes that her right cervical lymph was tuberculous lymphadenitis, and her left was sialadenitis. because of that result, we give her referral for tuberculosis clinic visit after she was discharged for further treatment and evaluation. discussion fever of unknown origin (fuo) is an increased body temperature (higher than 38,2oc) for three weeks or more without clear etiology even after extensive evaluation for at least 1-week in hospital. there’s no official guideline nor there is standardized approach to diagnose this condition.1 according to durack and street, fuo can be classified into 4 type: 1) classical fuo, fever longer than 3 weeks with unidentified cause after 3 days in hospital evaluation or more than 3 times outpatient visits, 2) nosocomial fuo, fever that manifested after 48 hours in hospital care without clear diagnosis after 3 days in hospital evaluation, 3) neutropenic fuo, fever with neutrophil count less than 500 cell/ul without clear diagnosis after 3 days in hospital evaluation, 4) hiv-related fuo, fever afflicting known hiv patient that was diagnosed more than 4 weeks in an outpatient setting, or diagnosed as hiv in hospital for more than 3 days.2 the patient experience fever for 24 days before admitted in hospital, with previous 16 days inpatient care in another hospital, thus fulfilled classical fuo criteria. there are more than 200 diseases that may became fuo differential diagnosis, subgroup of differentials that usually used in classical fuo consist of 4 categories: infection, malignancy, rheumatoid diseases, and other causes.1 each subgroup have distinct clinical characteristic. malignant etiology tends to cause early anorexia and significant weight loss, while infectious etiology may cause chill without apparent weight reduction. vasculitis and synovitis are signature clue for rheumatic etiology.3 drug related fever can be found in 1-3% of fuo cases.1 most experts suggested a wide array of standard testing panel, including blood tests, urinalysis, fecal examination, skin tests, and culture from different specimen, chest x-ray, and abdominal ultrasound. if there’s still no definite diagnosis, mourad states that its acceptable to order other tests such as hepatitis testing, liver biopsy, culture for mycobacteria, fungi, and other bacteria, echocardiography, abdominal and chest ct scan, and temporal artery biopsy for patient older than 55 years.4 the patient disease history began when she complained of severe headache that was treated with carbamazepine, followed by appearance of fever and skin rashes. she does not have history of staying on an endemic area nor surgery. she previously had a history of hospital stay, though she did not have her medication history on that hospital with her. she already did several of the examination suggested above, which is blood exam, ziehl neelsen stain for sputum sample, chest x-ray, abdominal ultrasound. from this data, differentials were made, and rheumatologic condition was excluded from etiological possibility. infection and malignancy were still possible at the time, considering her fever, weight loss, lymph enlargement that has yet to be examined histopathologically. from her initial blood exam, she has known to have anemia, increased conjugated bilirubin, and transaminase. abdominal ultrasound revealed liver inflammation, previously suspected as drug induced liver injury, though after dermatology consultation, concluded that it may be related to the possibility of dress involvement. drug reaction with eosinophilia and systemic symptom (dress) is an adverse drug reaction (adr) that may potentially kevin fachri muhammad, ferdy ferdian, et al 42 international journal of integrated health sciences (iijhs) life threatening. this disease has multiorgan manifestation, including hematologic, hepatic, renal, pulmonary, cardiac, neurologic, gastrointestinal, and endocrine system. dermatological manifestation in dress can be diverse, with morbilliform rash as its common sign. this syndrome have 10% mortality rate, usually derived from fulminant hepatitis with hepatic necrosis.5 a systematic review from pubmedmedline, january 1997 to may 2009 stated that there are 44 drugs that was associated with 172 reported cases. carbamazepine was the most frequently reported drug and was found in 47 cases (27% from total cases in this series).6 dress syndrome can manifest 2 months after drug consumption, although its usually happened 2–6 weeks after the patient first exposure to drug. symptom may appear earlier and heavier to those with repeated exposure to offending drug. carbamazepine had an onset of 21–28 days.7 the patient clearly said her medication history with carbamazepine 2 months before, and she became feverish 5 weeks after that. usual clinical manifestation for dress patient are fever, rash, lymphadenopathy, leukocytosis, and liver function abnormalities. skin afflictions are explicitly clear, urticaria and maculopapular rash being the most common, though vesicle, bullae, pustule, cheilitis, purpura, target lesion, and erythroderma were also reported.7 although skin eruption in dress is extensive, its morbidity and mortality were caused by systemic involvement. the most common involvement was fever (temperature >38°c) in 95% of cases with visceral organ involvement from lymphatic, hematology, hepatic, followed by renal, pulmonary, and cardiac. severe and atypical cases can involve neurology, gastrointestinal, or endocrine dysfunction. certain drugs may have specific organ predilection.5 the patient was afflicted with extensive skin lesion in the form of erythematous macule and desquamation. lymphadenopathy, local or generalized, can be found on 75% of dress. the most common lymph node involvement was in cervical, axillary, and inguinal area. histopathologically, there’s 2 main variant, benign and pseudolymphomatous type.8 hematological disturbance was frequently encountered and happened 2 weeks after drug eruption onset. leukocytosis, with high atypical lymphocyte that preceded by leukopenia or lymphopenia, with eosinophilia that may contribute to visceral organ manifestation. there is also thrombocytopenia and anemia.8 hepatic involvement may manifest as hepatocellular or cholestatic liver injury, and on severe cases may become fulminant hepatic failure that require liver transplantation.8 dress could be included in one of the phenotypes of drug-induced liver injury (dili), and some authors recommend the dili severity index to evaluate the degree of liver injury. it is described that patients with severe acute liver damage may shows an overall survival of 75%, with hepatic encephalopathy, factor v level, prothrombin time were predictors of poor prognosis.9 lung involvement from dress may decrease lung capacity as this condition may take form as acute interstitial pneumonitis, lymphocytic interstitial pneumonia, pleuritis, and acute respiratory distress syndrome (ards). lung involvement may also be described by signs such as cough, dyspnea, pleuritic pain and/or radiological findings such as unilateral or bilateral pulmonary infiltrates, lobar infiltrates, and pulmonary nodules.10 the patient had many symptoms that formerly thought as several diseases, eventually all those symptoms can be explained as systemic manifestation of dress. she had bilateral cervical lymphadenopathy, hematological manifestation in the form of anemia and atypical lymphocyte. she got cholestatic type liver injury with jaundiced sclerae, hepatomegaly that was confirmed by physical exam and ultrasound, increased ast/alt and conjugated bilirubin. there is no increase in bun nor creatinine, but we found microscopic hematuria. lung involvement can be suspected from bilateral infiltrate on her chest x-ray, that was interpreted as bronchopneumonia, in the absence of symptom and sign of infection. patient suspected with dress must undergo extensive evaluation. deciding the associated drug oftentimes difficult in polypharmacy or when symptom appeared after long latency period. clinical examination that was developed to point out dress causative agent was not reliable. regular testing method that was used is skin patch test and lymphocyte transformation test (ltt). systematic review show that ppv from skin patch test in optimal setting can be as high as 80–100%. for optimal result, patch test must be done 2–6 months after resolution of symptom. positive ltt result consequential in differential diagnosis of fever of unknown origin in drug reaction with eosinophilia and systemic symptom (dress) international journal of integrated health sciences (iijhs) 43 diagnosis and determining causative drug in dress. negative ltt result could not rule out drug hypersensitivity.11 the patient’ causative drug can be easily identified so further examination was not required. up until this point there’s no gold standard diagnostics for dress. european registry of severe cutaneous adverse reaction study group invent scoring system called regiscar, based on the criteria invented by bocquet et al. japanese consensus group also used the same criteria with different terminology, which they called drug induced hypersensitivity syndrome (dihs).7 this study was calculated regiscar score on the patient with a total score of four, interpreted as probable dress. common differential for dress is other systemic cutaneous adverse reaction (scar), such as stevens johnson syndrome/toxic epidermal necrolysis, acute generalized exanthematous pustulosis, and erythroderma which also manifesting skin lesion and visceral involvement. it is important to differentiate dress from dermatological findings from exanthem virus (kawasaki, ebv, viral hepatitis, influenza, cmv, and hiv). dress also have to be differentiated from lymphoma, pseudolymphoma, collagen vascular disease, serum sickness-like reaction. other differentials include kawasaki syndrome, still’s disease, syphilis, porphyria, and hypereosinophilic syndrome.12 in the beginning, this study did not administer any treatment for the patient. the reason was because empirical therapy was not recommended in patient with fuo, as it may cloud disease manifestation and delay diagnosis, thus may hindering proper treatment.4 patient without clear diagnosis and clinical improvement advised to be kept on as minimal medication as possible and wait. antipyretic can mask patient symptom and can only be given to those who were unable to tolerate their fever. in a certain working diagnosis, empiric therapy is allowed, for example empiric antibiotic is given in bacterial endocarditis even though its blood culture turn out to be negative, antituberculosis drug is given in suspected tuberculosis infection, and glucocorticoid is administered in suspected temporal arteritis with risk of blindness.4 consultation with subspecialists (infectious disease specialist, rheumatologist, haematooncologist) is the correct way to get an insight on working diagnosis.1 the biggest challenge in dress is early identification of this condition and termination of causative drug. inability to do so may increase morbidity and mortality.11 all patients must be given adequate supportive measures to stabilize their hemodynamics, given antipyretic for their fever, emolien and topical steroid for their skin condition. empirical antibiotic must be avoided because it can crossreact with other drugs and may exacerbate the condition.7 systemic corticosteroid is the main therapeutic option for dress. it was given in prednisone equivalent dose of 1mg/kg/day. steroid must be tapered slowly in 6-8 weeks, even after clinical resolution is achieved, to prevent relapse. it was done in this fashion because dress patient also has higher risk to experience immune reconstitution inflammatory syndrome if steroid is withdrawn recklessly.7,13 severe cases or where dress is refractory to conventional steroid dose, intravenous methylprednisolone can be given in pulse dose of 30mg/kg/day for 3 days.11 intravenous immunoglobulin (ivig) have been tried before in patient unresponsive to steroid or had contraindication to steroid.14 other modalities in dress treatment are plasmapheresis and immunosuppressive drug such as cyclophosphamide or cyclosporine. n-acetylcysteine may help to detoxify circulating drug and limit reactive metabolite in anticonvulsant induced dress. valgancyclovir can minimize complication related to hhv-6 reactivation and can be given in combination with prednisone.15 the patient is given steroid therapy as described, using dexamethasone 7.5 mg intravenously per day (equivalent to 50mg prednisone, based on the patient body weight). her skin affliction gradually gets better, along with her other systemic symptoms. this study repeat her blood smear, and the atypical lymphocyte is nowhere to be found. interestingly, her leukocyte and thrombocyte increased significantly on the 5th day since steroid administration (24110/ ul and 959,000/ul respectively). this may be caused by high dose steroid effect, because the patient was getting better and there is no sign of infection. patient who received 40–80 mg prednisone-equivalent may have leukocytosis since a few hours to 2 weeks after administration.16 corticosteroid was also known to cause transient thrombocytosis through splenic release of pooled thrombocyte into systemic circulation.17 histopathologically, drug induced lymphadenopathy is flooded with polymorphic cellular infiltrate comprised of lymphocyte, plasma cell, eosinophil, and histiocyte. some may have focal hemorrhagic necrosis without kevin fachri muhammad, ferdy ferdian, et al 44 international journal of integrated health sciences (iijhs) fibrosis, with endothelial hyperplasia. on the other hand, tuberculous lymphadenopathy showed epithelioid granuloma with giant langhans cell accompanied with central necrosis.18 the patient showed tuberculous characteristic on her right lymph node biopsy, though on her left lymph node it was found to support drug reaction because histopathologically comprised more with lymphocyte and polymorphonuclear cell. another reason why tuberculosis cannot be excluded completely is that steroid was used. anti-inflammatory effect from corticosteroid may null the body fever generating mechanism through prostaglandin inhibition from arachidonic acid release blockade. corticosteroid also able to halt interleukin-1 transcription which is important to augment t-cell proliferation.19 however, we know that dress’s mortality and morbidity is caused by its systemic involvement. fever is manifested in 90% cases and usually very high in dress (>38°c), while in tuberculous lymphadenitis, systemic manifestation is uncommon, and fever is reported in hiv coinfection as a lowgrade fever. in immunocompetent patient, fever only reported in 20–50% cases.7 therefore, this study conclude from the patient characteristics, that dress is the main cause of fever in this patient. diagnosis of dress must be suspected from the symptom of skin rash, liver involvement, fever, and lymphadenopathy in patient with history of drug use. fuo is one of the possible manifestations of dress, but thorough investigation still needed to be done, considering the possibility of more than one entity of disease that can cause fuo in one patient. termination of drug, accurate treatment, supportive measures, wound care, multidisciplinary approach, and early systemic steroid initiation is crucial to reduce mortality and morbidity in dress. 1. hersch ec, oh rc. prolonged febrile illness and fever of unknown origin in adults. am fam physician. 2014;90(2):91–6. 2. varghese gm, trowbridge p, doherty t. investigating and managing pyrexia of unknown origin in adults. bmj. 2010;341:878– 81. 3. cunha ba, lortholary o, cunha cb. fever of unknown origin: a clinical approach. the am j med. 2015;128:1138.e1-1138.e15. 4. unger m, karanikas g, kerschbaumer a, winkler s, aletaha d. fever of unknown origin (fuo) revised. wien klin wochenschr. 2016;128(21-22):796–801. 5. husain z, reddy by, schwartz ra. dress syndrome: part i. clinical perspectives. j am acad dermatol. 2013;68:693.e1–14. 6. mardivirin l, valeyrie-allanore l, branlantredon e, beneton n, jidar k, barbaud a, et al. amoxicillin-induced flare in patients with dress (drug reaction with eosinophilia and systemic symptoms): report of seven cases and demonstration of a direct effect of amoxicillin on human herpesvirus 6 replication in vitro. eur j dermatol. 2010;20:68–73. 7. de a, rajagopalan m, sarda a, das s, biswas p. drug reaction with eosinophilia and systemic symptoms: an update and review of recent literature. indian j dermatol. 2018;63(1):30– 40. 8. kano y, ishida t, hirahara k, shiohara t. visceral involvements and long-term sequelae in druginduced hypersensitivity syndrome. med clin north am. 2010;94:743–59. 9. delgado mg, casu s, montani m, brunner f, semmo n, berzigotti a, et al. hepatic manifestations of drug reaction with eosinophilia and systemic symptoms syndrome. exploration med. 2021;2:122–34. 10. taweesedt pt, nordstrom cw, stoeckel j, dumic i. pulmonary manifestations of drug reaction with eosinophilia and systemic symptoms (dress) syndrome: a systematic review. biomed res int. 2019;2019:7863815. 11. husain z, reddy by, schwartz ra. dress syndrome: part ii. management and therapeutics. j am acad dermatol. 2013;68:709. e1–9. 12. kumari r, timshina dk, thappa dm. drug hypersensitivity syndrome. indian j dermatol venereol leprol. 2011;77:7–15. 13. shiohara t, kano y. review of drug-induced hypersensitivity: special emphasis on druginduced hypersensitivity syndrome. expert rev dermatol. 2012;7:539–47. 14. kito y, ito t, tokura y, hashizume h. high-dose intravenous immunoglobulin monotherapy for drug-induced hypersensitivity syndrome. acta references differential diagnosis of fever of unknown origin in drug reaction with eosinophilia and systemic symptom (dress) international journal of integrated health sciences (iijhs) 45 derm venereol. 2012;92:100–1. 15. moling o, tappeiner l, piccin a, pagani e, rossi p, rimenti g, et al. treatment of dihs/dress syndrome with combined n-acetylcysteine, prednisone and valganciclovir – a hypothesis. med sci monit. 2012;18:cs57–62. 16. epomedicine. steroid induced leukocytosis 2016 [updated 23 december 2016. available from: https://epomedicine.com/medicalstudents/steroid-induced-leukocytosis/. 17. subramaniam n, mundkur s, kini p, bhaskaranand n, aroor s. subramaniam n, mundkur s, kini p, bhaskaranand n, aroor s. clinicohematological study of thrombocytosis in children. isrn hematol. 2014;2014:389257. 18. balakrishna j. drug hypersensitivity 2018 [updated 30 july 2020; cited 2020 17 september]. available from: http:// w w w . p a t h o l o g y o u t l i n e s . c o m / t o p i c / lymphnodesdrughypersensitivity.html. 19. uda h, suga y, toriba e, staub ay, shimada t, sai y, et al. multiday corticosteroids in cancer chemotherapy delay the diagnosis of and antimicrobial administration for febrile neutropenia: a double-center retrospective study. j pharm health care sci. 2019;5:3. kevin fachri muhammad, ferdy ferdian, et al 8 international journal of integrated health sciences. 2017;5(1) original article morphological changes of cisplatin-resistant human breast cancer mcf-7 cell line correspondence: nanda ayu puspita, departement of biochemistry, faculty medicine, syiah kuala university jl. t. nyak arief darussalam banda aceh 23111, banda aceh, indonesia e-mail: n.a.puspita@edu.salford.ac.uk abstract objective: to evaluate morphological changes of breast cancer cell line mcf-7 following the development of acquired resistance towards cisplatin. resistance towards anticancer agents still plays an important role in the breast cancer chemotherapy failure. methods: the cisplatin resistant subline mcf-7/cisr was developed in-vitro by cultivating the parental cell line cisplatin-sensitive mcf-7 with raising concentration of cisplatin (from 0.01 to 2.3 µm) for four months. the cell morphology was observed by giemsa staining. results: the resistance was shown by the increase of ic50 by 9 folds on mcf-7/cisr compared to the initial ic50 value of mcf-7. the change in cisplatin cytotoxic potency on the resistant cell line was accompanied by the morphological modification, including the enlargement of cell size, the increase of nucleus and cytoplasm ratio, and the increase of the number of microvesicular and cytoplasmic granules. conclusions: this result has supported the underlying mechanism of cisplatin resistance, including the ability of the cells to decrease intracellular cisplatin concentration and repair dna damage effects. keywords: drug resistance, human breast cancer, cisplatin, mcf-7 pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v5n1.960 ijihs. 2017;5(1):8–14 nanda ayu puspita,1,2 amy bedford3 1departement of biochemistry, faculty medicine, syiah kuala university, banda aceh, indonesia 2biomedical research centre, university of salford, the crescent, salford, united kingdom 3faculty of biology, medicine and health, university of manchester, oxford road, manchester, united kingdom introduction breast cancer is known as the most common cancer in women.1,2 in the developed world, for example, in the united kingdom, around 150 new cases are diagnosed every day; 1 in 8 women are predicted to be diagnosed with breast cancer during their lifetime. meanwhile, in less developed countries, the breast cancerrelated deaths reach a significant number, which is more than 50% of the diagnosed cases.3 in combating breast cancer, the modality of therapy can include surgery, chemotherapy, and radiotherapy.1–3 for a systemic approach, chemotherapy is counted as a key strategy to treat breast cancer due to eliminate residual cancer after surgery or possible occurrence of metastatic cells.4 however, chemotherapy is frequently accompanied by the occurrence of drug resistance of the cancer cells towards one or multiple drugs which accounts for the failure of the breast cancer treatment.1,3,4 breast cancer cells were notably reported to develop resistance towards chemotherapy agents, including platinum derivatives such as cisplatin.4–6 until recently, the clear mechanism of drug resistance of breast cancer cell is still in debate.4–8 many studies have reported several possible mechanisms which are related to chemo-resistance, including over-expression of p-glycoprotein, alteration of cell cycle arrest and apoptosis, the expression of multidrug resistance-associated protein (mrp).5,6 overall, all these molecular mechanisms will result in the drug-resistant phenotype modification, which could be accompanied by changes in proliferation potential and morphological structure.5 therefore, in order to observe the received: december 14, 2016 revised: february 17, 2017 accepted: february 27, 2017 :8–14 international journal of integrated health sciences. 2017;5(1) 9 characteristics in the early stages of acquired drug-resistance in breast cancer, structure of the cell cancer might provide an initial insight of the development of chemo-resistance. the aim of this study was to observe the morphological changes on human breast cancer cell line mcf-7 following the in-house development of the subline resistant to cytotoxic effects of cisplatin (mcf-7/cisr). methods in this study, the cell line used was human breast cancer cell line mcf-7 from attc, united kingdom (uk). the cell culture and other laboratory procedures were conducted in the biomedical research centre (bmc), university of salford, uk. culture media and all media supplements were obtained from lonza, walkersville, md. dimethyl sulfoxide (dmso), cisplatin, and thiazolyl blue tetrazolium bromide (mtt salt) were purchased from sigma-aldrich, dorset, uk. the mcf-7 cell line was cultivated in dulbecco’s modified eagle (dmem) medium supplemented with 10% (v/v) fetal bovine serum (fbs), 2 mm l-glutamine, 50 iu/ml penicillin, and 50 µg/ml streptomycin, at 37 ⁰c in a humidified atmosphere containing 5% co2. the cells were subcultured twice a week or after reaching 70–80% confluence. the cisplatin resistant variant (mcf-7/ cisr) was developed from the parental line mcf-7 by cultivating the parental cell line with raising concentration of cisplatin (from 0.01 to 2.3 µm). cisplatin was added twice a week following subculturing. the cell viability and confluence were checked regularly before reseeding. the drug was only given when the viability >90% and the confluence >50%. otherwise, the cell line was grown in drug-free media until the cells returned to confluence and the viability has recovered. sensitivity to cisplatin was measured every 8 weeks using mtt-colorimetric test. healthy cells, which had been sub-cultured at least once and subsequently reached 70– 80% confluency, were used for the mtt assay. briefly, 100 µl cell suspensions (105 cells/ml) were plated in 96-wells microplate. cisplatin with raising concentration was added into the corresponding well; the control wells were left untreated. after 5 days incubation in 37 ⁰c with 5% co2, 30 µl of mtt solution (5 mg/ml) was added into each well and the incubation was continued for a further 4 hours. subsequently, 100 µl dmso was added into each well to dissolve the formazan crystal. the optical density (od) was measured using multiskan fc® (test wavelength of 590 nm and reference wavelength at 690nm). cell viability was calculated using the following equation: cell viability (%) = od0/odn x 100% where od0 is the od from the control wells and odn is the od of the treated cells. the ic50 values were calculated as the concentrations that show 50% inhibition of cell. the cell slides were prepared from cell suspension (105 cells/ml) and stained with hematoxylin-eosin staining. the morphological changes were observed to evaluate the signs of apoptosis, such as plasma membrane blebbing, condensation of chromatins, nuclear condensation, and formation of apoptotic bodies.7 the statistical analyses were performed using graphpad prism software version 5.0 (graphpad software, san diego california usa). data was presented as mean±standard mean error (sem). the comparison of means was performed by using student’s t-test and anova with tukey multiple comparison as a post hoc analysis. p-value smaller than 0.05 was considered statistically significant. results in this study, the mcf-7 resistance to cisplatin was developed in-vitro by introducing an increasing dose of cisplation, using a low startup dose (0.01 µm). cisplatin is known as one of several platinum based anticancer drugs which are widely used in cancer therapy and have demonstrated a successful outcome in breast cancer therapy.4,5,7 in this study, the parental cell line mcf-7 exerted sensitivity to cisplatin, demonstrated by a low ic50 value (2.72±0.51 µm) (fig. 1). the sensitivity towards cisplatin and high successful rate of cisplatin therapy is attributed to multiple molecular mechanisms in combating cancer cells, which is mediated by its ability to interact with deoxyribonucleic acid (dna) strands causing dna adduct.6,11,12 the dna damage is recognised by several proteins as a signal to activate further pathways, including p53, atr, and mapk. the crosstalk between these pathways ultimately leads to cell cycle arrest, apoptosis and cell death.8 despite the effectiveness of cisplatin as chemotherapy agent, cancer cells might have a natural ability to turn this cytotoxic effect, which might be a result from continuous drug exposure.4,5,9 in the establishment of the drug nanda ayu puspita, amy bedford :8–14 10 international journal of integrated health sciences. 2017;5(1) resistance on one particular cancer cell line, the mode of drug administration is a key factor that needs careful consideration. in a clinical setting, chemotherapy is given in cycles by intravenous administration on a weekly or monthly basis.10 the amount of chemotherapy agents given is based on individual needs and will be adjusted based on response to the chemotherapy; the dose is often expressed as milligrams per square meter unit which can be converted to micromolar (µm) unit.11 in this study, the parental line was carefully observed during the cisplatin-resistance development process by conducting evaluation to the viable cells before increasing the cisplatin dose. this method was applied to mimic the clinical treatment, where the response to chemotherapy was reduced/ increased based on the patient response. the range of cell viability was maintained between 93–100%, in order to ensure that the cells were growing in an optimum condition and able to escape the toxic effect of cisplatin. after 3 months treatment, the mcf-7/cisr cell line has developed a significant resistance, demonstrated the ic50 value which was more than 5 times compared to parental cell ic50 value (13.93±1.8 µm). when the treatment was continued, the ic50 value rose to 18.46±2.1 µm (almost 7 times parental cell ic50). at this stage, the cisplatin-resistant phenotype was established in-vitro. although there is no clear-cut value for the resistance level of cisplatin therapy, previous clinical studies have suggested that at least twofold resistance can be considered as resistance in chemotherapy.4 this present study has successfully developed acquired resistance on the mcf-7 cell line, noted as cisplatin resistant subline mcf-7/cisr. drug resistance is the condition where cisplatin was initially efficient to kill the cancer cells, but became ineffective over time following continuous drug exposure.5 the resistance mechanism is believed as a net effect from intracellular changes that inhibit cisplatin interaction with dna, and/ or alter the transduction of dna damage signal to activate the apoptotic pathways.9,12 the former mechanism arises form direct correlation between the level of dna adduct with the cytotoxicity and, therefore, reducing the extent of dna damage increases cisplatin resistance.4,9 other intracellular mechanisms which have a correlation to acquired resistance to cisplatin include a reduction of intracellular cisplatin accumulation, increase inactivation of cisplatin (detoxification) via gluthationmediating intoxication pathway, and improved repair of and/or tolerance to nuclear lesions/ dna damage.4 all these mechanisms work together simultaneously to develop and maintain cancer cell resistance to cytotoxic agents.4,12,14,17 morphological changes of cisplatin-resistant human breast cancer mcf-7 cell line :8–14 cell growth curve showing the percentage of mcf-7 cell growth againts a serial dose of cisplatin (1a). the ic50 of parental cell line before exposure to cisplatin (control), after 3 months, and after 4 months ((1b). for the calculation of ic50 value, the largest value in the data set corresponded to 100% and the smallest value corresponded to 0%. log-transformed drug concentrations were plotted against the dose response and the ic50 values were determined using non-linear regression analysis (*p <0.05, anova) fig. 1 a b international journal of integrated health sciences. 2017;5(1) 11 nanda ayu puspita, amy bedford discussion the change of the proliferation potential on mcf-7 resistant subline mcf-7/cisr is an ultimate effect of molecular mechanisms by which the cancer cells obtain an ability to avoid the cytotoxic effect of anti-cancer drugs. accumulating evidence suggests that breast cancer cell resistance is strongly related to several theories, namely the existence of cancer stem cells (cscs) which is marked by the increased of cscs markers including cd44+/cd24-, high level of phosphorylated stat-3 and its downstream effector proteins, and the occurance of breast cancer resistance protein (bcrp).13 more importantly, all these molecular and phenotypic modifications on one cell are often accompanied by changes in morphological features.11 this current study observed important morphological parameters of mcf-7 cells following continuous treatment with cisplatin; including cell shape, cell size and cell appearance. in a normal environment, regulation of cell size is differentiated into two distinct processes, namely cell growth and cell proliferation. both processes can be independent of each other as one cell can grow without cell proliferation, and vice versa.14 several growth pathways are responsible for controlling cell proliferation and cell growth, for example, the pi3k/ akt pathway, which is noted as the major determinant and major regulator of cell size.14– 16 cancer cells are often developed through the loss of control to maintain normal cell growth and proliferation rate, as the result from the alteration of these growth pathways. as the hallmark of cancer cells is able to escape :8–14 a b c microscopic observation of mcf-7 parental cells, mcf-7/cisr after 3 months and 4 months of cisplatin exposure (at magnification 400x). mcf-7 parental cell line shows a regularity in shape and size, with 2–5 nucleoli (2a). after 3 months treatment with cisplatin, cell edge became irregular, accompanied by irregularity of the plasma membrane and microvesicular formation. after the mcf-7/cisr was established on the 4th month of cisplatin treatment, large cells were seen, with the increase of cytoplasmic granules (2c) fig. 2 12 international journal of integrated health sciences. 2017;5(1) programmed cell death and possess limitless proliferation potential, it is not surprisingly, the cells are able to maintain their intrinsic signal to survive any unfavourable external stimulus given. in their effort to escape the deadly effect of chemotherapy drugs, cancer cells must be able to modify their intrinsic developmental program, in a way that makes the extracellular signals are less harmless to the cell growth and proliferation. the result showed that, according to the relative size of the cells, parental cells mcf-7 have a relatively similar size (20–25 microns), whereas resistant cell mcf-7/cisr population comprised a wider range of cell size (20 microns up to more than 50 microns in diameter). mcf-7/cisr cells have a larger nucleus, although the nucleolus number is similar to the parental cell line (2–5 nucleoli). the variation of the cell size is determined by the intrinsic developmental program and by extracellular signals, where the combination of these factors will integrate to control cell number and cell proliferation.14 irregularity of the cell shape and nuclear enlargement showed that cells within the population of mcf-7/ cisr were in various stages of the cell cycle. during the cell cycle, there are two important checkpoints, g1 and g2, which simultaneously search for the occurrence of dna damage and determine whether the cell can proceed to the next cell cycle stage or not.15 when dna damage is detected, the cells are arrested for dna repair or, when the damage is irreversible, checkpoint effector mechanisms will activate the so-called self-destruction mechanism or apoptosis.15,16 cancer cells possess an ability to avoid this checkpoint mechanism and to escapes apoptosis.17 cisplatin therapy is aiming at the re-activation of the apoptosis cascade by inducing dna damage, due to its ability to crosslink with the purine bases of the dna.6,7 cisplatin binding to cancer cell’s dna causes dna adduct, which is recognised by dna damage recognition proteins, for example p53 protein and its affector proteins.5,6 in the case of cisplatin resistance, some cells might survive the cytotoxic effect of cisplatin, causing the resistant cells to grow and to proliferate at a different state within the cell cycle and, accordingly, demonstrate a wide range of cell sizes at one point of time, as shown in our result. in agreement with the results in this study, some reports have suggested that cisplatin resistance on mcf-7 involves antiapoptotic mechanisms, demonstrated by a decrease of dna-damage effector proteins, which is strongly related to the ability of the resistant cells to tolerate and repair the dna damage due to cisplatin activity.5,6,18 in this present study, we demonstrated that in comparison to its parental cell line mcf-7, mcf-7/cisr demonstrated several observable morphological changes. parental cell line mcf-7 exhibited a regular spindle shape with a smooth cell membrane border, while the resistant cells demonstrated an irregular and spherical shape where some parts or the cell border are unclear (fig. 2). the result is in line with other research in cancer chemoresistance. one study on colon cancer (using hct 116 cell lines) conducted by pasqualato et al.20 demonstrated a significant change in cell membrane following continuous treatment with anticancer drugs, accompanied by the alteration of other biological parameters. the studies also argued that the changes of cell morphology would be an indicator of chemoresistance, thereby marking the level of malignancy.19,20 in line with previous reports, the result in this study has demonstrated an insight on the relationship between phenotype and morphological changes in mcf-7 cisplatin resistance. the result in this study showed that the number or microvesicular and cytoplasmic granules increased significantly in mcf-7 resistant cells (fig. 2). the increase of the microorganelles might be related to the molecular transport from intracellular to extracellular compartment. the microvesicular formation indicates cell activity to increase drug efflux from the cytoplasm, to reduce net concentration of cisplatin in the cells. there is a considerable number or evidence indicating a significant contribution of the reduction of intracellular drug accumulation in the cisplatin resistance mechanism.7,9,12 although many questions still remain, which stem from the multifactorial nature of drug uptake and drug efflux processes. for example, in the case of mcf-7 resistance to cisplatin, a study reported that exporter proteins, for example p-glycopotein, are less likely to be involved in the cisplatin chemoresistance.5 furthermore, a particular number of evidence has suggested that there is an extensive change of the ultrastructural organization in resistant cell lines, including extensive golgi apparatus with many multivesicular bodies, the increase on the number of microtubules and microfilaments, and a significant rise of the mitochondria number.5,6 a previous study revealed that the resistance to cisplatin is directly related to the morphological changes of cisplatin-resistant human breast cancer mcf-7 cell line :8–14 international journal of integrated health sciences. 2017;5(1) 13 hyperactivity of mitochondria in performing oxidative phosphorylation, which can increase the intracellular metabolism rate.19 moreover, growing evidence has shown that significant morphological changes is also linked to cell energy states.19 with an excessive energy production, the resistant cell lines are able to proceed with dna repair and expelled cisplatin from the intracellular environment. therefore, this present study might explain that the mechanism of cisplatin efflux is more likely controlled by cellular metabolic activity, rather than drug transporter activity, which ultimately decreases cisplatin accumulation within the cells. despite the limitation of our study, which restrains the detailed observation of cell morphology, our result has provided a vibrant supporting evidence for further confirmation of microorganelles changes as a results from molecular mechanism of cisplatin resistance in mcf-7 cell line. in conclusion, different therapies have been established for combating breast cancer. however, drug resistance is still counted as a major drawback in cancer treatment, particularly in cancer chemotherapy. cisplatin, although known as one of effective chemotherapy agents for breast cancer, frequently confronts the problem of resistance. this study demonstrated that morphological changes occur in mcf-7 cisplatin resistant cells, including the enlargement of cell size, the increase of nucleous and cytoplasm ratio, the increase of the number of microvesicular and cytoplasmic granules. the result supported the previous studies which have indicated that the cisplatin-resistance mechanism is related to the ability of the cells to decrease intracellular cisplatin concentration and to repair the effects of dna damage. nevertheless, there are major gaps that need to be filled to fully understand the clear links between molecular mechanisms and morphological changes of mcf-7 resistant phenotype. references 1. gonzalez-angulo am, morales-vasquez f, hortobagyi gn. overview of resistance to systemic therapy in patients with breast cancer. adv exp med biol. 2007;608(1):1–22. 2. sun h , jia j, wang x, ma b, di l, song g, et al. cd44+/cd24− breast cancer cells isolated from mcf-7 cultures exhibit enhanced angiogenic properties. clin translational oncol. 2013;15(1):46–54. 3. who. breast cancer: prevention and control. [cited 2011 nov 1]. available from: h t t p : / / w w w. w h o . i n t / c a n c e r / d e t e c t i o n / breastcancer/en/index1.html. 4. florea am, büsselberg d. breast cancer and possible mechanisms of therapy resistance. j local global health sci. 2013;2(2):2. 5. lukyanova ny, rusetskya nv, tregubova na, chekhun vf. molecular profile and cell cycle in mcf-7 cells resistant to cisplatin and doxorubicin. exp oncol. 2009;31(2):87–91. 6. meijera c, van luyn mja, nienhuis ef, blom n, mulder nh, de vries ege, et al. ultrastructural morphology and localisation of cisplatininduced platinum–dna adducts in a cisplatinsensitive and -resistant human small cell lung cancer cell line using electron microscopy. biochem pharmacol. 2001;61(5):573–8. 7. dasari s, tchounwou pb. cisplatin in cancer therapy: molecular mechanisms of action. eur j pharmacol. 2014;5(1):364–78. 8. cepeda v, fuertes ma, castilla j, alonso c, quevedo c, pérez jm. biochemical mechanisms of cisplatin cytotoxicity. anti-cancer agents medicinal chem. 2007;7(1):3–18. 9. siddik zh. cisplatin: mode of cytotoxic action and molecular basis of resistance. oncogene. 2003;22(47):7265–79. 10. byrski t, huzarski t, dent r, marczyk e, jasiowka m, gronwald j, et al. pathologic complete response to neoadjuvant cisplatin in brca1-positive breast cancer patients. breast cancer research and treatment.2014;147(2): 401–5. 11. mcdermott m, eustace aj, busschots s, breen l, crown j, clynes m, et al. in vitro development of chemotherapy and targeted therapy drugresistant cancer cell lines: a practical guide with case studies. frontier oncol. 2015;4(40):32– 48. 12. rebucci m, michiels c. molecular aspects of cancer cell resistance to chemotherapy. biochem pharmacol. 2013;85(9):1219–26. 13. mao q, unadkat jd, role of the (bcrp/ abcg2) in drug transport--an update. aaps j. 2015;17(1):65–82. 14. lloyd ac. the regulation of cell size. cell. nanda ayu puspita, amy bedford :8–14 14 international journal of integrated health sciences. 2017;5(1) 2013;154(6):1194–205. 15. dickson ma, schwartz gk. development of cell cycle inhibitors for cancer therapy. curr oncol. 2009;16(2):36–43. 16. bucher n, britten c. g2 checkpoint abrogation and checkpoint kinase-1 targeting in the treatment of cancer. br j cancer. 2008;98(3):523–8. 17. lazebnik y. what are the hallmarks of cancer? nat rev cancer. 2010;10(4):232–33. 18. lapensee ew, ben-jonathan n. novel roles of prolactin and estrogens in breast cancer: resistance to chemotherapy. endocrine-related cancer. 2010;17(2): r91–107. 19. d’anselmi f, valerio m, cucina a, galli l, proietti s, dinicola s, et al. metabolism and cell shape in cancer: a fractal analysis. int j biochem cell biol. 2011;43(7):1052–8. 20. pasqualato a, palombo a, cucina a, mariggiò ma, galli l, passaro d, et al. quantitative shape analysis of chemoresistant colon cancer cells: correlation between morphotype and phenotype. exp cell res. 2012;318(7):835–46. morphological changes of cisplatin-resistant human breast cancer mcf-7 cell line :8–14 international journal of integrated health sciences. 2017;5(2) 57 correspondence: alya putri khairani, faculty of medicine, universitas padjadjaran jl. raya bandung-sumedang km 21 jatinangor, indonesia e-mail: alyakhairani95@gmail.com role of risk factors in the incidence of multidrug-resistant tuberculosis alya putri khairani,1 prayudi santoso,2 elsa pudji setiawati3 1faculty of medicine, universitas padjadjaran 2department of internal medicine, faculty of medicine universitas padjadjaran-dr. hasan sadikin general hospital, bandung 3department of public health faculty of medicine, universitas padjadjaran abstract objective: to determine the risk factors that played roles in the incidence of multidrug-resistant tuberculosis (mdr-tb) in such patients. multidrugresistant tuberculosis is a form of tuberculosis caused by mycobacterium tuberculosis that is resistant to at least isoniazid and rifampicin. methods: this was a case control study to compare mdr-tb to non-mdr-tb pulmonary tuberculosis outpatients in dr. hasan sadikin general hospital, bandung on august–september 2014. fifty mdr-tb outpatients were included as the cases and 50 non-mdr-tb outpatients as controls. data was collected by questionnaires and patient’s registration forms. bivariate and multivariate analyses were performed using chi-square test and multiple logistic regression test, with p<0.05 considered significant. results: from bivariate analysis, number of previous tuberculosis treatments, regularity of previous treatment, and burden of cost were significant risk factors for developing mdr-tb (p<0.05); while from multivariate analysis, number of previous tb treatments was the only risk factor that played a significant role in the incidence of mdr-tb (or 24.128 95% ci 6.771-85,976). conclusions: patients and medication factors are risk factors that play roles in the incidence of mdr-tb. the significant risk factor is the number of previous tb treatment. keywords: multidrug-resistant tuberculosis, resistance, risk factors, tuberculosis pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v5n2.991 ijihs. 2017;5(2):57–63 introduction global situation of tuberculosis (tb) is getting worse with increasing numbers of tb case year by year. worldwide, the rate of tb incidence reduction remained at only 1.5% from 2014 to 2015 with a mortality rate of 100,000 cases at the end of 2015. currently, indonesia is in the second country with the highest burden of tb.1 another problem occurs when tb patients develop drug resistance. multidrug resistant tuberculosis or known as mdr-tb is defined as a mycobacterium tuberculosis infection that is resistant to at least two of the first line drug, i.e. isoniazid and rifampicin.2,3 multidrugresistant tuberculosis patients will have to take a new type of drug that is less effective, more complex, and also more expensive than the old regiment. hence, the world health organization (who) declares mdr-tb as a threat for global health due to its high burden, both in social and economic aspects.1 in 2015, there were 480,000 new cases of mdr-tb worldwide. from all tb cases identified in indonesia, 2.8% of the cases are primary mdr-tb while 16% of the cases are secondary mdr-tb. these numbers increase globally every year.1 mycobacterium tuberculosis resistance can be triggered by multiple factors, both from the bacteria and human host.4–6 therefore, the aim of this study was to explore the risk factors that play roles in the incidence mdroriginal article received: january10, 2017 revised: may 16, 2017 accepted: august 24, 2017 :57–63 58 international journal of integrated health sciences. 2017;5(2) tb in the population of patients in dr. hasan sadikin general hospital, bandung, which is the highest health referral center in west java. methods this was a case-control observative analytical study performed at the respirology and critical respiratory care division of the internal medicine department, dr. hasan sadikin general hospital during the period of august to september 2014. this study was approved by the ethical committee of dr. hasan sadikin general hospital bandung. all tb patients who were on tb treatment during the study period were included in this study. cases were collected from mdr-tb outpatients under directly observed treatment, short-courseplus (dots-plus) treatment in mdr-tb clinic while controls were taken from pulmonary tb outpatients under direct observed treatment, short-course (dots) treatment in dots clinic. based on the minimum sample requirement calculated by using lemeshow formula, 100 samples (consisted of 50 cases and 50 controls) were recruited using the consecutive sampling method. the inclusion criteria for cases were patients who had been diagnosed as mdrtb patients based on drug susceptibility test (dst) and genexpert. meanwhile, patients who were confirmed as pulmonary tb patients based on either microbiological examination, smear test, chest x-ray, or other clinical means of diagnosis by experts were included as controls. subjects who refused to participate were excluded. data collected were number of previous tb treatments, regularity of previous treatment, cost burden, side effects, and communication, information, and education measures provided by health provider regarding tb, tb treatment, consequences from defaulting the treatment, and mdr-tb. a self-administered questionnaire that had been tested for validity and reliability were used to collect data. subjects’ demography were collected from the patient registration form. statistical analyses conducted included chi-square test for bivariate analysis and multiple logistic regression for multivariate analysis. results the demographic characteristics of the study subjects were described (table 1). multidrugresistant tuberculosis patients were mostly men (66%) in their productive age, i.e. 14 to 54 years old (44%). many mdr-tb patients were unemployed at the time of the study (50%). the same situation was also seen in the control population (38%). in addition, the mdr-tb (64%) patients and their controls (70%) also did not have daily nor monthly income. most mdr-tb patients used the national insurance (bpjs) to pay their treatment expenses (84%). a great proportion of the mdr-tb patients had their first tb treatment at the primary health care (puskesmas) setting (60%). the risk factors studied were factors that significantly correlated with the incidence of mdr-tb, including number of previous tb treatments (p=0.000), regularity of tb treatment (p=0.001), and also burden of cost (p=0.003). multiple logistic regression was applied in the study (table 3). the p value for these factors was considered significant if p<0.05. final regression showed that the only factor that played a significant role in the incidence of mdr-tb was the number of the previous tb treatments with and odd ratio (or) of 24.128 (confidence interval 95%, 6.771–85.976). discussion most of the mdr-tb patients in this study are men in productive age (table 1). this is similar to the result of a study by law et al.8 stating that many mdr-tb cases occur in patients with an average age of 48 years old. the same employment situation is also found for mdr-tb patients in this study and also in the study by law et al.8 in which most patients are unemployed. the mdr-tb treatment which must be implemented daily at the hospital is the cause this situation. results in this study show that most mdrtb patients had experienced >2 previous tb treatments (table 2). such a high number is also found in various studies.6,8 from the perspective of the regularity of the previous treatment(s), it is revealed that there are 27 mdr-tb patients did not regularly consume the tb drugs during their previous treatment. the difference between the number of mdr-tb patients with regularl and irregular treatment is 4 patients with more patients performed irregular treatment. this slight difference can also be seen in a study concucted by sarwani et al.9 for burden of cost, the majority of mdr-tb patients felt that cost becomes a burden, with the ratio of 16:9. similar numbers can also role of risk factors in the incidence of multidrug-resistant tuberculosis :57–63 international journal of integrated health sciences. 2017;5(2) 59 alya putri khairani, prayudi santoso, et al. :57–63 table 1 characteristics of mdr-tb patients and their controls characteristics categories mdr-tb (n=50) % non-mdr-tb (n=50) (%) sex men 33 66 28 56 women 17 34 22 44 age (yrs.) 14–54 44 88 41 82 ≥55 6 12 9 18 occupation civil servant 0 0 2 4 private employee 2 4 4 8 enterpreneur 11 22 8 16 housewife 7 14 7 14 labor/farmer 3 6 0 0 student 0 0 9 18 unemployed 25 50 19 38 income per month <idr 500,000 3 6 1 2 idr 500,000–1,000.000 10 20 7 14 >idr 1,000.000 5 10 7 14 none 32 64 35 70 healthcare payment national insurance (bpjs) 42 84 32 64 insurance from workplace 0 0 4 4 personal/family 4 8 12 24 other party 0 0 2 4 others 4 8 2 4 place to receive first tb treatment primary healthcare (puskesmas) 30 60 2 4 center for lung disease treatment (bp4) 2 4 0 0 dr. hasan sadikin general hospital 2 4 42 84 other government general hospital 10 20 3 6 private hospital 2 4 2 4 private practice doctor 4 8 1 2 note: yrs.= years; idr= indonesian rupiahs 60 international journal of integrated health sciences. 2017;5(2) role of risk factors in the incidence of multidrug-resistant tuberculosis :57–63 table 2 risk factors that played roles in the occurrence of mdr-tb in mdr-tb patients factors mdr-tb n (%) non-mdr-tbn (%) p value number of previous tb treatment 1 8 (16) 42 (84) 0.000 ≥2 42 (84) 8 (16) regularity of previous treatment regular 23 (46) 39 (78) 0.001 irregular 27 (54) 11 (22) burden of cost yes 32 (64) 17 (34) 0.003 no 18 (36) 33 (66) side effects yes 32 (64) 23 (46) 0.070 no 18 (36) 27 (54) communication, information, education given by health officers completely given 20 (40) 27 (54) 0.161 incompletely given 30 (60) 23 (46) be found for the side effects. this situation explained that factors related to the patients, i.e. regularity of previous treatment, burden of cost, and side effects) would provide sufficient differences in the high frequency distribution of the mdr-tb patients.10 results from the questionnaires showed that some mdr-tb patients claimed that they had not received complete information on tb and mdr-tb. the complete information should include information on tb, tb treatment, consequences related to defaulting tb treatment, and mdrtb. the health providers tend to forget to give information about mdr-tb. nofizar et al.6 showed the same finding. health providers do explain about mdr-tb with 98% of mdrtb patients in persahabatan general hospital, where the study was conducted, agreed to the statement. the risk factors that played roles in the incidence of mdr-tb in mdr-tb patients are described (table 2). previous tb treatment is a strong factor that plays a role in the incidence of mdr-tb. a study in belarus has revealed that the risk of mdr-tb to occur in tb patients increased 6.1 times if the patients were under tb treatments before mdr-tb.11 in uganda, a study revealed that relapsed tb cases and failed tb treatment are associated with the occurrence of mdr-tb.12 thus, it is possible that the number of tb treatment and the regularity of previous treatment affect the occurrence of mdr-tb. to study about the relationship between the number of previous tb treatments before mdr-tb and the incidence of mdr-tb, it is important to understand the quality of the tb treatment first. good quality treatment shows an adequate treatment. an inadequate treatment provides more opportunities for the accumulation of individual mutations.13 the treatment will not be able to eradicate the mutated bacteria. this circumstance will make the tb patients receive more than one treatment. eventually, resistance develops and mdr-tb occur. the regularity of tb treatment has a causal relationship with the occurrence of mdrtb. irregular treatment, meaning that there are occasions where patients do not take the tb drugs as instructed, could increase the risk of relapse and eventually cause mdrtb.1,3,4 a study by barroso et al.13 shows that irregularly treated patients has 7 times higher international journal of integrated health sciences. 2017;5(2) 61 risk to develop mdr-tb when compared to the regularly treated patients.13 another study also shows the same conclusion.9 results from the questionnaires in the present study shows variety of circumstances known to be the reason for patients to take the treatment irregularly, and even cause the patients to not completely follow the scheduled treatment. those circumstances are (1) patients are busy with their daily activities that they forget to take their medicine, (2) patients feel better making them only take the medicine once in a while, (3) patients do not have money during the treatment. same situations are found in a study by jaggarajamma et al.14 it follows that the number of previous tb treatments and the regularity of previous treatments are interrelated.13,15 an adequate tb treatment is defined as a treatment that follows the established rules, including the rule to take the medicine regularly. if the drugs are consumed irregularly, the treatment will be inadequate, hence it becomes a poor quality treatment. in the end, this may affect the number of tb treatments received and may lead to the occurence of mdr-tb.13 similar pattern can be seen in this study. burden of cost during tb treatment affects the incidence of mdr-tb. the costs that are incurred during treatment is also taken into considerations when tb patients considering whether to continue the treatment during the course of treatment. many patients decided to stop treatment due to the burden of cost. hill et al.16 found the same situation in gambia. there are many situations related tothe burden of cost during treatment that causes patients to default from treatment and contributes to the occurrence of mdr-tb. according to wahab et al.17 one of the situations is the drug financing that is applied when tb treatment is obtained outside the dots program. however, this study found another situation. according to the mdr-tb patients, the burdens that they felt as the most difficult is the lost of working time and being unemployed during the treatment. patients who are enterpreneurs and labors admitted that tb, mdr-tb, and their treatment disturb their work during the day and make them delay their work, especially during the intensive months of treatment (1–2 months). in the meantime, patients do not receive daily nor monthly income as usual. those situations make the financial burden more difficult to bear.16 furthermore, due to the long period of tb treatment, transportation cost also becomes a heavy burden to the patients. those problems are felt by both mdr-tb patients and their control. result of this study shows that the side effects of the treatment do not play roles in the incidence of mdr-tb. this statement is supported by the fact that both groups are complaining about side effects during tb treatment. although the side effects are disturbing, some patients are not bothered alya putri khairani, prayudi santoso, et al. :57–63 multiple linear regression analysis and estimation of odds ratio (or) for the risk factors that played significant roles to the incidence of mdr-tb table 3 variables coef b se(b) p value adj or (ci 95%) initial regression model number of previous tb treatment 3.183 0.648 0.000 24.128 (6.771–85.976) regularity of previous treatment -0.102 0.659 0.877 0.903 (0.248–3.287) burden of cost 0.509 0.564 0.367 1.663 (0.551–5.023) side effects 0.260 0.567 0.646 1.297 (0.427–3.940) communication, information, education given by health officers 0.548 0.629 0.327 1.729 (0.579–5.168) final regression model number of previous tb treatment 3.183 0.648 0.000 24.128 (6.771–85.976) 62 international journal of integrated health sciences. 2017;5(2) references by the effects and can continue the treatment without any obstacle. as a result, this study cannot prove the causal relationship between side effects and the incidence of mdr-tb. a previous study stated otherwise by stating that the side effects is a strong factor that influences the incidence of mdr-tb.10 communication, information, and education given by the health provider do not have any causal relation with the occurrence of mdr-tb. the result of the questionnaires have shown that some mdrtb patients and their controls did not receive information about mdr-tb and only received information regarding tb, its treatment, and the consequences from defaulting the tb treatment, which is incomplete. on the contrary, despite those problems, there are patients who still adhere well to the treatment. this situation shows that this incomplete communication, information, and education may lead to disappointment among patients and still reminds the patients to adhere with treatment. however, nofizar et al.6 found the contrary with ninety percents of mdr-tb patients stated that the health provider did not communicate, educate, and give information regarding mdr-tb and they did not follow the treatment thoroughly. the results from the multivariate analysis show that of all possible risk factors that may influence the incidence of mdr-tb, the number of previous tb treatments is the only risk factor with is significant statistically (table 3). patients with ≥2 previous tb treatments have a 24 times higher risk to obtain mdr-tb. this statement is also supported by studies by barroso et al.13 and zhao et al.7 in which patients who had received multiple treatments for tuberculosis are 13 times as likely to have mdr tuberculosis compared to those who had received only one prior treatment. despite the fact that the number of previous tb treatments is strongly correlated with the regularity of previous treatment, multivariate analysis shows that the regularity of previous treatment is not a risk factor that plays a significant role in the incidence of mdr-tb. this result is also found in a study by garcia vázquez et al.18 if the mdr-tb patients had tb treatment(s) before the occurrence of mdrtb, the patients will have at least a minimum risk to develop mdr-tb, even though the previous treatment was adequate.13,18 this situation can be explained as follow. in the first month of tb, patients might receive mutated mycobacterium and become resistant to the treatment even before the treatment is started.7 this situation is called primary mdr-tb. the signs and symptoms of mdr-tb are not different from tb, making it common that patients with primary mdr-tb receive the usual first line tb treatment. in fact, any drug for susceptible-tb will not be effective to eliminate resistant mycobacterium. the mdr-tb patients are likely to continue with the tb treatment, then move to the second line, until a screening for mdr-tb suspects is conducted.19,20 nevertheless, garcia vázquez et al.18 stated that the risk of mdr-tb to occur by the factor of the number of previous tb treatments alone is minimum. burden of cost is not one of the risk factors that play a significant role to the occurrence of mdr-tb. this study shows that most mdr-tb patients received previous tb treatment at the primary health center. some of these patients stated that they went to the primary health center on foot. in primary health center, the tb treatment program is paid by the government, thus provided free of charge. this makes things easier for the patients. although patients may have financial problems in other aspects, they can still go to the primary health center to receive treatment. the major limitations of this study is that the cases and controls were not ‘matched’ beforehand. in this study, the calculation of pharmacokinetic drug levels in the two groups of the samples are also not considered. in addition, comorbids are not taken into account. in conclusions, the risk factors to develop mdr-tb can come from patients themselves, including the regularity of the treatment and burden of cost, and can also be generated from the drug factor, which is the number of previous tb treatments. of these, the number of previous tb treatments plays an important role in the incidence of mdr-tb. 1. who. global tuberculosis report 2016. geneva, switzerland: who; 2016. 2. nathanson e, nunn p, uplekar m, floyd k, jaramillo e, lönnroth k, et al. mdr tuberculosis—critical steps for prevention and control. n eng j med. 2010;363(11):1050–8. 3. gandhi nr, nunn p, dheda k, schaaf hs, zignol m, soolingen dv, et al. multidrug-resistant role of risk factors in the incidence of multidrug-resistant tuberculosis :57–63 international journal of integrated health sciences. 2017;5(2) 63 alya putri khairani, prayudi santoso, et al. :57–63 and extensively drug-resistant tuberculosis: a threat to global control of tuberculosis. lancet. 2010;375(9728):1830–43. 4. chiang cy, centis r, migliori gb. drug-resistant tuberculosis: past, present, future. respirology. 2010;15(3):413–32. 5. fauci as. multidrug-resistant and extensively drug-resistant tuberculosis: the national institute of allergy and infectious diseases research agenda and recommendations for priority research. j infect dis. 2008;197(11):1493–8. 6. nofizar d, nawas a, burhan e. identification of risk factors in multidrug resistant tuberculosis. mji. 2011;60(12):537–45. 7. zhao y, xu s, wang l, chin dp, wang s, jiang g, et al. national survey of drugresistant tuberculosis in china. n engl j med. 2012;366(23):2161–70. 8. law ws, yew ww, chiu leung c, kam km, tam cm, chan ck, et al. risk factors for multidrugresistant tuberculosis in hong kong. int j tuberc lung dis. 2008;12(9):1065–70. 9. sarwani d, nurlaela s, isnani za. analisis faktor risiko multidrug resistant tuberculosis (mdrtb) (studi kasus di bp4 purwokerto). jkm. 2013;8(1):62–8. 10. caminero ja. multidrug-resistant tuberculosis: epidemiology, risk factors and case finding [state of the art series. drug-resistant tuberculosis. int j tuberc lung dis. 2010;14(4):382–90. 11. who. multidrug-resistant tuberculosis in belarus: the size of the problem and associated risk factors. bull who. 2013;91(1):36–45. 12. temple b, ayakaka i, ogwang s, nabanjja h, kayes s, nakubulwa s, et al. rate and amplification of drug resistance among previously-treated patients with tuberculosis in kampala, uganda. clin infect dis. 2008;47(9):1126–34. 13. barroso ec, mota rms, santos ro, sousa alo, barroso jb, rodrigues jln. risk factors for acquired multidrug-resistant tuberculosis. j pneumologia. 2003;29(2):89–97. 14. jaggarajamma k, sudha g, chandrasekaran v, nirupa c, thomas a, santha t, et al. reasons for non-compliance among patients treated under revised national tuberculosis control programme (rntcp), tiruvallur district, south india. indian j tuberc. 2007;54(3):130–5. 15. lomtadze n, aspindzelashvili r, janjgava m, mirtskhulava v, wright a, blumberg hm, et al. prevalence and risk factors for multidrugresistant tuberculosis in the republic of georgia: a population-based study. int j tuberc lung dis. 2009;13(1):68–73. 16. hill pc, stevens w, hill s, bah j, donkor sa, jallow a, et al. risk factors for defaulting from tuberculosis treatment: a prospective cohort study of 301 cases in the gambia. int j tuberc lung dis. 2005;9(12):1349–54. 17. wahab f, ashraf s, khan n, anwar r, afridi mz. risk factors for multi-drug resistant tuberculosis in patients at tertiary care hospital, peshawar. j college physicians surg pakist. 2009;19(3):162–4. 18. garcía vázquez e, esteban j, de gorgolas m, fernández guerrero ml. infection by resistant mycobacterium tuberculosis in a hospital population. a longitudinal study of incidental cases at the fundacion jimenez diaz. revista clinica espanola. 1999;199(9):564–8. 19. otero l, krapp f, tomatis c, zamudio c, matthys f, gotuzzo e, et al. high prevalence of primary multidrug resistant tuberculosis in persons with no known risk factors. plos one [serial on the internet]. 2011 oct [cited 2014 aug 12];6(10):[about 7p.]. available from: http://journals.plos.org/plosone/ article?id=10.1371/journal.pone.0026276. 20. turbawaty dk, gustiani n, noviani l, parwati i. validity of mycobacterium tuberculosis antigens cocktail: esat-6, cfp-10 and mpt64 in sputum and cerebrospinal fluid for pulmonary tuberculosis and tuberculous meningitis diagnosis. ijihs. 2015;3(2):60–5. 84 international journal of integrated health sciences. 2018;6(2) original article :84–90 osteoporosis prevention exercise effects to bone density in children with thalassemia major occurrences are found in various areas including mediteranian, middle east, central asia, north africa, and souh america.2 in indonesia, thalassemia affects 3–5% of the total population.3 data published in 2014 by yayasan thalassaemia indonesia (indonesia thalassemia foundation) and perhimpunan orangtua penderita thalassemia indonesia (indonesia parent association of thalassemia children) has described that the number of thalassemia patients has considerably rising wit 2,500 out of 6,647 thalassemia patients ae children.3 several chronic diseases and complications are commonly found in thalassemia patients such as disorders of sex development (dsd), growth hormone disorders, osteoporosis, and osteopenia.2,4 some studies stated thalassemia occurences in children are often followed by osteopenia and osteoporosis, leading to abstract objective: to discover recommendation of osteoporosis prevention exercise (ope) for children with thalassemia. methods: this study was conducted in the period of april–june 2017 by using quasi experimental and pretest-posttest designs. eleven thalassemia patients who were the members of a thalassemia patient foundation and an association of parents of thalassemia patients, yayasan thalassaemia indonesia and perhimpunan orangtua penderita thalassemia indonesia, were enrolled in the study as the subjects. sample calculation was carried out by using consecutive sampling method. the subjects were given ope intervention 2 times per week during 12 weeks with 35 minutes of each session. bmd of spinal lumbar examination was performed before and after practicing ope. collected data were analyzed statistically by using paired t and wilcoxon tests with p value <0.05. results: after the intervention, bmd value of l1, l2, and l3 segments did not improve significantly while bmd value of l4 segment and average z-score showed significant improvement (p<0.05). conclusions: osteoporosis prevention exercise can improve bmd in children with thalassemia. continuous ope program can be recommended for children with osteoporosis-induced thalassemia. keywords: bone mineral density, osteoporosis, osteoporosis prevention exercise, thalassemia, z-score pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v6n2.1349 ijihs. 2018;6(2):84–90 received: july 13, 2018 revised: september 13, 2018 accepted: september 17, 2018 andreas arie widiadiaksa waluyojati, marietta shanti prananta, marina annete moeliono department of physical medicine and rehabilitation, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital, bandung introduction thalassemia is defined as hemoglobinopathies of autosomal recessive condition, genetically inherited and is characterized by a decrease in the polipeptida globin chain synthesis in hemoglobin.1 it is considered as an identical genetic abnormality in the form of a singleallele gene disorder in alleles that play a role in hemoglobin production.2 there are two categories of thalassemia, alpha and beta types. beta thalassemia can be further divided into two types, major and minor. beta thalassemia correspondence: andreas arie widiadiaksa waluyojati, department of physical medicine and rehabilitation, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital, bandung jl. pasteur no. 38, bandung, indonesia e-mail: arie.widiadiaksa@gmail.com international journal of integrated health sciences. 2018;6(2) 85 bone mineral density (bmd) decrease. this condition becomes a serious problem for thalassemic young adult patients as it may cause a higher risk for fractures due to the fact that osteopenia and osteoporosis prevalence is 50% the thalassemia patients. the prevalence of fracture is high in thalassemia patients with more than 50% of beta thalassemia major patients experience fracture.2,5,6 a previous study has stated that the upper extremity fractures are the most dominant fractures in thalassemia patients, which is followed by spinal and pelvis compression fractures. the spinal and pelvis compression fractures typically found in thalassemia causes back pain, leading to decreased quality of life (qol).8 hence, proper treatments should be given to the patients to reduce the risk of fractures that is caused by decreased bmd. decreased bmd can be prevented through practicing weight-bearing aerobic exercise, with or without resistance training.9 several studies have conducted investigations on the relationship between the aerobic exercise and weight-bearing exercise with treadmill and resistance trainings on hemophilia patients as the subjects. it was shown that a significant bmd increase was seen after this intervention was performed.10,11 having been widely socialized since 1991 in indonesia to elderly, osteoporosis prevention exercise (ope) can improve several aspects, such as muscular flexibility, muscular strength, bone strength, endurance, balance, and also coordination and is considered as low impact aerobic.12 the ope impact investigation had been conducted and the results determined practicing ope can maintain bmd and reduce osteoporosis risk in elderly.12 this study aimd to examine the effect of ope to bmd in children with thalassemia. methods this study included children with thalassemia major diagnosis who lived in bandung, west java, indonesia as the subjects. the subjects received routine blood transfusion in hospitals. inclusion criteria in this study were children aged 10–14 years, diagnosed as suffering from thalassemia major, able to communicate, able to stand and walk without supports, able to do daily activities without supports, receiving regular blood transfusion at least once in a month, receive regular iron chelation therapy, willing to be included in the study, and gain permission from the parents. the exclusion criteria included pain with nrs >4, osteoporosis, musculoskeletal deformity, fracture history, and a berg balance scale of <41. meanwhile, dropout criteria were not practicing exercise >18 times and unwilling to continue the exercise. sample calculation formula was used due to discover total samples for paired category and numeric analyses. based on the sampling method, the total minimal sample size was 11. sampling was performed by using consecutive sampling method with statistical examination with a confidence interval of 95% and power test of 95%. the method used in the study was quasi experimental because the experiment did not include a control group. quasi experimental method is suitable for one of the three terms of true experiment design: random sampling, inclusion of control group, and inclusion of intervention. pretest-posttest design was used by examining before and after the intervention. the data were collected through anamnesis, physical examination, and bmd assessment.13 the variables analyzed in the study were ope (independent variable), bmd (dependent variable), physical activity, body mass index/ bmi, as well as nutrition intake (confounding variable). materials and devices used in this study were sphygmomanometer for childdren with riester brand, stethoscope with littman brand, pulse oxymetri breuer brand, height and weight measurement device, 250 grams load, music players for ope, and oxygen tube. dual energy x-ray absorptiometry (dexa) scanner was used to assess bmd. subjects received ope intervention twice a week for 12 weeks. the intervention was guided by training instructures and supervised by medical doctors. in order to encourage the subjects, education related to osteoporosis in thalassemia, osteoporosis prevention, and physicosocial knowledge was given monthly. either the subjects or the parents signed the informed consent describing about willingness to participate in the study and were asked to fill questionnaires to assess daily activities, regularity of receiving blood transfusion and iron chelation therapy. measurements of the blood pressure, pulse, and oxygen saturation were performed while the in sitting position. weight and height were measured to calculate bmi. afterwards, body balance was measured by using berg balance scale. assessment of initial bmd was conducted by using dexa scan between the lumbars before the intervention. repeated :84–90 andreas arie widiadiaksa waluyojati, marietta shanti prananta, et al. 86 international journal of integrated health sciences. 2018;6(2) bmd assessment was later conducted by using dexa after week 12. subjects practiced ope for 35 minutes in each exercise which contained several steps as follows: (a) warming up (5 minutes), dynamic and static streches (5 minutes), training i (10 minutes), weight training ii (10 minutes), and cooling down (5 minutes).12 the load used during the exercise was 250 grams held by each hand. to obtain maximal results, pulse was monitored at the start and the end of every exercise step. the subjects were informed to stop excercising if they feel problems such as pain, asphyxia, nausea, dizziness, exhaustion, and uncomfortable feelings. categorical data were examined using mc. nemar test. before the statistical tests were performed, numerical data was examined for their normality test using shapiro wilks test due to the fact that the number of the total data was less than 50. another statistical test was used to compare the result characteristics before and after the intervention, i.e. paired t-test. a significant value was represented with p≤0.05 and non-significant value was p>0.05. the study was conducted in the period of april–juni 2017 and held in the teaching hospital building of the faculty of medicine, universitas padjadjaran, bandung and rumah singgah sahabat talassemia, bandung. all data and information were kept confidential. ethical approval for this study was obtained from the health research ethic committee, faculty of medicine, universitas padjadjaran. results the subjects in this study were 11 children with thalassemia major aged 10–14 who met the inclusion criteria. basic characteristics of the subjects was represented (table 1).the subjects’ characteristics were examined based on age, sex, weight, height, bmi, berg balance scale in numbers and percentage. the average age of the subjects in this study was 12.25±1.650 with predominantly female subjects. the average weight was 30.95±8.647 and average height was 137.90±12.895. data were normally distributed and could be analyzed by using paired t test. bone mineral density comparison between l1, l2,l3, l4 segments, lumbar, and z-score of the subjects were presented (table 2). since the total subjects were 11 children, bmd of the l1, l2, and l3 segments was p>0.05. this determined that no significant improvement was seen. bone mineral density improvement was found in l4 segment from average 0.56±0.139 before exercising to become 0.60±0.129 after exercising with p value <0.05. the lumbar spine average value improved from 0-4.00±1.449 before exercising to become -3.81±1.376 after exercising with p<0.05 (fig). :84–90 osteoporosis prevention exercise effects to bone density in children with thalassemia table 1 the subjects’ characteristics variables n=11 age mean±std 12.25±1.650 median 12.5 range (min–max) 10–14 sex male 7 female 13 weight mean±std 30.95±8.647 median 30 range (min–max) 20–51 height mean±std 137.90±12.895 median 136.5 range (min–max) 122–173 body mass index mean±std 15.92±1.785 median 15.985 range (min–max) 13.01–18.72 note: categorical data were presented by total/frequency and percentage while numerical data were presented by average, median, standard deviation, and range 0,5 0,52 0,54 0,56 0,58 0,6 0,62 0,64 0,66 0,68 0,7 l1 l2 l3 l4 average z-score preope post ope fig. bone mineral density value pre ope and post ope international journal of integrated health sciences. 2018;6(2) 87 discussion several studies have reported that children with thalassemia are prone to osteoporosis.6,10,14 in the present study, a value of bmd that was less than 2.5 sd of bmd reflects that the subject had low bmd or in the range of osteopenia based on the inclusion criteria. neither primary nor secondary osteoporosis patients were enrolled in the study. thalassemia major becomes a main factor of secondary osteoporosis found in the subjects. the subjects with secondary osteoporosis were not included in the study due to different condition from osteoporosis generally found in elderly. estrogen deficiency causes an increase in the osteoclastogenesis activity within bone metabolism. therefore, thalassemia patients commonly suffer from estrogen disorder.15,16 other factors can also influence bmd values including, among others, endocrine disorders, kidney or hematological problems that is caused by congenital diseases, metabolic problems, and medical management to osteoporosis patients or commonly called secondary osteoporosis.15 both male and female subjects aged 10–14 years were enrolled in this study. the subjects had entered puberty period since all female subjects had menstruation period. menstrual cycle becomes one of several factors which can influence bone metabolism. based on natural process, menstruation is caused by dynamical condition between estrogen and progesteron. a study has described that bone resorption activity improvement occurs during menstrual cycle.16 estrogen becomes protector within table 2 bone mineral density value comparison between l1. l2, l3, l4 segments variables groups p value pre n=11 post n=11 segment l1 0.982 mean±std` 0.54±0.123 0.54±0.136 median 0.513 0.515 range (min–max) 0.36–0.74 0.37-0.77 segment l2 0.923 mean±std 0.59±0.147 0.59±0.130 median 0.560 0.563 range (min–max) 0.39–0.91 0.40-0.84 segment l3 0.278 mean±std 0.58±0.156 0.59±0.151 median 0.542 0.570 range (min–max) 0.32–0.92 0.32-0.86 segment l4 0.034** mean±std 0.56±0.139 0.60±0.129 median 0.553 0.603 range (min–max) 0.40–0.86 0.41-0.86 average bmd 0.134 mean±std 0.57±0.141 0.58±0.134 median 0.525 0.551 range (min–max) 0.37–0.87 0.38-0.83 note: p value of numerical data were analyzed by using paired t test if the data were normally distributed. *statistically significant p<0.05 :84–90 andreas arie widiadiaksa waluyojati, marietta shanti prananta, et al. 88 international journal of integrated health sciences. 2018;6(2) body which can maintain inner stability from many diseases. nevertheless, estrogen ability decreases after women entering menopause. fifty percent of women with thalassemia do not have menstrual period leading to earlier estrogen protection loss.16 bone metabolism phase including bone remodeling occurs during life but peak bone mass in normal people occurs until 20–30 years old. after entering this period, the bone remodeling in males and females gradually decreases while the catabolic process occurs. the immediate bone resorption increases in females when entering the menopause period. since females not having menstrual period as found in thalassemia patients, the absence of estrogen from the beginning in life causes problems in the bone remodeling phase and the catabolic and anabolic imbalance. however, normal females face bone resorption activity starting form menarche to menopause.16 the absence of menstrual period can affect the sop results caused by physical and psychological changes. in this study all subjects had regular menstrual cycle, showing that no estrogen disorder occurred. however, further estrogen examination of the subjects was not performed in the study. weight-bearing exercise will increase the bmd in people of all age groups if they do not suffer from osteoporosis. therefore, during the immature bone period, impact of weightbearing exercise can influence bone growths and developments. weight-bearing exercise given to the subjects in pubertal growth spurt can increase bmd due to the immature bone condition. the exercise given to young adult subjects can improve size, shape, and structure of bones.17 the subjects in this study received blood transfusion once in a month and iron chelation therapy. regular transfusion and iron chelation therapy were done to reduce iron toxicity effect and chronic anemia toward bmd. chronic anemia influences bone metabolism including vitamin d, estrogen receptor, and collagen formation.18,19 beside chronic anemia, another problem found is iron overload. iron overload in tissues and bones causes growth failure and bone abnormality. iron chelation therapy can reduce ferritin level in tissues and blood. iron toxicity to osteoblasts and iron chelation agents causes decreased bmd in thalassemia patients.6 receiving blood transfusion and iron chelation therapy are proper treatments among many factors which can maintain bmd in children with thalassemia. osteoporosis prevention exercise was given although the subjects receiving blood transfusion and iron chelation therapy in order to improve and maintain bmd. the assessment of bmd was performed by dexa in the subjects’ spinal lumbar due to its beneficial characteristics including immediate use, high accuracy, low radiation, and high precision. in addition, it is considered as the most suitable bmd assessment method for children.20 the assessment results by using dexa were z-score and t-score, however, in this study the data used was z-score. z-score is a comparison between bone density based on the assessment and bone density based on age. bone mineral density assessment by using dexa can be performed in seveal area such as spine, pelvis, and wrist. however, in this study the assessment was performed only in the spinal lumbar. there were several reasons that the assessment which had been performed. first, spinal fracture incidence ratio was 13–36% in thalassemia patients. the bmd assessment values in thalassemia patients were lower in the spine which were approximately 62% and 35% in pelvis.4,8 second, spine is the center of body weight-bearing which can be a main focus for monitoring improvements after weightbearing exercise. the spinal lumbar becomes the main focus of all spinal movements.7,10,17 third, the spine is primary trabecular bone which is an area mostly influenced by enlarged bone marrow occurrence.4 the three conditions are considered the major causes that the spine having the lowest bmd value when compared to the results discovered in other bone areas. this condition determines that dexa scan in the lumbar is the most appropriate effort to examine the bmd. the bone mineral density assessment results in the spinal lumbar were obtained from l1–l4 segments. therefore, l5 segment was not investigared due to potential influence by density value from the pelvis. this study discovered lower bmd of the subjects before the intervention. the lower bmd value leads to a higher risk for spinal fracture.6 lower bmd value in the thalassemia patients is influenced by many factors. the factors include liver disease, diabetes mellitus, hyperthyroidism, growth hormone and insulin growth factor deficiency, inhibited sexual maturity, ineffective haematopoiesis followed by enlarged bone marrow, parathyroid gland dysfunction, iron toxicity to osteoblast, iron chelating agent toxicity, and liver diseases.4–8 however, only several influencing factors related to lower bmd value were included in this study. :84–90 osteoporosis prevention exercise effects to bone density in children with thalassemia international journal of integrated health sciences. 2018;6(2) 89 1. galanello r, origa r. beta-thalassemia. orphanet j rare dis [serial on the internet]. 2010 may [cited 2017 nov 20];5(11):[about 15p.]. available from: https://ojrd.biomedcentral. com/articles/10.1186/1750-1172-5-11. 2. yaman a, isik p, yarali n, karademir s, cetinkaya s, bay a, et al. common complications in betathalassemia patients. int j hematol oncol. 2013;23(3)193–9. 3. yayasan thalassaemia indonesia.data penderita thalassemia di indonesia. [cited 2018 jan 6]. available from: https://www. thalassaemia-yti.org/ 4. wong lp, george e, tan j-ama. public perceptions and attitudes toward thalassaemia: influencing factors in a multi-racial population. bmc public health [serial on the internet]. 2011 mar [cited 2017 nov 20];11(193):[about 9p.]. available from: https://www.ncbi.nlm. nih.gov/pmc/articles/pmc3076274/. 5. chapin jc, vogiatzi m, kleinert d, defilippis e, christos p, giardina p. fracture prevalence in adults with transfusion-dependent thalassemia is related to osteoporosis and age. blood [serial on the internet]. 2014 [cited 2017 dec 3];124(21):[about 3p.]. available from:http:// www.bloodjournal.org/content/124/21/4902. 6. wong p, fuller pj, gillespie mt, milat f. bone disease in thalassemia: a molecular and clinical overview. endocrine rev. 2016;37(4):320–46. 7. vogiatzi mg, macklin ea, fung eb, cheung am, vichinsky e, olivieri n, et al. bone disease in thalassemia: a frequent and still unresolved problem. j bone min res. 2009;24(3):543–57. 8. haidar r, mhaidli h, musallam km, taher at. the spine in β-thalassemia syndromes. spine. 2012;37(4):334–9. 9. body jj, bergmann p, boonen s, boutsen y, bruyère o, devogelaer j-p, et al. nonpharmacological management of osteoporosis: a consensus of the belgian bone club. osteoporosis int. 2011;22(11):2769–88. 10. eid ma, ibrahim mm, aly sm. effect of resistance and aerobic exercises on bone mineral density, muscle strength and functional ability in children with hemophilia. egypt j med human genetics. 2014;15(2):139–47. 11. el-shamy s. effect of whole body vibration training on quadriceps strength, bone mineral density, and functional capacity in children with hemophilia: a randomized clinical trial. j musculoskelet neuronal interact. references :84–90 andreas arie widiadiaksa waluyojati, marietta shanti prananta, et al. average bmi of the subjects in this study was low (15.92±1.785). this finding is similar to another study conducted in pakistan stated bmi of children with thalassemia aged 2–15 years was low.20 several factors which influence lower bmd in children with thalassemia are multiple endocrinopathies, iron deficits in main organs, and low nutrition intake. no significant bmd improvement in the overall lumbar segment was discovered in this study. however, significant improvement was discovered in l4 segment and z-score. the data revealed that practicing ope can increase bmd in children with thalassemia. improvements were also influenced by exercise frequency and duration. different bmd value was found in l4 segment of the spine after 12 week intervention. this finding is in accordance with several studies which described that improvement occurs because l4 and l5 segments of spinal lumbar between center pivot point which becomes the center of all spinal movements in sagittal for flection and extension movements.7,10,17 while practicing ope, axial load and shear stress force continuously occur in the spine. shear stress is caused by gravitation and muscular contraction effects. this study has several limitations to be consiered. the hormonal functions, nutrition intake, and activity levels in assessing subjects’ bmd were not investigated. further studies can be conducted by investigating nutrition intake functions within body, and also daily activities performed by the subjects. as the intervention was held in a centralized venue, this condition might cause higher number of dropouts. another factor of higher number of dropouts was the distance of the venue and inflexible time of the intervention for students. alternative ways should be discovered in order to obtain higher total samples such as availability of nearby venue in each community. in conclusion, increased bmd in the lumbar was discovered in children with thalassemia after practicing the ope session. continuous ope program becomes suitable effort due to prevent osteoporosis in children with thalassemia. 90 international journal of integrated health sciences. 2018;6(2) 2017;17(2):19–26. 12. widianti, atikah. senam kesehatan. yogyakarta: muha medika; 2010. 13. sudigdo s. dasar-dasar metodologi penelitian klinis. 4th ed. jakarta: sagung seto; 2011. 14. mohseni f, mohajeri-tehrani m, larijani b, hamidi z. bone density changes in thalassaemic patients with age and time period. hk j paediatr. 2016;21(4):257–61. 15. lorentzon m, cummings s. osteoporosis: the evolution of a diagnosis. j internal med. 2015;277(6):650–61. 16. chiu km, ju j, mayes d, bacchetti p, weitz s, arnaud cd. changes in bone resorption during the menstrual cycle. j bone miner res. 1999;14(4):609–15. 17. behringer m, gruetzner s, mccourt m, mester j. effects of weight-bearing activities on bone mineral content and density in children and adolescents: a meta-analysis. j bone miner res. 2014;29(2):467–78. 18. toumba m, skordis n. osteoporosis syndrome in thalassaemia major: an overview. j osteoporosis [serial on the internet]. 2010 jun [cited 2002 aug 12];2010(2010):[about 7p.]. available from: https://www.hindawi.com/ journals/jos/2010/537673/. 19. chan y-l, pang l-m, chik k-w, cheng jc, li c-k. patterns of bone diseases in transfusiondependent homozygous thalassaemia major: predominance of osteoporosis and desferrioxamine-induced bone dysplasia. pediatr radiol. 2002;32(7):492–7 20. shepherd ja, sommer mj, fan b, powers c, stranix-chibanda l, zadzilka a, et al. advanced analysis techniques improve infant bone and body composition measures by dual-energy x-ray absorptiometry. j pediatr. 2017;181(1):248–53. osteoporosis prevention exercise effects to bone density in children with thalassemia :84–90 international journal of integrated health sciences. 2018;6(2) 73 original article correspondence: nanda ayu puspita, departement of biochemistry, faculty medicine, syiah kuala university jl. t. nyak arief darussalam banda aceh 23111, banda aceh, indonesia e-mail: n.a.puspita@edu.salford.ac.uk effect of 3-day storage and temperature on adp-induced platelet aggregation abstract objective: to observe platelet functions during the 3 days of platelet storage and to evaluate the effect of storage temperature towards platelet aggregation response. methods: two conditions of platelet storage were used in this study: at room temperature and in a cold condition at 4 °c to observe the temperature effect on platelet aggregation. the aggregation test was performed using a 96-wells plate platelet aggregation method. results: at room temperature on day 1, the response of platelet aggregation reduced to 34.9±10.6%, which was less than half of the aggregation of fresh platelet (100%). the aggregation on day 2 reduced modestly (26.8±4.2%), in comparison with that seen on the first day. on day 3, platelet aggregation deteriorated significantly (6±1.2%), which was comparable to the control group without the presence of platelet agonist (6.1±1.4%). when platelets are stored at 4 °c, the aggregation response to adp stimulation was slightly different to that shown by platelets stored at room temperature (22 °c). at the 4 °c, the aggregation response was 68.11±34.2%, 57.1±21.4%, and 5.9±2.6% at day 1, day 2, and day 3, respectively. the result showed that storing the blood at 4 ˚c or room temperature was not able to preserve platelet function, as the deterioration of platelet aggregation response over time was still taking place. although was not statistically significant, our result indicated that cold storage reduced platelet responsiveness toward adp activation. conclusions: this current study provides evidence of the deterioration of platelet function during first 3 days of platelet storage. moreover, we found that storing platelets in 4 °c showed no significant benefit in preserving the adp-induced platelet aggregation capacity compared to that stored in 22 °c. keywords: adenosine diphosphate, platelet, platelet aggregation, platelet storage pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v6n2.1375 ijihs. 2018;6(2):73–9 nanda ayu puspita,1,2 suryawati3 1departement of biochemistry, medical faculty of syiah kuala university, banda aceh, indonesia 2biomedical research centre, university of salford, the crescent, salford, united kingdom 3departement of pharmacology, medical faculty of syiah kuala university, banda aceh, indonesia introduction in hemostasis, platelet is the most important blood cell. the natural life span of circulating platelets in a physiological condition is up to 8–12 days before they are eventually removed by the resticuloendothelial system. however, the life span will be shorter when platelets are taken from the blood vessels for the purpose of platelet transfusion or research.1 due to the complex and time-consuming process of producing platelet concentrates, the time required for blood withdrawal, processing, delivery, and storage before the platelet concentrates are ready for transfusion or research might vary from 1 day to several days.1 in the case of clinical purposes, platelet concentrates are generally used after 3–5 days of blood collection, although platelets can be stored longer when the platelet concentrates is stored in plasma in some cases.2,3 the length of platelet storage clinically is primarily received: august 23, 2018 revised: september 5, 2018 accepted: september 10, 2018 :73–9 74 international journal of integrated health sciences. 2018;6(2) limited by the abundant presence of bacterial contamination and the occurrence of platelet structural lesions (psls) after the platelets are stored for 5 days.1,3 the potential shelf-life of platelet storage is still debatable until now.1,2 undue platelet activation, platelet membrane protein changes, and bacterial contamination are known as the most commonly found changes occurring on platelets due to storage, resulted in a significant alteration in platelet function.4,5 when blood is withdrawn from the blood vessel, platelets are activated by physical stress from the syringe and rapid blood suction, which then leads to minor changes on platelet membrane as well as glycoprotein expression.4,5 during storage, this minor stimulus might be enhanced due to the changes of platelet glycolysis, loss of membrane components, the release of alphagranule contents, and alteration in contractile proteins and metabolic atp.6 as physical stress during blood withdrawal is unavoidable. also, time and environmental condition during the storage of platelet are also crucial factors that influence platelet deterioration.2 despite the fact that there is an evidence of metabolic and biological activities in platelets after 7 days of storage, platelets have started the morphological and physiological changes from the moment when blood is being withdrawn from the blood vessel.7 several studies have revealed that platelet functions start to deteriorate after 3 days of storage, marked by the occurrence of psls, a decrease in platelet mitochondrial activity, increase of reactive oxygen species (ros) production, and platelet apoptosis.1,8,9 however, it is also important to note that, during the first 3 days of blood withdrawal, platelet activity may have also changed, as a response to the exposure to various conditions during storage.2 recent evidence suggests that the temperature of platelet storage is considered as one of the key points in maintaining platelet function.8 many researchers have argued that storing platelets in 4 °c will prevent bacterial growth and will lower the platelet metabolic rate, although it is still controversial if cold storage gives more benefit in preserving platelet responsiveness to agonist activation.8,10,11 in this study, the platelet functions during 3 days of platelet storage was evaluated using the platelet aggregation test despite the fact that the light transmission aggregatory (lta) is widely used as a gold standard for platelet function test.12 platelet aggregation evaluation is considered as the easiest and the most economical method for the purposes of platelet abnormality screening, diagnosis, monitoring therapy, predicting bleeding, and assessing stored platelet.13 two conditions of platelet storage were used in this current study: at room temperature and in a cold condition, in order to observe the effect of environment condition on platelet aggregation. this current study provides evidence of the level of deterioration of platelet function, as the effect of time and temperature during platelet storage. methods human citrated whole blood was purchased from the national health service (nhs) blood and transplant, manchester, united kingdom (uk) (application number m061) while collagen, adp, adenosine, prostaglandin-e1, 4 (2-hydroxyethyl) piperazine-1-ethanesulfonic acid, and n(2-hydroxyethyl) piperazine-n′ (2-ethanesulfonic acid) or hepes as well as ethylene-bis (oxyethylenenitrilo) tetraacetic acid or etga, and apyrase were purchased from sigma-aldrich, dorset, uk. all reagents were purchased from sigma-aldrich, dorset, uk, unless it is otherwise stated. citrated whole blood was centrifuged at 1,250 rpm for 15 minutes to obtain platelet rich plasma (prp). prostaglandin e1 (pge1) was added at a final concentration of 1 μm, then incubated at 37 °c for 10 minutes, followed by subsequent centrifugation at 2,500 rpm for 10 minutes. the platelet pellet was resuspended in a ca2+ free tyrode’s buffer (140 mm nacl, 3 mm kcl, 12 mm nahco3, 0.4 mm nah2po4, 2 mm mgcl2, 5.6 mm glucose; ph 6.2) in the addition of 1 μm prostaglandin e1 (pge1) and centrifuged at 2,500 rpm for 10. platelet pellet was then resuspended in a tyrode’s buffer to give an isolated platelet suspension with a final concentration of 1-3 × 108 cells/ml. an automated haematology analyser poch-100i (sysmex corporation, kobe, japan) was used to count the platelet numbers. the aggregation test was performed in a 96well plates, according to a method described previously.14 as much as 100 µl of platelet suspension was transferred into each well of a 96-well microplate. subsequently, platelet aggregation was induced by the addition of adp at a final concentration of 10 µm. the first reading was taken using a multiskan fctm microplate photometer with 405 nm wavelength (thermo scientific, massachusetts, united states). after the first reading, the plate was continuously agitated at 1,000 rpm and subsequent readings were recorded at 1 minute :73–9 effect of 3-day storage and temperature on adp-induced platelet aggregation international journal of integrated health sciences. 2018;6(2) 75 nanda ayu puspita, suryawati intervals for 10 minutes. platelet aggregation was calculated by subtracting the final reading from the initial reading collected from the same well. in-vitro platelet morphology and aggregates were performed by microscopic observation of a giemsa-stained thin blood film. data normalisation was performed by comparing with the maximum response from the corresponding platelet agonists controls. statistical analysis was performed using graphpad prism software version 5.0 from (graphpad software, san diego california usa). data were presented as mean ± standard mean error (sem). comparison of means was performed using one-way anova with bonferroni’s multiple comparison as a post hoc analysis. p-value smaller than 0.05 was considered statistically significant. results morphologically, resting platelets are relatively round and solitary. however, even with the absence of adp to induce platelet activation, the platelets had developed fine pseudopodia, indicating the early sign of platelet stimulation (fig. 1). no significant morphological changes on platelets on day 1, day 2, and day 3 (fig. 1). a preliminary study, adp was demonstrated to have a potential to induce the aggregation of platelet within the dose range of 1–10 µm (data not published). after adp activation, platelets are activated, leading to the aggregation of platelets. consequently, single platelets were rarely found amongst the other blood cell population (fig. 1). this platelet aggregation is marked by the formation of platelet clumps as an ultimate result from platelet activation. the highest platelet aggregation response was seen on the day of blood withdrawal (fig. 1). in the absence of adp, platelet aggregation was not formed, despite the continuous shaking as mechanical stimulation given to the control group. upon platelet storage, the deterioration platelet aggregation response was seen. on day 1, platelet aggregation response reduced more than 50% when compared to the one in fresh blood (maximum response was 34.9±10.6%). the platelet aggregation on day 2 reduced modestly (26.8±4.2%), in comparison with that seen on the first day. on day 3 of platelet storage, the platelet aggregation deteriorated significantly (6±1.2%), which was comparable to the control group (6.1±1.4%). the result demonstrated the evidence of deterioration of :73–9 microscopic observation of platelet slides. giemsa-stained blood smear (at 400x magnification) from whole blood. in resting condition (top figures), platelets appeared amongst the other blood cells as an individual small fragment. there were no morphological changes observed on day 1, day 2, and day 3. upon adp activation (bottom figures), platelet population is markedly diminished, and replaced with the appearance of platelet aggregates which contain a vast number of activated platelets fig. 1 76 international journal of integrated health sciences. 2018;6(2) platelet function during first 3 days of platelet storage. in order to evaluate the variation of platelet reactivity after adp stimulation under various external temperature, platelets were kept at room temperature (22°c) and at 4 °c. platelet response to stimulation with adp were slightly different when platelets were stored at 4 °c or at room temperature for 3 days (fig. 3). at 4 °c, the aggregation response was 68.11±34.2% at day 1, 57.1±21.4% at day 2, and 5.9±2.6% at day 3. the result showed that storing the blood at 4 °c or in room temperature was not able to preserve the platelet function because the deterioration of platelet aggregation response still took place. although it is not statistically significant, results indicated that cold storage might reduce platelet responsiveness toward adp activation (fig. 3). discussion platelet concentrates are generally used within a period of 3–5 days due to to the long and time consuming procedure and screening to make sure that the platelets can be used safely. this present study evaluated platelet aggregation response during the first three days of storage, because this period of time is considered as the window period before platelets start to lose their viability.9,13,18 results in this study demonstrate that, after one day of storage, there is a significant deterioration of adpinduced platelet aggregation response. it is in agreement with previous reports on platelet storage effect on platelet activation, which suggested that platelets have started to lose their activity from the first day of storage.17 platelets only have 45% activity towards adp activation on day 1, and gradually decrease to 12% on day 5.10 similarly, another study reported that platelet aggregation response towards adp and collagen activation decrease gradually from day 1 to day 5, from 78% to 17%.16 contrary to those reports, this study observed that platelets have no measurable response to adp-induced aggregation on day 3, whilst, from earlier reports, the activity was still measurable until day 5. having said that, this study has provided evidence that on day 3, adp-induced platelet aggregation activity was similar to that shown by platelets without adp, which indicates the incapability of platelets to react to adp activation. despite evidence of platelet activity after 5 days, to our knowledge the earlier reports have not compared the aggregation activities with activities in the stored resting platelets. finding in this study is clinically important as, in general, platelet effect of 3-day storage and temperature on adp-induced platelet aggregation :73–9 maximum response of platelet aggregation over time. blood samples were kept at room temperature (22 °c) and platelet aggregation was induced by adp at a concentration of 10 µm). data on the graph represent the maximum response of platelet aggregation from four replicates of the experiment (n=4) as means±sem. statistical analysis was performed using one-way anova with bonferroni’s multiple comparison post-test (*p<0.05) fig. 2 international journal of integrated health sciences. 2018;6(2) 77 transfusion takes place after 3 days of storage.9 although progression has been made in terms of platelet storage technology to increase the platelet shelf life, the loss of platelet function during 3 days of storage must be taken into account when providing platelet transfusion to patients with thrombocytopenia in which platelets cannot function.7,18 when stored, platelets show morphological and biological changes.19 a study has reported the presence of platelet storage lesion (psl) on stored concentrated platelet.1 this platelet storage lesion reflects all deleterious changes in the platelet structure and function starting from the moment blood is drawn from the blood vessel until the platelets are transfused back into the circulatory system.7,18 all these tchanges result in the alteration of platelet response to agonist stimulation.7,19 after blood withdrawal, the study found that platelets have shown signs of activation, attributed to the mechanical procedure of blood withdrawal. however, the result of this present study does not demonstrate the presence of any significant morphological changes on platelets following 3 days of storage. despite the limitations of the method used to observe platelet morphology, this study presents further evidence in terms of the deterioration of platelet aggregation response towards adp stimulation over time. many researchers have concluded that the deterioration of platelet function is linear to platelet mitochondrial dysfunction, since the initiation and also further events following the activation of platelet are strongly related to the platelet energy metabolism.1,9 most of platelet intracellular adp are stored in dense granules as a storage atp, and the remaining atps are present in the cytoplasm as metabolic atp.1 the main source of energy is generated through mitochondrial oxidative phosphorylation in platelets, accounting for almost 80% of total energy in platelet metabolism. in anaerobic conditions, platelets produce energy through cytosolic anaerobic glycolysis, which generates far less atp than that produced by aerobic metabolism. when the platelet mitochondrial respiration is decreased, platelet intracellular level decrease, leading to the reduction of platelet aggregation capacity. the alteration of mitochondrial capacity of isolated platelet has started on day 1, followed by a significant :73–9 the effect of the temperature on platelet aggregation. platelets were kept at room temperature (22 °c) and 4 °c. platelet aggregation induced by adp (10 µm) was measured on day 1, day 2, and day 3. data shown on each bar represents the maximum response of platelet aggregation from four replicates of the experiment (n=4) as mean±sem. statistical analysis was performed using oneway anova with bonferroni’s multiple comparison post-test (*p<0.05) fig. 3 nanda ayu puspita, suryawati 78 international journal of integrated health sciences. 2018;6(2) effect of 3-day storage and temperature on adp-induced platelet aggregation :73–9 decrease in respiratory activity on day 2.9 this fact is in agreement with the finding in this study which shows that platelet aggregation activity is relatively stable on day 1 and day 2. it is likely that platelet mitochondria is still able to provide sufficient energy for cell metabolism on day 1, whilst on day 2 when mitochondrial activity started to deteriorate, platelets use storage atp from dense granules for their metabolism. however, as the atp pool decreased, platelet activity reduced significantly. thus, the deterioration of platelet aggregation response is strongly related to the intracellular atp level.20 with regards to the optimum temperature of platelet storage, some researchers have reported that storing platelet at a temperature of -4°c have preserved platelet aggregation potential, compared to 22 °c-stored platelets.4,5 conflicting with an earlier finding, this study shows that storing platelet in 4°c fails to preserve adp-induced platelet aggregation. it is indicated that the aggregation capacity of platelets stored in 4°c is similar, if not less, than the platelets stored at room temperature. these isin agreement with past studies conducted by baimukanova that show the functionality of cold-stored platelets are equivalent to those platelets stored in the room temperature.11 recently, it is well known that that platelets stored in 4 °c are relatively superior compared to 22 °c because they exhibited more viable metabolic characteristics, release fewer proinflamatory mediators, hemostatically more effective, has ability to regulate endothelial barrier integrity, and has a more stable clot formation.5 in addition this, cold storage also gives benefit in preventing bacterial growth and the occurrence of the pls during platelet storage. however, in spite of these superiority, there are growing evidence of the occurrence of cold lesion on cold-stored platelet, leading to avcold-induced platelet activation.8 coldinduced lesion is primarily characterized by morphological changes, accompanied by the increase in intracellular calcium level and actin polymerisation degree.8 the mechanism of cold-induced platelet activation is not fully understood.8 nevertheless, these drawbacks have raised questions regarding the hemostatic function of platelets stored cold at 4°c. this study demonstrated that, from day 1 to 3, the decline of adp-induced platelet aggregation response is more visible on 4°c-stored platelet, compared to those of 22 °c-stored platelets. the results indicated that cold-stored platelet function is deteriorating in a same manner as the platelets stored at room temperature. it is important to note that this present study has provided another evidence that cold-stored platelets are not ultimately superior compared to room temperature stored platelets in term of their functionality. one might argue that the differences of platelet response may be due to the procedure of platelet collection and the aggregation test method. however, recent evidence suggests that there is no difference between platelet collection procedures on platelet activation.16 moreover, this study used plate reader method to measure platelet aggregation response, whilst most of other studies apply standard aggregometer or flow cytometry to measure the platelet aggregation response. the platelet reader method, although not superior to the standard agregometer, gives more benefit in assessing a large number of sample while only using a small amount of platelet sample.14 using the aggregometer and plate reader, the results from platelet agonist-induced platelet aggregation response was qualitatively and quantitatively similar.14 therefore, the effect of the dissimilarity in blood collection procedure and aggregation assay to this contradictory results can be excluded. in summary, data demonstrated that the platelet functions are seen to be deteriorated significantly during the first 3 days of storage. the study found that platelets have lost more than half of their adp-induced aggregation capacity on the day 1, which is likely due to deterioration of platelet mitochondrial activity. on day 3, the aggregation activity is diminished and comparable to that seen on non-activated platelets, which indicate that platelet have lost their functional in aggregation response. this effect is strongly related to the reduction of intracellular atp level due to deterioration of platelet mitochondrial activity. moreover, storing platelets in 4 °c showed no significant benefit in preserving the aggregation capacity compared to that stored in 22 °c. the study has supported the early consensus in storing platelets, where platelet concentrates shelf life was shorter and must be used immediately in transfusion to avoid the loss of platelet functionality. furthermore, storing platelets in 22 °c may improve their availability and avoid the occurrence of cold-induced lesion and coldinduced activation. nevertheless, additional works are needed for further investigation on storage time and condition, to improve the platelet storage method for clinical use. international journal of integrated health sciences. 2018;6(2) 79 references 1. ohto h, nollet ke. overview on platelet preservation: better controls over storage lesion. transfus apher sci. 2011;44(3):321–5. 2. tynngård n. preparation, storage and quality control of platelet concentrates. transfus apher sci. 2009;41(2):97–104. 3. zhang jg, carter cj, culibrk b, devine dv, levin e, scammell k, et al. buffy-coat platelet variables and metabolism during storage in additive solutions or plasma. transfusion. 2008;48(5):847–56. 4. nair pm, pandya sg, dallo sf, reddoch km, montgomery rk, et al. platelets stored at 4 degrees c contribute to superior clot properties compared to current standard-ofcare through fibrin-crosslinking. br j haematol. 2017;178(1):119–29. 5. bynum ja, adam m, getz tm, rodriguez ac, aden jk, cap ap, et al. bioenergetic profiling of platelet mitochondria during storage: 4 °c storage extends platelet mitochondrial function and viability. transfusion. 2016;56(suppl 1):s76–84. 6. yang j, yin w, zhang y, sun y, ma t, gu s. et al. evaluation of the advantages of platelet concentrates stored at 4 °c versus 22 °c. transfusion. 2018;58(3):736–47. 7. thon n, schubert p, devine dv. platelet storage lesion: a new understanding from a proteomic perspective. transfus med rev. 2008;22(4):268–79. 8. egidi mg, d’alessandro a, mandarello g, zolla l. troubleshooting in platelet storage temperature and new perspectives through proteomics. blood transfus. 2010;8(suppl 3):73–81. 9. villarroel jpp, figueredo r, guan x, tomaiuolo m, karamercan ma, welsh j, selak ma, et al. increased platelet storage time is associated with mitochondrial dysfunction and impaired platelet function. j surg res. 2013;184(1):422– 9. 10. bakry r, sayed d, galal h, shaker s. platelet function, activation and apoptosis during and after apheresis. ther apheres dialysis. 2010;15(5):457–64. 11. baimukanova g, miyazawa b, potter dr, gibb sl, keating s, danesh a, et al. the effects of 22 0c and 4 0c storage of platelets on vascular endothelial integrity and function. transfusion 2016;56 (suppl 1):s56–64. 12. podda gm, scavone m, femia ea, cattaneo m. aggregometry in the settings of thrombocytopenia, thrombocytosis and antiplatelet therapy. platelets [serial on the internet] 2018 mar [cited 2018 jul 12];14(1):[about 6p.]. available from:https:// www.tandfonline.com/doi/abs/10.1080/095 37104.2018.1445843?journalcode=iplt20. 13. michelson ad. methods for the measurement of platelet function. am j cardiol. 2009;103(suppl 3):s20–6. 14. vinholt pj, nybo m, nielsen cb, hvas am. light transmission aggregometry using pre-coated microtiter plates and a victor x5 plate reader. plos one [serial on the internet]. 2017 oct [cited 2018 jan 20];12(10):[about 12p.]. available from: https://journals.plos.org/plosone/ article?id=10.1371/journal.pone.0185675. 15. dumont lj, aubuchon jp, whitley p, herschel lh, johnson a, mcneil d, et al. seven-day storage of single-donor platelets: recovery and survival in an autologous transfusion study. transfusion. 2002;42(7):847–54. 16. akay om, gündüz e, başyiğit h, gulbas z. platelet function testing during 5-day storage of single and random donor plateletpheresis. transfus apheres sci. 2007;36(3):285–9. 17. reddoch km, pidcoke h, montgomery rk, fedyk cg, aden jk, ramasubramanian ak, et al. hemostatic function of apheresis platelets stored at 4 degrees c and 22 degrees c. shock. 2014;41(suppl 1):54–61. 18. shrivastava m. the platelet storage lesion. transfus apheres sci. 2009;41(2):105–13. 19. braune s, walter m, schulz f, lendlein a, jung f. changes in platelet morphology and function during 24 hours of storage. clin hemorheol microcirc. 2014;58(1):159–70. 20. diab a, thomas a, luban nlc, wong ecc, wagner sj, levy rj. acquired cytochrome c oxidase impairment in apheresis platelets during storage: a possible mechanism for depletion of metabolic adenosine triphosphate. transfusion. 2012;52(5):1024–30. :73–9 nanda ayu puspita, suryawati vol 11 no 1 2023 (2) rev-2.indd 50 this is an open access article licensed under the creative commons attribution-noncommercial 4.0 international license (http:// creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original author and source are properly cited association between maternal hemoglobin level and incomplete abortion in a west java tertiary hospital, indonesia lisa milena anabela,1 budi handono,2 delita prihatni,3 muhammad alamsyah aziz,2 mulyanusa amrullah ritonga2 1faculty of medicine, universitas padjadjaran, sumedang, indonesia. 2department of obstetrics and gynecology, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital, bandung, indonesia 3department of clinical pathology, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital, bandung, indonesia introduction incomplete abortion is partial expulsion of conception or placenta weighing 500 grams or less with some parts left inside the uterus at gestational age before 20 weeks.1 the incidence of spontaneous abortion is estimated at 23 million each year, globally.2 the cause of spontaneous abortion is multifactorial, primarily due to chromosomal anomalies.3 in indonesia, according to a meta-analytic study, the most prominent factors are maternal age and parity.4 other factors include, education, early menarche, interpregnancy intervals, previous abortion, anemia, infections, hypertension and obesity.3,4 original article international journal of integrated health sciences (iijhs) issn print: 2302-1381; issn online: 2338-4506 received: january 13, 2023 accepted: macrh 28, 2023 published: march 30, 2023 correspondence: lisa milena anabela faculty of medicine, universitas padjadjaran, jalan raya bandung –sumedang km.21 jatinangor, sumedang, west java, indonesia e-mail: lisa19002@mail.unpad.ac.id doi: 10.15850/ijihs.v11n1.3284 ijihs. 2023;11(1):50-56 article history abstract objective: to evaluate the association between maternal hemoglobin concentrations and incomplete abortion. methods: an analytic, cross-sectional study with consecutive sampling method was conducted using medical records of 45 pregnant women aged 18–35 years old visiting the obstetrics and gynecology department of dr. hasan sadikin general hospital, bandung, indonesia from january 1, 2017 to december 31, 2019. participants were grouped into incomplete abortion and non-abortion groups. results: maternal characteristics in the incomplete abortion group showed that the majority of pregnant women in this group were 25.58 years of age, non-anemic (n=37, 82.22%), had no previous spontaneous abortion (n=40, 88.89%), and were nulliparous (n=25, 55.55%) with a mean interpregnancy interval of 4.03 years. the characteristics in both incomplete abortion group and non-abortion group were homogenous in the level of anemia (p-value=0.380), previous spontaneous abortion (p-value=1.00), and interpregnancy intervals (p-value=0.667). the mean hemoglobin concentration for the incomplete abortion group was 11.81 gr/dl (95% ci, 11.30 to 12.26). heterogenous data was found in age (p-value=<0.001) and parity (p-value=0.002). parity was a strong confounder, causing the hemoglobin concentration insignificantly associated to incomplete abortion (p-value=0.884). conclusion: no statistically significant association is found between hemoglobin concentration and incomplete abortion. most women with incomplete abortion are around 25 years old, nulliparous, non-anemic with a mean hemoglobin concentration of 11.81 gr/dl with no history of previous abortion, and a rather secure interpregnancy intervals. keywords: anemia, hemoglobin, incomplete abortion, interpregnancy intervals, parity international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 51 anemia in pregnancy is a condition in which pregnant women have hemoglobin (hb) concentration below 11 gr/dl.5 it can be caused by hemodilution, inadequate intake, heavy menstruation, excretion of iron through sweat, malaria or parasitic infection, and anemia before gestation.3 the world health organization (who) states that the global prevalence of anemia in 2019 among pregnant women aged 15 to 49 years is 36.5%.6 nationally, the prevalence is 48.9% or 5 out of 10 pregnant women suffer anemia in 2018.7 a study by judistiani et al.8 in padjadjaran university following first-trimester pregnant women, showed an increasing number of anemia in the first trimester from 7.5% to 8.48% in 2020. the increased number is concerning as anemia is related to premature birth, low birth weight, preeclampsia, infections, and cardiac failure which ultimately increases mortality and morbidity rate of mother and baby.3,9 some theories correlate anemia to a decrease in oxygen supply or iron for fetus’ development, an increase in oxidative stress production and infection risk, and also a dysfunction in iron-dependent thyroid peroxidase.10,11 a large-scale study involving almost 4 million women in china shows a significant association between severe anemia (<7 gr/dl) and an increased risk of abortion, while mild anemia (<11 gr/dl) is protective towards abortion.10 although various studies had been done regarding anemia and spontaneous abortion, they are rarely being specifically connected with incomplete abortion or using hemoglobin concentration without being categorized, moreover in west java. hence, this study aims to evaluate the association between maternal hemoglobin concentration and incomplete abortion. methods this study was an analytic observational study with cross-sectional design using secondary data. subjects were pregnant women with diagnosis of incomplete abortion (with gestational age <20 weeks) treated at department of obstetrics and gynecology, rsup dr. hasan sadikin bandung for 3 years, from 1st january 2017 to 31st december 2019. data collection was carried out following the obtention of ethical exemption from the research ethic committee universitas padjadjaran bandung (1155/un6.kep/ ec/2022) and rsup dr. hasan sadikin bandung (lb.02.02/x.2.2.1/292/2023). the inclusion criteria were: (1) pregnant women within 18 – 35 years of age, (2) diagnosed as incomplete abortion confirmed by ultrasound, and (3) recorded hemoglobin concentration when patient first came to the emergency department. the exclusion criteria were: (1) incomplete data such as patients’ age, gestational age, and recorded hemoglobin concentration, (2) history of diabetes mellitus and thyroid dysfunction, (3) history of hypertension, (4) multiple gestation, (5) history of lupus, antiphospholipid syndrome, and thalassemia. data required were age, interpregnancy intervals, and hemoglobin concentration as numerical variables; abortion incomplete, concluded level of maternal anemia, history of previous abortion, and parity as categorical variables. consecutive sampling technique was used with minimal sample of 35 for each group of incomplete abortion and non-abortion calculated by unpaired numeric formula based on the hemoglobin concentration in a study by guo et al.12 diagnosis of incomplete abortion were confirmed by ultrasound. hemoglobin concentration were obtained on admission from medical records for incomplete abortion cases. hospital information system (sirs) was used to obtain data for non-abortion cases from women with spontaneous delivery in the same time period. the data presented in mean, median, standard deviation, minimum, maximum values, and further categorized for anemia. classification of anemia according to who consisted of non-anemia (hb ≥11 gr/ dl), mild anemia (hb 10 – 10.9 gr/dl), and moderate anemia (hb 7 – 9.9 gr/dl).5 this study also categorized parity based on number of delivery at gestational age ≥24 weeks as nulliparity (0 child), primiparity (1 child), and multiparity (≥2 children). qualified data was processed using microsoft excel and ibm® spss® 26. univariate analysis was done to describe subjects’ characteristics. hemoglobin concentration data was tested for its normality using the kolmogorov-smirnov test. a subsequent bivariate analysis with confidence intervals (ci) of 95% was used to test the hypothesis regarding the association of maternal hemoglobin concentration and incomplete abortion. chi square test was used for level of anemia and parity, whereas, fisher-exact test was used to analyze number of previous spontaneous abortion. the results were considered statistically significant and interpreted as having cause-effect association association between maternal hemoglobin level and incomplete abortion in a west java tertiary hospital, indonesia 52 international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 if p-value ≤0.05. results consecutive sampling was taken from secondary data registry and 45 samples were selected in each group of incomplete abortion and non-abortion from 1st january 2017 to 31st december 2019. maternal characteristics (table 1) showed mean age for incomplete abortion group were 25.58 years old. high cases of non-anemia was found in both incomplete abortion and non-abortion groups. mild and moderate anemia cases was higher among non-abortion group, although not significantly different. most subjects in both groups had no previous spontaneous abortion. interpregnancy intervals in abortion incomplete group had mean of 4 years, meanwhile in non-abortion group was 3.45. both incomplete abortion and non-abortion cases had a high number among women with zero parities, although it was significantly higher in non-abortion group. this study presented that 2 compared groups, incomplete abortion and non-abortion groups, had similar baseline characteristics to be compared in level of anemia (p-value 0.380>0.05), number of previous spontaneous abortion (p-value 1.00>0.05), and interpregnancy intervals (p-value 0.667>0.05). however in both groups, number parity (p-value 0.002<0.05) and age (p-value <0.001<0.05) were not similar. post hoc test was done to each parity category. the results for nulliparity, primiparity, and multiparity were 1.00>0.05, 0.833>0.05, and 1.00>0.05, respectively. this showed that heterogeneity of parity in the compared groups were significantly associated with the association between hemoglobin concentration and incomplete abortion. hence, the number of parity could confound and cause no significant association between hemoglobin concentration and incomplete abortion. the mean and median of hemoglobin concentration in incomplete abortion population was 11.81 gr/dl and 11.80 gr/ dl, respectively. in non-abortion population, the mean was 11.90 gr/dl and the median was 12.20 gr/dl. further analysis was done to define the association between hemoglobin concentration and incomplete abortion after normality test. non-parametric independent-samples mann-whitney u test was used due to abortion group was normally distributed and non-abortion group was not normally distributed. this analysis showed lisa milena anabela, budi handono, et al table 1 characteristics of the study population characteristics incomplete abortion(n=45) non-abortion (n= 45) p-value age (years) mean (sd) 25.58 (4.59) 29.16 (4.79) <0.001 anemia level, n (%) non-anemia 37 (82.22%) 32 (71.11%) 0.380 mild anemia 2 (4.45%) 5 (11.11%) moderate anemia 6 (13.33%) 8 (17.78%) number of previous spontaneous abortion, n (%) 0 40 (88.89%) 40 (88.89%) 1.001 5 (11.11%) 5 (11.11%) interpregnancy intervals (years) mean (sd) 4.03 (2.86) 3.45 (3.08) 0.667 parity, n (%) nulliparity 25 (55.55%) 40 (88.89%) 0.002primiparity 12 (26.67%) 1 (2.22%) multiparity 8 (17.78%) 4 (8.89%) international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 53 p-value 0.884>0.05, there was no statistical significant association between hemoglobin concentration and incomplete abortion (table 2). discussion in this study, we found that maternal hemoglobin concentration in early pregnancy was not associated with incomplete abortion. hemoglobin concentration in incomplete abortion had lower mean number of 11.81 gr/ dl compared to non-abortion group of 11.90 gr/dl. similar difference in concentration was also reported by guo et al.12 among women treated at the beijing obstetrics and gynecology hospital, in which first trimester pregnant women had higher mean hemoglobin concentration of 13.22 gr/dl as opposed to women with spontaneous abortion of 12.59 gr/dl. a study by díazlópez et al.11 in 2021 and xu et al.10 in 2020 did not correspond to our findings which showed that an increased risk of spontaneous abortion was found in women with severe anemia (p-value=<0.001; or, 1.52; 95% ci, 1.25 to 1.86), low concentration (hb <11 gr/dl; p-value=0.002<0.05) and high concentration (hb>14 gr/dl; p-value=0.012<0.05). the association result might have appeared due to the fact that women were hemorrhaging for hours to days before hospital admittance, a strong confounding factor of parity and age, and/or other factors that were not established in current study. moreover, blood tests used as data was taken on the patient’s admittance to the hospital, the very first antenatal care (anc) hemoglobin data were not available as most patients had anc outside the area of study and some may not even seek any care at all. although current study showed that most pregnant women in first trimester had hemoglobin concentration above lower cutoff of 11 gr/dl determined globally, this number was still lower compared to other pregnant women outside of indonesia. this might be due to the fact that there were differences in demography, climate, lifestyle, and healthseeking behaviors. low hemoglobin level during adolescence (aged 10-18 years) was said to be carried over to adulthood and contribute to anemia in pregnancy, hence it had become important to prepare early in reaching adequate hemoglobin level for preconception.13 mean age for incomplete abortion cases was 25 years, which was younger than nonabortion cases. a study in norway showed an absolute lowest risk of spontaneous abortion in pregnant women 27 years of age, ranging among women of 25–29 years old.14 a case-control study by yanti l.15 showed that maternal age had significant positive correlation with spontaneous abortion (p-value=<0.01; r=0.297), although another study showed that there was no significant correlation (or, 1.587; p-value=0.202<0.05).16 findings in the current study might show that women with more mature age had a more solid plan to conceive, therefore they were more open in finding support or information, restricting their daily activities and sought more care or supplementations in order to achieve a successful pregnancy. most women in incomplete abortion group fell in non-anemia category and this corresponded with a study done at bahagia general hospital in makassar, but did not correspond with a study done in kediri district in 2017, where the highest occurrence of abortion happened in subjects with severe anemia (59.5%; ρ value=0,000<0,05; r=0.504).17,18 the non-anemic state presented by most subjects might suggest that they had received adequate care in terms of fe or multi-vitamins supplementations, nutritious intake and healthy lifestyle. although, the number of hemoglobin concentration alone could not be accounted for adequate iron stores. several mechanism due to anemia and iron deficiency in pregnancy could cause association between maternal hemoglobin level and incomplete abortion in a west java tertiary hospital, indonesia table 2 the association between hemoglobin concentration and incomplete abortion variable hemoglobin concentration (gr/dl) 95% ci p-value mean (sd) median (range) incomplete abortion 11.81 (1.53) 11.80 (7.60-14.70) 11.30 – 12.26 0.884 non-abortion 11.90 (1.68) 12.20 (8.30-14.70) 11.31 – 12.31 54 international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 spontaneous abortion. hypoxic state due to decreased in oxygen supply could stimulate the production of cortisol by fetus which disturbed fetal development and estrogenprogesteron function, that caused cervix dilation and myometrium contraction.11,19 increased oxidative stress could disturb trophoblast invasion and the development of spiral arteries which were not yet embedded firmly.18 therefore, explained the early expulsion of conception. most subjects with incomplete abortion had no history of previous spontaneous abortion (88.89%), corresponded with a study done in the same bandung region which showed higher number of subject in incomplete abortion group without previous abortion of 56.98% (p-value=0.111>0.05) at al-ihsan regional general hospital with no significant correlation.20 another study by arnianti et al.21 in 2021 had different results which abortion group with previous abortion had percentage of 56.5% and increased risk of 2.97 times (95% ci, 1.05 to 8.37) for subsequent abortion. history of spontaneous abortion did not determined that the subsequent pregnancy would end in another abortion, although it would increase the risk up to 20%.3 it was speculated that history of spontaneous abortion could cause trauma physically and psychologically. curettage could scar the endometrium, leading to suboptimal condition for the fetus and placenta to grow. the preceding loss could lead to stress, substance abuse, and unhealthy lifestyle that could put current pregnancy at risk. according to the interpregnancy intervals, subjects with incomplete abortion had mean intervals of 4 years differing from 4 months to 9 years. a case-control study by purwaningrum et al.22 stated that pregnant women with interpregnancy intervals of less than 6 months or more than 48 months had a four-fold increased risk (or, 4.2; p-value=0.01<0.05) of spontaneous abortion rather than intervals between 6 to 48 months. mremi et al.23 in 2022 found that interpregnancy intervals was significantly correlated with anemia post-partum and was 10 times higher in women who had less than 2 years between pregnancies. pregnancy had been progressively using maternal iron stores for the development of the fetus in each trimester, hence it would be deficient by the end of the term. it was said that the body needed at least eight weeks to return red blood cells volume and hematocrit to normal, not to count other events that could make the wait time longer, such as anemia during pregnancy, blood loss during delivery, postpartum hemorrhage, and lochia that happened for weeks.3 a big gap between pregnancies (>5 years) was also considered to be a risk due to an increased in maternal age and the need for the uterine wall to adjust as if it was the first pregnancy. hence, preconception counseling and supplementations became important to anticipate such factors that could contribute to spontaneous abortion. incomplete abortion most often occurred in nulliparity or women who were pregnant for the first time (55.56%). these findings corresponded to a study done in mojokerto in 2022 which stated that first pregnancy had risk for abortion (42.4%).24 different results were reported from a study in al-ihsan general hospital bandung in 2020 that multiparity had higher number (66.67%) among women with incomplete abortion and more number of parity was causing higher proportion of abortion (p-value=0.08<0.05).20 this study, supported by another study in nepal showed that parity was a significant predictor of hemoglobin concentration, as well as maternal age.25 increasing parity numbers could lead to decrease hemoglobin concentration and serum ferritin in the subsequent pregnancy due to inadequate replenishment from the preceding spent of iron stores, which was also influenced by interpregnancy intervals.4 this study concludes that there is no significant association between maternal hemoglobin concentration in early pregnancy and incomplete abortion. this study also reveals that parity could be a strong confounder and prevalence of anemia in pregnant women in rsup dr. hasan sadikin bandung is low, hence can be a factor in explaining the nonassociation. this study has several limitations. most subjects are not anemic and study populations are quite different as data for incomplete abortion were taken from medical records and non-abortion were taken from sirs. hemoglobin concentration data from the very first antenatal care cannot be acquired considering the subjects were receiving care outside of the study location. a limited period of time and being single-centred have made the sample study small and might not accurately reflect the actual condition. future studies are suggested to be multi-centred and have a longer period of time in hope that more precise results can be obtained. it is recommended to do analysis solely among pregnant women with anemia. lisa milena anabela, budi handono, et al international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 55 1. kemenkes, r. i. pedoman nasional asuhan pasca keguguran yang komprehensif komprehensif. jakarta kementerian kesehatan ri. 2020. 2. miscarriage: worldwide reform of care is needed. the lancet. 2021; 2021-05-01:1597. 3. dutta dc, konar h. dc dutta’s textbook of obstetrics: including perinatology and contraception. ninth edition. ed. new delhi: jaypee; 2018. 4. akbar a. faktor penyebab abortus di indonesia tahun 2010-2019: studi meta analisis. jurnal biomedik (jbm). 2019;11:182–91. 5. who. haemoglobin concentration for the diagnosis of anaemia and assessment of severity. who/nmh/nhd/mnm/11.1. [cited 2022 october 26]. available from: https://apps.who. int/iris/bitstream/handle/10665/85839/ w h o _ n m h _ n h d _ m n m _ 1 1 . 1 _ e n g . pdf ?sequence=22&isallowed=y. 6. who. prevalence of anaemia in pregnant women (aged 15-49) (%). [cited 2022 october 26]. available from: https://www.who.int/ data/gho/data/indicators/indicator-details/ gho/prevalence-of-anaemia-in-pregnantwomen-(-). 7. badan pusat statistik. prevalensi anemia pada ibu hamil 2020. [cited 2022 october 26]. available from: https://www.bps.go.id/ i n d i k a t o r / i n d i k a t o r / v i e w _ d a t a / 0 0 0 0 / data/1333/sdgs_2/1. 8. judistiani rtd, madjid th, handono b, sukandar h, irianti s, gumilang l, et al. first trimester ferritin is superior over soluble transferrin receptor and hepcidin in predicting anemia in the third trimester: result from a cohort study in indonesia. anemia. 2020;2020:1–6. 9. smith c, teng f, branch e, chu s, joseph ks. maternal and perinatal morbidity and mortality associated with anemia in pregnancy. obstet gynecol. 2019;134(6):1234–44. 10. xu q, yang y, liu f, wang l, wang q, shen h, et al. preconception hb concentration with risk of spontaneous abortion: a populationbased cohort study in over 3–9 million women across rural china. public health nutr. 2020;23(16):2963–72. 11. díaz-lópez a, ribot b, basora j, arija v. high and low haemoglobin levels in early pregnancy are associated to a higher risk of miscarriage: a population-based cohort study. nutrients. 2021;13(5):1578. 12. guo y, zhang n, zhang d, ren q, ganz t, liu s, et al. iron homeostasis in pregnancy and spontaneous abortion. am j hematol. 2019;94(2):184–8. 13. handari srt, anies, kartasurya mi, nugraheni sa. haemoglobin level of pregnant women was associated with history of anemia during adolescent period: findings from the indonesia family life survey. bali medical journal. bali medical journal; 2022;11(3):1710–6. 14. magnus mc, wilcox aj, morken nh, weinberg cr, håberg se. role of maternal age and pregnancy history in risk of miscarriage: prospective register based study. bmj. 2019;364:l869. 15. yanti l. faktor determinan kejadian abortus pada ibu hamil: case control study. medisains. 2018;16(2):95. 16. muliana n, fitriani ad, nasution ye. kejadian abortus inkompletus di rsud chik di tiro sigli. jurnal serambi akademica. 2019;7(3):194– 204. 17. ruqaiyah r, herliana e, mirnawati m. faktorfaktor yang berhubungan terhadap kejadian abortus pada ibu hamil di rumah sakit umum bahagia makassar 2019. jurnal kesehatan delima pelamonia. 2019;3(1):1–9. 18. jayani i. tingkat anemia berhubungan dengan kejadian abortus pada ibu hamil. care: jurnal ilmiah ilmu kesehatan. 2017;5(1):59-68. 19. wu l, sun r, liu y, liu z, chen h, shen s, et al. high hemoglobin level is a risk factor for maternal and fetal outcomes of pregnancy in chinese women: a retrospective cohort study. bmc pregnancy childbirth. 2022;22(1):290. 20. puspita t, widjajanegara h, setiapriagung d. hubungan antara usia, paritas dan riwayat abortus dengan kejadian abortus inkomplit di rumah sakit umum daerah al-ihsan bandung periode januari 2017-agustus 2019. prosiding pendidikan dokter. 2020;27:402–6. 21. arnianti a, umami n. faktor risiko usia dan riwayat abortus dengan kejadian abortus. jurnal berita kesehatan; 2021;14(1):1–11. 22. purwaningrum ed, fibriyana ai. faktor risiko kejadian abortus spontan. higeia (journal of public health research and development). 2017 aug 4;1(3):84–94. 23. mremi a, rwenyagila d, mlay j. prevalence of post-partum anemia and associated references association between maternal hemoglobin level and incomplete abortion in a west java tertiary hospital, indonesia 56 international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 factors among women attending public primary health care facilities: an institutional based cross-sectional study. plos one. 2022;17(2):e0263501. 24. pricilia lepith p, lestari i, lukita dewi cp. faktor-faktor yang mempengaruhi abortus inkomplit. jbs (jurnal bina sehat): jurnal ilmu keperawatan dan kebidanan. mojokerto.2022. 25. sharma d, amgain k, panta pp, pokhrel b. hemoglobin levels and anemia evaluation among pregnant women in the remote and rural high lands of mid-western nepal: a hospital based study. bmc pregnancy childbirth. 2020;20(1):182. lisa milena anabela, budi handono, et al 22 international journal of integrated health sciences. 2018;6(1) original article correspondence: triagung yuliyana, masters program in human nutrition, sebelas maret university jl. danau sentani utara viii block h3/h8, sawojajar, malang, indonesia e-mail: yanacool44@gmail.com associations between nutrition knowledge, vitamin c intake, nutritional status, and blood pressure among elderly with hypertension in klaten, central java, indonesia abstract objective: to analyze the correlation between nutrition knowledge, vitamin c intake, and nutritional status on blood pressure among elderly with hypertension. methods: this was a cross-sectional study with purposive random sampling which was conducted from april to may 2017. this study included one hundred twenty-five elderly subjects with hypertension who met the inclusion criteria (17 males and 108 females), aged ≥60 years, who lived in the work area of juwiring public health center in klaten district, central java, indonesia. the data were analyzed statistically by using normality, correlation, and multiple linear regression tests. results: the results of the correlation test showed that there was a correlation between nutrition knowledge (p=0.011), vitamin c intake (p=0.012), nutritional status (p=0.048), and blood pressure hypertension in elderly based on the results of multiple linear regression. all data were analyzed statistically using spearman correlation test to examine the distributed data. a significant correlation was found between nutrition knowledge, vitamin c intake, and nutritional status (p<0.05) using multiple linear regression (p<0.05). a normality test using the kolmogorov-smirnov test resulted in normal residue with p-value 0.000. the results showed that the regression analysis could be used to predict the blood pressure. conclusions: there was a correlation between nutrition knowledge and blood pressure of hypertension in elderly. there was a correlation between vitamin c intake and a blood pressure of hypertension in elderly. there was a correlation between nutritional status and a blood pressure of hypertension in elderly. keywords: blood pressure, elderly hypertension, nutrition knowledge, nutritional status, vitamin c intake pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v6n1.1114 ijihs. 2018;6(1):22–9 triagung yuliyana,1 kusnandar,2 diffah hanim3 1master program in human nutrition, sebelas maret university 2departement of agribusiness science program, sebelas maret university 3departement of nutrition health science program, sebelas maret university introduction data from world health organization (who) in 2013 stated that high blood pressure is one of the most important risk factors for cardiovascular disease (cvd), contributing to half of the prevalent coronary heart disease and approximately two-thirds of the prevalent cerebrovascular disease burdens, the leading cause of mortality among indonesian elderly. the indonesian population is aging and it is projected that the number of indonesian adults ≥60 years of age will be doubled by 2020.1 the incidence and prevalence of noncommunicable diseases (ncds), including hypertension, increase with age. therefore, the impact of high blood pressure among received: september 20, 2017 revised: october 27, 2017 accepted: february 20, 2017 :22–9 international journal of integrated health sciences. 2018;6(1) 23 older adults on morbidity and mortality is expected to grow over the coming decades. the joint national committee (jnc-7) recently recommended a higher systolic blood pressure (sbp) threshold (≥160 mmhg) for adults ≥60 years of age without diabetes or chronic kidney disease.2 almost forty-one million elderly people do not know what to do to control their blood pressure. among the several reasons for this situation lack of knowledge and control of hypertension might be potentially included.3 elderly nutrition problems increases due to various factors such as lack of knowledge on elderly nutrition and good food processing for the elderly which then directly affects the status of elderly nutrition. psychological influence, dietary errors, and low economic status of the families may also lead to inadequate nutrition among elderly.4 elderly are characterized by their unique conditions as a result of physiological changes which are characteristics of aging, as well as diseases and psychosocial and dietary factors that influence their nutritional status.5 in general, elderly experiences increased risk of malnutrition caused by insufficient food intake (amount) and poor selection of food (quality). this situation is aggravated when they are institutionalized. a study has shown that the occurrence of nutritional disorders in institutionalized elderly ranges from 30% to 80% with negative health consequences.6 any deficiency, such as nutrient deficiency can compromise the health of the elderly, leading to loss of muscle mass, poor wound healing, depression, reduced memory and dementia, situations which are aggravated by the presence of malnutrition. in contrast, inadequate consumption of calories and lipids can contribute to a higher occurrence of excess weight, a condition that is also prevalent in this group, as well as cardiovascular diseases, neoplasms, and other disorders.5 a significant body of epidemiological and clinical trial data suggest that diets that are known to contain significant concentration of naturally occurring antioxidants appear to reduce blood pressure and may reduce the risk for cardiovascular diseases.2 vitamin c (ascorbic acid) is an essential micronutrient required for normal metabolic functioning of the body. human and other primates have lost the ability to synthesize vitamin c as a result of a mutation in the gene coding for l-gulonolactone oxidase, an enzyme required for the biosynthesis of vitamin c via the glucuronic acid pathway. thus, vitamin c must be obtained through the diet. the vitamin is especially plentiful in fresh fruit, in particular citrus fruit, as well as vegetables, supplements, fortified beverages, and fortified breakfast or “ready to eat” cereals.7 vitamin c is known as a powerful aqueous phase antioxidant that can reduce oxidative stress and enhance endothelial function by way of its effects on nitric oxide production. antihypertensive effects of vitamin c has been hypothesized as early as 1946.8 consumption of fruit and vegetables has a particularly strong association with lower levels of blood pressure and a lower risk of hypertension. intake of vitamin c derived from plants has also been shown to be associated with lower levels of blood pressure. inadequate food intake may cause vitamin c concentrations to decrease. vitamin c has important biological functions, including an increase in nitric oxide endothelial bioactivity.7 the intraarterial administration of ascorbic acid is reported to reverse impaired endothelium-dependent vasodilation found in various conditions associated with increased cardiovascular risk. a randomized, doubleblind, placebo-controlled study was conducted to investigate the hypothesis that chronic supplementation of oral ascorbic acid may help to reduce systemic arterial stiffness.9 this study aimed to observe the correlation between knowledge on nutrition, vitamin c intake, nutritional status, and blood pressure among elderly with hypertension. methods this was a cross-sectional descriptive study performed in juwiring public health center, klaten district, central java, indonesia during a period of april to may 2017. this study has received an ethical approval from the ethical committee of dr. moewardi public general hospital with the issuance of ethical clearance no 468/v/hrec/2017. total sampling approach was applied for data collection using the purposive random sampling technique with a sample size of 361 elderly based on the result of the calculation using the sample size formula for descriptive study. only 125 elderly with hypertension met the inclusion criteria: (1) elderly having id card, (2) age ≥60 years old, (3) blood pressure >140 mmhg, (4) male and female, (5) be able to hear, see, read, write, and communicate well. the exclusion criteria used in this study were (1) elderly with chronic kidney disease (ckd), diabetes mellitus (dm) and stroke, (2) triagung yuliyana, kusnandar, et al. :22–9 24 international journal of integrated health sciences. 2018;6(1) associations between nutrition knowledge, vitamin c intake, nutritional status, and blood pressure among elderly with hypertension in klaten, central java, indonesia moving home during the period of the study, (3) consumption antihypertensive drugs. face-to-face interview technique was used based on several questionnaires administered by the author. data on nutrition knowledge were collected through twelve questions that has been validated by way of a nonparametric correlation instrument. the confidentiality of personal information was assured during the interview. instrument used for data collection on vitamin c intake was performed using food frequency questionnaire (ffq) as well as the 2x24 hour food recall form. blood pressure was measured one time during the study. body weight and height were also measeured during the interview. uncontrolled hypertension is indicated with a systolic blood pressure (sbp) of >140 mm hg and diastolic blood pressure (dbp) of >90 mm hg based on the standard used by the seven joint national committee (jnc-7). the body mass index (bmi) as a ratio of weight (kg) to height (m2) was also measured in this study. patients were considered obese if the bmi was >30 kg/m2, which was based on the who criteria. :22–9 table 1 data characteristics subject characteristics average ± sd median(min-max) n sex male 17 female 108 blood pressure (mmhg) systole 162.10±16.98 80 (140–220) 125 diastole 90.58±10.43 30 (90–120) age (years) 68.46±6.66 30 (60–90) 125 body weight (kg) 52.66±11.34 73 (32–105) 125 body height (cm) 151.86±6.710 34 (136–170) 125 bmi (kg/m2) 22.71±.39.18 21 (15–36) 125 nutrition knowledge 7.89±2.541 11 (1–12) 125 level of education not attend school 39 elementary school 67 middle school 0.94±0.905 4(0–4) 11 high school 4 university 4 nutrient intake energy (calorie/day) 1122.72±523.32 1573.8 (367.45–1941.3) 125 protein (g/day) 25.31±9.58 50.2 (9.15–59.35) 125 fat (g/day) 25.10±10.47 51.96 (6.6–58.55) 125 carbohydrate (g/day) 116.19±45.99 235.15 (50–285.15) 125 vitamin c (mg/day) 41.44±55.20 508 (1–509) 125 note: bmi= body mass index *normally distributed data using normality kolmogorov-smirnov test international journal of integrated health sciences. 2018;6(1) 25 statistical tests were used to determine the relationship between nutrition knowledge, vitamin c intake, nutritional status, and blood pressure. the statistical tests used in this study were normality test descriptive statistics, pearson correlation based on data distribution, and multiple regression test. results the general characteristics of the elderly are presented in details (table 1). one hundred twenty-five participants were initially invited to participate in this study but only 17 males and 108 males, the number of a female was higher than the male participants (table 1). most of the patients were in the age range of 60–90 years old. based on the level of education, most participants were elementary school graduates. in this study, the results from the blood pressure measurement was then classified according to jnc-7 standard into degree 1 (systolic pressure of 140–159 mmhg) and degree 2 (systolic pressure of ≥160 mmhg). it turned out that the number of participants with degree 1 blood pressure was higher than those in degree 2. analysis was then performed to explore the correlation between nutrition knowledge, vitamin c intake, and nutritional status (table 2 and 3). the results showed the presence of correlations between the nutrition knowledge (p=0.002), vitamin c intake (p=0.025), and also nutritional status (p=0.039) in elderly hypertension (table 2). these correlations were also found to be statistically significant for nutrition knowledge (p=0.011), vitamin c intake (p=0.012) and nutritional status (p=0.048) (table 3). sex, age and level of education were the main variables influencing results and are shown to have a correlation with blood pressure in elderly hypertension. however, this correlation was not statistically significant. regression analysis was repeatedly done for the independent variables in the study, such as sex, age and level of education. the residual descriptive statistical test was performed by analyzing residual distribution using the kolmogorov-smirnov test. here, the residual distribution was defined by normal distribution with a mean = 0 (t test) while the t value for the blood pressure in the current study was found to be 0.404 with p>0.05 and mean=0. the residual distribution results were: nutrition knowledge = 0.515, vitamin c intake = 0.375 and nutritional status = 0.404. this showed that the residual distribution was based on a normal distribution with mean = 0. discussion most elderly participating in this study had good nutrition knowledge (table 1). results of the multivariate analysis indicate that there is a significant influence of nutrition knowledge on high blood pressure after the confounding variables were controlled (table 3). only two questions in the twelve-question nutrition knowledge questionnaire that received correct answers from less than 50% participants. the first question was regarding potassium intake through banana to reduce hypertension and the second question was about grains and nuts as the source of vitamin e. the nutrition knowledge was good because most participants answered correctly for more than 50% of the questions (10 questions). from the observation it was revealed that most elderly in this study was classified to have degree 1 blood pressure (78 of 125) that it can be concluded that the better the triagung yuliyana, kusnandar, et al. :22–9 elderly hypertension (n=125) nutrition knowledge vitamin c intake (mg/day) nutritional status(kg/m2) correlation coefficient (r) -0.471 0.410 0.323 p value 0.002 0.025 0.039 *p value <0.05 table 2 pearson correlation test between nutrition knowledge, vitamin c intake, nutritional status, and elderly hypertension 26 international journal of integrated health sciences. 2018;6(1) nutrition knowledge, the lower the degree of hypertension is in elderly. with better knowledge, it is expected that the blood pressure can be modified towards normal. this is in accordance with the notion that the level of one’s health can be determined by the level of knowledge of the person; hence, the better the level of one’s knowledge, the better the health level that person is.10 information/knowledge about nutrition was obtained through various sources. educational level, communication, information received, culture, and personal experience will affect the knowledge on health. appropriate information on hypertension provided to the elderly will give sufficient knowledge and will enable them to adopt healthy lifestyle as well as reducing the risk for degenerative diseases, especially hypertension and cardiovascular disease.3 the results of this study is in line with those of a previous study stating significant relationship between knowledge and blood pressure significantly (p=0.016) and controlled blood pressure (p=0.032).4,10 there are several ways to obtain knowledge, including trial and error, will power, personal experience, and thinking. information is one way to gain knowledge. correct information on hypertension received by elderly will provide sufficient knowledge to be able to implement healthy lifestyle.10 the level of knowledge on hypertension is related to patient’s compliance to hypertension treatment and adherence to hypertension diet.11 the implementation of a healthy lifestyle and appropriate treatment will be able to reduce the risk for hypertension and cardiovascular diseases.4 a survey in the usa among people older than 65 years found a similar knowledge level regarding lifestyle factors that may influence blood pressure but with higher knowledge level on the prevalence of knowledge on complications of untreated high blood pressure.12 awareness on hypertension increase with age among elderly, making the probability of having been identified as hypertensive rises with age. surprisingly, people that have higher educational levels were often less informed on their hypertension compared to those with an average educational level.13 elderly ignorance to nutrition may lead to malnutrition. this ignorance may start from the childhood or due to very limited education. the importance of nutritional knowledge is based on three facts: (1) sufficient nutritional status is important for health and well-being; (2) everyone will only get enough nutrition if the food he or she eats is able to provide the nutrients needed for the optimal body growth, maintenance, and energy; and (3) nutrition science provides the necessary facts so that people can learn to use food well for nutritional improvement.14 most elderly only consumes a small amount of vitamin c with only a small percentage has high vitamin c intake (table 1). this shows that the general intake of vitamin c subjects is inadequate for elderly aged 60 years and over. the multivariate analysis shows that there was a significant effect of vitamin c intake on high blood pressure after controlled by other factors (table 3). the results of the 2 x 24 hours food interviews revealed an intake of vitamin c of 56.8% less than recommended dietary allowance (rda) and the food frequency questionnaire (ffq) results presented that 125 study subjects were classified as those who frequently consume vitamin c sources, such as orange juice in 24 people (1x/week), melon in 18 people (1x /week), papaya in 30 people (1x/week), banana in 21 people (1x/ day), watermelon in 12 people (1x/week), tomatoes in 18 people (1x/week), vegetables (cassava leaves, spinach, long beans, green associations between nutrition knowledge, vitamin c intake, nutritional status, and blood pressure among elderly with hypertension in klaten, central java, indonesia :22–9 variable beta st.err. of beta b st.err. of b t p value nutrition knowledge 0.067 6.453 -2.702 1.062 -3.278 0.011 vitamin c intake (mg/day) 2.834 6.337 1.042 0.414 2.633 0.012 nutritional status (kg/m2) 1.625 3.105 0.486 0.276 -0.260 0.048 *p value <0.05 table 3 coefficient regression analysis and p value to between nutrition knowledge, vitamin c intake, nutritional status and elderly hypertension international journal of integrated health sciences. 2018;6(1) 27 triagung yuliyana, kusnandar, et al. :22–9 mustard, carrots, cabbage, white broccoli, beans, cucumbers and sprouts) in 30 people (1x/day) and in 59 people (2–3x/day). this leads to inadequate vitamin c intake, causing higher degree of hypertension. the results of this study are in line with the results of a previous studies stating that vitamin c intake is significantly associated with blood pressure (p=0.043), suggesting that inadequate vitamin c intake may lead to lipid peroxidation, increased enzyme work, and increased oxidative stress, causing blood pressure to increase.5 this is also consistent with the study stating that if a person has inadequate intake of vitamin c, it can influence the oxidative stress, weaken the immune system and increase the blood pressure.7 the results in this study were also reinforced by a statement that adequate intake of vitamin c lowers systolic and diastolic blood pressure.6 this drop in blood pressure is attributed to the antioxidant properties of vitamin c that improves the endothelial dysfunction.7 blood pressure depends on the cardiac output and total peripheral resistance. one of the main determinants of total peripheral resistance is blood viscosity.7 in one prospective cohort study performed on 2,596 study subjects with year 7 diet quality score and year 10 plasma ascorbic acid in the incident of hypertension, plasma ascorbic acid was seen to have a stronger correlation with diet quality score (pearson’s r=0.29) when compared to single fruit and vegetable intakes. the food groups with strongest correlations with plasma ascorbic acid were fruit (r=0.18) and dark green vegetables (r=0.16), while the correlation between plasma ascorbic acid and dietary vitamin c was 0.24. lower consumption of ascorbic acid is found to be associated with a higher risk for hypertension.15 in 242 subjects crossectionally studied by measuring blood pressure across quartiles of plasma ascorbic acid at the 10th annual visit, a similar effect is seen in the form of changes in systolic blood pressure, p = 0,005. this study suggested that vitamin c may be an important factor in blood pressure regulation.16 vitamin c works as an antioxidant by way of donating hydrogen from its hydroxyl group to superoxide radicals, making them harmless radicals.5 antioxidant in vitamin c is able to eliminate free radical compounds in cells in the presence of ascorbate peroxidase (apx), which is found in the form of isoenzymes in vitamin c and which plays an important role in inhibiting oxidation in the body by acting as an inhibitor.6 in the mitochondria, oxidants are reduced through the nadph oxidase process into an intermediate needed for enzyme reactions (xanthine oxidase) and endogenous antioxidant support in the form of superoxide dismutase (sod). the superoxide dismutase antioxidants convert superoxide radicals into hydrogen peroxidase. the most efficient hydrogen peroxidase is prevented by gpx enzymes that require gsh as an electron donor. gsh oxidase is then converted back into gsh with the help of glutathione reductase enzyme that converts nadph as its electron donor. some metals (fe2 +, cu + and others) may suffer from hydroperoxidase damage due to hydroxyl radicals.8 hydroxyl radicals obtain electrons from polyunsaturated fatty acids that can form lipid radicals. lipid radicals may become peroxyl radicals when they interact with oxygen. in addition, radical peroxyl, if it is not reduced by antioxidants, will become lipid peroxidase, which may trigger oxidative stress.7 most elderly subjects in the current study had normal nutritional status and only a small percentage experienced obesity (table 1). this shows that the nutritional status of the subjects of the study is generally normal. multivariate analysis have shown that nutritional status significantly influence the blood pressure (table 3). obesity seems to have an active influence on hypertension with obesity nutritional status is found to be 4.57 times higher (95% ci: 1.497–13.958) in hypertensive patients compared to those who are thin and have normal body weight after other factors are controlled.17 prevalence of overweight is associated with obesity and cardiovascular diseases. meanwhile, bmi is highly correlated with body weight and has proximity to the body energy stores, without the ability to predict the distribution of fat.18 previous studies have found a significant relationship between the nutritional status and socio economic status. elderly with low socioeconomic status is shorter and thinner than the those with moderate and high economic status.6 the same study also stated that there is a significant relationship between obesity and hypertension where individuals with obesity have 2.41 times higher risk to suffer from hypertension than individuals who are not obese.19 nutritional status significantly correlates with blood pressure after age, sex, smoking status, sodium intake, and potassium intake factors are controlled. elderly with mobility impairments have lower performance 28 international journal of integrated health sciences. 2018;6(1) references 1. ministry of health of the republic of indonesia. gambaran kesehatan lanjut usia di indonesia. 1st ed. jakarta: buletin jendela data dan informasi kesehatan; 2013. 2. paul mc, barrett b, daichi s. systolic blood pressure goals to reduce cardiovascular disease among older adults. am j med sci. 2014;348(2):129–134. 3. ding m, huang t, bergholdt hk, nordestgaard bg, ellervik c, qi l, et al. dairy consumption, systolic blood pressure, and risk of hypertension: mendelian randomization study. bmj. [serial on the internet]. 2017 mar [cited 2017 apr 20];356(1000):[about 10p.]. available from: http://www.bmj.com/ content/356/bmj.j1000.long. 4. anthony jv, lauren wc. madeline m, philip ds. high blood pressure knowledge among primary care patients with known hypertension: a north carolina family medicine research network (nc-fm-rn) study. j am board fam med. 2008;21(4):300–8. 5. chen st, maruthur nm, appel lj. the effect of dietary patterns on estimated coronary heart disease risk results from the dietary approaches to stop hypertension (dash) trial. circ cardiovasc qual outcomes. 2010; 3(5):484–9. 6. costa bvl, fonseca lm, lopes acs. nutritional status and associated factors in institutionalized elderly. j nutr disorders ther. 2012; 2(3):1–5. 7. yokoyama y, nishimura k, barnard nd, takegami m, watanabe m, sekikawa a, et al. vegetarian diets and blood pressure: metaanalysis. jama intern med. 2014;174(4):577– 87. 8. stephen pj, eliseo g, lawrence ja, edgar rm. meta-analysis of vitamin c and blood pressure. am j clin nutr. 2012;95(5):1079–88. 9. utsugi mt, ohkubo t, kikuya m, kurimoto a, sato ri, suzuki k, et al. fruit consumption and risk of home hypertension. hypertens res. 2008; 31(7):1435–43. 10. anthony jv, lauren wc, philip ds. blood pressure knowledge among hypertensive patients. j am board fam med. 2008; 21(4):300–8 11. ina q, marie dt, jes sl, hans i, jeroen mlh, lars f, et al. self-reported knowledge and awareness about blood pressure and hypertension: a cross-sectional study of a random sample of men and women aged 60–74 years. clin epidemiol. 2014;6(3):81–7. 12. asgedom sw, gudina ek, desse ta. assessment of blood pressure control among hypertensive patients in southwest ethiopia. plos one. 2016;1(11):1–12. 13. macia e, duboz p, gueye l. prevalence, awareness, treatment and control of hypertension among adults 50 years and older in dakar, senegal. cardiovasc j afr. 2012; 23(5):265–9. 14. ijarotimi os, keshinro oo. nutritional knowledge, nutrients intake and nutritional status of hypertensive patients in ondo state, nigeria. tanzan j health res. 2008; 10(2): 59– 67 15. buijsse b, jacobs drj, steffen lm, kromhout d, gross md. plasma ascorbic acid, a priori diet quality score, and incident hypertension: a prospective cohort study. plos one. 2015; 10(12):1–13. 16. gladys b, christopher dj, edward pn, mark h, patricia bc. vitamin c in plasma is inversely related to blood pressure and change in blood pressure during the previous year in young black and white women. nutr j. 2008;7(35):1– 9. 17. macia e, gueye l, duboz p. hypertension and obesity in dakar, senegal. plos one. 2016; 11(9):1–14. 18. wilbert sa. association of obesity with hypertension. ann transl med. 2017;5(17):350. 19. wang sk, ma w, wang s, yi xr, jia hy, xue f, et al. obesity and its relationship with hypertension among adults 50 years and older in jinan, china. plos one. 2014;9(12):1–10. 20. maeve r, phyo k, heiko m, anne m, pooler r, associations between nutrition knowledge, vitamin c intake, nutritional status, and blood pressure among elderly with hypertension in klaten, central java, indonesia :22–9 in the ability to perform activities of daily living and greater dependence on care, including for getting meals and purchasing food.20 it is concluded that the majority of subjects in this study have good nutrition knowledge, low vitamin c intake, and normal nutritional status based on bmi. elderly with hypertension may associate with female sex, older age, lower vitamin c intake, lower bmi, and lower educational level. international journal of integrated health sciences. 2018;6(1) 29 archbold, helene mn, chris cp, et al. nature or nurture; bmi and blood pressure at 90. indings from the belfast elderly longitudinal freeliving aging study (belfast). age (dordr). 2009;31(4):261–7. triagung yuliyana, kusnandar, et al. :22–9 vol 9 no 1 2021 (2).indd 36 international journal of integrated health sciences (iijhs) glioblastoma following hemorrhagic stroke: a case report abstract objective: to report a glioblastoma (gbm) case preceded by a hemorrhagic stroke. methods: this case reported a 53-year-old male presenting at at murni teguh memorial hospital, medan, indonesia, with a chief complaint of an altered mental state. the condition had been worsened for two weeks. on anamnesis, he was identified to have experienced intracerebral hemorrhage in january 2020. a follow-up head computed tomography scan was conducted in september 2020, showing a normal condition of the brain. other oncogenic risk factors were not found. due to convulsion in october 2020, the patient underwent a magnetic resonance imaging examination showing a cystic right temporoparietooccipital lesion and cerebral edema. craniotomy tumor removal surgery was performed while the tumor was further examined for histopathological findings. the tumor was diagnosed as glioblastoma with microvascular proliferation and palisading necrosis. results: there was some associations between hemorrhagic stroke and glioblastoma development. conclusion: gbm preceded by hemorrhagic stroke is a rare case that can be diagnosed thoroughly by complete clinical and adjunct examinations. keywords: brain tumor, glioblastoma, hemorrhagic stroke received: september 21, 2020 accepted: march 30, 2021 correspondence: bayu dewanto, department of neurosurgery, murni teguh memorial hospital, medan, indonesia e-mail: bayudewanto02@yahoo.com case report kevin,1 zulham yamamoto,2 bayu dewanto3 1murni teguh memorial hospital medan, indonesia, 2department of histology, faculty of medicine, universitas sumatera utara, indonesia, 3neurosurgery department murni teguh memorial hospital, indonesia pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ ijihs.v9n1.2142 ijihs. 2021;9(1):36–41 introduction stroke is a type of neurovascular disease that still remains as one of the major causes of disability, morbidity, and mortality in indonesia.1 indonesian basic health research (riset kesehatan dasar) in 2018 reported that the prevalence of stroke increased as compared to 2013.2 stroke is classified into ischemic and hemorrhagic one while the manifestation itself depends on the brain area involved. ischemic stroke occurs when brain blood vessels were, either partially or totally, occluded by thrombus or embolus. on the other hand, hemorrhagic stroke occurs when the blood vessels in brain parenchyma rupture and the blood disseminates into subarachnoid space.3 furthermore, ruptured blood vessels induce hypoxic condition in the distal area of the ruptured vessels due to diminished blood vessels capability in delivering oxygenated blood. hence, this hypoxic area lately may cause other brain cellular changes since neurons are highly oxygen-dependent cells in nature.1 glioblastoma (gbm) is one of the most common primary malignant brain tumors. due to its distinct biology and recurrence rate, the disease prognosis is poor despite optimal treatment such as surgical resection and aggressive adjuvant treatment were conducted.4 gbm showed angiogenesis induced by vascular endothelial growth factor hypersecretion implying its invasiveness character. correspond to its invasiveness nature, this tumor is challenging to be resected totally.5 the advances of gbm international journal of integrated health sciences (iijhs) 37 biology and pathophysiology are critical to allow various novel therapeutic modalities including targeted therapy, gene therapy, and immunotherapy.4 gbm and hemorrhagic stroke are two different diseases. the gbm risk may increase in hemorrhagic stroke patients.6 this study reported a case of 53-year-old male diagnosed with gbm with a hemorrhagic stroke history. case an otherwise healthy 53-year-old male revealed that in 2 january 2020 he had brain surgery. before that time, he presented spontaneous loss of consciousness and, subsequently, was diagnosed with intracerebral hemorrhage based on head ct scan examination (fig. 1). decompressive craniectomy was done for the lesion and skull reimplantation was performed 3 months afterward. he received a standardized herbal medicine namely neuroaid®. after skull reimplantation, he fully recovered and completed the treatment. in september 2020, a follow up head ct scan was performed and the conclusion was normal (fig. 2). in october 2020, he presented 2-weeks history of progressively worsening convulsion, and described it as rigidity in his body and drop afterward. following convulsion, he vomited in projectile description, suggesting an intracranial mass. the complaint did not precede by any other situation or condition. oncogenic risk factors, such as genetic predisposition, previous head injury, and exposure of oncogenic agent (pesticide, rubber, radiation, and smoke) were not found in this patient. physical examination demonstrated somnolence sensorium with glasgow comma scale score of 12 (e4m4v4), blood pressure of 150/90 mmhg, weakness on left extremities, and right temporal craniotomy scar. patient arrived at the hospital with the karnofsky performance status scale of 40. this study was performed preoperative contrast-enhanced brain magnetic resonance fig. 1 head ct scan showed an intracranial hemorrhage in right parietooccipital region with midline shift kevin, zulham yamamoto, et al. 38 international journal of integrated health sciences (iijhs) fig. 2 follow up head ct scan showed post right parietal decompressive craniotomy with normal brain imaging finding fig. 3 preoperative mri showed cerebral tumor on the right temporoparietooccipital region that extend to right cerebellum with extracranial protrusion from craniotomy remnant glioblastoma following hemorrhagic stroke: a case report international journal of integrated health sciences (iijhs) 39 imaging (mri). the radiological examination demonstrated a 6.8 × 7.1 x 8.6 cm cystic right temporoparietooccipital lesion. the lesion was surrounded by area of heterogeneous contrast enhancement extending to the right corona radiata and periventricular white matter that is associated with cerebral edema (fig. 3). furthermore, a mass extension to right brain stem was found. craniotomy tumor removal procedure was performed at supine position. surgery was performed with incision in the previous surgical site. after opening the dura mater and bleeding control, the tumor was then removed by using piecemeal manner. the tumor removal procedure was completed but not all the tumor mass was technically resectable due to the brain stem tumor extension. the tumor had characteristic of cystic, grey and black in color, and can be suctioned during operation. the patient was hemodynamically stable during the surgery and transferred to intensive care unit for post-operative care. his condition improved post-operatively and later he was discharged from hospital. the biopsy specimen was sent for histopathology examination. histopathological examination concluded that the brain tumor was glioblastoma with microvascular proliferation and palisading necrosis (fig. 4). discussion epidemiological studies showed increased brain tumor incidence in previously stroke or head injury patients. previously stroke patients could increase brain tumor development risk.7 ruptured blood vessels in hemorrhagic stroke result in decrease in cerebral blood flow, a mechanism for reducing bleeding, and if the hypoperfusion persists beyond several minutes, brain ischemia arises and brain cells hypoxia ensues.8 hypoxic condition may induce brain mesenchymal cells changes into glioma cells.9 ngb overexpression promoted the proliferation of neural progenitor cells (npc), enhanced neuronal differentiation of cultured npc under differentiation conditions, promotes neurogenesis in mice brain after stroke.10 gbm can also considered to be developed after infarction that could possibly arising from glial scar. hence, reactive gliosis may lead to brain tumor development, as gbm proposed to be originated from glial progenitor cells and reactive astrocytes, a type of neuroglia.11 when brain undergo hypoxia, neuroglobin (ngb) is expressed by neuronal and neuroglial cells in order to increase brain cells survival.1 ngb, the heme-containing protein, is involved in metabolism of reactive nitrogen and oxygen species as well as in intracellular signaling pathways.12 in cultured neural (hn33) cells lentiviral vector-mediated overexpression of the hypoxia inducible factor (hif-1α) subunit, increased expression of hif-1α was associated with an ∼2-fold increase in the expression of ngb.13 vegf and epo contribute to hypoxiainduced ngb up-regulation. in cortical neuron cultures, administration of vegf increased ngb protein expression however ngb overexpression in turn suppressed vegf fig. 4 histopathological appearance of the resected specimens showed the palisading necrosis (a) garland pattern of microvascular proliferation; (b) and glomeruloid pattern of microvascular proliferation; (c) magnification 100x, he staining kevin, zulham yamamoto, et al. 40 international journal of integrated health sciences (iijhs) expression.14 this may explain the palisading necrosis and microvascular proliferation in gbm histopathological examination (fig. 4). the ngb expression also increased in human glioblastoma cells during hypoxia in vitro.10 furthermore, ngb increase tumor survival capability via ngb ability to enhance proliferation and inhibit apoptosis by regulating phosphatidylinositol 3-kinase (pi3k)/akt pathway. the roles of pi3k/ akt pathway in cell proliferation, apoptosis resistance, and cell cycle progression of glioma cells, includes mtor, bax, cyclin d1, bcl-2, and bcl-2-like 1. mtor promotes cell survival and proliferation in glioma cells. altered expression of bcl-2/bax has an association with altered levels of glioma cells apoptosis.9 in cultured mouse astrocytes, ngb blocks the stimulation of bax (pro-apoptotic) and the inhibition of bcl-2 (anti-apoptotic) expression induced by oxidative stress, and subsequently eliminates caspase 3 activation.15 astrocytes have the capabilities to mount antioxidative responses that allow astrocytes to cope with an ischemic environment. ischemic condition then could activate astrocytes ischemic tolerance that further reduce future ischemic episodes damage from sub threshold ischemic insults. area of focal brain hypoxia correlates with area of infarction that could be due to impaired reactive oxygen species elimination that result from lack of vimentin and glial fibrillary acidic protein (gfap). gfap upregulation indicates astrocytes reactivity found in vast neuropathology conditions such as stroke, neurotrauma, brain tumor, perinatal asphyxia, epilepsy, parkinson’s disease, alzheimer’s disease, or multiple sclerosis.11 in an injured brain, glial cells express glial cell-derived neurotrophic factor (gdnf) de novo. in addition, neuroinflammation has been reported to induce gdnf expression in activated astrocytes and microglia, infiltrating macrophages, nestin-positive reactive astrocytes, and neuron/glia (ng2) positive microglia-like cells.16 the potential of ngb in astrocytes proliferation remains unclear. after brain injury, reactive astrogliosis showed molecules expression changes and astrocytes hypertrophy proliferation. therefore, tissue damage and inflammation results in areas of glial scar, proliferating astrocytes, fibromeningeal cells and other glial cells, as well as collagen deposition in extracellular matrix.17 in conclusion, gbm case preceding hemorrhagic stroke is rarely reported and hard to be diagnosed. in this case report study, gbm diagnosis in this patient was confirmed by histopathological examination postoperatively. 1. mudjihartini n, nurhayati l, saekhu m, jusman s, purba j, sadikin m. responses of brain tissues against hypoxic condition in hemorrhagic stroke patients: neuroglobin expression in brain tissue and plasma. asian j pharmaceutic clin res. 2017; 10(2):5–7. 2. kementerian kesehatan republik indonesia. hasil utama riskesdas 2018. jakarta: kementerian kesehatan badan penelitian dan pengembangan; 2018. 3. kuriakose d, xiao z. pathophysiology and treatment of stroke: present status and future perspectives. int j mol sci. 2020;21:2–3. 4. wilson ta, karajannis ma, harter dh. glioblastoma multiforme: state of the art and future therapeutics. surg neurol int. 2014;5:64. 5. lara-velazquez m, al-kharboosh r, jeanneret s, vazquez-ramos c, mahato d, tavanaiepour d, et al. advances in brain tumor surgery for glioblastoma in adults. brain sciences. 2017;7(166):1–16. 6. hu j, cao x, pang d, luo q, zou y, feng b. tumor grade related expression of neuroglobin is negatively regulated by pparγ and confers antioxidant activity in glioma progression. redox biology. 2017;12:682–9. 7. chen c, cheng t, ho c, wang j, weng s, hou y. increased risk of brain cancer incidence in stroke patients: a clinical case series, population-based and longitudinal followup study. oncotarget. 2017;8(65):108989– 99. 8. ostrowski r. stępień k. pucko e, matyja e. the efficacy of hyperbaric oxygen in hemorrhagic stroke: experimental and clinical implications. arch med sci. 2017;13(5):1217–23. 9. wojtasiewicz t, ducruet a, noticewala s, canoll p, mckhann g. de novo glioblastoma in the territory of a prior middle cerebral artery infarct. case rep neurol med. 2013;2013:356526. 10. yu z. cheng c. liu y. liu n. lo e, wang x. neuroglobin promotes neurogenesis references glioblastoma following hemorrhagic stroke: a case report international journal of integrated health sciences (iijhs) 41 through wnt signaling pathway. cell death dis. 2018;9(10):1–12. 11. zhang b. liu y. li y. zhe x. zhang s, zhang l. neuroglobin promotes the proliferation and suppresses the apoptosis of glioma cells by activating the pi3k/akt pathway. mol med rep. 2018;17(2):2757–63. 12. alekseeva o. grigor’ev i, korzhevskii d. neuroglobin, an oxygen-binding protein in the mammalian nervous system (localization and putative functions). j evolutionary biochem physiol. 2017; 53(4):249–58. 13. haines b, demaria m, mao x, xie l, campisi j, jin k. et al. hypoxia-inducible factor-1 and neuroglobin expression. neurosci lett. 2012;514(2):137–40. 14. qiu x, chen x. neuroglobin–recent developments. biomol concepts. 2014;5(3):195–208. 15. amri f, ghouili i, amri m, carrier a, masmoudi-kouki o. neuroglobin protects astroglial cells from hydrogene-peroxide induced oxidative stress and apoptotic cell death. j neurochem. 2017;140:151–69. 16. xu h, rahimpour s, nesvick c, zhang x, ma j, zhang m, et al. activation of hypoxia signaling induces phenotypic transformation of glioma cells: implications for bevacizumab antiangiogenic therapy. oncotarget. 2015;6(14):11882–93. 17. cheng xy, wang j, sun x, shao ls, guo zy, li y. morphological and functional alterations of astrocytes responding to traumatic brain injury. j integr neurosci. 2019;18(2):203–15. kevin, zulham yamamoto, et al. volume 9 no 2 2021 fix.indd 60 international journal of integrated health sciences (iijhs) correlation between serum interleukin-6 level and modified rodnan skin score in systemic sclerosis patients abstract objective: to determine the correlation between serum levels of il-6 and mrss in systemic sclerosis patients. methods: this was a crossectional observational study on patients with ssc visiting the rheumatology clinic of dr. hasan sadikin general hospital bandung, indonesia from january 2019 to december 2020. registered ssc patients, with validated mmrs by a rheumatologist, and available biological materials for il-6 measurement were included. patients with other autoimmune diseases, acute infection, diabetes mellitus, and obesity were excluded from this study results: of the 51 ssc patients, 42 patients met the inclusion criteria. women comprised the majority of these patients (95.2%), while patients’ mean age was 43±12 years. the mean duration of disease was 20 months, with diffuse ssc (78.6%) as the most frequent type. bivariate analysis showed that il-6 was positively correlated with mrss (100-scale) with r=0.397 and p=0.005. conclusion: there is a medium positive correlation between mrss and interleukin-6 serum among systemic sclerosis patients visiting dr. hasan sadikin general hospital bandung, indonesia. keywords: disease activity interleukin-6, modified rodnan skin score, systemic sclerosis received: july 3, 2021 accepted: september 30, 2021 original article dania artriana riswandi, sumartini dewi, andri reza rahmadi department of internal medicine, faculty of medicine universitas padjadjaran-dr. hasan sadikin general hospital bandung, indonesia pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ ijihs.v9n2.2478 ijihs. 2021;9(2):60–65 correspondence: dania artriana, department of internal medicine, faculty of medicine universitas padjadjaran-dr. hasan sadikin general hospital bandung, indonesia, e-mail: daniaartriana@yahoo.com introduction systemic sclerosis is a chronic systemic autoimmune disease affecting multisystem connective tissue characterized by fibrosis of the skin and visceral organs and microvascular abnormalities. to date, the etiology of ssc is still unknown, and the clinical course of the disease is unpredictable. extensive and progressive organ fibrosis may occur. systemic sclerosis has the potential to become a severe and life-threatening connective tissue disease.1 systemic sclerosis is a sporadic disease with a worldwide distribution and affects all races.2 the number of ssc cases in indonesia is increasing every year. a prior research conducted at hasan sadikin general hospital, indonesia, in 2014 has shown a significant increase in visits by patients with connective tissue disease from 51.2% to 63.5% of the total annual visits before and after the national health insurance policy. based on these data, ssc ranks the third most common connective tissue disease after systemic lupus erythematosus (sle) and rheumatoid arthritis (ra).3 systemic sclerosis can cause progressive multiorgan fibrosis with a high mortality rate. assessment of disease activity is an important aspect of patient management and can be assessed using simple clinical parameters. international journal of integrated health sciences (iijhs) 61 modified rodnan skin score is the most widely used clinical parameter for assessing skin fibrosis. modified rodnan skin score has some limitations. the examination is subjective and not sensitive enough to assess small changes since the changes are recognized after three to six months. therefore, biological markers that can support mmrs are needed to assess disease progress more objectively, quantitatively, sensitively, and quickly, especially assessing fibrosis, which is a significant factor in the clinical course.1,4,5 interleukin-6 is a pro-inflammatory cytokine that plays an essential role in the pathogenesis of ssc. overproduction of il-6 activates fibroblast, which results in cell proliferation and migration accompanied by increased cytokine production. cell differentiation into myofibroblasts can also occur. fibroblasts can activate the il-6 gene, which results in increased il-6 production. this cycle continues to repeat, resulting in a vicious cycle or fibrosis cascade. the process can be permanent and progressive, leading to tissue accumulation and fibrosis.6 interleukin-6 has potential as a marker of disease activity. this study aims to determine the correlation between serum levels of il-6 and mrss in ssc patients. this research is expected to provide information about the role of il-6 to measure disease activity and as a more objective and rapid therapeutic target. methods this was an observational study with a cross-sectional method in patients with systemic sclerosis. data is retrieved based on the systemic sclerosis registry. all patients were treated in the rheumatology clinic of hasan sadikin general hospital from january 2019 to december 2020. the diagnosis of ssc was based on the american college of rheumatology/european league against rheumatism (acr/eular) 2013. patient data listed on the ssc registry with mmrs validated by a rheumatologist and available biologic material in the form of serum for measurement of il-6 was included. patients with other autoimmune diseases, acute infection, diabetes mellitus, and obesity were excluded from this study. this study had received approval from the health research ethics committee of hasan sadikin general hospital, ethical number lb.02.01/x.6.5/44/2021. interleukin-6 measurements were done in the clinical pathology laboratory of hasan sadikin general hospital. materials were stored at a temperature of -80⁰c. serum sampling and biological material were storaged immediately after the mmrs examination. examination of il-6 using the human il-6 elisa kit (elabscience®) with the sandwich elisa method. continuous variables with normal distribution were presented as mean and standard deviation (sd). otherwise, it was reported as median and range. categorical variables were described as numbers (percentage). log transformation was conducted for il-6 serum levels. the mrss was transformed to a scale of 100. the correlation between il6 and mmrs was assessed using pearson’s correlation test. results there were 51 ssc patients from january 2019 figure scatter plot diagram between il-6 and mrss shown that mmrs and il-6 have a weak positive correlation dania artriana riswandi, sumartini dewi, et al 62 international journal of integrated health sciences (iijhs) table 1 patient’s characteristic variables number (%) a (n=42) age (years), mean ± sd 43±12 gender men 2 (4,8) women 40 (95.2) ethincity sundanese 39 (92.9) others 3 (7.1) subtype diffuse ssc 33 (78.6) limited ssc 9 (21.4) duration of illness (months), median (range) 30 ( 4–180 ) treatment history methylprednisolone 36 (85.7) methotrexate 33 (78.6) mycophenolate mofetil 2 (4.8) azathioprine 2 (4.8) cyclosporine 1 (2.4) nifedipine 11 (26.2) diltiazem 18 (42.9) cyclophosphamide 7 (16.7) mrss, median (range) 19 ( 2 – 45 ) mrss (100-scale), mean±sd 37±20 il-6 serum (pg/ml), median (range) 15.72 ( 1.79–246.69 ) a) otherwise presented; sd: standard deviation; mrss: modified rodnan skin score: il: interleukin table 2 the association between il-6 and mrss (100-scale) variable mrss (100-scale) r p-value interleukin-6 seruma (pg/ml) 0,397 0,005* a) log-transformation; mmrs: modified rodnan skin score to december 2020. nine patients were excluded due to overlap autoimmune syndrome. a total of 42 patients met the inclusion criteria. most of the patients were women (95.2%), with a mean age of 43±12 years. the mean duration of disease was 20 months, with diffuse ssc (78.6%) as the most frequent type. a total of 36 subjects (85.7%) received methylprednisolone. other treatments administered included methotrexate (78.6%), diltiazem (42.9%), nifedipine (26.2%), mycophenolate mofetil (4.8%), azathioprine (4.8%), and cyclosporine (2.4%). seven patients had received chemotherapy with cyclophosphamide. patient’s characteristic is shown in table 1. the median of mmrs was 19 (2 – 45) with a mean of 100-scale of 37±20. serum levels of il-6 were (15.72 (1.79–246.69) pg/ml. bivariate analysis showed il-6 was positively correlation between serum interleukin-6 level and modified rodnan skin score in systemic sclerosis patients international journal of integrated health sciences (iijhs) 63 correlated with mrss (100-scale) with r=0.397 (figure 1) and p=0.005 (table 2). discussion this study showed mean age was 43±12 years at the time of mmrs examination and serum collection. ssc mainly occurs in the fourth to fifth decades of life. the results follow other studies conducted by sato et al.7, which found the mean age of ssc was 47±18. on the other hand, muangchan et al.8 in canada found the mean age of 55.39±12.13 years. the mean age differences in specific populations may be influenced by racial differences resulting in differences in autoantibody expression and genetic factors that play a role in the pathophysiology of systemic sclerosis. the incidence of ssc tends to be more common in older people in caucasians than asians.9 systemic sclerosis occurs more frequently in women. a previous study conducted by sato et al.7 and royce et al.10 (83.2%) found women were more likely affected with proportion 90.62% and 83.2%, respectively. in men, the incidence of ssc is higher in the european than asian. women were more likely to develop ssc. several reasons can cause this, one of which is genetic factors, namely the irak1 genes, x-linked genes that influence the pathogenesis of ssc 11 most of the patients had diffuse systemic sclerosis (78.6%). these results were similar to komura et al.12, which found the prevalence of diffuse ssc was 55%, while another study by muangchan et al.8 in kanada found limited ssc was more common (62%). the type of ssc difference can be caused by ethnicity and skin color. patients with darker skin color tend to have more severe manifestations resulting in diffuse skin and lung involvement. another possible cause is antibodies involved, one of which is the anti-fibrillarin antibody (afa). afa is found more frequently in blacks and is associated with diffuse skin and internal organ involvement.2 the median duration of illness in this study was 30 months. the treatment follows the recommendations from eular and is adjusted based on the patient’s clinical manifestations.13 corticosteroids were the most commonly given treatment. the use of corticosteroids is based on the fact that an inflammatory component in systemic sclerosis may cause skin and musculoskeletal involvement. corticosteroids can reduce pain and itching of the skin and reduce musculoskeletal symptoms such as arthralgia and myalgia, which are also caused by inflammation.14 based on this, in this study, corticosteroids were still the most widely administered treatment (85.7%). however, there is still controversy in the use of corticosteroids in ssc patients. although corticosteroids can suppress the musculoskeletal manifestations and pruritus that are very disabling in early disease, patients with early dcssc are those at high risk of developing scleroderma renal crisis.14 methotrexate is the most commonly used disease modifying anti-rheumatic drugs or dmard (78.6%). methotrexate is the firstline treatment for skin involvement and inflammatory arthritis. calcium channel blockers such as diltiazem and nifedipine were administered to patients with raynaud’s phenomenon accounting for 42.9% and 26.2% of patients, respectively. calcium channel blockers are the first-line treatment for patients with raynaud’s phenomenon and digital ulcers because of their vasodilator effect.13 the median of mrss in this study was 19 (2 –45). this result is higher compared to a study by muangchan et al.8 in canada, which found the mean of mmrs was 10.04±9.54. however, this results are almost identical to those of komura et al.12 and sato et al.7 in japan, with a mean mmrs of 19.7±4.2 and 19.1±8.6, respectively. asians have higher mrss scores than caucasians or europeans. patients with darker skin color tend to have more severe manifestations resulting in more diffuse skin involvement.2 the median of interleukin-6 was 15.72 pg/ml, with a range of 1.79 – 246.69 pg/ml. these results are consistent with khan et al.15, which obtained a mean il-6 of 14.39, a median of 10.1, and a range of 3.23-51.3 pg/ml but higher than a study by sato et al. al.7 with a mean of 3.5 ± 8.5. the high levels of il-6 in this study contradict previous studies, which stated that pro-inflammatory levels in asians were lower than caucasians and african-americans. 16 varied il-6 levels in systemic sclerosis, which are characterized by high ranges and standard deviations, are not only influenced by racial differences but may also be caused by other diseases that have not been detected, such as under stress conditions that occur in tissue damage, infection, or inflammation and chronic disease.16,17 the wide range of values of il-6 can affect the strength of the correlation because the value of r in the correlation test is strongly influenced by outliers. analysis showed there was a significant dania artriana riswandi, sumartini dewi, et al 64 international journal of integrated health sciences (iijhs) 1. christian b, distler o, jorg hw, distler jh. scleroderma from pathogenesis to comprehensive management. 2nd ed. usa: springer; 2013. p. 285-8. 2. reveille jd. ethnicity and race and systemic sclerosis: how it affects susceptibility, severity, antibody genetics, and clinical manifestations. curr rheumatol rep. 2003;5(2):160–7. 3. mulasimadhi k, wachjudi rg, rahmadi ar. perubahan pola penyakit pasien di klinik reumatologi rsup dr. hasan sadikin sebelum dan sesudah era jaminan kesehatan nasional. rematologi klinik bandung bandung; 2015. 4. valentini g, iudici m, walker ua, jaeger vk, baron m, carreira p, et al. the european scleroderma trials and research group (eustar) task force for the development of revised activity criteria for systemic sclerosis: correlation between mrss and interleukin-6 serum with r=0.397 and p=0.005. these results are similar to the study of khan et al.15, which found a positive correlation between il-6 and mrss with r=0.514 and p=0.000 at the time of the first visit. after 36 months of follow-up, there was still a positive correlation between il-6 at the first visit and mrss with r=0.795 and p <0.001, indicating a very strong correlation. interleukin-6 may predict disease progression in the next three years. however, the study did not mention the intervention given in three years.15 a prior study conducted by sato et al.7 also found a positive correlation between serum interleukin-6 levels and mrss with r=0.625 and p <0.0001, which also showed a strong correlation between the two variables. hax et al.18 also reported a positive correlation between serum interleukin-6 levels and mrss, although with a weak relationship with r=0.291 and p=0.041. on the other hand, hasegawa et al.19 showed no significant correlation between serum interleukin-6 and mrss. these results may be due to the method used to detect serum chemokines and cytokines that are less sensitive so that serum il-6 in most patients and controls cannot be detected. interleukin-6 is a pro-inflammatory cytokine produced by many immune cells and plays a role in t cell activation. il-6 also stimulates hematopoietic precursors that cause b cell maturation into antibody-producing cells and cell differentiation. therefore, il-6 is elevated in most autoimmune diseases such as systemic sclerosis, rheumatoid arthritis, systemic lupus erythematosus, and psoriasis. 20 interleukin-6 can also be elevated in stressful conditions such as tissue damage, infection, inflammation, and chronic diseases such as malignancy, castleman disease, multiple myeloma, anemia in chronic disease, crohn’s disease, alzheimer’s disease, idiopathic juvenile arthritis, ankylosing spondylitis, diabetes mellitus, and obesity.17 given the number of diseases that can increase il-6, complete exclusion criteria would increase the accuracy of the correlation between il-6 and mrss. the different results between our study and previous studies may be due to the exclusion criteria used. in the study conducted by khan et al.15, no other diseases were excluded that could increase the il-6 concentration. in the study of sato et al.7, which had a strong correlation, only patients who had other rheumatic diseases were excluded and still included patients with sjogren’s syndrome. in the study conducted by hax et al.18, which had a weak correlation, the exclusion criteria used included: patients who had overlap syndrome, lymphoproliferative disease, cancer, and acute infections such as hiv, hepatitis b, or hepatitis c but did not mention the exclusion criteria for subjects with other chronic diseases. in our study, subjects with other autoimmune conditions, acute infection, diabetes mellitus, and obesity were excluded. thus, the fewer exclusion criteria applied, the stronger the correlation. this shown il-6 increased can be caused by many factors. limitation of this study is most patients had received therapy that may affect interleukin-6 and mrss. further studies are needed with a larger population and sample with stricter exclusion criteria and in patients who have not received therapy since a larger nunber of samples will overcome the problem of outliers. interleukin-6 was significantly correlated with mrss in patients with systemic sclerosis, reflecting disease activity. il-6 and mrss had a medium positive correlation with r=0.397 and p=0.005. references correlation between serum interleukin-6 level and modified rodnan skin score in systemic sclerosis patients international journal of integrated health sciences (iijhs) 65 derivation and validation of a preliminarily revised eustar activity index. ann rheum dis. 2017;76(1):270–6. 5. muangchant c, pope j. il-6 in scleroderma; potential implications for targeted therapy: a systematic analysis. j rheumatol. 2012;39(6):1120–4. 6. wynn ta, ramalingam tr. mechanisms of fibrosis: therapeutic translation for fibrotic disease. nat med. 2012;18(7):1028–40. 7. sato s, hasegawa m, takehara k. serum levels of interleukin-6 and interleukin-10 correlate with total skin thickness score in patients with systemic sclerosis. j dermatol sci. 2001;27(2):140–6. 8. muangchan c, harding s, khimdas s, bonner a, group csr, baron m, et al. association of c-reactive protein with high disease activity in systemic sclerosis: results from the canadian scleroderma research group. arthritis care res (hoboken). 2012;64(9):1405–14. 9. alba ma, velasco c, simeón cp, fonollosa v, trapiella l, egurbide mv, et al. earlyversus lateonset systemic sclerosis: differences in clinical presentation and outcome in 1037 patients. medicine (baltimore). 2014;93(2):73–81. 10. royle jg, lanyon pc, grainge mj, abhishek a, pearce fa. the incidence, prevalence, and survival of systemic sclerosis in the uk clinical practice research datalink. clin rheumatol. 2018;37(8):2103–11. 11. dieude p, bouaziz m, guedj m, riemekasten g, airo p, müller m, et al. evidence of the contribution of the x chromosome to systemic sclerosis susceptibility: association with the functional irak1 196phe/532ser haplotype. arthritis & rheumatism. 2011;63(12):3979– 87. 12. komura k, fujimoto m, matsushita t, yanaba k, kodera m, kawasuji a, et al. increased serum soluble cd40 levels in patients with systemic sclerosis. j rheumatol. 2007;34(2):353–8. 13. kowal-bielecka o, fransen j, avouac j, becker m, kulak a, allanore y, et al. update of eular recommendations for the treatment of systemic sclerosis. ann rheum dis. 2017;76(8):1327– 39. 14. herrick al. controversies on the use of steroids in systemic sclerosis. j scleroderma related disorders. 2017;2(2):84–91. 15. khan k, xu s, nihtyanova s, derrett-smith e, abraham d, denton cp, et al. clinical and pathological significance of interleukin 6 overexpression in systemic sclerosis.ann rheum dis. 2012;71(7):1235–42. 16. coe cl, love gd, karasawa m, kawakami n, kitayama s, markus hr, et al. population differences in proinflammatory biology: japanese have healthier profiles than americans. brain behav immun. 2011;25(3):494–502. 17. tanaka t, narazaki m. interleukin-6 inhibition in inflammatory diseases: results achieved and tasks to accomplish. j scleroderma related disorders. 2017;2(2_suppl):s20–8. 18. hax v, gasparin aa, schneider l, monticielo oa, soares hmf, streit mda, et al. vitamin d and cytokine profiles in patients with systemic sclerosis. j clin rheumatol. 2020;26(7):289– 94. 19. hasegawa m, fujimoto m, matsushita t, hamaguchi y, takehara k, sato s. serum chemokine and cytokine levels as indicators of disease activity in patients with systemic sclerosis. clin rheumatol. 2011;30(2):231–7. 20. muangchan c, pope je. interleukin 6 in systemic sclerosis and potential implications for targeted therapy. j rheumatol. 2012;39(6):1120–4. dania artriana riswandi, sumartini dewi, et al vol 10 no.1 2022 rev.2.indd international journal of integrated health sciences (iijhs) 1 renal parameters in mild, moderate, and chronic cigarette smokers abstract objective: to explore the link between cigarette smoking and kidney function through renal parameter assessment. methods: the present study was performed at the department of biochemistry santosh medical college, ghaziabad, india, from september 2019 to april 2021. in this study, 140 subjects were included, out of which 35 were non-smokers, 35 smoked <5 cigarette per day, 35 smoked 5–10 cigarette per day, and the remaining 35 smoked more than 10 cigarettes per day. results: blood urea, serum creatinine, urinary albumin, and uacr levels were found to increase significantly (p<0.001) in smokers as compared to non-smokers. these increases were higher among chronic cigarette smokers (p<0.001) as opposed to mild and moderate smokers. in contrast, serum uric acid, e-gfr, and urinary creatinine levels decreased significantly (p<0.001) in smokers when compared to non-smokers, with a higher decrease observed in chronic cigarette smokers (p<0.001) as opposed to the mild and moderate cigarette smokers. conclusion: alterations in urinary albumin, serum urea, serum creatinine, urinary creatinine, and e-gfr are associated with the risk of renal dysfunction. keywords: albuminuria, cigarette smokers, e-gfr, kidney function, uacr received: october 7, 2021 accepted: january 19, 2022 correspondence: sumesh prasad sah, muzaffarnagar medical college campus, muzaffarnagar, uttar pradesh, india e-mail: sumesh.sah@gmail.com original article dinesh kumar,1 preeti sharma,2 sudeep kumar,1 sumesh prasad sah,1 manisha arora,3 shahid iqbal,1 pradeep kumar4 1muzaffarnagar medical college, muzaffarnagar, uttar pradesh, india 2santosh medical college & hospital, ghaziabad, uttar pradesh, india 3department of metabolism & nutrition, medical university of americas, st. kitts & nevis 4autonomous state government medical college, fatehpur, uttar pradesh, india pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ ijihs.v10n1.2558 ijihs. 2022;10(1):1–6 introduction cigarette smoking is one of the most serious public health concerns of these days. worldwide, an estimate of 4 million people is affected by smoking-related disorders every year which is expected to rise to a staggering 10 million a year over the next two decades if the same trend continues.1 adolescence is a developmental period that is most affected by emotional and social functions. tobacco companies use sophisticated marketing campaigns to attract people to begin this practice early. the rate of adolescents getting addicted to smoking is very high in india. it is mostly observed that once an adolescent is initiated into tobacco use, he/she abuse it lifelong, with very low withdrawal rates.2 cigarette smoking is one of the main causes of preventable fatalities, with cardiovascular disease (cvd) and cancer being the most common.3 kidney illness is on the rise in developing countries, owing to a rise in diabetes mellitus (dm) and hypertension.4 traditional risk factors for the development of ckd have included advanced age, diabetes, and hypertension.5 according to the global adult tobacco 2 international journal of integrated health sciences (iijhs) survey, more than half of the smokers initiate smoking in their adolescence in india.1 highstress jobs also trigger addictive behaviour towards smoking. tobacco smoke contains more than 4,000 gases and particulate matter, most of which are reported to be damaging and destructive for various organs of the body. smoking is highly significant remediable renal risk factors. it not only negatively impacts renal function in subjects without any renal disease but also adversely affects the patients with different types of kidney disease and contributes in increasing the disease severity.6 nicotine, tar and some toxic gases (mainly carbon monoxide) are the main hazardous constituents of cigarette smoke. 7 smoking is known to cause tachycardia, hypertension and increases, copd, blood clot formation and triggers fat deposition in the arteries.8 urinary albumin is a well-known responsive marker of glomerular injury. this indicates clearly that direct renal damage is induced by tobacco chewing or smoking.9 the study on renal parameters in cigarette smokers is limited in western uttar pradesh, india region; hence the purpose of this study was to evaluate the effect of cigarette smoking on renal parameters in this region. methods the present study was carried out in the department of biochemistry santosh medical college, ghaziabad from september 2019 to april 2021. this study was approved from institutional ethical committee f.no. su/2020/536(48) and informs consent was taken from all the patients prior to the study. all the subjects were divided in to 4 groups. the participants in first groupwere nonsmokers, the participants consuming 1–5 cigarettes per days were included in group 2, the participants consuming 5–10 cigarettes per day were grouped as 3 and the participants taking more than 10 cigarettes per day were in group 4. in this study we included all the subjects who had been smoking for two or more years and all the participants were male and their age was 20–60 years. patients with diabetes mellitus, subjects with hypertension, chronic diseases, known hepatitis b, c, or hiv/aids and patients consuming alcohol & other drugs were excluded from the study. a 3 ml venous blood sample was collected from medial cubital from each participant, into a plain vial. after centrifugation at 1500 rpm for 3 minutes, the serum was assayed. all the parameters were measured by enzymatic method by using automated analyzer (beckman coulterau-480). for the screening of urinary albumin and urinary creatinine concentration, first morning void (timed) quantitative midstream urine sample was taken. urinary albumin (bcg method) and urinary creatinine (jaffe’s method) were measures by using fully automated analyzer (beckman coulterau480) and egfr were estimated by mdrd equation.10 statistical analysis was performed using spss software, version 16. a two-sided p value <0.05 was considered statistically significant. the statistical differences between the groups were determined by student independent sample t-test. results the mean levels of blood urea, urinary albumin and uacr were found to be increased significantly (p<0.001) in smokers who were fig. 1 comparison of serum urea, urinary albumin, and uacr in mild, moderate and chronic smokers renal parameters in mild, moderate, and chronic cigarette smokers international journal of integrated health sciences (iijhs) 3 table mean and standard deviation (s.d) of biochemical parameters in studied subjects variables control less than 5 cigarette per day 5–10 cigarette per day more than 10 cigarette per day blood urea (mg/dl) 27.7 ± 5.01 27.54 ± 2.78 39.54 ± 3.17 50.14 ± 5.17 p-value <0.001 <0.001 <0.001 serum creatinine (mg/dl) 0.85 ± 0.13 0.94 ± 0.15 0.97 ± 0.16 1.32 ± 0.16 p-value 0.007 <0.001 <0.001 serum uric acid (mg/dl) 5.05 ± 0.69 4.91 ± 0.72 4.5 ±0.70 3.99 ± 0.76 p-value 0.39 <0.001 <0.001 urinary albumin (mg/day) 18.69 ± 2.3 25 ± 4.65 31.2 ± 5.84 50.4 ± 8.96 p-value <0.001 <0.001 <0.001 urinary creatinine (mg/ day) 963.83 ± 40.41 907.86 ± 49.03 879.77 ± 44.77 849.26 ± 65.09 p-value <0.001 <0.001 <0.001 uacr* (mg/gm) 19.36 ± 2.12 27.54 ± 4.91 35.51 ± 6.62 59.61 ± 10.94 p-value <0.001 <0.001 <0.001 e-gfr** (ml/min/1.72 m2) 102.28 ± 17.64 90.69 ± 16.30 88.17 ± 17.40 61.0 ± 9.32 p-value 0.005 <0.001 <0.001 fig. 2 comparison of serum creatinine, urinary creatinin, and serum uric acid in mild, moderate and chronic smokers consumed 5 to 10 cigarettes per day, as compared to smokers who were consumed less than 5 cigarette. the mean levels of blood urea, urinary albumin and uacr were found to be increased significantly (p<0.001) in smokers who were consumed more than 10 cigarettes per day, as compared to smokers who were consumed less than 05 cigarettes per day.the mean levels of blood urea, serum creatinine, urinary albumin and uacr were found to be increased significantly ((p<0.001) in smokers who were consumed more than 10 cigarettes per day, as compared to smokers who were consumed 05 to 10 cigarettes per day (fig. 1). the level of serum uric acid and urinary creatinine were found to be decreased significantly (p<0.001) while the mean level of dinesh kumar, preeti sharma, et al 4 international journal of integrated health sciences (iijhs) serum creatinine were found to be increased in-significantly (p=0.44) in smokers who were consumed 06 to 10 cigarettes per day, as compared to smokers who were consumed less than 05 cigarette. the level of serum uric acid and urinary creatinine were found to be decreased significantly (p<0.001) in smokers who were consumed more than 10 cigarettes per day, as compared to smokers who were consumed less than 5 cigarettes per day.the level of serum uric acid and urinary creatinine were found to be decreased significantly (p<0.001) in smokers who were consumed more than 10 cigarettes per day, as compared to smokers who were consumed 05 to 10 cigarettes per day (fig. 2). the mean level of e-gfr is decreased insignificantly (p=0.53) in subjects who were consumed 05 to 10 cigarettes per day, as compared to smokers who were consumed less than 05 cigarette. the level of e-gfr were found to be decreased significantly (p=<0.05) in smokers who were consumed more than 10 cigarettes per day, as compared to smokers who were consumed less than 5 & 5 to 10 cigarettes per day (fig. 3) discussion among the health risks of tobacco smoking carcinogens, coronary disease and lung disease have got a lot of attention, but the possible influence of smoking on renal function and illness has gotten a lot less attention. tobacco smoking has lately been shown to play a significant effect in renal disease.11 in the present study we found that the mean levels of blood urea, serum creatinine, uacr and urinary albumin were found to be increased significantly in all the study groups as compared to control group and more increase in the parameters in the study subjects who were smoking more than 10 cigarettes per day. in this study, the mean levels of urinary creatinine, gfr and serum uric acid were found to be decreased significantly in all the smoking groups as compared to control and the decrease were more in the subjects who were smoking more than 10 cigarettes per day.mustafa et al studied on smokers and found a positive association between number of cigarette per day and uacr and urinary albumin.12 this study is in accordance with the previous study ahmed et al., in which they found that there were an elevated value of blood urea and serum creatinine in smoker people at (p<0.05) in comparison with the control subjects and the level of uric acid in smokers is significantly lower than the nonsmokers group (p<0.05).13 metwally et al. concluded in their study that there is an insignificant change in blood urea, serum creatinine, gfr in smokers as compared to non-smokers and urinary –n-acetyl glucosaminidase is found to be significantly elevated in smokers as compared to non-smokers.14 the higher readings in the participants recruited suggest that tobacco may include some toxic substances that are nephrotoxic, as urea and creatinine are recognized to be indicators of a kidney problem. previous research has linked increasing kidney fig. 3 comparison of estimated glomerular filtration rate (egfr) in mild, moderate, and chronic smokers renal parameters in mild, moderate, and chronic cigarette smokers international journal of integrated health sciences (iijhs) 5 failure to a steady decline in renal and nonrenal nicotine elimination, which raises the risk of nephrotoxicity.15 another proposed mechanism for cigarette-induced kidney damage is the effects of heavy metals in tobacco, such as cadmium (cd) and lead (pb).16 the exact mechanism by which smoking causes kidney damage is unknown, however it could be through an increase in free radical generation that alters glomerular function, as a result, cigarette smokers have increased urea and creatinine levels.17 reduced renal plasma flow and glomerular filtration rate may damage some glomeruli, resulting in hyperfiltration and albumin leakage from capillaries. urinary albumin has been recognized as a sensitive indicator of glomerular damage, and there is a link between smoking and albuminuria. this suggests that smoking has caused direct or indirect kidney impairment. one of the mechanisms by which smoking leads to albuminuria and renal dysfunction is the production of advanced glycation end products (ageps). the nonenzymatic interaction of reducing sugars with the amino groups of plasma proteins, lipids, and nucleic acids produces ageps, which are cross-linking moieties.18 albuminuria’s enhanced vascular permeability effects could be due to ageps. a researcher in their study found that both aqueous extracts of tobacco and cigarette smoke include glycotoxins, which are highly reactive glycation products that can cause agep production on proteins very quickly.19 as a result, ageps generated by the reaction of cigarette-derived glycotoxins with blood and tissue proteins are expected to have the same effect on renal function. this study backs up the theory that smoking play a role in the development of renal impairment and subsequent renal diseases. previous researchers have found a strong link between smoking and renal diseases. in cigarette smokers, we found higher levels of microalbumin, serum urea, and serum creatinine, indicating that smoking is significantly linked to renal impairment, which could lead to future renal function abnormalities. cigarette smoking is potentially harmful to the kidneys’ function. as a result, now is the moment to educate consumers about the potentially harmful effects of smoking and the resulting health consequences. the results are in accordance with study done by desai et al. stated that the kidney function is affected adversely in the smoker group, indicated by the elevation of serum creatinine, urea, and a reduction of serum uric acid.20 the elevation of creatinine and urea almost attributed to a significant fall in glomerular filtration rate (gfr), and a reduction of serum uric acid was attributed to reduced endogenous production by virtue of exposure to toxic cigarette smoke that is a remarkable source of oxidative stress as suggested by the research done by ahmed et al.13 the overall tobacco smoking situation in india appears to be very concerning, with an increase in the number of individuals with chronic renal failure in cigarette smoking subjects. changes in urinary microalbumin, serum urea, serum creatinine, urinary creatinine, and creatinine clearance are linked to an increased risk of renal dysfunction, which can lead to a many renal disorders and using these biochemical parameters as a tool for early detection and reducing the risk of kidney function deterioration could be beneficial. this could be the most reliable approach to renal dysfunction diagnosis, prognosis, and prevention in a tobacco-smoking population. this study concluded that the smoking is a risk factor for the development and progression of chronic kidney diseases in western uttar pradesh, india. the goal of this study was to evaluate biochemical changes in renal function as a result of smoking. the kidney function of smokers is affected, as seen by an increase in serum creatinine, urea, and a decrease in serum uric acid. the increase in creatinine and urea virtually correlated with a considerable drop in glomerular filtration rate (gfr), whereas the decrease in serum uric acid was linked to decreased endogenous synthesis as a result of cigarette smoking. these findings provide conclusive evidence that, impact of smoking on renal parameters was very high who were taking more cigarettes per day. references 1. who. who global report on trends in prevalence of tobacco use 2000–2025, third edition. geneva: world health organisation;2019. available from: https://apps.who.int/iris/ rest/bitstreams/1263754/retrieve. 2. thakur d, gupta a, thakur a, mazta sr, sharma d. prevalence of cigarette smoking and its predictors among school going adolescents dinesh kumar, preeti sharma, et al 6 international journal of integrated health sciences (iijhs) of north india. south asian j cancer. 2014;3(4):193–5. 3. taghizadeh n, vonk jm, boezen hm. lifetime smoking history and cause-specific mortality in a cohort study with 43 years of follow-up. plos one. 2016;11:e015331. 4. xia j, wang l, ma z, zhong l, wang y, gao y, et al. cigarette smoking and chronic kidney disease in the general population: a systematic review and meta-analysis of prospective cohort studies. nephrol dial transplant. 2017;32(3):475–87. 5. mallamaci f. highlights of the 2015 era-edta congress: chronic kidney disease, hypertension. nephrol dial transplant. 2016;31:1044:46 6. kidney disease: improving global outcomes (kdigo) ckd work group. kdigo 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. kidney inter suppl. 2013;3:1–150. 7. brewer nt, morgan jc, baig sa, mendel jr, boynton mh, pepper jk, et al. public understanding of cigarette smoke constituents: three us surveys. tob control. 2017;26(5):592– 9. 8. onor io, stirling dl, williams sr, bediako d, borghol a, harris mb, darensburg tb, et al. clinical effects of cigarette smoking: epidemiologic impact and review of pharmacotherapy options. int j environ res public health. 2017;14(10):1147. 9. maeda i, hayashi t, sato kk, koh h, harita n, nakamura y, et al. cigarette smoking and the association with glomerular hyperfiltration and proteinuria in healthy middle-aged men. clin j am soc nephrol. 2011;6(10):2462–9. 10. boriani g, laroche c, diemberger i, popescu mi, rasmussen lh, petrescu l, et al. glomerular filtration rate in patients with atrial fibrillation and 1-year outcomes. sci reports. 2017;7:42379. 11. laecke sv, biesen wv. smoking and chronic kidney disease: seeing the signs through the smoke. nephrol dial transplant. 2017;32(3):403–5. 12. mustafa i, kumar s, arora m, batra j, sah sp. effect of cigarette smoking on microalbuminuria and other kidney functions in normotensive nondiabetic smokers. int j contemporary med res. 2017;4(9):1912–4. 13. ahmed mme, jawad asa, osman hm, shayoub me. the effect of smoking cigarette on kidney functions among sundaes peoples. int j development res. 2015;5(5):4473–75. 14. metwally fm, mohammed am. impact of tobacco smoking on renal function tests in asymptomatic individuals. international j pharm clin res. 2016;8(12):1629-33. 15. pizzorno j. the kidney dysfunction epidemic, part 1: causes. integr med (encinitas) 2015;14(6):8–13. 16. ashraf mw. levels of heavy metals in popular cigarette brands and exposure to these metals via smoking. scientific world journal. 2012;2012:729430. 17. arany i, hall s, reed dk, reed ct, dixit m. nicotine enhances high-fat diet-induced oxidative stress in the kidney. nicotine tob res. 2016;18(7):1628–34. 18. lim akh. diabetic nephropathy complications and treatment. int j nephrol renovasc dis. 2014;7:361:81. 19. noborisaka y, ishizaki m, nakata m, yamada y, honda r, yokoyama h, et al. cigarette smoking, proteinuria, and renal function in middle-aged japanese men from an occupational population. environ health prev med. 2012;17(2):147–56. 20. desai sv, nagane ns, jagtap pe, dhonde sp, belwalkar gj. tobacco smoking-risk for renal diseases. biomed res. 2016;27(3):682–6. renal parameters in mild, moderate, and chronic cigarette smokers vol 10 no.1 2022 rev.2.indd 26 international journal of integrated health sciences (iijhs) infection, immobilization, or patient request.2,4 however, hardware removal procedures are still controversial among orthopedic surgeons because indications of metal implant removal have not been clearly documented.5,6 in addition, findings of complication from metal implant removal, such as neurovascular injury, refracture, infection, or problems in wound healing have caused indications of metal implant removal still controversial.7,8,9 hardware removal is usually done in lower or upper extremities, such as ankle and wrist, radius, and femur. based on population based studies in 2009 and 2010 in germany, metal implant removal procedures were mostly performed in ankle and wrist joints. besides, indications and complications of orthopedic hardware removal in an indonesian tertiary hospital: a descriptive study abstract objective: to acquire clinical data regarding indications of implant removal and complications in orthopedic metal implant removal. methods: this was a cross-sectional observational descriptive study using patient medical records. the inclusion criterion was all patients who underwent orthopedic metal implant removal during 2018–2020 while the exclusion criterion was unintentional implant removal due to subsequent injury or loosening. data regarding anatomic regions, indications, and complications were collected and presented in tables. results: in 112 patients participated in this study consisting of 75 (67%) men and 37 (33%) women, the implants were mainly located in thigh, lower leg, and ankle (53% combined). the most common indication for metal implant removal was conversion (31%), followed by infection (25%) and patient’s request (20%). the only complication observed in orthopedic metal implant removal in this study was disturbed wound healing in a small percentage of the patients (16%). most patients (84%) did not experience any complication due to metal implant removal. conclusions: indications for metal implant removal may vary, with or without symptoms. disturbed wound healing is a complication observed in metal implant removal. despite the advantages of removal, further analysis and guidelines are needed to avoid unnecessary hardware removal considering the risk of complications. keywords: complication, hardware, indication, removal received: february 24, 2022 accepted: march 30, 2022 correspondence: r. andri primadhi department of orthopaedics and traumatology faculty of medicine universitas padjadjaran, indonesia. e-mail: randri@unpad.ac.id original article shadrina affifa azzahra,1 r. andri primadhi,2 titing nurhayati,3 achadiyani, 3 m. naseh sajadi2 1faculty of medicine universitas padjadjaran, indonesia 2department of orthopaedics and traumatology, faculty of medicine universitas padjadjaran-dr. hasan sadikin general hospital, bandung, indonesia 3department of biomedical science faculty of medicine universitas padjadjaran, indonesia pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ ijihs.v10n1.2695 ijihs. 2022;10(1):26–31 introduction internal fixation procedures using metallic hardware have been chosen as fracture management in several last decades due to its generally good results.1,2 after fractures had healed, typically the hardware will be removed from the body.3,4 hardware removals are usually done in patients with or without any symptoms such as pain sensation, international journal of integrated health sciences (iijhs) 27 indication that was mainly found was due to doctors recommendation as much as 68%, followed by pain (31%) and impaired function (31%).4 in view of the surgeons, hardware removal is often needed after fractured has united, especially in a weight bearing long bones that risk an local osteoporosis due to prolonged load shielding to the bone structures, although this considerations is still disputable. from a biomaterial view, orthopedic implants is inert that will not result in reactions from the patients’ body, but in some cases allergic reactions was reported, as well as implant related microorganism adherence. based on a research conducted in the netherlands in 2012, 89% of dutch surgeons agreed to the metal implant removal procedures with implant infection as the main indication as much as >90%.10 complications of metal implant removal varied based on each patient’s condition. based on a study in japan from 2010 to 2015, perioperative complications were found after metal implant removal in 11 from 80 patients including arterial injury, blisters, nerve injury, skin necrosis, and infection.2 in addition, 13 patients (22.4%) had infection with revision surgery based on a different study in germany in 2014.11 to the best of our knowledge, there was no prior study reporting orthopedic hardware removal in indonesia yet. there is no clear guideline whether patients with metal implant table 1 distribution of bone injuries bone distribution n=112 % upper extremity upper arm 4 4 forearm 7 6 wrist 10 9 hand 13 12 shoulder 2 2 elbow 2 2 lower extremity thigh 15 13 lower leg 28 25 knee cap 1 1 ankle 17 15 foot 8 7 pelvis 4 4 spine 1 1 fixation should perform hardware removal or not. the objective of this study was to identify the indication and complication of metal implant removal to provide information for a clinical guideline for hardware removal in orthopedic practice. methods this was a descriptive study with a cross sectional approach that has been approved by padjadjaran university ethics committee (no.694/un6.kep/ec/2021) and from dr. hasan sadikin central general hospital bandung (no.7830/un6.c1/tu.00/2021). secondary data using patient medical records with history of orthopedic hardware removal from january 2018–december 2020 were collected. anatomic region of the applied hardware, indications, and complications were gathered. inclusion criteria was all patients that had orthopedic metal implant removal in hasan sadikin hospital, and exclusion criteria was the patients with unintentionally removed implants due to subsequent injury or loosening. all data obtained in this study were presented in a table and descriptive calculation was done using software ibm spss statistics for windows ver. 26.0 (armonk, ny: ibm corp.). result as many as 112 patient’s data were included to this study. as can be seen in table 1, hardware removals were mostly performed in lower leg region (25%). indication of the removal included conversion (31%), infection (25%), patient’s request (20%), movement alteration (15%) and pain problems (9%) as shown in table 2. types of removed implants was described table 2 indications/reasons for implants removal indication/reason n=112 % symptomatic pain sensation 10 9 motor function impairment 17 15 infection 28 25 asymptomatic patient’s request 22 20 conversion 35 31 shadrina affifa azzahra, r. andri primadhi, et al 28 international journal of integrated health sciences (iijhs) in table 3, depicting plate and screws as the most common implant construction to be removed. table 4 showed the complications of hardware removal procedures. the complications were found in 18 patients (16%) comprised of disturbed wound healing. discussion this was the first study in indonesian hospitals concerning indications and complications of metal implant removal. it was revealed that the complications and indications were varied table 3 types of removed implants types n=112 % plate and screws 45 40 screw(s) 20 18 intramedullary nail 19 17 kirschner wire 16 14 schanz screw / steinmann pin 12 10 table 4 complication of implants removal complication n=112 % wound healing 18 16 no complications* 94 84 *complications that were expected but not found in this study including refracture, neurovascular injury, blistering, skin necrosis, and prolonged numbness fig. 1 (a) preoperative clinical picture depicting a patient complaining pain due to irritation of the hardware to surrounding tissue; (b) radiograph showing a united fracture with plate and screws applied fig. 2 intraoperative finding showing bone formation and inflamed tissue indications and complications of orthopedic hardware removal in an indonesian tertiary hospital: a descriptive study international journal of integrated health sciences (iijhs) 29 among the patients. indications of metal implant removal have not been clearly validated and secondly because complications of metal implant removal were found.5,6 in indonesia, many patients wanted the hardware to be removed for some religious reasons, e.g. they did not want the foreign material still inside their body when they were deceased. other irrelevant reason included some false information regarding the danger of the hardware, for example, the fear of the metallic hardware will attract lightning strike. as shown in table 1, fractures were mostly found in lower extremity, specifically in lower leg as much as 25%. this result is slightly different from previous research by georg reith et al. in germany.4 based on their research, fractures were mostly found in the ankle joint (21%) and wrist joint (15%). according to a study in german by onche et al., femoral fractures were the most common findings with 42,6%.5 the differences between this study and previous studies might be attributable to different injury pattern in different community, such as traffic regulations and people habit regarding daily transportation, housing, or sports activities. in general, it is widely accepted that orthopedic hardware on lower leg should be removed after fracture healing, due to its weight bearing features. in a weight bearing bones, the internal fixation will induce local osteoporosis because of its load sharing characteristics. as shown in table 3, most common removed implants are plate and screws construction. this was reasonable due to the extramedullary feature of plate and screws implantation in which they cause attrition and inflammation to surrounding tissues. however, intramedullary nails were also considerably removed despite less risk of tissue attrition. in long bones, especially weight bearing bones, nail can be removed after union to restore the physiological mechanical loading to the bone, also to decrease the pain an insertion site. there were several indications of metal implant removal found in this study. the main indication was presenting symptoms such as pain (fig. 1–3), movement system impairment, infection, or surgeon’s decision including hardware conversion. other indications were patient’s wishes without any symptoms. the hardware conversion is the changing of implanted metal implant to other type of hardware, due to inefficacy of prior hardware or fixation failures. this procedure was part of the metal implant reconstruction that must be done intentionally by the surgeon. based on this study, symptomatic indication of metal implant removal that was mostly found in this study was infection as much as 25% cases. this data showed similar result with the study that have been done in holland which the main indication of metal implant removal was infection with >90%.10 the infection indication can also be called as infection after fracture fixation (iaff). iaff that occurred in patients in this study mostly caused by bacterial growth on metal implant and spread to necrotic bone tissues. based on time of onset, iaff was classified into early infection (<2 weeks), delayed infection (2–10 weeks), and late fig. 3 extracted hardware consisted of one plate and seven screws shadrina affifa azzahra, r. andri primadhi, et al 30 international journal of integrated health sciences (iijhs) infection (>10 weeks).12 as the complication of metal implant fixation, infection can be the most feared and challenging complication in treating patients with musculoskeletal trauma. this is because the complication can be progressive and lead to delay healing, permanent functional loss, or even amputation of the affected limb.12 focusing into infection after hardware removal, it is attributable to poor soft tissue due to repeated surgery, especially in regions that muscle pad is so thin that the underlying bone is directly beneath the skin, that will become a port d’entrée for subsequent infections. the other indications were patient’s demand (20%), motor function impairment (15%), and pain sensation (9%). there is a little difference between this findings and findings from previous research that mostly had pain as an indication for metal implant removal.1,4,5 this difference was caused by the variety of indications or reasons which depended on complaints or reactions from implant fixation in patients. a research that was conducted by r shrestha et al. in nepal showed that 45% of metal implant removal indications were pain.6 based on different research by georg reith et al., surgeons’ recommendation (68%) was the most indication, followed by pain (31%) of metal implant removal. in this study, surgeons’ recommendation were not included as measurement result because it can be interpreted as presenting symptoms in patients due to metal implant fixation.4 the pain sensation which felt by patients with implant metal fixation can be caused by varied factors: intrinsic factors and extrinsic factors. the usually occurring intrinsic factors were the malunion or nonunion of the metal implant fixation, thus led to longer period of rehabilitation and might resulted in disability. the external factors were due to poor postoperative pain control which had been explained in a study done in marshall university of united states. in that study, the difficulty in pain controlling was caused by the high incidence of tolerance to narcotics as analgesics. 13,14 based on literature, the findings of complication of metal implant removal vary and differ depending on the type of implant and the anatomic site of the removal. most of the complications can be subjective depending on patient’s complaints such as a larger scar or increased numbness at the anatomic site of removal.15 out of 112 samples, 94 samples did not experience complications due to metal implant removal as much as 84% (table 3). the other 18 samples only experienced wound healing complications by 16% in which inflammatory process did not go as expected. it is known that wound healing is a physiological process of the body that aims to maintain the integrity of the skin after trauma. there were 3 phases of wound healing, that were homeostasis/inflammation, proliferation and remodeling phase.16,17 this wound healing complication occurs due to trauma caused by open surgery from the metal implant removal. other complications of metal implant removal such as arterial injury, nerve injury, blistering, skin necrosis, infection and increased numbness were not found in data from patients with metal implant removal. the results obtained in this study were similar with previous studies, where in previous studies there were various types of complications from metal implant removal. based on research in japan from 2010 to 2015 by t kasai et al., perioperative complications were found after metal implant removal in 11 (14%) from 80 patients. complications that were found such as 1 patient with arterial injury, 3 patient blistering, 3 patient nerve injury, 2 patient skin necrosis, and 2 patient infection.2 this study had four main limitations: (1) the specific bones was not described, instead we chose to mention only the region, because there are some region containing too many bones to described one by one; (2) the surgical features including followup period were not homogenous so that will complicate the analysis when clinical consideration was taken into account; (3) various first surgeons or hospitals, making it more difficult to investigate the causes and indications of implant removal; and (4) singlecentered study origin that might result in lack of external validity and scientific flaw. as a conclusion, indications for metal implant removal still be vary in different hospital referral level. considering the risk of developing complications from hardware removal, it is recommended that further research be conducted on the indications and complications of metal implant removal in a larger scale, more understanding to unnecessary hardware removal urge from the patients, and to promote a guideline regarding this matter to be used in orthopaedic practice. indications and complications of orthopedic hardware removal in an indonesian tertiary hospital: a descriptive study international journal of integrated health sciences (iijhs) 31 1. haseeb m, butt mf, altaf t, muzaffar k, gupta a, jallu a. indications of implant removal: a study of 83 cases. int j health sci (qassim). 2017;11(1):1–7. 2. kasai t, matsumoto t, iga t, tanaka s. complications of implant removal in ankle fractures. j orthop. 2019;16(3):191–4. 3. williams br, mccreary dl, parikh hr, albersheim ms, cunningham bp. improvement in functional outcomes after elective symptomatic orthopaedic implant removal. jaaos glob res rev. 2020;4(9):e20.00137. 4. reith g, schmitz-greven v, hensel ko, schneider mm, tinschmann t, bouillon b, et al. metal implant removal: benefits and drawbacks a patient survey. bmc surg. 2015;15(1):1–8. 5. nwosu c, ademeyi to, salawu on, mejabi jo, fadimu aa. orthopaedic implan removal: epidemiology and outcome analysis. niger j orthop trauma. 2018;17:12-6. 6. shrestha r, shrestha d, dhoju d, parajuli n, bhandari b, kayastha sr. epidemiological and outcome analysis of orthopedic implants removal in kathmandu university hospital. kathmandu univ med j. 2013;11(42):139–43. 7. barcak ea, beebe mj, weinlein jc. the role of implant removal in orthopedic trauma. vol. 49, orthopedic clinics of north america. w.b. saunders; 2018. p. 45–53. 8. kaiser pb, watkins i, riedel md, cronin p, briceno j, kwon jy. implant removal matrix for the foot and ankle orthopaedic surgeon. foot ankle specialist. 2019;12(1):79-97 9. williams aa, witten dm, duester r, chou lb. the benefits of implant removal from the foot and ankle. j bone jt surg. 2012;94-a(1):1316– 20. 10. 10. vos d, hanson b, verhofstad m. implant removal of osteosynthesis: the dutch practice. results of a survey. j trauma manag outcomes. 2012;6(1):1. 11. suda aj, winkler ka, grützner pa, thoele pc, heppert vg, franke j. high complication rate after septic orthopaedic implant removal of the lower leg. arch orthop trauma surg. 2014;1655–60. 12. metsemakers wj, kuehl r, moriarty tf, richards rg, verhofstad mhj, borens o, et al. infection after fracture fixation: current surgical and microbiological concepts. injury. 2018;49(3):511–22. 13. koso re, terhoeve c, steen rg, zura r. healing, nonunion, and re-operation after internal fixation of diaphyseal and distal femoral fractures: a systematic review and metaanalysis. int orthop. 2018;42(11):2675–83. 14. barry rg, wolbert tt, gress tw, ray pd, mozaffari fb. outcomes after open reduction with internal fixation of mandible fractures. j craniofac surg. 2018;29(5):1237–40. 15. granlund as, troelsen a, ban i. indications and complications in relation to removal of clavicle implants. dan med j. 2017;64(12):1–4. 16. wang ph, huang bs, horng hc, yeh cc, chen yj. wound healing. j chinese med assoc. 2018;81(2):94–101. 17. gonzalez acdo, andrade zda, costa tf, medrado arap. wound healing a literature review. an bras dermatol. 2016;91(5):614–20. references shadrina affifa azzahra, r. andri primadhi, et al vol 9 no 1 2021 (2).indd international journal of integrated health sciences (iijhs) 19 association between malnutrition inflammation score and latent tuberculosis among chronic hemodialysis patients abstract objective: to investigate the association of malnutrition with latent tuberculosis (tb) among chronic kidney disease (ckd) patients on hemodialysis (hd). methods: this was a cross-sectional study conducted at the hemodiaylisis unit of dr. hasan sadikin general hospital, bandung, indonesia. subjects were patients aged >18 years who had undergone hd twice a week for at least three months. patients suspected of active tuberculosis (tb), malignancy, or immunocompromised were excluded. latent tb was diagnosed using the interferon-gamma release assays (igra). malnutrition was defined by a malnutrition inflammation score (mis) of less than 5. all data including age, sex, ckd etiologies, and laboratory findings were obtained and recorded in a case report form. results: a total of 120 subjects were involved in this study. subjects with positive, negative, and indeterminate igra results were 39.2%, 56.7%, and 4.2%, respectively. there was no significant differences in subjects characteristics between positive and negative igra subjects. the mis>5 was shown to have no statistically significant association with positive igra subjects (or=3.47, 95%ci 0.93–12.93). conclusion: malnutrition based on an mis score of less than 5 is not statically associated, but clinically associated, with latent tb. further causal inference study to investigate these associations is needed. keywords: chronic kidney disease, hemodialysis, latent tuberculosis, malnutrition received: february 24, 2021 accepted: march 30, 2021 correspondence: ria bandiara, department of internal medicine, faculty of medicine universitas padjadjaran-dr. hasan sadikin general hospital bandung, indonesia e-mail: ria.bandiara@unpad.ac.id original article ria bandiara, lilik sukesi, astried indrasari, alif bagus rakhimullah, afiatin afiatin, prayudi santoso department of internal medicine, faculty of medicine universitas padjadjaran-dr. hasan sadikin general hospital, bandung, indonesia pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ ijihs.v9n1.2370 ijihs. 2021;9(1):19–24 introduction chronic kidney disease (ckd) patients have a greater risk of tuberculosis (tbc) compared to normal kidney function population. suggestively, uremic retention in ckd patient alters immune response through various mechanisms. declined phagocytosis function of granulocytes and monocytes/macrophages, suboptimal capacity of antigen presentation by antigen presenting cells (apcs), decreased b lymphocytes production ability, decreased cd4+ and cd8+ t lymphocytes due to increased t lymphocytes apoptosis, and disturbed cell-mediated immunity are the implication of chronic uremic retention.1 protein energy wasting (pew) and its consequences are commonly occurred among ckd patients, particularly in patients on chronic haemodialysis (hd). malnutrition also contributes to declined various physiologic functions. estimating prevalence of pew in ckd on hd patients is 18–75%.2 malnutrition inflammation score (mis) is one of the quantitative nutrition assessment tools. it consists of medical history, physical examination, anthropometry, and laboratory parameters such as albumin, transferrin, total iron binding capacity (tibc). previous studies 20 international journal of integrated health sciences (iijhs) proposed mis as risk stratification among ckd on hd patients in asia. five-years study to 809 chronic hd outpatients in south california investigated the association between mis and health-related quality of life (hr-qol). increased mis (>2) is associated with double risk of mortality. another study investigated 155 ckd on hd patients, and concluded that mis ≥5 is considered as malnutrition.3,4muscle wasting and cachexia are common and strongly associated with mortality in ckd, which is reviewed here. recent findings: the malnutrition-inflammation score (kalantar score malnutrition has strength relationship with tbc infection. malnutrition on tbc infection decreases immunity secondary to lymphocyte production and immune cells proliferation. as a consequence, it aggravates the growth of mycobacteria and increases dissemination risk. reactivation of latent or previous subclinical tbc infection is associated with nutrition status worsening.5,6as defined by low body mass index (bmi moreover, low protein intake is also observed in latent tbc on ckd patients.7 latent tbc infection is frequently not proper documented in ckd on hd patients. ironically, ckd on hd patient is the one of high-risk population to develop tbc infection. a reported tbc prevalence among ckd on hd patients is 10.6%.8 in patient with chronic dialysis, the risk of tbc reactivation is increases 10–25 times. based on interferongamma release assay (igra), latent tbc is occurred in 22,2% among ckd on hd patients. malnutrition status on ckd patient can affect the immune response. it can increase risk of the developing active tbc from the latent one. furthermore, investigation about association between mis and latent tbc is needed. by understanding its, progressivity latent-to-active tbc can be monitored. it makes the management of ckd on hd patient more comprehensive, and be able to decreases morbidity and mortality, as well as hrqol. our study is aimed to investigate the association of mis with latent tuberculosis on chronic hd patients. methods this was an analytic-observational study with cross-sectional approach. this study is conducted on routine hd patients in hemodialysis unit of dr. hasan sadikin general hospital bandung, with the subjects recruitment period of march–may 2020. subjects aged >18 years and at least threemonths with twice a week of hd were included in this study. patients with malignancy history, infected by human immunodeficiency virus (hiv)/acquired immune deficiency syndrome (aids), getting immunosuppressive therapy, have tb history, or receiving anti-tuberculosis drugs were excluded from this study. mis have ten components including change in end-dialysis dry weight, dietary intake, gastrointestinal symptoms, functional capacity, comorbidity, decreased fat stores or loss of subcutaneous fat, muscle wasting, body mass index (bmi), serum albumin, and total iron binding capacity (tibc). each component has 0–3 severity score, hence mis have 0–30 score in range.9we matched 203 nd-ckd and 203 tx patients from two independently assembled cohorts of patients based on estimated glomerular filtration rate (egfr malnutrition was defined as mis greater than 5.473% of hd and 71% of pd patients exhibited moderate malnutrition, whilst using mis, 88% and 90%, respectively were malnourished. dms and mis correlated significantly in hd (r2=0.552, p<0.001 latent tb was diagnosed according to igra results (quantiferon-tb igra). igra test has been done in 24–48 hours and can be interpreted based on interferon gamma qualitatively according to table 1.10 subjects that fulfil inclusion criteria and not meet the exclusion criteria was examined by the assessor including history taking, physical examination, and laboratory examination. tb symptoms and sign is consisted of fever, dyspnea, decreased body weight, chronic diarrhea, and lymph node enlargement. all patients were examined for thorax x-ray that expertized by independent radiologist. by certain indications, acid fast bacilli (afb) staining, afb culture, abdominal ultrasound, and histopathological examination for lymph node enlargement. all asymptomatic patients were examined for igra before hd procedure. all data were analyzed using spss 25.0. data were managed using redcap electronical data recorder. categorical descriptive such as prevalence was analyzed using binomial exact test to reveal its 95% confidence interval. unpaired t-test with mann-whitney as alternative was used for numerical comparison for two-groups. each p value <0.05 was considered as statistically significant. this study was conducted and ethically approved by health research ethics committee of medical research, dr.hasan sadikin general hospital. this study is a part of study project of association between malnutrition inflammation score and latent tuberculosis among chronic hemodialysis patients international journal of integrated health sciences (iijhs) 21 tuberculosis on chronic kidney disease (ckd) on routine hemodialysis in dr. hasan sadikin general hospital bandung and habibie kidney hospital, bandung with ethical clearance number of lb.02.01/x6.5/302/2019. results a total of 120 subjects were involved in this study. subjects with positive, negative, and indeterminate igra results were 39.2%, 56.7%, and 4.2%, respectively. due to small number indeterminate igra results (5 subjects), we did not perform further analysis for indeterminate igra subjects. hypertension was predominant as cause of ckd. there was no significant difference in sex distribution, mean of age, hemodialysis duration, hemoglobin levels, serum iron, transferrin saturation, tibc, and serum albumin between positive and negative igra subjects (p>0.05). etiologies of ckd, such as hypertension, diabetes mellitus, etc, were also not significantly different between positive and negative igra subjects (p>0.05). detailed baseline characteristics of the subjects was described in table 2. according to bivariate analysis in table 3, malnutrition (mis>5) was more prevalent in positive igra subjects compared to negative igra subjects (93.6% vs 80.9%), but not statistically significant (p=0.052). mis>5 was not significantly associated with positive igra results (or=3.47, 95%ci 0.93–12.93). discussion according to our results, the prevalence of latent tb among routine hd patients was 40.9%. this results is higher than two studies reported prevalence in taiwan, as highprevalence ckd country.11,12 another study in korea has similar prevalence of positive igra results. forty-two percent of patients who underwent kidney transplantation has positive igra results.13 a study in india also reported the prevalence of latent tb among ckd on hd patients was 36%.14 these facts are the evidence of latent tb is common in ckd on hd patients. in our study, among 5 indeterminate igra subjects, two subjects has nill value more than 8, meanwhile the others have low mitogen value. this pattern can be occurred due to inadequate lymphocyte amount, decreased lymphocytes activities, ifn-inability of lymphocytes to produce ifn-γ, as well as inappropriate specimen handling.10 in our study, among 5 indeterminate igra subjects, two subjects has nill value more than 8, meanwhile the others have low mitogen value. this pattern can be occurred due to inadequate lymphocyte amount, decreased lymphocytes activities, ifn-inability of lymphocytes to produce ifn-γ, as well as inappropriate specimen handling. on the other hand, indeterminate igra results also can be occurred suboptimal immune response to mitogen control or excessive baseline immune activity of the subjects (high nill value). sharninghausen et al.15 reported the indeterminate results occurred in 3.8% of their subjects, and is associated with low mitogen levels and high nill. furthermore, asian ethic, anemia, and hypoalbuminemia are the independent risk factors. genetic polymorphism on the t cells and natural killer (nk) cells are also related with mitogen control. phytogemagglutinin is also associated with genetic loci that causing alteration of the lymphocytes activity. on latent tb infection, host immunity and mycobacteria virulence reach equilibrium state. hence, it does not yield inflammation state that have effects on symptoms, body composition and size alteration, fat stores, muscle mass, and laboratory findings that table 1 interpretation of quantiferon-tb igra interpretation nill tb response mitogen response positive ≤8.0 ≥0.35 iu/ml and ≥25% of nill any negative ≤8.0 <0.35 iu/ml and <25% of nill ≥0.5 indeterminate ≤8.0 <0.35 iu/ml and <25% of nill <0.5 ≥8.0 any any ria bandiara, lilik sukesi, et al. 22 international journal of integrated health sciences (iijhs) table 2 subjects characteristics subjects characteristics totaln=115 igra (+) n=47 igra (-) n=68 p value age (years) mean ± sd 47±13 48±12 47±14 0.669a sex male 54 (47.0) 26 (55.3) 28 (41.2) 0.135c female 61 (53.0) 21 (44.7) 40 (58.8) hemodialysis duration median (iqr) 50 (27–83) 45 (26–80) 52 (28–87) 0.527b etiology of ckd hypertensive kidney disease 60 (52.2) 26 (55.3) 34 (50.0) 0.619c diabetic nephropathy 18 (15.7) 9 (19.1) 9 (13.2) uric acid nephropathy 4 (3.5) 2 (4.3) 2 (2.9) lupus nephropathy 2 (1.7) 1 (2.1) 1 (1.5) obstructive nephropathy 1 (0.9) 1 (2.1) 0 (0.0) glomerulopathy 23 (20.0) 6 (12.8) 17 (25.0) chronic pyelonephritis 6 (5.2) 2 (4.3) 4 (5.9) polycystic kidney diseases 1 (1.5) 0 (0.0) 1 (1.5) laboratory hemoglobin (g/dl) median (iqr) 9.3 (8.2–10.3) 9.4 (8.4 –9.7) 9.3 (8.2–10.3) 0.639b serum iron (ug/dl) median (iqr) 50 (41–72) 48 (41–72) 51 (41–72) 0.842b transferrin saturation (%) median (iqr) 25.3 (19.9 – 37.8) 25.9 (20.4 – 37.3) 24.5 (19.3–37.3) 0.585b ferritin (ng/ml) median (iqr) 412.6(166.6–780.3) 397.8 (139.0–704.9) 427.9 (245.2–963.9) 0.270 b tibc (mg/dl) median (iqr) 201 (174–242) 190 (166–246) 204 (178–237) 0.400b albumin (g/dl) median (iqr) 3.36 (3.17–3.54) 3.35 (3.20–3.46) 3.36 (3.17–3.57) 0.680b test used: aunpaired t-test bmann whitney, cchi square, dfisher exact table 3 association of latent tb based on igra and malnutrition based on mis mis categories igra (+)n=47 igra (-) n=68 p value or (95% ci) >5 44 (93.6) 55 (80.9) 0.052 3.47(0.93 – 12.93) ≤5 3 (6.4) 13 (19.1) aanalyzed by chi square; igra: interferon-gamma release assay association between malnutrition inflammation score and latent tuberculosis among chronic hemodialysis patients international journal of integrated health sciences (iijhs) 23 associated with inflammation. accordingly, in latent tb infection, mycobacteria proliferation is controlled. it is indicated by efficient cellular interaction and granuloma formation to prevent mycobacteria dissemination.16 latent phase of tb infection represents equilibrium state, when host immunity capable to control the infection, but not fully eradicate the pathogens. granuloma represents immunological and physical barrier to suppress the infection and prevent the dissemination. they play dynamic and sustainable immune control to the mycobacteria replication. latent tb patients are the highest reservoir for transmission potential. although majority of patients are not death due to tuberculosis, the highest hazard are tb reactivation and close contact transmission. estimated risk for tb reactivation is 10%. disrupted immunity, such as hiv infection, increases the risk up to 10% per year.6 this study reveals no significant difference of mis between positive and negative igra results. suggestively, it is caused by subjective component in mis assessment such as medical history. mis have several subjective components such as daily nutritional intake and gastrointestinal symptoms. depression, fatigue, and cognitive alteration are commonly occurred on ckd on hd patients. hence, the assessment can be biased. however, mis is still comparable with dialysis malnutrition score, and strongly correlated with other objective malnutrition parameters including bmi, triceps skin folds, mid-arm muscle area, mid-arm muscle circumference, and serum albumin.17one of the strongest predictors of morbidity and mortality in maintenance haemodialysis (hd although, statistically no significant association of malnutrition (based on mis>5) with latent tb, with odds ratio of 3.47 (95%ci 0.93–12.93), we consider it as clinically significant. since no difference subjects’ characteristics between positive and negative igra, we did not performed analysis for confounding in this study. variably results on the previous studies are existed about association between nutrition status and latent tb. baek et al7whether hemodialysis adequacy is associated with ltbi in the esrd population is unclear. in this study, we aimed to investigate the association between hemodialysis adequacy and ltbi in esrd patients. methods: in the present crosssectional study, we reviewed all outpatientbased esrd patients in our artificial kidney room. interferon gamma release assay (igra assessed nutrition status by normalized protein catabolic rate (npcr) measurement and latent tb by igra. nutrition inadequacy based on npcr value less than 0.87 g/kg/ day predicts latent tb among hd patients significantly. on the other hand, another study revealed no significant association between latent tb and malnutrition among ckd on hd patients.18 using simple assessment, such as bmi only, patient with malnutrition were similarly distributed in positive and negative tuberculin skin test subjects. 19 this study used cut-off >5 of to determine malnutrition in this study. it refers to some previous studies. another study revealed that mis score higher than 7 can be able to predict mortality for 18–24 months follow up.20 it indicates that mis > 5 has significant risk for 1-year mortality. mis >5 also used by harvinder et al on hd and peritoneal dialysis patients. with this cut-off and compared to established guidelines by international society of renal nutrition and metabolism for protein energy-wasting, mis had modest sensitivity detect malnutrition in dialysis patients (60– 80%).4 further diagnostic analysis with higher sample size might be required to support and reveal the fixed and better diagnostic value for mis cut-off. as a limitation, our study is merely crosssectional study. hence, this is a snapshot representation of association between latent tb and malnutrition, as well as could not determine causal inference of those. furthermore, other more objective malnutrition assessment tools might be required to accompany the mis one. as mentioned above, mis has subjective components of medical history taking that can biased by some condition that commonly occurred in ckd on hd patients, such as depression, fatigue, and cognitive disturbance. these probably affects the assessment. however, our study is the first documentation in indonesia that investigates the association of nutrition status based on mis with latent tb among ckd on hd patients. mis could be used as detection tools of latent tb, even though the further validation and diagnostic investigation are required. further study to evaluate the causal inference of latent tb and malnutrition is needed. in conclusion, malnutrition according to mis > 5 is not statistically associated, but clinically associated with latent tb infection based on igra positivity. further causal inference study is needed to determine, strengthen, and re-evaluate this association. ria bandiara, lilik sukesi, et al. 24 international journal of integrated health sciences (iijhs) 1. hsu hw, lang cl, wang mh, chiang ck, lu kc. a review of chronic kidney disease and the immune system: a special form of immunosenescence. j gerontol geriatr res. 2014;3:1–6. 2. ebrahimzadehkor b, dorri a, yapan gharavi a. malnutrition inflammatons score in hemodialysis patients. zahedan j res med sci. 2014;16(8):25–8. 3. obi y, qader h, kovesdy cp, kalantarzadeh k. latest consensus and update on protein-energy wasting in chronic kidney disease. curr opin clin nutr metab care. 2015 may;18(3):254–62. 4. harvinder gs, swee wcs, karupaiah t, sahathevan s, chinna k, ahmad g, et al. dialysis malnutrition and malnutrition inflammation scores: screening tools for prediction of dialysis-related proteinenergy wasting in malaysia. asia pac j clin nutr. 2016;25(1):26–33. 5. anuradha r, munisankar s, bhootra y, kumar np, dolla c, kumaran p, et al. coexistent malnutrition is associated with perturbations in systemic and antigen-specific cytokine responses in latent tuberculosis infection. clin vaccine immunol. 2016 apr;23(4):339–45. 6. rao m, ippolito g, mfinanga s, ntoumi f, yeboah-manu d, vilaplana c, et al. latent tb infection (ltbi)-mycobacterium tuberculosis pathogenesis and the dynamics of the granuloma battleground. int j infect dis. 2019;80s:s58–61. 7. baek sd, jeung s, kang jy. nutritional adequacy and latent tuberculosis infection in end-stage renal disease patients. nutrients. 2019;11(10):2299. 8. rao t, ram r, swarnalatha g, santhosh pai b, ramesh v, rao c, et al. tuberculosis in haemodialysis patients: a single centre experience. indian j nephrol. 2013;23(5):340–5. 9. molnar mz, carrero jj, mucsi i, remport a, rhee cm, kalantar-zadeh k, et al. comparison of the malnutritioninflammation score in chronic kidney disease patients and kidney transplant recipients. int urol nephrol. 2015;47(6):1025–33. 10. lalvani a, pareek m. interferon gamma release assays: principles and practice. enferm infecc microbiol clin. 2010;28(4):245–52. 11. shu c, wu v, yang f, pan s, lai t, wang j, et al. predictors and prevalence of latent tuberculosis infection in patients receiving long-term hemodialysis and peritoneal dialysis. plos one. 2012;7(8):e42592. 12. wu c, su h, chou c, liu j, lee c, dai l, et al. an observational study on prevalence of latent tuberculosis infection and outcome of 3hp treatment in patients under hemodialysis in taiwan. j formos med assoc. 2021;120(6):1350–60. 13. kim sy, jung gs, kim sk, chang j, kim ms, kim ys, et al. comparison of the tuberculin skin test and interferon-γ release assay for the diagnosis of latent tuberculosis infection before kidney transplantation. infection. 2013;41(1):103–10. 14. agarwal s, singh u, zaidi s, gupta s, pandey r. comparison of interferon gamma release assay & tuberculin skin tests for diagnosis of latent tuberculosis in patients on maintenance haemodialysis. indian j med res. 2015;141(4):463–8. 15. sharninghausen jc, shapiro ae, koelle dm, kim hn. risk factors for indeterminate outcome on interferon gamma release assay in non-us-born persons screened for latent tuberculosis infection. open forum infect dis. 2018;5(8):ofy184. 16. sharma sk, mohanan s, sharma a. relevance of latent tb infection in areas of high tb prevalence. chest. 2012;142(3):761–73. 17. harvinder gs, swee wcs, karupaiah t, sahathevan s, chinna k, ahmad g, et al. dialysis malnutrition and malnutrition inflammation scores: screening tools for prediction of dialysis-related protein energy wasting in malaysia. asia pac j clin nutr. 2016;25(1):26–33. 18. fonseca jc, caiaffa wt, abreu mns, farah k de p, carvalho w da s, spindola de miranda s. prevalence of latent tuberculosis infection and risk of infection in patients with chronic kidney disease undergoing hemodialysis in a referral center in brazil. j bras pneumol. 2013;39(2):214–20. 19. sutanto ys, makhabah dn, setyawati a. risk factors of latent tuberculosis among hemodialysis patient with advanced chronic kidney disease. respirology. 2019;24:136. 20. borges mc, vogt bp, martin lc, caramori jc. malnutrition inflammation score cutoff predicting mortality in maintenance hemodialysis patients. clin nutr espen. 2017;17:63–7. references association between malnutrition inflammation score and latent tuberculosis among chronic hemodialysis patients vol 10 no.1 2022 rev.2.indd 46 international journal of integrated health sciences (iijhs) introduction immune thrombocytopenia (itp) is a bleeding disorder characterized by isolated thrombocytopenia (platelet count <100,000/ μl), and can be caused by various etiologies.1 primary itp is idiopathic, whereas secondary itp is linked to an underlying condition.2 it has been reported that approximately 20% of cases of itp are associated with underlying factors, such as other autoimmune diseases, drugs, viral infections, or helicobacter pylori secondary chronic immune thrombocytopenia in diffuse large b-cell lymphoma: a rare case report abstract objective: to present a case of rare secondary chronic immune thrombocytopenia in diffuse large b-cell lymphoma. methods: a case of secondary itp associated with diffuse large b-cell lymphoma (dlbcl) in a 58-year-old woman suffering from hemorrhagic tendencies that was refractory to conventional treatments of itp was reported. this case is a rarity because there are not many cases of secondary chronic itp due to dlbcl have been reported to date. results: a 58-year-old woman was diagnosed with itp around 11 months before she was admitted to the emergency room with bleeding. previous treatment with steroid and azathioprine was only temporarily effective. during the course of treatment, splenomegaly and lymphadenopathy were identified, but lymph node biopsy was delayed by the thrombocytopenia. the drug was then replaced to the eltrombopag, which showed good response. however, the patient had to undergo splenectomy because of the mechanical effect of splenomegaly, with the biopsy result showed dlbcl. immune thrombocytopenia then went into a complete remission after splenectomy. conclusion: in cases of itp that are refractory to conventional treatments, a thorough search for secondary itp might be helpful, even if no underlying disorder is detected at the initial presentation. keywords: diffuse large b-cell lymphoma, refractory, secondary immune thrombocytopenia, splenectomy received: december 04, 2021 accepted: march 30, 2022 case report putri vidyaniati, fransisca, kiki akhmad rizki, amaylia oehadian department of internal medicine, faculty of medicine universitas padjadjaran dr. hasan sadikin general hospital bandung, indonesia pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ ijihs.v10n1.2603 ijihs. 2022;10(1):46-50 correspondence: putri vidyaniati, division of hematology and medical oncology, department of internal medicine, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital bandung, indonesia email: p.vidyaniati@gmail.com infection. in cases of itp that are refractory to conventional treatment, a thorough search for secondary itp might be helpful, even if no underlying disorder is detected at the initial presentation.3 this study presented a rare case of secondary itp associated with diffuse large b-cell lymphoma (dlbcl) in a 58-year-old woman which was refractory to conventional treatments of immune thrombocytopenia. case a 58-year-old woman was admitted to our hospital emergency room (er) in march 2020 due to oral mucosal bleeding accompanied by a red skin rash, bruised skin, and red-coloured urine that appeared three days prior to the patient’s admission. eleven months before the er admission, international journal of integrated health sciences (iijhs) 47 hospitalization showed that her vital signs were stable. she was anemic with petechiae on her skin and oral mucosal bleeding was identified. the lymph nodes in the neck were not palpable. an abdominal examination revealed splenomegaly (schuffner iii). laboratory examinations showed pancytopenia with a hemoglobin level of 8.9 g/dl, a leukocyte count of 2,800/μl, and a platelet count of 2,000/μl. a peripheral blood smear analysis revealed anisocytosis, some polychromasia, a normal leucocyte count without immature cells, and thrombocytopenia without giant platelets. there was microscopic hematuria. she was treated with a pulse dose of dexamethasone (40 mg intravenously) daily for four days, 50 mg of azathioprine orally twice daily, and platelet transfusion until the platelet count >50,000/μl or until the bleeding stops. on the third day of hospitalization, the platelet count decreased to 1,000/μl. she underwent another abdominal ultrasonography on the fourth day of hospitalization which revealed a lymphadenopathy in the right para-iliac region with a diameter of ±1.74 cm. on the fifth day of hospitalization the platelet count was 4,000/ μl. we stopped azathioprine and started giving her 25 mg of eltrombopag orally once daily. after the seventh day of eltrombopag, the platelet count was 70,000/μl. the patient was discharged on the tenth day of hospitalization and was scheduled to have an abdominal ct with contrast after discharged. the patient’s clinical course can be summarised in fig. 1. the abdominal ct revealed multiple hypodense lesions, lobulated, conglomerated in paraaorta region and the enlargement of multiple inguinal lymph nodes bilaterally, suggestive of lymphoma and hepatosplenomegaly. the laboratory test twelve days after discharge revealed a platelet count of 93,000/μl. two weeks after discharge, the spleen size increased to schuffner vi so the patient underwent a splenectomy in consideration of mechanical problems caused by the size of the spleen, pursuit of tissue histopathological diagnosis, and possible hypersplenism. macroscopic and microscopic views of the spleen can be seen in fig. 2a and 2b. a histopathological examination of the spleen revealed diffuse large b-cell lymphoma with positive immunohistochemical (ihc) staining for expression of cd20, cd5, and ki67 (positive >40%) but negative for expression of cd10. the microscopic view shows tumor mass consists of proliferation of small cells with follicular structure, clear cytoplasm and she came to our hematology outpatient clinic with oral mucosal bleeding. she had been receiving treatment for itp from another hospital with methylprednisolone for six months. the steroid was then tapered down and azathioprine 50 mg was added. one week later, her platelet count had increased from 34,000/µl to 58,000/μl and immature platelet fraction was 7,9. the diagnosis remained and the treatment of methylprednisolone 4 mg and azathioprine 50 mg were continued. two months before the er admission, the patient came to hematology outpatient clinic again with left upper quadrant abdominal pain. a physical examination revealed splenomegaly (schuffner i), and an abdominal ultrasonography examination confirmed a splenomegaly of 8x5x6 cm. we still considered itp diagnosis even though other causes were still possible, and more examinations were planned to look for secondary causes. the antinuclear antibody (ana) test was negative. she continued methylprednisolone and azathioprine, and 2 weeks later the platelet count increased to 81,000/μl. methylprednisolone was then stopped, while azathioprine was continued. a chest computed tomography (ct) with contrast that had been done prior to er admission showed right superior and inferior paratracheal lymphadenopathy and left supraclavicular lymphadenopathy with the largest size ± 1.1 x 1.3 x 1 cm in the left supraclavicle. lymphoma or tuberculosis was suspected as the underlying disease. she was referred to a surgical oncologist for an excisional biopsy of the lymph node, but by then her platelet count had decreased to 2,000/μl and bleeding occurred, so eventually she was sent to our er. a physical examination on the day of fig. 1 the patient’s clinical course putri vidyaniati, fransisca, et al 48 international journal of integrated health sciences (iijhs) irregular nucleus. centrum germinativum infiltrated by small lymphoid cells. sinuses and cords of billroth are infiltrated by lymphoid cells. laboratory tests one day after the splenectomy showed a significant increase in the platelet count to 265,000/μl. microscopic view of the spleen shows tumor mass consists of proliferation of small cells with follicular structure, clear cytoplasm and irregular nucleus. centrum germinativum infiltrated by small lymphoid cells. sinuses and cords of billroth are infiltrated by lymphoid cells. the final diagnosis of the patient was stage iv high grade b-cell lymphoma (diffuse large b-cell lymphoma) and secondary immune thrombocytopenia (lymphoma-associated). discussion the incidence of itp is estimated to be 2 to 5 per 100.000 persons in the general population.4 immune thrombocytopenia can manifest before, during, or after the diagnosis of lymphoma.5 immune thrombocytopenia occurring prior to the diagnosis of aggressive dlbcl is rare.6 ogata et al., 2019 revealed only 10 cases of dlbcl, which is the most common type of non-hodgkin lymphoma (nhl), complicated by itp have been reported to date.7 tan et al. retrieved published papers from 1960 to 2010 and in three reported cases the itp occurred 4, 18 and 46 months preceding dlbcl. in five cases itp and dlbcl occurred concurrently.6, 8 our case is itp in a 58-year old women, slightly older than reported in previous studies which identified a median age of 50–55 years.9 our case presented with thrombocytopenia 11 months before her lymphoma diagnosis, similar to cases reported by tan.6 primary splenic dlbcl is very rare as it occurs in less than 1% of nhl. it is most commonly found in females and older males.10 shi et al., revealed that in 1,085 patients, 679 (62.6%) cases were nodal dlbcl (n-dlbcl) with the most common sites being the lymphonodus (64.8%), waldeyer’s ring (19.7%), the mediastinum (12.8%) and the spleen (2.7%).11 in previously untreated dlbcl, chemotherapy of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone (r-chop) remain the backbone of therapy, with the total number of cycles and addition of radiation dependent on the stage at presentation and tumour bulk. this approach can achieve durable remission in approximately 60% of patients.12,13 r-chop is most often given in cycles 3 weeks apart.14 khalid et al.10 revealed that effective treatment options for massive splenomegaly include splenectomy, chemotherapy and/or radiation.a splenectomy not only releases the pressure on adjacent organs and solves the issues of hypersplenism, but it also provides a definitive histopathological diagnosis of the underlying cause. after a splenectomy, cytopenias resolve in most cases. djokic et al.15 revealed a case of a patient with resolved cytopenias in the weeks after the splenectomy. the prognosis of dlbcl-associated itp is still not fully understood because of only 10 cases being reported before. in most of these cases, the dlbcl-associated itp was refractory to conventional treatments for 2a. macroscopic view of the spleen; 2b. microscopic view of the spleen shows tumor mass consists of proliferation of small cells with follicular structure, clear cytoplasm and irregular nucleus. centrum germinativum infiltrated by small lymphoid cells. sinuses and cords of billroth are infiltrated by lymphoid cells fig. secondary chronic immune thrombocytopenia in diffuse large b-cell lymphoma: a rare case report international journal of integrated health sciences (iijhs) 49 1. rodeghiero f, stasi r, gernsheimer t, michel m, provan d, arnold dm, et al. standardization of terminology, definitions and outcome criteria in immune thrombocytopenic purpura of adults and children: report from an international working group. blood. 2009;113(11):2386– 2393. 2. schifferli a, cavalli f, godeau b, liebman h, recher m, imbach p, et al. understanding immune thrombocytopenia: looking out of the box. frontiers in medicine. 2021;8:929. 3. ono k, onishi y, kobayashi m, ichikawa s, hatta s, watanabe s, et al. successful treatment of aggressive mature b-cell lymphoma mimicking immune thrombocytopenic purpura. intern med. 2018;57(17):2573–9. 4. neunert c, terrell dr, arnold dm, buchanan g, cines db, cooper n, et al. american society of hematology 2019 guidelines for immune thrombocytopenia. blood adv. 2019;3(23):3829–66. 5. güler s, aktekin eh, uyar sbş, şimşek n, arslan d. immune thrombocytopenia as a presenting manifestation of hodgkin’s lymphoma. anatol clin.23(3):186–8. 6. tan j, wei j, ni x, zhou j. immune thrombocytopenic purpura occurred prior to multiple extranodal diffuse large b cell lymphoma. platelets. 2011;22(1):79–81. 7. ogata t, shimomura y, yamashita d, imai y, ishikawa t. substantial improvement in immune thrombocytopenic purpura associated with t-cell/histiocyte-rich b-cell lymphoma treated with chemotherapy: a case report. mol clin oncol. 2019;10(4):441–5. 8. hauswirth aw, skrabs c, schützinger c, raderer m, chott a, valent p, et al. autoimmune thrombocytopenia in non-hodgkin’s lymphomas. haematologica. 2008;93(3):447– 50. 9. matzdorff a, meyer o, ostermann h, kiefel v, eberl w, kühne t, et al. immune thrombocytopenia-current diagnostics and therapy: recommendations of a joint working group of dgho, ögho, sgh, gpoh, and dgti. oncol res treat. 2018;41(suppl. 5):1–30. 10. khalid s, daw jh, daw h, haddad a. primary splenic diffuse large b-cell lymphoma: a rare case of massive splenomegaly and thrombocytopenia. cureus. 2018;10(7):e3026. 11. shi y, han y, yang j, liu p, he x, zhang c, et al. clinical features and outcomes of diffuse large b-cell lymphoma based on nodal or extranodal primary sites of origin: analysis of 1,085 who classified cases in a single institution in china. chin j cancer res. 2019;31(1):152. 12. liu y, barta sk. diffuse large b-cell lymphoma: 2019 update on diagnosis, risk stratification, and treatment. am j hematol. 2019;94(5):604– 16. 13. jardin f. improving r-chop in diffuse large b-cell lymphoma is still a challenge. lancet oncol. 2019;20(5):605–6. 14. the american cancer society. treating b-cell non-hodgkin lymphoma [cited 2020 june 24]. available from: https://www.cancer.org/ cancer/non-hodgkin-lymphoma/treating/bcell-lymphoma.html. 15. djokic m, plesnik b, petric m, trotovsek b. massive splenomegaly due to b-cell lymphoma: a case report. int j surg case rep. 2018;48:76– 8. itp, being refractory to steroid therapy in four cases.16,17 in all ten cases, the patients underwent specific therapy for dlbcl.3,6,16-18 in seven cases, the itp went into remission after treatment.3,19,20 three patients underwent an additional splenectomy.18,19,21 the splenectomy rather than the treatments for lymphoma might have been responsible for the remission seen in these cases. this case suggests that controlling the lymphoma can have beneficial effects on dlbcl-associated itp. our case develops itp remission after a splenectomy without specific therapy for dlbcl. ideally the patient was also given chemotherapy with r-chop regimen, which comprises rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone.3 but our patient refused further treatment. our case report has some limitations, such as no bmat carried out to assess the diagnosis of hypersplenism and bone marrow involvement, and no data on ldh level. diagnosis of lymphoma should still be considered as one of the underlying diseases for itp in middle-aged patients, even if lymphoma symptoms are absent in the initial presentation. a thorough search for underlying disorders is important in cases of itp that are refractory to conventional treatments. the precise pathogenesis of lymphoma-associated itp needs further investigation. references putri vidyaniati, fransisca, et al 50 international journal of integrated health sciences (iijhs) 16. nobuoka a, sakamaki s, kogawa k, fujikawa k, takahashi m, hirayama y, et al. a case of malignant lymphoma producing autoantibody against platelet glycoprotein ib. int j hematol. 1999;70(3):200–6. 17. uchiyama m, sato k, ikeda t. diffuse large b-cell lymphoma complicated with autoimmune thrombocytopenia. intern med j. 2011;50(11):1215–8. 18. takahashi t, maruyama y, saitoh m, itoh h, yoshimoto m, tsujisaki m, et al. synchronous occurrence of diffuse large b-cell lymphoma of the duodenum and gastrointestinal stromal tumor of the ileum in a patient with immune thrombocytopenic purpura. intern med j. 2016;55(20):2951–6. 19. yamamoto e, ozaki n, nakagawa m, kimoto m. primary bilateral adrenal lymphoma associated with idiopathic thrombocytopenic purpura. j leuk lymphoma. 1999;35(3-4):403–8. 20. berrang t, holloway c, hart j, yee a, berry b, kotb r. successful treatment of nonhodgkin lymphoma associated immune thrombocytopenia with involved field radiotherapy. hematol oncol. 2013;31(4):218– 20. 21. park sy, kim s, kim es, choi su, hyun hj, ahn jy, et al. a case of non-hodgkin’s lymphoma in patient with coombs’ negative hemolytic anemia and idiopathic thrombocytopenic purpura. cancer res treat. 2012;44(1):69–72. secondary chronic immune thrombocytopenia in diffuse large b-cell lymphoma: a rare case report vol 10 no.1 2022 rev.2.indd international journal of integrated health sciences (iijhs) 7 original article paraoxonase 1 activities and lipid parameters in hypertension and their association with chronic alcoholism abstract objective: to determine lipid profile, antioxidant vitamin (e and c), and malondialdehyde (mda) levels, as well as superoxide dismutase (sod) levels and paraoxonase 1 (pon 1) activities in alcoholic hypertensive patients. methods: five hundred subjects were selected for this study consisting of 250 normal healthy individuals and 250 alcoholic hypertensive subjects. total cholesterol, triglyceride, and hdl levels were measured using the enzymatic method while the ldl and vldl levels were calculated by friedwald equation. the mda level were measured using thiobarbiturate (tba) and the vitamin e and c were measured using the enzymatic method. the sod and pon 1 activities were measured using phenyl acetate as the substrate. results: total cholesterol, triglycerides, ldl, vldl, and mda levels were found to be significantly high while the hdl and vitamin e and c levels decreased among the alcoholic hypertensive subjects when compared to the control. furthermore, significant decreases in sod and pon 1 activities were also found among the alcoholic hypertensive subjects as compared to control. conclusion: alterations in lipid parameters, antioxidant vitamin levels, mda level, sod activities, and pon 1 activities are associated with hypertension that may be enhanced by alcohol intake, which may lead to the development cardiovascular disease. keywords: alcoholism, hypertension, mda, lipid parameter, antioxidants vitamins (e and c) received: november 24, 2021 accepted: february 16, 2022 correspondence: sumesh prasad sah muzaffarnagar medical college campus, muzaffarnagar, up, india e-mail: sumesh.sah@gmail.com sudeep kumar,1 jyoti batra,2 sumesh prasad sah,1 dinesh kumar,1 shahid iqbal,1 manisha arora,3 shivani sharma4 1muzaffarnagar medical college, muzaffarnagar, uttar pradesh, india 2santosh medical college & hospital, ghaziabad, uttar pradesh, india 3department of metabolism & nutrition, medical university of the americas, st. kitts & nevis 4department of physiology, medical university of the americas, st. kitts & nevis pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ ijihs.v10n2.2595 ijihs. 2022;10(1):7–11 introduction alcohol abuse leads to the buildup of fat in the liver. in alcoholics, significant amounts of alcohol disrupt many metabolic processes in the liver, resulting in the formation of reactive oxygen species (ros). under mammalian tissue, free radicals are produced in both healthy and pathological situations. in chronic alcoholism, free radicals have an impact and there is oxidative damage, which is a shift in the oxidant-antioxidant balance.1 chronic liver disease is the tenth leading cause of mortality in adults, with alcoholic cirrhosis accounting for over 40% of cirrhosisrelated deaths. three enzymes, alcohol dehydrogenase (adh), cytochrome p-4502e1 (cyp2e1), and mitochondrial catalase, metabolise alcohol in the liver. heavy drinkers have steatosis in 90 percent to 100 percent 8 international journal of integrated health sciences (iijhs) of cases, alcoholic hepatitis in 10% to 35% of cases, and alcoholic cirrhosis in 8% to 20% of cases. alcoholic fatty liver eventually leads to alcoholic hepatitis, cirrhosis, and liver failure.2 the enzyme paraoxonase (pon) has both paraoxonase and aryl esterase activity. aromatic carboxylic acid esters and certain organophosphorus insecticides, particularly paraoxon and nerve gas, are hydrolyzed. pon1, pon2, and pon3 are members of the pon gene family, which are found on chromosome 7q21.3–22.1. pon1 is primarily produced in the liver and is firmly linked to hdl, protecting both ldl and hdl against lipid peroxidation (lpo).3 paraoxonase 1 (pon1) activity varies up to 40-fold between individuals4, and it is regulated by genetic, developmental, environmental, and pathologic factors.5,6 low pon1 and arylesterase (ae) activity has been linked to a number of health problems.7 due to the liver damage produced by high alcohol use, it has been hypothesised that excessive alcohol consumption would result in a decrease in serum pon1 and ae activity, which has been seen in a few studies.8 excess synthesis of peroxides and free radicals causes oxidative stress, which is described as an imbalance between oxidants and reductants within the body. oxidative stress is linked to an increase in the generation of oxidizing species or a considerable reduction in the efficiency of antioxidants and antioxidant enzymes chemically. lpo is a free radical-related process that can be damaging if it goes unchecked; the self-enhancing process disrupts membranes, lipids, and other cell components.9 as a result, the presence of lpo in the blood can help determine the prognosis of non-alcoholic fatty liver disease (nafld) patients. the study on pon 1 activity in hypertension and its association with chronic alcoholism is limited hence the objective of this study was to evaluate the effect of chronic alcohol intake on lipid parameters, oxidative stress and paraoxonase 1 activity in hypertensive subjects. methods the present cross-sectional study was carried out in the department of biochemistry santosh medical college and hospital ghaziabad, department of biochemistry, muzaffarnagar medical college and hospital, muzaffarnagar. this study was approved by institutional ethical committee and informed consent was taken from the subjects, prior to study. the minimum sample size has been calculated using the appropriate sample size formula: n=z2pq/d2 where z=1.96 at 95 % confidence interval, p=0.20 and q=1-p=0.80, d=absolute error 5% n= (1.96)2×0.20×0.80/(0.05)2 =245.86≈246 in this study, 500 subjects were included out of which, 250 were already diagnosed hypertensive subjects with alcoholism and 250 were normal and healthy controls. all the subjects were male with 30-60 years of age. patients with type 2 diabetes mellitus, hepatic disease, cardiovascular disease, renal disease, pulmonary tuberculosis, acute or chronic inflammatory illness, gout and arthritis, prolonged illness, subjects not willing to give consent in the study, patients receiving medicines known to alter glucose and lipid metabolism were excluded from the study. the subjects were requested individually for overnight fasting. blood samples were drawn with the help of disposable syringe and collected in clean vials. the serum was separated and lipid profile was done on fresh serum and remaining serum sample was kept in small fractions at -200c. total cholesterol and hdl cholesterol were measured by chod-pap method, triglyceride by gpo-pap method and the level of ldl-c and vldl-c were calculated by friedwald equation. mda was measured by chemical method by using thiobarbituric acid (tba). sod was measured by modified marklund and marklund method by using pyrogallol. vitamin e & c were determined by chemical method. the activity of pon 1 was measured by chemical method by using phenyl acetate as a substrate. statistical analysis between controls & study subjects were performed by the student’s t test using spss package for windows. the data were expressed as mean ± sd. p<0.05 was considered as highly significant. result the difference between alcoholic hypertensive subjects and control subjects were statistically significant. alcoholic hypertensive patients were showed significant increase in cho, tg, ldl and vldl (p<0.001) and significantly decrease in hdl (p<0.0001) as compared to healthy control. the level of antioxidant vitamins (e&c) were found significantly paraoxonase 1 activities and lipid parameters in hypertension and their association with chronic alcoholism international journal of integrated health sciences (iijhs) 9 table 1 demographical parameters in studied subjects variables controls hypertensive with alcoholics p-value age (years) 42.93 ± 6.32 42.99 ± 6.53 >0.05 ns sbp (mm of hg) 113.86 ± 4.99 160.15 ± 6.47 <0.001 s dbp (mm of hg) 81.42 ± 3.82 100.15 ± 3.66 <0.001 s bmi* (kg/m2) 24.92 ± 3.29 27.71 ± 3.17 <0.001 s whr** 0.80 ± .058 1.08 ± 0.11 <0.001 s sbp: systolic blood pressure; dbp: diastolic blood pressure; bmi: basic metabolic index; whr: waist to height ratio; s: statistically significant; ns: statistically non-significant lower (p<0.001) and mda (p<0.001) was found significantly higher in alcoholic hypertensive subjects as compared to normal healthy individuals. superoxide dismutase and paraoxonase 1 activity were found to be reduced in alcoholic hypertensive subjects as compared to normal healthy controls (table 2). upon correlation analysis, a significant and negative correlation of mda with sod & pon 1 and a significant positive correlation of sod and pon 1 were observed (table 3). discussion multiple metabolic abnormalities often accompany essential hypertension. essential hypertension is associated with increased production of ros predisposing to increase in lipid peroxidation which is a marker for cellular damage. mda can exacerbate the actions of superoxide ions by impairing endothelium-dependent relaxation and propagation of lipid peroxidation by a chain reaction in membranes. in this study, increased bmi and waist/hip ratio (whr) were observed in hypertensive subjects with alcoholics as compared to controls. as bmi and whr being the markers of general obesity and central obesity, increased bmi and whr in hypertensive subjects with alcoholics predispose these subjects to an increased risk for cvd. table 2 biochemical parameters in studied subjects variables controls hypertensive with alcoholics p-value total cholesterol (mg/dl) 197.75 ± 23.21 280.52 ± 31.64 <0.001 triglycerides (mg/dl) 125.93 ± 18.72 239.18 ± 46.16 <0.001 hdlcholesterol (mg/dl) 48.82 ± 7.68 32.24 ± 4.62 <0.001 ldl-cholesterol (mg/dl) 123.75 ± 21.18 200.45 ± 30.18 <0.001 vldl-cholesterol (mg/dl) 25.19 ± 3.74 47.84 ± 9.23 <0.001 mda (nmol/ml) 2.92 ± 0.45 5.05 ± 1.41 <0.001 pon 1 (u/ml) 67.61 ± 7.45 47.21 ± 13.45 <0.001 sod (u/ml) 10.88 ± 1.87 7.63 ± 1.65 <0.001 vitamin-e (mg/dl) 1.76 ± 0.25 1.30 ± 0.12 <0.001 vitamin-c (mg/dl) 1.57 ± 0.18 1.19 ± 0.092 <0.001 mda: malondialdehyde; pon 1: paraoxonase 1; sod: superoxide dismutase table 3 correlation coefficient among parameters in hypertensive subjects with alcoholism variable pon1 sod vitamin e vitamin c mda r=-0.740 p<0.001 r=-0.620 p<0.001 r=-0.244 p<0.01 r=-0.512 p<0.001 sudeep kumar, jyoti batra, et al 10 international journal of integrated health sciences (iijhs) in this study, significantly increase in cho, tg, ldl-c, vldl-c and significantly decrease in hdl-cholesterol were observed in alcoholic hypertensive subjects as compared to normal healthy individuals. a study by paneri et al.10 concluded that there is rise in mda level in alcoholic hypertensive individuals as compared to normal controls. decrease in the serum hdl and tac is also observed in alcoholic individuals when compared to normal controls. serum total cholesterol, tg, ldl, vldl were also found to be elevated in the study group when compared to the normal controls. chen et al.11 found significant increase in total cholesterol, triglycerides, ldl-c and vldl-c in heavy alcohol consuming individuals. consumption greater than 50 g/ day significantly reduced the risk of developing low levels of hdl-c, but elevated the risks of developing high levels of cholesterol. increased plasma total cholesterol levels which are known to be associated with decreased ldl receptor gene expression and protein abundance in the liver, may be a factor for the change. chronic alcohol exposure may activates down-regulating the activation of a signaling enzyme that is known to be associated with decreased ldl receptor expression in hepatocytes, suggesting that multiple mechanisms are involved in alcoholinduced down-regulation of ldl receptor. this study revealed that there was significantly increase in mda levels associated with high alcohol consumption as compared to control. our results are in consistent with deshpande et al.12 who concluded that increase in mda levels are related to the alcohol consumption and that may be associated with pathogenesis and progression of liver disease. a study by tan et al.13 reported the same results. an increased mda level inactivates the antioxidant enzyme (sod) in untreated hypertension 14 causing damage to various proteins that may also the cause for reduced enzymatic activity of sod.15 the body produces its own antioxidants as a protective mechanism against oxidative stress. vitamin-like beta carotene, ascorbic acid, vitamin e, antioxidants enzyme like glutathione peroxidase, catalase and superoxide dismutase are natural antioxidants, which maintain the balance between oxidants and antioxidants. as discussed earlier, antioxidant vitamin (e & c) decrease the superoxide anion level in the presence of superoxide dismutase in a healthy individual. in case of hypertension, it was found in the present study that there was a direct correlation between the activity of superoxide dismutase (sod) and the levels of vitamin e and ascorbic acid. the significant rise in the levels of reactive oxygen species and decrease antioxidant enzyme may be explained as the combat mechanism showing a relationship between oxidant and antioxidant that has been further raised in alcoholic with hypertensive subjects. this study observed a significant decrease in pon 1 activity in hypertensive with alcoholic patients as compared to control. a positive correlation was also observed between antioxidant vitamin (e & c) and pon 1. individuals carrying low pon 1 activity may have a higher risk for cvd. a case-control study has shown that the reduced pon 1 activity is very common in chd patients.16 previous studies, including ours, have suggested that the pon1 provides the protection for ldl and hdl oxidation and pon1 confers antioxidant activity on hdl. while the susceptibility of hdl to lipid peroxidation and the antioxidant effect of hdl were not measured in our population, the increased risk of cvd in subjects carrying low pon 1 activity could be attributed to the acceleration of atherosclerotic process in these subjects, i.e., an increased susceptibility of ldl to oxidation, a reduction in the antioxidant effect of hdl, and an alteration of their functionality.17 serum pon 1 levels decline in various types of liver diseases. pon1 in association with hdl in the circulation protects ldl from peroxidation. the lowering of pon 1 may be due to peroxidative changes that occur in the hepatocytes. a fall in serum pon 1 could be taken as a manifestation of the different liver function tests i.e., synthesis, detoxication, and secretion. correlation studies have found that mda was positively and significantly correlated with tc where as it was significantly negatively correlated with hdl, pon1, sod, vit e and vit c. however, pon1 was significantly and negatively correlated with tc and mda where as it was positively correlated with hdl, sod, vit e and c. furthermore, sod was significantly and negatively correlated with tc and mda. however, it was positively correlated with hdl, pon1, vit e and c in hypertensive subjects with alcoholism. moreover, vitamin e was significantly and negatively correlated with tc and mda and positively correlated with hdl, pon1, sod and vit c. similarly, vitamin c was significantly and negatively correlated with tc paraoxonase 1 activities and lipid parameters in hypertension and their association with chronic alcoholism international journal of integrated health sciences (iijhs) 11 1. shinde a, ganu j, naik p, sawant as. oxidative stress and antioxidant status in patients with alcoholic liver disease. biomed res. 2012;23(1):105–8. 2. bruha r, dvorak r, petrtyl j. alcoholic liver disease. world j hepatol 2012;4(3):8–90. 3. mohammed h, ali b, norallah h, abdolkarim mr, sara s, alireza b, et al. serum paraoxonase and arylesterase activities in iranian patients with non alcoholic fatty liver disease. pathophysiology. 2012;19(2):115–9. 4. singh s, kumar v, thakur s, banerjee bd, rautela rs, grover ss, et al. paraoxonase-1 genetic polymorphisms and susceptibility to dna damage in workers occupationally exposed to organophosphate pesticides. toxicol appl pharmacol. 2011;252(2):130–7. 5. acay a, erdenen f, altunoglu e, erman h, muderrisoglu c, korkmaz gg, et al. evaluation of serum paraoxonase and arylesterase activities in subjects with asthma and chronic obstructive lung disease. clin lab. 2013;59(1112):1331–7. 6. kota sk, meher lk, kota sk, jammula s, krishna svs, modi kd. implications of serum paraoxonase activity in obesity, diabetes mellitus, and dyslipidemia. indian j endocrinol metab. 2013;17(3):402–12. 7. cervellati c, trentini a, romani a, bellini t, bosi c, ortolani b, et al. serum paraoxonase and arylesterase activities of paraoxonase-1 (pon-1), mild cognitive impairment, and 2-year conversion to dementia: a pilot study. j neurochem. 2015;135(2):395–401. 8. mogarekar mr, talekar sj. serum lactonase and arylesterase activities in alcoholic hepatitis and hepatitis b. indian j gastroenterol. 2013;(32)5:307–10. 9. ramprasad n. evaluation of lipid peroxidation and antioxidant enzyme status in ihd patients. medical science 2014;7(24):38–43. 10. paneri s, panchonia a,varma m, sarkar pd, yadav s. evaluation of oxidative stress in chronic alcoholic males of indore district. curr res microbial biotechnol. 2013;1(2):50–2. 11. chen cc, lin wy, li ci, liu cs, li tc, chen yt, et al. the association of alcohol consumption with metabolic syndrome and its individual components: the taichung community health study. nutr res. 2012;32(1):24-9. 12. deshpande n, kandi s, kumar pvb, ramana kv, muddeshwar m. effect of alcohol consumption on oxidative stress markers and its role in the pathogenesis and progression of liver cirrhosis. american j med and bio res. 2013;1(4):99–102. 13. yadav rd, momin aa, banker mp, durgawle pm, bhoite mg, satpute sb, et al. oxidative stress and antioxidant vitamin levels in alcoholic liver disease patients. int j hea sc res. 2012;2(1):27–32. 14. ahmad a, hossain mm, singhal u, islam n. comparative study of marker of oxidative stress among normotensive, pre-hypertensive and hypertensive subjects. biomed res. 2013;24(4):491–5. 15. jha s, shrestha s, parchwani h, rai r. study on the levels of oxidant and anti-oxidant enzymes in hypertensive patients. int j med sci public health. 2014;3(9):1074–8. 16. hassan ma, al-attas os, hussain t, al-daghri nm, alokail ms, mohammed ak, et al. the q192r polymorphism of the paraoxonase 1 gene is a risk factor for coronary artery disease in saudi subjects. mol cell biochem 2013;380(1-2):121–8. 17. bounafaa a, berrougui h, ikhlef s, essamadi a, nasser b, bennis a, et al. alteration of hdl functionality and pon1 activities in acute coronary syndrome patients. clin biochem. 2014;47(18):318–25. references and mda and positively correlated with hdl, pon1, sod and vit e in hypertensive subjects with alcoholism. this study showed a negative correlation between mda & vitamin c, vitamin-e, sod, pon1 and positive correlation between pon1 & antioxidants (sod, vitamin-e & c). results of present study demonstrate that serum pon1 activity measurement may add a significant contribution to cardiac marker. thus the present study concluded that the decreased activity of pon1 and hdl-c levels may be contributed to the risk of atherosclerosis via alteration in oxidized-ldl and oxidative stress. sudeep kumar, jyoti batra, et al vol 10 no.1 2022 rev.2.indd 20 international journal of integrated health sciences (iijhs) vascular disease, consists of antiphospholipid syndrome, microscopic angiitis, granulomatous polyangiitis, cryoglobulinemia, systemic lupus erythematosus, systemic sclerosis, mixed connective tissue disease, and rheumatoid arthritis.1 immune system dysregulation in pras leads to intetstital lung disease (ild).2 data showed that 13.9–15% of sard patients get ild.3 the main investigation modalities in establishing the diagnosis of ild are conventional x-ray and thorax hrct. conventional x-rays have relatively low sensitivity.4 thorax hrct is the gold standard of ild diagnosis with a sensitivity of 95% which can also determine the severity of ild.5 hrct examination is not introduction systemic autoimmune rheumatic disease (sard) is a multiorgan systemic inflammatory disease associated with immune system dysregulation and leading to disability, organ failure, and premature death. systemic autoimmune rheumatic disease, also known as connective tissue disease or collagen correlation between serum kl-6 level and severity of sard-related ild abstract objective: to understand the correlation between serum kl-6 level and severity of sard-related ild in indonesia. methods: this was a cross-sectional study to evaluate the correlation between serum kl-6 level and interstitial lung disease (ild) severity based on chest high-resolution computed tomography (chest hcrt) among patients with systemic autoimmune rheumatic disorders (sard) who visited the rheumatology clinic of dr. hasan sadikin general hospital during the period of january 2019 to february 2020. secondary data were retrieved from a study on the effects of ciplukan herbs on organ fibrosis. kl-6 serum concentration was measured from stored biological material and the correlation between the serum kl-6 level and ild severity was analyzed by rank spearman’s test. results: thirty-four patients participated in this study with a median age of 37 years-old. most of the participants were female (94.1%), sundanese (64.7%), and had systemic sclerosis as an underlying disease (48.5). the median serum kl-6 level was 57.1 u/ml (21.6-444.1). most participants belonged to severe ild group (58.8%) with a mean serum kl-6 level of 65.1±48.9 u/ml. the highest mean serum kl-6 level (111.6±121.8) was observed in the moderate ild group comprising of 32.4% of the participants. the remaining 11.8% participants belonged to mild ild group with a mean serum kl-6 level of 61.1±24.9 u/ml. serum kl-6 level was demonstrated to have a weak correlation with ild severity (r=0.229, p=0.193). conclusion: there is an insignificant weak correlation between serum kl-6 level and ild severity based on chest hrct in sard patients. keywords: ild, kl-6, sard received: january 28, 2022 accepted: march 30, 2022 correspondence: emmy hermiyanti pranggono pulmonology division, internal medicine department, faculty of medicine universitas padjadjaran/hasan sadikin general hospital, bandung, indonesia e-mail: emmyhermiyanti@gmail.com original article emmy hermiyanti pranggono, alvy syukrie, valentine natasya moenardi, sumartini dewi department of internal medicine, faculty of medicine universitas padjadjaran dr. hasan sadikin general hospital, bandung, indonesia pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ ijihs.v10n1.2652 ijihs. 2022;10(1):20–25 international journal of integrated health sciences (iijhs) 21 yet widely available, limited to certain health care centers, and relatively expensive.6 thorax hrct also carries a risk of radiation exposure so it is not safe for routine disease monitoring.7 krebs von den lugen-6 (kl-6) serum is a biological marker that has high sensitivity in the diagnosis of ild, monitoring the course of the disease, assessing therapeutic response, and predicting the prognosis of ild.8 secretion of kl-6 into the bloodstream occurs due to severe damage to the alveolar basement membrane and increased permeability of the blood-air barrier. high serum kl-6 levels were found in more than 70% of sard associatedild cases.9. serum kl-6 level had a strong and significant correlation with the severity of ppi and the area of lung segments involved based on chest hrct.10,11 lee et al. showed that kl-6 levels had a strong and significant correlation with the severity of ild and the area of the involved lung segment (r=0.561, p <0.001) based on thorax hrct.10,11 yamakawa et al. reported a significant correlation between serum kl-6 levels and ild severity in sard (r=0.418, p=0.010).8 another study by cho et al. concluded that kl-6 correlated with ild severity based on thorax hrct for interstitial lung disease (r=0.561).11 serum kl-6 levels were influenced by ethnic differences. evidence from previous studies in asia and europe showed different levels of kl6. most of the information regarding the role of serum kl-6 as a biological marker of ild were obtained from studies in japan and western countries. the effect of ethnic differences on ild progression has been reported by ishikawa et al., cao et al., and horimasu et al. the difference in kl-6 levels was caused by the polymorphism of the muc1 gene.12 research regarding the relationship between serum kl-6 levels and ild severity is important to be carried out to serve as the basis for evaluating the use of serum kl-6 as a modality for regular monitoring of ild in sard population. research regarding sardrelated ild is still limited and to date there have been no studies regarding the use of serum kl-6 in the diagnosis or monitoring of ild in indonesian patient population. in this study, we evaluated the correlation between serum kl-6 levels and ild severity based on chest hrct in sard patients. methods participants of this study was sard patients in rheumatology clinic of hasan sadikin general hospital bandung, indonesia in 20192020. inclusion criteria were aged 18-60 years, diagnosed with sard whose data was recorded in the research “effects of ciplukan herbs on organ fibrosis”, had been scored and staged for ild severity based on hrct thorax, and had stored biological material (less than 2 years) for serum kl-6 examination. exclusion criteria were pneumonia, tuberculosis, history of tuberculosis, malignancy or history of malignancy, and functional class iii-iv cardiac decompensation. data collection was initiated by looking for sard patients with ild who participated in the research “effects of ciplukan herbs on organ fibrosis”.13 serum kl-6 levels were collected as primary data. blood samples from all the patients were collected in the same day or in maximum interval of 7 days from thorax hrct examination. serum were stored in the refrigerator at -80oc. serum kl-6 concentrations were measured using an enzyme-linked immunosorbent assay kit (bioassay technology laboratory, china), according to the manufacturer’s instructions. the ild score and severity data were taken from the registry confirmed by two thoracic radiology consultants at the radiology department. the scoring system used is the warrick et al. method which combines the severity and extent of the lesion.14 the severity of the ild was determined by the method of mohammadi et al. which classifies the scoring results into mild, moderate, or severe degrees.15 this was a cross-sectional study with correlation analysis. sample measurement was determined using the correlation test formula, with a minimum total sample of 32 participants was required. secondary data for baseline characteristic was obtained from medical records, including age, sex, and medications. the data that had been collected from research participants who met the inclusion and exclusion criteria were analyzed using the statistical package for the social science (spss) program. the numerical scale was presented with the mean and standard deviation if the distribution is normal or median and the range if the distribution was not normal. categorical scale data was presented in the form of frequency and percentage.16 bivariate analysis was performed to examine the correlation of kl-6 levels with ild severity based on chest hrct. the correlation test was carried out using the spearman’s rank correlation test. this study had been approved by the ethics emmy hermiyanti pranggono, alvy syukrie, et al 22 international journal of integrated health sciences (iijhs) committee of hasan sadikin general hospital bandung with ethical approval number lb.02.01/x.6.5/132/2021. for all patients who were enrolled in this study, the informed consent form was signed by the patient herself/ himself. result a total of 60 medical record of sard patients with ild were obtained during the study period. there were 26 patients excluded, consisting of 25 patients with incomplete data and 1 patient with active pulmonary tuberculosis infection. data analysis was performed on 34 patients who met the inclusion and exclusion criteria. almost all of this study participants were women. the most common underlying disease is systemic sclerosis. the most common types of therapy are methylprednisolone and methotrexate. complete baseline characteristics can be seen in table 1. the median kl-6 level in this study was 57.1 u/ml (21.6-444.1) and the mean ild table 1 baseline characteristics variable n=34 age (years) median (minimum-maximum) 37 (21-64) sex, (n (%)) female 32(94,1) male 2(5,9) underlying disease, (n(%)) systemic sclerosis 16(48,5) sle 14(40) mctd 3(8,6) rheumatoid arthritis 1(2,9) medications, (n(%))* methylprednisolone 33(97,1) metothrexate 32(94,1) aspilet 26(62,9) nifedipin 19(55,9) ciplukan herbs 17(50,0) diltiazem 13(38,2) mycophenolate mofetil 11(32,4) ppi/ h2 receptor antagonist/ antasida 9(26,5) azatioprin 9(26,5) cyclophosphamid 9(26,5) cyclosporin 6(17,6) note: *one patient could get multiple medications; ppi: proton pump inhibitor; mctd: mixed connective tissue disease; sle: systemic lupus erythematous score based on the warrick et al. was 16.8±6.4. the largest proportion of participants were in severe ild group (table 2.). table 3 and figure showed that most of the participants had a severe ild while the highest mean serum kl-6 level was found in the moderate ild severity group. dosage and duration of therapy could affected the severity of ild and serum kl-6 levels but the secondary data source in this study did not record the dose and duration of therapy. correlation analysis using rank-spearman test at 95% confidence level showed that there was a weak correlation in a negative direction (r=-0,229) that was not statistically significant (p=0.193). discussion this was the first study in indonesia to assess the value of kl-6 in diagnosing and rmonitoring sard related-ild in indonesia. the results of this study showed a weak correlation which is statistically insignificant between kl-6 levels and disease severity table 2 concentration of kl-6, ild score, and severity of ild variable n=34 kl-6 concentration (u/ ml) median (range) 57.1 (21.6–444.1) ild score mean ± standard deviation 16.8±6.4 ild severity (n(%)) mild 3 (11.8) moderate 11 (32.4) severe 20 (58.8) figure frequency of ild severity and serum kl-6 correlation between serum kl-6 level and severity of sard-related ild international journal of integrated health sciences (iijhs) 23 although based on a literature review, kl-6 was the biological marker with the best diagnostic value in the identification of ild, followed by surfactant protein-d (spd) and matrix metalloproteinases 12 (mmp 12). ).17 spearman’s rank correlation test with a 95% confidence level between serum kl-6 levels and ild severity showed a weak correlation with a negative direction (r=-0.229) which was not statistically significant (p>0.05). this weak correlation was thought because kl-6 was influenced by many factors apart from the severity of the ild including genetic factors medications consumed by the patient. most of the study participants had a severe ild while the highest mean kl-6 levels were found in the moderate ild severity group. the low kl-6 levels in the severe group were thought to be due to medications, hook effect, radiological features that persisted regardless of clinical improvement or discontinued disease progression. the correlation value of kl-6 levels with ild severity was expected to be better and has a positive direction if kl-6 levels also increase with increasing disease severity. the ild treatment strategy is based on stopping or suppressing the inflammatory process. corticosteroids, immunosuppressants, cytotoxic agents, and antifibrotic agents, either alone or in combination, are used in this disorder.18 almost all research participants received methylprednisolone and methotrexate therapy. mycophenolate mofetil and cyclophosphamide are the treatment of choice for severe ild according to clinical guidelines our hospital. mycophenolate mofetil is a drug with tablet preparations that are more practical than cyclophosphamide which given intravenously. this convenience may be the reason that more numbers of severe ild patients received mycophenolate mofetil therapy (40%) than cyclophosphamide therapy (15%). dose and duration of therapy were not recorded on the registry so that the precise influence of these factor could not be determined on this study. kl-6 levels in the moderate-severity group (111.6±121.8 u/ml) were higher than those in the mild-grade group (61.1±24.9 u/ml). these findings were consistent with the relationship between kl-6 levels and the degree of lung tissue damage.9 the small proportion (18.2%) of moderate ild participants receiving mycophenolate mofetil therapy was thought to be the reason of the high levels of kl-6 in this group because this drug could inhibit the proliferation of fibroblasts which associated with the secretion of kl-6 into the circulation.19 most of the participants were in severe ild group but the average kl-6 level in this group tended to be lower than the moderate ild group (65.1±48.9 u/ml vs. 111.6±121.8 u/ml). ml). the combination of the effect of mycophenolate mofetil, the drug most often given in this group, with other therapies (cyclophosphamide, methotrexate, and adjuvant therapy of ciplukan herbs extract) could be the reason of low kl-6 levels. mycophenolate mofetil was most often given to the severe ild group because this drug is the table 3 serum kl-6 and medications according to ild severity mild moderate severity total n (%) 3 (11.8) 11 (32.4) 20 (58.8) 34 (100) serum kl-6 (u/ml) mean±standard deviation 61.1±24.9 111.6±121.8 65.1±48.9 medications, n(%)* methylprednisolone 3 (100) 11 (100) 19 (95.0) 33 (97.1) methothrexate 3 (100) 11 (100) 18 (90.0)# 32 (94.1) ciplukan herbs 1 (33.3) 6 (54.5) 10 (50.0) 17 (50) mmf 1 (33.3) 2 (18.2) 8 (40.0) 11 (32.4) azatioprin 2 (66.7) 4 (36.4) 3 (15.0) 9 (26.5) siklofosfamid 3 (100) 3 (27.3) 3 (15.0) 9 (26.5) siklosporin 1 (33.3) 1 (9.1) 4 (20.0) 6 (17.6) note: *) one patient could get multiple medications; #) methotrexate was topped once patient received cyclophosphamide or mmf. mmf: mycophenolate mofetil emmy hermiyanti pranggono, alvy syukrie, et al 24 international journal of integrated health sciences (iijhs) treatment of choice for severe ild according to clinical guidelines at the rshs rheumatology clinic along with cyclophosphamide. serum kl-6 levels could be influenced by several other factors, including genetic differences and hook effect. horimasu et al.’s obtained higher kl-6 levels in the patient group in germany than in the group in japan. this difference in levels was caused by the polymorphism of the muc1 gene.20 there are currently no data regarding the genetic profile of the indonesian population. the hook phenomenon that causes lower than expected results had been widely reported. hook effect has been reported to affect various tests using the elisa method, including the examination of -hcg, prolactin, calcitonin, aldosterone, and tumor markers (ca 125 and psa).21 the sample in this study was not re-examined by dilution when a low kl-6 result was obtained at the initial examination. dilution would result in higher kl-6 levels if there was a hook effect that interferes with the test results. duration of sample storage was thought did not influence the concentration of kl-6 since most of the samples for examination of serum kl-6 levels were taken on the same day of examination of hrct of the thorax, while some examinations were carried out with a maximum length of 1 week. there is a weak correlation between serum kl-6 levels and ild severity based on chest hrct in sard patients. serum kl-6 levels in this study is in the low range presumably due to drugs, ethnicity, and hook effects. there is tendency of higher serum kl-6 level on moderate ild group than mild ild group while the level tends to lower in severe ild group compared to moderate ild group. in conclusion, there is a weak correlation which is statistically insignificant between kl-6 serum and ild severity found in this study. 1. kono dh, theofilopoulos an. autoimmunity. dalam: firestein gs, gabriel se, mcinnes ib, o’dell jr, editor. kelley and firestein’s textbook of rheumatology. edisi ke-10. philadelphia: elsevier; 2017. p. 301–17. 2. ha y-j, lee yj, kang eh. lung involvements in rheumatic diseases: update on the epidemiology, pathogenesis, clinical features, and treatment. biomed res int. 2018;2018:6930297-. 3. singh s, collins bf, sharma bb, joshi jm, talwar d, katiyar s, et al. interstitial lung disease in india. results of a prospective registry. am j respir crit care med. 2017;195(6):801–13. 4. vizioli l, ciccarese f, forti p, chiesa am, giovagnoli m, mughetti m, et al. integrated use of lung ultrasound and chest x-ray in the detection of interstitial lung disease. respiration. 2017;93(1):15–22. 5. mikolasch ta, garthwaite hs, porter jc. update in diagnosis and management of interstitial lung disease. clin med (lond). 2017;17(2):146–53. 6. rivera-ortega p, molina-molina m. interstitial lung diseases in developing countries. ann glob health. 2019;85(1):4. 7. zheng p, liu x, huang h, guo z, wu g, hu h, et al. diagnostic value of kl-6 in idiopathic interstitial pneumonia. j thorac dis. 2018;10(8):4724–32. 8. yamakawa h, hagiwara e, kitamura h, yamanaka y, ikeda s, sekine a, et al. serum kl-6 and surfactant protein-d as monitoring and predictive markers of interstitial lung disease in patients with systemic sclerosis and mixed connective tissue disease. j thorac dis. 2017;9(2):362-71. 9. ishikawa n, hattori n, yokoyama a, kohno n. utility of kl-6/muc-1 in the clinical management of interstitial lung disease. respiratory investigation. 2012;50:3–13. 10. lee js, lee ey, ha y-j, kang eh, lee yj, song yw. serum kl-6 levels reflect the severity of interstitial lung disease associated with connective tissue disease. arthritis res ther. 2019;21(1):58. 11. cho e-j, park k-j, ko d-h, koo hj, lee sm, song jw, et al. analytical and clinical performance of the nanopia krebs von den lungen 6 assay in korean patients with interstitial lung diseases. ann lab med. 2019;39:245–51. 12. hu y, wang ls, jin yp, du ss, du yk, he x, et al. serum krebs von den lungen-6 level as a diagnostic biomarker for interstitial lung disease in chinese patients. clin res j. 2017;11(3):337–45. 13. dewi s, isbagio h, purwaningsih eh, kertia references correlation between serum kl-6 level and severity of sard-related ild international journal of integrated health sciences (iijhs) 25 n, setiabudy r, setiati s. a double-blind, randomized controlled trial of ciplukan (physalis angulata linn) extract on skin fibrosis, inflammatory, immunology, and fibrosis biomarkers in scleroderma patients. acta med indones. 2019;51(4):303–10. 14. warrick jh, bhalla m, schabel si, silver rm. high resolution computed tomography in early scleroderma lung disease. j rheumatol. 1991;18(10):1520–8. 15. mohammadi a, oshnoei s, ghasemi-rad m. comparison of a new, modified lung ultrasonography technique with highresolution ct in the diagnosis of the alveolointerstitial syndrome of systemic scleroderma. med ultrason. 2014;16(1):27–31. 16. field ap, field ap. discovering statistics using ibm spss statistics.2018. 17. shao t, shi x, yang s, zhang w, li x, shu j, et al. interstitial lung disease in connective tissue disease: a common lesion with heterogeneous mechanisms and treatment considerations. front immunol. 2021;12:684699. 18. pitoyo cw. penyakit paru interstitial. in: setiati s, alwi i, sudoyo aw, k ms, setiyohadi b, syam af, editor. buku ajar ilmu penyakit dalam. edisi ke-vi. jakarta: interna publishing; 2014. p. 1667–74. 19. bergner r, hoffmann m, geibel-werle g, uppenkamp m. mycophenolate mofetil (mmf) for treatment of pulmonary fibrosis in patients with systemic sclerosis (pss) and polymyositis. ann rheum dis. 2004;suppl 1(63):344. 20. horimasu y, hattori n, ishikawa n, kawase s, tanaka s, yoshioka k, et al. different muc1 gene polymorphisms in german and japanese ethnicities affect serum kl-6 levels. respir med. 2012;106(12):1756–64. 21. turgeon ml. linne & ringsrud’s clinical laboratory science: the basics and routine techniques. 6th ed. us: mosby; 2015. emmy hermiyanti pranggono, alvy syukrie, et al volume 9 no 2 2021 fix.indd 66 international journal of integrated health sciences (iijhs) hook effect and serum kl-6 in patients with systemic sclerosisassociated interstitial lung disease (ssc-ild) abstract objective to determine whether serum kl-6 can be used as an alternative diagnostic tool for systemic sclerosis-associated ild (ssc-ild). methods: this was a cross-sectional study with compatibility analysis of ssc patients visiting the rheumatology clinic of dr. hasan sadikin general hospital, bandung, indonesia in 2019-2020. inclusion criteria were aged 18-60 years, diagnosed with ssc, restrictive spirometry results followed by hrct thorax, having stored biological materials (<2 years) for serum kl-6 examination, and body mass index of <23 kg/m2. patients with pneumonia, tuberculosis, history of tuberculosis, malignancy, and cardiac decompensation were excluded. serum kl-6 level of >397.5 unit/ ml was declared as ild. the compatibility analysis was performed using the cohen’s kappa test. results: thirty-eight subjects, mostly women (94.7%), with mean age of 39 years participated in this study. most of the subjects suffered from diffuse systemic sclerosis subtypes (57.9%). subjects had received cyclophosphamide (10.5%), mmf (2.6%), and other medications. almost all subjects (97.4%) demonstrated ild features on hrct thorax. the median serum kl-6 level was 53.22 units/ml, which was much lower than the findings in other studies, but the hook effect could not be proven. the kappa coefficient was found to be 0.003 with a p-value of 0.811. conclusion: there is no compatibility between serum kl-6 level and ild features based on hrct thorax in ssc-ild. the presence of hook effect needs more attention. keywords: hook effect, ild, kl-6, systemic sclerosis received: july 22, 2021 accepted: september 25, 2021 original article emmy hermiyanti pranggono, valentine natasya moenardi, alvy syukrie, sumartini dewi department of internal medicine, faculty of medicine universitas padjadjaran-dr. hasan sadikin general hospital bandung, indonesia pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ ijihs.v9n2.2448 ijihs. 2021;9(2):66–72 correspondence: emmy hermiyanti pranggono, department of internal medicine, faculty of medicine universitas padjadjaran-dr. hasan sadikin general hospital bandung, indonesia, e-mail: emmyhermiyanti@gmail.com introduction interstitial lung disease (ild) is a group of diseases that involve the walls and tissues surrounding the alveoli.1 damage to the lung parenchyma triggers a fibrotic process that causes severe gas exchange and ventilation disorders. the etiology of this disease varies, among which occurs in 50% of patients with systemic sclerosis (ssc) which is influenced by genetic factors, ethnicity, and environmental exposure.2 this disease is difficult to diagnose, especially in developing countries due to limited diagnostic facilities.3 pulmonary function tests can show restrictive lung abnormalities but cannot differentiate the cause.2 radiological examinations such as chest x-ray are inexpensive and easy to perform and have little radiation exposure but can give a normal picture on ild. therefore, hrct thorax is an option for establishing the diagnosis of ild even though it causes radiation exposure, requires high costs and is difficult to perform due to limited facilities so that routine examinations cannot be carried out to monitor the progress of the disease course in short time intervals, whereas in ssc international journal of integrated health sciences (iijhs) 67 patients with ild need periodic examinations to assess the progress of ild and response to therapy.2, 3 another safer and cheaper assay is serum kl-6 which has been known to enhance the chemotactic and anti-apoptotic effects of fibroblast cells.4 krebs von den lungen-6 is an ild biomarker that has high sensitivity and specificity for diagnosing, monitoring, and predicting prognosis.5 thus, serum kl-6 is expected to be an alternative examination for ild in patients with systemic sclerosis. despite the specificity, numerous interferences are possible. interferences can be defined as the effect of substances present in an analytical system which causes deviation of the measured value from the true value. the interferences can cause false increase or false decrease of measured result, which might cause misleading laboratory report.6 this study aims to determine if serum kl-6 can be used as an alternative diagnostic tool for sscassociated ild (ssc-ild). methods subjects of this study was ssc outpatient in rheumatology clinic of hasan sadikin general hospital bandung, indonesia in 2019-2020. inclusion criteria were aged 18-60 years, diagnosed with ssc in line with the american college of rheumatology/european league against rheumatism (acr/eular) 2013 classification criteria for ssc, restrictive spirometry results and continued with hrct thorax, having stored biological material (less than 2 years) for serum kl-6 examination, and body mass index less than 23 kg/m2. exclusion criteria were pneumonia, tuberculosis, history of tuberculosis, malignancy or history of malignancy, and functional class iii-iv cardiac decompensation. all patients underwent hrct thorax examination as gold standard for ild. the results of the hrct thorax were grouped based on the presence or absence of ild features contained in the expertise of the thoracic team of the radiology department, faculty of medicine, universitas padjadjaran/hasan sadikin general hospital bandung, which were approved by 2 consultants, including features of fibrosis, ground glass opacities, irregular pleural margins, septal or subpleural lines, honeycombing, and subpleural cyst. serum kl-6 levels were collected as primary data. blood samples from all the patients were collected in the same day or 7 days maximum length from hrct thorax examination. serum were stored in the refrigerator at -80oc. serum kl-6 concentrations were measured using an enzyme-linked immunosorbent assay kit (bioassay technology laboratory, china), according to the manufacturer’s instructions. serum kl-6 levels >397.5 unit/ml were declared as ild, using cut-off from a study in china that met the clinical trial requirements, since there has been no diagnostic study for serum kl-6 in indonesia. data collection began with searching for data on patients with systemic sclerosis at the hasan sadikin general hospital rheumatology clinic for 2019-2020 in the ssc registry. blood samples of patients who met the inclusion and exclusion criteria were collected in the form of stored biological material at the department of clinical pathology under the ssc registry research. the length of blood sampling and thorax hrct examination is a maximum of 7 days. examination of serum kl-6 levels done with elisa technique. this is a cross-sectional study method with diagnostic test evaluation. sample measurement was determined using the compatibility test formula, with a minimum total sample of 37 subjects was required. secondary data for baseline characteristic was obtained from hasan sadikin general hospital systemic sclerosis registry, including age, sex, disease duration, medications, and modified rodnan skin score (mrss). number and percentage were used for categorical variables. the continuous variables were tested by kolmogorov-smirnov normal distribution. mean ± standard deviation was used for measurement data following the normal distribution. median was used for non-normal distribution measurement data. a value of p<0.05 suggested the result was statistically significant. cohen’s kappa test was used to analyze compatibility of serum kl-6 levels with hrct thorax. this study was approved by the health research ethics committee of dr. hasan sadikin general hospital bandung with ethical approval number lb.02.01/x.6.5/318/2020. for all patients who were enrolled in this study, the informed consent form was signed by the patient herself/himself. result there were 85 patients with systemic sclerosis recorded in the ssc registry, with 7 people over 60 years old, 33 people having no data of hrct thorax, 23 people not having bbt. the subjects analyzed in this study were 38 emmy hermiyanti pranggono, valentine natasya moenardi, et al 68 international journal of integrated health sciences (iijhs) patients who met the inclusion and exclusion criteria. almost all of this study subjects were women. other baseline characteristics showed some differences from other studies, such as the age of the subjects in this study which was lower than studies in other countries, and the diffuse ssc (dssc) subtype which was more than the limited ssc (lssc) subtype. complete baseline characteristics can be seen in table 1. subgroup analysis was carried out because the results of this study were different from other studies. subtype and administration of therapy are known to affect serum kl-6 levels. the dssc subtype was said to have higher serum kl-6 levels than the lssc subtype. administration of cyclophosphamide therapy, which is the treatment of choice for pulmonary table 1 subject characteristics variable n = 38 age (years), mean ± sd 39 ± 11 female, n (%) 36 (94,7) disease duration (month), median (range) 24 (4–168) overlap syndrome, n (%) 7 (18,4) subtype, n (%) dssc 22 (57,9) lssc 16 (42,1) medications, n (%) history of cyclophosphamide 4 (10,5) history of physalis angulata linn. 6 (15,8) methylprednisolone 33 (86,8) methotrexate 27 (71,1) mmf 1 (2,6) azathioprine 3 (7,9) cyclosporin 1 (2,6) mrss, mean ± sd 17,53±6,425 serum kl-6 level (unit/ml), median (range) 53,22 (21,62–444,07) ild features in hrct thorax, n (%) 37 (97,4) dssc, diffuse systemic sclerosis; hrct, high resolution computed tomography; kl-6, krebs von den lungen-6; lssc, limited systemic sclerosis; mmf, mycophenolate mofetil; mrss, modified rodnan skin score; ild, interstitial lung disease. median serum kl-6 levels in this study was 53.22 units/ml (range 21.62-444.07 units/ml), lower than studies in various countries, although the results of hrct thorax with ild features were found in almost all study subjects. there were only 3 subjects in this study who had serum kl-6 levels more than 200 unit/ml. table 2 compatibility between serum kl-6 levels (cut off 397,5 unit/ml) and ild features based on hrct thorax ild variable total yes no kappa coefficient p value n=37 n=1 serum kl-6 levels > 397,5 u/ml yes 2 2 0 0,003 (-0,004 – 0,010) 0,811 no 36 35 1 hrct, high resolution computed tomography; kl-6, krebs von den lungen-6 hook effect and serum kl-6 in patients with systemic sclerosis-associated interstitial lung disease international journal of integrated health sciences (iijhs) 69 fibrosis, is said to reduce serum kl-6 levels. the result showed that the differences in serum kl-6 levels between the dssc subtype groups and lssc, as well as between the group receiving cyclophosphamide therapy and the group without cyclophosphamide therapy were not statistically significant. analysis testing using the cohen kappa formula was carried out to test the compatibility between serum kl-6 levels and ild features based on hrct thorax in ssc patients with restrictive lung disease. cohen’s kappa analysis with a cut off value of serum kl-6 levels of 397.5 units/ml showed no agreement, so an analysis was carried out using the median in this study (53.22 units/ ml), as can be seen in table 3. the kappa coefficient was in the range of 0.0–0.20 indicating a very low concordance with a p-value>0.05 which indicated that these results were not statistically significant. the results of this study showed that there was no compatibility between serum kl-6 levels and ild features based on hrct thorax in ssc-ild. discussion this is the first study in indonesia to assess the compatibility between serum kl-6 levels and ild features based on hrct thorax in ssc-ild. the presence of previously unknown interferences needs to be considered because this study showed different results from other similar studies, the results did not match the clinical picture of the study subjects, and did not match the gold standard of imaging results. the interferences can be defined as the effect of the substance contained in the examination that causes the deviation of the measured value from the true value. interferences in the immunoassay examination can cause false increases or false decreases. the hook effect that can occur in this study corresponds to the saturation curve between analyte (antigen) and antibody. the hook effect indicates the presence of a very large amount of analyte which saturates the binding sites on the antibody. this phenomenon is common in analytes whose serum levels have a very wide range, such as c-reactive protein, hormones, and tumor markers. the hook effect can be proven if the diluted sample shows a higher value than the undiluted sample, which unfortunately could not be done in this study.6 serum kl-6 levels in this study were so low in 36 subjects that they could not be categorized as ild when using a cut off value of 397.5 units/ml. these results were not in accordance with the ild features obtained from almost all hrct thorax examinations in this study. another study showed that the examination of serum kl-6 levels had a sensitivity and specificity of above 80% for the incidence of ilds.7 the difference of the results in this study, the low serum kl-6 level, indicated a hook effect. the incidence of hook effect on serum kl-6 examination had never been recorded before so it was not listed in the reagent kit. unfortunately, this study could not prove the hook effect. examination of serum kl-6 levels without dilution of the sample was a limitation of this study. this phenomenon became a note for further research on serum kl-6 levels, that it is necessary to dilute the sample. serum kl-6 levels can be influenced by several factors, including the hook effect as previously discussed, ethnic and genetic differences, ages, ssc subtype, and the administration of therapy. cut off values for serum kl-6 levels had known different in 2 ethnicities and 3 genotypes, including german and japanese ethnicities and genotypes a/a, a/g, and g/g.8 differences in cut off values for serum kl-6 levels were also found among various asian populations.4,7,9,10 this may also explain the difference in mean or median serum kl-6 levels in studies in various table 3 compatibility between serum kl-6 levels (threshold 53,22 unit/ml) and ild features based on hrct thorax variable total ild kappa coefficient p valueyes no n=37 n=1 kl-6 > 53,22 u/ml yes 19 19 0 0,053 (-0,049 – 0,154) 0,311 no 19 18 1 hrct, high resolution computed tomography; kl-6, krebs von den lungen-6 emmy hermiyanti pranggono, valentine natasya moenardi, et al 70 international journal of integrated health sciences (iijhs) countries, including this study.4,8 this study had a mean age of 39 years. the japanese and hungarian studies had an older mean age.11, 12 the differences in mean age show the differences in the characteristics of ssc patients in various countries. serum kl-6 levels increase with age.13 age-related physiological changes occur in the respiratory system, including reduced elastic recoil, chest wall stiffness, changes in gas exchange, and increased flow resistance. these changes contribute to increased morbidity and mortality of lung diseases in the elderly, including chronic obstructive pulmonary disease, lung cancer, pulmonary fibrosis, and infection, which may affect serum kl-6 levels in older individuals.14 as many as 52.6% of this study subjects were dssc, while other studies in china and hungary were more of the lssc subtype.9,11 the difference could be due to differences in the characteristics of ssc patients related to ethnicity and genetics. interstitial lung disease is found in the lssc subtype with slow progression and generally mild. interstitial lung disease in the dssc subtype was more common, with an earlier onset, faster progression and more severe clinical course, so that the serum kl-6 level in the dssc subtype was higher than in the lssc subtype.15 serum kl-6 levels in this study should be similar to other studies with more dssc subtypes, or higher than other studies with more lssc subtypes. administration of therapy to ssc-ild does not necessarily lead to low serum kl-6 levels. methotrexate has not shown improvement in pulmonary function on ild, whereas idiosyncratic drug-related hypersensitivity pneumonitis is known.16 there was a decrease in serum kl-6 levels after 1 year of administration of cyclophosphamide and mmf with an average decrease of 100.6 units/ ml. the use of mmf and cyclophosphamide in this study was only found in a small number of study subjects so that the low serum kl-6 did not thought to be due to the effects of therapy. in addition, serum kl-6 levels after 1 year of cyclophosphamide and mmf therapy remained higher than in healthy subjects.11, 17 several subjects in this study had participated in a randomized, double-blind clinical trial that added physalis angulata linn. ethanol extract in ssc patients who had received standard therapy conducted by dewi, et al.18 this study proved that physalis angulata linn. had a repairing effect on skin fibrosis as assessed by a decrease in mrss and a decrease in serum fibrosis biomarkers, namely procollagen type in terminal propeptide (p1np). physalis angulata linn. is known to have therapeutic potential, as anti-inflammatory, antioxidant, immunomodulatory, antiproliferative, and anticancer. epidemiological data on the use of physalis angulata linn. and the efficacy of physalis angulata linn. for pulmonary fibrosis disorders as well as for reducing serum kl-6 levels are still in the research stage.18 physalis angulata linn. use was not recorded in this study. however, history of using physalis angulata linn. can be considered as one of the confounding factors that affect serum kl-6 levels in this study. most of the samples taken for examination of serum kl-6 levels and examination of hrct of the thorax were carried out on the same day, while some examinations were carried out with a maximum length of 1 week. all study subjects were patients who had been diagnosed with ssc who were undergoing outpatient treatment. sampling of serum kl-6 levels and hrct thorax examination were carried out on subjects with equally controlled disease activity and not relapse or had infection, according to inclusion and exclusion criteria. thus, disease activity and infection were not considered as confounding factors that could influence the results of this study. another limitation of this study related to the study subjects who were not firstly diagnosed so that they have received therapy, both standard therapy and physalis angulata linn. in addition, the duration of therapy was not included. in this study, lung fungtion test were carried out using spiromerty. however preferable lung function test for ild is diffusing capacity of the lungs for carbon monoxide (dlco), not spirometry. dlco is not used in this study because the device is not available. study by yani, et al.19 at dr. hasan sadikin general hospital bandung showed that there was no relationship between serum kl-6 levels with forced vital capacity (fvc) and modified rodnan skin score (mrss) in patients with restrictive lung disease in diffuse type systemic sclerosis.there was a possibility that serum kl-6 cannot be used to diagnose ssc-ild in indonesia population. several plasma or serum proteins that can be candidate biomarkers to diagnose, monitor, and predict the prognosis of ild include interleukin-6 (il-6), c-reactive protein (crp), cc chemokine ligand (ccl)2, ccl-18, cxcl4, matrix metalloproteinases hook effect and serum kl-6 in patients with systemic sclerosis-associated interstitial lung disease international journal of integrated health sciences (iijhs) 71 1. rockey dc, bell pd, hill ja. fibrosis--a common pathway to organ injury and failure. n engl j med. 2015;372(12):1138–1149. 2. pitoyo cw. interstitial lung disease. in: setiati s, alwi i, sudoyo aw, simadibrata m, setiyohadi b, syam af, editors. internal medicine textbook. ii. 6th ed. jakarta: interna publishing; 2014. p. 1667–74. 3. zheng p, liu x, huang h, guo z, wu g, hu h, et al. diagnostic value of kl-6 in idiopathic interstitial pneumonia. j thorac dis. 2018;10(8):4724–32. 4. ishikawa n, hattori n, yokoyama a, kohno n. utility of kl-6/muc-1 in the clinical management of interstitial lung disease. respiratory investigation. 2012;50:3–13. 5. cho e-j, park k-j, ko d-h, koo hj, lee sm, song jw, et al. analytical and clinical performance of the nanopia krebs von den lungen 6 assay in korean patients with interstitial lung diseases. ann lab med. 2019;39:245–51. 6. dodig s. interferences in quantitative immunochemical methods. biochemia medica. 2009;19:50–62. 7. guo z, zheng p, hu h, huang h, wei n, luo w, et al. association between serum krebs von den lungen-6 (kl-6), carcinoma antigen 15-3 (ca15-3), and connective tissue diseaserelated interstitial pneumonia (ctd-ild). int j clin exp med 2018;11(8):8043–53. 8. horimasu y, hattori n, ishikawa n, kawase s, tanaka s, yoshioka k, et al. different muc1 gene polymorphisms in german and japanese ethnicities affect serum kl-6 levels. respiratory medicine. 2012;106(12):1756–64. 9. cao xy, hu ss, xu d, li mt, wang q, hou y, et al. serum levels of krebs von den lungen-6 as a promising marker for predicting occurrence and deterioration of systemic sclerosisassociated interstitial lung disease from a chinese cohort. international journal of rheumatic disease. 2019;22:108–15. 10. jiang y, luo q, han q, huang j, ou y, chen m, et al. sequential changes of serum kl-6 predict the progression of interstitial lung disease. j thorac dis. 2018;10(8):4705–14. 11. kumánovics g, görbe é, minier t, simon d, berki t, czirják l. follow-up of serum kl-6 lung fibrosis biomarker levels in 173 patients with systemic sclerosis. clin exp rheumatol. 2014;32:s138–44. 12. yamakawa h, hagiwara e, kitamura h, yamanaka y, ikeda s, sekine a, et al. serum kl-6 and surfactant protein-d as monitoring and predictive markers of interstitial lung disease in patients with systemic sclerosis and mixed connective tissue disease. j thorac dis. 2017;9(2):362–71. 13. ishikawa n, mazur w, toljamo t, vuopala k, rönty m, horimasu y, et al. ageing and longterm smoking affects kl-6 levels in the lung, induced sputum and plasma. bmc pulmonary medicine. 2011;11(1):22. 14. brashers vl. pathophysiology the biologic basis for disease in adults and children. canada: elsevier; 2019. 15. nakashita t, motojima s, jibatake a, yoshida a, yamamoto y. serum level of kl-6, a biomarker of interstitial lung disease (ild), is higher in diffuse ssc than in limited ssc and ra even when the activity of ild is low. 2016 acr/ arhp annual meeting: arthritis rheumatol; 2016. 16. connors gr, christopher-stine l, oddis cv, danoff sk. interstitial lung disease associated with the idiopathic inflammatory myopathies: what progress has been made in the past 35 years?. chest. 2010;138(6):1464–74. 17. 17. volkmann er, tashkin dp, kuwana m, li n, roth md, charles j, et al. progression of interstitial lung disease in systemic sclerosis: the importance of pneumoproteins krebs von den lungen 6 and ccl18. arthritis rheumatol. 2019;71(12):2059–67. 18. dewi s, isbagio h, purwaningsih eh, kertia n, setiabudy r, setiati s. a double-blind, randomized controlled trial of ciplukan (mmps) and surfactant protein-d (sp-d).12, 17, 20 there is no agreement between serum kl-6 levels and ild features based on hrct thorax in ssc-ild. the hook effect affect serum kl-6 levels so that it cannot be used as an alternative diagnostic test for ssc-ild. a diagnostic study is suggested to determine cut off value of serum kl-6 levels for patients who are firstly diagnosed ssc-ild and not received any therapy yet, with dilution during the examination of serum kl-6 levels, in the indonesian population, in the diffuse ssc subtype. references emmy hermiyanti pranggono, valentine natasya moenardi, et al 72 international journal of integrated health sciences (iijhs) (physalis angulata linn) extract on skin fibrosis, inflammatory, immunology, and fibrosis biomarkers in scleroderma patients. acta med indones. 2019;51(4):303–10. 19. yani h, dewi s, rahmadi ar. correlation between serum krebs von den lungen-6 levels with forced vital capacity and modified rodnan skin score of patients with restrictive lung disease in diffuse-type systemic sclerosis. indonesian j rheumatology. 2019;11(2):28– 31. 20. todd jl, vinisko r, liu y, neely ml, overton r, flaherty kr, et al. circulating matrix metalloproteinases and tissue metalloproteinase inhibitors in patients with idiopathic pulmonary fibrosis in the multicenter ipf-pro registry cohort. bmc pulm med. 2020;20(1):64. conflict of interest declaration here by the author(s) certify(s) that the manuscript entitled: association between diabetes retinopathy, hypertension and body mass index in diabetic patients in republic of zimbabwe: retro perspective study is an original work and is not under review at any other publication. author and all co-authors have seen and agreed with the contents of the manuscript and there is no financial interest to report. author (s) (please write your name with academic degree(s) and sign) 1st author name: tatenda lewis musokeri,  signature : 2nd author wani .mena name: signature : 3rd author maibouge tanko mahamane salissou name: signature : author’s data title of manuscript: association between diabetes retinopathy, hypertension and body mass index in diabetic patients in republic of zimbabwe: retro perspective study enter the names of everyone who contributed to your manuscript by entering all required information. author(s) 1st author first name : musokeri last name : tatenda lewis academic degree(s):bachelor affiliation: africa university: college of health agricultural and natural sciences address pox box 1320 mutare phone: email: email : musokeril@africau.edu 2nd author first name: wani last name : mena academic degree(s): mbbs .msc/med affiliation: highland eye clinic medical center, in suite 19 address: .,123 herbert chitepo street, third floor mutare zimbabwe phone: email : wanigmena@gmail.com 3th author first name: maibouge tanko last name : mahamane salissou academic degree(s): bsc.msc/med/ phd affiliation: africa university college of health agricultural and natural sciences address: pox box 1320 phone: email : salissoum @africau.edu cover letter 07/02/2021 to. editor in chief dear sir, please find the submission of our manuscript, (association between diabetes retinopathy, hypertension and body mass index in diabetic patients in republic of zimbabwe: retro perspective study) which we would like to submit for publication our manuscript, which is a retro perspective study on association of diabetes mellitus, with several risk factors as well its prevalence in zimbabwe where data are lacking in this debilitating disease commonly found in developing countries. author and all co-authors have seen and agreed with the contents of the manuscript and there is no financial interest to report. we certify that the manuscript submitted is an original work and is not under review at any other publication. we thank you for considering our manuscript for publication in your journal and look forward to hearing from you at your earliest convenience. sincerely yours, signature [corresponding author*] dr maibouge tanko mahamane salissou; phd [affiliation*] endow chair of pathology at college of health agriculture and natural sciences africa university mutare zimbabwe: [phone*] +263-78007945 [email*] salissoum@africau.edu / salissoutanko@gmail.com p.o.box 1320 vol 10 no.1 2022 rev.2.indd 12 international journal of integrated health sciences (iijhs) introduction the novel coronavirus 2019 (covid-19) is one of the global infections currently a pandemic in 215 countries globally, including indonesia. indonesia is currently ranked first as the country with the most covid-19 cases in asean, with more than 41 thousand total cases and a mortality of 5.5%.1 as of february 2022, the number of positive cases of covid-19 in indonesia reached more than 5,1 million positive cases and more than 146 thousand mortality cases while bali reached more than 146 thousand positive cases with a mortality of more than 4200 people.2 depression, anxiety, and stress due to changes in employment status during covid-19 pandemic: a study in badung districts, bali indonesia abstract objective: to determine the relationship between depression, anxiety, and stress with the employment status of people in bali during covid-19 pandemic. methods: this study was a cross-sectional analytical study conducted in bali, indonesia, in 2021. the instrument used was dass-21 questionnaire, which was distributed to a total sample size of 96 people. the relationship between variables were analyzed with a p-value of <0.05 as the cut-off for a significant relationship. results: depression symptoms had a significant relationship with gender (p=0.024) while anxiety symptoms had a significant association with the employment status during the pandemic (p=0.027). similarly, stress symptoms also had a significant relationship with gender (p=0.007) and employment status during covid-19 pandemic (p=0.007). conclusion: there is a relationship between depression, anxiety, and stress due to changes in employment status during the covid-19 pandemic in badung districts, bali. keywords: anxiety, depression, covid-19, employment status, stress received: september 19, 2021 accepted: february 23, 2022 correspondence: ni ketut sri diniari; department of psychiatry, faculty of medicine, udayana university/sanglah general hospital denpasar, bali, indonesia e-mail: sridiniari@ymail.com original article made violin weda yani,1 made sindy astri pratiwi,1 agus indra yudhistira diva putra,1 ni ketut sri diniari2 1faculty of medicine, udayana university, denpasar, bali, indonesia 2department of psychiatry, faculty of medicine, udayana university/sanglah general hospital denpasar, bali, indonesia pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ ijihs.v10n1.2541 ijihs. 2022;10(1):12–19 the covid-19 pandemic has also had an impact on indonesia’s economic conditions, according to data from the international labor organization (ilo), which states that quarantine during the pandemic caused 2.7 billion workers or the equivalent of 81% of the world’s workforce, to experience income imbalances.3 this condition triggers an estimate of an increase in the number of open unemployment in 2020, which will reach 9.35 million workers.4 bali is a province in indonesia that is highly dependent on tourism conditions. the covid-19 pandemic has certainly caused instability in the tourism sector’s growth due to a decrease in tourists visiting bali. seventy-five thousand workers have been temporarily fired and laid off, which led to an increase in bali’s unemployment rate by 5.63%.5 this situation will undoubtedly impact health conditions such as depression, anxiety, and stress due to decreased income. all international journal of integrated health sciences (iijhs) 13 individuals from various groups can feel stress conditions, ranging from school-age students who feel stress due to the distance learning system, productive age who experience stress due to employment termination, to older people who experience anxiety and depression due to limited time to socialize.6 however, there is no descriptive or analytical data that assess the level of depression, anxiety, and stress in people in bali and their relationship to work status during the pandemic covid-19 in bali, indonesia. therefore, this study aims to determine the relationship between depression, anxiety, and stress conditions with the work status of people in badung districts bali during the covid-19 pandemic. methods this study is an analytical study with a crosssectional design carried out during juneaugust 2020 to determine the relationship between individual characteristics and levels of depression, anxiety, and stress in bali province. this research started from proposal preparation, research implementation, data collection, and analysis to prepare a research report that lasted four months. the population in this study were all residents who live in badung district, bali province. badung was chosen as the sampling location because badung district is the 3rd with the highest number of confirmed positive cases in bali, representing the population.2 there are many tourism-based economic sectors in badung. badung district had become the center of tourism activities in bali, with a portion reaching 60% of the total tourists in bali. in reviewing this, most of the businesses in badung certainly ran in the tourism sector. as many as 85% of its citizens made a living by working in the tourism sector, and only 15% work in other sectors. it is quite representative to show changes in economic status and chances of being stressed. based on calculations using the analytical research formula with the cross-sectional method, the minimum subject was obtained 48 people, and in this study, 96 people were obtained as samples. the method of selecting samples in this study uses simple random sampling. according to the inclusion criteria, all subjects previously determined are bali province residents with the latest education, junior high school/ equivalent, have reading and writing skills, and are willing to become research respondents by signing informed consent will immediately become research subjects. the data collected in this study were divided into independent and dependent variables. the independent variables are work status during the pandemic, and the dependent variable is depression score, anxiety, and stress. the sample collection was carried out by google form. the questionnaire questions use questions from the depression anxiety stress scale-21 (dass-21), consisting of 21 questions. the results of filling out the participant questionnaire will be calculated based on the scoring according to table 1. all data collected will be analyzed univariate and bivariate using data analysis software. data on numerical variables such as age and scores for depression, anxiety, and stress will be tested for normality first with the kolmogorov-smirnov test. univariate data analysis is used to see the distribution description of each dependent and independent variable. bivariate analysis of categorical data used the chi-square test. bivariate analysis of numerical variable data with unpaired categorical uses the mannwhitney test and kruskal wallis because the data is not normally distributed. a significant value states that there is a relationship between the dependent and independent variables if the p-value is obtained <0.05. ethical approval for this study has been granted by the health research ethical committee, faculty of medicine, udayana university, with 1836/ un14.2.2.vii.14/lt/2020. results the characteristics of the research respondents in this study are in table 2. it was found that table 1 final score classification from dass-21 classification depression score anxiety score stress score normal 0–9 0–7 0–14 mild 10–13 8–9 15–18 moderate 14–20 10–14 19–25 severe 21–27 15–19 26–33 extremely severe >27 >19 >33 made violin weda yani, made sindy astri pratiwi, et al 14 international journal of integrated health sciences (iijhs) table 2 characteristics of research respondents characteristic sample (n=96) frequency (n) percentage (%) respondent’s age mean ± sd 38.41±11.96 median (year) 41 minimummaximum (year) 18-64 sex male 53 55.2 female 43 44.8 marital status not married 25 26 married 71 74 living status main family 43 44.8 big family 53 55.2 latest education junior high school (jhs) 3 3.1 senior high school (shs) 66 68.8 diploma 9 9.4 bachelor 18 18.8 job before pandemic civil servant 5 5.2 private employees 53 55.2 farmer 3 3.1 seller 11 11.5 others 24 25.0 job after pandemic sent home for a while 24 25 dismissal 5 5.2 work from home 56 58.3 still working 11 11.5 chronic disease nothing 90 93.8 diabetes 1 1.0 hypertension 2 2.1 asthma 3 3.1 smoking status yes 16 16.7 never 74 77.1 yes before 6 6.3 depression yes 3 3.1 no 93 96.9 anxiety yes 8 8.3 no 88 91.7 stress yes 5 5.2 no 91 94.8 depression, anxiety, and stress due to changes in employment status during covid-19 pandemic: a study in badung districts, bali indonesia international journal of integrated health sciences (iijhs) 15 ta bl e 3 cr os sta bu la ti on b et w ee n r es po n de n t c ha ra ct er is ti cs a n d d ep re ss io n , a n xi et y an d st re ss l ev el s b as ed o n th e d a ss -2 1 sc or e ch ar ac te ri st ic s d ep re ss io n l ev el n ( % ) a n xi et y le ve l n ( % ) st re ss l ev el n ( % ) n or m al m il d m od er at e n or m al m il d m od er at e n or m al m il d se x m al e 53 ( 10 0) 0 (0 ) 0 49 ( 92 .5 ) 1 (1 .9 ) 3 (5 .7 ) 52 ( 98 .1 ) 1 (1 .9 ) fe m al e 40 ( 93 ) 2 (4 .7 ) 1 (2 .3 ) 39 ( 90 .7 ) 1 (2 .3 ) 3 (7 .0 ) 39 ( 90 .7 ) 4 (9 .3 ) a ge <3 9 ye ar s ol d 39 ( 97 .5 ) 1 (2 .5 ) 0 36 ( 90 .0 ) 2 (5 .0 ) 2 (5 .0 ) 39 ( 97 .5 ) 1 (2 .5 ) ≥3 9 ye ar s ol d 54 ( 96 .4 ) 1 (1 .8 ) 1 (1 .8 ) 52 ( 92 .9 ) 0 4 (7 .1 ) 52 ( 92 .9 ) 4 (7 .1 ) m ar it al s ta tu s n ot m ar ri ed y et 25 ( 10 0) 0 0 23 ( 92 .0 ) 0 2 (8 .0 ) 24 ( 96 .0 ) 1 (4 .0 ) m ar ri ed 68 ( 95 .8 ) 2 (2 .8 ) 1 (1 .4 ) 65 ( 91 .5 ) 2 (2 .8 ) 4 (5 .6 ) 67 ( 94 .4 ) 4 (5 .6 ) li vi ng s ta tu s m ai n fa m ily 41 ( 95 .3 ) 1 (2 .3 ) 1 (2 .3 ) 40 ( 93 .0 ) 1 (2 .3 ) 2 (4 .7 ) 42 ( 97 .7 ) 1 (2 .3 ) b ig fa m ily 52 ( 98 .1 ) 1 (1 .9 ) 0 48 ( 90 .6 ) 1 (1 .9 ) 4 (7 .5 ) 49 ( 92 .5 ) 4 (7 .5 ) le ve l o f e du ca ti on jh s 3 (1 00 ) 0 0 3 (1 00 ) 0 0 3 (1 00 ) 0 sh s 69 ( 97 .2 ) 2 (2 .8 ) 0 60 ( 90 .9 ) 1 (1 .5 ) 5 (7 .6 ) 61 ( 92 .4 ) 5 (7 .6 ) d ip lo m a 8 (8 8. 9) 0 1 (1 1. 1) 8 (8 9) 1 (1 1) 0 (0 ) 9 (1 00 ) 0 b ac he lo r 18 ( 10 0) 0 0 17 ( 94 .4 ) 0 1 (5 .6 ) 18 ( 10 0) 0 e m pl oy m en t st at us b ef or e pa nd em ic g ov er nm en t e m pl oy ee s 5 (1 00 ) 0 0 4 (8 0) 1 (2 0) 0 5 (1 00 % ) 0 pr iv at e em pl oy ee 52 ( 98 .1 ) 1 (1 .9 ) 0 48 ( 90 .6 ) 1 (1 .9 ) 4 (7 .5 ) 49 ( 92 .5 ) 4 (7 .5 ) fa rm er 3 (1 00 ) 0 0 3 (1 00 ) 0 0 3 (1 00 ) 0 se lle r 9 (8 1. 8) 1 (9 .1 ) 1 (9 .1 ) 10 ( 90 .9 ) 0 1 (9 .1 ) 10 ( 90 .9 ) 1 (9 .1 ) o th er s 24 ( 10 0) 0 0 23 ( 95 .8 ) 0 1 (4 .2 ) 24 ( 10 0) 0 em pl oy m en t st at us d ur in g pa nd em ic te m po ra ri ly fi re d 23 ( 95 .8 ) 1 (4 .2 ) 0 24 ( 10 0) 0 0 23 ( 95 .8 ) 1 (4 .2 ) w or k fr om h om e 55 ( 98 .2 ) 1 (1 .8 ) 0 52 ( 92 .9 ) 2 (3 .6 ) 2 (3 .6 ) 55 ( 98 .2 ) 1 (1 .8 ) la id o ff 5 (1 00 ) 0 0 1 (2 0) 0 4 (8 0) 2 (4 0) 3 (6 0) st ill w or ki ng 10 ( 90 .9 ) 0 1 (9 .1 ) 11 ( 10 0) 0 0 11 ( 10 0) 0 ch ro ni c di se as e n ot hi ng 87 ( 96 .7 ) 2 (2 .2 ) 1 (1 .1 ) 82 ( 91 .1 ) 2 (2 .2 ) 6 (6 .7 ) 85 ( 94 .4 ) 5 (5 .6 ) d ia be te s 1 (1 00 ) 0 0 1 (1 00 ) 0 0 1 (1 00 ) 0 h yp er te ns io n 2 (1 00 ) 0 0 2 (1 00 ) 0 0 2 (1 00 ) 0 a st hm a 3 (1 00 ) 0 0 3 (1 00 ) 0 0 3 (1 00 ) 0 sm ok in g st at us n ev er 72 ( 97 .3 ) 1 (1 .4 ) 1 (1 .4 ) 67 ( 90 .5 ) 2 (2 .7 ) 5 (6 .8 ) 70 ( 94 .6 ) 4 (5 .4 ) st op > 6 m on th s 5 (8 3. 3) 1 (1 6. 7) 0 6 (1 00 ) 0 0 5 (8 3. 3) 1 (1 6. 7) a ct iv e 16 ( 10 0) 0 0 15 ( 93 .8 ) 0 1 (6 .3 ) 16 ( 10 0) 0 *j h s: ju ni or h ig h sc ho ol , s h s: s en io r h ig h sc ho ol made violin weda yani, made sindy astri pratiwi, et al 16 international journal of integrated health sciences (iijhs) table 4 the relationship between respondents’ characteristics and depression, anxiety and stress based on the dass-21 score variable depression score p value anxiety score p value stress score p value gender male female 0.55±1.13 1.63±3.25 0.024* 1.47±2.82 2.19±3.40 0.077 1.55±3.21 3.07±4.67 0.007* age <39 years old ≥ 39 years old 1.15±2.25 0.95±2.48 0.220 1.88±3.27 1.73±3.00 0.569 1.83±3.01 2.52±4.56 0.883 marital status not married yet married 0.76±1.02 1.13±2.70 0.602 1.68±2.96 1.83±3.16 0.772 1.76±3.20 2.39±4.23 0.985 living status main family big family 1.23±3.03 0.87±1.69 0.906 1.74±3.17 1.83±3.07 0.451 1.84±3.33 2.55±4.45 0.818 level of education moderate education high education 1.02±0.16 1.07±0.38 0.422 1.15±0.53 1.11±0.42 0.774 1.07±0.26 1.00±0.01 0.227 work status before the pandemic government employees private employee farmer seller others 0.80±1.30 0.70±1.53 1.67±2.88 2.91±5.54 0.88±1.29 0.885 1.60±3.57 1.67±3.02 1.00±1.73 3.00±4.42 1.88±2.67 0.507 1.60±1.81 2.32±4.49 3.00±5.19 3.36±5.42 1.54±1.71 0.791 work status during the pandemic sent home for a while work from home dismissal still working 1.38±2.24 0.73±1.94 0.40±0.54 2.09±4.36 0.112 1.17±1.52 1.45±2.84 8.60±4.82 1.82±2.75 0.027* 1.96±3.22 1.34±2.77 11.8±6.79 3.00±3.89 0.007** chronic disease nothing hypertension asthma 1.08±2.45 0.50±0.70 0.33±0.57 0.855 1.83±3.17 2.00±2.82 1.00±1.73 0.833 2.27±4.09 2.50±0.70 1.67±2.08 0.519 smoking status never stop>6 months active 0.96±2.36 2.17±3.86 0.94±1.76 0.491 1.78±3.21 2.17±2.13 1.69±2.98 0.471 2.24±4.07 4.50±5.54 1.31±2.60 0.151 depression, anxiety, and stress due to changes in employment status during covid-19 pandemic: a study in badung districts, bali indonesia international journal of integrated health sciences (iijhs) 17 the age of the patients was 13-64 years old, with an average age value of 36.46 years. the study’s respondents were dominated by male gender (55.2%) with marital status, married (74%). based on the residence characteristics, it was found that 55.2% of the respondents lived with their big family. most of the research respondents had the latest education level at the senior high school level/equivalent (68.8%). the work status of respondents before the covid-19 pandemic was dominated by private employees (55.2%), while the work status of respondents during the pandemic was dominated by work from home (58.3%). most of the respondents in this study did not have a history of chronic disease (93.8%) and had no smoking habits (77.1%). based on the dass-21 interpretation, it was found that three people (2.9%) had depressive symptoms, nine people (8.6%) had anxiety, and 5 (4.8%) had stress. table 3 presents a cross tabulation between data on characteristics and work status with depression, anxiety, and stress conditions during the covid-19 pandemic. most of the respondents have mild depression and stress levels and have mild to moderate levels of anxiety. the bivariate test between individual characteristic variables with depression, anxiety and stress score is presented in table 4. this study indicates that depression symptoms significantly correlate with gender (p=0.024). anxiety symptoms have a significant relationship with work status during the pandemic (p=0.027) and stress symptoms had a significant relationship with gender (p=0.007) and work status during the pandemic (p=0.007). discussion the covid-19 pandemic caused most countries to implement social restrictions to control the virus’s spread, including indonesia. these social restrictions affect various aspects of life, such as economic conditions and education, and cause psychological impacts such as depression, anxiety, and stress.7 this study indicates that people in bali who have depression, anxiety, and stress symptoms are below 50%. it was found that people with depression, anxiety, and stress were 2.9%, 8.6%, 4.8%. these results are in line with gonzales et al., which showed that out of 2530 study respondents, symptoms of depression, anxiety, and stress during the covid-19 pandemic were experienced by less than 50% of respondents 34.19%; 21.34%; 28.14%.8 elbay et al. study with 442 participants showed opposite results, there were more than 50% of respondents who experienced symptoms of depression (64.7%) and anxiety (51.6%), but respondents who experienced stress were below 50%. (41.2%).9 this study shows a significant relationship between depression, anxiety, and stress scores with gender and work status, but no significant relationship exists between the respondents’ marital status. these results are similar to research by elbay et al., that state symptoms of depression, anxiety, and stress have a significant relationship with age (p <0.001), gender (p=0.025), and job position (p= 0.001).9 the study showed that being married and having children was associated with lower dass-21, while unmarried and younger had higher dass-21. also, respondents who live with their spouses and children have lower scores than those who live alone. regression analysis shows that female gender, unmarried status, and a history of psychiatric disorders are independent predictors for mental health deterioration.9 lai et al. also showed similar results that dass-21 is significantly related to gender. female respondents have a greater risk of having a risk of psychiatric disorders during the covid-19 outbreak in china.10 the difference in stress response between males and females is caused by the hypothalamic-pituitary-adrenal (hpa) axis and the sympathetic nervous system, which provides negative feedback when an individual experiences stress. the sympathetic nervous system regulates heart rate and blood pressure, while hpa regulates the hormone cortisol regulation. the response of the sympathetic nervous system and hpa in men is higher than in women to influence the individual’s attitude in responding to stressors. there are sex hormones in females that affect the sympathetic response and hpa. there is a decrease in negative feedback on the hormone cortisol to the brain, which causes women to have a higher tendency to experience stress.11,12 this study indicates that individuals laid off have more symptoms of depression, anxiety, and stress. this result is in line with volaco et al. research that individuals with relatively low economic conditions have a greater chance of experiencing stress, which causes an increase in stress hormones such as cortisol and catecholamines glucagon and growth hormone.13 another study evaluating 108 men and 94 women showed that low economic made violin weda yani, made sindy astri pratiwi, et al 18 international journal of integrated health sciences (iijhs) income individuals experience increased blood pressure and cortisol output during the workday, allowing activation of biological pathways related to stress mechanisms.14 worse, several reported suicide-related cases to stress due to covid-19 are based on job loss, sudden extreme poverty, economic crisis, hunger, and inability to cope with social problems. traumatic situations must be immediately handled through counseling and counseling to the community appropriately. a study in bangladesh found that lockdown policies caused mental stress due to covid-19 without ensuring the community’s basic needs.15 several individual characteristics associated with depression, anxiety, and stress were also explored in this study. this study found that individuals who act as students are very few who experience symptoms of depression, anxiety, or stress. this result is contrary to research by livana et al., which shows that most students experience stress during the covid-19 pandemic, which is caused by learning tasks (70.29%), the boredom of the online learning system (55.8%), and not able to meet peers (40.2%).16 the cause of stress is reinforced by a study that states that academic stress has a significant relationship with the workload.17 this condition shows that the covid-19 pandemic has a negative effect on students’ educational process and mental health growth.8 this study found that depression, anxiety, and stress symptoms were more common in individuals living with big families. cao et al. show a similar result that living with parents was a factor preventing student anxiety during the pandemic (or = 0.752, 95% ci = 0.5960.950).18 multivariate analysis in the study of gonzales et al. (2020) also showed that there was a significant relationship between stress scores on dass-21 and residence status (p <0.05).8 individuals who live alone have greater stress symptoms than individuals who live in the same house with 2-4 family members. this condition shows that the covid-19 pandemic has increased communication relationships and the closeness of individuals with their families so that stress symptoms are decreasing more.8 this study concluded that depression symptoms have a significant relationship with gender; anxiety has a significant relationship with work status during the pandemic. in contrast, stress has a significant relationship with gender and work status during the pandemic. this study has limitations in forming a cross-sectional study with a relatively small sample size compared to the total population. therefore, it is suggested that future research use a longitudinal study design to analyze the long-term impact of the covid-19 pandemic on an individual’s psychological state to conclude the main and accompanying factors that trigger psychological symptoms in individuals. second, this study only took a sample from bali province, so large-scale survey with various respondents was still needed to expand and generalize the research results. 1. rampal s, rampal l, jayaraj vj, pramanick a, choolani m, liew bs, et al. the epidemiology of covid-19 in ten southeast asian countries. med j malaysia. 2021;76(6):783–91. 2. han y, yang h. the transmission and diagnosis of 2019 novel coronavirus infection disease (covid-19): a chinese perspective. j med virol. 2020;92(6):639–44. 3. international labour organization. covid-19 and the world of work [internet]. 2020. available from: https://www.ilo.org/global/ topics/coronavirus/lang--en/index.htm 4. meilianna r, purba ya. the impact of covid-19 on worker layoffs and income in indonesia. j kependud indones. 2020;2902:43–8. 5. purwahita aaarm, bagus p, wardhana w, ardiasa ik. dampak covid-19 terhadap pariwisata bali ditinjau dari sektor sosial , ekonomi , dan lingkungan (suatu tinjauan pustaka). j kaji dan terap pariwisata. 2021;1(2):68–80. 6. meng h, xu y, dai j, zhang y, liu b, yang h. analyze the psychological impact of covid-19 among the elderly population in china and make corresponding suggestions. psychiatry res. 2020;289:1–3. 7. wang c, pan r, wan x, tan y, xu l, ho c, et al. immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china. int j env res public heal. 2020;17:1729. references depression, anxiety, and stress due to changes in employment status during covid-19 pandemic: a study in badung districts, bali indonesia international journal of integrated health sciences (iijhs) 19 8. gonzales p, gomez a, irurtia m, garcia r. psychological effects of the covid-19 outbreak and lockdown among students and workers of a spanish university. psychiatry res. 2020;290:1–41. 9. elbay r, kurtulmus a, arpacioglu s, karadere e. depression, anxiety, stress levels of physicians and associated factors in covid-19 pandemics. psychiatry res. 2020;290:1–6. 10. lai j, ma s, wang y, cai z, hu j, wei n. factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. jama netw open. 2020;3(3):1– 12. 11. wang j, korczykowski m, rao h, fan y, pluta j, gur r. gender difference in neural response to psychological stress. scan. 2011;2:227–39. 12. verma r, balhara y, gupta c. gender differences in stress response: role of developmental and biological determinants. ind psychiatry j. 2011;20(1):4–10. 13. volaco a, cavalcanti a, filho r, précoma d. socioeconomic status: the missing link between obesity and diabetes mellitus?. curr diabetes rev. 2018;14(4):321–6. 14. santos rm. isolation, social stress, low socioeconomic status and its relationship to immune response in covid-19 pandemic context. brain, behav immunity-health. 2020;7:1–21. 15. shami m, doza m, islam a, rahman m. covid-19 pandemic, socioeconomic crisis and human stress in resource-limited settings: a case from bangladesh. heliyon. 2020;6(5):1–24. 16. livana p, mubin m, basthomi y. tugas pembelajaran penyebab stres mahasiswa selama pandemic covid-19. j ilmu keperawatan jiwa. 2020;3(2):203–8. 17. maharani e. analisis komparatif faktor penyebab dan tingkat stres guru paud selama menjalani tugas belajar strata-1 (s1). indones islam educ sci. 2017;437. 18. cao w, fang z, hou g, han m, xu x, dong j. the psychological impact of the covid-19 epidemic on college students in china. psychiatry res. 2020;287:112934. made violin weda yani, made sindy astri pratiwi, et al vol 11 no 1 2023 (2) rev-2-edited ver 1 dep.indd 1 this is an open access article licensed under the creative commons attribution-noncommercial 4.0 international license (http:// creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original author and source are properly cited fetal exposure to risky drugs: analysis of antenatal clinic prescriptions in a nigerian tertiary care hospital received: june 01, 2022 accepted: june 06, 2023 published: march 30, 2023 correspondence: paul otor onah department of clinical pharmacy and pharmacy administration, faculty of pharmacy, university of maiduguri, borno state, nigeria e-mail: onahpaul@unimaid.edu.ng original article paul otor onah,1 catherine chioma idoko,2 siyaka abdulateef1 1department of clinical pharmacy and pharmacy administration, faculty of pharmacy, university of maiduguri, borno state, nigeria 2department of clinical pharmacy and pharmacy practice, faculty of pharmacy, university of benin, edo state, nigeria introduction pregnancy is a time of rapid fetal development and administration of drugs during pregnancy can carry the risks that could interfere with the organogenesis, structural growth, and other physiological processes of the fetus, which is particularly high in the first trimester of pregnancy. this is possible because many drugs can circulate freely in the maternal body and easily reach fetal circulation in concentrations that can cause major disruptions to development. in addition to the risk of disruptions to the fetal growth and development, drugs also have the potential to produce other subtle effects during postdelivery functional development of infants. there is literature evidence linking fetal drug exposure and learning difficulties, mental health disorders, obesity, organ dysfunction, and also a high risk of chronic diseases later in adult life.1 fetal drug exposure is widely reported in high income countries; however data from low income countries is limited.2 recent studies in sub-saharan african countries reported risky fetal exposure to antibiotics, analgesics, and antimalarial drugs.3 the exposure, which is largely from prescriptions, is also exacerbated by the widespread self-medication practice among pregnant women as well as the general population.4 one study reported that up to 80% of pregnant women may have used at least one risky drug through medical prescription or as over-the-counter medication.5 among the most commonly reported fetal drug exposures that have been associated with various adverse outcomes are exposures to benzodiazepines5, quinolones6,7, antifungals,8 opioids,9 nsaids,10 amlodipine,11 and aceis/ doi: 10.15850/ijihs.v11n1.2840 ijihs. 2023;11(1):1-6 article history international journal of integrated health sciences (iijhs) issn print: 2302-1381; issn online: 2338-4506 abstract objective: to assess fetal outcomes after in-utero exposure to unsafe drugs. methods: this was a retrospective cohort study using data from medical records of pregnant women who received antenatal care over a two-year period (2019/2020). inclusion was based on identification of prescription of potentially risky medications during pregnancy. medication records, as well as delivery data, were extracted for analysis. the australian drug evaluation committee classification system of risky medications was used for analysis. results: results showed that 44–65% of medicines prescribed in pregnancy carry significant risks to fetal wellbeing. fetal outcomes showed high levels of low birth weight, still birth, and early neonatal death. the common medicines prescribed irrationally in pregnancy were, among others, antibiotics, aceis, nsaids, biguanides, and opiates, all of which are associated with adverse fetal outcomes. conclusion: there is a high level of fetal exposure to risky medications and adverse delivery outcomes. there is a need to improve prescription through prescriber training and awareness raising on existing guidelines on good prescribing practice for pregnant women. keywords: drug prescriptions, fetal drug exposure, fetal wellbeing, low birth weight, pregnancy 2 international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 arbs.12 fetal exposure to certain types of drugs significantly increases the risk of low birth weight infant,13 attention deficit problems in childhood, congenital malformations, as well as increased risk of childhood asthma.14 the decision to prescribe drug(s) rests with the healthcare provider who is expected to follow the same principles of rational and safe use of drugs during pregnancy. the safety and audit of prescription medicines in pregnancy have received little research interest in this part of the country; therefore, this study aimed to audit prescription medicines given to pregnant women and also identify potential risks to fetal wellbeing. methods this study was performed at the obstetrics and gynecology department of the university of maiduguri teaching hospital, nigeria. this was a retrospective study using medical records of women who received full antenatal care during a two-year period (january 2019–december 2020) from the hospital. the sample size was determined using the andrew fishers method and sample of medical records of five hundred women were selected using the simple random sampling method. eligibility criteria included pregnant women who had received at least six months of antenatal care and also delivered in the hospital. those who had missed more than half of their regular antenatal visits or were on antiretroviral therapy were not included in the study. the data extracted from the medical records were of the subjects were demographic data, gravida, morbidity, potentially risky drugs, neonatal weight, neonatal deaths, stillbirth, apgar score (5 minutes), and other relevant data. data were entered into the spss version 21 for descriptive statistics, and the fetal drug risk assessment was carried out using the australian drug evaluation committee classification (adec). the approval for this study was obtained from the health research ethics committee of the university of maiduguri teaching hospital borno state, nigeria. results demographic data showed that most pregnant women had secondary to tertiary education level (89%) with an average of 1 – 3 pregnancies (88%) per woman. most of them presented themselves for their first antenatal care at 9 to 16 weeks of pregnancy (74.6%; table 1). anemia was found to be common among fetal exposure to risky drugs: analysis of antenatal clinic prescriptions in a nigerian tertiary care hospital table 1 demographic data variable n (%) education illiterate 2 (0.4) primary 53 (10.6) secondary 261 (52.2) tertiary 184 (36.8) occupation civil service 139 (27.8) self-employed 169 (33.8) housewife 141 (28.2) student 51 (10.2) gravida 1–3 440 (88) 4–6 51 (10.2) >6 9 (1.8) average 2.4 time of first antenatal visit (weeks) 4–8 47 (9.4) 9–12 225 (45) 13–16 148 (29.6) 17–20 39 (7.8) 21–24 41 (8.2) mean (sd) 12.9 ± 4.4 mean age (yrs.) 34.9 ± 7.4 pregnant women as reflected in the average pack cell volume of 30.4%, which was well below the recommended value. the results also showed that a quarter of them experienced pre-eclampsia (25.8%), while 4.6% experienced post-partum hemorrhage. there was a high incidence rate of low birth weight (64.8%), while stillbirths and early neonatal deaths occurred in 4% and 5.8% of pregnancies, respectively (table 2). the most frequent morbidities encountered were hypertension (53%), anemia (31.8%), and pre-eclampsia (25.8%). other encountered diseases, albeit less frequently, were malaria, urinary tract infections, and also gestational hyperglycemia (fig. 1). fetal exposure to potentially risky drugs was observed thoughout pregnancy with metronidazole (34.4%), diclofenac (20.3%), and captopril (21.1%) being most frequently international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 3 paul otor onah, catherine chioma idoko, et al table 3 prescription drugs and risk description drug one two three classification risk description metronidazole + + + b2 low birth weight, preterm delivery diclofenac + + + c premature closure of ductus arteriosus captopril/ lisinopril + + d teratogenic amlodipine + + + c heart malformation, hypospadia diazepam early motor deficit metformin + + + c low birth weight, high bmi, long term cardiometabolic disorders hydralazine + + + c low birth weight gentamycin + b3 ototoxicity levofloxacin + + + b3 arthropathy, preterm delivery codeine + + + a neonatal respiratory depression notes: + = potentially risky, one, two and three = trimesters table 2 maternal and fetal data variable result maternal data packed cell volume 30.4±5.6 bacteriuria 60.4% pre-eclampsia 25.8% post-natal hemorrhage 4.6% neonatal data birth weight (kg) 2.6±0.7 apgar score (5 minutes) 7.7±2.3 still births 4% early neonatal death 5.8% fig. 1 prevalence of morbidities (n=500) encountered. other drugs of concern included metformin, levofloxacin, and codeine, which were mostly prescribed during the third trimester of pregnancy (fig. 2). the prevalence of potentially risky drugs increased from 44.2% in the first trimester of pregnancy to 65.6% in the second trimester and then 60% in the third trimester. this represent an average of 56.6% of pregnancies had fetal exposure to risky drug (fig. 3). based on the risk classification and risk description of drugs, it has been demonstrated that certain drugs, such as captopril/lisinopril (d), diclofenac/amlodipine and metformin (c), levofloxacin (b3), and metronidazole (b2), pose significant risks to the fetal organogenesis and development. in the case of codeinecontaining analgesics, despite the 4 international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 fact that it may not pose a direct teratogenic risk, it carries significant risk for post-delivery respiratory depression with the potential for early neonatal death (table 3). discussion fetal exposure to drugs cannot be completely avoided in pregnancy because of the need to manage maternal medical conditions. while general guidelines for drug safety in pregnancy are available, the decision for drug therapy rests with the physicians and other healthcare professionals caring for these pregnant women. the results of this study showed that almost two thirds of pregnant women were prescribed drugs that are potentially risky to fig. 2 comparison of fetal exposure to risky drugs (n=500) fig. 3 potentially risky prescription drugs the fetal wellbeing. this result is comparable to a previous study,15 although a similar study had reported much lower figure.2 while there appeared to be more prescription drugs given as pregnancy progressed, there was a lack of due diligence on the fetal safety consideration on the part of prescribers. there are much safer alternatives to these risk drugs that are capable of producing comparable clinical outcomes. for instance, oral hypoglycemic drugs are contraindicated, with guidelines recommending a switch to the insulin therapy once pregnancy occurs. the risk of arthropathy associated with quinolones, as well as cranial nerve damage with aminoglycosides and low birth weight with metronidazole has been reported and are well documented,6 despite the existing contradictory conclusions on the fetal safety of metronidazole. in addition to these known associations, antibiotics are well known to alter maternal and feto-placental microbiome,16 which has been linked to childhood asthma.17 they are also reported to cause altered fetal growth and childhood growth trajectory. 13,18 some studies specifically reported increased risk of cerebral palsy and/or epilepsy with fetal exposure to macrolides.14 the recommendation for the treatment of hypertension in pregnancy has exluded the use of aceis because of their risk of teratogenicity; thus, the prescription of captopril/lisinopril is irrational when compared to the safer alternatives such as methyldopa, labetolol, and others that are also effective in achieving blood pressure control. in the case of calcium fetal exposure to risky drugs: analysis of antenatal clinic prescriptions in a nigerian tertiary care hospital international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 5 channel blockers, there is limited safety data, though, in recent years, nifedipine has been considered safe in pregnancy. nevertheless, some studies have reported the potential association between calcium channel blockers and birth defects, such as heart malformation, hypospadias and low birth weight. 19,20 the use of nsaids in pregnancy is not generally recommended because of their risk of premature closure of ductus arteriosus in the newborn and decreased neonatal renal function.21,22 they have also been reported to carry the risk of low birth weight and development of asthma in infants.5 opioid use also carry a high risk of the occurrence of spina bifida among other congenital malformations.9 metformin use in pregnancy exposes the fetus to the risk of higher body mass index in childhood and a significantly higher risk of cardiometabolic disorders later in adulthood. 23, 24 benzodiazepines are not known to carry significant risk of congenital abnormalities; 12 however, some previous studies have linked them to childhood motor and communication deficits.5, 25 although it is challenging to track the individual outcomes of fetal drug exposure, the high prevalence of low birth weight, still births, and early neonatal should be a matter of public health concern. it should also be acknowledged that a certain amount of the observed adverse fetal outcomes may be caused by other confounding variables acting alone or in conjunction with prescription drug exposure in utero. in conclusion, the prescription of contraindicated or unsafe drugs in pregnancy carries a significant safety risk to fetal wellbeing in utero and also to the post-delivery development. there should be improved awareness of safety guidelines and training of prescribers on safe use of drugs among pregnant women. references 1. ross ej, graham dl, money km, stanwood gd. developmental consequences of fetal exposure to drugs; what we know and what we still must learn. neuropsychopharmacol. 2015;40(1):61– 87. 2. trønnes jn, lupattelli a, nordeng h. safety profile of medication used during pregnancy: results of a multinational european study. pharmacoepidemiol drug saf. 2017;26(7): 802–11. 3. molla f, assen a, abrha s, et al. prescription drug use during pregnancy in southern tigray region, north ethiopia. bmc pregnancy childbirth. 2017;17(1):170. 4. mwita s, jande m, marwa k, hamasaki k, katabalo d, burger j et al. medicine dispensers knowledge on the implementation of artemisinin based combination therapy policy for treatment of uncomplicated malaria in tanzania. j pharm health serv res. 2017;8:227– 33 5. lupattelli a, chambers cd, bandoli g, handal m, skurtveit s, nordeng h. association of maternal use of benzodiazepines and z-hypnotics during pregnancy with motor and communication skills and attention-deficit/hyperactivity disorder symptoms in preschoolers (published correction appears in jama netw open. 2019 may 3;2(5):e194291). jama netw open. 2019; 2(4):e191435. 6. yefet e, schwartz n, chazan b, salim r, romano s, nachum z. the safety of quinolones and fluoroquinolones in pregnancy: a metaanalysis. bjog. 2018;125(9):1069–76. 7. muanda ft, sheehy o, bérard a. use of antibiotics during pregnancy and the risk of major congenital malformations: a population based cohort study. br j clin pharmacol. 2017; 83(11):2557–71. 8. pilmis b, jullien v, sobel j, lecuit m, lortholary o, charlier c. antifungal drugs during pregnancy: an updated review. j antimicrob chemother. 2015; 70(1):14–22. 9. fishman b, daniel s, koren g, lunenfeld e, levy a. pregnancy outcome following opioid exposure: a cohort study. plos one. 2019; 14(7):e0219061. 10. nezvalová-henriksen k, spigset o, nordeng h. effects of ibuprofen, diclofenac, naproxen, and piroxicam on the course of pregnancy and pregnancy outcome: a prospective cohort study. bjog. 2013; 120(8):948–59. 11. mito a, murashima a, wada y, et al. safety of amlodipine in early pregnancy. j am heart assoc. 2019;8(15):e012093. 12. ban l, west j, gibson je, et al. first trimester exposure to anxiolytic and hypnotic drugs and the risks of major congenital anomalies: a united kingdom population-based cohort study. plos one. 2014;9(6):e100996. paul otor onah, catherine chioma idoko, et al 6 international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 fetal exposure to risky drugs: analysis of antenatal clinic prescriptions in a nigerian tertiary care hospital 13. zhao y, zhou y, zhu q, xia b, ma w, xiao x, et al. determination of antibiotic concentration in meconium and its association with fetal growth and development. environ int. 2019;123:70– 78. 14. fan h, li l, wijlaars l, gilbert re. associations between use of macrolide antibiotics during pregnancy and adverse child outcomes: a systematic review and meta-analysis. plos one. 2019;14(2):e0212212. 15. rouamba t, valea i, bognini jd, kpoda h, mens pf, gomes mf, et al. safety profile of drug use during pregnancy at peripheral health centres in burkina faso: a prospective observational cohort study. drugs real world outcomes. 2018;5(3):193–206. 16. mensah kb, opoku-agyeman k, ansah c. antibiotic use during pregnancy: a retrospective study of prescription patterns and birth outcomes at an antenatal clinic in rural ghana. j pharm policy pract. 2017;10:24. 17. loewen k, monchka b, mahmud sm,’t jong g, azad mb. prenatal antibiotic exposure and childhood asthma: a population-based study. eur respir j. 2018;52(1):1702070. 18. schwartz bs, pollak j, bailey-davis l, hirsch ag, cosgrove se, nau c, et al. antibiotic use and childhood body mass index trajectory. int j obes (lond). 2016;40(4):615–21. 19. fisher sc, van zutphen ar, werler mm, lin ae, romitti pa, druschel cm, et al. maternal antihypertensive medication use and congenital heart defects: updated results from the national birth defects prevention study. hypertension. 2017;69(5):798–805. 20. antza c, dimou c, doundoulakis i, akrivos e, stabouli s, haidich ab, et al. the flipside of hydralazine in pregnancy: a systematic review and meta-analysis. pregnancy hypertens. 2020;19:177–86. 21. durudogan l. nsaid use increases risk of miscarriage in early pregnancy. clin res pract. 2019;5(2):ep1946 22. li dk, ferber jr, odouli r, quesenberry c. use of nonsteroidal antiinflammatory drugs during pregnancy and the risk of miscarriage. am j obstet gynecol. 2018; 219(3):275.e1-275.e8. 23. gui j, liu q, feng l. metformin vs insulin in the management of gestational diabetes: a metaanalysis. plos one. 2013; 8(5):e64585. 24. tarry-adkins jl, aiken ce, ozanne se. neonatal, infant, and childhood growth following metformin versus insulin treatment for gestational diabetes: a systematic review and meta-analysis. plos med. 2019; 16(8):e1002848. 25. radojčić mr, el marroun h, miljković b, stricker bhc, jaddoe vwv, verhulst fc, et al. prenatal exposure to anxiolytic and hypnotic medication in relation to behavioral problems in childhood: a population-based cohort study. neurotoxicol teratol. 2017;61:58–65. vol 11 no 1 2023 (2) rev-2.indd 57 this is an open access article licensed under the creative commons attribution-noncommercial 4.0 international license (http:// creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original author and source are properly cited removal technique of penetrating nail in head: a case report agus suhendar,1 effendy2 1department of neurosurgery, faculty of medicine, lambung mangkurat university, banjarmasin, indonesia 2faculty of medicine, lambung mangkurat university, banjarmasin, indonesia introduction since the 1980s, the use of nail guns has become widespread due to their efficiency in increasing productivity. however, their usage has also been associated with a rise in injury incidents. according to reports, there were approximately 5,000 cases of injuries caused by pneumatic nail guns per year in the united states between 1991 and 1993. this number significantly increased to as much as 15,000 cases per year from 2001 to 2003. penetrated brain injury is a challenge in the case of brain surgery because this trauma can cause damage to the blood vessels of the brain. complications arising from this condition may involve bleeding and thrombosis, both of which can cause additional neurological deficits, such as paresis or seizures. furthermore, in cases where the bleeding or infarct is extensive, there may be an increase in intracranial pressure leading to further complications. cases of nail injuries have a better prognosis than cases of penetrated brain injury by a knife or bullet. the surgical procedure to remove the nail not only addresses the physical trauma but also serves as a means to prevent potential infections, such as meningitis or encephalitis, which can have severe consequences. ideally, surgery for penetrating brain injuries should be conducted within 12 hours, especially in cases where there are no signs of mass effect or active bleeding. therefore comprehensive treatment and follow-up care are essential for ensuring the best possible outcome.1,2 in general, surgical treatment for penetrating brain injury primarily focuses on treating mass effect and decreasing the risk of infectious complications. small entrance wounds to the scalp and skull can be managed with local wound care, but larger or more complex injuries may require extensive debridement with subsequent primary closure or grafting to achieve a watertight closure. case report international journal of integrated health sciences (iijhs) issn print: 2302-1381; issn online: 2338-4506 received: november 24, 2022 accepted: march 11, 2023 published: march 30, 2023 correspondence: effendy faculty of medicine, lambung mangkurat university, banjarmasin, indonesia. email: effendyzhuo@gmail.com doi: 10.15850/ijihs.v11n1.3105 ijihs. 2023;11(1):57-62 article history abstract objective: to present a unique case involving a 44-year-old man who sustained a penetrating head injury after nailing his head with a hammer. despite the severity of his injury, the patient underwent successful surgical treatment and experienced a good recovery. methods: clinical and imagery review was performed on a cranial puncture trauma caused by a metal nail, which penetrated the cranium, dura mater, right parietal cerebral parenchyma, and right ventricle. the nail was lodging next to midline without damaging the superior sagittal sinus. the patient underwent craniotomy nail removal and debridement with normal saline and metronidazole antibiotics. results: craniotomy, careful nail extraction, wound debridement, and duraplasty remain the treatment standard for penetrating nail injury in the head. patient in this case study did not exhibit any signs of neurologic deficit or infection. conclusion: proper diagnosis and treatment are required in patients with penetrating brain trauma, with head x-rays and ct scans help in evaluating vascular depth and damage. craniotomy and debridement are the main treatments for this type of trauma. keywords: nails, head injury, surgery 58 internati onal journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 routine removal of small bone and missile fragments is not recommended due to the associated high morbidity. delayed removal of contaminated foreign bodies like wood has been linked to higher rates of complications compared to immediate surgical intervention. people with psychiatric disorders such as schizophrenia and major depressive disorder have been associated with previous cases of intracranial nail gun injuries. it is therefore recommended that psychiatric services be involved in the diagnosis and management of any suicide attempt survivors during and after their injury treatment. this underscores the importance of ongoing mental health maintenance and follow-up.33 case a 44-year-old man came with his family to the er with nailing his head with a hammer. the patient is conscious but complains of headaches and hallucinations. a head ctscan was performed, resulting in an elongated metallic foreign body with a defect in the right parietal bone penetrating through the right parietal lobe and right ventricle (fig. 1). on blood examination, there was leukocytosis (19.18 thousand/ul), with dominant neutrophils (76.9%). the patient had a history of trauma from falling two years ago during a flood that caused the patient to suffer brain contusion. at that time the patient complained of headache, without neurological deficit. the patient was treated at the stroke center for 3 days and then moved to the inpatient room for one week. after returning from the hospital the patient is still working. but in the next 1 month, the patient’s family complains of changes in the patient’s attitude, mood, and memories that often repeat themselves. the patient also had attempt to kill himself by slashing his hand because he heard whispers. the patient routinely controls to psychiatric with diagnosis organic mental disorder, he had removal technique of penetrating nail in head: a case report fig. 1 patient head ct scan pre-operation (a-d) internati onal journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 59 total mini mental status examination (mmse) score was 23 with the impression of moderate cognitive-dementia impairment. the patient also did a clock drawing test (cdt) and could only draw a closed circle. the operation was performed 12 hours after the patient was pierced by the nail. prior the surgery, the patient received broad-spectrum antibiotics, ceftriaxone iv 2x1 gr, anticonvulsants phenytoin iv 3x100 mg, tetanus immunoglobulin im 250 iu and tetanus toxoid im 0.5 ml. the patient was placed in the supine position under general anesthesia with endotracheal intubation. the patient’s hair was shaved and then treated with antisepsis sepsis with povidone-iodine, and the operating field was narrowed with a sterile dressing. marking was done in the operating area followed by making a lazy s incision up to the cranium. after that, a retractor was placed on the skin and a 2 cm en block craniotomy was performed around the nail perimeter by avoiding the superior sagittal sinus. cranium is lifted along with the nail (fig. 2). the nail track was evaluated, debrided, washed with normal saline around the nail track, and flushed with metronidazole into the track. evaluate bleeding, and control bleeding with a hemostatic sponge. then proceed with duraplasty. the operation was completed and a head ct scan post operation was performed (fig. 3). after the operation, the patient immediately regained consciousness. the patient was treated for 2 days in the intensive care unit (icu). postoperative head ct scan results showed a post-puncture intracranial wound with intracerebral hemorrhage and perifocal vasogenic edema (fig. 3). the patient went agus suhendar, effendy fig. 2 durante operation pictures (a-e). the nail and bone has been extracted (a). design of the incision with lazy s incision and play close attention to superior sagittal sinus (b). craniotomy around the nail perimeter (c). the nail track was debrided and control bleeding (d-e). 60 internati onal journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 home after undergoing 11 days of treatment at the hospital. he had no complained of seizure neither tetanus nor meningitis. the patient was on leave from work for 3 months and continued treatment at the psychiatric department. discussion head trauma due to foreign body penetration is less common than closed head trauma but has a worse prognosis.1 penetrating head trauma can be classified as a missile or non-missile injury. the difference between a missile and a non-missile is, missile trauma has velocities of more than 100 m/s causing damage by heat and kinetic trauma. missile trauma has worse morbidity and mortality. non-missile trauma has a lower velocity and usually causes tissue laceration and maceration. although nonmissile trauma is less common this trauma has a better prognosis and effect on treatment.3 non-missile trauma is usually caused by accidents, crimes, and attempted suicides. in this case, the patient had non-missile trauma caused by attempted suicide. according to the literature in developing countries, it is reported that there are many nail penetration traumas with the intention of suicide.4 diagnosing brain trauma requires a detailed history, physical examination, and investigations. x-ray photos are useful for diagnosing trauma caused by metal materials. investigations with head ct scans are useful for evaluating foreign bodies and predicting the depth of foreign bodies, besides that, a head ct scans can be useful for monitoring postoperative complications. mri examination is very limited for diagnosing metallic foreign bodies because of the ferrous content of the metallic material. ct angiography is usually performed in cases of penetrating trauma to fig. 3 patient head ct scan post operation (a-e) removal technique of penetrating nail in head: a case report international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 61 look for vascular complications.5,6 in this case, ct angiography was not performed due to limited facilities at our center. craniotomy remains the preferred method of neurosurgical treatment for penetrating foreign body injuries, as it is associated with fewer complications compared to blind removal. reports indicate that blind removal of foreign bodies can result in subdural hematoma and intraparenchymal hemorrhages. to ensure safe removal, the craniotomy should be performed around the area where the foreign body entered. bone fragments should also be removed with the aid of brain navigation if required, and the area should be thoroughly cleaned to prevent brain abscess formation.7 the operations performed are aimed at removing the foreign body as soon as possible, removing bone fragments, focal debridement of nail track, decompression of neovascular structures, hemostasis, and duramater repair.8 in this case, nails were taken and debridement was performed using normal saline and metronidazole antibiotics. after confirming that there was no bleeding, a duraplasty was performed to prevent cerebral fistula. there is no specific antibiotic for the treatment of penetrating trauma caused by nail. our treatment was immediate and identical to the of several similar case reports. broad spectrum antibiotic therapy, vaccination, craniotomy, careful nail extraction, wound debridement, and duraplasty was performed. complications such as meningitis and cerebral abscess increase in patients with penetrating brain trauma due to contamination with foreign bodies, skin, and bone fragments carried by the brain parenchyma along the wound track.9,10 staphylococcus aureus and gram-negative bacteria have been reported to be associated with secondary infections.3 recent guidelines recommend using ceftriaxone, metronidazole, or vancomycin for 7-14 days in cases like our patient. however, some sources argue that antibiotics should not be used as a preventative measure unless there is a known bacterial source or a specific clinical need. at present, there is limited highquality evidence from randomized controlled trials to guide treatment, indicating the need for further research in this area. in our case, we used ceftriaxone and metronidazole as therapeutic. antibiotics were continued for up to 2 weeks postoperatively.11 the prognosis for patients with penetrating brain trauma is usually good if the cerebral vessels and brainstem are not involved. in this case, a good outcome was obtained in the patient because it did not involve blood vessels and brainstem.2 whether antiepileptic drugs should be used to prevent seizures after penetrating traumatic brain injury remains a controversial issue. early seizures (within 1 week of injury) occur in 6 to 10% of cases, and this percentage can increase to 53% in those with penetrating head injury. the surgical critical care guidelines committee issued a set of recommendations in 2017 that suggest ant seizure prophylaxis should only be given to patients with severe tbi, such as those with a brain contusion, intracranial hematoma, loss of consciousness, posttraumatic amnesia for more than 24 hours, or a gcs score of 3 to 8.12 the patient did not complain of headaches or seizures when he was discharged. late seizure cannot be evaluated because the patient died because of kidney and heart failure 9 months. there still no research study reported the rate of tetanus incidence in penetrating brain injury and the tetanus prophylaxis, in this patient we administer tetanus prophylaxis for prevention measures. references 1. wang sh, chen my, yan jl, huang ty, chang cc, chien cy. survival after multiple nail gun injuries to the brain, lung, and heart: a case report and a review of the literature. j int med res. 2021;49(10):3000605211049923. doi:10.1177/03000605211049923. 2. arham a, zaragita n. penetrating injury of superior sagittal sinus. asian j neurosurg. 2021;16(01):132–5. 3. zhu rc, yoshida mc, kopp m, lin n. treatment of a self-inflicted intracranial nail gun injury. bmj case rep. 2021;14(1):e237122. 4. fahde y, laghmari m, skoumi m. penetrating head trauma: 03 rare cases and literature review. pan afr med j. 2017;28:305. 5. wu r, ye y, liu c, yang c, qin h. management of penetrating brain injury caused by a nail gun: three case reports and literature review. world neurosurg. 2018;112:143–7. 6. zyck s, toshkezi g, krishnamurthy s, carter agus suhendar, effendy 62 international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 da, siddiqui a, hazama a, et al. treatment of penetrating nonmissile traumatic brain injury. case series and review of the literature. world neurosurg. 2016;91:297–307. 7. ferraz vr, aguiar gb, vitorino-araujo jl, badke gl, veiga jce. management of a low-energy penetrating brain injury caused by a nail. case rep neurol med. 2016;2016:1–4. 8. pniel d, withers tk. a case of multiple nail gun injuries to the head and one to the heart. surg neurol int. 2018;9:221. 9. miki k, natori y, kai y, mori m, yamada t, noguchi n. how to remove a penetrating intracranial large nail. world neurosurg. 2019;127:442–5. 10. yuh sj, alaqeel a. ten self-inflicted intracranial penetrating nail gun injuries. neurosciences. 2015;20(3):267–70. 11. hoey a, troy c, bauerle w, xia a, hoey b. delayed-onset seizures following self-inflicted nail gun injury to the head: a case report and literature review. j neurol surg rep. 2022;83(02):e54–62. 12. rojas k, birrer k.seizure prophylaxis in patients with traumatic brain injury (tbi). department of surgical education, orlando regional medical centerpublished 2017. available from: http:// www.surgicalcriticalcare.net/guidelines/ seizure%20prophylaxis%20in%20tbi%20 2017.pdf. removal technique of penetrating nail in head: a case report vol 11 no 1 2023 (2) rev-2.indd 27 this is an open access article licensed under the creative commons attribution-noncommercial 4.0 international license (http:// creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original author and source are properly cited oxidative stress in seminal plasma negatively influences sperm quality in infertile males roshan kumar mahat,1 dhananjay vasantrao bhale,2 vedika rathore3 1department of biochemistry, american international institute of medical sciences (aiims) and gbh general hospital, udaipur (rj), india 2department of biochemistry, mgm medical college and hospital, aurangabad (mh), india 3department of biochemistry, shyam shah medical college, rewa (mp), india introduction fifteen percent of couples have infertility due to a variety of causes. infertility is defined as the failure to achieve a spontaneous pregnancy after 12 months or more of frequent, unprotected sexual intercourse.1 nearly half of all infertility cases can be traced back to male factors, which are just as important as female factors.2 the global prevalence of infertility ranges from 2.5% to 15%, which corresponds to at least 30 million infertile males.3 numerous researches pointed to oxidative stress, a condition marked by an imbalance between the generations of reactive oxygen species (ros) and antioxidant defense mechanisms, as a newly discovered cause of unexplained male infertility.4,5 when kept within healthy limits, ros mediate vital physiological activities crucial to ensuring normal male reproductive functions including sperm viability, maturation, hyper activation, sperm capacitation, motility, acrosome reaction, and oocyte interaction.6,7 however, excessive ros can lead to infertility via a variety of mechanisms, including lipid peroxidation, dna damage, enzyme inactivation, and protein oxidation in spermatozoa.7 spermatozoa are extremely vulnerable to oxidation because of the high concentration of unsaturated fatty acids found in their membranes and the absence of cytoplasmic antioxidant enzymes; as a result, oxidation has a negative impact on the quality and functionality of sperm.7,8 we, therefore, set out to evaluate mda (as a marker of oxidative stress) and investigate how it relates to the quality of sperm in infertile males. original article international journal of integrated health sciences (iijhs) issn print: 2302-1381; issn online: 2338-4506 received: november 03, 2022 accepted: march 27, 2023 published: march 30, 2023 correspondence: dr. roshan kumar mahat department of biochemistry, american international institute of medical sciences and gbh general hospital, udaipur (rj), india. e-mail: mahatroshan79@gmail.com doi: 10.15850/ijihs.v11n1.3079 ijihs. 2023;11(1):27–31 article history abstract objective: to investigate the association between malondialdehyde concentration in the seminal plasma of infertile men and sperm quality. methods: this case-control study included 60 male participants ranging from 25-40 years old with half of them were fertile and the other half were infertile. semen analysis was performed as per the who standards, and spectrophotometric measurement of seminal plasma malondialdehyde level was done. results: results showed that infertile men had significantly a higher mean level of malondialdehyde in their seminal plasma than fertile men (p<0.001), which was inversely associated with sperm count and motility. also, malondialdehyde was positively associated with abnormal sperm morphology. conclusions: elevated malondialdehyde levels in seminal plasma are associated with poor sperm quality. malondialdehyde testing can, therefore, be used to diagnose and predict the outcome of male infertility. antioxidants should also be administered to men with infertility to help counteract the effects of oxidative stress. keywords: male infertility, malondialdehyde, sperm quality 28 international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 methods the present case-control study was carried out in the department of biochemistry and invitro fertilization (ivf) center of mgm medical college and hospital, aurangabad. the study was carried out from january 2013 through december 2013. the study was carried out after getting approval from the institutional ethical and research committee (reference no: ec/056/2012, dated 02 november 2012). the case group comprised 30 infertile men (with abnormal semen analysis) between the ages of 25 and 40 years, whose wives had not conceived after a year of having regular, unprotected sex. thirty healthy, fertile male volunteers in the same age range who were in good health and had normal semen parameters were used as controls. patients in the case group were excluded from the study if they had testicular damage, varicocele, leukocytospermia, hypogonadism, genital tract infections, cryptorchidism, tuberculosis, diabetes mellitus, heart disease, renal disease, or prolonged illness. the written consent was taken from both infertile males and healthy controls. from both patients and controls, semen samples were collected. after a period of abstinence of three to four days, specimens were obtained by masturbating into widemouth sterile plastic containers and analyzed within an hour of collection. after letting the semen liquefy for at least 30 minutes, it was analyzed to measure sperm concentration, motility, and morphology following who guidelines. mda levels were analyzed by the method described by nourooz-zadeh et al.9 in brief, the first semen sample was centrifuged after liquefaction to get the seminal plasma. to 100 µl of seminal plasma, 1000 µl of 0.67% tba (thiobarbituric acid) and 500 µl of 20% tca (trichloroacetic acid) were added and incubated for 20 minutes at 1000c. after centrifugation at 12,000 rpm for 5 minutes, the optical density (od) of the supernatant was taken at 532 nm spectrophotometrically. mda concentration was calculated using the molar extinction coefficient for the mda-tba complex of 1.56×105 mol-1lcm-1. the data were statistically analyzed using ibm spss statistics, version 20. data were presented as mean±sd. the statistical differences between cases and controls were established by the student-independent sample t-test. to find out how the variables related to one another, a pearson correlation analysis was done. values were considered statistically significant when p<0.05. results table 1 shows the comparison of sperm characteristics and seminal plasma mda between infertile and fertile males. the level of mda in the seminal plasma of infertile men was significantly higher than that of the fertile control group. subjects with infertility had significantly lower sperm counts and motility compared to those with fertile men. additionally, abnormal sperm morphology was shown to be significantly higher in infertile males than in normal, healthy fertile males. mda was significantly negatively correlated with sperm count and motility in infertile males and are presented in fig 1 and 2 respectively. however, there was an insignificant positive correlation of mda with sperm abnormal morphology in infertile males, which is presented in fig. 3. discussion by modifying membrane fluidity and permeability and reducing sperm functional competence, oxidative stress negatively impacts sperm function. to evaluate the membrane damage, the quantity of mda, the final product of lipid peroxidation, can oxidative stress in seminal plasma negatively influences sperm quality in infertile males table 1 comparison of sperm characteristics and mda between fertile and infertile males parameters fertile males (n=30) infertile males (n=30) sperm count (millions/ml) 79.17±10.97 32.03±11.29* sperm motility (%) 74.57±5.67 32.66±8.18* sperm abnormal morphology (%) 17.93±3.77 35.4±4.90* mda 1.56±0.34 3.00±0.49* *highly significant (p<0.001); mda: malondialdehyde international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 29 roshan kumar mahat, dhananjay vasantrao bhale, et al fig. 1 correlation between mda and sperm count in infertile males (r=-0.447; p<0.05) fig. 2 correlation between mda and sperm motility in infertile males (r=-0.374; p<0.05) be taken into account.10 the purpose of this study was to determine whether or not there is a connection between the amount of malondialdehyde found in the seminal plasma of infertile men and the quality of their sperm. in the present study, a significant increased level of mda was observed in the seminal plasma of infertile males as compared to the fertile group. this is in accordance with the studies done by atig et al.11 more et al.12 and dorostghoal et al.13 who also reported increased seminal mda in infertile male patients. similarly, in a study conducted by muley and muley,14 insignificant higher seminal plasma mda was observed in asthenoteratozoospermic and azoospermic 30 international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 males as compared to normozoospermics. however, a significant rise in mda levels was observed in the oligoasthenoteratozoospermic group. in contrast, palani et al.15 did not find any significant difference in mda levels between studied fertile and infertile males. the disparity between the results of the aforementioned research can be attributed, in part, to the variability of those studies with regard to patient selection, methodology, and oxidative stress assessment techniques, as well as genetic and racial characteristics.15 increased mda levels in the seminal plasma of infertile males indicate excessive ros is responsible for lipid peroxidation of the membrane lipids. because the sperm plasma membrane contains a high concentration of polyunsaturated fatty acids (pufas), which are essential for ion transport and membrane fluidity, peroxidation of the pufas in the membrane by excessive ros disrupts the functions of the sperm membrane and decreases the ability of spermatozoa to fertilize.12 it has been shown that both qualitative and quantitative sperm abnormalities exist in the semen of infertile males. the sperm count and motility were found to be significantly decreased in infertile men as compared to fertile ones. also, abnormal morphology of sperm was reported to be significantly high in infertile males as compared to normal healthy fertile males. the findings of the present study indicate that elevated oxidative stress in the seminal plasma of infertile males is associated with poor sperm quality. these results are well supported by the findings of previous studies.12,14 in the current study, mda showed a significant negative correlation with sperm count and motility. also, a positive correlation was observed between seminal mda and sperm abnormal morphology. these results are in line with the findings of more et al12 and mehrotra et al.16 dorostghoal et al.13 also reported significant negative correlations between mda levels and sperm motility and normal morphology. an excessive amount of ros can decrease sperm motility most likely through a rapid loss of intracellular atp leading to axonemal damage, decrease sperm viability, and increased mid-piece morphological defects with deleterious effects on sperm capacitation and acrosome reaction.17,18 according to the findings of the research, ros are responsible for inducing base modification, dna strand breakage, and chromatin crosslinking, all of which are detrimental to the integrity of the dna in the sperm nucleus.19 on the other hand, dna damage caused by high levels of ros may hasten the process of germ cell apoptosis, resulting in a drop in sperm counts associated with male infertility.20 due to the small sample size and lack of follow-up of patients in the present study, among other limitations, additional large-scale prospective investigations are necessary to strengthen the findings of this investigation. in conclusion, the results of the present study indicate that increased oxidative stress (reflected by fig. 3 correlation between mda and sperm abnormal morphology in infertile males (r = 0.208; p>0.05) oxidative stress in seminal plasma negatively influences sperm quality in infertile males international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 31 1. aitken rj. impact of oxidative stress on male and female germ cells: implications for fertility. reproduction. 2020;159(4):r189–r201. 2. wagner h, cheng jw, ko ey. role of reactive oxygen species in male infertility: an updated review of literature. arab j urol. 2017;16(1):35– -43. 3. agarwal a, ahmad g, sharma r. reference values of reactive oxygen species in seminal ejaculates using chemiluminescence assay. j assist reprod genet. 2015;32:1721–9. 4. agarwal a, ahmad g, sharma r. reference values of reactive oxygen species in seminal ejaculates using chemiluminescence assay. j assist reprod genet. 2015;32(12):1721–9. 5. cito g, becatti m, natali a, et al. redox status assessment in infertile patients with nonobstructive azoospermia undergoing testicular sperm extraction: a prospective study. andrology. 2020;8(2):364–71. 6. du plessis ss, agarwal a, halabi j, tvrda e. contemporary evidence on the physiological role of reactive oxygen species in human sperm function. j assist reprod genet. 2015 apr;32(4):509–20. 7. barati e, nikzad h, karimian m. oxidative stress and male infertility: current knowledge of pathophysiology and role of antioxidant therapy in disease management. cell mol life sci. 2020 jan;77(1):93–113. 8. agarwal a, roychoudhury s, sharma r, gupta s, majzoub a, sabanegh e. diagnostic application of oxidation-reduction potential assay for measurement of oxidative stress: clinical utility in male factor infertility. reprod biomed online. 2017;34(1):48–57. 9. nourooz-zadeh j, tajaddini-sarmadi j, mccarthy s, betteridge dj, wolff sp. elevated levels of authentic plasma hydroperoxides in niddm. diabetes. 1995;44(9):1054–8. 10. collodel g, moretti e, micheli l, menchiari a, moltoni l, cerretani d. semen characteristics and malondialdehyde levels in men with different reproductive problems. andrology. 2015;3(2):280–6. 11. atig f, raffa m, ali hb, abdelhamid k, saad a, ajina m. altered antioxidant status and increased lipid per-oxidation in seminal plasma of tunisian infertile men. int j biol sci. 2012;8(1):139–49. 12. more k, badade zg, narshetty jg, joshi ds, mukherjee s, deepak ad, et al. lipid peroxidation, sperm dna fragmentation, total antioxidant capacity and semen quality in male infertility. mgm j med sci. 2014;1(1):1–6. 13. dorostghoal m, kazeminejad sr, shahbazian n, pourmehdi m, jabbari a. oxidative stress status and sperm dna fragmentation in fertile and infertile men. andrologia. 2017;49(10):e12762. 14. muley pp, muley pa. oxidative stress in seminal plasma and its relation to fertility potential of human male subjects. j datta meghe inst med sci univ. 2020;15:172–5. 15. palani a, alahmar a. impact of oxidative stress on semen parameters in normozoospermic infertile men: a case–control study. afr j urol. 2020;26:50. 16. mehrotra a, katiyar dk, agarwal a, das v, pant kk. role of total antioxidant capacity and lipid peroxidation in fertile and infertile men. biomed res. 2013;24(3):347–52. 17. agarwal a, virk g, ong c, du plessis ss. effect of oxidative stress on male reproduction. world j mens health. 2014;32(1):1–17. 18. fatima, s. role of reactive oxygen species in male reproduction. in: atukeren, p., editor. novel prospects in oxidative and nitrosative stress [internet]. london: intechopen; 2018 [cited 2023 jan 15]. available from: https:// www.intechopen.com/chapters/59757 doi: 10.5772/intechopen.74763 . 19. alahmar at. role of oxidative stress in male infertility: an updated review. j hum reprod sci. 2019;12(1):4–18. 20. agarwal a, allamaneni ssr. oxidants and antioxidants in human fertility. mid east fert society j. 2004;9:187–97. references increased mda levels) in seminal plasma is associated with poor sperm quality (reflected by decreased sperm count, decreased sperm motility and increased abnormal sperm morphology) in infertile males. therefore, determining mda levels in seminal plasma can help in the diagnosis and prognosis of male infertility. to verify these results, nevertheless, additional research with a large sample size is required. roshan kumar mahat, dhananjay vasantrao bhale, et al vol 11 no 1 2023 (2) rev-2-edited ver 1 dep.indd 7 this is an open access article licensed under the creative commons attribution-noncommercial 4.0 international license (http:// creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original author and source are properly cited adenosine deaminase as inflammatory marker in type ii diabetes mellitus sushil yadav,1 megha bansal,2 pradeep kumar,3 preeti sharma3 1 department of biochemistry, tmmc & rc, moradabad, uttar pradesh, india 2department of pathology, tsm medical college and hospital, lucknow, india 3department of biochemistry, autonomous state medical college, fatehpur, uttar pradesh, india introduction diabetes mellitus is a known chronic metabolic disorders characterized by the presence of hyperglycemia caused by the derangements in the metabolism of carbohydrates, lipids, and proteins. a large number of diabetes mellitus cases remains undiagnosed. this disorder is deemed incurable and persists life-long. type ii diabetes mellitus is considered as a lifestyle disorder, which develops due to a sedentary lifestyle, lack of physical activities, low intake of dietary fibers, etc. type ii diabetes mellitus can lead to morbidity and mortality through numerous microvascular and macrovascular changes. various other risk factors that have significant contributions to the development of this disease include the environmental, genetical, and behavioral factors.1 in type ii diabetes mellitus, alterations in the functions of the immune system is also observed. the t-cell mediated immunity is disturbed, leading to the impairment in the insulin responses.2 this results in adverse changes such as the activation of leucocytes, elevated levels of cytokines in the circulation, as well as increased apoptosis. these changes suggest that inflammatory changes occur in diabetes mellitus. various pro-inflammatory mediators are released from different tissues including activated leucocytes, adipocytes, and endothelial cells. the role of various biochemical products, i.e., interleukin-6, c reactive protein (crp), tumor necrosis factor (tnfα), leptin, and others have been studied widely and many researchers have proposed their potential involvement in inducing the pathogenesis of type ii diabetes mellitus. also, some metabolic and inflammatory factors and their serum levels has also been shown to have original article international journal of integrated health sciences (iijhs) issn print: 2302-1381; issn online: 2338-4506 received: july 08, 2022 accepted: june 04, 2023 published: march 30, 2023 correspondence: dr. preeti sharma associate professor department of biochemistry, autonomous state medical college, fatehpur, uttar pradesh, india e-mail: prcdri2003@yahoo.co.in doi: 10.15850/ijihs.v11n1.2887 ijihs. 2023;11(1):7-11 article history abstract objective: to evaluate the enzymatic activity of adenosine deaminase (ada) in type ii diabetes mellitus (t2dm). methods: this study was conducted on 60 clinically diagnosed type ii diabetes mellitus patients, with 60 healthy subjects as the control group. subjects were enrolled in the study only after their written consent was obtained. the inclusion of diabetes mellitus cases (dm) was conducted as per the who guidelines. estimation of enzymatic activity of serum ada was performed by kinetic method using a commercial kit. result: the observed serum ada activity in dm patients was 48.34± 21.05 u/l, which was significantly higher in comparison to healthy controls (25.02±5.78 u/l). the serum activity raised in about 80% of patients and they had higher values above the reference activity of 30 u/l. the increased activity of ada among the diabetic subjects indicates inflammatory changes in these individuals. conclusion: it is possible that in the coming years, a new therapeutic strategy based on anti-inflammatory properties with beneficial effects on diabetic complications can be translated into real clinical treatments. keywords: adenosine deaminase, inflammatory markers, type ii diabetes mellitus 8 international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 a direct effect on the amount of adipose tissues in the body.3, 4 adenosine deaminase (ada), a metabolic enzyme catalyzing deamination, has been shown to deaminate adenosine into inosine while also acting as a regulatory enzyme that maintains the extracellular and intracellular concentrations of adenosine.5 ada is an enzyme that is expressed ubiquitously and its activity is seen higher in tissues like thymus, gi tract, brain, and lymphoid tissues.6 the enzymatic activity of ada has been seen to be higher in lymphoid tissues and aids in increasing lymphocyte proliferation and differentiation. it has also been found as a producer of oxygen derived reactive oxygen species (ros), as well as a stimulator for lipid peroxidation.7 adenosine acts through g protein-couples receptor and facilitates the normal cell physiology regulation in various tissues.8 it also plays the role of a suppressant of inflammation for its ability to inhibit the inflammatory mechanisms, such as inhibiting t-cell activation and proliferation. meanwhile, adenosine is supposed to mimic the activity of insulin on glucose and might somehow play a role in causing insulin resistance. since, the concentration of adenosine is regulated by the activity of ada, the insulin resistance can have ada as the triggering factor. the increased ada activity in diabetic subjects might be due to deranged insulin activity linked to the t-lymphocyte function.9 this study aimed to evaluate the enzymatic activities of adenosine deaminase in type ii diabetes mellitus and whether there is a possibility of an association between inflammatory and diabetic markers in this disease. methods this study was a case-control study performed at the teerthanker mahaveer medical college and research center in 2019 after receiving the approval from the institutional ethical committee of the college under the ethical clearance number iec/17–18/030. the study was conducted on 60 clinically diagnosed type ii diabetes mellitus patients with 60 healthy subjects as the control group. sample size calculation was performed using the statistical formula. all subjects aged between 30 and 45 years old and were only enrolled in the study after their written consent was obtained. the inclusion of diabetes mellitus cases was done according to the who guidelines. individuals having a fasting plasma glucose level of ≥ 126 mg/dl or a random glucose level of ≥ 200 mg/dl on two occasions were included as cases in this study. those individuals having inflammatory diseases like tuberculosis, cancer, gout, liver diseases, and kidney diseases were excluded from the study to rule out any increase in the ada activities due to other inflammation conditions. pregnant female subjects were also excluded. the estimation of enzymatic activity of serum ada was performed using the kinetic assay method with commercially available kits.10 data obtained were tabulated and analyzed using the spss. results table 1 and table 2 describe the demographic distribution of the participant and the study parameter comparisons between subjects and adenosine deaminase as inflammatory marker in type ii diabetes mellitus table 1 demographic distribution of the study population s.n subject male female total 1. healthy control 34 26 60 2. diabetes mellitus 37 23 60 table 2 comparison of study parameters between diabetic patients and healthy controls parameters type ii diabetes mellitus healthy control p-value fasting plasma glucose (mg/dl) 178.96±53.98 90.16±12.23 <0.001 * hbalc (%) 8.65±1.83 5.26±0.68 <0.05 adenosine deaminase (iu/l) 48.34±21.05 25.02±5.75 <0.001 * international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 9 control. as described in table 1 and fig. 2, the study parameter, i.e serum ada activities as one of the inflammatory markers, was found to be higher among type ii diabetic subjects compared to the healthy subjects, and the difference in activity between the study groups was highly significant statistically (p<0.01). the correlation analysis between serum ada activities and glycemic indices as shown in table 2 also highlighted the fact that serum ada activity was significantly correlated with fasting blood sugar (p<0.05) and hba1c levels (p<0.05). discussion type ii diabetes mellitus is a heterogeneous group of disorders that is featured by impaired insulin secretion and insulin resistance, as well as increased blood glucose. this disorder is supposed to be associated with an acute phase reaction, suggesting that a low-grade sushil yadav, megha bansal, et al table 3 correlation of serum ada activity with glycemic status in diabetic individuals glycemic status r-value p-value fasting plasma glucose 0.24 <0.05 hbalc 0.38 <0.0.5 fig. 1 comparison of fasting plasma glucose levels fig. 2 comparison of adenosine deaminase activity 10 international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 inflammation might also be involved in its pathogenesis.11 serum adenosine deaminase activity in this study was found to be elevated among the type ii diabetes mellitus patients. on comparing the mean values using student’s t-test between the study groups, the serum activity of ada in diabetic patients was seen to be 48.34±21.05 u/l, which was significantly higher than that of healthy controls of 25.02±5.78 u/l, as shown in table 2 and fig. 2. the serum activity was raised in about 80% of the patients and the value was higher than the reference activity, i.e., up to 30 u/l. an attempt to analyze the relationship of ada as an inflammatory marker with the glycemic status of an individual was also made in the current study by applying the karl pearson’s correlation coefficient. as a result, a positive and statistically significant correlation was observed with r= 0.385 (p<0.05). several previous studies have reported an altered serum ada activity, which is quite variable. kurtul n et al have shown increased level of serum ada activity in diabetic patients and its correlation with hba1c, and suggested that ada might be an important enzyme for modulating the bioactivity of insulin effect and glycemic control. ada may serve as an immune-enzyme marker in the etiopathology of type ii diabetes mellitus according to some researchers. a study by gitanjali g et al have reported an elevated serum activity of ada and concluded that higher blood glucose levels aggravate the oxidative stress as well as raises ada activity, which may be due to the local insulin resistance in the target organs. in the present study, since the serum activity of ada was significantly highest among diabetic cases in comparison to non-diabetic subjects, it can be suggested that ada is an effective marker for inflammation in the case of type ii diabetes mellitus. adenosine deaminase plays an important role in the proliferation and differentiation of lymphocytes, especially for t-lymphocytes. a higher activity of ada is due to deranged t-lymphocyte responses, pointing towards the mechanism to release ada into the circulation.12 it is also speculated that an altered insulin related t-lymphocyte function could be the reason for the increased ada activity in diabetes mellitus. also, with the role of adenosine in the inhibition of lipolysis through the a1 receptors, as well as due to increased adenosine deaminase, the inactivation of adenosine and activation of lipolysis are observed .13,14 this markedly potentiates the increment in the camp accumulation via norepinephrine action. thus, deregulated lipid metabolism and consequent elevation of free fatty acids might lead to the pathogenesis of the type ii diabetes mellitus.15, 16 in this study, it was found that the activity of ada was higher in diabetic patients. meanwhile, this particular inflammatory marker was also found to be positively correlated with the glycemic status of a diabetic patient. furthermore, the pearson’s correlation coefficient results showed a significant and positive correlation with the hba1c levels of these patients. the positive significant correlation between serum ada activity with the short term and longterm glycemic control indicates the important role of ada in glucose and lipid metabolism fig. 3 comparison of glycosylated hemoglobin level adenosine deaminase as inflammatory marker in type ii diabetes mellitus international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 11 derangements seen in type ii diabetes mellitus. nevertheless, this present study was limited in a way that only ada is included as a marker for inflammation, and a small sample size also have weaken the findings of the study. a large extended prospective study at the molecular level is suggested to explore the pathophysiological processes that are involved in the mediation of inflammation in diabetes mellitus circulatory levels that underlie the inflammatory mediators correlation with insulin resistance and the significant increase in groups at risk of type ii diabetes mellitus. the present study has shown that inflammatory marker like ada is linked to the development of insulin resistance and progression to diabetes mellitus type ii. it is possible that in the coming years, the hope of new therapeutic strategies based on antiinflammatory properties with beneficial effects on diabetic complications can be translated into real clinical treatments. the present study was limited to the sample size and a larger sample size studies would help in extrapolating the inflammatory role of ada in t2dm. the role of several other inflammatory markers like hs-crp, interleukins, etc. in metabolic disorders would be an open area for future studies. 1. olokoba ab, obateru oa, olokoba lb. type 2 diabetes mellitus: a review of current trends. oman med j. 2012;27(4):269–73. 2. sapkota lb, thapa s, subedi n. correlation study of adenosine deaminase and its isoenzymes in type 2 diabetes mellitus. bmj open diabetes res care. 2017;5(1):e000357. 3. berbudi a, rahmadika n, tjahjadi ai, ruslami r. type 2 diabetes and its impact on the immune system. curr diabetes rev. 2020;16(5):442–9. 4. halim m, halim a. the effects of inflammation, aging and oxidative stress on the pathogenesis of diabetes mellitus (type 2 diabetes). diabetes metab syndr. 2019;13(2):1165–72. 5. yu m, zhou h, li q, ding j, shuai h, zhang j. serum adenosine deaminase as a useful marker to estimate coronary artery calcification in type 2 diabetes mellitus patients. clin appl thromb hemost. 2021;27: 1-5. 6. sauer av, brigida i, carriglio n, aiuti a. autoimmune dysregulation and purine metabolism in adenosine deaminase deficiency. front immunol. 2012;3:265. 7. costa lr, souza aky, scholl jn, figueiró f, battastini amo, jaques jads, et al. biochemical characterization of adenosine deaminase (cd26; ec 3.5.4.4) activity in human lymphocyte-rich peripheral blood mononuclear cells. braz j med biol res. 2021;54(8):e10850. 8. sheth s, brito r, mukherjea d, rybak lp, ramkumar v. adenosine receptors: expression, function and regulation. int j mol sci. 2014;15(2):2024–52. 9. khemka vk, bagchi d, ghosh a, sen o, bir a, chakrabarti s, et al. raised serum adenosine deaminase level in nonobese type 2 diabetes mellitus. scientificworldjournal. 2013;2013:404320. 10. giusti g, galanti b. rapid colorimetric method for determination of some deaminase activities. boll soc ital biol sper. 1966;42(19):1312–6. 11. cruz ng, sousa lp, sousa mo, pietrani nt, fernandes ap, gomes kb. the linkage between inflammation and type 2 diabetes mellitus. diabetes res clin pract. 2013;99(2):85–92. 12. flinn am, gennery ar. adenosine deaminase deficiency: a review. orphanet j rare dis. 2018;13(1):65. 13. hariprasath, g., ananthi, n. glycemic control and raised adenosine deaminase activity in type 2 diabetes mellitus. iosr j dent med sci. 2017; 16(01): 53–6. 14. patel b, taviad d, malapati b, chhatriwala, m, shah r. serum adenosine deaminase in patients with type-2 diabetes mellitus and its relation with blood glucose and glycated haemoglobin levels. int j biomed res. 2014; 5(9):556. 15. athyros vg, doumas m, imprialos kp, stavropoulos k, georgianou e, katsimardou a, et al. diabetes and lipid metabolism. hormones (athens). 2018;17(1):61–7. 16. aron-wisnewsky j, warmbrunn mv, nieuwdorp m, clément k. metabolism and metabolic disorders and the microbiome: the intestinal microbiota associated with obesity, lipid metabolism, and metabolic healthpathophysiology and therapeutic strategies. gastroenterology. 2021;160(2):573–99. references sushil yadav, megha bansal, et al conflict of interest declaration here by the author(s) certify(s) that the manuscript entitled: correlation of abdominal ct scan score and alpha-fetoprotein levels in hepatocellular carcinoma is an original work and is not under review at any other publication. author and all co-authors have seen and agreed with the contents of the manuscript and there is no financial interest to report. this manuscript is ready for publication in the international journal of integrated health science. author (s) 1st author name: indira prawita martani, md signature : 2nd author name: firman parulian sitanggang, md signature : 3rd author name: ni nyoman margiani, md signature : 4th author name: i gde raka widiana, md, phd signature : 5th author name: made widhi asih, md signature : 6th author name: i made dwijaputra ayusta, md signature : author’s data title of manuscript: correlation of abdominal ct scan score and alpha-fetoprotein levels in hepatocellular carcinoma author(s) 1st author first name: indira last name: martani academic degree(s): md affiliation: department of radiology, faculty of medicine, udayana university/ sanglah general hospital denpasar address: departemen radiologi rsup sanglah denpasar bali, jalan diponegoro, dauh puri klod, kecamatan denpasar barat, kota denpasar, bali 80113 phone: 08125936955 email: indiraprawitamartani@gmail.com 2nd author first name: firman last name: sitanggang academic degree(s): md affiliation: department of radiology, faculty of medicine, udayana university/ sanglah general hospital denpasar address: departemen radiologi rsup sanglah denpasar bali, jalan diponegoro, dauh puri klod, kecamatan denpasar barat, kota denpasar, bali 80113 phone: 089687456712 email: firmandsr@yahoo.com 3rd author first name: ni last name: margiani academic degree(s): md affiliation: department of radiology, faculty of medicine, udayana university/ sanglah general hospital denpasar address: departemen radiologi rsup sanglah denpasar bali, jalan diponegoro, dauh puri klod, kecamatan denpasar barat, kota denpasar, bali 80113 phone: 081337401240 email: nym.margiani@unud.ac.id 4th author first name: i gde last name: widiana academic degree(s): md, phd affiliation: department of internal medicine, faculty of medicine, udayana university/ sanglah general hospital denpasar address: departemen penyakit dalam rsup sanglah denpasar bali, jalan diponegoro, dauh puri klod, kecamatan denpasar barat, kota denpasar, bali 80113 phone: 0816297956 email: rakawidiana@yahoo.com 5th author first name: made last name: asih academic degree(s): md affiliation: department of radiology, faculty of medicine, udayana university/ sanglah general hospital denpasar address: departemen radiologi rsup sanglah denpasar bali, jalan diponegoro, dauh puri klod, kecamatan denpasar barat, kota denpasar, bali 80113 phone: 081916442626 email: widhie1604@yahoo.com 6th author first name: i made last name: ayusta academic degree(s): md affiliation: department of radiology, faculty of medicine, udayana university/ sanglah general hospital denpasar address: departemen radiologi rsup sanglah denpasar bali, jalan diponegoro, dauh puri klod, kecamatan denpasar barat, kota denpasar, bali 80113 phone: 08123670195 email: dp.ayusta@gmail.com cover letter march 30th, 2022 to. editor in chief international journal of integrated health and science dear sir, please find the submission of our manuscript, correlation of abdominal ct scan score and alpha-fetoprotein levels in hepatocellular carcinoma which we would like to submit for publication in the international journal of integrated health science. this manuscript aims to assess the correlation between afp levels and the characteristics of liver lesions listed in abdominal ct scan scores in hepatocellular carcinoma. this was a retrospective analytic observational study with a cross-sectional design conducted at sanglah hospital in january 2017 – january 2021. we found a strong positive correlation between serum afp levels and abdominal ct scan scores in hepatocellular carcinoma patients. author and all co-authors have seen and agreed with the contents of the manuscript and there is no financial interest to report. we certify that the manuscript submitted is an original work and is not under review at any other publication. we thank you for considering our manuscript for publication in the international journal of integrated health science and look forward to hearing from you at your earliest convenience. sincerely yours, indira prawita martani, md prospective reviewer i hereby suggest prospective reviewer(s) to international journal of integrated health sciences (ijihs) by filling in all required information: reviewer 1 full name with academic degree(s): affiliation/institution: email: expertise: reviewer 2 full name with academic degree(s): affiliation/institution: email: expertise: vol 11 no 1 2023 (2) rev-2-edited ver 1 dep.indd 12 this is an open access article licensed under the creative commons attribution-noncommercial 4.0 international license (http:// creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original author and source are properly cited secondary seizures in pediatric population in two tertiary hospitals in india arun kumar,1 thangaraj marimuthu,2 lakshminarayanan kannan,3 vikash agarwal,4 dinesh nayak5 1neurologist and epileptologist, apollo speciality hospitals, vanagaram, chennai, india 2department of neurology government thanjavur medical college thanjavur, india 3pediatric neurologist gleneagles global health city chennai, india 4neurologist sm hospital assam, india 5neurology program– advanced epilepsy center gleneagles global health city chennai, india introduction there are many causes attributed to seizures and it is now well recognized that seizure is a symptom and not a disease. a seizure is defined as transient occurrence of signs and symptoms, resulting from abnormal, excessive or synchronous neuronal activity in the brain. according to the world health organization (who), secondary seizures are defined as seizures whose underlying cause is known. secondary seizures in this study include those conventionally called as acute symptomatic seizures and remote symptomatic epilepsy. incidence of seizures during the first five years is about 5%, and around 4-10% of children experienced at least one seizure episode in the first 16 years of life. the prevalence of childhood seizures varies between 5.2-8.1 per 1000 population. the most common type (60%) of seizures are convulsive, of which two-thirds begin as focal seizures (which may then become generalized), while one-third begin as generalized seizures. the remaining 40% of seizures are non-convulsive.1 although seizures have been classified in many ways according to their site of origin, electroencephalogram (eeg) abnormalities, types of seizures, and response to therapy, a broad-based classification developed by gastaut is applicable globally.2 furthermore, the international league against epilepsy original article international journal of integrated health sciences (iijhs)issn print: 2302-1381; issn online: 2338-4506 received: august 16, 2022 accepted: march 27, 2023 published: march 30, 2023 correspondence: arun kumar neurologist and epileptologist apollo, vanagaram, chennai, india e-mail:akvegita87@gmail.com doi: 10.15850/ijihs.v11n1.2962 ijihs. 2023;11(1):12–19 article history abstract objective: to evaluate the clinical pattern of secondary seizures which includes acute and remote symptomatic seizures among hospitalized patients in two healthcare centers and to assess the outcomes among hospitalized patients having secondary seizures. methods: this multicentric cross-sectional study was conducted in two tertiary hospitals in odisha and tamil nadu, india, for a period of four years. a total of 274 patients in the age group between 6 months to 12 years participated in the study. a structured proforma was used to document the clinical pattern and causes of the secondary seizures. results: among the participants in odisha and tamil nadu hospitals, focal seizures constituted 67.5%. generalized seizures were present in 32.4%. the key causes of seizures in odisha were malaria, cerebral palsy, and viral meningitis, while in tamil nadu, the causes were neurocysticercosis, cerebral palsy, and viral meningitis. conclusion: since the majority of the causes are preventable, it is important to address the issue at the public health level, by providing improved sanitation and adequate awareness on the secondary seizure and its causes. it is also important that the physicians are well conversant with the early case detection and treatment of primary diseases causing secondary seizures. keywords: convulsion, encephalitis, malaria, secondary seizures international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 13 (ilae) 2017 has provided a broad classification of epilepsy as focal, generalized, and unknown onset, with additional etiological classification that includes structural, genetic, infectious, metabolic, immune, and unknown etiology. seizures with unknown causes presumed to be of genetic in origin, while symptomatic seizures, either of genetic causes or acquired causes like hippocampal sclerosis, perinatal and infantile causes, cerebral trauma, tumor or cerebrovascular causes, provoke seizures secondary to provoked factors and are cryptogenic in nature where presumed symptomatic nature in which the cause has not been identified.3 seizures are considered as one of the nonspecific symptoms expressed in a variety of many different pathologies. in most cases, seizure phenomenology depends upon the cortical location of the lesion rather than on specific population. also, early recognition of the treatable causes of this common neurologic symptom and the institution of proper and adequate treatment, will ensure normal physical, mental and psychological development of the child. 4 from the perspective of the clinical patterns of secondary seizures, it can be challenging to identify of a single underlying pathology of the seizure. a brain tumor may produce seizures that are similar to other intracranial pathologies, such as infections and birth injury, and the treatment is incomplete unless there is a correlation between the clinical and pathological aspects of seizures. as far as possible, the underlying pathology should be investigated for better management of secondary seizure disorders.5 the present study was carried out to evaluate the clinic pathological profile of secondary seizures in pediatric population and to assess the outcomes of hospitalized pediatic patients with secondary seizures. methods the present study was carried out as a multicentric cross sectional study in two tertiary care teaching hospitals with a total bed capacity of 1,000 in odisha and tamil nadu, respectively. the study was conducted for a period of four years of october 2012-2014 and nov 2016-2018. children in the age group of 6 months to 12 years were taken up for the study. children with generalized convulsion with or without neurological deficit, clearly appreciable focal seizures with or without neurological deficit, intermittent quivering movements affecting one or more extremities with altered sensorium, facial grimace with altered sensorium, staring look with altered sensorium, chewing and sucking motion with sensorium deficit and slight posturing or barely perceptible tremor with disturbance in tone and reflex activity, and irregular movements with constant crying and irritability with known definite underlying cause for seizures were included in this study. all cases were included on the basis of history and examination of a senior pediatric consultant or pediatric neurologist. idiopathic generalized epilepsy and conditions mimicking seizure disorders like apneic spells, tremors, and syncopal attacks were excluded. approval was obtained from the institutional ethics committee prior to the data collection. detailed explanation on the study was given to each participant’s parent or guardian and informed consent was obtained from the parent prior to the data collection. all pediatric patients who were admitted to the respective hospitals during the study period was taken purposively as the subjects of this study. a total of 264 patients participated: 168 patients participated in odisha and 96 participated in tamil nadu. a structured proforma was used to obtain the history and clinical information regarding the subjects. particulars regarding the course in the hospital, laboratory parameters, and outcomes were also documented. data were entered into and analyzed using spss ver.20 software. descriptive statistics were used. the comparison of seizure profile with risk factors was evaluated using the chi square test with a p value of <0.05 considered statistically significant. ethical approval for this study has been granted by the health research ethics committee from the communication of decision of the instuitional ethics committee (iec)/institutional review board (irb), indian council of medical research, under iec/irb:43/12. results most subjects were in the age group of 3.67 years in both teaching hospitals (41.6%). females constituted the majority of the population in odisha and tamil nadu (57.2%). most subjects in both locations belonged to lower socioeconomic status and to rural areas. the most common type of seizures in studied cases were found to be partial seizures, which were seen in 185 (67.51%) cases, followed by generalized seizures (32.4%). amongst those with partial seizures, simple partial seizures were most common and were seen in 67 secondary seizures in the pediatric population in two tertiary hospitals in india 14 international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 arun kumar, thangaraj marimuthu, et al table 1 background characteristics and type of seizures demographic characteristics odisha & tamil nadu details and type of seizures n % age (in years) 0.6–3.5 53 19.3 3.6–7 114 41.60 7.1–10.5 60 21.8 10.6–12 35 12.7 sex males 107 39.05 females 157 57.2 socioeconomic status lower 137 50 middle 73 26.6 upper 54 19.7 location urban 101 36.8 rural 163 59.4 type of seizures generalized 89 33.71% gtcs 50 18.94% tonic 22 8.33% atonic 6 2.27% clonic 9 3.41% myoclonus 2 0.76% focal 175 66.29% aware 76 28.79% impaired awareness 25 9.47% focal to bilateral tonic clonic 74 28.03% fig. 1 causes of seizures in odisha and tamil nadu international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 15 (27.7%) cases, whereas amongst those with generalized seizures generalized tonic-clonic seizures were the most common and seen in 50 (18.94 %) patients (table 1). the predominant causes of the seizures in odisha were malaria, cerebral palsy, and viral meningitis, while in tamil nadu, the predominant causes were neurocysticercosis, cerebral palsy and viral meningitis. (fig. 1). from the clinical presentation for infective causes, it was demonstrated that fever was the most important symptoms and meningeal signs were the most important signs for most of the infective etiology. convulsion being the inclusion criteria were seen in all cases (table 2). for the congenital etiology, the variation in head size either microcepahly or macrocepahly was the predominant sign. for those with metabolic etiologies, convulsions and altered sensorium were the dominant symptoms and most of the cases manifested with generalized systemic signs (table 3). the majority of the diagnosis in odisha was based on ct scan, while the mri scan is predominantly used in tamil nadu. the other investigations which were done to establish the etiology of seizures were complete blood count, rapid malarial antigen test, serum electrolyte test, hepatic and renal function tests, random blood sugar levels, and csf examination in selected cases. the outcomes of various causes of secondary seizures was determined by using electroencephalograms in three successive follow up visits in 3 month interval [3, 6 and 9 months] after the discharge. secondary seizures in the pediatric population in two tertiary hospitals in india table 2 clinical presentation of infective causes symptom no of cases (%) sign no of cases (%) malaria fever 29 (90.6) pallor 11 (34.3) lassitude 26 (81.2) icterus 5 (15.6) convulsions 32 (100) hepatosplenomegaly 8 (25) altered sensorium 17 (53.1) meningeal signs 3 (9.3) decreased urination 11 (34.3) papilledema 4 (12.5) viral meningitis fever 22 (91.6) meningeal signs 19 (79.1) convulsions 24 (100) papilledema 8 (33.3) viral meningoencephalitis fever 8 (40) meningeal signs 5 (25) altered sensorium 18 (90) papilledema 3 (15) convulsions 20 (100) loose stools 7 (35) vomiting 4 (20) bacterial meningitis fever 14(70) meningeal signs 17 (85) altered sensorium 8 (40) papilledema 10 (25) convulsions 20(100) neurocysticercosis fever 2 (8) meningeal signs 5 (20.8) altered sensorium 7 (29.1) papilledema 3 (12.5) convulsions 24 (100) brain abscess fever 7 (70) meningeal signs 8 (80) altered sensorium 7 (70) papilledema 5 (50) convulsions 10 (100) 16 international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 table 3 clinical presentation of congenital, metabolic, and other causes clinical presentation symptom odisha & tamil nadu sign odisha & tamil nadu n (%) n (%) congenital causes cerebral palsy (n=40) convulsions 40(100) microcephaly 40 (100) fever 5 (12.5) increased tone 31 (77.5) tonic posturing 27 (67.5) hepatosplenomegaly 0 (0) brain malformation (n=3) convulsions 3 (100) microcephaly 3(100) increased tone 2 (66.6) hypertonia 2 (66.6) congenital hydrocephalus (n=6) convulsions 6 (100) macrocephaly 6 (100) increased head size 6 (100) macewens and transillumination 6 (100) altered sensorium 6 (100) papilledema 3 (50) metabolic causes electrolyte imbalance (n=14) convulsions 14 (100) signs of dehydration (sunken eyes, delayed skin pinch, dry mucosa) 5 (35.7) altered sensorium 14 (100) loose stools 14 (100) vomiting 7 (50) decreased urination 6 (42.8) hypoglycemia (n=7) convulsions 7 (100) convulsions 7 (100) altered sensorium 7 (100) altered sensorium 7 (100) hypoxia (n=6) convulsions 6 (100) crepitations on auscultation 6 (100) altered sensorium 6 (100) tender hepatosplenomegaly 5 (83.3) hurried breathing 6 (100) fever 4 (66.6) other causes stroke (n=12) weakness of body and limbs 12 (100) hemiplegia 10 (83.3) convulsions 12 (100) facial palsy 10 (83.3) tuberculoma (n=14) convulsions 14 (100) meningeal signs 3 (21.4) fever 4 (28.5) papilledema 3 (21.4) altered sensorium 7 (50) brain tumors (n=9) convulsions 9 (100) meningeal signs 6 (66.6) altered sensorium 6 (66.6) papilledema 3 (33.3) organ failure (n=7) convulsions 7 (100) icterus 7 (100) altered sensorium 7 (100) meningeal signs 2 (28.5) yellowish discoloration of body 7 (100) papilledema 2 (28.5) although significant drop outs of more than 50% of patients were observed, there was an overall significant improvement of outcome, i.e., seizure free or seizure reduction along with eeg normalization, during the follow up period based on the evaluation using the eeg in both the centers. the outcome was better in children with acute causes of secondary seizures and also in causes in where no permanent brain injury was seen compared arun kumar, thangaraj marimuthu, et al internati onal journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 17 to remote symptomatic causes like cerebral palsy (fig. 2 and fig. 3). discussion secondary seizures are rampantly increasing in developing countries, including in india. however, there is considerable paucity in the availability of literature. the present study was carried out as a multicentric study in odisha and tamil nadu on 168 and 96 patients, respectively. in this study, the incidence of seizures was more in early childhood between the ages of 3.5 to 7 years in both centers. similar findings were observed in a study done by kotsopoulos et al. and neubauer et al. 4, 5 therefore, the need for early detection of the symptomatology is high among younger children. the majority of the subjects were diagnosed with partial seizures fig. 2 outcomes during follow up (odisha) fig 3 outcomes during follow up (tamil nadu) secondary seizures in the pediatric population in two tertiary hospitals in india 18 international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 (71.5% in odisha and 57.2% in tamil nadu). the findings are similar to the studies done by unver et al.6, where the prevalence of partial seizures is 56.5%. the dominant causes of seizures among the study population are infective cause, essentially parasitic infections, with malaria as the strongest cause for seizures in odisha (17.8%) while neurocysticercosis was the most common cause in tamil nadu (17.7%). symptomatic infective etiology was present in 47.1% of the subjects. in a review done by vezzani et al.8, infections of the central nervous system constituted the predominant cause for seizures similar to this study.7 in another study done by gowda et al., the predominant cause for seizures was structural abnormalities, while torch infections contribute 7.2% of the seizures. the reason for the high prevalence of malaria induced seizures in odisha is due to the epidemiological vulnerability of the state. odisha has several rural and tribal districts that are endemic to falciparum malaria. in a study done by das et al.9, the prevalence of cerebral malaria was found to be 18.5% among pediatric population in odisha and 44.4% of the deaths in the pediatric age group was attributed to seizures in malaria. there has been a steady rise in the prevalence of seizures associated with neurocysticercosis in recent years. in various studies carried out in south india, the incidence of seizures was as as high as 94.8% among children with neurocysticercosis. this has been largely attributed to the changing lifestyle patterns resulting in formation of solid cystic granuloma by the taenia solium parasite. 10 according to a study by nelson et al. the incidence of nonfebrile convulsions was highest in the first year of life, especially in the first month. children with neurological or developmental abnormality assessed in the first year of life did not have their first seizure earlier than children without any abnormality. neurological abnormalities in the first year of life before any seizure, and the presence of minor motor seizures, are associated with an increased rate of mental retardation and cerebral palsy at age of seven, but early age at onset appears to have little prognostic value regarding intellectual function, cerebral palsy, and epilepsy.11 malaria and neurocysticercosis were the most common infective pathologies seen in studied cases. in various developing countries infective pathologies remain common cause of secondary seizures. other than infective causes, non-infective causes such as cerebral palsy and dyselectrolytemia were the common causes of secondary seizures in these children. based on the study findings, it may be considered that secondary seizures are not recurrent, unlike primary idiopathic seizures, when the underlying cause is treated properly. recurrent secondary seizures are observed in patients with residual brain damages due to primary disease or due to persisting primary disease and these children have much poorer outcomes. age of onset and cause of secondary seizures have found to have important effect on the outcome of secondary seizures so our study is not compatible with their study since the trend secondary seizures is different from primary idiopathic seizures.12 this study is limited in terms of a relatively small number of patients; thus, a study with a larger number of pediatric patients will further substantiate the findings of this study. moreover, in this study, neuroimaging such as computerized tomography or mr imaging could not be done in all cases. the present study has emphasized on the role of infectious etiology, specifically malaria as a cause of secondary seizures. majority of the causes of secondary seizures in pediatric age group in our study were found to be either preventable or treatable. precise etiological diagnosis will help in proper management of children having secondary seizures. 1. pujar ss, martinos mm, cortina-borja m, chong wkk, de haan m, gillberg c, et al. long-term prognosis after childhood convulsive status epilepticus: a prospective cohort study. lancet child adolesc health. 2018;2(2):103–11. 2. stafstrom ce, carmant l. seizures and epilepsy: an overview of neuroscientists. cold spring harb perspect med. 2015;5(6):a022426 3. scheffer ie, berkovic s, capovilla g, connolly mb, french j, guilhoto l, et al. ilae classification of the epilepsies: position paper of the ilae commission for classification and terminology. epilepsia. 2017;58(4):512–21. 4. rozensztrauch a, kołtuniuk a. the quality of life of children with epilepsy and the impact of the disease on the family functioning. int j references secondary seizures in the pediatric population in two tertiary hospitals in india international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 19 environ res public health. 2022;19(4):2277. 5. kotsopoulos ia, van merode t, kessels fg, de krom mc, knottnerus ja. systematic review and meta-analysis of incidence studies of epilepsy and unprovoked seizures. epilepsia. 2002;43(11):1402–9. 6. neubauer ba, gross s, hahn a. epilepsy in childhood and adolescence. dtsch arztebl int. 2008;105(17):319-27. 7. unver o, keskin sp, uysal s, unvar a. the epidemiology of epilepsy in children: a report from a turkish pediatric neurology clinic. j child neurol.2015;30(6):698–702. 8. vezzani a, fujinami rs, white hs, preux pm, blümcke i, sander jw, et al. infections, inflammation and epilepsy. acta neuropathol. 2016;131(2):211–34. 9. gowda vk, kulhalli p, benakappa n, benakappa a. etiological profile of afebrile seizures in infants in a tertiary care center from southern india. j pediatr neurosci. 2019;14(2):82–5 10. das lk, padhi b, sahu ss. prediction of outcome of severe falciparum malaria in koraput, odisha, india: a hospital based study. trop parasitol. 2014;4(2):105–10 11. amudhan s, gururaj g, satishchandra p. epilepsy in india i: epidemiology and public health. ann indian acad neurol. 2015;18(3):263–77. 12. abdel maksoud yh, suliman ha, elsayed abdulsamea s, mohamed kamal n, al-shokray ah, ibrahim ao, et al. risk factors of intractable epilepsy in children with cerebral palsy. iran j child neurol. 2021;15(4):75–87. arun kumar, thangaraj marimuthu, et al vol 11 no 1 2023 (2) rev-2-edited ver 1 dep.indd 20 this is an open access article licensed under the creative commons attribution-noncommercial 4.0 international license (http:// creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original author and source are properly cited clinical profile of mucormycosis during the second wave of covid-19 in a tertiary care center in india sunil kumar kunhiparambath,1 beena oommen,1 sajeeth kumar keeriyatt govindan,2 karichery shilpa nair,1 sagesh madayambath1 1department of ent, government medical college kozhikode, kerala, india 2department of gen medicine, government medical college kozhikode, kerala, india introduction since the emergence of covid-19 pandemic in march 2020, the medical fraternity all over the world have been constantly witnessing new paradigms of its clinical manifestations and other illnesses associated with this disease. otolaryngologists have been involved in the management of covid-19 at various levels and have to face new challenges thereof. one such example was that of the higher than ever number of mucormycosis infections, especially during the second wave of the covid-19 pandemic.1,2 an exponential increase in the number of mucormycosis cases was seen in the entire country when compared to the rest of the world.3 a literature review on mucormycosis would reveal that several studies have been published so far, describing the different aspects of mucormycosis. here, an attempt is made to revisit the clinical profile as well as the surgical strategies in the original articleinternational journal of integrated health sciences (iijhs)issn print: 2302-1381; issn online: 2338-4506 received: november 03, 2022 accepted: march 13, 2023 published: march 30, 2023 correspondence: sagesh m. department of ent, government medical college kozhikode, kerala, india e-mail: drsageshm@gmail.com doi: 10.15850/ijihs.v11n1.3073 ijihs. 2023;11(1):20–26 article history abstract objective: to study the clinical profile and treatment outcome of mucormycosis associated with the second wave of covid-19 pandemic. methods: an observational study was conducted in a tertiary care center over a period of 12 months, including a 6-month post treatment follow up. study included all covid positive patients with a clinical and radiological evidence of rhino-orbito-cerebral mucormycosis during the second wave of covid-19. all patients underwent further diagnostic workups and confirmed cases underwent surgical debridement, and amphotericin b was started. results: a total of 59 patients presented with mucormycosis with the mean age being 52.7 years with unilateral facial and orbital edema as the most common symptoms (28.8%). all were diabetic with hba1c >7 (54.2%). the mean duration of presentation was 20.7±7.9 days from the onset of covid-19 infection. unilateral involvement of the paranasal sinuses was the most common finding in mri. early administration of amphotericin b with prompt surgical debridement was performed in all cases. orbital exenteration was conducted in nine patients for better fungal load clearance. patients showed a good response to surgical debridement and prompt medical treatment, with a mortality rate of 27%. conclusion: covid-19 associated mucormycosis is difficult to treat and often presents in late stage. uncontrolled diabetes, immunocompromised state, and steroid-induced immunosuppression were important risk factors. a close surveillance for early identification and initiation of treatment is mandatory. repeated surgical debridement to clear the dead tissue is effective to control fungal load. keywords: amphotericin b, covid-19, invasive fungal sinusitis, mucormycosis international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 21 management of mucormycosis under the new scenario of covid-19 pandemic. the different presentations of these cases, as encountered in a tertiary care center, would be highlighted. the aim is to study the clinical profile of mucormycosis as an effort to throw lights into a few risk factors and to present the details of the medical and surgical management of this disease. methods this study was conducted at the government medical college hospital kozhikode, which is a tertiary care teaching center in india. an observational study design was followed. the total duration of the study was one year from may 2021 to april 2022, which included inpatient observation as well as a six-month post discharge follow-up of the patient. all patients who were covid positive with clinical and radiological evidence of mucormycosis, as well as a histopathological or microbiological evidence of mucormycosis, were included in the study. a convenience, purposive sampling method was employed and a written informed written consent was obtained from all patients or from their primary care givers (in case of debilitated patients) before enrolment into the study. a scientific committee approval as well as ethics committee approval was obtained from the institutional ethics committee of the government medical college hospital kozhikode (ref no. gmc kkd /rp 2022/ iec/14). after the initial work-up, all patients had a ct scan and mri of the nose and paranasal sinuses. all patients had a diagnostic nasal endoscopy done and samples were taken for koh smear preparation, fungal culture, and histopathology examinations. the confirmed cases of mucormycosis were taken up for surgical debridement and amphotericin b, which was already started empirically, would be continued. results a total of 59 cases were enrolled in the study, mostly referred from peripheral hospitals. most of the patients were males (67.8%), and the majority of patients belonged to the age group of 45-60 years. all of them were detected to be covid-19 positive either during the admission or were previously infected within the past 2 months. about 59.3% had received the first dose of vaccination before the infection and one had received two doses of vaccination. almost all the patients were diabetics, of which 45.8 % had the disease for more than 10 years while six were recently detected as diabetics and were not on any medications. one patient with type 1 diabetes was on insulin for the last 30 years. hypertension was the most common coexisting disease (18.6%), followed by chronic kidney disease (16.9%) and coronary artery disease (8.5%). one patient had undergone renal transplant 10 years back for diabetic kidney disease. most patients presented within an average clinical profile of mucormycosis during the second wave of covid-19 in a tertiary care center in india fig 1. palatal perforation 22 international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 duration of 20.78±7.9 days from the day of onset of covid symptoms. eleven patients were detected to experience an active covid infection at presentation, with symptoms of mucormycosis. about 48% patients had received intravenous corticosteroids as a part of the covid treatment. unilateral orbital and facial edema (28.8%) were the most common presenting symptom, followed by headache in 25.4% patients. in the majority of patients, the disease was lateralized to the right side; however, six patients experienced a bilateral involvement. the clinical examination revealed periorbital and facial edema as the primary signs in 44.1% patients, while nasal discharge was seen in 22 patients, of which 15 had a characteristic blackish discharge. around 22% of these patients experienced a numbness of the face. a defective vision was noted in 20 patients of which 17 had only perception of light in the affected eye. ptosis and ophthalmoplegia were noticed in 28.8% cases while proptosis was seen in 21 patients. there were 3 patients with a lower motor neuron type of facial nerve palsy and one patient presented with palatal perforation (fig 1). blood investigations showed high levels of glycated hemoglobin with hba1c levels >7 in 54.2% of the patients. the esr and c-reactive protein (crp) levels were elevated in all patients. in all cases referred to this center, computerized tomography (ct) scan of the nose and paranasal sinuses was the first radiological investigation done. an mri scan with a gadolinium contrast was done in all, except in the 10 patients with chronic kidney disease. based on these findings the patients were staged as per the honavar staging for covid-19 associated rhino-orbital-cerebral mucormycosis.4 of the 35.5% patients who presented with a stage 4 disease and five (5) patients were in stage 4d, 8 in stage 4c, four (4) in stage 4a and 4b, respectively. the remaining 23.7% patients had a stage 3 and 33.8% had stage 2 disease (fig 2). unilateral involvement of the paranasal sinuses was the most common finding noted. most commonly involved sinuses were the ethmoids (89.8%), followed by the maxillary sinus (79.7%). despite being a rare finding, isolated sphenoid sinus involvement was observed in one patient. orbit involvement was seen in 57.6 %, of which 22% were an early involvement of the medial part of orbit as a result of the erosion of lamina papyracea. an involvement of the pterygopalatine fossa was noted in 31 patients (52.5%). intracranial extension was seen in 19 patients, mostly in the form of cavernous sinus involvement mainly sunil kumar kunhiparambath, beena oommen, et al fig 2. mri staging based on the honavar staging for covid-19 associated rhino-orbital-cerebral mucormycosis cerebral mucormycosis1 1 7 9 4 0 8 1 4 3 4 4 8 0 1 0 5 0 1 2 3 4 5 6 7 8 9 10 stage 1 stage 2 stage 3 stage 4 n um be r of c as es stage and s ubs tage mri staging substage a substage b substage c substage d international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 23 through the superior orbital fissure (78.9%). there were four cases of direct extension into the frontal lobe through the cribriform plate. diffuse cns involvement were seen in five (5) patients in the form of multiple infarcts, possibly embolic dissemination of the fungal materials. a diagnostic nasal endoscopy was done in all patients and 39 patients, showing the characteristically described black eschar in the nasal cavity. a discoloration of middle turbinate was noticed as the earliest finding in the study group. a nasal swab and a nasal mucosal biopsy were done. koh mount gave a positive report in 69.5 % of patients. fungal culture yielded rhizopus in 64.4% of patients. both koh mount and fungal culture were found positive in 38.9 %. histopathological examination and special staining were done in all patients and invasive fungal hyphae were demonstrated in 62.5% of patients. all the specimens were sent for microbiological and histopathological confirmation after surgical debridement was performed. in 14 cases, a coexisting invasive mucormycosis and aspergillus infections were present. patients were treated empirically using intravenous amphotericin b based on clinical suspicion. most patients underwent their first surgical debridement within a week of admission and were later followed up with clinical profile of mucormycosis during the second wave of covid-19 in a tertiary care center in india fig. 3 black turbinate sign daily clinical progress with the esr and crp measurement repeated once every three days. in patients who did not show a significant improvement, further mris were performed to assess the need to undergo subsequent endoscopic examinations and debridement. most common focus of residual disease during the re-examination was found to be at the pterygopalatine fossa. a repeat debridement had to be done in 86.4% of cases and 21 patients (35.5%) even had it done three times. retrobulbar amphotericin injection for local control were given in four (4) patients, who had significant orbital involvement. despite all these measures, orbital exenteration had to be carried out in nine patients for better clearance of fungal load. one patient experienced a frontal cerebritis which evolved into an abscess, which was drained by the neurosurgical team. two patients underwent a high-resolution ct scan of the thorax in view of their persistent chest symptoms and were later found to have pulmonary involvement too. the cumulative dose of amphotericin b injection for most patients was 3gm (56 %), whereas 4 gm had to be given to 12 patients (20.3%) with stage 4 disease. the mean length of hospital stay was 27.7 days. a consolidation therapy with oral posaconazole was started for patients on discharge. among the patients in the study group, 13 (22%) succumbed to the disease during the hospital stay. two patients had to be readmitted during the period of one month after the discharge but expired soon afterwards. one patient died as a result of his medical ailments within two months after the discharge. the remaining 43 patients showed a good clinical improvement during the followup period and were relatively symptom free at the end of the follow-up period. discussion mucormycosis is an uncommon and aggresive fungal infection that usually affects patients with an altered immunological system.5 this disease was first described by fürbinger in germany (1876). arnold paltauf published the first case of disseminated mucormycosis in 1885.5 the prevalence of mucormycosis in india is estimated to be 0.14 cases per 1000 population, or approximately 80 times of the worldwide estimated rate.5 among the different types of mucormycosis, the rhinoorbito-cerebral form is the most common type, especially in patients with uncontrolled diabetes mellitus.6 several explanations 24 international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 have been provided to explain the increased incidence of mucormycosis cases in diabetic patients. the most accepted theory is that persistent hyperglycemia causes an impaired chemotaxis affecting the phagocytic function of neutrophils. in addition, the ketoacidosis impairs the binding of iron to transferrin, thus increasing the amount of free iron in the body that in turn promotes fungal growth.7 a steroid-induced immunosuppression, as well as immune dysregulation associated with covid-19 infection due to reduced numbers of cd8 and cd4 t lymphocytes, have also been considered as important factors in the current setting.8 a recent indian study by honavar et al reported a mean age of 51.9 years and a male preponderance of 71%.4 in a meta-analysis of 600 articles conducted by jeong et al with 851 cases, the median age was 51 years and 63% patients were males.9 this study yielded a similar finding with the mean age being 52.7 years and a significant male predominance of 67.8%. in their meta-analysis, jeong et al found diabetes mellitus as the most common underlying condition.9 they found the use of corticosteroids at the time of presentation as the most common predisposing factor (33%). all patients in this study were diabetics of which 6 were recently detected diabetics and almost 48% patients had received intravenous corticosteroids as a part of the covid treatment. the patients presented with features of mucormycosis on an average of 21 days from the day of onset of covid infection. on the contrary, in a review of cases from 18 countries, hoenigl et al reports a median duration of 10 days between covid-19 and mucormycosis diagnosis.10 in patients without a concurrent covid infection, uncontrolled diabetes with ketoacidosis played a significant role. in this study, headache and facial edema remain the earliest the presenting complaints followed by proptosis, ptosis and visual disturbances. a complete loss of vison was seen in 4 patients (6.7%) due to a central retinal artery occlusion. central retinal artery occlusion bears an incidence of 16-20% and is thought to be due to the vasculitis caused by the direct infiltration of the fungi in to the retinal artery.11 facial paresthesia was commonly seen in patients with extensive orbital involvement. a black necrotic eschar seen on the palate or nasal mucosa were noted in 39 patients. mri with gadolinium contrast assists in staging the disease and planning the extent of surgical debridement. the classical black turbinate sign described by safder et al in mri,12 occurs due to the occlusion of small vessels causing a lack of contrast enhancement of invaded mucosa (fig 3). yield from a combination of diagnostic nasal endoscopy, microscopy and fungal culture were usually high. this warrants a close follow up of covid-19 recovered patients with routine screening nasal endoscopies and guided swabs for early detection. the treatment for mucormycosis of the paranasal sinuses revolves around a combination of systemic antifungal therapy, the reversal of immunocompromised state and radical surgical debridement. a proper and rapid correction of the metabolic abnormalities along with the complete removal of all infected tissues gives a definite benefit.13 time is a crucial factor as far as the treatment is concerned. any inadvertent delay can significantly affect the treatment outcome. treatment with liposomal or conventional amphotericin b should be given as per recommendations, along with strict glycemic control and continuous renal function monitoring. there was a difficulty in procuring liposomal amphotericin b for these patients, as there was a nation-wide shortage of amphotericin b owing to the rapid increase in the number of mucormycosis cases. but somehow, the patients were put on a combination of liposomal or conventional amphotericin b, depending on the availability. surgical debridement needs to be done at the earliest. surgical debridement slows the progression of the disease, reduces fungal load and it provides a specimen for culture. several factors can delay the early surgical intervention. even though the earliest surgical intervention was on the second day of admission, in few other cases the intervention had to be delayed due to an active covid infection in the patient. even though the recommendations at that period was to defer the surgical debridement in covid positive patients, an early intervention and emergency surgical debridement had to be done, to save few critically ill patients. for the post procedure clinical assessment, patients had their routine esr and crp value estimation, which were helpful in marking the progress of the disease. a repeat mri with contrast was taken on noticing any clinical deterioration or increasing levels of the inflammatory markers. the subsequent scan helped in picking up any residual disease in the orbit and pterygopalatine fossa. these areas are usually neglected during the initial surgical debridement because on visualizing an intact posterior wall of maxilla and lamina, the sunil kumar kunhiparambath, beena oommen, et al international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 25 surgeon hopes that the disease would not have breached the intact bony wall. even though plowes et al mentions 100% involvement of the pterygomaxillary fissure in their series of five patients, the present study found the area to be involved in 52.5% (31 patients).14 complete clearance of the fungal load is mandatory and hence a good exposure of the surgical field is very essential. a modified endoscopic denker’s method, removing the posterior wall of maxilla, debriding devitalized tissue in the pterygopalatine fossa and drilling of pterygoid base would be a good option to ensure a reasonably good clearance. even though there is no clearcut evidence, topical antifungal therapy is primarily used adjunctively in invasive fungal sinusitis.15 considering the relatively low systemic absorption, topical amphotericin gel for local application was used in some cases, at surgical sites where the complete clearance was still doubtful. while managing the orbital counterpart of this disease, cosmetic outcome becomes an important aspect and hence a trial with retrobulbar amphotericin injections should always be considered first. in this series, a retrobulbar amphotericin injection was given in 4 patients. a meticulous orbital debridement helps in removing all devitalized orbital tissues and gives an option of preserving the globe. it helps in eliminating the fungal load and can very well prevent a dreaded intracranial extension. but in a worsening clinical scenario, with cavernous sinus thrombosis, an orbital exenteration is warranted so as to avoid an intracranial involvement. plowes et al.14 considered orbital apex syndrome and cavernous sinus thrombosis as the only criterion for an orbital exentration. seiff et al.14 considered removing the infected orbital tissues conservatively and irrigating the remaining tissue with a solution of amphotericin b.16 they claimed that their technique avoided an orbital exenteration in most cases. despite doing a thorough orbital debridement, using local amphotericin b wash and retrobulbar injections in selected cases, an orbital exenteration had to be done in 9 cases. in the study by jeong et al.,9 the overall mortality was 46% whereas in the review by hoenigl et al. 10 mortality was reported in 37% cases. in this series, the mortality was only 27 % which was possible due to the prompt response of the surgical team in clearing the fungal load along with maximal medical therapy. hence a close surveillance post covid, early recognition of symptoms and early initiation of treatment can drastically improve the prognosis in patients. in conclusion, mucormycosis cases spiked up in india in association with covid 19 infection and added to the disease morbidity and mortality. uncontrolled diabetes, immunocompromised state and steroid-induced immunosuppression were the important risk factors for covid-19 associated mucormycosis. routine nasal endoscopies, meticulous sampling and an mri with gadolinium contrast in suspicious cases will help in accurate diagnosis. a thorough monitoring of immunocompromised state and an early initiation of liposomal amphotericin b therapy is indicated, along with repeated surgical debridement till a complete clearance of dead tissue is obtained. these measures can help in reducing the mortality associated with this disease to a great extent. references 1. pal r, singh b, bhadada sk, banerjee m, bhogal rs, hage n, et al. covid-19-associated mucormycosis: an updated systematic review of literature. mycoses. 2021;64(12):1452–9. 2. hoenigl m, seidel d, carvalho a, rudramurthy sm, arastehfar a, gangneux jp, et al. the emergence of covid-19 associated mucormycosis: a review of cases from 18 countries. lancet microbe. 2022;3(7): e543– 52. 3. muthu v, rudramurthy sm, chakrabarti a, agarwal r. epidemiology and pathophysiology of covid-19-associated mucormycosis: india versus the rest of the world. mycopathologia. 2021;186(6):739–54 4. sen m, honavar sg, bansal r, sengupta s, rao r, kim u, et al. epidemiology, clinical profile, management, and outcome of covid-19-associated rhino-orbital-cerebral mucormycosis in 2826 patients in india – collaborative opai-ijo study on mucormycosis in covid-19 (cosmic), report 1. indian j ophthalmol 2021;69(7):1670–92. 5. skiada a, pavleas i, drogari-apiranthitou m. epidemiology and diagnosis of mucormycosis: an update. j fungi (basel). 2020;6(4):265. clinical profile of mucormycosis during the second wave of covid-19 in a tertiary care center in india 26 international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 6. chakrabarti a, singh r. mucormycosis in india: unique features. mycoses. 2014;57 suppl 3:85– 90. 7. balai e, mummadi s, jolly k, darr a, aldeerawi h. rhinocerebral mucormycosis: a ten-year single centre case series. cureus. 2020;12(11):e11776. published 2020 nov 29. 8. gangneux jp, bougnoux me, dannaoui e, cornet m, zahar jr. invasive fungal diseases during covid-19: we should be prepared. j mycol med. 2020;30(2):100971. 9. jeong w, keighley c, wolfe r, lee wl, slavin ma, kong dcm, chen sc. the epidemiology and clinical manifestations of mucormycosis: a systematic review and meta-analysis of case reports. clin microbiol infect. 2019;25(1):26– 34. 10. hoenigl m, seidel d, carvalho a, rudramurthy sm, arastehfar a, gangneux jp, et al. the emergence of covid-19 associated mucormycosis: a review of cases from 18 countries. lancet microbe. 2022;3(7):e543– 52. 11. kamath s, kumar m, sarkar n, ahmed t, sunder a. study of profile of mucormycosis during the second wave of covid-19 in a tertiary care hospital. cureus. 2022;14(1):e21054. 12. safder s, carpenter js, roberts td, bailey n. the “black turbinate” sign: an early mr imaging finding of nasal mucormycosis. ajnr am j neuroradiol. 2010;31(4):771–4. 13. skiada a, lass-floerl c, klimko n, ibrahim a, roilides e, petrikkos g. challenges in the diagnosis and treatment of mucormycosis. med mycol. 2018;56(suppl_1):93–101. 14. plowes hernández o, prado calleros hm, soberón marmissolle daguerre gs, sadek gonzález a. rhino-orbito-cerebral mucormycosis. management strategies to avoid or limit intracraneal affection and improve survival. acta otorrinolaringol esp. 2015;66(6):348–52. 15. luk lj, delgaudio jm. topical drug therapies for chronic rhinosinusitis. otolaryngol clin north am. 2017;50(3):533–43. 16. seiff sr, choo ph, carter sr. role of local amphotericin b therapy for sino-orbital fungal infections. ophthalmic plast reconstr surg. 1999;15(1):28–31. clinical profile of mucormycosis during the second wave of covid-19 in a tertiary care center in india vol 11 no 1 2023 (2) rev-2.indd 37 this is an open access article licensed under the creative commons attribution-noncommercial 4.0 international license (http:// creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original author and source are properly cited effect of eye exercises on computer vision syndrome among medical students of universitas sumatera utara, indonesia angella zhuang, 1 bobby ramses erguna sitepu, 2 1faculty of medicine, universitas sumatera utara, medan, indonesia 2department of opthalmology, universitas sumatera utara, medan, indonesia introduction computer vision syndrome (cvs) is a complex eye discomfort condition in the form of visual impairment symptoms caused by prolonged exposure to digital displays.1 globally, it is estimated around 60 million people and one million new cases occur annually.2 the pathophysiology was divided into three mechanisms: ocular mechanism, related to dryness and redness of eyes are reduction in blink rate; visual mechanism cause blurring of vision, double vision and slowness of focus change; extraocular mechanism, associated with non-ergonomic posture in front of computer screen cause musculoskeletal symptoms such as headaches and shoulder pain. 3 the covid-19 pandemic poses a risk of increasing cases of computer vision syndrome due to changes in environment for study because of the implementation of the online learning methods policy.4 garg et al reported more than 70% of medical students at rama university, india spent more than 4 hours using computers. about 40% of students learn about cvs but only 10% take cvs precautions. 5 another study by muma et al. of 348 students in kenya, showed the prevalence of cvs was 60,4% with a low level of knowledge about cvs was 46,8% and those who didn’t take preventive measures was 40%. it showed that student’s prevention efforts against cvs are still relatively low. eye exercises can be considered as a nonpharmacological therapy to prevent and reduce symptoms of computer vision syndrome. eye exercises therapy is a series of movement performed repeatedly by the eyes to train our eye muscles and its surroundings to be elastic and strong, relax the eyes as to reduce discomfort in the eyes.6 study by intan putri et al. regarding the effectiveness of eye exercises on cvs in nursing students of riau university, it was concluded that there was a significant difference in the decrease of cvs scores in the experimental group after eye exercises intervention.7 in connection with problems above, the purpose original article international journal of integrated health sciences (iijhs) issn print: 2302-1381; issn online: 2338-4506 received: december 21, 2022 accepted: march 26, 2023 published: march 30, 2023 correspondence: angella zhuang faculty of medicine, universitas sumatera utara, medan, indonesia. e-mail: gelll2710@gmail.com doi: 10.15850/ijihs.v11n1.3136 ijihs. 2023;11(1):37-41 article history abstract objective: to determine the effect of eye exercises on computer vision syndrome among batch 2019 medical students of the faculty of medicine, universitas sumatera utara, and indonesia. methods: this study used analytical true experimental with a pretestposttest control group design. sample consisted of 86 respondents who were divided into two groups: control and experimental (intervention) groups. each group consisted of 43 respondents who were sampled randomly using the simple random sampling technique. data were collected through the computer vision syndrome questionnaire (cvs-q) and analyzed using a statistical software application with a p-value of < 0.05 considered significant. results: a decrease in the score of computer vision syndrome in the experimental (intervention) group after the eye exercise was observed with a p-value of 0.001 (<0.05). conclusion: eye exercise has an effect on the computer vision syndrome. keywords: computer vision syndrome, eye exercise 38 international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 of this study is to determine the effect of eye exercise on reducing and preventing computer vision syndrome complaints in medical student of universitas sumatera utara during online learning during covid-19 pandemic with different types of eye exercise, and subjects. researcher selected several types of eye exercises that can be implemented effectively both in time and place. eye exercises in this study were carried out twice a week, for one month, with a duration of approximately 10 minutes and can be done anywhere without using an object. methods this research is a quantitative study with a true experimental design and a preand post-test design. in this design, two group were randomly selected, samples was divided into two groups (control and intervention). the intervention group was given eye exercises, while the control group was not given an intervention. each group was asked to fill cvs-q one day before doing eye exercises and one day after the last day of doing eye exercises. this study was performed from september to october 2022. the sampling technique used is the simple random sampling technique with a total sample of 86 medical students of universitas sumatera utara who met the inclusion and exclusion criteria. the inclusion criteria were medical students who use computers at least 4 hours a day and willing to be the subject of the research, whereas the exclusion criteria were medical students that do not agree to be participate in the study. computer vision syndrome score data obtained from filling out cvs-q (computer vision syndromequestionnaire) from segui et al. pre-and-post eye exercises. ethical approval for this study has been granted by the health research ethical committee, faculty of medicine, universitas sumatera utara, with 797/kepk/ usu/2022. eye exercises in this study were carried out twice a week, for one month, with a duration of approximately 10 minutes. each eye exercises sessions involves the following steps in sequence: blinking, palming, figure of eight, eye movements, 20-20-20 rules, near and far focus. the following are steps for doing eye exercises: (1) sit on a chair with straight body and head straight forward as comfortable as possible; (2) blink 1-2 times every 10 seconds; effect of eye exercises on computer vision syndrome among medical students of universitas sumatera utara, indonesia table 1 individual characteristic variable n=86 ages (years) 20 21 22 sex female male 27 (31.4) 53 (61.6) 6 (7) 66 (76.7) 20 (23.3) (3) rub your palms together to warm them up, put them on your eyes and breathe deeply for 1 minute; (4) then focus on an area on the floor around 8 feet away, and move the eyes in the shape of a figure 9. trace the imaginary figure of 8 for 30 seconds, then switch direction; (5) move the eyeball right and left, repeat 3 times; (6) move the eyeball up and down, repeat 3 times; (7) move the eyeball in a clockwise circle and counterclockwise, repeat 3 times; (8) direct your eyes to look at something 20 feet away for 20 seconds, every 20 minutes; (9) last, positioning your fingers a few inches away from the eyes, then focus your gaze on your fingers. move your fingers away and slowly point them back closer to eyes. sample measurement was determined using the wilcoxon test. secondary data for individual characteristic was obtained from age and gender. results characteristic was obtained from 86 respondents who were divided based on gender, age. data regarding individual characteristic can be seen in the following table. based on table 1, the respondents in this study were mostly women and was dominated by respondent from age 21 years old because they are working on a thesis which increase their usage of computers. table 2 and fig. 1 shows there are three symptoms that respondents complained the most before and after intervention were headache, tearing, and itching. based on table 3, experimental group p value = 0,001 (p<0, 05) so it can be concluded that eye exercise caused a significant decrease in cvs score in experimental group while control group showed a p value = 0,802 which means that it didn’t show a significant decrease in cvs score. two respondents in experimental group showed an increase in cvs score after international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 39 intervention, whereas in control group there were 17 respondents who experienced an increase in cvs score. discussion computer and vdt(visual display terminal) have become an essential part of modern lifestyle, hence the term “computer vision syndrome” appears associated with prolonged use of vdt. therefore, by doing eye exercises could help to prevent and reduce the occurrence of computer vision syndrome. distribution frequency of symptoms preandp-post intervention, headache, tearin, and angella zhuang, bobby ramses erguna sitepu table 2 computer vision syndrome symptoms before and after intervention symptoms before intervention after intervention n=86 n=86 burning itching feeling of a foreign body tearing excessive blinking eye redness eye pain heavy eyelids dryness blurred vision double vision difficulty focusing for near vision increase sensitivity to light colored halos around objects feeling that sight is worsening headache 25 (29) 74 (86.1) 67 (77.9) 75 (87.2) 34 (39.6) 57 (66.3) 60 (69.8) 47 (54.6) 54 (62.8) 60 (69.8) 27 (31.4) 32 (37.2) 47 (54.7) 21 (24.5) 43 (50) 77 (89.5) 20 (23.2) 61 (70.9) 43 (50) 64 (74.4) 29 (33.7) 43 (50) 48 (55.9) 40 (46.6) 52 (60.5) 48 (55.9) 21 (24.4) 19 (22.1) 36 (41.9) 14 (16.3) 32 (37.2) 67 (77.9) fig 1. symptoms of cvs table 3 wilcoxon test analysis between control and experimental group ranks group control experimental (n=43) (n=43) negative ranksa positive ranksb 17 25 1 0.802 2 37 4 0.001ties c p value note: * a. (score (pre) < (score (post); b. (score (pre)> (score (post); c. (score (pre)= (score (post) 40 international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 itching are the most complaints symptoms by participants. however, there was a decrease in the number and percentage of symptoms postintervention compared to pre-intervention. the result of this study supported with study by ranasinghe and altalhi which also show that the most complained symptoms is headache.8,9, 10 excessive tear production of watery eyes is not directly related to the duration of vdt use, but is an increased reflex in the eye to increase tear production 11. the result of wilcoxon test in experimental group obtained a p value =0,001 (p<0, 05). thus, it can be concluded that there was an effect of eye exercises on reducing the cvs score in the intervention group. this research show a similar result that there is a significant decrease in cvs score on intervention groups after eye exercises7,12. a significant relationship in this study due to the obedience of the respondents in following each eye exercise properly and routinely twice a week in a month. eye exercises are proven able to improve vision and the performance of muscular and motor activities of the eyes. palming helps to relax the ocular muscles and all sensory nerves related with vision. eye movements and figure of eight help the eyes muscle to controlling back and movement of eye’s lens, to achieve sight at multiple distances13. blinking replenishes the tear film by redistributing tears from the lacrimal glands and lipids from meibomian glands on the surface of eye14. in conclusion, there is an effect of eye exercise to computer vision syndrome. this research can be used as a reference for the effect of eye exercise to computer vision syndrome. however, this study has limitations, such as the lack of number of respondents and short period of eye exercises, which leads to less data variation. if this research is continued, it would be better to add the number of respondents, extend the period eye exercises or using other types of eye exercises, in order to get more representative research results. 1. derbew h, nega a, tefera w, zafu t, tsehaye k, haile k, et al. assessment of computer vision syndrome and personal risk factors among employees of commercial bank of ethiopia in addis ababa, ethiopia. j environ public health. 2021(2):1–8 2. sheppard al, wolffsohn js. digital eye strain: prevalence, measurement and amelioration. bmj open ophthalmol. 2018; 3:146. 3. coronel-ocampos j, gómez j, gómez a, quiroga-castañeda pp, valladares-garrido mj. computer visual syndrome in medical students from a private university in paraguay: a survey study. front public health. 2022; 10:935405. 4. rahmania a. hubungan penggunaan gawai dengan sindrom penglihatan komputer (computer vision syndrome/cvs) pada mahasiswa fk universitas sriwijaya selama masa pembelajaran jarak jauh. sriwij university repository. 2020;14. 5. garg s, mallik d, kumar a, chunder r, bhagoliwal a. awareness and prevalence on computer vision syndrome among medical students: a cross-sectional study. asian j med sci. 2021;12(9):44–8. 6. kusuma u, surakarta h, solikah sn, hasnah k, insan p. terapi senam mata sebagai upaya preventif miopi pada anak di masa pandemi covid-19. j kesehat kusuma husada. 2022; 13(1):109–18. 7. arisandi ip, utami gt, novayelinda r. efektivitas senam mata terhadap computer vision syndrome (cvs). j online mhs. 2018; 5(2):520–5. 8. ranasinghe p, wathurapatha ws, perera ys, lamabadusuriya da, kulatunga s, jayawardana n, et al. computer vision syndrome among computer office workers in a developing country: an evaluation of prevalence and risk factors. bmc res notes. 20169;9(1):150. 9. altalhi aa, khayyat w, khojah o, alsalmi m, almarzouki h. computer vision syndrome among health sciences students in saudi arabia: prevalence and risk factors. cureus. 2020; 12(2): e7060. 10. sánchez-brau m, domenech-amigot b, brocalfernández f, quesada-rico ja, seguí-crespo m. prevalence of computer vision syndrome and its relationship with ergonomic and individual factors in presbyopic vdt workers using progressive addition lenses. int j environ res public health. 2020;17(3):1003. 11. nau s, sagita s, setiawan im, artawan i. senam mata menurunkan computer vision syndrome (cvs) pada mahasiswa universitas nusa cendana. cendana medical journal (cmj). 2022:10(1):58–66. 12. pradeep kurunhikattil. role of eye exercises references effect of eye exercises on computer vision syndrome among medical students of universitas sumatera utara, indonesia international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 41 in improving performance of professionals working with computers. joinsysmed. 2016;4(3):145–8. 13. bron aj, de paiva cs, chauhan sk, bonini s, gabison ee, jain s, et al. tfos dews ii pathophysiology report. ocul surf. 2017;15(3):438–510. 14. seguí mdel m, cabrero-garcía j, crespo a, verdú j, ronda e. a reliable and valid questionnaire was developed to measure computer vision syndrome at the workplace. j clin epidemiol. 2015;68(6):662–73. angella zhuang, bobby ramses erguna sitepu vol 11 no 1 2023 (2) rev-2.indd 42 this is an open access article licensed under the creative commons attribution-noncommercial 4.0 international license (http:// creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original author and source are properly cited autoantibody profile and thorax hrct scan in systemic sclerosis with restrictive lung disease winda agnestia maranna saragih,1 rachmat gunadi wachjudi,2 verina logito,3 anna tjandrawati,3 sumartini dewi2 1department of internal medicine, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital, bandung, indonesia 2division of rheumatology, department of internal medicine, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital, bandung, indonesia 3department of pathology clinic, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital, bandung, indonesia introduction interstitial lung disease is the leading cause of death in ssc patients.1-2 early diagnosis and assessment of the organs involved, especially the lung, will have an impact on morbidity, mortality, and quality of life of patients by providing early treatments.1-3 but early diagnosis of systemic sclerosis is difficult. many patients come to the hospital with advanced disease or visceral organ involvement. early diagnosis of organ involvement in the early stages will have implications for more aggressive treatment. immunosuppressants original article international journal of integrated health sciences (iijhs) issn print: 2302-1381; issn online: 2338-4506 received: october 07, 2022 accepted: march 06, 2023 published: march 30, 2023 correspondence: winda agnestia maranna saragih, department of internal medicine, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital, bandung, indonesia e-mail: windasaragih2010@gmail.com doi: 10.15850/ijihs.v11n1.3023 ijihs. 2023;11(1):42–49 article history abstract objective: to identify auto-antibodies in systemic sclerosis with interstitial lung disease (ild). method: this was a descriptive categorical study on auto-antibody profile in systemic sclerosis patients visiting the rheumatology clinic of dr. hasan sadikin general hospital, west java, and bandung during the period of january 2018 to december 2019 who were registered in the west java systemic sclerosis registry. auto-antibody identification was performed using the euroline immunoblot assays. results: thirty six cases were identified during the study period with most of the cases involved women (n=35, 97.2%). the average age of patients participating in this study was 40 years, with an average duration of disease of 18 months. diffuse cutaneous systemic sclerosis was found in 22 (61.1%) cases and limited cutaneous systemic sclerosis was observed in 14 (38.9%) cases. specific autoantibodies were positive in 33 (91.6%) cases, with anti-topoisomerase i as the largest group, positive in 22 (52.9.3%) cases. this was followed by anti-th/to in eight (15.7%) cases; anti-ro52 in four (7.8%) cases; anti-centromere in three (5.9%) cases; anti-rna polymerase in three (5.9%) cases; anti-fibrillarin in three (5.9%) cases; anti-ku in two (3.9%) cases; and anti-pdgf in one (2.0%) case. high-resolution computed tomography of the lung showed 34 (94.4%) cases with ild and 22 (61.1%) cases with severe lung fibrosis. usual interstitial pneumonia was seen in 19 (52.8%) cases and non-specific interstitial pneumonia in 15 (41.7%) cases. conclusion: anti-topoisomerase i, anti-th/to, and anti-ro52 are the most common autoantibodies observed in systemic sclerosis patients with ild as the most prevalent feature detected with lung hrct. keywords: autoantibodies, diffuse cutaneous, lung fibrosis, restrictive lung disease, systemic sclerosis international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 43 (mycophenolate sodium, cyclophosphamide) given in the early stage will decrease the disease progression as seen with decreased autoantibody titer. intravenous chemotherapy, such as cyclophosphamide is given in ssc patients with interstitial lung disease. delays in this therapy will increase morbidity and mortality. thorax hrct scan is the gold standard for diagnosis of ild, especially for early-stage disease.4,5. usual interstitial pneumonia is associated with a worse prognosis due to rapid disease progression. pulmonary function test with spirometry as a screening test often shows restrictive lung disease, but this result should be viewed cautiously because the extrapulmonary factor may influence the result.6-7 autoantibody testing has become the gold standard for the detection of autoimmune disease and is often associated with disease progression. early assessment of autoantibody testing will benefit the patients, especially in the early diagnosis ssc with organ involment. in addition, autoantibody testing has become the gold standard for detecting autoimmune disease and may contribute to the diagnosis of ssc and the organs involved, especially the lung.8,9 autoantibody titers are often associated with disease progression. previous study conclude that ssc specific-autoantibody is associated with organ involvement. 9 for example, anti-topoisomerase i, anti-u11/ u12, anti-ro52, and anti th/to are associated with lung involvement. anti-centromere is associated with cardiovascular involvement (pah). anti-rna polymerase is associated with cardiovascular (pah) and kidney (acute renal crisis). anti-fibrillation is associated with cardiovascular involvement (pah) and musculoskeletal injury (myositis). there is an association between autoantibody subtype and clinical manifestation along with organ involvement. severe manifestation is found in ssc with lung involvement; thus patients will seek treatment earlier. to date, there are no specific clinical markers for lung involvement. therefore in the future, it is expected that the ssc specific autoantibodies testing may be used as a modality for diagnosis organ involvement. specially detecting ssc patients with interstitial lung disease in the early stages.7,8 methods this was a descriptive study with a crosssectional method. data were collected from west java systemic sclerosis registry. diffuse and limited ssc outpatients visiting the rheumatology clinic at dr. hasan sadikin general hospital, who were treated from january 2018 to december 2019, aged over 18 years old, were included in this study. systemic sclerosis patients with overlap syndrome with other rheumatic autoimmune diseases and incomplete medical records were excluded from this study. systemic sclerosis was diagnosed based on acr/eular 2013 criteria.10 restrictive lung disease was defined based on ats criteria.11 using spirometry data, all participans meet restrictive lung disease criteria. all patients underwent hrct thorax examination as gold standard for ild. interstitial lung disease was defined based on wernick’s semi-quantitative scoring system category.12 the scoring describe ild progressivity by radiological pattern and lung segments involved. statistical product and service solution (spss) version 22 for windows was used for data analysis. number and percentage were used for categorical variables. mean ± standard deviation was used for measurement data following the normal distribution. median was used for non-normal distribution measurement data. this study had approved by the ethical committee of dr. hasan sadikin general hospital (reference no: lb.02.01/x.6.5/24/2020). the patient’s selection is shown in fig 1. results there were 4653 outpatients visiting rheumatology clinic at dr. hasan sadikin general hospital, with all rheumatology cases were 1923 patients, rheumatoid arthritis is 435 patients, systemic lupus erythematosus is 730 patients, and ssc is 70 patients. there were 36 patients in west java systemic sclerosis registry from january 2018 to december 2019 who met the criteria for this study. the patient’s characteristics are shown in table 1. more women were affected by ssc in this study (35, 97.2%). mean age at diagnosis was 40 ± 12 years. the median disease duration was 18 (4-58) months. patient with dcssc was the common subtype in this study (22, 61.6%), followed by lcssc (14, 38.9%). raynaud’s phenomenon was the most common clinical manifestation found (34, 94.4%) followed by sclerodactyly (30, 83.3%), skin stiffness (23, 63.9%), fingertip scar (21, 58.3%), salt and pepper appearance (20, 55.6%), telangiectasia (18, 50%), puffy fingers (5, 13.9%), and fingertip ulcer (4, 11.1%). autoantibody profile and thorax hrct scan in systemic sclerosis with restrictive lung disease 44 international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 winda agnestia maranna saragih, rachmat gunadi wachjudi, et al fig 1. patient’s selection table 1 patient’s baseline characteristics variables number of participants (n=36) age at diagnosis (years) 40 ± 12 female n (%) 35 (97.2) duration of disease (months) median (min-max) 18 (4 – 58) subtype, n (%) dcssc 22 (61.1) lcssc 14 (38.9) mrss median (min-max) 18 (5-45) restrictive lung disease, n (%) moderate to severe 13 (36.1) severe 7 (19.5) moderate 6 (16.7) mild 6 (16.7) very severe 4 (11.0) clinical manifestation, n (%) raynaud’s phenomenon 34 (94.4) sclerodactyly 30 (83.3) skin stiffness 23 (63.9) fingertip scar 21 (58.3) salt and pepper appearance 20 (55.6) telangiectasia 18 (50.0) puffy fingers 5 (13.9) fingertip ulcer 4 (11.1) immunosuppressant therapy methotrexate 32 (88.9) cyclophosphamide 4 (11.1) mycophenolate sodium 4 (11.1) azathioprine 3 ( 8.3) dssc, diffuse systemic sclerosis; hrct, high resolution computed tomography; lssc, limited systemic sclerosis; mrss, modified rodnan skin score; ild, interstitial lung disease. all participant meet criteria restrictive lung disease. all patients receive immunosuppressant therapy because the ssc severity manifestation international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 45 anti-topoisomerase i was predominantly found in interstitial lung disease, both as single and overlap autoantibody, followed by anti-th/to, and anti-ro52, as shown in fig 2. two types of specific autoantibodies for ssc was positive in half of the patients (50%), followed by one type autoantibody (41.7%), and negative autoantibody (8.3%). overview of specific autoantibody is shown in fig 2. hrct showed that almost all patients had ild (34, 94.4%) with lung fibrosis 22 (61.1%) cases among it. further classification using wernick’s semi-quantitative scoring system category, found that severe ild was the most common finding (22, 61.1%), followed by moderate cases (6, 16.7%), and mild cases (6, 16.7%).12,13 severe ild was found 41.7% in dcssc and 19.4% in lcssc, respectively. hrct showed usual interstitial pneumonia (uip) was 52.8% cases, followed by non-specific autoantibody profile and thorax hrct scan in systemic sclerosis with restrictive lung disease fig 2. overview of ssc specific autoantibody fig 3. interstitial lung disease morphology15 46 international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 interstitial pneumonia (nsip) (41.7%) cases. ild morphology is shown in fig 3. discussion this study describes specific autoantibodies and thorax hrct in ssc patients. this result differs from other studies and may suggest there is a difference in characteristics and disease progression of ssc patients in indonesia. younger age at diagnosis and shorter duration of illness was found in this study compared to other studies conducted in singapore, malaysia, australia, and europe. 1,2,7,14 even though early case finding better in those counties. interstitial lung disease occurs in an early stage and younger age, is usually severe and have strong relation with higher standardized mortality rate.1,2,15 subtype ssc classification is useful for the prediction of organ involvement and disease prognosis. the dsssc subtype is at higher risk of death. it is associated with rapid progression and the risk of organ involvement in the early stage of the disease.16 this study showed dsssc subtype was more common and consistent with the finding of younger age at diagnosis and shorter duration of illness. higher prevalence of dcssc and ata compared with caucasians have been reported in han chinese, also suggesting that racial differences may contribute.17 the environment is also a trigger factor for ssc, even though it was not fully understood. some environmental factors that may trigger ssc, include chemical exposure of vinyl, chemical solvents, epoxy resin dan silica. infection cytomegalovirus (cmv), parvovirus, smoking and alcohol is also play a role in triggering ssc.16,18 specific autoantibodies testing has become the gold standard for the diagnosis of ssc, in which it is often associated with disease progression. early assessment of specific autoantibodies will give benefit to the patients, especially ssc with organs involvement. in this study, we found three dominant specific autoantibodies for ssc : anti-topoisomerase i, anti-th/to, and anti-ro52. studies conducted by ibrahim et al. in malaysia and ching et al. in thailand reported anti-topoisomerase, anti-th/to, anti-ro52, and anti-centromere as major autoantibodies in ssc.14,19 anti-th/ to and anti-ro52 are not included in acr/ eular 2013 for the diagnosis criteria of ssc, due to the difference of populations that were studied. specific autoantibodies differences between asian and european. singapore and malaysia, which are multi-racial countries, showed differences with the population in this study.2,14 this might be due to the more diversity in human races of the two countries. hla-drb1*11 is found in anti-topoisomerase i; hla-drb1*01, hla-drb1*04 hla-drb1*05 are found in anti-centromere and hladrb1*04, hla-dqb1*03 are found in anti-rna polymerase of caucasians-hispanics.17,18,20 not much research on chromosomes has been done before. further research is needed in asian populations, especially in indonesia, to determine the differences between major autoantibody and disease progression between asian and european. specific ssc autoantibodies is associated with organ involvement. there is an association between autoantibody subtype and clinical manifestation along with organ involvement.21,22 two types of specific autoantibodies for ssc was positive in half of the participants (50%) followed by one autoantibody (41.7%), and negative autoantibody (8.3%). in several studies using iif, immunoprecipitation, and immunodiffusion, only a very small proportion of ssc specific autoantibodies were found to have more than one ssc-related antibody.7,19 anti-topoisomerase i was the dominant autoantibody found in ild, both as single and overlap autoantibody, followed by anti-th/to, and anti-ro52, where this autoantibody related to ssc-ild. this fact is consistent with this study finding. anti-topoisomerase was found in 31.4% of diffuse subtype cases and 21.6% of limited subtype cases. anti-topoisomerase i is often associated with diffuse subtype and interstitial lung disease occurrence. other studies, found anti-topoisomerase i as the most common finding in diffuse ssc with interstitial lung disease.1,8,10,22 anti-th/to was found in 15.7% cases and second most dominant autoantibodies. these results were not consistent with the literature, which states that anti-th/to is lesser compared with other autoantibodies, study in japan shows only 2-5% of cases and none were found in greece population .20,21 in our study from 7 of 8 positive anti-th/to patients, had interstitial lung disease. this result was similar to the previous study in malaysia and thailand, which reported ssc with anti-th/to positively increases the severity and mortality rate and due to lung involvement.14,19 there are differences in dominan autoantibody found in japan and greece population, compared to our population. anti-ro52 was found in 5.9% of diffuse subtype cases and 2% of limited subtype cases. all patients with anti-ro52 positive had winda agnestia maranna saragih, rachmat gunadi wachjudi, et al international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 47 interstitial lung disease. this result is similar to a study conducted by ibrahim et al.14 anticentromere was found in 5.9% of a diffuse subtype with overlapping anti-topoisomerase i autoantibody. this group showed severe interstitial lung disease. this finding is not consistent with the literature, which stated that anti-centromere has a good prognosis because it is often found in a limited subtype with rarely visceral organ involvement.21 this may be associated with the presence of two or more autoantibodies simultaneously, especially high titer anti-topoisomerase i. anti-rna polymerase was found in 3.9% of diffuse subtype cases and 2% of a limited subtype with overlapping anti-topoisomerase i autoantibody. the literature states ssc with anti-rna polymerase rarely develops into severe interstitial lung disease. this is not consistent with the results. interstitial lung disease in this group can be associated with the presence of two concurrent autoantibodies, especially high titer anti-topoisomerase i. this study found three dominant autoantibodies, which consist of anti-topoisomerase i, antith/to, and anti-ro52. studies conducted by ibrahim et al. in malaysia and ching et al. in thailand reported anti-topoisomerase, antith/to, anti-ro52, and anti-centromere as dominant autoantibodies.14,19 anti-th/to and anti-ro52 are not included in acr/eular 2013 for the diagnosis of systemic sclerosis. this is because acr/eular 2013 is based on the european and american populations, while there is differences in autoantibody dominant between asian and european populations.10,17,23, 24 this study also found three negative cases on specific autoantibodies but with a positive ana test. factors that may play a role in autoantibody difference results include autoantibodies test and autoantibodies titer.9,22 euroline immunoblot assay can detect 13 autoantibodies, but there are several other autoantibodies related to systemic that are not included in this kit such as anti-endothelial, anti-fibroblast, anti-matrix metalloproteinase, and anti-survivin which cannot be examined in this study. a high titer is associated with disease progression. hrct showed that almost all patients had ild and with uip pattern. these results differ from the other studies conducted in europe, which nsip was the common pattern.13,25 uip is associated with worse prognosis due to rapid disease progression, it’s presents a craniocaudal gradient of peripheral septal thickening, bronchiectasis, and honeycombing.26 further classification by wernick’s semi quantitative scoring system found that severe ild was the most common finding, consist with the uip pattern.12 ild progression is related to morphology of lung lesion.13,25 . this study showed that many patients seek healthcare after later stages of the disease with visceral organ involvement such as interstitial lung disease. risk factors for interstitial lung disease in ssc include men, older age, african-american, duration of illness, diffuse subtype, presence of ata, decreased forced vital capacity (fvc), and biomarker.26,27 the participants in this study were mostly women, aged between 30 – 40 years, duration of illness less than 18 months, diffuse subtype, anti-topoisomerase 1 positive with decreased fvc. there were differences in gender, age, race, and duration of illness in this study. in west java, ssc with ild is commonly found, with diffuse cutaneous subtype as the predominant group. anti-topoisomerase i, anti-th/to and anti-ro52 were the most common autoantibodies. in line with the pathogenesis, antitopoisomerase i trigger adhesion and activation of monocytes by binding to dna–topoisomerase i expressed on fibroblasts.28 this potentially lead to amplification of the fibro genetic cascade. anti-th/to and anti-ro52 are also associated with higher prevalence of ssc-ild. hrct demonstrated majority of ssc with ild in this population. this study identify similar autoantibodies associate with ild amongst ssc patients. some limitations should be noted. there are no data of living environment, profession, chemical exposure and previous disease history from west java systemic sclerosis registry because the registry is still in progress. references 1. proudman sm, huq m, stevens w, wilson me, sahhar j, baron m, et al. what have multicentre registries across the world taught us about the disease features of systemic sclerosis?. j scleroderma related disorders. 2017;2(3):169–82. autoantibody profile and thorax hrct scan in systemic sclerosis with restrictive lung disease 48 international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 winda agnestia maranna saragih, rachmat gunadi wachjudi, et al 2. santosa a, tan cs, teng gg, fong w, lim a, law wg,. lung and gastrointestinal complications are leading causes of death in score, a multiethnic singapore systemic sclerosis cohort. scand j rheumatol. 2016;45(6):499–506. 3. herrick al. systemic sclerosis: clinical features and management. medicine. 2018;46(2):131– 9. 4. chowaniec m, skoczyńska m, sokolik r, wiland p. interstitial lung disease in systemic sclerosis: challenges in early diagnosis and management. reumatologia. 2018;56(4):249–54. 5. schoenfeld sr, castelino fv. evaluation and management approaches for scleroderma lung disease. ther adv in respir dis. 2017 aug;11(8):327–40. 6. allanore y, simms r, distler o, trojanowska m, pope j, denton cp, et al. systemic sclerosis. nat rev dis primers. 2015;1:15002. 7. cappelli s, bellando rs, camiciottoli g, de paulis a, guiducci s, matucci-cerinic m. interstitial lung disease in systemic sclerosis: where do we stand?. eur respir rev. 2015;24:411–9. 8. bahmer t, romagnoli m, girelli f, claussen m, rabe kf. the use of auto-antibody testing in the evaluation of interstitial lung disease (ild)-a practical approach for the pulmonologist. respir med. 2016;113:80–92. 9. kayser c, fritzler mj. autoantibodies in systemic sclerosis: unanswered questions. frontiers in immunology. 2015;6:167. 10. frank van den h, dinesh k, jaap f, sindhu rj, murray b, alan tyndall, et al. 2013 classification criteria for systemic sclerosis: an american college of rheumatology/european league against rheumatism collaborative initiative. arthritis rheum. 2013;65(11):2737–47. 11. american society thoracis. lung function testing: selecting of reverence value and interpretative strategies. american rev res dis. 1991;144(5):1202–18. 12. assayag d, kaduri s, hudson m, hirsch a, baron m. high resolution computed tomography scoring systems for evaluating interstitial lung disease in systemic sclerosis patients. rheumatology. 2012;1. 13. bastos al, correa ra, ferreira ga. tomography patterns of lung disease in systemic sclerosis. radiol bras. 2016;49:316–21. 14. sujau i, ng ct, sthaneshwar p, sockalingam s, cheah te, yahya f, et al. clinical and autoantibody profile in systemic sclerosis: baseline characteristics from a west malaysian cohort. int j rheum dis. 2015;18:459–65. 15. marco aa, cesar v, carmen ps, vicent f, luis t, maria ve, et all. earlyversus late-onset systemic sclerosis: differences in clinical presentation and outcome in 1037 patients. medicine (baltimore). 2014;93(2):73–81. 16. denton cp, khanna d. systemic sclerosis. lancet. 2017;390(2017):1685–99. 17. jiucun w, shervin a, gang g, wenzhen t, wenyu w, li y, et al. clinical and serological features of systemic sclerosis in a chinese cohort. clin rheumatol. 2013;32(5):617–21. 18. domsic rt, medsger ta. autoantibodies and their role in scleroderma clinical care. curr treat options in rheum. 2016;2:239–51. 19. foocharoen c, watcharenwong , netwijitpan s, mahakkanukrauh a, suwannaroj s, nanagara r. relevance of clinical and autoantibody profiles in systemic sclerosis among thais. int j rheumatic dis 2017;20:1572–81. 20. murdaca g, miriam c, gulli r, mandich p, puppo f. genetic factors and systemic sclerosis. autoimmunity reviews. 2016;15:427–32. 21. mastaka kuwana. circulating anti-neclear antibodies in systemic sclerosis:utility in diagnosis and disease subsetting. j nippon med sch. 2017;84:56–63. 22. liaskos c, marou e, simopoulou t, barmakoudi m, efthymiou g, scheper t, et al. disease-related autoantibody profile in patients with systemic sclerosis. autoimmunity. 2017;50:414–21. 23. le gouellec n, duhamel a, perez t, hachulla al, sobanski v, faivre jb, et al. predictors of lung function test severity and outcome in systemic sclerosis-associated interstitial lung disease. plos one. 2017;12(8):e0181692. 24. jung e, suh ch, kim ha, jung jy. clinical characteristics of systemic sclerosis with interstitial lung disease. arch rheumatol 2018;33(3):322–7. 25. cottin v, brown kk. interstitial lung disease associated with systemic sclerosis (ssc-ild). respir res. 2019;20(1):13. 26. silver cp, silver rm. management of systemicsclerosis-associated interstitial lung disease (ssc-ild). rheum dis clin of north am. 2015;41:439–57. 27. de martinis m, ciccarelli f, sirufo mm, ginaldi l. an overview of environmental risk factors in systemic sclerosis. expert rev clin immunol. 2015;12:465–78. 28. maaike b, jaap ab, annette g, maarten kn, nina am, corrie me, et al. association of international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 49 anti-topoisomerase i antibodies of the igm isotype with disease progression in antitopoisomerase i-positive systemic sclerosis. arthritis rheumatol. 2020;72(11):1897–1904. autoantibody profile and thorax hrct scan in systemic sclerosis with restrictive lung disease conflict of interest declaration here by the author(s) certify(s) that the manuscript entitled: assessment of haemopoietic properties of justicia secunda ethanol leaf extract and fractions in mice is an original work and is not under review at any other publication. author and all co-authors have seen and agreed with the contents of the manuscript and there is no financial interest to report. this manuscript is ready for publication in the international journal of integrated health sciences. author (s) (please write your name with academic degree(s) and sign) 1st author name: omo eric irinmwinuwa, bsc signature: 2nd author name: emeka chinedu ifediba, phd signature: 3rd author name: joseph oyindamola, msc signature: 4th author name: onyenmechi johnson afonne, phd, ert signature: author’s data title of manuscript: assessment of haemopoietic properties of justicia secunda ethanol leaf extract and fractions in mice enter the names of everyone who contributed to your manuscript by entering all required information. author(s) 1st author first name: omo last name: irinmwinuwa academic degree(s): bsc affiliation: nnamdi azikiwe university, nnewi campus, nnewi, nigeria address: department of pharmacology and therapeutics, faculty of medicine, nnamdi azikiwe university, nnewi campus, nnewi, nigeria phone: +2347038910757 email: ericirins@gmail.com 2nd author first name: emeka last name: ifediba academic degree(s): phd affiliation: nnamdi azikiwe university, nnewi campus, nnewi, nigeria address: department of pharmacology and therapeutics, faculty of medicine, nnamdi azikiwe university, nnewi campus, nnewi, nigeria phone: +2348034459936 email: ec.ifediba@unizik.edu.ng 3rd author first name: joseph last name: oyindamola academic degree(s): bsc affiliation: nnamdi azikiwe university, nnewi campus, nnewi, nigeria address: department of pharmacology and therapeutics, faculty of medicine, nnamdi azikiwe university, nnewi campus, nnewi, nigeria phone: +2347066575641 email: joyins2001@gmail.com 4th author first name: onyenmechi last name: afonne academic degree(s): phd, ert affiliation: nnamdi azikiwe university, nnewi campus, nnewi, nigeria address: department of pharmacology and therapeutics, faculty of medicine, nnamdi azikiwe university, nnewi campus, nnewi, nigeria phone: +2348037973397 email: oj.afonne@unizik.edu.ng cover letter date: 30th may 2022 to: editor in chief international journal of integrated health and science dear sir, please find the submission of our manuscript, assessment of haemopoietic properties of justicia secunda ethanol leaf extract and fractions in mice, which we would like to submit for publication in the international journal of integrated health science. in this manuscript, we assessed the haemopoietic properties of the ethanol leaf extract and fractions of justicia secunda in mice. the study showed that the ethyl acetate fraction of j. secunda leaf possesses significant haemopoietic effect in comparison to the standard drugs, ferric sulphate and vitamin b12. author and all co-authors have seen and agreed with the contents of the manuscript and there is no financial interest to report. we certify that the manuscript submitted is an original work and is not under review at any other publication. we thank you for considering our manuscript for publication in the international journal of integrated health science and look forward to hearing from you at your earliest convenience. sincerely yours, corresponding author prospective reviewer i hereby suggest prospective reviewer(s) to international journal of integrated health sciences (ijihs) by filling in all required information: reviewer 1 full name with academic degree(s): anthonet ndidiamaka ezejiofor, phd affiliation/institution: university of port harcourt, port harcourt, nigeria email: ndidiezejiofor@yahoo.com expertise: pharmacology and toxicology reviewer 2 full name with academic degree(s): ejeatuluchukwu obi, phd affiliation/institution: nnamdi azikiwe university, awka, nigeria email: e.obi@unizik.edu.ng expertise: biochemical pharmacology conflict of interest declaration here by the authors certify that the manuscript entitled : prevalence of allergic rhinitis in a class of 2018-2019 medical students of universitas padjadjaran is an original work and is not under review at any other publication. author and all co-authors have seen and agreed with the contents of the manuscript and there is no financial interest to report. this manuscript is ready for publication in the international journal of integrated health science. authors 1st author name: sheila rafifah yuliantoputri, s.ked signature : 2nd author name: dr. melati sudiro, dr., sp. t.h.t.k.l(k)., m.kes signature : 3rd author name: arif dermawan, dr., sp. t.h.t.k.l(k)., m.kes signature : 4th author name: dr. lina lasminingrum, dr., sp. t.h.t.k.l(k)., m.kes signature : 5th author name: sally mahdiani, dr., sp. t.h.t.k.l(k)., m.kes signature : author’s data title of manuscript: prevalence of allergic rhinitis in a class of 2018-2019 medical students of universitas padjadjaran authors 1st author first name : sheila rafifah last name : yuliantoputri academic degree(s): sarjana kedokteran affiliation: faculty of medicine universitas padjadjaran, indonesia address: batik ayu street number 19 bandung, indonesia phone:082190110180 email: rafifahs@gmail.com 2nd author first name: melati last name : sudiro academic degree(s): otorhinolaryngologist doctor, phd affiliation: department of otolaryngology-head and neck surgery faculty of medicine universitas padjadjaran, indonesia address: griya utara street number 26 bandung, indonesia phone: 08112212745 email: melati.sudiro@unpad.ac.id 3rd author first name: arif last name : dermawan academic degree(s): dokter umum, magister kesehatan, spesialis ik. t.h.t.k.l., spesialis ik. t.h.t.k.l. konsultan affiliation: department of otolaryngology-head and neck surgery faculty of medicine universitas padjadjaran, indonesia address: belleza housing complex number b1 bandung, indonesia phone: 08122015818 email: a.dermawan@unpad.ac.id 4th author first name: lina last name : lasminingrum academic degree(s): dokter umum, magister kesehatan, doktor, spesialis ik. t.h.t.k.l., spesialis ik. t.h.t.k.l. konsultan affiliation: department of otolaryngology-head and neck surgery faculty of medicine universitas padjadjaran, indonesia address: alam nirwana street number 23 bandung, indonesia phone: 08112343536 email: lina.lasminingrum@unpad.ac.id 5th author first name: sally last name : mahdiani academic degree(s): dokter umum, magister kesehatan, spesialis ik. t.h.t.k.l., spesialis ik. t.h.t.k.l. konsultan affiliation: department of otolaryngology-head and neck surgery faculty of medicine universitas padjadjaran, indonesia address: department of otorhinolaryngology head and neck surgery, faculty of medicine universitas padjadjaran, pasteur street number 38 bandung, indonesia phone: 081220024003 email: sally.mahdiani@unpad.ac.id cover letter march 3, 2022 to. editor in chief international journal of integrated health and science dear sir, please find the submission of our manuscript, prevalence of allergic rhinitis in a class of 2018-2019 medical students of universitas padjadjaran which we would like to submit for publication in the international journal of integrated health science. in this manuscript, we aim to determine the prevalence of ar in a class of 2018-2019 medical students of universitas padjadjaran and the validity and reliability of the indonesian version of the patient allergic rhinitis questionnaire. the research was carried out during the period november-december 2021 using an online questionnaire. author and all co-authors have seen and agreed with the contents of the manuscript and there is no financial interest to report. we certify that the manuscript submitted is an original work and is not under review at any other publication. we thank you for considering our manuscript for publication in the international journal of integrated health science and look forward to hearing from you at your earliest convenience. sincerely yours, sheila rafifah yuliantoputri prospective reviewer i hereby suggest prospective reviewer(s) to international journal of integrated health sciences (ijihs) by filling in all required information: reviewer 1 full name with academic degree(s): affiliation/institution: email: expertise: reviewer 2 full name with academic degree(s): affiliation/institution: email: expertise: note: this is a tentative submission requirement to ijihs. we kindly expect authors can suggest reviewer(s) who may come from different institution. if you find difficulty to meet the requirement, you can suggest only one reviewer. the suggested reviewer can be your lecturers, colleagues, and others who may potentially review your article. thank you. (please delete this note after filling in the form) vol 11 no 1 2023 (2) rev-2.indd 32 this is an open access article licensed under the creative commons attribution-noncommercial 4.0 international license (http:// creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original author and source are properly cited sedative effect of intraperitoneal diazepam in mice marsha vania, shinta dewi permata sari, bambang siswitono, endin nokik stujanna faculty of medicine, universitas muhammadiyah prof. dr. hamka, jakarta, indonesia introduction induction of anesthesia is the administration of drugs approximately 1-2 hours before anesthesia to assist the process of anesthesia. pre-medication can be given before general or local anesthesia by intravenous (iv), intramuscular (im), or subcutaneous (sc). pre-medication drugs are classified into sedatives (diazepam and phenobarbital) and non-sedative drugs such as atropine.1 generally, phenobarbital and diazepam can be delivered by im injection. meanwhile, the most frequently used injections for solutions or suspensions were sc, ip, and iv injections. ip injection is a simple technique because the large surface area of the peritoneal cavity and many blood vessels allow for rapid absorption.2 phenobarbital is a derivative of the barbiturate group for hypnotic therapy and the treatment of epilepsy. phenobarbital has a long-acting period, used as general anesthesia in rats with a small dose.3 diazepam has the same use as phenobarbital and can be used as an anesthetic induction and antiepileptic therapy. diazepam is widely used for anxiety disorder, short-term relief of anxiety symptoms, alcohol withdrawal, and insomnia.4 therefore, diazepam has largely replaced phenobarbital for anxiety and sleep disorders treatment due to fewer side effects. however, diazepam and phenobarbital have the same general side effect, sedation.4 diazepam was also used frequently as a positive control in study behavior in mice. meanwhile, phenobarbital is commonly used as a positive control in study anesthesia in rodents.3,5,6 the phenobarbital side effect was hepatotoxicity, which may affect the use of anesthesia that assess the effects on the liver.7,8 these may limit the use of phenobarbital as a positive control. the alternative positive control needs to be studied. marina’s study showed a diazepam sedative effect rather than an anxiolytic effect in mice.9 this finding may use as basic information to develop diazepam use in experimental animal research. the study regarding the sedative original articleinternational journal of integrated health sciences (iijhs)issn print: 2302-1381; issn online: 2338-4506 received: december 29 2022 accepted: march 11, 2023 published: march 30, 2023 correspondence: shinta dewi permata sari, universitas muhammadiyah prof. dr. hamka, jakarta, indonesia email: shinta.dps@uhamka.ac.id doi: 10.15850/ijihs.v11n1.3139 ijihs. 2023;11(1):32-36 article history abstract objective: to determine the effectiveness of diazepam in comparison with phenobarbital. methods: twenty-seven male swiss webster mice were used and randomly divided into three groups of negative control (ns), positive control (phenobarbital), and diazepam group. two tests were performed on these group: the traction test and the fireplace test. pupillary diameter was also observed. results: a significant difference based on the kruskal wallis statistical test was observed between the positive control and the diazepam group (<0.05) in the traction test, which was also true for the fireplaced test (p<0.05). the pupillary diameter in the test animals in the positive control and diazepam group was not statistically significant (p>0.05). conclusion: diazepam has a better sedative effect than phenobarbital. the sedative effect produced by diazepam is stronger, with faster onset and longer half-life than the phenobarbital the positive control. however, different test methods and comparisons should be sought to support this conclusion. keywords: diazepam, fireplace test, phenobarbital, traction test international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 33 effect of diazepam in experimental animals is still limited. otherwise, diazepam is potentially used as an alternative positive control in study anesthesia and as a pre-medication anesthesia in the animal study. the route of administration is a critical factor for the availability of the drugs in plasma and could affect pharmacodynamics. in experimental animal research, ip injection used frequently because the simplicity of technique and minimal stress for the animal study.10 the study regarding diazepam’s effectiveness in various injection routes is also still limited. at the same time, it can be informative to other researchers especially in experimental animal research. further study needs to be conducted to assess how the effectiveness of diazepam sedative effect in experimental animals (mainly mice and rats) by various routes of administration. therefore, this study aimed to determine the duration and effectiveness of diazepam sedative effect by ip injection in mice. methods the experimental study was conducted in the faculty of medicine universitas muhammadiyah prof. dr. hamka. this study used male swiss-webster mice (mus musculus) aged 3-6 months and weighed 20-30 grams. the mice are cared for under standard conditions, by the temperature of 26 – 28 °c, 12-hour light/dark cycle, and humidity. animal acclimatization was carried out for ten days before the test, had free access to food and water in their cages. the animal experiments were carried out under the supervision of veterinarians to ensure their health during acclimatization until the tests of study. the animal experiments were eligible to undergo several study tests. the procedures of study were approved by animal ethics committee, universitas muhammadiyah prof. dr. hamka (protocol no.kepkk/fk/024/01/2022). this animal research applies ethical principles 3r (replacement, reduction, and refinement). the ethical principles also refer to the 5f (five freedom) consist of freedom from hunger and thirst (free from hunger and thirst), freedom from discomfort (free from discomfort), freedom from pain, injury, and disease (free from pain, injury, and illness), and freedom to express normal and natural behavior. the number of samples was calculated with the federer formula, resulting in 27 mice for three groups (n=9) by random sampling. the groups were group i (normal saline as negative control), group ii (phenobarbital as positive control), and group iii (intervention with diazepam). all the interventions by ip injection. the dosage of 0.325 mg phenobarbital for 20 g mice is equivalent to 100 mg phenobarbital in humans and adjustable as the weight. diazepam dosage use 0.0325 mg as for 20 g mice, equivalent with 10 mg of diazepam in humans. the animals performed several tests such as traction test, fireplace test, and examination of pupil diameter. the traction test was conducted first after the acclimatization and ensured all the animals were eligible for the study. the test was started when the mice was confirmed under sedation effect by touching the mice and showed less or no response. the onset of the drugs may vary each other. the traction test aimed to observe muscle relaxation activity by placing the mice with the anterior body position facing a wire stretched horizontally, then the tail is pulled up. the animal tests that fail to make a reestablishment of at least one of its posterior limbs to reach the wire are considered under a sedative effect. the duration of mice to make re-establishment were recorded by stopwatch. the fireplace tests were conducted three days after the fireplace tests were finished. the animal tests considered under sedation effect when showed no response or less response. the fireplace test was used to observe decreased activity and sensitivity toward the environment. the test was conducted by placing the mice individually in a cylindrical tube to assess the time mice get out quickly. the duration of mice attempting to escape the cylindrical tube was recorded by stopwatch. the pupillary reflex is used to determine the sedation effect by observing the pupil diameter. the normal pupil diameter in mice was 2 mm. this test is conducted during the fireplace test. the statistical product and service solution (spss) program was used to analyze the results. the kruskal–wallis test was performed to measure the significance of differences among groups. a value of p<0.05 is considered a statistically significant difference. result the animal tests weighed during the study period presents in table 1. the weight of animal tests was not varied among groups because there was no significant elevated body weight during the study. the pupil diameter before tests were homogenous among groups sedative effect of intraperitoneal diazepam in mice 34 international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 with normal-sized diameter pupil for mice (2 mm). there were no significant differences statistically in the body weight between groups. table 1 also showed the onset of the drugs (phenobarbital and diazepam) in traction and fireplace tests were not far different. the onset of the drugs also may vary each other’s. the animal test undergoes several interventions based on their group test. several test parameters, such as traction test, fireplace test, and assessment of diameter pupil, collected the data results. table 3 presents the results of those several parameters test. the tests were conducted to determine the effect of sedation in animal tests by the following results. the negative control group took an average of two seconds in the traction and fireplace test. meanwhile, the positive control group took longer by an average of five seconds in the traction test and 80 seconds in the fireplace test. the diazepam group showed a more prolonged sedation effect than the positive control by an average of seven seconds in the traction test and 500 seconds in the fireplace test (table 2). the assessment of the diameter pupil in the negative control group, positive control group, and diazepam group, respectively, 2 mm, 1mm, and 1 mm (table 2). the statistical analysis presents data results that were not distributed normally (p<0.05) by the shapiro wilk test. table 3 shows the traction test result’s significant difference between the positive control and the diazepam group (p<0.05). moreover, the fireplace test also performed a statistically significant difference between the positive control and the diazepam group (p<0.05) by the kruskal – wallis test. pupillary diameter in marsha vania, shinta dewi permata sari, et al table 1 general characteristics of mice parameters groups negative control (ns) positive control (phenobarbital) diazepam n 9 9 9 body weight (g) 32.9 33.2 32.8 pupil diameter (mm) 2 2 2 onset: traction test (min) 0 15 5 fireplace test (min) 0 10 3 table 2 parameter tests results of sedation effect parameter test group negative control n=9 positive control n=9 diazepam n=9 traction test 2 seconds ± 0.5 5 seconds ± 1.5 7 seconds ± 1.8 fireplace test 2 seconds ± 0.5 80 seconds ± 72.8 500 seconds ± 141.4 pupil diameter 2 mm 1 mm 1 mm table 3 statistical analysis results in several parameter tests groups traction test fireplace test pupillary diameter p p p ns with diazepam 0.000 0.000 0.000 phenobarbital with diazepam 0.015 0.001 1.000 international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 35 the animal test was not statistically different between the positive control and diazepam groups (p>0.05). the negative control and diazepam groups showed a statistical difference in pupillary diameter (table 3). discussion a significance different among parameter tests between positive control and diazepam groups indicates a decrease in the activity of the animal’s test. these may show the occurrence of central nervous system (cns) suppression.11 mostly, the pharmacokinetics of sedative drugs are fat soluble, well absorbed, and distributed to the brain. high lipid solubility drugs can quickly enter the cns. sedative drugs are metabolized by liver enzymes and excreted by the kidney. however, there are different metabolic rates in each drug class. diazepam belongs to benzodiazepine groups with anxiolytic action, hypnotic, muscle relaxation, and anti-convulsion, used in anesthesia and insomnia conditions. diazepam elevated gaba potential action by opening chloride channels, leading to hyperpolarization membrane, inducing cns depression and sedative activity. the traction and fireplace tests were used as assessment parameters for the sedative effect in mice.12,13 the traction test showed the length of time in mice to turn around and fall. the sedative effect becomes significant if the mice take longer to turn around. moreover, the fireplace test showed the length of time mice jumped out of the tube. the sedative effect gets stronger if the mice take longer to jump out. pupillary diameter changes may show decreased spontaneous activity in mice as a sedative effect.14the onset of the drugs varied among groups and could be affected by the route of administration. the administration by intraperitoneal injection was to avoid the potential degradation or modification of the drugs.2 meanwhile, the iv injection was hard to use in rodents. the ip injection was minimally used in clinics but preferred in animal studies. durk and colleagues’ studies showed that ip administration resulted in lower tmax and higher cmax than sc injection.15 the diazepam group’s traction and fireplace test results showed longer than the positive control (phenobarbital) group. these may cause the benzodiazepine group (diazepam) to become an active metabolite with a long half-life resulting in a more prolonged effect sedative than the positive control group. meanwhile, barbiturates, especially phenobarbital, are partly excreted in the urine, and some undergo extensively metabolized.16 sadanandan’s study shows diazepam has a long duration of sleep than ganaxolone.17 diazepam is frequently used as a comparator drug in studies related to sedative effect and anesthesia (intravenously). in used to anesthesia, diazepam is mainly combined with other agents.16 in experimental animal models, benzodiazepines and older sedativehypnotic drugs can exert an anti-anxiety effect. however, not all sedative effects drugs have it.16 the sedative-hypnotic drug group are dosedependent and induce sleep in high dose. the specific drug and administration frequency could affect the sleep stages in the sedativehypnotics effect.16 phenobarbital has a long duration of action and long half-life (80-120 hours), although the traction and fireplace test results showed a shorter duration of sedative effects in phenobarbital than diazepam. phenobarbital has low lipid solubility, protein binding to albumin at approximately 55%, and a long onset delay.18 meanwhile, diazepam has a 20-80 hours half-life, highly lipid soluble and highly protein bound, and easily crosses the blood-brain barrier. diazepam is considered a better choice because of its rapid onset and long half-life compared to phenobarbital or in the benzodiazepine group.19 based on the traction and fireplace test results, this study concluded that diazepam has a better sedative effect than phenobarbital. the sedative effect produced by diazepam is more prolonged compared to phenobarbital as a positive control. these findings may be helpful to other researchers as an alternative agent to anesthesia the animal study or as a positive control in an anesthesia study. however, there were still several areas for improvement in this study, as we did not collect the blood sample to measure the drug plasma concentration or collect the organ to assess molecular parameters regarding the sedative effect. these could be used as complementary data to resulting comprehensive results. despite that, this study followed the ethical principle of animal welfare, the sample size counted based on the federer formula, the animal study health was under expert supervision, and used established methods. therefore, suggestions for further research to be performed with different test methods, parameters, and comparisons. sedative effect of intraperitoneal diazepam in mice 36 international journal of integrated health sciences (iijhs), vol 11, number 1, march 2023 1. zadrazil m, marhofer p, schmid w, marhofer d, opfermann p. adv6209 for premedication in pediatric anesthesia: a double-blinded , randomized controlled trial. pharmaceutics. 2022;14(10):2062. 2. al shoyaib a, archie sr, karamyan vt. intraperitoneal route of drug 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(meliaceae) prevents seizures and reduces anxiety in kainate-treated rats: modulation of gaba neurotransmission, oxidative stress, and neuronal loss in the hippocampus. heliyon. 2022;8(5):e09549. 6. frankel s, medvedeva n, gutherz s, kulick c, kondratyev a, forcelli pa. hhs public access. 2017;57:34–40. 7. pathak s, catanzaro r, vasan d, et al. benefits of aged garlic extract in modulating toxicity biomarkers against p dimethylaminoazobenzene and phenobarbital induced liver damage in rattus norvegicus. drug chem toxicol. 2018;0(0):1–14. 8. yamaguchi t, maeda m, ogata k, abe j, utsumi t. the effects on the endocrine system under hepatotoxicity induction by phenobarbital and di ( 2-ethylhexyl ) phthalate in intact juvenile male rats. 2019;44(7):459–69. 9. reis mp, nôga da, tort abl, blunder m. diazepam causes sedative rather than anxiolytic effects in c57bl / 6j mice. sci rep. 2021;11(1):9335. 10. al shoyaib a, archie sr, karamyan vt. intraperitoneal route of drug administration: should it be used in experimental animal studies?. pharm res. 2019;37(1):12. 11. akkol ek, ilhan m, karpuz b, genç y, sobarzosánchez e. sedative and anxiolytic activities of opuntia ficus. molecules. 2020;25(8):1844. 12. kinda pt, guenné s, compaoré m, et al. toxicological characterization and central nervous system effects of calotropis procera ait. aqueous extracts in mice. asian pac j trop med. 2019;12(7):329–36. 13. novindriani d, novindriana d, wijianto b, andrie m. studies on the sedative effect of mitragyna speciosa korth. as an endemic plant in west borneo, indonesia. lett appl nanobioscience. 2021;11(2):3344–9. 14. kelbsch c, strasser t, chen y, feigl b, gamlin pd, kardon r, et al. standards in pupillography. front neurol. 2019;10:129. 15. durk mr, deshmukh g, valle n, ding x, liederer bm, liu x. use of subcutaneous and intraperitoneal administration methods to facilitate cassette dosing in microdialysis studies in rats. drug metab dispos. 2018;46(7):964–9. 16. katzung b, masters s, trevor a. basic & clinical pharmacology. 12th ed. newyork: mcgraw hill; 2015. 17. sadanandan s, jadhav sa, matule sm. an experimental evaluation of ganaxolone and its comparison with sodium valproate and diazepam for its sedative property in rats. 2022;13(7):6173–82. 18. trinka e. phenobarbital in status epilepticus –rediscovery of an effective drug. epilepsy behav. 2023;141:109104. 19. salehiomran m, hoseini sm, ghabeli juibary a. intermittent diazepam versus continuous phenobarbital to prevent recurrence of febrile seizures: a randomized controlled trial. iran j child neurol. 2016;10(1):21–4. references marsha vania, shinta dewi permata sari, et al volume 8 no 1 2020 v2.indd 38 international journal of integrated health sciences disorder. patients with sle are almost always positive for ana, meanwhile patients with other autoimmune disoreders who have positive ana result are varies, even a significant number patients with other types of disorders and some healthy people might have positive ana, especially at low levels. moreover, american college of rheumatology (acr) 1997 recommends immunoflourecence assay (ifa) method as a gold standard of ana test which can help clinician to diagnose the autoimmune disorder more specifically besides another manifestations showed by the patient. it can also help to reduce risk of false positive or errorneous.1 by the result of the test, the clinician might see the titers and different types of ana through the staining pattern. based on international consensus of ana pattern (icap), ana is divided into pattern of indirect immunofluorescence assay antinuclear antibody in pediatric lupus nephritis correspondence: fadhila novianti, faculty of medicine universitas padjadjaran e-mail: fadhilanovianti@gmail.com fadhila novianti,1 reni ghrahani,2 noormarina indraswari3 1faculty of medicine universitas padjadjaran, bandung, indonesia 2departement of child health, faculty of medicine universitas padjadjaran-dr. hasan sadikin hospital, bandung, indonesia 3department of public health, faculty of medicine universitas padjadjaran, bandung, indonesia abstract objective: to determine the association between anti-nuclear antibody (ana) pattern in pediatric systemic lupus erythematosus (sle) patients and proteinuria as a sign of renal involvement in sle. methods: this was a cross-sectional study, using data from medical records involving 89 newly diagnosed with sle (aged ≤18 years) in department of child health dr. hasan sadikin general hospital, bandung, from january 1, 2018 to june 30, 2019. data of ana pattern and proteinuria were collected from medical record. ana pattern was examined by immunofluorescence assay (ifa) method. chi-square was used to analyze the association between ana pattern and proteinuria as a sign of renal involvement in pediatric sle patients. results: there were 89 patients, consisting of 7 male (7.9%) and 82 female (92.%) with median age of 14 (iqr=12–16). there were only 44 pattern of ana as follow: homogenous 56.8%, speckled 36.4%, and nucleolar 6.8%. however, there is no significant association between homogenous pattern with proteinuria events (p=0.831). conclusions: homogenous pattern was the most frequent ana pattern in children with sle, and the pattern has no association with proteinuria events. keywords: antinuclear antibody pattern, indirect immunofluorescence assay; proteinuria, systemic lupus erythematosus received: january 3, 2020 accepted: may 21, 2020 pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ ijihs.v8n1.1911 ijihs. 2020;8(1):38–42 original article introduction systemic lupus erythematosus (sle) is a chronic autoimmune disease characterized by a loss of tolerance from the immune system and formed autoantibodies. the autoantibody also known as anti-nuclear antibody (ana) which have many subtypes that can attack self-antigens and cause inflammation in several organs, such as skin, joints, kidneys, blood-forming cells, blood vessels, and central nervous system.1,2, 3,4 ana test is one of tests that used for helping diagnose autoimmune international journal of integrated health sciences 39 three major categories, namely nuclear (such as homogeneous, speckled, centromere, nucleardots and nucleolar), cytoplasmic and mitotic patterns. the results of the titer and ana pattern will be varied in each patients.7,15,16 systemic lupus erythematosus can occur in both adults and children. however, when compared with adults, children and adolescents have a higher risk of severity and involvement of other organs as a manifestation in sle.5,6 the most common and difficult manifestation of sle is renal involvement. the involvement of the renal as a clinical manifestation will cause inflammation in the renal called nephritis.5,6,8 one of the result of the inflammation is the presence of protein in the urine, which called proteinuria. in the case of pediatric sle, lupus nephritis is more common in females than males with a ratio of 8-13: 1 and in the age range of 14-16 years.5 also, pediatric sle with nephritis having poorer prognosis than others without nephritis.8,9 the study about relevance of ana in sle has been adressed repeteadly. through the studies, ana is known to have a correlation with the clinical manifestations of sle, especially in patient with positive antitable 1 characteristics of systemic lupus erythematosus patients characteristics total (n=89) age (years) median [iqr] 14 (12–16) gender (n, %) boys 7 (7.9%) girls 82 (92.1%) skin manifestation (n, %) malar rash discoid rash photosensitivity mouth ulcers 32 (44.4%) 14 (22.6%) 29 (36.7%) 12 (19.7%) renal manifestation (n, %) proteinuria hematuria hematological manifestation (n, %) anemia leukopenia thrombocytopenia neuropsychiatric manifestation (n, %) 46 (51.7%) 42 (47.2%) 61 (77.2%) 19 (24.1%) 10 (12.7%) 7 (9.2%) dsdna and/or anti-sm. the presence of anti-dsdna was found to be associated with renal disorder, haematological involvemnet and serositis, meanwhile patient with antism had the highest frequency of malar rash, oral ulcers, arthritis, and serositis.18 whereas, studies about ana pattern and its relation with the clinical manifestation of sle are very scarce especially proteinuria. a few studies stated, there were no association between ana pattern and clinical manifestation of sle, frodlund m et al. observed that some pattern may have an association with the clinical manifestation of sle.10,12,13,14 however, this finding needs more confirmation by others.10,14,17,18 this study is aimed to determine the association between ana pattern in pediatric sle patients and proteinuria as a sign of renal involvement in department of child health hasan sadikin bandung general hospital. methods this was a cross-sectional study conducted of 89 subejct newly diagnosed patients with systemic lupus erythematosus (aged ≤18 years), in department of child health dr. hasan sadikin general hospital, bandung, from january 1st 2018 until june 30th 2019. secondary data from medical records of newly diagnosed with sle were used in this study. data of age, gender, ana pattern, and proteinuria were collected from the medical records. ana pattern was examined by immunoflourecence assay method. data was taken after obtaining ethical clearance issued by health research ethics committee of universitas padjadjaran bandung no. 719/ un6.kep/ec/2019 and research licensing letter issued by research ethics committee of dr. hasan sadikin general hospital bandung no. lb.02.01/x.2.2.1/10047/2019. microsoft® excel 2013 and ibm® spss® version 20 were used to process the data. chisquare was used to analyze the association between ana pattern and proteinuria as a sign of renal involvement in sle and p<0.05 was considered statistically significant. results there were 89 subjects, consisting of 7 male and 82 female with median age of 14 (iqr=12– 16) (see table 1). besides hematological manifestation, renal was the most frequent manifestation in pediatric sle patients (see table 1). pattern of ana was analyzed and fadhila novianti, reni ghrahani, et al. 40 international journal of integrated health sciences homogenous was the most common type followed by speckled, and nucleolar (table 2). further data processing was performed with chi-square to assess the association between ana pattern and proteinuria events as a sign of renal involvement in pediatric sle patients (table 3). there is no significant association between homogenous pattern with proteinuria events. discussion based on the study, it is known that the subjects are mostly girls. similar with the result of other studies that have been done, one of them is study from almaani s, et al. which stated that the most of children with sle were girls than boys, with female-to-male ratio range between 8-13 : 1 and in the age range of 14-16 years.5 this finding was because of hormonal factors such as sex steroids which are owned by girls, thus will increasing the risk of sle.1,6 in patients with sle, we can find the presence of ana. ana is autoantibodies which formed by the immune system that can attack self-antigen and cause inflammation in many tissues and organs.1,2,3,4,5 ana test is a primary test to determines the presence of ana. despite this, acr 1997 recommends immunoflourecence assay (ifa) method as a gold standard of ana test, because it can help the clinician to diagnose the patient more specifically and reduce risk of false positive or errorneous based on the results of the test. from the test, the clinician might see the titers and patterns ana of the patient.7,15,16,19 however, only few patients are checked for table 2 ana pattern of systemic lupus erythematosus patients category total (n=44) homogenous (n, %) speckled (n, %) nucleolar (n, %) 25 (56.8%) 16 (36.4%) 3 (6.8%) ana with ifa method, while the rest patients only reported whether ana is reactive or nonreactive.10,11 according to the icap, ana have associated with some autoimmune diseases which show based on the staining pattern. homogeneous patterns was common in sle, drug-induced lupus, and juvenile idiopathic arthritis (jia) patients, while speckled was common in mixed connective tissue disease (mctd), sle, sjogren syndrome (sjs), and systemic sclerosis (ssc) patients.15,17 in this study, ana pattern of the patients only homogeneous, speckled, and nucleolar. the most frequent pattern was homogeneous (56.8%) followed by speckled (36.4%), and nucleolar (6.8%). this is similar with the study of yilmaz o et al. which reported homogenous pattern were the most common patterns, the result of the study showed that homogenous pattern in more than half of their patients.13 but differ with the study of ghrahani r, et al. which are speckled (40.3%) was the most frequent of ana pattern, followed by nucleolar (16.1%), nucleardot (9.7%), and combination of nucleardot with speckled (3.2%).10 also, mengeloglu z, et al. reported speckled patterns were the most common patterns.12 frodlund m et al. observed that ana is known to have a correlation with the clinical manifestations of sle, especially in patient with positive anti-dsdna and/or anti-sm. the presence of anti-dsdna was found to be associated with renal disorder, haematological involvement, and serositis, meanwhile patient with anti-sm had the highest frequency of malar rash, oral ulcers, arthritis, and serositis. some ana pattern may have an association with the clinical manifestation of sle. organ damage was less common among patients with speckled pattern. however, this finding needs more confirmation by others.18 there is no association between ana pattern with the proteinuria events in this study. this result is similar with the study of ghrahani r, et al. which stated that there was no association between ana pattern table 3 association between ana pattern and proteinuria events category proteinuria p or(95% ci)positive negative ana pattern (n=44) 0.831* 0.875 (0.256–2.989)homogenous 15 12 non homogenous 10 7 *chi-square test, or: odds ratio, ci: confidence interval pattern of indirect immunofluorescence assay antinuclear antibody in pediatric lupus nephritis international journal of integrated health sciences 41 1. vinay k, abul ka, jon ca. robbins and cotran pathologic basis of disease. 9th edition. philadelphia: elsevier saunders. 2014. p. 211– 226. 2. lehman tja, taber sf, nuruzzaman f. systemic lupus erythematosus in childhood and adolescence. in: dubois’ lupus erythematosus and related syndromes. 9th ed. elsevier inc. 2018. p. 520–531. 3. samanta m, nandi m, mondal r, hazra a, sarkar s, sabui t, et al. childhood lupus nephritis: 12 years of experience from a developing country’s perspective. eur j rheumatol. 2017;4(3):178– 183. 4. kasjmir yi, handono k, wijaya lk, hamijoyo l, albar z, kalim h, et al. rekomendasi perhimpunan reumatologi indonesia untuk diagnosis dan pengelolaan lupus eritematosus sistemik. 2011. p. 1–54. 5. almaani s, meara a, rovin bh. update on lupus nephritis nephrology rounds. clin j am soc nephrol. 2017;12:825–35. 6. szymanik-grzelak h, kuźma-mroczkowska e, małdyk j, pańczyk-tomaszewska m. lupus nephritis in children-10 years’ experience. cent eur j immunol. 2016;41(3):248–54. 7. lam n-cv, ghetu m v, bieniek ml. systemic lupus erythematosus: primary care approach to diagnosis and management. am fam physician. 2016;94(4):284–94. 8. sinha r, raut s. pediatric lupus nephritis: management update. world j nephrol. 2017;3(2):16. 9. zhu j, wu f, huang x. age-related differences in the clinical characteristics of systemic lupus erythematosus in children. rheumatol int. 2013;33(1):111–15. 10. ghrahani r, setiabudiawan b, sapartini g. karakteristik pola antibodi antinuklear pada anak dengan systemic lupus erythematosus serta komplikasinya. j indon med assoc. 2012;62(7:)273–76. 11. gomez rla, uribe u, uribe o, romero hg, cardiel mh, wojdyla d, et al. childhood systemic lupus erythematosus in latin america: the gladel experience in 230 children. lupus. 2008;17(6):592–604. 12. mengeloglu z, tas t, kocoglu e, aktas g, karabork s. determination of anti-nuclear antibody pattern distribution and clinical relationship. pak j med sci. 2014;30(2):380–3. 13. yilmaz o, karaman m, ergon mc, bahar ih, yulug n. comparison of indirect immunoflourescence and enxyme immunoassay methods for the determination of antinuclear antibodies. mikrobiyol bul. 2014;38(1-2):85–90. 14. damoiseaux j, andrade lec, carballo og, conrad k, francescantonio plc, fritzler mj, et al. clinical relevance of hep-2 indirect immunoflourescent patterns: the international concensus on ana patterns (icap) perspective. ann rheum dis. 2019;78:879–89. 15. damoiseaux j, andrade lec, carballo og, conrad k, francescantonio plc, fritzler mj, et al. international consensus on ana patterns (icap): the bumpy road towards a consensus on reporting ana results. 2016;7(1);1–8. 16. cruvinel wdm, andrade lec, von mühlen ca, dellavance a, ximenes ac, bichara cd, et al. v brazilian consensus guidelines for detection references with the proteinuria events with chi-square test p=0.680.10 it can be said that there is no difference with the studies even though being conducted in the different periods and the same place. damoiseaux j, et al stated that there are several reasons for not finding an association between the ana pattern and the manifestations of the disease. first, determination of the patterns in laboratories is inconsistent because of the subjectivity and experienced of the staff in interpretation the results. second, healthy individual may have autoantibodies. third, the result of the patterns may slightly differ depending on the substrate used.14,17 this study had several limitations, the data was collected retrospectively and not all samples have the variables needed (i.e. anti nuclear antibody pattern), based on this study, we concluded that ana can be checked by ifa. by the test, clinician might see the different types of ana through staining pattern. in this study, homogenous pattern was the most frequent ana pattern in patient with sle. renal involvement was common in children and adolescents compared to adults patient with sle, besides hematological involvement. involvement of the renal can cause inflammation and one of the result is the presence of proteinuria. the homogeneous pattern has no association with proteinuria events. fadhila novianti, reni ghrahani, et al. 42 international journal of integrated health sciences of anti-cell autoantibodies on hep-2 cells. adv rheumatol. 2019;59(1):28. 17. chan ekl, damoiseaux j, cruvinel wdm, carballo og, conrad k, francescantonio plc, et al. report on the second international consensus on ana patterns (icap) workshop in dresden 2015. lupus. 2016;25:797–804. 18. frodlund m, dahlstrom o, kastbom a, skogh t, sjowall c. associations between antinuclear antibody staining patterns and clinical features of systemic lupus erythematosus: analysis of a regional swedish register. bmj open. 2013;3(6):1–8. 19. ricchiuti v, adams j, hardy dj, katayev a, fleming jk. automated processing and evaluation of anti-nuclear antibody indirect immunofluorescence testing. front immunol. 2018;9:927. pattern of indirect immunofluorescence assay antinuclear antibody in pediatric lupus nephritis volume 8 no 1 2020 v2.indd 32 international journal of integrated health sciences comparison of cognitive functions between paroxysmal and persistent atrial fibrillation patients without clinical stroke correspondence: caepy gomer, department of neurology, faculty of medicine universitas padjadjaran-dr. hasan sadikin general hospital, bandung, indonesia e-mail: caepygomer@gmail.com caepy gomer,1 paulus anam ong,1 sobaryati sobaryati,1 badai bhatara tiksnadi2 1 department of neurology, faculty of medicine universitas padjadjaran-dr. hasan sadikin general hospital, bandung, indonesia 2 department of cardiology and vascular medicine, faculty of medicine universitas padjadjaran-dr. hasan sadikin general hospital, bandung, indonesia abstract objective: to compare cognitive functions between paroxysmal and persistent atrial fibrillation patients without clinical stroke, in terms of moca-ina total score and moca-ina cognitive subdomains scores. methods: a comparative study that compared moca-ina scores between paroxysmal and persistent af patients without clinical stroke, who came for treatment at the cardiology clinic dr. hasan sadikin general hospital, bandung and dustira hospital, cimahi from september 2018–january 2019. results: sixty four subjects were recruited, consisted of 24 paroxysmal and 40 persistent af patients. there were no difference in clinical characteristics between two groups, except that there were more subjects in the persistent af group using anticoagulants therapy: 97.5% vs 62.5% (p=0.005) and more prevalence of type 2 diabetes mellitus in the paroxysmal af group: 25% vs 2.5% (p=0.009). cognitive impairment (moca-ina score <25) were seen in 70.8% of paroxysmal af group and 82.5% of persistent af group (p=0.274). the mean moca-ina total score in the paroxysmal and persistent af groups were 21.04±4.75 vs 20.70±4.21 (p=0.989), respectively. the median moca-ina cognitive subdomains scores were similar for the two groups (p>0.05). conclusion: there were no differences in cognitive functions between paroxysmal and persistent af patients, both in terms of moca-ina total score and moca-ina cognitive subdomains scores, although in both groups had cognitive decline. keywords: atrial fibrillation, cognitive impairment, moca-ina, paroxysmal af, persistent af received: january 28, 2020 accepted: may 16, 2020 pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ ijihs.v8n1.1974 ijihs. 2020;8(1):32–7 original article introduction many studies have reported a significant association between atrial fibrillation (af) and cognitive impairment and a faster incidence of dementia, both with and without the occurrence of clinical stroke that preceded it.1,2 the prevalence of mild cognitive impairment (mci) and dementia in af patients was estimated at 40%, higher than patients without af.2,3 the mechanism of cognitive impairment in af patients is mostly related to the incidence of cardioembolic stroke, but it is well known that without a stroke, af also can cause cognitive impairment. although the mechanisms that play a role in this case are not fully understood, several hypotheses have been stated i.e the occurrence of the silent cerebral infarct (sci), cerebral hypoperfusion, vascular inflammation and processes involving small vessels (small vessel disease/svd).3-5 paroxysmal and persistent af are thought to have different pathophysiology of thrombus formation. some experts argue that the short international journal of integrated health sciences 33 duration of af in paroxysmal af patients is associated with smaller and newly formed thrombus so that early recanalization is easier. in the contrary, thrombus in the persistent af may be larger due to the larger size of the left atrial auriculum. besides that the thrombus in persistent af is more organized and stronger so that it tends to respond less to early recanalization. in addition, persistent af is also associated with a greater number of lesions than paroxysmal af. therefore, persistent af is considered more associated with a higher incidence of sci and lower cognitive function as compared to paroxysmal af, even without previous stroke events.6 the moca-ina test (indonesian version of montreal cognitive assessment) is one of the most frequently used and validated test for cognitive impairment screening.7 this test has a higher sensitivity and specificity in diagnosing mild cognitive disorders compared to the mmse (mini mental state examination) test because it covers all cognitive domains including executive functions.8 this study was aimed to compare cognitive function between paroxysmal and persistent af patients without a clinical stroke, in terms of moca-ina total score and moca-ina cognitive subdomains score. methods this was a comparative study of adult patients (age >18 years) with paroxysmal and persistent af in the cardiology clinic at hasan sadikin hospital bandung and dustira hospital cimahi. patients were excluded if they have had one of the following: a history of clinical stroke, diagnosed as rheumatic heart disease (rhd), a history of central nervous system abnormalities (i.e epilepsy, parkinson’s disease, multiple sclerosis, moderate to severe head injury or brain infections), a history of systemic abnormalities (i.e moderate to severe congestive heart failure, chronic kidney disease, routine hemodialysis or hivaids), using memory enhancer or other psychopharmaceutical drugs and had a severe impaired vision, hearing and motor function that hampered the examination. ethical approval from the health research ethics committee of the dr. hasan sadikin general hospital bandung under the ethical clearance no. lb.04.01/a05/ec/273/ ix/2018 was gained prior the study. sampling was conducted consecutively from september 2018 to january 2019. a comprehensive range of sociodemographic and clinical data were collected through questionnaires. cognitive function data was obtained through the mocaina test. the elegible subjects were examined with moca-ina test after signing the informed consent. the moca-ina test was performed by a trained neurology resident. moca-ina total score and moca-ina cognitive subdomains scores were compared between the two af groups. the research datas are described using tables according to the variables identified during the study. data was analyzed using spss version 24.0 for windows. the probability value p<0.05 is considered statistically significant. results sixty four subjects were recruited during the study’s period, consisted of 24 paroxysmal and 40 persistent af patients. the comparison of the basic characteristics of the subjects between the two af groups was shown on table 1. there were no significant differences in demographic characteristics (age, gender and education level) between the two af groups, so that both of groups could be considered homogeneous and could be compared. from the clinical characteristics there were also no statistically significant difference, except for the history of taking anticoagulant therapy and the presence of type 2 dm variables, where there were more subjects in the persistent af group who used anticoagulant therapy i.e. 97.5% vs 62.5% (p=0.005) and more comorbidities of type 2 dm in the paroxysmal af group of 25% vs 2.5% (p=0.009). both of these variables may act as confounding variables which can influence further statistical analysis. the comparison of the results of the mocaina test of the subjects between the two af groups was shown on table 2. cognitive impairment (moca-ina total score <25) were found in paroxysmal and persistent af groups (82.50% vs 70.80%, p=0.274). similarly, the moca-ina total score was decrease in the both af groups with a mean of 21.04±4.75 vs 20.70±4.27 (p=0.989), respectively for the paroxysmal and persistent af groups. moca-ina cognitive subdomain score were low in both groups, especially the executive functioning and memory, but did not show a statistically significant difference. (table 2). domains that were mostly disturbed in the paroxysmal af group were the executive functioning (95.8%), memory (87.5%) and language (79.2%), while in the persistent af group were memory (95%), executive caepy gomer, paulus anam ong, et al. 34 international journal of integrated health sciences table 1 subject characteristics variable group p–valueparoxysmal af persistent af (n=24) (n=40) age (years) 61.32±11.45 60.12±9.59 0.655 mean±sd gender 8 (33.30%) 16 (40.00%) 0.594 male 16 (66.70%) 24 (60.00%) female education (years) 9.00 9.00 0.412 median 6.00–16.00 6.00–16.00 range (min–max) occupation 23 (95.80%) 38 (95.00%) 1.000 active 1(4.20%) 2 (5.00%) not active duration of af (years) 2.25 4.00 0.237 median 0.02–20.00 0.08–21.00 range (min–max) antiarrhythmic therapy 22 (91.70%) 38 (95.00% 0.627 yes 2 (8.30%) 2 (5.00%) no anticoagulant therapy 12 (50.00%) 38 (95.00%) 0.005* warfarin 3 (12.50%) 1 (2.50%) noac 9 (37.50%) 1 (2.50%) none inr value 21(87.50%) 24 (60.00%) 0.207 <2 3 (12.50%) 10 (25.00%) 2–3 0 (0.00%) 6 (15.00%) >3 0 6 comorbidities hypertension 16 (66.70%) 19 (47.50%) 0.136 type 2 dm 6 (25.00%) 1 (2.50%) 0.009* ischemic heart disease 12 (50.00%) 12 (30.00%) 0.110 heart failure 12 (50.00%) 28 (70.00%) 0.110 cha2ds2–vasc scores median 3.00 3.00 0.068 range (min–max) 1.00–6.00 0.00–5.00 note: *statistically significant, sd: standard deviation, min: minimal, max: maximal, af: atrial fibrillation, noac: non vitamin k–antagonist oral anticoagulant, inr: international normalized ratio, dm: diabetes mellitus, cha2ds2–vasc: congestive heart failure, hypertension, age ≥75 years, diabetes, stroke, vascular disease, age ≥65 years, sex category– female functioning (90%) and attention (82.5%). orientation domain was less disturbed in both groups. (table 2) discussion in this study, cognitive impairment in af patients was prominent, as shown by the high proportion of low moca-ina total score and its cognitive subdomain score. the average moca-ina total score in this study was lower than the average moca total score for the normal population with the same age (23.20 ± 3.96).9 the proportion of cognitive impairment in this study were almost the same with one study in indonesia, that was 86.70%, with mean moca-ina total score was 21.77±2.87.10 deficits in executive functioning and memory comparison of cognitive functions between paroxysmal and persistent atrial fibrillation patients without clinical stroke international journal of integrated health sciences 35 were common, as were overlapping deficits across multiple cognitive subdomains.11 in– this study there was no statistically significant difference in cognitive function between paroxysmal and persistent af patients. this condition was also failed to be shown in some previous studies, although some clinical parameters showed differences between the two groups.12,13 on the contrary, several previous studies had found significant differences in cognitive function between patients with paroxysmal and persistent af, but with different cognitive examinations.6,14,15 these different results might be causes table 2 results of moca–ina test variable group p–valueparoxysmal af persistent af (n=24) (n=40) cognitive decline based on moca–ina score 0.274 ≥25 7 (29.20%) 7 (17.50%) <25 17 (70.80%) 33 (82.50%) moca–ina total score mean±sd 21.04±4.75 20.70±4.27 0.989 attention domain median score 4.00 4.00 0.938 range (min–max) 2.00–6.00 0.00–6.00 normal 6 (25.0%) 7 (17.5%) abnormal 18 (75.0%) 33 (82.5%) 0.470 memory domain median score 2.00 2.00 0.943 range (min–max) 0.00–5.00 0.00–5.00 normal 3 (12.5%) 2 (5.0%) abnormal 21 (87.5%) 38 (95.0%) 0.355 language domain median score 4.00 4.00 0.842 range (min–max) 1.00–6.00 2.00–6.00 normal 5 (20.8%) 9 (22.5%) abnormal 19 (79.2%) 31 (77.5%) 0.876 visuospatial domain median score 3.00 3.00 0.825 range (min–max) 2.00–4.00 2.00–4.00 normal 9 (37.5%) 15 (37.5%) abnormal 15 (62.5%) 25 (62.5%) 1.000 executive functioning domain median score 1.00 1.00 0.611 range (min–max) 0.00–4.00 0.00–4.00 normal 1 (4.2%) 4 (10.0%) abnormal 23 (95.8%) 36 (90.0%) 0.642 orientation domain median score 6.00 6.00 0.993 range (min–max) 3.00–6.00 2.00–6.00 normal 16(66.7%) 27(67.5%) abnormal 8(33.3%) 13(32.5%) 0.945 note: sd: standard deviation, min: minimal, max: maximal, moca–ina: indonesian version of montreal cognitive assesment, af: atrial fibrillation caepy gomer, paulus anam ong, et al. 36 international journal of integrated health sciences by several things i.e differences in the characteristics of the subjects, differences in the methodology, differences in cognitive function tests and differences in other comorbidities that can also affect cognitive function. in this study, between the two af groups there were significant differences in two variables of clinical characteristics i.e the anticoagulant therapy and comorbidity of type 2 dm (table 1). these two variables in the paroxysmal af group could cause more severe cognitive impairment than they should be. the majority of subjects in this study, especially the paroxysmal af group, received less anticoagulant therapy and did not achieved therapeutic inr range so that they were at high risk for thromboembolism, including microemboli which could cause microinfarct in the brain, leading a cognitive impairment. this was in accordance with several previous studies, who stated that anticoagulant therapy and therapeutic inr were important to prevent embolism.16,17 futhermore, there was more comorbidity of type 2 dm in the paroxysmal af group, where as it was known that af patients who had type 2 dm comorbidity would have a higher tendency for cerebral ischemic which of course will have a negative impact on cognitive function, as showed in some previous studies.18,19 however, subsequent analysis of these two variables, both with multiple regressions (with adjusted) and other subanalysis, showed that there were no significant effects of these two variables on the analysis of the comparison of moca-ina scores between the paroxysmal and persistent af groups, even though the characteristics of the two variables significantly different between the two groups. one reason that can be considered is whether there are differences in the characteristics of anticoagulant therapy and comorbidity of type 2 dm variables which have not been further evaluated in this study such as the small number of samples with type 2 dm comorbidity, the effect of type 2 dm treatment and glycemic control, duration of drug use, compliance, the type of drug, the effectiveness and drug interactions that might be different in the two af groups thus affecting the results of this study. the results of several additional analyses above, most likely indeed illustrate that in this study most patients in the paroxysmal af group had cognitive decline as well as in the persistent af group. although not in line with the differences in the pathophysiology of thrombus formation described previously, this is still possible because both groups have a median cha2ds2-vasc score =3 which means that they have a high risk of thromboembolism/ microembolism as well as the risk of sci. several studies linking cha2ds2-vasc scores with cognitive impairment, reported a 2-fold increased risk of cognitive decline in patients with a score of ≥3.2,11 nowadays screening and administration of anticoagulants in af patients is not based on af type but based on thromboembolic risk, one of which is using the cha2ds2-vasc score. 20 many guidelines have recommended the administration of anticoagulants for paroxysmal af patients with the same criteria as those applied to persistent af patients.21 by assuming that cognitive impairment is a predictor of sci in paroxysmal af patients, it is expected that different approaches can be given for the management of paroxysmal af patients, such as periodic cognitive function screening, neuroimaging examination to see lesions of sci and most importantly, early anticoagulant therapy can be given to the patients with impaired cognitive function even though the cha2ds2-vasc score <2. in addition to sci, several other mechanisms need to be considered as the pathophysiology that causes cognitive impairment in af patients, such as cerebral hypoperfusion and vascular inflammation.4 however, there has been no studies that specifically analyzed them in paroxysmal and persistent af patients. furthermore, this study also did not collect and analyze variables that might be different in the two af groups based on the above mechanisms, such as measurement of cardiac output or cardiac index which could be indicators of cerebral hypoperfusion or measurement of inflammatory mediators that could support the presence of vascular inflammation. in conclusion, cognitive function in paroxysmal af patients did not show differences with persistent af patients in terms of moca-ina total score and mocaina cognitive subdomain score. both af groups had lower cognitive function than the general population without af. therefore, it is important to screen cognitive function in all af patients using the moca-ina test, besides that it is necessary to consider giving anticoagulants for the prevention of stroke or sci in af patients. comparison of cognitive functions between paroxysmal and persistent atrial fibrillation patients without clinical stroke international journal of integrated health sciences 37 caepy gomer, paulus anam ong, et al. 1. singh–manoux a, fayosse a, sabia s, canonico m, bobak m, elbaz a, et al. atrial fibrillation as a risk factor for cognitive decline and dementia. eur heart j. 2017;38(34):2612–8. 2. alonso a, knopman ds, gottesman rf, soliman ez, shah aj, o’neal wt, et al. correlates of dementia and mild cognitive impairment in patients with atrial fibrillation: the atherosclerosis risk in communities neurocognitive study (aric-ncs). j am heart association. 2017;6(7):e006014. 3. alonso a, de larriva apa. atrial fibrillation, cognitive decline and dementia. eur cardiol rev. 2016;11(1):49–53. 4. rivard l, khairy p. mechanisms, clinical significance, and prevention of cognitive impairment in patients with atrial fibrillation. canadian j cardiol. 2017;33(12):1556–64. 5. kalantarian s, ay h, gollub rl, lee h, retzepi k, mansour m, et al. association between atrial fibrillation and silent cerebral infarctions: a systematic review and meta–analysis. ann intern med. 2014;161(9):650–8. 6. gaita f, corsinovi l, anselmino m, raimondo c, pianelli m, toso e, et al. prevalence of silent cerebral ischemia in paroxysmal and persistent atrial fibrillation and correlation with cognitive function. j am college cardiol 2013;62(21):1990–7. 7. husein n, lumempouw s, ramli y, herqutanto. montreal cognitive assessment versi indonesia (moca–ina) untuk skrining gangguan fungsi kognitif. neurona. 2010;27(4):1–13. 8. nasreddine zs, phillips na, bédirian 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. 9. rossetti hc, lacritz lh, cullum cm, weiner mf. normative data for the montreal cognitive assessment (moca) in a population–based sample. neurology. 2011;77(13):1272–5. 10. salam s, muis a, aliah a, akbar m, kabo p, jaya ganda i. hubungan fibrilasi atrium dengan gangguan kognitif. 2014 april [cited 2018 january 14]. available from: http://repository. unhas.ac.id/handle/123456789/9626. 11. ball j, carrington mj, stewart s, investigators s. mild cognitive impairment in high–risk patients with chronic atrial fibrillation: a forgotten component of clinical management?. heart. 2013;99(8):542–7. 12. knecht s, oelschläger c, duning t, lohmann h, albers j, stehling c, et al. atrial fibrillation in stroke–free patients is associated with memory impairment and hippocampal atrophy. european heart journal. 2008;29(17):2125– 32. 13. gardarsdottir m, sigurdsson s, aspelund t, rokita h, launer lj, gudnason v, et al. atrial fibrillation is associated with decreased total cerebral blood flow and brain perfusion. ep europace. 2018;20(8):1252–8. 14. rozzini r, sabatini t, trabucchi m. chronic atrial fibrillation and low cognitive function. stroke. 1999;30(1):190–1. 15. chen ly, agarwal sk, norby fl, gottesman rf, loehr lr, soliman ez, et al. persistent but not paroxysmal atrial fibrillation is independently associated with lower cognitive function: aric study. j am college cardiol. 2016;67(11):1379– 80. 16. jacobs v, woller sc, stevens s, may ht, bair tl, anderson jl, et al. time outside of therapeutic range in atrial fibrillation patients is associated with long–term risk of dementia. heart rhythm. 2014;11(12):2206–13. 17. demir s, ozdag mf, kendirli mt, togrol re. what do anticoagulants say about microemboli?. j stroke cerebrovascular dis. 2015;24(11):2474–7. 18. marseglia a, fratiglioni l, kalpouzos g, wang r, bäckman l, xu w. prediabetes and diabetes accelerate cognitive decline and predict microvascular lesions: a population– based cohort study. alzheimers dement. 2019;15(1):25–33. 19. gudala k, bansal d, schifano f, bhansali a. diabetes mellitus and risk of dementia: a metaanalysis of prospective observational studies. j diabetes investig. 2013;4(6):640–50. 20. jia x, levine gn, birnbaum y. the cha2ds2– vasc score: not as simple as it seems. int j cardiol. 2018;257:92–6. 21. freedman b, potpara ts, lip gy. stroke prevention in atrial fibrillation. lancet. 2016;388(10046):806–17. references volume 9 no 2 2021 fix.indd international journal of integrated health sciences (iijhs) 73 introduction spinal cord infarction (sci) is a rare disease and constitutes one of the acute spinal emergencies. in comparison to brain ischemic stroke, the spinal cord infarction it presents an extremely low incidence, perhaps due to the abundance of the arterial anastomosis and low evidence of atherosclerosis in the spinal arteries. since the first spinal cord infarction reported in early nineteenth century, there have been remarkable progresses in the understanding of this disease entity.1 review on acute cardio-cerebral infarction: a case report abstract objective: to describe a case of a cardio-cerebral infarction (cci) male patient presented with a history of chest pain recognized using electrocardiography, brain computed tomography, and percutaneous coronary intervention (pci). methods: a 69 years old man came with history of chest pain since 13 hours before to the emergency room. electrocardiography, brain computed tomography, and pci were performed, leading to the diagnosis of cci. results: the electrocardiography showed st elevation in antero-lateral, atrial fibrillation and left-sided hemipharesis, which occurred on the second day. brain computed tomography demonstrated acute infarct stroke, while the percutaneous coronary intervention (pci) showed one vessel disease with severe stenosis in lad and implanted stent in proximal-mid lad. therapy prescribed was providing antiplatelet and anticoagulation. discussion: acute myocardial infarction (ami) and acute infarct stroke (ais) have a narrow therapeutic time-window and a delayed intervention may results in morbidity and death. antiplatelet and anticoagulant used in pci for ami increase the risk for hemorrhagic, and ais with thrombolytic increase the risk of cardiac wall rupture in ami. direct oral anticoagulant (doac) treatment should reduce ischaemia and lower bleeding. the optimal time point to start anticoagulant treatment might be between 4-14 days after the onset of stroke. duration of post-pci triple therapy should be minimized depending on bleeding and risks of ischemia. keywords: infarction, magnetic resonance, relapse, spinal cord received: january 14, 2020 accepted: september 28, 2021 case report maria sofia cotelli,1 filippo manelli2 1neurology unit asst valcamonica esine, italy 2emergency unit, asst valcamonica esine, italy pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ ijihs.v9n2.1962 ijihs. 2021;9(2):73–78 correspondence: maria sofia cotelli, neurology unit asst valcamonica esine, italy, e-mail: cotellim@gmail.com however, the fact that there is no established standard of care treatment as of today highlights the complexity and challenging nature of sci.1 here we report the case of 84 years-old man who suffered from spine infarction with relapse after initial improvement. case this case of 84 years-old caucasian man who was in hospitalized due to sudden appearance, since about one month, of lumbar pain, bilateral lower limbs weakness, paresthesias from the knees to feet, associated with urge incontinence. computed tomography (ct) without contrast was normal. his vital signs upon arrival at the emergency 74 international journal of integrated health sciences (iijhs) were bilaterally moderately brisk at the lower limb with mild prevalence at the left al while babinski resulted mildly positive at left arm. his medical history was positive for chronic anemia due to iron deficiency and colon cancer about three years before, surgically treated with left hemicolectomy. he was previously a heavy smoker (he used to smoke about one package of cigarettes in a day for about forty years, at the time of in-hospitalization, used to smoke 8 cigarettes in a day). he performed spine magnetic resonance imaging (mri) (fig. 1) showing hyperintensity at posterior lateral columns of d10-d12 at diffusionweighted imaging (dwi), without bleedings or expansive lesions and without enhancement after gadolinium. digital subtraction angiography was not performed and no sign of radiculomedullary artery was detected. heart and abdomen ultrasounds resulted all negative except for mild aortic valve stenosis and aortic calcifications. brain mri showed subcortical ischemic lacunae. carotid ultrasound showed calcific plaques involving internal carotid arteries bilaterally the internal carotid artery (ica), which resulted in a bilateral stenosis of about 30–35%. 24hour holter monitoring resulted normal. blood exams resulted negative except for triglycerides (263 mg/dl normal value <150), cholesterol (238 mg/dl normal value<190). routine immunodeficiency virus and syphilis screening, antinuclear antibodies, extractable nuclear antigen antibodies, cytoplasmic neutrophil antibodies resulted all normal. he was discharged and rehabilitation room were as follows: body temperature, 36.2°c; pulse rate, 67 beats per minute; respiratory rate, 16 breaths per minute; blood pressure, 140/80 mm hg; and oxygen saturation, 98% on ambient air. neurological examination at inhospitalization showed bilateral weakness (4/5 medical research council at the right lower arm, 3/5 at the left lower arm), with persistent paresthesias from the knees with distal spreading. osteo-tendineous reflexes fig. 1 dwi sequences showing d10-d12 hyperintensity fig. 2 dwi sequences showing relapse of stroke involving also the medullary cone review on acute cardio-cerebral infarction: a case report international journal of integrated health sciences (iijhs) 75 was promptly started. urinary catheter was inserted due to persistent urinary incontinence. antiaggregation with acetylsalicylic acid 100 mg 1/day was started, together with subcutaneous low molecular weight heparin (lmwh 4000 ui/day) and rosuvastatin 10 mg/day. neurological weakness improved in the first ten days, but, suddenly, he developed lower limbs paraplegia with bilateral hypoesthesia from the thighs with paresthesias at left limb from the knee to foot. neurological examination showed lower limbs areflexia with negativity of babinski. contemporary lone atrial fibrillation with rapid ventricular response (160 beats per minute) was detected at monitor, so intravenous diltiazem was promptly started together with contemporary anticoagulation oral therapy with warfarin (maintaining inr between 2 and 3). central pain at the lower limb was controlled with oxycodone-naloxone and pregabalin. spine mri showed, at dwi sequences, relapse of stroke involving also the medullary cone (fig. 2). both magnetic resonances had to be quickly interrupted due to patient’s intolerance with continuous movements. axial sequenced resulted full of artifacts and unreliable. clinical course was complicated by left orchitis urinary tract infection (uti) due to klebsiella pneumoniae. lower limbs movement didn’t improve and urinary catheter was maintained. ethics approval and informed consent to participate were both given. discussion spinal cord ischemia (sci) is rare and represents only 1.2% of strokes.1 given the rarity, it may be misdiagnosed as other pathologic processes such as transverse myelitis.1 sudden reduction of blood flow to spinal cord gray matter or white matter, which results in disrupted oxygen and glucose delivery, causing metabolic failure of affected spinal cord tissue, constitute the main pathogenetic mechanism for sci.2 various etiologies that cause either global flow insufficiency or selective occlusion of a radiculomedullary artery.2, among which we can include atherosclerosis, coagulation disorders, vasculitis, infections, systemic hypotension, emboli, aortic dissection, decompression sickness.2 iatrogenic causes of spinal cord infarction include aortic stentgrafting, vascular surgery with aortic cross clamping, open hiatal hernia repair, lumbar sympathectomy, chest and abdomen surgery, adrenalectomy, and anesthetic procedures, such as epidural anesthesia, intercostal and celiac plexus block.2 the spinal cord receives its vascular support from three arteries: one anterior spinal artery (asa) and two posterior (psa) that span the length of the cord longitudinally. they originate from the vertebral arteries at the level of the craniocervical junction, anastomose via the vasocorona and transverse radicular branches forming the pial plexus, and in the end they originate perforating branches that can enter the spinal cord and supply different levels.3 the asa gives origin to the sulcocommissural artery, which is also responsible for providing blood supply to the anterior of the spinal cord.4, while the psa can generate posterior inferior cerebellar arteries (pica) and can also rely on posterior radicular arteries (originating from a vertebral artery) for vascular supply.4 five to eight of the radicular arteries can be actively involved in supplying the asa. in 90% of people one of the thoracolumbar arteries, known as the artery of adamkiewicz,4provides vascular perfusion to the lower thoracic, lumbar spinal cord and to the conus medullaris.1,2 high level of collateral circulation in spinal cord decrease its susceptibility to vascular injury4. perfusion of the anterior two-thirds of the spinal cord and the anterior portion of the posterior column occurs via the anterior spinal artery (asa), while the posterior remnant region is provided by the two posterior spinal arteries (psa).4 the psa supplies the posterior columns, posterior dorsal horns, portions of the corticospinal and spinothalamic tracts.4 each radicular artery supplies a different functional region of the spinal arteries, particularly the anterior spinal artery. the first region extends from c1 until t3.4 the second region extends from t3 until t7 and sometimes receives a branch from the intercostal artery (usually at t7 level).4 the third region extends from t8 to the cone and receives a branch (adamkiewicz artery) from the intercostal artery.4 there is sometimes a cone artery originating from the internal iliac artery (desproges-gotteron artery) at the l27 or l58 level.4 the most common clinical presentation of a spinal cord infarction is characterized by anterior spinal artery syndrome. anterior spinal artery infarct typically presents with bilateral weakness and pain/temperature hypo-anesthesia, with relative sparing of maria sofia cotelli and filippo manelli 76 international journal of integrated health sciences (iijhs) proprioception and vibration below the level of the lesion.5 the acute stages are characterized by sudden appearance of flaccidity and loss of deep tendon reflexes; spasticity and hyperreflexia develop during ensuing days and weeks. autonomic dysfunction may be also observed and can manifest as hypotension, sexual dysfunction, and/or bowelbladder dysfunction. if the lesion is in the rostral cervical cord, breathing can be compromised.5 ischemia may be localized at the level of the anterior horns; in this case, clinical presentations may be characterized by sudden paraplegia (pseudopoliomyelitic form) without sensory abnormalities or sphincter dysfunction, painful bilateral brachial diplegia (the man-in-the-barrel syndrome in cervical sci), progressive distal amyotrophy due to chronic lesions of the anterior horns.7 clinical features are variable, and include loss of vibratory sensation and proprioception, suspended global anesthesia and segmental areflexia due to posterior horn involvement, with paresis below the level at which the posterior portion of the lateral column containing the crossed corticospinal tract is affected.5 central sulcal artery occlusion can cause brown-sequard syndrome, which typically presents with ipsilateral weakness and posterior column sensory deficit (vibration and proprioception) below the lesion and contralateral decrease in pain and temperature sensation a few segments below the lesion.6 central cord syndrome may theoretically be a manifestation of spinal cord ischemia, but commonly result from cervical spondylosis, trauma, syringomyelia, or other tumors. location is the cervical or upper thoracic regions, involving the central portions of the spinal cord. the hallmark sign weakness in both the upper arms, with relative sparing of the legs. affected patients also have varying degree of sensory loss below the lesion and urinary retention.7-9 less common manifestations can be constituted by spinal cord transient ischemic attack, infarct of the conus medullaris, transverse medullary infarctions. laboratory examinations can include: blood cell count, copper, zinc, human t-lymphotropic virus 1 serology, vitamin b12, folate, homocysteine, cholesterol and tryglicerides, anti-cyclic citrullinated peptide, antiphospholipid antibodies, complement level essay, glucose, thyroid function, antinuclear antibody, anti-neutrophil cytoplasmic antibody, angiotensin-converting enzyme, aquaporin-4-igg, myelin oligodendrocyte glycoprotein, hypercoagulable profile, and paraneoplastic autoantibody assessment, erythrocyte sedimentation rate, c reactive protein, protein c, s, electrolytes, lyme disease, herpes virus, human immunodeficiency virus, human t-cell leukemia type 1, hepatitis b and syphilis serology.7 ct and conventional angiography are not considered as the first choice for the evaluation of sci, the gold standard for diagnosis is mr imaging, which can be performed with both 1.5t and 3t scanners: sagittal spin-echo t2 or t2 stir, sagittal spin-echo t1, axial gradientecho t2 at the cervical and dorsal levels, spinecho t2 at the medullary conus, and diffusionweighted images in the sagittal or axial planes.6 the typical mri findings in sci diagnosis include isolated pencil-like area of t2 hyperintensity mostly confined to centromedullary region with sparing of the anterior rim, often involving more than two vertebral segments on sagittal images.11 bilateral hyperintense t2 alterations that are mostly confined to the anterior horn area, leading to the axial “snake eyes or owl’s eyes” configuration, can be observed among 90 % of patients with sci, they are not specific or sensitive (in the acute phase, only 50 % of the cases shows a demarcation of t2 hyperintensity of the spine within the first 24 hours from symptoms appearance).1 differential diagnosis of spinal cord infarction is broad and holds multiple entities, usually included among“acute nontraumatic myelopathy.” these can be categorized into (a) inflammation, (b) infection, (c) compressive myelopathy, (d) venous congestion related to vascular malformations such as spinal dural arteriovenous fistula (sdavf), and (e) tumor. distinction of sci from “mimics” is challenging especially in subacute stage. hyperintensities on t2-wi can also be seen in inflammatory diseases and tumors.1 while the short-term mortality rate is 2025% in the first month from symptoms onset, any spinal cord infarction patients experience significant improvement with time, perhaps due to better cares and improvement in rehabilitation techniques. up to half of the patients who were unable to walk one week after spinal cord infarction reveal great improvement in the following months; particularly two-thirds are able even to walk without aids. in the long-term, almost all surviving patients <60 years with sci onset are able to work, consequently long term prognosis is favourable.8 review on acute cardio-cerebral infarction: a case report international journal of integrated health sciences (iijhs) 77 up to 79% of spinal cord infarction patients report chronic pain on follow-up, and this is more frequent than in cerebral infarction patients where less than half report pain on follow-up.8 pain is not associated with functional state in spinal cord infarction patients.9 prompt surgical management is necessary in cases of vascular compression and acute aortic event in addition to maintaining hemostatic equilibrium.11 in the setting of aortic surgery, lumbar drainage and blood pressure augmentation are often options for management.11 a review of spinal manifestations of patients with vertebral artery dissection revealed the use of anticoagulation was the sole form of therapy in spinal ischemia; antiplatelet therapy was also administered in conjunction with anticoagulants.11 another investigation used antiplatelet therapy in all 36 participants, including aspirin and clopidogrel.11 we reported the case of an 84 years old caucasian man who was heavy smoker with dyslipidemia, who also developed lone atrial fibrillation. the particularity of the case was the relapse of stroke after one month with relative improvement of weakness, after which he was confined to wheelchair with paraplegia, urinary catheter. the possible presentation of sci in in 2 acute stages has been already considered. in the study performed by novy in 20,065 patients presented with a biphasic stroke. two of these 5 patients had a deficit that was initially unilateral and then became bilateral, while in another patient the deficit increased secondarily. the 2 remaining patients experienced transient ischemic attacks (tias) before spinal cord infarction (1 patient experienced several tias per year for 6 years). the tias had the same motor features as the definitive stroke. in these cases of progressive stroke or tias, the infarct was frequently localized at the cervical level (4 of 5 cases). etiologies of sci are very heterogeneous and include thromboembolic events, aortic dissection, mechanical injury and trauma. cheng et al.12 reported the case of one patient, who had had 2 similar episodes 3 weeks apart. the first attack was tingling sensation and slight weakness in one lower extremity followed by the second on the opposite side. the spinal cord mri revealed a posterior spinal arterial infarction in the thoracic region. we didn’t find in literature a relapsing case after one month of acute stroke, not preceded by tias. we considered the possible role of lone atrial fibrillation in the pathogenesis of sci. in a retrospective cohort study performed by mir in 2017 atrial fibrillation was associated with increased risk of subsequent sci. the association between af and sci persisted or grew stronger after excluding those with concomitant diagnoses of spinal cord injury, spinal abscess, and spinal or aortic surgery.13 however, wang et al in 2016 determined that sci could predispose also to atrial fibrillation, but when strokes occurred above t6 level, due to the abnormal disruption of the communication between the brainstem and the autonomic nervous system.14 that’s not the case of patients, but it is difficult to find the causes of the first stroke (he presented to emergency department after 20 days from the beginning of symptoms). atrial fibrillation could have been in the trigger factor (undiagnosed at home). intravenous tissue plasminogen activator is currently considered the only therapy that can improve the outcome of acute ischemic stroke if administered within 3 hours (or 4.5 if we consider a recent randomized controlled trial). hyperbaric oxygen therapy has been proven to be neuroprotective when administered before or after spine stroke, through various mechanisms such as. improved spinal cord oxygen tension, reduced apoptosis and inflammation, improvement of oxidative stress and angiogenesis. in conclusion this case reported a very rare event in literature. we think that it should be useful to perform a strict follow up of risk factors for sci, expecially among older patients and to consider the risk of relapse, even rare, which could have even more devastating effects on patients’ disability and outcome. 1. boddu sr, cianfoni a, kim kw, banihashemi ma, pravatà e, gobin yp et al. spinal cord infarction and differential diagnosis. in: saba l., raz e. (eds) neurovascular imaging. springer: new york, ny; 2015. p. 1–64. 2. vuong sm, jeong wj, morales h, abruzzo ta. vascular diseases of the spinal cord: infarction, hemorrhage, and venous congestive references maria sofia cotelli and filippo manelli 78 international journal of integrated health sciences (iijhs) myelopathy. semin ultrasound ct mr. 2016; 37(5):466–81. 3. kramer cl. vascular disorders of the spinal cord. continuum (minneap minn). 2018;24(2, spinal cord disorders):407–26. 4. rubin mn, rabinstein aa. vascular diseases of the spinal cord. neurol clin. 2013; 31(1):153– 81. 5. vargas mi, gariani j, sztajzel r, barnaurenachbar i, delattre bm, lovblad ko, et al. spinal cord ischemia: practical imaging tips, pearls, and pitfalls. ajnr am j neuroradiol. 2015;36 (5):825–30. 6. dobkin b, havton l paraplegia and spinal cord syndromes. in: bradley’s neurology in clinical practice, 6th ed. philadelphia: saunders/ elsevier; 2012. p. 286–89. 7. zalewski nl, rabinstein aa, krecke kn, brown rd, wijdicks efm, weinshenker bg, et al characteristics of spontaneous spinal cord infarction and proposed diagnostic criteria. jama neurol. 2019;76(1):56–63. 8. hanson sr, romi f, rekand t, naess h: longterm outcome after spinal cord infarctions. acta neurol scand. 2015;131:253–57. 9. romi f, naess h. spinal cord infarction in clinical neurology: a review of characteristics and long-term prognosis in comparison to cerebral infarction. eur neurol. 2016;76(3-4): 95–8. 10. yadav n, pendharkar h, kulkarni gb. spinal cord infarction: clinical and radiological features. j stroke cerebrovasc dis. 2018;27(10):2810–21. 11. kumral e, polat f, güllüoglu h, uzunköprü c, tuncel r, alpaydin s. spinal ischaemic stroke: clinical and radiological findings and shortterm outcome. eur. j. neurol. 2011;18(2):232– 9. 12. cheng my, lyu rk, chang yj, chen rs, huang cc, wu t, et al: spinal cord infarction in chinese patients. clinical features, risk factors, imaging and prognosis. cerebrovasc dis 2008;26:502– 8. 13. mir s, pishanidar s, merkler s, navi b, kamel h. association between atrial fibrillation and spinal cord infarction neurology. stroke. 2017;48:awp217. 14. wang cc, chang ct, lin cl, huang br, kao ch. spinal cord injury is associated with an increased risk of atrial fibrillation: a population-based cohort study. heart rhythm. 2016;13(2):416–23. review on acute cardio-cerebral infarction: a case report international journal of integrated health sciences. 2013;1(1) 1 integrating basic sciences into global health by implementing the translational research correspondence: muhamad nurhalim shahib, department of biochemistry and molecular biology, faculty of medicine, universitas padjadjaran jl. eijkman no. 38, bandung 40161, indonesia e-mail: nurhalimshahib@yahoo.com muhamad nurhalim shahib,1 diah dhyanawati,1 elrade rofaani2 1department of biochemistry and molecular biology, faculty of medicine, universitas padjadjaran 2pharmacy and medisch technology center, agency for the assessment and application of technology, indonesia :1 ̶ 7 abstract an emphasize on herbal medicine in cancer therapy is also included as an example of translational research implementation. a translational research in faculty of medicine, universitas padjajaran, has been conducted to develop a novel genomic approach (herbal genomic) on herbal crude extracts. this study focuses on the effects of the extracts on specific gene expressions. in this aspect, the concept of molecular targets is slightly different from pharmaceutical approaches that aim to find compounds that interact with a specific molecule or macromolecule with known function. in this research strategy, the herbal genomic approaches involve screening of herbal extracts that affect particular gene expression related to cell responses rather than a single proteins. the determination of herbal concentration is based on differential gene expression before and after treatment which is analyzed by real time pcr. the results are being compared to the existing small molecule (active molecule) on the gene expressions. all these academic activities require biomedical research workforce to implement the translational research which, in the faculty of medicine, universitas padjadjaran, is fulfilled by involving the postgraduate students. new crude extract formulation plus specific gene expression profile is a concept required for developing chemotherapeutic agent in indonesia. hopefully, this review can support increased cooperation between hospital and academic institutions in implementing translational research in indonesia. keywords: cancer prevention, cancer therapy, global health, herbal medicine, translational research ijihs. 2013;1(1):1–7 introduction the global health program is very popular in the millennium development era because it proposes efforts to improve the health of people in many countries, including for diseases typically associated with advanced economics. varmus and timble have analyzed that the program is directed towards diseases-related problems in developing countries including those related to infectious diseases and nutritional deficiencies.1 the increased number of cancer deaths in developing countries has also drawn the attention of the health community in the world. we are interested in the epidemiological data shown by vermus and timble that 25% of life threatening cancers in the developing world are caused by infections.1 despite the fact that successful effective prevention efforts for some infectious diseases and therapy for cancer have been implemented, they are not adequate yet to satisfy the community needs, especially in indonesia. this situation affords an opportunity to create innovations in our strategy to develop translational research in order to strengthen the vision of “from bench to bedside” which focuses on oncology and infection. from the perspective of the government policy to develop and increase the utilization of generic drugs in indonesia, the use of natural resources that takes in the form of traditional medicine is strongly recommended. still, clinical trials to provide strong evidence supporting this national commodity in medicine should be conducted. with this policy, it is expected that the needs for affordable medicine among people of indonesia can be met and domestic medical industries will grow. received: january 21, 2013 revised: may 8, 2013 accepted: may 21, 2013 review 2 international journal of integrated health sciences. 2013;1(1) this review describes studies that are based on current gene expression science in herbal chemotherapeutic development. the focus of this review is herbal medicines that can be tested and applied in clinical trials through translational research. cancer or neoplasm is a group of diseases with multifactorial etiologies that causes abnormal cell proliferation. basically, cancer is caused by abnormalities in cell cycle and its regulations which are organized by specific proteins coded by specific genes. the development of natural products for cancer therapy in indonesia has not shown any progress in terms of clinical trials, which leads to a situation where almost all cancer therapies depend on imported products. the barriers in developing cancer therapy in indonesia are due to rigid strategy of using the bioactive form of the natural products where the modern medicine is only based on the active molecule. this approach is time consuming and needs high budget to obtain optimal results. in addition, the cell death and survival pathways have not yet completely elucidated when the avoidance of some specific types of cell death in cancer is very important to prevent injury in normal cells.2,3 some cancers are drug resistant and others tend to relaps. this indicates that the cell deaths associated to the cell survival pathway do not involve a single pathway only, which leads to difficulties in killing cancer cells. therefore, the cancer treatment cannot rely on a single active compound and should be based on a combination therapy to eliminate cancer cells. enthusiasm on developing natural products as therapeutic agents in cancer has grown in indonesia, especially for natural sources that are already known as having anticancer activities. however, the scientific aspect of it has not been tested yet. this problem is not easy to solve and a multi-discipline cooperation is needed, both from basic and applied sciences. this will be an opportunity to innovate by integrating translational research into the ongoing studies. the global concept of herbals development in medicine herbal medicine is made of natural substances containing small molecules, macromolecules, and complex molecules/crude extracts. it has been noted that 60% of the approved regimens used for treating cancer are derived from natural sources.4,5 traditional indonesian medicine is a well-known herbal decoctions and consumed by many people in indonesia as a supplement for maintaining their health. unfortunately, information on their mechanism and potential drug ability is limited making it difficult to develop herbal medicine. herbal decoctions can nourish the body holistically and support various organ systems.6 the general concept of this phenomenon is based on natural products and tissue/organ interaction (fig. 1) which can be studied from the gene expression perspective, resulting in opportunities for future research and integrating basic sciences into global health by implementing the translational research natural products and tissue/organ interaction new function determination of crude extract new molecular target and drug formulation characterization and identification of “small molecules”/ bioactive compound for medicine clinical trial program (phases) perspective for the research and development herbal medicine/natural products (small molecules/crude extracts) natural products and genes expression interactions natural products and cellular component interactions and in vivo gene expression analysis (animals) fig. 1 the global concept of herbal development in medicine :1 ̶ 7 international journal of integrated health sciences. 2013;1(1) 3 development. furthermore, the scheme shows that natural products and cellular component interactions and in vivo gene expression analysis perspective can be continued into a clinical trial program. on the other hand, after the in vivo experiment is conducted, the herbal medicine can be developed based on the new functions found in the crude extracts. a research program that includes characterization and identification of natural products supported by gene expression interaction to promote new molecular target and herbal formulations is also available. jain used natural products for treating cancer and they listed name of herbs associated with method and use for cancer treatment including phyllanthus niruri and vitis vinifera.7 jang published the natural product derived from grape’s resveratrol having chemopreventive activity.8 both phyllanthus niruri and vitis vinifera are investigated in our research program as a single agent and combination to treat cancer cells. in recent years, it has been reported that many natural substances have been used for prevention and treatment of various degenerative diseases, such as diabetes, hypertension, obesity, cancer, and other similar diseases.9-12 colic and pavelic reported their research about natural compounds with multifunctional activity and promoted both cytostatic and cytotoxic activities towards cancer cells.13 historically, human choose non-toxic vegetable or plants. it means in human intestine or gastrointestinal tract, the plant will be digested into small molecules, macromolecules and/or still in complex molecules that meet body requirements (fig. 2). these molecules enter blood circulation and interact with target cell by binding cell surface proteins or enter the cytoplasma to bind with specific proteins. these scientific facts show that although there are many molecules surrounding the outer part of the cell target, only few are able to enter the cell and interact with specific receptors or proteins. these interactions trigger the corresponding pathways and cellular responses. in cancer cell, many possible cellular responses will appear, such as cell death, cell silence, cell resistance, cell migration, cell competition, cell survival, and cell senescence. each cellular response will impact related organs/tissues. therefore, it is possible to expand global health from gene expressions to personalized health care. this finding is particularly interesting in terms that the functional assay was used to evaluate inhibitory effect of this herbal crude extract on cell proliferation compared to the same effect of chemotherapeutic agents (doxorubicin and cisplatin). the scientific aspects of herbal genomic it has been identified by the scientific community that important issues related to herbal medicine should be addressed to retain the best of the current academical research strategy including muhamad nurhalim shahib, diah dhyanawati, et al. fig. 2 molecular interactions of crude extract and target cell ic50 (inhibition of proliferation) :1 ̶ 7 4 international journal of integrated health sciences. 2013;1(1) avoiding stagnant basic theories and supporting the need of clinical trials. it is noted by nilsen and bierer that the translational medical research is an important, legitimate, and necessary effort for scientists in universities and research hospitals.14 interestingly, a central goal of academic medical institutions is to ensure that their innovation ultimately benefit patients. a tentative design that combines both traditional and modern medicine including its pharmaceutical approach in equal share is shown (fig. 3). an overlapped area of both circles containing herbal genomics is seen. this herbal genomics cover the scientific issues starting from genome to the cellular responses. the herbal genomics are embedded into both traditional and modern medicines. pharmaceutical approach or modern medicine ↓ specific target (a single molecule/a single macromolecule as a target) from genome to the cellular responses (as a target of crude extract) traditional medicine ↓ unspecified (a whole body target/ organism as a target) herbal genomics fig. 3 herbal genomics as a mediator between traditional and modern medicine strategy the profile of gene expressions is used as an indicator of the effective dose of related herbal extract to inhibit cell proliferation or increase cell death. this molecular level interaction has been implemented to determine effective dose of herbal crude extract.15 the characterization and identification of the natural products may involve various molecule types including small molecules, macromolecules and complex molecules (fig. 1). these substances are going to be analyzed and developed by pharmaceutical approaches such as clinical trials that are targetted to a single protein or a single molecule. our concept uses herbal products as a crude extract formulation relying on gene expressions leading to cellular responses and not only a single protein. if this product can be tested in vivo, a crude extract as an anti-cancer can be created. gene expressions which play a role in cell cycle and other genes associated with cell death (apoptosis, necrosis, autophagy) will be analyzed. the scientific aspects of this approach include the use of molecular biology concept based on interactions between herbal extracts and the cellular components of cancer cell as the molecular target that affects gene expressions. these targets can only be gained by determining the concentration of each herbal component compared to the cancer drugs such as cisplatin and doxorubicin. the equality of concentration of cisplatin and doxorubicin in killing the cancer cells by using gene expressions will be used as an indicator to determine the concentration of the herbs combination. gene expressions are going to be measured based on the quantity of rna molecules using real time pcr. gene expression based herbal formula is not yet generally known in indonesia and they will be developed as an oral powder prototype. this will be an excellent innovation in the national scientific community, which should be proposed to get a patent right, to fulfill the need for cancer therapeutic agent in indonesia. those innovations above are currently listed in the phase 1 of the translational research in the faculty of medicine, universitas padjadjaran. the research program is designed in three phases. the first phase is the laboratory and animal experiments based on basic theories to build a foundations for the next phases. this will be followed by the second phase, that includes in vivo experiments to determine a formula which is harmless and beneficial for human being. the third phase includes several types of clinical trials. after completing all phases, the formula will be used in health care. in this regards, an entrepreneurship strategy will also be needed. this research strategy may be slightly different from khoury et al.16 these initiatives are intended to integrate and develop a system for learning, comparative effective research, as well as quality health care and generating additional hypothesis for future investigations. chemical compounds of crude extract and their actions on selective pathway the use of traditional medicine in indonesia is not an unfamiliar part of disease treatment in the community. unfortunately, its development cannot compete with modern medical science which prioritizes on active molecule substances as a center of treatment mechanism. the author wanted to increase the utilization of natural resources of indonesia in the form of crude integrating basic sciences into global health by implementing the translational research :1 ̶ 7 international journal of integrated health sciences. 2013;1(1) 5 extracts. due to limited human and financial resources, it is difficult for indonesia to obtain the active compounds to achieve the ideal results. historically, it has been noted that most people in daily treatment of disease use herbal medicine in the form of crude extracts and experience a positive effect on certain clinical symptoms. indeed, we are very familiar with the superiority of the active compound in medicine where the molecular interactions can be obviously observed and the dosage can also be determined accurately. in respond to this scientific requirement, laboratory results from the studies on the effects of herbal medicine in the form of crude extracts on inhibiting cancer cell proliferation by analyzing gene expression were referred to the ic50.15 these molecular data can explain the response of a cell and the pathway that is activated or inhibited by natural compounds. for certain disease, especially degenerative disease such as cancer, the activities of more than one type of signal transductions and pathways are always involved and it may even comprise a series of reactions that also have multiple or more than one pathway. it is debated whether a single active substance can act on so many different biochemical pathways in the cell target. it can be understood that all signs and symptoms of the disease are not pathogenically resulted from the work of a single molecule, but from tens or hundreds of molecules and even tens of biochemical pathways. although, the modern medicine and the pharmaceutical approach have been able to determine the pathway of the biochemical reactions by targeting a specific molecule as a key molecule that effect the pathway, the cellular pathway is not a single process but always associated with other reactions or networks. thus, the question whether a single active substance is able to inhibit the whole reactions or pathways in cancer cells. in fact, there is no single chemotherapeutic agent being able to recover completely the cancer patients. this leads to the notion that at the molecular level the body is naturally governed by many reaction mechanisms. this molecular process extends the research that can be categorized as a gene to protein level research through gene expressions. these processes aim to maintain homeostasis. thus, even if an active substance is required, it would still be necessary to combine it with other active substances. based on that idea, we should be able to develop herbal crude extracts with equal effect to active compounds and focus on molecular targets. if this can be implemented, the development of crude extract in medicine will have similar quality with modern medicine although it is still on the level of crude extract. this strategy is important for the development of generic drugs in indonesia. a cell could be surrounded by various molecules contained in the crude extract (fig. 4). the substance varies from large molecules or complex molecules to small molecules. these molecules will interact with their respective receptors on the cell membrane, cytoplasm or cell nucleus. the results from our studies on hela cells showed that the crude extract conferred inhibition of cell proliferation (ic50).15–22 muhamad nurhalim shahib, diah dhyanawati, et al. :1 ̶ 7 chemical compounds of crude extract affecting on selective biochemical pathway in target cell fig. 4 inactive cell membrane small molecule (active compound) virus complexes molecule (crude extract) = active protein = viral protein = tumor suppresor = protein receptors ic50 (ip) ? ? 6 international journal of integrated health sciences. 2013;1(1) it is already well known that the use of the crude extract with various molecules will result in a variety of cellular responses. by setting the optimal dosage and making comparison with the existing commercial chemotherapeutic agent as a marker, a target for cancer therapy will be obtained and unwanted effects can be minimized. the implementation of this strategy to treat cancer cells can be analyzed using ic50 determination. from bench to bedside with the outcomes of the study conducted in faculty of medicine, universitas padjadjaran, that combines basic, clinical and public health sciences, some new discoveries have been made. however, moving the scientific discoveries of herbal medicine into clinical trials have always been slow, expensive, and difficult achieved.17 it is not surprising that even in the developed countries it takes an average of 17 years for herbal medicine to enter day to day clinical practice, and that is only for 14% of all new scientific discoveries.18 a study by contopolous showed that only 5% of highly promising basic science findings were licensed for clinical use and only 1% were actually used for the licensed indication.19 therefore, there are several key questions to be asked: is translational medicine research important in indonesia? what should the role of the health department of republic of indonesia be in supporting clinical trial originating from university research program? in this matters, we support meyers and pomeroy that knowledge and technology that produce sustainable improvements in health and quality of life begin with early translational research efforts and are in need of biomedical research workforce.20 sung described some barriers to translational research that range from a lack of willing participants to the lack of funding.21 in indonesia, little is known about translational research in medicine that transfer new understanding of disease mechanisms gained in basic laboratories into the development of new methods for diagnosis, therapy and prevention, as well as the clinical trials in hospitals. goldblatt and lee mentioned in their article that primary goal of translational research is to integrate progresses in molecular biology with clinical trials, taking research from “bench to bedside”.22 in this review on translational research, a description on the effects of herbal medicine in the form of crude extracts to inhibit cancer cell proliferation has been given and a gene expression analysis is currently performed in the faculty of medicine, universitas padjadjaran, to create a chemotherapeutic agent. the team has introduced a new terminology of herbal medicine, namely herbal genomics. this new terminology can be used in recent clinical campaigns for traditional medicine including for herbal chemotherapeutic development that addresses crude extract and genomic analysis. in this analysis, a ic50 determination of phyllanthus niruri and vitis vinifera that were designed for complementary therapy of cancer were performed.23 these systematic efforts of translat ional research will increase extensive cooperation between basic researchers, clinicians and industries that integrate basic sciences into human health in indonesia. references integrating basic sciences into global health by implementing the translational research :1 ̶ 7 1. varmus h, timble el. integrating cancer control into global health. sci trans med. 2011;3(101);101–28. 2. kasibhatla s, tseng b. why target apoptosis in cancer treatment? mol cancer ther. 2003;2(6):573–80. 3. schwarts gk, shah ma. targeting the cell cycle: a new approach to cancer therapy. j clin oncol. 2005;23(36):9408–21. 4. farnsworth nr, akerele o, bingel as, soejarto dd, guo z. medical plants in therapy. bull world health organ. 1985;63(6):951–81. 5. cragg gm, newman dj, snader km. natural products in drug discovery and development. j nat prod. 1997;60(1):52–60. 6. treadway s. an ayurvedic herbal approach to a healthy liver. clin nutr insights. 1998;6(16):1–3. 7. jain s, gill v, vasudeva n, singla n. ayurvedic medicines in treatment of cancer. j chinese integrative med. 2009;7(11):1096–9. 8. jang m, udean go, slowing kv, thomas cf, beecher cw, fong hh, et al. cancer chemopreventive activity of resveratrol, a natural product derived from grapes. science. 1997;275(5297):218–20. 9. barnes s. role of phytochemicals in prevention and treatment of prostate cancer. epidemiol rev. 2001;23(1):102–5. international journal of integrated health sciences. 2013;1(1) 7 muhamad nurhalim shahib, diah dhyanawati, et al. :1 ̶ 7 10. shahib mn, syamsunarno mraa, faried a, yuliana d, anggraeni d, yuniarti l, et al. the effect of glycine max extract diets on changesin nr2b gene expression, cognitive vitality andneurotoxicity in high concentrate consumption. kitakanto med j. 2010;60:41–7. 11. sureban ms, subramaniam d, rajendran p, ramanujam rp, dieckgraefe bk, houchen cw, et al. therapeutic effects of phyllantus species: induction of tnf-α mediated apoptosis in hepg2hepatocellular carcinoma cells. am j pharmacol toxicol. 2005;1(4):65–71. 12. lee jc, kim j, jang ys. ethanol-eluted extract of rhus verniciflua stokes inhibits cell growth and induces apoptosis in human lymphoma cells. j biochem mol biol. 2003;36(4):337–43. 13. colic m, pavelic k. molecular mechanism of anticancer activity of natural dietetic products. j mol med. 2000;78(6):333–6. 14. nelsen ll, bierer be. biomedical innovation in academic institutions: mitigating conflict of interest. sci transl med. 2011;3(100):100–26. 15. shahib mn. molecular targeting therapy in oncology: implementation of herbal therapy based on genes expression and strategy to improve the translational research. proceedings of the 2nd bandung biomolecular medicine conference; 2012 october 5–6; bandung. indonesia. 2012. 16. khoury mj, gwinn m, yoon pw, dowling n, moore ca, bradley l. the continuum of translation research in genomic medicine: how can we accelerate the appropriate integration of human genome discoveries into health care and disease prevention? gen med. 2007;9(10):665–74. 17. collin fs. reengineering translational science: the time is right. sci transl med. 2011;3(90):1–6. 18. westfall jm, mold j, fagnan l. practice based research blue highways on the n1h road map. jama. 2007;297(4):403–6. 19. contopolous-ioannidis dg, ntzani e, ioannidis jp. translation of highly promising basic science research into clinical applications. am j med. 2003;114(6):477–84. 20. meyers fj, pomeroy c. creating the future biomedical research workforce. sci transl med. 2011;3(102):102–5. 21. sung ns, crowley wf jr, genel m, salber p, sandyl, sherwood lm, et al. central challenges facing the national clinical research enterprise. jama. 2003;289(10):1278–87. 22. goldblatt em, lee wh. from bench to bedside: the growing use of translational research in cancer medicine. am j transl res. 2010;2(1):1–18. 23. shahib mn. the effects of phyllanthus niruri and vitis vinifera extracts on hela cell associated with gene expression analysis. proceeding of the aaaam world asia; 2012 october 12–4; bali. indonesia. 2012. volume 8 no 1 2020 v2.indd 14 international journal of integrated health sciences (puskesmas). the prolanis is a program that organized various activities to control the chronic diseases, prevent it from reaching complications, and finally increasing the health status of the elderly.3 the success of the prolanis is still not satisfactory. the compliance level is still low.4 the monitoring of the patient’s blood sugar levels and the treatment compliance are not optimal.5 one of the causes of this low compliance is satisfaction.4 patient satisfaction is one of the indicators of the quality of care. it indicates the success of the health providers to meet the patient’s expectations of the health care they received.6 the satisfaction level can be measured through an instrument known as service & quality (servqual).7,8 the study about the satisfaction level of the elderly on the prolanis by using servqual has not been carried out. based on this information, the purpose of this study was to identify the satisfaction level of the elderly on the health services provided by the prolanis in the puskesmas. original article elderly satisfaction on chronic disease management program at public health center, bandung city, west java, indonesia correspondence: james maladi akbar, faculty of medicine universitas padjadjaran, indonesia e-mail: maladiakbarjames@yahoo.co.id james maladi akbar,1 sharon gondodiputro,2 ardini saptaningsih raksanagara2 1faculty of medicine universitas padjadjaran, indonesia 2department of public health faculty of medicine universitas padjadjaran, indonesia abstract objective: to identify the satisfaction level of the elderly on the health services provided by the chronic disease management program (prolanis) at the public health center (puskesmas). methods: a descriptive quantitative study with a cross-sectional approach had been carried out to 112 elderly from 8 puskesmas in bandung city, west java, indonesia. this study was conducted from august until november 2019. the variables in this study were 5 dimensions of the servqual. the collected data were analyzed using percentages and the importance-performance matrix. results: the satisfaction level of the elderly on the health services provided by the prolanis was 92%. the dimension that has the highest satisfaction level was the assurance dimension (94,6%) and the lowest one was the tangibles dimension (84,8%). the result of the importanceperformance matrix showed that assurance, responsiveness, and empathy dimensions needed to be maintained to reach the patient’s satisfaction. conclusions: the elderly satisfaction on the health services provided by the prolanis is high in every dimension of the servqual. keywords: chronic disease management program, elderly, importance performance matrix, satisfaction, servqual received: january 9, 2020 accepted: may 27, 2020 pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ ijihs.v8n1.1935 ijihs. 2020;8(1):14–21 introduction indonesia has an increase in the total population of the elderly. it is reported that in 2019 there was 25.64 million elderly in indonesia (9.60%) and this percentage is predicted to increase each year.1 the aging process causes the elderly more susceptible to disease. the overall morbidity rate both in urban and rural areas in three consecutive years from 2013 to 2015 was 24.8%, 25.05%, and 28.62%, respectively. stroke, malignancy, asthma, and diabetes mellitus type 2 are the common diseases occurred.2 the indonesian social security agency in the health sector, developed a chronic disease management program (prolanis) for the national health insurance (jkn) participants, conducted especially at the public health center international journal of integrated health sciences 15 james maladi akbar, sharon gondodiputro, et al. methods this study was a descriptive study with a cross-sectional method, conducted from august 2019 to november 2019 in bandung city, west java indonesia. the total number of puskesmas that provided prolanis was 16 puskesmas and from that number, 50% (8 puskesmas) were selected by simple random sampling. the inclusion criteria were elderly aged 60 years and over, willing to participate in the study, able to communicate well, and came for treatment at the puskesmas, whereas the exclusion criteria were elderly that did not take the interview completely. the total samples were calculated by using sample formula for categorical descriptive study, with α=5%, and p value=0.88.9 based on that formula, the total samples needed in this study were 112 respondents. before determining the number of elderly in each puskesmas, the researchers requested data on the presence of the elderly for 3 months in each selected puskesmas. this data was used as a denominator in calculating the number of samples in each puskesmas. the number of respondents in each puskesmas was calculated by the number of elderly visits at the puskesmas (n) divided by the total number of elderly visits to the 8 puskesmas (n) and multiplied by the number of samples needed. on the day of data collection, the number of the elderly present was uncertain, therefore the respondents were selected using consecutive sampling, a sampling technique in which every subject meeting the criteria of inclusion was selected until the required sample size was achieved. permission to do the study was obtained from three institutions, namely the bandung city mayor office, bandung city health office, and the selected puskesmas. this study had received the ethical clearance from the health research ethics committee of universitas padjadjaran bandung, indonesia under the ethical clearance 1036/un6.kep/ ec/2019. the questionnaire of the servqual consisted of 22 statements and divided into 5 dimensions, namely tangibles, reliability, assurance, responsiveness, and empathy7,8, and was developed by the departement of public health faculty of medicine universitas padjadjaran in 2011, based on the servqual by parasuraman. it was tested to 53 respondents from bandung city. a content and construct analysis were carried out. the result of the cronbach’s alpha was between 0,801 and 0,977 for each dimension.10 the tangibles dimension consisted of 4 statements, namely visually appealing rooms; complete facilities; employees who have a neat, professional appearance; and complete medical equipment. the reliability dimension consists of 5 statements, namely, providing services as promised; dependability in handling customers’ problems; simple procedures; providing services at the promised time; and prompt administrative services. the assurance dimension consisted of 4 statements, namely health providers who instill confidence in customers; making customers feel safe; respect the customers; and health providers who have the knowledge to answer customer questions. the responsiveness dimension consisted of 4 statements, namely keeping customers informed about when services will be performed; prompt service to customers; willingness to help the customers; and readiness to respond to customers’ requests. the empathy dimension consisted of 5 statements, namely giving customers individual attention without any discrimination; convenient business hours; health providers who understand the needs of their customers; having the customer’s best interest at heart; and health providers who deal with customers in a caring fashion.10 each statement had two columns namely “expectation” and “reality” columns that had a score ranging from 1 to 10. prior to data collection, the selected respondents were given explained about the purpose and procedure of the study. after they understood and agreed to participate in this study, they signed the informed consent form. the researcher read and explained the meaning of each statement one by one to the respondents and the respondents chose the right score for each statement both for the “expectation” and “reality” aspects. the average score of the “expectation” and the “reality” was calculated by adding up the total score of “expectation” or “reality” divided by the number of samples. the satisfaction level was calculated by dividing the “reality” average score with the “expectation” average score and multiplied by 100%. satisfied if the percentage reached ≥ 80%, and dissatisfied if the percentage was <80%.11 the collected data were statistically analyzed using fisher’s exact test or kolmogorov-smirnov test to identify the difference of satisfaction according to the characteristics of the respondents. the importance and performance matrix had 2 components, those were the x-axis (performance/reality axis) and the y-axis 16 international journal of integrated health sciences table 1 respondent’s characteristics and satisfaction characteristic frequency(n=112) (%) dissatisfied (n=9) (%) satisfied (n=103) (%) p-value age (years old) 60–69 >70 70 (62.5) 42 (37.5) 3 (4.3) 6 (14.3) 67 (95.7) 36 (85.7) 0.078* education ≤ elementary school junior high school senior high school >senior high school 44 (39.3) 26 (23.2) 27 (24.1) 15 (13.4) 3 (6.8) 2 (7.7) 1 (3.7) 3 (20.0) 41 (93.2) 24 (92.3) 26 (96.3) 12 (80.0) 0.831** marital status not married married divorce 1 (0.9) 60 (53.6) 51 (45.5) 0 (0.0) 5 (8.3) 4 (7.8) 1 (100) 55 (91.7) 47 (92.2) 1.000** occupation retired employed 88 (78.6) 24 (21.4) 6 (6.8) 3 (12.5) 82 (93.2) 21 (87.5) 0.400* disease hypertension diabetes mellitus hypertension and diabetes mellitus 49 (43.8) 34 (30.4) 29 (25.9) 5 (10.2) 0 (0.0) 4 (13.8) 44 (89.4) 34 (100) 25 (86.2) 0.889** notes: *fisher’s exact test; ** kolmogorov-smirnov test (importance/expectation axis).12 the value of the x-axis was the “reality” average score and the value of the y-axis was the “expectation” average score.12 this matrix created using imb spss 22.0. both axes create a cartesian diagram that had four quadrants. (figure 1). quadrant i showed customers feel that the health services provided by the prolanis was high, but the performance was low. the quality of health services that entered main priority (i) maintain achievement (ii) low priority (iii) overload (iv) x y figure 1 importance-performance matrix this quadrant should be prioritized to be improved because of the high importance and low satisfaction. quadrant ii showed the area in which health services at the prolanis needed to be maintained to make sure that the customers were still satisfied with the health services provided because the level of importance and performance were both high. quadrant iii showed a low priority area because of the low importance and low performance. the performance of the prolanis was low, and the importance perceived by the customer was also low. this situation did not mean that the organization did not have to enhance the quality of their services. they still had to provide health care better than before. quadrant iv was categorized as overload area because there were factors that were not important for consumers (low importance level), but the organization provided the health care with a high performance.12,13 results the study on the satisfaction level of the elderly on the health care provided by the prolanis in bandung city has been conducted using servqual questionnaires with total respondents of 112 elderly. table 1 showed elderly satisfaction on chronic disease management program at public health center, bandung city international journal of integrated health sciences 17 t ab le 2 s at is fa ct io n l ev el p k m t ot al s at is fa ct io n t an gi bl es r el ia bi li ty r es po n si ve n es s a ss ur an ce em pa th y sa ti sf y n ( % ) d is sa ti sf y n ( % ) sa ti sf y n (% ) d is sa ti sf y n ( % ) sa ti sf y n ( % ) d is sa ti sf y n ( % ) sa ti sf y n (% ) d is sa ti sf y n ( % ) sa ti sf y n ( % ) d is sa ti sf y n ( % ) sa ti sf y n ( % ) d is sa ti sf y n ( % ) pk m 1 36 (9 4. 7) 2 (5 .3 ) 37 (9 7. 4) 1 (2 .6 ) 35 (9 2. 1) 3 (7 .9 ) 37 (9 7. 4) 1 (2 .6 ) 37 (9 7. 4) 1 (2 .6 ) 38 (1 00 ) 0 (0 .0 ) pk m 2 5 (8 3. 3) 1 (1 6. 7) 0 (0 .0 ) 6 (1 00 ) 1 (1 6. 7) 5 (8 3. 3) 6 (1 00 ) 0 ( 0. 0) 6 (1 00 ) 0 (0 .0 ) 6 ( 10 0) 0 ( 0. 0) pk m 3 8 (1 00 ) 0 (0 .0 ) 8 (1 00 ) 0 (0 .0 ) 8 (1 00 ) 0 ( 0. 0) 8 (1 00 ) 0 (0 .0 ) 8 (1 00 ) 0 (0 .0 ) 8 (1 00 ) 0 (0 .0 ) pk m 4 11 (7 8. 6) 3 (2 1. 4) 11 (7 8. 6) 3 (2 1. 4) 11 (7 8. 6) 3 (2 1. 4) 12 (8 5. 7) 2 (1 4. 3) 10 (7 1. 4) 4 (2 8. 6) 13 (9 2. 9) 1 (7 .1 ) pk m 5 16 (1 00 ) 0 (0 .0 ) 15 (9 3. 8) 1 (6 .3 ) 16 (1 00 ) 0 (0 .0 ) 16 ( 10 0) 0 (0 .0 ) 15 (9 3. 8) 1 (6 .3 ) 16 (1 00 ) 0 (0 .0 ) pk m 6 7 (1 00 ) 0 (0 .0 ) 6 (8 5. 7) 1 (1 4. 3) 7 (1 00 ) 0 (0 .0 ) 7 (1 00 ) 0 (0 .0 ) 7 (1 00 ) 0 (0 .0 ) 6 (8 5. 7) 1 ( 14 .3 ) pk m 7 10 (9 0. 9) 1 (9 .1 ) 10 (9 0. 9) 1 (9 .1 ) 10 (9 0. 9) 1 (9 .1 ) 10 (9 0. 9) 1 (9 .1 ) 10 (9 0. 9) 1 (9 .1 ) 10 (9 0. 9) 1 (9 .1 ) pk m 8 10 (8 3. 3) 2 (1 6. 7) 10 (8 3. 3) 2 (1 6. 7) 11 (9 1. 7) 1 (8 .3 ) 10 (8 3. 3) 2 (1 6. 7) 12 (1 00 ) 0 (0 .0 ) 6 (5 0) 6 (5 0) to ta l 10 3 (9 2. 0) 9 (8 .0 ) 95 (8 4. 8) 9 (8 .0 ) 99 (8 8. 4) 13 (1 1. 6) 10 4 (9 2. 9) 8 (7 .1 ) 10 6 (9 4. 6) 6 (5 .4 ) 10 3 (9 2. 0) 9 (8 .0 ) n ot e: p k m : p us ke sm as james maladi akbar, sharon gondodiputro, et al. 18 international journal of integrated health sciences that most of the respondents were aged 60-69 years old, low education, married, retired, and had hypertension. there was no difference in satisfaction level satisfaction for all characteristic variables (p-value ≥0.05). this study discovered that the satisfaction level was very high. the dimension that had the highest satisfaction level was the assurance dimension (94,6%) and the lowest was the tangibles dimension (84,8%; table 2). this study revealed that there were differences in the total satisfaction and in every dimension that existed in the eight puskesmas. in the puskesmas number 2, the total satisfaction was high, but in the tangibles and reliability dimensions, the satisfaction was low. puskesmas number 4 had the lowest level of satisfaction compared to the other puskesmas (table 2). this study discovered that tangibles and reliability dimensions placed inside the quadrant iii, which means that both dimensions had a low priority to be improved, while assurance, responsiveness, and empathy dimensions placed inside the quadrant ii which means the health providers needed to maintain the health service quality in these three dimensions (figure 2). every statement in every dimension was plotted also into the importance-performance matrix. this study discovered that “the complete medical equipment” statement (tangibles) placed in the first quadrant. moreover, the “simple procedures” statement figure 2 importance-performance matrix for 5 dimensions of satisfaction notes: 1. tangibles; 2. reliability; 3. responsiveness; 4. assurance; 5.empathy figure 3 tangibles and reliability importance-performance matrix elderly satisfaction on chronic disease management program at public health center, bandung city international journal of integrated health sciences 19 figure 4 assurance, responsiveness, and empathy importance-performance matrix (reliability) placed in the first quadrant as well (figure 3). regarding the assurance dimension, this study discovered that the statement about “health providers who knew to answer customer questions” placed in the first quadrant (figure 4). discussion prolanis is a health service system that involves patients, as members of the jkn, primary health facilities, and the indonesian social security agency in the health sector, who suffer from chronic diseases, especially hypertension and diabetes mellitus. six prolanis activities consist of: (1) medical consultation; (2) health education; (3) sms gateway reminder; (4) home visit; (5) physical exercise (gymnastics) and; (6) monitoring health status.3 the goal of the prolanis is to encourage participants to come to the puskesmas for monitoring and treating their diseases so that they achieve optimal quality of life and prevent complications.3 patient satisfaction is one of the indicators for measuring the quality of health care services. measuring the level of satisfaction is very important as satisfaction might affect adherence to treatment for chronic diseases such as hypertension and diabetes mellitus.14 moreover, assessing the level of satisfaction can give information on whether the services provided by the puskesmas are in accordance with the customer expectation.6 this study discovered that most of the respondents were satisfied with the health services provided at the prolanis in every dimension, however, the tangible dimension had the lowest satisfaction james maladi akbar, sharon gondodiputro, et al. 20 international journal of integrated health sciences level compared to the other dimensions of servqual. moreover, the responsiveness, assurance, and empathy dimensions placed in the quadrant ii of the importance-performance matrix which means that the quality of those dimensions should be maintained.12,13 from the tangible dimension, the main component that needed to be improved is the availability of medical equipment such as the insulin syringe. in indonesia, hypertension and diabetes mellitus are chronic diseases that have become the primary concern for the public health sector.15 the hypertension prevalence in indonesia is quite high as many as 8.6–10%16, while the diabetes prevalence is as many as 4,6%.17 the management of hypertension and diabetes without complications is the authority of doctors who work at the puskesmas, therefore the availability of medicines and insulin syringes need to be considered. the reliability dimension placed inside the quadrant iii of the importance-performance matrix which means that this dimension had a low priority to be improved, however, there is one component of the reliability dimension that should be improved, namely the procedures at the prolanis was complicated, not a simple one, especially when the puskesmas referred them to the hospital. this is in accordance with the study by nurheda et al., that the respondents were not satisfied because they had not been served promptly and tended to be convoluted.18 the ability of the health providers to answer the patients’ questions is a component of the assurance dimension placed in the quadrant i. a study conducted by andrew h. van de ven et al discovered that patients will feel satisfied if the health providers were able to explain about the condition of illness, the treatment given and the side effects of the medicine given to the patients.19 this study discovered that tangible and reliability dimension, and several components in other dimensions placed inside the quadrant iii. this quadrant described that the respondents had a low expectation and the performance of the health care provided at the prolanis was low.13the purpose of this paper is to measure service quality provided to surgical and medical inpatients at kerman medical sciences university (kums compared to other quadrant, dimensions or statements placed in this quadrant showed a low priority to be intervened.12,13 sanam roder-dewan et al. stated that the low expectation of the patients, made them feel satisfied with the low quality of the health services. there was no demand to improve the quality of the health services and in the end the health providers will not make efforts to enhance the quality of their health services.20 this study has some limitations. this study did not link the satisfaction level with treatment adherence. there were lots of statements in the servqual questionnaire that require a considerable amount of time to answer by the respondents. this causes some of the elderly were suspected of not answering them in accordance with their choices. the conclusion of this study is the satisfaction level of the elderly on the health care provided at the prolanis is high. the dimension with the highest satisfaction level is the assurance dimension (94,6%) and the lowest in the tangibles dimension (84,8%). the responsiveness, assurance, and empathy dimensions should be maintained so that the elderly satisfied with the health care provided, however, some of the components of tangible and reliability dimensions should be improved. further study needed to be conducted to analyze the relationship between satisfaction level and the treatment adherence of patients with hypertension and diabetes. elderly satisfaction on chronic disease management program at public health center, bandung city 1. bps-statistics indonesia. statistik penduduk lanjut usia 2019. jakarta; 2019. 2. indonesian ministry of health. riset kesehatan dasar 2018. jakarta: badan penelitian dan pengembangan kesehatan kemenkes ri; 2018. 3. rosdiana ai. implementasi program pengelolaan penyakit kronis (prolanis). higeia j public heal res dev. 2017;1(3):140–50. 4. asfiani lv, ilyas y. level of adherence and its determinants of prolanis attendance in type 2 diabetes mellitus participants at five bpjs primary health care in bekasi 2016. j indones heal policy adm. 2017;2(2):6–13. 5. raraswati a, heryaman h, soetedjo nnm. peran program prolanis dalam penurunan kadar gula darah puasa pada pasien diabetes melitus tipe 2 di puskesmas kecamatan jatinangor. j sist kesehat. 2018;4(2):65–70. 6. xesfingi s, vozikis a. patient satisfaction with the healthcare system: assessing the impact references international journal of integrated health sciences 21 james maladi akbar, sharon gondodiputro, et al. of socio-economic and healthcare provision factors. bmc health serv res. 2016;16(1):1–7. 7. sari dp, harmawan a. usulan perbaikan kualitas pelayanan pada instalasi rawat jalan dengan metode servqual dan triz. j tek ind. 2012;95–6. 8. rinnasa p-a, nababan esm, bu’ulolo f. strategi peningkatan kualitas pelayanan kesehatan menggunakan integrasi metode fuzzy servqual. saintia mat. 2013;1(6):529–41. 9. oktavia d. gambaran tingkat kepuasan dan harapan pasien pada pelayanan program pengelolaan penyakit kronis (prolanis) di wilayah kerja puskesmas kalimanah purbalingga. [thesis]; 2018. 10. rinawan fr, djuhaeni h, arisanti n, gondodiputro s, pudjisetiawati e, wiwaha g, et al. kajian kepuasan pasien terhadap kualitas layanan ppk primer kota bandung. bandung: dinas kesehatan kota bandung; 2011. 11. rajbanshi l, dungana g, gurung y, koirala d. satisfaction with health care services of out patient department at chitwan medical college teaching hospital, nepal. j chitwan med coll. 2014;4(7):11–2. 12. gonçalves jr, pinto a, batista mj, pereira ac, bovi ambrosano gm. importance-performance analysis: revisiting a tool for the evaluation of clinical services. scires. 2014;06(05):285–91. 13. izadi a, jahani y, rafiei s, masoud a, vali l. evaluating health service quality: using importance performance analysis. int j health care qual assur. 2017;30(7):1–9. 14. bakar za, fahrni ml, khan tm. patient satisfaction and medication adherence assessment amongst patients at the diabetes medication therapy adherence clinic. diabetes metab syndr clin res rev. 2016;10(2):1–17. 15. dyanneza f, tamtomo ds. the effectiveness of chronic disease management program in blood pressure control among hypertensive patients. indones j med. 2017;2(1):52–62. 16. syahrini en, susanto hs, udiyono a. faktorfaktor risiko hipertensi primer di puskesmas tlogosari kulon kota semarang. j kesehat masy. 2012;1(2):315–25. 17. mihardja l, soetrisno u, soegondo s. prevalence and clinical profile of diabetes mellitus in productive aged urban indonesians. j diabetes investig. 2014;5(5):507–12. 18. nurheda, usman, rusman adp. hubungan kualitas pelayanan kesehatan dengan kepuasan pasien pengguna badan penyelenggara jaminan sosial (bpjs) di puskesmas maiwa kabupaten enrekang. j ilm mns dan kesehat. 2018;1(3):201–16. 19. van de ven ah. what matters most to patients? participative provider care and staff courtesy. patient exp j. 2014;1(1):131–9. 20. roder-dewan s, gage ad, hirschhorn lr, twum-danso nay, liljestrand j, asanteshongwe k, et al. expectations of healthcare quality: a cross-sectional study of internet users in 12 lowand middle-income countries. plos med. 2019;16(8):e1002879. vol 9 no 1 2021 (2).indd 30 international journal of integrated health sciences (iijhs) pulmonary embolism in high-risk patients: how to select standard imaging and management strategy? abstract objective: to describe the use of computed tomography pulmonary angiography (ctpa) for diagnostic purposes and percutaneous catheterdirected thrombolysis (pcdt) as a treatment choice for high-risk pulmonary embolism (pe) patients. methods: this case report describes a case of an elderly female presented with dyspnea, cough, fever, and chest pain. no significant medical history was identified. results: ctpa was conducted and showed multiple thrombus with significant stenosis in several branches of pulmonary artery. initial anticoagulation was administered without delay. patient then underwent pcdt to remove the thrombus. no post intervention symptom and systemic complications were noted. conclusions: computed tomography pulmonary angiography is useful as the standard imaging modality to help evaluating suspected pulmonary embolism. percutaneous catheter-directed thrombolysis is indicated to treat high-risk patients with high risk of bleeding. keywords: computed tomography pulmonary angiography, elderly people, high-risk pulmonary embolism, pulmonary embolism, treatment received: september 21, 2020 accepted: march 30, 2021 correspondence: sidhi laksono purwowiyoto, faculty of medicine universitas muhammadiyah prof. dr. hamka, tangerang, indonesia e-mail: sidhilaksono@uhamka.ac.id case report sidhi laksono,1,2 firizkita dewi,1 reynaldo halomoan3 1department of cardiology and vascular medicine, pertamina central hospital, south jakarta, indonesia, 2faculty of medicine universitas muhammadiyah prof. dr. hamka, tangerang, indonesia, 3faculty of medicine universitas katolik indonesia atma jaya, jakarta, indonesia pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ ijihs.v9n1.2142 ijihs. 2021;9(1):30–35 introduction pulmonary embolism (pe) is a life-threatening thromboembolic event.1 the incidence of pe has been growing and has reached the rate of 65 cases in 100.000 population.2 patients may experience various unspecific symptoms. acute dyspnea is the most common symptom in pe. chest pain is commonly associated with coronary events, but patients with pulmonary embolism may also experience chest pain with elevated levels of troponin. unspecific symptoms such as fever may also appear although fever has no impact on disease severity or prognosis.3,4 the clinical condition could go from low risk to high-risk with complications. therefore, early diagnosis is important to determine the treatment strategy and prevent the mortality of the patient.5 imaging modality could be useful to help establish the diagnosis. various imaging modalities are available for evaluation of pe includes chest radiographs, echocardiography, computed tomography (ct) pulmonary angiography (ctpa), ct venography, magnetic resonance (mr) pulmonary angiography (mrpa), and ventilation/perfusion scan. each modality has their own characteristics and diagnostic role.6 the purpose of this article is to describe the use of ctpa as the standard imaging modality to help establish the diagnosis of pulmonary embolism and its treatment based on patient’s clinical condition. international journal of integrated health sciences (iijhs) 31 case the case describes a 70-years-old female who was admitted to our hospital due to dyspnea since 7 days before admission and became worsen, accompanied by cough, intermittent fever, and chest pain after 3 days since the initial onset of dyspnea. the patient was ill with gcs e4v5m6. the diagnosis of pleuropneumonia was made at the beginning with pulmonary embolism as a differential diagnosis, supported by infiltrates appearance in chest computerized tomography (ct) scan. there were not any significant past medical history. the physical examination showed rhonchi in both lungs and the cor was normal. our patient then had a cardiac arrest and we conducted cardiopulmonary resuscitation (cpr). the rhythm was shockable and we shocked the patient. the return of spontaneous circulation (rosc) was achieved. due to the suspicion of pe, we administered enoxaparin. after the international normalized ratio (inr) had been achieved, we also administered warfarin. electrocardiography (ecg) and laboratory tests were done. the ecg (fig. 1) showed a deep s wave in lead i, q wave in lead iii, and an inverted t wave in iii. t-wave inversions in precordial leads also appeared. the blood cell count was normal, arterial blood ph was 7.39, po2 250 mmhg, pco2 30 mmhg, hco3 18 meq/l, and base excess was -5 meq/l. another laboratory test showed an increased high-sensitivity troponin t (39.79 ng/l) and nt-probnp (11178 pg/ml). the patient then underwent a computerized tomography pulmonary angiography procedure. the ct showed thrombus in the right pulmonary artery truncus, anterior truncus of the right pulmonary artery, and right interlobar pulmonary artery (fig. 2 and fig. 3). thrombus was also shown in the left interlobular pulmonary artery (fig. 4). there were also significant stenosis in the right pulmonary artery truncus, right pulmonary artery anterior truncus, and left interlobular pulmonary artery (fig. 2-fig. 4). the patient was given systemic thrombolysis and underwent a percutaneous catheter-directed thrombolysis (pcdt) procedure, and the symptoms had improved (fig. 5). consent was given to the patient for this procedure and case report publication. discussion pulmonary embolism is a condition that occurs because of a blood clot that travels to the pulmonary vessel. pe could be misdiagnosed at the beginning because the other diseases can mimic the symptoms of pe in the elderly.7 pe is the most common type of cardiovascular fig. 1 ecg of the patient showed s1q3t3 (s wave in lead i, w wave and inverted t wave in lead iii) pattern and t-inverted waves in precordial leads sidhi laksono, firizkita dewi, et al. 32 international journal of integrated health sciences (iijhs) fig. 2 thrombus in right pulmonary artery truncus with significant stenosis (blue arrow) fig. 3 thrombus in right interlobar pulmonary artery (blue arrow) and anterior truncus of right pulmonary artery with significant stenosis (red arrow) pulmonary embolism in high-risk patients: how to select standard imaging and management strategy? international journal of integrated health sciences (iijhs) 33 fig. 4 thrombus in left interlobular artery at posterior basal segment with significant stenosis (blue arrow) fig. 5 percutaneous catheter-directed thrombolysis procedure in our patient sidhi laksono, firizkita dewi, et al. 34 international journal of integrated health sciences (iijhs) disease after coronary artery disease and stroke. the obstruction in the pulmonary vessels could manifest in right ventricular failure. thus, early diagnosis is very important because pe could cause sudden death within 2 hours after presentation, and also associated with a quite high mortality rate, 30% if it is not treated.8 several risk factors could make someone more susceptible to experience pe, such as older age (>60 years old), history of venous thromboembolism events, trauma, previous major surgery, malignancy, coagulation disorders, and hormonal therapy.9 the most common symptoms that patients may experience are dyspnea (~92% of all patients with pe), pleuritic chest pain (49%), and also cough (20%). the symptoms occur due to disruption in pulmonary circulation, increased pulmonary arterial pressure, and disturbance in coronary circulation.10,11 in this case, our patient presented with several common symptoms of pe with older age as the only known risk factor. our patient also experienced a fever. a study explained that fever (38 oc -38.5oc) may present in pulmonary embolism and is associated with higher morbidity and clot burden. the mechanism of fever in pe is still unknown but may be related to inflammation cascade due to vascular irritation, tissue injury, or atelectasis.12 clinical signs that refer to pe should be assessed to establish the diagnosis of pe. ctpa is the standard imaging modality with high sensitivity and specificity. the finding in ctpa are filling defects (gray) in pulmonary arteries (white). ctpa may be contraindicated in patients with kidney disease, pregnancy, or allergy to contrast. patients who are contraindicated to undergo ctpa may undergo ventilation/perfusion lung scanning.13 risk stratification is essential to do because it will determine the treatment strategy. the presence of shock, right ventricular dysfunction, and biomarkers elevation are signs of high-risk pe.6 the patient had a cardiac arrest suggesting the presence of shock. the ecg of our patient showed the s1q3t3 pattern (acute right ventricle dysfunction).14 further evaluation of rv function can be done by echocardiography. some echocardiography findings in pe are rv hypokinesis/dilatation, rv/lv ratio end-diastolic diameter >1, rv end-diastolic diameter >30 mm, d-sign (ventricular septum pushed towards the lv), increased pressure of pulmonary artery, and inferior vena cava dilatation.15,16 this study also conducted laboratory tests to determine the nt-probnp and troponin t levels in our patient. the result showed the elevation of both biomarkers. elevation of these biomarkers could show right ventricular dysfunction and have roles in risk stratification and prognostic indicators in pe cases.17 management of pulmonary embolism is based on the severity of the disease. our patient was classified into high-risk pe. the management of high-risk pe should be started with anticoagulant administration without delay, even while waiting for another diagnostic test result. we administered enoxaparin (lmwh) to our patient as the initial anticoagulant. lmwh was chosen instead of ufh because it carried a reduced risk of major bleeding and heparininduced thrombocytopenia.18 high-risk pe is an absolute indication for thrombolytic treatment. thrombolysis is beneficial in patients with the onset of symptoms range for 6-14 days and it can significantly reduce the mortality and recurrence of pe in the high-risk patients. thrombolytic therapy can be done by administering systemic thrombolysis or by using catheter-directed thrombolysis (cdt). while systemic thrombolysis is effective as a treatment, it is also associated with a higher risk of severe bleeding (9.9%). thus, cdt can be done as an alternative treatment in patient who has a high risk of bleeding, such as an elderly patient. cdt is also indicated in a patient with a shock that can cause death, before systemic thrombolysis has its effect.19,20 in conclusion, the risk of experiencing pe is increased in the elderly. proper diagnosis and treatment could prevent mortality. ctpa is useful to help make the diagnosis in suspected pe patient, so the clinician could determine the treatment strategy. pcdt is indicated in high-risk pe patient with a life-threatening condition that needs prompt treatment. 1. badireddy m, mudipalli vr. deep venous thrombosis (dvt) prophylaxis. treasure island (fl): statpearls publishing llc; 2020. 2. smith sb, geske jb, kathuria p, cuttica m, schimmel dr, courtney dm, et al. analysis of national trends in admissions for pulmonary references pulmonary embolism in high-risk patients: how to select standard imaging and management strategy? international journal of integrated health sciences (iijhs) 35 embolism. chest. 2016;150(01):35–45. 3. tarbox ak, swaroop m. pulmonary embolism. int j crit illn inj sci. 2013; 3(1):69–72. 4. ashorobi d, ameer ma, fernandez r. thrombosis. treasure island (fl): statpearls publishing llc; 2020. 5. jaff mr, mcmurtry ms, archer sl, cushman m, goldenberg n, goldhaber sz, et al. management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the american heart association. circulation. 2011;123(16):1788–830. 6. moore aj, wachsmann j, chamarthy mr, panjikaran l, tanabe y, rajiah p. imaging of acute pulmonary embolism: an update. cardiovasc diagn ther. 2018; 8(3):225–43. 7. yayan j. relative risk of pulmonary embolism in the very elderly compared with the elderly. clin interv aging. 2013;8: 861–70. 8. bĕlohlávek j, dytrych v, linhart a. pulmonary embolism, part i: epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism. exp clin cardiol. 2013;18(2): 129–38. 9. turetz m, sideris at, friedman oa, triphathi n, horowitz jm. epidemiology, pathophysiology, and natural history of pulmonary embolism. semin intervent radiol. 2018;35(2):92–8. 10. sanchez o, caumont-prim a, riant e, plantier l, dres m, louis b, et al. pathophysiology of dyspnoea in acute pulmonary embolism: a cross-sectional evaluation. respirology. 2017;22(4):771– 7. 11. morrone d, morrone v. acute pulmonary embolism: focus on the clinical picture. korean circ j. 2018;48(5):365–81. 12. saad m, shaikh dh, mantri n, alemam a, zhang a, adrish m. fever is associated with higher morbidity and clot burden in patients with acute pulmonary embolism. bmj open respir res. 2018;5(1):e000327. 13. corrigan d, prucnal c, kabrhel c. pulmonary embolism: the diagnosis, riskstratification, treatment and disposition of emergency department patients. clin exp emerg med. 2016;3(3):117–25. 14. duru s, keleşoğlu a, ardıç s. clinical update on pulmonary embolism. arch med sci. 2014;10(3):557–65. 15. mediratta a, addetia k, medvedofsky d, gomberg-maitland m, mor-avi v, lang rm. echocardiographic diagnosis of acute pulmonary embolism in patients with mcconnell’s sign. echocardiography. 2016;33(5):696–702. 16. vyas v, goyal a. acute pulmonary embolism. treasure island (fl): statpearls publishing llc; 2020. 17. lankeit m, jiménez d, kostrubiec m, dellas c, kuhnert k, hasenfub g, et al. validation of n-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism. eur respir j. 2014;43(6):1669–677. 18. cossette b, pelletier me, carrier n, turgeon m, lecalir c, charron p, et al. evaluation of bleeding risk in patients exposed to therapeutic unfractionated or lowmolecular-weight heparin: a cohort study in the context of a quality improvement initiative. ann pharmacother. 2010;44(6): 994–1002. 19. konstantinides sv, meyer g, becattini c, bueno h, geersing gj, harjola vp, et al. 2019 esc guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the european respiratory society (ers). eur heart j. 2020;41(4):543–603. 20. brown kn, devarapally sr, lee l, gupta n. catheter directed thrombolysis of pulmonary embolism. treasure island (fl): statpearls publishing llc; 2020. sidhi laksono, firizkita dewi, et al. 8 international journal of integrated health sciences hepatic entero circulation, which will then be metabolized in the liver.4 in addition to being a predisposing factor for oral candidiasis, continuous use of immunosuppressive drugs can affect the function of hepatocytes as a major part of metabolic agents, which can subsequently cause liver injury.4,5 any abnormalities in the liver can be identified using liver function tests, one of them by evaluating serum albumin. it also can provide information about liver function.6,7 changes in its levels more or less than normal, can be a sign of liver damage, and also determine the prognosis of liver disease. the levels of this serum albumin can be used as indicators in hepatocellular function. a decrease in albumin levels can indicate liver disease such as cirrhosis hepatis.8 introduction oral candidiasis is a fungal infection that occurs in the oral cavity. the cause of this infection, as many as 95% of cases are candida albicans.1 one of the predisposing factors for this infection is the use of immunosuppressive drugs, which can enhance the growing colonies of candida albicans.2,3 the liver is one of the organs in the body that liable for drug metabolism. drugs contained in the blood will be absorbed through the original article serum albumin levels of oral candidiasis immunosuppressed rats treated with hyperbaric oxygen correspondence: agni febrina pargaputri department of oral biology, faculty of dentistry universitas hang tuah surabaya, indonesia e-mail: agni.febrina@hangtuah.ac.id agni febrina pargaputri, dwi andriani department of oral biology, faculty of dentistry universitas hang tuah surabaya, indonesia abstract objective: to investigate serum albumin levels in oral candidiasis immunosuppressed rats treated with hyperbaric oxygen. one of the predisposing factors for oral candidiasis was the use of immunosuppressive drugs continuously. it can also affect the work of the liver because it’s one of the organs responsible for drug metabolism. hyperbaric oxygen therapy was used not only to suppressing fungal infections, but also to improve liver function by evaluating the serum albumin levels. methods: this study used a post-test only control group design. fifteen wistar rats were divided into 3 groups(n=5/3): g1 (healthy group), g2 (oral candidiasis immunosuppressed rats group without hyperbaric oxygen therapy), and g3 (oral candidiasis immunosuppressed rats group with hyperbaric oxygen therapy). g2 and g3 groups were immunosuppressed by giving dexamethasone 0,5mg/day/rat orally for 14 days, added with tetracycline 1 mg/day/rat. hyperbaric oxygen therapy was given to the g3 group in 5 days. blood serum of rats in all groups was taken to calculate albumin levels. results: the average value of albumin levels in g2 group showed a decrease compared to the g1 group, while g3 showed the highest level. one way anova test showed a significant difference among groups (p<0,05). to compare the difference between each group we used lsd test and showed a significant difference (p<0,05) between g1 compared to g2, g1 compared to g3, and g2 compared to g3. conclusion: liver albumin levels of oral candidiasis immunosuppressed rats treated with hyperbaric oxygen therapy showed higher levels than those without therapy. keywords: albumin, hyperbaric oxygen, immunosuppressed, liver, oral candidiasis received: july 15, 2020 accepted: october 26, 2020 pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ ijihs.v8n1.2086 ijihs. 2020;8(1):8–13 international journal of integrated health sciences 9 hyperbaric oxygen therapy (hbot) has been reported as one of the therapies that had a significant effect on suppressing fungal infections.9,10 previous study showed that hyperbaric oxygen therapy 2.4 ata which was given 3x30 minutes/day for 5 days, could increase the number of lymphocytes in oral candidiasis immunosuppressed model. it could be used as one of the adjuvant therapy in eliminating oral candidiasis infections.11 hyperbaric oxygen therapy was also reported as therapy used in several liver diseases, such as acute liver injury, liver fibrosis, nonalcoholic steatohepatitis, cancer, and also has a beneficial effect on liver regeneration due to the antioxidant and anti-inflammatory effect derived from its mechanism.12 based on the description above, the aim of this study was to investigate serum albumin levels of wistar rats in oral candidiasis immunosuppressed condition which was treated with hyperbaric oxygen. methods this study used a post-test only control group design. the population of this study was fifteen male wistar strain rats, 6 months old, weighs 200–250 grams, and divided randomly into three groups: g1 (healthy rats group), g2 (oral candidiasis immunosuppressed rats group without hyperbaric oxygen therapy), and g3 (oral candidiasis immunosuppressed rats group treated with hyperbaric oxygen 2,4 ata 3x30 minutes/day for 5 days). immunosuppressed condition in rats was made by giving dexamethasone 0,5 mg/day and tetracycline 1 %/day orally. on the 4th day, we reduce the dose as much as 10% for dexamethasone and tetracycline, then rats were induced with candida albicans (atcc10231) 6x108 as much as 0,1 cc, applied on table 1 the mean and standart deviation (sd) of albumin levels in each group groups albumin (g/dl)mean+sd g1 (healthy rats) 3.2+0.12 g2 (oral candidiasis immunosuppressed rats without hbot) 2.96+0.17 g3 (oral candidiasis immunosuppressed rats with hbot) 3.4+0.12 the dorsum tongue of rats using a sterile cotton bud, given once every two days for 12 days.11,13 hyperbaric oxygen therapy was given to the g3 group for five days. during therapy with hyperbaric oxygen, rats were still given tetracycline 0,1 mg/day to prevent bacterial infection. the rats were placed in the monoplace chamber, the pressure was increased to 2,4 ata, then pure oxygen (100%) was flowed for 3x30 minutes, with intervals breathing normal air for 5 minutes. after that, the pressure was lowered to the initial pressure (1 ata).11 the blood of rats in all groups was taken from their heart using a syringe, as much as + 3cc, then centrifuged to obtain the blood serum for counting albumin levels. statistical analyses were done with the lavene statistical test to perform the homogeneity of the data. we used a statistical one-way anova test to show the different levels of serum albumin among groups, then the post hoc lsd test to show the significant difference among each group. to compare the serum albumin levels between groups that were given hyperbaric oxygen therapy and group which did not, we used an independent sample t-test. this study was conducted in the oral biology laboratory of dentistry faculty universitas hang tuah surabaya, faculty of medicine universitas hang tuah surabaya, and balai besar laboratorium kesehatan surabaya, which was held during august-december 2019. this study has been approved by ethics commission of dentistry faculty universitas hang tuah surabaya (no: ec/010/kepkfkguht/vii/2019). results the mean value of serum albumin levels in the g2 group showed the lowest, compared to g1 and g3 group, while in g3 showed the highest mean value of serum albumin levels. we used the homogeneity of variances test using the lavene statistic test and showed the homogeneous data (p>0.05). one way anova test showed a significant difference among groups (p<0.05). lsd test was used to compare the difference between each group and showed significance value (p<0.05) between g1 compared to g2, g1 compared to g3, and g2 compared to g3. this means that there was a significant difference between g1 group compared to g2, between g1 compared to g3, and between g2 compared to g3. to ascertain the differences between groups of agni febrina pargaputri, dwi andriani 10 international journal of integrated health sciences table 2 serum albumin levels between oral candidiasis immunosupressed (oci) rats group with and without hyperbaric oxygen therapy variable oci without hbot oci with hbot p value serum albumin (g/dl) 2.96+0.17 3.4+0.12 0.001* p value was obtained from independent sample t-test fig. 1 graphics of average value of albumin levels in each group. healthy rats group (g1), oral candidiasis immunosupressed (oci) rats group without hyperbaric oxygen therapy (g2), and oral candidiasis immunosupressed (oci) rats group treated with hyperbaric oxygen 2,4 ata 3x30 minutes/day for five days (g3) fig. 2 diagram of the significance value in each group obtained from lsd test *significant difference (p<0.05) oral candidiasis immunosuppressed rats given hyperbaric oxygen therapy and those which did not, we used an independent sample t-test, and showed a significant difference between groups (sig.2 tailed <0,05). discussion serum albumin levels of oral candidiasis immunosuppressed rats treated with hyperbaric oxygen 2,4 ata 3x30 minutes/ day with 5 minutes interval breathing in normal air, given for five days continuously (g3 group), showed the highest levels compared to the g1 and g2 groups. this elevation of serum albumin levels was in line with a previous study which showed that the administration of hyperbaric oxygen therapy could significantly increase serum albumin levels in patients with diabetic foot ulcers.14 several studies revealed serum albumin levels of oral candidiasis immunosuppressed rats treated with hyperbaric oxygen international journal of integrated health sciences 11 the effect of hyperbaric oxygen therapy on liver disease. this therapy could increase the proliferation of hepatocytes in liver injury, and preserved hepatocyte cells from necrosis on liver transplantation rats model.12 this therapy also reported having a hepatoprotective effect in hepatocellular necrosis which was caused by excessive administration of acetaminophen in rats model.18 hyperbaric oxygen therapy could increase the level of dissolved oxygen transported to the tissues systemically,14 moreover, oxygen transported to the injured liver will also increase. serum albumin is the most substantial plasma protein in the body, about 50% of the total protein, which is mainly synthesized in the liver. albumin acts as the main modulator in the distribution of fluids throughout the body’s space. some of the albumin functions are maintaining colloid oncotic pressure in plasma and interstitial fluid, responsible for water retention, as an antioxidant and anti-inflammatory, and also in endothelial protection.8,15 treatment using albumin, is currently become one of the choices in the treatment of liver disease, especially in liver cirrhosis.8 based on the results of this study, serum albumin levels of oral candidiasis immunosuppressed rats without hyperbaric oxygen therapy (g2) showed a decreased when compared with healthy rats group (g1) and oral candidiasis immunosuppressed rats treated with hyperbaric oxygen 2,4 ata 3x30 minutes/day for five days (g3). the decrease in serum albumin levels was likely because of enhanced leakage in the outside vascular system.17 it also indicates a disruption in liver hepatocytes function, as hepatocytes are an important part of the liver that is responsible for metabolizing drugs.4 continuous use of immunosuppressant drugs could resulting in hepatocytes to work harder, which then caused injury and reduced its function.5 a previous study using dexamethasone as immunosuppressive drugs showed an increase in serum alt and ast levels. the elevation of alt and ast levels could show the damage of the hepatocellular liver.16 hepatocytes are also being the major part in albumin synthesis, the integrity of these cells will effect on albumin production.17 this was similar to a previous study that showed a decreased in the amount of albumin caused by a reduced in production by hepatocytes.19 the impact of hyperbaric oxygen therapy on serum albumin has never been explained in prior studies.14 in this study, the increased serum albumin level in g3 group was likely due to the antioxidant function possessed by albumin. albumin becomes primary circulating antioxidant in the body, main extracellular source of thiols and reduced sulfhydryl group, which then act as scavengers of reactive oxygen and nitrogen species.15,19 albumin also known can decrease malondialdehyde levels, increased catalase activity, and glutathione levels significantly, therefore diminished reactive free radicals lead to oxidative damage, protected the tissues from highly reactive hydroxyl radicals, and impaired lipid peroxidation.17,19 increased oxygen level derived from oxygen-based therapy will be accompanied by increased production of its product, reactive oxygen and nitrogen species, which has a role in the pathogenesis of the disease.11,19 however, oxygen therapy given at pressure 2,4 ata will produce reactive oxygen species as a signaling molecule, in relevant levels for inducing antioxidants activity which can then accelerate the healing process of injured tissues, also will give benefits to regeneration of hepatocyte cells.12 hyperbaric oxygen therapy not only able to increase tissue oxygen level, but also could elevate growth factors and reduce inflammatory cytokines.14 reactive oxygen species derived from cyclic periods of hyperbaric and normoxic oxygen will affect the release of multiple growth factors by transducing signaling pathways, including those that lead to angiogenesis.20 giving hyperbaric oxygen therapy will modulate nitric oxide (no) to enhance expression of multiple growth factors such as vascular endothelial growth factor (vegf) and fibroblast growth factor (fgf) which able to trigger neovascularization and angiogenesis for healing injured tissue.20, 21 hyperbaric oxygen therapy was able to reduce the inflammatory cytokines il-1, il-6, and tnf-α.22 this was in line with the function of albumin which was capable of binding to inflammatory mediators, thus inhibited inflammatory signaling pathway and prevent inflammation in injured tissue. the previous study showed that albumin becomes an effective modulator of the innate immune system that could provide benefits in administration of acute-on-chronic liver failure.23 based on the result in this study, it can be concluded that serum albumin levels of oral candidiasis immunosuppressed rats treated with hyperbaric oxygen 2,4 ata 3x30 minutes/ day with 5 minutes interval breathing in normal air, given for five days, agni febrina pargaputri, dwi andriani a b 12 international journal of integrated health sciences shows the significant enhancing levels compared to those group without therapy. further study can be designed to evaluate the number of hepatocytes and other biochemistry parameters such as malondialdehyde, catalase enzim, and glutathione, to find out the hepatocellular liver function in oral candidiasis immunosuppressed rats model. serum albumin levels of oral candidiasis immunosuppressed rats treated with hyperbaric oxygen references 1. vila t, sultan as, montelongo-jauregui d, jabra-rizk ma. oral candidiasis: a disease of opportunity. j fungi (basel). 2020;6(1):15. 2. zhang m, yang x, wang d, yu c, sun s. antifungal activity of immunosuppressants used alone or in combination with fluconazole. j appl microbiol. 2019;126(5):1304–17. 3. keerthi m, reddy gs, shekar pc, chandra kl, kumar kk, reddy b. a study on isolation, identification, and antifungal susceptibility of various oral candidal species in renal transplant patients. j ntr univ health sci [serial online]. 2015 [cited 2020 jul 1];4:1705. available from: http://www.jdrntruhs.org/ text.asp?2015/4/3/170/165399. 4. jeanne louise schonborn. the role of the liver in drug metabolism. anaesthesia tutorial of the week. 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herbrecht, et al. diagnosis and treatment of mucormycosis in patients with hematological malignancies: guidlines from the 3rd european conference on infections in leukimia (ecil 3). haematologica. 2013:98(4):492–501. 10. fanny margaretha laihad, i ketut sudiana, m guritno. hyperbaric oxygen therapy on mucormycosis infection in oral cavity. folia medica indonesiana. 2017; 53(2):163–8. 11. agni febrina pargaputri dan dwi andriani. pengaruh pemberian terapi oksigen hiperbarik terhadap jumlah limfosit darah pada kandidiasis oral imunosupresi model. denta jurnal kedokteran gigi. 2018;12(2):36. 12. yun sun, yankai wen, chanjuan shen, yuanrun zhu, wendong you, yuanyuan meng, et al. hyperbaric oxygen therapy in liver disease. int j med sci. 2018;15(8):782–7. 13. andriani d, pargaputri af. enhance of il-22 expression in oral candidasis immunosuppressed model with acanthus ilicifolius extract therapy. iop conference series : earth and environmental science 217. 2019:1–6. 14. irawan h, semadi in, devi a. effect of hyperbaric oxygen therapy to improve serum albumin for patients with diabetic foot ulcers. biomed pharmacol j. 2018;11(1):569–75. 15. bernardi m, maggioli c, zaccherini g. human albumin in the management of complication in liver chirrosis. critical care. 2012;16(211):1–7. 16. rosida a. pemeriksaan laboratorium penyakit hati. berkala kedokteran. 2016;12(1):123–31. 17. saad ra, fathelbab mf, el-saba aa, shalaby. aa. the effect of albumin administration on renal dysfunction after experimental surgical obstructive jaundice in male rats. journal of taibah university for science. 2016;10(6):877– 86. 18. my taslipinar, i aydin, u kaldirim, fn aydin, m agilli, ye eyi, et al. hyperbaric oxygen treatment and n-acetylcysteine ameliorate acetaminophen-induced liver injury in a rat model. hum exp toxicol. 2013;32(10):1107– 16. 19. garcovich m, zocco ma, gasbarrini a. clinical use of albumin in hepatology. blood transfus. 2009;7(4):268–77. 20. prameswari n, sunaryo ir, damayanti dw, pargaputri af. the influence of hyperbaric oxygen therapy (hbot) to intercausal relationship between blood vessels, osteoblast, and new bone formation during maxillary international journal of integrated health sciences 13 agni febrina pargaputri, dwi andriani suture expansion. padjadjaran journal of dentistry. 2020; 32 (1):14–21. 21. dirmadana ra, mediani gs, sandana iki, alief f, yasin jj, brahmanta a. inovasi stichopus hermanii dan tohb dalam meningkatkan jumlah fibroblas pada ligamen periodontal. denta jurnal kedokteran gigi. 2017;11(1):15– 24. 22. yasin jj, brahmanta a, pargaputri af. inovasi terapi oksigen hiperbarik dan stichopus hermanii terhadap jumlah makrofag pada ligamen periodontal antara daerah tekanan dan tarikan selama pergerakan gigi ortodonti. denta jurnal kedokteran gigi. 2018;12(1):1– 10. 23. arroyo v, clària j. acute-on-chronic liver failure, human serum albumin, and immune modulation: the beginning of an exciting adventure. clin gastroenterol hepatol. 2018;16(5):633-636. volume 9 no 2 2021 fix.indd international journal of integrated health sciences (iijhs) 79 infective endocarditis with multiple valvar vegetation in uncorrected tetralogy fallot: a case report of rare condition abstract objective: to describe a case of an adult patient with uncorrected tetralogy of fallot (tof) who suffered from infective endocarditis (ie) that involved the tricuspid and aortic valves. methods: on october 2019, a-twenty-year-old male with uncorrected tof was admitted to the emergency department of dr. hasan sadikin general hospital with a chief complaint of fever. the echocardiography showed the presence of vegetation on the tricuspid valve and aortic valve. the patient was given empirical antibiotics therapy for ie treatment. the serial blood cultures did not yield any organism growth and the transthoracic echocardiography evaluation showed healed vegetation after 21 days of antibiotics treatment. results: a high turbulence in small vsd and valvular stenosis, as found in tof, can injure the endocardial surface. while bacterial adherence to the injured endocardial surface can cause ie, no specific criteria available for diagnosing ie in congenital heart disease (chd) patients compared to other population. in chd patients, it is necessary to consider the diagnosis of ie presenting with signs of infection or fever. the patients was known to have uncorrected tof and was admitted to the hospital with a chief complaint of fever. the uncorrected tof was complicated by an unusual form of aggressive vegetation involving multiple valves. conclusion: the incidence of ie in uncorrected tof is around 4%. patient is advised to receive a corrective surgery for the cardiac anomaly. surgical repair of chd with no residual lesion reduces the risk of ie. keywords: infective endocarditis, multiple valvar vegetation, tetralogy of fallot received: october 12, 2020 accepted: september 28, 2021 case report charlotte johanna cool, eliza techa fattima, mega febrianora, aninka saboe department of cardiology and vascular medicine, faculty of medicine universitas padjajaran-dr. hasan sadikin general hospital bandung, indonesia pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ ijihs.v9n2.2165 ijihs. 2021;9(2):79–83 correspondence: charlotte johanna cool, department of cardiology and vascular medicine, faculty of medicine universitas padjajaran/dr. hasan sadikin general hospital bandung, indonesia e-mail: charlotte@unpad.ac.id introduction infective endocarditis (ie) describes especially to an infection of the heart valves and endocardium or a prosthetic valvular implant. infective endocarditis (ie) is a life-threatening disease, a rare and that has long-lasting effects even among patients who are cured and survived. because of tetralogy of fallot (tof) is associate multiple cardiac lesions, it carries a higher risk for ie.1-3 the factors that influence the prognosis of ie: the cardiac and noncardiac complications, patient characteristics, the echocardiographic findings and the infecting organism. based on 2015 esc guideline for the management of ie, there were three categories of patients with the highest risk of ie. first, patients that use prosthetic material or with a prosthetic valve.2 second, patients with uncorrected chd and chd patients who have postoperative palliative shunts, prosthetic material or other conduits. third, patients known with previous ie. these patients have a greater risk, higher incidence of complications and higher mortality and 80 international journal of integrated health sciences (iijhs) than patients with a new episode of ie.3,4 ie antibiotic prophylaxis is recommended for the first six months after surgical repair with no residual defects. the prophylaxis is given after the procedure until endothelialisation of the prosthetic material has occurred.2 presented here is an adult patient with uncorrected tof that was complicated by an unusual form of aggressive vegetation involving multiple valves. case on october 2019, a 20 years old man with known uncorrected tof was admitted to the emergency department hasan sadikin hospital with a chief complaint of fever for seven days before admission. he was aware of his congenital heart disease since he was twoyears-old and suggested surgical correction, but his parents refuse due to financial problem. there was a history of cyanosis on the lips and fingertips when activity and crying since a child. growth and development are smaller compared to his peers at the same age. there is no history of frequent respiratory infections at the age of children. there was no history of family members with similar complaints. the patient had poor dental hygiene. he looked moderately ill, fully alert and dyspnea with obvious work of breathing. he was febrile, and his blood pressure was 110/60 mmhg, his pulse was 107 bpm with positive pulses deficit, and his respiratory rates was 26 bpm. the head examination showed perioral cyanosis. the jugular vein pressure showed 5+3 cm h2o with positive hepatojugular reflux. the thoracal examination showed cardiomegaly with pansystolic murmur grade 3/6 at lower left sternal border with positive carvallo’s sign and systolic murmur grade 3/6 at the upper left sternal border. other physical examinations were unremarkable. the electrocardiography examination showed atrial flutter, right axis deviation and biventricular hypertrophy (left ventricular hypertrophy with sokolow lyon criteria, r/s ratio >1 and dominant s wave in v5 or v6). the laboratory examination showed hb 18.3 g/dl, ht 64.2%, leukocyte 12.040 / mm3, thrombocyte 165.000/mm3, ureum 88.8 mg/dl, creatinine 1.28 mg/dl. chest x-ray examination showed cardiomegaly without lung oedema and right loculated pleural effusion. the patient underwent transthoracic echocardiography examination with result situs solitus, av-va concordance. all pv drain to la. asd (-), pda (-). vsd perimembranous (33-34 mm) r to l shunt with overriding aorta 50%. dilated all chambers. reduced lv systolic function with global hypokinetic. diastolic dysfunction cannot be measured due to fusion and reduced rv contractility. mild ar, trivial mr, mild tr. severe ps valvar, ps gradient 88 mmhg. pa confluence, mpa diameter 14 mm, rpa diameter 9 mm, lpa diameter 8 mm. left ao arch, coa(-). mild pericardial effusion is circumferential with conclusion tetralogy of fallot and vegetation at tricuspid valve (8x11 mm) and ncc of the aortic valve (6x12 mm). the serial blood cultures did not yield any organism growth. patients then diagnosed with tetralogy of fallot, afnvr, acute decompensated heart failure, possible ie (duke fig. 1 ecg showed atrial flutter, right axis deviation, and biventricular hypertrophy infective endocarditis with multiple valvar vegetation in uncorrected tetralogy fallot: a case report of rare condition international journal of integrated health sciences (iijhs) 81 criteria: 1 major criterion: echocardiography positive for ie (vegetation), two minor criteria: the presence of cardiac abnormalities predisposing to ie, fever), and right pleural effusion and were given ampicillin sulbactam 4 x 3 gr iv, gentamicin 1 x 160 mg iv, sildenafil 3 x 25 mg po, methylprednisolone 1 x 19.2 mg iv, sucralfate 4 x 10 cc, omeprazole 2 x 40 mg iv. for treatment. he was symptom-free and went home after 21 days of hospitalisation. the echocardiography evaluation after 1 month showed healed vegetation (2x6 mm at ncc) in response to antibiotics treatment. he was advised periodic follow-up and advised corrective surgery for the cardiac anomaly. fig. 2 chest x-ray showed cardiomegaly without lung oedema and right loculated pleural effusion discussion congenital heart disease (chd) is responsible for 10%–20% of ie cases, with tetralogy of fallot and other uncorrected cyanotic congenital heart diseases.5,6 the incidence of ie in chd patients has been increased.7 in spite of the improvement of antibiotics, ie is still high frequency, observed in the adult with chd. it could be due to improvement in catheter intervention and cardiac surgery that increase in the survival rate of adult patients with complex chd. the incidence of ie in corrected tof is around 18%. the incidence of ie in uncorrected tof is around 4%.5 as patients with tff are born with a high risk of ie because of the nature of their chd the exact pathophysiological mechanism remains speculative it is paramount to examine the risk of ie from the day of birth. in this case, the uncorrected tof was complicated by an unusual form of aggressive vegetation involving multiple valves. each chd lesion has varying pathogenesis which leads to endocardial injury. whereas, high turbulence in small vsd and valvular stenosis as in tof can injure endocardial surface.5 the vegetations at tricuspid valve due to endocardial injury because high turbulence from vsd. the vegetations at aortic valve due to endocardial injury because overriding aorta. the pathogenesis of ie requires several independent factors such as injury of endocardial surface, thrombus formation, bacterial entry and adherence to the injured endocardial area. the injury and thrombus formation conditions provide a good environment to infection, whereas the next two allow the organism to implant on the endocardial area. the preexisting valvular fig. 3 echocardiography showed vegetation at tricuspid valve in rv inflow view (a), vegetation at ncc of aortic valve in short axis view (b) tricuspid valve aortic valve charlotte johanna cool, eliza techa fattima, et al 82 international journal of integrated health sciences (iijhs) disease makes the turbulence blood flow. the turbulence makes injury of the endothelium. mostly endocarditis patients have hemodynamic or structural abnormalities.8 while the endocardial surface is injured, platelets adhere to initiate sterile vegetation (called nonbacterial thrombotic endocarditis) formation from fibrin deposition in the injured endothelial surface.8 nowadays, ie is usually an acute disease, that associated with healthcare, often with early presentations due to streptococcus aureus in developed countries. fever is nonspecific but is the most common presenting symptom nowadays.2,3 patient’s was admitted to the hospital with a chief complaint of fever. the serial blood cultures did not yield any organism growth. the patient was diagnosed possible ie (duke criteria: 1 major criteria: echocardiography positive for ie (vegetation), two minor criteria: the presence of cardiac abnormalities predisposing to ie, fever). right-sided infective endocarditis is more frequent in congenital heart disease than in acquired cardiac disease. however, the basic principal symptoms, diagnosis and complication same from ie in general.2 the use of transesophageal echocardiography is favourable in an adult with artificial material and complex cardiac anatomy. the superiority of transesophageal echocardiography over transthoracic echocardiography has not been systematically studied in this setting. the antibiotic treatment is started after taking the blood culture.9 the patient was given empirical antibiotics therapy for ie treatment. the serial blood cultures did not yield any organism growth. the transthoracic echocardiography evaluation showed healed vegetation after 21 days of antibiotics treatment. in chd, patients with ie should see chd centres. the specialist chd centres provide expertise in microbial examination, imaging, surgery and intensive care unit.2 the principles of diagnostic and management in ie patients with or without chd is same. the management is mainly appropriate antimicrobial treatment based on the respective microorganism.2 surgery is limited to those with failure of medical treatment, serious haemodynamic complications, ie with a prosthetic material, and when there is a high risk of devastating septic embolism.4 in another study, cardiac surgery should be considered in the presence of heart failure, a perivalvular abscess, aortic valve ie, and the change of antibiotics.10 the patient was advised periodic follow-up and advised corrective surgery for the cardiac anomaly. primary prevention for ie with chd is vital. it is important to maintain good oral and dental hygiene and skin hygiene. in patients not followed in specialist, chd centres could cause education problem about prevention of recurrent ie.11 the patients are suggested to avoid piercing and cosmetic tattooing. the limitation of this case report is we could not do pathological examination of resected valvar or embolic fragment because surgery was not performed as gold standard for diagnoses of ie. the incidence of ie in uncorrected tof is around 4%. the patient was advised corrective surgery for the cardiac anomaly. surgical repair of chd with no residual lesion reduces the risk of ie. 1. rodger l, glocker-lauf s, shojaei e, sherazi a, hallam b, koivu s, et al. clinical characteristics and factors associated with mortality in firstepisode infective endocarditis among persons who inject drugs. jama netw open. 2018; 1(7):e185220 2. habib g, lancelloti p, antunes m j, bongiorni mg, casalta j, zotti fd, dulgheru r, et al. 2015 esc guidelines for the management of infective endocarditis. european society of cardiology. eur heart j. 2015;36(44):3075–128. 3. baddour lm, freeman wk, suri rm, wilson wr. cardiovascular infections, braunwald’s heart disease a textbook of cardiovascular medicine 10th ed. philadelphia: elsevier saunders; 2015. 4. zuttere d, lardoux h, rocha p, plassart s, sanasinlard j, grinda jm. simultaneous bilateral infective endocarditis with right ventriular mural involvemet. j cardiovasc ultrasound. 2015;23(2): 19–20. 5. keynan y, rubinstein e. pathophysiology of infective endocarditis. curr infect dis rep. 2013;15(4):342–6. 6. mulder bjm. endocarditis in congenital heart disease. circ aha j 2013;128(13):1396–7. 7. werdan k, dietz s, löffler b, niemann s, bushnaq h, silber r, et al. mechanisms of infective endocarditis: pathogen–host interaction and references infective endocarditis with multiple valvar vegetation in uncorrected tetralogy fallot: a case report of rare condition international journal of integrated health sciences (iijhs) 83 risk states. nat rev cardiol 2013;11(1):35–50. 8. lilly ls. pathophysiology of heart disease. 5th ed. philadelphia: wolter kluwer/lippincott, williams & wilkins; 2011. 9. nishimura ra, otto cm, bonow ro, carabello ba, erwin jp iii, guyton ra, et al. 2014 aha/ acc guideline for the management of patients with valvular heart disease: executive summary: a report of the american college of cardiology/american heart association task force on practice guidelines. j am coll cardiol 2014;63:2438–88. 10. niwa k, nakazawa m, tateno s, yoshinaga m, terai m. infective endocarditis in congenital heart disease: japanese national collaboration study. heart. 2005;91:795–800. 11. warnes ca, williams rg, bashore tm, child js, connolly hm, dearani ja, et al. acc/aha 2008 guidelines for the management of adults with congenital heart disease: a report of the american college of cardiology/american heart association task force on practice guidelines. j am coll cardiol 2008;52:e143– e263. charlotte johanna cool, eliza techa fattima, et al volume 8 no 1 2020 v2.indd international journal of integrated health sciences 1 and good communication aimed at to get the best treatment results for patients. ic can be defined as the consent given by the patient and or his family to the doctor based on an explanation of the medical actions to be taken against the doctor and the risks associated by it.2 ic is a method for sharing information between the doctor and the patient so it must occur collaboratively (cooperation) that both between doctors and patients and their families to get the best choice for the patient treatment.3 the patient-doctor relationship will be well established if each part understands the role itself and functions concerning ic. a relationship between the quality of informed consent at surgical procedure in terms of ethics and medicolegal with satisfaction of patient health service in dr. zainoel abidin hospital abstract objective: to determine the relationship between the quality of informed consent in terms of ethics and medicolegal with patient health service satisfaction at the dr. zainoel abidin hospital (zah) banda aceh. methods: this study is an observational analytic with a cross-sectional method. subject selection through a total sampling method. this study involved patients who were treated at dr. zainoel abidin hospital (zah) banda aceh and a total of patients were 100 (52 men and 48 women) who met the inclusion criteria carried out on 16 december 2019 to 31 december 2019. results: as many as 90% of respondents rated informed consent made at zah as good quality and 85% expressed the satisfaction with health services at zah. an ethical and medicolegal review of informed consent emphasizes the basic principles of bioethics. as many as 84% of respondents stated that their autonomy rights had been fulfilled, 92.50% thought that the doctor had done beneficence, nonmaleficence, and justice well in the process of informed consent and 92.33% of respondents rated the three elements of informed consent as being well implemented. based on the results of the chi-square statistical test showed a significant relationship between the quality of informed consent in terms of ethics and medicolegal with patient health service satisfaction under the value of p=0.001 (p≤0.05). conclusion: good quality of informed consent in terms of ethics and medicolegal has an important role in increasing patient satisfaction with health services at the dr. zainoel abidin hospital of banda aceh. keywords: ethics, informed consent, medicolegal, satisfaction received: january 12, 2020 accepted: march 30, 2020 correspondence: taufik suryadi, department of forensic medicine and medicolegal, faculty of medicine, universitas syiah kuala/ zainoel abidin hospital banda aceh, indonesia, e-mail: taufik.suryadi.ts@gmail.com, taufiksuryadi@ unsyiah.ac.id original article taufik suryadi,1 putra safana,2 dedy syahrizal3 1department of forensic medicine and medicolegal, faculty of medicine, universitas syiah kuala/zainoel abidin hospital banda aceh, indonesia 2medical student faculty of medicine, universitas syiah kuala, banda aceh, indonesia 3department of biochemistry, faculty of medicine, universitas syiah kuala, banda aceh, indonesia introduction informed consent (ic) consists of two words, namely informed which means that it has received an explanation or information, and consent means approval or giving permission.1 ic is an embodiment of the patient-doctor relationship based on trust pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ ijihs.v8n1.2000 ijihs. 2020;8(1):1–7 2 international journal of integrated health sciences doctor understands how to provide adequate information that can be accepted by patients. the doctor should provide information using language that is understood easily by patients. the doctor must also understand the sociocultural and emotional aspects of the patient.4 the ic process does not only to get the patient’s signature but rather respects the patient’s right to autonomy.5 ic while viewing through ethical principles is included in the basic rules of bioethics autonomy and when it views in the context of patient rights, ic is included in the right to self-determination.6 the quality of informed consent in terms of ethics can be assessed from the fulfillment of four basic principles of bioethics, that are beneficence, nonmaleficence, justice, and autonomy. beneficence contains how the doctor will make informed consent which gives attention, friendliness, compassion, and empathy to patients. nonmaleficence means that doctors try to minimize harm to patients with not to force it to frighten, and do not lie to patients in making decisions. justice is genuinely done by doctors in conveying information and every patient is given an informed consent process before medical treatment. autonomy is a right that is owned by the patient, namely how the patient gets information, giving choices, privacy, confidentiality and the right to give consent.6,7,8 based on medicolegal, ic is a legal concept that guarantees the patients have the right to know about the risks, benefits and alternative therapies to be taken,7 also if included in the approval of civil medical actions which if not implemented can be categorized as violating the law.2,8 quality of informed consent in terms of medicolegal can be assessed from fulfillment based on three aspects, namely, the approver must be competent that is aged 21 years or more (threshold element), the giver of explanation and the contents of the explanation (information element), and approval (consent element). this concentration element consists of two parts, namely, voluntariness (freedom) and authorization (authority).8 the fundamental problem is that there are still many findings in the field about the informed consent process that have not been implemented properly so that it has the potential to be a problem of ethical and medicolegal violations. the ethical aspects related to ic focus on autonomy, trust, self-determination, personal integrity, and non-dominance. while the medicolegal aspect is protection, prevention of deviant behavior and procedures that are not essential. ic is still often become a cause of conflicts between doctors and patients.6,7,8 from previous study reported that poor communication is the highest cause of patient complaints with prevalence in jakarta 66,3%.3 in indonesia, obstacles in conducting ics, including explanation problems which the patient does not understand. the results of the study of patient safety management team for hospital services obtained information that giving of informed consent in various health service institutions only asks patients to sign an informed consent sheet so that it affects the knowledge of patients and families.9,10 the main of purpose this study was to determine the relationship between the quality of informed consent in terms of ethics and medicolegal at surgical procedures with the satisfaction of patient health services in dr. zainoel abidin hospital (zah) of banda aceh. methods this research is an observational analytic with a cross-sectional method. subject selection through a total sampling method. this study involved patients who were treated at the dr. zainoel abidin hospital of banda aceh numbered 100 people (52 men and 48 women) who met the inclusion criteria carried out on december 16, 2019, to december 31, 2019. this study has conducted ethical clearance and has been approved by the ethics committee of the health research, the faculty of medicine, syiah kula university / zainoel abidin hospital no. 333/ea/fk-rsudza / 2019. inclusion criteria in this study include (1) male and female patients over the age of 21 years, (2) patients who have had surgery, (3) patients who have given informed consent before the treatment, (4) patients who can read and write and communicate well. exclusion criteria: (1) patients suffering from mental disorders. the data taken is the primary data. primary data were obtained from the results of filling out the informed consent quality questionnaire to determine the quality of the informed consent in terms of ethical and medicolegal aspects, and also the satisfaction of patient to health services obtained from the results of filling out the questionnaire that had been tested for validity. the questionnaire used in this study was made by the research team and has been validated with a validity value> 0.361 and reliability 0.871. relationship between the quality of informed consent at surgical procedure in terms of ethics and medicolegal with satisfaction of patient health service in dr. zainoel abidin hospital international journal of integrated health sciences 3 taufik suryadi, putra safana, et al. results the study was conducted on patients treated in raudhah rooms of zah as many as 100 respondents, with characteristics based on age and gender presented in table 1. the average value of participant age was 51.52 (sd 15.51), 50.50 median, 47 modus, 21 minimum, and 83 maximum. table 1 shows that based on gender, most respondents are male with 52 respondents (52%) and based on age group, most respondents aged between 56 to 65 years are 26 respondents (26%), although the mode of age of respondents is not from these group but from the age group of 46–55 years that is 47 years old respondents are 7 respondents (7%). in terms of age, all respondents have the right to give consent which is 21 years or older so that the threshold element is fulfilled 100%. all participants stated that the doctor who explained was the doctor who took the surgery, from this statement it could be concluded that there was fairness in treating respondents in the ic process (justice fulfilled 100%). the description of the quality of informed consent in terms of ethics and medicolegal is shown in table 2: table 2 shows that the basic rules of bioethics have been implemented well. as many as 84% of respondents stated that their autonomy rights had been fulfilled and on average 92.50% thought that the doctor had done beneficence, nonmaleficence, and justice well in the informed consent process. medicolegal obtained an average of 92.33% table 1 characteristics of respondents characteristics frequency of respondents (n=100) % age 21–25 years 8 8 26–35 years 14 14 36–45 years 12 12 46–55 years 20 20 56–65 years 26 26 >65 years 20 20 gender man 52 52 women 48 48 table 2 the description of the quality of informed consent in terms of ethics and medicolegal rated aspect assessment fulfill (%) (%) ethics beneficence 93 (93) 7 (7) non maleficence 93 (93) 7 (7) justice 100 (100) 0 autonomy 84 (84) 16 (16) average 92,50 (92,50) 7,50 (7,50) medicolegal threshold element 100 (100) 0 information element 93(93) 7 (7) consent element 84 (84) 16 (16) average 92,33 (92,33) 7,67 (7,67) ic quality ethics and medicolegal 90 (90) 10 (10) of respondents rated the three elements of informed consent as fulfilling the medicolegal rules. accumulatively, the assessment of ethical and medicolegal aspects is carried out simultaneously, the fulfillment of the basic ethical principles of beneficence and nonmaleficence is assessed when the doctor provides information (information element), while the autonomy rules are assessed together with the consent element. from the tabulation obtained data about the quality of informed consent in the hospital room zah cumulatively percent shows that of 100 respondents regarding the quality of informed consent, 90 respondents rated good (met the ethical and medicolegal rules) and 10 respondents rated not good. the level of patient satisfaction with health services in zah was assessed based on 5 aspects, there are tangibles, reliability, responsiveness, assurance, and empathy. obtained an overview of the level of satisfaction of health services from each respondent as listed in table 3. 4 international journal of integrated health sciences table 3 shows that from 100 respondents, most respondents expressed satisfaction with the reality (tangibles) and empathy in providing health services as much as 96 and 95 percent. from the tabulation obtained data about patient satisfaction with health services in the hospital room of zah cumulatively based on statistical calculations showed that out of 100 respondents, 85 respondents rated satisfaction with services in zah and 15 respondents rated dissatisfaction in service at zah. in this study to assess the relationship between the quality of informed consent in terms of ethical and medicolegal aspects with the satisfaction of health services, the chisquare statistical test is used in table 4. in this study, the chi square test was used to determine the relationship or effect of two nominal variables and to measure the strength of the relationship between these variables. based on table 4 it can be explained that the results of the chi-square statistical test showed a significant relationship between the quality of informed consent in terms of ethics and medicolegal with patient health service satisfaction with a value of p=0.001 (p≤0.05). discussion ic must make the patient understand in the context of receiving information before the patient gives consent for medical treatment against them, this can be achieved if there is effective doctor-patient communication.3 patient satisfaction is also related to the quality of ic. patient satisfaction is always the main target of health services. quality treatment results are indicators of the quality of health services.5 discussing patient satisfaction with health care, especially in surgical procedures and its relation to ic quality is not easy, because it is difficult to determine how the patient’s understanding of surgical procedures.1 determination of patient satisfaction with health services is also not easy to achieve because of many factors that influence it, including socioeconomic, knowledge, culture, health status, doctor-patient relationship, staff performance, number of facilities, and medical records system.5 regarding surgery, two principles of medical ethics are related closely, namely the principle of autonomy and non-maleficence. a patient must get full information before getting surgery and enough data must be submitted by the doctor to the patient so that ethical and medicolegal aspects can be accomplished. 2 the principle of autonomy means the doctor’s moral principle to always respect the patient’s rights, especially in this case is the right to table 3 overview of patient satisfaction with service quality based on the five dimensions of service quality service satisfaction satisfied % not satisfied % tangibles 96 96 4 4 reliability 81 81 19 19 responsiveness 86 86 14 14 assurance 92 92 8 8 emphaty 95 95 5 5 over all of service satisfaction 85 85 15 15 table 4 the relationship between the quality of informed consent in terms of ethical and medicolegal aspects with the satisfaction of health services health service satisfaction satisfied not satisfied (n=100) p-value the quality of informed consent good 81 9 90 0,001* not good 4 6 10 relationship between the quality of informed consent at surgical procedure in terms of ethics and medicolegal with satisfaction of patient health service in dr. zainoel abidin hospital international journal of integrated health sciences 5 determine what can be done to him (the right to self-determination), which is then developed in the doctrine of informed consent. the principle of non-maleficence is the moral principle of the doctor not to take actions that will worsen the patient’s condition (primum non nocere, above all, do no harm).8 the results of this study conducted at the raudhah ward (surgery ward) of zah in 100 respondents found a relationship between the quality of informed consent in terms of ethics and medicolegal with patient health service satisfaction. this is in line with a study conducted by jhonson et al, in which result there was a significance relationship between giving informed consent and the level of satisfaction on the day of surgical procedure (p=0,02).11 the results of this study were also supported by sari’s study showed that there was a relationship between giving informed consent before surgery and patient satisfaction.12 when viewed specifically, the quality of informed consent at zah most of the respondents rated good for both the giver of explanation, the contents of the explanation, and the giver of approval. judging from the results of this study it was found that the doctors at zah had given good informed consent judged from ethical and medicolegal aspects. during the interview with the respondent, the respondent also stated that the doctor who gave the ic was patient enough to wait for the patient’s answer, allow to asking questions, and when giving consent there was no pressure and force. thus the nonmaleficence code of ethics has also been implemented well which means that the doctor has tried to minimize losses to the patient due to decision making without coercion, fear or deception from the doctor. however, there are 7% of respondents who stated that there was a compulsion but not from a doctor but from a patient’s family who wanted an immediate operation even though the patient himself did not want to. this research is different from research conducted by aldossari et al.,5 who found that 8.3% of respondents felt pressured by medical staff in decision making. from an ethical perspective, in this study, there were still 16% of respondents who had not been accommodated in their autonomy rights. this shows that respondents and the indonesian people, in general, are still not strong in autonomy because it is common knowledge that indonesia is still communal, that is, everything is left to the family and not yet entirely dependent on independent decisions. the right of autonomy that has not yet been fulfilled is privacy (freedom of choice) because it still depends on the family of 14% and the right to give consent of 2%. from the aspect of justice, doctors have done well both when giving information and when getting patient approval, all done fairly. ic is a process that shows effective communication between doctors and patients and the meeting of thoughts about what will and what will not be done to patients. ic viewed from the legal aspect is not as an agreement between two parties, but rather towards unilateral agreement on services offered by other parties. viewed from civil law, the relationship between health care providers and health service recipients is a contractual relationship. from this relationship, a bind of agreement between the two parties arises and rights and obligations emerge from each side. what is the right of the first side will become an obligation for the other side, and vice versa.7,8,13 in medicolegal, ic has 3 elements, namely threshold elements, information elements, and consent elements. the threshold element, ie the consent giver must be competent. by law a person is considered competent (competent) is when an adult, conscious and in a mental state that is not under control. an adult is defined as an age that has reached 21 years or has ever been married.13,14 information elements, consisting of two parts, namely disclosure and understanding. in this study, doctors have provided adequate information (93%), but there are also 7% inadequate that is related not given information about the benefits of the actions taken (5%) and doctors do not introduce themselves when giving ic (2%). understanding based on adequate understanding brings consequences to medical personnel to provide information (disclosure) in such a way that the patient can reach an adequate understanding. many experts say that if this element is not done then the doctor is considered to have neglected to carry out his duty to provide adequate information.7,8,13 consent elements also consist of two parts, namely, voluntariness (freedom, freedom) and authorization (approval). volunteering requires no deception, misrepresentation or coercion. patients must also be free from “pressure” by medical personnel who behave as if to be “left” if they do not agree to the offer. many experts still argue that carrying out “not excessive” persuasion can still be morally justified.8,13 the description of patient health service taufik suryadi, putra safana, et al. 6 international journal of integrated health sciences satisfaction shows that of 100 respondents, 85 respondents rated satisfaction with the service and 15 respondents rated dissatisfaction. following the research objective of knowing the level of satisfaction of raudhah inpatients with services, the following discussion will be carried out the results of research on patient satisfaction in evaluating the quality of health services by applying the concept of “rater” that is reliability, assurance (guarantee), reality (tangibles), empathy and responsibility.14 according to muninjaya14 which states that satisfaction is defined as the recipient’s service response to the suitability of the customer’s interest level with real performance can be felt after the service user receives the service. the suitability of ic quality with patient satisfaction with health services is reflected in what is delivered to the patient at the time of providing information following what the patient feels after the surgical procedure is performed.6,7,8 this conformity is described: reliability criteria reflected by attitude the hospital staff who able to handles patient care issues precisely and professionally and who arrive on time to the room when the patient needs it, this is in accordance with the ethical principles of beneficence and non-maleficence. hospital staff informs clearly them of the things that must be followed in treatment (autonomy and beneficence). hospital staff notifies clearly about matters that are prohibited in treatment (autonomy and nonmaleficence).7,8 assurance criteria reflected by attitude the hospital staff who pays attention to complaints the patient feel, who can answer questions about the treatment actions given, who honest in providing information about the situation and who always gives greetings and smiles when meeting to the patient, this is in accordance with beneficence and autonomy. tangibles criteria reflected by attitude the hospital staff who always maintains neatness and appearance (beneficence). emphaty criteria reflected by attitude the hospital staff who gives information about all treatments that will be carried out (autonomy-beneficence), who attentives and provides moral support for the patients (beneficence), services provided by hospital staff do not look at rank / status but are based on patients conditions (justice-autonomy), responsiveness criteria reflected by attitude the hospital staff who are are willing to offer assistance to the patient when patient experience difficulties even without being asked (beneficence and nonmaleficence).6,7,8,13 the results of the study on the level of patient satisfaction with health services in the raudhah room of zah showed that expressed satisfaction generally with the health services. chi-square statistical test results obtained p-value 0.001 in this study showed that there was a significant relationship between the quality of informed consent of surgical procedures in terms of ethics and medicolegal with patient health service satisfaction in zah (p<0.05). this shows that the quality of informed consent at zah which has been good also contributed to the level of patient satisfaction. the results of the study are supported by hallock et al.1 study which states there was a significant association between satisfaction and knowledge of informed consent. according to sari’s study, that the patient’s health condition includes the diagnosis of the course of the disease, the process of medical treatment, and the results of services. indicators of health services chosen by patients are priority measures of the quality of health services, tend to be the main source of the formation of patient satisfaction.12 this study shows that there is a relationship between the basic rules of bioethics applied to the ic process with patient satisfaction criteria. good quality ic in terms of ethics and medicolegal have an important role in increasing patient satisfaction with health services at the dr. zainoel abidin hospital of banda aceh. a limitation of this study is that data collection is limited to respondents in the operating theater at the time of the study, so the results of the study may not reflect all patients who had undergone previous operations. it might also not be relevant to the experience of patients in other rooms. but in general, this study is very useful for the development of hospital service systems in the future. relationship between the quality of informed consent at surgical procedure in terms of ethics and medicolegal with satisfaction of patient health service in dr. zainoel abidin hospital references 1. hallock jl, rios r, handa vl. patient satisfaction and informed consent for surgery. am j obstet gynecol. 2017;217(2): 181.e1-181.e7. 2. akasha ra, beshi l, el-fadul m. mapping the quality of informed consent for major surgeical prosedures in public dental hospital in khartoum state, sudan, 2017: a crross sectional study. dentristy. 2018;8 (11):1–7. international journal of integrated health sciences 7 taufik suryadi, putra safana, et al. 3. afandi d. aspek medikolegal dan tata laksana persetujuan tindakan kedokteran. jurnal kesehatan melayu. 2018;1(2):99–105. 4. sukendar s, rahim ah, hutabarat s. tanggung jawab rumah sakit atas kelengkapan informed consent pada saat operasi di rs primier jatinegara jakarta. soepra jurnal hukum kesehatan. 2016;2 (2):229–40. 5. aldossari sh, alfayed ss, al mutlaq ri, alturki di, aljaser ak, nouh ta. the relationship between quality of informed consent and perioperative care, and patient satisfaction: a tertiary-care hospital’s experience. international journal of medical and health research. 2017;3(9):107–12. 6. beauchamp tl, childress jf. principles of biomedical ethics. 7th ed. new york: oxford university press. 2013. p. 190-317. 7. shaha kk, patra ap, das s. the importance of informed consent in medicine. sch j app med sci; 2013;1(5):455–63. 8. sharma r. informed consent in clinical practice and research: ethical and legal perspective. int j healthcare biomed res. 2014;3(1):144–151. 9. realita f. implementasi persetujuan tindakan medis (informed consent) pada kegiatan bakti sosial kesehatan di rumah sakit islam sultan agung semarang. jurnal involusi kebidanan. 2014:4(7):25–39. 10. kustiawan r, lesharini e. pengalaman pemberian informed consent tindakan pembedahan pada pasien pre operatif elektif di ruang iiia rsu kota tasikmalaya. jurnal kesehatan bakti tunas husada. 2014;(11)1:68– 77. 11. johnson mr, singh jh, steaward t, gioe tj. patient understanding and satisfaction in informed consent for total knee arthroplasty: a randomized study. artritis care res. 2011;63(7):1048–54. 12. sari pd. hubungan antara pemberian informed consent sebelum tindakan operasi dengan kepuasan pasien. jurnal infokes. 2016;6(2):1–4. 13. patil am, anchinmane vt. medicolegal aspects of consent in clinical practice. bombay hospital journal. 2011;53(2)203–8. 14. muninjaya g. manajemen kesehatan. 3rd ed. jakarta: penerbit egc; 2011. vol 9 no 1 2021 (2).indd 42 international journal of integrated health sciences (iijhs) congenital complete heart block in young women abstract objectives: to present a rare case of congenital complete heart block (cchb) in the setting of post-cesarean delivery of an asymptomatic young patient. methods: a 30-year-old female patient complained of sudden weakness after c-section delivery with spinal anesthesia. she presented a slow heart rate and complete heart block (chb) on electrocardiogram (ecg). after one week of observation, the ecg still presented a chb condition. a permanent pacemaker (ppm) with dddr mode was then installed for this patient. result: the etiology of chb, especially at a young age, is unclear, hence challenging. a patient with a cchb is difficult to diagnose, especially without any previously related symptoms. this abnormality is usually detected during routine screening not related to cardiovascular disease. the patient in this case study presented an ecg of persistent chb from the time this patient was admitted until one week after observation. the echocardiography showed normal results. other modalities to confirm diagnosis and evaluate the prognosis of a cchb should be done. conclusion: establishing the etiology of chb in young patients is challenging. the implantation of ppm is needed because the condition is permanent, regardless the etiology. however, implanting a permanent pacemaker is not always an easy decision, especially in young patients. keywords: complete heart block, congenital, young received: september 21, 2020 accepted: march 30, 2021 correspondence: triwedya indra dewi, department of cardiology and vascular medicine, faculty of medicine universitas padjadjaran-dr. hasan sadikin general hospital bandung, indonesia e-mail: adeindradewi@gmail.com case report triwedya indra dewi, giky karwiky, rekha nova iyos, mega febrianora department of cardiology and vascular medicine, faculty of medicine universitas padjadjaran-dr. hasan sadikin general hospital bandung, indonesia pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ ijihs.v9n1.2142 ijihs. 2021;9(1):42–48 introduction heart block is a disturbance of impulse conduction that can be permanent or transient, depending on the anatomic or functional impairment. it must be distinguished from interference, a normal phenomenon that is a disturbance of impulse conduction caused by physiologic refractoriness resulting from inexcitability secondary to a preceding impulse. interference or block can occur at any site where impulses are conducted, but they are recognized most often between the sinus node and atrium (sa block), between the atria and ventricles (av block), within the atria (intra-atrial block), or within the ventricles (intraventricular block).1,2 complete heart block can be acquired or congenital. it can occur due to multiple pathological conditions. the etiology of complete heart block, which ensues in the young population, was only identified in approximately half the patients, in whom complications to cardiac surgery or congenital complete heart block were the most common aetiologies. the acquired chb occurs due to various reasons: medicines, acute myocardial infarction, chronic ischemic heart disease, degenerative diseases, rheumatic diseases, infiltrative processes, neuromyopathy, infectious diseases, iatrogenic, and av blocks international journal of integrated health sciences (iijhs) 43 fig. 1 ecg with complete heart block mediated by vagal processes. in some rare cases, spinal anesthesia can cause chb. congenital heart block that occurs after spinal and epidural anesthesia may combine several processes, such as drugs, iatrogenic, and vagal.1,3-7 the incidence of cchb varies from 1 in 15,000 to 1 in 22,000 live births.1 the signs and symptoms of patients with cchb depend on the baseline ventricular rate and underlying structural defects. patients may be asymptomatic until cardiac decompensation begins to occur in adulthood.8 in this case report, the author will discuss etiology of cchb in a young post partum patient and diffrentiate it from other causes of chb. case a thirty-year-old female (p1, a0) was referred from a satellite hospital and consulted in the emergency room due to a complete heart block after caesarean delivery with spinal anesthesia. she complained of progressive generalized fatigue a few hours after caesarean delivery, so that she was unable to perform a regular activity. there were no accompanying neurological symptoms, heart failure, nor a history of hypertension. the patient’s heart rate was reported to be slow by her husband, with no significant symptoms before the procedure. spinal anesthesia was performed using bupivacaine 10 mg and fentanyl 25 u. the procedure went smooth with 2900 gram healthy baby girl was delivered. shortly after the delivery, the patient has hypotension and bradycardia. resting ecg showed a complete heart block with qrs duration 0.08 s and prolonged qtc of 516 ms. soon thereafter, she was referred to hasan sadikin general hospital for temporary percutanues pacemaker (tpm). on arrival in the emergency room, the vital signs showed a slow heartbeat of 40 beats per minute and the blood pressure 120/80 mmhg. her physical examination was unremarkable. the ecg showed chb with qrs duration 0,08 s and prolonged qtc of 574 ms. her chest x-ray examination revealed an enlarged heart. her blood examination showed; hemoglobin 12.3 g/dl, leukocyte 7,200 /mm3, thrombocyte 342,000, urea 52 mg/dl, creatinine 0.98 mg/ dl, sodium 137 mg/dl, potassium 4.2 mg/dl, calcium 4.81 mg/dl, magnesium 2.1 mg/dl. the transthoracic echocardiogram showed normal heart chambers, normal valves, and normal systolic and diastolic functions. there was no lv or rv thickening, no “granular sparking” or “speckling,” and aneurysm. based on the data above, the patient was diagnosed with a chb, possibly due to spinal anesthesia. we still investigated the other cause of the chb. we suspected a congenital involvement as a cause due to the previous history of slow heart rate but undocumented ecg. we then put her on a temporary pacemaker. afterward, she was transferred to the high care cardiac unit and was monitored intensively for one week. however, the ecg showed persistent chb, triwedya indra dewi, giky karwiky, et al. 44 international journal of integrated health sciences (iijhs) time needed for the heart’s impulse to return to sinus rhythm after chb was 4 minutes. another case report by mchugh et al.5 said that 5 minutes after subarachnoid injection, the non-specific symptoms were noted, and a chb was revealed. it sustained first-degree heart block for 6 hours after subarachnoid injection, and afterward, the rhythm returned to sinus rhythm. in this patient, we rejected the possibility of complications of spinal anesthesia as the cause of the heart block because the chb persisted after one week. in contrast, most chb caused by spinal anesthesia would return to sinus rhythm after several hours. this patient complained of symptoms of chb after the caesarean delivery had finished, where most of the spinal anesthesia complications would be seen several minutes after the spinal anesthesia drug was injected. the etiologies of cchb include the following: autoimmune antibodies, structural heart abnormalities due to congenital heart disease (e.g., congenitally corrected transposition of the great arteries, endocardial cushion defects), idiopathic familial cchb.6,7,9 cchb due to the autoimmune disease usually begins in utero, though clinical detection may occasionally be postponed until after birth or during early childhood.10 in many cases, the block is a complete heart block. the mechanism is due to damage to the development of specialized conduction tissue from passive transplacental passage of maternal autoantibodies to ro/ ssa and/or la/ssb intracellular ribonuclear proteins.9 the etiology possibility of chb in this patient due to congenital cause is getting more likely because the etiology of chb at a young age, such as cardiomyopathy, infection, infiltrative disease, and ischemic heart disease, had been excluded based on the clinical history and examinations that have been carried out. the patient reported no prior history of complaints. this study found several data that support this condition. baruteau et al.8 and bordachar et al.11, said that some people with chb are asymptomatic with bradycardia and detected only during routine screening. patients may be asymptomatic until cardiac decompensation begins to occur in adulthood. it raised suspicion of cchb as the mechanism of the slow heartbeat in this patient. postnatally, neonates and young children present in a wide variety of different ways. some are asymptomatic with bradycardia and detected only during routine screening. others may present with nonspecific symptoms, such despite the already diminished effect of the anesthetic drug. doctors have excluded spinal anesthesia as the etiology and perform workup for other etiology such as congenital or autoimmune. unfortunately, the patient’s mother was not present, so we could not examine immunoassays for ssa/ro or ssb/la antibodies, but this patient did not have any signs and symptoms of autoimmune disease. patient heart rate persists below 50 beats per minute and still with prolonged qtc of 515 ms. based on the recommendation by guideline, we decided to perform a permanent pacemaker (ppm) installation on the patient and programmed with dddr mode without any complications. the patient had provided informed consent for scientific publication and agreed to be published. this case report was conducted from january 2019 to february 2019. discussion the etiology of chb was unclear, hence challenging. a complete heart block in this patient was initially suspected of spinal anesthesia complication after the caesarean delivery procedure. in a case report by joseph et al.4, they said that they recorded the systemic symptoms after spinal anesthesia injection after 4 minutes, and a chb was reported several minutes afterward. the reported fig. 2 chest x-ray congenital complete heart block in young women international journal of integrated health sciences (iijhs) 45 as poor growth, abnormal tiredness, sleep disturbance, or frequent nightmares. syncope, heart failure, or sudden death may be the first manifestation of congenital av block in the absence of previous symptoms and signs of cardiovascular disease.11 congenital chb is related to congenital heart defects. in various series of fetal cchb, 30 to 53% of cases have associated congenital heart disease. various forms of congenital heart disease are related to abnormalities in the development of av conduction tissue, such as l-looped transposition of the great arteries (l-tga), endocardial cushion defects, and syndromes with simple atrial septal defects. anatomic disruption between the atrial musculature and peripheral parts of the conduction system and nodoventricular discontinuity are two common histologic findings.2,12 idiopathic familial cchb — non-immune chb in patients with a structurally normal heart has also been described as an idiopathic disorder with a strong familial tendency. in a retrospective cohort of 141 children with av block diagnosed in utero or up to age 15 years (51% female, 84% asymptomatic, 71% with chb on presentation, with an additional 21% progressing from incomplete to chb), 112 patients (79%) received permanent pacemakers, most prophylactically in asymptomatic patients (70 of 112 patients [63%]).13 there were several modalities that can be utilized to diagnose cchb. electrocardiography can be used used to diagnose arrhythmia and the type of heart block. an electrophysiology study can be performed to locate the level block in the conduction system. the treadmill stress test was needed to evaluate functional capacity. holter monitoring can be conducted to determine how heart rate and rhythm vary with activities of daily living. immunoassays for ssa/ro or ssb/la antibodies. lastly, echocardiography can be used to determine structural problems.8,11 patients with cchb may undergo routine 12-lead ecg, echocardiography, holter monitoring, electrophysiology studies, and treadmill testing to determine the effects of the disease process. the results of diagnostic tests are not predictive of who will die from cchb, but the results do indicate risk factors and can be used to determine which patients should receive a pacemaker. resting heart rate decreases with age in patients with cchb during infancy and childhood, and heart rates less than 50/min are associated with signs and symptoms and increasing mortality.14 in nearly all cases, the diagnosis of complete heart block can be made by obtaining a surface ecg, ideally a full 12-lead ecg, but sometimes a single-lead rhythm strip is adequate if a full 12-lead ecg cannot be obtained. the diagnosis is usually suspected when a slow pulse is detected, and heart block is confirmed by ecg or by ambulatory ecg monitoring.14,15 as mentioned in several previous studies, a cchb could be initially recognized from routine ecg records. in our patient, we suspected having a complete heart block by ecg recorded after the caesarean delivery procedure, even though there was no previous record of such findings. the recorded ecg of this patient revealed a complete heart block with prolonged qtc of 516 ms and 574 ms. this is in accordance with the conditions described in previous studies that chb might have prolonged qtc. seven percent of the patients were identified as having a prolonged qt interval (corrected qt interval 450 ms) at the time of presentation in the study by michaelsson et al.14 in other ecg evaluations, our patient had a narrow qrs complex of 80 ms. the width of the qrs complex is used to infer whether hemodynamically unstable cardiac rhythms may develop. a ventricular rhythm with a wide complex (>120 ms) and a prolonged qtc (>450 ms) in patients with cchb is an unfavorable prognostic sign because it may be related to underlying myocardial damage.14 prolonged qtc is associated with congenital chb and occurs in approximately 15% to 22% of patients.16 in multiple studies, a greater percentage of patients with congenital chb and qtc prolongation greater than 450 ms had signs and symptoms related to the cchb or suddenly died than did cchb patients without qtc prolongation.8 michaelsson et al.14, described the electrocardiographic characteristics in a large population of patients with congenital av block; the mean heart rate was 41 beats/min, the heart rate usually decreased as the child grew older, and they observed a broad complex escape rhythm in 10% of the patients. two mechanisms have been proposed for the development of qt prolongation in patients with cchb. first, the conduction disorder and resultant bradycardia may be the initial phenomenon that subsequently leads to the development of altered repolarization. this is supported by data from animal models of chronic complete heart block. second, patients with congenital av block who develop qt triwedya indra dewi, giky karwiky, et al. 46 international journal of integrated health sciences (iijhs) prolongation may manifest phenotypic latent congenital long qt syndrome.11 in prenatal conditions, echocardiography may be helpful. with fetal echocardiography, a high proportion of autoimmune-mediated complete heart block cases are now identified in utero (in populations where routine fetal echocardiography is performed). the finding may be an incidental finding. fetal echocardiography remains the standard gold method for diagnosing congenital chb. the diagnosis is made by establishing atrioventricular dissociation by using m mode or doppler echocardiographic techniques. reference values have been defined, and surveillance protocols have been designed to be implemented between 16 and 24 weeks of gestation, the period during which the fetus is at the highest risk of developing complete heart block.11 the patient had normal echocardiography results without structural abnormalities. the suspicions of congenital complete because there was no symptom nor chronic hf symptoms and no history of autoimmune disease. this condition might be due to idiopathic familial cchb. anti ro/la negative cases constitute around 30% of all congenital chb.17 fetal conduction tissue injury caused by transplacental exposure to maternal autoantibodies related to autoimmune disease is responsible for 70 to 90 percent of cases cchb.15 as stated by bordachar et al.11, he family history of autoimmune disease, especially in the patient’s mother, was possible in a patient with congenital av block. once heart block has been diagnosed, the mother should be screened for evidence of connective tissue disease. immunoassays for ssa/ro or ssb/la antibodies should be performed.11 unfortunately, we did not perform any examinations to prove it in this patient. the incidence of cchb is 2% in maternal anti-ro/ssa antibody positivity cases, 3% when both anti-ro/ssa and anti-la-ssb are positive. isolated cchb or cchb with a structurally normal heart is frequently associated with ro/ssa and la/ssb maternal autoantibodies. in this series of cases, all the mothers were positive for ana, ss-a (ro), antibodies, and ss-b (la) antibodies, except in the first case where ss-b (la) antibodies were negative. pregnant women whose sera contain anti-sjögren’s syndrome a (ssa)/ ro antibodies (in the presence or absence of anti-ssb/la antibodies) have a 1–7.5% risk of having a child with third-degree chb.18 thus, in cases of children with chb, the patient’s mother should be examined for anti-ro / ssa and anti-la-ssb. despite the conduction disorder, many patients have a normal exercise treadmill evaluation in terms of performance.11 treadmill exercise testing is done mainly to evaluate functional capacity.8 in patients with cchb without structural heart disease, up to 90% have normal results in exercise treadmill tests.14,16 in this case treadmill test was not performed. this patient has eventually implanted a ppm with dddr mode. this was following the 2018 acc/aha/hrs guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay:19 in adults with a congenital complete atrioventricular block with any symptomatic bradycardia, a wide qrs escape rhythm, mean daytime heart rate below 50 bpm, complex ventricular ectopy, or ventricular dysfunction, permanent pacing is recommended. a similar statement was also mentioned in the 2021 esc guidelines on cardiac pacing and cardiac resynchronization therapy:20 pacing is indicated in a high degree and complete heart block in symptomatic patients and in asymptomatic patients with any of the following risk conditions: ventricular dysfunction, prolonged qtc interval, complex ventricular ectopy, wide qrs escape rhythm, ventricular rate < 50 b.p.m., ventricular pauses > three-fold the cycle length of the underlying rhythm. a patient with cchb was hard to detect, especially without any previous related symptoms. this abnormality was usually detected from routine screening or when ecg was performed for other complaints related to the non-cardiovascular disease. other modalities to confirmed diagnosis and evaluate the prognosis of cchb could be done. congenital complete heart block in young women international journal of integrated health sciences (iijhs) 47 1. issa zf, miller jm, zipes dp. clinical arrhythmology and electrophysiology : a companion to braunwald’s heart disease. philadelphia: elsevier; 2019. 2. zipes dp, libby p, bonow ro, mann dl, tomaselli gf, braunwald e. braunwald’s heart disease : a textbook of cardiovascular medicine 11th ed. philadelphia: elsevier; 2018. 3. jordi em, marsch sc, strebel s. third degree heart block and asystole associated with spinal anesthesia. anesthesiology. 1998;89(1):257–60. 4. joseph se, minehart rd. third-degree heart block during spinal anesthesia for cesarean delivery. a a case rep. 2014;3(1):3–5. 5. mchugh sm, ibinson jw. development of third-degree heart block due to thoracic epidural anaesthesia. injury extra. 2012;43(2):18–20. 6. rudbeck-resdal j, christiansen mk, johansen jb, nielsen jc, bundgaard h, jensen hk. aetiologies and temporal trends of atrioventricular block in young patients: a 20-year nationwide study. europace. 2019;21(11):1710–6. 7. barra s, providência r, paiva l, nascimento jw, leitão-marques a. pacing clin electrophysiol. 2012;35(11):1395–405. 8. chronister cs. congenital complete atrioventricular block in a young man: a case study. crit care nurse. 2009;29(5):45– 56. 9. brito-zeron p, izmirly pm, ramoscasals m, buyon jp, khamashta ma. autoimmune congenital heart block: complex and unusual situations. lupus. 2016;25(2):116–28. 10. eliasson h, sonesson se, sharland g, granath f, simpson jm, carvalho js, et al. isolated atrioventricular block in the fetus: a retrospective, multinational, multicenter study of 175 patients. circulation. 2011;124(18):1919–26. 11. bordachar p, zachary w, ploux s, labrousse l, haissaguerre m, thambo jb. pathophysiology, clinical course, and management of congenital complete atrioventricular block. heart rhythm. 2013;10(5):760–6. 12. friedman d, duncanson l, glickstein j, buyon j. a review of congenital heart block. images paediatr cardiol. 2003; 5(3): 36–48. 13. baruteau ae, fouchard s, behaghel a, mabo p, villain e, thambo jb, et al. characteristics and long-term outcome of non-immune isolated atrioventricular block diagnosed in utero or early childhood: a multicentre study. eur heart j. 2012;33(5):622–9. 14. michaelsson m, jonzon a, riesenfeld t. isolated congenital complete atrioventricular block in adult life. a prospective study. circulation. 1995;92(3):442–9. 15. jaeggi et, hamilton rm, silverman ed, zamora sa, hornberger lk. outcome of children with fetal, neonatal or childhood diagnosis of isolated congenital atrioventricular block. a single institution’s experience of 30 years. j am coll cardiol. 2002;39(1):130–7. 16. kertesz nj, fenrich al, friedman ra. congenital complete atrioventricular block. texas heart institute journal. 1997;24(4):301–7. 17. mitra s, saha ak, sardar sk, singh ak. remission of congenital complete heart block without anti-ro/la antibodies: a case report. ann pediatr cardiol. 2013;6(2):182–4. 18. kapur a, dey m, tangri m, bandhu hc. maternal anti-ro/ssa and anti-la/ ssb antibodies and fetal congenital heart block. j obstet gynaecol india. 2015;65(3):193–5. doi:10.1007/s13224014-0608-2. 19. kusumoto fm, schoenfeld mh, barrett c, edgerton jr, ellenbogen ka, gold mr, et al. 2018 acc/aha/hrs guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay: executive summary: a report of the american college of cardiology/american heart association task force on clinical practice guidelines, and the heart rhythm society. [published correction appears in j am coll cardiol. 2019 aug 20;74(7):1014– 1016]. j am coll cardiol. 2019;74(7):932– 87. 20. glikson m, nielsen jc, kronborg mb, michowitz y, auricchio a, barbash im, et al. 2021 esc guidelines on cardiac pacing and cardiac resynchronization therapy: developed by the task force on cardiac pacing and cardiac resynchronization therapy of the european society of references triwedya indra dewi, giky karwiky, et al. 48 international journal of integrated health sciences (iijhs) cardiology (esc) with the special contribution of the european heart rhythm association (ehra). eur heart j. 2021;42(35):3427–520. congenital complete heart block in young women 36 international journal of integrated health sciences. 2014;2(1):36–9 original article morphometric analysis of the corpus, spinal canal and torg ratio using midsagittal cervical vertebrae computed tomography scan: indonesian population correspondence: farid yudoyono, spine research laboratory, department of neurosurgery, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital jl. pasteur no. 38, bandung, indonesia e-mail: faridspine@gmail.com rully hanafi dahlan,1 farid yudoyono,1 priandana adya eka saputra,2 sevline esthetia ompusunggu,1 muhammad zafrullah arifin,2 agung budi sutiono,2 ahmad faried2 1spine research laboratory, department of neurosurgery, faculty of medicine, universitas padjdajaran dr. hasan sadikin general hospital 2department of neurosurgery, faculty of medicine, universitas padjajaran-dr. hasan sadikin general hospital abstract objective: to determine the normal ranges of cervical spinal canal morphometry in indonesian population and to compare the acquired data collected from other populations methods: computed tomography measurements on the diameter of midsagital spinal canal and corpus of cervical vertebrae and its torg ratio from the lower cervical (c3–c7) canal from 24 normal indonesian adults were performed at the radiology department of dr. hasan sadikin general hospital. patients who had cervical spine disorders and those under 20 years old were exluded. we used computed tomography scan midsagittal view to measure the aforementioned parameters. results: the average diameter for the cervical spinal canals for the indonesian population is comparable with those of other asian populations such as hongkong and india, albeit with smaller torg ratio. conclusions: this study reports the normal radiological anatomy of the midsagital spinal canal and corpus of cervical vertebrae as well as torg ratio from the lower cervical vertebrae among indonesian population. the measurements result of this study shows that, although slightly smaller, the measurement results for those parameters are identical with other asian populations. keywords: corpus cervical vertebrae, midsagittal cervical spinal canal, torg ratio ijihs. 2014;2(1):36–9 introduction one of the predisposing factors for neck problems is cervical spinal canal stenosis, a condition in which the diameter of the cervical spinal canal is less than the normal measurement for the relevant age or sex of the individuals.1–5 so far, there are several radiological and morphological anatomic studies on the size of spinal canal in different populations in the world.1–6 plain lateral x-ray is usually used to determine the canal diameter. however, there are many limitations found in terms of value intepretation when using this method.1,3,7,8 we used computed tomography (ct) scan imaging to measure the parameters being studied, i.e. midsagital spinal canal and corpus of cervical vertebrae diameters and the torg ratio from lower cervical (c3–c7) canal. the method of analyis used was torg and pavlov canal-to-corpus ratio, in which the magnification factor could be omitted.2,3,9 cervical ct scan was used because it gives better image of the bone; thus, allows us to gain more accurate measurements compared to manual measurement.9,10 to our knowledge, until recently, there have been no report or study mentioning the cervical spinal canal morphometry for indonesian population. therefore, this study aimed to received: february 3, 2014 revised: april 14, 2014 accepted: june 24, 2014 international journal of integrated health sciences. 2014;2(1) 37:36–9 determine the normal ranges of cervical spinal canal morphometry in indonesian population and to compare the acquired data from other populations. methods computed tomography measurements of the midsagital spinal canal and corpus of cervical vertebrae diameters and the torg ratio from lower cervical (c3–c7) canal were performed on 24 normal indonesian adults at the department of radiology, dr. hasan sadikin general hospital. patients with cervical spine disorders and those under 20 years old were excluded. we used ct scan of midsagittal cervical to measure aforementioned parameters. results the means of the cervical spinal canal diameter are presented below (table 1). in terms of torg ratio criteria, the hongkong population has the smallest value in all spinal level and india has the biggest value in all spinal level. although slightly smaller, the measurement results for those parameters in this study are identical with those from other asian population (table 2). discussion the cervical spines consist of eight vertebras. the third until eight cervical vertebras are “common” cervical vertebra, while c1 (atlas) and c2 (axis) are the atypical ones. the cervical spinal canal is an opening within cervical vertebras in which the cervical spinal cord runs. its boundaries are vertebral bodies, bilateral pedicles and laminae, and spinous processes. the canal follows the normal contour of spine. the shape of the cervical spinal canal is triangular, which is the same as the lumbar region. the diameter of the cervical spinal canal is fairly large in the upper cervical region but narrows down from c3 and inferiorly, where the diameter is approximately 12–13 mm in the table 1 cervical vertebrae spinal canal diameters, vertebral body diameters and torg ratio in indonesian population parameter c3 (n=25) c4 (n=25) c5 (n=25) c6 (n=25) c7 (n=25) mean±sd mean±sd mean±sd mean±sd mean±sd spinal canal diameter (mm) 11.24±1.15 11.32±1.27 1153±1.21 11.97±1.55 12.32±1.36 vertebral body diameter (mm) 14.37±2.20 14.90±2.03 15.09±1.78 15.60±1.83 15.41±1.35 torg ratio 0.81±1.9 0.78±0.18 0.78±0.15 0.78±0.15 0.81±1.15 spinal canal computed tomography scan (fig. 1a) measurement of midsagittal cervical corpus (fig. 1b) fig. 1 a b rully hanafi dahlan, farid yudoyono, et al. 38 international journal of integrated health sciences. 2014;2(1):36–9 anteroposterior plane. the space in the spinal canal allows for the free movement of the canal contents without tension or pressure during these movements. therefore, the normal size of the canal is important. an abnormal reduction in the size of the spinal canal could predispose the individual to neck pain. due to the narrowing, the lower cervical cord is particularly vulnerable to a variety of pathological entities, one of which is canal stenosis, that could compromise the cord within the vertebral canal. the stenosis of the cervical spinal canal is an anatomical anomaly which is more common than realized. individuals with this anomaly tend to remain neurologically asymptomatic until a complicating feature, such as osteophytes or herniated intervertebral discs, develops. several studies have been performed to prove that measurement of the sagittal diameter of the cervical canal in plain lateral radiography is a useful method for detecting cervical spinal stenosis.2,4,7,11 however, comparison of published data reveals that the range of variation in the reported sagittal diameter is considerable.1,3–6,10 those diversity is partly due to the variation in the radiographic technique (focus-to-film distance) and variation in the body build of the subjects (affecting the object-to-film distance). in an attempt to find a solution to these discrepancies, torg et al.12 devised a measurement ratio that compares the sagittal diameter of the spinal canal with the anteroposterior width of the vertebral body, in which both of those are equally affected by radiological magnification factors.2,6,9 table 2 torg ratio on lateral radiographs of cervical spine country author's (year) sample's number torg ratio (mean±sd) c3 c4 c5 c6 c7 indonesia arifin et al. (2013) 25 0.81±1.9 0.78±0.18 0.78±0.15 0.78±0.15 0.81±1.15 india kathole et al. (2012) 300 1.005±0.06 1.01±0.07 1.015±0.07 1.02±0.07 1.015±0.07 korea song et al. (2009) 53 0.84±0.13 0.83±0.13 0.85±0.14 0.85±0.13 0.85±0.12 turkey karabulut and karabulut (2007) 90 0.86±0.14 0.76±0.17 0.83±0.16 0.825±0.14 0.81±0.13 hongkong wong et al. (2004) 36 0.77±0.17 0.75±0.17 0.76±0.17 0.76±0.17 0.78±0.21 a b ilustration of torg ratio = b/a, (a) anterior posterior corpus length, (b) spinal canal length fig. 2 morphometric analysis of the corpus, spinal canal and torg ratio using midsagittal cervical vertebrae computed tomography scan: indonesian population international journal of integrated health sciences. 2014;2(1) 39 references 1. maqbool a, athar z, hussain l. midsagittal diameter of cervical spinal canal and torg’s ratio of the cervical spine in pakistanis. pakistan j med sci. 2003;19(3):203–10. 2. wong tm, leung hb, wong wc. correlation between magnetic resonance imaging and radiographic measurement of cervical spine in cervical myelopathy patients. j orthop surg. 2004;12 (2):239–42. 3. song kj, choi bw, kim sj, kim gh, kim ys, song jh. the relationship between spinal stenosis and neurological outcome in traumatic cervical spine injury: an analysis using pavlov ratio, spinal cord area and spinal canal area. clin orthop surg. 2009;1(1):11–8. 4. tossel g. dimension of the cervical spinal canal in the south african negroid population. [dissertation]. south africa: school of medicine, faculty of health science, university of pretoria; 2005. 5. tjahjadi d, onibala mz. torg ratios based on cervical lateral plain films innormal subjects. universa medicina. 2010;29(1):8–13. 6. kathule ma, joshi ra, herekar ng, jadhav ss. dimensions of cervical spinal canal and their relevance in clinical practice. int j recent trends sci tech. 2012;3(2):54–8. 7. karabulut ő, karabulut z. the variations of torg ratio with gender in patients with neck pain. dicle med j. 2007;34(4):272–4. 8. choudhary s, kattimuthu p, kataria sk. a radiographic study of sagittal diameter of cervical spinal canal in adult male population of rajasthan. asian j med res. 2013;2(1):7–9. 9. gour kk, shrivastava sk, thakare ae. size of cervical vertebral canal-measurements in lateral cervical radiographs & dried bones. int j biol med res. 2011;2(3):778–80. 10. suk ks, kim kt, lee jh, lee sh, kim js, kim jy. reevaluation of the pavlov ratio in patients with cervical myelopathy. clin orthop surg. 2009;1(1):6–10. 11. kang sk, park jy, chin dk, kim kh, kuh su, kim ks, et al. a pet/ct-based study of spinal canal in korean young adults: anteroposterior diameter from cervical vertebra to sacrum. korean j spine. 2012;9(3):165–9. 12. torg js, corcoran ta, thibault le, pavlov h, sennett bj, naranja rj jr, et al. cervical cord neurapraxia: classification, pathomechanics, morbidity, and management guidelines. j neurosurg. 1997;87(6):843–50. :36–9 this ratio is obtained by dividing the midsagittal diameter of the cervical spinal canal at any particular cervical segment by the midsagittal diameter of the corresponding vertebral body. it has been reported that, using the ratio method as standard, a measurement of less than 0.80 indicates significant spinal stenosis. usefulness of torg’s ratio in the diagnosis of cervical spinal canal stenosis has also been confirmed by several other studies.1,7,10 studies have also been performed in order to determine the mean anteroposterior diameter of the cervical spinal canal at different vertebral levels in normal subjects making it possible, clinicians to diagnose cervical spinal stenosis by consulting these reference values.1–4,7 comparing those studies with ours, it is revealed that our measurement data is similar with those of other studies. in conclusion, this study reports the normal radiological anatomy of the midsagital spinal canal and corpus of cervical vertebrae and the torg ratio from the lower cervical vertebrae among adult indonesian. the measurements results of this study show that, although the torg ratio is slightly smaller, they are similar and comparable with those from other asian populations. rully hanafi dahlan, farid yudoyono, et al. vol 9 no 1 2021 (2).indd international journal of integrated health sciences (iijhs) 1 correlation between mmp-9 level and diastolic dysfunction in concentric left ventricular hypertrophy patients abstract objective: to establish the relationship between plasma matrix metalloproteinase (mmp)-9 levels and diastolic functional abnormalities using the e/e’ measurement in concentric type hypertensive heart disease (hhd) patients. methods: a cross-sectional study was conducted from november 2014 to january 2015 in population with hypertension and concentric left ventricular hypertrophy (lvh). diastolic function was assessed with e/e’ measurement using echocardiography. the relationship between the two variables was analyzed using spearman correlation. results: thirty-nine subjects (14 males, 35.9%) with the average relative wall thickness of 0.7(±0.15), average body weight of 63.45 (±12.97) kg, average height of 155.51 (±7.12) cm, average body mass index of 26.23 (±5.08) kg/m2, and mean age of 55 (±10) years were fit to be included in the analysis. the median systolic blood pressure was 140 (110–220) mmhg while the median diastolic blood pressure and median left ventricular mass index were 80 (70–110) mmhg and 119.24 (103.05205.69) g/m2, respectively. the median mmp-9 was measured at 108 (4–460) ng/ml and the median e/e’ was 10.99 (6.2-20.42). there was a significant positive correlation between mmp-9 and e/e’ (r=0.416, p=0.004). conclusion: there is a significant moderate positive correlation between the mmp-9 level and diastolic dysfunction in concentric lvh patients. keywords: diastolic dysfunction, hypertensive heart disease, left ventricular hypertrophy, matrix metalloproteinase-9 received: october 18, 2020 accepted: march 30, 2021 correspondence: miftah pramudyo, department of cardiology and vascular medicine, faculty of medicine universitas padjadjaran-dr. hasan sadikin hospital, bandung, indonesia, e-mail: miftah.pramudyo@gmail.com original article miftah pramudyo, ridho jungjunan, erwan martanto, chaerul achmad department of cardiology and vascular medicine, faculty of medicine universitas padjadjaran-dr. hasan sadikin hospital, bandung, indonesia pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ ijihs.v9n1.2175 ijihs. 2021;9(1):1–6 introduction hypertension is a major risk factor for coronary artery disease (cad), stroke, and heart failure.1 the risk of heart failure in hypertensive patients is threefold higher than those without hypertension.2 hypertension is one of the most prevalent diseases in the world. the prevalence of hypertension in >25-year-old worldwide is 40.6% in men and 35.8% in women. the prevalence varies based on geographical location as well. in southeast asia, the prevalence of hypertension is approximately 37.3% in men and 34.9% in women.3 based on the 2013 indonesia basic health research (riset kesehatan dasar/ riskesdas), the prevalence of hypertension is 25.8%, with west java sits on one of the top four most prevalent province with hypertension in indonesia.4 non-communicable diseases contributed to 63% of mortality worldwide in 2008 (36 out of 57 million deaths), mostly caused by cardiovascular diseases.5 hypertension is one of many major cardiovascular disease risk factors. in indonesia, hypertension related to 20-25% of all coronary artery disease cases 2 international journal of integrated health sciences (iijhs) correlation between mmp-9 level and diastolic dysfunction in concentric left ventricular hypertrophy patients and 36-42% of all strokes.6 prolonged hypertension may injure the cardiovascular system, with secondary damages to the brain, eyes, and kidneys. the presence of target organ damage can also impact therapeutic strategies, targeted blood pressure, and specific recommended medications.1,7 chronic hypertension may lead to remodeling of the heart. cardiac remodeling involves changes in genomic, cellular, and interstitial levels that can be clinically evaluated as alterations of the heart’s shape, size, and function.8 concentric hypertrophy is the most common pattern of hypertrophy found in hypertension.8 cardiac remodeling may also affect the heart physiology and is manifested as diastolic dysfunction. gold standard assessment of diastolic function involves invasive measurement, but recently has been replaced by non-invasive techniques, with one of the methods is echocardiography.9 the method for assessing diastolic dysfunction recommended by the european society of cardiology (esc) is the examination of the ratio between trans mitral inflow doppler and tissue doppler imaging (tdi) early diastolic velocity (e/e ‘). e/e ratio of ≥13 was related to increased risk of cardiovascular event and was independent of left ventricular mass and relative wall thickness in hypertensive patients.7,10 plasma matrix metalloproteinase (mmp)-9 is one of the collagen turnover markers that is widely used as an indicator of ventricular remodeling in cases of heart failure.11-13 there is a lot of studies done about mmp-9 and ventricular remodeling, both in pre-clinical studies and clinical studies. however, there are not many studies on the relationship of diastolic dysfunction with mmp-9 and these studies have had different results in terms of the relationship between mmp-9 levels and diastolic function abnormalities. this study aims to analyze the relationship between mmp9 levels and diastolic function abnormalities. methods a cross-sectional study was conducted in bandung from november 2014 to january 2015 with ethical clearance from dr. hasan sadikin general hospital. the subjects in this study included patients clinically diagnosed with concentric-type left ventricular hypertrophy hhd, age >18 years old in out-patient department dr. hasan sadikin general hospital. consecutive sampling was used. the sample size (n) in this correlation analysis study was determined by the sample and power calculation program with the calculation of the test for one correlation. the minimum number of samples that must be obtained is 30 samples. exclusion criteria include patients with atrial fibrillation, aortic stenosis, cad, diabetes mellitus (dm), cancer, hypertrophic obstructive cardiomyopathy, mitral stenosis, coarctation of the aorta, chronic kidney disease (ckd) stage ≥3, and septic shock. the independent variable of this study is the mmp-9 plasma level, while the dependent variable is diastolic dysfunction (e/e’). mmp9 levels were assessed from peripheral venous blood sampling on the same day of echocardiography examination. the blood was drawn and put into a tube containing ethylenediamino-tetraacetic acid (edta) and then centrifuged at 4°c. plasma component was isolated and kept frozen at -70°c for further storage. mmp-9 plasma levels were examined using enzyme-linked immunosorbent assay (elisa), expressed in ng/ml units.14 diastolic dysfunction was assessed by echocardiography using a vivid 7 echocardiography machine. parameters were measured using the mitral inflow ratio to tissue doppler imaging method or the e/e’ ratio. e/e’ values parameter is obtained from the mean values of e/e’ septal and e/e’ lateral.7,10 a standard echocardiographic examination is performed by a technician. the results were then confirmed by a cardiologist specialized in echocardiography. blood samples were drawn after echocardiographic examinations on the same day by trained nurses using a tourniquet and 3cc syringes. all samples were stored collectively at the hasan sadikin hospital clinical pathology laboratory and mmp-9 levels were assessed together on february 15, 2015. for statistical analysis, we do a normality test using the saphiro-wilks or kolmogorov smirnov test, followed by descriptive statistics and correlation test analysis between plasma mmp-9 levels and the degree of diastolic dysfunction using pearson product-moment correlation analysis if data is normally distributed, or with rank spearman if the data is not normally distributed. confounding variables that cannot be excluded will be analyzed through multivariate analysis. this study has been approved by dr. hasan sadikin bandung hospital’s health research ethic committee number lb.04.01/a05/ ec/019/i/2015. international journal of integrated health sciences (iijhs) 3 miftah pramudyo, ridho jungjunan, et al. results forty-six subjects met the inclusion criteria, and seven subjects were excluded with the following causes: 1 have incomplete data (no lateral e/e’ data); 1 has cad and dm; 4 have dm; 1 has ckd stage 3. the total number of research subjects was 39 people who were involved in the data processing. in table 1, there are 39 samples included in the study. the normality test done on numerical data was shapirowilk test because n ≤50. normality tests show that the data on variables relative wall thickness, age, weight, height, and body mass index are normally distributed, whereas left ventricular mass, systolic blood pressure, and diastolic blood pressure were not normally distributed. there are 14 male subjects in this study (35.9%) with 25 females (64.1%). the average age of the subjects was 55 (± 10) year, the average weight was 63.45 (±12.97) kg, mean height was 155.51 (±7.12) cm, mean body mass index 26.23 (± 5.08) kg/ m2, and average wall thickness was 0.7 (±0.15). median systolic blood pressure was 140 (110-220) mmhg, median diastolic blood pressure was 80 (70-110) mmhg, and the median left ventricular mass index was 119.24 (103.05-205.69) g/m2. the median value of plasma mmp-9 levels in this study was 108 (4–460) ng/ml fig. 1 process flow of obtaining research samples table 1 basic characteristics of hhd patients characteristics mean (±sd) median (min-max) n (%) (n = 39) age (years) 55 (±10) sex (male) 14 (35.9) weight (kg) 63.45 (±12.97) height (cm) 155.51 (±7.12) body mass index (kg/m2) 26.23 (±5.08) systolic blood pressure (mmhg) 140 (110–220) diastolic blood pressure (mmhg) 80 (70–110) left ventricle mass index (g/m2) 119.24 (103.05–205.69) male 117.5 (115.03–146.9) female 122.03 (103.05–205.69) relative wall thickness 0.7 (±0.15) left ventricular ejection fraction 72.62 (±8.537) 73 (56–88) sd: standard deviation 4 international journal of integrated health sciences (iijhs) is smaller than a similar study conducted by ahmed et al.15 (162±6 g/m2), but greater than that of tayebjee et al.16 the difference between this study and those studies may be due to the differences of inclusion criteria and the criteria for left ventricular hypertrophy used. this study used left ventricular hypertrophy criteria based on ase and eae guidelines, which are 115 g/m2 for males and 95 g/m2 for females for left ventricular mass index.10 plasma mmp-9 median level in this study was 108 (4–460) ng/ml. other studies have had differing mmp-9 levels and these differences may occur due to differences in the testing technique used. this study revealed mmp-9 plasma levels were positively correlated with e/e‘, which means that the higher the plasma levels of mmp-9, the higher the e/e’ value. this concludes that mmp-9 plasma levels are positively correlated with diastolic dysfunction in concentric hhd patients. the association of mmp-9 level with left ventricular function has been under extensive studies. mmp-9 level relationship with left ventricular systolic function in post-myocardial infarction patients and low ejection fraction-heart failure have been widely investigated, but few studies have looked at the association of mmp-9 with diastolic function. in previous studies done on this topic, the relationship between mmp-9 plasma levels and diastolic function is still controversial. and the median value of e/e’ was 10.99 (6.220.42) (table 2). the correlation analysis between plasma levels of mmp-9 and e/e’ was shown in table 3 and fig. 2, presented in a scatter plot. based on the data elaborated above, we can conclude that the mmp-9 plasma level is moderate-positively correlated with e/e’ parameter, with r value=0.416 and p=0.004 (<0.05). discussion the median left ventricular mass index in this study was 119.24 (103.05-205.69) g/m2, which table 2 median value of plasma mmp-9 and e/e’ parameters median (min.-max.) plasma mmp-9 level (ng/ml) 108 (4–460) e/e’ 10,99 (6.2–20.42) table 3 correlation between plasma mmp 9 level and e/e’ parameter coefficient correlation (r) p-value mmp-9 — e/e’ 0.416 0.004 note: correlation analysis uses rank spearman correlation analysis, significant if p<0.05 fig. 2 correlation between plasma mmp-9 levels and diastolic dysfunction as measured by the e/e’ test correlation between mmp-9 level and diastolic dysfunction in concentric left ventricular hypertrophy patients international journal of integrated health sciences (iijhs) 5 this study result is supported by ahmed et al.15 and martos et al.17 studies, with the result of a significant relationship between mmp-9 levels and diastolic dysfunction. this study is not supported by the result of the study conducted by tayebjee et al.16 who stated that there was no significant relationship between mmp-9 levels and diastolic dysfunction. the coefficient correlation (r) between mmp-9 and e/e’ in tayebjee, et al16 was -0.115, which did not statistically significant (p=0.349). unfortunately, studies conducted by ahmed et al.15 and martos et al.17 did not mention the coefficient correlation between mmp-9 and e/e’. the difference of results in the study by tayebjee et al.16 and this study may be caused by the differences in the study population. the study of tayebjee et al.16 compared all hypertensive patients with or without left ventricular hypertrophy, whereas in this study, the population is patients with a more specific left ventricular hypertrophy, which is the concentric type of left ventricular hypertrophy. a process that may explain the increase in plasma mmp-9 levels in patients with hhd with diastolic dysfunction is described by martos et al17. matrix metalloproteinase-9 has collagen and extracellular matrix (ecm) turnover activity. changes in cardiac ecm have an extensive role in terms of ventricular contraction function, both systolic and diastolic. high levels of mmp-9 cause a high turnover of collagen which is the main component of ecm. among these collagens, there is elastin which functions to maintain the flexibility of the heart muscle. one of the activities of mmp-9 is to activate elastase which causes an increase in elastin degradation. the loss of elastin in the heart muscle and blood vessels causes stiffness of the heart and blood vessels that contribute to an increase in the degree of diastolic dysfunction. matrix metalloproteinase-9 also has a profibrotic effect, which means that the increasing levels of mmp-9 will increase the occurrence of fibrosis processes which will also increase the stiffness of the heart muscle and blood vessels, thus worsening the degree of diastolic dysfunction.17 the limitation of this study is that most of the exclusion criterias were obtained from the patient’s history with only a small part of the study sample had the results of diagnostic examinations, thus allowing for information bias. in conclusion, there is a moderate positive correlation between plasma mmp-9 levels and diastolic function abnormalities as measured by e/e’ examination in concentric hhd patients. further study is needed to compare the normal population and the population with diastolic dysfunction to determine the cut-off value of mmp-9 levels in diastolic dysfunction. miftah pramudyo, ridho jungjunan, et al. 1. james pa, oparil s, carter bl, cushman wc, dennison-himmelfarb c, handler j, et al. 2014 evidence-based guideline for the management of high blood pressure in adults. j am med assoc. 2014;311(5):507– 20. 2. messerli fh, rimoldi sf, bangalore s. the transition from hypertension to heart failure. j am coll cardiol hear fail. 2017;5(8):543–51. 3. world health organization. global status report on noncommunicable diseases 2010. alwan a, editor. geneva: who; 2011. 4. kementerian kesehatan republik indonesia. riset kesehatan dasar kementerian ri. riskesdas. 2013. 5. krishnani a, gargii r, kahandaliyanageiii a, editors. hypertension in the south-east asia region: an overview. regional health forum; 2013. 6. soenarta aa, buranakitjaroen p, chia y, chen c, nailes j, hoshide s, et al. an overview of hypertension and cardiac involvement in asia: focus on heart failure. j clin hypertens. 2020;22:423–30. 7. mancia g, fagard r, narkiewicz k, redon j, zanchetti a, böhm m, et al. 2013 esh/ esc guidelines for the management of arterial hypertension: the task force for the management of arterial hypertension of the european society of hypertension (esh) and of the european society of cardiology (esc). eur heart j. 2013;34(28):2159–219. 8. gonzález a, ravassa s, lópez b, moreno mu, beaumont j, san josé g, et al. myocardial remodeling in hypertension. hypertension. 2018;72(3):549–58. 9. nagueh sf, smiseth oa, appleton cp, byrd bf, dokainish h, edvardsen t, et al. recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the references 6 international journal of integrated health sciences (iijhs) american society of echocardiography and the european association of cardiovascular imaging. j am soc echocardiogr. 2016;29(4):277–314. 10. lang rm, badano lp, mor-avi v, afilalo j, armstrong a, ernande l, et al. recommendations for cardiac chamber quantification by echocardiography in adults: an update from the american society of echocardiography and the european association of cardiovascular imaging. j am soc echocardiogr. 2015;28(1):1–39. e14. 11. lacchini r, jacob-ferreira alb, luizon mr, gasparini s, ferreira-sae mcs, schreiber r, et al. common matrix metalloproteinase 2 gene haplotypes may modulate left ventricular remodelling in hypertensive patients. j hum hypertens. 2012;26(3):171–7. 12. deleon-pennell ky, meschiari ca, jung m, lindsey ml. matrix metalloproteinases in myocardial infarction and heart failure. 2017. p. 75–100. 13. doxakis a, polyanthi k, androniki t, savvas p, eleni z. targeting metalloproteinases in cardiac remodeling. j cardiovasc med cardiol. 2019 31;6(3):51–60. 14. weintraub ws, karlsberg rp, tcheng je, boris jr, buxton ae, dove jt, et al. accf/aha 2011 key data elements and definitions of a base cardiovascular vocabulary for electronic health records. circulation. 2011;124(1):103–23. 15. ahmed sh, clark ll, pennington wr, webb cs, bonnema dd, leonardi ah, et al. matrix metalloproteinases/tissue inhibitors of metalloproteinases: relationship between changes in proteolytic determinants of matrix composition and structural, functional, and clinical manifestations of hypertensive heart disease. circulation. 2006;113(17):2089–96. 16. tayebjee m, nadar s, macfadyen r, lip g. tissue inhibitor of metalloproteinase-1 and matrix metalloproteinase-9 levels in patients with hypertension relationship to tissue doppler indices of diastolic relaxation. am j hypertens. 2004;17(9):770–4. 17. martos r, baugh j, ledwidge m, o’loughlin c, conlon c, patle a, et al. diastolic heart failure: evidence of increased myocardial collagen turnover linked to diastolic dysfunction. circulation. 2007;115(7):888–95. correlation between mmp-9 level and diastolic dysfunction in concentric left ventricular hypertrophy patients vol 10 no.1 2022 rev.2.indd 32 international journal of integrated health sciences (iijhs) unexpected infective endocarditis in corrected congenital heart disease: a case report abstract objective: to describe patients with corrected congenital heart disease (chd) who experienced infective endocarditis (ie). methods: two cases of ie were observed in 2019. the first case involved a 36-year-old woman with previous percutaneous transcatheter perimembranous ventricular septal defect (vsd) closure four months before admission. echocardiography showed vegetation at noncoronary cusps of the aortic valve. patient received antibiotics for six weeks and underwent surgery for evacuation of vegetation and device, along with vsd closure with a cardiovascular patch (gore-tex). the second case involved a 43-year-old woman with a history of surgical closure in secundum atrial septal defect (asd) by pericardial patch two months before admission. echocardiography showed vegetation at the tricuspid valve. patient received antibiotics for four weeks and planned for surgery to evacuate vegetation. results: ie is one of the major complications in chd, whether uncorrected, treated, or corrected. the risk of ie increased with an invasive procedure. post closure ie is rare. poor dental hygiene and immunocompromised also increased patient’s risk to be exposed to ie as shown in the first patient who had dental caries and the second patient who was on methylprednisolone for post-surgical pericardial effusion treatment. conclusion: the risk of ie increases with invasive procedures in chd patients. although the incidence of ie is quite rare, its possibility should become of a serious concern among physicians. keywords: atrial septal defect, closure, infective endocarditis, ventricular septal defect received: october 12, 2020 accepted: february 03, 2021 case report charlotte johanna cool, rachmi anasthasia, aninka saboe department of cardiology and vascular medicine, faculty of medicine universitas padjadjaran dr. hasan sadikin general hospital bandung, indonesia pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ ijihs.v10n1.2166 ijihs. 2022;10(1):32–38 correspondence: charlotte johnna cool, department of cardiology and vascular medicine, faculty of medicine universitas padjadjaran-dr. hasan sadikin general hospital bandung, indonesia e-mail: charlotte@unpad.ac.id introduction congenital heart disease (chd) is the most common underlying heart condition in indonesia in patient with infective endocarditis (ie). increased survival in children with chd and the possible use of channels and prosthesis in corrective surgery contributes to an increase in the incidence of ie even though the patient has taken prophylactic antibiotics in ie. however, chd related ie mortality rates had decreased substantially to 10% due to improvements in ie diagnoses, antimicrobial treatment, cardiac surgery, and intervention therapy. given the prognosis, morbidity, and expensive of ie management, ie prophylaxis has long been recommended in an effort to minimize the onset of ie.1,2 chd patient have a high risk of ie in their lifetime. one complication of ie remains a major concern in patient with chd, whether uncorrected, treated, or corrected. the prevalence of endocarditis in an adult with chd is 11 per 100,000 people per year higher than the general population that is 1.5-6 per 100,000 people per year. mortality ie based on contemporary grown-up congenital heart disease (guch) still 16% and 1-year mortality international journal of integrated health sciences (iijhs) 33 is 19%. adults with repaired or palliated pulmonary atresia and corrected congenital transposition of the great arteries (tga) have the highest incidence of ie with total cases 5.8 and 2.3 per 1000 patient-years. patient with pulmonary stenosis (ps) or atrial septal defect (asd) had a very low-risk incidence of ie, even in the adults with repaired or still patent arterial duct (pda) ie non exists.2,5 until now, very rarely ie reported in corrected chd patients. in this case report, we discuss ie in patient with corrected chd and what possible risk factors may underlie the occurrence of this condition. case illustration first case first case, a 36 year-old asian woman, a teacher, came to our emergency department with chief complaint weak left limb three days before hospitalization with lips deviation and slurred speech. she didn’t complaint severe headache and projectile vomit. there was a history of dyspnea on the effort since childhood. there was no history of fever before. she complained of painful in legs two months before being hospitalized and resolved with pain medication. the patient complained that there are reddish spots on the palms and soles of the feet 1 month before admission, she also complained of a lump in the tips of the fingers that felt painful one month before being hospitalized. the patient has never experienced reddish lines on the nails. the patient never experiences redness in the eyes. her complaints of reddening urination without pain which is accompanied by pain when urination is denied. patient did not complain about a decrease in consciousness. there were cavities that have only been known in the past two months before being hospitalized, but the patient did not go to the doctor. the patient was known as a patient with congenital heart disease since childhood. previously, she underwent corrected vsd with amplatzer duct occluder (ado) 4 months before hospitalization. in our emergency room, the patient looks moderately ill, fully alert. the blood pressure was 80/50 mmhg, 75 x/minutes of resting heart rate, 20 x/minutes of respiratory rates, and normal temperature 36,7°c. in physical examination showed jugular vein pressure normal. the thoracic examination showed there is no cardiomegaly, and there is no additional heart sound. there was pansystolic murmur with grade 3/6 in linea left sternalis border with carvallo sign negative, and pansystolic murmur with grade 3/6 in apex referred to the axilla. other physical examinations were unremarkable. in neurology examination showed positive light reflex in both eyes; there was no roth spot’s, eyeball movements were normal. there was a history of the parenthesis of central nerve vii and left nerve, xii. in motoric examination were found 5 in the right upper and right lower extremity and in the left upper and left lower extremity the motoric were 0. the physiologic reflex score was +2/+2 and pathologic reflex negative. the laboratory examination showed fig. 1 echocardiography showed vegetation at ncc of the aorta fig. 2 transesophageal echocardiography showed multiple vegetation attach of the tip of aortic valves charlotte johanna cool, rachmi anasthasia, et al 34 international journal of integrated health sciences (iijhs) anaemia and other examination within normal limits. electrocardiography, chest x-ray, and other examination within normal limits. the patient was diagnosed on the emergency department with stroke infarct dd stroke haemorrhage, congenital heart disease vsd post transcatheter closure, possible infective endocarditis. (duke criteria: 3 minor criteria: predisposing heart condition (vsd) osler node, janeway lesion). the patient was given antibiotic empiric with adjusted dose ceftriaxone 1x2 g iv dan gentamicin 3mg/ kg/48 hour iv, aspilet 1x81 mg po, paracetamol 3x 500 mg po. blood culture was taken three times with a time interval between first examinations and last examination 1 hour. results of culture showed enterococcus sp which sensitive to all antibiotics except tetracycline. patient undergoing echocardiography (fig.1) examination on march 1, 2019, showed vsd perimembranous (pm) s/p device closure with suspect additional vsd pm left to right shunt, moderate ps due to protruding device, vegetation at ncc of aorta. patient undergoing transesophageal echocardiography (tee) (fig.2) examination on march 4, 2019, showed vsd pm s/p closure, residual shunt (-); moderate ps due to protruding part of the device (right ventricle (rv) part); small, mobile, multiple vegetation attach of the tip of aortic valves; mild ar, eccentric jet due to mal-cooptation of aortic valves. the patient then diagnosed with definite infective endocarditis, vsd perimembranous with complication suspected of cardioembolic stroke infarction (duke criteria: 1 major criterion: echocardiography positive for ie (vegetation), 3 minor criteria: predisposing heart condition (vsd) osler node, janeway lesion), suspect additional vsd perimembranous. the patient was given antibiotic treatment vancomycin 3x500 mg iv for four weeks. during the treatment, there were no complications. after two weeks of therapy, the patient was taken blood culture two times with negative culture results, and antibiotic therapy continued until six weeks. after 17 days of treatment, the patient has re-evaluated echocardiography and found that vegetation disappeared. the patient then scheduled for surgery for evacuation of vegetation; the device removes and vsd closure. the patient underwent surgery on the 30th day of treatment, and an intra-operative finding was found: dislocated aplazter partially, supracristal or doubly committed (sadc) position vsd, closure of vsd with gore-tex, vegetation (-). second case second case, a 43-year old batak woman, a house wife, came to our emergency department with palpitations. there was no history of fever before. she never experienced pain in legs, reddish spots on the palms and soles of the feet, a lump in the tips of the fingers that feels painful, reddish lines on the nails, redness in the eyes, reddening of urination without pain or decrease in consciousness. the patient was known as a patient with congenital fig. 3 echocardiography showed vegetation at tricuspid valve fig. 4 echocardiography showed vegetation size was increased unexpected infective endocarditis in corrected congenital heart disease: a case report international journal of integrated health sciences (iijhs) 35 heart disease. previously, she already had corrected asd with a pericardial patch (goretex) 2 months before hospitalization. she also had a pericardial window because of severe pericardial effusion one months before admission, and she took corticosteroid 24 mg per day since one months before admission. in physical examination, the patient looks moderately ill, fully alert. the blood pressure was 110/70 mmhg, 68 x/minutes irregularly irregular of resting heart rate, pulse was 60 beats per minutes irregularly, unequal, 20 x/minutes of respiratory rates, and normal temperature 36,8°c. in physical examination showed jugular vein pressure normal. the thoracic examination showed there are cardiomegaly and variable of heart sounds. there was pansystolic murmur with grade 3/6 in linea left sternalis border with carvallo sign positive. other physical examinations were unremarkable. in neurology examination showed positive light reflex in both eyes; there was no roth spot’s, eyeball movements were normal. the laboratory examination showed anaemia and other examination within normal limits. chest x-ray showed cardiomegaly with the sign of pulmonary hypertension. on electrocardiography showed atrial fibrillation with right axis deviation and right ventricle hypertrophy. patient were taken blood culture three times with a time interval between first examinations and last examination 1 hour. results of culture showed acinetobacter sp which sensitive to all antibiotics except cotrimoxazole. she underwent tee (fig.3) one day after admission, with the results asd s/p surgical closure, multiple residual shunts, vegetation at tricuspid valve with size (2x6 mm). the patient was diagnosed with asd postsurgical closure with a residual shunt, af nvr, possible infective endocarditis. (duke criteria: 1 major criterion: echocardiogram showed vegetation, 1 minor criterion: predisposing heart condition (asd)). the patient was given antibiotic empiric with adjusted dose ampicillin sulbactam 4x3 gr iv and gentamycin 1x160 mg iv. the patient was given antibiotic treatment ampicillin sulbactam 4x3 gr iv and gentamycin fig. 5 echocardiography showed multiple vegetation with various size charlotte johanna cool, rachmi anasthasia, et al 36 international journal of integrated health sciences (iijhs) 1x160 mg iv for four weeks. during the treatment, there were no complications. after two weeks of therapy, the patient was taken blood culture two times with negative culture results, and antibiotic therapy continued until six weeks. after 22 days of treatment, the patient has re-evaluated echocardiography (fig.4) and found vegetation increases in size became 3x3 mm. after 34 days of treatment, the patient has re-evaluated echocardiography (fig.5) and found multiple vegetation with various size from 3.9x9.4 mm until 7x3 mm. in 28 days of treatment, she got urticaria in her body, and she was found suspect allergic from ampicillin and gentamycin, so the antibiotic was replaced with ceftriaxone 2x2 gr iv in 28 days of treatment. the patient then scheduled for surgery for evacuation of vegetation, double valve replacement and asd repair. discussion bacteremia following cardiac catheterization is rare. in a prospective study from banai, etc., they evaluated 960 patient undergoing catheterization, only 0.4% of patient had positive blood cultures that significantly associated with cardiac catheterization. in the literature, there were 8 cases of ie after catheterization. from the 8 cases, there were found four patient with a history of valve disease and ie occurred after catheterization. signs and symptoms of catheterization are obtained from day one until one week after the procedure.3,6-9 risk factor for ie is patient with prosthetic cardiac valves, iv drug users, patient with mitral valve prolapse (mvp) or nonrheumatic heart disease (chd, bicuspid aortic valves), rheumatic heart disease. the risk of ie increases in patient who undergo invasive procedures. patient with old age, alcoholics, sufferers of chronic inflammatory bowel disease, poor dental hygiene, repeated dialysis, diabetes mellitus, and patient with immunosuppressants are at risk to be exposed from ie.5,10 patient with a moderate risk of developing ie include patient with pda, bicuspid aortic valve, and coarctation of the aorta, rheumatic heart disease (rhd) or hypertrophic obstructive cardiomyopathy (hcom). adults with chd (guch), including groups with lowrisk factors.3,11 patient with a high risk of developing ie include patient who have prosthetic heart valves, a history of previous endocarditis, cyanotic chd, surgically constructed systemic pulmonary shunts or conduit. patient with prosthetic valves have 5-10 times the risk compared with native valves.3,11 ie related to post-closure is a rare case, but there are several case reports. there is one case report from minnesota with one 66-yearold male with a large asd that has been catheterized with a 32-mm asd amplazter occlude 30 months before the incident. a case report from india also discusses the same thing. in the first case, the treatment was done by surgery, and the patient received iv antibiotic vancomycin for six weeks while the second patient was given daptomycin iv for six weeks. from these two patient, significant clinical signs and outpatient were obtained after six weeks. there is one case report of ie on vsd after closure reported by schuerman in 2005 in a 22-month-old baby girl. she is experiencing a fever one month after the closure that lasted for one month and did not respond by giving antibiotics.12-15 in the first case, we found several risk factors for ie namely vsd that has high risk developing of ie, and patient had undergone the invasive procedure and this increase the risk of ie. she also had cavities which is one of a risk factor for ie. maintaining good oral hygiene and infection control can decrease the incidence of ie. it should be emphasised to patients that maintaining optimal oral health and hygiene and regular dentist visits may reduce the incidence of bacteraemia from brushing teeth, chewing food and daily activities, and thus are particularly important in reducing the risk of ie. in the second case, we consider the risk factor of ie that patient had immunocompromised state because she took corticosteroid for a long time beside she already had chd.15,16 patient with a high risk of ie should be given prophylaxis before medical treatment. prophylactic antibiotics only needed if the patient undergoes the invasive procedure. in action in the field of cardio, prophylactic antibiotics can be given to patient who will undergo prosthetic valve implantation or pacemaker installation. prophylactic antibiotics must be considered in patient who will undergo dental procedures. atrisk procedures involve manipulation of the gingival or periapical region of the teeth or perforation of the oral mucosa (including scaling and root canal procedures). antibiotic prophylaxis should only be considered for patient at highest risk for endocarditis.17 prophylactic antibiotics must be started unexpected infective endocarditis in corrected congenital heart disease: a case report international journal of integrated health sciences (iijhs) 37 as soon as possible before the action starts and stops after 48 hours post-procedure. the recommended prophylactic antibiotic dose in patient with high risk are amoxicillin or ampicillin 2 g oral or intravenously. if the patient has an allergy to penicillin or ampicillin, 600 mg of oral or intravenous clindamycin can be given.16 management of ie should be started promptly. in esc 2015 about ie we can give empirical treatment in patient whose microorganisms have not yet been identified. once the pathogen is identified, the antibiotic treatment must be adapted to its antimicrobial susceptibility pattern.17 in the first case, the patient has been given ceftriaxone 1 x 2 g iv and gentamicin 3 mg/ kg / 48 hours iv, and in the second case, the patient has given ampicillin sulbactam 4x3 gr iv and gentamycin 1x160 mg iv. as we know in 2015 european society of cardiology (esc) guidelines about ie, in patient with unknown types of bacteria can be given gentamicin 3 mg/kg/hour iv. in the guideline mentioned, gentamicin administration can be given with vancomycin, but the patient did not get vancomycin but get ceftriaxone at the emergency room due to unavailability of drugs. patient get vancomycin 3x500 mg iv when entering the ward. after the results of the culture came out, we found the bacteria that causes ie in these patient was enterococcus spp. based on the 2015 esc guidelines on ie, there are three choices of ie antibiotic therapy regimens caused by enterococcus spp. i.e. amoxicillin 4 x 200 mg / kg / day iv plus gentamicin 1x 3 mg / kg / day intravenous (iv) or intramuscular (im) for 4-6 weeks or can be given ampicillin 4 x 200 mg / kg / day iv plus ceftriaxone 2x4 gr / day iv for 6 weeks or vancomycin 2x 30 mg / kg / day plus gentamicin 1 x 3 mg / kg / day given for 6 weeks. valve surgery is fundamental in the standard of care of selected ie patient. surgical intervention can be a lifesaving procedure in complicated, critically ill endocarditis patient. heart failure, uncontrolled and persistent infection despite optimal antibiotic therapy and recurrent emboli are the major indications for valve surgery in ie population. 17-18 in the first case, the patient had a complication that is acute stroke. the timing valve surgery in ie patient with stroke remains controversial. stroke is an independent risk factor for postoperative mortality in ie patient. one clinical quandary is whether early valve surgery can be safely performed within seven days after a stroke or if it is better to postpone surgery for at least one week. no randomized trials have addressed this conundrum. investigations have suggested a better outcome for ie patient with ischemic stroke who undergo early cardiac surgery. ruttmann et al. analyzed 65 patient who underwent cardiac surgery after cardioembolic (embolic) stroke (median time, four days; range, 0–38 days). surgery in this time frame was not associated with worse patient outcomes. 18 in the second case, the patient had locally uncontrolled infection marked by enlarged vegetation size and multiple vegetation in 22 days of treatment. uncontrolled infection is most frequently related to a perivalvular extension or “difficult-to-treat” organism. unless severe co-morbidity exists, the presence of locally uncontrolled infection is an indication for early surgery in patient with ie.17 in this case report, there were two women with chd post corrected and experienced ie with a different risk factor. from the first case, the risk factor was cavities and didn’t go to the dentist; meanwhile, in the second case, the risk factor was immunocompromised because she took methylprednisolone for treatment pericardial effusion. although the incidence is rare, the possibility of ie must be a concern for a physician, especially for those who have other clinical condition like poor dental hygiene and immunocompromised. references 1. stout kk, daniels cj, aboulhosn ja, bozkurt b, broberg cs, colman jm, et al. 2018 aha/ acc guideline for the management of adults with congenital heart disease: executive summary: a report of the american college of cardiology/american heart association task force on clinical practice guidelines [published correction appears in j am coll cardiol. 2019;73(18):2361]. j am coll cardiol. 2019;73(12):1494–563. 2. moore j, hegde s, el-said h, beekman r, benson l, bergersen l, et al. transcatheter device closure of atrial septal defects: a safety review. jacc cardiovasc interv. 2013;6(5):433–42. charlotte johanna cool, rachmi anasthasia, et al 38 international journal of integrated health sciences (iijhs) 3. mulder bjm. endocarditis in congenital heart disease: who is at highest risk?. circulation. 2013;128(13):1396–7. 4. libby p, zipes d. cardiovascular infections, braunwald’s heart disease a textbook of cardiovascular medicine. 10th ed. philadelphia: elsevier saunders; 2015. 5. baddour lm, wilson wr, bayer as, fowler vg jr, tleyjeh im, rybak mj, et al. infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications: a scientific statement for healthcare professionals from the american heart association. circulation. 2015;132(15):1435–86. 6. slesnick tc, nugent aw, fraser cd, cannon bc. incomplete endothelialization and late development of acute bacterial endocarditis after implantation of an amplatzer septal occluder device. circulation. 2008;117(18):326–7. 7. plante g, boutin c, dahdah n.. late bacterial endocarditis after amplatzer atrial septal occluder without residual shunt in a pediatric patient. mathews j case rep. 2019;4(3):54. 8. amedro p, soulatges c, fraisse a. infective endocarditis after device closure of atrial septal defects: case report and review of the literature. catheter cardiovasc interv. 2017;89(2):324–34. 9. zahr f, katz we, toyoda y, anderson wd. late bacterial endocarditis of an amplatzer atrial septal defect occluder device. ajc. 2010;105(2):279–80. 10. habib g, lancellotti p, antunes mj, bongiorni mg, casalta jp, del zotti f, et al. 2015 esc guidelines for the management of infective endocarditis the task force for the management of infective endocarditis of the european society of cardiology (esc) endorsed by : european association for cardio-thoracic surgery. eur heart j. 2015;36(44):3075–128. 11. cahill tj, baddour lm, habib g, hoen b, salaun e, pettersson gb, et al. challenges in infective endocarditis. j am coll cardiol. 2017;69(3):325–44. 12. moore j, hegde s, el-said h, beekman r, benson l, bergersen l, et al. transcatheter device closure of atrial septal defects: a safety review. jacc cardiovasc interv. 2013;6(5):433–42. 13. janszky i, gémes k, ahnve s, asgeirsson h, möller j. invasive procedures associated with the development of infective endocarditis. j am coll cardiol. 2018;71(24):2744–52. 14. aruni b, sharifian a, eryazici p, herrera cj. late bacterial endocarditis of an amplatzer atrial septal device. ihj. 2013;65(4):450–1. 15. scheuerman o, bruckheimer e, marcus n, hoffer v, garty bz. endocarditis after closure of ventricular septal defect by transcatheter device. pediatrics. 2006;117(6):e1256–e58. 16. błochowiak kj. dental treatment and recommended management in patients at risk of infective endocarditis. kardiochir torakochirurgia pol. 2019;16(1):37–41. 17. knirsch w, nadal d. infective endocarditis in congenital heart disease. eur j pediatr. 2011;170(9):1111–27. 18. bin abdulhak aa, tleyjeh im. indications of surgery in infective endocarditis. curr infect dis rep. 2017;19(3):2013–7. unexpected infective endocarditis in corrected congenital heart disease: a case report volume 7 no 2 2019 (3).indd international journal of integrated health sciences. 2019;7(2) 61 clinical manifestations and hematological profiles of pediatric acute myeloblastic leukemia patients: 3 years observational study in a west java tertiary hospital, indonesia abstract objective: to determine and describe the clinical manifestations and hematological profiles of pediatric acute myeloblastic leukemia (aml) in dr. hasan sadikin general hospital (rshs), bandung as a tertiary hospital in west java, indonesia. methods: a retrospective cross-sectional study using the total sampling method was performed on the medical records of pediatric patients (0-18 years old)who were diagnosed as aml for the first time through bone marrow examination during the period of january 1, 2015–december 31, 2017. results: of the 54 subjects who met the inclusion criteria, 42.6% were aml patients in the age group 6-12 years with male patients comprised 59.3% of the total number of subjects. patients generally experienced pallor (83.3%), fever (75.9%), and decreased appetite (70.4%). the hematological profiles showed that 35.2% of patients had hb <6.5 g/dl and 44.4% had a leukocyte count of of >50,000 cells/mm3. the majority of the subjects had a platelet count of <50,000 cells/mm3 (83.3%) and almost half of them had a peripheral blasts count of >50% (46.3%). conclusions: clinical manifestations and hematological profiles are important to diagnose aml, especially in pediatric patients. by assessing the manifestations and profiles, it is feasible to access and detect suspected cases of aml. keywords: acute myeloblastic leukemia, clinical manifestation, hematological profile, pediatric pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v7n2.1480 ijihs. 2019;7(2):61–6 received: october 12, 2018 revised: september 09, 2019 accepted: october 19, 2019 correspondence: agustinus wiraatmadja, faculty of medicine, universitas padjadjaran jalan raya bandung sumedang km. 21 jatinangor, sumedang indonesia, e-mail: agustinuswiraatmadja@gmail.com original article :61–6 agustinus wiraatmadja,1 nur suryawan,2 adhi kristianto sugianli3 1faculty of medicine universitas padjadjaran, indonesia 2department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia 3department of clinical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia introduction acute myeloblastic leukemia (aml) is a type of acute leukemia with rapid and progressive infiltrations of myeloid/myeloblast cells to the bone marrow, blood, and other organs.1 in united states, 350 new cases of aml in pediatric are identified annuallya.2 approximately 15– 20% of leukemia cases in children ≤15 years old are aml.2, 3 in indonesia, acute leukemia is the most common type of cancer in children.4 data from a department of pediatrics in a tertiary hospital in jakarta demonstrated that 21.8% of acute leukemia in 2007-2010 are aml.5 another study in a tertiary hospital in yogyakarta also showed that 27.7% of acute leukemia are aml, which is higher than in western countries.6 to be able to improve the survival rate of pediatric aml patients, it is necessary to understand the characteristics of clinical and hematological profiles of the patients to facilitate early diagnosis. pediatric aml have various clinical manifestations, with anemia (pale, weak, decreased in appetite and body weight), bleeding, and infection as the most common. in addition, cancer cells can migrate 62 international journal of integrated health sciences. 2019;7(2) clinical manifestations and hematological profiles of pediatric acute myeloblastic leukemia patients :61–6 and cause manifestations in other organs such as in the liver, spleen, and lymph nodes.7, 8 based on the hematological examination, aml patients generally experience anemia, leukocytosis, thrombocytopenia, and increased number of blast cells.9 a study in dharmais cancer hospital jakarta showed that 83% of aml patients have a hemoglobin level of <12 g/dl, 61% have a leukocyte count of ≥50,000 cells/mm3, and 57% have a platelet count of <30,000 cells/mm3.4 data from a tertiary hospital in jakarta (2007–2009) revealed that aml patients that male patients with hepatomegaly and a platelet count of <20,000 cells/mm3 tend to experience failure to achieve remission.5 reports on clinical and hematological profiles of pediatric aml patients in tertiary hospitals are still lacking. therefore, this study aimed to gather information on clinical manifestations and hematological profiles of pediatric aml patients in a tertiary hospital in west java province, indonesia. methods this was a cross-sectional study on all inpatient medical records of aml pediatric patients treated in dr. hasan sadikin general hospital bandung, west java, indonesia during the period of january 1, 2015 to december 31, 2017 using the total sampling approach. the study was performed from june to july 2018 the inclusion criteria of this study was all medical records of pediatric (0–18 years old) patients who were diagnosed as aml in dr. hasan sadikin general hospital (rumah sakit hasan sadikin, rshs) for the first time based on the results of the bone marrow examination. medical records were excluded if they were incomplete, lost, or contained inaccessible data. medical records of patients who who did not come to rshs for the first time, refused to undergo bone marrow examination, and diagnosed as non-aml were also excluded. this study had been approved by the research ethical committee of universitas padjadjaran, bandung through issuance of the ethical clearance number 202/ un6.kep/ec/2018 and by the medical research ethical committee of dr. hasan sadikin general hospital, bandung with the issuance of ethical clearance number lb.02.01/x.2.2.1/9375/2018. this study was also acknowledged and approved by the pediatrics department and clinical pathology department of dr. hasan sadikin general hospital bandung, indonesia. variables of this study were patient demographics (including age and sex), clinical manifestations of aml, and hematological profiles (hemoglobin level, leukocyte count, thrombocyte count and peripheral blast count). hemoglobin level was categorized into <6.5, 6.5–7.9, 8.0–9.4, 9.5–10.9 and ≥11 g/dl. leukocyte count was classified into <10,000, 10,000–50,000, and >50,000 cells/mm3. platelet count was grouped into <50,000, 50,000-99,999, 100,000–149,999, 150,000–450,000, and >450,000 cells/mm3 while peripheral blast count was categorized into <20, 20–50, and >50%. data were then selected and sorted based on the inclusion criteria and analyzed using descriptive statistics and processed using microsoft® excel 2016 and ibm® spss® version 20. tables, percentages, and charts were used to present patient demographics, clinical manifestations, and hematological profiles. results of the seventy-three medical records retrieved, 54 met the inclusion criteria of this study. the flow diagram used for the selection process is presented in figure 1. the age and gender distribution of the aml pediatric patients in rshs from 2015–2017 were depicted in figure 2. most patients were in the age group 6–12 years old (42.6%) and males (59.3%). figure 3 displays the clinical manifestations of pediatric aml patients in rshs during the period of 2015–2017. the most frequently observed clinical manifestations were pallor (83.3%), followed by fever (75.9%), loss of appetite (70.4%), as well as weight loss and hepatomegaly (each 59.3%). table 1 illustrates the hematological profiles of pediatric aml patients in rshs. most subjects had a hemoglobin level of <6.5 g/dl (35.2%) whereas the leukocyte and platelet counts were mostly in the category of >50,000 cells/mm3 (44.4%) and <50,000 cells/mm3 (83.3%), respectively. the number of blast cells on peripheral blood examination were mostly in the category >50% (46.3%). discussion this study demonstrated that 42.6% of children with aml in rshs from 2015-2017 belonged to the age group 6–12 years old and most of the patients were males (59.3%). this finding is similar to the finding of a study international journal of integrated health sciences. 2019;7(2) 63:61–6 agustinus wiraatmadja, nur suryawan, et al. figure 1 flow diagram for medical record selection process table 1 hematological profiles of pediatric aml patients hematological profiles (n=54) % hemoglobin level (g/dl) <6.5 19 35.2 6.5–7.9 17 31.5 8.0–9.4 9 16.7 9.5–10.9 8 14.8 ≥11 1 1.9 leukocyte count (cells/mm3) <10,000 15 27.8 10,000–50,000 15 27.8 >50,000 24 44.4 platelet count (cells/mm3) <50,000 45 83.3 50,000–99,999 4 7.4 100,000-149,999 1 1.9 150,000–450,000 3 5.6 >450,000 cells/mm3 1 1.9 peripheral blast count (%) <20 16 29.6 20–50 13 24.1 >50 25 46.3 64 international journal of integrated health sciences. 2019;7(2):61–6 figure 3 clinical manifestations in pediatric aml patients figure 2 age and gender of pediatric aml patients clinical manifestations and hematological profiles of pediatric acute myeloblastic leukemia patients international journal of integrated health sciences. 2019;7(2) 65 by supriyadi e et al. stating 41.4% of the pediatric aml patients were 6–12 years old when diagnosed.10 another study conducted by rahadiyanto et al.11 and sjakti ha et al. also stated that aml in children is more frequent in males (52.4% and 61.3% respectively).5 most of the pediatric aml patients had more than one clinical manifestation. results showed that pallor was the clinical manifestation with the highest frequency that was seen in 83.3% of the patients, followed by fever (75.9%), decreased appetite (70.4%), as well as weight loss and hepatomegaly (each 59.3%). these data resemble the results of a study by hu et al.12 which concluded that the most common manifestations of pediatric aml patients are pallor (60.3%), fever (40.5%), and mucosal bleeding (15.5%). another study from asif and hassan13 in pakistan also stated that pallor is the most common manifestations (86.6%), followed by fever (82.9%) and bleeding (52.4%), while hepatomegaly is found in 38 of 82 patients (46.3%). hematopoietic disorders of aml cause several clinical manifestations such as symptoms of anemia (most commonly paleness, weakness, and decreased appetite), infection, and an increased probability to bleed.13 in aml, the cancer cells do not only accumulate in the bone marrow, but also in other organs, such as liver, spleen, lymph nodes, central nervous system, and skin, which were also identified in this study.14 the hemoglobin level of this study was mostly found in the category of <6.5 g/dl (35.2%). this was in line with a study by chang et al.15 most patients in were in the category of <8 g/dl (45.8% of 107).similar findings are presented by rahmadin et al.8 who reported that 48.57% of aml patients had a hemoglobin level of <6 g/dl. anemia is usually caused by inadequate hematopoiesis triggered by abundant proliferation of leukocytes in bone marrow.7,8 most patients in this study had a leukocyte count in the category of >50,000 cells/mm3 (44.4%). this is similar to the findings of johnston et al.16 which revealed that 50.7% of their patients had 10,000-99,999 cells/mm3 leukocytes.it is concluded that the majority of pediatric aml patients in this study experienced hyperleukocytosis caused by blocked leukocyte maturation leading to the accumulation of myeloid cells in bone marrow and vessels.7, 8 in this study, the platelet count was predominantly in the category of <50,000 cells/ mm3, which reflects severe thrombocytopenia (83.3%). this is supported by a finding from mehta et al.17 stating that 88.9% of the patients have thrombocytopenia (<150,000 cells/mm3). thrombocytopenia can be caused by bone marrow infiltration, disseminated intravascular coagulation, immunological reactions or secondary hypersplenism due to an enlarged spleen.18 in this study, 46.3% of the patients had >50% blast cells on peripheral blood examination, which is similar to a previous study by rendra et al.19 with 41.02% of their patients had 50–59% blasts.this condition is a result of disturbed myeloid cell development that leads to blast accumulation in bone marrow and blood.8 the initial suspicion of aml may arise when the blasts count is >20% on bone marrow or peripheral blood examination, when bone marrow is not possible.7 this study also has limitations. one of them is the difficulty in reading and accessing patient medical records. in addition, researchers were not able to collect data other than those from 2015 to 2017 due to limited time for data collection and incomplete medical records from before 2015. it is recommended that this type of study is performed in a longer period of time and with a larger sample size or other variables that have not been studied yet. subsequent studies can also explore the links between variables discovered in this study. in conclusion, clinical manifestations and hematological profiles are important for diagnosing aml, especially in pediatric patients, to make it feasible to detect aml cases earlier. references 1. döhner h, weisdorf dj, bloomfield cd. acute myeloid leukemia. nejm. 2015;373(12):1136– 52. 2. aquino vm. acute myelogenous leukemia. current problems in pediatric and adolescent health care. 2002;32(2):50–8. 3. deschler b, lübbert m. acute myeloid leukemia: epidemiology and etiology. cancer. 2006;107(9):2099–107. 4. simanjorang c, kodim n, tehuter e. perbedaan kesintasan 5 tahun pasien leukemia limfoblastik akut dan leukemia mieloblastik akut pada anak di rumah sakit kanker “dharmais” jakarta, 1997-2008. indonesian journal of cancer. 2013;7(1):15–21. 5. sjakti ha, gatot d, windiastuti e. hasil :61–6 agustinus wiraatmadja, nur suryawan, et al. 66 international journal of integrated health sciences. 2019;7(2) pengobatan leukemia mieloblastik akut pada anak. sari pediatri. 2016;14(1):40–5. 6. supriyadi e, widjajanto ph, purwanto i, cloos j, veerman aj, sutaryo s. incidence of childhood leukemia in yogyakarta, indonesia, 1998–2009. pbc. 2011;57(4):588–93. 7. bacârea a. diagnosis of acute myeloid leukemia, myeloid leukemia-clinical diagnosis and treatment. intech [internet]. 2012 [cited 2018 jul 18];1(8):[about 30p]. available from: http://www.intechopen.com/books/myeloidleukemia-clinical-diagnosis-and-treatment/ diagnosis-of-acute-myeloid-leukaemia. 8. rahmadin b, wahid i, yaswir r. profil penderita leukemia mieloblastik akut di bagian penyakit dalam rsup dr. m. djamil padang. jka. 2018;6(3):495–501. 9. lanzkowsky p, lipton jm, fish jd. lanzkowsky’s manual of pediatric hematology and oncology. 6th ed: elsevier science; 2016. 10. supriyadi e, purwanto i, widjajanto ph. terapi leukemia mieloblastik akut anak: protokol ara-c, doxorubycine dan etoposide (ade) vs modifikasi nordic society of pediatric hematology and oncology (m-nopho). sari pediatri. 2016;14(6):345–50. 11. rahadiyanto ky, liana p, indriani b. pola gambaran darah tepi pada penderita leukimia di laboratorium klinik rsup dr. mohammad hoesin palembang. mks. 2014;46(4):259–65. 12. hu r, wu y, jiang x, zhang w, xu l. clinical symptoms and chemotherapy completion in elderly patients with newly diagnosed acute leukemia: a retrospective comparison study with a younger cohort. bmc cancer. 2011;11(1):224. 13. asif n, hassan k. clinical manifestations of acute myeloid leukemia. jimdc. 2012;1(1):6-9. 14. asif n, hassan k, yasmeen n. acute myeloblastic leukemia in children. int j pathol. 2011;9(1):67–70. 15. chang f, shamsi t, waryah a. clinical and hematological profile of acute myeloid leukemia (aml) patients of sindh. journal of hematology and thromboembolic diseases. 2016;4(2):1–5. 16. johnston dl, alonzo ta, gerbing rb, aplenc r, woods wg, meshinchi s, et al. central nervous system disease in pediatric acute myeloid leukemia: a report from the children’s oncology group. pbc. 2017;64(12):1–9. 17. mehta s, shukla s, vora h. comprehensive flt3 analysis in indian acute myeloid leukaemia. j blood lymph. 2012;2(1):1–13. 18. rofinda zd. kelainan hemostasis pada leukemia. jka. 2012;1(2):68–74. 19. rendra m, yaswir r, hanif am. gambaran laboratorium leukemia kronik di bagian penyakit dalam rsup dr. m. djamil padang. jka. 2013;2(3):141–5. :61–6 social determinant factors of elderly as an input in enhancing primary health care in indonesia 30 international journal of integrated health sciences. 2014;2(1):30–5 original article mycoplasma genitalium infection prevalence in patients with human immunodeficiency virus abstract objective: to determine the prevalence of mycoplasma genitalium (m. genitalium) infection in hiv positive patients by pcr examination in teratai clinic of dr. hasan sadikin general hospital, bandung in order to reduce sexually transmitted diseases, especially m. genitalium infection in hiv positive patients. methods: this study was a cross-sectional study with consecutive sampling methods. eighty one hiv positive patients attending the teratai clinic of dr. hasan sadikin general hospital, bandung were recruited to be the subjects of this study. all subjects underwent history taking, physical examination, and pcr examination for m. genitalium. specimens were taken from cervical smear in females and first void urine in male. results: the prevalence of m. genitalium based on the pcr examination in hiv positive patients attended to teratai clinic dr. hasan sadikin general hospital bandung was 9%. conclusions: mycoplasmal infection identification based on pcr examination should be considered for routine screening test to reduce the incidence of sexually transmitted diseases in hiv positive patients. keywords: human immunodeficiency virus, mycoplama genitalium, polymerase chain reaction ijihs. 2014;2(1):30–5 introduction mycoplama genitalium (m. genitalium) is the smallest bacterium, with a genome size of 580 kb, of the mollicutes class (mollis:soft, cutis:skin, in latin) that is mainly found in human genital tract.1,2 several studies have already shown that m. genitalium is a sexually transmitted organism that causes asymptomatic or non-gonococcal urethritis (ngu) in males as well as cervicitis, endometritis, pelvic inflammatory disease in females.3-7 mycoplama genitalium infection can be detected through culture, serological, and polymerase chain reaction (pcr) examinations. the culture examination may take several weeks or even months to grow m. genitalium. hence, it cannot be used as a routine diagnostic tool in every day practice. in the serological examination, cross reactions may occur between m. genitalium and m. pneumoniae due to some similar structures, thereby decreasing the specificity of the test. the pcr examination can detect the microorganism in samples collected from the reproductive tracts in a highly sensitive, accurate, and specific manner. this leads to a situation where pcr is the only reliable diagnostic tool for m. genitalium infection.8 currently, the pcr examination to detect m. genitalium is available for research only and not available comercially.9 cross-sectional studies have shown a strong association between m. genitalium and hiv.10 m. genitalium may play an important role in the acquisition and transmission of hiv as also in other sexually transmitted diseases. several in vitro studies have shown that the inflammatory response and mucosal disruption associated rini rasianti,1 hartati dharmadji,2 risa miliawati,2 diah puspitosari,1 feilicia henrica teja,1 rasmia rowawi,2 rahmatdinata,2 tony djajakusumah2 1faculty of medicine, universitas padjdajaran-dr. hasan sadikin general hospital 2department of dermatology and venereology, faculty of medicine, universitas padjajaran-dr. hasan sadikin general hospital correspondence: rini rasianti, faculty of medicine, universitas padjadjarandr. hasan sadikin general hospital jl. pasteur no. 38, bandung, indonesia e-mail: r_rasianti@yahoo.com received: january 10, 2013 revised: april 1, 2013 accepted: april 10, 2014 international journal of integrated health sciences. 2014;2(1) 31:30–5 rini rasianti, hartati dharmadji, et al. with m. genitalium infection will increase either the susceptibility or transmissibility, or both, to hiv infection.11 research regarding the relationship between m. genitalium and hiv will provide knowledge on hiv cofactors that can be intervened. studies among hiv positive patients in several clinics in italy, brazil, united states, and india have found that the prevalence rates of m. genitalium vary between 1% and 10%.10,12–15 there is no data on the prevalence m. genitalium in hiv positive patients in indonesia, especially in west java. the examination and treatment of m. genitalium infection in high-risk populations should be investigated as a potential strategy to prevent hiv.11 therefore, a descriptive study was done to determine m. genitalium prevalence in hiv positive patients who visited teratai clinic of dr. hasan sadikin general hospital, bandung through the use of pcr. methods this study was an observational study with cross sectional design. the subjects were 81 table 1 distribution of all participant based on pcr result variable pcr m. genitalium total positive negative n (%) sex male 4 44 48 (59) female 3 30 33 (41) total (male+female) 7 74 81 (100) education no education 0 0 0 (0) elementary school 0 4 4 (5) junior high school 1 3 4 (5) senior high school 3 38 41 (51) college/university 3 29 32 (39) occupation entrepreneur 3 32 35 (43) employee 0 21 21 (26) commercial sex worker 0 1 1 (1) student 1 0 1 (1) not working 3 20 23 (29) marital status single 3 15 18 (22) married 3 42 45 (56) widowers/widows 1 17 18 (22) hiv positive patients who visited teratai clinic of dr. hasan sadikin general hospital bandung who were taken in consecutive admission in july 2012. the hiv serostatus of the study population had already been determined and confirmed based on national hiv guideline in teratai clinic before this study. the inclusion criteria for this study were male and female hiv patients in teratai clinic who were sexually active. female patients who were having her menstrual period were excluded from this study. the study design was approved by the research ethics committee of health, dr. hasan sadikin general hospital, bandung. the subjects were given a description on the research and if they were willing to participate in the study, they 32 international journal of integrated health sciences. 2014;2(1):30–5 mycoplasma genitalium infection prevalence in patients with human immunodeficiency virus table 2 sexual behavior of participants based on pcr result variable pcr m. genitalium total positive negative n (%) sexual orientation heterosexual 6 66 72 (89) homosexual 1 4 5 (6) bisexual 0 4 4 (5) sexual practises genital-genital (gg) 5 32 37 (46) gg+oral-genital (og) 1 31 32 (39) og+anal-genital (ag) 0 4 4 (5) gg+og+ag 1 5 6 (7) gg+og+ag+oral-anal (oa) 0 2 2 (3) number of sexual partner in the last month 0 person 4 23 27 (33) 1 person 3 45 48 (59) ≥2 persons 0 6 6 (8) number of sexual partner in the last 3 months 0 person 2 18 20 (25) 1 person 5 41 46 (57) ≥2 persons 0 15 15 (18) number of lifetime sexual partner 1 person 2 19 21 (26) 2–5 persons 5 34 39 (48) ≥6 persons 0 21 21 (26) condom use never 2 18 20 (25) seldom 2 19 21 (26) always 3 37 40 (49) sti history positive 5 38 43 (53) negative 2 36 38 (47) were asked to sign the informed consent. the subjects then underwent history taking, physical examination, and samples for pcr examination were collected from the first void urine in males and cervical swab in females. the results were presented descriptively to determine the prevalence of m. genitalium based on pcr examination in hiv positive patients. the study was conducted at teratai clinic of dr. hasan sadikin general hospital, bandung and the pcr examination for m. genitalium was performed at the laboratory of molecular biology department of microbiology/health research unit of the faculty of medicine, universitas padjadjaran, bandung. thirty to fifty ml first void urine samples were collected from male patients in sterile specimen collection manner after the patient had not urinated for 2 hours. the cervical swabs for female patients were collected using a specimen international journal of integrated health sciences. 2014;2(1) 33 rini rasianti, hartati dharmadji, et al. :30–5 collection kit (roche ltd., basel, switzerland) and they were transported to the laboratory in transport medium tubes (roche ltd., basel, switzerland). both specimens were transported to the laboratory on the day of collection. the dnas from urine were isolated using qiamp dna extraction kit and the dnas from cervical smears were isolated using roche preparation kit. pcr for m. genitalium was performed using the pcr kit from genekam biotechnology ag. the pcr results were interpreted with agarose gel using a uv chamber. positive results were established in accordance with the positive control bands (341bp) and no band on the negative control. the data were then stored in a file. the data were recorded in the prepared research form, then the editing, verification, coding, and data entry were conducted using spss 17.0. after that, the collected data were calculated for the percentage of m. genitalium positive pcr results. data on subject characteristics and sexual behaviors were also presented descriptively. results a total of 81 hiv positive patients were examined as a part of this cross-sectional study in order to determine the m. genitalium status. the prevalence of m. genitalium infection was 7/81. m. genitalium positive result for female was 3/33 and 4/48 males were positive. discussion culture examination may take several weeks or even months to grow m. genitalium, which makes it impossible to use it for diagnostic purpose in clinical practice. in serological testing, m. genitalium may have cross-reactivity with m. pneumoniae due to the similarity in structure, thereby decreasing the specificity of the serological tests. currently, examination by pcr is the method of choice for the detection of m. genitalium and the most published target genes are major adhesin mgpa genes or 16s rrna gene.1,9,16 the most sensitive clinical samples for testing m. genitalium in females when pcr is used, according to the study performed by wroblewski et al.,17 is from the vaginal swab (91%) compared to the cervical smear (53%) and urine (65%). however, the vaginal smear examination has not been approved by the food and drug administration. jensen et al. in shipitsyna et al.8 found that the first void urine in males can detect higher m. genitalium infections (98%) than urethral swabs (82%). to our knowledge, this is the first prevalence study of m. genitalium infection among hiv positive patients in indonesia, especially in west java. in this study, the m. genitalium infection prevalence in hiv positive patients in teratai clinic of dr. hasan sadikin general hospital, bandung was 7/81. the m. genitalium positive results for female were found in 3/33 of the subjects and 4/48 were found in males. the results of this study were not much different from previous studies. research conducted by da costa et al.13 in 2009 in 223 males with hiv-1 who visited the hiv clinic in sao paulo general hospital has obtained similar results, with the m. genitalium infection was found in 13 (6%) urine samples. manhas et al.14 conducted a study on urine samples of 100 males patients who visited the ngu hiv and sti clinic in chandigarh india in 2010, i.e. 70 hiv-positive cases and 30 hiv-negative cases. in their study, m. genitalium infection was higher in hiv positive patients (7%), whereas in hiv negative patients, the infections was only 3%. however, the results showed no statistically significant difference in the frequency of m. genitalium infection in hiv positive and hiv negative patients.14 gatski et al.10 in 2011 revealed that the prevalence of m. genitalium was 10% in hiv positive females in an hiv clinic in new orleans, the united states, with samples taken from the cervix. in the study by martinelli et al.12 it was found that the prevalence of m. genitalium was significantly higher statistically in males with aids (56%) compared to hiv positive patients (10%) and the normal population (7%). this may happen for two reasons: first, defects in humoral and cellular immunity in patients with aids, making them more prone to infection; second, the colonization of m. genitalium in urethral tract of aids patients that was resistant to antibiotics due to the use of broad-spectrum antibiotic prophylaxis in those patients.12 this study shows that the average age of patients with pcr m. genitalium positive was 32 years old, with the youngest of 26 years old, and the oldest was 36 years old. these results suggested that m. genitalium infections generally occur during sexually active ages. it was found by da costa et al.13 that the average age of subjects with positive m. genitalium in hiv positive males was 43 years old. gatski et al.10 revealed that the average age of the hiv positive females subjects who were positive for m. genitalium was less than 35 years old, which were the sexually active population. another study conducted by anagrius et al.16 found that of 946 patients attending an sti clinic in sweden the median age of m. genitalium infection was 34 international journal of integrated health sciences. 2014;2(1) references 1. totten pa, robinson dt, jensen js. genital mycoplasma. in: holmes kk, sparling pf, stamm we, piot p, wasserheit j, corey l, editors. sexually transmitted diseases. 4th ed. new york: mcgrawhill; 2008. p. 709–29. 2. uuskula a, kohl pk. genital mycoplasmas, including mycoplasma genitalium as sexually transmitted agents. int j std aids. 2002;13(2):79– 85. 3. uno m, deguchi t, saito a, yasuda m, komeda h, kawada y. prevalence of mycoplasma genitalium in asymptomatic men in japan. int j std aids. 1997;8(4):259–60. 4. taylor-robinson d, renton a, jensen js, ison ca, filatova e, dmitriev g, et al. association of mycoplasma genitalium with acute nongonococcal urethritis in russian men: a comparison with gonococcal and chlamydial :30–5 mycoplasma genitalium infection prevalence in patients with human immunodeficiency virus 26 years with a range of 17–40 years. in this study, the prevalence of m. genitalium infection is similar between males and females. studies that compare the prevalence of stis in males and females are very limited. there is an extensive agreement that females are more frequently and are more heavily exposed to stis than males.18 this condition may occur because females are more vulnerable to stis anatomically and they have limitations to seek for sti treatment.2,19 the education level of subjects with positive m. genitalium infection was similar between high school and academic or university graduates. in contrast to this study, gatski et al.10 found that most of the subjects with positive pcr result for m. genitalium were less educated or equivalent to high school graduates (72%). pe’pin et al.20 discovered a significant association between m. genitalium infection in female sex worker (fsws) in west africa with the level of education from no formal education to elementary school. one of the high risk factors for transmitting stis is a low level of education. those with an educational level of high school or less are more frequently exposed to stis than the academic or university graduates.21 the average age of the first sexual intercourse for the group with positive m. genitalium result was 21.3 years. in the group with positive m. genitalium, approximately (6/13) had their first sexual intercourse before the age of 15.13 the first experience of sexual intercourse has a great influence on future sexual behaviors and sexual health. in males, first sexual intercourse at a young age is associated with the number of lifetime sexual partners and high-risk sexual behaviors. in females, the first sexual intercourse at a young age is often associated with early marriage.18 in this study, the age of the first sexual intercourse was higher than that of the other studies because the religious values and traditions held in this area are against sex before marriage. most subjects with positive m. genitalium have a heterosexual orientation (6/7). this result is different from that of the da costa et al.13 study which revealed infection of m. genitalium in hiv positive males were most common in men who have sex with men (msm), i.e. 77%. research conducted by andersen et al.22 in males found that most subjects (69%) had sex only with other males in the last 12 months. aleung et al.23 stated that most patients infected with m. genitalium are heterosexual, although it is not statistically significant. most subjects with positive m. genitalium performed genital-to-genital sexual intercourse (6 people). this result was different from the result of da costa et al.13 study that found hiv male patients with positive m. genitalium often practice oral sex (38%). the use of condoms has only a slight effect on m. genitalium infection. three subjects who were m. genitalium positive always use condoms and four m. genitalium positive subjects never use any condom. in a study performed by gatski et al.,10 from 32 hiv positive females with positive m. genitalium, most of them used condom in the last vaginal intercourse (78%). research conducted by anagrius et al.16 found that the use of condoms cannot protect individuals against m. genitalium infection significantly. condoms will reduce sti transmission to their sexual partner if they are used consistently and correctly.24 however, it is difficult to measure the effectiveness of condom.25 in summary, the prevalence of m. genitalium infection in hiv positive patients based on pcr examination in teratai clinic of dr. hasan sadikin general hospital, bandung was 9%. even though the prevalence of m. genitalium infection in hiv positive patients is low in this study, identifying mycoplasma infection based on pcr examination should be considered for routine screening test to reduce the incidence of sexually transmitted diseases in hiv positive patients. international journal of integrated health sciences. 2014;2(1) 35 urethritis. int j std aids. 2009;20(4):234–7. 5. taylor-robinson d. mycoplasma genitalium -an up-date. int j std aids. 2002;13(3):145–51. 6. oakeshott p, aghaizu a, hay p, reid f, kerry s, atherton h, et al. is mycoplasma genitalium in women the “new chlamydia?” a communitybased prospective cohort study. clin infect dis. 2010;51(10):1160–6. 7. thurman ar, musatovova o, perdue s, shain rn, baseman jg, basemen jb. mycoplasma genitalium symptoms, concordance, and treatment in highrisk sexual dyads. int j std aids. 2010;21(3):177– 83. 8. shipitsyna e, savicheva a, sokolovsky e, ballard rc, domeika m, unemo m, et al. guidelines for the laboratory diagnosis of mycoplasma genitalium infections in east european countries. acta derm veneorol. 2010;90(5):461–7. 9. eastick k, leeming jp, caul eo, horner pj, millar mr. a novel polymerase chain reaction assay to detect mycoplasma genitalium. mol pathol. 2003;56(1):25–8. 10. gatski m, martin dh, theall k, amedee a, clark ra, dumestre j, et al. mycoplasma genitalium infection among hiv-positive women: prevalence, risk factors and association with vaginal sheeding. int j std aids. 2011;22(3):155–9. 11. napierala mavedzenge s, weiss ha. association mycoplasma genitalium and hiv infection: a systematic review and meta-analysis. aids. 2009;23(5):611–20. 12. martinelli f, garrafa e, turano a, caruso a. increased frequency of detection of ureaplasma urealyticum and mycoplasma genitalium in aids patients without uretral symptoms. j clin microbiol. 1999;37(6):2042–4. 13. da costa fa, da silva rc, arruda lb, montanheiro p, da silva duarte aj, casseb j. prevalence of mycoplasma genitalium among hiv-infected men in sao paulo city detected by realtime polymerasi chain reaction. int j std aids. 2010;21(1):23–5. 14. manhas a, sethi s, sharma m, wanchu a, kanwar aj, kaur k, et al. association of genital mycoplasmas including mycoplasma genitalium in hiv infected men with nongonococcal urethritis attending std & hiv clinics. ind j med res. 2009;129(3):305–10. 15. cordova cm, blanchard a, cunha ra. higher prevalence of urogenital mycoplasmas in human immunodeficiency virus-positive patients as compared to patients with other sexually transmitted diseases. j clin lab anal. 2000;14(5):246–53. 16. anagrius c, loré b, jensen js. mycoplasma genitalium: prevalence, clinical significance, and transmission. sex transm infect. 2005;81(6):458– 62. 17. wroblewski jk, manhart le, dickey ka, hudspeth mk, totten pa. comparison of transcriptionmediated amplification and pcr assay results for various genital spesimen types for detection of mycoplasma genitalium. j clin microbiol. 2006;44(9):3306–12. 18. buve a, gourbin cc, laga m. gender and sexually transmitted disease. in: holmes kk, sparling pf, stamm we, piot p, wasserheit jn, editor. sexually transmitted disease. 4th ed. new york: mcgrawhill; 2008. p. 151–201. 19. hook ew. gender differences in risk for sexually transmitted diseases. am j med sci. 2012;343(1):10–1. 20. pe´pin j, labbe´ a-c, khonde n, deslandes s, alary m, dzokoto a, et al. mycoplasma genitalium: an organism commonly associated with cervicitis among west african sex workers. sex transm infect. 2005;81(1):67–72. 21. lu f, jia y, bin s, li c, limei s, kristensen s, et al. predictors for casual sex and/or infection amongsexually transmitted disease clinic attendees in china. int j dermatol. 2009;20(4):241–8. 22. andersen b, sokolowski i, østergaard l, kjølseth møller j, olesen f, jensen js. mycoplasma genitalium prevalence and behaviour risk factor in the general population. sex transm infect. 2007;83(3):237–41. 23. leung a, eastick k, haddon le, horn ck, ahuja d, horner pj. mycoplasma genitalium is associated with symptomatic urethritis. int j std aids. 2006;17(5):285–8. 24. garnet jp. the transmision dynamic of sexually transmitted infection. in: holmes kk, sparling pf, stamm we, piot p, wasserheit jn, editors. sexually transmitted diseases. 4th ed. new york: mcgraw-hill; 2008. p. 27–40. 25. aral so, holmes kk. the epidemiology of stis and their social and behavioral determinants: industrialized and developing countries. in: holmes k, sparling s, stamm w, piot p, wasserheit j, corey l, editors. sexually transmitted diseases. 4th ed. new york: mcgraw-hill; 2008. p. 52–97. :30–5 rini rasianti, hartati dharmadji, et al. international journal of integrated health sciences. 2014;2(1) 15 correspondence: muhammad ramli ahmad, department of anesthesiology, intensive care and pain management, faculty of medicine, hassanudin university, dr. wahidin sudirohusodo general hospital jl. perintis kemerdekaan km 10, makassar, indonesia e-mail: m_ramli_ahmad@yahoo.co.id multimodal analgesic effect on proinflammatory and anti-inflammatory cytokines serum muhammad ramli ahmad,1 tatang bisri2 1department of anesthesiology, intensive care and pain management, faculty of medicine, hassanudin university-dr. wahidin sudirohusodo general hospital 2departement of anesthesiology and intensive care, faculty of medicine universitas padjadjaran-dr. hasan sadikin general hospital abstract objective: to investigate the effect of combination epidural bupivacaine and intravenous parecoxib analgesia on immune response in patients who underwent open reduction and internal fixation of the lower limb under epidural anesthesia. methods: this research was conducted using the randomized, placebo-controlled double blind trial method on 52 patients who were randomly divided into 2 groups: the parecoxib group which received 40 mg intravenous parecoxib for 30 minutes before incision and the control group which received an equal volume of 0.9% normal saline. both groups received epidural anesthesia and postoperative epidural 0.125% bupivacaine analgesia continously. venous blood samples were obtained before parecoxib administration, 2 and 24 hours after the surgery. the data were analyzed using mann whitney u and independent t tests (p<0.05). results: there was a significant difference between the two groups (p<0.05) in il-1β, il-6, il-10 levels and proinflammatory to anti-inflammatory ratio, 2 hours after surgery. conclusions: multimodal analgesic combination of 40 mg iv parecoxib and 0.125% bupivacaine epidural analgesia have the effect to alter and stabilize the systemic immune response. keywords: cytokines, epidural analgesia, interleukins, immune response, parecoxib, tissue damage ijihs. 2014;2(1):15–22 introduction postoperative pain brings a significant impact on patients. however, the management of the postoperative pain is still occasionally overlooked even though there are recent developments and extensive understandings on postoperative pain mechanism. almost half of all postoperative patients had not received proper postoperative pain management and about 80% of them were still in acute pain postoperatively.1 research conducted in maastricht university hospital, the netherlands, showed that about 41% of 1,490 postoperative patients were still in moderate to severe pain on the 1st to 4th day post-surgery in spite of the standard pain management protocol. about 30–55% of post abdominal surgery patients were still in moderate to severe pain on the 1st day, about 20–71% of post lower extremity surgery and 30–64% of post spinal surgery were still in moderate to severe pain on the 1st to 4th day.2 the inflammation responses to postoperative trauma may induce the neuroendocrine stress responses. the inflamed peripheral tissue produces cytokines, i.e. interleukin-1β (il-β), il-2, il-6 and tumor necrosis factors (tnf). the humoral signal induces the cyclooxygenase 2 (cox-2) activity and, therefore, prostaglandin synthesis in central nervous system (cns) which leads to sensitization. this cannot be inhibited effectively by regional anesthesia. however, the original article received: september 17, 2013 revised: january 25, 2014 accepted: april 10, 2014 :15–22 16 international journal of integrated health sciences. 2014;2(1) centrally-acting cox-2 inhibitor administration will reduce this activity.3 the circulation of the t-helper cell (th) is associated with cytokine expression. th1 cell is associated with immune cells, e.g. interferon γ (inf-γ), il-2 while th2 produces il-4, il-5 and il-10, which are associated with the immunosupression response. the balance of il-6 and il-10 is an important factor in the series of immune responses.4 the cox2 expression is stimulated by proinflammatory cytokine and inhibited by anti-inflammatory mediators, such as il-10 and il-4, through transformation growth factor-beta (tgf-beta).5 a study on preemptive analgesia by using epidural technique associated with pain score and the cytokine production proved that the use of epidural preemptive could reduce the pain score and production of il-1β, il-6, il-1ra.6 on the other hand, another research showed that epidural technique could only inhibit the neural line and could not inhibit the humoral line.7 the use of rofecoxib combination and spinal anesthesia on pelvic surgical operation showed reduction in il-6 and prostaglandin e2 (pge2) levels in cerebrospinal fluid (css), plasma, and wound side while tnfα dan il1β could not be detected both in plasma and css.8 a study on the effect of a single parecoxib administration on cytokine response, and stress response as well as the administration of ophthalmological postoperative analgesia showed significant decreases in il-6, il-8, cortisol adrenocorticotropic, and vas (p<0.001) compared to the control groups. there were no decreases in epinephrine and norepinephrine levels in both group.9 another study suggested that the use of multimodal analgesia with iv tramadol and iv flurbuprofen combination in thoracotomy postoperative pain management were able to reduce the pain score, il-6, and postoperative c-reactive protein (crp) compared to the pain score in the control groups. the tnf-α level was similar for both groups.10 epidural preemptive analgesia showed lower pro-inflammation/antiinflammatory cytokine ratio than the control groups, but the difference was not significant. this proved that epidural preemptive could not reduce central sensitization through the hormonal line.11 the effect of centrally-acting multimodal analgesia cox-2 inhibitor combined with epidural analgesia on immune response and pain intensity has not been studied extensively. hence, in order to improve our understanding, holistic studies are needed to examine the inflammation and anti-inflammatory cytokine level as well as the il-6/il-10 ratio in patients receiving 40 mg iv parecoxib and with 0.125% epidural bupivakain analgesic combination. methods this study was conducted in dr. wahidin sudirohusodo general hospital, makassar from april to july 2012 and was approved by the ethics committee of hasanuddin university makassar. all patients who met the inclusion criteria were consecutively enrolled. this study was performed using the clinical double-blind randomized case-control study design. male patients who underwent open reduction internal fixation elective surgical operation of lower hip fracture with epidural anesthesia and who met the following inclusion criteria, i.e. ps asa 1–2, 18–50 years of age, height more than 155 cm and normal bmi, were included in this table 1 demographic characteristics of patients variable group p value*) parecoxib (n=26) control (n=26) range mean±sd range mean±sd age 23–50 35.96±10.25 18–48 29.15±9.43 0.61 height 157–174 16.8 ±4.43 154–173 165.15± 5.51 0.53 bmi 20.20–24.38 21.93±1.38 20,01–24,80 21.18±1.36 0.36 duration of operation 100–175 141.73±20.73 100–175 139.61±25.33 0.57 consumption of local anesthesia 90–135 110.76±22.87 90–135 110.76±22.87 0.57 ps asa 1–2 1.00 1–2 1.00 0.81 multimodal analgesia effect on proinflammatory and anti-inflammatory cytokines serum :15–22 international journal of integrated health sciences. 2014;2(1) 17 study. patients who had contraindications for epidural catheter placement, history of allergy to study medicines, cardiovascular disease, renal failure, liver damage, signs of sirs, under nsaid less than 5 days before the procedure, and under corticosteroid were excluded. patients who experienced intraoperative complications, needed resurgery during observation period, needed blood transfusion, had non-optimal epidural anesthesia, and underwent more than 3-hour operative procedure were also excluded. samples were obtained using consecutive random method. fifty two patients were enrolled and divided into 2 groups, which was parecoxib group and control group. patients were given 5 mg alprazolam prior to the operation as the inclusion criteria met. epidural catheter insertion at the level of of l2–3 or l3–4 was done at the operation room. fourty milligrams intavenous parecoxib was given to the parecoxib group about 30 minutes prior to incision, while the control group were given 2 cc 0.9% nacl. bupivakain epidural anesthesia, 0.5% 1–2 ml/dermatome, was administered 30 minutes prior to the incision until the block reached t12-s2. during the procedure, patients were sedated with 25–100 µg/kg/minute iv propofol. after the procedure, both groups were given continuous 0.125% bupivacaine, 5 cc/hour, as the post-operative analgesia. blood samples was taken 2 and 24 hours after the procedure and the il-1β and il-6 serum levels were measured. the pain intensity was assessed using numeric rating score (nrs) and 3 ml of 0.125% bupivacaine was given when the nrs was more than 4/10. the human interleukin immunoassay quantikine hs serum (r & d system) was used to measure the cytokine level using the enzyme linked immunosorbent assay with elisa reader organon 680 (biorad) equipment. the collected data were then processed with spss 15.0 software for windows. data were examined using t test for characteristics of samples. the differences of variables between both groups were examined using mannwhitney u-test. the number of samples needed in each group were 26 (α=0.05 and power=0.8). differential test between variables in both groups was considered significant if p<0.05. data are presented in mean ±sd and minimummaximum/median. results demographic characteristics of both groups in age,height, body mass index, duration of operation, consumption of local anesthesia and asa between the two group, therefore the two group were considered homogenous (table 1). the difference of il-1β level between the parecoxib group and the control group was not statistically significant (p>0.05), both in preoperation and 24 hours post-operation levels. at two hours after the surgery, the il-1β level in parecoxib group was significantly different (p<0.05) from the control group (fig. 1). the il-6 average value in parecoxib group and control group was not significantly different in pre-operation (p>0.05) and 24 hours postoperation (p>0.05). however, based on the ob at 2 hours of post-operation, the parecoxib group showed a significantly lower level (p<0.05) than the control group (fig. 2). muhammad ramli ahmad, tatang bisri :15–22 fig. 1 serum interleukin -1β level le ve ls o f i l1β (p g/ m l) 18 international journal of integrated health sciences. 2014;2(1) interleukin 10 level in both groups increased at two hours post-operation and no significant difference was found between the level in the parecoxib group (4.46±3.51) and the control group (2.44 ±1.18) (p=0.028) (fig. 3). discussion interleukin -1β level interleukin-1β, which is a protein precursor, is produced by the macrophages and monocytes, known as non-immune cells, that is activated by fibroblast and endothelial cell during the occurence of tissue damage, infection, invasion and inflammation. it is now found that il-1β also appears on nociceptive neurons in the dorsal root ganglion. interleukin-1β contributes to the systemic inflammation through cox-2 activation to form pge2. the result of this study shows that the il-1β level in the parecoxib group decreased at 2 hours post-operation (p<0.05), which is significantly different from the control group. however, 24 hours after operation, the il-1β level in both groups decreased. another study combining spinal anesthesia and rofecoxib shows that the il-1β level was undetected in plasma and lcs at 1, 3, 9, and 24 hours after surgery, and was only found in fluid from the drain of the surgery side.8 a study on ophthalmological surgery shows that there was no significant difference (p>0.05) in il-1β level between groups with parecoxib and without parecoxib.9 in that particular study, the il-1β level showed a tendency to incline in both groups, with the parecoxib group showing less increase. multimodal analgesia effect on proinflammatory and anti-inflammatory cytokines serum :15–22 fig. 3 serum il-10 level ra tio il -1 β/ il -1 0 (p g/ m l) fig. 2 serum interleukin-6 level il -6 l e v e l ( p g /m l) international journal of integrated health sciences. 2014;2(1) 19 interleukin-6 level surgical procedures are associated with tissue damages that activate both local and systemic nociceptive and inflammatory responses. this is then followed by proinflammatory cytokine increases, including the il-6.8 the interleukin-6 as the proinflammatory cytokine plays major roles in the acute protein phase of the tissue damages resulting from surgical trauma. from all body responses to surgical trauma, the il-6 level is reported to be the sensitive indicator of surgical stress. the interleukin-6 concentration in a normal condition is usually low and may not be detected.10 after a trauma, the plasma il-6 concentration can be detected in 60 minutes and will reach its peak after 4–6 hours. it starts to decrease between 24–48 hours after the trauma; however, it can persist until 10 days. interleukin-6 is the most sensitive marker of tissue damages. the longer the il-6 persists in the plasma, the higher the post-operative morbidity will be.13 the results of control group in this study are in agreement with the theories about il-6. it is found that the il-6 level increased at the 2nd and 24th hour after surgery (p<0.05). this finding is in line with the findings in a study performed on patients who underwent a transabdominal hysterectomy procedure using epidural analgesia preemptive technique, which was followed by patient controlled epidural analgesia (pcea), where the il-6 level increased in the first 24 hours post-operation (p<0.03) but it was lower than pcea group (p<0.04).6 the il-6 dynamic in the control group is in line with the il-6 serum level dynamic in a study on patients who underwent lower extremity surgical operation with epidural preemptive technique.11 interleukin-6 will directly and indirectly affect the production of cox-2 and prostaglandin through il-1. it is presumed that il-6 can also activate the glia cell.13 it is stated that two pathways may be induced by peripheral inflammation. first, it induces the production and spread of cox2 and prostaglandin e synthase (pges) at the inflammation site, leading to the sensitization of nerves innervating the injured tissue by reducing their threshold and increasing their excitability. second, the humoral pathway will be induced by the peripheral inflammation and this will increase the production and spread of cox-2 in cns through nf-kβ by il-1β, tnf-α, and il-6.7 the results of this study show that the il-6 level in the parecoxib group decreased 2 hours after the surgery when it is compared to the presurgical value (p<0.05) and it increased again at 24 hours after surgery (p<0.05). in the control group, the il-6 level keeps increasing during 24 hours after the surgery. there is a statistically significant difference of il-6 level in both groups, particularly at two hours after the surgery (p<0.05). no significant difference in il-6 level between both groups before the surgery and 24 hours after surgery (p>0.05). these findings are presumably resulted from the inhibition of prostaglandin synthesis by parecoxib, which in turn affects the il-6 production. the interleukin-6 production is initiated by the pge2 receptor agonists. e-series prostaglandin receptors (ep) are the stimulated ep1 which enhances mobilization of calcium (ca) from extracellular to intracellular compartment, while ep2 and ep4 receptors as g-protein-coupled receptors activate the camp and nf-kβ level.14 recently, it is discovered that inflammation responses caused by surgical trauma cannot be muhammad ramli ahmad, tatang bisri :15–22 fig. 4 ratio il1β/il-10 ra ti o il -1 β/ il -1 0 (p g/ m l) 20 international journal of integrated health sciences. 2014;2(1) effectively inhibited merely by peripheral nerve inhibition or single neuraxial block. peripheral inflammation induces cox-2 spread and pges expression in cns. studies on animal subjects found that the proinflammatory cytokine, il-6, induces cox-2, both in the inflamed peripheral tissue and cns. in postoperative pain, il-6 is known as a major mediator that increases the cox-2 in the cns. new evidence has shown that parecoxib administration works centrally by inhibiting the cox-2; therefore, decreasing the expression of pge2. this is different from ketorolac since this agent inhibits the cox-2 peripherally.15 the results of this study support the findings in a study on preemptive analgesia that used 40 mg parecoxib adminitered intramuscularly before an ophthalmological surgery was performed under general anesthesia.9 it has been proven that the il-6 plasma level in early post-operation until 6 hours post-surgery decreases (p<0.05) compared to the control group but the difference of il-6 level at 24 hours after surgery is not significant compared to the control group.9 based on a previous study that used oral preemptive cox-2 inhibitor combined with spinal anesthesia in arthroplasty, it is found that the il-6 plasma experienced dynamic increases at the first 1, 3, 9, and 24 hours, and then decreases at 30 hours post-operation (p<0.05). overall, the il-6 level is lower than in the control group. this study is also supported with the measurement of pge2 plasma level, which decreases at all times of the postoperative assessment (p<0.05).8 the results of this study contradicts findings from a previous study that involved the use of iv cox-2 inhibitor in thoracotomy patients. in that study, the il-6 level in both study groups increased until 24 hours after the surgery and decreased after that point. however, the il-6 level in the treatment group was lower than in the control group (p<0.05).10 differences of il-6 dynamic in those studies may be caused by the use of different types of cox-2 inhibitors. the similarity found among these studies is that in the group receiving cox-2 inhibitor, the il-6 level is found to be lower than in the control group, although the il-6 increases at the first 24 hours after surgery. these findings show that the administration of cox-2 inhibitor has an effect on the il-6 dynamic and level. therefore, a suggestion is proposed that the administration of 40 mg iv parecoxib 30 minutes before a surgical incision can reduce and stabilize the il-6 level. from this, we can conclude that parecoxib affects the dynamic of il-6. interleukin-10 level the involvement of il-10 in pain is thought to be through the effect on pge2. the interleukin 10 can inhibit the production of prostaglandin (pg) from peripheral blood mononuclear cells which is stimulated by the proinflammation cytokine. anti-inflammatory cytokine increases after a trauma to maintain the balance between the anti-inflammation cytokine and the proinflammatory cytokines. the interleukin 10 also inhibits the production of pg through a feedback mechanism.17 results of this study show that the level of il-10 increases in both groups and the difference is not significant. this shows that epidural analgesia, with or without parecoxib, causes an anti-inflammatory action through il-10 response. this study is in line with multimodal analgesia effect on proinflammatory and anti-inflammatory cytokines serum :15–22 fig. 5 ratio il-6 to il-10 11 .5552 11.9324 8.0284 12.5217 6. 2561 7.4512 0 2 4 6 8 10 12 14 presurgery 2 ho urs p ostop 24 hou rs po stopr at io il -6 / il -1 0 (p g/ m l) co ntroll ed p arecoxib p=0.001 p=0.756 p=0.687 ra tio il -6 / i l10 (p g/ m l) international journal of integrated health sciences. 2014;2(1) 21 another study that found il-10 level increase after parecoxib administration.17 proinflammatory to anti-inflammatory cytokines ratio the balance between proinflammatory and anti-inflammatory cytokines are very important to maintain the homeostasis. in this study, the parecoxib group has lower il-6/il-10 and the il1β/il-10 ratios at the 2nd hour post-operation compared to control group. this shows that the administration of parecoxib has an effect on the systemic immune response. peak levels of antiinflammatory cytokine il-10 occurs two hours after the surgery and is higher in the parecoxib group. an increase in the ratio of il-6 to il-10 indicates a correlation with a poor outcome. this study has in line with the previous study.18 a different result is shown in an animal study in which the il-6 and il-10 levels decreases after parecoxib administration with poor outcome. multimodal analgesia the multimodal analgesia concept has been introduced more than a decade ago as a technique to increase the effect of analgesia and decrease unexpected incidences related to the use of opioid. the rationale for this strategy is the achievement of sufficient analgesia due to the additive or synergistic effects between different classes of analgesics.3 this method can decrease the dosage of each individual drug, thus decreasing the adverse effects from each drug used in surgical procedure. nowadays, the american society of anesthesiologist task force on acute pain management suggested the use of this multimodal analgesia.3,18,19 the use of multimodal analgesia technique aims to decrease the stress response caused by surgical operations, reduce the mobility pain, ease the body recovery after surgery and increase the clinical improvement as well as decreasing the side effects of medications.20 in conclusion, the combination of 40 mg of iv parecoxib and 0.125% bupivacaine epidural analgesia can change and stabilize the systemic immune response. this combination technique can also be used as a preventive multimodal analgesia to prevent chronic pains. further studies are needed to measure the change in prostaglandin level as a direct effect from cox2 inhibitor and also to observe patients’ clinical outcome. references 1. apfelbaum jl, chen c, mehta ss, gan tj. postoperatif pain experience: result from a national survey suggest postoperatif continues to be undermanage. anesth analg. 2003;97(2):534−40. 2. sommers m, rijkea jm, kleefa m, kesselsa agh, petersa ml, geurtsa j, et al. the prevalence of postoperative pain in a sample of 1490 surgical inpatients. eur j anaesthesiol. 2008;25(04):267−74. 3. buvanendran a, kroin js. multimodal analgesia for controlling acute postoperative pain. curr opin anaesthesiol. 2009;22:588−93. 4. mahdy am, galley hf, abdel-wahed ma, el-korny kf, sheta sa, webster nr. differential modulation of interleukin-6 and interleukin-10 by diclofenac in patient undergoing major surgery. br j anesth. 2002;88(6):797−802. 5. almaida jljd, jukemura j, coelho amm, patzina ra, machado mcc, cunha jemd. inhibition of cyclooxygenase-2 in experimental severe acute pancreatitis. clinics. 2006;6(4):301−6. 6. beilin b, bessler h, mayburd e, smirnov g, dekel a, yerdeni i, et al. effect of preemtive analgesia on pain and cytokine production in postoperative period. am societ anesth. 2003;98(1):151−5. 7. kawasaki t, ogata m, kawasaki ck, okamoto, sata t. effects of epidural anaesthesia on surgical stress-induced immunosuppression during upper abdominal surgery. br j anaesth. 2007;98(2):196– 203. 8. buvanandran a, kroin j, berger r, hallab n, saha c, negrescu c, et al. upregulated of prostaglandin e2 and interleukins in the central nervous system and peripheral tissue during and after surgery in humans. anesthesiology. 2006;104(3):403−10. 9. xu ll, shen jj, zhou hy. effects of parecoxib sodium preemtive analgesia on perioperative cytokine responses and stress responses in patients undergoing opthalmology surgery. chin j med gen. 2010;90(27):1893−6. 10. esme h, kesli r, apliogullari b, duran fm, yoldas b. effect of flurbiprofen on crp, tnf-α, il-6, and postoperative pain of thoracotomy. int j med sci. 2011;8(3):816−221. 11. ahmad mr. peran analgesia epidural preemtif terhadap intensitas nyeri, respon hemodinamik serta dinamika kadar sitokin proinflamasi dan muhammad ramli ahmad, tatang bisri :15–22 22 international journal of integrated health sciences. 2014;2(1) antiinflamasi pada pasca bedah ekstremitas bawah [desertation]. makassar: universitas hasanuddin; 2012. 12. beillin y, hossain s, bodian ca. numeric rating scale and labor epidural analgesia. anesth analg. 2003;109(3):943−50. 13. jun-hua z, yu-guang h. immune system: a new look at pain. chin med j. 2006;119(11):930−8. 14. hamza m, dionne ra. mechanisms of non-opioid analgesics beyond cyclooxygenase enzyme inhibition. curr mol pharm. 2009;2(1):1−14. 15. katz j, clarke h. preventive analgesia and beyond: current status. evidence, and future directions. in: rice as, justins d, newton t, howard rf, miaskowski ca, editors. clinical pain management. 2nd ed. london: hodder arnold; 2008. p. 154−91. 16. kim mh, hahm ts. plasma levels of interleukin-6 and interleukin-10 are affected by ketorolac as an adjunct to patient-controlled morphine after abdominal hysterectomy. clin j pain. 2001;17(1):72−7. 17. wu q, purusram g, wang h, yuan r, xie w, gui p, et al. effecacy of parecoxib on systemic inflammatory response assosiated with cardiopulmonary bypass during cardiac surgery. br j clin pharmacol. 2013;75(3):769−78. 18. white pf, sacan o, tufanogullari b, eng m, nuangchamnong n, ogunnaike b. effect of short term postoperative celecoxib administration on patient outcome after outpatient laparascopic surgery. can j anaesth. 2007;54(5):342−8. 19. fitzerald ga, patrono c. coxib, selective inhibitors of ciclooxygenase-2. n eng j med. 2001;345(6):433−42. 20. reuben s, buvanendran a. the role of preventive multimodal analgesia and impact on patient outcome. in: sinatra rs, leon-casasola oad, ginsberg b, viscusi er, mcquay h, editors. acute pain management. 1st ed. new york: cambridge university press; 2009. p. 172−83. multimodal analgesia effect on proinflammatory and anti-inflammatory cytokines serum :15–22 international journal of integrated health sciences. 2014;2(1) 23:23–9 original article correspondence: mintareja teguh, department of obstretics and gynecology, faculty of medicine, universitas udayanakarangasem hospital jl. ngurah rai no. 58, amlapura 80811, bali, indonesia e-mail: mintareja.teguh@gmail.com correlation between protein-with-molecular-weight-53 (p53), burkit cell lymphoma 2 (bcl2), and fas ligand (fasl) and vascular-cell-adhesionmolecule-1 (vcam-1) mrna expression levels in a pathogenesis study of preeclampsia abstract objective: to determine the role of protein-with-molecular-weight-53 (p53), burkit cell lymphoma 2 (bcl2), fas ligand (fasl) mrna, and vascular cell adhesion molecule 1 (vcam-1), known as the apoptosis-related molecular pathway, in preeclamptic patients. methods: observation on the correlation between the mrna levels of p53, bcl2 and fasl and vcam-1 in 31 subjects at 28-42 weeks gestational age was performed in this study using the real time reverse transcriptase-polymerase chain reaction (rt-pcr). results: the results showed that p53 mrna increased (>1.2350 ng/μl) in the preeclampsia group compared to the normal pregnancy group (p=0.010), bcl2 mrna was lower (≤0.9271 ng/μl) in the preeclampsia group than the control group (p=0.041). there was also a tendency of increased fasl mrna expression (>0.5509 ng/μl) in the preeclampsia group compared to the normal pregnancy group (p=0.300). the level of vcam-1 elevated (>890.08 ng/ml) in the preeclampsia group compared to the normal pregnancy group (p=0.001). in preeclampsia, the correlation between the bcl2/p53 ratio and vcam-1 was r=0.541 (p=0.002), whereas the correlation in normal pregnancy was r=0.099 (p=0.595). conclusions: there are correlations between the mrna expression levels of p53 and bcl2 as an intrinsic pathway of apoptosis along with the vcam-1 levels in the incidence of preeclampsia. however, no correlation is found between fasl mrna expression and the incidence of preeclampsia. keywords: bcl2, fasl, p53, preeclampsia, vcam-1 ijihs. 2014;2(1):23–9 mintareja teguh,1 made kornia karkata,2 firman fuad wirakusumah,3 johanes cornelius mose,3 mieke hemiawati satari,4 leri septiani3 1department of obstetrics and gynecology, faculty of medicine, universitas udayana-karangasem hospital 2department of obstetrics and gynecology, faculty of medicine, universitas udayana-sanglah hospital 3department of obstetrics and gynecology, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital 4faculty of dentistry, universitas padjadjaran introduction preeclampsia in pregnancy is characterized by blood pressure of ≥140/90 mmhg in two or more measurements which is accompanied by proteinuria (30 mg/dl) in two separate tests with a nominal measurement scale. there are three stages involved in the pathogenesis of preeclampsia: abnormal vascular remodeling of placenta, placental ischemia, and endothelial cell dysfunction.1 some previous studies have hypothesized that the causes of preeclampsia originally involve genetic, immunological, and other factors resulting in a failure in trophoblast proliferation and invasion. these factors lead to abnormal placental vascular remodeling and endothelial dysfunction, causing the syndrome of preeclampsia. protein-with molecular weight-53, or p53, protects cells against the deoxyribonucleic acid received: april 16, 2013 revised: june 12, 2013 accepted: april 10, 2014 24 international journal of integrated health sciences. 2014;2(1) (dna) damage.2 dna damage and hypoxia, which increases the phosphorylation of p53, occur when metabolic processes enhance the role of p53 and decrease murine double minute-2 protein (mdm-2) that will ultimately enhance the role of p53 in apoptosis.2–4 however, the biosynthetic mechanisms associated with p53 and apoptosis in pregnancy are not known.2,5 in the intrinsic pathway of apoptosis, the mitochondrial genes are primarily regulated by burkit cell lymphoma 2 (bcl2). tissue samples from patients with preeclampsia have shown that the expression of the antiapoptotic protein bcl2 is lower than that of patients with normal pregnancy. increased apoptotic activity in the placental bed of preeclampsia patients inhibits trophoblast invasion into the spiral artery.6 the ligand receptor pathway, or the extrinsic pathway, is mediated by cytokines such as the tumor necrotic factor alpha (tnfα) and fas ligand (fasl). fasl/fas plays an important role in protecting the fetus from the maternal immune system. in mouse experiments, fasl played a role to prevent changes in immune cell activation between the maternal-fetal surface. this showed a decreased expression of fasl on the surface of decidual leukocyte infiltration and enhanced placental fetal death.6,7 the number of markers indicating endothelial dysfunction increase in the blood or urine of preeclamptic women. most of these markers, including the vascular cell adhesion molecule 1 (vcam-1) and cellular fibronectin, increase during several weeks of pregnancy. placental ischemia occurs due to hypoxia, which is presumed to be related to the vascular endothelial damage. this condition is characterized by increased levels of vcam-1. increased levels of vcam-1 improve the regulation of the apoptotic caspase cascade. the apoptosis that occurs in preeclampsia may occur through the intrinsic and extrinsic pathways. the role of p53, bcl2, and fasl messenger ribonucleic acid (mrna) in apoptosis in preeclampsia and the uncertainty in which apoptotic pathway table 1 characteristic of research subjects variable group significance preeclampsia (n=31) control (n=31) x2/t p value maternal age (yrs.) 0.000 1.000*) <20 3 3 20–34 21 21 ≥35 7 7 mean 29.29 (7.98) 29.61 (7.40) median 18–45 18–44 gestational age (wks.) 1.409 0.600*) 28–32 1 0 33–37 8 8 38–42 22 23 mean 37.87 (1.56) 38.23 (0.88) median 31–40 37–40 parity 0.862 0.654*) 0–1 17 17 2–3 10 12 ≥ 4 4 2 bmi (kg/m2) 0.595 0.554**) mean 22.77 (2.93) 22.27 (3.66) median 15–31 18–29 bmi, body mass index; statistical test *)chi-square and **)independent t correlation between protein-with-molecular-weight-53 (p53), burkit cell lymphoma 2 (bcl2), and fas ligand (fasl) and vascular-cell-adhesion molecule-1 (vcam-1) mrna expression levels of in a pathogenesis study of preeclampsia :23–9 international journal of integrated health sciences. 2014;2(1) 25 mintareja teguh, made kornia karkata, et al. used have prompted further studies. this study aimed to determine the role of p53, bcl2, and fasl mrna and vcam-1 in preeclampsia. methods research subjects pregnant women who visited dr. hasan sadikin general hospital, as well as its teaching hospital network (cibabat hospital and astana anyar maternity hospital) at 28–42 weeks gestational age and who were diagnosed with preeclampsia (according to the protocol of the division of feto-maternal department of obstetrics and gynecology, dr. hasan sadikin general hospital, faculty of medicine, universitas padjadjaran, bandung, indonesia, 2008) served as the case group. to comply with the approval from the ethical committee of dr. hasan sadikin general hospital, informed consent was obtained from every single participant in this study. statistical calculations were obtained from a sample size of 31 patients for both the case and control groups from july 2009–april 2010. the specimens were taken from the placental tissue, immediately after the placenta was born. using tweezers and a scalpel, the placental tissue was cut approximately 2x2 cm in size and put in a sterile tube and received label for the rna expression inspection: p53, bcl2 and fasl in real time-polymerase chain reaction (pcr). the placental specimens were immediately frozen in liquid nitrogen, then stored in the freezer with a temperature of -80 °c until it was used. clinical examination the physical examination performed in this study included the general condition, weight, height, as well as a heart and lung examination. systolic and diastolic blood pressure were also measured after the patient rested for 15 minutes on her left side. the blood pressure was the average of two examinations performed at 5-minute intervals. determination of vcam-1 levels the levels of vcam-1 protein were determined in duplicate experiments by using the enzymelinked immunosorbent assay (elisa) with the human vcam-1 immunoassay kit (quantikine) in table 2 relationship between high-low expression of mrna; p53; bcl2 and fasl and the level of vcam-1 in preeclampsia variable group significance preeclampsia (=31) control (n=31) x2 p value or (95% ci) p53 (ng/µl) mean 1.18 (0.32) 1.08 (0.17) > 1.2350 13 4 6.565 0.000 4.87 (1.37–17.35) ≤ 1.2350 18 27 bcl2 (ng/µl) mean 0.84 (0.18) 0.95 (0.20) ≤ 0.9271 18 10 4.168 0.041 2.91 (0.92–9.43) > 0.9271 13 21 fasl (ng/µl) mean 0.69 (0.28) 0.64 (0.32) > 0.5509 21 16 1.072 0.300 0.51 (0.18–1.42) ≤ 0.5509 10 15 vcam-1 (ng/ml) mean 1077,63 (413.88) 823.99 (271.48) > 890.08 23 10 10.949 0.001 6.04 (2.01–18.17) ≤ 890.08 8 21 statistical, chi-square test; determination cut-off for p53, bcl2, fasl and vcam-1 based on receiver operating characteristics curve (roc) :23–9 26 international journal of integrated health sciences. 2014;2(1) table 3 multivariate analysis of risk factors relationship mrna expression; p53 and bcl2 and vcam1 levels with the incidence of preeclampsia based on multiple logistic regression analysis variable coefficient b se p value or (95% ci) p53 (ng/µl) 2.572 1.010 0.011 13.09 (1.81–94.70) bcl2 (ng/µl) 1.363 0.749 0.069 3.91 (0.90–16.98) vcam-1 (ng/ml) 2.820 0.809 < 0.001 16.77 (3.44–81.82) constant -2.646 accuracy of the model = 74.2% table 4 the correlation between mrna expression; p53 and bcl2 with vcam-1 levels in preeclampsia and normal pregnancy correlation group preeclampsia (n=31) control (n=31) r p value r p value p53 with vcam-1 -0.490 0.005 -0.415 0.020 bcl2 with vcam-1 -0.093 0.619 -0.201 0.278 ratio bcl2/p53 with vcam-1 0.541 0.002 0.099 0.595 accuracy of the model = 74.2% accordance with the manufacturer’s instructions (r & d systems inc., minneapolis, mn). the elisa kit is based on a solid phase sandwich elisa that consists of anti-vcam-1 polyclonal antibody and perioxidase conjugated anti-vcam-1 polyclonal antibody. the concentration of vcam-1 in each preparation was determined using the standard curve available. rna isolation and cdna synthesis total rna was extracted from fresh frozen sections with rneasy mini kit (qiagen, hilden, germany) in accordance with the instructions from the manufacture. the isolated rna quantity was measured by a nd-1000 spectrophotometer (nanodrop tech., wilmington, delaware). the template cdna was synthesized from 13.5 μg of total rna using the omniscript reverse transcriptase kit (qiagen), random primer (hexadeoxyribonucleotide mixture, takara, shiga, japan), and ribonuclease inhibitor (porcine liver, takara). total rna was reverse transcribed with 4 u of omniscript reverse transcriptase in 20 μl reaction volume (60 minutes at 37 °c, 5 minutes at 93 °c, and finally put on ice). resulting cdna samples were then stored at -30 °c until the analysis was performed. real time reverse transcriptase-polymerase chain reaction (rt-pcr) real-time rt-pcr analyses were performed using the abi prism 7000 sequence detection system (applied biosystems, foster city, ca). the standard reaction volume was 20 μl and the pcr kit used was go green master mix-taq (promega, madison), 5.0 μl of cdna template, and 4 μm of both forward and reverse primers. the initial step of pcr was pre-heated at approximately 95 °c for 3 minutes; denaturated for 39 cycles at 95 °c for 30 seconds, annealed at 55 °c for 1 minute, and extended at 72 °c for 1 minute with additional final extension at 72 °c for 10 minutes. the p53 fragment was 741 base pairs (bp). glyceraldehydes-3-phosphate dehydrogenase (gapdh) was used for normalization. the p53 fragment was isolated using 5’aga gtc tat agg ccc acc cc3’ forward primer and 5’gct cga cgc tag gat ctg ac3’ reverse primer following the reseach of ohtani.8 the bcl2 fragment was isolated using 5’gac aga aga tca tgc cgt cc3’ forward primer and 5’ggt acc aat ggc act tca ag3’, the bcl2 fragment was 76 bp, reverse primer based on the research by mbazima.9 the fasl fragment was isolated using 5’gca gcc ctt caa tta ccc at3’ forward primer and 5’cag agg ttg gac agg gaa gaa3’, the fasl fragment was 101 bp, reverse primer based on the research by das.10 data analysis the statistical analyses used were shapiro-wilk test, independent t test, chi-square test, anova correlation between protein-with-molecular-weight-53 (p53), burkit cell lymphoma 2 (bcl2), and fas ligand (fasl) and vascular-cell-adhesion molecule-1 (vcam-1) mrna expression levels of in a pathogenesis study of preeclampsia :23–9 international journal of integrated health sciences. 2014;2(1) 27 test, pearson’s correlation and the regression test (which is used to compare two groups of subjects or bivariate) as well as the multiple logistic regression test (multivariate). the data analysis was performed using spss ver. 13.0 at a 95% confidence interval (p≤0.05). results identification of preeclamptic subjects (n=31) were made based on preeclampsia clinical diagnosis which includes the presence of hypertension (>140/90 mmhg). normortensive pregnant women were included as the control subjects (n=31). the main clinical parameters include gestational age, body mass index, age, and parity (table 1). during the period of july 2009 and april 2010, a continuous series of 31 preeclamptic patients were studied. no significant differences were found between the preeclamptic and normal pregnancies in terms of gestational age, bmi, maternal age, and parity (table 1). therefore, the characteristics of both groups can be considered homogeneous and the results of subsequent examinations can be considered as comparable. based on the chi-square test, a significant correlation was seen between the incidence of preeclampsia and vcam-1(p=0.001), p53 mrna expression (p=0.010) and bcl2 mrna (p=0.041), whereas the fasl mrna expression showed no significant relationship with the incidence of preeclampsia (p=0.300) (table 2). multivariable tests were performed on variables that had a value of p<0.25 (table 3). multiple logistic regression analysis showed that the most dominant molecule associated with the incidence of preeclampsia was vcam1 (or=16.77), which indicates that the levels of vcam-1 are not normal, showing a 17-fold higher incidence risk for preeclampsia than the normal levels of vcam-1. this result shows that vcam1 is the most dominant risk factor in predicting the incidence of preeclampsia (p<0.001). for the preeclamptic group, there was a significantly negative correlation between the levels of p53 and vcam-1 (p=0.005 and r=0.490) which indicates a weak association. for the normal pregnancy group, there was a significantly negative correlation between p53 and higher levels of vcam-1 (p=0.0200 and r=0.415), indicating a weak association. there was a negative but statistically insignificant correlation between the levels of bcl2 and vcam-1 (p=0.093 and r=0.619) in the preeclamptic group, indicating that the power of the correlation is weak. for the normal pregnancy group, there was a negative correlation between the levels of bcl2 and vcam-1, but this correlation was not statistically significant (p=0.278 and r=0.201), indicating that the correlation is very weak (table 4). the correlation between the levels of bcl2/p53 ratio and vcam-1 in the preeclamptic group was significantly positive (p=0.002 and r=0.541) which indicates a weak relationship. in the normal pregnancy group, there was no significant positive correlation (p=0.595 and r=0.099), indicating that the strength of the correlation is very weak (table 5). discussion the symptoms of hypertension associated with preeclampsia is developed during pregnancy and disappear after birth. this condition suggested that the placenta plays an important role as a source of preeclampsia. there is growing evidence for the notion that the dysfunction of endothelial cells is the major contributor to preeclampsia. although the mechanism of the activation of endothelial dysfunction is already well understood, there is evidence suggesting that leukocytes play a role in this destructive process. endothelial dysfunction leads to increased levels of vcam-1 in the blood or urine of women with preeclampsia several weeks before and during pregnancy. the mean levels of vcam-1 in the preeclampsia group were higher (1,077.63 ng/ ml) than the controls (823.99 ng/ml), (p=0.006). vcam-1 indicates the presence of inflammation in preeclampsia. the inflammation results from endothelial damage; therefore, vcam-1 is a marker of endothelial damage.11 in our study, medium levels of vcam-1 (>890.08 ng/ml) were not significantly associated with preeclampsia (p=0.401). this result is understandable because there are many factors that trigger preeclampsia other than the endothelial damage. one of the factors that allegedly contribute to triggering the onset of preeclampsia is apoptosis as a result of placental hypoxia leading to placental ischemia. our study indicated that the levels of vcam-1 were high (>890.08 ng/ml) in 23 preeclampsia individuals (74.2%), compared to only 10 in the control group (32.3%), whereas 8 individuals (25.8%) of the preeclampsia case group and 21 individuals of the control group (67.7%) showed low levels of vcam-1 (<890.08 ng/ml). this result is consistent with the theory that placental ischemia plays a role in preeclampsia syndrome; whereas in preeclampsia, increased adhesion molecule expression in the maternal circulation and elevated levels of homocysteine are found. elevated level of vcam-1 is one of the mintareja teguh, made kornia karkata, et al. :23–9 28 international journal of integrated health sciences. 2014;2(1) characteristics of the endothelial dysfunction, resulting in a lack of uteroplacental perfusion. uteroplacental insufficiency leads to the release of free radicals and induces hypoxia. hypoxia is thought to cause the increased phosphorylation of p53 if there is an increased metabolic process at the level of the p53 gene and reduces the role of mdm-2, which will ultimately enhance the role of p53 in the apoptotic process. the relationship between p53 mrna expression and the incidence of preeclampsia was significant (p=0.010, table 2). these results are consistent with in vitro and in vivo models.6,12 the p53 gene protects cells against dna damage and plays a role in dna repair. the loss or inactivation of p53 would result in the disruption of genetic equilibrium. the relation between the level of bcl2 mrna expression and the incidence of preeclampsia (table 2) in this study was significant (p=0.041). this result is consistent with the theory that the pathway that is more involved in the hypoxic conditions in preeclampsia is the more dominant intrinsic pathway in which the expression of bcl2 decreased to induce apoptosis. it has been hypothesized that hypoxia would cause the loss of bcl2 and/or bcl-xl from the mitochondrial membrane and these proteins would be replaced by proapoptotic proteins, such as bak, bax and bim. our results on bcl2 are in agreement with the results from previous reports.13,14 the fasl/fas pathway is one of the body’s main pathways to control placental apoptosis. extrinsic pathways are thought to be the pathogenesis of preeclampsia. as reported by laskowska15, when apoptosis occurred in normal pregnancy, a more advanced stage of pregnancy was associated with a higher rate of apoptosis in placentas. in preeclamptic pregnancies, cd4+ t cells produce more th1 cytokines, such as il2, ifnα and tnfβ, which induce an increase in apoptosis. this result was shown by zou et al.16 who showed that a large concentration of ifnα induced the increased expression of fasl/ fas.16 the results of the multivariable analysis of the relationship between risk factors (table 3). the mrna expression levels of p53 and bcl2 and vcam-1 levels were associated with preeclampsia, and vcam-1 was the primary risk factor in predicting the incidence of preeclampsia (p< 0.001). the results of this study showed a significant negative correlation between the expression of p53 mrna and vcam-1 levels in both the preeclampsia and normal pregnancy groups. the possible absence of correlation between vcam1 and p53 may be due to many other factors that cause endothelial dysfunction in addition to vcam-1, such as ldl, icam1, pecam1 and von willebrand factor viii. it was reported on a study that a significant increase in icam1 expression but not vcam-1 expression was found in preeclampsia. this result is in contrast with reports by ohtani et al.8 who showed that icam1, vcam-1, e-selectin and pecam1 levels were significantly elevated in preeclampsia. it is possible that these results could explain the negative correlation between the expression of p53 and bcl2 mrna with vcam-1 levels. in summary, these results indicate a positive weak correlation between the bcl2/p53 ratio and higher levels of vcam-1 in the preeclamptic group. in the normal pregnancy group, there is a very weak positive correlation between the bcl2/ p53 ratio and higher levels of vcam-1. these results show that increases in the bcl2/p53 ratio will be followed by elevated levels of vcam1 in preeclampsia, in which the expression of p53 would affect the balance of bcl2 and bax, as an intrinsic pathway of apoptosis in the mitochondrial membrane and the occurrence of placental apoptosis resulting in hypoxia. hypoxia will increase the levels of free radicals that cause damage to endothelial cells which is characterized by increased levels of vcam-1. acknowledgements we thank prof. hiroyuki kuwano, md., phd., facs., from gunma university, japan; bethy s. hernowo, md., ph.d., ahmad faried, md., ph.d., and rizky abdulah, ph.d., from universitas padjadjaran, bandung; yelliantty from school of life science and technology, bandung institute of technology, indonesia, for fruitful discussions. references correlation between protein-with-molecular-weight-53 (p53), burkit cell lymphoma 2 (bcl2), and fas ligand (fasl) and vascular-cell-adhesion molecule-1 (vcam-1) mrna expression levels of in a pathogenesis study of preeclampsia :23–9 1. masuyama h, nakatsukasa h, takamoto n, hiramatsu y. correlation between soluble endoglin, vascular endotel growth factor receptor-1, and adipocytokines in preeclampsia. j clin endocrinol metab. 2007; 92(7):2672–9. 2. savion s, lepsky e, orenstein h, carp h, shepshelovich j, torchinsky a, et al. apoptosis in the uterus of mice with pregnancy loss. am j reprod immunol. 2002;47(2):118–27. 3. hat b, lipniacki t. single cell experiments and modelling of p53/mdm2 pathway. proceedings of 23rd ifip tc 7 conference on system modelling international journal of integrated health sciences. 2014;2(1) 29 and optimization; 2007 july 23–27; cracow. poland. poland: ifip; 2007. 4. zhang z, wang h, li m, rayburn e, agrawal s, zang r. novel mdm2 p53-independent funtions identified through rna silencing technologies. ann n y acad sci. 2005;1058: 205–14. 5. kundaje a, eisenman s. modelling of the p53 pathway to cell cycle arrest and apoptosis: relevance to cancer. in: bower jm, bolouri h, editors. computational modeling of genetic and biochemical networks. seattle: a bradford book; 2001. p. 1–19. 6. levy r. the role of apoptosis in preeclampsia. isr med assoc j. 2005;7(3):178–81. 7. haupt s, berger m, goldberg z, haupt y. apoptosis p53 network. j cell sci. 2003;116(pt 20):4077–85. 8. ohtani s, kagawa s, tango y, umeoka t, tokunaga n, tsunemitsu y, et al. quantitative analysis of p53-targeted gene expression and visualization of p53 transcriptional activity following intramural administration of adenoviral p53 in vivo. mol cancer ther. 2004;3(1):93–100. 9. mbazima vg, mokgotho mp, february f, ress djg, mampuru lj. alteration of bax-to-bcl2 ratio modulates the anticancer activity of methanolic extract of commelina benghalensis (commlinaceae) in jurkat t cells. afr j biotechnol. 2008;7(20):3569–76. 10. das h, koizumi t, chakraborty s, ichimura t, hasegawa k, nishimura r. quantitation of fas and fasligand gene expression in human ovarian, cervical and endometrial carcinomas using real-time quantitative rt-pcr. br j cancer. 2000;82(10):1682–8. 11. kim sy, ryu hm, yang jh, kim my, ahn hk, lim hj, et al. maternal serum levels of vcam-1, icam-1 and e-selectin in preelampsia. j korean med sci. 2004;19(5):688–92. 12. pham td, maclennan nk, chiu ct, laksana gs, hsu jl, lane rh. uteroplacental insufficiency increases apoptosis and alters p53 gene methylation in the full-term iugr rat kidney. am j physiol regul integr comp physiol. 2003;285(5):r962–70. 13. difederico e, genbacev o, fisher sj. preeclampsia is associated with widespread apoptosis of placental cytotrophoblasts within the uterine wall. am j pathol. 1999;155(1):293–301. 14. nomura k, saito s, ide k, kamino y, sasahara h, nakamoto t, et al. caffeine suppresses the expression of the bcl2 mrna in bewo cell culture and rat placenta. j nutr biochem. 2004;15(6):342– 9. 15. laskowska m, leszczynska-gorzelak b, oleszczuk j. maternal and umbilical soluble fas concentration in normotensive and preeclamptic pregnancies. inter j gynecol obstet. 2005;89(1):45–6. 16. zou gm, reznikoff-etievant mf, hirsch f, milliez j. ifn-γ induced apoptosis in mouse embryonic stem cells, a putative mechanism of its embryotoxicity. develop. growth differ. 2000;42(3):257–64. mintareja teguh, made kornia karkata, et al. :23–9 international journal of integrated health sciences. 2014;2(1) 9:9–14 original article tyt curve: pilot study on alternatives standards of reference to determine intrauterine growth in low resource setting in indonesia correspondence: yessika adelwin natalia, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital jl. pasteur no. 38, bandung, indonesia e-mail: yessika.adelwin@yahoo.com abstract objective: to develop a new intrauterine growth curve based on local population for accurate intrauterine growth retardation (iugr) infant identification. methods: an observational analytic method was applied to develop tina-yessikatetty (tyt) curve derived from 13,405 neonatal anthropometric measurements taken from the medical record database of dr. hasan sadikin general hospital, bandung, indonesia. the infants included in this study were born during the period of january 1st, 2005 to december 31st, 2009. the new curve was then compared to the lubchenco and alisjahbana curves. only 6,814 data met the inclusion and exclusion criteria. results: the mean birth weight in this study was lower compared to that of the lubchenco and alisjahbana studies. comparison of the three curves showed that there was a significant difference among the three curves (r=0.998, r2=0.996, p<0.001), which indicates a probability for a new newborn classification. conclusions: tyt curve may be used as an alternative to identify iugr immediately after birth, especially when detection during pregnancy is not available in low resource setting. a prospective study with a larger population is needed; however, this study has provided an evidence to support the need for timely evaluation for such growth chart as they change over time. keywords: alisjahbana curve, intrauterine growth, lubchenco curve, tyt curve ijihs. 2014;2(1):9–14 tina dewi judistiani,1 tetty yuniaty,2 yessika adelwin natalia3 1department of epidemiology and biostatistics, faculty of medicine, universitas padjadjaran 2department of child health, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital 3faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital introduction infant mortality is still considered to be one of the major health problems in indonesia. in 2010, data from statistics indonesia show that the infant mortality rate (imr) in this country was 26.89 per 1000 live births in 2010.1 this rate is higher than the rate targeted in the millenium development goals (mdgs), which is 23 per 1,000 live births by year 2015.2 infant deaths related to low birth weight comprised around 11.5% from all births, mainly caused by intrauterine growth restriction (iugr) with a prevalence of about 4.4%.3–7 the iugr was also considered to be responsible for 26% of stillbirths and may increase infant mortality and morbidity by 7 to 8 times.8 some iugr related morbidities are also found later in life such as hypertension, coronary heart disease, diabetes mellitus type 2, obesity, osteoporosis, and metabolic syndrome.8–14 for that reason, iugr prevention, early detection, and appropriate management are required, which starts with the intrauterine growth evaluation.15 the gold standard for iugr diagnosis is serial ultrasonography throughout pregnancy, but it is not evenly accessible to all patients.6,16 an indirect method by plotting newborns anthropometric measurement into a growth curve is considered more suitable for use in population, providing that the intrauterine growth curve is kept ‘current’. the lubchenco curve is still used as the standard in indonesian hospitals. this curve was developed in american population, which leads to a situation where the genetic differences may inhibit its suitability to be used for other population.17,18 many researchers kept updating intrauterine growth curve for their population, including those in united states, which is the country of origin of received: march 4, 2013 revised: may 27, 2013 accepted: april 10, 2014 10 international journal of integrated health sciences. 2014;2(1) the lubchenco curve.19–21 alisjahbana et al.22 had developed an intrauterine growth curve for the indonesian population.23 since the curve was dated in 1994, the changes in fetal growth rate may limit its suitability for current use. therefore, consequently, a new curve should be developed based on our population. therefore, this study aimed to develop a new intrauterine growth curve based on our population to make identifications of iugr babies more appropriate. methods data for this study were retrieved from the child health department and obstetrics department of dr. hasan sadikin general hospital, bandung for the anthropometric measurement and maternal complications, respectively, during the period of january 1st, 2005 to december 31st, 2009. dr. hasan sadikin general hospital, bandung is the top referral hospital in west java; therefore, the subjects came from surrounding areas in west java. inclusion criteria were live birth, singleton pregnancy, and precise menstrual period of the mother. the exclusion criteria were gestational age less than 34 weeks and/or more than 42 weeks, since data from these gestational age periods were not available in any of lubchenco or alisjahbana studies. infants with congenital defect, maternal iugr-related complication of pregnancy such as hypertension, tuberculosis, diabetes mellitus, hepatitis b infection, cardiac defect, anemia, and high fever. cases with missing data were also excluded. the gestational age was calculated from the tyt curve: pilot study on alternatives standards of reference to determine intrauterine growth in low resource setting in indonesia :9–14 table 1 study subjects characteristics criteria male female both n % n % n % live birth 3,610 53.0 3,204 47.0 6,814 100 gestational age (weeks) 28–36 335 4.3 294 4.9 629 9.2 37–42 3,275 42.7 2,910 48.1 6,185 90.8 birth weight (grams) <1,000 0 0 0 0 0 0 1,000–2,499 355 5.2 367 5.4 722 10.6 2,500–3,999 3,206 47.1 2,819 41.4 6,025 88.4 ≥4,000 49 0.7 18 0.3 67 1.0 table 2 male birth weight percentiles by gestational age ga n 10 th percentile 25th percentile 50th percentile 75th percentile 90th percentile mean sd 34 68 1,632 1,750 1,935 2,300 2,786 2,371 530.7 35 105 1,723 1,900 2,200 2,450 2,858 2,523 506.0 36 162 1,942 2,100 2,459 2,750 3,135 2,786 508.9 37 393 2,250 2,400 2,630 2,900 3,250 2,941 438.7 38 678 2,330 2,500 2,750 3,013 3,275 3,011 387.7 39 897 2,418 2,600 2,850 3,125 3,400 3,127 405.4 40 830 2,500 2,656 2,900 3,200 3,488 3,187 398.7 41 322 2,600 2,730 2,994 3,220 3,470 3,223 367.9 42 158 2,499 2,600 2,904 3,200 3,450 3,185 400.8 international journal of integrated health sciences. 2014;2(1) 11 maternal first day of the last menstrual period to the date of birth. scattered plot graphics for every newborn were then further developed to create the tina-yessika-tetty (tyt) curve model. the mean birth weight was calculated for each gestational age group and sex. identification of iugr based on the three curves under study was then carried out. results there were 13,405 newborns recorded during the selected period consisting of 7,067 male and 6,338 female newborns. exclusion from this study were done for the following reasons: 51 cases of missing data, 754 stillbirths, 2 infants with sexual ambiguity, 522 with uncertain maternal last menstrual period, 540 multiple gestations, 2,000 cases of possible congenital anomalies, and 2,111 cases of iugr-related maternal complications leading to a total inclusion of 7,425 newborns, i.e. 3,924 male and 3,501 female infants. outliers during statistical analysis were ruled out leading to 6,814 clean data (50.83% of original data) with 3,610 male infants (52.98%) and 3,204 female infants (47.02%). the characteristics of the subjects show that most of the newborns had a gestational age of 37 to 42 weeks and a weight of between 2,500 and 3,999 grams (table 1). the 10th, 25th, 50th (median), 75th, and 90th percentile as well as the mean and sd birth weights for male, female, and both sex infants are presented (table 2, 3, and 4). a final weightfor-gestational age curves for female and male infants were then created (fig. 1). the crude curves show some “bumps” in several percentiles, leaving some assumptions that some truly term births are misclassified at these gestational ages. the tyt curve was compared to lubchenco and alisjahbana curves. the comparison of mean birth weight for each curve is presented (fig. 2). generally, the tyt study curve had lower average weights for each gestational age compared to the lubchenco curve except for 34– 37 weeks. compared to the alisjahbana curve, the tyt curve also generally had lower average weights except for 37–39 weeks. the curve model estimation showed that the appropriate model was the quadratic regression model. for the lubchenco curve, the formula to estimate birth weight is -21043.733 + 1134.926 x ga 13.208 x ga2 (r2= 0.992, p<0.001) while for alisjahbana curve the formula is -4661.533 + 317.166 x ga 3.067 x ga2 (r2= 0.968, p>0.05). tyt study curve formula to estimate birth weight is -24852.567 + 1365.165 x ga 16.635 x ga2 (r2= 0.996, p<0.001). after all data were plotted into the tyt study curve, a significant difference among the three curves was found (fig. 3). discussion the differences of the ‘normal’ standard of reference birth weight per gestational age and sex between the tyt, lubchenco, and alisjahbana curves support the need for updated gestational age and gender-specific growth curves for certain population. the three curves used quite a reasonable tina dewi judistiani, tetty yuniaty, et al. :9–14 table 3 female birth weight percentiles by gestational age ga n 10 th percentile 25th percentile 50th percentile 75th percentile 90th percentile mean sd 34 66 1,332 1,578 1,926 2,243 2,563 2,243 510.7 35 96 1,799 2,099 2,309 2,683 3,040 2,654 461.9 36 132 2,100 2,215 2,400 2,630 2,963 2,685 389.8 37 311 2,084 2,254 2,500 2,765 3,090 2,803 438.9 38 574 2,359 2,463 2,664 2,915 3,236 2,951 386.6 39 814 2,425 2,550 2,770 3,000 3,300 3,036 390.1 40 736 2,450 2,575 2,800 3,075 3,335 3,084 389.5 41 338 2,405 2,598 2,850 3,100 3,393 3,109 395.5 42 141 2,500 2,657 2,838 3,040 3,318 3,083 358.2 12 international journal of integrated health sciences. 2014;2(1) tyt curve: pilot study on alternatives standards of reference to determine intrauterine growth in low resource setting in indonesia :9–14 sample size of more than 5,000 births in each study. the lubchenco curve offers advantages over the alisjahbana curve due to a reasonable small grid increments (i.e., weekly for ga; every 200 g of weight; percentiles (versus sds from mean)) for easier interpretation. the alisjahbana curve offers superiority in terms of data sources that was retrieved from 14 hospitals in indonesia. there are similar drawbacks found in the three studies. first, there are possible errors in the gestational age calculation. to get more accurate gestational age, ultrasonography can be perfomed during the first trimester. second, the limited population at dr. hasan sadikin general hospital due to the fact that most patients came from west java makes this curve may not be appropriate for the whole indonesian population. prospective, multicenter research is needed to represent all indonesian populations, especially from centers where ultrasonography is available. the use of the tyt curve value to determine intrauterine growth should be assessed in larger population. it is concluded from this study that the new gender-specific intrauterine growth curves created will provide clinicians with an updated tool for the assessment of newborn intrauterine a. male b. female tyt study curve (gender specific and combined). tyt study curve for: (a) male infants, (b) female infants, (c) both sex fig. 1 c. combined 10th percentile 25th percentile 50th percentile 75th percentile 90th percentile 10th percentile 25th percentile 50th percentile 75th percentile 90th percentile 10th percentile 25th percentile 50th percentile 75th percentile 90th percentile gestational age (weeks) gestational age (weeks) gestational age (weeks) international journal of integrated health sciences. 2014;2(1) 13 tina dewi judistiani, tetty yuniaty, et al. :9–14 growth status in west java. we strongly suggest nation-wide research using ultrasonography to assess gestational age more accurately starting in the first trimester. acknowledgements we thank dr. hadiyana sukandar, drs., msc for the statistical assistance. references 1. badan pusat statistik. perkembangan beberapa indikator utama sosial-ekonomi indonesia. jakarta: statistics indonesia; 2010. 2. badan perencanaan pembangunan nasional (bappenas). laporan pencapaian tujuan pembangunan milenium di indonesia 2010. jakarta: 2010. 3. badan penelitian dan pengembangan kesehatan. comparison of quadratic regression curve of mean birth weight from lubchenco, alisjahbana, and tyt study curve fig. 3 gestational age (weeks) comparison of mean birth weight for each gestational age from lubchenco, alisjahbana, and tyt study curve fig. 2 gestational age (weeks) 14 international journal of integrated health sciences. 2014;2(1) tyt curve: pilot study on alternatives standards of reference to determine intrauterine growth in low resource setting in indonesia :9–14 laporan hasil riset kesehatan dasar (riskesdas) nasional. 2007 [cited 2013 october 19]. available from: http://www.litbang.depkes.go.id/bl_ riskesdas2007. 4. world health organization. nutrition landscape information system country profile indicators interpretation guide 2010. [cited 2013 october 19]. available from: http://www.who.int/ nutrition/nlis/en/. 5. united nations children’s fund. child info: monitoring the situation of children and women statistics by area child nutrition low birth weight. 2009 [updated november 2009; cited 2010 october 19]. available from: http://www. childinfo.org/low_birthweight_table.php. 6. cunningham fg, leveno kj, bloom sl, hauth jc, gilstrap lci, wenstrom kd. williams obstetrics. 22nd ed. new york: mcgraw-hill; 2005. 7. ross mg, mansano rz. fetal growth restriction. 2010 [updated 2013 may 8; cited 2013 october 19]. available from: http://www.emedicine. medscape.com/article/261226. 8. pasaribu hp. pertumbuhan janin terhambat. medan: 2009 [cited 2013 october 19]. available from: http://repository.usu.ac.id/bitstream/123 456789/6466/1/09e00704.pdf. 9. gluckman pd, hanson ma, cooper c, thornburg kl. effect of in utero and early-life conditions on adult health and disease. n engl j med. 2008;359(1):61–73. 10. kensara oa, wootton sa, phillips di, patel m, jackson aa, elia m. fetal programming of body composition: relation between birth weight and body composition measured with dual-energy x-ray absorptiometry and anthropometric methods in older englishmen. am j clin nutr. 2005;82(5):980–7. 11. elia m, betts p, jackson dm, mulligan j. fetal programming of body dimensions and percentage body fat measured in prepubertal children with a 4-component model of body composition, dualenergy x-ray absorptiometry, deuterium dilution, densitometry, and skinfold thicknesses. am j clin nutr. 2007;86(3):618–24. 12. hemachandra ah, howards pp, furth sl, klebanoff ma. birth weight, postnatal growth, and risk for high blood pressure at 7 years of age: results from the collaborative perinatal project. pediatrics. 2007;119(6):e1264–70. 13. shankaran s, das a, bauer cr, bada h, lester b, wright l, et al. fetal origin of childhood disease: intrauterine growth restriction in term infants and risk for hypertension at 6 years of age. arch pediatr adolesc med. 2006;160(9):977–81. 14. rueda-clausen cf, morton js, davidge st. effects of hypoxia-induced intrauterine growth restriction on cardiopulmonary structure and function during adulthood. cardiovascular research. 2009;81(4):713–22. 15. world health organization expert committee on the use and interpretation of anthropometry. physical status: the use and interpretation of anthropometry. geneva, switzerland: world health organization; 1995. 16. decherney ah, nathan l, goodwin tm, laufer n, editors. current diagnosis & treatment obstetrics & gynecology. 10th ed. new york: mcgraw-hill; 2007. 17. lubchenco lo, hansman c, dressler m, boyd e. intrauterine growth as estimated from liveborn birth-weight data at 24 to 42 weeks of gestation. pediatrics. 1963;32(5):793–800. 18. lubchenco lo, hansman c, boyd e. intrauterine growth in length and head circumference as estimated from live births at gestational ages from 26 to 42 weeks. pediatrics. 1966;37(3):403– 8. 19. kramer ms, platt rw, wen sw, joseph ks, allen a, abrahamowicz m, et al. a new and improved population-based canadian reference for birth weight for gestational age. pediatrics. 2001;108(2):e35. 20. olsen ie, groveman sa, lawson ml, clark rh, zemel bs. new intrauterine growth curves based on united states data. pediatrics. 2010;125(2):e214–24. 21. fenton tr. a new growth chart for preterm babies: babson and benda’s chart updated with recent data and a new format. bmc pediatr. 2003;3(1):13. 22. alisjahbana a, chaerulfatah a, usman a, sutresnawati s. anthropometry of newborn infants born in 14 teaching centers in indonesia. paedtr indones. 1994;34:62–123. 23. mandruzzato g, antsaklis a, botet f, chervenak fa, figueras f, grunebaum a, et al. intrauterine restriction (iugr). j perinat med. 2008; 36(4):277–81. international journal of integrated health sciences. 2014;2(1) 1:1–8 gonorrhoea infection prevalence in human immunodeficiency virus positive patients based on polymerase chain reaction examination introduction gonorrhea is the second most common sexually transmitted infection (sti) in the united states and it infects more than 700,000 people per year with an equal ratio between male and female.1 it was stated by the united nations joint program on human immunodeficiency virus/acquired immunodeficiency syndrome (unaids) that the gonorrhea prevalence in the general population in indonesia was 20 to 31% in 2004.2 meanwhile, data from 2007 integrated biological and behavioral surveillance (ibbs) on the prevalence of stis in female sexual workers (fsws) in indonesia show that the prevalence of gonorrhea ranged between 16% and 44%, with the highest incidence found in west java.3 established diagnosis of gonorrhea infection is made through neisseria gonorrhoeae (n. gonorrhoeae) identification in the genital tract, rectal, pharyngeal, and ocular secretion, which can be done using several methods, such as microscopic examination, culture, and molecular techniques.1,4–6 polymerase chain reaction (pcr) examination is one of the molecular techniques with a higher sensitivity, from 90–100%, than culture technique which has 68% sensitivity.4–7 this technique has been stated to replace the culture technique, including for asymptomatic patients.7 human immunodeficiency virus (or referred to as hiv) infection causes an immunosuppressed condition that could increase the number of stis and lead to greater co-diagnosis condition.8,9 people with active stis are more prone to hiv infection, and vice versa. hiv positive patients who are exposed to stis also have a greater risk to transmit hiv.9 some epidemiological data have suggested that gonorrhea contributes to abstract objective: to determine the prevalence of gonorrhoea infection in male and female hiv positive patients based on polymerase chain reaction (pcr) examination at the teratai clinic, dr. hasan sadikin general hospital bandung. methods: this study was conducted in july, 2012 at the teratai clinic, while the pcr examination was performed at the molecular biology laboratory of microbiology department, faculty of medicine, universitas padjadjaran, bandung. this was a cross-sectional observational study. the subjects were 81 hiv positive patients who were taken in consecutive admission. they underwent history taking and physical examination. samples were taken from urethral swab in males and cervical swab in females for pcr examination. results: the pcr examination result was positive for gonorrhea in 36% subjects. from all male subjects participating in the study, 37% were positive while 33% of the female subjects were also positive for gonorrhea. conclusions: the prevalence of gonorrhoea infection in male and female hiv positive patients at the teratai clinic, dr. hasan sadikin general hospital bandung is quite high, i.e 37% and 33%, respectively. keywords: gonorrhoea, human immunodeficiency virus, polymerase chain reaction, prevalence ijihs. 2014;2(1):1–8 received: january 4, 2013 revised: april 7, 2013 accepted: april 10, 2014 diah puspitosari,1 asmaja soedarwoto,2 dendi sandiono,2 feilicia henrica teja,1 rini rasianti,1 rasmia rowawi,2 rahmatdinata,2 tony djajakusumah2 1faculty of medicine, universitas padjdajaran-dr. hasan sadikin general hospital 2department of dermatology and venereology, faculty of medicine, universitas padjajaran-dr. hasan sadikin general hospital correspondence: diah puspitosari, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital jl. pasteur no. 38, bandung, indonesia e-mail: diahpoppy@gmail.com original article 2 international journal of integrated health sciences. 2014;2(1) increased hiv transmission.10 the frequency of mucosal hiv increases by 32–41% in gonorrhea patients and its transmission risk increases to approximately 2–5 times higher.11–14 several factors that contribute to the increase of hiv infection are hiv-infected cell withdrawal in the genital tract as a part of the immune response and cluster of differentiation, in this case the cd4, lymphocyte stimulation that will eventually lead to increased replication of hiv.12 from the immunology perspective, the presence of gonorrhea increases hiv shedding on the genital tract which attracts cd4 t lymphocytes as a part of the inflammatory response against patogen.10,11,15 in addition to the viral sheddings, the fact that some people with hiv and aids are still engaged in some high risk sexual behaviors becomes the key factor in sti co-infections, including gonorrhea, with hiv and aids.16–20 sexually transmitted infections in people with hiv suggest the possibility that these people may still be engaged in risky sexual behaviors. these infections could be a risk factor for hiv transmission to uninfected population.16 other studies also support this.9,17 manning et al.18 revealed that high-risk sexual practices still occur among some segments of hiv positive population. to decrease associated morbidity and prevent the secondary spread of hiv and stis, prevention efforts should focus on hiv positive patients who are still engaged in highrisk sexual practices. thus, data regarding gonorrhea infection in people with hiv are critical for the prevention, screening, and treatment of hiv to reduce hiv transmission.16,19 however, until recently, data on sti prevalence, including data on asymptomatic gonorrhea in individuals with hiv positive, are still limited.3,10,21 until now, there are still limited numbers of publication available on the prevalence of gonorrhea infection among hiv positive patients in indonesia; therefore this study aimed to determine the prevalence of gonorrhea infection in male urethra and female cervix of hiv positive patients based on pcr examination results in teratai clinic, dr. hasan sadikin general hospital, bandung. methods this study is a cross-sectional observational study performed to 81 hiv positive patients who visited teratai clinic, dr. hasan sadikin general hospital bandung, indonesia. the subjects were taken in consecutive admission in july 2012. the hiv serostatus of the study population had already been determined and confirmed based on the procedures stated in the national guideline for hiv before the study. sexually active hiv positive patients attending teratai clinic were offered to participate in this study. fourty eight males and 33 females were enrolled after signing written informed consent. women having her menstrual period were excluded from the study. the subjects underwent history taking and physical examination. sample was collected from urethral swab in male and cervical swab in female for pcr examination. comprehensive data on patient’s characteristics and sexual history were obtained through history taking and medical records. the history taking, clinical examination, and specimens collections were performed in teratai clinic while the specimen processing was conducted at the biology molecular laboratory, microbiology department, faculty of medicine, universitas padjadjaran, bandung. the protocol of this study was reviewed and approved by the ethical committee of the faculty of medicine of universitas padjadjarandr. hasan sadikin general hospital, bandung. specimen collection kits (roche) was used for urethral swab for male patients and endocervical swab for female patients. transport medium tubes (roche) were used for transporting the specimens to the laboratory on the day of the collection. immediately after arrival at the laboratory, the urethral and endocervical swab specimens were prepared for the pcr assay as instructed by the manufacturer, kept frozen at -20 °c, and analyzed within 14 days of sampling. transport medium tubes were thoroughly mixed and 100 ml was withdrawn and diluted to 1 ml with sucrose-phosphate medium. after that, 1 ml of swab specimen diluent (f. hoffmann-la roche ltd., basel, switzerland), was added and the prepared specimens were frozen at -20 °c for pcr. the pcr assay was accomplished using roche ct/ng amplicor pcr kit and the amplification process was conducted by using a thermocycler machine. roche ct/ng amplicor pcr kit for n. gonorrhoeae (roche moecular system, inc., brancburb, usa) is a qualitative in vitro test for the detection of n. gonorrhoeae dna in urine from symptomatic and asymptomatic males and in endocervical swab specimen from symptomatic and asymptomatic females as evidence of n. gonorrhoeae infection. n. gonorrhoeae dna is detected by pcr amplification of target dna and by hybridization capture of amplified target. after the amplification, the amplified nucleotide sequences were detected using an enzyme immunoassay and the a450s were then gonorrhoea infection prevalence in human immunodeficiency virus positive patients based on polymerase chain reaction examination :1–8 international journal of integrated health sciences. 2014;2(1) 3 measured with a spectrophotometer (multiskan; labsystems ltd., findland). as stated in the operator’s manual for the amplicor analyzer, the results were seen in the print out for the flags. interpretation of the results is as follow: positive result for n. gonorrhoeae is confirmed if the value of the examination materials >3.5 and a negative result is confirmed if the value of the examination materials <0.2. the results were calculated by statistic test spss 17.0 and presented descriptively by percentage. results subjects of the study were 81 patients averaging 32.8 years old with the youngest age was 23 years old and the oldest was 62 years old (data not shown). table 1 shows the characteristics of subjects by sex, education level, occupation, and marital status. the most frequently found characteristics of the subject were male gender (59%), high school education (51%), selfemployed (43%), and married (57%). we can see that of the 81 subjects, 29 people (36%) gave positive results and 52 subjects (64%) were negative (table 2). the average age of subjects with pcr positive result for n. gonorrhoeae in this study was 32 years old with the youngest being 23 years old and the oldest being 62 years. meanwhile, for the subjects with negative pcr results, the average age was 33 years old with the youngest was 23 years old and the oldest was 44 years old (data not shown). based on sex, 18 males (37%) and 11 females (33%) had positive pcr result for n. gonorrhoeae while 30 males (62%) and 22 females (67%) were negative (table 3). fifteen subjects with positive n. gonorrhoeae pcr results were self-employed. a total of nine subjects were merchants, two of the subjects were the owner of a beauty parlour, and the others were owner of a bike shop, a tattoo shop, an eo, and a catering company. of the seven subjects with positive pcr results who worked as private employees, two subjects were hotel employees, two were salesmen, one was a social worker, and the others were private employees of unknown companies. as many as 30% unemployed subjects showed positive results and 70% were negative. subjects who worked as commercial sexual workers and students gave negative pcr results. most of the subjects were married. among subjects with positive pcr result, 14 of them were married, 9 were single, and 6 were widows or widowers. data show that the subjects with positive pcr result for n. gonorrhoeae had their first sexual intercourse at an average age of 19.5 years, while the average age of the subjects with a negative pcr result were 21.3 years. most of the subjects in this study were heterosexual. the majority of subjects with homosexual orientation (60%) showed gonorrhea infection. of the 29 subjects with positive pcr results, as many as 23 subjects were heterosexual, 3 subjects were homosexual, and 3 subjects were bisexual (table 4). table 1 the baseline characteristics of participants variabel n % sex male 48 59 female 33 41 education no formal education 0 0 primary school 4 5 junior high school 4 5 senior high school 41 51 college 32 49 occupation self-employed 35 43 employee 21 26 commercial sexual worker 1 1 student/college student 1 1 unemployed 23 28 status single 18 22 married 45 57 widow 18 22 eleven subjects (52%) who had more than 6 lifetime sexual partners showed positive pcr test results, and 10 (48%) were negative. most of the subjects in both groups stated that they always use condoms during sexual intercourse. fourteen subjects wih positive pcr results stated that they constantly used condoms, 6 expressed that they sometimes used condoms, and 9 declared that they had never used a condom during sexual intercourse. in patients with hiv diah puspitosari, asmaja soedarwoto, et al. :1–8 4 international journal of integrated health sciences. 2014;2(1) infection in this study, the history of previous sti was not associated with the incidence of gonorrhea. most of subjects with positive pcr result stated that they did not have a previous history of stis. table 2 the results of pcr n. gonorrhoeae examination the results of pcr n. gonorrhoeae examination n % positive 29 36 negative 52 64 total 81 100% discussion belongia et al.21 in minessota found that the prevalence of gonorrhea infection in patients with hiv infection and aids was more common in the age group of 25–34 years. bastos et al.22 in rio de janeiro found that gonorrhea in patients with hiv infection related to the young age of approximately in the early 30s. in 2001, stolte et al.23 in amsterdam found that gonorrhea infection in people with hiv and aids were more common at age less than 31 years. the average age of subjects with n. gonorrhoeae positive pcr result in this study was 32.1 years old. gonorrhea is more commonly found in young people, probably because at young age there is a tendency of high risk sexual intercourse, such as having sex with multiple sexual partners or without using condom.21–24 in this study, gonorrhea was more commonly found in male gonorrhoea infection prevalence in human immunodeficiency virus positive patients based on polymerase chain reaction examination :1–8 table 3 n. gonorrhoeae pcr result based on characteristic of participants variabel pcr n. gonorrhoeae result total positive negative sex male 18 30 48 female 11 22 33 education no formal education 0 0 0 primary school 0 4 4 junior high school 2 2 4 senior high school 15 26 41 college 12 20 32 occupation self-employed 15 20 35 employee 7 14 21 commercial sexual worker 0 1 1 student/college student 0 1 1 unemployed 7 16 23 status single 9 9 18 married 14 31 45 widow 6 12 18 international journal of integrated health sciences. 2014;2(1) 5 diah puspitosari, asmaja soedarwoto, et al. :1–8 subjects than in females, i.e. 37% vs 33%. hamlyn et al.25 found that gonorrhea infection in people with hiv were more commonly found in males than in females, i.e. 53% vs 17%. studies by manning et al.18 in new york and gore-felton et al.13 also found the incidences of gonorrhea infection were higher in males than in females, 84% vs 16% and 59% vs 41%, respectively. norms lead to differences in sexual behavior between men and women. women are more constrained by the norms; thus less exposed to stis due to less frequent sexual relations.26 most of the subjects with positive pcr results in this study were senior high school graduates. individuals with low levels of education tend to have risky sexual behaviors. lu et al.27 found a significant association between the level of education and gonorrhea infection in people with hiv. in this study, most subjects who were infected with gonorrhea had lower educational table 4 n. gonorrhoeae pcr examination result based on sexual history of participants variable pcr n. gonorrhoeae result total positive negative average age of sexual debut 19 21 sexual orientation heterosexual 23 49 72 homosexual 3 2 5 bisexual 3 1 4 number of sexual partners in the last month 0 person 11 16 27 1 person 15 33 48 ≥2 persons 3 3 6 number of sexual partners in the last 3 months 0 person 8 12 20 1 person 16 30 46 ≥2 persons 5 10 15 number of lifetime sexual partners 1 person 9 12 21 2–5 persons 9 30 39 ≥6 persons 11 10 21 condom use never 9 11 20 seldom 6 15 21 always 14 26 40 sti history positive 12 31 43 negative 17 21 38 6 international journal of integrated health sciences. 2014;2(1) gonorrhoea infection prevalence in human immunodeficiency virus positive patients based on polymerase chain reaction examination :1–8 levels which was senior high school level or lower. most of the subjects with positive pcr results were self-employed and employees. a study conducted by castor et al.28 in india found a significant relationship between occupation and the incidence of gonorrhea. in the study, subjects who worked as an employee or selfemployed with an income between $1,000–5,000 per year had 3-fold higher risk for gonorrhea as it was possible for them to have sex with multiple partners. research conducted by lu et al.27 in china in 2005 found that gonorrhea in patients with hiv infection were more frequent in unmarried, widow, and widower subjects. similarly, the study conducted by castor et al.28 in india found a significant association between the incidence of gonorrhea and the unmarried status. this might be because the subjects who are not married, widow, or widower, are likely to have no steady sexual partner.27 studies regarding sexual behaviors often give inaccurate results due to social desirability bias and recall.25,29,30 social desirability bias might increase in direct anamnesis data retrieval if it is compared to audio computer assisted selfinterview because subjects tend not to disclose the actual data.25,30 the subjects with pcr positive result for n. gonorrhoeae in this study had their first sexual intercourse at the average age of 19.5 years. the majority of women with hiv infection who were exposed to gonorrhea in venkatesh et al.31 study had their first sexual intercourse between the ages of 16–20 years old. first sexual intercourse at young age was closely related to the number of sexual partners, delayed marriage, as well as high-risk sexual behaviors affected by stis.27,29 most of subjects with a positive pcr result in this have heterosexual orientation. studies by young et al.32 and castor et al.28 found a high incidence of gonorrhea in heterosexual subjects. it was suspected that it is related to the number of multiple sexual partners and a history of previous gonorrhea.28,32 a total of 11/21 subjects who had more than six lifetime sexual partners had positive pcr results. significant correlation between the incidence of gonorrhea infection and the number of lifetime sexual partners was found in the study conducted by venkatesh et al.,31 namely in women with 2–3 and more than 4 multiple sexual partners. a study regarding female sexual workers by jin et al.33 found that multiple sexual partners was a risk factor for gonorrhea infection. reitmeijer et al.24 in his study found that the number of multiple sexual partners in the last 4 months was one of the risk factors for incidence of gonorrhea and other stds in men who have sex with men (msm) patients with hiv infection. based on the research by ghanem et al.30 it is stated that data on the sexual behaviors of a sensitive nature are more at risk for bias. hamlyn et al.25 suggested the possibility of sexual relations or sexual partners reported by the subjects affect research results. in this study, most subjects with positive pcr results stated that they always use condom when having sex. about 90% of subjects who were infected with gonorrhea in the study by jin et al.33 declared that they always use condom when having sex. in this study, there was no significant difference between condom use and gonorrhea infection. this result was suspected due to a bias in reporting condom use by the subjects. in addition, incorrect condom use is also suspected as a risk factor associated with the transmission of gonorrhea.33 study by hamlyn et al.25 toward hiv infection patients found that most subjects exposed to gonorrhea stated inconsistent condom use. only less than 50% of subjects who stated that they always use condom when having sex but more than 25% of the subjects showed the positive pcr results for n. gonorrhoeae. this may be due to inaccurate research data from history taken.25 in this study, data on condom use history only include the frequency of condom use without information about how the subjects use it. lee et al.34 in his research in thailand found that 68.3% of patients with hiv infection stated that they always use condom when having sexual intercourse but 8.9% of them were exposed to gonorrhea and other stis. this result was considered as the result of the fact that the questionnaire used in the study did not include any question about correct condom use. several other studies found that condom use is associated with gonorrhea infection, although some did not reach statistical significance.22,24,27,35 in research by lu et al.27 in people living with hiv, most of the subjects who were infected by gonorrhea claimed that they rarely or never use condoms. similarly, the research by bastos et al.22 in rio de janeiro stated that an increase in the incidence of gonorrhea is associated with less consistent condom use. history of previous stis was not associated with the incidence of gonorrhea in patients with hiv infection in this study. majority of subjects with positive pcr result stated that they do not have a previous history of sexually transmitted infections. these results are in accordance with the results of rieg et al.20 on msm patients with hiv infection in los angeles in 2006 which found international journal of integrated health sciences. 2014;2(1) 7 references diah puspitosari, asmaja soedarwoto, et al. :1–8 1. garcia al, madkan vk, tyring sk. gonorrhea and other veneral disease. in: freedberg im, eisen az, wolff k, austen kf, goldsmith la, katz si, editors. fitzpatrick’s dermatology in general medicine. 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human immunodeficiency that a history of previous stis was not associated with the incidence of gonorrhea. it is presumably because most stis are asymptomatic so they are not recognized by the patients.20 in conclusion, the prevalence of gonorrhea infection in male urethra and female cervix of hiv positive patients based on pcr examination in teratai clinic of dr. hasan sadikin general hospital bandung were quite high, 37% and 33% respectively. identifying gonorrhea infection based on pcr examination should be considered for routine screening test in hiv positive patients. positive n. gonorrhoeae pcr results were found in subjects with an average age of first intercourse at 19.5 years old. in addition, positive results were more common in heterosexual subjects and those with more than six lifetime sexual partners. 8 international journal of integrated health sciences. 2014;2(1) virus. j am osteopath assoc. 2004;104(12):527– 35. 20. rieg g, lewis rj, miller lg, witt md, guerrero m, daar es. asymptomatic sexually transmitted infections in hiv-infected men who have sex with men: prevalence, incidence, predictors, and screening strategies. aids patient care stds. 2008;22(12):947–54. 21. belongia ea, danila rn, angamuthu v, hickman cd, deboer jm, macdonald kl, et al. a population-based study of sexually transmitted disease incidence and risk factors in human immunodeficiency virus-infected people. sex trans dis. 1997;24(5):251–6. 22. bastos fi, lowndes cm, castello-branco lr, linhares-de-carvalho mi, oelemann w, bernier f, et al. sexual behaviour and infection rates for hiv, blood-borne and sexually transmitted infections among patients attending drug treatment centres in rio de janeiro, brazil. int j std aids. 2000;11(6):383–92. 23. stolte ig, dukers nhtm, de wit jbf, fennema jsa, coutinho ra. increase in sexually transmitted infection among homosexual men in amsterdam in relation to haart. sex transm inf. 2001;77(3):184–6. 24. rietmeijer ca, patnaik jl, judson fn, douglas jm jr. increases in gonorrhoea and sexual risk behaviors among men who have sex with men: a 12 years trend analysis at the denver metro health clinic. sex trans dis. 2003;30(7):562–7. 25. hamlyn e, welz t, rebaudengo s, simms h, poulton m. sexual behaviour, condom use and rates of sexually transmitted infections in hiv clinic attendees in south east london. int j std aids. 2009;20(11):757–60. 26. buve a, gourbin c, laga m. gender and sexually transmitted disease. in: holmes kk, sparling pf, stamm we, piot p, wasserheit jn, corey l, et al., editors. sexually transmitted diseases. 4th edition. new york: mcgraw hill; 2008. p. 151–64. 27. lu f, jia y, bin s, li c, limei s, kristensen s, et al. predictors for casual sex and/or infection among sexually transmitted disease clinic attendees in china. int j std aids. 2009;20(4):241–8. 28. castor d, prabhakar p, furlonge c, rao a, brown a, camara b, et al. determinants of gonorrhoea infection among std clinic attenders in trinidad-i: sociodemographic factors, kwowledge, risk perception and history of std. int j std aids. 2002;13(1):39–45. 29. fenton k, johnson a, mcmanus s, erens b. measuring sexual behavior: methodological challenges in survey research. sex transm infect. 2001;77(2):84–92. 30. ghanem kg, hutton he, zenilman jm, zimba r, erbelding ej. audio computer assisted self interview and face to face interview modes in assessing response bias among std clinic patients. sex transm infect. 2005;81(5):421–5. 31. venkatesh kk, van der straten a, mayer kh, blanchard k, ramjee g, lurie mn, et al. african women recently infected with hiv-1 and hsv2 have increased risk of acquiring neisseria gonorrhoeae and chlamydia trachomatis in the methods for improving reproductive health in africa trial. sex transm dis. 2011;38(6):562–70. 32. young h, mcelhinney j, palmer hm. extended surveillance of gonorrhoea in scotland 2003. int j std aids. 2006;17(10):687–92. 33. jin x, chan s, ding g, wang h, xu j, wang g, et al. prevalence and risk behaviours for chlamydia trachomatis and neisseria gonorrhoeae infection among female sex workers in an hiv/aids highrisk area. int j std aids. 2011;22(2):80–4. 34. lee hc, ko ny, lee ny, chang cm, liu sy, ko wc. trends in sexually transmitted diseases and risky behaviors among hiv-infected patients at an outpatient clinic in southern taiwan. sex transm dis. 2010;37(2):86–93. 35. ndinya-achola jo, ghee ae, kihara an, krone mr, plummer fa, fisher ld, et al. high hiv prevalence, low condom use and gender differences in sexual behaviour among patients with std-related complaints at a nairobi primary health care clinic. int j std aids. 1997;8(8):506–14. gonorrhoea infection prevalence in human immunodeficiency virus positive patients based on polymerase chain reaction examination :1–8 40 international journal of integrated health sciences. 2014;2(1) correspondence: nanang winarto astarto, department of obstetrics and gynaecology, faculty of medicine, universitas padjdajarandr. hasan sadikin general hospital jl. pasteur no. 38, bandung, indonesia e-mail: nw_astarto@yahoo.com comparison between two-layer density gradient and three-layer density gradient technique for sperm preparation at aster fertility clinic, dr. hasan sadikin general hospital abstract objective: to compare the efficacy of sperm preparation techniques modified by two layer density gradient technique (80%, 40%). methods: sperm preparation was performed by twoand three-layer density gradient technique by centrifugation at 500 rpm for 20 minutes using spermgrad (vitrolife, sweden). results: the average concentration of total sperm preparation by two-layer density gradient was 23.19 million with a standard deviation of 11.9 million while the result of three-layer density gradient preparation obtained a mean total sperm concentration of 19.64 million with a standard deviation of 10.033 million. the mean total concentration of sperm in three-layer was lower than two-layer density gradient with p <0.001. conclusions: this study concludes that there was a significant difference between the concentration of sperm prepared using two-layer and three-layers density gradient technique. keywords: density gradient, spermatozoa ijihs. 2014;2(1):40–4 nanang winarto astarto,1 dian tjahyadi,1 sintya jatnikasari2 1department of obstetrics and gynaecology, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital 2aster fertility clinic, dr. hasan sadikin general hospital introduction current assisted reproductive technologies such as intrauterine insemination (iui) and in vitro fertilization (ivf)/intracytoplasmic sperm injection (icsi) have been widely applied in the treatment of infertility. ejaculated spermatozoa should be separated from seminal plasma in order to function properly. the presence of prostaglandins in seminal plasma may cause uterine contractions. in addition, seminal plasma also contains several substances that may reduce the ability of sperm to fertilize. therefore, sperm preparation techniques have become an integral part in assisted reproductive techniques (art).1 various kinds of sperm preparation techniques have been developed, such as swim-up, swimdown, and density gradient techniques. these techniques aimed to produce a ready to use sperm suspensions that are free from plasma, non-motile sperm, debris, leukocytes, and other contaminants, with a high recovery of motile sperms. sperm separation by density gradient has become a standard technique in many art laboratories because it can be done easily and quickly resulting a high motile sperm recovery. in addition, the density gradient has become a common procedure that is widely known.2 percoll density gradient procedure has been used extensively in a variety of art procedures. however, several studies reported that the percoll gradient containing endotoxin can cause irritation to the tissue after iui and the silica particles might damage the sperm membrane.2 consequently, a wide range of products and density gradient procedures were developed and have produced different effects on the quantity of sperm preparation outcome and fertilization rate.3 aster clinical laboratory, dr. hasan sadikin general hospital, routinely uses three-layer density gradient technique (90%, 70%, 40%) by original article received: march 21, 2014 revised: may 12, 2014 accepted: june 24, 2014 :40–4 international journal of integrated health sciences. 2014;2(1) 41 centrifugation at 500 rpm for 20 minutes using spermgrad® (vitrolife, sweden) while several journals and many studies reported the use of two-layer density gradient technique with 1,750 rpm centrifugation for 10 min.4 the purpose of this study was to determine which density gradient technique is more effective and efficient between the three-layer density gradient (90%, 70%, 40%) and two-layer density gradient (80%, 40%). methods objects the sperm samples were obtained from 25 adults who signed up for routine sperm analysis in aster clinical laboratory dr. hasan sadikin general hospital, bandung. each semen sample was divided into two equal parts and each aliquot was prepared using three-layer and two-layer density gradient density techniques. the research was conducted in the period of september and october 2010. the research took place in aster ivf clinic, dr. hasan sadikin general hospital. semen samples and medium semen samples were collected through masturbation and collected in sterile containers after 3 days of sexual abstinence. each sample was examined for volume, motility, and sperm concentration using the world health organization (who) 1999 manual standard. every post liquefaction sperm samples were divided into two equal parts and each aliquot was prepared using three-layers discontinuous density gradient (90%, 70%, 40%) with a speed of 500 rpm centrifugation for 20 minutes, followed by two-layer discontinuous density gradient (80%, 40%) with a speed of 1,750 rpm for 10 minutes. spermrinse® medium (vitrolife, sweden) were equilibrated for 24 hours in a 5% co 2 incubator at 37 °c. gradient stock solution 100% spermgrad® (vitrolife, sweden) was diluted using spermrinse® to generate a concentration gradient medium, respectively 90%, 80%, 70%, and 40%. sperm preparation experiment 1: sperm preparation using three layers density gradient (90%, 70%, 40%) a total of 1 ml aliquot spermgrad® 40% was inserted into the tube. spermgrad® 70% and 90% were placed respectively at the bottom of the tube. about 1 ml of semen was inserted into the tube diligently through the tube wall. all samples were then centrifuged at 500 rpm for 20 minutes. after centrifugation, 1 ml spermgrad 40% and 70% and 0.5 ml of 90% spermgrad were discarded. residual 0.5 ml spermgrad 90% was diluted in 2 ml medium and centrifuged at 1,500 rpm for 10 minutes. sperm pellet was then diluted in 0.5 ml spermrinse®. experiment 2: separation of sperm density gradient using two layers of 80% and 40% approximately 1 ml aliquot spermgrad® 40% was put into the tube, followed by 1 ml spermgrad® 80% at the bottom of the tube. one ml aliquot of semen was inserted into the tube table 1 sperm concentration differences between three-layer and two-layer density gradient techniques concentration three-layer density gradient two-layer density gradient p value (n=25) (in milllions) (n=25) (in milllions) mean (sd) 21.96 (11.01) 27.32 (13.27) 0.0001 range 12–63 7–49 sd: standard deviation; the p-value is calculated based on the independent t-test table 2 sperm motility differences between three-layer and two-layer density gradient techniques motility three-layer density gradient two-layer density gradient p value (n=25) (in percent) (n=25) (in percent) mean (sd) 89.24 (7.16) 84.32 (8.89) 0.0001 range 80–95 70–90 description: the p-value calculated by wilcoxon signed-rank test :40–4 nanang winarto astarto, dian tjahyadi, et al. 42 international journal of integrated health sciences. 2014;2(1) diligently. the sample was centrifuged at 1,750 rpm for 10 minutes. the pellet that was obtained using 2 ml spermrinse® was washed, rotated at 1,500 rpm for 5 minutes and the pellet was then diluted in 0.5 ml spermrinse®. measured parameters of this study are the value of recovery of motile sperm, motility percentage, sperm concentration, and total concentration of the post washing sperms. results the mean concentration of sperm preparation technique with two-layer density gradient was 27.32 millions with a standard deviation of 13.272 millions. for the three-layers density gradient preparation, the mean sperm concentration obtained was 21.96 millions with a standard deviation of 11.013 millions. a visible difference between the average value of two-layer density gradient and three-layer density gradient was 5.36 with a standard deviation of 5.384 with a p value of <0.001. it can be concluded that there were significant differences between the concentration of sperm preparation prepared by density gradient techniques using two-layer and three-layer density gradient. the average concentration of the sperm preparation obtained by three-layer gradient technique was 21.96 millions with a standard deviation of 11.013 millions. the mean concentration of sperm preparation by two layer density gradient was 27.32 millions with a standard deviation of 13.272 millions. the visible difference between the average value of two-layer and three-layer density gradient was 5.36 millions with a standard deviation of 5.384 millions. there was a significant difference between the concentration of sperms in two-layer and three-layer density gradient preparations, statistically. the mean sperm motility that was obtained with three-layer density gradient technique was 89.24 percent with a standard deviation of 7,155 percent. the mean sperm motility preparation by two-layer density gradient group was 84.32 percent with a standard deviation of 8.892 percents. the difference between the average value of two-layer and three-layer density gradient motility density was 4.92 with a standard deviation of 5.291. the statistical test result showed that there was a significant difference of sperm motility between the two-layer and three-layer density gradient preparation. the mean total sperm concentration in three-layer density gradient technique group was 19.64 millions with a standard deviation of 10.033 millions. the mean concentration of total sperm preparation with two-layers density gradient was 23.19 millions with a standard deviation of 11.902 millions. the difference between the average value of two-layers and three-layers density gradient was 3.54 millions with a standard deviation of 4.390 millions. there was a significant difference between the concentration of sperms in two-layer and threelayer density gradient preparations. discussion the purpose of sperm preparation in assisted reproductive technology is to obtain recovery of sperm from the seminal fluid with the highest results and without any iatrogenic effects that can reduce sperm motility, viability, and capability to fertilize. discontinuous density gradient appears to be the most effective method to remove seminal fluid and other cellular elements in the semen.5 sperm separation technique with a density gradient can vary, by using one layer up to ten layers. however, the most widely known technique uses two or three layers. many studies reported that the result of the sperm preparation using four-layer density gradient has lower quality than the two or three layers technique.6 this study demonstrated that the motility of sperm prepared using three-layer density gradient technique was higher than the twolayer density gradient technique. it was caused table 3 distribution of total sperm concentrations between three-layer and two-layer density gradient techniques motility three-layer density gradient two-layer density gradient p value*) (n=25) (in milllions) (n=25) (in milllions) mean (sd) 19.64 (10.03) 23.19 (11.9) 0.0001 range 6.30–44.10 9.10–53.55 sd: standard deviation; the p-value calculated by independent t-test :40–4 comparison between two-layer density gradient and three-layer density gradient technique for sperm preparation at aster fertility clinic, dr. hasan sadikin general hospital international journal of integrated health sciences. 2014;2(1) 43 by the number of percoll layers in the three-layer technique that was higher than in the two-layer density gradient technique. this resulted in only sperms with excellent motility were able to pass through the three-layers density gradient of percoll. our results are relevant with chen’s study that suggested puresperm 3-layer gradients for sperm preparation have been reported to result in specimens with highly motile and morphologically normal spermatozoa.2 total concentration of sperm in the two-layer density gradient technique was higher than in the three-layer density gradient technique group. this suggests that the two-layer density gradient technique produces a higher sperm recovery technique of density gradient than the threelayer technique. the number of layers in the three-layer density gradient percoll technique was higher than in the two-layer density gradient technique; therefore the ability to select sperm in the three-layer density gradient technique is higher, with only a small amount of sperms was able to pass through. hence, the concentration of sperms in the three-layer density gradient technique was lower than that of the two-layer density gradient technique group. the two-layer density gradient is a suitable method for sperm preparation in iui that requires a high number of sperms to reach a higher chance of successful fertilization. the concentration that resulted from this method is higher than from the three-layer method. although the recovery motility is lower than that of the three-layer technique, it is still considered as normal. the swim-up technique and the density gradient have different efficiency in separating the sperms. the sperms isolated with the technique are clean and motile, but damaged by the reactive oxygen species (ros) with high deoxyribonucleic acid (dna) integrity. the sperms isolated with the density gradient centrifugation are not damaged by the ros but with low dna integrity.7 another study showed that the sperms which are obtained through twolayer density gradient centrifugation provide spermatozoa with a higher quality in terms of the motility, viability, and low dna fragmented as compared to those which are obtained by the other conventional sperm preparation methods.8 a comparative study of two-layer density gradient technique and swim-up method showed that the outcome of two-layer density technique is better than the swim-up method. two-layer density gradient method is superior to the swim-up method for sperm preparation and also more rapid and simpler technique compared to the swim-up method. spermatozoa separated in two-layer gradient yields a higher number of motile sperms that can withstand cryopreservation that changes better than the specimens prepared by swim-up method. it may provide higher rates of recovery of mature, motile sperms in the specimens processed for art, which may result in higher fertilization and pregnancy rates.9,10 the three-layer density gradient is a more suitable method for ivf and icsi techniques. the three-layer density has a higher recovery motility value than the two-layers, despite its lower concentration. since ivf techniques require a higher motility without considering the concentration, the three-layer density gradient is the best choice for these purposes. in addition, aneuploidy frequencies are lower in specimens enriched by the gradient centrifugation compared with unprocessed semen. a study shows that semen processed by density gradient centrifugation is very efficient in reducing sperms with aneuploidy and diploidy.11 the two-layer density gradient sperm preparations have a greater total sperm concentration than the three-layer gradient sperm preparations. it was concluded that the selected method should depend on the proposed clinical use. if the sperm preparation is performed for iui, it is better to use the twolayer density gradient method to reach a higher total sperm concentration. if the goal is that the sperms are to be used for ivf or icsi, it is better to use the three-layer density gradient method. references :40–4 1. al-hasani s, alpüstün s, ludwig m, diedrich k, bauer o, küpker w, et al. the combination of two semen preparation techniques (glass wool filtration and swim-up) and their effect on the morphology of recovered spermatozoa and outcome of ivf-et. int j androl. 1996;19(1):55– 60. 2. chen mj, bongso a. comparative evaluation of two density gradient preparations for sperm separation for medically assisted conception. hum reprod. 1999;14(3):759–64. 3. hammoud ao, gibson m, peterson mc, carrell dt. effect of sperm preparation techniques by density gradient on intra-individual variation of nanang winarto astarto, dian tjahyadi, et al. 44 international journal of integrated health sciences. 2014;2(1) sperm motility. arch androl. 2007;53(6):349–51. 4. centola gm, herko r, andolina e, weisensel s. comparison of sperm separation methods: effect on recovery, motility, motion parameters, and hyperactivation. fertil steril. 1998;70(6):1173–5. 5. sakkas d, manicardi gc, tomlinson m, mandrioli m, bizzaro d, bianchi pg, et al. the use of two density gradient centrifugation techniques and the swim-up method to separate spermatozoa with chromatin and nuclear dna anomalies. hum reprod. 2000;15(5):1112–6. 6. sbracia m. sperm function and choice of preparation media: comparison of percoll and accudenz discontinous density gradients. j androl. 1996;17(1):61–7. 7. natali i. sperm preparation techniques for artificial insemination comparison of sperm washing, swim up, and density gradient centrifugation methods. in: manafi m, editor. artificial insemination in farm animals. iran: in tech; 2011. p. 115–22. 8. amiri i, ghorbani m, heshmati s. comparison of the dna fragmentation and the sperm parameters after processing by the density gradient and the swim up methods. j clin diagn res. 2012;6(9):1451–3. 9. allamaneni ss, agarwal a, rama s, ranganathan p, sharma rk. comparative study on density gradients and swim-up preparation techniques utilizing neat and cryopreserved spermatozoa. asian j androl. 2005;7:86–92. 10. tsai yc, lin my, chen sh, kang cy, tsai yt, lin ly, et al. comparing the clinical outcomes of intrauterine insemination by two different density gradient preparation methods. j chin med assoc. 2004;67(4):168–71. 11. brahem s, letaief k, ben ali h, saad a, mehdi m. efficacy of the density gradient centrifugation method in eliminating sperm with aneuploidy. andrologia. 2013;45(3):158–62. :40–4 comparison between two-layer density gradient and three-layer density gradient technique for sperm preparation at aster fertility clinic, dr. hasan sadikin general hospital international journal of integrated health sciences. 2014;2(1) 45 correspondence: sri endah rahayuningsih, department of child health, faculty of medicine, universitas padjdajaran-dr. hasan sadikin general hospital jl. pasteur no. 38, bandung, indonesia e-mail: endah.perkani@gmail.com cardiovascular disorders in adolescents with chest pain abstract objective: to detect cardiovascular abnormalities in adolescents with chest pain. methods: in this cross sectional study, the subjects were 25 adolescents with chest pain who came to the cardiac center of dr. hasan sadikin general hospital, bandung during the period of january 2008 to january 2011. the presence of established cardiovascular disorders were based on history, physical examination, electrocardiography and echocardiography results: it was found that 13/25 adolescents with chest pain had cardiovascular abnormalities. of the 25 teens that came with chest pain, most of which showed normal electrocardiographic results, only 9/25 of those with dysrhythmias experienced sinus tachycardia and 8 had a first degree av block. echocardiography examination showed only four patients with abnormal cardiac anatomy. no correlation between nutritional status and chest pain, and cardiovascular abnormalities and chest pain (p=0.206 and p=0.632, respectively). there was a positive correlation between sex and cardiovascular abnormalities in adolescents with chest pain (p=0.007). chest pain is a prevalent problem that is usually benign and that it frequently signals underlying cardiac disease. conclusions: cardiovascular abnormalities in adolescents with symptoms of chest pain are found in some cases. there is no correlation between female and male adolescents with chest pain and cardiovascular abnormalities. keywords: adolescents, cardiovascular, chest pain ijihs. 2014;2(1):45–8 sri endah rahayuningsih, rahmat budi, herry garna department of child health, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital :45–8 introduction adolescence is a transition period in human life cycle characterized by dynamic changes of physical and psychological status.1 adolescents face many complex issues that are associated with changes in physical condition, nutritional adequacy, psychosocial development, emotion and intelligence that may create conflicts in their health. one of the disorders that often trigger teenagers to see the doctor is chest pain.2 chest pain in children and adolescents is one of the symptoms which often causes concerns among parents that triggers them to bring their children to the pediatrician, pediatric cardiologist, or to the emergency room. chest pain in adult patients is often associated with serious heart problems, but this situation does not occur in children and adolescent. it is mainly associated with the problems in the lung as well as the idiopathic, musculoskeletal, gastrointestinal, and psychogenic problems.3–8 a careful and an accurate approach, therefore, is necessary to determine the etiology of the chest pain. in most cases, determination of the cause is sufficient by history taking and physical examination. further diagnostic examination should be selected appropriately to reduce the cost of unnecessary examinations.5,9,10 in spite of the low prevalence of chest pain that is associated with cardiovascular abnormalities in children and adolescents, this type of chest pain still need to be considered and appropriate examinations should be selected to reduce unnecessary costs. the objective of this study was to detect cardiovascular abnormalities in adolescents with chest pain methods this is a cross-sectional study wich was conducted at dr. hasan sadikin hospital, bandung. subjects received: february 26, 2014 revised: june 8, 2014 accepted: june 24, 2014 original article 46 international journal of integrated health sciences. 2014;2(1) were adolescents who visited the cardiac centre, dr. hasan sadikin general hospital, bandung with chest pain as the primary complaint from january 2008 to january 2011. the presence of established cardiovascular disorders was based on history, physical examination, electrocardiography, and echocardiography. the electrocardiography (ecg) was performed by using the fx-7000 electrocardiograph (fukuda denshi medical instruments co., ltd.) and the electrocardiograms were further interpreted by a pediatric cardiologist. the echocardiography was done by a pediatric cardiologist from the department of child health, dr. hasan sadikin general hospital, bandung. this was performed using echocardiography vivit7 general electric with 2.4 and 5 mhz transducers. the exclusion criteria were parents of patients who refused to participate in the study. no patient refused to join the study. all subjects were examined in the supine position, then all subjects were subjected to twodimensional echocardiography examination, m-mode and m-mode with color doppler. all test results were printed and stored in a cd. recorded data on height, weight, body mass index, history taking, physical examination, and the results of echocardiography were grouped into 3 age group: 1) early adolescence/early (early adolescence), 11–13 years old or junior high school, 2) mid adolescence (adolescence middle); 14–16 years old or senior high school, 3) adolescence-up (late adolescence): 17–20 years old or college.11 the classification of nutritional status was used for children aged 5–19 years to assess the z score of the body mass index (bmi) by age and gender according to the who reference 2007. the classification of nutritional status is as follow: z score >2 standard deviation (sd): obesity >1 sd–<1 sd: overweight >-1 sd– <1 sd: nutrition normal <-1 sd: nutrition less.12 results data were collected from 25 adolescents with symptom of chest pain who visited the cardiac centre, dr. hasan sadikin general hospital, bandung, indonesia. this number of adolescents represented about 2.1% of all children and adolescents who visited the hospital during the study. the characteristics of the subjects are also listed (table 1). the subjects consisted of 10 males and 15 females categorized as early adolescence/early (11–13 years; n=9; 3 male and 6 female), middle adolescence (14–16 years; n=11, 6 male and 5 female), and advance adolescence (17–20 years; n= 5, 1 male and 4 female). the nutritional status were obesity 2/25, overweight 16/25, normal nutrition 5/25, and malnutrition 2/25 subjects. no adolescent who woke up during sleep due to chest pain was found. two teenagers with chest pain had fever and the two teenagers showed sinus tachycardia dysrhythmias in ecg. fever in the two teenagers was caused by an upper respiratory tract infection. two teenagers experienced chest pain that was accompanied table 1 characteristics of subjects characteristics male n = 10 female n = 15 age early adolescence/early (11–13 years) 3 6 middle adolescence (14–16 years) 6 5 advanced adolescence (17–20 years) 1 4 body mass index (kg/m2) 22.86 (14.97–32.91) 23.82 (15.62–34.91) nutritional status obesity 1 1 overweight 9 7 normal nutrition 0 5 malnutrition 0 2 systolic pressure (mmhg) (mean sd) 75 (8.49) 80.33 (11.09) diastolic pressure (mmhg) (mean sd) 117 (4.83) 114.66 (6.39) sd: standard deviation :45–8 cardiovascular disorders in adolescents with chest pain international journal of integrated health sciences. 2014;2(1) 47 sri endah rahayuningsih, rahmat budi, et al. by burning sensation in the epigastric region showing a sinus tachycardia rhythm disturbance on electrocardiography. the serological testing in the two teenagers also show positive results for helicobacter pillory. a teenager was found with chest pain and had previously been identified as having congenital heart disease, i.e. atrial septal defect (table 2). table 2 characteristics of chest pain characteristics of chest pain number acute pain 2 awakened during sleep due to pain chest pain associated with activity, syncope 2 chest pain accompanied by fever 2 chest pain accompanied by intense burning epigastria area 2 a history of congenital heart disease who had been diagnosed previously 1 there were 13/25 adolescents with chest pain who had cardiovascular abnormalities. of the 25 teenagers that came with chest pain, most of them showed normal electrocardiographic results with only 9 of them experienced dysrhythmias, 8 had sinus tachycardia and a teenager had a firstdegree av block. echocardiography examination showed that only four patients had anatomic abnormalities of the heart (table 3). table 3 cardiovascular abnormalities in adolescents with chest pain cardiovascular abnormalities number electrocardiography normal 16 dysrhythmias sinus tachycardia 8 first-degree av block 1 echocardiography normal 21 anatomical abnormalities mitral valve prolapse is mild 1 small secundum atrial septal defect 2 large secundum atrial septal defect 1 there was no correlation between nutritional status and adolescents. no correlation was also found between cardiovascular abnormalities and adolescents with chest pain (p=0.206 and p=0.632). there was a positive correlation between sex and cardiovascular abnormalities in adolescents with chest pain (p=0.007) (table 4). table 4 cardiovascular abnormality correlation in adolescents with chest pain correlation of cardiovascular abnormalities p gender 0.007 age 0.632 nutritional status 0.206 discussion adolescence is the transitional period between the childhood and adulthood and is influenced by complex neuroendocrine factors. it is often associated with the myth of morbidity and behavioral aberrations. adolescents often experience stress due to pressures resulting from the development process and from the outside environment leading to misalignment between emotional disturbance and behavioral disorders.2,12 one complaint that is often found in adolescence is chest pain. in this study we found 25 adolescents with chest pain. epidemiological data in the united states shows that the percentage of cases of chest pain in children who come to the emergency room is between 0.3 and 0.6% per year with an average age of 12 to 13 years and a ratio of boy to girl of 1:1 to 1.6:1. among adolescents, this condition is more common in female sex, which is similar to this study that shows chest pain is more common in young women. 13 chest pain in children can be caused by various factors. some of the frequent causes are abnormalities of the chest wall (12–85%), as a secondary condition to respiratory disorders (12–21%), and psychiatric (5–17%) and gastrointestinal (4–7%) causes. meanwhile, the etiology of congenital heart as the cause of chest pain is only found in 0–6%.14 in contrast to a recent study, we found anatomical abnormalities in 4 of 25 adolescents with chest pain that include mild mitral valve prolaps and small secundum atrial septal defect. only a teenager with a large secundumatrial septal defect requiring interventional cardiology was found. :45–8 48 international journal of integrated health sciences. 2014;2(1) references 1. ho tf. cardiovascular risks associated with obesity in children and adolescents. ann acad med singapore. 2009;38(1):48–56. 2. pratiwi ry. kesehatan remaja di indonesia. the 2nd adolescent health national symposia: current challenges in management. child health department school of medicine university of indonesia and adolescent task force indonesian pediatric society. 3. jindal a, singhi s. acute chest pain. indian j pediatr. 2011;78(10):1262–7. 4. selbst s. approach to the child with chest pain. pediatr clin n am. 2010;57(6):1221–34. 5. friedman k, kane d, rathod r, renaud a, farias m, geggel r, et. al. management of pediatric chest pain using a standardized assessment and management plan. pediatrics. 2011;128(2):1–7. 6. reddy s, singh hr. chest pain in children and adolescents. pediatr rev. 2010;31(1):e1–9. 7. hanson cl, hokanson js. etiology of chest pain in children and adolescents referred to cardiology clinic. wmj. 2011;110(2):58–62. 8. danduran mj, earing mg, sheridan dc, ewalt la, frommelt pc. chest pain: characteristics of children/adolescents. pediatr cardiol. 2008;29(4):775–81. 9. thull-freedman j. evaluation of chest pain in the pediatric patient. med clin north am. 2010;94(2):327–47. 10. bader r. children with chest pain presenting to a pediatric cardiology service or emergency department in an academic centre. j saudi heart assoc. 2008;20:15–20. 11. who. bmi–for–age (5–19 years). 2007 [cited mei 2010 20]. available from: http://www.who. int/growthref/who2007_bmi_for_age/en/index. html. 12. dhamayanti m. overview adolescent health problems and services. the 2nd adolescent health national symposia: current challenges in management. child health department school of medicine university of indonesia and adolescent task force indonesian pediatric society. 13. thull-freedman j. evaluation of chest pain in the pediatric patient. med clin north am. 2010;94(2):327–47. 14. park mk. pediatric cardiology handbook. 5th ed. philadelphia: mosby; 2008. 15. eslick g. epidemiology and risk factors of pediatric chest pain: a systematic review. pediatr clin n am. 2010;57(6):1211–9. eight adolescent chest pain in this study presented sinus tachycardia on ecg examination. this condition occurs when the sinoatrial node issues higher impulses that subsequently lead to an increase in heart rate. increased impulse in the sinoatrial node is due to the lack of oxygen, pain, fever, stress, dehydration, and activities.14 in this study, 2/25 adolescents with sinus tachycardia also experienced fever, 2/25 had chest pain with burning sensation in the epigastric region and positive serological result for helicobacter pylory. this study did not differ with previous reports stating that the percentage of chest pain due to gastrointestinal disorders is 6.4%.15 we also found a teenager with chest pain and an electrocardiographic examination that shows an av block degree. the av block degree slows the delivery of impulses in the atria, av node. this block shows the type of conduction disturbances in normal sinus impulse and the ventricular response. ecg shows sinus rhythm, normal qrs segment and a pr interval that extends beyond the upper limit of interval adjusted to age. singledegree av block can occur in normal children. most patients are asymptomatic and require no further therapy.14 the national hospital ambulatory medical care survey in the united states in 2002–2006 found that chest pain complaints in children is associated with infection (21.1%).15 in this study, the number of infection-associated chest pain is found to be lower than in previous studies since we only found two teenagers with fever associated with upper respiratory tract infection. this study shows that only 52% adolescents have chest pain associated with cardiovascular abnormalities. others have unknown etiology. this is consistent with previous reports stating that the etiology of 40% of chest pain in adolescents is not known.15 this study only found one male teenager with chest pain that relates to cardiovascular abnormalities. the finding that more girls experience chest pain in this study compared to boys might associate with emotions and stress factors and might not associate with cardiovascular abnormalities. :45–8 cardiovascular disorders in adolescents with chest pain volume 7 no 2 2019 (3).indd international journal of integrated health sciences. 2019;7(2) 67:67–73 original article antibiotic use pattern in orthopedics and traumatology ward: a 6 month survey in a tertiary hospital abstract objective: to determine and describe the antibiotic use pattern in the orthopedics and traumatology ward of dr. hasan sadikin general hospital bandung as a tertiary hospital in west java, indonesia. methods: a retrospective cross-sectional study using the total sampling method was performed on the medical records of orthopedics and traumatology patients treated using antibiotics during the period of january 1, 2016 and june 31, 2016. results: from the 261 subjects who met the inclusion criteria, it was discovered that the most common antibiotics used were in the following order: cefazolin (54.41%), ceftriaxone (21.84%), and cefotaxime (10.35%). most antibiotics (75.86%) were given as prophylaxis. antibiotics were most often administered for 2–3 days (42.53%), intravenously (97.7%), and with a dose of 2x1 gram (92.16%). conclusions: the most frequently used antibiotics in the orthoaedics and traumatology ward of dr. hasan sadikin general hospital (rshs) was cefazolin, which was mostly used as a pre-surgical antibiotic. the use of third-generation cephalosporin antibiotics as pre-surgical antibiotics is still observed during this study. keywords: antibiotic, orthopedics, traumatology pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v7n2.1522 ijihs. 2019;7(2):67–73 received: december 12, 2018 revised: september 08, 2019 accepted: october 19, 2019 correspondence: stanislaus gerald ethelie faculty of medicine universitas padjadjaran jalan raya bandung sumedang km. 21 jatinangor, sumedang, indonesia e-mail: gethelie@gmail.com stanislaus gerald ethelie,1 adi imam tjahjadi,2 andri primadhi3 1faculty of medicine universitas padjadjaran, indonesia 2department of biomedical science, faculty of medicine universitas padjadjaran, indonesia 3department of orthopaedics and traumatology, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia introduction infection is one of the most potentially harmful problems in orthopedics and traumatology wards. musculoskeletal infection is still one of the main causes of morbidity which may occur even with good and correct antiseptic techniques.1 infection can significantly prolong treatment time, increase treatment costs, and reduce quality of life. rational use of antibiotics can reduce the risk of infection.2 irrational use of antibiotics can cause adverse side effects such as the emergence of antibiotic resistance.3 research conducted in the orthopedics surgical ward of dr. kariadi hospital, indonesia, in 2015 revealed that the irrational use of antibiotics contributes 53.3% of the total antibiotic use, while other studies demonstrated the rise of antibiotic resistance in indonesia.4,5 the use of antibiotics in orthopedics ward considerably varies. a survey of 297 members of the orthopaedics trauma association (ota) in 2015 in the united states showed that the majority of respondents (96%) use cefazolin as the first-line prophylaxis when fixing closed fractures of long bones. there is still no agreement for the most appropriate use of cefazolin. most of the respondents (58%) gave antibiotics one hour before the incision and repeat the dose within 24 hours. others give antibiotics half an hour or one hour before 68 international journal of integrated health sciences. 2019;7(2) incision without any repeat dose.6 another study conducted on orthopedics patients at dr. kariadi hospital from july to december 2014 showed that ceftriaxone (41.40%) is the most frequently used antibiotic, followed by cefazolin (38.85%).7 antibiotic use pattern, such as antibiotic selection, dosage, administration time, administration duration, toxicity, and administration route, considerably varies; hence this study aimed to provide an overview of antibiotic use pattern in the orthopedics and traumatology ward of dr. hasan sadikin hospital (rumah sakit hasan sadikin, rshs) which may be used as a preliminary information for further studies. methods this was a cross-sectional study on secondary data collected in june-august 2018 obtained from drug prescription in non-computerized medical records of orthopedics patients who used antibiotics in rshs, bandung, indonesia during the period of january 1, 2016 to june 31, 2016. a total sampling approach was used in this study by including all medical records of orthopedics patients who used antibiotics in rshs. the exclusion criteria were incomplete or lost medical record data, inaccessible data, and patients with tuberculosis as their primary diagnosis. this study had been approved by the research ethical committee of universitas padjadjaran, bandung through the letter of approval number 236/un6.kep/ec/2018 and permitted by the medical research ethical committee of dr. hasan sadikin general hospital bandung through the issuance of letter number lb.02.01/x.2.2.1/13207/2018. this study was also acknowledged and approved by the orthopedics and traumatology department of dr. hasan sadikin general hospital bandung, indonesia. variables of this study were antibiotic name and type, dosage, administration route, and duration of use. data were selected and sorted out according to the inclusion and exclusion criteria, then analyzed using descriptive statistics and processed with microsoft® excel 2016. after that, the data were presented in the form of tables, percentages, and charts to describe the pattern of antibiotic use. results of the 23medical records collected and among them 261 met the inclusion and exclusion criteria of this study. fifty-one records were excluded because the patients did not use antibiotics while another 11 records were excluded because the patients received tuberculosis diagnosis as their primary diagnosis. the flow diagram of the study selection process is summarized in figure 1. figure 1 study of selection process flow diagram antibiotic use pattern in orthopedics and traumatology ward :67–73 international journal of integrated health sciences. 2019;7(2) 69 table 2 antibiotic use distribution variable (n=261) % antibiotic cefazolin 142 54.41 ceftriaxone 57 21.84 cefadroxil 3 1.15 cefixime 3 1.15 cefepime 1 0.38 cefotaxime amikacin levofloxacin ciprofloxacin meropenem combination route intravenous -2x1 gram -others per oral type of therapy definitive prophylaxis empirical antibiotic replacement yes no culture yes no 27 1 1 4 1 21 255 235 20 6 9 198 54 39 222 16 245 10.34 0.38 0.38 1.53 0.38 8.05 97.70 92.16 7.84 2.30 3.45 75.86 20.69 14.94 85.06 6.13 93.87 stanislaus gerald ethelie, adi imam tjahjadi, et al. :67–73 table 1 patient demographics age group patient (n=261) male (n=171) female (n=90) (n=261) % toddlers (0–5 years old) 7 6 13 4.98 children (6–11 years old) 3 1 4 1.53 teens (12–25 years old) 56 19 75 28.74 adults (26–45 years old) 59 24 83 31.80 elderly (46–65 years old) 41 31 72 27.59 seniors (>65 years old) 5 9 14 5.36 70 international journal of integrated health sciences. 2019;7(2) patients’ age and gender information is listed in table 1. most patients were in the age group of 26–45 years old (31.8%) and males (65.51%). analysis showed that cefazolin was the most frequently used antibiotic (54.41%), followed by ceftriaxone (21.84%) and cefotaxime (10.34%). a total of 21 subjects (8.05%) received combination antibiotics. the most common combination was cephalosporin groups with either aminoglycosides or metronidazole. most subjects (97.70%) received antibiotics intravenously and 92.16% of them received 2x1 gram doses. of the 261 subjects, 198 subjects (75.86%) received antibiotics as pre-surgical antibiotics, 54 subjects (20.69%) received antibiotics as an empirical therapy, and 9 subjects (3.45%) received antibiotics as a definitive therapy. replacement of antibiotic used was performed in 39 subjects (14.94%). only a small portion of subjects (6.13%) had culture before receiving antibiotics, usually in open fracture and osteomyelitis cases. the use of antibiotics can be described more specifically based on the type of therapy, i.e. prophylaxis, empirical therapy, and definitive therapy. the most commonly used antibiotics as prophylaxis were cefazolin (n=141, 71.21%), followed by ceftriaxone (n=31, 15.66%) and cefotaxime (n=20, 10.10%) (figure 2a). in empirical therapy, the most frequently used antibiotics were ceftriaxone (n=24, 44.44%), followed by combination antibiotics of 16 data (29.63%), and cefotaxime with 7 data (12.96%) (figure 2b). the most commonly used antibiotics for definitive therapy are combination antibiotics which are as much as 4 data (44.44%) and followed by ceftriaxone in 2 data (22.22%) (figure 2c). data determined that cefazolin was almost entirely (99.30%) used as a pre-surgical antibiotic while ceftriaxone was mostly used as a pre-surgical antibiotic (54.39%) and in empirical therapies (42.10%). cefadroxil and figure 2 antibiotics used in different therapies (a) pre-surgical antibiotics (prophylaxis); (b) empirical therapy; (c) definitive therapy combination a b c antibiotic use pattern in orthopedics and traumatology ward :67–73 international journal of integrated health sciences. 2019;7(2) 71 figure 2 antibiotics used in different therapies (a) pre-surgical antibiotics (prophylaxis); (b) empirical therapy; (c) definitive therapy combination table 3 antibiotic use antibiotic prophylaxis(n=198) % empirical (n=54) % definitive (n=9) % cefazolin 141 99.30 1 0.70 0 0 ceftriaxone 31 54.39 24 42.10 2 3.51 cefadroxil 0 0 3 100 0 0 cefixime 3 100 0 0 0 0 cefepime 0 0 0 0 1 100 cefotaxime amikacin levofloxacin ciprofloxacin meropenem combination 20 0 1 1 0 1 74.07 0 100 25 0 4.76 7 0 0 2 1 16 25.93 0 0 50 100 76.19 0 1 0 1 0 4 0 100 0 25 0 19.05 table 4 antibiotic provision duration by type antibiotic single dose (n=21) % 2–3 days (n=111) % 4–7 days (n=92) % >7 days (n=37) % cefazolin 17 11.97 56 39.44 52 36.62 17 11.97 ceftriaxone 3 5.26 29 50.88 20 35.09 5 8.77 cefadroxil 0 0 2 66.67 0 0 1 33.33 cefixime 0 0 2 66.67 0 0 1 33.33 cefepime 0 0 0 0 0 0 1 100 cefotaxime amikacin levofloxacin ciprofloxacin meropenem combination 0 0 0 0 0 1 0 0 0 0 0 4.76 14 0 0 1 0 7 51.85 0 0 25 0 33.33 11 1 0 2 0 6 40.74 100 0 50 0 28.57 2 0 1 1 1 7 7.41 0 100 25 0 33.33 stanislaus gerald ethelie, adi imam tjahjadi, et al. :67–73 table 5 antibiotic provision duration by therapy antibiotic single dose (n=21) % 2–3 days (n=111) % 4–7 days (n=92) % >7 days (n=37) % prophylaxis 20 10.10 85 42.93 72 36.36 21 10.61 empirical 1 1.85 22 40.74 17 31.48 14 25.93 definitive 0 0 4 44.44 3 33.33 2 22.22 72 international journal of integrated health sciences. 2019;7(2) meropenem were only used for empirical therapies. cefixime and levofloxacin are exclusively used as pre-surgical antibiotics while cefepime and amikacin were only used in definitive therapies. cefotaxime (74.07%) was mostly used as a pre-surgical antibiotic. however, it was also used in empirical therapies (25.93%). ciprofloxacin was mostly (50%) used for empirical therapies. meanwhile, combination antibiotics were most often used in empirical therapies (76.19%) and definitive therapies (19.05%). data demonstrated that most antibiotics were administered for 2–3 days (n=111, 42.53%) with similar percentages for prophylaxis (42.93%), empirical therapy (40.74%), and definitive therapy (44.44%). discussion data from the study showed that the most frequently used antibiotics in the orthopedics and traumatology ward of dr. hasan sadikin hospital, bandung, indonesia from january to june 2016 was cefazolin (54.41%) and ceftriaxone (21.84%). this is similar to the findings from the orthopedic ward of dr. kariadi hospital semarang, indonesia, in the second half of 2014 (ceftriaxone, 41.40% and cefazolin, 38.85%).7 another study on 297 members of the orthopaedic trauma association (ota) in 2015 in the united states also showed that the majority of respondents (96%) use cefazolin as the firstline prophylaxis.6 most antibiotics in this study were used as pre-surgical antibiotics or prophylaxis (75.86%). of the 198 uses of antibiotics as prophylaxis, 141 used cefazolin (71.21%). cefazolin is the first choice as a prophylactic antibiotic as it is effective for the spectrum of gram-positive bacteria such as staphylococcus epidermidis, which will not disappear completely when in contact with alcohol.13 staphylococcus epidermidis is an opportunistic normal flora of the skin that can cause infections when there is a trauma to the skin.9 moreover, cefazolin is the most easily tolerated antibiotic whether it is given intravenously and intramuscularly. cefazolin also has a longer half-life compared to other first-generation cephalosporins; hence, it can be given less frequently.8 this is also in accordance with the indonesian minister of health’s decreeno. hk.02.02/ menkes/523/2015 on national formulary which stated that cefazolin should be used for prophylaxis to prevent surgical site infections. other antibiotics are considered to be used as prophylaxis if cefazolin is not available or if the patient is diagnosed with a disease with certain antibiotic resistance patterns. it is apparent from this study that the third generation cephalosporins are still widely used for pre-surgical antibiotics although they do not show superiority in preventing surgical site infections (ssis) compared to the conventional regimens.10 of the 63 antibiotics (24.14%) used in therapies, 54 (85.71%) were used in empirical therapies while 9 were in definitive therapies. ceftriaxone is an antibiotic that is most often used as a therapeutic antibiotic (41.27%). third-class cephalosporins, alone or in combination with aminoglycosides, is considered the antibiotic of choice for managing serious infections caused by klebsiella, enterobacter, proteus, providencia, serratia, and haemophilus spp.8 most subjects (97.70%) were given antibiotics intravenously with 92.16% received 2x1 gram doses. antibiotics given intravenously have a higher bioavailability and a faster effect than oral antibiotics. however, oral antibiotics are more economical and have fewer side effects.8 the antibiotic dose is adjusted to the age of the patient. doses of less than 2x1 gram were identified in some records for pediatric patients under 12 years of age. antibiotic doses for children under 12 years should be adjusted to the body weight.12 antibiotics were most commonly prescribed for 2-3 days in this study. the regulation of the minister of health of the republic of indonesia no. hk.02.02/menkes/523/2015 on national formulary stated that the maximum prescription of antibiotics should be 10 days. this study showed that there were antibiotics that were prescribed more than 10 days in patients with long los (length of stay) and repeated medical procedures a small number of subjects used combination antibiotics (8.05%) and culture was carried out in 6.15% subjects. these approaches were applied in cases with infection or had a highrisk for infection, such as in patients with open fractures and osteomyelitis. a combination therapy is given because it can expand the antibacterial spectrum and anticipates antibiotic resistance.11 this study has several limitations, including the study period that does not reach one year, making it impossible to capture seasonal diseases. another limitation is incomplete information in the medical record with regards to antibiotic use, especially information on the purpose of antibiotic use. therefore, it is antibiotic use pattern in orthopedics and traumatology ward :67–73 international journal of integrated health sciences. 2019;7(2) 73 suggested that an action should be taken by the hospital to make sure that medical record information is complete. it is also necessary to perform a further study with primary data collected from doctors who prescribe the antibiotic to gain a more indepth insight on the antibiotic use pattern. cefazolin is the most frequently used antibiotic, followed by ceftriaxone and cefotaxime, in patients in the orthopedics and traumatology ward. antibiotics are commonly given intravenously, 2x1 gram, as prophylaxis. cefazolin is the most commonly used antibiotics for prophylaxis before surgery; however, third-generation cephalosporin antibiotics, such as ceftriaxone and cefotaxime, are still used in a small number of cases. references 1. fleischman an, austin ms. local intra-wound administration of powdered antibiotics in orthopedics surgery. j bone jt infect. 2017;2(1): 23–8. 2. jenks pj, laurent m, mcquarry s, watkins r. clinical and economic burden of surgical site infection (ssi) and predicted financial consequences of elimination of ssi from an english hospital. j hosp infect. 2014;86(1):24– 33. 3. frieri m, kumar k, boutin a. antibiotic resistance. j infect public health. 2017;10(4): 369–78. 4. susilo d, priambodo a, lestari es. kualitas penggunaan antibiotik pada kasus bedah. 2015;4(4):618–25. 5. hadi u, qiptiyah m, paraton h. problem of antibiotic use and antimicrobial resistance in indonesia : are we really making progress ? indones j trop infect dis. 2013;4(4):5–8. 6. gans i, jain a, sirisreetreerux n, haut er, hasenboehler ea. current practice of antibiotic prophylaxis for surgical fixation of closed long bone fractures: a survey of 297 members of the orthopedics trauma association. patient saf surg. 2017;11(1):2. 7. haryanto a, priambodo a, lestari es. kuantitas penggunaan antibiotik pada pasien bedah ortopedi rsup dr. kariadi semarang. 2016;5(3):188–98. 8. brunton l. goodman & gilman’s the pharmacological basis of therapeutics. 12th ed. mcgrawhill; 2011. 9. otto m, ph d. staphylococcus epidermidis the “accidental” pathogen. nih public access. 2010;7(8):555–67. 10. liu w, christoph m, groen rjm, michael c, grundmann h. third-generation cephalosporins as antibiotic prophylaxis in neurosurgery : what’s the evidence ?. clin neurol neurosurg. 2014;116:13–9. 11. ahmed a, azim a, gurjar m, baronia ak. current concepts in combination antibiotic therapy for critically ill patients. indian j crit care med. 2014;18(5):310–4. 12. who. antibiotic dosing for children : expert recommendations for children ages 2 months to 12 years. 2017. 13. adebayo a, parikh jg. shifting trends in in vitro antibiotic susceptibilities for common bacterial conjunctival isolates in the last decade at the new york eye and ear infirmary. 2011;111–9. stanislaus gerald ethelie, adi imam tjahjadi, et al. :67–73 international journal of integrated health sciences. 2017;5(2) 75 original article quality of life in thalassemia major patients: reliability and validity of indonesian version of tranqol questionnaire correspondence: billy ng setiawan rachmat poengoet, department of physical medicine and rehabilitation, faculty of medicine, universitas padjdajaran-dr. hasan sadikin general hospital jl. pasteur no. 38, bandung, indonesia e-mail: billyscorp@yahoo.com billy ng setiawan rachmat poengoet, ellyana sungkar, tri damiati pandji department of physical medicine and rehabilitation, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital, bandung abstract objective: to determine the validity and reliability of tranqol questionnaire that has been translated into indonesian to be used in indonesian thalassemia major patients. the quality of life problems among these patients can be detected earlier because tranqol is more precise compared to the pediatric quality of life inventory (pedsqltm), world health organization quality of life instruments (whoqol), and sf-36 questionaire. methods: this study was conducted in bandung, indonesia from october 2015 to march 2016 and used a standard “forward-backward” translation procedure. it involved 60 adults and 73 children who are thalassemia major patients, and 71 parents of patients in dr. hasan sadikin general hospital. tranqol was processed through forward and backward translation approach and evaluation was conducted by the tranqol author. after the translation process, a cognitive debriefing was performed and the translated tranqol was tested to all subjects. results: cronbach’s alpha >0.7 was used for all tranqol categories. front validity and content validity testing was performed. the internal validity results showed that some questions were not valid. conclusions: tranqol reliability in indonesian language for every category is good. validity for tranqol in indonesian language shows that the translated tranqol is not quite suitable that it still cannot be used. keywords: tranqol indonesia, validity indonesia, reliability indonesia pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v5n2.1011 ijihs. 2017;5(2):75–9 introduction thalassemia is a monogenic disease that is caused by the disturbance in the hemoglobin formation that is observed around the world.1 india has alpha thalassemia cases of 12.9% and beta thalassemia cases of 3–4%.2,3 beta thalassemia is mostly found in mediteranian countries, middle east, middle asia, india, south china and countries along north africa and south america beach.4 the indonesian thalassemia foundationassociation of thalassemia patients’ parents or known as yti-popti (yayasan thalassemia indonesia-perhimpunan orang tua pasien thalassemia) has reported increased number of thalassemia patients in indonesia to 7,028 in 2015.5 the prevention of thalassemia is difficult because of its genetic nature. blood transfusion and iron chelating agent increase the survival rate of thalassemia major patients. they will have more opportunities to reach higher education, to work, and to have a better quality of life. in addition, patients may experience complications from the procedure (i.e: osteoporosis, infertility and psychiatric problem). iron absorption problem in guts and blood transfusion can lead to chronic health problems due to iron acumulation in the body. these will affect thalassemia patients’ quality of life. research has been done in many countries to evaluate thalassemia patients’ quality of life. received: may 5, 2017 revised: july 21, 2017 accepted: august 30, 2017 :75–9 76 international journal of integrated health sciences. 2017;5(2) some questionnaires are already used to assess it, such as pediatric quality of life inventory (pedsqltm), the world health organization’s quality of life instruments (whoqol), and sf-36 questionaire.6–11 these are not specific enough for thalassemia patients. tranqol was created and published on july 22, 2013. tranqol is a self-report tool used in children, adult, parents or proxy.12,13 there are 4 groups of questions in this tool: physical health, emotional health, family, school and career. there is only one question regarding the sexual aspect in this tool. the original tranqol have been evaluated for its reliability and validity. it is already acknowledged as a valid and reliable tool to be used specifically for thalassemia patients. original english tranqol cannot be used in indonesia because the different interpretation will reduce its validity and reliability. hence, its has to be translated and evaluated for its validity and reliability before it can be used in indonesia. methods a standard forward and backward translation procedure was performed by native speakers for the source and target languages after approval was gained from the author and mapi research institute. the procedure was based on linguistic validation of a patient reported outcome measure guideline. after that, a cognitive debriefing was conducted. the result was consulted to the author. the final tranqol in indonesian language was then distributed for a try out among thalassemia patients. this involved 60 adult and 73 child thalassemia major patients and 71 parents, as proxy, who were selected randomly. the study has received ethical approval from the ethics committee of dr. hasan sadikin general hospital, bandung and health research ethics committee faculty of medicine universitas padjadjaran. the statistical analyses were performed using a computerized program. cronbach’s alpha was used to assess the reliability and the internal consistency of the questionnaire. validity was evaluated using the spearman correlation. results the mean age of the respondents in this study was 12.60 for children, 23.34 for adults, and 39.87 for parents and proxy. blood transfusion frequency (in weeks) for children was 3.73 and 4.95 for adults. the reliability of tranqol in indonesian language was tested by cronbach’s alpha. the reliability was proven good with >0.7 cronbach’s alpha for children, adults, parents, and proxy (i.e. 0.806 for child, 0.877 for adult, 0.926 for parent, and 0.755 for proxy). validity was tested by correlating each with the total score. tranqol in indonesian validity testing included all 38 questions for parents but not included 9 of 28 questions in children, 10 of 36 questions for adults, 12 of 28 questions for proxy because those questions were left blank. this interfered the correlation with total score. those unanswered questions could be not included in the evaluation based on the result of a discussion with the author of tranqol (table 3 and 4). discussion the questions in the tranqol are more targeted for thalassemia patients when compared to pediatric quality of life inventory (pedsqltm), the world health organization quality of life instruments (whoqol), and also the sf-36 questionaire. some questions in the tranqol ask about the direct impact of thalassemia to the patients’s life. the impact of regular transfusion and iron removal treatment that are specific for thalassemia were asked too. the benefit is that thalassemia patients’s quality of life problems can be detected earlier, making early intervention possibler for optimal result. tranqol in indonesian language for children did not include all questions. questions 3, 6, 7, 8, 12, 13, 18, 22 and 23 are excluded. question number 3 is about pain, 6 is about social activity, 7 is about painful examination, 18 is about negative effects of thalassemia, 22 and 23 are about decision of thalassemia care which were considered not specific and hard to be understood by children. table 1 subject characteristics children adult parent or proxy n 73 60 71 mean 12.60 23.34 39.87 median 13 22 39 minimum 7 19 23 maximum 17 39 62 :75–9 quality of life in thalassemia major: reliability and validity of indonesian version of the tranqol questionnaire international journal of integrated health sciences. 2017;5(2) 77 billy ng setiawan rachmat poengoet, ellyana sungkar, et al. question number 8 about feeling different from others, 12 about feeling angry, 13 about feeling sad are subjective and cannot be well understood by children under 10 years of age. tranqol in indonesian language for adults did not include questions 10, 15, 24, 25, 31, 32, 33, 34, 35, and 36. question number 10 about thlassemia impact in preventing activity, 15 about feeling anxious, 24 about feeling different with others were viewed to be not specific enough to be understood that it was decided not to include them in the indonesian version of tranqol.question 25 about sexual aspect was not answered by many participants because many respondents were not married yet or they consider the question is too sensitive from the perspective of indonesian culture, which considers discussion on sexual topic as taboo. questions number 31, 32, 33 on school and 34, 35, 36 on work were not answered by many respondents because most of them did not continue their education to the higher education level or work due to their disability. tranqol in indonesian language for proxy did not include questions 3, 6, 16, 17, 19, 20, 21, 24, 25, 26, 27, and 28. question number 3 on pain felt by patient, 6 on social activity, 16 family support, and 17 on friends support were considered to be not specific so they would be hard to answer. questions number 19, 20, 21 on relation between patient and his/her family were not answered because proxy did not have exact knowledge, patient had lost his/her parents, or patient was not carried by his/her parent anymore. parents were also considered proxy that it may lead to confusion. question number 24 regarding the child opinion about family economic problem was not answered by many because they did not know the answer or the children were too young to have opinion about it. question number 25, 26, 27, 28 about school are not relevant for those who do not get higher education. all questions in the indonesian version of tranqol for parents were well understood and answered well by all the respondents. spearman correlation analysis was done :75–9 table 2 internal validation for children and proxy children spearman (r) p value proxy spearman (r) p value question 1 and score 0.228 0.052 question 1 and score 0.5919 0.0000 question 2 and score 0.531 0.000 question 2 and score 0.5550 0.0000 question 4 and score 0.431 0.000 question 4 and score 0.6481 0.0000 question 5 and score 0.563 0.000 question 5 and score 0.7570 0.0000 question 9 and score 0.442 0.000 question 7 and score 0.5764 0.0000 question 10 and score 0.604 0.000 question 8 and score 0.6085 0.0000 question 11 and score 0.593 0.000 question 9 and score 0.6007 0.0000 question 14 and score 0.594 0.000 question 10 and score 0.6619 0.0000 question 15 and score 0.332 0.004 question 11 and score 0.5892 0.0000 question 16 and score -0.017 0.885 question 12 and score 0.6237 0.0000 question 17 and score 0.266 0.023 question 13 and score 0.7498 0.0000 question 19 and score 0.122 0.304 question 14 and score 0.7178 0.0000 question 20 and score 0.519 0.000 question 15 and score 0.4486 0.0001 question 21 and score 0.379 0.001 question 18 and score 0.4660 0.0000 question 24 and score 0.515 0.000 question 22 and score 0.3997 0.0006 question 25 and score 0.743 0.000 question 23 and score 0.2985 0.0121 question 26 and score 0.669 0.000 question 27 and score 0.578 0.000 question 28 and score 0.509 0.000 78 international journal of integrated health sciences. 2017;5(2) table 3 internal validity for adults and parents adult spearman (r) p value parent spearman (r) p value question 1 and score 0.168 0.203 question 1 and score 0.2599 0.0286 question 2 and score 0.056 0.670 question 2 and score 0.4118 0.0004 question 3 and score 0.486 0.000 question 3 and score 0.3286 0.0051 question 4 and score 0.399 0.002 question 4 and score 0.5990 0.0000 question 5 and score 0.479 0.000 question 5 and score 0.5503 0.0000 question 6 and score 0.115 0.386 question 6 and score 0.1765 0.1438 question 7 and score 0.593 0.000 question 7 and score 0.2694 0.0231 question 8 and score 0.491 0.000 question 8 and score 0.5901 0.0000 question 9 and score 0.394 0.002 question 9 and score 0.5800 0.0000 question 11 and score 0.546 0.000 question 10 and score 0.6397 0.0000 question 12 and score 0.514 0.000 question 11 and score 0.6187 0.0000 question 13 and score 0.541 0.000 question 12 and score 0.5030 0.0000 question 14 and score 0.452 0.000 question 13 and score 0.5341 0.0000 question 16 and score 0.272 0.037 question 14 and score 0.4115 0.0004 question 17 and score 0.049 0.711 question 15 and score 0.5333 0.0000 question 18 and score 0.681 0.000 question 16 and score 0.5017 0.0000 question 19 and score 0.719 0.000 question 17 and score 0.5155 0.0000 question 20 and score 0.500 0.000 question 18 and score 0.4975 0.0000 question 21 and score 0.669 0.000 question 19 and score 0.7320 0.0000 question 22 and score 0.693 0.000 question 20 and score 0.5324 0.0000 question 23 and score 0.203 0.120 question 21 and score 0.5931 0.0000 question 26 and score 0.181 0.166 question 22 and score 0.4294 0.0002 question 27 and score 0.522 0.000 question 23 and score 0.6494 0.0000 question 28 and score 0.438 0.000 question 24 and score 0.5892 0.0000 question 29 and score 0.453 0.000 question 25 and score 0.2858 0.0165 question 30 and score 0.577 0.000 question 26 and score 0.3312 0.0281 question 27 and score 0.5150 0.0000 question 28 and score 0.5376 0.0000 question 29 and score 0.6093 0.0000 question 30 and score 0.6099 0.0000 question 31 and score 0.5402 0.0000 question 32 and score 0.2301 0.0572 question 33 and score 0.1870 0.1212 question 34 and score 0.6671 0.0000 question 35 and score 0.5765 0.0000 question 36 and score 0.5977 0.0000 question 37 and score 0.5089 0.0000 question 38 and score 0.6412 0.0000 quality of life in thalassemia major: reliability and validity of indonesian version of the tranqol questionnaire :75–9 international journal of integrated health sciences. 2017;5(2) 79 for every question with the total score after selection of questions. results of correlation analysis in this study show that 2 questions in tranqol for children are not valid (table 3). question number 16 about family support seems to be not specific so that it is difficult to answer. question number 19 about decision on treatment is too hard to be understood by children and they usually follow their parents’ decision. question number 6 in tranqol for adult is not valid. question number 1 on sleep difficulty, 2 on pain, 6 on ability to do activity, 17 on telling thalassemia to others, 23 on guilty feeling when do not follow the treatment will be better understood if they are simplified and made more specific. question number 6 on feeling disturbed by their child treatment and number 33 on support from friends might be difficult to understand due to their unspesific nature. all selected tranqol questions for proxy are valid. in conclusion, the reliability of indonesian version tranqol is good but many questions from each category are still not valid. further studies are needed to validate the translated tranqol before it can be used in indonesia. it can be considered to translate tranqol by a certified translator. tranqol for proxy has the highest number of unanswered questions. decreased concentration and motivation may be caused by the fact that parents had to answere tranqol for proxy in succession. :75–9 1. weatherall dj. thalassemia as a global health problem: recent progress towards its control in the developing countries. ann n y acad sci. 2010;1202(1):17–23. 2. nadkarni a, phanasgaonkar s, colah r, mohanty d, ghosh k. prevalence and molecular characterization of alpha-thalassemia syndromes among indians. genet test. 2008;12(2):177–80. 3. mohanty d, colah rb, gorakshakar ac, patel rz, master dc, mahanta j, et al. prevalence of β-thalassemia and other haemoglobinopathies in six cities in india: a multicentre study. j community genet. 2013;4(1):33–42. 4. flint j, harding rm, boyce aj, clegg jb. the population genetics of the haemoglobinopathies. baillieres clin haematol. 1998;11(1):1–51. 5. stastitical data of thalassemia patients in indonesia. yayasan talasemia indonesiaperhimpunan orangtua penderita talasemia indonesia; 2015. [cited 2015 jan 10]. available from: http://www.thalassaemia-yti.org/. 6. ayoub md, radi sa, azab am, abulaban aa, balkhoyor ah, bedair s-ew, et al. quality of life among children with beta-thalassemia major treated in western saudi arabia. saudi med j 2013;34(12):1281–6. 7. jafari h, lahsaeizadeh s, jafari p, karimi m. quality of life in thalassemia major: reliability and validity of the persian version of the sf-36 questionnaire. j postgrad med. 2008;54(4):273–5. 8. ansari s, baghersalimi a, azarkeivan a, nojomi m, hassanzadeh rad a. quality of life in patients with thalassemia major. iran j ped hematol oncol. 2014;4(2):57–63. 9. wahyuni ms, ali m, rosdiana n, lubis b. quality of life assessment of children with thalassemia. paediatr indones. 2011;51(3):163–9. 10. haghpanah s, nasirabadi s, ghaffarpasand f, karami r, mahmoodi m, parand s, et al. quality of life among iranian patients with beta-thalassemia major using the sf-36 questionnaire. sao paulo med j. 2013;131(3):166–72. 11. ismail m, chun cy, yusoff nam, shahar s, manaf za, rajikan r, et al. quality of life among thalassaemia children, adolescent and their caregivers. sains malaysiana. 2013;42(3):373– 80. 12. klaassen rj, alibhai s, allen mk, moreau k, pulcini mm, forgie m, et al. introducing the tran qol: a new disease-specific quality of life measure for children and adults with thalassemia major. j blood disorders transf [serial on the internet]. 2013 jun [cited 2015 jan 12];5(150):[about 5p.]. available from: https://www.omicsonline.org/introducingthe-tran-qol-a-new-disease-specific-qualityof-life-measure-for-children-and-adults-witht h a l a s s e m i a m a j o r 2 1 5 5 9 8 6 4 . 1 0 0 0 1 5 0 . php?aid=15595. 13. klaassen rj, barrowman n, merelles-pulcini m, vichinsky ep, sweeters n, kirby-allen m, et al. validation and reliability of a disease-specific quality of life measure (the tranqol) in adults and children with thalassaemia major. bjh. 2014;164(3):431–7. billy ng setiawan rachmat poengoet, ellyana sungkar, et al. references 84 international journal of integrated health sciences. 2017;5(2) effects of quadriceps strengthening exercise on quadriceps muscle strength and its relation to lower extremity lean mass introduction osteoarthritis or oa is a non-communicable disease with a high prevalence in indonesia, i.e. 30.3%, with 65.4% cases found in older patients who are above 75 years old.1 knee osteoarthritis is a complex disease marked by changes of all parts of the joint. these changes are thought to be triggered by biochemical and biomechanical factors, most importanly is obesity and quadriceps muscle weakness.2 muscle strength is found to be decreasing in elderly with smaller cross-sectional area which then affects the quadriceps muscle strength.3,4 central obesity measurement, such as body mass index, waist circumference, and waist-hip ration, has a significant correlation with knee oa (koa) and also known as a risk for koa. however, this kind of measurement has some weaknesses due to the fact that it only measure general fat and cannot differentiate between fat mass and lean mass.5 body composition consists of lean mass, fat mass, and bone mass. lean mass is furthermore divided into upper extremity, trunk, and lower extremity lean mass which can be measured using bioelectrical impedance analysis (bia).6 conroy et al.3 found that the lower extremity lean mass (lelm) in women with koa aged 45–69 years old is lower when compared to control group. this study presents a hypothesis that decreased lelm plays an important role in the pathogenesis of koa.3 blumenfeld et al.5 found that lelm is an strong predictor for defining kelgreen-lawrence score and medial osteophyte in koa. knee oa risk is increasing in women after menopause due to hormonal fluctuations, sedentary lifestyle, and fat-rich food consumption that contribute to weight gain.7 weight loss in patients with knee oa should be managed through an exercise regimen in order to restore or increase the muscle mass. abstract objective: to discover whether quadriceps resistance exercise could increase quadriceps strength as well as its relation to lower extremity lean mass. methods: this study was a preand postexperimental study in which 36 participants with knee oa grade 2 and 3 were recruited. assesment of leg lean mass and quadriceps strength was taken before and after intervention. participants practiced quadriceps isotonic resistance exercise 3 times a week for 8 weeks. this study was conducted in dr. hasan sadikin general hospital, bandung from september 2014 to february 2015. results: after the intervention, an increase in quadriceps strength was seen but not in the lower extremity lean mass. statistical analysis showed that there was no correlation between lower extremity lean mass and quadriceps strength. conclusions: quadriceps strength is found to increase after intervention. no increase is found in the lower extremity lean mass. keywords: osteoarthritis, leg lean mass, quadriceps strength, quadriceps strengthening exercise pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v5n2.1010 ijihs. 2017;5(2):84–8 received: may 5, 2017 revised: august 8, 2017 accepted: september 4, 2017 istingadah desiana, marina annette moeliono, tertianto prabowo department of physical medicine and rehabilitation, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital, bandung correspondence: istingadah desiana, department of physical medicine and rehabilitation, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital jl. pasteur no. 38, bandung, indonesia e-mail: istingadah@gmail.com :84–8 original article international journal of integrated health sciences. 2017;5(2) 85 henriksen et al.8 found that lelm increase and knee flexion-extension muscle strength with the use of low-energy diet are not found to be significantly correlated. this method can lead to muscle tissue loss and reduced lower limb muscle strength. increased lelm is also found to contribute to increased muscle strength in seven young individuals. progressive resistance exercises can help increasing muscle mass. in addition, muscle strengthening exercises three times per week improve muscle strength and value of fat-free mass compared to the strengthening exercises only once per week.9,10 the aim of this study was to assess whether quadriceps strengthening exercise correlates with quadriceps strength and lelm. methods participants included in the study were patients visited department of physical medicine and rehabilitation of dr. hasan sadikin general hospital, bandung. thirty-six women were selected through consecutive sampling. the inclusion criteria were aged 40– 70 years old, kelgreen-lawrence grade ii or iii knee oa in subacute or chronic phase, walked without any assistive device, and understood verbal, written, and gesture instructions. the confirmation of knee oa diagnosis using the ap/lateral knee radiographic examination was made and the results from all participants were read by a same person. the exclusion criteria were history of having stroke or other nerve system dysfunctions, knee deformity (such as knee valgus-varus deformity, recurvatum), history of knee trauma (fracture, ligament or meniscus rupture), or any other knee surgery, did high intensity sport regularly or joined other muscle strengthening exercise in the last six months. the attendance was recorded in each training session to monitor compliance. all participants provided written informed consent, and this study was approved by the ethical comittee of dr. hasan sadikin general hospital, bandung. lower extremity lean mass was measured using bioelectrical impedance analysis (tanita mc-180, japan). data were collected two days prior to the first exercise and the participants were asked not to do any exercise 24-hours before, not consuming any alcohol 48-hours before, and not consuming any diuretics 7 days before. the participants were asked to empty the bladder before examination. during the measurement, the patient were forbidden to use any metal accesories and socks. if the partcipant skipped one exercise, she would be excluded from the study. the measurement of the quadriceps muscle exercise strength using a push-pull handheld dynamometer was performed during the first exercise and after the whole intervention was completed. the measurement was peformed using 1 repetition maximum(rm) in which the participants performed the movement against the tester three times and the average result was calculated. the tester here was the same for all participants both before and after the intervention. the intervention was implemented for eight weeks, three times a week in pmr gymansium using quadriceps bench exercise (fig. 1). the intensity of quadriceps strengthening exercise was 60% of 1 repetition maximum (rm). in the study, 1 rm was measured by extending the knee three times and 1 rm score was recorded every week. the 60% intensity of the exercise was then fitted for the next week exercise. the exercise repetition was 10–15 times, with 1–2 seconds of resting. before the exercise, a warming-up exercise was peformed for 10 minutes dan a stretching exercise was performed for 5 minutes. after the exercise, the participants performed the cooling down movements. data were analysed using the shapiro wilks for normality of distribution. to compare the relationship between two variables before and after exercise between two average data a paired t test was used. data were processed by statsoft program version 3.5 and minitab 16 for windows with a statistical significance test results determined based on p≤0.05 value. results thirty six participants were recruited in this study. only females participated in this study. the mean age of subjects of this study was 57.26 (sd+7.45) years with an average body mass index (bmi) of 27.89 (sd+3.52). the mean height was 149.8 (sd+4.65) cm (table). the means of quadriceps muscle strength before the intervention were 12.72 kg and 13.15 kg for the left and right sides, respectively. after the intervention, the quadriceps muscle strength means were 16.43 kg for left side and 16.45 kg for right side. this study found increased quadriceps muscle strength, i.e. 3.125 kg for left le and 2.5 kg for right le. this study found a significant difference before and after intervention. :84–8 istingadah desiana, marina annette moeliono, et al. 86 international journal of integrated health sciences. 2017;5(2) the means of the lower extremity lean mass before intervention were 39.47% and 39.37% for the left and right sides, respectively. after the intervention, the lelm means became 39.23% for the left side and 39.09% for the right side. no significant difference was seen between before and after the intervention (p=0.095 and p=0.67 for left and right sides). the quadriceps muscle difference between before and after intervention were 3.125 kg for the left side and 2.5 kg for the right side while the lelm difference were -0.025 and 0.053 for the left and right sides, respectively. the correlation of the lelm and quadriceps muscle strength before and after intervention was also not found based on the result of the paired t-test statistical analysis (p>0.05). discussion the participants of this study were women with knee oa grade ii–iii aged less than 70 years old and met the inclusion criteria. they were given 24 times strengthening quadriceps exercise over eight weeks. this study aimed to assess whether the quadriceps strengthening exercise could increase lelm and whether it correlated to the quadriceps muscle strength. the participant’s mean age in this study was 57.26+7.45 years. a study also found that the knee oa prevalence in the age group of more than 45 years old is 27.8%, whereas the prevalence age for the age group of 60 years old and above is 37%.10 all participants in this study are accidentally women, which is concomittant with the epidemiology data that women have a higher risk of developing oa compared to men.7 the bmi mean for subjects in this study was 27.34 kg/m2 with the lowest bmi of 16.01 kg/m2 and the highest bmi was 37.65 kg/m2. most subjects in this study was overweight (66.67%). this is consistent with the finding of the previous studies that the majority of knee oa patients are overweight, in which the risk for knee oa is 8.1 times higher than those with normal bmi.2,5,8 the quadriceps muscle strength increased significantly after the intervention, which is consistent with findings of previous studies stating that there is an increase in quadriceps muscle strength after the quadriceps muscle strengthening exercises were performed three times a week.9,11 aaboe et al.12 also found an increase in quadriceps muscle strength after walking exercise three times a week for twelve weeks. the muscle strength increases through two mechanisms: through changes in peripheral muscles and through adaptations of the nervous system. the major factor contributing to the muscle strength increase is a neural factor occuring in the first two weeks in exercise, while the peripheral muscle change, i.e. muscle hypertrophy, occurs a few weeks after exercise.13 lower extremity lean mass did not increase in this study. this is different from nilwik et al.14 (2013) findings in which the lean mass increase 3% after the muscle strengthening exercises three times per week for six months with 60–75% intensity 1 rm among male subjects over 70 years old. this result could be explained by the different duration of study. nilwik’s study was carried out for six months while this study was conducted in only eight weeks. the correlation between quadriceps muscle strength increase and lelm was found to be insignificant. this is different from findings from previous studies showing an increase in muscle strength along with the lean mass. in these studies, the dose for exercise was 8–12 repetitions per muscle group, with the intensity of 70–85% 1rm, three sets every two to three times per week for 8–12 week.15 table subject demographics (n=36) mean sd age 57.26 (51–68) 7.45 height 149.86 (139–161) 4.65 weight 62.57 (37–77) 7.49 body mass index 27.89 (16.01–37.65) 3.52 :84–8 effects of quadriceps strengthening exercise on quadriceps muscle strength and its relation to lower extremity lean mass fig. intervention flowchart knee oa women grade ii-iii confirmed with radiology examination and included in inclusion criteria 1 day before exercise: lelm measurement quadriceps muscle strength measurement quadriceps strengthening exercise for 8 weeks, 3 times/week 2 days after exercise (25th session): lelm measurement quadriceps muscle strength measurement data analyses agreed to join, she would sign informed consent international journal of integrated health sciences. 2017;5(2) 87 istingadah desiana, marina annette moeliono, et al. :84–8 this study was conducted with the same exercise frequency and duration, but the intensity given was only 60% of 1 rm. muscle strengthening exercises with low-moderate intenstity would lead to the recruitment of slow-twitch muscle fibers while increasing the cross-sectional area in small size. the increase in the size of slow-twitch muscle fibers occured in months to years. muscle resistance exercise require more power because it can make muscle size and recruited muscle fibers increase. muscle hypertrophy itself is the result of an increase in the size and number of myofibrils in the fast-twitch muscle fibers and slow-twitch.16 muscle strength is determined by various factors, one of them is lelm. this study found that lelm has no correlation with quadriceps strength, which might indicate that lelm plays a small role in increasing muscle strength. a review study suggests that the large variations in muscle strength and cross sectional area are caused by other variables that accounted for differences in strength rather than size alone.17 meanwhile aagard et al.18 found a different result in which the increase in muscle strength after muscle strengthening exercises for six up to nine weeks in elderly subjects (>60 years) concomittantly happens with increased muscle strength and also increased diameter of thigh muscles of 10%. muscle cross-sectional area is relative to the number and size of muscle fibers. the muscle fibers consist of two types: type 1 and 2. type 1 fibers or a slow-twitch muscle fibers contract slowly, red coloured, and have oxidative metabolism. type 2 muscle fibers are fast contracting muscle fibers, white coloured, and contains mostly glycolytic with fewer oxidative enzymes than type 1. type 2 responds to a great power in a short time period.13 structural adaptations that occurs in older adults is found to be similar to those of young adults, i.e. adaptation of protein synthesis as well as the contractile elements. this process is started by changes in cell shape leading to mechanical signals that influence gene expression. the protein synthesis then occurs in two stage: posttranslational and translational phases. in posttranslational phase, the messenger rna (mrna) myofibrilar protein increases due to increases in the regulation of mrna by satellite cells. in posttranslasional phase, the satellite cell fused with mature muscle fibers resulting in the synthesis of myonucleus proteins. the satellite cells are also linked to the quantity of genetic and protein needs of muscle fibers in hipertophy phase. the pathway that causes muscle hypertrophy is still unknown but it is thought to be caused by an increase in the number of satellite cells in the muscle, leading to the muscle adaptive response.9 muscle adaptive response only happens in type ii muscle fibers. the type ii muscle fibers are the ones that experience detrimental loss caused by changes in muscle mass. atrophy of type ii muscle fibers without any reduction in the number of muscle cells is also found in nilwik’s study.13–15 a previous study also found the presence of increased lelm after performign the muscle strengthening exercises. these differences are attributed to the fact that the all participants are women in the age range of 46–56 years in this study while the research done by thomas consists of 30–40 years old male sand females. women are more likely to have a greater fat mass due to hormonal factors. lean mass is more in men because testosterone is a major regulator of body composition, particularly the muscle mass.9 women will experience decrease in the production of estrogen that regulates skeletal muscle mass. estrogen receptor α and β are expressed by myoblasts, myotube, and mature muscle fibers. this statement reinforces the hypothesis of the existence of a direct effect of estrogen on the muscles, but the clear relationship regarding the estrogen regulation not yet known.19 muscle strength decreases by 1.5–5% per year while the leg lean mass only decreases at a rate of 1–2% annually in individuals who are 50 years old or above.20 the lelm value in this study does not experience many changes after muscle strengthening exercises for eight weeks. another study found that without intervention, the ml will increase 0.45 kg and the mbl will decrease 0.23 kg per year. this shows that by doing resistance exercises, the decrease in lm can be prevented. regular physical activities can prevent the increase of lm in older adults. fatty infiltration of the muscle can be significantly reduced in subjects with physical activities and weight loss treatment.3,18 there are limititations in this study that several variables (i.e. age and menopause) that could affect the lelm are not accounted. it is suggested that the future study should be done in a longer period of intervention, higher exercise intensity and with a control group. 88 international journal of integrated health sciences. 2017;5(2):84–8 effects of quadriceps strengthening exercise on quadriceps muscle strength and its relation to lower extremity lean mass references 1. departemen kesehatan republik indonesia. riset kesehatan dasar: laporan nasional 2007. jakarta: kementrian kesehatan ri; 2007. 2. segal n, glass n, felson dt, hurley m, yang m, nevitt m, et al. the effect of quadriceps strength and proprioception on risk for knee osteoarthritis. med sci sports exerc. 2010;42(11):2081–2. 3. conroy mb, kwoh ck, krishnan e, nevitt mc, boudreau r, carbone ld, et al. muscle strength, mass, and quality in older men and women with knee osteoarthritis. arthritis care res. 2012;64(1):15–21. 4. petterson sc, barrance p, buchanan t, bindermacleod s, syder-mackler l. mechanisms undlerlying quadriceps weakness in knee osteoarthritis. med sci sports exerc. 2008;40(3):1–13. 5. blumenfeld o, williams f, hart d, arden nk, spector td, livshits g. lower limbs composition and radiographic knee osteoarthritis (rkoa) in chingford sample-a longitudinal study. arch gerontol geriatr. 2013;56(1):148–54. 6. sowers mf, yosef m, jamadar d, jacobson j, karvonen-gutierres c, jaffe m. bmi vs. body composition and radiographically defined osteoarthritis of the knee in women: a 4-year follow-up study. osteoarthr cartil. 2008;16(3):367–72. 7. silverwood v, blagojevic-bucknall m, jinks c, jordan jl, protheroe j. current evidence on risk factors for knee osteoarthritis in older adults: a systematic review and meta-analysis. osteoarthr cartil. 2015;23(4):507–15. 8. henriksen m, christensen r, danneskiold l, bliddal h. changes in lower extremity muscle mass and muscle strength after weight loss in obese patients with knee osteoarthritis: a prospective cohort study. arthritis rheum. 2012;64(2):438–42. 9. thomas mh. increasing lean mass and strength; a comparison of high frequency strength training to low frequency strength training [desertation]. missouri: university of central missouri; 2011. 10. zhang y, jordan j. epidemiology of osteoarthritis. clin geriatr med. 2010;26(3):355–69. 11. terzis g, georgiadis g, stratakos g, vogiatzis i, kavouras s, manta p, et al. resistance exerciseinduced increase in muscle mass correlates with p70s6 kinase phosphorylation in human subjects. eur j appl physiol. 2008;102(2):145– 52. 12. aaboe j, henriksen m, bartholdy c, leonardis j, rider p, jorgensen l, et al. the effect of quadriceps strengthening exercise on quadriceps and knee biomechanic during walking in adults with knee osteoarthritis: a randomized controlled trial. osteoarth. cartl. 2014;95(22):900–7. 13. frontera w, moldover j, borg-stein j, watkins p. exercise. in: gonzales e, myers s, downey ja, darling rc, editors. downey and darling’s physiological basis for rehabilitation medicine. boston: butterworth heinemann; 2008. p. 456–88. 14. nilwik r, snijders t, leenders m, bart b, kranenburg j, verdijk b, et al. the decline in skeletal muscle mass with aging is mainly attributed to a reduction in type ii muscle fiber size. exp gerontol. 2013;48(5):492–8. 15. mayer f, scharhag-rosenberger f, carlsohn a, cassel m, muller s, scharhag j. the intensity and effects of strength training in the elderly. dtsch arztebl int. 2011;108(21):359–64. 16. hardman ae, stensel dj. physiologic response and long-term adaptation to exercise. in: physical activity and health: the evidence explained. 2nd ed. boston: routledge; 2009. p.54–6. 17. jones ej, bishop pa, woods ak, green jm. cross-sectional area and muscular strength. sports med. 2008;38(12):987–94. 18. aagard p, suetta c, caserotti p, magnusson s, kjaer m. role of the nervous system in sarcopenia and muscle atrophy with strength training as countermeasure. scand j med sci sports. 2010;20(1):49–64. 19. svensson j, moverare-skrtic s, windahl s, swanson c, sjogren k. stimulation of both estrogen and androgen receptors maintains skeletal muscle mass in gonadectomized male mice but mainly via different pathways. j molecular endocrinol. 2010;45(1):45–7. 20. keller k, engelhardt m. strength and muscle mass loss with aging process. age and strength loss. muscle, ligaments, tendon j. 2013;3(4):346–50. volume 7 no 2 2019 (3).indd 108 international journal of integrated health sciences. 2019;7(2) post lumbar puncture chronic intracranial subdural hematoma abstract objective: to describe a case of cranial subdural hematoma as an atypically sporadic and potentially devastating complication of a lumbar puncture mimicking post-dural puncture headache which may lead to delayed diagnosis. methods: this is a case report of chronic intracranial subdural hematoma as a complication of lumbar puncture for spinal anesthesia in a forty-eight-yearold male underwent an uneventful ureterolithotomy. in the postoperative period, the patient complained of excruciating headaches, which partially subsided with symptomatic treatment. however, after four weeks, the patient presented with worsening headache and vomiting. results: a contrast-enhanced computer tomography study revealed a subdural hematoma in the left frontotemporoparietal region. the patient underwent an immediate decompressive craniectomy for subdural hematoma. the postoperative period was uneventful, and the patient was discharged without any neurological deficits. conclusions: intracranial complication such as subdural hematoma is rare after a dural puncture and is often masquerading as a post-dural puncture headache. imaging studies like computerized tomography and magnetic resonance imaging are to be considered in earlier stages of non-retractable headache to rule out such rare complications. keywords: ct, intracranial subdural hematoma, post-dural puncture headache pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v7n2.1679 ijihs. 2019;7(2):108–11 received: march 23, 2019 revised: august 19, 2019 accepted: october 19, 2019 correspondence: sherman david mathew, department of radiology, apollo hospital, muscat, oman e-mail: sher_mat@yahoo.com sherman david mathew,1 betsy abraham2 1department of radiology, apollo hospital, muscat, oman 2department of critical care, royal hospital, muscat, oman case introduction cranial subdural hematoma is an unusually infrequent and potentially cataclysmic complication of a lumbar puncture. the prevalence of subdural hematoma as a complication after lumbar puncture is probably inaccurate due to delay in diagnosis, misdiagnosis, or under-reporting. case a 48 year-old male with no comorbidities had undergone ureterolithotomy under spinal anesthesia using a twenty-five-gauge quincke spinal needle in a single attempt. after the procedure, he developed a severe headache, which was treated as a post-dural puncture headache with bed rest, paracetamol, and caffeine. the intensity of the headache eventually decreased with this treatment. however, after four weeks, he was presented to the emergency room with a worsening excruciating headache and multiple episodes of vomiting. there was no history of trauma during this period. he was then referred to the radiology department for contrast-enhanced computerized tomogram [ct] imaging of the brain to rule out any underlying cerebral pathology. on ct imaging, a hypo-dense subdural collection with a tiny hyper-dense component was noted on the left frontotemporoparietal region, showing a mass effect that triggered :108–11 international journal of integrated health sciences. 2019;7(2) 109 a midline shift (about thirteen millimeters towards the right) with compression of the ipsilateral ventricles and effacement of the sulcal spaces (fig. 1). on the post-contrast imaging, no area of significant enhancement was seen in the adjacent areas (fig. 2). given the imaging findings and clinical history, the possibility of a chronic subdural hematoma with an acute component was suggested. the patient was immediately sent for an urgent neurosurgical consultation, then received decompression of subdural fig. 1 ct brain, axial view showing subdural collection over the left frontotemporoparietal region. mass effect with midline shift and compression of ipsilateral ventricles is observed fig. 2 ct brain, coronal view showing the subdural collection with no significant areas of adjacent enhancement sherman david mathew and betsy abraham :108–11 110 international journal of integrated health sciences. 2019;7(2) hematoma, which was later confirmed by histopathology. the patient had an uneventful postoperative period and was discharged without any neurological deficits. discussion cranial subdural hematoma is an unusually rare and potentially catastrophic complication of a lumbar puncture secondary to spinal anesthesia, myelography, discography, diagnostic lumbar puncture, and accidental dural puncture with an epidural needle.1 the accurate prevalence of subdural hematoma post lumbar puncture is inconclusive, probably due to delay in diagnosis, misdiagnosis, or under-reporting; however, some authors have reported an incidence of one in five million in obstetric procedures for this complication.2,3 the clinical presentations of subdural hematoma depend on age, size, site, pace of formation of the blood collection, compression of intracranial structures, and clinical state of the patient. usually, in the initial phase, symptoms may resemble that of post-dural puncture headache with postural changes related to low cerebrovascular fluid pressure. in the second phase, there is a worsening headache with a lack of improvement with pharmacological treatment or after the provision of an epidural blood patch. clinical manifestations ranging from alterations in headache from postural to non-postural, vomiting, diplopia, cognitive changes, changes in consciousness level, focal neurological signs like ptosis, paresis, weakness, and language deficits are also noted.2, 4, 5 the period of headache triggered by subdural hematoma is categorized into three patterns. the first pattern, which is the most common, is a headache that presents early (within four days) after dural puncture and lingers with subsequent onset of subdural hemorrhage. the second pattern comprises a headache that prevails early after the dural puncture which then fizzled out or attenuated briefly but resurfaced with an aggravation that is followed by the inception of subdural hemorrhage. the third pattern is a headache that does not appear early after dural puncture but emerges later with the commencement of subdural hemorrhage.3 due to unknown reasons, cerebral subdural hemorrhage after spinal anesthesia occurs more regularly on the left side, as early as six hours and at the latest by twenty-nine weeks. 5 risk factors for the emergence of subdural collections are cerebral atrophy, cerebral aneurysms, blood dyscrasias, platelet anti-aggregation drugs, arteriovenous malformations, pregnancy, dehydration, alcohol consumption, multiple punctures, thick bore needles, epidural needles, and fenestrations from previous punctures.5,6,7 spinal anesthesia performed with fine needles of the whitacre-, sprotteand atraucan-type bevel have not been reported to prevent this complication.4 certain studies have displayed that the puncture aperture can stay for up to eighteen weeks. extravasation of cerebrospinal fluid can reach up to two hundred and forty milliliters per day in orifices of six hundred micrometers of diameter, which causes dissipation of the autoregulation mechanisms of intracranial pressure dynamics. this condition leads to an incessantly low cerebrospinal fluid pressure and imposes traction that causes a relative ventricular collapse and a rostrocaudal movement of the central nervous system, resulting in extension of the pain-sensitive structure and intracranial subdural bridging veins.4 the precipitous depletion in the cerebrospinal fluid volume may also trigger adenosine receptors, leading to arterial and venous vasodilatation and subsequently presenting as the clinical symptoms of post-dural puncture headache.2 if the traction expended on the bridging veins is considerable, it may disrupt its most fragile point, triggering a development of hematoma between the dura and arachnoid mater.4 the wall composition of the bridging subdural veins is microscopically weaker with variable thickness. circumferential arrangement of collagen fibers, lacking the outer reinforcement by arachnoid trabeculae compared to other venous walls, makes them more vulnerable to tear. 8 the elevation in intracranial pressure by the evolution of intracranial hematoma may compensate for the depletion in the intracranial pressure by spinal fluid leakage.6 a computed tomography scan or magnetic resonance imaging will authenticate the diagnosis and must be urgently executed when there is a doubt in making the diagnosis.6 the management of subdural hematoma is conservative, consisting of clinical observation and possible intracranial pressure monitoring or surgical evacuation. a prompt diagnosis of the hematoma can expedite the medical treatment of subdural hematoma and, thus, surgical evacuation may be circumvented. hematomas less than five millimeters often spontaneously subside. [9] a prompt epidural blood patching may restrict post lumbar puncture chronic intracranial subdural hematoma :108–11 international journal of integrated health sciences. 2019;7(2) 111 the risk of subdural bleeding by preventing a fall in cerebrospinal fluid pressure and has resulted in an equivocal outcome in certain cases.10 acute subdural hematomas are deftly identified by a cranial computerized tomogram scan, whereas chronic intracranial lesions may need magnetic resonance imaging or cerebral angiography. as time advances, hematoma and surrounding brain tissue show similar radiographic density, making early diagnosis baffling.4 an expeditious subdural hematoma evacuation is usually associated with a favorable neurological outcome. references 1. d. saha,s. swaika,d. bhattacharya,t. joseph,p. mukherjee chronic subdural haematoma following spinal anaesthesia-a case report. indian j. anaesth. 2004;48(4):312–3. 2. schweiger v, zanconato g, lonati g, baggio s, gottin l, polati e. intracranial subdural hematoma after spinal anesthesia for cesarean section. case rep obstet gynecol. 2013; 253408:3. 3. hagino t, ochiai s, watanabe y, senga s, saito m, naganuma h, et al. acute onset of intracranial subdural hemorrhage five days after spinal anesthesia for knee arthroscopic surgery: a case report. j med case rep. 2012;6:75. 4. amorim ja, remigio ds, damazio filho o, de barros ma, carvalho vn, valenca mm. intracranial subdural hematoma postspinal anesthesia: report of two cases and review of 33 cases in the literature. rev bras anestesiol. 2010;60(6):620–9. 5. moradi m, shami s, farhadifar f, nesseri k. cerebral subdural hematoma following spinal anesthesia: report of two cases. case rep med. 2012;352028;4. 6. al-zaben k, ja’bari aa, massad i, zuabi w, tamimi a, quatawneh a,et al. intracranial subdural hematoma following spinal anesthesia in a pregnant patient: case report and review of the literature. j anesth clin res 2014;5:430. 7. srivastava u, agrawal a, gupta a, dwivedi y, pilendran s, shukla v. intracranial subdural hematoma after spinal anesthesia for cesarean section: case report and review of literature. j obstet anaesth crit care 2014;4:45–7. 8. kumar s, prasad m, kumar r. acute onset of intracranial subdural haematoma 2 days after spinal anaesthesia. indian j anaesth. 2015;59(3):201–2. 9. iwase y, suzuki m, bito h. a case report of intracranial hemorrhage after spinal anesthesia. ja clinical reports. 2017;3(1):11. 10. kim kt, kim jy, kim em, kim jh. subdural hematoma occurred after spinal anesthesia in a human immunodeficiency virus-infected patient. saudi j anaesth. 2017;11(1):102–5. sherman david mathew and betsy abraham :108–11 international journal of integrated health sciences. 2013;1(1) 49 correspondence: dedi rachmadi, department of child health, faculty of medicine, universitas padjdajaran-dr. hasan sadikin general hospital jl. pasteur no. 38, bandung, indonesia e-mail: deddyrachmadi@yahoo.com nephropathy and encephalopathy in an indonesian patient with dengue viral infection abstract objective: to describe unusual manifestation of dengue virus infection that has been increasing in number and elucidate the indirect effect of dengue infection on the central nervous system which may explain the occurence of dengue encephalopathy. methods: a case report of 6-year-old boy who was admitted with a history of fever for three days, accompanied with decreased consciousness, hypertension, and edema is presented. laboratory examination showed hemoconcentration, thrombocytopenia, with positive anti dengue immunoglobulin g (igg) and igm, microscopic glomerular hematuria, and proteinuria as well as normal creatinine serum level. he was treated with supportive treatment. results: after six days, the consciousness was improved and blood pressure was normal. proteinuia was alleviated by day 11 and completely negative on day 19. microscopic glomerular hematuria was negative after 6 months. conclusions: recognition of unusual dengue manifestations is important in early diagnosis and effective treatment of the disease. keywords: dengue virus infection, encephalopathy, nephropathy ijihs. 2013;1(1):49–52 dedi rachmadi, mohamad yanuar anggara department of child health, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital :49–52 introduction dengue virus infection can be classified clinically into dengue and severe dengue infections. it is a common arthropod-borne viral disease which is endemic in more than one hundred countries. this infection is caused by 4 serotypes of dengue virus; den-1, den-2, den-3, and den-4, an rna flavivirus member within the flaviviridae family. worldwide, more than 2.5 billion people are at risk and about 50–100 million dengue infection cases occur annually.1 in recent years, there have been increasing reports of unusual manifestation of dengue viral infection that includes manifestations in renal and central nervous systems. renal involvement in several cases has been reported to be accompanied by acute kidney injury with or without shock, hemolyisis, rhabdomyolysis, as well as sepsis. in several cases, glomerular injury was shown to be mediated by the immune complex.2,3 renal injury may manifest as increased creatinine excretion, proteinuria, glomerulonephritis, acute kidney injury and hemolytic uremic syndrome.2,4,5 the indirect effect of dengue infection on the central nervous system may explain the occurrence of encephalopathy. the encephalopathy was considered to be secondary to vasculitis with resultant fluid extravasation, cerebral edema, hypoperfusion, hyponatremia. this condition is also accompanied by renal and hepatic failures.6 other mechanisms involved have been attributed to microcapillary hemorrhage and release of toxic substances.7 case a 6-year-old boy was admitted to dr. hasan sadikin general hospital with a history of tonicclonic type seizure an hour prior to admission. the seizure lasted for 5 minutes after which the patients looked drowsy. there was a history of edema since 10 days prior to admission and fever for 6 days prior to edema. there was no history of rash, sore throat, skin infection, icteric, or photosensitivity. this was the first seizure received: november 28, 2012 revised: december 28, 2012 accepted: february 1, 2013 case report 50 international journal of integrated health sciences. 2013;1(1) occurrence and there was no history of seizure in the family. on physical examination, the patients seemed drowsy and confused (glasgow coma scale/gcs=12), the blood pressure was 150/100 mmhg. there was edema observed in the palpebra, the pretibial and also the dorsum of pedis. hepatosplenomegaly was also seen. other physical and neurological examinations were unremarkable. laboratory investigations showed hemoconcentration, thrombocytopenia, hypoalbuminemia (1.9 g/dl) with a normal total protein level (7.7 g/dl). ureum and creatinine serum level were within normal limits (17 mg/ dl and 0.17 mg/dl). liver function test and electrolyte serum level were also within normal limits. urinalysis revealed +2 proteinuria and 6–8/ hpf positive hematuria. serological examinations with anti-dengue igg and igm rapid test were positive, anti-streptolysin-o (asto), antibody antinuclear (ana) and anti-double stranded dna (anti-ds-dna) were negative. c-reactive protein (crp) and c3 protein levels were also within normal values. lumbal puncture was normal and blood culture was negative. all laboratory investigations were performed at the clinical pathology laboratory of dr. hasan sadikin general hospital, except for c3 protein examination which was performed at prodia laboratory. for hematological examination, kx21 machine was used. ana test was conducted by microelisa technique, anti-ds dna was conducted by immunofluorescent technique, and dengue serology test was conducted using rapid technique with pandio kit. chest x-ray showed neither cardiomegaly or pulmonary edema. the patient was treated with ringer lactate infusion 3 ml/kg body weight/hr, intravenous furosemid 2x15 mg and oral captopril 2x6.25 mg. during hospitalization, consciousness improved dramatically, no repeated seizure, and blood pressure was normalized on day 11. urinalysis showed improvement of proteinuria. on day 12, the patient was discharged and was followed up in the out-patient clinic. during follow up, the clinical conditions improved and proteinuria was finally negative on day 19. microscopic glomerular hematuria were not found after 6 months. discussion the pathogenic link between viral infections and concomitant renal dysfunction is often difficult to establish. the causal association may be suggested by the findings of specific viral antigen serology and host antibodies in the renal structures. improvement of the renal disease accompanied by the clearance of viral antigen or recurrence of renal dysfunction following reinfection may offer the causal-effect link.8 the case presented here raises some issues related to the immunopathologic mechanisms in the course of dengue infection and its implication in renal injury. the pathogenesis of dengue nephropathy may be the same to that in acute-post streptococcal glomerulonephritis, where an table 1 laboratory investigation follow up of the patient laboratory examination day of illness 6 7 11 19 28 68 185 hematocrit (%) 40 33 30 thrombocyte (x106/l) 98 117 187 ureum (mg/dl) 17 creatinine (mg/dl) 0.17 urine protein ++ ++ + negative negative negative negative erythrocyte urine (/hpf) 6-8 >10 >10 >10 >10 8 negative cholesterol (mg/dl) 124 albumin (g/dl) 1.9 protein (g/dl) 7.7 igg/igm anti-dengue +/+ asto negative crp (mg/l) 1.3 :49–52 nephropathy and encephalopathy in an indonesian patient with dengue viral infection international journal of integrated health sciences. 2013;1(1) 51 dedi rachmadi, mohamad yanuar anggara references :49–52 antigen-antibody complex was found in the glomerulus in several cases. various mechanisms are involved in this pathogenesis which can be classified as a circulation mechanism or an insitu mechanism. in the circulation mechanism, the viral antigen would be deposited alone or as an antigen-antibody complex. the insitu immune mediated mechanisms involving viral antigens result in humoral and cellular responses, including the release of cytokines and chemokines.8 appel underlined how the immune complex-induced glomerular injury occurs in viral disease. the glomerular injury was induced by the immune complex through various mechanisms including immune complex deposit circulation in the glomerular structures, mimicry effect, autoimmune reaction, activation of cytokines and adhesion molecules by virus, or direct cytopathic effect of viral proteins on glomerular and tubular cells.9 included also in the pathogenesis are the host factors such as age, sex, genetic background, socio-economic status, and access to health services. in addition, there was a hypothesis that some viruses have a nephropathogenic characteristics. there were 15 cases of nephropathy dengue that have been reported.8 mostly, the dengue infection induced renal injury was accompanied by shock, rhabdomyolysis, and hypotension. in contrast to the previous reports on dengue infection induced renal injury, a case of dengue infection induced glomerulonephritis without shock, hypotension, or rhabdomyolyisis was reported.10 in thailand, some similar cases were also reported. renal biopsy showed mesangial and endotel hypertrophy and hyperplasia, presence of monocyte-like cells in some of the glomerular capillary lumen, and focal thickening of the glomerular basement membrane. immune complexes (igg, igm or both and c3) were found at glomeruli and arterioles wall.2 in this patient there was neither sign of shock or acute renal failure but there were signs of acute nephritic syndrome with igg antigenemia and igm anti dengue without elevated asto level. renal biopsy was not conducted. microscpoic hematuria is a common finding in nephropathy. hematuria is defined as the presence of red blood cells more than five per high power field in the urine in more than two occasions.9,10 microscopic abnormalities including hematuria and proteinuria may persist for months to a year and, rarely, even longer but it will show marked improvement on nephropathy.10 in the present case, on day 19 proteinuria disappeared and microscopic hematuria disappeared after 6 months. encephalopathy dengue was thought to be secondary to vasculitis with resultant fluid extravasation, cerebral edema, hypoperfusion, hyponatremia, hepatic and renal failure, frank hemorrhage or microvascular or encephalitis from dengue virus infection.11 in this patient, there was decreased level of consciousness without csf abnormality. in conclusion, we have presented a case of dengue encephalopathy with nephropathy without any evidence of acute renal failure, shock, hypovolemia, or sepsis. we attributed nephropathy to dengue infection following positive igg and igm anti dengue and after exccluding all other possible causes. we proposed a notion that nephropathy occurrence in dengue is an immune complex mediated phenomenon. 1. world health organization. dengue guideline for diagnosis, treatment, prevention, and control. geneve: who press; 2009. 2. nair vr, unnikrishnan d, satish b, sahadulla mi. case report acute renal failure in dengue fever in the absence of bleeding manifestations or shock. infect dis in clin pract. 2005;13:142–3. 3. karakus a, banga n, voorn gp, meinders aj. dengue shock syndrome and rhabdomyolisis. neth j med. 2007;65(2):78–81. 4. uphadaya bk, sharma a, khaira a, dinda ak, agrawal sk, triwari sc. transient iga nephropathy with acute kidney injury in a patient with dengue fever. saudi j kidney dis transpl. 2010;21(3):521–5. 5. lima qe, gorayeb fs, zanon jr, nogueira ml, ramalho hj, burdmann ea. dengue haemorrhagic fever-induced acute kidney injury without hypotension, haemolysis or rhabdomyolysis. nephrol dial transplant. 2007;22(11):3322–6. 6. witayathawornwong p. fatal dengue encephalitis. southeast asian j trop med public health. 2005;36(1):201–2. 7. cam bv, fonsmark l, hue nb, phuong nt, poulsen a, heegard ed. prospective case control study of encephalopathy in children with dengue hemorrhagic fever. am j trop med hyg. 2001;65(6):848–51. 52 international journal of integrated health sciences. 2013;1(1) 8. kimmel pl, moore jr. viral glomerulonephritis. in: schrier rw, editor. disease of the kidney and urinary tract. 8th ed. philadelphia: lipincott williams and wilkins; 2007. p. 1478–80. 9. appel g. viral infections and the kidney. cleve clin j med. 2007;74(5):353–60. 10. feld lg, meyers kec, kaplan bs, stapleton fb. limited evaluation of microscopic hematuria in pediatrics. pediatrics. 1998;102(4):1–5. 11. chotmongkol v, sawanyawisuth k. case report dengue hemorrhagic fever with encephalopathy in an adult. am j trop med hyg. 2004;35(1):160– 3. :49–52 nephropathy and encephalopathy in an indonesian patient with dengue viral infection 8 international journal of integrated health sciences. 2013;1(1) correspondence: dimyati achmad, department of surgical oncology, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital jl. pasteur no. 38, bandung, indonesia e-mail: dimachmad@yahoo.com strategy for the use of erythropoetin alpha to maintain hemoglobin level in breast cancer patient treated with anthracycline-base of adjuvant chemotherapy abstract objective: to evaluate the value of erythropoietin alpha (epoetin) administration, as an alternative treatment of anemia in the operable breast cancer patients. methods: this is a multicenter phase iii randomized clinical trial to evaluate the value of epoetin administration among anemic breast cancer patients who are undergoing anthracyclin-based adjuvant chemotherapy. sixty four patients were incuded in this trial with initial hemoglobin (hb) level of 10–12 g/dl. the patients were randomly distributed into two groups: one group received aministration of 40,000 iu epoetin/week for six times a week after operation and the other did not. in the third week after the operation, both groups were started on a 6 cycles of adjuvant chemotherapy with three weeks intervals. hb levels were evaluated during every chemotherapy cycle. results: the hb levels in the epoetin group were always above 10 g/dl up until the end of the sixth chemotherapy cycle or until the twenty first week post operation without blood transfusion. conclusions: the administration of epoetin 3 weeks prior and 3 weeks after the first cycles of chemotherapy, maintains a sufficient/normal hb level in breast cancer patients receiving anthracycline-based chemotherapy. keywords: anthracyclin-based chemotherapy, breast cancer, erythropoietin alpha ijihs. 2013;1(1):8–12 dimyati achmad,1 yusuf hariady,1 benny isakh,1 maman abdurrahman,1 ahmad faried2 1department of surgical oncology, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital 2oncology and stem cell working group, health research unit, faculty of medicine, universitas padjadjarandr. hasan sadikin general hospital :8 ̶ 12 introduction in the management of operable breast cancer with histopathologically proven lymph nodes metastasis, adjuvant chemotherapy has to be given.1 for optimal adjuvant chemotherapy result, drug type accuracy, dosage and consistent schedule have to be obtained. however, the inconsistency in therapy sometimes occured due to the side effects of chemotherapy on the hematopoietic system, causing a decrease in the hemoglobin level. in several studies, some researchers reported that anthracycline-based chemotherapy could lead to 4–63% of anemia, depending on the number of chemotherapy cycles.2 it is also reported that 25% patients who received 21-day cyclophosphamide, epirubicin, 5-fluorouracil (cef) regiment [600/60/600 mg/m2] developed anemia.3 other researchers have reported that anemia occurred at the beginning of the first week of chemotherapy in 88.3% patients receiving adriamycin-cyclophosphamide (ac) regiments [60/600 mg/m2, three weekly].3 blood transfusion is the recommended treatment for chemotherapy related anemia. the result is fast achieved but the side effect of blood transfusion should not be ignored. these side effects ranging from allergic reaction to anaphylactic shock with possible risks for viral infections such as hepatitis and human immunodeficiency virus (hiv) infections.4 in 2002, the american society of clinical oncology (asco) has recommended the usage received: september 18, 2012 revised: january 31, 2013 accepted: march 6, 2013 original article international journal of integrated health sciences. 2013;1(1) 9 of erythropoietin alpha (epoetin) as a therapy for chemotherapy induced anemia.5 epoetin boosts erythrocyte production by proliferating and differentiating the erythroid precursor in the bone marrow. it also stimulates reticulocyte release from bone marrow and increases cellular hemoglobin (hb) synthesis due to colony forming unit-erythroid (cfu-e) differentiation into erythroblast.6-10 asco recommended that epoetin treatment should be started when the hb level is ≥10 g/dl but also in mild anemia where the hb level is 10–12 g/dl. the recommended dosage is 150 iu/kg, three times a week or 40,000 iu once a week.5 del mastro and venturini reported that in 20–40% cases of patients with hb <10 g/dl, transfusion was still required even after epoetin alpha was given.6 this failure may account to the delay in treatment, since epoetin response in cancer patients occurred in a range of 3–12 weeks. an alternative strategy that can be selected is to use epoetin to prevent the occurence of severe anemia in patients with normal hb level or mild anemia. the goal of this third phase clinical trial, which was to understand the role of epoetin alpha in maintaining hb levels in breast cancer patients who was receiving anthracycline-based adjuvant chemotherapy. positive results of this clinical trial would suggest the use of epoetin alpha to replace blood transfusion and may also be used as a consideration in developing treatment protocols for operable breast cancer patients treated with anthracycline-based adjuvant chemotherapy. methods research subjects this trial involved two groups of operable breast cancer patients, the erythropoietin and control groups. the inclusion criteria were having undergone a modified radical mastectomy with an hb level ranging from 10 to 12 g/dl and receiving doxorubicin(a)-cyclophosphamide/ fluorouracil-doxorubicin-cyclophosphamide (ac/fac) or epirubicin-cyclophosphamide/ fluorouracil-epirubicin-cyclophosphamide (ec/ fec) adjuvant chemotherapy. patients with anemia due to other causes such as nutritional deficiency, renal malfunction, vitamin (iron, folic acid and b12) deficiency and hypersplenism were excluded from the trial. this is a multicenter third phase clinical trial study in department of surgical oncology, dr. hasan sadikin general hospital, bandung, west java; dr. kariadi general hospital, semarang, central java; and dr. soedarso general hospital, pontianak, kalimantan with paralleled design, 1:1 randomize-controlled. approval was gained from the ethical committee of dr. hasan sadikin general hospital, bandung, indonesia. subjects who met the inclusion criteria were recorded and randomly distributed into the group receiving epoetin or control group. one week folowing the radical matectomy surgery, the epoetin group was given 40,000 iu/week epoetin alpha for 6 times. in the 3rd week both groups underwent adjuvant chemotherapy for 6 cycles with 3 weeks intervals. hb levels were evaluated in every chemotherapy cycle. table 1 patient characteristics characteristics epoetin alpha (n=32) control (n=32) age (yrs.) mean±sd 43.63±8.167 45.13±8.393 range 30–63 24–61 stage iia 30 (93.7%) 2 (6.25%) iib 29 (90.6%) iiia 2 (6.3%) 1 (3.12%) hemoglobin (g/dl) mean±sd 11.1±0.67 11.16±0.74 median 10.9 10.9 sd, standard deviation :8 ̶ 12 dimyati achmad, yusuf hariady, et al. 10 international journal of integrated health sciences. 2013;1(1) the level of hemoglobin in the 3rd, 6th and 21st week in both groups were analyzed statistically by using unpaired t-test technique. data analysis was performed using spss for windows version 13.0. with 95% degree of confidence with a p-value of ≤ 0.05. results effectiveness and safety evaluation sixty four patients were recruited from three centers (bandung, semarang, and pontianak) where 32 patients were given epoetin alpha and 32 patients were included in the control group. the demographic and characteristic distributions of the patients were generally equal in both groups (table 1). need of transfusion no transfusion was needed during chemotherapy in the epoetin alpha group. in contrast, 9 (28.1%) patients in the control group needed transfusion. transfusion was mostly required after the 4th cycle or the 12th week post-operation (5 patients, 15.6%) (table 2). hematopoetic responses it shows the mean level of hemoglobin from the beginning of the clinical trial up to the 21st week in both groups (fig. 1). patients in the epoetin alpha group showed a gradual elevation in the mean hemoglobin level, visible in the 3rd week, and reached the hemoglobin level of 12 g/dl after the 6th week and maintained the level of around 11.5 g/dl until the 21st week. there were significant differences from the 3rd week onward (table 3). discussion anemia is a common condition found among cancer patients, caused by either the cancer itself, blood loss in the operating procedure, chemotherapy or radiation anemia which will affect the whole organ and tissue function, prognosis of therapy, morbidity, and survival rates of the patient. the common cause of anemia in cancer patients is the cancer itself that causes inadequate production of erythropoietin and vitamin deficiencies (iron, folic acid, and b12), infiltration of cancer cells to the bone marrow, excessive bleeding during the operation, and bone marrow suppression after chemotherapy or radiation. previous randomized double blind clinical trials with larger sample numbers had shown that recombinant epoetin alpha was effective in treating anemia and was safe for cancer patients.7,8 however, these earlier studies were generally focused in correction of anemia on patients with hemoglobin levels below 10.5 table 2 the need of transfusion during chemotherapy chemotherapy periods weeks epoetin group (n=32) control group (n=32) 1st chemotherapy 3 2nd chemotherapy 6 2 3rd chemotherapy 9 1 4th chemotherapy 12 5 5th chemotherapy 15 1 6th chemotherapy 18 percentage (%) 0 (0%) 9 (28.1%) :8 ̶ 12 strategy for the use of erythropoetin alpha to maintain hemoglobin level in breast cancer patient treated with anthracycline-base of adjuvant chemotherapy table 3 statistical analysis of hemoglobin level at week 3, 6 and 21 week mean hb (g/dl) 95% ci p value hemapo group control group 3 11.7 11 0.33 ̶ 1.11 <0.001 hemapo group control group 6 12.5 10.9 1.05 ̶ 2.08 <0.001 hemapo group control group 21 11.8 10.7 0.71 ̶ 1.34 <0.001 international journal of integrated health sciences. 2013;1(1) 11 dimyati achmad, yusuf hariady, et al. or 11 g/dl, thus circumventing the need for blood transfusion. the benefit of epoetin as a prophylaxis againts anemia in patients undergo chemotherapy has not been fully attested. savonije et al.9 compared the admistration of epoetin alpha to supportive therapy on cancer patients who underwent chemotherapy with a goal of evaluating hematologic parameters and the need for transfusion. the study involved 316 patients with hemoglobin stratification baseline <9.7 g/dl, 9.7–10.5 g/dl, 10.5–11.3 g/ dl and >11.3 g/dl. the study has shown that erythropoietin increased the hb level significantly and decreased the need of transfusion. patients with mild anemia in the epoetin group were able to maintain their hb level steady and decrease the need for transfusion, which was also seen among patients with a higher initial hb level. in this study 40,000 iu epoetin alpha was given per week to each patient, started 2 weeks prior to anthracycline-based chemotherapy up to the 2nd cycle or for 6 weeks. it showed that patients receiving epoietin were able to maintain their hb level above 10 g/dl until the end of the 6th cycle of chemotherapy or until the 21st weeks after the operation without blood transfusion. six weeks adminstration of epoetin alpha therapy, three weeks prior and three weeks after the first cycle of anthracyclin-based chemotherapy, maintains the hemoglobulin level in breast cancer patients receiving anthracyclinebased chemotherapy. acknowledgements the authors thank all the members of the department of surgical oncology, faculty of medicine, universitas padjadjaran who were involved in the planning and execution of this study and we are indebted to all the study participants. author disclosure statement authors have no conflict of interests. fig. 1 mean level of hemoglobin during the clinical trial :8–12 1. national comprehensive cancer network (nccn) guidelines for patient. [cited: 2011 january 6]. available from: http://www.nccn.com/files/ cancer-guidelines/breast/index.html. 2. groopman je, itri lm. chemotherapy induced anemia in adults: incidence and treatment. j natl cancer inst. 1999;91(19):1616–34. 3. kirshner j, hatch m, hennessy dd, fridman m, tannous re. anemia in stage ii and iii breast cancer patients treated with adjuvant doxorubicin and cyclophosphamide chemotherapy. oncologist. 2004;9(1):25–32. 4. brown m, whalen pk. red blood cell transfusion in critically ill patients. emerging risks and alternatives. crit care nurse. 2000; suppl:1-14:15–6. 5. rizzo jd, lichtin ae, woolf sh, seidenfeld j, bennett cl, cella d, et al. use of epoetin in patients with cancer: evidence based clinical practice guidelines of the american society of references 12 international journal of integrated health sciences. 2013;1(1):8–12 clinical oncology and the american society of haematology. j clin oncol. 2002;20(19):4083– 107. 6. del mastro l, venturini m. strategies for the use of epoetin alfa in breast cancer patients. oncologist. 1998;3(5):314–8. 7. littlewood tj, bajetta e, nortier jw, vercammen e, rapoport b. effects of epoetin alfa on hematologic parameters and quality of life in cancer patients receiving nonplatinum chemotherapy: results of a randomized, double-blind, placebo-controlled trial. j clin oncol. 2001;19(11):2865–74. 8. demetri gd, gabrilove jl, blasi mv, hill rj jr, glaspy j. benefits of epoetin alfa in anemic breast cancer patients receiving chemotherapy. clin breast cancer. 2002;3(1):45–51. 9. savonije jh, van groeningen cj, wormhoudt lw, giaccone g. early intervention with epoetin alpha during platinum based chemotherapy: an analysis of the results of a multicenter, randomized, controlled trial based on initial hemoglobin level. oncologist. 2006;11(2):206–16. 10. chang j, couture f, young s, mcwatters kl, lau cy. weekly epoetin alfa maintains hemoglobin, improves quality of life, and reduces transfusion in breast cancer patients receiving chemotherapy. j clin oncol. 2005;23(12):2597–605. strategy for the use of erythropoetin alpha to maintain hemoglobin level in breast cancer patient treated with anthracycline-base of adjuvant chemotherapy international journal of integrated health sciences. 2013;1(1) 37 correspondence: aly diana, department of medical nutrition, faculty of medicine, universitas padjadjaran jl. eijkman no. 38, bandung 40161, indonesia e-mail: diana.aly@gmail.com preliminary study: glycemic index of brown and white rice variant ir64 in healthy adult men nur irika binti idril,1 aly diana,2 abdullah firmansyah wargahadibrata2 1faculty of medicine, universitas padjadjaran 2department of medical nutrition, faculty of medicine, universitas padjadjaran :37–41 abstract objective: to measure the glycemic index of brown and white rice in healthy adult men. methods: the study was conducted in april 2010 at universitas padjadjaran, jatinangor. subjects of 21 healthy male students were randomly divided into 3 groups, which were given white bread (wb), white rice (wr) and brown rice (br). results: the results show that the highest and lowest average values of the blood glucose response was in the wr group at 30 minutes (126.9 mg/dl) and at 120 minutes (87.4 mg/dl), respectively. the glycemic index of brown rice (97.28) was lower compared to the white rice (99.26). conclusions: both wr and br are classified as high glycemic index food. the higher glycemic index of brown rice, compared to the index found in other literatures, may be caused by differences in variant and/or production process. this study suggested the importance of evaluation of local products before promoting it to the community. keywords: blood glucose level, brown rice, glycemic index ijihs. 2013;1(1):37–41 introduction in most countries, especially in many developing countries, have undergone the dual burdens of disease. the prevalence of non-communicable and degenerative diseases has increased while the prevalence of communicable diseases is still high.1,2 a lot of studies indicated that most of the degenerative diseases are related to current lifestyle, especially the nutrition intake related to high glycemic index.3,4 this fact has urged other studies to find alternative food which provide less risk and can add benefits to health. since rice is the major source of carbohydrate in most asian populations, including indonesia, finding better alternative types of rice is essential. many studies have explained the health benefits of brown rice (br), including its advantages for diabetic patients.5,6 brown rice still has its bran layers, which make the br an excellent source of magnesium, iron, selenium, manganese, vitamins b1, b2, b3 and b6, dietary fiber, and protein.5 the dietary fiber in bran layer traps nutrients, delaying their transit through gastrointestinal tract which leads to slower glucose absorption. as a result, the glycemic index of br is lower than white rice (wr).5-7 consequently, br is considered as a healthier and safer substitute for wr. nevertheless, the positive effect of br (ir64 variant) which is locally produced and commonly consumed in indonesia, on blood glucose level of the adult population is unknown. therefore, this study aims to measure glycemic index of br and wr after consumption in healthy adult men. methods this study was an experimental study. men, 19– 24 years old with normal body mass index (18.5– 22.9), waist circumference of ≤90 cm, no history of chronic disease, and were not on medication, were included as the subjects for the study. they also had normal fasting blood glucose level. the study was conducted in april 2010. the number of subjects in this study was 21 men, picked randomly from the population of medical students in universitas padjadjaran. they were received: january 3, 2013 revised: march 11, 2013 accepted: may 21, 2013 original article 38 international journal of integrated health sciences. 2013;1(1) further divided into 3 groups. white bread (wb) group was the standard group, which was given 108 gram wb and water. the wr group was the control group, which was given 113 gram wr of ir64 variant and water. the br group was the intervention group, which was given 123 gram br of ir64 variant and water. the amount of the food given was different, but they all contained 50 gram of carbohydrate. both wr and br were recently cooked and the subjects had to finish the food within 10 minutes. the independent variables included wr and br, while the dependent variable was glycemic index. the br glycemic index was lower (97.28) compared to that of wr (99.26) (table 2). wr in this study was the ir64 variant which was polished until its color became white. brown rice was the ir64 variant that was undergone several processes, including removal of the husk part. however, the bran layer is still intact because there was no polishing process performed. the glycemic index is the area under the blood glucose curve after consuming 50 gram of carbohydrate. the curve was calculated for each type of food by taking blood samples from participants at 0 minute (fasting blood glucose) and every 30 minutes after consumption for two hours. the analysis was conducted to compare the glycemic index of wr and br by using the glycemic index of bread as the standard measurement. the pleliminary study: glycemic index of brown and white rice variant ir64 after consumption in healthy adult men table 1 mean of blood glucose response in wb, wr, and br groups type of food sample time 30 min 60 min 90 min 120 min wb 1 85 102 88 91 2 116 81 118 95 3 108 96 108 106 4 111 86 87 87 5 91 109 105 100 6 136 135 101 99 7 129 114 111 98 mean±sd 110.9±18.5 103.3±18.3 102.6±11.6 96.6±6.2 wr 1 130 97 93 84 2 125 107 104 100 3 119 91 88 87 4 153 107 76 87 5 98 105 102 80 6 120 100 98 84 7 143 121 112 90 mean±sd 126.9±17.9 104.0±6.4 96.1±10.4 87.4±6.9 br 1 114 118 119 99 2 111 105 91 96 3 147 81 113 107 4 117 77 99 84 5 140 124 95 92 6 102 91 86 83 7 93 87 87 85 mean+sd 117.7±19.5 97.6±18.4 98.6±12.8 92.3±9.0 sd: standard deviation :37–41 international journal of integrated health sciences. 2013;1(1) 39 confounding factors, i.e. age, gender, bmi, and waist circumference were controlled through the inclusion criteria. therefore, these factors were not taken into account in the analysis. table 2 glycemic index of both br and wr type of food increment area under the curve (iauc) glycemic index (gi) wb 9287.14 100.00 wr 9218.57 99.26 br 9034.29 97.28 results the lowest and highest average values of the blood glucose response were found in the wr group at 120 minutes (87.4 mg/dl) and at 30 minutes (126.9 mg/dl), respectively. there was no significant difference in mean and median of each group (table 1). the glycemic index was then calculated using the trapezoidal method to measure the increment area under the curve (iauc) and the formula below:8 iauc for blood glucose response for a type of food glycemic index = x 100 corresponding area after equicarbohydrate portion of reference food discussion the blood glucose increment in br group was lower than wr group in the first 30 minutes in this study. however, the blood glucose level in wr group seemed to decrease to a lower level compared to the blood glucose level in br group. blood glucose level in br group was seen at a higher level, which was sustained until 120 minutes. various literatures consist of grey literatures and clinical studies7, 9–11 suggest that br has lower glycemic index and can be classified as food with day 1 explanation of study procedure and informed consent recording of personal data waist circumference, weight, height and bmi measurement history taking of disease history, medication and supplement intake physical examination screening of blood glucose level day 3 all subjects ate dinner normally at about 8 pm and began fasting for 8 hours day 4 measurement of fasting blood glucose (0 minute) subjects (21 adult males) randomly divided into 3 groups group a white bread group b white rice group c brown rice blood glucose level measurement at 30, 60, 90 and 120 minutes plotting the glucose response curve calculating glycemic index analyzing data and making conclusion fig. 1 experimental procedure scheme nur irika binti idril, aly diana, et al. :37–41 40 international journal of integrated health sciences. 2013;1(1) moderate glycemic index (55–70). however, our experiment shows that although the glycemic index of br is lower than wr, both br and wr glycemic index is classified as high (70–100). the study in japan stated that the glycemic index of br is 61.5, lower than the finding in this experiment.7 these different results may be related to the variant or species of rice used in the study. in the previous study in japan, the type of br tested was the short grain rice (japonica) produced in hokkaido, japan. meanwhile, the br variant used in this study is ir64. the ir64 variant was used because it is considered the type of rice most commonly consumed in indonesia. the different variant may influence the starch content in the rice. although it was not tested in this experiment, the ir64 br might have a higher starch content compared to japonica variant. the different variants may have different fiber content in the bran layer. the japonica variant might have higher fiber content than the ir64 which making it more resistant to the α-amylase activity and slowing down the absorption process in the intestine. the wr from japonica variant has moderate glycemic index.11 the participant individual differences may also affect the glycemic index of the br and wr. these differences may be due to the race or the rice consumption habit of the participants.12 frequent rice consumption might have influenced the digestion or digestive enzymes by increasing the efficacy of the digestive enzymes. this leads to faster and more efficient carbohydrate absorption that triggers a higher blood glucose response.13 there are several limitations in this study. first, the study was only performed in 1 day whereas in a previous similar study, the measurement was performed after the participants consumed both br and wr for several days. the second limitation is that the measurement of carbohydrate in the food given to all participants is done based on the food composition table (daftar komposisi bahan makanan, dkbm).14 dkbm is the standard food reference table in indonesia. however, the dkbm values may not be accurate as food may vary depending on the method of production, the species or variant of rice, and other factors. despite the limitations, this study showed that rice variant and production method may impact the glycemic index. therefore, this result also suggested the importance of local product evaluation. this is especially important for food products that are not only affected by geographic conditions (soil contains, environment factors) but also the variant and the processes from the production to consumption.13 an experimental study that addressed all of these contributing factors should be conducted before a decision to encourage or discourage promotion of br as a better substitute for wr to public in indonesia is made. pleliminary study: glycemic index of brown and white rice variant ir64 after consumption in healthy adult men references 1. popkin bm. global nutrition dynamics: the world is shifting rapidly toward a diet linked with noncommunicable diseases. am j clin nutr. 2006;84(2):289–98. 2. doak cm, adair ls, bentley m, monteiro c, popkin bm. the dual burden household and the nutrition transition paradox. int j obes. 2005;29(1):129–36. 3. augustin ls, franceschi s, jenkins dj, kendall cw, la vecchia c. glycemic index in chronic disease: a review. eur j clin nutr. 2002;56(11):1049–71. 4. jenkins dj, kendall cw, augustin ls, franceschi s, hamidi m, marchie a, et al. glycemic index: overview of implications in health and disease. am j clin nutr. 2002;76(1):266–73. 5. babu pd, subhasree rs, bhakyaraj r, vidhyalakshmi r. brown rice beyond the color reviving a lost health food a review. americaneurasian j agronomy. 2009;2(2):67–72. 6. panlasigui ln, thompson lu. blood glucose lowering effects of brown rice in normal and diabetic subjects. int j food sci nutr. 2006;57(3– 4):151–8. 7. ito y, mizukuchi a, kise m, aoto h, yamamoto s, yoshihara r, et al. postprandial blood glucose and insulin responses to pre-germinated brown rice in healthy subjects. j med invest. 2005;52(3– 4):159–64. 8. sugiyama m, tang ac, wakaki y, koyama w. glycemic index of single and mixed meal foods among common japanese foods with white rice as a reference food. eur j clin nutr. 2003;57(6):743– 52. 9. the gi diet guide [database on the internet]. 2011 [cited 2012 jan 25]. available from: http:// www.the-gi-diet.org/lowgifoods/. 10. indrasaria sd, purwanib ey, wibowoa p, jumalia. glycemic indices of some rice varieties. indonesian j agriculture. 2010;3(1):9–16. 11. foster-powell k, holt sh, brand-miller jc. :37–41 international journal of integrated health sciences. 2013;1(1) 41 nur irika binti idril, aly diana, et al. :37–41 international table of glycemic index and glycemic load values: 2002. am j clin nutr. 2002;76(1):5– 56. 12. egede le, mueller m, echols cl, gebregziabher m. longitudinal differences in glycemic control by race/ethnicity among veterans with type 2 diabetes. med care. 2010;48(6):527–33. 13. vosloo mc. some factors affecting the digestion of glycaemic carbohydrates and the blood glucose response. j family ecol consumer sci. 2005;33:1–9. 14. direktorat gizi departemen kesehatan. daftar komposisi bahan makanan. jakarta: bhratara karya aksara; 1981. 6 international journal of integrated health sciences. 2018;6(1) original article characteristics and complications of tuberculous meningitis patients with hydrochepalus undergone fluid diversion in dr. hasan sadikin general hospital, bandung correspondence: adriani lawrencia novalia, faculty of medicine, universitas padjadjaran jl. raya bandung-sumedang km 21 jatinangor, indonesia e-mail: adrianilawrencianovalia@gmail.com abstract objective: to describe the clinical characteristics and complications observed in tuberculous meningitis (tbm) patients with hydrocephalus who had undergone fluid diversion management. methods: this was a cross-sectional descriptive observational study involving 28 tbm patients with hydrocephalus aged 0–5 years who had undergone ventriculoperitoneal shunt or extraventricular drainage in the period of july 2011 to july 2016 in dr. hasan sadikin general hospital, bandung. age, gender, head circumferences, nutritional status, and classical characteristics such as sunset eye, frontal bossing, cracked pot sign, venectation as well as complications such as infection, phlebitis, and exposed shunt documented in the hospital medical records were analyzed. results: the study discovered that infant group was predominant (21/28). some of the patients had macrocephalus (7/28) and 18 had good nutrition status (18/28). there were 4 patients with frontal bossing characteristics (4/28) and almost none was found with others classic hydrocephalus characteristics. this study found no complication such as infection, phlebitis, and exposed shunt in tbm patients with hydrocephalus who had undergone fluid diversion therapy in dr. hasan sadikin general hospital, bandung. conclusions: one of the most dominan characteristics of tbm patients with hydrocephalus is frontal bossing. tuberculous meningitis patients with hydrocephalus in our center did not show any fluid diversion-related complications such as infection, phlebitis, or exposed shunt. keywords: tuberculous meningitis, hydrocephalus, fluid diversion pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v6n1.1048 ijihs. 2018;6(1):6–10 adriani lawrencia novalia,1 afiat berbudi,2 ahmad faried,3 heda melinda nataprawira4 1faculty of medicine, universitas padjadjaran 2department of microbiology and parasitology, faculty of medicine, universitas padjadjaran 3department of neurosurgery, faculty of medicine universitas padjadjaran-dr. hasan sadikin general hospital, bandung 4department of child health, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital, bandung introduction tuberculous meningitis, or commonly known as tbm, is inflamation of the brain meningenlayer caused by mycobacterium tuberculosis.1 tuberculous meningitis is regarded as one of extrapulmonary tuberculosis (tb) diseases. the world health organization or who has shown that there is a high number of extrapulmonary tb cases in indonesia. in 2014, 19.653 cases was found in indonesia.2 tuberculous meningitis often leads to hydrocephalus as its complication. multiplication of mycobacterium tb establishes a rich focus in meningen-tissue or brain parenchyma which will increase the responses from t-cell, tumor necrosis factor-alpha (tnf-α), and interferon-gamma (ifn-γ), causing the necrosis of the rich focus leading to spreading of the bacteria into subarachnoid space via the blood brain barrier. this will stimulate the secretion of cytokine, tnf-α, and other inflammation received: july 10, 2017 revised: october 26, 2017 accepted: february 19, 2018 :6–10 international journal of integrated health sciences. 2018;6(1) 7 factors, triggering the formation of exudate in the subarachnoid space. this exudate contains erythrocytes, neutrophils, macrophages, and lymphocytes and will condense and adhere to villi arachnoid, impairing cerebrospinal fluid absorption. this will then followed by the accumulation of cerebrospinal fluid in brain ventricle, causing it to dilate and eventually leads to hydrocephalus.3,4 the hydrocephalus in tbm is classified into the communicating obstructive hydrocephalus. the classic clinical presentations of hydrocephalus are increased head circumference, frontal bossing, sunset eye phenomenon, cracked pot sign, venectation, and neurological impairment.5 treatments for cerebrospinal accumulation in brain include ventriculoperitoneal shunt (vp shunt) and external ventricular drain (evd) that are intended for draining excess fluid from the ventricular system into a part of the body that has a better ability to absorb. however, a former study has shown that vp shunt or evd therapy causes many complications including infection, shunt obstruction, peritonitis, and slit-ventricular syndrome.6 however, the data from this previous study came from cases of hydrocephalus complication that is not caused by tbm. hence, it is necessary to perform a study on clinical characteristics and complications of tbm with hydrocephalus after fluid diversion therapy. the aim of this study was to describe the clinical characteristics and complications of tbm with hydrocephalus after receiving fluid diversion therapy. the result could be used as scientific data for better management. methods this study was a cross-sectional descriptive observational study targeted to all patients registered at the department of neurosurgery, dr. hasan sadikin general hospital, bandung who were diagnosed as suffered from tbm with hydrocephalus, aged 0–5 years old, during july 2011 until july 2016. tuberculous meningitis and hydrocephalus patients with hiv, cerebral palsy history, congenital anomaly, spinal cord injury, spondylitis tb, and those who did not undergo vp shunt or evd were excluded from this study. data collected in this study were age, sex, nutritional status, head’s circumference, and hydrocephalus clinical characteristics that include frontal bossing, sunset eye, cracked pot sign and venectation. nutritional status and head circumference were determined using the who growth charts. complications found in the hydrochepalic tbm patients such as infection, phlebitis, or exposed shunt were observed two weeks after fluid diversion therapy. medical records of the patients were used to look for complications after fluid diversion from patients receiving vp shunt and evd at our center in dr. hasan sadikin hospital, bandung. the patients with incomplete or missing medical records were excluded. analysis was performed by using computerizad software. this study was approved by the research ethics committee of dr. hasan sadikin general hospital, bandung and all medical records are kept confidential and protected. results seventy nine patients, 0–5 years old, with tbm and hydrocephalus with no congenital abnormality and hiv infection were identified. of these patients, only 39 patients received fluid diversion therapy with only 28 patients had complete information recorded in their medical records. most common age group from all 28 tbm with hydrocephalus patients receiving fluid diversion therapy was infancy (0–1 year old) age group (21 patients) followed by toddler (3–5 years old) and preschool(4 patients) age groups. in sex characteristics, there was no domination. sex ratio of tbm patients with hydrocephalus who received fluid diversion therapy was 1:1 (table 1). the majority of patients had normal head circumference (17 patients), followed by macrocephalus group and microcephalus group (table 2). all patients with macrocephalus were those aged 0–24 months old or was in the infant category and open anterior fontanel. adriani lawrencia novalia, afiat berbudi, et al. :6–10 characteristics of tuberculosis menginitis with hydrocephalus patient by age and gender table 1 characteristics total age (yrs.) infancy (0–1) 21 toddlerhood (2–3) 3 preschool (3–5) 4 gender male 11 female 14 note: yrs.= years 8 international journal of integrated health sciences. 2018;6(1) characteristic total head circumference normal 17 macrocephalus 7 microcephalus 3 nutritional status obesity 1 good nutrition 18 malnutrition 2 severe malnutrition 7 from the body weight and height, it was identified that 18 tbm with hydrocephalus patients receiving the fluid diversion therapy had good nutritional status. approximately 7 were severely malnourished, another 7 were malnourished, and only one was obese (table 2). from the data fround regarding the classic characteristics of tbm-related hydrocephalus, ifrontal bossing was found to be the most common characteristic (4), followed by the presence of venectation (2), and sunset eye (1). based on data, there was no cracked pot sign found in all 28 sampled patients (table 3). however, the incidence of frontal bossing in tbm with hydrocephalus patients receiving fluid diversion therapy was still too diminutive. from 28 tbm patients with hydrocephalus receiving fluid diversion therapy, none of them had experienced infection, phlebitis, or exposed shunt during two weeks after fluid diversion therapy (table 4). however, based on the data, there were two patients experiencing proximal shunt malfunction. discussion tuberculous meningitis with hydrocephalus is an inflammation of brain meninges caused by mycobacterium tb accompanied by dilatation of all brain ventricle systems. hydrocephalus is formed in 42% of tbm patients.7,8 in a former study, the average age of tbm patients is 4 months to 18 years old.9 in this study, 21 subjects were from infant (0–1 year old) age group. this is an agreement with a previous study performed by tung et al.10 with an average of patients of 7.6 months old with an age span of 5–11 months old. the high numbers of tbm in infancy is because infants are more susceptible to infection due to their immature immune system, which allows tb mycobacterium multiplication and increasing disease progressivity.4 a previous study also discovered that boys have a higher tendency to have tbm, both in children or adults.8,9 however, those studies are limited to tbm only without considering the presence of hydrocephalus. it was found that tbm patients with hydrocephalus in the age group of 0–5 years old does not show a sex presentation difference one of the characteristics of hydrocephalus is increasing head circumference. a previous study, head circumference correlates with the brain volume and is very much affected by age; hence, head circumference measurement by age can be used to determine the presence of brain volume abnormality.11 result of this study showed that seven patients had macrocephaly. patients with macrocephaly are within 0–24 months old with open anterior fontanel. this matches the theory stated that 93% baby’s fontanel are closed at 24 months old.12 head circumference enlargement rate may increase because of accumulation of fluid in ventricle and subarachnoid space, leading to dilatation of membrane connecting cranial bones. in addition to increased head circumference, another thing that may occur in hydrocephalus characteristics and complications in tuberculous meningitis hydrocephalus patient undergone fluid diversion in department of neurosurgery, dr. hasan sadikin general hospital, bandung :6–10 characteristics of tuberculous menginitis with hydrocephalus patients by head circumference and nutritional status table 2 characteristic yes no sunset eye 1 27 frontal bossing 4 24 cracked pot sign 0 28 venectation 2 26 characteristic yes no infection 0 28 phlebitis 0 28 exposed shunt 0 28 table 4 complication on tuberculous menginitis with hydrocephalus patients with vp shunt treatment table 3 classic characteristics of tuberculosis menginitis with hydrocephalus international journal of integrated health sciences. 2018;6(1) 9 adriani lawrencia novalia, afiat berbudi, et al. patients with open anterior fontanel is frontal bossing.12 in this study, frontal bossing was found in up to 17% of the patients. all of them are in infancy category. this was caused by the fact that open anterior fontanel allows the accumulated fluid in ventricular system to press the intracranial components, leading to the enlargement anterior parts. enlargement of head circumference and the presence of frontal bossing leads to upper retraction of the eyelids and the accumulation of cerebrospinal fluid press brain component creates increased intracranial pressure and repression of cranial nerves, causing the sunset eye phenomenon or the condition in which the eyelids are retracted above and the eyeball is deviated downward, creating a sunset-like look.13 in this study, sunset eye phenomenon was seen in patients with frontal bossing. the increased intracranial pressure will repress the cranial nerve and giving symptoms like oculomotor palsy. it will be happened if the third cranial nerve is stretched due to intracranial pressure. repression of the sixth cranial nerve leads to diplopia.7 hydrocephalus patients who experience severe enlargement of head circumference as well as severe frontal bossing will be seen with venectation and cracked pot sign (sign of percussion sound like a cracking pot). however, in this study there is no cracked pot sign found. this is influenced by the growth progressivity of tb bacteria that adher to arachnoid villi that leads to cerebrospinal fluid malabsorption. with time, without therapy, hydrocephalus complication increases. theoretically, cerebrospinal fluid is absorbed via the arachnoid villi and virchowrobin spaces (vrs). cerebrospinal fluid absorption via vrs may happen during an increase in hydrostatic pressure in the arteriole, pushing fluid into vrs, causing the fluid to flows into ventricle and enter the lymphatic system, back to blood vessels.14 this explains the ability of the early treatment for tbm patients with hydrocephalus to diminish the all four characteristics. patients who are suffering from tuberculous meningitis with hydrocephalus receive not only anti-tb therapy to eradicate the bacteria, but also fluid diversion therapy to relieve the hydrochepalus. based on existing literatures, 36 infection cases following vp shunt and 46 shunt cases were found.15 a previous study showed that about 58% shunt infection are caused by gram negative bacilli bacteria, followed by s. aureus, s. epidermidis, and staphylococcus haemolyticus.16 another study has reported exposed shunt at perioral area in 1 year old children.17 based on medical record analysis, it was found that all samples do not present any information of the presence of infection, phlebitis, or exposed shunt after vp shunt or evd procedure. however, this result needs further investigation, since patients data are taken in only in one center and only focusing in patients receiving fluid diversion at the department of neurosurgery, dr. hasan sadikin hospital, bandung; therefore, it cannot be said that patient with fluid diversion will have no complication. multicenter collaboration and data collections are needed in the near future. the limitation in this study is in the small sample size due to the difficulties in finding good and complete medical records. further studies about the clinical characteristics of tbm with hydrocephalus involving other centers are needed. in spite of the limitation, the results can be used as a reference to provide an explanation of the patient’s condition and the complications that occur after fluid diversion therapy. hence, characteristics such as enlargement of head circumference and frontal bossing are influenced by the patient’s age because the fontanel closure influences the characteristics of hydrocephalic tbm patients. complications that are usually seen after fluid diversion are not found in this study. it can be assumed then that fluid diversion therapy at the department of neurosurgery, dr. hasan sadikin hospital, has fulfilled the infection prevention standards. :6–10 references 1. kasper d. harrison’s principles of internal medicine, 19th ed. new york: mcgraw-hill; 2015. 2. world health organization. global tuberculosis report 2015, geneva: world health organization; 2015. 3. rock rb, olin m, baker ca, molitor tw, peterson pk. central nervous system tuberculosis: pathogenesis and clinical aspects. clin microbiol rev. 2008;21(2):243–61. 4. newton sm, brent aj, anderson s, whittaker e, kampmann b. paediatric tuberculosis. lancet infect dis. 2008;8(8):498–510. 10 international journal of integrated health sciences. 2018;6(1) characteristics and complications in tuberculous meningitis hydrocephalus patient undergone fluid diversion in department of neurosurgery, dr. hasan sadikin general hospital, bandung :6–10 5. wu t, li hq. changes of anterior fontanel size in children aged 0–2 years. zhonghua er ke za zhi. 2012;50(7):493–7. 6. athanasakis e, ermidou d. post-operative complications of ventriculoperitoneal shunt in hydrocephalic pediatric patients-nursing care. int j caring sci. 2011;4(2):66–71. 7. anderson ne, somaratne j, mason df, holland d, thomas mg. neurological and systemic complications of tuberculous meningitis and its treatment at auckland city hospital, new zealand. j clin neurosci. 2010;17(9):1114–8. 8. güneş a, uluca ü, aktar f, konca ç, şen v, ece a, et al. clinical, radiological and laboratory findings in 185 children with tuberculous meningitis at a single centre and relationship with the stage of the disease. italian j pediatr. [serial on the internet]. 2015 oct [cited 2016 mar 20];41:(75):[about 6p.]. available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ pmc4606503/. 9. miftode eg, dorneanu os, leca da, juganariu g, teodor a, hurmuzache m, et al. tuberculous meningitis in children and adults: a 10-year retrospective comparative analysis. plos one. [serial on the internet]. 2015 jul [cited 2016 mar 20];10(7):[about 10p.]. available from: http://journals.plos.org/plosone/ article?id=10.1371/journal.pone.0133477. 10. tung yr, lai mc, lui cc, tsai kl, huang lt, chang yc, et al. tuberculous meningitis in infancy. pediatr neurol. 2002;27(4):262–6. 11. treit s, zhou d, chudley ae, andrew g, rasmussen c, nikkel sm, et al. relationships between head circumference, brain volume and cognition in children with prenatal alcohol exposure. plos one. [serial on the internet]. 2016 feb [cited 2016 jul 27];11(2):[about 15p.]. available from: http://journals.plos. org/plosone/article?id=10.1371/journal. pone.0150370. 12. kiesler j, ricer r. the abnormal fontanel. am family phys. 2003;67(12):2547–52. 13. boragina m, cohen e. an infant with setting-sun eye phenomenon. cmaj. 2006;175(8):878–9. 14. brinker t, stopa e, morrison j, klinge p. a new look at cerebrospinal fluid circulation. fluids and barriers of the cns. [serial on the internet]. 2014 may [cited 2016 jul 27];11(10):[about 16p.]. available from: https://fluidsbarrierscns.biomedcentral.com/ articles/10.1186/2045-8118-11-10. 15. park m-k, kim m, park k-s, park s-h, hwang j-h, hwang sk. a retrospective analysis of ventriculoperitoneal shunt revision cases of a single institute. j korean neurosurg soc. 2015;57(5):359–63. 16. wu x, liu q, jiang x, zhang t. prevention options for ventriculoperitoneal shunt infections: a retrospective analysis during a five-year period. int j clin experimental med. 2015;8(10):19775–80. 17. agarwal m, adhana r, namdev h, yadav yr, agrawal t. transoral extrusion of the ventriculo-peritoneal shunt: a case report and review of literature. j pediatr neurosci. 2011;6(2):149–51. volume 7 no 2 2019 (3).indd international journal of integrated health sciences. 2019;7(2) 81 original article antibiotic utilization pattern in tertiary hospital intensive care unit in west java, indonesia abstract objective: to explore the pattern of antibiotic utilization in intensive care unit (icu). methods: this was a retrospective study on patients in icus of a tertiary hospital intensive care unit in west java, indonesia. subjects were recruited using the total sampling method during the period of january to june 2016. data collected were processed using the anatomical therapeutic chemical (atc) classification/defined daily dose (ddd) system as the international measurement standard for analysis and comparison from the world health organization (who). results: fifty-seven medical records were collected with the total antibiotics used of 295.72 ddd/100 bed-days. levofloxacin, meropenem, ceftriaxone, ceftazidime, and metronidazole were the five most frequently used antibiotics with 143.18, 49.88, 30.62, 19.74, and 16.99 ddd/100 bed-days, respectively. conclusions: ceftriaxone is the predominantly used antibiotics that is provided to 54.39% of the patients while levofloxacin is the antibiotics with the highest number of doses used with a total of 143.18 ddd/100 bed-days. keywords: antibiotics, ddd, intensive care unit pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v7n2.1633 ijihs. 2019;7(2):81–7 received: february 19, 2019 revised: september 08, 2019 accepted: october 19, 2019 correspondence: taradharani wikantiananda, faculty of medicine universitas padjadjaran jalan raya bandung sumedang km. 21 jatinangor, sumedang, indonesia e-mail: t.wikantiananda@gmail.com taradharani wikantiananda,1 adi imam tjahjadi,2 reza widianto sudjud3 1faculty of medicine universitas padjadjaran, indonesia 2department of biomedical science, faculty of medicine universitas padjadjaran, indonesia 3department of anesthesiology and intensive care faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia introduction intensive care unit (icu) is a dedicated area to support the lives of critical patients in health care facilities. icu plays an important role in treating patients with severe infectious diseases; however, it should also be noted that icu stays may trigger several complications and even death.1 nosocomial infections can occur in the intensive care units due to invasive actions, such as the installation of mechanical ventilation, urinary catheters, and various other invasive procedures.2 antibiotic resistance continues to increase as inappropriate administration of antibiotics sustains. currently, antibiotic resistance has become one of the biggest global health threats. who has declared antibiotic resistance as one of the three most important problems for public health in this century.3 a 2011 who survey in indonesia demonstrates that the antibiotics consumption contributes 22–41% of the total number of drugs distributed in the country.4 a study on quantitative antibiotic use in university of zurich hospital that antibiotic use in icu ranks third among the top used drugs in the hospital with 451.80 defined daily dose (ddd)/100 patients. a study of antimicrobial resistance in two indonesian hospitals in 2000–2004 discovered that 30–80% of the antibiotics were not used as indicated.5 changes in bacterial resistance patterns occur due to different therapeutic patterns in each period of time, especially because of the inappropriate administration :81–7 82 international journal of integrated health sciences. 2019;7(2) or inappropriate type of antibiotics given.6 antibiotic resistance increases due to improper use of antibiotics as a consequence of the lack of a standardized antibiotic use guideline and supervision.7 this study aimed to explore antibiotic use in the icu to identify its utilization pattern. it is expected that the result of this study can be used as a reference and consideration when evaluating which antibiotics should be use and how to provide antibiotic treatment more effectively. methods this was a retrospective descriptive study conducted in august 2018 on patients treated in the intensive care unit of a tertiary hospital in west java, indonesia, during the period of january to june 2016. the ethical clearance for this study has been obtained from the ethics committee for health research, faculty of medicine, universitas padjadjaran (no. 218/ un6.kep/ec/2018), and ethics committee of dr. hasan sadikin, bandung general hospital (no. lb.02.01/x.2.2.1/8353/2018). data used in this study were secondary data collected from the medical records by applying the total sampling method. fiftyseven patient’s medical records were used in the study. the inclusion criteria used was all medical records of icu patients who were given antibiotics while medical records with incomplete and missing data were excluded. variables collected were patient’s length of stay in the intensive care unit, type of antibiotics, antibiotic dose, and antibiotic resistance test. data were then analyzed using the anatomical therapeutic chemical (atc) classification/ defined daily dose (ddd) system from the who, which is an international measurement standard for analyzing and comparing drug use. the ddd was divided by the patient days and presented as ddd/100 bed-days. the atc code and who ddd antibiotic numbers are available at https://www.whocc.no/atc_ddd_ index/. results there were 86 patients treated in the intensive care unit during the study period but the medical records of 13 patients were not stored at the medical record unit of the hospital. of these, 57 medical records met the inclusion criteria while 14 medical records table 1 patient characteristics patient characteristics male(n=23) female (n=34) (n=57) % 0–5 years 0 0 0 0 6–11 years 0 0 0 0 12–25 years 3 4 7 12 26–45 years 4 12 16 28 46–65 years 10 13 23 40 >65 years 6 5 11 19 table 2 number of antibiotic type prescribed per patients number of antibiotic type patient (n=57) n % 1 type of antibiotic 16 28.07% 2 types of antibiotics 14 24.56% 3 types of antibiotics 16 28.07% 4 types of antibiotics 7 12.28% 5 types of antibiotics 3 5.26% 6 types of antibiotics 1 1.75% antibiotic utilization pattern in tertiary hospital intensive care unit in west java, indonesia :81–7 international journal of integrated health sciences. 2019;7(2) 83 table 5 shows that 131 antibiotic regimen were used in the icu and 57.25% of the therapy included a combination of antibiotics. in total, there were 48 types of antibiotics that were used, both in combination and as an individual antibiotic (table 6). discussion on average, 2.47 antibiotics were administered to each patient in the intensive care unit during the period of january–june 2016. this number is comparable to the number presented by a study in north india which found that the average antibiotic administration per patient was 3.36. however, this number is low when compared to the finding in other similar studies in east india with an average antibiotic administration of 10.5.8,9 a study conducted in 2016 in south india found that the most frequently used antibiotic is ceftriaxone, which is given to 22.77% of patients.10 this is consisted with the finding in this study as the most frequently used antibiotics were, in a descending order, ceftriaxone (54.39%), meropenem (47.37%), levofloxacin (42.11%), metronidazole (31.58%), and ceftazidime (22.81%). the total number of antibiotic uses in this study reached 295.72 ddd/100 bed-days with levofloxacin, ceftriaxone, meropenem, ceftazidime, and metronidazole as the five most frequently used antibiotics. this is relatively high when compared to the finding of a similar study in the university of zurich hospital with a total number of antibiotic use of 125.88 ddd/100 bed-days. this is also high when compared to a study in south india in 2014 with a total use of antibiotics of 148.97 ddd/100 bed-days.10,11 the relatively higher use of antibiotics in this study probably links to the fact that other previous studies were performed in 2006 and 2014 while the use of antibiotics tends to increase from year to year. similar results are demonstrated by a study in brazil where antibiotic use increases from 83.8 ddd/100 bed-days in 1990 to 124.6 ddd/100 beddays in 1996.10,12 the higher use of antibiotics does not always reflect effective treatments and reduction in patient mortality rate. a retrospective study in germany found that the overall mortality rate and resistance level fall when antibiotic consumption drops from 67.1 to 51.0 ddd/100 bed-days.13 there is a fear that the relatively high antibiotic use in the icu of the tertiary hospital where this study conducted will were excluded because the medical records were not available in the icu. of the 57 patients who met the inclusion criteria, female comprised the majority of the patients with 34 patients (60%), while the number of male patients were 23 (40%). most patients treated in the intensive care unit belongs to the age category of 46–65 years. the patients’ total length of stay in the icu during the study period was 418 days. the distribution of subject characteristics is presented in table 1. there were 18 types of antibiotics used for these 57 patients. on average, 2.47 types of antibiotics were given to each patient during the study period. resistance tests were performed in 17 patients (29.82%). the frequency of each type of antibiotics is presented in table 3. the total number of antibiotic used in the icu was 295.72 ddd/100 bed-days. table 4 shows that the three most commonly used antibiotics were levofloxacin, ceftriaxone, and meropenem with the total use of 143.18, 49.88, and 30.62 ddd/100 bed-days, respectively. table 3 frequency of individual antibiotics prescribed antibiotic patient (n=57) n % amikacin 4 7.02 cefepime 1 1.75 cefotaxime 3 5.26 ceftazidime 13 22.81 ceftriaxone 31 54.39 cefazolin 5 8.77 ciprofloxacin 1 1.75 erythromycin 1 1.75 gentamicin 1 1.75 levofloxacin 24 42.11 linezolid 1 1.75 meropenem 27 47.37 metronidazole 18 31.58 piperacillin/tazobactam 1 1.75 teicoplanin 1 1.75 tetracycline 1 1.75 tigecycline 4 2.84 vancomycin 4 7.02 taradharani wikantiananda, adi imam tjahjadi, et al. :81–7 84 international journal of integrated health sciences. 2019;7(2) table 4 antibiotic use pattern type of antibiotic atc code who ddd (g) total ddd unit used ddd/100 bed-days amikacin j01gb06 1 19.00 4.55 cefepime j01de01 2 12.00 2.87 cefotaxime j01dd01 4 8.25 2.97 ceftazidime j01dd02 4 82.50 19.74 ceftriaxone j01dd04 2 128.00 30.62 cefazolin j01db04 3 16.00 3.83 ciprofloxacin j01ma02 0.5 14.40 3.44 erythromycin j01fa01 1 7.50 1.79 gentamicin j01gb03 0.24 10.67 2.55 levofloxacin j01ma12 0.5 598.50 143.18 linezolid j01xx08 1.2 7.00 1.67 meropenem j01dh02 2 208.50 49.88 metronidazole j01xd01 1.5 71.00 16.99 piperacillin/tazobactam j01ca12 14 0.03 0.01 teicoplanin j01xa02 0.4 10.00 2.39 tetracycline j01aa07 1 8.00 1.91 tigecycline j01aa12 0.1 19.00 4.55 vancomycin j01xa01 2 15.75 3.77 table 5 characteristics of antibiotic use in icu characteristics regiment (n=131) n % antibiotic use monotherapy 56 42.75 combination 75 57.25 number of antibiotic type used single antibiotic 56 42.75 combination of 2 antibiotics 54 41.22 combination of >2 antibiotics 21 16.03 duration of administration < 2 days 46 80.70 2-3 days 34 59.65 4-7 days 46 80.70 > 7 days 5 8.77 antibiotic utilization pattern in tertiary hospital intensive care unit in west java, indonesia :81–7 international journal of integrated health sciences. 2019;7(2) 85 table 6 frequency of antibiotic prescription antibiotics prescription (n=131) n % amikacin 2 1.53% cefepime 1 0.76% ceftazidime 3 2.29% ceftriaxone 22 16.79% cephazolin 5 3.82% levofloxacin 6 4.58% meropenem 13 9.92% metronidazole 1 0.76% tigecyclin 1 0.76% vancomycin 2 1.53% amikacin—levofloxacin 1 0.76% amikacin—meropenem 2 1.53% amikacin—tigecyclin 1 0.76% amikacin—vancomycin 1 0.76% cefotaxime—ceftazidime 1 0.76% cefotaxime—levofloxacin 1 0.76% cefotaxime—metronidazole 1 0.76% ceftazidime—levofloxacin 7 5.34% ceftazidime—meropenem 1 0.76% ceftazidime—metronidazole 2 1.53% ceftriaxone—gentamycin 1 0.76% ceftriaxone—levofloxacin 4 3.05% ceftriaxone—meropenem 2 1.53% ceftriaxone—metronidazole 7 5.34% ceftriaxone—vancomycin 1 0.76% ciprofloxacin—metronidazole 1 0.76% erythromycin—tigecyclin 1 0.76% levofloxacin—meropenem 11 8.40% meropenem—metronidazole 5 3.82% meropenem—vancomycin 1 0.76% teicoplanin—tigecyclin 1 0.76% tigecyclin—vancomycin 1 0.76% amikacin—levofloxacin—meropenem 1 0.76% ceftazidime— cefepime—levofloxacin 1 0.76% ceftazidime—ceftriaxone—levofloxacin 3 2.29% ceftazidime—levofloxacin—meropenem 1 0.76% ceftazidime—levofloxacin—tigecyclin 1 0.76% ceftriaxone—gentamycin—levofloxacin 1 0.76% taradharani wikantiananda, adi imam tjahjadi, et al. :81–7 86 international journal of integrated health sciences. 2019;7(2) increase antibiotic resistance and reduce the effectiveness of antibiotic treatment. in early 2018, a study in the united states found that the risk of individuals contracting antibioticresistant bacteria increases with the proportion of patients treated with antibiotics.14 a study in lebanon at the end of 2017 also revealed that antibiotic use in hospitals are generally associated with an increased vulnerability of a hospital to antibiotic resistance.15 the data in this study showed that there were 131 antibiotic prescriptions given and 57.25% of them consisted of an antibiotic combination. the most common single antibiotic used was ceftriaxone (16.79%), and the most common antibiotic combination used was the combination of levofloxacin and meropenem (8.40%). this antibiotic combination is considered necessary to increase the effectiveness of therapy by expanding the spectrum of therapy or to anticipate antibiotic resistance.16 in conclusion, the use of antibiotics in the intensive care unit of the tertiary hospital in this study is considered high with a total of 295.72 ddd/100 bed-days when compared to other similar studies. the most frequently used of antibiotics is ceftriaxone, which is used in 54.39% of patients. whereas in number, the most widely used antibiotic is levofloxacin with a total of 143.18 ddd/100 bed-days. this study has many limitations, such as the retrospective nature of the study, the limited time (six months) for observing the antibiotic use pattern, and that the data used are only based on medical records. however, it can be seen that the types and regimens for antibiotic administration are very diverse. the use of antibiotics must be evaluated and a policy of antibiotic administration should be applied to reduce the excessive use of antibiotics. references 1. kleinpell r, blosser s, goldner j, birriel b, fowler cs, byrum d, et al. icu admission, discharge, and triage guidelines: a framework to enhance clinical operations, development of institutional policies, and further research. crit care med. 2016;1553–1602. 2. kouchak f, askarian m. nosocomial infections: the definition criteria. iran j med sci. 2012;37(2):72–3. 3. who. antimicrobial resistance, global report on surveillance. 2014. 4. holloway k. pharmaceuticals in health care delivery. mission rep. 2011;(february):1–38. 5. kementrian kesehatan ri. penggunaan antibiotik bijak dan rasional kurangi beban penyakit infeksi. 2015; 6. wahjono h, kristina tn. auditing peta medan kuman dan antibiogram sebagai educatedguess penanganan penyakit infeksi. media med indones. 2012;46(36):6–11. 7. leung e, weil de, raviglione m, nakatani h. the who policy package to combat antimicrobial resistance. bull world health organ. 2011;89(5):390–2. 8. mahajan b, kaushal s, chopra sc. a drug utilization study of antimicrobial agents (amas) in the intensive care units (icus) at medical college hospital of north india. 2013;15(3):129–32. 9. patanaik sk, pattanayak c, prasad a, chauhan as. drug utilization pattern in an intensive care unit setting in eastern india. international journal of basic & clinical pharmacology. 2015;4(6):1136–41. 10. anand n, nagendra nayak im, advaitha ceftriaxone—levofloxacin—meropenem 1 0.76% ceftriaxone—meropenem—metronidazole 4 3.05% cephazolin—ciprofloxacin—metronidazole 1 0.76% ciprofloxacin—meropenem—metronidazole 1 0.76% levofloxacin—meropenem—metronidazole 1 0.76% levofloxacin—meropenem—tetracyclin 1 0.76% linezolide—meropenem—metronidazole 1 0.76% meropenem—metronidazole—vancomycin 1 0.76% teicoplanin—piperacillin/tazobactam—tigecyclin 1 0.76% cephazolin—levofloxacin—meropenem—metronidazole 1 0.76% antibiotic utilization pattern in tertiary hospital intensive care unit in west java, indonesia :81–7 international journal of integrated health sciences. 2019;7(2) 87 mv, thaikattil nj, kantanavar ka, anand s. antimicrobial agents’ utilization and cost pattern in an intensive care unit of a teaching hospital in south india. indian j crit care med. 2016;20(5):274–9. 11. kuster sp, ruef c, ledergerber b, hintermann a, deplazes c, neuber l, et al. quantitative antibiotic use in hospitals: comparison of measurements, literature review, and recommendations for a standard of reporting. urban & vogel. 2008;36(6):549–59. 12. de castro m, pilger d, ferreira m, kopittke l, de. trends in antimicrobial utilization in a university hospital, 1990-1996. rev saude publica. 2002;36(553–8). 13. scholze k, wenke m, schierholz r, groß u, bader o, zimmermann o, et al. the reduction in. 2015;2011(december 2013). 14. almagor j, temkin e, benenson i, fallach n, carmeli y. the impact of antibiotic use on transmission of resistant bacteria in hospitals: insights from an agent-based model. plos one. 2018;13(5)(e0197111). 15. wang a, daneman n, tan c, brownstein j, macfadden d. evaluating the relationship between hospital antibiotic use and resistance in common nosocomial pathogens. infect control hosp epidemiol. 2017;38(12):1457– 63. 16. ahmed a, azim a, gunjar m, baronia a. current concepts in combination antibiotic therapy for critically ill patients. indian j crit care med. 2014;18(5)(310–4). taradharani wikantiananda, adi imam tjahjadi, et al. :81–7 34 international journal of integrated health sciences. 2019;7(1) original article prevalence of hematotoxic effect of intravenous chemotherapy among retinoblastoma population in tertiary hospital in bandung, indonesia abstract objective: to observe the prevalence of hematotoxic effect in retinoblastoma patients who were given intravenous chemotherapy with vincristine, etoposide, and carboplatin (vec) regimen. retinoblastoma is the second most common cancer in children in indonesia. standard chemotherapy agents used in retinoblastoma treatment is vec given in 7 cycles intravenously. the most common side effect of vec regimen is hematotoxic effect which might lead to chemotherapy failure. methods: this study used descriptive method with cross sectional study design. data were collected from medical records of retinoblastoma patients in dr. hasan sadikin general hospital bandung, indonesia, from 2014 until 2016 using total sampling technique. results: forty-six patients were included in this study. of those subjects, 36 (78.3%) patients experienced hematotoxic effect. the most common hematotoxic effect occurred were anemia and neutropenia, that occurred in 32 (69.6%) and 18 (39.1%) patients, respectively. the most common hematotoxic effect severity occurred were grade 1 anemia, grade 1 leukopenia, grade 1 neutropenia, and grade 3 thrombocytopenia. percentage of patients experienced anemia tended to increase until the 7th cycle. seven (15.2%) patients had anemia prior to chemotherapy administration. conclusions: the majority (78.3%) of the patients experienced hematotoxic effect on intravenous chemotherapy administration with vec regimen. anemia was the most common hematotoxic effect occurred. keywords: hematotoxic effect, intravenous chemotherapy, retinoblastoma pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v7n1.1520 ijihs. 2019;7(1):34–8 introduction retinoblastoma is a tumor of retina originating form neuronal progenitor cell and is the most common ocular malignancy of childhood.1 in indonesia, retinoblastoma is regarded as the second of most common malignancy in children after leukemia.1 the retinoblastoma treatment required multidisciplinary approach with considering the effectivity and toxicity of therapy in order to preserve life, eyeball, and vision.2 there are several treatment choices for retinoblastoma, including chemotherapy, focal therapy, radiotherapy, and enucleation.3 chemotherapy can be given intravenously (systemically), intra-arterially, intravitreally, or subconjuctivally.4 standard chemotherapy agent used for retinoblastoma is the combination of vincristine, etoposide, and carboplatin (vec protocol), that is given intravenously, due to their good intraocular penetration.4 systemic chemotherapy might cause several side effects, including hematotoxicity, fever, ototoxicity, nephrotoxicity, and secondary leukemia.2 jennifer hadiman,1 susi susanah,2 adhi kristianto sugianli3 1faculty of medicine universitas padjadjaran 2division of microbiology, department of biomedical science, faculty of medicine universitas padjadjaran 3division of ankle and foot, department of orthopaedics and traumatology, faculty of medicine, universitas padjadjaran-dr. hasan sadikin hospital, bandung correspondence: jennifer hadiman, faculty of medicine, universitas padjadjaran jl. raya bandung-sumedang km 21 jatinangor, indonesia e-mail: jenniferhadiman@gmail.com received: december 11, 2018 revised: march 12, 2019 accepted: march 21, 2019 :34–8 international journal of integrated health sciences. 2019;7(1) 35 hematotoxicity is the effect of chemical agent exposure on the hematopoietic system, including blood and its components, and blood-forming organs.5 chemotherapy drugs can destroy cancer cells by inhibiting cancer cells ability to grow and divide, however, the damage might also occur on normal cells, including the cells in hematopoietic system, which might cause several hematotoxic effects such as anemia, thrombocytopenia, and neutropenia.5 hematotoxicity occurs due to chemotherapy failure caused by several mechanisms.6 anemia could cause delay in initiating chemotherapy, failure to complete the chemotherapy, and resistance to chemotherapy, so that it had impact on quality of life, disease progression, and survival of cancer patients.7 neutropenia could increase the risk of developing infections that could lead to oncology emergencies. thrombocytopenia is primary cause of bleeding in cancer patients and could cause anemia.8 the study relating to hematotoxic effect as the most common chemotherapy side effects was still limited in indonesia. this study aimed to observe prevalence of hematotoxic effect in retinoblastoma patients received intravenous chemotherapy in dr. hasan sadikin general hospital, bandung. methods this study used descriptive method with cross-sectional study design. data were collected based on medical records of patients who diagnosed as retinoblastoma in department of child health dr. hasan sadikin general hospital bandung, west java province, indonesia. population of this study was retinoblastoma patients who were given the systemic chemotherapy in dr. hasan sadikin general hospital, bandung between january 2014 to december 2016. the inclusion criteria were retinoblastoma patients that were given first cycle of systemic chemotherapy with vec regimen between 1 january 2014 to 31 december 2016. data were excluded if there was incomplete medical records data, absence of seventh cycle hematological data and the available hematological data were less than 4 cycles of chemotherapy. in this study, data were collected and observed until the first 7 cycle of chemotherapy, according to the standard regulation chemotherapy with vec regimen. the data were collected and recorded for age, sex, nutritional status, family history, :34–8 jennifer hadiman, susi susanah, et al. table 1 characteristic number (n=46) percentage (%) age (months) <13 5 10.9 13–36 25 54.3 37–60 10 21.7 >60 6 13.0 sex male 28 60.9 female 18 39.1 residency west java 33 71.7 central java 2 4.3 special region of yogyakarta 1 2.2 south kalimantan 1 2.2 lampung 7 15.2 no data 2 4.3 nutritional status undernutrition 8 17.4 normal 34 73.9 overnutrition 2 4.3 no data 2 4.3 family history no 46 100.0 yes 0 0.0 first clinical presentation leukocoria 25 54.3 strabismus 0 0.0 red eye 4 8.7 proptosis 2 4.3 periorbital edema 1 2.2 others 1 2.2 no data 13 28.3 laterality unilateral 39 84.8 bilateral 7 15.2 retinoblastoma patients characteristics 36 international journal of integrated health sciences. 2019;7(1) first clinical manifestation, laterality of retinoblastoma, and hematological data (hemoglobin, leukocyte, absolute neutrophil count, and thrombocyte). nutritional status was assessed by using world health organization (who) weight-for-length/height growth chart.9 all the hematological data were data prior to each chemotherapy cycles. the hematotoxic effects were categorized into anemia, leukopenia, neutropenia, and thrombocytopenia based on who toxicity grading scale recommendation.10 the who classification was listed in table as supplement. data were analyzed using ibm® spss® version 24 and presented as tables and graphs with number and percentage. this study was approved by research ethics committee faculty of medicine universitas padjadjaran (number 228/un6.kep/ec/2018). results there were 117 retinoblastoma patients came to department of child health dr. hasan sadikin general hospital bandung between 2014 and 2016. from 117 patients, 72 patients fulfilled inclusion criteria and 26 from 72 patients were excluded from this study (fig. 1). among 46 patients included in this study, 25 (54.3%) patients were between 13–36 months old. age range in this study was 3–130 months old. the numbers of males were higher than female patients.the majority of the patients (71.7%) were from several cities in west java province. all patients (100%) did not have family history of retinoblastoma. first clinical presentation in 25 (54.3%) patients was leukocoria. thirty-nine (84.8%) patients had unilateral retinoblastoma. the characteristics of the patients were described (table 1). there were 36 (78.3%) patients experienced hematotoxic effect, either anemia, leukopenia, neutropenia, or thrombocytopenia. in addition, the hematotoxic effect was more common in age group 13–36 months, male patients, and normal nutritional status (fig. 1). among 46 subjects, anemia, leukopenia, neutropenia and thrombocytopenia were observed in 32 (69.6%), 8 (17.4%), 18 (39.1%), and 4 (8.7%) patients, respectively. the most common hematotoxic effect severity occurred was grade 1 for anemia, leukopenia, and neutropenia, and grade 3 for thrombocytopenia (fig. 2). in this study, anemia commonly occurred as the hematotoxic effect. there were 7 patients already experienced anemia before given the first cycle of chemotherapy. the percentage of patients experienced anemia tended to increase from cycle 1 until cycle 7 (fig. 3). flow chart of patients who met inclusion/exclusion criteria of the study fig. 1 hematotoxic effect based on patients characteristics fig. 2 hematotoxic effect severity based on who toxicity grading9 fig. 3 prevalence of hematotoxic effect of intravenous chemotherapy among retinoblastoma population in tertiary hospital in bandung, indonesia :34–8 international journal of integrated health sciences. 2019;7(1) 37 discussion retinoblastoma patients in this study were mostly between 13–36 months old. this was similar with the previous study in east java that retinoblastoma most common occurred in children aged 12–<36 months old.11 a study in india also found that 54% of retinoblastoma patients were between 1–3 years old.12 the most common first clinical presentation was leukocoria. this finding was similar to studies in other countries in asia pacific that leukocoria was the most common first clinical manifestation.12,13 because of high incidences of leukocoria as the first clinical presentation in retinoblastoma, a child should be suspected retinoblastoma if his/her eye reflects light like a cat’s eye, particularly in children less than 3 years old. in this study, it was found that 36 (78.3%) patients experienced hematotoxic effect and the most common hematotoxic effect was anemia. a study conducted by qaddoumi et al.14 on retinoblastoma patients given topotecan and vincristine combination chemotherapy discovered that neutropenia occurred in all (100%) patient, while anemia occurred in 70% patients, and thrombocytopenia occurred in 59% patients. in other study by caubet at al.15 on prostate cancer patients that were given carboplatin and etoposide combination chemotherapy also found that the most common hematotoxic effect was anemia that occurred in 33.3% patients. the standard chemotherapy regimen for retinoblastoma consisted of 3 chemotherapy agents: vincristine, etoposide, and carboplatin. hematotoxic effect caused by vincristine was mild and not significant.16 hematotoxic effect caused by etoposide were mainly leukopenia and thrombocytopenia.16 the main side effect caused by carboplatin was hematotoxic effect, mainly neutropenia and thrombocytopenia.17 besides damaging hematopoietic cells in bone marrow, platinum-based chemotherapy agent like carboplatin was also nephrotoxic, so that erythropoietin production in kidney was impaired.18 this made carboplatin frequently caused anemia. in this study it was found that percentage of patients experienced anemia tended continue to increase until 7th cycle. in a study on breast, lung, colon/rectal, stomach, and ovarian cancer patients given chemotherapy, it was found that anemia occurrence continued to increase until 5th or 6th cycle.19 this was likely due to hematotoxic effect accumulation during chemotherapy administration.19 the most common hematotoxic effect severity occurred in this study tended to be mild, that was grade 1 for anemia, leukopenia, and neutropenia, and grade 3 for thrombocytopenia. in another study on retinoblastoma patients that were given intravenous chemotherapy with vincristine, etoposide, and carboplatin regimen in 3 cycles and vincristine, cyclophosphamide, and doxorubicin regimen in 3 cycles, the most common hematotoxic effect occurred were grade 3 anemia, grade 3 leukopenia, grade 4 neutropenia, and grade 3 thrombocytopenia.20 this difference was likely due to the different chemotherapy regimen given and the small number of subjects in this study. there were 32 patients experienced anemia in this study and in this study, it was found that 7 (15.2%) patients experienced anemia before given the first cycle of chemotherapy. therefore, anemia was a challenge in retinoblastoma treatment because besides retinoblastoma itself caused anemia due to chronic disease, the chemotherapy given also caused anemia by depressing bone marrow. because there were patients who had anemia prior to chemotherapy, it was important to do hematological screening before initiating chemotherapy. based on the result of the study, a conclusion can be made that there are 78.3% retinoblastoma patients who received intravenous chemotherapy with vec regimen experience hematotoxic effect. anemia is the most common hematotoxic effect that occur in 69.6% patients and 15.2% patients have anemia prior to initiating chemotherapy. limitation of this study was this study was done retrospectively from the medical record percentage of patients experienced anemia in each chemotherapy cycle fig. 4 jennifer hadiman, susi susanah, et al. :34–8 38 international journal of integrated health sciences. 2019;7(1) prevalence of hematotoxic effect of intravenous chemotherapy among retinoblastoma population in tertiary hospital in bandung, indonesia references 1. kementerian kesehatan republik indonesia. pedoman penemuan dini kanker pada anak: jakarta: kementerian kesehatan republik indonesia; 2011. 2. ghassemi f, khodabande a. risk definition and management strategies in retinoblastoma: current perspectives. clin ophthalmol. 2015;9(3):985–94. 3. mendoza pr, grossniklaus he. therapeutic options for retinoblastoma. cancer control. 2016;23(2):99–109. 4. yanik ö, gündüz k, yavuz k, taçyıldız n, ünal e. chemotherapy in retinoblastoma: current approaches. turk j ophthalmol. 2015;45(6):259–67. 5. sherley jl. human stem cell toxicology. cambridge: the royal society of chemistry; 2016. 6. papież ma. the effect of quercetin on oxidative dna damage and myelosuppression induced by etoposide in bone marrow cells of rats. acta biochimica polonica. 2014;61(1):7–11. 7. busti f, marchi g, ugolini s, castagna a, gerelli d. anemia and iron deficiency in cancer patients: role of iron replacement therapy. pharmaceuticals.2018;11(94):1–14. 8. brigle k, pierre a, oliver ef, faiman b, tariman jd, miceli t, et al. myelosuppression, bone disease, and acute renal failure. clin j oncol nurs. 2018;21(5):60–76. 9. world health organization. who multicentre growth reference study group. geneva: world health organization; 2006. 10. world health organization. guidelines for monitoring and reporting adverse events drug reactions 2013. [cited 2018 dec 6]. available from: https://apps.who.int/medicinedocs/ documents/s18571en/s18571en.pdf. 11. soebagjo hd, prastyani r, sujuti h, lyrawati d, sumitro sb. profile of retinoblastoma in east java, indonesia. world j med med sci res. 2013;1(3):51–6. 12. subha l, reddy as, ramyaa. a clinical study of retinoblastoma. j pharm bioallied sci. 2015;7(suppl 1):s2–s3. 13. choi s, han jw, kim h, kim bs, kim dj, lee sc, et al. combined chemotherapy and intra-arterial chemotherapy of retinoblastoma. korean j pediatr. 2013;56(6):254–9. 14. qaddoumi i, billups ca, tagen m, stewart cf, wu j, helton k, et al. topotecan and vincristine combination is effective against advanced bilateral intraocular retinoblastoma and has manageable toxicity. cancer. 2012;118(22):5663–70. 15. caubet m, dobi e, pozet a, almotlak h, montcuquet p, maurina t et al. carboplatinetoposide combination chemotherapy in metastatic castration-resistant prostate cancer: a retrospective study. molecular and clinical oncology. 2015;3(6):1208–12. 16. chu e, devita vt. physicians’ cancer chemotherapy drug manual. massachusetts: jones & bartlett learning; 2015. 17. chen x, wang j, fu z, zhu b, wang j, guan s, et al. curcumin activates dna repair pathway in bone marrow to improve carboplatin-induced myelosuppression. sci reprt. 2017;7(1):1–11. 18. doleschel d, rix a, arns s, palmowski k, gremse f, markle r, et al. erythropoietin improves the accumulation and therapeutic effects of carboplatin by enhancing tumor vascularization and perfusion. theranostics. 2015;5(8):905–18. 19. xu h, xu l, page jh, cannavale k, sattayapiwat o, rodriguez r, et al. incidence of anemia in patients diagnosed with solid tumors receiving chemotherapy. clin epidemiol. 2016;8(1):61– 71. 20. sullivan em, wilson mw, billups ca, wu j, merchant te, brennan rc, et al. pathologic riskbased adjuvant chemotherapy for unilateral retinoblastoma following enucleation. j pediatr hematol oncol. 2014;36(6):335–40. of retinoblastoma patients and there were many incomplete or unreadable data. this study was beneficial to physicians, particularly pediatricians, to anticipate hematotoxic effects related to chemotherapy administration, and anemia, as well. the physicians should also anticipate anemia occurrence which tended to increase as more chemotherapy cycles were given. it is important to do hematological screening before chemotherapy administration, so that the cause of anemia can be investigated and treated prior to chemotherapy. :34–8 international journal of integrated health sciences. 2018;6(1) 1 correlation between handgrip strength, mobilization function, physical activity level, and muscle mass in community-dwelling elderly in bandung, west java province, indonesia abstract objective: to investigate correlation between handgrip strength, mobilization function, and physical activity level (pal), and muscle mass in communitydwelling indonesian elderly. methods: this was a cross-sectional study 193 subjects aged 60–90 years. handgrip strength was measured using handgrip dynamometer while the mobilization function was assessed by performing gait speed test. global physical activity questionnaire (gpaq) was used to assess the participant’s pal and bio impedance analyzer was used to measure the participant’s muscle mass based on skeletal mass index. results: significant positive correlations were discovered between handgrip strength and walking speed (rs. 0.501; p<0.001), pal (rs. 0.153; p=0.003), and muscle mass (rs. 0,452; p<0.001). conclusions: stronger handgrip determines greater mobilization function, physical activity level, and bigger muscle mass in community-dwelling indonesian elderly. keywords: gait speed, handgrip strength, muscle mass, physical activity pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v6n1.1047 ijihs. 2018;6(1):1–5 received: july 10, 2017 revised: august 8, 2017 accepted: february 19, 2018 correspondence: sari sekarsari, rehabilitation medicine instalation, west java province mental hospital jl. kolonel masturi km 07, cipada, cisarua, kabupaten bandung barat, west java, indonesia e-mail: sarisekarsari@gmail.com introduction one of the triggers of decrease in muscle mass and strength is aging. a decrease of 1–2% per year is usually seen after the age of 50 years old.1 longitudinal and interventional studies reveal that muscle atrophy slightly contributes to the reduction in muscle strength.2 lower extremity muscle strength is regarded as one of mobilization predictors. decreased lower extremity muscle strength leads to limitation of mobilization function which becomes a major factor in reduced physical and functional performance among elderly.3 a previous study stated that the handgrip strength is an indicator of the overall muscle strength. handgrip strength was found to be correlated with lower extremity strength.4 various factors could influence the handgrip strength value, which maybe different among countries.5 data related to handgrip strength in indonesian elderly are still scarce. therefore, this study aimed to examine the correlation between handgrip strength and mobilization function, physical activity level (pal), and muscle mass in indonesian elderly. methods this was a cross-sectional study conducted in bandung from september 2015 to march 2016. the subjects in the study were communitydwelling elderly who visited public health centers in three subdistricts in bandung city, indonesia i.e. batununggal, cibeunying, and coblong. consecutive sampling was used in this study. original article :1–5 sari sekarsari,1 vitriana,2 irma ruslina defi2 1rehabilitation medicine instalation, west java province mental hospital 2department of physical medicine and rehabilitation, faculty of medicine, universitas padjajaran-dr. hasan sadikin general hospital, bandung 2 international journal of integrated health sciences. 2018;6(1) inclusion criteria in the study were elderly aged 60–90 years old, had mini mental status examination (mmse) score of ≥24, able to walk independently both indoors and outdoors with or without a walker, signing the approval form after informed consent, and not staying at any retirement home. subjects were excluded from this study if subject had musculoskeletal and neuromuscular disorders that prevent them to walk independently; used artificial metal implant including the use of cardiac pacemaker that may interfere with the accuracy of the assessment; suffered from any malignancy, chronic inflammation, congestive cardiomyopathy, as well as kidney disorders which caused muscle mass decrease; and deformity and weakness in upper extremity that influence the handgrip. this study was approved through the ethical clearance by the health research ethic committee, faculty of medicine, universitas padjadjaran. handgrip strength is the maximum muscle strength produced by the contraction of the hand muscle during handgrip. the handgrip strength measurement was performed using lafayette hand dynamometer in a standing position. the measurement results were then interpreted in kilogram (kg).6 mobilization function physical performance assessment was conducted by performing gait speed test. at the beginning of the test, the subjects stood behind the starting line. the subjects were instructed to walk a 11-meter distance with possible speed and stop after entering the finish line. the subjects were previously informed about the possibility of experiencing problems such as shortness of breath and weakness while walking. if problems were found when performing the test, the subjects were allowed to slow the steps or stop. the results were the gait speed taken from 5 to 11 meter (the last 6 meter). therefore, the results were interpreted into meter/second.7 physical activities are considered as all body movements performed by skeletal muscles that requires the expenditure of energy, such as working, playing, and traveling.8 the physical activity level in this study was assessed using global physical activity questionnaire (gpaq) standardized by the world health organition (who) which had been validated or translated into indonesian. the questionnaire consists of 16 questions related to the intensity of the physical activities done by the subjects in three conditions i.e. physical activity while working, moving from a place to another place, recreating, and sedentary behavior. the data were assessed by using gpaq analysis guide and metabolic equivalent per minute (metminutes) and the results were calculated every week and classified based on age. high activity duration time coefficient equals to met energy of 8, while moderate activity duration time coefficient equals to met energy of 4. high pal were those who reached minimum 1500 met-times in 3 days per week or 7 days or more doing walking combination of moderate and high pals reaching minimum 3000 met-minutes per week. moderate pal typically found in those who performed 3 days or more high pal minimum 20 minutes per day or 5 days or more doing moderate pal or walking minimum 30 minutes per day or 5 days or more doing combination of walking, moderate and high pals reaching minimum 600 met-minutes per week. low pal are those who did not meet moderate and high pals criteria. sedentary behavior was classified based on the total minutes per day in sitting, traveling using a vehicle, watching television, reading, playing cards, and sleeping without any time estimation.8 in addition, the pal assessment was performed through selfreported questionnaire. data on the appendicular skeletal muscle mass index (asmi) were collected by using bio impedance analyzer (bia/tanita bc601, tanita corp, tokyo, japan). in the study, the formula used to measure the muscle mass is the appendicular skeletal muscle mass index= asmi/(height)2. the data obtained would be interpreted in kilogram (kg/m2).7 shapiro wilks test was used to investigate the normality of data distribution. correlational analysis was used to examine the correlation between handgrip strength, walking speed, pal, and muscle mass using pearson or rank spearman correlation test depending on data distribution. results of 203 participants, only 193 subjects, which consisted of 130 females and 63 males, met the inclusion criteria. characteristics of subjects were described in details (table 1). the mean age of the study subjects was 68.14±7.2 years for female and 70.84 years for male, with half of the study subjects had moderate pal. the average asmi value for female subjects was lower than for male subjects (6.9 vs. 8.12 kg/m2), while the average gait speed value was higher in males than in females (0.68 vs. 0.57 m/second). male handgrip strength was correlation between handgrip strength, mobilization function, physical activity level, and muscle mass in community-dwelling elderly in bandung, west java province, indonesia :1–5 international journal of integrated health sciences. 2018;6(1) 3 sari sekarsari, vitriana, et al. :1–5 table 1 subject characteristics characteristics female (n=130) male (n=63) age (years)* ≤70 83 (63.8%) 32 (50.8%) 71–80 40 (30.7%) 24 (38.1%) 81–90 7 (5.4%) 7 (11.1%) mean (sd) 68.14 (7.2) 70.84 (7.69) physical activity level* low 35 (26.9%) 15 (23.8%) moderate 59 (45.4%) 32 (50.8%) high 36 (27.7%) 16 (25.4%) asmi (kg/m2)* mean (sd) 6.90 (1.09) 8.12 (1.13) gait speed* (m/second) mean (sd) 0.57 (0.2) 0.68 (0.2) handgrip strength* (kg) mean (sd) 14.14 (4.6) 25.03 (5.76) notes: *distribution is not normal by shapiro wilks normality test asmi= appendicular skeletal muscle mass index; bmi= body mass index stronger than female handgrip strength (25 vs. 14 kg). the correlations between the handgrip strength, walking speed, physical activity level, and muscle mass were considered statistically significant, albeit not strong (table 2). discussion the number of female subjects in this study was higher. this is consistent with the data that is published by the ministry of health of republic indonesia in 2014 stating that the prevalence of life after middle age of females is higher than males.9 the higher life expectancy for females is influenced by the physicological indulgent condition and the ability to control emotion and feelings, describing that females are more prepared to face problems than males. the ability to adapt to various aspects of life becomes the main reason that female elderly can show satisfaction in any condition in life.10 another possibility is that women are more likely to participate in community activities than men; hence, women visit public health care more than men.11 in this study, the average handgrip strength value in males (25 kg) is higher than females (14 kg). the values gained in this study are lower than those of a similiar study conducted on elderly aged >65 years old in korea (27.7 kg in males, 14.9 kg in females) and also when compared with the results of a study conducted on elderly >60 years old in germany (45 kg in males, 26 kg in females).12 the difference in handgrip strength is caused by ethnicityrelated anthropometric differences as well as different muscle characteristics. africans and americans have the highest skeletal muscle mass values, followed by white, hispanic, and asian people.13 a significant correlation between handgrip strength and gait speed was ascertained in this study. an earlier study has shown a correlation between upper extremity muscle mass and handgrip strength as well as between lower extremity muscle mass and gait speed.14 this is also supported by a study which reported that handgrip strength in elderly correlates with hand flexion, knee extensor, and trunk flexion and extension that play a role in walking; therefore, the correlation between handgrip strength and gait speed can be explained.15 correlation rs* p value handgrip strength and asmi 0.4516 < 0.001** handgrip strength and physical activity level 0.1527 0.0340** handgrip strength and gait speed 0.501 < 0.001** minimum 7 19 maximum 17 39 table 2 correlation between handgrip strength, gait speed, physical activity level, and skeletal mass index 4 international journal of integrated health sciences. 2018;6(1) gait speed is associated with age, strength, physical activity, and cardiovascular diseases.16 it is also used as an indicator of the physical performance mobilization in elderly because walking requires energy, movement control, and support from particular systems in the body including the cardiovascular, neural, and musculoskeletal systems.15 in this study, half of the total number of subjects have moderate pal. a study using gpaq on pal among > 65 years old elderly in czech republic has revealed that 52.8% of the subjects have a low pal while 18.9% and 28.3% of the subjects have a moderate and high pal scores, respectively.17 the results in this study are higher when compared to the previous study.17 this might be due to the fact that the age range of the subjects in this study is younger than the subjects in the study conducted in czech republic (60–90 vs 65–90 years). the average asmi scores are 6.9 kg/m2 and 8.12 kg/m2 for females and males, respectively, which is in line with the result of a previous study stating that male muscle mass is higher than females in the later stages of life. this is associated with the presence of testosterone hormone. meanwhile, the fat composition in females is higher than in males.18 a correlation between the handgrip strength and asmi is found. skeletal muscles play a role in voluntary movements. in elderly, decrease in muscle mass occurs due to the decrease in muscle fiber, motor unit and muscle fiber size. decrease in muscle fiber becomes a trigger for a decrease in muscle strength. cellular, neural, and metabolical factors also play a role in the reduction of the muscle strength.1,19 a careful interpretation on the results of this study is needed due to its cross-sectional design and the fact that it only included local citizens of bandung, making it less likely to represent indonesian elderly. with that in mind, it can be concluded that stronger handgrip may determine greater mobilization function, physical activity level, and bigger muscle mass in community-dwelling indonesian elderly. :1–5 references 1. keller k, engelhardt m. strength and muscle mass loss with aging process age and strength loss. muscles ligaments tendons j. 2013;3(4): 346–50. 2. delmonico m, harris t. longitudinal study of muscle strength, quality and adipose tissue infiltration. am j clin nutr. 2008;90(6): 1579– 85. 3. liu lk, lee wj, liu cl, chen ly, lin mh, pneg ln, et al. age-related skeletal muscle mass loss and physical performance in taiwan: implications to diagnostic strategy of sarcopenia in asia. geriatr gerontol int. 2013;13(4):964–71. 4. wang cy, olson sl, protas ej. lower extremity muscle performance associated with community ambulation in elderly fallers. asian j gerontol geriatr. 2009;4(1):52–7. 5. sirajudeen mh, shah u, pillai ps, mohasin n, shantaram m. correlation between grip strength and physical factors in men. int j health rehabil sci. 2012;1(2):58–63. 6. el-sais wm, mohammad ws. influence of different testing postures on hand grip strength. eur sci j. 2014;10(36):290–301. 7. chen lk, liu lk, woo j, assantachai p, auyeung tw, bahyah ks, et al. sarcopenia in asia: consensus report of the asian working group for sarcopenia. j am med dir assoc. 2014;15(2):95–101. 8. world health organization. global physical activity surveillance. [cited 2015 july 6. available form: http://www.who.int/chp/ steps/gpaq/en/. 9. yudianto, budijanto d, hardhana b, soenardi t. profil kesehatan indonesia 2014. jakarta: kementrian kesehatan republik indonesia; 2015. 10. yuliati a, baroya n, ririanty m. perbedaan kualitas hidup lansia yang tinggal di komunitas dengan di pelayanan sosial lanjut usia. pustaka kesehatan. 2014;2(1)87–94. 11. prachuabmoh v. preparation for old age and social participation of present and future old persons in thailand: gender difference. in: devasahayam wt, editor. gender and ageing: southeast asian perspectives. singapore: iseas; 2014. p. 115–7. 12. lee je, kim kw, paik n, jang h, chang cb, et al. evaluation of factors influencing grip strength in elderly koreans. j bone metab. 2012;19(2):103–10. 13. silva a, shen w, heo m, gallagher d, wang z, sardina lb, et al. ethnicity-related skeletal muscle differences across the lifespan. am j correlation between handgrip strength with mobilization function, physical activity level, and muscle mass in community-dwelling elderly in bandung, west java province, indonesia international journal of integrated health sciences. 2018;6(1) 5:1–5 hum biol. 2010;22(1):76–82. 14. wang cy, olson sl, protas ej. lower extremity muscle performance associated with community ambulation in elderly fallers. asian j gerontol geriatr. 2009;4(1):52–7. 15. deeg d, bouter l. skeletal muscle mass and muscle strength in relation to lower extremity performance in older men and women. j am geriatr soc. 2000;49(4):380–7. 16. busch t, duarte y, nunes d, lebrao m, naslavsky m, rodrigues a, et al. factors associated with lower gait speed among the elderly living in a developing country: a crosssectional population-based study. bmc geriatr [serial on the internet]. 2015 apr [cited 2016 mar 7];15(35):[about 9p.]. available from: h t t p s : / / b m c g e r i a t r. b i o m e d c e n t ra l . c o m / articles/10.1186/s12877-015-0031-2. 17. hamrik z, sigmundora d, sigmund e. physical activity and sedentary behavior in czech adults. eur j sport sci. 2014;14(2):193–8. 18. bai hj, sun jq, chen m, xu df, xie h, yu zw, et al. age related decline in skeletal muscle mass and function among elderly men and women in shanghai, china: a coss sectional study. asia pac j clin nutr. 2016;25(2)326–32. 19. clark g, kortebein p, siebens h. aging and rehabilitation. in: fontera w, editor. delisa’s physical medicine and rehabilitation. philadelphia: lippincot williams & wilkins; 2010. p. 1545–77. sari sekarsari, vitriana, et al. international journal of integrated health sciences. 2019;7(1) 9 original article prevalence of trichomonas vaginalis based on clinical manifestation and polymerase chain reaction among reproductive women correspondence: huriyah hafizhotul ‘ummah, faculty of medicine, universitas padjadjaran jl. raya bandung-sumedang km 21 jatinangor, indonesia e-mail: huriyah.hafizhotul@gmail.com abstract objective: to measure the prevalence of trichomonas vaginalis (t. vaginalis) based on clinical manifestations and polymerase chain reaction (pcr) among reproductive women. methods: subjects of the study were the vaginal swab obtained from reproductive women who attended the gynecology examination at kandanghaur and sindang primary health care of indramayu district, west java in 2016. this study was a descriptive study with cross-sectional method. sampling was performed with total sampling method and 76 of vaginal swabs were included in this study. the prevalence of t. vaginalis was measured using pcr. the vaginal specimens were collected and then processed for pcr analysis using tvk3/tvk7. results: prevalence of t. vaginalis among reproductive women in indramayu district, west java that analyzed using pcr was 0%. this result could be affected by the study setting in community, presence or absence of symptoms, and population studied. conclusions: there were no positive results of t. vaginalis, suggested by the samples that obtained from community-based of a low-risked population. keywords: trichomonas vaginalis, polymerase chain reaction, prevalence, reproductive women pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v7n1.1490 ijihs. 2019;7(1):9–15 introduction trichomonas vaginalis (t. vaginalis) is a flagellated protozoa known as the most common human parasite that responsible for sexually transmitted infection (sti) in the world.1–5 world health organization (who) estimated that there were 170–190 million cases of t. vaginalis infection worldwide each year and nearly 90% of these infections occur in resource-limited settings country.1,2,4 according to who estimation, the prevalence of t. vaginalis infection in women between the ages of 15 and 49 in 2008 were 22% in america, 20.2% in africa, 8% in eastern mediterranean, 5.8% in europe, 5.7% in western pacific, and 5.6% in southeast asia.6 the prevalence of the t. vaginalis infection in indonesia had not been clearly studied. however, a study showed that the prevalence of t. vaginalis among female workers in kupang, nusa tenggara timur province was 5%.7 the trichomonas vaginalis infection or trichomoniasis among women has been associated with mild to severe reproductive health outcomes including vaginitis, cervicitis, urethritis, low birth weight, premature rupture of membranes, pre-term delivery, and pelvic inflammatory disease.3,4 trichomoniasis also have several serious complications received: november 26, 2018 revised: february 24, 2019 accepted: march 19, 2019 :9–15 huriyah hafizhotul ‘ummah,1 gita widya pradini,2 reiva farah dwiyana,3 muhammad ersyad hamda2 1faculty of medicine, universitas padjadjaran 2department of microbiology and parasitology, faculty of medicine, universitas padjadjaran 3department of dermatology and venereology, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital, bandung 10 international journal of integrated health sciences. 2019;7(1) including increased risk of hiv acquisition, increased risk of cervical cancer, and shedding of herpes simplex virus-2 (hsv-2) in the genital tract of women, which could result in increased transmission of other stis.1,3,4 while 73% of women infected with t. vaginalis are asymptomatic, one-third of them became symptomatic within six months.3 in women who have symptoms, usually the symptoms are similar to other stis, include vaginal discharge which is often malodorous and yellow-green colour, dysuria, itching, vulvar irritation, and abdominal pain.1,8 however, trichomoniasis has specific symptoms that only occurred in 2–5% of women, known as “strawberry cervix”, as well as frothy vaginal discharge in 12% of women with trichomoniasis.8 there are several methods to identify t. vaginalis include wet mount microscopy, culture, and nucleic acid amplifications tests (naats).9 wet mount microscopy method has low sensitivity, which ranges from 44% to 68% and requires trained microscopist.10 the sensitivity can dramatically reduce if there was a delay as short as 10–30 minutes between collection and microscopic examination.10 meanwhile, culture method provides sensitivity that ranges from 44–75% but needs daily examination by a trained microscopist and the final result may take up to a week.10 both wet mount microscopy and culture method, require specimen handling, processing, and transport conditions to preserve viable, motile organism.10 in contrast with naats method, polymerase chain reaction (pcr) is one of the naats method using replication and amplification technique from specific individual deoxyribonucleic acid (dna) target sequences. thus, the sensitivity of naats is inherently greater than other methods ranges from 76–100%.10 primer sets tvk3/tvk7 known as the most sensitive primer among others primer sets to identify t. vaginalis because the target of this primer is a repetitive dna fragment that improve the detection level and produce positive results on specimens from asymptomatic women.11 the prevalence of t. vaginalis has been found to vary according to geographical location, study setting (sexual health clinic or community setting), the presence or absence of symptoms, population studied (ethnic group, age, and sex), and the diagnostic techniques used.7 this study identified t. vaginalis from reproductive women using vaginal swab as the specimen and pcr method with tvk3/tvk7 as the primer sets. methods this was a descriptive study with crosssectional method. subjects of the study were the vaginal swab obtained from reproductive women who attended gynecology examination at kandanghaur and sindang primary health care of indramayu district, west java, indonesia, in 2016 by total sampling. inclusion criteria for this study were vaginal swab from women with positive visual inspection with acetic acid (via) test, or women with vaginal discharge, or women with vaginal discharge with itching, or women with malodorous vaginal discharge. exclusion criteria was the volume of the vaginal swab which less than 5μl. the vaginal swab had already been obtained in year 2016 and stored in -20 oc for long-term examination. therefore, samples used in this study were stored biological material, thus the informed consent was unnecessary. the extracted genomic dna samples underwent pcr and electrophoresis at the microbiology and molecular laboratory of faculty of medicine, universitas padjadjaran, bandung, indonesia. the pcr kit consist of, primer sets tvk3/tvk7 and kapa taq extra hotstart readymix pcr kit®. the electrophoresis kit consist of peqgreen dna and rna dye®. the pcr master mix was made according to the procedures provided by manufacturer. the initial reaction for pcr was performed at 95 oc for 5 minutes and then repeated 35 cycles of 30 sec at 95 oc, 30 sec at 57.4 oc, 2 minutes at 72 oc, finally additional extensions were done at 72 oc for 7 minutes and hold at 4 oc. upon completion of pcr, an aliquot was analyzed by electrophoresis in a 3% agarose gel in tae buffer. the gel was stained with peqgreen dna and rna dye® and was photographed under short ultraviolet light. the primer sets tvk3/tvk7 specifically amplify a 300 bp fragment of t. vaginalis genome.11 the size of amplified products was assessed by comparison with a commercial weight marker (1kb ladder). positive and negative controls were included in all pcr runs. the dna extract from motile t. vaginalis in wet mount examination was used as a positive control. the negative control consisted of pcr master mix without dna. this study was approved through the ethical clearance number 595/un6.kep/ ec/2018 by the health research ethic committee, faculty of medicine, universitas padjadjaran, bandung. :9–15 prevalence of trichomonas vaginalis based on clinical manifestation and polymerase chain reaction among reproductive women international journal of integrated health sciences. 2019;7(1) 11 table 1 characteristics of the subjects characteristics frequency (n) pcr positive of t. vaginalis frequency (n) percent (%) age 20–29 years old 9 0 0 30–39 years old 42 0 0 40–49 years old 24 0 0 50–59 years old 1 0 0 marital status yes 76 0 0 no 0 0 0 obstetrical status p0a0 5 0 0 p1a0 23 0 0 p1a1 3 0 0 p1a3 1 0 0 p2a0 17 0 0 p2a1 7 0 0 p3a0 9 0 0 p3a2 2 0 0 p4a0 3 0 0 p4a1 1 0 0 p4a2 1 0 0 p4a4 1 0 0 p5a0 1 0 0 p5a1 1 0 0 education level uneducated 2 0 0 elementary school 28 0 0 junior high school 24 0 0 senior high school 16 0 0 diploma 2 0 0 bachelor 4 0 0 occupation housewife 68 0 0 farmer 5 0 0 government officer 1 0 0 midwifery 1 0 0 nurse 1 0 0 huriyah hafizhotul ‘ummah, gita widya pradini, et al. :9–15 12 international journal of integrated health sciences. 2019;7(1) prevalence of trichomonas vaginalis based on clinical manifestation and polymerase chain reaction among reproductive women results during the gynecology examination at kandanghaur and sindang primary healthcare in 2016, from 147 women attended, 143 vaginal swabs were obtained, and 76 samples were stored in laboratory and underwent pcr examination for this study, while the rest of the samples could not be extracted because of the volume less than 5μl. the characteristics of subjects which vaginal swab underwent pcr were described (table 1). the prevalence of t. vaginalis based on pcr were shown. based on these data, the pcr results of t. vaginalis were negative in all samples. the prevalence of t. vaginalis based on clinical manifestation was shown (table 2). from this data, in some subjects who had one symptom or more, the pcr results were negative for t. vaginalis. result of electrophoresis was revealed (fig. a–b). in all of the electrophoresis results, there was the positive control that has length 300kbp appropriate for the size of the dna that amplified by tvk/tvk7 primer sets, but none of the samples have a positive result because there was no band appeared in all of the results. discussion the prevalence of trichomoniasis reported in this study was 0% using pcr method (fig. a–b). the socio-demographic characteristics and clinical manifestation of the study population may affect this finding.12 the sociodemographic characteristics of the study population are portrayed (table 1). among 76 women who examined for t. vaginalis, :9–15 electrophoresis sample 1–12 (a), electrophoresis sample 13–24 (b), electrophoresis sample 25–28 (c), electrophoresis sample 65–76 fig. a b c d international journal of integrated health sciences. 2019;7(1) 13 42 women in this study belonged to the age group of 30–39 years, but none of them were positive for t. vaginalis infection. this result was similar to several previous studies which majority of infected women were between the ages of 35–40 years, 26–35 years (37.93%), and 21–45 years (76%), respectively.6,8,12 unlike other nonviral stis, trichomoniasis does not primarily reach young women (15–25 years old). it affects women during reproductive years, and high rates of infection are found in women between the ages of 35 and 40. predisposing factors comprise of older age, use of oral contraceptives, trading sex, smoking, single marital status, and low socioeconomic class.6 other socio-demographic factors for trichomoniasis are marital status and obstetrical status. all women in this study have the same marital status, while obstetrical status varied and the result was 17 women (22.36%) had history of abortion. this result was in contrast to a study which reported women who have abortion previously will have a higher prevalence of t. vaginalis infection.13 both occupation and education level are predisposing factors for trichomoniasis in published literature. in the previous study, majority of those with trichomoniasis were unemployed and has less education level.12 however, in this study, there was no difference between the occupation and education level with t. vaginalis infection. the overall prevalence of t. vaginalis identification using pcr method was 0%. a previous study identified t. vaginalis with the same method as in this study which found the prevalence of the infection was 30%.8 the negative findings of t. vaginalis in this study could be affected by samples that obtained from low-risked women and the study setting was community-based study. in contrary, in clinic-based studies there was a higher prevalence than community-based studies. in community-based study, the prevalence was 1% and 0.6% respectively. while in clinicbased study, the prevalence was 4.4% and 4.2% respectively.14 another risk factor associated with trichomoniasis was the last sexual intercourse. therefore, the normal incubation period for trichomoniasis is 4–28 days. if the patients are infected by trichomoniasis, the patients are expected to be symptomatic within this period or immediately after. this may explain the lower risk of finding in those who had sexual intercourse over 30 days in :9–15 huriyah hafizhotul ‘ummah, gita widya pradini, et al. table 2 prevalence of t. vaginalis based on clinical manifestation characteristics frequency (n) pcr positive of t. vaginalis frequency (n) percent (%) vaginal bleeding yes 1 0 0 no 75 0 0 vaginal discharge yes 24 0 0 no 52 0 0 vaginal discharge with itching yes 19 0 0 no 57 0 0 malodorous vaginal discharge yes 10 0 0 no 66 0 0 via test positive 15 0 0 negative 61 0 0 14 international journal of integrated health sciences. 2019;7(1) references 1. ryu js, min dy. trichomonas vaginalis and trichomoniasis in the republic of korea. korean j parasitol. 2006;44(2):101–16. 2. menezes cb, frasson ap, tasca t. trichomoniasis are we giving the deserved attention to the most common non-viral sexually transmitted disease worldwide? microb cell. 2016;3(9):404–19. 3. kissinger p. trichomonas vaginalis: a review of epidemiologic, clinical and treatment issues. bmc infect dis. 2015;15(1):1–8. 4. harp df, chowdhury i. trichomoniasis: evaluation to execution. eur j obstet gynecol reprod biol. 2011;157(1):3–9. 5. queza mi, rivera wl. diagnosis and molecular characterization of trichomonas vaginalis in sex workers in the philippines. pathog glob health. 2013;107(3):136–40. 6. bouchemal k, bories c, loiseau pm. strategies for prevention and treatment of trichomonas vaginalis infections. clin microbiol rev. 2017;30(3):811–25. 7. johnston vj, mabey dc. global epidemiology and control of trichomonas vaginalis. curr opin infect dis. 2008;21(1):56–64. 8. patil mj, nagamoti jm, metgud sc. diagnosis of trichomonas vaginalis from vaginal specimens by wet mount microscopy, in pouch tv culture system, and pcr. j glob infect dis. 2012;4(1):22–5. 9. muzny ca, schwebke jr. the clinical spectrum of trichomonas vaginalis infection and challenges to management. sex transm infect. 2013;89(6):423–5. 10. hobbs mm, seña ac. modern diagnosis of trichomonas vaginalis infection. sex transm infect. 2013;89(6):434–8. 11. conrad md, gorman aw, schillinger ja, fiori pl, arroyo r, malla n, et al. extensive genetic diversity, unique population structure and prevalence of trichomonas vaginalis based on clinical manifestation and polymerase chain reaction among reproductive women advance.12 in this study, there were no data about last sexual intercourse. the clinical manifestations varied among the 76 women, 52 women had no vaginal discharge, 57 women had no vaginal discharge with itching, 66 had no malodorous vaginal discharge, and 61 women had no cervicitis, indicated by negative via test. most of women are asymptomatic but none of them had positive result for t. vaginalis. it is very difficult to predict the t. vaginalis infection only on clinical findings, compare to previous study in belgium, 50% of the patient had normal vaginal findings and 20% of them were positive for trichomoniasis. while 36% of the patient had cervicitis and 44% of them were positive for trichomoniasis.8 this study was used pcr method to detect t. vaginalis since it offers an advantage of extreme sensitivity and ability to detect nonviable organisms.8 since most cases of trichomoniasis are asymptomatic and the infection could cause serious complication such as hiv, cervical cancer, hsv-2, and other stis.1,3,4 thus, it is important to screen t. vaginalis infection in low-risked women to prevent it complications. moreover, diagnosis of trichomoniasis cannot be made solely on the basis of clinical presentation because the clinical symptom may be synonymous with those of other stis, the specific symptom like strawberry cervix is seen approximately 2% of patients, and frothy discharge is seen only in 12% of women with trichomoniasis. it has been demonstrated that if these classical features are used alone in the diagnosis of trichomoniasis, 88% of these cases will not be diagnosed and 29% of uninfected women will be falsely indicated as having t. vaginalis infection. this suggests that clinical manifestation are not reliable diagnostic parameters and hence laboratory diagnosis is necessary for early and accurate diagnosis.8 this study had limitations such as the examination only covered the low-risked women and the study settings was a community-based study. therefore, a further study can be conducted by using a broader population including high-risk subject. in conclusion, the prevalence of t. vaginalis based on clinical manifestation and pcr among reproductive women in this study was 0%. however, the samples that obtained and stored from 2 years ago have a limited possibility to become contaminated because the samples already been extracted into dna and stored in -20 oc. it was proven from the positive control that appeared in each electrophoresis results. the positive control used in this study was also obtained 2 years ago from motile t. vaginalis that underwent dna extraction and stored together with other samples. :9–15 international journal of integrated health sciences. 2019;7(1) 15 evidence of genetic exchange in the sexually transmitted parasite trichomonas vaginalis. plos neglect trop dis [serial on the internet]. 2012 mar [cited 2017 jan 20];6(3):[about 11p.]. available from: https://journals.plos. org/plosntds/article?id=10.1371/journal. pntd.0001573. 12. fernando sd, herath s, rodrigo c, rajapakse l. clinical features and sociodemographic factors affecting trichomonas vaginalis infection in women attending a central sexually transmitted diseases clinic in sri lanka. indian j sex transm dis aids. 2012;33(1):25–31. 13. gavgani am, namazi a, ghazanchaei a, alizadeh s. prevalence and risk factors of trichomoniasis among women in tabriz. iranian j clin infect dis. 2008;3(2):67–71. 14. fernando sd, herath s, rodrigo c, rajapakse s. improving diagnosis of trichomonas vaginalis infection in resource limited health care settings in sri lanka. j glob infect dis. 2011;3(4):324–8. huriyah hafizhotul ‘ummah, gita widya pradini, et al. :9–15 volume 8 no 1 2020 v2.indd 22 international journal of integrated health sciences in the lower extremities. several cases of venous thrombosis may cause embolization, particularly to lungs. the emboli may cause partial or complete obstruction of pulmonary arteries or its branches.1 predisposing factors of venous thrombosis may be defined using virchow triad, consisting of: stasis of blood flow, hypercoagulability, and endothelial injury. stasis of blood flow may be caused by several conditions, such as immobilization, bed rest, congestive heart failure, and previous history of venous introduction venous thromboembolism is characterized with venous thrombosis, frequently occurring original article venous thromboembolism prophylaxis and the international medical prevention registry on venous thromboembolism (improve) score in medical illness patients correspondence: dania artriana, department of internal medicine, medical hematology oncology division, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia e-mail: daniaartriana@yahoo.com dania artriana riswandi, amaylia oehadian department of internal medicine, medical hematology oncology division, faculty of medicine universitas padjadjaran-dr. hasan sadikin general hospital bandung, indonesia abstract objective: to describe applicability of the international medical prevention registry on venous thromboembolism (improve) score to implement venous thromboembolism prophylaxis in patients with medical illness in hasan sadikin general hospital bandung. methods: this study was descriptive, cross-sectional research from database was performed on december 2018. inclusion criteria in this study were all patients hospitalized in department of internal medicine, hasan sadikin general hospital in november 2018 with medical illness, which is patients with medical condition involves a more systemic, pharmaceutical approach to treatment. exclusion criteria were surgical disease, which is requires some form of intervention such as surgery, also patients with incomplete medical record were excluded. results: there were 162 patients (56% male and 44% female). median age were higher in males compared to females (53 [18–76] vs. 49 [18– 85]) years. low-risk (score <2), medium-risk (score 2 – 3), and high-risk (score >4) for improve venous thromboembolism score were 77.2%, 17.3%, and 5.6% respectively. ). low-risk (score <7) and high-risk (score >7) for improve bleeding score were 75.9% and 24.1% respectively. medical thromboprophylaxis were given to 14.8% patients, with 91.7% and 8.3% of the patients received unfractionated heparin (ufh) and lowmolecular weight heparin (lmwh) respectively. thromboprophylaxis was given in 88.9% of high-risk patients for venous thromboembolism. there were 18.7% patients with low-risk and 2.6% with high-risk for bleeding that received prophylaxis. conclusion: the majority of inpatients treated with thromboprophylaxis had low-risk for both thromboembolism and bleeding. the rate of thromboprophylaxis usage was still low; with the most frequently used thromboprophylaxis agent was ufh. most of high-risk patients for venous thromboembolism received thromboprophylaxis. keywords: bleeding risk, improve score, thromboembolism risk, thromboprophylaxis received: august 31, 2019 accepted: march 31, 2020 pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ ijihs.v8n1.1773 ijihs. 2020;8(1):22–6 international journal of integrated health sciences 23 thrombosis. hypercoagulability may be found in patients with history of malignancy, anticardiolipin antibody, nephrotic syndrome, essential thrombocytosis, estrogen therapy, heparin usage (heparininduced thrombocytopenia), inflammatory bowel disease, paroxysmal nocturnal hemoglobinuria, disseminated intravascular coagulation, and deficiency of several proteins (such as protein c, protein s, and antithrombin iii). endothelial injury may occur due to trauma or internal bleeding.2 annual incidence of venous thromboembolism in europe and united states were approximately 50/100,000 persons per year. genetic variability may be noted, with lower incidence were found in asian and hispanic population compared to caucasians, african americans, latino, and asia-pacific populations. no significant incidence between both sexes were noted. increasing trend in incidence of lung emboli were noted, with annual incidence rate of lung emboli of 1 in 1000 persons in united states. pulmonary emboli occurs in 60–80% cases of venous thromboembolism, 50% of which cases were asymptomatic. lung emboli is one of the most frequent cause of death, ranking 3rd and casing about 650,000 mortalities each year.3-6 approximately 100,000 and 300,000 deaths related to venous thromboembolism were reported annually in united states and europe, respectively. venous thromboembolism related mortalities may be prevented by using thromboprophylaxis medications. no consensus regarding the dosage of the medication has been reached, due to the risk of bleeding as a possible side effect of thromboprophylaxis medications.7 the improve (international medical prevention table 2 improve score for bleeding8 parameter score previous history of gastroduodenal ulcer 4.5 history of bleeding (last 3 months) 4 platelet count <50x109 /l 4 previous history of hepatic failure (inr>1.5) 2.5 history of admittance to intensive care unit 2.5 history of central venous catheter insertion 2 rheumatic diseases 2 history of malignancy 2 male sex 1 age 40–84 vs ≥ 85 years 1.5 vs 3.5 glomerular filtration rate 30-59 vs <30 1 vs 2.5 table 1 improve score for thromboembolism8 parameter score history of thromboembolism 3 thrombophilia 2 paralysis of lower extremities 2 malignancy 2 immobilization ≥7 days 1 history of admittance to intensive care unit 1 age >60 years 1 registry on venous thromboembolism) predictive score was designed to assesses the risk of vte in hospitalized medical patients. improve scores may be utilized to assess the risk of thromboembolism and bleeding.8 this study aims to assess the risk factors associated with venous thromboembolism and bleeding according to improve scores and administration of thromboprophylaxis medications of inpatients with medical illness in department of internal medicine , hasan sadikin general hospital. methods the descriptive, cross-sectional study was performed on december 2018. data were collected from database of inpatients hospitalized with medical illness in department of internal medicine dr. hasan sadikin general hospital bandung. inclusion criteria in this study were all patients hospitalized in november 2018 with medical illness, which is patients with medical condition involves a more systemic, pharmaceutical approach to treatment. exclusion criteria were surgical disease, which is requires some form of intervention such as surgery, also patients with incompleted medical record were excluded. several variables included in this study are as described below. risk for venous thromboembolism, dania artriana riswandi, amaylia oehadian 24 international journal of integrated health sciences categorized according to improve score: low risk (score <2), moderate risk (score 2–3), and high risk (score >4) (table1). risk for bleeding, categorized according to improve score: low risk (score <7) and high risk (score >7) (table 2). thromboprophylaxis refers to administration of anticoagulants, specifically unfractionated heparin (ufh) or lowmolecular weight heparin (lmwh) during the period of hospitalization. descriptive statistics were used in presenting the results. median, mean, and percentage were used as descriptive statistics in describing the patients with risk of venous thromboembolism and bleeding. table 3 subjects characteristics characteristics total(n=162) sex, n (%) male 91 (56) female 71 (44) age (years) median (range ) 51 ( 18–85) vte risk, n (%) low risk 125 (77,2) moderate risk 28 (17,3) high risk 9 (5,5) bleeding risk, n (%) low risk 123 (75,9) high risk 39 (24,1) thromboprophylaxis, n (%) ufh 22 (13,6) lmwh 2 (1,2) no thromboprophylaxis 138 (85,2) vte risk with thromboprophylaxis, n (%) low risk 0 (0) moderate risk 16 (57,1) high risk 8 (88,9) bleeding risk with thromboprophylaxis, n (%) low risk 23 (18,7) high risk 1 (2.6) results total participants from database who fulfilled inclusion were 162 patients, with distribution of 56% males and 44% females. male patients were older compared to female patients (median 53 [18–76] vs 49 [18–85]) years. risk of thromboembolism was assessed using improve score: 77.2% low risk patients (scores <2); 17.3% moderate risk patients (score 2–3); and 5.6% high risk patients (scores >4). risk of bleeding was assessed using improve score: 75.9% low risk patients (scores <7) and 24.1% high risk patients (scores >7). thromboprophylaxis medications were given to 14.8% of the patients included in the study. the medications given were unfractionated heparin (ufh) in 91.7% patients and low-molecular weight heparin (lmwh) in 8.3% patients. patients with low risk for venous thromboembolism did not receive thromboprophylaxis. there were 57.1% medium risk and 88.9% of high risk patients for venous thromboembolism that received thromboprophylaxis medications. there were 17.8% low risk and 2.6% medium risk patients for bleeding that received thromboprophylaxis medications. subject’s characteristics were described in table 3. from 37 patients with venous thromboembolism, the majority of these patients had previous history of malignancy. there were 27 (73%) patients with previous history of malignancy and 10 (27%) patients with previous history of prolonged immobilization. the majority of the patients with previous history of malignancy had received thromboprophylaxis: 22 (81.5%) patients received thromboprophylaxis and 5 (18.5%) patients did not receive thromboprophylaxis. on subjects with previous history of prolonged immobilization, 2 (20%) patients had received thromboprophylaxis and 8 (80%) patients did not receive thromboprophylaxis. there were 3 high risk patients for bleeding: 2 (66.7%) of the patients had not received thromboprophylaxis and 1 (33.3%) patient had received thromboprophylaxis. the patient that was given thromboprophylaxis had previous history of malignancy. discussion international medical prevention registry on venous thromboembolism (improve) score was formulated in order to assess the risk of venous thromboembolism and bleeding. the venous thromboembolism prophylaxis and the international medical prevention registry on venous thromboembolism (improve) score in medical illness patients international journal of integrated health sciences 25 score had listed 7 risk factors in assessing the risk of venous thromboembolism: previous history of venous thromboembolism; thrombophilia; paralysis of lower extremities; previous history of malignancy; prolonged immobilization (>7 days); and previous history of admittance in intensive care unit (in patients aged >60 years). there are three risk stratifications in thromboembolism risk: low risk (score <2), moderate risk (score 2–3), and high risk (score >4). assessment of risk for bleeding utilize 13 risk factors to be examined on the patient: previous history of gastroduodenal ulcers; previous history of bleeding in the last 3 months; platelet count <50x109/l; previous history of hepatic failure; previous history of admittance in intensive care unit ; previous history of central venous catheter insertion; previous history of rheumatic diseases; previous history of malignancy; age; sex; and glomerular filtration rate. the risk is further stratified into low risk (score <7) and high risk (score >7). patients with moderate risk for thromboembolism (score >2) and low risk for bleeding (score <7) are recommended to be given thromboprophylaxis medication in order to prevent emboli formation. in patients with high risk of bleeding (score >7), mechanical thromboprophylaxis is recommended in order to reduce the risk of emboli formation.9 improve scoring system has been routinely utilized in 12 countries: australia, brazil, canada, colombia, france, germany, italy, japan, spain, england, united states, and venezuela. previously, a multicenter study conducted in 52 hospitals from the 12 aforementioned counties were performed during the period of july 2002–september 2006, with total of 15,156 individuals diagnosed with venous thromboembolism; 3,410 of subjects in united states and 11,746 in other countries. the patients’ age range were 52–79 years old with median of 68 years old; the majority of the patients were females (50.6% vs. 49.4%). compared to the previous study, this study had lower median (51 years old) and range for age (18 – 85 years old). the patients in our study were predominantly male (56% vs. 44%).10,11 in this study, 22.8% of patients had high risk for venous thromboembolism with 64.9% of the patients had received medication (ufh or lmwh) for thromboprophylaxis. in comparison with other studies, less number of patients were at high risk for thromboembolism despite the higher rate of thromboprophylaxis medication. in other study, 52% patients in united states and 43% patients in other countries had moderate to high risk for venous thromboembolism. there were 7,640 (50%) patients that had received either medical or mechanical thromboprophylaxis. there were 33% patients in united states and 47% patients in other countries that had received ufh or lmwh as thromboprophylaxis. the study had suggested several factors that may be associated with lower usage of thromboprophylaxis, notably the lack of awareness regarding thromboprophylaxis usage, lack of thromboprophylaxis algorithms in the said institution, and risk of bleeding that may occur during thromboprophylaxis procedure.10-12 other countries, in contrast, had preferred the usage of lmwh compared to ufh (82.1% vs. 17.9%). overall, higher usage of lmwh was found in the study compared to the ufh usage (74.8% vs. 25.2%). in our study, the vast majority of the patients were treated with ufh (91.7% vs. 8.35). the choice for medical thromboprophylaxis were similar with studies from united states, which ufh usage was preferred compared to lmwh in thromboprophylaxis. costs in utilizing lmwh was not significantly different compared to usage of ufh, thus, lmwh may be safer that ufh, particularly in minimizing the risk of heparin induced thrombocytopenia (hit).10-14 in this study, there were 75.9% patients with low risk (score <7) and 24.1% patients with high risk (score >7) for bleeding. in comparison, a retrospective study consisted of 12,082 subjects from academic health system in united states during the period of october 1, 2012–july 31, 2014, had found the majority (81% vs. 19%) of the patients had low risk of bleeding. other study had noted that 90.3% of patient had low risk for bleeding and 9.7% had high risk for bleeding. the results of these studies concur with our study, that the majority of the patients in hasan sadikin general hospital had low risk for bleeding.7 according the previous study from academic health system, bleeding had occurred on 2.6% patients with venous thromboembolism, with 1.8% patients had major bleeding (defined as bleeding that cause decrease of hemoglobin >2 g/dl or may require 2 units of blood transfusion). major bleeding may occur as intracranial, intraocular, adrenal gland, and/ or pericardial hemorrhage. in other studies, 3.2% of patients had suffered from bleeding after thromboprophylaxis therapy, with 1.2% of these patients had suffer from major bleeding.7 in contrast, no cases of bleeding dania artriana riswandi, amaylia oehadian 26 international journal of integrated health sciences after thromboprophylaxis therapy were found on our patients. in this study there were 162 subjects with mean age 51 years old. most of subjects were male (56% vs. 44%). there were 22.8% of patients had high risk for venous thromboembolism with 64.9% of the patients had received medication (ufh or lmwh) for thromboprophylaxis. there were 75.9% patients with low risk (score <7) and 24.1% patients with high risk (score >7) for bleeding. the majority of inpatients had low risk for both venous thromboembolism and bleeding. the administration of thromboprophylaxis is still uncommonly performed, only given in 14.8% subjects. thromboprophylaxis was given in 88.9% of high risk patients for venous thromboembolism .the majority of patients with high risk of venous thromboembolism received ufh as thromboprophylaxis medication. venous thromboembolism prophylaxis and the international medical prevention registry on venous thromboembolism (improve) score in medical illness patients 1. goldhaber sz, bounameaux h. pulmonary embolism and deep vein thrombosis. the lancet. 2012;379(9828):1835–46. 2. members atf, konstantinides sv, torbicki a, agnelli g, danchin n, fitzmaurice d, et al. 2014 esc guidelines on the diagnosis and management of acute pulmonary embolism: the task force for the diagnosis and management of acute pulmonary embolism of the european society of cardiology (esc) endorsed by the european respiratory society (ers). eur heart j. 2014;35(43):3033–80. 3. heit ja, spencer fa, white rh. the epidemiology of venous thromboembolism. j thromb thrombolysis. 2016;41(1):3–14. 4. goldhaber sz. venous thromboembolism: epidemiology and magnitude of the problem. best pract res clin haematol. 2012;25(3):235– 42. 5. delluc a, tromeur c, le ven f, gouillou m, paleiron n, bressollette l, et al. current incidence of venous thromboembolism and comparison with 1998: a community-based study in western france. thromb haemost. 2016;116(11):967–74. 6. einstein–pe investigators, büller hr, prins mh, lensin aw, decousus h, jacobson bf, et al. oral rivaroxaban for the treatment of symptomatic pulmonary embolism. n engl j med. 2012;366(14):1287–97. 7. rosenberg dj, press a, fishbein j, lesser m, mccullagh l, mcginn t, et al. external validation of the improve bleeding risk assessment model in medical patients. thromb haemost. 2016;116(3):530–6. 8. spyropoulos ac, anderson jr fa, fitzgerald g, decousus h, pini m, chong bh, et al. predictive and associative models to identify hospitalized medical patients at risk for vte. chest. 2011;140(3):706–14. 9. spyropoulos ac, raskob gejth. new paradigms in venous thromboprophylaxis of medically ill patients. 2017;117(9):1662–70. 10. decousus h, tapson vf, bergmann j-f, chong bh, froehlich jb, kakkar ak, et al. factors at admission associated with bleeding risk in medical patients: findings from the improve investigators. chest. 2011;139(1):69–79. 11. rosenberg d, eichorn a, alarcon m, mccullagh l, mcginn t, spyropoulos ac. external validation of the risk assessment model of the international medical prevention registry on venous thromboembolism (improve) for medical patients in a tertiary health system. j am heart assoc. 2014;3(6):e001152. 12. abdel-razeq h. venous thromboembolism prophylaxis for hospitalized medical patients, current status and strategies to improve. ann thorac med. 2010;5(4):195-200. 13. nagase y, yasunaga h, horiguchi h, hashimoto h, shoda n, kadono y, et al. risk factors for pulmonary embolism and the effects of fondaparinux after total hip and knee arthroplasty: a retrospective observational study with use of a national database in japan. bone joint surg am. 2011;93(24):e146. 14. junqueira dr, zorzela lm, perini e. unfractionated heparin versus low molecular weight heparins for avoiding heparininduced thrombocytopenia in postoperative patients. cochrane database syst rev. 2017;4(4):cd007557. references volume 7 no 2 2019 (3).indd 96 international journal of integrated health sciences. 2019;7(2) defined daily dose and cost of therapy of empirical ceftriaxone pre and post-antimicrobial stewardship program model implementation in sepsis patients in dr. hasan sadikin general hospital bandung, indonesia abstract objective: antibiotic resistance requires substantial responses through two mechanisms: new antibiotic development and smart antibiotic use. antibiotic stewardship program (asp) is one of the responses that reduce the overall antibiotics use and prevent the overuse of antibiotics to avoid antibiotic resistance. the purpose of this study was to assess the difference in defined daily dose (ddd) and the cost of therapy (cot) for empirical ceftriaxone therapy in sepsis patients preand post-asp model implementation in dr. hasan sadikin general hospital, bandung. methods: a preand post-intervention quasi-experimental study on asp model implementation in empirical ceftriaxone therapy provided to sepsis patients treated in the intensive or semi-intensive care units was performed from december 2015 to july 2016 using the mann whitney test and t-test. the ddd was calculated as ddd/100 patient-days, while the cot was calculated as the cot/patient-day. the asp model intervention implemented in these units applied 2 main strategies: ceftriaxone use restriction and ceftriaxone therapy duration audit. results: participants of this study consisted of 112 sepsis subjects (n=112) with 55 subjects in the pre-asp group and 57 subjects in the post-asp group. the mean ddd/100 patient-days in the post-asp subject was lower than that of the pre-asp (16.3±4.3 and 45.8±16.8; p=0.018). the median cot/patientdays in post-asp subject was idr 42,000 (idr 14.000–42.000), which was lower than that of the pre-asp group of idr 84.000 (idr 28.000–420.000, p=0.001) conclusions: the differences in the ddd/100 patient-day and cot/patientday values between the pre-asp and post-asp are significant. the asp model applied in dr. hasan sadikin general hospital, bandung leads to a smart use of ceftriaxone and reduces costs for the empiric ceftriaxone therapy in sepsis patien keywords: antimicrobial stewardship programs, cost of therapy, defined daily dose, sepsis pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v7n2.1693 ijihs. 2019;7(2):96–101 received: april 23, 2019 revised: september 20, 2019 accepted: october 19, 2019 correspondence: uun sumardi, department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, jalan pasteur no. 38 bandung, west java, indonesia, e-mail: uun_s_sppd@yahoo.co.id uun sumardi,1 anggra filani,1 evan susandi,1 ida parwati2 1department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia 2department of clinical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin hospital bandung, indonesia introduction antimicrobial resistance associated with antibiotic uses, it is predicted of 50% or more antibiotic uses in hospital were inappropriate.1 signs and symptoms of infection in sepsis are insignificant due to immunity changes, thus increases worries of death if broad spectrum antibiotic therapy were not given early in sepsis patients. therefore, broad spectrum antibiotic was overused, such as ceftriaxone, and will increase pathogenic bacterial resistance in sepsis patients.2 pradipta et al. show that ceftriaxone is one of six most common used original article :96–101 international journal of integrated health sciences. 2019;7(2) 97 antibiotic in hospital with resistance value more than 50% in sepsis patients in bandung.3 antimicrobial stewardship program (asp) is a coordinate intervention based programs to increase and measure appropriate antibiotic use, by promoting optimal antibiotic choices, including doses, duration and route of therapy.4 this programs aims to measure hospital antibiotic use, antibiotic resistance, and clinical outcomes.5 some measurement of antibiotic uses are defined daily dose (ddd), days of therapy (dot), and cost of therapy (cot) per 100 patient per day.6 asp model rsup dr. hasan sadikin, are expected to reduce uses and cost of ceftriaxone.5 this study enrolled to find differences value of ceftriaxone use as empiric therapy, ddd/100 patient-day and cot/ patient-day pre and post asp model rsup dr. hasan sadikin in sepsis at intensive and semiintensive care unit.7 sepsis with various source of infection, will increase risk of mortality.8 infection occurs in 51% of intensive care unit (icu) patients, in which 71% were bacterial infection and treated with antibiotics.9 pathophysiological changes in critical illness causes alternation of drugs pharmacokinetic, especially hydrophilic antibiotics. these pathophysiological changes will make decision making difficult to determine the dosage and selection of antibiotics. both the doses and class of antibiotics are important parameters of antibiotic therapy in septic patients. antibiotic resistance requiring substantial response through two mechanisms: new antibiotic development and smart antibiotic use. this requires substantial changes, by implementing antibiotic stewardship programs (asp) that reduce overall antibiotics use and prevents overuse for reduce antibiotic resistance.10 methods sepsis subject were chosen from medical records with ceftriaxone empirical therapy. the ethical clearance number lb.04.01/a05/ ec/262/viii/2016 from ethical committee general hospital dr. hasan sadikin bandung. subject criteria for this study are sepsis patients, aged more than 15 years old and diagnosed with presumptive criteria of sepsis based on surviving sepsis campaign 2012 and not with chronic illness nor comorbidity.8 subjects pre asp were chosen from medical records, since december 2015 until march 2016. sepsis subjects post asp with intervention by asp model dr. hasan sadikin general hospital, bandung were chosen fig. 1 study result (sepsis patients, n=112) based on arrival of sepsis patients within study period (consecutive sampling from admissions) during of april until july 2016 in intensive and semi-intensive care unit. this is a quasi-experimental study with unpaired numerical, comparative analysis by using mann whitney and t tests, the number of subjects in each group of at least 55 subjects in the pre-asp and post asp models. the asp model intervention with 2 main strategies, restrictions on ceftriaxone use and an audit for the duration of ceftriaxone therapy that has been given. measurement method of quantitative ceftriaxone uses are defined daily dose (ddd) per 100 patient per day as recommended by the world health organization (who). calculation of ddd/100 patients-day using this formula: ddd = ddd(who)/100 patients-day. the direct cost of therapy (cot) ceftriaxone: ceftriaxone daily dose multiplied by the number of days ceftriaxone therapy.6,7 results sepsis subjects (n=112) in intensive and semiintensive care unit rsup dr. hasan sadikin general hospital, bandung from december 2015 to july 2016 (fig. 1). sepsis subjects in both groups with an average age under 60 years and more in men. source of infection as a cause of sepsis, especially in the lower respiratory tract and digestive tract. the treatment of patients with sepsis was found to be more in the icu room than the high care room, the length of stay in the post asp group was shorter than that of the pre-asp group. clinical features :96–101 uun sumardi, anggra filani, et al. 98 international journal of integrated health sciences. 2019;7(2) table 1 subject characteristics characteristics preasp (n=55) post asp (n=57) p-value age (years old) 44±17 43 ± 16 0.844a sex male female 29 (52.7) 26 (47.3) 28 (49.1) 29 (50.6) 0.703c source of infection intraabdominal pulmonary skin and soft tissue genitourinary 23 (41.8) 21 (38.2) 9 (16.4) 2 (3.6) 20 (35.1) 20 (35.1) 16 (28.0) 1 (1.8) 0.543c ward icu hcu kemuning mic flamboyan 28 (50.9) 21 (38.2) 4 (3.7) 2 (3.6) 58 (51.7) 36 (32.1) 11(9.8) 7 (6.2) 0.371c length of stay 20 (5-57) 16 (3-72) 0.071b vital signs gcs<10 temperature (0c) heart rate (beats per minute) respiratory rate (breaths per minute) systolic blood pressure (mmhg) diastolic blood pressure (mmhg) 20 (36.3) 37.8 (34-40.2) 111 (56-160) 28 (18-47) 113 (56-160) 70 (34-90) 12 (21.1) 37.8 (35.2-40.6) 110 (100-165) 28 (16-52) 119 (88-173) 70 (52-90) 0.089c 0.493b 0.726b 0.724b 0.346b 0.541b laboratory values leukocyte (103/mm3) thrombocyte (103/mm3) nlcr crp (mg/dl) crp>50 mg/dl paco2 (mmhg) creatinine (mg/dl) inr aptt (seconds) total bilirubin (mg/dl) lactate (mmol/l) 17.2 (2.2-53.9) 256 (8-950) 9 ± 9.2 51.3 (1.5-282.6) 5 (50) 31.6 (14.7-99.0) 1.0 (0.3-6.3) 1.0 (0.8-3.7) 25.9 (15.3-114.7) 0.6 (0.1-24.9) 1.8 (0.6-9.8) 17.1 (1.8-42.6) 260 (52-981) 11 ± 10.7 80.0 (4.5-408.4) 6 (54.5) 29.0 (16.5-87.0) 0.9 (0.3-5.6) 1.0 (0.8-2.3) 27.8 (18.2-50.3) 0.7 (0.3-30.8) 3.1 (0.4-13.8) 0.710b 0.707b 0.743a 0.526b 0.758c 0.252b 0.974b 0.837b 0.153b 0.622b 0.047b* duration of ceftriaxone use as empirical treatment ≤72 hours >72 hours 19 (34.5) 36 (65.5) 57 (100.0) 0 (0.0) <0.001c* note: data presented as n (%), mean± sd, median (range), analysis with dt-test, bmann whitney, and cchi square test, *significance defined daily dose and cost of therapy of empirical ceftriaxone preand post-antimicrobial stewardship program model implementation in sepsis patients :96–101 international journal of integrated health sciences. 2019;7(2) 99 of sepsis subjects in both groups were in accordance with ssc 2012.8 the duration of using ceftriaxone as an empirical treatment was less than 72 hours in post asp group that significantly different compared to the preasp group. the asp model intervention, as the main strategy in limiting the use of ceftriaxone as an empirical therapy, is aimed at empiric antibiotic therapy not more than 72 hours.11 consideration for substituting for definitive therapy is a clinical decision policy that refers to the clinical condition of the patient and the results of bacterial culture examination from the source of infection as a cause of sepsis.12 (table 1). mean of ddd/100 patient-day of ceftriaxone use as empirical treatment in post asp was lower than those in pre-asp (16.3±4.3 and 45.8±16.8, consecutively) with p=0.018. (figure 2). median value of cot/patient-day of ceftriaxone use as empirical treatment post asp were 42.000 idr (14.000-42.000 idr), lower than pre-asp which were 84.000 idr (28.000-420.000 idr), with p-value <0.001 (table 2). discussion all subject with sepsis, also met with new definition of sepsis (sepsis 3), quick sofa was 3, in all subject as well, with not fully alert, tachycardia and tachypnoea. looking in sequential [sepsis-related] organ failure assessment score (sofa), all subject with gcs below 10, that means all subject with sofa score at least 3, which relevant to sepsis patents. lactate level were significant high in post asp (p=0.047) also like sepsis patients pattern.13 according to the new sepsis bundle as in sepsis bundle 1 hour, if initial lactate over 2 mmol/l, must be repeated measure fig. 2 the ddd/100 patient-day of ceftriaxone empirical treatment pre and post asp. (n=112) table 2 cot/patient-day value of ceftriaxone empirical treatment pre and post asp. cot pre-asp (n=55)(idr) post-asp (n=57) (idr) difference (idr) (95%ci) p-value cot/patient-day 84.000(28.000 –420.000) 42.000 (14.000 – 42.000) 42.000 (28.000 – 70.000) <0.001 note: data presented in median, analysis using mann whitney test. uun sumardi, anggra filani, et al. :96–101 100 international journal of integrated health sciences. 2019;7(2) lactate level after initial fluid resuscitation for stabilizing hemodynamic parameters.14 all sepsis subject, with various causes of infections, like intra-abdominal, pulmonary, urinary tract, skin and soft tissue infections. markers of infection were reactive in all subject, like leukocytosis and crp over 50 mg/dl. blood cultures before antibiotic treatment were done 50.9% in post asp, in pre-asp blood cultures were done only in 43.7%. in post asp, diagnosis for sepsis is more accurately, by perform blood culture for finding the cause of bacterial pathogen this result is similar to robertson c l and haddad a. m., for appropriate antibiotic treatment base on culture result and antibiotic susceptibility test.8 all sepsis subject treated with empiric ceftriaxone antibiotic, in post asp, empiric ceftriaxone use was 0% for over 72 hours and 65.5% in pre-asp (p<0.001). asp model dr. hasan sadikin general hospital, bandung, could guide prudent empiric ceftriaxone use in this study.11 the most common method used to accurately reflect antimicrobial usage is the defined daily dose (ddd) promoted by the world health organization (who). who defines ddd as “the assumed average maintenance dose per day for a drug used for its main indication in adults” to estimate the total number of days of antimicrobial therapy, healthcare personnel should divide the total grams of each antimicrobial used for a given period of time by the who-defined ddd for the individual antimicrobials.15 calculation of ceftriaxone ddd/100 patients-day shows, that ceftriaxone ddd/100 patients-day, in post asp were lower than those pre-asp (16.3±4.3 and 45.8±16.8, p=0.018). these results are similar to cairn et al., lin et al., studies, in which show decrease of ddd/100 patients-day after asp intervention.16,17 value of ceftriaxone cot/patient-day in post asp were lower than those in pre-asp [consecutively idr 42.000 (idr 14.000– 42.000) and idr 84.000 (idr 28.000– 420.000), p<0.001]. the result is similar to the previous studies by lin et al.,20 which showed that there is reduction of cot/patient-day after asp intervention. the difference of cot value in pre-asp and post asp were idr 42.000 per patient per day. it describes that there is daily antibiotic cost savings up to idr 42.000 per patient after intervention asp model dr. hasan sadikin general hospital, bandung. consistence with jci, asp’s can consider using a hybrid program that implements both approaches. formulary restriction and preauthorization may be better at saving money and optimizing doses, whereas a prospective audit and feedback program addresses resistance problems, and improves overall antimicrobial use, like asp model dr. hasan sadikin general hospital, bandung.18 limitations in this study, this study must be continued with the design of rct study and conduct with blood culture results or antibiotic susceptibility tests to determine patterns of antibiotic resistance, which can be used for optimal definitive antibiotic treatment and outcomes in sepsis patients. differences ddd/100 patient-day and cot/ patient-day value in pre-asp and post asp are significant. asp model general hospital dr. hasan sadikin, bandung can achieve smart use and improve cost saving in empiric ceftriaxone therapy in sepsis patients. restrictions on the use of ceftriaxone for empirical therapy are intended as not to increase the resistance of pathogenic bacteria to ceftriaxone and as a prevention of over use. references 1. cdc. the core elements of human antibiotic stewardship programs in resource-limited settings: national and hospital levels. 2018. 2. robertson cl, haddad am. recognizing the crtitically ill patients. anaesth and intensive care. 2013; 14(1): 11-4. 3. pradipta is, ronasih e, kartikawati ad, hartanto h, amelia r, febrina e, et al. three years of antibacterial consumption in indonesian community health centers: the application of anatomical therapeutic chemical/ defined daily doses and drug utilization 90% method to monitor antibacterial use. j family community med. 2015; 22(2):101–5. 4. society for healthcare epidemiology of america, infectious diseases society of america, pediatric infectious diseases society. policy statement on antimicrobial stewardship by the society for healthcare epidemiology of america (shea), the infectious diseases society of america (idsa), and the pediatric infectious diseases society (pids). infect control hosp epidemiol. 2012;33(4): 322–77. 5. morris am. antimicrobial stewardship programs: appropriate measures and metrics to study their impact. curr treat options infect dis.2014;6:101–12. 6. pharmaceutical services division, medical :96–101 defined daily dose and cost of therapy of empirical ceftriaxone preand post-antimicrobial stewardship program model implementation in sepsis patients international journal of integrated health sciences. 2019;7(2) 101 development division and family health development division ministry of health malaysia. protocol on antimicrobial stewardship program in healthcare facilities. eds. din rm, mohamad n, arifin nm, kamal m, sim b, husin sa, et al, editor. edisi ke 1. malaysia; 2014; hlm.1-22. 7. jason ra, roberts b, pharm b, lipman j. pharmacokinetic issues for antibiotics in the crtitically ill patient. crit care med. 2009, 37;3: 840-51. 8. robertson cl, haddad am. recognizing the crtitically ill patients. anaesth and intensive care. 2013; 14(1): 11-4. 9. sango a, mccarter ys, johnson d, ferreira j, guzman n, jankowski ca. stewardship approach for optimizing antimicrobial therapy through use of a rapid microarray assay on blood cultures positive for enterococcus species. j clin microb. 2013,51;12:4008-11. 10. blot si, pea f, lipman j. the effect of pathophysiology on pharmacokinetics in the crtitically ill patients : concepts appraised by the example of antimicrobial agents. adv drug deliv rev. 2014; 77: 1-7. 11. keputusan direktur utama rsup dr.hasan sadikin bandung nomor : hs.1.b47.10.00070 tentang prosedur penatalayanan penggunaan antimikroba rsup dr.hasan sadikin bandung. 12. tamar f. barlam, sara e. cosgrove, lilian m. abbo, conan macdougall, audrey n. schuetz, edward j. septimus et al. implementing an antibiotic stewardship program: guidelines by the infectious diseases society of america and the society for healthcare epidemiology of america. cid 2016,62:51-77. 13. mervyn singer, clifford s. deutschman, christopher warren seymour, manu shankarhari, djillali annane, michael bauer et al. the third international consensus definitions for sepsis and septic shock (sepsis-3). jama. 2016,8;315: 801-810. 14. mitchell m. levy, laura e. evans, andrew rhodes. the surviving sepsis campaign bundle: 2018 update. intensive care med. https://doi.org/10.1007/s00134-018-5085-0. 15. world health organization. guidelines for atc classification and ddd assignment 2012. 16. cairns ak, jenney aw, abbott ji, skinner jm, doyle sj, dooley m, et al. prescribing trends before and after implementation of an antimicrobial stewardship program. med j aust. 2013,198;5: 262–6. 17. lin ys, lin if, yen yf, lin pc, shiu yc, hu hy, et al. impact of an antimicrobial stewardship program with multidisciplinary cooperation in a community public teaching hospital in taiwan. am j infect control. 2013,41;11:1069– 72. 18. joint commission international. joint commission international (jci) accreditation standards for hospitals (including standards for academic medical center hospitals), 6 ed.2017. uun sumardi, anggra filani, et al. :96–101 international journal of integrated health sciences. 2019;7(1) 1 social determinant factors of elderly as an input in enhancing primary health care in indonesia abstract objective: to analyze the differences of social determinant factors among elderly according to gender, in urban and rural areas in indonesia. indonesia is one of the most populated countries in the world, faces an increased number of elderly. this situation leads to the increase of degenerative diseases and demands of caregivers as well. the identification of social determinant factors of elderly has an important role in enhancing primary health care. methods: a comparative study was carried out in 33 provinces in indonesia using secondary data from statistics indonesia 2013. the variables included in this study were percentage of elderly according to education, marital status, occupation, income and living arrangements, divided in gender, urban and rural areas. the normally distributed data were analyzed using unpaired t test and not normally distributed data were analyzed using mann-whitney test. results: this study showed that there were differences in education, occupation and income between urban and rural areas. in urban area, most of the elderly worked in industry and trade and in rural area they worked in agricultural, indicated huge risks of occupational haxards. most of them were poor, still married, lived with spouses and family of three generations. conclusions: it can be concluded that there were differences of social determinant factors (education, occupation and income) in elderly who live in urban and rural areas that can contribute to the risks of disease in elderly and these situations must be considered as an input to enhance the primary health care. keywords: elderly, gender, rural, social determinants, urban pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v7n1.1495 ijihs. 2019;7(1):1–8 received: december 11, 2018 revised: january 25, 2019 accepted: march 19, 2019 correspondence: sharon gondodiputro, department of public health, faculty of medicine, universitas padjadjaran jl. dr. eyckman no. 38, bandung, indonesia e-mail: sharon_gondodiputro@yahoo.com introduction indonesia, which is considered as one of many countries with the biggest population in the world, faces increased of life expectancy from 70.9 years in 2015–2020 to 72 years in 2025– 2030.1 an increase of elderly population and the percentage of elderly will increase from 8.5% in 2015 to 11.8% in 2025.1 indonesia’s success in increasing life expectancy, has many concequences, among others increase of noncommunicable diseases. the situation is worsened by the presence of multimorbidity or comorbidity.2–4 moreover, problems faced by the elderly are not just about disease and disability, but also about social problems that can influence their health, known as the social determinants of health (sdh).5 the world health organization commission on the social determinants of health, defined sdh as “the structural determinants and conditions of daily life responsible for a major part of health inequities between and within countries”.6 the sdh is a complex factor consits of economic, political, social, environmental, and cultural conditions that can act as risk factors which have an impact on health.5,6 original article :1–8 sharon gondodiputro,1 henni djuhaeni2 1department of public health, faculty of medicine, universitas padjadjaran 2master program of management, faculty of economics and business, universitas padjadjaran 2 international journal of integrated health sciences. 2019;7(1) the identification of sdh in the elderly can contribute to the development of many health preventive and promotive actions. based on these descriptions, the aim of this study was to identify the social determinants of health of the elderly by gender, urban, and rural area. social determinant factors of elderly as an input in enhancing primary health care in indonesia provinces 60–69 years (%) 70–79 years (%) 80+ (%) 60+(%) aceh 3.74 1.67 0.58 5.99 north sumatra 4.06 1.67 0.61 6.33 west sumatra 4.99 2.36 1.06 8.41 riau 2.98 1.09 0.38 4.46 jambi 3.83 1.53 0.64 6.00 south sumatra 4.16 1.75 0.70 6.6 bengkulu 3.83 1.57 0.72 6.13 lampung 4.53 2.10 0.87 7.5 bangka belitung islands 4.04 1.63 0.66 6.32 riau islands 2.58 0.90 0.28 3.76 jakarta 4.10 1.47 0.34 5.91 west java 4.71 2.14 0.73 7.58 central java 6.34 3.45 1.32 11.11 yogyakarta 6.98 4.35 1.86 13.2 east java 6.53 3.28 1.15 10.96 banten 3.29 1.24 0.42 4.95 bali 6.02 2.98 1.07 10.07 west nusa tenggara 4.59 2.03 0.76 7.38 east nusa tenggara 4.44 2.12 0.85 7.4 west borneo 4.22 1.71 0.44 6.37 central borneo 3.26 1.17 0.49 4.92 south borneo 3.99 1.58 0.56 6.13 east borneo 3.24 1.06 0.36 4.66 north celebes 5.66 2.65 0.84 9.14 central celebes 4.34 2.00 0.62 6.96 south celebes 5.14 2.53 0.88 8.54 south east celebes 3.74 1.62 0.70 6.07 gorontalo 4.38 1.74 0.46 6.58 west sulawesi 3.89 1.66 0.71 6.26 maluku 4.00 1.79 0.58 6.37 north maluku 3.49 1.29 0.41 5.19 west papua 2.63 0.81 0.20 3.63 papua 1.86 0.55 0.14 2.56 indonesia 4.91 2.31 0.83 8.05 table 1 percentage of elderly population from total population in indonesia, 2012 :1–8 international journal of integrated health sciences. 2019;7(1) 3:1–8 provinces urban rural male (%) female (%) total (%) male (%) female (%) total (%) aceh 5.03 5.9 5.47 5.61 6.78 6.2 north sumatra 5.61 6.73 6.17 5.72 7.26 6.49 west sumatra 6.79 8.42 7.61 7.95 9.88 8.92 riau 4.16 4.39 4.27 4.49 4.66 4.57 jambi 5.8 6.13 5.96 5.89 6.14 6.01 south sumatra 5.97 6.94 6.45 6.36 7.04 6.69 bengkulu 5.06 5.4 5.23 6.35 6.74 6.54 lampung 6.63 7.07 6.85 7.62 7.85 7.73 bangka belitung islands 6.13 6.99 6.54 5.8 6.45 6.11 riau islands 3.21 3.3 3.25 6.21 6.46 6.33 jakarta 5.66 6.17 5.91 0* 0* 0* west java 6.52 7.26 6.89 8.46 9.42 8.94 central java 9.74 11.3 10.53 10.82 12.37 11.6 yogyakarta 10.28 12.45 11.37 15.15 18.3 16.77 east java 9.26 10.89 10.08 10.74 12.74 11.76 banten 4.29 4.66 4.47 5.58 6.37 5.96 bali 8.05 9.26 8.65 11.51 13.02 12.27 west nusa tenggara 6.92 7.4 7.17 7.38 7.69 7.54 east nusa tenggara 6.04 6.77 6.4 7.36 7.93 7.65 west borneo 6.56 6.84 6.7 6.15 6.32 6.23 central borneo 4.65 4.73 4.69 4.95 5.14 5.04 south borneo 5.28 6.26 5.76 5.73 7.09 6.4 east borneo 4.54 4.4 4.47 5.1 4.82 4.97 north celebes 7.85 9.45 8.64 8.78 10.38 9.55 central celebes 5.92 6.61 6.27 7.06 7.33 7.19 south celebes 6.46 8.15 7.32 8.26 10.21 9.26 south east celebes 4.72 5.45 5.08 6.01 6.89 6.45 gorontalo 5.8 7.27 6.55 6.15 7.05 6.59 west sulawesi 6.03 7.08 6.57 5.82 6.52 6.17 maluku 5.7 6.61 6.15 6.29 6.71 6.5 north maluku 4.61 5.13 4.87 5.36 5.26 5.31 west papua 3.58 3.35 3.47 3.94 3.45 3.71 papua 4.01 3.74 3.89 2.34 1.82 2.1 indonesia 6.91 7.94 7.43 8.07 9.28 8.67 table 2 percentage of elderly population from total population, according to sex and urban/rural area in 33 provinces of indonesia, 2012 sharon gondodiputro, henni djuhaeni 4 international journal of integrated health sciences. 2019;7(1):1–8 elderly urban (%) rural (%) p value percentage of elderly 6.35 (1.90)* 6.49(0.00–16.77)** 0.172 percentage of male elderly 5.80(3.21–10.28) 6.15(0.00–15.15) 0.147 percentage of female elderly 6.74(2.16) 6.89(0.00–18.30) 0.308 social determinants of health urban (%) rural (%) p value education never/no 13.96(9.54)* 22.86(0.00–57.90)** 0.000 not finished elementary school 25.98(12.99–33.77) 38.35(0.00–58.57) 0.000 elementary school 28.25(5.19) 25.66(8.24) 0.131 yunior high school 11.41(3.73) 3.84(0.00–12.77) 0.000 senior high school 15.30(4.82) 3.10(0.00–9.43) 0.000 higher education 6.39(2.37) 0.81(0.00–3.50) 0.000 illiteracy male illiteracy 4.53(0.45–37.37) 19.62(0.00–60.62) 0.000 female illiteracy 11.98(2.82–41.90) 36.59(17.98) 0.000 occupation still working 36.32(4.28) 52.8(0.00–70.97) 0.000 household 35.61(4.09) 25.52(0.00–32.17) 0.000 agriculture 31.46(11.18) 80.32(0.00–88.86) 0.000 industry 7.77(2.94–17.71) 4.55(2.42) 0.000 trade 34.78(6.44) 8.64(3.17) 0.000 services 13.62(4.48) 3.07(0.00–11.84) 0.000 unemployed 0.23(0.00–0.71) 0.09(0.00–0.80) 0.162 own company 34.95(6.52) 27.25(9.70) 0.000 own company with employees 31.60(7.92) 47.29(0.00–57.74) 0.000 as employee 17.68(7.68) 4.36(0.00–14.27) 0.000 independent worker 4.76(0.00–17.85) 4.50(0.00–20.22) 0.521 family business, unpaid 9.66(3.80) 13.06(0.00–32.35) 0.000 income >idr 2,500,000 10.6(3.24–60.00) 3.70(0.00–15.82) 0.000 table 3 percentage of elderly from total population, according to sex and urban/rural area in indonesia 2012 table 4 percentage of elderly according to education, literacy, occupation, income and home ownership in urban and rural area, indonesia 2012 methods a comparative study was carried out to data of social determinants of elderly in 33 provinces of indonesia using secondary data from statistics indonesia 2013. the variables included in this study were percentage of elderly according to gender, education, marital status, occupation, income and living arrangements. normality of data was analyzed using shapiro-wilk test. the comparative analysis was conducted between male-female and social determinant factors of elderly as an input in enhancing primary health care in indonesia international journal of integrated health sciences. 2019;7(1) 5 urban-rural areas for each variable. the normally distributed data were analyzed using unpaired t test and not normally distributed data were analyzed using mann-whitney test. (α=0.05) results the proportion of elderly population in the provinces of indonesia was varied, but a large proportion live on the island of java. this study discovered that provinces with the percentage of elderly population more than 10% were yogyakarta, followed by central java, east java and bali (13.2%, 11:11%, 10.96% and 10.07%, respectively) (table 1). from all provinces, the age of 60–69 years constitutes the largest proportion, moreover there were five provinces which have more than 1% of elders over 80 years old, namely west sumatra, yogyakarta, central java, east java and bali. the elderly who lived in rural area covered approximately 8.67% of the total population. this was higher than the elderly who lived in urban area. statistically, there was no difference between the percentage of elderly population in urban and rural areas (p=0.172), in other provinces than the provinces already mentioned, two provinces i.e. north celebes and south celebes had more than 10% elderly female in rural area (table 2). overall, the elderly female who lived in rural area covered approximately 9.28% of the total population, higher than in urban area. this situation occured in the elderly male as well. although, the proportion of elderly female and male were higher in rural compared to urban area, there was no statistically significant (table 3). the level of education of the elderly population was still low. most of them studied only up to elementary school (table 4). percentage of elderly population who never or did not finished elementary school was higher in rural than in urban area (p=0.000). the opportunity of the elderly to receive higher education in rural area was very low. this was proven by the very low percentage of the elderly who had higher education in rural area (0.81%) compared to 6.39% in urban area. moreover, although the elderly had received basic education, the ability to read and write (literacy) was low, especially in rural female. (p=0.000) almost half of the percentage of elderly population was still working, especially in the rural area. the main occupation in the rural area was agriculture (80.32%) and in urban area was household (35.61%), followed by trade and services (34.78% and 13.62%, respectively). most of the elderly had their own company or had their own company with employee. there was still elderly who helped their family business, but unfortunately they were not paid, especially in the rural area. indonesia has determined the minimum income standard was indonesian rupiahs (idr) 2,500,000 per person permonth. this study showed that percentage of elderly population who had an income of more than idr 2,500,000 was very low, only 10.63% in urban area and 3.70% in rural area (p=0.000). most of the elderly male was still married compared to the elderly female (p=0.000), but more than half of the elderly female was widowed (table 5). moreover, most of the :1–8 social determinants of health male (%) female (%) p value marital status still married 81.72(2.84) 39.23(5.71) 0.000 widow/widower 15.64(2.19) 56.04(5.82) 0.000 living arrangements live alone 4.20(1.32) 11.52(4.70) 0.000 with spouses 20.35(5.45) 11.61(3.10) 0.000 with family member 36.37(7.35) 25.11(5.15) 0.000 with three generations 37.37(7.86) 47.39(6.56) 0.000 table 5 percentage of elderly according to their marital status and living arrangements, indonesia 2012 sharon gondodiputro, henni djuhaeni 6 international journal of integrated health sciences. 2019;7(1):1–8 elderly still lived with other family members, with 3 generations especially the elderly female. however, the percentage of elderly female who lived alone was higher than the elderly male. discussion the percentage of elderly in indonesia was quite high and varied from one province to another, some even exceeding 10% with the highest percentage of 60–69 years old. this situation showed that indonesia’s population moves to aging population. in general, there was no difference in the percentage of elderly population between urban and rural area. the number of elderly population in rural area, was caused by the urbanization of young people looking for jobs outside the village and also to the big cities.7,8 a study conducted by kreager8 showed that 46–75% of younger people in the village migrated from their village to another village or city, although this migration could be near or far. the impact of this situation is 12–37 per cent of elderly in the lower strata were currently vulnerable both physically and economically. education is a foundation to build health literacy and at the end is one of the factors that determine health outcomes. in this study, almost more than 90% of the elderly population had low education, especially in the rural area. a study conducted discovered that participants with no educational qualifications were four times more likely to have low health literacy compared to participants with degree level qualifications (21.3% v 4.9%).9 this situation affects the complexity of decision making in all areas including health, unawareness of the need for health, does not know where to seek treatment and gap in health information, such as reading of drug prescription, how to take medicine and how to prevent diseases. lower health literacy was associated with a higher prevalence of depressive symptoms, physical limitations, chronic diseases, higher prevalence of smoking and physical inactivity.9,10 presumably, this occurs because of lack of access to and use of health care services, ineffective patientprovider communication, self care behaviours, and less health information seeking.9,10 this study revealed that almost half of the percentage of elderly population was still working, especially in rural areas. the main occupation in the rural area was agriculture. elderly people who worked in agriculture area were vulnerable to a variety of disease because of heat/sunlight exposure, pesticides, traditional farm tools, musculosceletal problems, animals (snake) or insect bites. exposure to sunlight has advantages and disadvantages. one of the advantage is metabolism of vitamin d which have an impact to bone metabolism and prevent malignancies.11,12 long-term exposure to sunlight is known to be associated with the development of skin cancer, skin aging, immune suppression, and eye diseases such as cataracts and macular degeneration.13,14 exposure to pesticides can cause poisoning and malignant diseases such as lymphoma.15 furthermore, like other traditional farmers in other countries, most of the indonesian farmers are using agricultural hand tools for cutting, digging and scrapping.16 those mechanical hazards are the risk factors of development of musculosceletal problems because of bowing, bending at the knees, squatting or kneeling and constant hand grip.17 in accordance with economic status, this study discovered that poverty was higher in rural than in urban area. a report by priebe and howell stated that with increasing age, the percentage of poverty among the elders was rising.17 aware of this fact, the government needs to develop income security programs for the elderly so that they will not depend financially on their family and can live properly. this study discovered that more elderly women were widowed compared to elderly men and lived alone. a report by witoelar, using data from indonesian family live survey in 1993–2007, discovered that elderly men who lived with an adult child was as much as 68.7% in 1993 and decreased slightly to 65.1%, whereas the elderly women was 75.2% in 1993 and decreased to 63.8%.18 furthermore, the elderly man who lived alone was of 0.4% in 1993 to 2.5% in 2007, whereas the elderly women was 3% in 1993 to 11.1% in 2007.18 the change of living arrangement can cause the need of caregiver. caregiver is the person who supports and assists disabled person or provides care for elders.19 the study had limitations since the secondary data did not provide all components of the social determinants of health such as availibility and accessibility to health care services, local culture that can affect the health outcomes, cognitive impairment status and living conditions which can be a source of hazard. although most of the elderly lived with their family, the secondary data could not identify whether the family member stayed almost all day with the elderly or worked the social determinant factors of elderly as an input in enhancing primary health care in indonesia international journal of integrated health sciences. 2019;7(1) 7 whole/part of the day. the provided data could not identify who was the caregiver for the elderly as well. it can be concluded that the indonesian population moves to aging population with varied percentage across provinces. most of the elderly have low education and income especially in the rural area. there were various occupational hazards among elderly population according to their occupation that could contribute to the emergence of occupational disorders. this situation has to be a concern for primary health care providers. most of the elderly had low economic status which led to the need for financial support either from members of their family or from the government to develop an income security plan. moreover, if needed, their spouses or other family members could be their caregivers. references 1. statistics indonesia. population projection 2010–2035. jakarta: statistics indonesia; 2013. 2. wang hh, wang jj, wong sys, wong mcs, li fj, wang pk et al. epidemiology of multimorbidity in china and implications for the healthcare system: cross-sectional survey among 162,464 community household residents in southern china. bmc med. 2014;12(188):1–12. 3. pati s, agrawal s, swain s, lee jt, vellakkal s, hussain ma, et al. non communicable disease multimorbidity and associated health care utilization and expenditures in india: crosssectional study. bmc health service res. 2014;14(451):1–9. 4. amrina rosyada, indang trihandini. determinan komplikasi kronik diabetes mellitus pada lanjut usia. j kese masyarakat nasional. 2013;7(9):395–401. 5. viner rm, ozer em, denny s, marmot m, resnick m, fatusi a, et al. adolescence and the social determinants of health. lancet. 2012;379(9826):1641–52. 6. rasanathan k, montesino ev, matheson d, etienn c, evans t. primary health care and the social determinants of health: essential and complementary approaches for reducing inequities in health. j epidemiol community health. 2011;65(8):656–60. 7. firman t. the continuity and change in megaurbanization in indonesia: a survey of jakarta– bandung region (jbr) development. habitat international. 2009;33(4):327–39. 8. kreager p, schröder-butterfill e. age-structural transition in indonesia: a comparison of macro and micro-level evidence. asian popul stud. 2010;6(1):25-45. 9. bostock s, steptoe a. association between low functional health literacy and mortality in older adults: longitudinal cohort study. bmj. [serial on the internet] 2012 mar [cited 2018 jan 21];2012:(344):[about 10p.]. available from: https://www.bmj.com/content/344/bmj. e1602.long. 10. berkman n, sheridan sl, donahue ke, halpern dj, crotty k. low health literacy and health outcomes: an updated systematic (review). ann intern med. 2011;155(2):97–107. 11. mason rs, reichrath j. sunlight vitamin d and skin cancer. anticancer agents med chem. 2012;13(1):83–97. 12. hossein-nezhad a, holic mf. vitamin d for health: a global perspective. mayo clin proc. 2013;88(7):720–55. 13. evans je, johnson ej. the role of phytonutrients in skin health. nutrients. 2010;2(8):903–28. 14. bethel jw, harger r. heat-related illness among oregon farmworkers. int j environ res public health. 2014;11(9):9273–85. 15. alavanja mcr, hofmann jn, lynch cf, hines cj, barry kh,, barker j, et al. non-hodgkin lymphoma: risk and insecticide, fungicide and fumigant use in the agricultural health study. plos one [serial on the internet] 2014 oct [cited 2018 jan 21];9:(10):[about 17p.]. available from: https://journals.plos.org/plosone/ article?id=10.1371/journal.pone.0109332. 16. neitzel rl, krenz j, de castro ab. safety and health hazard observations in hmong farming operations. j agromedicine. 2014;19(2):130– 149. 17. priebe j, howell f. old-age poverty in indonesia. a role for social pensions. jakarta: tim nasional percepatan penanggulangan kemiskinan; 2014. 18. witoelar f. household dynamics and living arrangements of the elderly in indonesia: evidence from a longitudinal survey. in: smith jp, majmundar jp, editors. aging in asia: findings sharon gondodiputro, henni djuhaeni :1–8 8 international journal of integrated health sciences. 2019;7(1):1–8 from new and emerging data initiatives. usa: national academy of sciences; 2012. 19. kamel ama. who are the elder’s caregivers in jordan: a cross-sectional study. j nurs edu pract. 2016;6(3):116–21. social determinant factors of elderly as an input in enhancing primary health care in indonesia volume 7 no 2 2019 (3).indd 88 international journal of integrated health sciences. 2019;7(2) original article high tissue factor microparticle level in major thalassemic patients with pulmonary hypertension abstract objective: to analyze the correlation between tissue factor microparticles (tf-mp) levels and pulmonary hypertension (ph) in adult thalassemic patients. methods: this study was conducted from september to october 2018, using secondary and primary data. the secondary data consisted of the ph parameter, which was retrieved from a 2017 previous study entitled ‘clinical characteristic and complication due to iron overload in thalassaemic patients‘in 2017 while the primary data were the tf-mp which were obtained from the analysis of frozen serum of the same population using elisa method. the mean pulmonary arterial pressure (mpap) values were obtained from echocardiography results and ph was defined as mpap >25 mmhg. results: seven (16.7%) major thalassemic patients experienced ph. the median values of tf-mp levels were higher among major thalassemic patients with ph when compared to the non-ph patients (1569 vs 11.5 pg/ dl; p=0.023). no significant difference was observed in the median tf-mp levels between subjects with splenectomy and subjects without splenectomy (11.6 vs 12.3 pg/dl; p=0.44). there was also no difference in mpap values between subjects with splenectomy and subjects without splenectomy (18.0 vs 17.0 mmhg; p=0.663). when the median tf-mp levels among major thalassemic patients were analyzed in terms of correlation with transfussion level, no statistically significant difference was seen between subjects who received sufficient transfusions (≥180 ml/kgbb/year) and those who received insufficient transfusions (<180 ml/kgbb/year) (r = 0.138; p=0.390). conclusions: there is a positive correlation between the tf-mp levels and ph in adult major thalassemic subjects. keywords: major thalassemia, pulmonary hypertension, tissue factor microparticles pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v7n2.1658 ijihs. 2019;7(2):88–95 received: march 11, 2019 revised: september 17, 2019 accepted: october 19, 2019 correspondence: dimmy prasetya, department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, jalan psteur no. 38 bandung, west java, indonesia e-mail: dimmy.prasetya@unpad.ac.id dimmy prasetya, pandji irani fianza, erwan martanto, teddy arnold sihite department of internal medicine faculty of medicine universitas padjadjaran dr. hasan sadikin general hospital bandung, indonesia introduction homozygous β-globin carrier defects in thalassemia patients can give rise to several complications due to hemolysis, chronic anemia, and continuous transfusions. in the last few decades, major thalassemia patients can live longer with the availability of blood transfusion and iron chelation. with the longer survival, the previously unrecognized complications associated with hypercoagulability become visible.1,2 complications associated with hypercoagulability appear to be subclinical, marked only by changes in the hemostasis parameters, until thromboembolic processes such as stroke, transient ischemic attack, deep vein thrombosis (dvt), and pulmonary embolism occur. pulmonary hypertension (ph) in thalassemia is included in the 5th class :88–95 international journal of integrated health sciences. 2019;7(2) 89 of the ph classification of the 2013 american college of cardiology and is considered to happen via multifactorial mechanisms. it is considered as the complication that becomes the main factor of morbidity and mortality in these patients. pulmonary hypertension involves several mechanisms such as endothelial dysfunction, inflammation, and chronic thromboembolism. the mechanism of thromboembolism in thalassemia patients with ph has not been clearly understood.3, 4 the multifactorial mechanism requires microparticles to play distinctive roles in the cellular interactions related to ph pathogenesis. microparticles are vesicles from the plasma membrane, ranging from 0.1 to 1 µm in size, that are released by cells through activation by their agonists, physical and chemical stresses, and apoptosis. tissue factor microparticles (tf-mp) or circulating tissue factor (ctf) is a protein released by cellular activation or apoptosis that plays an important role in producing thrombin in the propagation phase of the cell-based coagulation. cellular activation in thalassemia is caused by negatively-charged cell membranes and hemolysis process disorders. previous studies have reported that increased tf-mp levels are found in thalassemia patients, as well as in patients with 1st and 3rd group ph.5, 6 no data available yet on the roles of tf-mp in thalassemia patients with ph. this study aimed to analyze the correlation between tf-mp level and ph in major thalassemia patients in dr. hasan sadikin general hospital, bandung, west java, indonesia. methods this was a cross-sectional quantitative study using numeric-numeric correlative statistical analysis conducted from september to october 2018. subjects in the study were thalassemia patients treated at the hematology-medical oncology clinic, internal medicine department, faculty of medicine, universitas padjadjaran/ dr. hasan sadikin general hospital bandung. ph parameters were collected as secondary data from a previous study entitled ‘ clinical characteristic and complication due to iron overload in thalassaemic patients ‘ which was conducted in 2017 while data on tf-mp were collected by testing the frozen serum of the same population of this 2017 study. the inclusion criteria were thalassemia patients aged ≥14 years who had received treatments and regular transfusions for more than two years after diagnosis, had echocardiographic data, and had their frozen serum stored. the exclusion criteria were intermediate thalassemia patients and patients with left ventricular or left atrial hypertrophy. pulmonary hypertension (ph) was measured using the ge vivid s6 echocardiography device. meanwhile, the severity of ph was determined by estimating the mean pulmonary arterial pressure (mpap) (≥25 mmhg). the mpap was measured while the patient was resting through the use of the pulmonary velocity accelerated time (pvacct) calculation [mpap =80-(pvacct/2)]. data on the mp-tf levels were collected through subject serum analysis using the elisa method and the results were reported in pg/dl. before statistical analyses were performed, data normality testing was performed on numerical data, such as age, period of suffering from thalassemia, transfusion period, total transfusions volume, sufficiency of transfusions, ferritin levels, hemoglobin (hb) levels, thrombocyte counts, mpap values, and tf-mp levels. the shapiro-wilk test was selected for this testing because the number of subjects was less than 50. data on age, ferritin levels, hematocrit percentages, thrombocyte counts, ferritin levels, period of suffering from thalassemia, sufficiency of transfusions, mpap values, and mp-tf levels were not normally distributed (p>0.05), while data on hb level were normally distributed (p>0.05). normally distributed data were presented in mean and analyzed using pearson correlation (r) test, while data that were not normally distributed were presented in median and analyzed using non-parametric spearman correlation test (rs). point biserial correlation (rpb) analysis was performed to observe the correlation between numerical and categorical data. results were declared as significant if p<0.05. results subject characteristics, including age, sex, ferritin levels, hb levels, ht percentages, thrombocyte counts, sufficiency of transfusions, numbers of subjects with ph or without ph, mpap values, and tf-mp levels, are presented in table 1. the median age was 20 years old. more females were included in the study than males (38.1% versus 61.9%). the median period of suffering from thalassemia was 198 months. the sufficiency of transfusion was 65.6 cc/kgbw/year while the mean hb level, median thrombocyte count, and median ferritin level were 7.0±1.3 g/dl, dimmy prasetya, pandji irani fianza, et al. :88–95 90 international journal of integrated health sciences. 2019;7(2) 137,000, and 3,940 ng/dl, respectively. the subjects characteristics including the age, sex, ferritin levels, hb levels, ht percentages, thrombocyte counts, sufficiency of transfusions, numbers of subjects with ph or without ph, mpap values, and tf-mp levels can be seen in table 1 below. the median of age was 20, consisting of males (38.1%) and females (61.9%). the median of period of suffering from thalassemia was 198 months. the sufficiency of transfusions was 65,6 cc/ kgbb/year, the mean of hb level was 7.0±1.3 g/dl, the median of thrombocyte count was 137.000, and the median of ferittin level was 3940 ng/dl. when the correlation between mp-tf level and mpap value was assessed using the spearman correlation test with a 95% confidence interval, it was revealed that the mp-tf level had a statistically significant correlation with the mpap value (r=0.481; p=0.001). (r=0.481; p=0.001). discussion this study presented a correlation between table study subject basic characteristics variable n=42 age (years old), median (min–max) 20 (16–36) sex, n (%) male 16 (38.1) female 26 (61.9) period of suffering from thalassemia (months), median (min–max) 198 (68–291) group, n (%) splenectomy 12 (28.6) non-splenectomy 30 (71.4) hb (g/dl), mean±sd 7.0±1.3 hb category <9 g/dl 40 (95.2) ≥9 g/dl 2 (4.8) ht (%), median (min–max) 22.0 (9.1–51.9) thrombocyte count (x1000/mm3 ), median (min–max) 137 (18–903) ferritin ng/dl, median (min–max) 3940 (948–14030) ferritin category ng/dl, n (%) (ng/dl) <2,500 13 (31.0) ≥2,500 29 (69.0) sufficiency of transfusion (ml/kgbb/year), median (min–max) 65.6 (0.0–339.9) sufficiency of transfusion category, n (%) n=41 ≥180 ml/kgbb/year 5 (11.9) <180 ml/kgbb/year 36 (85.7) ph and non-ph group ph 7 (16.7) non-ph 35 (83.3) mpap (mmhg), median (min–max) 17.0 (9.0–43.0) mp-tf (pg/dl), median (min–max) 12.1 (5.3–2615.2) note: sd= standard deviation, n= total, %=percentage high tissue factor microparticle level in major thalassemic patients :88–95 international journal of integrated health sciences. 2019;7(2) 91 fig 1 scatter diagram of correlation between mp-tf level and mpap value fig. 2 boxplot of median mp-tf level in ph and non-ph groups transfusion sufficiency fig. 3 scatter diagram of correlation between transfusion sufficiency and tf-mp level dimmy prasetya, pandji irani fianza, et al. :88–95 92 international journal of integrated health sciences. 2019;7(2) increased mp-tf levels and high mpap values (moderate correlation; r=0.481; p<0.001). based on the point biserial analysis to observe a direct correlation between the mp-tf level and the presence of ph, a significant difference was observed between ph and non-ph subjects (p<0.05; rpb=0.311). a study conducted by bakoubula et al. in 2008 that examined the correlation between mp-tf levels and ph by enrolling 20 subjects with 1st and 3rd group of ph discovered a statistically significant correlation between the mp-tf level and ph (p<0.001). dhiel et al. in 2010 who studied 19 subjects with ph caused by chronic thromboembolism, idiopathic ph, rheumatic-related ph, and chronic pulmonary disease (cpd)-related ph also found a positive correlation between procoagulant mp level and occurrence of ph in study subjects when compared to the normal control.7, 8 hypercoagulability complications in thalassemia patients are characterized by splenectomy non-splenectomy groups fig. 4 boxplot of tf-mp level in splenectomy and non-splenectomy groups fig. 5 boxplot of mpap levels in splenectomy and non-splenectomy groups splenectomy non-splenectomy groups high tissue factor microparticle level in major thalassemic patients :88–95 international journal of integrated health sciences. 2019;7(2) 93 subclinical defects marked by hemostasis parameter changes until the occurrence of thromboembolic events such as stroke, transient ischemic attack, dvt, and chronic pulmonary embolism. the ph in thalassemia can be included in the 5th group of the 2013 acc classification. pulmonary hypertension in thalassemia is caused by various factors and mechanisms, including pulmonary arteriole in situ thrombosis. interactions among factors that play the roles in the occurrence of ph in major thalassemia patients require a medium such as procoagulant mp.5, 9 this study reveals a correlation between mptf level and mpap value in major thalassemia population. this study supports findings of previous studies and adds supporting data of in situ thrombosis process in the pathogenesis of the 5th group ph through the roles of procoagulant microparticles, such as tf-mp.5 the correlation between the tf-mp level and ph discovered in this study is considered moderate (r=0.481). this may relate to other mechanism pathways, such as the endothelial dysfunction pathway, triggered by decreased nitric oxide and inflammation. endothelial dysfunction causes an imbalance in mediator production, which leads to vasoconstriction, smooth muscle hyperplasia, and pulmonary arterial remodeling. other factors that can influence the occurrence of ph are not included in this study despite the possibility that they may also influence the significance of the correlation. hence, this is considered a limitation in this study.5,10 of all thalassemia patients in this study, 16.7% had ph. this is different from a previous study by fayed et al. in 2017 which reported that 36% of major thalassemia children have ph. the presence of ph in their study was determined through echocardiographic examination by calculating mpap using a different formula.11 based on the 2015 esc, mpap is not used for echocardiographic diagnosis of ph. instead, the 2015 esc uses the tricuspid regurgitant velocity (trv) and other imaging techniques for assessing complications of ph in the right side of the heart. this method is more specific and widely used. the results are categorized as low, moderate, or high probability for ph. this study uses secondary data from a previous study. however, the reference study did not use trv calculation in the determination of ph, which creates another limitation of this study.12 the median tp-mf level of the subjects of this study was 12.1 pg/dl, which is much higher than the tp-mf level in normal people, which is less than 0.21 pg/dl. the increase in the tf-mp level in major thalassemia patients in comparison to the normal population is also demonstrated in some previous studies. a higher level of tf-mp can also be found in several other diseases such as hiv, diabetes mellitus, and sickle cell disease.13, 14 the determinant factors of defect in thalassemia are chronic hemolysis and ineffective erythropoiesis with iron overload which leads to complications in thalassemia, including hypercoagulability. hemichrome precipitation due to thalassemic erythrocyte globin chain defect can cause heme disintegration, enhance intracellular labile iron, and produce reactive oxygen species, which lead to endothelial activation and dysfunction.10 the majority of the subjects in this study (95.2%) had a pre-transfusion hb level of <9 g/dl, which was caused by insufficient transfusions. the median of transfusion sufficiency in this study was 65.6 cc/kg bw/ year, which is below the standard of ≥180 cc/kg bw/year. no significant correlation was observed between the insufficiency of transfusions and either tf-mp level and the presence of ph. a previous study by hastuti in dr. hasan sadikin general hospital, bandung, indonesia in 2007 on major thalassemia patients discovered a correlation between the sufficiency of transfusions and the hypercoagulability index when examined by teg. the insufficiency of transfusions can cause a higher level of thalassemic erythrocyte cells.15 the results of this study were different from the results reported by agouti et al. in 2015 on 37 major thalassemia patients. their study described higher tf-mp in subjects who received insufficient transfusions, which was assessed using the flow cytometry test. flow cytometry test is considered to be more sensitive and has the ability to identify the cell origin of tf-mp. literature stated that complications due to chronic hemolysis and ineffective hematopoiesis in relation to the thromboembolic processes are more frequently seen in intermediate thalassemia than in major thalassemia. agouti’s study does not include intermediate thalassemia patients so complications caused by insufficiency of transfusions do not influence the higher tfmp level and ph.16 splenectomy in thalassemia patients triggers an increase in thrombocyte count, activation, and aggregation. these conditions may lead to a higher level of tf-mp derived dimmy prasetya, pandji irani fianza, et al. :88–95 94 international journal of integrated health sciences. 2019;7(2) from thrombocytes. splenectomy is also associated with an increase in mpap values in thalassemia patients and previous studies have discovered a higher ph incidence in patients with splenectomy when compared to those without splenectomy.11 the result of this study showed no significant correlation between splenectomy and increased tf-mp level and mpap value. a previous study stated that the incidence of ph is higher in thalassemia patients who had undergone splenectomy. the difference in result is probably caused by the number of the subjects in the study which is lower (36 subjects) than in this study, along with the higher frequency (47.2%) of ph in their study. the mean thrombocyte count in their study is 548.200±242.500/mm3, which is higher than in this study (137.000/mm3).11 several limitations are noted in this current study, including ph examination using pvacct calculation, which is less specific than other methods such as the trv from echocardiography. this study does not analyze the origin of cells that activate and release tfmp, thus unable to describe the influence of sufficiency of transfusions on the tf-mp level. this study also does not analyze major factors that can influence the pathogenesis of ph from the endothelial dysfunction and inflammation pathways; hence, major determinants in the significance of the correlation between tfmp level and ph in major thalassemia patients cannot be discovered.17, 18 in summary, this study proves that the tf-mp level influences in situ thrombosis in the mechanism of ph in major thalassemia patients. further studies with cohort design and multiple regression analysis of other determinant factors in the endothelial dysfunction and inflammation pathways that might contribute to the mechanism of ph should be conducted. in major thalassemic patients with sufficient transfusions, it is not crucial to discover the origin of cells that release tf-mp using flow cytometry test. references 1. nienhuis aw, nathan dg. pathophysiology and clinical manifestations of the β-thalassemias. cold spring harb perspect med. 2012;2(12):a011726. 2. sabath de. molecular diagnosis of thalassemias and hemoglobinopathies: an aclps critical review. am j clin pathol. 2017;148(1):6–15. 3. hoeper mm, bogaard hj, condliffe r, frantz r, khanna d, kurzyna m, et al. definitions and diagnosis of pulmonary hypertension. j am coll cardiol. 2013;62(25 suppl):d42–50. 4. fraidenburg dr, machado rf. pulmonary hypertension associated with thalassemia syndromes. ann n y acad sci. 2016;1368(1): 127–39. 5. amabile n, guignabert c, montani d, yeghiazarians y, boulanger cm, humbert m. cellular microparticles in the pathogenesis of pulmonary hypertension. eur res j. 2013;42(1):272–9. 6. barteneva ns, fasler-kan e, bernimoulin m, stern jn, ponomarev ed, duckett l, et al. circulating microparticles: square the circle. bmc cell biol. 2013;14(1):23. 7. bakouboula b, morel o, faure a, zobairi f, jesel l, trinh a, et al. procoagulant membrane microparticles correlate with the severity of pulmonary arterial hypertension. am j respir crit care med. 2008;177(5):536–43. 8. diehl p, aleker m, helbing t, sossong v, germann m, sorichter s, et al. increased platelet, leukocyte and endothelial microparticles predict enhanced coagulation and vascular inflammation in pulmonary hypertension. j thromb thrombolysis. 2011;31(2):173–9. 9. abosdera mm, almasry ae, abdel-moneim es. coagulation defects in thalassemic patients. pediatr neonatol. 2017;58(5):421–4. 10. elsayh ki, zahran am, el-abaseri tb, mohamed ao, el-metwally th. hypoxia biomarkers, oxidative stress, and circulating microparticles in pediatric patients with thalassemia in upper egypt. clin appl thromb hemost. 2014;20(5):536–45. 11. fayed ma, abdel-hady he-s, hafez mm, salama os, al-tonbary ya. study of platelet activation, hypercoagulable state, and the association with pulmonary hypertension in children with β-thalassemia. hematol oncol stem cell ther. 2018;11(2):65–74. 12. galiè n, humbert m, vachiery j-l, gibbs s, lang i, torbicki a, et al. 2015 esc/ers guidelines for the diagnosis and treatment of pulmonary hypertension: the joint task force for the diagnosis and treatment of pulmonary hypertension of the european society of cardiology (esc) and the european respiratory society (ers): endorsed by: association for european paediatric and congenital cardiology (aepc), international society for heart and lung transplantation (ishlt). eur heart j. high tissue factor microparticle level in major thalassemic patients :88–95 international journal of integrated health sciences. 2019;7(2) 95 2016;37(1):67–119. 13. baker jv, hullsiek kh, bradford rl, prosser r, tracy rp, key ns. circulating levels of tissue factor microparticle procoagulant activity are reduced with antiretroviral therapy and are associated with persistent inflammation and coagulation activation among hiv positive patients. j acquir immune defic syndr. 2013;63(3):367–71. 14. singh a, boden g, homko c, gunawardana j, rao ak. whole-blood tissue factor procoagulant activity is elevated in type 1 diabetes and effects of hyperglycemia and hyperinsulinemia. diabetes care. 2012;35(6):1322–7. 15. hastuti ts. hubungan volume darah transfusi dengan koagulabilitas pada penderita thalassemia yang mendapat transfusi berkala dan belum menjalani splenektomi [thesis]. bandung: fakultas kedokteran universitas padjadjaran, 2011. 16. agouti i, cointe s, robert s, judicone c, loundou a, driss f, et al. platelet and not erythrocyte microparticles are procoagulant in transfused thalassaemia major patients. br j haematol. 2015;171(4):615–24. 17. parasuraman s, walker s, loudon bl, gollop nd, wilson am, lowery c, et al. assessment of pulmonary artery pressure by echocardiography—a comprehensive review. . int j cardiol heart vasc. 2016;12:45-51. 18. anthi a, orfanos se, armaganidis a. pulmonary hypertension in β thalassaemia. lancet res med. 2013;1(6):488–96. dimmy prasetya, pandji irani fianza, et al. :88–95 volume 7 no 2 2019 (3).indd 102 international journal of integrated health sciences. 2019;7(2) elevated endothelin-1 in intradialytic hypertension abstract objective: to determine the relative change in endothelin-1 (et-1) during hemodialysis procedure in stage five dialysis-dependent chronic kidney disease (ckd-5d) patients with and without intradialytic hypertension (idh). methods: this was a cross-sectional, observational study involving 40 ckd-5d patients who received two hemodialysis per week for at least three months at the dialysis unit of dr. hasan sadikin hospital general bandung, indonesia, during september 2016. subjects were divided into two groups: with idh (n=20) and without idh (n=20). plasma et-1 level was examined before and after hemodialysis. results: there was a significant elevation of et-1 level (mean±sd pg/ml) between preand post-dialysis states in patients with idh (3.33±1.28 vs. 3.84±1.75; relative changes: 15.32%, p=0.013). no change was observed in patients without idh (3.99±2.30 vs. 4.38±1.81; relative changes: 9.77% p=0.083). the post-dialysis absolute et-1 level was significantly lower in ckd-5d patients with idh (3.84±1.75 vs. 4.38±1.81; p=0.024). conclusions: there was a significant elevation of et-1 level in ckd-5d patients with idh during the hemodialysis procedure at the dialysis unit of dr. hasan sadikin general hospital bandung. keywords: endothelin-1, hemodialysis, intradialytic hypertension pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v7n2.1737 ijihs. 2019;7(2):102–7 received: july 10, 2019 revised: september 28, 2019 accepted: october 19, 2019 correspondence: rubin s. gondodiputro, department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, jalan pasteur no. 38 bandung, west java, indonesia, e-mail:r.surachno@yahoo.com rubin surachno gondodiputro, andika wiratama, stefanie yuliana usman, erma arnika dewi, evan susandi, afiatin, ria bandiara department of internal medicine faculty of medicine, universitas padjadjaran/ dr. hasan sadikin general hospital bandung, indonesia introduction hemodialysis is the main renal replacement therapy (rrt) option for patients with endstage kidney disease who cannot undergo renal transplantation. although techniques in hemodialysis are advancing rapidly, intradialytic hypertension (idh) is still one of the most poorly-recognized complications in patients receiving hemodialysis.1 idh is associated with increased rates of hospitalization, poorer survival rate, and death in dialysis-dependent stage five chronic kidney disease patients (ckd-5d).2-5 idh occurs in 10-12% hemodialysis patients. 3, 6 the pathogenesis of idh in patients undergoing routine hemodialysis has not been fully understood. many factors are considered to be the cause of this complication.2 studies demonstrated that the endothelin-1 (et-1) level significantly increases in idh patients in comparison to controls.7-11 in a pathological condition, the et-1 may induce endothelial dysfunction, increase peripheral resistance, and eventually lead to idh.6,12 a study in bandung and a study by the indonesian renal registry showed that idh accounts for 35–36% of complications in hemodialysis patients.13,14 furthermore, a study which included some hospitals in bandung showed a different ratio from earlier studies in other countries.14 this raises the question of whether there are differences in the cause of high idh incidence, particularly original article :102–7 international journal of integrated health sciences. 2019;7(2) 103 in the et-1 level as a marker of endothelial dysfunction. previous studies determined the absolute changes of et-1 before and after dialysis in patients with idh and controls. since many factors may contribute to the et-1 baseline level alterations, a significant difference in plasma et-1 may be found in patients with and without idh. hence, it is crucial to establish the relative change in the et-1 level between the two groups during the hemodialysis procedure. this study aimed to determine the relative change of et-1 levels in the ckd-5d patients with and without idh treated at the dialysis unit of dr. hasan sadikin general hospital bandung, indonesia. methods this study was a cross-sectional observational study on ckd-5d patients who underwent routine hemodialysis twice a week for more than three months in dr. hasan sadikin general hospital bandung, indonesia, during september 2016. from the calculation using the formula below, a minimum of 16 subjects for the group with predictor (idh) and 16 subjects for the group without predictor (without idh) were required. the alpha standard deviation was 5%; therefore, the zα/2 was 1.96, and the beta standard deviation was 10%. hence, the zβ would be 1.28. a consecutive sampling technique was applied for subject recruitment. patients were categorized into the group with idh (n=20) or without idh (n=20). the inclusion criteria were adult patients aged 18 years old or older who took anti-hypertensive drugs. patients who had atrial fibrillation or whose blood pressure (bp) could not be measured by standard procedures were excluded. patients’ blood pressure was measured before and after each hemodialysis session. idh was defined as a difference in systolic bp (post-dialytic bp minus pre-dialytic bp) of more than 10 mmhg, with a bp of above 130/80 mmhg after completing the hemodialysis session. 1,3 patient’ body weight was measured before and after hemodialysis sessions. the idwg was calculated as predialysis weight minus post-dialysis weight of the previous hemodialysis session. 15 the ultrafiltration rate was defined by dividing the ultrafiltration volume (ml) by the length of time of the dialysis session (hours) and target dry weight (kg).16 the difference in et-1 level between the preand post-dialysis was evaluated by using the paired t-test. while the comparison of et-1 level and their changes between idh and non-idh groups were performed using the unpaired t-test. p-value <0.05 was considered statistically significant. the ethical clearance for this study was obtained from the ethics committee of the faculty of medicine of universitas padjadjaran under the ethical clearance number: lb.04.0l/ ao5/ec/250/vll/2016. results a total of 40 subjects were included in the study, with twenty subjects for each group. table 1 presents the baseline characteristics of the study subjects. other than the interdialytic weight gain (idwg), ultrafiltration, and history of hypertension in the last one month, the baseline characteristics between the ckd-5d patients with and without idh were similar. in subjects with idh, the mean age was 54±12 years old. the mean pre-dialytic and post-dialytic bp in this group were 160/79 mmhg and 186/89 mmhg, respectively, while the mean dry body weight was 50.2±10.6 kg. the mean idwg was significantly higher (p=0.048) in subjects without idh, with 80% (n=16) of patients experiencing an increase in idwg. the mean ultrafiltration volume was also significantly higher (p=0.009) in subjects without idh. on pulse pressure and pulse rate examination, the mean values between subjects with and without idh were similar (81±20 mmhg versus 75±25 mmhg and 75±10 times per minute versus 81±11 75. respectively). the hematocrit and sodium levels were also found to be similar between the two groups. based on the diagnosis of ckd, hypertension was the most common cause (65%) in subjects with intradialytic group, followed by diabetic kidney disease (25%), primary glomerulopathy (5%), and lupus nephritis (5%). whereas, in the group without idh, the most common cause of ckd was hypertension (55%), followed by diabetic kidney disease (25%), pnc (10%), and primary glomerulopathy (10%). the history of idh in the last one month was significantly higher (p=0.034) in subjects with idh, occurring 2–9 times a month. table 2 shows the et-1 level in the study subjects before and after dialysis. in the idh group, the mean (±sd) of pre-dialytic and post-dialytic et-1 level was 3.33±1.28 pg/ml and 3.84±1.75 pg/ml, respectively, and the rubin surachno gondodiputro, andika wiratama, et al. :102–7 104 international journal of integrated health sciences. 2019;7(2) table 1 baseline characteristics variable idh(n =20) without idh (n =20) p-value age (years) (mean±sd) 54±12 52±14 0.730* gender (n, %) male female 8 (40.0) 12 (60.0) 12 (60.0) 8 (40.0) 0.206† pre-dialytic blood pressure (mean±sd; mmhg) systolic diastolic 160±22 79±9 158±26 84±11 0.835* 0.118* hemodialysis duration (months) (median (min-max)) 24 (3 – 77) 27 (3 – 87) 0.797‡ dry weight (mean±sd; kg) 50.2±10.6 57.1±15.5 0.107* idwg (mean±sd) elevated not elevated 2.9±1.1 13 (65.0) 7 (35.0) 3.6±0.9 16 (80.0) 4 (20.0) 0.048*¶ 0.288† ultrafiltration (mean±sd; ml/hour/kg) elevated not elevated 3.240±981 17 (85.0) 3 (15.0) 4.055±882 17 (85.0) 3 (15.0) 0.009*¶ 1.000§ pulse pressure (mean±sd; mmhg) elevated not elevated 81±20 19 (95.0) 1 (5.0) 75±25 19 (95.0) 1 (5.0) 0.363* 1.000§ pulse rate (mean±sd; beat per minute) elevated not elevated 75±10 7 (35.0) 13 (65.0) 81±11 12 (60.0) 8 (40.0) 0.082* 0.113† hematocrit (mean±sd, %) elevated not elevated 28±4 6 (30.0) 14 (70.0) 30±5 8 (40.0) 12 (60.0) 0.128* 0.507† esa therapy yes no 4 (20.0) 16 (80.0) 3 (15.0) 17 (85.0) 1.000§ diagnosis hypertension diabetic kidney disease chronic pyelonephritis primary glomerulopathy lupus nephritis 13 (65.0) 5 (25.0) 0 (0.0) 1 (5.0) 1 (5.0 11 (55.0) 5 (25.0) 2 (10.0) 2 (10.0) 0 (0.0) 0.478† history of idh in the last one month (median (min-max)) 4 (2 – 9) 3 (1 – 5) 0.034‡¶ sd: standard deviation; esa: erythropoietin stimulating agents; analysis was performed using *t-test, †chi square, ‡mann whitney, §fisher exact, ¶statistically significant (p<0.05); idwg = interdialytic weight gain elevated endothelin-1 in intradialytic hypertension :102–7 international journal of integrated health sciences. 2019;7(2) 105 mean absolute change of the et-1 level in this group was 0.51 pg/ml (95% ci: 0.07–0.96 pg/ ml), with a relative change of 15.32% (95% ci: -6.19–19.17%). the mean absolute change of post-dialytic et-1 level was significantly higher when compared to the pre-dialytic level (p=0.013), but the relative change was not significantly altered (p>0.05). in the ckd-5d patients without idh, the mean (± sd) pre-dialytic et-1 level was 3.99±2.30 pg/ml, while the post-dialytic level was 4.38±1.81 pg/ml. the mean absolute change of the et-1 level in this group was 0.39 pg/ml (95% ci: -0.18–0.97 pg/ml), and the relative change was 9.77% (95% ci: 6.25– 36.72%). however, neither absolute change nor relative change of et-1 level differed significantly between pre and post-dialysis (p=0.083) groups. the pre-dialytic et-1 level was not significantly different between subjects with idh and without idh. in the post-dialytic state, a significantly higher et-1 level in the idh group was observed (p=0.024). however, the absolute and relative changes were not significantly different. discussion in this study, the subjects’ mean age was slightly higher in those with idh when compared to the subjects without idh, although no significant mean age difference was identified between the two groups. inrig et al. previously presented that idh is commonly found in elderly ckd subjects who had routine hemodialysis. endothelial dysfunction in elderly patients was thought to be a risk factor for idh.3 the mean dry weight of subjects with idh table 2 endothelin-1 level et-1 level p-value* pre-dialysis (pg/ml) post-dialysis (pg/ml) absolute change (pg/ml) relative change (%) mean±sd mean±sd mean(95% ci) mean (95% ci) idh 3.33±1.28 3.84±1.75 0.51(0.07–0.96) 15.32 (2.56–24.49) 0.013 ‡ without idh 3.99±2.30 4.38±1.81 0.39(-0.18–0.97) 9.77 (-6.19–19.17) 0.083 p-value† 0.135 0.024‡ 0.367 0.293 sd: standard deviation; ci: confidence interval; analysis were performed using *paired t-test, †independent t-test, ‡statistically significant (p<0.05) fig. absolute change of et-1 level before and after dialysis rubin surachno gondodiputro, andika wiratama, et al. :102–7 106 international journal of integrated health sciences. 2019;7(2) was lower than that of subjects without idh. this result was in accordance with a previous study by van buren et al., although both studies showed no significant difference between the two groups.6 this study demonstrated that the absolute values of idwg and ultrafiltration were significantly lower in subjects with idh, albeit this was not the case in the relative change. the idwg and ultrafiltration have been proposed to be involved in the pathogenesis of idh. patients with idh had lower body weight, smaller idwg, and slower ultrafiltration rates. idh patients tend to gain less weight between procedures, making it necessary to prescribe slower ultrafiltration. the smaller the ultrafiltration rate, the less volume depletion occurs. this condition promotes idh. 2, 6 the absolute value of idwg and ultrafiltration in subjects with idh was significantly lower. this result was similar to previous data.4,6,17 however, a contradicting result from a recent large cohort study showing that the higher the idwg, both absolute and relative, the more frequent the intradialytic event is.18 therefore, the relation between idwg and intradialytic blood pressure is still controversial. lopez et al. stated that excessive idwg is a sign of excess sodium level and water, which could cause fluid overload. this might contribute to arterial hypertension in ckd patients undergoing routine hemodialysis. 19 other studies found that hypervolemia and body weight have no effect on systolic and diastolic blood pressures in patients with routine hemodialysis and that there is no direct association between idwg and blood pressure in dialysis patients. 20, 21 of the few previous studies, no conclusive evidence can be drawn. this is likely due to the complexity of hypertension pathophysiology. in this study, the post-dialysis et-1 level was higher in patients without idh. however, the pre-dialysis level of et-1 was similar in patients with or without idh. this was in accordance with earlier studies.8,10hematocrit (hct however, in contrary to this study, previous studies demonstrated that the postdialysis et-1 level is significantly higher in patients with idh.8, 10 this discordance may be partially explained by the higher absolute values of idwg and ultrafiltration in patients without idh in this study. as it is previously mentioned, one large cohort study associated the increase in idwg and ultrafiltration with a greater idh incidence. in addition, ultrafiltration is shown to affect the et-1 release in hemodialysis patients.22 in this study, a greater ultrafiltration absolute value found in patients without idh may cause a higher et-1 outcome. the increase in et-1 levels was not only observed in the patients with idh but also in patients without idh. another plausible explanation is the discrepancy in the absolute et-1 values across studies. although using the same reagent (r&d system inc., minneapolis, mn, usa), the et-1 levels obtained vary widely. chou et al. found a much higher average level of et-1. (510.9±43.3 vs. 276.7±30.1 pg/ml in subjects with and without idh, respectively).8 while teng et al. (4.09±2.06 vs. 2.75±1.34 pg/ml) showed similar values to this study.10 this might be influenced by different sampling techniques or racial factors, which had not been well studied. a significant et-1 level elevation was demonstrated in patients with idh in this study; however, no significant alteration was seen in patients without idh. the absolute change was also significantly elevated, but this was not the case in the relative change of the et-1 level. this is parallel with previous research, which revealed a significant elevation of et-1 level in the idh group albeit no change was observed in the control group.8, 10 these results indicate a relationship between idh incidence and et-1 level. there are limitations to this study. the sampling was performed consecutively, not randomly. in addition, the dry weight was only measured clinically, and no accurate tool with the ability to measure the volume of fluid in the body (multiple frequency bioimpedance spectroscopy) was used. in summary, there is a significant elevation of the et-1 level in ckd-5d patients with idh during the hemodialysis procedure. however, no ckd-5d patients in this study population, both with and without idh, experience a relative change in the et-1 level. a cohort study is needed in patients with elevated et-1 levels to evaluate the incidence of subsequent idh in order to assess whether et-1 levels can predict an idh event. furthermore, a comprehensive multivariate study is needed to establish the relationship between risk factors for idh, both for clinical and biochemical risk factors. references 1. rocco m, daugirdas jt, depner ta, inrig j, mehrotra r, rocco mv, et al. kdoqi clinical practice guideline for hemodialysis adequacy: 2015 update. am j kidney dis. 2015;66(5):884‒930. elevated endothelin-1 in intradialytic hypertension :102–7 international journal of integrated health sciences. 2019;7(2) 107 2. locatelli f, cavalli a, tucci b. the growing problem of intradialytic hypertension. nat rev nephrol. 2010;6(1):41–8. 3. inrig jk, patel ud, toto rd, szczech la. association of blood pressure increases during hemodialysis with 2-year mortality in incident hemodialysis patients: a secondary analysis of the dialysis morbidity and mortality wave 2 study. am j kidney dis. 2009;54(5):881‒90. 4. choi cy, park js, yoon kt, gil hw, lee ey, hong sy. intra-dialytic hypertension is associated with high mortality in hemodialysis patients. plos one. 2017;12(7):e0181060. 5. raikou vd, kyriaki d. the association between intradialytic hypertension and metabolic disorders in end stage renal disease. int j hypertens. 2018;2018:1681056. 6. van buren pn. pathophysiology and implications of intradialytic hypertension. curr opin nephrol hypertens. 2017;26(4):303–10. 7. hompesch c, ma t-w, neyra ja, ripley l, xiao g, inrige j, et al. comparison of ambulatory blood pressure patterns in patients with intradialytic hypertension and hemodialysis controls. kidney blood press res. 2016;41(3):240‒9. 8. chou kj, lee pt, chen cl, chiou cw, hsu cy, chung hm, et al. physiological changes during hemodialysis in patients with intradialysis hypertension. kidney int. 2006;69(10):1833– 8. 9. hajal j, saliba y, joubran n, sleilaty g, chacra d, assaad s, et al. new insights into the pathogenesis of intradialytic hypertension. open urol nephrol j. 2018;11:87‒99. 10. teng j, tian j, lv wl, zhang xy, zou jz, fang y, et al. inappropriately elevated endothelin-1 plays a role in the pathogenesis of intradialytic hypertension. hemodialysis international international symposium on home hemodialysis. 2015;19(2):279–86. 11. gutiérrez-adrianzén oa, moraes mea, almeida ap, lima jwo, marinho mf, marques al, et al. pathophysiological, cardiovascular and neuroendocrine changes in hypertensive patients during the hemodialysis session. j hum hypertens. 2015;29:366–72. 12. chazot c, jean g. intradialytic hypertension: it is time to act. nephron clinical practice. 2010;115(3):c182-8. 13. indonesian society of nephrology. report of indonesian renal registry: program indonesian renal registry (irr). 14. afrianti r, ruly r, afiatin. gambaran faktorfaktor risiko klinis kejadian hipertensi intradialitik penderita penyakit ginjal kronik stadium v pada unit dialisis rumah sakit di bandung. bandung: universitas padjadjaran; 2016. 15. fouque d, vennegoor m, ter wee p, wanner c, basci a, canaud b, et al. ebpg guideline on nutrition. nephrology, dialysis, transplantation: official publication of the european dialysis and transplant association european renal association. nephrol dial transplant. 2007;(22 suppl 2):ii45–87. 16. ipema kjr, kuipers j, westerhuis r, gaillard cajm, van der schans cp, krijnen wp, et al. causes and consequences of interdialytic weight gain. kidney blood pressure res. 2016;41(5):710–20. 17. meyring-wosten a, luo y, zhang h, preciado p, thijssen s, wang y, et al. intradialytic hypertension is associated with low intradialytic arterial oxygen saturation. nephrol dial transplant. 2018;33(6):1040–5. 18. stefansson bv, brunelli sm, cabrera c, rosenbaum d, anum e, ramakrishnan k, et al. intradialytic hypotension and risk of cardiovascular disease. clinical journal of the american society of nephrology: cjasn. 2014;9(12):2124–32. 19. lopez-gomez jm, villaverde m, jofre r, rodriguez-benitez p, perez-garcia r. interdialytic weight gain as a marker of blood pressure, nutrition, and survival in hemodialysis patients. kidney int suppl. 2005;(93):s63–8. 20. khalaj a-r, sanavi s, afshar r, rajabi m-r. effect of intradialytic change in plasma volume on blood pressure in patients undergoing maintenance hemodialysis. j lab physicians. 2010;2(2):66-9. 21. testa a, plou a. clinical determinants of interdialytic weight gain. journal of renal nutrition: the official journal of the council on renal nutrition of the national kidney foundation. 2001;11(3):155–60. 22. surdacki a, sulowicz w, wieczorek-surdacka e, herman zs. effect of a hemodialysis session on plasma levels of endothelin-1 in hypertensive and normotensive subjects with end-stage renal failure. nephron. 1999;81(1):31-6. rubin surachno gondodiputro, andika wiratama, et al. :102–7 international journal of integrated health sciences. 2013;1(1) 29 correspondence: theresia chandra tania novy, department of physical medicine and rehabilitation, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital jl. pasteur no. 38, bandung, indonesia e-mail: tctnovyss@gmail.com effect of overground walking and treadmill exercise on walking speed and walking ability in elderly theresia chandra tania novy, vitriana, sunaryo barki sastradimaja, irma ruslina defi department of physical medicine and rehabilitation, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital :29–36 abstract objective: to compare the effect of overground walking and treadmill exercise on walking speed and ability in elderly from week to week. methods: this study was conducted in 6 weeks to 18 elderly at panti wreda karitas and nazareth bandung (september–december 2011). they were divided into two groups; overground walking exercise group and treadmill group. walking speed and ability was measured using 10 meter walk test and 6 minute walk test consecutively. results: both group walking speed was improved after 1 and 2 weeks exercise (p=0.019 and p=0.050), consecutively. walking ability in the overground and treadmill group was improved after 1 and 3 weeks exercise (p=0.019 and p=0.009), consecutively. overground walking group showed greater improvement in walking speed and ability after 3 weeks exercise (p=0.008 and p=0.017) consecutively. conclusions: three weeks overground walking exercise improves walking speed and ability better than treadmill exercise. keywords: elderly, overground walking exercise, treadmill exercise, walking ability, walking speed ijihs. 2013;1(1):29–36 introduction there are two causal factors for the risk of falling in elderly: intrinsic factor (physical and neuropsychiatric conditions, decreased vision and hearing, neuromuscular changes, walking pattern, and postural reflect due to aging process) and extrinsic factor (medicines taken, walking-aid, and unsupportive/dangerous environment).1–3 poor balance and abnormality of walking pattern contribute to 10–15% of the risk of falling in elderly. normal walk parameters include velocity or speed, i.e. the walking speed in meter second; stride length or cycle length, i.e. the length from one heel strike to another heel strike of the same foot; stride time, i.e. distance between a heel strike of a foot and another heel strike of the other foot; and cadence or walking speed, i.e. the walking speed in number of steps per minute.4 walking quality is one of the factors that will determine the quality of life. however, in elderly, this function can be disrupted. walking quality includes locomotor instability and walking ability. in general, the locomotor instability in elderly is caused by decreased muscle mass, strength, power, joint movement area scope, and flexibility. these result in changes in terms of elderly walking pattern (decreased stride length, stance phase and expanded double support, as well as decreased stride symmetry),5 which leads to increased energy expenditure and decreased ability for long distance walk. the elderly muscle strength and endurance that are under the threshold will limit the elderly to ambulate outside the house. therefore, the elderly will tend to stay home which less activities, causing further decrease in the functional capacity and higher risk for fall.2,3,6 the elderly stride length is shorter than that of adults but the elderly cadence is relatively similar to adults and even sometimes smaller than adults, making the elderly walking speed received: november 28, 2012 revised: march 13, 2013 accepted: january 31, 2013 original article 30 international journal of integrated health sciences. 2013;1(1) inside and outside a room lower than those of the adults. a 70-year-old elderly walks with a speed of 1.1±0.2 m/sec for females and 1.2±0.2 m/sec for male when a person should walk with a minimum speed of 1.4 m/sec to be effective enough to walk in an environment such as to cross a street safely.2,6 exercise interventions can be provided to deal with reduced locomotor functions among elderly, which include exercises to improve muscle mass and durability, strength, power, joint movement area scope, flexibility, balance, reaction time, and endurance. walking is an aerobic exercise that has been promoted to improve physical and cognition functions in elderly. this exercise is usually done by using two methods, i.e. treadmill and over ground walking.6–8 overground walking exercise is carried out by walking on a flat surface with or without visual and auditory aids. meanwhile, treadmill is one of the instruments used to exercise a dynamic walk in one place. treadmill exercise using the forced use-method is intended to improve step length and walking speed. the treadmill movement will regulate the movement of both legs appropriately.6,7 some studies have been performed to look at the differences between walking exercises using treadmill and overground walking in terms of the biomechanical outputs and walking patterns in elderly. however, only one study had compared the effect of treadmill and overground exercise on elderly daily activities, especially walking.5–7 marsh et al.8 from the department of health and exercise science, wake forest university, north carolina, united state, performed a study on treadmill and overground exercise effects in 23 elderly people. at the end of the study, marsh et al.8 found that the walking speed of the overground walking group was higher that the treadmill ground, and the overground walking group also showed more appreciation and interest on the exercise compared to the treadmill group. there are only a few studies of overground walking and treadmill exercise effects on elderly walking speed and ability available. therefore, our present study specifically compares the overground walking and treadmill effects on elderly walking speed and ability in indonesia which is monitored weekly using 10 meter walking test and 6 minute walking test in order to determine the exact time when the exercise effects appear and to identify which exercise is better between the this two exercises. methods this study received ethical approval from the ethical committee of dr. hasan sadikin general hospital and every participant has signed an informed consent. the subject includes all elderly in karitas and nazareth nursing home during the period of september–december 2011 who met the inclusion criteria and were not excluded based on the exclusion criteria. the inclusion criteria include 60–90 years old males and females who are able to understand verbal and written instructions, able to sign the instructions (mini mental state evaluation/ mmse = 24–30), able to walk without any walking aid/orthosis, have minimum motoric strength of 4 for lower limbs, are cooperative tabel 1 before and after walking speed in overground walking group week of observation walking speed (in meters/second) p value*) overground walking group before (n=9) after (n=9) mean±sd mean±sd 1st week 1.08±0.18 1.28±0.20 0.058 2nd week 1.08±0.18 1.33±0.26 0.019 3rd week 1.08±0.18 1.43±0.22 0.001 4th week 1.08±0.18 1.47±0.13 0.001 5th week 1.08±0.18 1.56±0.19 0.001 6th week 1.08±0.18 1.71±0.19 <0.001 *) dependent t test sd: standard deviation effect of overground walking and treadmill exercise on walking speed and walking ability in elderly :29–36 international journal of integrated health sciences. 2013;1(1) 31 and willing to participate in the study, and able to perform the walking training. the exclusion criteria include cardiovascular problems such as unstable angina pectoris and congestion heart disorder, neuromuscular disorders, and musculoskeletal disorders, making it impossible to perform the exercise procedures. elderly with a history of falling during the last 6 months was also excluded. there were 24 subjects who met the inclusion and exclusion criteria. all subjects were divided randomly using the block permutation method into two groups, (a) overground walking group and (b) treadmill group. each group consisted of 12 people. during the process, 6 people dropped out (do) (25%), which included 3 people from each group. one person from group a dropped out because the person did not want to continue the exercise while 2 people from the same group dropped due to sickness. in group b, one person dropped out because of unwillingness to continue the exercise, another one dropped out because of exhaustion and the last person dropped out due to sickness. the overground training given in this study included walking training on flat surface floor without any visual or auditory aids.8 the training was performed according to the participant’s ability with a maximum of 60 minutes per exercise, 3 times a week for 6 weeks, with the following details: 1. week i (to improve step length): participant was walking with the most comfortable step length, by taking as little step as possible and maintaining one foot as long as possible in the air. 2. week ii–iv (to increase speed): when the comfortable step length was achieved, the speed was increased to a rating of perceived excertion (rpe) of 12–13 or 60% of the maximum heart rate. the treadmill exercise was performed on a treadmill which is one of the tools used to exercise dynamic walking that enable enforced walking with certain speed and can be adjusted according to the user’s need.7 the participants performed the exercise according to the participant’s ability with a maximum of 60 minutes per exercise, 3 times a week for 6 weeks, using the following treadmill exercise procedure: 1. the participant was standing on a treadmill with hands on the hand support. 2. week i (to improve step length): treadmill was set on the lowest speed (0.5 km/hour) and a constant elevation degree of 0° during the study. the participants were asked to walk according to the treadmill speed, then the speed was increased to reach the most comfortable speed for the participant to walk by taking as little step as possible and maintaining one foot as long as possible in the air. week ii–vi (to increase speed): when the most comfortable step length was achieved, the speed was increased to rpe 12–13 or 60% of the maximum heart rate. before the exercises, all participants were measured for the blood pressure and the heart rate. the exercise was started by stretching the quadriceps, hamstring, anterior tibia and gastrocnemius muscles table 2 before and after walking speed in treadmill group week of observation walking speed (in meters/second) p value*) treadmill group before (n=9) after (n=9) mean±sd mean±sd 1st week 1.04±0.22 1.16±0.22 0.050 2nd week 1.04±0.22 1.13±0.17 0.017 3rd week 1.04±0.22 1.15±0.15 0.003 4th week 1.04±0.22 1.15±0.20 <0.001 5th week 1.04±0.22 1.22±0.17 <0.001 6th week 1.04±0.22 1.24±0.16 0.003 *) dependent t test sd: standard deviation theresia chandra tania novy, vitriana, et al. :29–36 32 international journal of integrated health sciences. 2013;1(1) table 3 differences of changing walking speed between overground walking group and treadmill group time of observation change of walking speed (∆, in meters/second) p value*)overground walking group (n=9) treadmill group (n=9) mean±sd median range mean±sd median range beginning of 1st week 0.20±0.17 0.30 -0.18–0.60 0.17±0.15 0.18 -0.13–0.43 0.442 beginning of 2nd week 0.25±0.20 0.12 -0.05–0.66 0.89±0.14 0.08 -0.13–0.37 0.114 beginning of 3rd week 0.35±0.21 0.35 0.05–0.72 0.11±0.10 0.13 -0.07–0.31 0.008 beginning of 4th week 0.39±0.21 0.35 0.15–0.84 0.10±0.08 0.12 -0.07–0.21 0.002 beginning of 5th week 0.48±0.28 0.34 0.17–1.07 0.17±0.07 0.20 0.04–0.24 0.010 beginning of 1st week 0.53±0.30 0.61 0.21–1.16 0.19±0.10 0.19 0.02–0.34 0.002 *) independent t test sd: standard deviation outcome measurements are performed by: 1. six minute walking test for walking ability. the participant’s walking ability to walk for 6 minutes (6 minute walking test) which is measured by the distance achieved (meter).9 2. ten meter walking test for walking speed. walking speed that is measured by 10 meter walking test with a distance unit that is divided by the time (m/sec).10–12 every week, the 10 meter walking test and 6 minute walking test were performed by both groups on the same day with 10 minute time interval for resting between the tests. results statistical test results on the overground walking and treadmill group characteristic comparisons, including age, body mass index (bmi), duration of stay in the nursing home, gender and education, show that both groups are homogenous. the normality test with the shapiro wilks test for a sample size of less than 50 people shows that the walking speed change in the overground walking and treadmill groups is normally distributed, and the walking ability in the overground walking and treadmill groups is not normally distributed. to test the comparison between the speed and ability of the elderly in the overground walking and treadmill groups before and after the study, the bivariate analysis was performed using the dependent t-test because the data are normally distributed. the independent t-test was used for the bivariate analysis to compare the walking speed change of the overground walking and treadmill groups because the data are normally distributed, and for the comparison of walking ability change of the overground walking and treadmill groups the mann whitney test was used because the data are not normally distributed. walking speed comparison between elderly in overground walking and treadmill groups for six week exercise can be observed in table 1 and table 2, showing increased walking speed starting two weeks after the overground walking exercise was started (p=0.019) and since one week after the treadmill exercise was started (p=0.050). table 3 shows that the overground walking group has better walking speed increase compared to the treadmill group after three weeks of exercise (p=0.008). the comparison between walking ability of the elderly overground walking and treadmill groups after six weeks shows that the walking ability improvement was observed since one week after the overground walking exercise was effect of overground walking and treadmill exercise on walking speed and walking ability in elderly :29–36 international journal of integrated health sciences. 2013;1(1) 33 started (p=0.019) and since three weeks after the treadmill exercise was started (p=0.009) (table 4, 5). the overground walking group has better walking ability improvement than the treadmill group after three weeks of exercise (p=0.017) (table 6). discussion walking is an excellent aerobic exercise mode and has been promoted to improve physical and cognition functions in elderly. for some elderly, walking can be performed comfortably at home, in the mall or park environment. walking function declines due to the age factor, making the overground walking and treadmill walking exercises useful to improve the elderly’s aerobic capacity. a significant aerobic capacity improvement will be seen in 4–6 weeks of an aerobic exercise. marsh et al.8 had performed a study on treadmill and overground walking impact towards elderly physical functions and attitude. in this study, both groups performed 6 weeks exercises (18 sessions) which is similar to the present study, i.e. 6 weeks with 3 exercises per week (18 sessions), were also applied in this study. in elderly, female walking speed is slower than the male’s because the males are taller than the females and they have more and stronger muscle. in addition, males walk more compared to females.13–16 furthermore, elderly walking speed is affected by education level.15,16 these confounding factors was already eliminated by the statistic test results that show the fact that both groups are homogeneous. changes in walking characteristics among elderly lead to decreased walking speed.2,5 this is in agreement with the present study results showing that the overground walking group average walking-speed is 1.08 m/sec and the treadmill group is 1.04 m/sec (table 1 and 2). the increased walking speed after two weeks of overground walking exercise (p=0.019) and after one week of treadmill exercise (p=0.050). the overground walking group had better speed that the treadmill group after three weeks of exercise (p=0.008) (table 3). this is related to the fact that the treadmill forced the participants to follow its rotation speed. sohn et al.17 studied about the possibility of increased stress because of walking on a treadmill. likewise, marsh et al.8 found that the overground walking group showed more appreciation and interest to the exercise compared to the treadmill group so they performed the exercise better. in this study, the participants also completed a questionnaire that, later on, was analyzed statistically with the results show that the elderly in karitas and nazareth nursing home in bandung preferred the overground walking exercise to the treadmill although there was no significant difference in the subjective perception based on the exercise given and when the group was asked to perform other group’s exercise, no significant difference in subjective perception between the overground walking and treadmill exercise was found. this may lead to the overground walking group trains better in the second weeks and, comparing to the treadmill group, results in better speed increase in the overground walking group. from week to week, the overground walking group speed was higher than that of the treadmill theresia chandra tania novy, vitriana, et al. :29–36 table 4 before and after walking ability in overground walking group week of observation walking ability (in meters) p value*) overground walking group before (n=9) after (n=9) mean±sd mean±sd 1st week 314.89±14.33 369.55±66.31 0.019 2nd week 314.89±14.33 374.89±50.43 0.003 3rd week 314.89±14.33 390.00±58.55 0.003 4th week 314.89±14.33 400.67±49.09 <0.001 5th week 314.89±14.33 408.94±48.11 <0.001 6th week 314.89±14.33 419.11±44.01 <0.001 *) dependent t test sd: standard deviation 34 international journal of integrated health sciences. 2013;1(1) group, and still showed an increase after the sixth week, whereas the treadmill group started to reach plateau after the sixth week. therefore, a longer study is needed to see the time when the walking speed from the overground walking and treadmill exercises reach the plateau and then maintained according to the elderly’s needs for daily activities. in addition, it is observed that the overground walking group reached the minimum walking speed needed for safe ambulation (1.4 m/sec) in the third week and still increases in the following weeks, while the treadmill group had not reached the minimum walking speed needed for safe ambulation. the results of this study are similar to those of a former study performed by marsh et al.8 which stated that the elderly walking speed after overground walking exercises is higher when it is compared to the treadmill exercise group after 6 weeks (18 sessions) (t(22)=-8.54, p<0.001, t(22)=-10.87, p=0.001, respectively). however, the former researchers did not examine the elderly walking speed change improvement in each exercise group from week to week. the statistic test results used dependent t-test with 95% confidence level (table 4). this shows that statistically there is a significant difference in elderly walking ability in karitas and nazareth nursing home in bandung before and after the overground walking exercise was performed for one week with p=0.019, and after the second week and afterwards with p≤0.05. in addition, table 5 shows a significant difference in elderly walking ability in karitas and nazareth nursing home in bandung before and after the treadmill exercise that started to appear after three weeks of exercise with p=0.009 and after the fourth week with p≤0.05. furthermore, it can be seen that the walking ability improvement in both groups still continue after the sixth week of the exercise and the statistic test using mann whitney test with 95% confidence level shows a significant difference between the overground walking and treadmill exercise effects on elderly walking ability improvement after three weeks of exercise with p=0.017 (p≤0.05) and after the fourth week and afterwards with p≤0.05 (table 6), so a longer study is needed to see when the elderly walking ability starts to be stable in both groups. this study shows that the overground walking group has better subjective perception regarding the exercise compared to the treadmill group, albeit statistically insignificant. this makes the elderly in the overground walking group performs better than those in the treadmill group, leading to higher walking ability improvement in this group. muscle adaptation towards aerobic exercises such as walking includes improved capillaries, increased number of mitochondria and size improvement as well as early improvement in oxidative enzyme activities (in 7–10 days). this adaptation increases the muscle capacity to extract oxygen from arteries for metabolism. a significant aerobic capacity improvement will be seen in 4–6 weeks of aerobic exercise. aerobic capacity improvement in this study is noticed from improved elderly walking speed and ability after two weeks and one week of the overground walking exercise and also in the treadmill group after one week and three weeks of exercise. several previous studies have been performed to compare walking temporal parameter, joint kinematics, and muscle activation pattern in treadmill and overground walking, often leading tabel 5 before and after walking ability in treadmill group week of observation walking ability (in meters) treadmill group before (n=9) after (n=9) p value*) mean±sd mean±sd 1st week 282.94±57.69 290.83±55.91 0.183 2nd week 282.94±57.69 298.38±41.98 0.053 3rd week 282.94±57.69 307.50±55.97 0.009 4th week 282.94±57.69 311.27±60.64 0.014 5th week 282.94±57.69 321.27±62.23 0.002 6th week 282.94±57.69 325.94±64.41 0.001 *) dependent t test sd: standard deviation effect of overground walking and treadmill exercise on walking speed and walking ability in elderly :29–36 international journal of integrated health sciences. 2013;1(1) 35 to contradictory results. a study done by lee and hidler6 on healthy subjects without any gait problem showed that, generally, the temporal parameter and kinematic pattern of treadmill or overground walking are quite same. riley et al.17 suggested that the kinematic and kinetic differences between treadmill and overgound walking exercises are less than three degrees and can be ignored. tulchin et al.18 evaluated ankle movement in treadmill walking and overground walking with results showed that the segmented multi feet kinematics of both methods do not show any significant difference. sohn et al.19 stated that the walking kinematics on treadmill and overground walking were very similar, even though the value difference in every joint was significant (p≤0.05) with a general differences of less that 3o. the walking energy expenditure on treadmill is significantly higher than that of the overground walking and it is thought that there is an increased stress in treadmill exercise induced by the treadmill track. improvement or change resulted from the training on a treadmill is not always transferable to the daily walking activity. readjustment is needed to be included into the daily walking activity for the elderly, especially in terms of identifying obstacles and changing the strategy for walking inside and outside the house in a daily basis20 and, for this study, in six minute walking test and ten meter walking test. when walking on a treadmill, the muscle activation pattern and, later, joint moments and powers change while the body tries to maintain the extremity kinematics and spatiotemporal parameter of the relatively constant walking pattern. this explanation could help us to understand why overground walking gave better results compare with treadmill. in summary, the elderly walking speed and walking ability are better after overground walking exercise compared to the treadmill. the effect of exercise was seen at three weeks after exercise given. tabel 6 differences of changing walking ability between overground walking group and treadmill group time of observation change of walking ability (∆, in meters) p value*)overground walking group (n=9) treadmill group (n=9) mean±sd median range mean±sd median range beginning of 1st week 54.66±50.25 49.0 -27.5–132.5 7.89±6.23 9.00 -18.0–30.0 0.566 beginning of 2nd week 60.00±42.41 52.5 2.5–129.5 15.44±10.47 10.0 0.5–64.5 0.233 beginning of 3rd week 75.11±52.08 65.5 -18.5–137.5 24.56±21.42 18.0 0.5–75.0 0.017 beginning of 4th week 85.78±45.31 71.0 18.0–140.0 28.33±27.26 25 2.5–93.0 0.002 beginning of 5th week 94.06±45.72 81.0 33.0–154.0 38.33±25.73 39.0 7.5–95.0 0.002 beginning of 6th week 104.22±42.70 94.0 54.0–163.0 43.00±28.09 42 11.5–107.5 0.001 *) mann whitney test sd: standard deviation theresia chandra tania novy, vitriana, et al. :29–36 references 1. felsenthal g, lehman ja, stein bd. principles of geriatric rehabilitation. in: braddom rl, editor. handbook of physical medicine and rehabilitation. 3th ed. philadelphia: saunders an imprint of elsevier inc.; 2007. p. 910–28. 2. lemaire e. biomechanics of elderly gait. 2011 [cited 24 januari 2011]. available at http://www. ispo.ca/member/files/lemaire-gait.ppt. 36 international journal of integrated health sciences. 2013;1(1) effect of overground walking and treadmill exercise on walking speed and walking ability in elderly :29–36 3. tinetti me. preventing falls in elderly persons. n eng j med. 2006;348:42–9. 4. masdeu jc, sudarsky l, wolfson l, eds. gait disorders of aging, falls and therapeutic strategies. 1st ed. philadelphia: lippincott-raven publishers; 1997. 5. rose j, gamble jg. human walking. 1st ed. philadelphia: lippincott williams and wilkins; 2006. 6. lee sj, hidler j. biomechanics of overground vs. treadmill walking in healthy individuals. j appl physiol. 2008;104(3):747–55. 7. monteiro ff. effect of treadmill-based gait training on the stationary balance. arch med sci. 2009;5(3):443–9. 8. marsh ap, katula ja, pacchia l. effect of treadmill and overground walking on function and attitudes in older adults. med sci sports exerc. 2006;38(6):1157–64. 9. nusdwinuringtyas n. exercise training in chronic pulmonary disease. in: nusdwinuringtyas n, editor: kumpulan makalah rehabilitasi respirasi. jakarta: departemen rehabilitasi medik rs dr. cipto mangunkusumo; 2006. p. 61–77. 10. hayes tl, hagler s, austin d, kaye j, pavel m. unobtrusive assessment of walking speed in the home using inexpensive pir sensors. conf proc ieee eng med biol soc. 2009:7248–51. 11. peters dm, fritz sl, krotish de. assessing the reliability and validity of a shorter walk test compared with the 10-meter walk test for measurements of gait speed in healthy, older adults. j geriatr phys ther. 2012;36(1):24–30. 12. kauffman il, barr j, morran m. geriatric rehabilitation manual. 2nd ed. china: elsevier, churchill livingstone; 2007. 13. raj r. one hundred-foot walk test for functional assessment of clinic patients. am j med sci. 2009;338(5):361–7. 14. novaes rd, miranda as, dourado vz. usual gait speed assessment in middle-aged and elderly brazilian subjects. rev bras fisioter. 2011;15(2):17–22. 15. callisaya ml, blizzard l, schmidt md, mcginley jl, srikanth vk. sex modifies the relationship between age and gait: a population-based study of older adults. j gerontol biol sci med sci. 2008;63(2):165–70. 16. magdalena it. sex-specific correlates of walking speed in a wide age-ranged population. j gerontol b psychol sci soc sci. 2010;65b(2):174–84. 17. riley p, paolini g, della cu, paylo k, kerrigan d. a kinematic and kinetic comparison of over-ground and treadmill walking in healthy subjects. gait posture. 2007;26(1):17–24. 18. tulchin k, orendurff m, karol l. a comparison of multi-segment foot kinematics during level over-ground treadmill walking. gait posture. 2010;31(1):104–8. 19. sohn rh, swang sh, kim yh. comparison of motion analysis and energy expenditure between treadmill and overground walking. proceedings of international federation for medical and biological engineering; 2009 nov 30–dec 1; italy. italy: ifmbe; 2009. 20. wert dm, brach j, perera s, van swearingen jm. gait biomechanics, spatial and temporal characteristics, and the energy cost of walking in older adults with impaired mobility. j phys ther. 2010;90(7):977–85. volume 8 no 1 2020 v2.indd international journal of integrated health sciences 43 development of brain metastases (bm) is one of the major challenges for patients with stage iii and iv breast cancer. in a recent study, brain metastases-free survival differed significantly between breast cancer subtypes and was shortest in patients with triple receptornegative cancer. central nervous system (cns) metastases account for the majority of malignant brain tumors, and may appear either within the brain parenchyma or along the leptomeninges. breast cancer is the second most common cause of cns metastases, and is the solid tumor most commonly associated with leptomeningeal metastases. 1,2 on the basis of case series from the 1960s intracranial metastasis as the initial presentation of a young woman with luminal b her-2 positive stage 4 breast cancer correspondence: santi christiani gultom, division of hematology and medical oncology, department of internal medicine, faculty of medicine universitas padjadjaran-dr. hasan sadikin general hospital bandung, indonesia e-mail: santich.gultom@gmail.com santi christiani gultom, amaylia oehadian division of hematology and medical oncology, department of internal medicine, faculty of medicine universitas padjadjaran-dr. hasan sadikin general hospital bandung, indonesia abstract objective: breast cancer is the second most common cause of brain metastasis (bm) among all of the solid cancers, with metastases occurring in 10%–16% of patients and in as many as 30% of autopsy studies. breast cancer-related bm usually has a poor prognosis and survival rate in the absence of any treatment within 2 months. survival after bm is related to the subtype of the primary tumor. human epidermal growth factor-2 (her-2)-positive patients have a significantly better prognosis compared with other subtypes. the prognosis for the majority of patients with bm remains poor, despite local and systemic therapies, with a median survival of around 10 months. methods: this case is interesting because our patient is very young, diagnosed with bm before breast cancer was identified, bit still surviving 12 months after her bm diagnosis. a 19-year old woman presented with seizures, vomit and headaches. results: a cranial ct-scan showed an intracranial mass. the intracranial tumor was removed, and yielded a histopathological result of metastatic adenocarcinoma. further examination found a lump in her right breast. she was diagnosed with intracranial metastatic stage 4 luminal b her 2(+) breast cancer. she was referred for wbrt, a mastectomy, chemotherapy with docetaxel cyclophosphamide 4 cycles, followed by 12 cycles of trastuzumab, and continued treatment with tamoxifen and goserelin. the last pet-scan showed no residual disease. conclusion: breast cancer as the primary tumor should be considered in women with a metastatic brain tumor. with appropriate treatment, even stage iv luminal b breast cancer with bm can still have a long life with good quality. keywords: breast cancer, brain metastasis, central nervous system (cns) received: december 16, 2019 accepted: march 9, 2020 pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ ijihs.v8n1.1911 ijihs. 2020;8(1):43–6 case introduction advanced breast cancer (abc) comprises both locally advanced breast cancer (labc) and metastatic breast cancer (mbc). although treatable, mbc remains an incurable disease with a median overall survival (os) of three years and a 5-years survival of only 25%. the 44 international journal of integrated health sciences and 1970s, the incidence of clinically evident brain metastases among women with stage iv breast cancer is estimated to be 10% to 16%. these figures underestimate the true incidence, given that brain metastases are found in 30% of patients at autopsy. parenchymal brain metastases typically follow a vascular distribution, consistent with a mechanism of hematogenous spread. supratentorial lesions are more common than infratentorial lesions, and there is a predilection for vascular border zones and the gray and white matter junction. in contrast, leptomeningeal metastases arise via multiple pathways, including hematogenous spread, direct extension, and infiltration from vertebral metastases via batson’s plexus. involvement of the leptomeninges is less common clinically than parenchymal metastases, and is found in 5% to16% of patients at autopsy.3,4 young age appears to be a risk factor for the development of cns metastases. for example, in an autopsy review of 1,044 patients with breast cancer, the median age of patients with cns metastases was about 5 years younger than that of patients without cns metastases. several groups have also found an association between the hormone receptor status and the incidence of cns relapse, although these studies generally have been small in scale. in one study of 217 women with primary breast cancer, estrogen receptor (er)–negative breast cancers were more likely to metastasize to the brain (10% vs 4% clinical incidence). in an autopsy study of 25 patients, er-negative tumors were also more likely to metastasize to the leptomeninges. whether this observed association relates to the inherent biology of er-negative tumors, the ability of hormonal therapy to penetrate the cns (thereby providing a relative risk reduction for er-positive tumors), and/or the inverse relationship between the hormone receptor and the her2 status is unclear on the basis of the available evidence. the association of cns metastases with the human epidermal growth factor receptor 2 (her2) overexpression merits special mention. an amplification of her2 is present in 25% to 30% of human breast cancers and correlates with diminished disease-free and overall survival. among 319 women with primary breast cancer, her2 overexpression was the strongest predictor of the site of the first relapse in a multivariate model, with a 4.3% vs 0.4% incidence of brain metastases.3,5 the most common presenting symptom of parenchymal brain metastases is a headache, occurring in 24% to 48% of patients. other common manifestations include mental status changes and cognitive disturbances, which are present in 24% to 34% of patients.6 this case is interesting because our patient is very young, presenting with bm before her breast cancer diagnosis, but still surviving 21 months after her bm diagnosis. case in april 2018, a 19-year-old woman came to our hospital with seizures, blurred eyes, headaches and vomiting. she consulted a neurosurgeon and underwent a brain ctscan on the 3rd of april, 2018. the ct-scan revealed a multilobulated tumor mass with cystic components on the edges including right ventricular posterior pericocalus / right parietal lobe and the medial right occipital lobe (size ± 4.54x3.88x4.27 cm) accompanied by extensive perifocal edema vitalizing the posterior right lateral and ventricular iii ventricles and a mild midline shift to the left as much as ± 0.76 cm pushing the midbrain to anterior inferior, suggestive of a high-grade glioma. there were also multiple lacunae / ischemic degeneration lesions in the white frontal lobe white matter. there was no acute infarction, bleeding, vascular malformations or intracranial space occupying lesions. a craniotomy with a biopsy was performed. histopathology showed metastatic of papillary adenocarcinoma with difficulty in ascertaining its origin. the patient was then treated with whole brain radiotherapy (wbrt). while undergoing wbrt, the patient was referred to medical oncology for further evaluation of the primary tumor. a palpable 4-cm hard, painless mass was found in the lower right quadrant of her right breast. she had had a lump in her right breast since november 2017 but it had not been evaluated. she had had menarche at the age of 11 and her grandmother had suffered from breast cancer. a positron emission tomography (pet) scan was carried out and showed an irregular mass in the lower right quadrant of the medial right breast with central necrosis accompanied by metabolic activity at the periphery, highly suggestive of malignancy. a hypermetabolic lobulated mass in the right parietooccipital surrounded by the peripheral area of the edema and pressing the posterior to the right lateral ventricle is consistent for a metastasis. no hypermetabolic lesions were seen in the lymph nodes or other organs suggestive of malignancies / other metastases. a reevaluation of the intracranial intracranial metastasis as the initial presentation of a young woman with luminal b her-2 positive stage 4 breast cancer international journal of integrated health sciences 45 biopsy tissue showed malignant tumor forming papillary structures section of the anaplastic cells with rounded and pleomorphic nuclei, hyperchromatic, a moderate amount of cytoplasm, the mitotic count was twenty two per ten high power field (22/10 hpf). the differential diagnosis were metastatic adenocarcinoma and anaplastic ependymoma. she underwent an incisional biopsy on her breast lump. breast histopathology showed a malignant breast tumor invading stroma and fat. the tumor was composed of anaplastic epithelial cells with marked pleiomorphic nuclei (score 3), coarse chromatin and prominent nuclei, the mitotic count was twenty five per ten hpf (score 3), arranged in solid clusters (tubular structures <10%, score 3), with necrosis in the central part of the tumor. there were ductal carcinoma insitu foci in peripheral parts of the tumor, mostly solid types with a few comedo types, high grade. lymphovascular and perineural invasion were not found. immunohistochemistry staining showed estrogen receptor (er) positive of 80%, weak to moderately stained, progesterone receptor (pr) positive of 5% weak stained, her-2 +3 for the herceptest score and a ki67 expression of 75% (an invasive breast carcinoma of no special type pathological grade iii luminal b, her2 positive). the patient underwent a right mastectomy which showed metastasis in 1 of 5 axillary lymph nodes. she underwent 4 cycles of chemotherapy with docetaxel and cyclophosphamide and 12 cycles with trastuzumab. in september 2018, the patient continued therapy with tamoxifen. in october 2018, a pet-scan showed no residual disease. the patient continued treatment with tamoxifen and goserelin and has since remained in remission. discussion generally, patients having breast cancer brain metastases (bcbm) is associated with a poor prognosis. the outcome for these patients remains poor even after chemotherapy and radiotherapy. most bcbm patients are characterized by rapid growing, hormone receptor negative and/or her-2 positive tumors concurrent with visceral metastases.7 breast cancer is divided into three distinct diseases with heterogeneous expression of estrogen receptor/progesteron receptor (er/ pgr) and her2 status. luminal type cancers, which are er/pgr positive without a her2positive status, tend to be the most favorable for long-term survival. whereas, the triple negative subtype (basal-like) and her2positive tumors are the most sensitive to chemotherapy, but have the poorest prognosis. of women diagnosed with advanced breast cancer, 10% to 16% develop central nervous system (cns) metastases. several risk factors have been associated with the development of cns lesions in patients with mbc, including being of a younger age (<50 year), having more than two metastatic sites at mbc diagnosis, and being her2-positive. patients with her2positive mbc tumors are 2 to 4 times more likely to develop cns tumors than patients who are her2-negative. the proportion of patients with brain metastases in triple-negative, her2positive status and luminal subtypes was 28%, 53% and 19%, respectively. this indicates that triple-negative and her2-positive breast cancer have a special predisposition to metastasize to the brain.8 in one study, mauer c et al., found that the median os for bc without bm was 46.7 months (iqr 23.0–145.6 months) and for bcbm patients 20.8 months (iqr 5.36not reached). patients without cns symptoms at the time of their bm diagnosis had a better os than patients with clinical signs related to their bm (hr 0.49, 95% ci 0.25 to 0.94).9 cns involvement typically occurs late in the course of metastatic breast cancer. in most cases, the involvement of the lungs, liver, or bone precedes the diagnosis of cns metastasis.10 in this case, cns metastasis was the first discovery so the patient underwent wbrt. at present, there is no evidence that early detection of brain metastases alters the chances of survival or the quality of life of patients with breast cancer, although no prospective studies have specifically addressed this issue. conversely, although corticosteroids, wbrt, surgery and stereotactic radiosurgery (srs) can provide excellent palliation of some symptoms, motor loss and other focal deficits are frequently not fully reversible. therefore, it is possible that early detection may improve the quality of life by identifying patients for treatment before irreversible neurologic damage has occured. for many years, chemotherapy and endocrine therapy have not been considered as playing a role in the treatment of patients with brain metastases because of the presence of the blood-brain barrier (bbb). most chemotherapy agents used in the treatment of breast cancer either do not cross an intact bbb, or are pumped out of the cns by phosphoglycoprotein in the endothelial cells comprising the bbb. they may not reach sufficient therapeutic levels to treat cns santi christiani gultom, amaylia oehadian 46 international journal of integrated health sciences metastases. the finding that chemotherapy and trastuzumab treatment are associated with improved survival even after adjusting for relevant variables in patients after the development of cns metastases is interesting. the studies have proved the permeability of the blood–brain barrier in patients with brain metastases and in patients after wbrt. it has also been observed that systemic therapy carried out after wbrt prolongs survival due to the control of extracranial disease. actually, after wbrt of brain metastases, the blood– brain barrier is, in part, disrupted so that many chemotherapeutics and hormonal agents may reach a therapeutic level in tumors.11 trastuzumab in combination with chemotherapy significantly improves os and disease-free survival in her2-positive bc. the median overall survival (os) for bcbm patients treated with whole brain radiotherapy (wbrt) alone is poor being of less than 6 months. more recent analyses suggest that the prognosis of bcbm patients, especially those with her2-positive bcbm is improving which is probably a result of better systemic treatment options leading to better control of the disease outside the central nervous system (cns).12,13 this case suggests that appropriate treatment with whole brain radiotherapy followed by trastuzumab combined with chemotherapy remains the best option for giving a long, good quality life to patients who present with brain metastasis in luminal b her2-positive stage iv breast cancer. 1. cardoso f, costa a, norton l. eso-esmo 2nd international consensus guidelines for advanced breast cancer (abc2). ann oncol. 2014;25(10): 1871–88. 2. cardoso f, spence d, mertz s, corneliussenjames d, sabelko k, gralow j, et al. global analysis of advanced/metastatic breast cancer: decade report (2005–2015). breast. 2018;39:131–38. 3. lin nu, bellon jr, winer ep. cns metastases in breast cancer. 2004;22(17):3608–17. 4. lee y-t. breast carcinoma: pattern of metastasis at autopsy. j surg oncol. 1983;23:175–80. 5. boogerd w, vos vw, hart aam. brain metastases in breast cancer; natural history, prognostic factors, and outcome. j neuro oncol. 1993;15:165–74. 6. lassman ab, deangelis lm. brain metastases. neurol clin. 2003;21(1):1-vii. 7. cagney dn, martin am, catalano pj, redig aj, lin nu, lee eq, et al. incidence and prognosis of patients with brain metastases at diagnosis of systemic malignancy: a population-based study. neuro oncol. 2017;19(11):1511–21. 8. weil rj, palmieri dc, bronder jl, stark am, steeg ps. breast cancermetastasis to the central nervous system. am j pathol. 2005;167:913– 20. 9. maurer c, tulpin l, moreau m, dumitrescu c, azambuja ed, paesmans p, et al. risk factors for the development of brain metastases in patients with her2positive breast cancer. esmo open. 2018;3:e000440. 10. engel j, eckel r, aydemir u, aydemir s, kerr j, schlesinger-raab a, et al. determinants and prognoses of locoregional and distant progression in breast cancer. int j radiat oncol biol phys. 2003;55(5):1186–195. 11. lin nu, bellon jr, winer ep. cns metastases in breast cancer. j clin oncol. 2004;22:3608–617. 12. brufsky am, mayer m, rugo hs, tan ce, tripathy d, tudor ic, et al. central nervous system metastases in patients with her2-positive metastatic breast cancer: incidence, treatment, and survival in patients from registher. clin cancer res. 2011;17(14):4834–43. 13. dawood s, broglio k, esteva fj, buzdar au, hortobagyi gn, giordano hg. defining prognosis for women with breast cancer and cns metastases by her2 status. ann oncol. 2008;19(7):1242–48. references intracranial metastasis as the initial presentation of a young woman with luminal b her-2 positive stage 4 breast cancer volume 7 no 2 2019 (3).indd 74 international journal of integrated health sciences. 2019;7(2) original article adherence to antihypertensive medication in patients with hypertension in indonesia abstract objective: adherence to medication is crucial for hypertension patients in order to control and prevent complications. this study aimed to describe the adherence to antihypertensive drugs among patients with hypertension in bandung district, west java, indonesia. methods: this was a cross-sectional observational study on patients with hypertension in the work area of cileunyi public health center (phc), bandung district, west java, indonesia. the inclusion criteria used were patients with hypertension who were prescribed an antihypertensive drug by a physician, above 18 years old, and had been using an antihypertensive medication for at least two months before the study. data were obtained through interviews during the month of july to august 2018 using a modified mmas-8 questionnaire of the morisky medication adherence scale (mmas8), which includes likert-type scale questions. data collected were then analyzed using the rasch model, and the mean logit person was used as a cut off between adherence and non-adherence categories. results: a total of 75 patients with hypertension were recruited. the prevalence of adherence to medication was 59%. most patients who adhered to the medication were > 55 years old (31%), female (59%), had been diagnosed with hypertension for < 5 years (31%), and received support from family/social environment (40%). conclusions: many factors support the adherence to antihypertensive medication, including age, gender, time of hypertension diagnosis, and support from family or social environment. the adherence to antihypertensive medication among patients with hypertension visited cileunyi primary health care, bandung district, west java, indonesia is good. keywords: adherence, antihypertensive medication, hypertension, indonesia, primary health care pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v7n2.1588 ijihs. 2019;7(2):74–80 received: january 9, 2019 revised: september 30, 2019 accepted: october 19, 2019 correspondence: vycke yunivita, department of biomedical science, faculty of medicine universitas padjadjaran e-mail: v.yunivita@unpad.ac.id tania,1 vycke yunivita,2 afiatin3 1faculty of medicine universitas padjadjaran, indonesia 2department of biomedical science faculty of medicine universitas padjadjaran, indonesia 3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin hospital bandung, indonesia introduction primary hypertension is a global health problem that affects most countries in the world. hypertension is defined as a condition with increased systolic blood pressure (sbp) above 130 mmhg and increased diastolic blood pressure (dbp) of more than 80 mmhg.1 an increase of about 20 mm hg in sbp and 10 mm hg in dbp increases the risk of death from vascular disease, stroke, and other vascular diseases. higher sbp and dbp were associated with increased risk of several vascular diseases, such as cardiovascular diseases (cvds), in more than one million adult patients aged >30 years worldwide.1 results of the indonesian basic health survey (ibhs) 2018 show that the prevalence of hypertension in indonesia for the population above 18 years old is 8.4% based on the selfreported answer from the respondents who :74–80 international journal of integrated health sciences. 2019;7(2) 75 stated that they had been diagnosed to be suffering from hypertension by a physician. meanwhile, the same survey also reported that the prevalence of hypertension is 34.1% based on blood pressure measurement performed during the survey. a higher prevalence of hypertension is seen among women when compared to men.2 in west java province, the west java provincial health office reported that, in 2016, there were 790,382 hypertension cases in the province with 118,751 of them were found in bandung district, which was the highest compared to the number found in other districts in the province.3 cileunyi sub-district is a peri-urban area of bandung district that has been transforming from a rural area to an urban area. cileunyi sub-district is an area that has access to several other districts: tasikmalaya and garut district in the south and sumedang and cirebon district in the east. it is also directly adjacent to jatinangor subdistrict of sumedang district. the fact that this subdistrict is highly accessible from many other areas making it one of the main destinations of migration, resulting in increased population and land-use shift from agricultural land into residential and commercial areas.4 this rural-to-urban shift does not only affect the land use and infrastructure development but also affects the lifestyle and culture of the community. changes in the lifestyle also include changes in the diet that tend to move towards instant food or fast food consumption. the higher tendency to use motorized vehicles has also reduced walking activities among people.5 these two changes create risk factors for non-communicable diseases. consequently, this leads to an increase in the incidence and mortality caused by non-communicable diseases, including hypertension, in cileunyi district.6 several factors affect a person’s adherence. first, the socioeconomic factors that include low education level and limited motivation. the second is the health service factors that include the uneven distribution of health facilities, inadequate number of health workers, limited consultation time, lack of communication with patients, and lack of health worker’s knowledge in treating chronic diseases. the third factor is the conditionrelated factors, for example, the severity of disease, complications, and prognosis. the fourth factor is therapy-related factors, such as complex therapy, duration of treatment, history of previous therapy errors mistake, and drug side effects. the last factor is the patient-related factors that include the level of knowledge and confidence, motivation in treatment, absence of symptoms, frustration caused by the disease, anxiety towards drug side-effects, and confidence to recover. the five factors above may reduce adherence to medication in almost every country, including indonesia.7 adherence to medication can be interpreted as a patient’s behavior in abiding to doctor’s recommendations in accordance with medical demands. the low adherence is the main cause of treatment failure, especially in the treatment of chronic diseases such as hypertension treatment.8 this study aimed to determine the level of adherence to antihypertensive drugs among hypertension patients visiting a public health center in bandung district, west java, indonesia. methods this is a cross-sectional quantitative descriptive study on adherence to medication for hypertensive patients. data were obtained by interview using the morisky medication adherence scale-8 (mmas-8) questionnaire, a structured self-report indicator of drugtaking behavior, which is commonly used and has been validated for antihypertensive drugs in different cultures.9 the study was performed from july to august 2018 in the working area of cileunyi primary health care (phc), bandung district, west java and has been approved by the health research ethics committee, faculty of medicine, universitas padjadjaran no 847/un6.kep/ec/2018. the subjects in this study were patients with hypertension treated at the cileunyi phc (n=75). the inclusion criteria were outpatients aged more than 18, had received hypertension diagnosis from a doctor, consumed antihypertensive agents prescribed by a doctor, duration of treatment minimum of two months, and had given consent to participate in the study. the exclusion criteria were the subjects who bought their own medicine without a doctor’s prescription, patients who came to the phc for the first time, and patients who could not communicate well. data collection was carried out by conducting interviews on patient’s characteristics and adherence using the mmas-8 questionnaire that had been tested for validity and reliability.10,11 the mmas questionnaire used in this study contained eight questions with seven dichotomy scale questions and one likert scale question. tania, vycke yunivita, et al. :74–80 76 international journal of integrated health sciences. 2019;7(2) data were then analyzed using the rasch model on winstep software 3.73 (winsteps, usa). results were represented as a logit person for each person to describe treatment adherence. the adherence level were classified into two categories. the first was the adherence category represented by a logit person value above the mean score and the second category was the non-adherence category, which was represented by a logit person value under the mean score. respondents characteristics in terms of adherence were processed using the spss version 22 (spss.license.unpad.ac.id). results seventy-five respondents who suffered from hypertension and visiting the cileunyi phc participated in this study. the wright distribution pattern of respondents and questionnaire items were represented in a wright’s map (fig.). the average logit person value based on analysis using the rasch model was -0.88. the wright’s map was then used to determine the adherence level. fortyfour respondents (59%) were included into the adherence category (59%) and 31 were classified into the non-adherence category (41%). the results exhibited that the majority of the respondents were over 55 years old, female, graduated from elementary school, and unemployed. all respondents were married and consumed only one type of figure wright distribution pattern of respondents and questionnaire items adherence to antihypertensive medication in patients with hypertension in indonesia :74–80 international journal of integrated health sciences. 2019;7(2) 77 table respondent characteristics by adherence characteristics adherence n (%) non-adherence n (%) total (%) n=75 age ≤ 55 years 21 (60%) 14 (40%) 35 (47%) > 55 years 23 (57%) 17 (43%) 40 (53%) gender male 7 (47%) 8 (53%) 15 (20%) female 37 (62%) 23 (38%) 60 (80%) education no school 2 (100%) 0 (0%) 2 (3%) elementary school 29 (63%) 17 (37%) 46 (61%) junior high school 6 (46%) 7 (54%) 13 (17%) senior high school 5 (42%) 7 (58%) 12 (16%) college 2 (100%) 0 (0%) 2 (3%) occupation employment 8 (67%) 4 (33%) 12 (16%) unemployment 36 (57%) 27 (43%) 63 (84%) marital status single 0 (0%) 0 (0%) 0 (0%) married 44 (59%) 31 (41%) 75 (100%) duration of being aware of hypertension status ≤ 5 years 23 (59%) 16 (41%) 39 (52%) >5 years 21 (58%) 15 (42%) 36 (48%) number of drug type 1 44 (59%) 31 (41%) 75 (100%) >1 0 (0%) 0 (0%) 0 (0%) drug type ace inhibitor 23 (70%) 10 (30%) 33 (44%) calcium channel blocker 21 (50%) 21 (50%) 42 (56%) other 0 (0%) 0 (0%) 0 (0%) income (indonesian rupiah/idr) <1,500,000 41 (57%) 31 (43%) 72 (96%) 1,500,000–2.500.000 2 (100%) 0 (0%) 2 (3%) 2,500,000–3,500,000 1 (100%) 0 (0%) 1 (1%) 3,500,000 0 (0%) 0 (0%) 0 (0%) cost coverage out-of-pocket 17 (81%) 4 (19%) 21 (28%) borne by other parties (insurance, family, etc.) 27 (50%) 27 (50%) 54 (72%) support from family/social environment yes 30 (64%) 17 (36%) 47 (63%) no 14 (50%) 14 (50%) 28 (37%) tania, vycke yunivita, et al. :74–80 78 international journal of integrated health sciences. 2019;7(2) drug. most respondents had known that they had hypertension for less than 5 years, took calcium channel blocker drugs, had a monthly income of less than indonesian rupiahs (idr) 1,500,000,00, had the treatment costs borne by other parties, and received good support and motivation from family or social environment. the number of respondents in the age group >55 years who were in the non-adherence category was higher (table 2). women showed a higher percentage of adherence than men and most of the non-adherence respondents were graduated from elementary school. respondents who were employed were most likely to be in the adherence group than those who were unemployed. married respondents tended to be adherent. when adherence was assessed from the perspective on how long the patients had known about their hypertension status, adherence was found to be more prevalent in the group who was were aware that they were hypertensive for less than 5 years. all respondents took one type of drug and mostly adhered to the treatment. in terms of the type of drug consumed, respondents in the non-adherence group were more likely to take calcium channel blocker. most respondents, who had an income less than idr 1,500,000, were adherent. respondents who use their own money tended to adhere to the treatment. family and social support also influenced the adherence with a higher percentage of respondents with good family and social supports adhered to the treatment. discussion patients with hypertension visited the cileunyi phc were analyzed based on several characteristics. when the age was crossexamined with adherence, it was revealed that more patients who were >55 years old were in the non-adherence group compared to the younger counterpart (≤55 years old). this is in accordance with the results of the ibhr 2018 stating that the most common disease in the elderly is hypertension (57.6%).2 it is expected that when a person is getting older, his or her incidence of having a high blood pressure increases. this is because the blood vessel structure and function change with aging, which in turns affect body hemodynamics or blood pressure regulation. these changes include the, including loss of connective tissue elasticity, decreased relaxation of vascular smooth muscle, and atherosclerosis.12 as people get older, the organ system also experiences declined function, including the limbic system which controls memories.13 as a result, patients who are >55 years may have a lower level of adherence than patients who are ≤55 years due to lower memory capacity. sixty women (80%) with hypertension participated as the respondents, which is far greater than men (n=15, 20%). this is consistent with the results of the ibhr 2018 that demonstrated a higher prevalence of hypertension among women in indonesia when compared to men.2 women experience menopause, which involves hormonal changes resulting in a decreased ratio of estrogen to androgen hormones that leads to higher renin release which then triggers an increase in blood pressure.14 nevertheless, women have a higher level of adherence than men, which is similar to the finding of a previous study that reported female respondents to be more concerned about their health due to the higher availability of time and opportunities to visit the phc than men.15 the respondents of this study were predominantly graduated from elementary school (n= 46, (61%) with varied adherence level. thus, education seems to not affecting patient’s adherence. a person with a higher education level does not necessarily have better adherence and vice versa. this is because respondents’ knowledge is not only obtained through formal education but also from experience or other information media, such as television, newspaper, radio, and the internet. the knowledge of treatment adherence could also be gained from the communication between patients and their healthcare provider.16 based on the occupational group, most respondents were unemployed. the reason for the high rates of hypertension among unemployed patients is that the physical activities of unemployed patients are less than those who work. physical activities can facilitate blood flow while the lack of physical activities can increase the risk of obesity and hypertension.17 respondents who work have higher adherence than those who do not work. on the contrary, a previous study stated that higher adherence is found among unemployed patients. their argument is that these patients have more time at home so they have more opportunities to take their medication regularly.18 all hypertensive patients in the cileunyi phc were married. no previous report has explained the relation between marital status and hypertension, but an assumption can be made that because hypertension is more common in old age and adherence to antihypertensive medication in patients with hypertension in indonesia :74–80 international journal of integrated health sciences. 2019;7(2) 79 one tends to get married at the age of 20 years old or older, more married patients experience hypertension. patients who are married have more family support for taking the medicine by reminding to take the medicine as prescribed. hence, they have more controlled hypertension.19 most respondents of this study have known about their hypertension status for less than 5 years and all of the respondents only took one type of drug. a previous study stated that patients with one drug regimen have a higher adherence level than patients with multiple drug regimens.8 this may be because patients who consume multiple drugs tend to forget to take their medicine and finally get tired of it, resulting in a lower adherence. based on the type of drug consumed, two classes of antihypertensive drugs were used by the respndents, namely ace inhibitors (captopril) and calcium channel blockers (amlodipine). the number of respondents who took captopril was less than those who took amlodipine, albeit with a higher level of adherence. this is in contrast with the adherence level is a previous study showing that patients who take amlodipine are more adherent that those who take captopril. the researchers assumed that it may be due to the most common side effect of captopril, which is coughing, that is less tolerable and may interfere with patients’ daily activities. this is also because patients only need to take amlodipine once a day.20 out of seventy-five respondents in the cileunyi phc, the majority had a monthly income below idr 1,500,000. there were two respondents whose income was between idr 1,500,000 and idr 2,500,000 and one respondent had an income of between idr 2,500,000 and idr 3,500,000. no statistically significant difference is found regarding income.18 however, this study cannot conclude the relationship due to limited sample size and possible bias. respondents who bear their own costs have higher adherence than respondents whose cost was borne by other parties. most of the respondents have their medical expenses covered by other parties such as by the national health insurance. this situation is the opposite of the findings of a previous study that shows a lower adherence level among those who pay for their own cost. other study reported that with the availability of health insurance, patients can obtain drugs regularly and, thus, more adherent than those who are not covered by insurance.18 this study shows that patients that do not have family/social support have a lower adherence level. the form of support can be a reminder to take the antihypertensive drug from the child or spouse. moral support from others can also increase patient’s selfmotivation and lead to a high adherence level. adherence to drugs is the most important aspect of a patient’s treatment. good support from the patient’s family or social environment is a social factor that can predict adherence.21 to summarize, the adherence to treatment is crucial for every patient. it is necessary to control hypertension and prevent complications. the primary health care plays a role in improving patient adherence. education about the benefit of taking antihypertensive drugs regularly should be provided to patients so they are more aware of their disease and the importance of taking medicine, thus leading to a high adherence level. education to the patient’s family members is also important. it can be concluded that the majority of the respondents are over 55 years old, female, graduated from elementary school, and unemployed. all respondents are married and take one drug regimen. most of the respondents have known that they have hypertension for less than 5 years, take calcium channel blocker, have monthly income less than idr 1,500,000,00, havve the costs borne by other parties, and get good motivational support from family or social environment. most patients with hypertension in cileunyi primary health care have good adherence to antihypertensive drugs. references 1. whelton pk, carey rm, aronow ws, casey de, collins kj, dennison himmelfarb c, et al. 2017 acc/aha/aapa/abc/acpm/ags/ apha/ash/aspc/nma/pcna guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the american college of cardiology/ american heart association task force on clinical pr. hypertension. 2018;71(6):e13–115. 2. kementerian kesehatan ri. hasil utama riskesdas 2018. riset kesehatan dasar. jakarta; 2018. 3. dinas kesehatan provinsi jawa barat. profil kesehatan di jawa barat tahun 2016. dinas kesehatan jawa barat. 2017. p. 188–196. 4. suparman e, afiatun e, rusmaya d. perencanaan sistem drainase berwawasan tania, vycke yunivita, et al. :74–80 80 international journal of integrated health sciences. 2019;7(2) lingkungan di kecamatan cileunyi kabupaten bandung. 2008. 5. mansur m. problematika urbanisasi. al-munzir. 2014;7(1):70–82. 6. handajani a, roosihermiatie b, maryani h. faktor-faktor yang berhubungan dengan pola kematian pada penyakit degeneratif di indonesia. bull heal syst res. 2010;13(1):42– 53. 7. reach g. a novel conceptual framework for understanding the mechanism of adherence to long term therapies. patient prefer adherence. 2008;2:7–19. 8. ramli a, ahmad ns, paraidathathu t. medication adherence among hypertensive patients of primary health clinics in malaysia. patient prefer adherence. 2012;6:613–22. 9. nasasira b, ndichu a, muiru w, link c, okello s, nasasira b, et al. validity and reliability of a self-reported measure of antihypertensive medication adherence in uganda. plos one. 2018;11(7):1–11. 10. de oliveira-filho ad, morisky de, neves sjf, costa fa, de lyra dp. the 8-item morisky medication adherence scale: validation of a brazilian–portuguese version in hypertensive adults. res soc adm pharm. 2014;10(3):554– 61. 11. alfian sd, sukandar h, lestari k, abdulah r. medication adherence contributes to an improved quality of life in type 2 diabetes mellitus patients: a cross-sectional study. diabetes ther. 2016;7(4):755–64. 12. fleg jl, strait j. age-associated changes in cardiovascular structure and function: a fertile milieu for future disease. heart fail rev. 2012;17(4–5):545–54. 13. st. jacques pl, dolcos f, cabeza r. effects of aging on functional connectivity of the amygdala for subsequent memory of negative pictures: a network analysis of functional magnetic resonance imaging data. psychol sci. 2009;20(1):74–84. 14. cannoletta m, cagnacci a. modification of blood pressure in postmenopausal women: role of hormone replacement therapy. int j womens health. 2014;6:745–57. 15. bidmon s, terlutter r. gender differences in searching for health information on the internet and the virtual patient-physician relationship in germany: exploratory results on how men and women differ and why. j med internet res. 2015;17(6):e156. 16. schoenthaler a, chaplin wf, allegrante jp, fernandez s, diaz-gloster m, tobin jn, et al. provider communication effects medication adherence in hypertensive african americans. patient educ couns. 2009 may;75(2):185–91. 17. diaz km, shimbo d. physical activity and the prevention of hypertension. curr hypertens rep. 2013;15(6):659–68. 18. cho s-j, kim j. factors associated with nonadherence to antihypertensive medication. nurs health sci. 2014;16(4):461–7. 19. lewis lm, askie p, randleman s, sheltondunston b. medication adherence beliefs of community-dwelling hypertensive african americans. j cardiovasc nurs. 2010;25(3):199– 206. 20. benowitz nl. antihypertensive agents. in: katzung bg, editor. basic and clinical pharmacology. 14th ed. usa: the mcgraw-hill companies; 2017. p. 173–276. 21. lewis lm. factors associated with medication adherence in hypertensive blacks: a review of the literature. j cardiovasc nurs. 2012;27(3):208–19. adherence to antihypertensive medication in patients with hypertension in indonesia :74–80 48 international journal of integrated health sciences. 2018;6(1) original article knee extensor strength prediction formula using modified aneroid sphygmomanometer in healthy female adults correspondence: erik setiawan, department of physical medicine and rehabilitation, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital, bandung jl. pasteur no. 38, bandung, indonesia e-mail: dr.eriksetiawan@gmail.com erik setiawan, marietta shanti prananta, novitri department of physical medicine and rehabilitation, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital, bandung abstract objective: to discover isometric knee extensor muscle strength prediction formula using hand-held dynamometer (hhd) through the use of modified aneroid sphygmomanometer (mas). isometric knee extensor muscle strength examination is required to diagnose and evaluate the treatment of quadriceps femoris weakness. methods: this was a quantitative observational and correlational analysis study with cross-sectional design. isometric knee extensor muscle strength was measured using hhd and mas with 60o knee flexion in sitting position. correlation tests were performed to investigate the correlation between hhd, mas, and other variables. regression test was carried out to analyze knee extensor strength regression using hhd through mas. results: subjects enrolled were 25 healthy females aged 23–52 years old. the correlation between hhd and mas was significant while age, body weight, body height, and body mass index (bmi) did not show correlation with hhd and mas. the isometric knee extensor muscle strength using hhd could be predicted by formula = 0.1041xmas. conclusions: isometric knee extensor muscle strength measured using hhd strongly correlates with that of using mas with 60o knee flexion in sitting position and can be predicted from measurement values of mas. the formula is only suitable for females. keywords: hand-held dynamometer, knee extensor, prediction formula, sphygmomanometer pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v6n1.1103 ijihs. 2018;6(1):48–55 introduction measurements of muscle strength become the basic components of the physical examinations commonly associated with physical medicine and rehabilitation study. the measurements of muscle strength appropriate for application in clinical practices can be performed using a manual muscle testing (mmt) and hand-held dynamometer (hhd).1–3 manual muscle testing is commonly used in clinical settings for screening muscle strength; however, it is subjective and less sensitive. on the other hand, hhd is able to give objective results and also more sensitive than the mmt; therefore, it is more suitable to be used for diagnosing weakness in quadriceps femoris muscle and for the post-treatment evaluation of the muscle. however, its high price becomes a major limitation, especially for developing countries, that the hhd is currently not widely available and is rarely used in rehabilitation clinics in indonesia.3–9 modified aneroid sphygmomanometer, or mas, is an alternative method for measuring muscle strength with a lot of advantages, such as its affordable price, wide availability, and objective assessment results. measurements using mas are quick and and can be repeated with consistent results. there are several mas methods used in several studies with the bag method as the most common method as it is received: july 19, 2017 revised: december 22, 2017 accepted: february 26, 2018 :48–55 international journal of integrated health sciences. 2018;6(1) 49 easier to stabilize and gives more consistent results.10–13 most of the studies done in the past assumed the 90o knee flexed in sitting position in order to assess the isometric knee extensor muscle strength.7,9,14 this posture is disadvantageous for quadriceps femoris muscle because the muscle is not in its optimal length considering its length-tension relationship and moment arm length. the maximum isometric knee extensor strength is peaked around 60o of knee flexion. hence, this study was performed using 60o knee flexed position.2,15 despite the fact that hhd has become the gold standard for evaluating muscle strength in clinical settings, its limited availability in developing country becomes a major limitation; while aneroid sphymomanometer is widely available and its modification is reversible and easy to do. this study aimed to explore knee extensor muscle strength prediction formula using hhd from measurement using mas with bag method in healthy adult subjects. methods this study was a quantitative observational and correlational study using cross-sectional design to explore the correlation and regression of isometric knee extensor muscle strength measured using hhd and mas in healthy adults. the sampling method used in the study was consecutive sampling. the minimum sample of this study was 25 subjects. the subjects were people who worked at the department of physical medicine and rehabilitation, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital, bandung. the inclusion criteria for this study were 20–59 years old subjects, capable of following instructions well, have a full range of motion of knee flexion of dominant leg, and was willing to participate in the study, proven by signing the informed consent. the exclusion criteria were neuromuscular or musculoskeletal disorders on the dominant leg; uncontrolled high blood pressure and metabolic disease; a history of heart disease; and suffering from rheumatic or degenerative joint diseases on the dominant leg. the subjects would be excluded if the mas measurement results were over the maximum scale range of >300 mmhg because it was not possible to read the objective data in this condition thus the data cannot be included in the analysis. the instruments used in this study were baseline analog push-pull dynamometer (with continuous dial that holds maximum force readings), fujito aneroid sphygmomanometer, a cotton bag sewn on the edge to contain the rubber sphygmomanometer cuff, and nk table with modified shin pads. the shin pads were modified so that the angle of the subjects’ knee would be the same as the torque arms when the leg being examined was placed in front of erik setiawan, marietta shanti prananta et al. subject’s positioning & stabilization. subject was in upright sitting position while holding the railings and examined knee in 60o flexion with straps on pelvis, thighs, and shins (left). stabilization of mas by the examiner (right) fig. 1 :48–55 50 international journal of integrated health sciences. 2018;6(1) the shin pads (fig. 1). the adaptation of the bag method was then performed by first removing the outer velcro of the sphygmomanometer cuff, then folded the rubber part of the cuff into three equal parts followed by inserting it into a cotton bag with zipper (fig. 2). before it could be used, the cuff was inflated to 100 mmhg and the valve was kept closed to remove the folds from the inflatable portion, then the pressure was reduced to 20 mmhg and the valve was closed again to prevent leakage. hence, the measurement range became 20–300 mmhg. after this adaptation, the size of the cuff was 11.5 cm long, 6.5 cm wide, and 6 cm thick.10 data were collected by one male examiner with a normal body mass index (bmi) level. the examiner was already familiar with the equipment. the examiner sat on a fixated chair during the measurements so that he was able to hold the examined leg of the male and female subjects without making any movement. the use of one examiner to hold the subjects’ legs while stabilizing the equipment, as well as to read the dial and to record the results was to simulate clinical settings. subjects who met inclusion criteria were given information about the objective of the study and data collection techniques used. the subjects then signed the informed consent form if they agreed to participate. the inclusion and exclusion criteria were determined from the anamnesis and physical examination by a senior physical medicine and rehabilitation resident doctor. subjects’ basic data were then collected: age, sex, side of dominant leg, body weight, and body height. the next step was measurements of knee extensor muscle strength of the dominant leg using a push-pull dynamometer. subjects were instructed to sit on nk table with the popliteal region adhere to the edge of the table (fig. 1). the examined leg was placed in front of the modified shin pad with the torque arm fixated at 60o of knee flexion, while the unexamined leg was placed behind the shin pad on the other side. the fixation strap was placed on the subjects’ lower leg, thigh, and hip. subjects were instructed to maintain an upright position and used both hands to hold the railings on the side of the table to fixate the trunk. the examiner then placed the pushpull dynamometer slightly above ankle joint perpendicular to the lower leg. then subjects were asked to push his examined leg forward gradually until maximum force in 5 seconds and the examiner hold the dynamometer to prevent any movement (make test). maximum isometric contraction strength that was shown in the hhd was the strongest muscle strength acquired directly before the leg moved. the initial measurements were performed to make subjects familiar with the devices (data were not taken). measurements were then repeated three times with a 30 seconds rest to prevent fatigue which might be experienced by both subjects and examiner. the results were then recorded in examination form. measurements of knee extensor muscle strength of the dominan leg using mas with bag method required the same posture and fixation straps of subjects as those using hhd. the bag was inflated to 100 mmhg and reduced to 20 mmhg as preparation before each measurements. the examiner placed the bag slightly above ankle perpendicular on the leg (fig. 1). the examiner maintained flat hands on the bag surface contact area and avoided grasping the bag. the dial aneroid reading was placed perpendicular to examiner’s eyes so that there was no deviation in reading the result. the instructions given to subjects and protocols to collect data were as same as those using hhd. data were then analyzed using statistical tests, including normality data test, descriptive statistics, and, depending on data distribution, pearson and/or spearman correlation test, as well as regression test. the regression test was used for prediction formula of isometric knee extensor muscle strength from examination result using mas. average from the three results of muscle strength measurement using hhd and mas of each subject were calculated so that every knee extensor strength prediction formula using aneroid sphygmomanometer in healthy female adults bag method modification of aneroid sphygmomanometer. sphygmomanometer before modification and the cotton bag (left). outer velcro of sphygmomanometer cuff was removed (middle). cuff was inserted into the bag and was inflated (right) fig. 2 :48–55 international journal of integrated health sciences. 2018;6(1) 51 table 1 subjects’ characteristic data variables mean (± sd) median (range) w p value age (years) 33 (23–52) 0.8486 0.001 weight (kg) 56.12 (± 12.34) 0.9935 0.1098* height (cm) 156.60 (± 6.63) 0.9597 0.1532* bmi (kg/m2) 22.80 (± 4.30) 0.9314 0.0901* hhd (kg) 29.83 (24.50–33.83) 0.8994 0.0174 mas (mmhg) 283.23 (± 10.92) 0.9440 0.1920* note: bmi=body mass index, hhd=hand-held dynamometer, mas=modified aneroid sphygmomanometer * p-value > 0.05 means normal distribution subject had one hhd mean value (hhd variable) and one mas mean value (mas variable). the hhd and mas variables were then included in the normality data test along with age, weight, height, and bmi variables. normality of data were tested to determine the data distribution. if data were distributed normally, the correlation test used would be pearson and if the data were not distributed normally, spearman test was selected as the correlation test. for both tests, the confidence interval used was confidence interval (ci) 95% or alpha 0.05. if the results showed a significant correlation, analysis would be continued with regression test with forward step-wise method to predict isometric knee extensor muscle strength using hhd from measurement results using mas. residual test was then performed to ensure that the prediction formula resulting from the regression test were valid. this study was conducted at the department of physical medicine and rehabilitation of the faculty of medicine, universitas padjadjarandr. hasan sadikin general hospital, bandung in december 2015–february 2016. it was approved by health research ethic committee, faculty of medicine, padjadjaran university (ethical exemption letter no: 727/un6.c1.3.2/ kepk/pn/2015). the study was commenced after receiving approval. all subjects’ data and information were confidential. results fifteen of 40 subjects, all males, were excluded because their objective data measurements were over the maximum scale of mas (>300 mmhg) that the objective data cannot be read. the subjects included in data analysis were 25 erik setiawan, marietta shanti prananta et al. variables r t(n-2) p value hhd and age 0.1745 0.8497 0.4043 hhd and weight 0.2023 0.9905 0.3322 hhd and height 0.2263 1.1144 0.2766 hhd and bmi 0.1409 0.6827 0.5016 hhd and mas 0.5931 3.5332 0.0018* mas and age 0.3112 1.5706 0.1299 note: hhd=hand-held dynamometer, mas=modified aneroid sphygmomanometer, bmi=body mass index * p-value was significant spearman correlation test between knee extensor muscle strength measurement results and other variables table 2 :48–55 52 international journal of integrated health sciences. 2018;6(1) healthy females. the subjects’ characteristic data were presented in the study (table 1). the median age of the subjects was 33 years old with 23 to 52 years old range. the means for body weight, body height, and bmi were 56.12±12.34 kg, 156.6±6.63 cm, and 22.80±4.30 kg/m2, respectively. the 3 trials of measurements using hhd ranged between 24.5–33.83 kg with a median of 29.83 kg. the mean of mas variables were 283.23±10.92 mmhg. the results of normality test using shapiro wilk test showed that body weight, body height, bmi, and measurement value using mas were normally distributed. however, the subjects’ characteristics data of age and measurement value using hhd were not normally distributed (p<0.05). results of spearman correlation analysis (ci 95% or alpha 0.05) between the measurement values using hhd, the measurement values using mas, and other variables that were not normally distributed are presented (table 2). the results of pearson correlation analysis (ci 95% or alpha 0.05) between measurement values using mas as well as other variables that were normally distributed were 0.3086; p=0.133 for mas and body weight, 0.3740; p=0.065 for mas and body height, and 0.2099; p=0.314 for mas and bmi. the only significant correlation discovered in the study was the correlation between measurement values using hhd and using mas (p=0.0018) (table 2). the correlations between measurement values using hhd and age, hhd and body weight, hhd and body height, as well as hhd and bmi were not significant (p>0.05). the correlations between measurement values using mas and age, mas and body weight, mas and body height, as well as mas and bmi were also not significant (p>0.05). the regression analysis was carried out using forward step-wise method with independent variables included in the analysis were age, weight, height, bmi, and measurement value using mas, while dependent variable was the measurement values using hhd. the variable taken into regression after the analysis was only the measurement values using mas. the contribution of measurement value using mas was 99.62%. this variable had a significant regression coefficient to predict value of knee extensor muscle strength using hhd with r=0.996. age, weight, height, and bmi were not taken into regression because mas variable by itself had a very strong correlation (99.62%) with the hhd variable so that other variables becomes insignificant in the formula. the regression formula was discovered to predict knee extensor muscle strength value using hhd in healthy adults is as follows: prediction value of the knee extensor muscle strength using hhd was equal to 0.1041 x knee extensor muscle strength value using mas. this prediction formula was only suitable for females. residual test was then conducted to analyze whether the regression formula was valid to be used as a predictor. the requirements for a regression formula to be considered valid to be used as a prediction formula are residue is normally distributed and mean residue=0. normality test using the shapiro wilk showed w=0.934 and p=0.11, meaning that the residue was distributed normally. the result of residual test was mean residue=-0.033 (sd±2.633). t count=-0.063, meaning that the p value>0.05, showing that mean residue=0. as the requirements of residual test had already been fulfilled, the regression formula could be used to predict knee extensor muscle strength value using hhd through mas measurement results. the chart presenting the prediction values of knee extensor muscle strength measurement using hhd from the regression formula to its actual observation values is depicted in (fig. 3). the observation value is the muscle strength value promptly measured using hhd. prediction value is the result of prediction formula of hhd=0.1041xmas, meaning that the muscle strength measurement value using mas times 0.1041 equals the prediction of muscle strength value using hhd. the redlined dash is regression line with ci 95%. knee extensor strength prediction formula using aneroid sphygmomanometer in healthy female adults correlation between observation values and prediction values of knee extensor muscle strength using hand-held dynamometer fig. 3 :48–55 international journal of integrated health sciences. 2018;6(1) 53 discussion most previous studies assessed isometric knee extensor muscle strength, either using hhd or mas, using sitting posture with 90o hip and knee flexion.7,9–11,14 other studies used sitting posture with 90o hip flexion and 45o knee flexion, supine posture with 30o knee flexion and prone posture with 90o knee flexion.5,12,16 these postures were less favorable for quadriceps femoris muscles because its not in its optimal length considering its lengthtension relationship and moment arm length. quadriceps femoris muscles can hold 90% of its maximum force in 80o to 30o knee flexion range. it can produce great force in 80o knee flexion because the length-tension relationship of vasti muscle are favorable at this angle. this factor combined with the change of patellar moment arm length as knee extends produce even greater quadriceps muscles force. the maximum isometric knee extensor strength is peaked around 60o of knee flexion.2,15 this study is concerned more about the positioning to allow the recording of absolute maximum force output in the isometric knee extensor muscles while still preventing the subjects to overpower the examiner and also preventing difficulties in stabilizing equipment on subjects’ legs. the previous studies stated that one of the problems found in isometric knee extensor muscle strength measurement is that the examiners were not able to give proper pressure against subjects’ maximum force while stabilizing the equipment on the legs.5,9,10,14 the use of bag method mas can help with the problem because it is easier to stabilize. consistent with souza et al.10 study, examiner could easily stabilize mas with bag method on subjects’ legs while resisting leg movements, but the examination table or the examiner’s seat was pushed away during the measurement of stronger subjects. by fixing the examination table and the examiner’s seat against the wall, the examined leg could be prevented from moving during examination. ford-smith et al.14 used steel iron frame fixated to thick carpet to hold hhd, but it is less practical in clinical settings. katoh9 used belt to fixate hhd, but the same modification cannot be used on mas with bag method because the pressure distribution on the bag might be uneven. the reason of unreadable data results in mas measurements of stronger subjects according to previous studies were the unability of the examiner to stabilize the equipment when force were given and the modification method of mas.10–12 although the examiner in this study was able to hold all subjects’ legs from moving while stabilizing the equipment when subjects extended their knees, the bag method of mas limited the readability of data results of stronger subjects. a comparation study of methods used in mas by souza et al.10 revealed that mas with permanently sewn bag method had more consistent results compared to the loosely rolled cuff method and was easier to stabilize on subjects’ body parts, although the bag method had lower ability to assess muscle strength of stronger subjects. it may be because the bag is more elastic, requires more air in the pre-inflation of the equipment, has larger contact area with the subjects’ skin and reaches higher pressure values when an external force is applied. moreover, in this study, the 60o angle of knee flexion in sitting posture provide more advantage to quadriceps femoris muscle group to produce its peak force, rather than the 90o or 45o knee flexion in sitting posture, 30o knee flexion in supine posture, and 90o knee flexion in prone posture used in the previous studies that were limiting the forces produced by the quadriceps muscle groups that are caused by its mechanical disadvantage and gave more mechanical advantage to the examiner.5,7,9–12,14,16 helewa et al.12 who examined knee extensors in supine posture with 30o of knee flexion using mas in rheumatoid arthritis subjects did not report any dropped out subjects caused by mas limitation in data reading. isometric knee extensor muscle strength measurement using mas with bag method may be able to be appropriately used for subjects with weakness in the quadriceps femoris muscle. for comparison, non-adapted sphygmomanometer method presents a better ability to assess stronger subjects, at the cost of greater difficulty for stabilizing the equipment because of its larger surface contact area. this method requires more training to maintain flattened hand on the equipment, otherwise the result will not be reliable.10,11,17 subjects enrolled in this current study only consisted of females. hence, it was not possible to see the correlation between gender and muscle strength measurement results using hhd and mas. in general, different sex can influence the individual’s muscle strength. young boys’ muscle strength is approximately the same as that of young girls before puberty. after puberty, males continue to increase their muscle strength while there is no change in the muscle strength of females. sex-related body composition changes account for the muscle erik setiawan, marietta shanti prananta et al. :48–55 54 international journal of integrated health sciences. 2018;6(1) strength difference. the greater strength of males related primarily by the greater muscle mass they develop after puberty. before about age 16, the ratio of lean body mass to whole body mass is similar in males and females. after the puberty, the muscle mass of males becomes 50% greater than that of females, and the ratio of lean body mass to whole body mass also becomes greater.15,18,19 age range among the subjects in this study was quite wide (23–52 years) that represents adult age. muscle strength in adult age reaches its maximum strength and size of crosssectional area between the age of 20 and 30 years, then gradually declining after age of 30 years for most of muscle groups. as individuals age, number of motor units decline. however, in this study, age did not correlate with hhd and mas measurement values. it was not included in the prediction formula because the contribution of the difference of knee extensor strengths between younger and older female adults was not significant, compared to the 99.62% contribution of mas variable. with very strong correlation between mas and hhd variables, other variables became less significant to be included into the prediction formula.15,18,19 in this study, body weight, body height, and bmi did not show correlation with knee extensor muscle strength values using either hhd or mas. it might be because bmi does not show direct correlation with muscle strength. bmi does not consider body’s fat and muscle components. individuals in the same level of bmi may have different muscle & fat mass distribution. in trained individuals, the bmi may be higher because of bulkier muscle mass which in general will have greater muscle strength. while in obese individuals, higher bmi with larger fat mass, is likely to have great muscle strength.15,18–20 there was significant correlation between knee extensor muscle strength measurements using hhd and mas. the regression analysis with forward stepwise method only included knee extensor muscle strength measurements using mas with 99.62% contribution, meaning that the measurements using hhd was very strongly correlated with the measurements using mas. this finding supports the usage of knee extensor muscle strength measurement using mas to predict that of using hhd. souza et al.11 who examined in stroke patients found that at least 57% of the variations in the hhd values, with coefficient of determination ranged between 0.57 and 0.79, which can be explained by variations in the mas measures and supported that it is important that the hhd values can be predicted since others have reported that the strength of specific muscles could predict independence in a given functional activity. this study has rechecked the formula using residual test by comparing the actual results of measurements using hhd and the predicted results of measurements using hhd through the formula. after the requirements for regression equation were fulfilled, the regression equation is valid to be used as predictor. it is noteworthy that the prediction formula was only suitable with females since the subjects enrolled was only females. in conclusion, there is a strong correlation between the isometric knee extensor muscle strength measurement values using mas with the bag method and hhd in female healthy adults with 60o knee flexion in sitting position. the isometric knee extensor muscle strength measured using hhd in female adults can be predicted through that of using mas. further studies may be necessary for subjects with neuromusculoskeletal diseases which cause quadriceps femoris muscle weakness. another study with lower pre-inflation pressure of mas with bag method may be able to overcome the limitation of measuring isometric knee extensor strength in stronger subjects. knee extensor strength prediction formula using aneroid sphygmomanometer in healthy female adults references 1. 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philadelphia: f. a. davis company; 2012. p. 125–57. 16. arnold cm, warkentin kd, chilibeck pd, magnus cr. the reliability and validity of handheld dynamometry for the measurement of lower-extremity muscle strength in older adults. jscr. 2010;24(3):815–24. 17. azad ak, nabi g, shakoor ma, moyeenuzzaman md. role of muscle strengthening exercise on osteoarthritis of the knee joint. jom. 2011;12(2):120–4. 18. yahin a, moeliono ma, prananta ms. handgrip strength prediction formula using aneroid sphygmomanometer in elderly. ijihs. 2016;4(2):47–55. 19. katch vl, mcardle wd, katch fi. essentials of exercise physiology. 4th ed. baltimore: lippincott williams & wilkins; 2011. 20. stone ca, nolan b, lawlor pg, kenny ra. hand-held dynamometry: tester strength is paramount, even in frail populations. j rehabil med. 2011;43(9):808–11. :48–55 international journal of integrated health sciences. 2013;1(1) 13 akt–the mammalian target of rapamycin (mtor) pathway inhibition increases cervical cancer cell chemosensitivity to active form of irinotecan (sn-38) correspondence: leri septiani, department of obstetrics and gynecology, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital jl. pasteur no. 38, bandung, indonesia e-mail: lsfaried@gmail.com abstract objective: to investigate the molecular pathway of the cytotoxic effect of sn-38 in human cervical cancer cell lines. methods: two human cervical cancer cell lines were treated with various concentrations of irinotecan for 24–72 hours and the sensitivity was analysed using the mtt assay. apoptosis was further observed through microscopic examinations. the protein expression was determined using western blot analysis. results: caski cells demonstrated the highest sensitivity to sn-38, whereas hela cells showed the lowest. in cervical cancer cells, sn-38 induced apoptosis through an intrinsicand extrinsic-pathways. in addition, we showed that sn-38 downregulated the phosphorylation of akt-mtor pathways in caski cells, but not in hela cells. interestingly, in hela cells, which were more suggestive of a resistant phenotype, pre-treatment with ly294002 and rapamycin inhibited activation of akt-mtor signaling and significantly enhanced the sensitivity of hela cells to sn38. conclusions: irinotecan exerts its anti-neoplastic effects on cervical cancer cells by inducing apoptosis through caspase-cascade. inhibition of akt-mtor, ly294002 and rapamycin, which is targeted to akt-mtor pathways, may sensitize irinotecan-resistant cervical cancer cells. keywords: akt-mtor pathways anti-neoplastic drugs, cervix cancer cells, ly294002, rapamycin ijihs. 2013;1(1):13–21 leri septiani,1 yudi mulyana hidayat,1 yusuf sulaeman effendi,1 tono djuwantono,1 dimas erlangga luftimas,2 ahmad faried2 1department of obstetrics and gynecology, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital 2oncology and stem cell working group, health research unit, faculty of medicine, universitas padjadjarandr. hasan sadikin general hospital :13–21 introduction carcinoma of the cervix is the second most common neoplasm in indonesian women and the second most common neoplasm leading to female cancer mortality.1 furthermore, it is also the second most frequently found cancer among women in reproductive age between 15– 44 years old.2 it constitutes almost 15,000 new cases and 7,500 deaths per annum.2 cervical cancer treatment depends on the fédération internationale de gynécologie et d’obstétrique (figo) staging. early stadium of cervical cancer is generally treated with radical operations but up to now there is no fixed standard therapy for figo stadium ib-iia of cervical cancer. cancer within these stadiums can be treated with radical operation, radiotherapy, surgery-radiotherapy combination, surgeryanticancer drug combination, or chemotherapy although these combination therapy protocols may vary. the administration of the combination therapy for each patient is based on many factors including age, general condition, and patient’s preference to achieve maximum therapy target with minimum complications. the standard surgery for cervical cancer in stadium ib and iia is radical hysterectomy with pelvic lymphadenectomy. the benefit of surgical therapy is the ability to extract primary tumor and apply staging accurately which leads to the received: october 31, 2012 revised: february 1, 2013 accepted: february 24, 2013 original article 14 international journal of integrated health sciences. 2013;1(1) selection of the most appropriate type of adjuvant therapy for the patient. for stadium ib2 and iia, neoadjuvant chemotherapy is one of several adjuvant therapy alternatives applied. the goal of this neoadjuvant chemotherapy is to eradicate micrometastasis and reduce primary tumor volume so the next treatment effectiveness can be improved both for surgery and radiotherapy. in addition to radiotherapy, chemotherapy is the standard treatment for advanced cervical cancers. however, the systemic therapy protocol for this kind of cervical cancer keeps changing. in the past, chemotherapy was used for recurrent and persistent cervical cancer, or cervical cancers with metastasis. currently, chemotherapy is the primary treatment for cervical cancers with a high risk of reccurrency. the best possible treatment of locally advanced cervical cancer is a combination of radiation and cisplatin-based chemotherapy. cisplatin-based chemotherapy as the main regimen is still the primary choice for advanced, metastatic, and recurrent cervical cancers. even with this regimen, the response rate of advanced stadium patients was only 23% with limited response time.3 from this data, it is suggested that conventional treatment methods have reached a plateau and, therefore, to overcome this problem, finding a good prognostic factor and predictor response to chemotherapy might be useful. irinotecan (cpt-11) and its analog have given promising results on many clinical trials. sn-38, which is a semi-synthetic derivative of camptothecin, is the active metabolite of irinotecan. like other camptothecin-derivatives, sn-38 inhibits topoisomerase i (topo i), a nuclear enzyme needed for replication and transcription by unwinding supercoiled dna.4 sn-38 interferes with topo i activity by trapping topo i-dna cleavage complexes, leading to lethal replication-mediated double strand breaks and ended with cell death.4 currently, irinotecan is used as a standard therapy for colon cancer but not for cervical cancer. irinotecan specificity against cervical cancer needs to be studied. chemotherapeutic agents kill cancer cells through interaction with several distinct intra cellular targets, including factors affecting cells cycles, apoptosis cell death, and survival pathways. class i phosphatidylinositol 3-kinase (pi3k) and its downstream effectors, such as akt and mtor, have emerged as a prominent proliferation and survival pathway. activation of the pi3k/akt-mtor pathway has been implicated in many human cancers and shown to be associated with chemoresistance.5 we have previously shown that advanced cervical cancer expressed akt and mtor and the expression of p-mtor could predict the response to neoadjuvants and the survival of the patients treated with cisplatin-based neoadjuvant chemotherapy.6,7 a therapeutic strategy for selectively modulating the expression of a gene of interest is the use of inhibitor agents of akt such as ly294002 and inhibitor agents of mtor such as rapamycin. we assessed whether the active form of irinotecan treatment enhanced the inhibition of proliferation signals, in this case the akt-mtor pathway, which led to increase of cell death. methods cell lines and culture conditions two human cervical cancer cell lines, the hela cell line which is an adenoma cell carcinoma with human papilloma virus or hpv-18 (+) and caski cell line which is a squamous cell carcinoma with hpv-16 (+), were purchased from the american type culture collection (atcc) (manassas, va). hela cells were maintained in eagle’s minimum essential medium (emem) obtained from sigma chemical co. (st. louis, mo), supplemented with 2 mm l-glutamine, 1.0 mm sodium pyruvate, and 10% heat-inactivated fetal bovine serum (fbs) obtained from gibco (brl, grand island, ny). the caski cells were maintained in rosewell park memorial institute-1640 (rpmi-1640) medium (gibco) supplemented with hepes (sigma) and 10% heat-inactivated fbs. drugs and cell treatment irinotecan was purchased from wako pure chemicals (osaka, japan) and received as sterile lyophilized powder. a stock solution of 5 mg/ ml was made in dimethylsulfoxide (dmso) and stored at 4 °c. further dilutions were made in culture media to reach the desired concentrations when the cells obtained approximately 80% confluency. the final concentration of dmso did not exceed 0.08%, a concentration that does not alter the growth or survival properties of any cell type. we used cpt-11 and sn-38 stock of 3 μm peak plasma concentration (ppc) with a range of 9.8 ng/ml–5 μm. ly294002 and rapamycin were purchased from calbiochem (san diego, ca). for ly294002 (25 μm) or rapamycin (100 nm), cells were pre-incubated with these inhibitors for 6 hours (h) prior to irinotecan treatment. drug sensitivity assay cell proliferation analysis was performed on human cervical cancer cell lines in the presence of various concentrations of drugs by a colorimetric akt–the mammalian target of rapamycin (mtor) pathways inhibition increases cervix cancer cell chemosensitivity to active form of irinotecan (sn-38) :13–21 international journal of integrated health sciences. 2013;1(1) 15 methyl thiazolyl tetrazolium (mtt) assay. briefly, exponentially growing cells (2x104 cells/well) were plated in 96-well plates. after an overnight culture, the medium was substituted by a fresh medium with different concentrations of drugs. at the end of various treatments, 10 μl of a cellcounting solution (wst-8, dojindo labs, tokyo, japan) was added. after dissolving the crystals with 1 n hcl-isopropanol, the absorbance was measured at a wavelength of 450 nm using a microtiter plate reader (beckton dickinson, franklin lakes, nj). a value of 100% was assigned to untreated control and the concentration of drug that reduced the number of viable cells to 50% after 24 h of exposure (cpi 50 ) was derived from cell survival plots. all experiments were performed in triplicate. light microscopy examination all cells were cultured in a 6-cm plate and treated with drugs as described previously. morphological changes were examined at the times indicated and photographed using a regular phase contrast microscope. western blot analysis western blot analysis was applied as described.5 cells were harvested at the time indicated and prepared in a buffer (20 mm tris–hcl, ph 7.6, 1 mm edta, 140 mm nacl, 1% nonidet p-40, 1% aprotinin, 1 mm phenylmethylsulfonylfluoride, and 1 mm sodium vanadate). the concentration of the sample protein was determined by bicinchoninic acid (bca) protein assay (pierce, rockford, il). equal amounts of protein (40 μg) were subjected to a 5–20% tris-tricine ready gel (bio-rad, tokyo, japan) and then transferred to nitrocellulose membrane (amersham pharmacia biotech, buckinghamshire, uk). membrane was blocked with tris-buffered saline/0.1% tween 20 with 5% nonfat dry milk and incubated in primary antibodies against caspase-3, caspase-8, caspase-9 and parp (santa cruz); phosphorylated akt (p-akt, ser473), phosphorylated mtor (p-mtor, ser2448) and phosphorylated p70 s6 kinase (ps6k1,thr389) from cell signaling at 4 °c overnight. the bands were visualised by a chemiluminescence system (amersham). the expression of beta-actin (sigma) served as a loading control. the density of the bands was quantified using quantity one (biorad). statistical analysis quantitative experiments were analyzed using student’s t test. the p value was gained from the two-sided tests and were considered significant when p<0.05. leri septiani, yudi mulyana hidayat, et al. :13–21 morphological assessment of hela (a) and caski cells (b) in control cultures and after sn-38 treatment in time-dependent manner using phase-contrast microscopy (200x magnification) fig. 1 (a) control 2 hours 24 hours 36 hours (b) control 2 hours 24 hours 36 hours 16 international journal of integrated health sciences. 2013;1(1) results sensitivity of human cervical cancer cells to cpt11 and sn-38 to investigate the sensitivity of human cervical cancer cells to cpt-11 and sn-38, the cells were treated for 24–72 h in a medium containing various concentrations of drugs. the exposure to drugs (9,8 ng/ml–5 μm) produced a dose and time dependent cell growth reduction in hela and caski cells (fig. 1-2). caski cells demonstrated a higher sensitivity compared to hela. the cell proliferation inhibition 50 (cpi 50 ) values for 72 h treated hela were 320 μm, 1.91 μm and 687.5 nm for cpt-11, sn-38 disolved with medium, and sn-38 disolved with pure water (h 2 o), respectively. on the other hand, for 72 h treated caski, the results were 224 μm, 50.8 nm and 18.6 nm for cpt-11, sn-38 disolved with medium, and sn-38 disolved with pure water, respectively (table 1). based on these results, both hela and caski cells treated in sn-38 disolved with pure water were used for further experiments. expression and modulation of other apoptosisrelated proteins by sn-38 in this study, it is also observed that sn-38 treatment had significantly upregulated the table 1 concentration proliferation inhibition 50 (cpi 50 ) of hela and caski cells to rinotecan, sn-38 disolved with medium, and sn-38 with pure water (h 2 o) cell type irinotecan sn-38 (med) sn-38 (h2o) hela 320 μm (72 h) 1.91 μm (72 h) 687.5 nm (72 h) caski 224 μm (72 h) 50.8 nm (72 h) 18.62 nm (72 h) akt–the mammalian target of rapamycin (mtor) pathways inhibition increases cervix cancer cell chemosensitivity to active form of irinotecan (sn-38) the effect of sn-38 on the growth inhibition of hela (left) and caski (right) cells using mtt assay. concentration-and time-related inhibition of cells growth at 24, 48 and 72 hours were shown fig. 2 table 2 concentration proliferation inhibition (cpi 50 ) of hela and caski cells to sn-38 alone, with pre-treatment ly294002 (ly), and rapamycin (rap) cell type sn-38 ly-sn-38 rap-sn-38 hela 687.5 nm 265.63 nm 181.6 nm caski 18.62 nm 15.68 nm 4.9 nm ly, ly294002; rap, rapamycin :13–21 international journal of integrated health sciences. 2013;1(1) 17 activation of caspase-8, caspase-9 (35 kda and 37 kda), and caspase-3 (19 kda and 17 kda) followed by the cleavage of its 89 kda substrate protein with parp as a hallmark of apoptosis in caski cells (fig. 3). this was seen as early as 2 hours and increased in a time dependent manner, demonstrating a significant role of sn-38induced apoptosis. on the other hand, the hela cells show that there are not much modification of active forms of caspase-cascade and parp’s expression (it reaches the plateu phase after 2 hours of treatment) found. these results indicate that sn-38 induced apoptosis differently in both cervical cancer cells. caski cells are more sensitive to sn-38 compared to hela cells. sn-38 treatment altered the expression of pi3k/ akt-signaling proteins one of the most important survival-signaling pathways is mediated by pi3k and its downstream targets, such as akt and mtor.8 it was recently reported that akt plays an important role in determining the chemosensitivity of many kinds of cells.9-11 we evaluated the expression of these survival signaling proteins in response to sn-38 exposure in cervical cancer cells. it showed that sn-38 inhibited the activation of akt in caski cells in dose and time dependent manner as shown by the reduced expression of active form or phosphorylated akt (ser473; 60 kda), phosphorylated mtor (ser2448; 289 kda) and phosphorylated p70 s6 kinase (thr389; 70 kda) (fig. 4). on the other hand, for hela cells, there is not much modification of the active form akt (p-akt), mtor (p-mtor) and ps6k1 expression. these results indicate that sn38 downregulated differently in both cervical cancer cells. caski cells are more sensitive to sn-38 treatment compared to hela cells. these results indicate that the akt-mtor pathway leri septiani, yudi mulyana hidayat, et al. sn-38 induced apoptosis; western blot analysis of active form of caspase-cascade and parp expression in hela and caski cells treated with sn-38. the expression of β-actin served as the loading control fig. 3 :13–21 18 international journal of integrated health sciences. 2013;1(1) might have an important role to maintain the survival of caski cells in response to sn-38. inhibition of akt-mtor pathway increases the sensitivity of sn-38 induced apoptosis to confirm whether the akt-mtor pathway plays a role in response to sn-38, the ly294002 and rapamycin as pretreatment to irinotecan were used. pre-treatment with ly294002 and rapamycin significantly enhance the cell proliferation inhibition in hela cells (p<0.05, table 2, fig. 5). as in caski cells, pre-treatment with ly294002 did not significantly enhance the cell proliferation inhibition. on the other hand, akt–the mammalian target of rapamycin (mtor) pathways inhibition increases cervix cancer cell chemosensitivity to active form of irinotecan (sn-38) (a) (b) sn-38 effect on p-akt, p-mtor and p-70s6k1 western blot analysis of active form akt-mtor pathways in hela and caski cells harvested for the time indicated (a) and different dose (b). β-actin served as control fig. 4 :13–21 international journal of integrated health sciences. 2013;1(1) 19 pre-treatment with rapamycin significantly enhanced the chemosensitivity of caski cells to sn-38 (p<0.05, table 2). to further evaluate the effect of pre-treatment with these inhibitor agents on apoptosis, an analysis on the morphological changes were performed using phase contrast microscopy. the results show that pre-treatment with rapamycin induced apoptosis in most of caski cells, which appeared as bright, rounded, and detached cells from the dish. discussion irinotecan, which is one of the anti-neoplastic agents with the broadest spectrum, is currently used in the treatment of many types of advanced cancers, but not in the cervical carcinoma. until now, the prognosis of patients with advanced, persistent, or recurrent squamous cell carcinoma of the cervix has been poor.1,2 resistance to chemotherapy is the most frequent obstacle to effective treatment. although the molecular mechanisms of paclitaxel in the mediation of cell death are well characterised, its effects on survival signaling remain unclear. this study determined the sensitivity of human cervical cancer cells to irinotecan (cpt-11) as well as its active form (sn-38) and the results from the mtt assay showed that caski cells had the highest sensitivity, whereas hela cells was the most resistant. furthermore, an examination on whether cpt-11 and sn-38 induced apoptosis in human cervical cancer cells was also performed. to determine the molecular mechanism that mediates the cytotoxic effect of sn-38 in human cervical cancer cells, we performed western blot analysis. in this study, it is demonstrated that sn38 activated caspase-8, caspase-9, caspase-3 and parp in caski cells. these results indicate that in sensitive caski cells the induction of apoptosis by sn-38 might take place through intrinsic and extrinsic pathways. it was recently reported that cpt-11 and sn38 activate a serine/threonin protein kinase akt, which is the downstream target of pi3k.10,12 our results demonstrated that sn-38 inhibits the activation of akt in caski cells, which were more suggestive of a sensitive phenotype, which is shown by the downregulation of phosphorylated akt at serine 473, phosphorylated mtor at ser2448, and phosphorylated p70 s6 kinase at thr389. akt-mtor pathways have the main role in promoting cell survival and are frequently associated with chemoresistance to cytotoxic drugs. the elevation level of phosphorylated akt-mtor pathways was reported to be involved in the mechanism of chemoresistance.13 surprisingly, however, in the hela cells, which were more suggestive of a resistance phenotype, leri septiani, yudi mulyana hidayat, et al. fig. 5 akt-mtor inhibitor enhances chemosensitivity of hela (left) and caski (right) cells to sn-38; cells treated with sn-38 alone, with or without 25 μm ly294002 or 100 μm rapamycin pre-treatment. the cells proliferation inhibition was determined by mtt assay :13–21 20 international journal of integrated health sciences. 2013;1(1) 1. ferlay j, bray f, pisani p, parkin d. globocan 2002. cancer incidence, mortality, and prevalence worldwide. iarc cancer base no.5, version 2.0. lyon: iarc press; 2004. 2. castellague x, de sanjose s, aguado t, louie ks, bruni l, munoz j, et al. hpv and cervical cancer in the world: 2007 report. vaccine [serial on the internet]. 2007 nov [cited 2012 april 5]: 2007;25(supp 3):[about 230]. available from: www.who.int/hpvcentre. 3. thigpen t, vance rb, khansur t. the platinum compounds and paclitaxel in the management of carcinomas of the endometrium and uterine cervix. semin oncol. 1995;22(5 suppl 12):67–75. 4. fiorica jv. the role of topotecan in the treatment of advanced cervical cancer. gynecol oncol. 2003;90(3 pt 2):s16–21. 5. faried ls, faried a, kanuma t, nakazato t, tamura t, kuwano h, et al. inhibition of the mammalian target of rapamycin (mtor) by rapamycin increases chemosensitivity of caski cells to paclitaxel. eur j cancer. 2006;42(7):934–47. 6. faried ls, faried a, kanuma t, sano t, nakazato t, tamamura t, et al. predictive and prognostic role of activated mammalian target of rapamycin in cervical cancer treated with cisplatinbased neoadjuvant chemotherapy. oncol rep. 2006;16(1):57–63. 7. faried ls, faried a, kanuma t, sano t, nakazato t, tamura t, et al. expression of p-mtor in adenocarcinoma of cervix: a potential biomarker and molecular target therapy. molecular carcinogenesis. 2008;47(6):446–57. 8. mccormick f. cancer: survival pathways meet their end. nature. 2004;428(6980):267–9. 9. nguyen dm, chen ga, reddy r, tsai w, schrump wd, cole g jr, et al. potentiation of paclitaxel cytotoxicity in lung and esophageal cancer cells by pharmacologic inhibition of the phosphoinositide 3-kinase/protein kinase b (akt)-mediated signaling pathway. j thorac cardiovasc surg. 2004;127(2):365–75. 10. mabuchi s, ohmichi m, kimura a, hisamoto k, hayakawa j, nishio y, et al. inhibition of phosphorylation of bad and raf-1 by akt sensitizes human ovarian cancer cells to paclitaxel. j biol chem. 2002;277(36):33490–500. 11. fahy bn, schlieman mg, virudachalam s, bold there was no altered activation of akt-mtor pathways to sn-38 treatment. it is tempting to speculate that the akt-mtor inhibitor might have an important role in promoting the cell death of hela cells. to elucidate this phenomenon, we have conducted experiments using ly294002 or rapamycin as the akt-mtor inhibitor. we observed that the inhibition of akt activation using ly294002 significantly enhance the sensitivity to sn-38 in hela cells (p<0.05). furthermore, the inhibition of mtor activation using rapamycin more significantly enhance the sensitivity to sn-38 in hela cells (p<0.01). rapamycin has been found to inhibit serine/threonin kinase mtor by binding to the immunophilin fk506-binding protein 12 (fkbp12). the inhibition of mtor kinase leads to dephosphorylation of its two major downstream signaling components, p70 s6 kinase (s6k1) and 4e-bp1.14 furthermore, we used rapamycin to inhibit akt-mtor activation in both hela and caski cells. as expected, we found that the inhibition of akt-mtor significantly enhanced the sensitivity of hela cells to irinotecan. analysis of the morphology of cells under lightmicroscopy strengthened our findings that the inhibition of akt-mtor effectively increased irinotecan-induced apoptosis. taken together, our results suggest that akt-mtor and its downstream effectors, s6k1, play a role in the survival of hela cells and that the inhibition of mtor signaling may substantially potentiate apoptosis. in summary, the study presented here is the first to directly address the potential of targeting akt-mtor protein in the enhancement of therapeutic efficacy of a topoisomerase i agent, irinotecan, in human cervical cancer cell lines. this information may increase our understanding to apply molecular targeting therapies that may improve the management of cancer with chemotherapy. acknowledgment this work was supported by grants-in-aid for post doctoral research (phk-pkpd sk no. 853/ un6.c/kep/hk/2011) from the indonesian directorate general of higher education (dikti)faculty of medicine, universitas padjadjaran, bandung (fk unpad) for leri septiani. author disclosure statement authors have no conflict of interests. akt–the mammalian target of rapamycin (mtor) pathways inhibition increases cervix cancer cell chemosensitivity to active form of irinotecan (sn-38) :13–21 references international journal of integrated health sciences. 2013;1(1) 21 rj. inhibition of akt abrogates chemotherapyinduced nfkb survival mechanisms: implications for therapy in pancreatic cancer. j am coll surg. 2004;198:591–9. 12. lin hl, lui wy, liu ty, chi cw. reversal of taxol resistance in hepatoma by cyclosporin a: involvement of the pi-3 kinase-akt1 pathway. br j cancer. 2003;88(6):973–80. 13. page c, lin hj, jin y, castle vp, nunez g, huang m, et al. overexpression of akt/akt can modulate chemotherapy-induced apoptosis. anticancer res. 2000;20(1a):407–16. 14. meric f, hunt k. translation initiation in cancer: a novel target for therapy. mol cancer ther. 2002;1(11):971–9. leri septiani, yudi mulyana hidayat, et al. :13–21 vol 9 no 1 2021 (2).indd international journal of integrated health sciences (iijhs) 7 community health perspective. the incidence of dengue infection has increased significantly every year, from 0.05/100.000 in 1968 to 35-40/100.000 in 2013.1 indonesia is a dengue virus (denv) endemic region and has experienced a 700-fold increase in incidence over the past 45 years.2 the hematological disorders known in dengue viral infection are temporary thrombocytopenia and leucopenia. the mechanism of neutropenia during dengue infection could be caused by bone marrow erythropoiesis differences in various clinical phases of dengue fever using immature reticulocyte fraction parameter abstract objective: to determine the mechanism of erythropoiesis that led to anemia using the immature reticulocyte fraction (irf) parameter in various clinical phases of dengue fever. methods: this study was a comparative analytical research using secondary data derived from the dengue-associated endothelial cell dysfunction and thrombocyte activation (decent) research. the study was performed at dr. hasan sadikin hospital bandung, indonesia from march 2011 to march 2012. patients were grouped into fever, critical, recovery, and convalescent phases and a healthy control was established. data collected were analyzed using the kolmogorov-smirnov normality test, followed by friedman test and mann-whitney post hoc test. results: there were 244 subjects participating in this study. the median irf for all subjects was 4.8% with an iqr of 2.4-8.1%. the values of immature reticulocyte fraction in fever-phase, critical-phase, recoveryphase, convalescent-phase and healthy-control were 1.8% (iqr of 0.5– 2.85%), 3.6% (iqr of 1.8–5.0%), 7.05% (iqr of 4.08–11.85%, 7.3% (iqr of 3.95–9.3%) and 4.1% (iqr of 2.2-6.6%), respectively. there was a significant difference in irf between groups (p<0.05). the immature reticulocyte fraction in fever phase was significantly different from the irf in other phases and healthy controls (p<0.05). conclusions: there are changes in erythropoiesis activities detected through the irf in various clinical phases of dengue infection. erythropoiesis suppression occurs mainly during the fever phase and starts to be restored in the critical phase. in the recovery and convalescent phases, the erythropoiesis activities increase. this is the first study describing irf in multiple phases of dengue disease. keywords: diastolic dysfunction, hypertensive heart disease, left ventricular hypertrophy, matrix metalloproteinase-9 received: october 18, 2020 accepted: march 30, 2021 correspondence: putri vidyaniati, department of internal medicine, faculty of medicine universitas padjadjaran-dr. hasan sadikin general hospital bandung, indonesia e-mail: p.vidyaniati@gmail.com original article amaylia oehadian, putri vidyaniati, jeffery malachi candra, uun sumardi, evan susandi, bachti alisjahbana department of internal medicine, faculty of medicine universitas padjadjaran-dr. hasan sadikin general hospital bandung, indonesia pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ ijihs.v9n1.1805 ijihs. 2021;9(1):7–12 introduction dengue infection is the most notable viral infection transmitted by mosquitoes, seen from the medical perspective and also the 8 international journal of integrated health sciences (iijhs) suppression or peripheral destruction. changes in erythropoiesis is also observed in dengue infection, which may be caused by the bone marrow suppression affecting all of the hematopoiesis series. it is hypothesized that a combination of viral infection on hematopoietic progenitor cells, and the viral infection on bone marrow stromal cells and dengue specific t-cell activation, both releasing cytokines that suppress the bone marrow.3,4 erythropoiesis suppression during dengue infection was also shown in the form of aplastic anemia by several case reports. khoj et al reported aplastic anemia occurred after dengue infection and ended with bone marrow transplantation.5 a study by lora et al.6 in dominican republic indicated that anemia related to the severity and mortality of dengue infection, found in 19% of patients and 32% of severe dengue infection with an odd ratio of 3 for mortality.clinical manifestation of dengue infection in thalassemic patients was different, where they experienced the decrease of hemoglobin rather than hemoconcentration.7 changes in erythropoiesis in dengue infection has not been extensively studied. bone marrow examination is an invasive procedure and not recommended in dengue infection. a simple hematological parameter such as immature reticulocyte fraction is expected to be able to indicate how active the erythropoiesis in the bone marrow is.8 immature reticulocyte fraction (irf) is a parameter reflecting the most immature reticulocyte fraction. this irf parameter is simple and can be obtained directly from the automated hematology analyzer sysmex xe-2100 (kobe, japan). the irf reflects erythropoiesis directly and identifies erythropoiesis earlier than reticulocyte and hemoglobin. a study from goncalo in hematological malignancy patients undergoing hematopoietic progenitor cells transplantation showed irf as an earlier indicator for success than neutrophil and thrombocyte with two to four days of difference.8-10 this study is aimed to order to observe whether erythropoiesis is really suppressed during dengue infection. methods this is a cohort study, using data derived from the dengue-associated endothelial cell dysfunction and thrombocyte activation (decent) research in the department of internal medicine which ran from march 2011 to march 2012. the decent study was designed as a cohort study that recruitted patients presenting with clinical signs of symptomatic dengue virus infection (sdvi) to dr. hasan sadikin general hospital in bandung. consecutive patients meeting inclusion criteria were enrolled and followed with daily clinical assessment, blood collection and, in a subgroup; assessment of plasma leakage until day 5 post-admission. temporal changes on laboratory (thrombocytes and endothelial cells) parameters and plasma leakage during the infection were determined. patients were asked to return for follow-up blood collection at >2 weeks (14–20 days) after discharge. inclusion criteria are subject must be 14 years old or above, and clinical suspicion or confirmation of having df or dhf/dss according to who criteria. exclusion criteria are pregnancy, clinical symptoms/signs of or known malignancy, known coagulation disorder, and any chronic diseases such as diabetes mellitus, chronic renal failure, hepatitis, auto-immune disorders, underlying hematological disease, using drugs causing myelosuppression and psychiatric disorders. health research ethics committee of the dr. hasan sadikin general hospital bandung, indonesia approved all legal and ethical aspects of the study (lb.04.01/ads/ec/551/ xii/2014). the statistical test using the friedmann test was used to examine the difference between the phases in dengue patients (4 groups), followed by a post hoc mann whitney test, the result is considered to be significantly different if the p value is <0.05.11 results there were 244 research subjects with a similar ratio of male and female, 56.6% of males and 43.4% of females, with the median age of 24 and iqr (interquartile range) of 14–67. the hemoglobin and hematocrit levels were normally distributed in every phase with a mean of 14.0±1.9 g/dl for hemoglobin and 41.1±5. % for hematocrit. whereas, the leucocyte and thrombocyte levels were not normally distributed, with the leucocyte median of 5.100/mm3 and iqr of 3.800/mm3 to 6.600/mm3, and the thrombocyte median of 78.000 mm3 and iqr of 41.000/mm3 to 177.000/mm3. the baseline characteristics for each phase and control group (table 1). the irf differences in various clinical phases of dengue infection and control group can be seen in table 2 below. the median irf for all the research subjects was 4.8% with erythropoiesis differences in various clinical phases of dengue fever using immature reticulocyte fraction parameter international journal of integrated health sciences (iijhs) 9 an iqr of 2.4–8.1%. the fever-phase group showed a median of 1.8% with an iqr of 0.5–2.85%. the critical-phase group showed a median of 3.6% with an iqr of 1.8–5.0%, while the median for the recovery-phase group was 7.05% with an iqr of 4.08-311.85%. the convalescent-phase group showed a median of 7.3 % with an iqr of 3.95–9.3%, and the healthy-control group showed a median of 4.1% with an iqr of 2.2–6.6%. the result of the statistical test using the friedman test on irf (%) in various fig. boxplot of irf in clinical phases of dengue infection **note : analysis using a post hoc mann whitney test shows significance with p<0.05 table 1 subjects characteristics variable clinical phase of dengue infection healthy control (n=27) p* valuefever phase (n=13) critical phase (n=77) recovery phase (n=74) convalescent phase (n=53) sex (n, %) male 8 (61.5) 46 (59.7) 42 (56.8) 32 (60.4) 10 (37.0) 0.292c female 5 (38.5) 31 (40.3) 32 (43.2) 21 (39.6) 17 (63.0) age (year) median iqr 24 (20–28) 24 (19–33) 23 (19–33) 25 (20–34) 25 (22–31) 0.810b hb (g/dl) mean±sd 13.8±2.4 14.5±2.1 13.7±1.7 13.9±1.7 14.2±1.8 0.076a ht (%) mean±sd 40.0±6.1 42.2±5.8 39.9±4.8 41.5±4.3 42.3±4.7 0.040 a leucocyte (x1000/mm3) median iqr 3.3 (2.4–4.3) 4.0 (3.0–5.6) 5.0 (4.0–6.0) 7.1 (5.7–8.8) 7.0 (6.5–8.0) <0.001 b thrombocyte (x1000/mm3) median iqr 66 (43–89) 36 (19–55) 94 (57–132) 265 (225–313) 293 (250–318) <0.001b *note : analysis using a: anova test, b: friedman test, c: chi square test, significant if p<0.05 amaylia oehadian, putri vidyaniati, et al. 10 international journal of integrated health sciences (iijhs) clinical phases of dengue infection showed a significant difference with a p value of < 0.001. the statistical analysis was then followed by a post hoc mann whitney test to examine the difference between each group, and the difference is considered to be significant if p<0.05 (fig). the irf (%) was lowest in the fever phase, then increased in the critical phase, reaching its highest in the recovery phase, and decreased in the convalescent phase. the irf (%) in the fever phase was significantly different when compared to all the other phases and the healthy control group, with all the p value <0.05. the irf (%) in the critical phase was significantly different when compared to the other phases in dengue infection (p<0.05), but not when compared to the healthy control group (p=0.218). the irf (%) in the recovery phase was significantly different when compared to the fever phase, critical phase, and the healthy control group, but not when compared to the convalescent phase (p=0.629). the irf (%) in the convalescent phase was significantly different when compared to the fever phase, critical phase, and the healthy control group (p<0.05). when compared to irf (%), rbc counts were not significantly different among the phases of clinical dengue and also healthy control group. discussion there were a total of 244 research subjects, with the median age 24 years and iqr (interquartile range) of 14–67 year. the number of male and female subjects was similar. the age and sex of the subjects in this reasearch were consistent with the report from pusat data dan surveilans kementrian kesehatan republik indonesia in 2010 stating that cases of dengue infection in indonesia occurred predominantly in the age group of more than 15 years old with the distribution of the cases nearly the same in both sexes.1 the hemoglobin levels in this research were not significantly different among the groups. a study by la russa concluded that the bone marrow suppression in dengue infection happened rapidly, that even though the bone marrow suppression affected all hematopoietic series, the substantial erythrocyte reserve can compensate for the decrease in erythrocyte production.3 the result of the statistical test on hematocrit levels in every group showed a significant difference between the groups, with the highest hematocrit level in the criticalphase group. the increase in hematocrit levels corresponds to the hemoconcentration and plasma leakage that happens during the critical phase. malavige and malasit suggested that the increase in capillary permeability was caused by the involvement of mediators such as tnf-α, il-2, il-8, and vegf that would disrupt endothelial cells permeability in vitro. the intensity of the immune response and the titer of plasma viremia are the strongest independent factors for plasma leakage.12-13 the leucocyte counts among the groups were significantly different. the results table 2 red blood cell quantity and immature red cell fraction in various phases of dengue infection variable clinical phase of dengue infection healthy control n=27 p* value fever phase (n=13) critical phase (n=77) recovery phase (n=74) convalescent phase (n=53) red blood cells (million/mm3) mean±sd 4.88±0.64 5.03±0.67 4.78±0.55 4.88±0.53 5.02±0.53 0.103a irf (%) median iqr 1.80 0.50–2.85 3.6 1.8–5.0 7.05 4.08–11.85 7.30 3.95–9.30 4.1 2.20–6.60 <0.001 b irf absolute (x1000/mm3) median iqr 93 25–141 165 89–249 331 201–532 351187–447 192 119–321 <0.001 b *note : analysis using a: anova test, b: friedman test, c: chi square test, significant if p<0.05 erythropoiesis differences in various clinical phases of dengue fever using immature reticulocyte fraction parameter international journal of integrated health sciences (iijhs) 11 showed that the lowest leucocyte count was found in the fever-phase group, then increased gradually according to the disease phase. a study by simmons, na-nakorn and larussa stated that leucopenia and neutropenia were found in the early phase of the disease, and a bone marrow biopsy in the early phase of the disease (less than five days of fever) also showed more hypocellularity.3,14 the statistical test on the variable of thrombocyte level showed significant difference between the groups. the thrombocyte level started decreasing in the fever phase, with the lowest level found in the critical phase and started increasing again in the recovery and convalescent phases. the result was consistent with the pathogenesis of dengue viral infection where the suppression of bone marrow happens in the early fever phase and reaches its lowest point in the critical phase.3 the irf in the fever phase was the lowest compared with other phases of dengue infection. the irf started rising in the critical phase and kept rising in the recovery and convalescent phases. the irf in the fever-phase group was significantly different compared with the other groups. the low irf reflected the bone marrow suppression occuring in the fever phase of dengue infection. this result was consistent with the bone marrow biopsy research done by simmons et al showing that the onset of bone marrow suppression could happen not more than 12 hours after the infection. a study by noisakran also showed that the dengue virus can reach the bone marrow compartment in a short period of time, confirming that bone marrow suppression occurs in the fever phase.3,15 the analytical result of irf in the critical phase showed a significant difference compared with other groups, except the healthy-control group. this showed that the recovery of bone marrow suppression has started in the critical phase. a study by noisakran showed that the number of dengue virus rna reached a peak in day 1 to day 3 after the infection and then the number decreased, so the bone marrow suppression by dengue virus rna lessened in the critical phase (day 4 of sickness). noisakran concluded that bone marrow recovery ended in day 10 (afebrile period) even though the blood cell destruction (especially thrombocyte) in the periphery reached its peak (owing to antibody and complement clearance).3,15 a research by clark kb also stated that a bone marrow examination in day 4 to day 8 (critical phase) of sickness showed erythroid hyperplasia with maturation disruption.14 the irf in the recovery-phase group was not significantly different compared to the convalescent-phase group. the irf in the recovery-phase group and convalescentphase group were higher than the criticalphase group and the healthy-control group. this result was similar with a bone marrow examination by clark kb in day 10–14 of sickness that showed erythropoiesis hyperplasia without maturation disruption.14 the analytical result of irf in the criticalphase group and healthy-control group using the mann-whitney test did not show any significant difference. the pathogenesis of dengue infection states that thrombocyte and leucocyte reach the lowest level in the critical phase, but the same thing did not happen to the erythrocyte in this reasearch, represented by the irf. this result was similar to research by clark and noisakran which showed that bone marrow suppression started its recovery in the critical phase, characterized by erythropoiesis hyperplasia with maturation disruption.3,14-15 the increase in erythropoiesis is usually followed by an increase in erythropoietin. the life span of reticulocytes in the circulation also increases for up to three days or even more, due to the release of ‘stress or shift’ reticulocytes from the bone marrow and the acceleration of erythroid differentiation. ‘stress or shift’ reticulocytes from the bone marrow have a large amount of rna in their cells. the population of existing reticulocytes can not only be counted, the rna content according to its maturity level needs to be assessed as well, and this has a significant clinical application in evaluating the erythropoiesis activity.16 the comparison between irf in the criticalphase group and healthy-control group did not show significant difference, which shows that bone marrow of dengue patients in the critical phase is not different from the bone marrow of healthy people in general. this result confirmed that thrombocytopenia occuring in critical phase of dengue infection is caused by cell destruction in the periphery, due to the antibody and complement clearance.3 the previous retrospective study in 26 parvovirus b-19 infection in 119 sickle cell disease patients found that irf is highly specific to detect severe aplasia. increasing irf predicts reticulocyte recovery in reticulocytopenia patients and could have utility in clinical decision making such as whether to transfuse packed red blood cells.17 amaylia oehadian, putri vidyaniati, et al. 12 international journal of integrated health sciences (iijhs) references 1. soepardi j. demam berdarah dengue di indonesia. buletin jendela epidemiologi. 2010;2:1–14. 2. utama ims, lukman n, sukmawati dd, alisjahbana b, alam a, murniati d, et al. dengue viral infection in indonesia: epidemiology, diagnostic challenges, and mutations from an observational cohort study. plos negl trop dis. 2019;13(10):e0007785. 3. vogt mb, lahon a, arya rp, clinton sjl, rico-hesse r. dengue viruses infect human megakaryocytes with probable clinical consequences. plos negl trop dis. 2019;13(11):e0007837. 4. srichaikul t. hematologic changes in dengue hemorrhagic fever. j hematol transfus med. 2014;24(1):47–56. 5. khoj l, baksh r, aslam m, kelta m, albeirouti b, rehman ju. a case of dengue fever-induced severe aplastic anemia salvaged by allogenic bone marrow transplant. j leukemia. 2013;1(3):1–3. 6. lora ajm, fernandez j, morales a, soto y, feris-iglesias j, brito mo. disease severity and mortality caused by dengue in a dominican pediatric population. am j trop med hyg. 2014;90(1):169–72. 7. natesirinilkul r, tantiworawit a, charoenkwan p. clinical course of dengue in patients with thalassaemia. paed int child health. 2013;33(1):32–6. 8. rauf se, khan sa, ali n, afridi nk, haroon m, arslan a. immature reticulocyte fraction and absolute neutrophil count as predictor of hemopoietic recovery in patients with acute lymphoblastic leukemia on remission induction chemotherapy. turk j haematol. 2016;33(2):131–4. 9. yesmin s, sulatana t, roy c, rahman m, ahmed a. immature reticulocyte fraction as a predictor in bone marrow recovery in children with acute lymphoblastic leukaemia on remission induction phase. bangladesh med res counc bull. 2011;37:57–60. 10. goncalo ap, barbosa il, campilho f, campos a, mendes c. predictive value of immature reticulocyte and platelet fractions in hematopoietic recovery of allograft patients. transplantation proceedings. 2011;43:241–3. 11. dahlan ms. statistik untuk kedokteran dan kesehatan. edisi ke-5. jakarta: salemba medika;2013. 12. malavige gn, ogg gs. pathogenesis of vascular leak in dengue virus infection. immunology. 2017;151(3):261–9. 13. cabezas s, bracho g, aloia al, adamson pj, bonder cs, smith jr, et al. dengue virus induces increased activity of the complement alternative pathway in infected cells. j virol. 2018;92(14):e00633–18. 14. clark kb, noisakran s, onlamoon n, hsiao hm, roback j, villinger f, et al. multiploid cd61+ cells are the pre-dominant cell lineage infected during acute dengue virus infection in bone marrow. plos one. 2012;7(12):e52902. 15. noisakran s, onlamoon n, hsiao h-m, clark kb, villinger f, ansari aa, et al. infection of bone marrow cells by dengue virus in vivo. exp hematol. 2012;40(3):250–9. 16. jwyrick-glatzel j, conway-klaassen j. clinical utility of the irf: assessment of erythroid regeneration following parvo b19 infection. clin lab sci. 2002;15(4):208–12. 17. mitrani r, gollomp k, labert mp, obstfeld a. the immature reticulocyte fraction as an aid in the diagnosis and prognosis of parvovirus b19 infection in sickle cell disease. blood 2018;132(suppl1):3678. in conclusion, this study was the first study describing irf in multiple phases of dengue disease. there was an erythropoiesis difference between the phases of dengue infection. bone marrow suppression for erythropoiesis reached the lowest point in the fever phase and started recovering in the critical phase. erythropoiesis in the critical phase was not different from the healthy control. erythropoiesis differences in various clinical phases of dengue fever using immature reticulocyte fraction parameter 42 international journal of integrated health sciences. 2013;1(1) chlamydial infection prevalence in human immunodeficiency virus patients correspondence: feilicia henrica teja, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital jl. pasteur no. 38, bandung, indonesia e-mail: feilicia.t@gmail.com feilicia henrica teja,1 rasmia rowawi,2 asmaja soedarwoto,2 diah puspitosari,1 rini rasianti,1 rahmatdinata,2 tony djajakusumah2 1faculty of medicine, universitas padjdajaran-dr. hasan sadikin general hospital 2department of dermatology and venereology, faculty of medicine, universitas padjajaran-dr. hasan sadikin general hospital :42–8 abstract objective: to determine the prevalence of chlamydial infection in male urethra and female cervix of hiv-positive patients based on pcr assay in teratai clinic, dr. hasan sadikin general hospital bandung. methods: a cross sectional observational study with consecutive sampling method, which was conducted in teratai clinic during the month of july 2012. all participants underwent history taking, physical examination, and pcr assay for c. trachomatis. swab samples were obtained from male urethra and female endocervix. results: eighty one hiv-positive patients, consisted of 48 males and 33 females were included in this study. the pcr examination for c. trachomatis was positive in 14 of 81 subjects (17.3%), with 10 (20.8%) urethral chlamydial infection in 48 males and four (12.1%) cervical chlamydial infection in 33 females. conclusions: the study concluded that the prevalence of chlamydial infection in male urethra and female cervix of hiv-positive patients were 20.8% and 12.1%, respectively. identifying chlamydial infection based on pcr testing should be considered for routine screening test in hiv-positive patients. keywords: chlamydia trachomatis, hiv, prevalence, pcr ijihs. 2013;1(1):42–8 introduction worldwide, chlamydia trachomatis is one of the most common etiologies for sexually transmitted infection.1 in 2009, 92 million new cases of chlamydial infection were reported by world health organization, including 43 million cases in south and south-east asia.2 most of chlamydial infections are asymptomatic (70% in female and 20–30% in male),3 making it difficult to diagnose clinically.1 nowadays, polymerase chain reaction (pcr) method has been approved by the food and drug administration (fda) as the new gold standard for the diagnosis of chlamydial infection.4 in comparison with culture, the pcr method has higher sensitivity in detecting chlamydial infection (90.4% vs 70.8%) which makes it the best method for screening.5 acquired immunodeficiency syndrome (aids) caused by human immunodeficiency virus (hiv) has become a great public health concern.6 in 2009, the united nations joint program on hiv/ aids (unaids) estimated 33.3 million cases of hiv infection with 4.1 million cases in south and south east asia.7 until september 2012, indonesian ministry of health reported 92,251 cases of hiv infections with most of them (50.8%) are heterosexually transmitted.8 the available epidemiological data showed that there is “epidemiological synergy” between sexually transmitted infections (sti) and hiv transmission.9 hiv transmission will increase 10 fold in sti and hiv co-infected patient10 and hivpositive patient has higher risk of being infected with other stis. high risk sexual behaviors and drug abuse are the two main factors causing sti and hiv co-infection.11 both ulcerated and nonulcerated stis may increase the risk of acquiring and transmitting hiv.12 ulcerated stis increase the risk of acquiring hiv 5 to 10 folds, while nonulcerated stis increase the risk 2 to 5 folds.13 received: january 1, 2013 revised: march 7, 2013 accepted: may 21, 2013 original article international journal of integrated health sciences. 2013;1(1) 43 although the impact of non-ulcerated stis is smaller than ulcerated stis, non-ulcerated stis are more commonly found and, therefore, could also increase the hiv epidemic.14 in 2008, it was reported in a study that the prevalence of sti in hiv patients in washington was 8% with 19.4% of them were infected by c. trachomatis.15 meanwhile, in india, the prevalence of chlamydial infection in hiv patients in 2011 was 7%.16 sexually transmitted infections among hivpositive patients usually suggest high risk sexual behaviors and hiv transmission to uninfected population.17 high-risk sexual behavior seems to be continually practiced among hiv-positive population.12 to decrease associated morbidity and prevent the secondary spread of hiv and stis, prevention efforts should focus on hivpositive patients who continue to be engaged in high-risk sexual practices. corrections of high-risk behavior and sti management could decrease the risk of hiv transmission as it is reported that .viral shedding in hiv-positive patients decreased significantly after the stis were treated.18–20 a study on sti intervention with syndromic management in several populations in mwanza has shown a successful reduction of hiv incidence by 38%.21 until currently, there has been no study conducted on the prevalence of chlamydial infection in hiv-positive patients in indonesia. therefore, this study will be the first one that aims to determine the prevalence of chlamydial infection in male urethra and female cervix of hiv-positive patients in indonesia. methods study population this study was conducted at teratai clinic in dr. hasan sadikin general hospital, bandung during the month of july 2012. sexually active hiv-positive patients attending teratai clinic were offered to participate in this study. eighty one hiv-positive participants (48 males and 33 females) were enrolled after written informed consent was obtained. women having her menstrual period were excluded from the study. the hiv serostatus of the study population was determined and confirmed before this study according to the national guideline for hiv/ aids. comprehensive data on characteristics and sexual history of the patients were collected through history taking and medical records. history taking, clinical examination, and specimen collections were conducted in teratai clinic, while the specimen processing was conducted in biology molecular laboratory, microbiology department of health research unit, faculty of medicine, universitas padjadjaran. the study was approved by the ethical committee of faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital bandung. specimen collection method urethral swab of male patients and endocervical swab of female patients were collected using specimen collection kit (roche) and transported to the laboratory in chlamydia transport tubes (roche), on the day of collection. at the laboratory, urethral and endocervical swab specimens for pcr assay were prepared immediately according to the instruction, frozen at -20 °c, and analyzed within 14 days of sampling. specimen processing method the roche amplicor pcr assay was used (the pcr was accomplished with thermocycler). after the amplification, the amplified nucleotide sequences were detected by an enzyme immunoassay and the optical density at wave length 450 nm was measured using a spectrophotometer. a positive result was defined as a reading above 0.5 while the result was considered equivocal when the reading is between 0.2 to 0.5. a negative result was assigned for a reading below 0.2. statistical analysis was performed using spss 17.0 results during the study, 81 hiv-positive participants were screened for chlamydial infection. among the 81 patients tested, 14 chlamydial infections were identified with 10 in male urethra and 4 in cervix. the prevalence of chlamydial infection in this study was 17.4%. meanwhile, the prevalence of urethral chlamydial infection in male was 20.8% and cervical chlamydial infection in female was 12.1%. a list of the 81 hiv-positive participants in this study is presented in table 1. male participants comprised 59.3% of the total participants and 69.1% participants were in 25–35 years old group. half of the participants were high-school graduates, 43.2% were self employed, and 55.6% were married. most of participants who were infected with chlamydia was in the age group of 25–35 years old, with 17.9% of them were chlamydia positive (table 2). c. trachomatis was detected in 20.8% males and 12.1% females. both single and divorced groups were infected with c. trachomatis as many as 27.8%. this number is :42–8 feilicia henrica teja, rasmia rowawi, et al. 44 international journal of integrated health sciences. 2013;1(1) much higher compared to only 8.9% of married group that were infected by c. trachomatis. table 1 baseline characteristics of participants variable n % age (yrs.) <25 5 6 25–35 56 69 >35 20 25 sex male 48 59 female 33 41 education no education 0 0 elementary school 4 5 junior high school 4 5 senior high school 41 51 college/university 32 40 occupation self employed 35 43 civil servant 1 1 working class 20 25 commercial sex worker 1 1 student 1 1 not working 23 28 marital status single 18 22 married 45 56 divorced 18 22 table 3 shows that 17.9% participants with the age of sexual debut of less than 20 years old were infected with chlamydia. this percentage is not significantly different from that of the participants with the age of sexual debut of more than 20 years old. there were 33.3% participants with 6 or more lifetime sexual partners were chlamydia positive, which is higher when it is compared to only 14.3% participants with 1 lifetime sexual partners. condom use behavior was also asked to the participants. almost half of the participants included in the study admitted that they always use condom. despite this statement, there were still 17.5% of the participants who were infected with chlamydia. this means that we have to consider the participants’ statement regarding condom use more carefully to understand the real condom use behavior. table 2 characteristics of participants with positive c. trachomatis variable c. trachomatis total (+) (-) n age (yrs.) <25 1 4 5 25–35 10 46 56 >35 3 17 20 sex male 10 38 48 female 4 29 33 marital status single 5 13 18 married 4 41 45 divorced 5 13 18 discussion the overall prevalence of chlamydial infection in this study was 17.3%, which was higher than any of the previous studies. this is probably due to the fact that sti screening is not routinely performed for hiv-positive patients in teratai clinic. since most of chlamydial infections are asymptomatic, most patients did not receive appropriate treatment and this could result in persistent chlamydial infection. several studies on prevalence of chlamydial infection using nucleic acid amplification test in hiv-positive patients have been conducted with varied results. a literature review of 37 clinical studies reported that chlamydia was the most common sti identified in hiv-positive patients, with 5% median prevalence, ranging from 3 to 10,9%.22 an evaluation on sexually active inuit women living in remote villages in alaska found that 114 (23%) of 493 women had cervical infection with c. trachomatis.23 as shown in this study, it has been repeatedly demonstrated that in sexually active populations in which little diagnostic testing and/ or specific treatment is used, the prevalence of infection may reach surprisingly high levels. this reflects the asymptomatic nature of chlamydial infection and the ability of the infection, when untreated, to persist for months or years.23 phipps reported that the prevalence of asymptomatic chlamydial infection in hiv:42–8 chlamydial infection prevalence in human immunodeficiency virus patients international journal of integrated health sciences. 2013;1(1) 45 feilicia henrica teja, rasmia rowawi, et al. positive patients was 8.3%,24 whereas iwuji reported that the prevalence of chlamydial infection was 2.7% in asymptomatic patients and 19% in symptomatic patients.25 the prevalence of urethral chlamydial infections in male participants in this study was 20.8%. the prevalence was higher than previous studies. several authors reported varying result of c. trachomatis prevalence in hiv-positive men. the prevalence of chlamydial infection in hivpositive men was 7% in india16 and america,15 9% in england,25 and 6% in us army.26 in this study the prevalence was higher in men than women. this is probably due to the fact that most of the patients who came to teratai clinic are male, and compared to women, men have higher tendencies to engage in high risk sexual behavior. the risk for chlamydial infection was twice higher in men than women.26 this is probably due to higher risk sexual practices in men. twenty nine point two percent of men admitted having more than 15 sexual partners, compared to 11.4% in women.27 a research in 11 cities in indonesia showed that 33% of men had sex with female sex worker in the previous year and 20% with nonmarital female partners. this study also showed consistent condom use was low in both sex workers (17%) and other non-marital partners (13%).28 the prevalence of cervical chlamydial infections in female participants in this study was 12.1%. previous studies have reported different results of chlamydial prevalence in hiv-positive women.18,29,30 the cervical chlamydial infection prevalence in women with hiv in 12 european countries was 11.8%.29 research in thailand found that the prevalence of chlamydial infection was 9.7% in hiv-positive woman.30 in an american study, it was reported that the prevalence of chlamydial infection was 3.6% in hiv-positive women.18 chlamydial infection in hiv-positive patients were found as more common in female, but not statistically significant12 which was affirmed by another study showing a correlation between female sex and chlamydial infection in hivpositive patients.31 women have twice the risk of infected with c. trachomatis than men. this is probably because women are anatomically more vulnerable to stis. anatomic considerations make the transmission of stis to women during sexual intercourse a biologically “more efficient” process. during intercourse, semen tends to pool in the vaginal vault causing prolonged contact with cervix epithelium. another factor is cervical ectopy, which is commonly found in prepubertal women caused by hormonal changes.27 norms regarding appropriate sexual behavior are usually more restrictive for women than for men in most societies. these norms not only limit women’s sexual freedom but also restrict their access to information about sexuality. in addition, lack of economic independence may prevent women from leaving a relationship that puts them at risk for acquiring stis. in many countries, wives have little control over marital sexuality and women’s ability to negotiate safer sexual practices, particularly condom use, is practically none.32 in this study, the average age of participants infected with c. trachomatis was 33.6 (34) years old, with a range of 23 to 71 years old. most participants were in the age of 25–35 years old. most authors confirmed young age as a risk factor for chlamydial infection.11,18,31 young age was significantly related to the risk for acquiring sti in hiv-positive patients.11 while another studies showed that an age of <35 years old with hiv positive were at risk of being infected with chlamydia.18,31 one study stated that the prevalence of chlamydial infection in <25, 25– 35, and >35 years old were 6.3%, 4.8%, 1.9%, consecutively.18 several factors that contributed to young age as a risk factor for acquiring chlamydial infection include higher number of sexual partners15 and less concerns about the risk of contracting hiv which lead to inadequate use of protective measures despite knowledge of hiv-positive status.26 onen reported that recent sexual activities decreased with increasing age which may be due to a number of factors, including partner availability, relationship satisfactory, social isolation, bereavement plus perceived ageism, and stigmatization. the presence of physical and medical illness can also impact sexual function and was a factor independently and negatively associated with recent sexual activity.15 contrary to other studies, iwuji found that age is not related with chlamydial infections in hiv-positive men.25 most authors discovered that chlamydial infection is related with sexual behavior. it is also reported that high risk sexual behavior increased the risk for acquiring chlamydial infection significantly.33 contrary to other studies, lee found no significant relation between sexual behavior and sti incident in hiv-positive patients.11 this is probably due to bias. many studies that observed sexual behavior frequently gave inaccurate result, because of recall and social desirability bias.34 sexual histories discussed in this study are age of sexual debut, number of sexual partners, :42–8 46 international journal of integrated health sciences. 2013;1(1) condom use, and sti history. in this study, the average age of sexual debut in chlamydial infected participants is 19 years old, with 7 of 14 participants infected with c. trachomatis having sexual debut at the age of <20 years old. this result is in accordance with the results from a study by ghosh who found the risk for acquiring chlamydial infection in hiv-positive patients increased in patients with age of sexual debut <20 years old.16 young sexual debut, particularly in men is correlated with increased number of sexual partners, while in women this correlates with early marriage and sexual coercion. sexual coercion is related to big age difference, infrequent condom use, and high sti risk.32 in this study, 6/27 of participants claimed not having sexual intercourse in the last month and 4/20 in the last three months infected with c. trachomatis. fifty percent of homosexual and 22% women who admitted not having sexual intercourse in the last three months were infected with sti.34 this may be due to several reasons, including recall and social desirability bias in reporting34 and persistent chlamydial infection transmitted through sexual encounters >3 months before.15 most of chlamydial infections are asymptomatic. therefore, if routine screening was not done, most of infections would not be treated and could persist months or even years.23 most of chlamydial infected participants in this study had ≥6 lifetime sexual partners. several authors found that the number of sexual partners correlated with chlamydial infection.35,36 findings show that increased number of sexual partners would increase the risk for acquiring chlamydial infection35 and ≥6 sexual partners would increased the risk for acquiring chlamydial infection 13.5 times in women and 5.3 times in men.36 most of participants in this study claimed always using condom in every sexual intercourse. seventeen point five percent (7/40) of the participants who claimed that they always use condom were infected by c. trachomatis. several authors reported conflicting results about condom use in chlamydial infection.11,34 one :42–8 table 3 sexual history of participants with positive c. trachomatis variable c. trachomatis total (+) (-) n age of sexual debut (yrs.) <20 7 32 39 ≥20 7 35 42 number of sexual partner in the last month 0 person 6 21 27 1 person 6 42 48 ≥2 persons 2 4 6 number of sexual partner in the last 3 months 0 person 4 16 20 1 person 7 39 46 ≥2 persons 3 12 15 number of lifetime sexual partner 1 person 3 18 21 2–5 persons 4 35 39 ≥6 persons 7 14 21 condom use never 4 16 20 seldom 3 18 21 always 7 33 40 chlamydial infection prevalence in human immunodeficiency virus patients international journal of integrated health sciences. 2013;1(1) 47 study found no correlation between condom use and incident of chlamydial infection11 while another study found that 20% of patients who always use condom were infected with sti.34 most patients infected with chlamydia claimed that they always use condom in the previous week.35 this finding may be influenced by several factors, including recall and reporting bias, inconsistent and inappropriate condom use,33 or latent chlamydial infection.23 contrary to other studies discussed above, van benthem found that inconsistent condom use with casual sex partners increased the risk for acquiring chlamydial infection in hiv-positive patients. hiv-positive women who used condoms in less than 50% of their sexual contacts with casual partners had almost eight-fold higher risk and those who used condoms in 50–99% of the contacts had two-fold higher risk than women who did not have a casual partner.29 based on the discussion in this paper, it is concluded that the prevalence of chlamydial infection in male urethra and female cervix of hiv-positive patients in teratai clinic, dr. hasan sadikin general hospital bandung were 20.8% and 12.1%, consecutively, based on the pcr results. identifying 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between cervicovaginal hiv shedding, sexually transmitted diseases, and immunodupression in female sex worker in abidjan, cote d’ivoire. aids. 1997;11(12):f86–93. 21. mayer kh, venkatesan c. interactions of hiv, other sexually transmitted diseases, and genital tract inflammation facilitating local pathogen transmission and acquisition. am j reprod immunol. 2011;65(3):308–16. 22. kalichman sc, pellowski j, turner c. prevalence of sexually transmitted co-infections in people living with hiv/aids: systematic review with implications for using hiv treatments for prevention. sex transm infect. 2011;87(3):183– 90. 23. toomey ke, rafferty mp, stamm we. unrecognized high prevalence of chlamydia trachomatis cervical infection in an isolated alaskan eskimo population. jama. 1987;258(1):53–6. 24. phipps w, stanley h, kohn r, stansell j, klausner jd. syphilis, chlamydia and gonorrhoea screening in hiv-infected patients in primary care, san fransisco, california, 2003. aids patient care and std. 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dis. 2011;38(6):562–70. 34. hamlyn e, welz t, rebaudengo s, simms h, poulton m. sexual behaviour, condom use and rates od sexually transmitted infections in hiv clinic attendees in south east london. int j std aids. 2009;20(11):757–60. 35. jin x, chan s, ding g, wang h, xu j, wang g, et al. prevalence and risk behaviour for chlamydia trachomatis and neisseria gonorrhoeae infection among female sex worker in an hiv/aids highrisk area. int j std aids. 2011;22(2):80–4. 36. götz hm, van bergen jeam, veldhuijzen ik, broer j, hoebe cjpa, richardus jh. a prediction rule for selective screening of chlamydia trachomatis infection. sex transm infect. 2005;81(1):24–30. :42–8 chlamydial infection prevalence in human immunodeficiency virus patients international journal of integrated health sciences. 2018;6(1) 11 correspondence: sitti juhana dwidarti, physical medicine and rehabilitation polyclinic, cicalengka hospital, kabupaten bandung jl. h. darham, no. 35 cikopo desa tenjolaya, cicalengka, kabupaten bandung, jawa barat, indonesia e-mail: sitti.jdwidarti@yahoo.com effects of core strength training using stable versus unstable surfaces on lower body quality in 8th grade male and female students in a junior high school in bandung sitti juhana dwidarti,1 tertianto prabowo,2 ellyana sungkar2 1physical medicine and rehabilitation clinic, cicalengka hospital, bandung district 2department of physical medicine and rehabilitation, universitas padjadjaran-dr. hasan sadikin general hospital, bandung abstract objective: to investigate the effects of core strength training performed on stable (csts) compared to unstable surfaces (cstu) on physical fitness in school-aged boys and girls. methods: in this study, 72 (36 males, 36 females) untrained healthy subjects (mean age: 14±1 years, age range: 13–15 years) were randomly assigned to a csts group for stable surface (n = 36; 18 males and 18 females) or a cstu group for unstable surface (n = 36; 18 males and 18 females). core strength training performed on stable as compared to unstable surfaces were assessed on preand post-tests. training period lasted 6 weeks (2 sessions/week). the components of physical fitness were assessed using standing long jump test, stand-and-reach test, 20-m sprint test, jumping sideway test, and y balance test. results: this study showed significant results in increased components of physical fitness in both csts and cstu groups (p<0.05). the increase of physical fitness for cstu was better than csts (p<0.05). there were differences of physical fitness between gender in both groups (p<0.05) except for stand-and-reach test (p>0.05). conclusions: core strength training performed on unstable and stable surfaces increases all components of physical fitness in youths. core strength training performed on unstable surface can better improve the physical fitness compared to the stable surface. there were differences of physical fitness between gender in both groups except for stand-and-reach test. keywords: resistance training, physical fitness, gender pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v6n1.1050 ijihs. 2018;6(1):11–21 introduction exercise physiology experts have agreed that exercises performed routinely in a scalable and programmed manner will affect the growth and development of children.1,2 a study in indonesia found that different physical activity levels affect physical fitness in boys and girls aged 13–15 years.3 anatomically, core can be represented as the muscular box with the abdomen in the front, the paraspinals and gluteus at the back, the diaphragm as the roof, and the pelvic floor and hip girdle musculature as the bottom.4,5 functionally, the core can be thought of as the kinetic link that facilitates the transfer of torques and angular momentum between the lower and upper extremities that is of vital importance for sport-specific and everyday activities in different age groups.4,6,–8 the core strength training may have the potentials to improve the core muscle strength as well as health-related (i.e., strength, flexibility) and skill-related (i.e., balance, coordination, speed) components of physical fitness in youth.4,9 original article received: july10, 2017 revised: november 17, 2017 accepted: february 20, 2017 :11–21 12 international journal of integrated health sciences. 2018;6(1) several daily and sports-related activities may occur on relatively unstable surfaces such as walking on cobblestone pavements jumping on uneven natural turf, landing on sand during beach-volleyball, and kicking a ball while being impeded by an opponent. thus, according to the concept of training specificity, training must attempt to closely address the demands of these activities.4 in this regard, behm and colado-sanchez have propagated strength training using unstable surfaces and/or devices to enhance performance and increase the musculoskeletal health in youth and old adults.4,10 in a recent study, a group performing 9-week progressive core strength training on unstable surfaces in community-dwelling old adults (age: 63–80 years) was compared to a passive control group. the intervention group presented significantly improved measures of trunk muscle strength, spinal mobility, functional mobility, and dynamic balance. it was concluded that core strength training conducted on unstable surfaces is a feasible and effective exercise program for attenuating age-related performance decrements among older adults.4,11 the use of unstable surfaces during youth strength training might be particularly beneficial due to the fact that the balance and coordination are not yet fully developed in school-aged children.12 unstable elements in strength training exercises lead to substantial force decrements while at the same time overall muscle activity appears to remain unchanged.13,14 that reduced loads combined with high repetitions still represent a sufficient training stimulus in youth which is why strength training performed on unstable surfaces seems to be well-suited for the promotion of health-related and skill-related components of physical fitness in youth.7,8,14 therefore, this study aimed to investigate the effects of core strength training performed on stable (csts) compared to unstable surfaces (cstu) on physical fitness in schoolaged boys and girls. methods this was randomized controlled study with 72 boys and girls participated in this study. the experimental procedures were explained (fig. 1a). the participants included 8th grade students in smpn 27 bandung, a public junior high school in bandung, who were recruited between september and october 2015. all participants could be classified as physically active according to the paq-c questionnaire. characteristics of the study population were also described (table 1). all participants were eligible for inclusion in this study because the participants had no history of musculoskeletal, neurological or orthopedic disorders that might affect the ability to perform physical fitness tests and core strength training. furthermore, none had previously participated in systematic strength or balance training. parents’ and participants’ informed consents were obtained before the start of the study. ethical approval was given by the health research ethic committee, faculty of medicine, universitas padjadjaran. the two programs were supervised and conducted by 2 physiotherapists. the ratio of participant-to-supervisor was kept small for both intervention groups with 2 supervisors to 9 participants. both programs include circuit training with each instructor supervising 4–5 participants. both training programs lasted 6 weeks and 2 training sessions per week with a total of 12 training sessions. each training session lasted 30 min, starting with warm-up and ending with a cool-down program. both groups mainly conducted the “big 3” exercises (curl-up, side bridge, and quadruped position). a detailed description of the core exercises was portrayed (fig. 1b). during the training weeks 1–2, participants from the csts and cstu groups performed exercises with 3 sets per exercise and 40 s contraction time or 20 repetitions. during training weeks 3–4, the contraction times and repetitions were increased to 45 s or 23 repetitions. during training weeks 5–6, the contraction times and repetitions were increased to 50 s or 25 repetitions. the rest between sets was similar to the respective contraction time (e.g., 40 s during weeks 1–2). an additional 2–3 min rest was given between exercises. prior to preand post-tests, all participants underwent a standardized 5-minutes warmup consisting of skipping exercises. thereafter, physical fitness tests were assessed. standing long jump test has been considered a general index of muscular fitness in youth. subjects were instructed to stand with both feet right behind a starting line and to jump as far as possible. the best trial in terms of maximal distance was from the starting line to the landing point at heel contact. maximum effort sprints were assessed from a stationary start. subjects were instructed to stand with one foot right behind the starting line and to accelerate at maximum effort to the finish line. effects of core strength training using stable versus unstable surfaces on lower body quality in 8th grade male and female students in a junior high school in bandung :11–21 international journal of integrated health sciences. 2018;6(1) 13 sitti juhana dwidarti, tertianto prabowo, et al. :11–21 fig. 1 flow chart of participants (a), description of the two programs (b) a b spinal and pelvic flexibility was then tested using the stand-and-reach test. all subjects were instructed to start the test in a standing position on an elevated platform while putting their feet together. they were then asked to bend over using their maximal range of motion. during the test, knees, arms, and fingers were fully extended. a tape measure was attached to the platform. the jumping sideways test evaluates motor coordination under time pressure. subjects were instructed to jump as many times as possible over a period of 15 s with both legs together back and forth across a strip of wood that was attached to a mat (50 × 100 cm). the y balance test is a dynamic test that requires the subjects to maintain a single leg stance while reaching as far as possible with the contralateral leg in 3 positions: anterior, posteromedial, and posterolateral positions. the distance from the centre of the grid to the touch point was manually measured and 14 international journal of integrated health sciences. 2018;6(1) table 1 participant characteristics characteristic groups total n (%) p value csts cstu sex boy 18 18 36 (50) girl 18 18 36 (50) age (years) 0.280μ m±std 13.36±0.59 13.17±0.38 median 13 13 range 13–15 13–14 total 1410 1218 0.872β body height (cm) m±std 151.64±7.75 151.97±9.62 median 151 150 range 139–176 136–170 0.640μ body mass (kg) m±std 46.17±7.37 46.03±10.93 median 47.5 43,5 range 33–63 31–72 0.589μ total 1355.5 1272.5 17 (23.6) body mass index (kg/m2) 55 (76.4) overweight 9 8 normoweight 27 28 m±std 20.01±2.75 19.70±2.97 median 19.1 19.1 0.839μ range 15.8–25.9 15.6–25.3 67 (93) total ranking 1362 1266 5 (7) paq-c very low (1) 34 33 0.054μ low (2) 2 3 range 1–2 1–2 total 1296 1332 leg length right (cm) 0.054μ m±std 82.58±4.62 85.36±4.71 median 83 84.5 range 73–93 78–100 total ranking 1143 1485 leg length left (cm) m±std 82.58±4.62 85.36±4.71 median 83 84.5 effects of core strength training using stable versus unstable surfaces on lower body quality in 8th grade male and female students in a junior high school in bandung :11–21 international journal of integrated health sciences. 2018;6(1) 15 sitti juhana dwidarti, tertianto prabowo, et al. range 73–93 78–100 total 1143 1485 note: m = mean; std = standard deviation; t test (β); mann whitney test (μ) :11–21 documented after each reach. a composite score was measured by using the formula of (cs) = [(maximum anterior reach distance + maximum posteromedial reach distance + maximum posterolateral reach distance)/(leg length × 3)] × 100. initially, descriptive statistics were done for all variables, followed by the normality test using the saphiro-wilks test. hypothesis test of physical fitness before and after core exercise for both kinds of surfaces. if there are differences between the gender in the physical fitness test the hypothesis then separated for girl and for boy. analysis of the data used in this study is the t-test to compare the difference between two average data that were independent and normally distributed between the core exercise group on stable and unstable surfaces. for data that were not normally distributed, mann whitney test was used. to tests the difference in the average value before and after practice, the t-test was used when the data was normally distributed while the wilcoxon match pair test was used for data that were not normally distributed. the significance level was set at p≤0.05. results the results for all outcome variables in pre and post-intervention results for all outcome variables are described (table 2). in this study, no statistically significant differences were found in the baseline between the 2 intervention groups (p>0.05). a significant difference (p<0.05) for all variables was found in the preand post-intervention for both groups. all variables of physical fitness tests on cstu group were higher than those of the csts group after intervention and for 20-m sprint test, the cstu group was faster than csts group. no significant difference in characteristics was found between boys and girls participated in this study (p>0.05) for all variables, except that the participants in csts group significantly different (p<0.05) for the length of the right leg and left leg length were described (table 3). there were significant differences in almost all physical fitness test results between boys and girls in the csts group both in preand post-intervention (p<0.05), except for standand-reach test (p>0.05) (table 4). there were also significant differences in almost all physical fitness test results between boys and girls in the cstu group both in preand post-intervention (p<0.05), except for stand-and-reach test in pre-intervention results (p>0.05) (table 5). discussion the main findings of this study are that (1) performance in physical fitness tests (i.e., standing long jump test, 20-m sprint test, stand-and-reach test, jumping sideways test, y balance test) was significantly improved in both intervention groups over the 6-week training period; (2) cstu as compared to csts has additional effects on physical fitness; (3) there are differences in physical fitness between gender except for the stand-andreach test. the present results are in accordance with the literatures regarding the effects of core strength training on tms and physical fitness in youth. following 6 weeks of core strength training (e.g., low plank obliques, push-up jacks) conducted during physical education classes (1 session/week), allen et al. 9 have found significant performance enhancement (f=0.27–0.69) in 5 different trunk muscle endurance tests (i.e., parallel roman chair dynamic back extension, prone plank, lateral plank, dynamic curl-up, static curl-up) in healthy untrained children with a mean age of 11 years. in a randomized controlled trial, hoshikawa et al.15 investigated the effects of a combined core strength training (e.g., prone and side bridging on elbows) and soccer training (e.g., technical drills, interval runs) as compared to soccer training only (e.g., technical drills, interval runs) in male outfield soccer players aged 12–13 years. both intervention groups exercised for 6 months. the combined training group conducted 4 core strength training and 5 soccer training sessions per week, while the soccer training group performed 5 soccer training sessions per week only. before and after training, subjects were tested for their hip flexors/extensors 16 international journal of integrated health sciences. 2018;6(1) table 2 effects of the two programs on measures of physical fitness variables csts cstu p-value cstscstu (post) pre post p value pre post p value yborl (%) 0,000μ* 0.000μ* 0.007μ* mean±std 90.45±15.43 97.55±15.56 91.00±10.42 102.44±11.45 median 90.27 98.18 91.69 102.18 range 60.21–131.2 65.10–139.19 63.46–125 73.58 total 1073 1555 yboll (%) 0.000μ* 0.000μ* 0.010μ* mean±std 89.89±15.21 97.53±15.55 90.95±10.43 102.12±11.34 median 90.3 98.15 91.69 101.74 range 60.26–131.34 65.05 63.45–125.88 73.55–140.99 total 1085 1543 sar (cm) 0.000μ* 0.000β* 0.005μ* mean±std 95.58±4.93 98.94±5.48 95.64±3.71 102.42±3.78 median 94.5 97.5 96 102 range 86–104 90–110 90–105 95–110 total 1064.5 1563.5 20-m sprint (s) 0.000μ* 0.000β* 0.007μ* mean±std 4.95±0.58 4.13±0.54 4.97±0.732 3.78±0.59 median 5 4.28 4.97 4.02 range 3.43–6.03 2.99–4.91 3.31–6.96 2.39–5.19 total 1552.5 1075.5 js 0.000 μ* 0.000μ* 0.000μ* mean±std 23.03±2.75 32.00±3.14 22.97±2.92 37.11±4.77 median 22 32 22.5 36 range 20–30 25–39 18–36 30–56 total 859.5 1768.5 slj (cm) 0.000μ* 0.000β* 0.021μ* mean±std 173.03±29.58 186.22±29.62 172.56±33.51 204.17±31.82 median 180 193 175 205 range 119–224 132–238 112–236 147–268 total 1230 1519.5 note: significance value based on the p-value <0,05 (*). notes: yborl= y balance on right leg, yboll= y balance on left leg, sar= stand-and-reach, js= jumping sideways, slj= standing long jump effects of core strength training using stable versus unstable surfaces on lower body quality in 8th grade male and female students in a junior high school in bandung :11–21 international journal of integrated health sciences. 2018;6(1) 17 table 3 characteristics of boys and girls variables csts cstu boys girls p value boys girls p value age (years) total 296 370 0.242μ 315 351 0.569μ body height (cm) mean 153.28 150 0.359β 153.72 150.22 0.327β body mass (kg) total 345.5 320.5 0.692β 344.5 321.5 0.716μ body mass index total 330 336 0.924μ 325 341 0.800μ paq-c total 351 315 0.570μ 360 306 0.390μ leg length right (cm) total 261 405 0.023β* 330.5 335.5 0.937μ leg length left (cm) total 261 405 0.023β* 330.5 335.5 0.937μ note. significance value based on the p-value <0,05 (*) sitti juhana dwidarti, tertianto prabowo, et al. :11–21 strength, cross-sectional area of trunk muscles, and athletic performance. with respect to hip strength and physical fitness measures, both intervention groups showed significant but similar performance enhancements in peak torque of the hip flexors (combined training group: f=0.45, isolated training group: f=0.74) and in 15-m sprint test (combined training group: f = .56, isolated training group: f=0.40) following training. however, the relative change in peak hip extensor torque was found to be significantly higher in the combined (f=1.26) as compared to the isolated (f = 0.68) training group. furthermore, significant gains in squatting (combined training group: f=0.33, soccer training group: f=0.06) and countermovement jump heights (combined training group: f=0.62, soccer training group: f=0.12) were observed in the combined training group only.15 our findings extend the existing results in as much as we additionally observed improvements in the measures for the flexibility, coordination, and balance following core strength training in youths. with reference to the literature and our own findings, core strength training appears to be a well-suited conditioning program to promote the healthand skill-related physical fitness in youth. 9,10 the positive effects of core strength training on the physical performance of the lower extremities can most likely be explained by the specific role of the trunk as a linkage between upper and lower extremities. during every-day or sports-related rotational torso movements, trunk muscles generate torque along diagonal proximal to distal path to enhance the extremity force production. 9,10 konin et al. referred to this as serape (or “shawllike”) effect. scientific evidence was provided by kibler who was able to show that 51% of total kinetic energy and 54% of total force are developed in the hip and trunk muscles during the tennis serve of professional athletes.6,16 young et al.17 stated that the muscles belonging to the global system (e.g., erector spinae, rectus abdominis, internal/external obliques, latissimus dorsi) primarily generate torque in a serape-like manner during the rotational movements (e.g., throwing). moreover, the trunk acts as a kinetic link that facilitates the transfer of torques and angular momenta between upper and lower extremities during the execution of whole body movements as part of sports and occupational skills, fitness activities, and activities of daily living. there is evidence for this hypothesis which indicates that during normal human movement, trunk muscle activations (e.g., musculus transversus abdominis) are organized well ahead (110 ms) in anticipation of movement or perturbation to balance in healthy young adults.17 hodges and richardson argued that this anticipatory muscle activation helps stiffening the spine to provide a foundation for the functional movements. therefore, muscles that belong to the local system (e.g., lumbar multifidus, transversus abdominis) appear to primarily provide proximal stability of the trunk for distal mobility of the limbs. it should be kept in mind, our core strength training protocols comprising multiple sets with many repetitions or long contraction times may have specifically induced adaptive processes in muscles of the local system (deep muscles) since those 18 international journal of integrated health sciences. 2018;6(1) effects of the two programs on measures of physical fitness in boys and girls in csts group table 4 variables csts pre post boy girl p value boy girl p value yborl (%) 0.007μ* 0.009μ* mean±std 96.46±17.75 84.44±9.94 103.17±18.21 91.93±9.99 median 94.23 86.42 98.68 94.06 range 60.21–131.20 60.23–97.21 65.10–139.19 66.83–104.47 total 418 248 416 250 yboll (%) 0.027μ* mean±std 95.31±17.72 84.47±10.00 103.16±18.21 91.91±9.98 0.009μ* median 91.53 86.38 98.6 94.23 range 60.26–131.34 60.48–97.49 65.05–139.85 66.67–104.88 total 403 263 416 250 sar (cm) 0.548μ 0.537μ mean±std 96.17±5.95 95.00±3.71 99.61±6.38 98.28±4.48 median 95.5 94 98 96.5 range 86–104 90–102 90.00–110.00 93–107 total 314 352.5 313.5 20-m sprint (s) 0.000μ* 0.000μ* mean±std 4.63±0.60 5.28±0.33 3.76±0.47 4.50±0.30 median 4.74 5.25 3.73 4.52 range 3.43–5.75 4.65–6.03 2.99–4.55 3.69–4.91 total 216.5 449.5 199.5 466.5 js 0.045μ* 0.001μ* mean±std 24.17±3.29 21.89±1.41 33.67±3.01 30.33±2.30 median 23.5 22 34 30.5 range 20.0–30.0 20–24 28.00–39.00 25–35 total 396.5 269.5 435 231 slj (cm) 0.000μ* 0.000μ* mean±std 195.44±16.84 150.61±21.29 208.83±16.30 163.61±21.41 median 199 153 212.5 165 range 157.00–224.00 119–186 170–238 132–199 total 477 189 480 186 notes: yborl= y balance on right leg, yboll= y balance on left leg, sar= stand-and-reach, js= jumping sideways, slj= standing long jump effects of core strength training using stable versus unstable surfaces on lower body quality in 8th grade male and female students in a junior high school in bandung :11–21 international journal of integrated health sciences. 2018;6(1) 19 effects of the two programs on measures of physical fitness in boys and girls in cstu group table 5 variables csts pre post boy girl p value boy girl p value yborl (%) 0.000μ* 0.001μ* mean±std 96.59±8.55 85.42±9.19 108.25±10.39 96.69±9.52 median 96.09 87.43 107.1 99.81 range 85.89–125.83 63.46–96.39 89.84–140.95 73.58–106.40 total 452 214 441 225 yboll (%) 0.000μ* 0.001μ* mean±std 96.54±8.53 85.36±9.21 107.66±10.51 96.59±9.46 median 95.99 87.53 107.16 99.65 range 85.43–125.88 63.45–96.73 89.64–140.99 73.55–106.83 total 453.5 212.5 434 232 sar (cm) 0.353β 0.046β* mean±std 96.22±3.42 95.06±3.99 103.67±3.34 101.17±3.87 median 96.5 95 104 101 range 91–104 90–105 98–110 95–110 total 20-m sprint (s) 0.000β* 0.000β * mean±std 4.56±0.63 5.38±0.55 3.35±0.45 4.21±0.37 median 4.71 5.4 3.38 4.15 range 3.31–5.67 4.45–6.96 2.39–4.07 3.50–5.19 total js 0.035β* 0.000μ* mean±std 24.00±3.58 21.94±1.59 39.56±5.44 34.67±2.17 median 23.5 22 38 35 range 20–36 18–25 35–56 30–38 total 399.5 266.5 453.5 212.5 slj (cm) 0.021μ* 0.002β* mean±std 185.22±32.95 159.89±29.77 220.06±29.13 188.28±26.49 median 194.5 155 225 190 range 112–228 118–236 163–268 147–242 total 409.5 256.5 notes: yborl= y balance on right leg, yboll= y balance on left leg, sar= stand-and-reach, js= jumping sideways, slj= standing long jump sitti juhana dwidarti, tertianto prabowo, et al. :11–21 20 international journal of integrated health sciences. 2018;6(1) references 1. klentrou p. influence of exercise and training on critical stages of bone growth and development. pediatr exerc sci. 2016;28(2):178–86. 2. chahar ps. physiological basis of growth and development among children and adolescent in relation to physical activity. am j sports sci med. 2014;2(5):17–22. 3. peltzer k, pengpid s. leisure time physical inactivity and sedentary behaviour and lifestyle correlates among students aged 13–15 in the association of southeast asian nations (asean) member states, 2007–2013. int j environ res public health. 2016;13(2):217–8. 4. granacher u, schellbach j, klein k, prieske effects of core strength training using stable versus unstable surfaces on lower body quality in 8th grade male and female students in a junior high school in bandung :11–21 muscles are characterized by a relatively high proportion of type i (slow-twitch) fibers.10 interestingly, the performance during physical fitness tests significantly improved although postural positions during training and testing conditions were different (i.e., horizontal lying during training vs. upright standing during testing). despite this difference, transfer effects were noticed from the core strength exercises performed in vertical directions while lying in horizontal positions to proxies of physical fitness predominately performed in vertical position.18 future studies have to elucidate whether core strength training programs conducted in an upright standing position (e.g., romanian deadlift) may be even more effective in enhancing components of physical fitness in adolescents. by integrating unstable surfaces in our cstu exercise protocol, we specifically aimed at activating the deep muscles that are responsible for trunk stability. nevertheless, our findings indicate that cstu as compared to csts has only limited additional effects (i.e., stand-andreach test) on physical fitness. in this regard, the previous study compared trunk muscle activities (which inludes rectus abdominis, external or internal oblique, transversus abdominis, erector spinae) during resistance exercises (i.e., back squat, dead lift, overhead press, curl lifts) performed on stable ground versus the bosu balance trainer in trained young men.18 the main finding of this study was that no significant differences were found in activity across all examined muscles and lifts when performing the resistance exercises on the bosu balance trainer as compared to stable ground. the authors concluded that the tested resistance exercises can be performed on stable ground without losing the potential trunk muscle training benefits. our findings regarding the limited additional effects of cstu as compared to csts are in line with the results of this cross-sectional study. to the authors’ knowledge, there is no other study available in the literature that compared the effects of csts versus cstu on measures of physical fitness. therefore, we will discuss a study that investigated the effects of lower extremity strength training using stable versus unstable surfaces on athletic performance in healthy, trained individuals. both intervention groups performed the same exercises (e.g., squats, deadlifts, lunges, single-leg squats) at identical training volumes but on different training surfaces (stable vs. unstable). following 10 weeks of training, findings were inconsistent in as much as the unstable group showed significantly greater improvements than the stable group in sprint time (stable group: f=1.33, unstable group: f=1.50) and in agility performance (stable group: f=0.97, unstable group: f=1.60). in terms of drop jump power performance, both groups showed similar performance enhancements (stable group: f =0.26, unstable group: f=0.11).19 seryozha et al.20 have conducted research in children aged 6–18 years. the result of the study stated that the standing long jump test results can be affected by age, bmi, and gender. boys showed better results in the standing long jump test than girls and this defferences becomes greater with age. there is improved performance in several tests on boys than girls aged 13–15 in dashes (speed) and the shuttle runs (agility and speed); vertical, standing long jumps and distance throw (coordination and explosive strength); flexed arm hang and sit-ups (local muscular endurance); beam walk and flamingo stand (balance).20 in summary, the results of this study have illustrated that the core strength training is a training modality that produces marked increases in health (i.e., strength, flexibility) and skill-related (i.e., balance, coordination, speed) components of physical fitness in healthy male and female youths. cstu can enhance physical fitness better than csts. there are differences in physical fitness between gender except for stand-and-reach test. international journal of integrated health sciences. 2018;6(1) 21 o, baeyens jp, muehlbauer t. effects of core strength training using stable versus unstable surfaces on physical fitness in adolescents: a randomized controlled trial. bmc sports sci med rehabil. 2014;6(1):40–1. 5. akuthota v, ferreiro a, moore t, fredericson m. core stability exercise principles. curr sports med rep. 2008;7(1):39–44. 6. kibler wb, press j, sciascia a. the role of core stability in athletic function. sports med. 2006;36(3):189–98. 7. nesser tw, huxel kc, tincher jl, okada t: the relationship between core stability and performance in division i football players. j strength cond res. 2008;22(6):1750–4. 8. okada t, huxel kc, nesser tw. relationship between core stability, functional movement, and performance. j strength cond res. 2011;25(1):252–61. 9. allen ba, hannon jc, burns rd, williams sm. effect of a core conditioning intervention on tests of trunk muscular endurance in school-aged children. j strength cond res. 2014;28(7):2063–70. 10. behm dg, colado jc, sanchez jc. instability resistance training across the exercise continuum. sports health. 2013;5(6):500–3. 11. granacher u, lacroix a, muehlbauer t, roettger k, gollhofer a. effects of core instability strength training on trunk muscle strength, spinal mobility, dynamic balance and functional mobility in older adults. gerontology. 2013;59(2):105–13. 12. behm dg, muehlbauer t, kibele a, granacher u. effects of strength training using unstable surfaces on strength, power and balance performance across the lifespan: a systematic review and meta-analysis. sports med. 2015;45(10):1645–69. 13. anderson kg, behm dg: maintenance of emg activity and loss of force output with instability. j strength cond res. 2004;18(3):637–40. 14. filipa a, byrnes r, paterno mv, myer gd, hewett te. neuromuscular training improves performance on the star excursion balance test in young female athletes. j orthop sports phys ther. 2010;40(9):551–8. 15. hoshikawa y, lida t, muramatsu m, ii n, nakajima y, chumank k, et al. effects of stabilization training of trunk muscularity and physical performance in youth soccer players. j strength cond res. 2013,27;(11)3142–9. 16. konin jg, beil n, werner g. facilitating the serape effect to enhance extremity force production. athlet ther today. 2003;8(2):54– 6. 17. young jl, herring sa, press jm, casazza ba. the influence of the spine on the shoulder in the throwing athlete. j back musculosceletal rehabil. 1996;7(1):5–17. 18. granacher u, schellbach j, klein k, prieske o, baeyens jp, muehlbauer t. effects of core strength training using stable versus unstable surfaces on physical fitness in adolescents: a randomized controlled trial. bmc sports sci med rehabil. [serial on the internet]. 2014 nov [cited 2017 jan 22];6(40):[about 11p.]. available from: https://www.ncbi.nlm.nih. gov/pmc/articles/pmc4290805/. 19. cressey em, west ca, tiberio dp, kraemer wj, maresh cm. the effects of ten weeks of lower body unstable surface training on markers of athletic performance. j strength cond res. 2007;21(2):561–7. 20. seryozha g, zivkovic v, velickovska la, naumovski m. first normative reference of standing long jump indicates gender difference in lower muscular strength of macedonian school children. health. 2014;6(1):99–106. sitti juhana dwidarti, tertianto prabowo, et al. :11–21 author’s data title of manuscript: to asses knowledge and practice on menstrual hygiene and reproductive tract infection in school going adolescent girls in doda district of j & k enter the names of everyone who contributed to your manuscript by entering all required information. author(s) 1st author first name: suresh last name: kotwal academic degree(s): m.b.b.s, m.d affiliation: assistant professor, government medical college, doda, j & k. address: email: drsureshkotwal@gmail.com 2nd author first name: garima last name: charak academic degree(s): m.b.b.s, m.d affiliation: assistant professor, government medical college, doda, j & k. address: phone: email: dr.garimacharak.com *3rd author first name: sudeep last name: kumar academic degree(s): m.sc. & ph.d. in medical biochemistry affiliation: associate professor, muzaffarnagar medical college, muzaffarnagar, u.p. address: b-09, faculty residences, mmc campus, muzaffarnagar. phone: +91-9719774253 email: sudeepty@gmail.com 4th author first name: sudhanshu last name: shekhar academic degree(s): m.sc. in medical physiology affiliation: academic degree(s): m.b.b.s, m.d affiliation: tutor, government medical college, doda, j & k. address: email: shekharsudhanshu09@gmail.com 5th author first name: kasturi last name: gupta academic degree(s): m.b.b.s, m.d academic degree(s): m.b.b.s, m.d affiliation: assistant professor, government medical college, doda, j & k. address: phone: email: klgupta77@gmail.com international journal of integrated health sciences. 2019;7(1) 39 original article :39–47 pattern of bacteria, antibiotic uses and sensitivity among ear, nose, and throat infectious disease in otolaryngology ward in tertiary hospital that from 429 cases, the incidences of throat disease was 239 cases (55.97%), nose disease 163 cases (38.17%) and ear disease 25 cases (5.85%). from this study it can be concluded that the 10 most common ent diseases, namely (1) acute pharyngitis, (2) epistaxis, (3) tonsillitis, (4) nasal polyps, (5) nasopharyngeal cancer, (6) benign neoplasm of connective or soft tissue of head, face, and neck, (7) laryngeal tumors, (8) tonsilopharyngitis, (9) laryngitis, and (10) sinusitis.4 five of the 10 diseases are infectious diseases. the ears, nose and throat are anatomically close and histologically similar so the infection in these structures is usually caused by the same bacteria. several studies have shown that 5 main causes of ent diseases are staphylococcus aureus, abstract objective: to provide an overview of antibiotic use, bacterial patterns and sensitivity to antibiotics in the otolaryngology ward. methods: this was a cross-sectional study, with total sampling method from medical record data of otolaryngology inpatients that use antibiotics for the period of january 1, 2016–june 30, 2016. exclusion criteria are incomplete patient medical records and chemotherapy or radiotherapy patients. the variables studied were antibiotic use, bacterial pattern and susceptibility. results: among 276 subjects included in the inclusion criteria, the most widely used are single antibiotics (98.9%), generally used for 2–3 days (73.9%), via intravenous lines (92%), and with indications as empirical+prophylaxis (77.5%). commonly used antibiotics are cefazolin (42.51%), ceftriaxone (29.54%), and cefotaxime (20.76%). the most common bacteria were e. coli (36.36%) and the most sensitive types of antibiotics were meropenem, amikacin, and tigecyclin, while the most resistant antibiotics were ampicillin, ciprofloxacin, and ceftriaxone. conclusions: the majority of antibiotics used in the otolaryngology treatment room are cefazolin as prophylaxis. e. coli were the most found culture results and the most sensitive types of antibiotics, namely meropenem, amikacin, and tigecyclin, while the most resistant antibiotics were ampicillin, ciprofloxacin, and ceftriaxone. keywords: antibiotics, antibiotic sensitivity, bacterial pattern, ears, nose, throat pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v7n1.1545 ijihs. 2019;7(1):39–47 received: january 30, 2019 revised: march 17, 2019 accepted: march 22, 2019 yolla sri agustina,1 imam megantara,2 arif dermawan3 1faculty of medicine, universitas padjadjaran 2departement of biomedical sciences, faculty of medicine, universitas padjadjaran 3departement of otolaryngology-head and neck surgery, faculty of medicine, universitas padjadjaran dr. hasan sadikin general hospital bandung introduction ear, nose, and throat (ent) disease have morbidity that can have a major effect on the life of the sufferer.1 for example, in patients with hearing loss can experience difficulties in communication.2 choking or swallowing foreign objects if not handled properly and quickly can cause death due to asphyxia.3 a study that conducted at department of ent, dr. r. d. kandou hospital, manado, indonesia about inpatient patterns in 2010-2012 showed correspondence: yolla sri agustina, faculty of medicine, universitas padjadjaran jl. raya bandung-sumedang km 21 jatinangor, indonesia e-mail: yollasa08@gmail.com 40 international journal of integrated health sciences. 2019;7(1) streptococcus sp., pseudomonas aeruginosa, proteus sp., and escherichia coli.5,6,7 antibiotics are one of the drugs that are often used in ent wards, as a causative therapy in infectious diseases and prophylaxis in surgical procedures. in its use, administration of antibiotics must be in accordance with the diagnosis of the disease and the cause of the microorganism. various studies state that around 40–62% of antibiotics are used inappropriately, for example it is used for diseases that do not actually require antibiotics. a previous study on the quality of antibiotic use in various parts of the hospital found 30% to 80% not based on indications. this can cause antibiotic resistance. antibiotic resistance can have an impact on morbidity and mortality, it also has a negative economic and social impact.8 antibiotic resistance has now become a common problem in indonesia such as in bandung, indonesia. based on a study on bacterial pattern and their sensitivity in patients with the ventilator-associated pneumonia (vap) in the intensive care unit (icu) of dr. hasan sadikin general hospital, bandung, the most common bacteria that cause vap are acinetobacter baumannii (41.9%), pseudomonas aeruginosa (18.6%), and klebsiella pneumoniae (16.9%). from the results of the sensitivity test, the sensitivity of the bacteria to some antibiotics decreased and some showed signs of resistance.9 the purpose of this study was to provide an overview of antibiotic use, bacterial patterns and their sensitivity to antibiotics in ent wards. the results of this study are expected to be a reference for the use of antibiotics for the antimicrobial prevention program (ppra) at dr. hasan sadikin general hospital, bandung. methods this was a descriptive study and conducted from august to november 2018. the study used a cross-sectional design using secondary data from the inpatient medical record installation at the dr. hasan sadikin general hospital, bandung in the period january– june 2016. inclusion criteria in this study were all medical record data of patients using antibiotics in ent wards at dr. hasan sadikin general hospital, bandung. exclusion criteria were incomplete or missing medical records and patients with the primary diagnosis of chemotherapy or radiotherapy. data was taken from the patient’s medical record by the total sampling method, and was processed using computerized software. data collection were carried out after obtaining ethical approval number 429/ un6.kep/ec/2018 issued by the health research ethics committee of the faculty of medicine, universitas padjadjaran and obtaining a research permit issued by dr. hasan sadikin general hospital, bandung (no. lb.02.01/x.2.2.1/14556/2018). selected data would be analyzed and presented in table form to illustrate patterns of antibiotic use, bacterial patterns and their sensitivity to antibiotics. results based on the list of names given by medical record installations, the number of ent inpatients in the study period was 493 people, but there were 139 data that were not stored in the medical record installation, leaving the remaining 370 data. among 370 data, 7 data were excluded because patients did not use antibiotics, and 71 data were excluded because patients had a primary diagnosis of chemotherapy and radiotherapy, leaving 276 data that met the inclusion criteria and were used in this study. the characteristics of ent inpatients could be seen (table 1). it revealed that the most frequently found age groups were adults with 160 patients (58%). pattern of bacteria, antibiotic uses and sensitivity among ent infectious disease in otolaryngology ward tertiary hospital table 1 characteristic n % age <1 years old (infant) 0 0 1–<10 years old (child) 22 8 10–<20 years old (teenager) 53 19.2 20–60 years old (adult) 160 58 >60 years old (elderly) 41 14.9 gender male 161 58.3 female 115 41.7 length of stay 1-3 days 90 32.6 4-6 days 120 43.4 ≥ 7 days 66 24 characteristics of ent inpatients (n=276) :39–47 international journal of integrated health sciences. 2019;7(1) 41 yolla sri agustina, imam megantara, et al. table 2 icd diagnosis n % c01 malignant neoplasm of base of tongue 2 0.72 c02 malignant neoplasm of other & unspecified parts of tongue 3 1.09 c05 malignant neoplasm of palate 1 0.36 c07 malignant neoplasm of parotid gland 1 0.36 c09 malignant neoplasm of tonsil 3 1.09 c11 malignant neoplasm of nasopharynx 7 2.54 c13 malignant neoplasm of hypopharynx 1 0.36 c30 malignant neoplasm of nasal cavity & middle ear 10 3.62 c31 malignant neoplasm of accessory sinuses 18 6.52 c32 malignant neoplasm of larynx 14 5.07 c44 other unspecified malignant neoplasm of skin 4 1.45 c73 malignant neoplasm of thyroid gland 3 1.09 c85 other specified & unspecified types of nonhodgkin lymphoma 1 0.36 d04 carcinoma in situ of skin 1 0.36 d10 benign neoplasm of mouth and pharynx 8 2.9 d11 benign neoplasm of major salivary gland 4 1.45 d14 benign neoplasm of middle ear & respiratory system 7 2.54 d18 hemangioma & lymphangioma 3 1.09 d21 other benign neoplasm of connective & other soft tissue 1 0.36 d34 benign neoplasm of thyroid gland 4 1.45 d36 benign neoplasm of other & unspecified sites 1 0.36 d37 neoplasm of uncertain behaviour of oral and digestive organs 2 0.72 e04 other non-toxic goiter 1 0.36 g47 sleep disorders 9 3.26 h61 other disorders of external ear 1 0.36 h66 suppurative and unspecified otitis media 6 2.17 h70 mastoiditis & related conditions 37 13.41 h71 cholesteatoma of middle ear 2 0.72 h72 perforation of tympanic membrane 18 6.52 h90 conductive and sensorineural hearing loss 2 0.72 j04 acute laryngitis and tracheitis 1 0.36 j05 acute obstructive laryngitis (croup) & epiglottitis 1 0.36 j30 vasomotor and allergic rhinitis 2 0.72 j31 chronic rhinitis, nasopharyngitis & pharyngitis 3 1.09 j32 chronic sinusitis 15 5.43 j33 nasal polyp 3 1.09 j34 other & unspecified disorders of nose and nasal sinuses 4 1.45 j35 chronic disease of tonsils and adenoids 6 2.17 j36 peritonsillar abscess 2 0.72 j39 other diseases of upper respiratory tract 3 1.09 j44 other chronic obstructive pulmonary diseases 4 1.45 j80 acute respiratory distress syndrome 2 0.72 j96 respiratory failure 2 0.72 j98 other respiratory disorders 7 2.54 k07 dentofacial anomalies 2 0.72 k09 cysts of oral region 1 0.36 diagnosis of ent inpatients (n=276) :39–47 42 international journal of integrated health sciences. 2019;7(1) pattern of bacteria, antibiotic uses and sensitivity among ent infectious disease in otolaryngology ward tertiary hospital the majority of sex distribution is male with 161 patients (58.3%). the length of stay was mainly for 4–6 days which was 120 data (43.4%). based on results on the study, 276 patients were divided into 61 types of diseases (table 2). mastoiditis is the disease with the highest number of patients, 37 patients (13.41%), followed by malignant neoplasm of paranasal sinus 18 patients (6.52%), tympanic membrane perforation 18 patients (6.52%), chronic sinusitis 15 patients (5.43%), and malignant neoplasm of larynx 14 patients (5.07%). the results showed that 273 patients (98.9%) used a single antibiotic (table 3). antibiotic changes were only carried out in 8 patients (2.9%). the antibiotics generally used for 2–3 days with 204 data (73.9%). antibiotics were widely used with empirical + prophylactic indications as shown in 214 patients (77.5%). majority of the antibiotics was administered via intravenous lines with 254 data (92%) among 276 patients given antibiotics, there were 13 types of single antibiotics and combinations given (table 4). among13 types of antibiotics, there were 10 single antibiotics (99.4%) and 3 combinations of 2 antibiotics (0.06%). the most widely administered type of single antibiotic was cefazolin as many as 213 data (42.51%), ceftriaxone 148 data (29.54%), and cefotaxime 104 data (20.76%). the combination antibiotic used was a combination of ceftriaxone with cefotaxime, cotrimoxazole, and levofloxacin with the use of each 1 datum (0.2%). the use of antibiotics can be described more specifically based on the type of therapy which includes prophylaxis, empirical, and k12 stomatitis and related lesions 5 1.81 l02 cutaneous abscess, furuncle & carbuncle 1 0.36 l92 granulomatous disorders of skin & subcutaneous tissue 1 0.36 m79 other soft tissue disorders 1 0.36 m95 other acquired deformities of the musculoskeletal system & connective tissue 3 1.09 q17 other congenital malformation of ear 2 0.72 q18 other congenital malformations of face & neck 1 0.36 s01 open wound of head 1 0.36 s02 fracture of skull and facial bones 8 2.9 s08 traumatic amputation of parts of head 1 0.36 s11 open wound of neck 1 0.36 t16 foreign body in ear 1 0.36 t17 foreign body in respiratory tract 3 1.09 t18 foreign body in alimentary tract 13 4.71 t81 complications of procedures 1 0.36 total 276 100 table 3 characteristic n % drug prescribed single antibiotic 273 98.9 combination of 2 antibiotic 3 1.1 combination of >2 antibiotic 0 0 antibiotic change yes 8 2.9 no 268 97.1 duration 1 day 15 5.4 2-3 days 204 73.9 4-7 days 36 13 > 7 days 21 7.6 indication definitive 7 2.5 empirical 42 15.5 prophylaxis 11 4 prophylaxis + definitive 2 0.7 prophylaxis + empiric 214 77.5 route intravenous 254 92 peroral 6 2.2 intravenous + peroral 16 5.8 characteristic of antibiotic use (n=276) :39–47 international journal of integrated health sciences. 2019;7(1) 43 definitive therapy. the most commonly used antibiotic as prophylaxis was cefazolin with 210 data (92.51%), as empirical therapy was ceftriaxone with 139 data (52.65%), and as definitive therapy was ceftriaxone with 5 data (50%). both culture and bacterial sensitivity tests were rarely carried out, only 13 patients (4.7%) were tested for culture and 7 patients (2.5%) were tested for bacterial sensitivity. of the 13 patients, 21 samples were tested, 10 of which had no bacterial growth. there were 6 types of bacteria found, e. coli with 4 data (36.36%), s. epidermidis 1 data (9.09%), k. pneumoniae 1 data (9.09%), pseudomonas aeruginosa 1 data (9.09%), a. baumannii 2 data (18.18%), and aeromonas salmonicida 2 data (18.18%). the results of the bacterial sensitivity test can be seen (table 6). e. coli is only sensitive to 7 of the 17 types of antibiotics tested. s. epidermidis is sensitive to 15 of the 19 types of antibiotics tested except chloramphenicol, ciprofloxacin, cotrimoxazole, and levofloxacin. k. pneumoniae is still sensitive to 13 of the 15 types of antibiotics tested. p. aeruginosa is still sensitive to amikacin, ceftazidime, ciprofloxacin, gentamicin, meropenem, and piperacillin/tazobactam. a. baumannii is only sensitive to amikacin, meropenem, piperacillin/tazobactam, tigecyclin, and trimethoprim-sulfamethoxazole. e. coli, p. aeruginosa, and a. baumannii isolates were resistant to cefazolin which was the most common antibiotic used in this study. resistance was found to be higher against ampicillin, ciprofloxacin, and ceftriaxone and was rarely found in meropenem, amikacin, and tigecyclin. table 4 distribution of antibiotic use antibiotics definitive empiric prophylaxis total n % n % n % n % single antibiotic amoxicillin 1 10 1 0.38 1 0.44 3 0.6 cefadroxil 0 0 0 0 1 0.44 1 0.2 cefazolin 1 10 2 0.76 210 92.51 213 42.51 cefixime 0 0 7 2.65 1 0.44 8 1.6 cefotaxime 0 0 94 35.61 10 4.41 104 20.76 ceftriaxone 5 50 139 52.65 4 1.76 148 29.54 ciprofloxacin 0 0 12 4.55 0 0 12 2.4 co amoxiclav 0 0 2 0.76 0 0 2 0.4 levofloxacin 1 10 4 1.52 0 0 5 1 ofloxacin 0 0 2 0.76 0 0 2 0.4 combination of antibiotic ceftriaxone + cefotaxime 0 0 1 0.38 0 0 1 0.2 ceftriaxone + cotrimoxazole 1 10 0 0 0 0 1 0.2 ceftriaxone + levofloxacin 1 10 0 0 0 0 1 0.2 total 10 100 264 100 227 100 501 100 yolla sri agustina, imam megantara, et al. table 5 test n % culture test tested 13 4.7 not tested 263 95.3 bacterial sensitivity test tested 7 2.5 not tested 269 97.5 overview of culture tests and bacterial sensitivity tests (n=276) :39–47 44 international journal of integrated health sciences. 2019;7(1) table 6 culture test and bacterial sensitivity tests results (n=9) organism (number of samples) antibiotics susceptible intermediate resistant n % n % n % e. coli (4) amikacin 4 100 0 0 0 0 ampicillin 0 0 0 0 2 50 ampicillin/sulbactam 0 0 0 0 4 100 aztreonam 0 0 0 0 4 100 cefazolin 0 0 0 0 4 100 cefepime 0 0 0 0 4 100 ceftazidime 0 0 0 0 4 100 ceftriaxone 0 0 0 0 4 100 ciprofloxacin 0 0 0 0 4 100 cotrimoxazol 1 25 0 0 1 25 ertapenem 2 50 0 0 0 0 gentamicin 0 0 0 0 4 100 meropenem 3 75 0 0 0 0 nitrofurantoin 1 25 1 25 0 0 piperacillin/tazobactam 0 0 0 0 4 100 tigecyclin 4 100 0 0 0 0 tmp-smx* 1 25 0 0 1 25 s. epidermidis (1) amoxicillin/clavulanate 1 100 0 0 0 0 ampicillin/sulbactam 1 100 0 0 0 0 cefadroxil 1 100 0 0 0 0 cefazolin 1 100 0 0 0 0 cefepime 1 100 0 0 0 0 cefixime 1 100 0 0 0 0 cefoperazon 1 100 0 0 0 0 cefotaxime 1 100 0 0 0 0 cefoxitin 1 100 0 0 0 0 ceftazidime 1 100 0 0 0 0 ceftriaxone 1 100 0 0 0 0 cefuroxime 1 100 0 0 0 0 chloramphenicol 0 0 0 0 1 100 ciprofloxacin 0 0 0 0 1 100 cotrimoxazol 0 0 0 0 1 100 erythromycin 1 100 0 0 0 0 gentamicin 1 100 0 0 0 0 levofloxacin 0 0 0 0 1 100 meropenem 1 100 0 0 0 0 k. pneumonia (1) amikacin 1 100 0 0 0 0 pattern of bacteria, antibiotic uses and sensitivity among ent infectious disease in otolaryngology ward tertiary hospital :39–47 international journal of integrated health sciences. 2019;7(1) 45 ampicillin 0 0 0 0 1 100 ampicillin/sulbactam 1 100 0 0 0 0 aztreonam 1 100 0 0 0 0 cefazolin 1 100 0 0 0 0 cefepime 1 100 0 0 0 0 ceftazidime 1 100 0 0 0 0 ceftriaxone 1 100 0 0 0 0 ciprofloxacin 1 100 0 0 0 0 ertapenem 1 100 0 0 0 0 gentamicin 1 100 0 0 0 0 meropenem 1 100 0 0 0 0 nitrofurantoin 0 0 1 100 0 0 tigecyclin 1 100 0 0 0 0 tmp-smx* 1 100 0 0 0 0 p. aeruginosa (1) amikacin 1 100 0 0 0 0 ampicillin 0 0 0 0 1 100 ampicillin/sulbactam 0 0 0 0 1 100 aztreonam 0 0 1 100 0 0 cefazolin 0 0 0 0 1 100 cefepime 0 0 1 100 0 0 ceftazidime 1 100 0 0 0 0 ceftriaxone 0 0 0 0 1 100 ciprofloxacin 1 100 0 0 0 0 gentamicin 1 100 0 0 0 0 meropenem 1 100 0 0 0 0 nitrofurantoin 0 0 0 0 1 100 piperacillin/tazobactam 1 100 0 0 0 0 tigecyclin 0 0 0 0 1 100 tmp-smx* 0 0 0 0 1 100 a. amikacin 2 100 0 0 0 0 baumannii (2) ampicillin 0 0 0 0 2 100 ampicillin/sulbactam 0 0 0 0 2 100 aztreonam 0 0 0 0 2 100 cefazolin 0 0 0 0 2 100 cefepime 0 0 0 0 2 100 ceftazidime 0 0 0 0 2 100 ciprofloxacin 0 0 0 0 2 100 gentamicin 0 0 0 0 2 100 meropenem 1 50 0 0 1 50 nitrofurantoin 0 0 0 0 2 100 piperacillin/tazobactam 1 50 0 0 1 50 yolla sri agustina, imam megantara, et al. :39–47 46 international journal of integrated health sciences. 2019;7(1) discussion the results of this study show that 273 patients (98.9%) were given a single antibiotic. antibiotic changes were only carried out in 8 patients (2.9%). the majority of the duration of antibiotic use is 2–3 days with 204 data (73.9%). the indications of giving antibiotics mostly are for prophylactic and empirical purpose with 214 patients (77.5%). the most widely used route is 254 intravenous data (92%). there are 13 types of single antibiotics and combinations given, 10 single antibiotics (99.4%) and 3 combinations of 2 antibiotics (0.06%). the most common type used as single antibiotic was cefazolin with 213 data (42.51%). the combination antibiotic used is a combination of ceftriaxone with cefotaxime, cotrimoxazole, and levofloxacin with the use of each 1 data (0.2%). a similar study in india stated that 1797 patients (69.11%) were given a single antibiotic, 398 patients (49.56%) were given a combination of 2 antibiotics. the most frequently used routes are as many as 2699 data (74.99%). the most commonly prescribed antibiotics are beta-lactam groups of 2724 data (75.68%).10 the results of this study are in line with the study because single antibiotics were given more to patients and the antibiotics prescribed by the majority were beta-lactam groups. the possibility of the beta-lactam group is used because of its broad spectrum making it effective for curing infectious diseases.11 in both studies there were differences in the route of administration of the most commonly used antibiotics. this might happen because in the study the number of outpatients was more than inpatients, so that the oral route was more preferred. in this study, the most commonly used antibiotic as prophylaxis was cefazolin with 210 data (92.51%), as empirical therapy was ceftriaxone with 139 data (52.65%), and as definitive therapy was ceftriaxone with 5 data (50%). other similar studies in the united states stated that antibiotics used as prophylaxis were 2230 data of ampicillin/ sulbactam (25.2%), clindamycin 1431 data (14.2%), cefazolin + metronidazole 1220 data (13.8%), cefazolin 835 data (9.5%), and others 3210 data (35.3%).12 there are differences in prophylactic antibiotics used in both studies, but not significant because the majority use beta-lactam groups. based on the regulation of the ministery of health of the republic of indonesia number 2406/ menkes/per/xii/2011 about general guidelines for the use of antibiotics, i and ii generation cephalosporins are recommended for use as surgical prophylaxis.8 according to the american academy of otolaryngologyhead and neck surgery, definitive therapy recommendations are adjusted to diseasecausing organisms, but the most recommended are penicillin groups. recommendations for empirical therapy may vary depends on the disease, but the majority recommended are beta-lactam groups (penicillins and cephalosporins).13 this indicates that the results of this study are in line with therapeutic recommendations because the majority of those used are ceftriaxone which is a betalactam group. in this study the culture and sensitivity tests were only carried out in a few patients, namely 13 patients (4.7%) who were tested for culture and 7 patients (2.5%) who were tested for bacterial sensitivity. there are 6 types of bacteria found, i.e., e. coli, s. epidermidis, k. pneumoniae, p. aeruginosa, a.baumannii, and aeromonas salmonicida. similar study conducted in germany states that there are 6 types of bacteria found, i.e. s. pneumoniae, moraxella catarrhalis, haemophillus influenzae, s. pyogenes, s. aureus, and p. aeruginosa. there is a type of bacteria found in both studies which is p. aeruginosa. the results of this study indicate that p. aeruginosa is still sensitive to amikacin, ceftazidime, ciprofloxacin, gentamicin, meropenem, and piperacillin/tazobactam. the results of this study were lower than the results of the study in germany because in the study p. aeruginosa was still sensitive to all the antibiotics tested. this can occur because research in germany uses more samples so the results are more diverse.14 this study had several limitations such as many medical record data that were not stored in the mci and the incomplete information contained in the medical record regarding the use of antibiotics, especially for indications of its use. resistance had also begun to emerge so that the use of antibiotics must be re-evaluated to prevent such resistance from increasing. suggestions for overcoming the limitations of this study are the writing of a complete medical record and conducting further research related to the pattern of antibiotic use, bacterial patterns and its sensitivity in the ent department so that the results of the study can be discussed further. in summary, there are several types of antibiotic used in ent department and also pattern of bacteria and its sensitivity. bacterial resistance can be prevented by giving proper antibiotics to the patients. pattern of bacteria, antibiotic uses and sensitivity among ent infectious disease in otolaryngology ward tertiary hospital :39–47 international journal of integrated health sciences. 2019;7(1) 47 1. farooq m, ghani s, hussain s. prevalence of ear, nose & throat diseases and adequacy of ent training among general physicians. int j pathol. 2016;14(3):113–5. 2. lemke u, scherpiet s. oral communication in individuals with hearing impairment— considerations regarding attentional, cognitive and social resources. front psychol [serial on the internet]. 2015 jul [cited 2018 aug 20];6(2015):[about 7p.]. available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ pmc4505078/. 3. kim ia, shapiro n, bhattacharyya n. the national cost burden of bronchial foreign body aspiration in children. laryngoscope. 2015;125(5):1221–4. 4. kandouw ce, palandeng oi, mengko s. pola penderita rawat inap t.h.t.k.l di blu rsup prof. dr. r. d. kandou manado periode januari 2010– desember 2012. j e-clinic. 2015;3(3):869–76. 5. saputra a, qamariah n, muthmainah n. pola kepekaan isolat bakteri aerob pada rhinosinusitis kronis tinjauan terhadap penderita dewasa di poliklinik t.h.t rsud ulin banjarmasin dan rsud moch. ansari saleh banjarmasin periode juni–agustus tahun 2016. berkala kedokteran. 2017;13(1):105–12. 6. waworuntu oa, palandeng oei, bernadus jbb. pola kuman penyebab otitis eksterna serta kepekaannya terhadap antibiotik di poliklinik t.h.t.k.l rsup prof. dr. r. d. kandou manado periode mei–oktober 2016. kedokt klin. 2017;1(3):56–64. 7. sembiring ro, porotu’o j, waworuntu o. identifikasi bakteri dan uji kepekaan antibiotik pada penderita tonsilitis di poliklinik t.h.t.k.l blu rsup prof. dr. r. d. kandou manado. e-biomedik. 2013;1(2):1053–7. 8. kementrian kesehatan republik indonesia. peraturan menteri kesehatan republik indonesia nomor 2406/menkes/per/ xii/2011 tentang pedoman umum penggunaan antibiotik. jakarta: kementrian kesehatan republik indonesia indonesia; 2011. 9. jundi af, kss nd, mulyana y. pattern of bacteria and its susceptibility of ventilator-associated pneumonia patients in icu at dr. hasan sadikin general hospital, bandung. althea med j. 2016;2(3):195–9. 10. khan fa, nizamuddin s, salman mt. patterns of prescription of antimicrobial agents in the department of otorhinolaryngology in a tertiary care teaching hospital. african j pharm pharmacol. 2011;5(14):1732–8. 11. katzung bg, masters sb, trevor aj. basic & clinical pharmacology. 12th ed. mcgraw-hill medical; 2012. 789-838 p. 12. langerman a, thisted r, hohmann s, howell m. antibiotic and duration of perioperative prophylaxis predicts surgical site infection in head and neck surgery. otolaryngol head neck surg. 2016;154(6):1054–63. 13. fairbanks dnf. pocket guide to antimicrobial therapy in otolaryngology. washington d.c.: american academy of otolaryngology, head & neck surgery foundation, inc.; 2007. 14. olzowy b, kresken m, havel m, hafner d, körber-irrgang b. antimicrobial susceptibility of bacterial isolates from patients presenting with ear, nose and throat (ent) infections in the german community healthcare setting. eur j clin microbiol infect dis. 2017;36(9):1685– 90. references yolla sri agustina, imam megantara, et al. :39–47 table 1. chemotherapy regimens on turkish pediatric oncology group neuroblastoma 2003.1 chemotherapy drugs schedule induction cycles a3 – 1 cycle 15-19 july 2019 vincristine 1.5 mg/m2/day, d 1 and 5, iv push ifosfamide 1.8 g/m2/day, d 1-5, iv continue infusion dacarbazine 250 mg/m2/day, d 1-5, iv 30 min adriamycin 20 mg/m2/day, d 1-3, iv over 4 h a5 – 1 cycle 15-19 august 2019 cisplatin 30 mg/m2/day, d 1-5, iv continue infusion cyclophosphamide 300 mg/m2/day, d 1-5, iv over 1 h etoposide 150 mg/m2/day, d 4 and 5, iv 1 h figure 1. (a-f): coronal and axial views of patients pet in 2014 (a and b); restaging pet showing progressive disease three years later (c). clinical views after the first radiotherapy, revealing a left-sided neck mass sized 12 cm x 10 cm x 10 cm (d), after two cycles of temozolomide, sized 10 cm x 8 cm x 8cm (e), and after debulking surgery (f). figure 2 (a-f). hematoxylin and eosin (h&e) staining from tissue biopsy (a)100x, (b)200x, and (c)400x, showing clusters and packets of small neoplastic cells forming homer-wright rosettes, with fairly dispersed chromatin, inconspicuous nucleoli and indistinct cytoplasm. cd56 (d), chromogranin (e), and synaptophysin (f) ihc stains are positive in this tissue. class : public health 5(5) lecturer : tri bayu purnama, s.k.m., m.med.sci leader class : yusuf hanafi lubis (0801193363) subject : management and analysis of data standard of quesionaire of pengaruh faktor bullying terhadap stress, depression and anxiety disorder questions: 1. karakteristik responden nama responden : jenis kelamin : 1. laki-laki 2. perempuan usia responden : tahun pekerjaan responden : tingkat pendidikan responden : 1. slta 2. diploma 3. strata lama waktu tidur : jam 1. < jam 10 malam 2. > jam 10 malam 2. tingkat bullying responden: pertanyaan respon (skala) 1. sampai saat ini (apakah anda di bully secara fisik?) 1. tidak pernah 2. jarang 3. kadang 4. sering 2. sampai saat ini (apakah anda pernah mendapat-kan bullyan seperti body shaming?) 1. tidak pernah 2. jarang 3. kadang 4. sering 3. sampai saat ini (apakah anda pernah mendapat-kan bullying seperti diskriminasi kecerdasan?) 1. tidak pernah 2. jarang 3. kadang 4. sering 4. sampai saat ini (apakah anda pernah mendapat-kan diskriminasi oleh orang dilingkungan anda?) 1. tidak pernah 2. jarang 3. kadang 4. sering 5. sampai saat ini (apakah anda pernah mendapat-kan bullyan dari segi finansial anda?) 1. tidak pernah 2. jarang 3. kadang 4. sering 6. sampai saat ini (apakah anda pernah mendapat-kan bullyan dari segi pekerjaan orang tua anda?) 1. tidak pernah 2. jarang 3. kadang 4. sering 7. sampai saat ini (apakah anda pernah mendapat-kan bullyan dari segi ras, warna kulit anda?) 1. tidak pernah 2. jarang 3. kadang 4. sering 8. sampai saat ini (apakah anda pernah mendapat-kan bullyan dari segi agama dan kepercayaan anda?) 1. tidak pernah 2. jarang 3. kadang 4. sering 9. sampai saat ini (apakah anda pernah mendapat-kan bullyan dari segi perkataan kasar yaitu dengan menyebutkan nama hewan, serta mengibaratkan anda seperti hewan tersebut?) 1. tidak pernah 2. jarang 3. kadang 4. sering 10. sampai saat ini (apakah anda pernah mendapat-kan bullyan secara kekerasan fisik?) 1. tidak pernah 2. jarang 3. kadang 4. sering 11. sampai saat ini (apakah anda pernah mendapat-kan bullyan secara melecehkan anda?) 1. tidak pernah 2. jarang 3. kadang 4. sering 12. sampai saat ini (apakah anda pernah mendapat-kan bullyan dari segi professi anda?) 1. tidak pernah 2. jarang 3. kadang 4. sering 3. tingat kecemasan responden pertanyaan respon 1. sampai saat ini (apakah anda merasa cemas serta berfikir keras saat anda ingin tidur setelah mendapatkan bullyan?) 1. tidak pernah 2. jarang 3. kadang 4. sering 2. sampai saat ini (apakah anda merasa takut serta berfikir keras saat anda mendapatkan bullyan?) 1. tidak pernah 2. jarang 3. kadang 4. sering 3. sampai saat ini (apakah anda merasa diri anda tidak berguna saat anda mendapatkan bullyan?) 1. tidak pernah 2. jarang 3. kadang 4. sering 4. sampai saat ini (apakah anda pernah berfikir untuk melakukan suicidal (bunuh diri) saat anda mendapatkan bullyan?) 1. tidak pernah 2. jarang 3. kadang 4. sering 5. sampai saat ini (apakah anda pernah menangis sejadi – jadinya dan menarik rambut anda serta menyalahkan diri sendiri ketika mendapatkan bullyan?) 1. tidak pernah 2. jarang 3. kadang 4. sering 6. sampai saat ini (apakah anda merasa bahwa anda sendirian dan tidak ada seorangpun yang peduli kepada anda?) 1. tidak pernah 2. jarang 3. kadang 4. sering 7. sampai saat ini (apakah anda merasa bahwa anda semakin anti sosial karena anda sering mendapatkan bullyan?) 1. tidak pernah 2. jarang 3. kadang 4. sering 8. sampai saat ini (apakah anda sulit percaya kepada orang lain karena anda sering mendapatkan bullyan?) 1. tidak pernah 2. jarang 3. kadang 4. sering 9. sampai saat ini (apakah anda sering gugup ketika berbicara kepada orang lain karena anda sering mendapatkan bullyan?) 1. tidak pernah 2. jarang 3. kadang 4. sering 10. sampai saat ini (apakah anda sering menggigit kuku anda ketika mendapatkan aksi bullyan yang sama seperti sebelumnya?) 1. tidak pernah 2. jarang 3. kadang 4. sering 26 international journal of integrated health sciences. 2019;7(1) original article correspondence: fifi akwarini, department of internal medicine, santosa hospital bandung central jl. kebonjati no.38, bandung, indonesia e-mail: f2akwarini@gmail.com triple negative breast cancer characteristics based on basal-like and non-basal-like subtypes abstract objective: to observe triple negative breast cancer (tnbc) characteristics in three hospitals located in bandung based on basal-like (bl) and non-basallike (nbl) subtypes. methods: this was a cross-sectional study which used descriptive categorical data from medical records and paraffin blocks of tnbc patients treated in dr. hasan sadikin general hospital, bandung; borromeus hospital; and santosa hospital bandung central in the period of january 1, 2012–december 31, 2016. the subjects of the study were 57 tnbc patients. the data collected in the study based on medical records were age, tumor size, histopathological images, severity, and immunohistochemical data. the paraffin blocks of the patients based on the completed medicals records were investigated through examinations of immunohistochemichal cytokeratin (ck) 5/6 expressions and epidermal growth factor receptor (egfr). results: prevalence of tnbc were 82.5% of basal-like subjects and 17.5% of non-basal-like subjects. among the tnbc subjects, median age of each subtype was 50 years of basal-like subtype and 45 years of non-basal-like subtype. both subtypes were mostly found in the subjects who aged >40 years. higher histopathological grade was discovered in both subtypes. the therapy mostly carried out to the subjects was adjuvant chemotherapy. majority of basal-like subtype subjects were still alive and had longer survival rate and lower incidences of deaths when compared to the non-basal-like subtype. conclusions: in tnbc, the basal-like subjects showed greater median age, lower severity stage, and longer survival rate than the non-basal-like subjects. there was no histopathology grade between both subtypes. keywords: basal-like and non-basal-like subtypes, breast cancer, characteristics, triple negative pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v7n1.1570 ijihs. 2019;7(1):26–33 fifi akwarini,1 trinugroho heri fadjari,2 bethy suryawathy hernowo3 1 department of internal medicine, santosa hospital bandung central 2division of medical oncology hematology, department of internal medicine, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital, bandung 2department of pathology anatomy, faculty of medicine, universitas padjadjaran-dr. hasan sadikin hospital, bandung introduction breast cancer (bc) is considered as one of many cancers mostly found in indonesian people. incidences of females with bc in indonesia were approximately 12/100,000 females while in united states 92/100,000 females suffering from bc leading to a large number of mortalities of 27/100.000 or 18% deaths. however, a study stated that in male population there may be 1% of them.1 breast cancer is characteristically a heterogenous disease consisting of numerous subtypes with distinctive disease history. it represents large spectrum based on clinical, pathological, and mulecular images and has various prognostic and therapy implications. recently, central focus related to bc is based on molecular clasification.2 received: february 6, 2019 revised: march 15, 2019 accepted: march 21, 2019 :26–33 international journal of integrated health sciences. 2019;7(1) 27 molecular classification of breast cancer can be distinguished into several groups based on gene expression images by using modest technology of microarray deoxyribonucleic acid (dna). from gene expression images, bc is classified into 5 subtypes: luminal a, luminal b, triple negative or basal-like, normal like, and excessive human epidermal growth factor receptor 2 (her2).3 the molecular subtypes are commonly associated with survival rate: luminal a tumor has favourable prognosis and normallike tumor has moderate prognosis. luminal b, her2 positive, and basal-like tumors are commonly associated with shorter relapsefree survival (rfs) and overall survival (os). the molecular subtypes can predict therapy response; her2 positive and basallike tumors show greater complete response (cr) after neoadjuvant chemotherapy when compared to luminal and normal-like tumors.4 triple negative is also known as breast cancer subtypes with estrogen receptor (er) negative, progresteron receptor (pr) negative, and lower her2. the triple negative breast cancer (tnbc) has represented 15–12% of newly bc incidences. it has epidemiological, hispathological, and clinical image which are different from other bc subtypes.5 it also shows characteristics of more agressive clinical behavior, particular metastasis images, and worse prognosis. the focus is on the tnbc is due to the limitations of the therapy. until today, the only therapy for tnbc patients is systemic chemotherapy.6 in many incidences the tnbc is categorized as basal-like bc. on the contrary, several studies revealed that tnbc and basal-like bc are biologically different tumors. there were many tnbc incidences which could not be identified as basal-like (nearly 80%) and there were basal-like tumors which could not be determined as tnbc.7 a previous study in 2013 stated that tnbc is a wide subject with various categories so that additional subclassifications is then required.8 gene expression profile (gep) examination divides tnbc into seven molecular subtypes i.e. basal-like 1, basal-like 2, mesenchymal (m), mesenchymal stem cell like (msl), immunomodulatory (im), luminal androgen receptor (ar)-like (lar), and unknown classification (unc).9 the classification based on these subtypes can cause distinctive response during the therapy perceived by each patient.10 the gene expression profile examination becomes a non-practical medical tool which is regularly conducted in the hospitals due to the expensive costs. pratt et al.8 suggested that a study on tnbc can be conducted by classifying the subjects based on basal-like tumor versus non-basal-like tumor. neilsen et al.6 proposed immunohistochemical examination can be used to substitute gep examination in order to identify bc of basal-like subtype which has the same definition as cdna microarray examinations such as erher-2 and ck 5/6 or egfr+. immunohistochemical examination can illustrate sensitivity (76%) and specifity (100%) in identifying bc of basallike subtype such as fenotype basal obtained through gep examination. the tnbc of basal-like subtype has the same morphological characteristics as the higher histopathology grade. the majority incidences found in tnbc of basal-like subtype were commonly associated with disease history, locoregional disease development, and more agressive metastasis in the first 5 year. this condition can cause shorter survival rate and higher mortalities. a previous study revealed that tnbc of basal-like subtype becomes an independent marker so that bc can have worse prognosis as commonly found in cancer with or without lymph node metastasis. tumor with basal-like fenotipe is a worse predictor for the patients such as histopathology grade 3, tumor without lymph node metastasis, and the patients with severe metastasis. the basal-like tumor determines that metastasis can occur in the brain and lung but metastasis rarely occurs in the bone or liver.7 there is another finding of various biological terms from tnbc which is applicable to spread knowledge regarding to effective systemical therapy, provide newly medication including immune checkpoint inhibitor, poly (adp ribose) polymerase (parp) inhibitor, cytotoxic therapy including platinum chemoherapy medication, phosphatidylinositol-3 kinase pathway inhibitors, and androgen receptor (ar) inhibitor.10 therefore, this study aimed to investigate tnbc characteristics based on basal-like and nonbasal-like subtypes in three hospitals in bandung. methods target population in this study was tnbc patients but the population included was carcinoma tnbc patients who had been treated in the three hospitals in bandung, west java, indonesia such as dr. hasan sadikin general hospital, bandung, borromeus hospital, and :26–33 fifi akwarini, trinugroho heri fadjari, et al. 28 international journal of integrated health sciences. 2019;7(1) triple negative breast cancer characteristics based on basal-like and non-basal-like subtypes santosa hospital bandung central, indonesia in the period of january 1 2012–december 31 2016. the study used cross-sectional method with descriptive categorical design. samples were the population which met the inclusion criteria. the inclusion criteria in the study were bc patients who histopathologically and immunohistochemical diagnosed suffering from tnbc carcinoma; slices of paraffin blocks with routine stain of hematoxylin-eosin, er-, pr-, dan her-2which could be examined; tissue of block paraffin could be evaluated through he stain or immunohistochemical ck 5/6 and egfr; the data in the medical records of tnbc patients consisted of age, severity, tumore grading, chemotherapy types, and chemotherapy response; tissue handling was performed based on the standard by using neutral buffer formalin. exclusion criteria were the patients who had given chemotherapy before histopathological and immunohistochemical examinations while tnbc treatments. the tnbc patients in the study were treated which were based on histopathological examinations from breast biopsy via immunohistochemical examinations er(-), pr(-), her2(-). the immunohistochemical examinations determined that the er or pr would be negative if the result was <1% while the her-2 would be negative if the result was <+1. the immunoexpressions of ck 5/6 and egfr were presented in percentage as the cell which expressed ck 5/6 and egfr from the total tumor cells in representative areas. the ck 5/6 and egfr assessments were calculated by using histoscore obtained through immunohistochemical examinations consisting of two positive values of qualitative calculations and distribution positive values in several quantitative calculations. nevertheless, this study could be considered as a semiquantitative study. the positive values of ck 5/6 and egfr were obtained from the brown color of bc cytoplasm cells observed by using light microscope which can be classified into 4 levels: 0 (negative) represented color intensity was the same as negative control which is not in brown color; 1 (low positive) was light brown color; 2 (moderate positive) was brown color; 3 (strong positive) was dark color which was the same color intensity as positive control. the positive values of tumor cells are quantitative values in the form of percentage of brown color intensity distribution per field of view based on the examinations by using light microscope by magnifications of 400 times. the values were categorized into 5 levels: 0 (negative); 1 (<25% if the tumor cells were in brown color); 2 (25–<50% if the tumor cells were brown color); 3 (50–75% if the tumor cells were brown color); 4 (>75% if the tumor cells were brown color). both values obtained were distributions of intensity and positivity. then, the intensity had been timed to positivity due to discover the final value which was regarded as histoscore (hs). this value was determined based on immunoreactive scoring system (irs) by remmele w. and stegner h. e. negative immunoexpression would be negative if the histoscore was <4 (0–3) and it would be positive if the histoscore was >4 (4–12) .11 histoscore= = i x d there are associations between cancers with the treatments and examinations. the tnbc of basal-like can be diagnosed via immunochemical examination of ck 5/6 (+) and egfr (+), or ck 5/6 (-) and egfr (+), or ck 5/6 (+) and egfr (-). the tnbc non-basallike can be examined by using examinations of immunochemical ck 5/6 (-) and egfr (-). neoadjuvant is a chemotherapy which is given before surgery.12 adjuvant chemotherapy is commonly carried out after surgery. while palliative chemotherapy is given to bc which has been metastased.12 neoadjuvant chemotherapy response are determined as clinical response based on response evaluation criteria in solid tumors (recist) with revision version of 1.1 year 2009. the patients may have response if the condition meets complete response (cr) criteria and partial response (pr) but the response does not meet the criteria if the conditions represent progressive disease (pd) and stable disease (sd).13 response of adjuvant chemotherapy in this study was not asssessed based on recist because bc mass had been resected. palliative chemotherapy response was diagnosed by using clinical response based on recist. the patients could have response if the condition met the cr, pr, and sd while no response was discovered if the condition met the criteria of pd.13 the data in this study were collected by discovering paraffin blocks, recording pathology anatomy, numbers and medica records’ numbers from the biopsy specimens of the tnbc patients at the department of pathology anatomy, dr. hasan sadikin general :26–33 international journal of integrated health sciences. 2019;7(1) 29 hospital, bandung; borromeus hospital; and santosa hospital bandung central. afterwards, the data of medical records were synchronized based on the data stored at the three hospitals. if the paraffin blocks were available and still in proper condition, the paraffin blocks would be observed relating to the immunohistochemical expressions of ck 5/6 and egfr at the laboratory of the department of pathology anatomy, dr. hasan sadikin general hospital, bandung. results this study was initiated to investigate the tnbc characteristics based on basal-like and non-basal-like subtypes during march 2017 to november 2017. population in the study was tnbc patients who were treated in dr. hasan sadikin general hospital, bandung; borromeus hospital; and santosa hospital bandung central in the period of january to december 2016. among the samples, only 57 samples were included in the study as the subjects. the study could be regarded as the first study which divided tnbc into basal-like and non-basallike in bandung, indonesia. among the subjects, fourty seven subjects had tnbc through ck5/6 and egfr (basallike subtype) examinations while 10 subjects were observed by using expressions of immunohistochemical ck 5/6 negative and egfr negative (nonbasal-like subtype) (table 1). adjuvant chemotherapy were mostly given to the subjects in the study (32 out of 57 subjects). the adjuvant chemotherapy commonly given to the subjects combination of were doxorubicin and cyclophosphamide (table 2). neoadjuvant chemotherapy was given to 4 tnbc of basal-like subtype subjects. the results revealed that the response showed partial response (par), the tumor shrinked >30% after neoadjuvant chemotherapy. additionally, all the subjects were given neoadjuvant chemotherapy with surgery and adjuvant chemotherapy. neoadjuvant chemotherapy was also given to a subject with non-basal-like with par then the subject was given surgery and adjuvant chemotherapy. after six months, metastasis occurred in the lung and brain and the subject died one month later. fifi akwarini, trinugroho heri fadjari, et al. :26–33 table 1 variables basal-like n=47 non-basal-like n=10 age (yrs.) mean (sd) 50 ± 11 45 ± 13 range 30 – 75 23 – 68 age group (yrs.) <40 10 (21.3) 3 (30.0) >40 37 (78.7) 7 (70.0) tumor size (cm) ≤2 10 (21.3) 2 (20.0) 2.1–5 23 (48.9) 2 (20.0) >5 14 (29.8) 6 (60.0) tumor necrosis existed 14 (29.8) 3 (30.0) none 30 (63.9) 6 (60.0) no data 3 (6.3) 1 (10.0) lymphocyte infiltration existed 24 (51.1) 2 (20.0) none 20 (42.6) 7 (70.0) no data 3(6.3) 1 (10.0) lymphovascular invasion existed 26 (55.3) 7 (70.0) none 21 (44.7) 3(30.0) histopathology grade grade 1 2 (4.3) 0 (0.0) grade 2 18 (38.3) 3 (30.0) grade 3 23 (48.9) 5 (50.0) no data 4 (8.5) 2(20.0) lymp node metastasis none 18 (38.3) 5 (50.0) 1–3 15 (31.9) 0 (0.0) ≥4 11 (23.4) 5 (50.0) no data 3(6.4) 0(0.0) tumor stage i 4(8.5) 1 (10.0) basic characteristics of the subjects based on triple negative breast cancer between basal-like and non-basallike subtypes 30 international journal of integrated health sciences. 2019;7(1) palliative chemotherapy was given to 3 tnbc subjects. among the 2 subjects with basal-like, 1 subject who was given palliative chemotherapy had lung metastasis and showed response after sd chemotherapy. palliative chemotherapy was carried out to a tnbc of non-basal-like subject with liver and bone metastases and showed response after sd chemotherapy. more than a half of tnbc of basal-like subtype subjects were still alive, 20% of nonbasal-like subtype subjects were alive, and 30% of the subjects died. however, a half of tnbc of non-basal-like subtype subjects until october 2017 relating to their status were still unknown (table 3). mean alive of the tnbc of basal-like subtype subjects had 7 months more of prolonged life when compared to the non-basal-like subtype. discussion prevalences of tnbc of basal-like subtype in this study were 82.5% (47 out of 57 subjects) while prevalences of tnbc non-basal-like subtype were 17.5% (10 out of 57 subjects). the results were in accordance with a previous study included gep examination reported that 70–80% tnbc subjects were basal-like subtype and 20–30% subjects were nonbasal-like subtype.9 the gep examination in bc can distinguish intrinsic subtype which has significant prognostic and predicative value but it is uneasily performed in daily clinical examination. the immunohistochemical is affordable for daily clinical examinations due to identify protein expression as a marker of tnbc of basal-like gene. the immunohistochemical examination is suitable to detect tnbc of basal-like (cytokeratin ck5/6 and or egfr positive, er negative, and her2 negative) which has 76% sensitivity and 100% specifity.4 the tnbc of basal-like subtype has different molecular lesion (p53 stabilization and more indication of mitosis) and is associated with lower level of survival rate when compared to the non-basal-like subtype.4,9 mean age of tnbc of basal-like subtype in this study was 50 years (ranged 30–75) which lower than the non-basal-like subtype (45 years ranged 23–68). a study by fadare and tavassoli revealed that mean age of basal:26–33 triple negative breast cancer characteristics based on basal-like and non-basal-like subtypes ii 21 (44.7) 3 (30.0) iii 18 (38.3) 4(40.0) iv 4 (8.5) 2 (20.0) histopathology types invasive ductal carcinoma mammae (idcm) / invasive carcinoma mammae non specified type 38 (80.9) 8(80.0) metaplastic carcinoma mammae 3 (6.4) 0 (0.0) invasive lobular carcinoma mammae (ilcm)/ ilcm plemorphic type 3 (6.4) 0 (0.0) mucoid carcinoma mammae 0 (0.0) 1 (10.0) secretory carcinoma mammae 1 (2.1) 0 (0.0) mixed idcm+ medulary 1 (2.1) 0 (0.0) mixed idcm+ mucoid carcinoma mammae 0 (0.0) 1 (10.0) mixed idcm + paget disease 1 (2.1) 0 (0.0) type of chemotherapy neoadjuvant 4 (8.5) 1 (10.0) adjuvant 29 (63.8) 3 (40.0) palliative 2 (8.5) 1 (10.0) no chemotherapy 5 (6.4) 0 (0.0) no data 7 (12.8) 5 (40.0) ki-67 <20% 17 (36.2) 8 (80.0) ≥20% 21 (44.7) 0 (0.0) without assessment 9 (19.1) 2 (20.0) p53 negative 12 (25.5) 5 (50.0) positive 14 (29.8) 4 (40.0) without assessment 21 (44.7) 1 (10.0) international journal of integrated health sciences. 2019;7(1) 31 fifi akwarini, trinugroho heri fadjari, et al. :26–33 like subtype subjects was 47.7–55 while mean age of analyses by using gep examination was 54.14 another previous study stated that tumor with greater basal was mostly found in 40–50 years.2 there is still unclear finding that tnbc of basal-like subtype subjects are younger than the non-basal-like subtype subjects because many related previous studies have different results.14 the basal-like subtype have significantly younger mean age when compared to non-basal-like subtype subjects. in contrary, polish breast cancer study (804 subjects) and nurses’s health study (872 subjects) reported that there was no difference age between tnbc of basal-like and non-basal-like subtypes.14 the tnbc of basal-like subtype was mostly found in subjects who were in stage ii while non-basal-like subtype was mostly found in stage iii. the stage iv of tnbc of basal-like subjects in this study had metastases in the lung, bone, and liver while metastases in the liver and bone were found in the non-basallike subjects. this finding is different from a cohort study in japan which described that tnbc basal-like subtype had brain and lung metastases. another study confirmed that tnbc of basal-like subtype and tnbc which has relation to brca1 mutation which has metastasis in the brain. the tnbc of basal-like had lower metastases in the bone and liver when compared to ductal carcinoma of stage iii non-basal-like subtype.14 there is no histopathology different type in both basal-like and non-basal-like subtypes in this study is invasive ductal carcinoma. this is suitable with a study in morphological basallike subtype with gep, 21 out 23 patients (91%) was ductal carcinoma. several studies with immunohistochemical examination also supported that ductal cancer is the mostly histological tnbc of basal-like subtype. if the analyses were focused on the ertumor group, the data would show that 80% of both tnbc of nonbasal-like and basal-like subtypes are considered as ductal carcinoma or combination of ductal carcinoma and another hisopathology types. beside invasive ductal carcinoma mammae histopathology, other histopathologies can be found in basal-like subtype subjects such as carcinoma metaplastic, invasive lobular carcinoma mammae pleomorphic type, secretory carcinoma mammae, medullary, dan paget disesase. among histopathologies, mucoid carcinoma mammae was frequently found in non-basal-like subtype subjects. this finding is similar to a previous study which stated that histopatologies such as medullary carcinoma or combination of ductal carcinoma and medullary carcinoma represents basallike phenotype. table 2 chemotherapy types responses basal-like n=36 non-basal-like n=5 neoadjuvant response (cr, par) 4 1 no respon (sd, pd) 0 0 cannot be assessed 0 0 adjuvant cannot be assessed 30 3 palliative response (cr, par, sd 1 1 no response (pd) 1 0 cannot be assessed 0 0 characteristic of chemotherapy response of triple negative breast cancer of basal-like and non-basallike subtypes based on chemotherapy types table 3 last condition basal-like n=47 (%) non-basallike n=10(%) alive 25 (53.2) 2 (20.0) dead 13 (27.7) 3 (30.0) unknown 9 (19.1) 5 (50.0) characteristics of the last condition between triple negative breast cancer of basal-like and non-basal-like subtypes 32 international journal of integrated health sciences. 2019;7(1) references 1. kementerian kesehatan republik indonesia. kanker payudara. jakarta: komite penanggunalangan kanker nasional; 2017. 2. choccalingan c, rao l, rao s. clinicopathological characteristic of triple negative and non triple negative high grade breast carcinomas with and without basal marker (ck5/6 and egfr) expresion at a rural tertary hospital in india. breast cancer (auckl). 2012;6(1):21–9. 3. pillai skk, tay a, nair s, leong co. triplenegative breast cancer is associated with egfr, ck5/6 and c-kit expression in malaysian women. bmc clin pathol. 2012;12(1):1–18. 4. toft dj, cryns vl. minireview: basal-like breast cancer: from molecular profiles to targeted therapies. mol endocrinol. 2011;25(2):199– 211. 5. metzger-filho o, tutt a, de azambuja e, saini ks, viale g, loi s, et al. dissecting the heterogeneity of triple negative breast cancer. j cklin oncol. 2012;30(15):1879–87. 6. thike aa, cheok py, jara lazaro, tan b, tan p, and tan ph. triple-negative breast cancer: clinicopathological characteristics and relationship with basal-like breast cancer. mod pathol. 2010;23(1):122–33. 7. jézéquel p, loussouarn d, guérin-charbonnel the gep examination from ductal carcinoma and medullary carcinoma with hispathology stage iii showed that 95% medullary carcinoma was the ductal basal-like subtype group.14 in this study, chemotherapy response was assessed in neoadjuvant and palliative chemotherapies. in the neoadjuvant chemotherapy group, the response was found in 3 basal-like subtype subjects and 1 basallike subtype subject. the subjects who had been given chemotherapies among 57 subjects were 5 subjects (neoadjuvant chemotherapy) and 3 subjects (palliative). therefore, this study could not clearly describe the response between neoadjuvant and palliative chemotherapies in tnbc of basal-like and non-basal-like subtypes. in this study, more than 50% subjects (32 out of 57 subjects) were given adjuvant chemotherapy because it is suggested for tnbc and her2 + subjects in the early up to locally advanced. the tnbc subjects negative who had been given neoadjuvant chemotherapy had pathologic complete response (pcr) approximately 27–45% while the pcr value in bc with her-2 negative and hormone receptor positive had 10% lower of pcr. in contrary, the tnbc subjects who had been given adjuvant chemotherapy did not show higher risk of pcr leading to early metastasis.4 this study determined that among tnbc subjects, non-basal-like subtype had worse condition when compared to the basal-like subtype. this finding is different from the previous study which stated that tnbc of basal-like subtype has worse result than other tnbc subtypes.10 this condition is caused by different race characteristics between this study and those previous studies. besides, the samples of tnbc non-basal-like subtype in this study were 10 out of 57 subjects. the results in the study cannot describe precise information relating to the tnbc of non-basal-like subtype so that larger samples are required in order to describe the real condition. this was a retrospective study which collected the data based on the medical records. uncompleted data found in the medical records caused problems to obtain sufficient data and information such as carcinoma history of the family, menarche and menopause statuses. the medical records of inpatiens or outpatients at the department of oncology surgery, department of internal medicine, and department of pathology anatomy, of both hospital in dr. hasan sadikin general hospital, bandung and borromeus hospital did not have integrated access so that the data were collected manually. in summary, tnbc in the hospitals in bandung was classified into two subtypes, basal-like and non-basal-like. the prevalences of tnbc of basal-like subtypes were higher than another one. mean age of tnbc basallike was higher than non-basal-like. there was no different type and degree of hispathology found in both subtypes. more severe bc was discovered in non-basal-like subtype. the theraphy commonly given to the subjects of both subtypes was adjuvant chemotherapy so that the chemotherapy response was hardly discovered in this study. among the subjects, deaths in this study were mostly found in tnbc of non-basal subtype when compared to the basal-like subjects. triple negative breast cancer characteristics based on basal-like and non-basal-like subtypes :26–33 international journal of integrated health sciences. 2019;7(1) 33:26–33 fifi akwarini, trinugroho heri fadjari, et al. c, campion l, vanier a, gouraud w. geneexpression molecular subtyping of triplenegative breast cancer tumours: importance of immune response. breast cancer res [serial on the internet]. 2015 mar [cited 2017 jun 12];17(43):[about 16p.]. available from: https://breast-cancer-research. b i o m e d c e n t r a l . c o m / a r t i c l e s / 1 0 . 1 1 8 6 / s13058-015-0550-y. 8. prat a., adama b, chang mcu, anders ck, carey la, perou cm. molecular characterization of basal-like and non-basal-like triple-negative breast cancer. oncologist. 2013;18(2):123–33. 9. sharma p. biology and management of patients with triple negative breast cancer. oncologist. 2016;21(9):1050–62. 10. seal md, chia sk. what is the difference between triple negative and basal breast cancer? cancer j .2010;16(1):12–6. 11. kaemmerer d, peter l, lupp a, schulz s, sanger j, baum rp, et al. comparing of irs and her2 as immunohistochemicl scoring schemes in gastropancreatic neuroendocrine tumors. int j clin exp pathol. 2012;5(3):187–94. 12. american cancer society. breast cancer facts & figures 2011–2012. atlanta: american cancer society inc.; 2011. 13. eisenhauer ea, therasse p, bogaerts j, schwartz lh, sargent d, ford r, et al. new response evaluation criteria in solid tumor: revised recist guideline (version 1.1). eur j cancer. 2009;45(2):228–47. 14. fadare o, tavassoli fa. clinical and pathologic aspects of basal-like breast cancers. review. nat clin pract oncol. 2008;5(3):149–59. 16 international journal of integrated health sciences. 2019;7(1) correspondence: jesslyn christianningrum putri, faculty of medicine, universitas padjadjaran jl. raya bandung-sumedang km 21 jatinangor, indonesia e-mail: christianningrumjesslyn@gmail.com correlation between learning comfort and the risk of musculoskeletal disorder in anatomy laboratorium activity based on rula method leonardo lubis,1,2 jesslyn christianningrum putri,3 mulya nurmansyah ardisasmita4 1department of medical sciences, faculty of medicine, universitas padjadjaran 2sports medicine department, koni jawa barat 3faculty of medicine, universitas padjadjaran 4department of public health, faculty of medicine, universitas padjadjaran abstract objective: to describe learning comfort in the anatomy class of the faculty of medicine, universitas padjadjaran as one of the learning facilities, to assess the risk of musculoskeletal disorders in students, and to observe correlation between learning comfort and the risk of musculoskeletal disorders in students. methods: a cross sectional research design conducted to the participants that were students from batch 2017 (second year), faculty of medicine, universitas padjadjaran as the population sample. data were taken using a likert scale questionnaire (very uncomfortable–very comfortable) about the comfort aspects in the class, meanwhile the risk of musculoskeletal disorders were assessed by using rapid upper limb assessment (rula). after data collection, there were 106 respondents with complete data, then the data were processed by using descriptive statistical analyses. the correlation between the two variables was analyzed using the gamma correlation test. results: majority of the students were very comfortable with the aspects of learning comfort (majority scale 5), except in aspects of furniture, work area, room aroma, personal storage area, maintenance and repair. a moderate risk level of musculoskeletal disorders (58.5%) was found in the majority of the students. there was a relative significant relationship between learning comfort and the risk of musculoskeletal disorders in the aspect of colors (γ=0.445, p<0.01). conclusions: there is a significant relationship between learning comfort in the aspect of colors and the risk of musculoskeletal disorders. other aspects do not indicate a significant relationship. keywords: learning comfort, risk of musculoskeletal disorders, rula pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v7n1.1566 ijihs. 2019;7(1):16–25 introduction comfort is one of many aspects required in each type of work, non-exceptional to learning. the individual comfort is determined by perception and several aspects of the surrounding environment, namely lighting, temperature, noise, and others. errors in one aspect of comfort can affect one’s perception which is defined as a feeling of “discomfort”. if this condition is maintained for a long duration, there will be some changes that are perceived by the individual, whether it is pain or aches. a study stated that discomfort is associated with musculoskeletal disorders.1 musculoskeletal disorders is defined as an abnormality which is frequently caused by a request of activity that exceeds the capacity or limits of the musculoskeletal component.1 the musculoskeletal component consists of bones, muscles, and joints that interact with each other to produce movement, including original article received: february 7, 2019 revised: march 5, 2019 accepted: march 21, 2019 :16–25 international journal of integrated health sciences. 2019;7(1) 17 isometric contractions that form the posture of the human body.2 a person’s posture can be determined by several indicators such as anthropometry, type of work, and the surrounding work area.3 a study conducted in a school discovered that furniture, seating distance, and vision can affect body posture when sitting.4 errors in one of these aspects can cause abnormal posture.3 the abnormal body postures maintained for prolonged duration will cause chronic musculoskeletal disorders such as carpal tunnel syndrome, tendinitis, and bursitis.3 these abnormalities require a long recovery period, even causing permanent disability that may reduce life’s potential productivity.4,5 therefore, prevention of risk of musculoskeletal disorders is very important to be done in order to reduce the rate of permanent disability.6 prevention of musculoskeletal risk can be intervened through approachment of aspect that affects work posture. screening the risk of musculoskeletal disorders, work environment improvements, and assessing work posture.3 the rapid upper limb assessment (rula) is one of several methods to assess work posture. the results obtained are final scores with recommendations according to the score category; whether the posture is worth maintaining, needs for a change, or changed as soon as possible. the rula has been widely used by researchers to assess work postures for factory employees, computer users, and other risky jobs that are capable of causing musculoskeletal disorders in the future.7 aspects that affect an individual’s posture intersect with several aspects that determine the comfort of an individual. anatomy class as one of the student learning facilities includes various kinds of activities, such as cadaveric observation, lecture and discussion, and the use of teaching aids. every job or activity requires different postures, and can pose a risk of musculoskeletal disorders, if done in poor posture and maintained for a long duration.4 methods this study was conducted by using analytical methods with cross-sectional approach. the subjects in this study were students of batch 2017 of the faculty of medicine, universitas padjadjaran, jatinangor west java, indonesia. the sample size was obtained by using a large proportion estimation formula, with a minimum sample of 97 people. the sample size used for proportions was the same as correlative, because the minimum sample used for correlative research was 60 people, so the largest minimum sample was taken. the inclusion criteria for this study were students who took part in the anatomy laboratory activities in building c.4.1.2 faculty of medicine, universitas padjadjaran. exclusion criteria were students who experienced musculoskeletal disorders due to other reasons (for example infection) and incomplete data. the variables in this study were student characteristics (gender, age, and body mass index), a description of comfort in the laboratory aspects, and the risk level of musculoskeletal disorders.characteristic data in the form of body mass index (bmi) were obtained by filling out questionnaires in the form of height and weight, then measured using the bmi formula. the results by using the formula would be categorized into four groups based on the asian world health organization (who) criteria: underweight (<18.5), normal (18.5–22.9), overweight (23–24.9), and obese (≥25). 8 comfort features in laboratory aspects were measured by using a comfort questionnaire consisting of twenty-eight aspects of comfort divided into eight major aspects such as temperature, aroma, noise, furniture comfort, lighting, work area, color, and building safety. every aspect of comfort were measured by likert scale, ranging from scale 1 (very uncomfortable) to 5 (very comfortable). this questionnaire has been tested for validity (significance level <0.05; rxy> 0.195, n=106) and reliability (cronbach’s alpha=0.928). the results obtained are the score obtained from each aspect, then classified into five categories: (1) very uncomfortable, (2) uncomfortable, (3) neutral, (4) comfortable, and (5) very comfortable. this questionnaire was also equipped with a critic column for each number. the risk of musculoskeletal disorders was measured using rula. assessment of work posture was done by observing the students during the class activity. the rula sheet was divided into three large tables: table a (assessing the posture of the forearm, forearm, and wrist), table b (assessing the neck, trunk, and legs), and the grand score table (final score based on the score of table a and table b). risk scores are assessed based on the figures provided in each table, then added to the score of muscle use and burden. the final score on the grand score table will be categorized into four categories: low risk (1–2), moderate (3– 4), high (5–6), and very high (≥7). data on respondents’ characteristics in the leonardo lubis, jesslyn christianningrum putri, et al. :16–25 18 international journal of integrated health sciences. 2019;7(1):16–25 form of gender, age, and bmi were analyzed using descriptive statistics, presented in the form of numbers and percentages. data in the form of age were presented in the mean and standard deviation. the correlation between comfort variables and the risk of musculoskeletal disorders were analyzed using the gamma correlation test. results data collection was carried out on the afternoon of class schedule (01.00 pm–03.30 pm) in three different days: day 1 was on monday, august 27, 2018 there were 54 students who met the inclusion criteria. after data collection and checking, there were 36 incomplete data, so that there were 18 complete data for analysis; day 2 was onn wednesday, august 29, 2018 there were 49 students who met the inclusion criteria. after data collection and checking, there was 1 incomplete data so that there were 48 complete data for analysis; day 3 was onn friday, august 31, 2018 there were 41 students who met the inclusion criteria. after data collection and checking, there was 1 incomplete data so that there were 40 complete data for analysis. there were 144 students who met the inclusion criteria. after taking and checking the data, there were 38 incomplete data. moreover, there were a total of 106 complete data for data analysis. number of female participants in this study were larger (67.92%) compared to men (32.07%), with an average age of 18.9 and standard deviation of 0.74. most participants had a normal distribution in bmi (69.81%). in this study, majority of students perceived very comfortable in aspects of temperature and air flow comfort (fig. 1a), shown by the majority scale of 5 (very comfortable) at room temperature aspects (36.8%), temperature shifts (39.6%), drafts (53.8%), ventilation (51.9%), air freshness (34%), air circulation (45.3%), and humidity (48.1 %). majority of the respondents perceived very comfortable with all aspects of sound and noise (fig. 1b), internal noise (48.1%), spesific noise (54.7%), noise from the air system (59.4%), and external noise (50%). the highest aspects of comfort were found in noise from lightning systems (80.2%). correlation between learning comfort and the risk of musculoskeletal disorder in anatomy laboratorium activity based on rula method fig. 1 learning comfort aspect graphics fig. 2 distribution of the risk degree of musculoskeletal disorders in students international journal of integrated health sciences. 2019;7(1) 19 leonardo lubis, jesslyn christianningrum putri, et al. :16–25 the respondents showed comfortness in the aspect of lighting, glare and visuals (fig. 1c). in this study, the respondents felt very comfortable with all these aspects: natural brightness (56.6%), electric lighting (67%), glare (65.1%), colors (63.2%), esthetic aspects (39,6%), and views from windows (57%). as with the privacy aspect, respondents felt very comfortable with aspects of visual privacy (41.5%) and conversation privacy (46.2%) (fig. 1f ). furniture, work area, and maintenance aspects showed that respondents felt neutral (scale 3) on furniture (38.7%), personal storage (27.4%), amount of workspace (32.1 %), as well as maintenance and repairs (36.8%) (fig. 1d). in another aspect, the respondents perceived very comfortable with the work storage (40.6%), furniture layout (34.9%), and building security (67%). the room odours aspect, majority of respondents showed comfortable (scale 4) with the room odours (34%) (fig. 1e). the majority of students perceived very comfortable with almost all aspects of the room (indicated by a majority scale of 5). there was a downgrade in comfort aspects of furniture, work area, maintenance and safety, and room odours. the highest aspect of comfort was found in the aspect of noise from the lighting (80.2%). the lowest aspect of comfort was personal storage areas (27.4%). data in the form of reason columns were not presented due to variation of answers, and many participants did not fill the critics column. the majority of students had moderate risk degrees (58.5%). the rest were at high risk level (36.8%), followed by low risk (3.8%) and very high risk (0.9%), respectively. characteristic of gender did not show a significant relationship with the risk of musculoskeletal disorders (kruskall-wallis test, p>0.001). the characteristics of age were not related to the risk level of musculoskeletal disorders (r = 0.066). body mass index have a weak, non-significant relationship with the risk of musculoskeletal disorders, with a γ value of 0.147. there was a relative strong significant relationship between aspects of colors and the risk of musculoskeletal disorders (γ=0.445, p <0.01). other aspects showed no significant relationship with the risk of musculoskeletal disorder. however, a weak relationship was found in some aspects: drafts (γ =0.151); ventilation (γ=0.120); air freshness (γ=-0.103); room odours (γ =-0.107); humidity (γ=-0,100); external noise (γ=-0,116); work storage (γ=0.145); amount of workspace (γ=0.159); furniture layout (γ=0.131); conversation privacy (γ=0.139); esthetic aspect (γ=0.175), with the risk of musculoskeletal disorder. aspect in noise from lightning system (γ=0.225); natural brightness (γ=0,250), electric lighting (γ=0,264); maintenance and repair (γ=0.038) and building security (γ=0.037) shows moderate non-significant relationship (table2). discussion learning comfort is influenced by perceptions and the surrounding environment, therefore definition of comfort is different by person. most of the students felt very comfortable with the condition of the surrounding area that supports their learning indicated by scale 5 in the comfort questionnaire. on the other hand, others felt some aspects were not optimal in their learning environment (1–4 scale). “neutral” comfort status (scale 3) showed that there was a vague perception of “comfortable” feeling, so it tends to be categorized as uncomfortable. comfort aspects that are considered less optimal are the room odours, furniture, personal storage, the amount of work space, maintenance and repair. thermal comfort is determined by several factors: temperature, air velocity, humidity, table 1 characteristics of respondents characteristics n=106 percentage (%) gender male 34 32,07 female 72 67,92 age (mean, sd) 18.9;0.74 17 2 0,018 18 26 24,52 19 56 52,83 20 21 19,81 21 1 0,009 bmi (kg/m2) underweight 17 16,03% normal 61 57,54% overweight 13 12,26% obese 15 14,15% note: bmi=body mass index, sd=standard deviation 20 international journal of integrated health sciences. 2019;7(1):16–25 solar radiation, type of activity, and type of clothing.9 in this study, thermal comfort in the laboratory was considered “very comfortable”. two air conditioners were provided on the left side of the room (fig. 3d). there is a slight difference between “comfortable” and “very comfortable” perceptions due to uneven temperature distribution, that is more dominant on the left side of the room. as a result, some students felt that the room temperature was too cold, and some even thought it was hot. factors as laboratory coat materials or air conditioners that cannot adjust the temperature to the conditions of the surrounding air temperature may contribute to the thermal comfort as well. therefore, thermal comfort in this room depends only on air conditioning, namely air flow, air freshness, air circulation, and air humidity. it is a room without the presence of ventilation with only one entrance to the laboratory room. windows cannot be opened, yet some of them found damaged. changes in room temperature are considered “very comfortable” because the air conditioner is turned on throughout the learning activities, and remote control is available to regulate the temperature of the air conditioner. predicted mean vote (pmv) is one method to objectively assess thermal comfort by measuring quantitative aspects. the advantage of this method is that it can directly determine the factors that affect thermal comfort and do immediate intervention. however, this research is limited by qualitative measurement.9 room odours aspect in the anatomy class was considered as “comfortable”. the participants who filled out the critics column state that the decrease in the comfort aspect was caused by the smell of formalin from the cadaveric room, next to anatomy classroom. the cadaveric room and clasroom are separated, but the mull post is not covered by a door panel. therefore, formalin odours infiltrate the classroom (fig. 3b). some of the participants were comfortable with the scent, and some didn’t smelt the formalin at all. the distance from the source of odor, the amount of formalin inhaled, and the amount of inhalation in one breath are other factors, but these variables are not measured.10 aspect of sounds and noise in this clasroom are “very comfortable”. none of echoes (internal noise) were heard, noises from the air and lightning systems were low, and the sound coming from outside the room is barely heard. few of the students felt uncomfortable with internal noise due to chatting during class, because they could not hear what the lecturer said. this is anticipated by the availability of a microphone with speakers placed in the front center of the room. however, lecturers rarely use this media due to the frequent microphone feedbacks, making them “uncomfortable”. the majority of students feel “very comfortable” and assume because it is still in reasonable condition. some important factors such as the distance of the loudspeaker, the distance of the listener, the angle between the listener to the wall and the size of the outdoors were not measured.11 the lighting system in the anatomy class depends on the 17 lamps in the room. as a class, the lightning power needs to range from 200–800 lux, estimated by measuring room size, light flux, armature efficiency, and room utilization factors.12 based on a previous study, light intensity is influenced by the color and size of the walls of the room. the color in this classroom is dominant with light colors; lilac on the front side and pale green on the other side, resulting considerable reflected light.13 intensity of light is enough and didn’t cause glare. the view from outside the window was limited by the opaque window glass on the lower half of the window, but students still feel “very comfortable” with this. natural brightness in the form of sunlight can still enter the room through the reflection of light from the canopy outside the laboratory room, therefore glare does not arise directly. despite natural brightness, the room was dark without the presence of electric lightning (fig. 3h). the furniture used by students in the anatomy class was folded chair with fixed tables. a table that could not be shifted causes an “obstacle” for students to move or change their sitting position. this raises the perception of a narrow work area, resulting uncomfortable feeling, illustrated by the majority of the score “neutral”. personal storage in the form of lockers and others were not provided. students tend to put their bags and personal belongings on the back of the chair or the floor. a lack in maintenance and repair of furniture in the anatomy class was a chair that loses its seat cushion, a chair does not stand upright, or a tilted table was shown, by not repairing or replacing the defects with a new one (fig. 3e, f ). the thin comfort response between “neutral” and “comfortable” is found in the privacy aspects of the room. the layout of the furniture (seats) were too close making the area less private, both in visual and auditory (fig. 3e). many of the students felt correlation between learning comfort and the risk of musculoskeletal disorder in anatomy laboratorium activity based on rula method international journal of integrated health sciences. 2019;7(1) 21 that this was reasonable because of the many discussion activities in the anatomy class. building security was still considered “very comfortable” by the majority of students, although in reality it was difficult to assess the robustness of the building, given that the anatomy laboratory was established since 1957. improvements may have been made to maintain building security, but the details were not explained. comfort aspects such as furniture, work area, room aroma, personal storage area, and maintenance and repairs show that they were still not optimal. this comfort status affects the modification of the work area, because it was not possible to create a perfect work area for each individual personally for a small fee. to create a good work area, objective measurement in every aspect of comfort is recommendable.3 this study was only limited to subjective measurements, so further research on these aspects is needed, hopefully that the comfort level of learning can achieve maximum results. a decrease in the level of comfort aspects will signal the central nervous system. the central nervous system will conduct the signal as a disruption in body homeostasis, so that the body will send effects such as pain or aches. attitude changes will be made to overcome this.14 changes in sitting posture that was originally done on the college chair, turned fig. 3 anatomy laboratory room, front view (a), lecturer’s point of view (b), right back view (c), left back view (d), facility: chair and space between chairs (e), position of student’s table (f), lecturer’s area (g), condition of the room without lightning systems (h) leonardo lubis, jesslyn christianningrum putri, et al. :16–25 22 international journal of integrated health sciences. 2019;7(1) into sitting with a cross-legged position on the floor to expand working area. this change in attitude causes sitting posture to be more bent because the back was not supported (fig. 4a). normally, the lumbar curve is in a neutral position (0o), with the cervical and lumbar regions are convex shaped anteriorly and concave posteriorly (lordosis), while the thoracic and sacrococygeal regions are kyphotic shaped. based on the data obtained, almost all students have a trunkal position of 20–60o with a degree of risk of +3 when scored using rula (fig. 4b). a bending position (columnar vertebral flexion) causes reduced lordosis in the cervical and lumbar regions, also the thoracic region will become more kyphotic. the form of an abnormal curvature will change the relationship table 2 correlation between learning comfort aspect with the risk of musculoskeletal disorder comfort aspect (1-5) γ* p interpretation temperature comfort 0.036 0.805 negligible temperature shift 0.051 0.737 negligible drafts 0.151* 0.321 weak ventilation 0.120* 0.427 weak air freshness -0.103* 0.457 weak air circulation 0.025 0.868 negligible room odours -0.107* 0.469 weak humidity -0.100* 0.533 weak internal noise (echoes) -0.055 0.736 negligible specific noise (equipments) -0.037 0.821 negligible noise by cooling devices 0.000 1.000 negligible external noise -0.116* 0.463 weak noise from lightning system 0.225* 0.319 moderate furniture -0.054 0.712 negligible work storage 0.145* 0.286 weak personal storage 0.091 0.482 negligible amount of workspace 0.159* 0.264 weak furniture layout 0.131* 0.365 weak visual privacy -0.017 0.907 negligible conversational privacy 0.139* 0.341 weak natural brightness 0.250* 0.192 moderate electric lightning 0.264* 0.155 moderate glare 0.050 0.790 negligible colors 0.445* 0.008** relatively strong esthetic aspect 0.175* 0.202 weak view from windows -0.006 0.968 negligible maintenance and repair 0.280* 0.038 moderate building security 0.347* 0.057 moderate note: *gamma’s correlation test (γ<0.01) correlation between learning comfort and the risk of musculoskeletal disorder in anatomy laboratorium activity based on rula method :16–25 international journal of integrated health sciences. 2019;7(1) 23 between the gravitational line and each region of the spine, which can increase stress in the muscles, ligaments, bones, joints, and spinal nerves.15 the neutral position of the cranio-cervical (neck) region posture is a slight extension (30–35 degrees). range of movement (rom) of neck flexion and extension involve several joints and muscles, namely: atlanto-occipital, anlanto axial, and intracervical articulation (c2–c7), sternocleidomastoid, longus colli and longus capitis. the writing posture on the low surface causes neck flexion that exceeds the neutral angle, so that the anterior longitudinal ligament relaxes, and the distance between the lamina widens.15 most students positioned their neck in a flexed position, more than 10 degrees (+2 and +3 risk degrees). although the risk obtained is at a moderate level, but the correlation with the work storage and the amount of workspace is still weak, and has not shown a significant correlation. overall, no significant relationship was discovered between the learning comfort and the risk of musculoskeletal disorders.16 although there are several aspects that show a weak to moderate correlation, the number of significance has not been achieved. aspects of changes in drafts, ventilation, air freshness, humidity, external noise, esthetic aspects, and conversation privacy indicate a “very comfortable” comfort level, but almost of the entire population have a moderate level of musculoskeletal risk. in addition, aspects in leonardo lubis, jesslyn christianningrum putri, et al. fig. 4 sitting posture of the students (a), sitting posture and risk score of musculoskeletal disorder (b, c) a b c :16–25 24 international journal of integrated health sciences. 2019;7(1) 1. bazley c, nugent r. patterns of discomfort. j ergonom. 2015;5(1):1–7. 2. wilson a, lichtwark g. the anatomical arrangement of muscle and tendon enhances limb versatility and locomotor performance. philos trans r soc lond b biol sci. 2011;366(1570):1540–53. 3. helander m. a guide to human factors and ergonomics. 2th ed. london: taylor & francis; 2006. 4. pîrvu c, pătraşcu i, pîrvu d, ionescu c. the dentist’s operating posture – ergonomic aspects. j med life. 2014;7(2):177–82. 5. shaik ar, rao sbh, husain a, d’sa j. workrelated musculoskeletal disorders among dental surgeons: a pilot study.contemp clin dent. 2011;2(4):308–12. 6. shiri r, heliövaara m, ahola k, kaila-kangas l, haukka e, kausto j, et al. a screening tool for the risk of disability retirement due to musculoskeletal disorders. scand j work environ heal. 2018;44(1):37–46. 7. jain r, meena ml, dangayach gs, bhardwaj ak. risk factors for musculoskeletal disorders in manual harvesting farmers of rajasthan. ind health. 2018;56(3):241–8. 8. flegal km, kit bk, graubard bi. body mass index categories in observational studies of weight and risk of death. am j epidemiol. 2014;180(3):288–96. the form of work storage, work space, furniture layout, and room odours with a “neutral” or “comfortable” comfort level also have a weak but not significant correlation to the risk of musculoskeletal disorders. the results obtained are in contrast to studies conducted by chiasson, that those who reported musculoskeletal pain, assessed their work area more negatively.17 one of the comfort aspect that has a relative strong significant relationship is colors (table 2), but there are no studies that can support this findings yet. anthropometry by measurements of body dimensions and body mass index is an aspect that is needed to form an ergonomical work area. height measurements namely sitting height, popliteal height, and knee height affect the approximate design of chair height. kneeknee length, distance between thigh and table, and body mass determine the area of the chair with the table. as a result of diverse human anthropometry, the determination of furniture dimensions is based on the population’s percentile. if the user had anthropometry measurements outside the average percentile, the position will change.3 abnormal positions may increase the risk of musculoskeletal disorders, as well as the appearance of pain. the results obtained did not show a significant association between bmi with musculoskeletal risk. this occurred because the bmi is only measured using height and weight data, while to assess ergonomic risk data is needed in the form of body dimensions as described previously. the findings were contrary to a previous study which stated that bmi has a relationship with the risk of musculoskeletal disorders. the modifications to class furniture, especially dimensional measurements in the form of seat height; seat depth and height; backrest; corner of the back with a chair; table height, width and depth can increase learning comfort and reduce the risk of musculoskeletal disorders.18 in this study, age and sex also showed no significant difference with the risk of musculoskeletal disorders. theoritically, age affects the amount of risk, because age shows the duration of work. in accordance with the previous statement, that musculoskeletal risk will occur if a bad posture is maintained for a long duration. this study states the opposite, similar to the research conducted by collins.19 in the study, the range of ages between 18–51 years did not show a significant difference. the narrow age range into a factor is the reason why the results obtained are not significant. men and women have biological features that are different in shape, size, and musculoskeletal components so the expected results are a large amount of musculoskeletal risk.19 however, in this study there were no significant differences between the gender with the risk of musculoskeletal disorders, in contrast to the statements of several studies that showed that women had a greater risk than men due to hormonal effects and psychosocial symptoms such as stress.19,20 in conclusion, the study shows that learning comfort relate to the risk of musculoskeletal disorders even though not all parameters have been proven but still hiding a potential risk in occurring the musculoskeletal disorders in students. correlation between learning comfort and the risk of musculoskeletal disorder in anatomy laboratorium activity based on rula method :16–25 references international journal of integrated health sciences. 2019;7(1) 25 9. carera a, prianto e. karakter kenyamanan thermal pada bangunan ibadah di kawasan kota lama, semarang. proceedings of the seminar nasional sains dan teknologi; 2016 august 3; semarang. indonesia: universitas wahid hasyim; 2016. 10. enrique cometto-muñiz j, abraham mh. doseresponse functions for the olfactory, nasal trigeminal, and ocular trigeminal detectability of airborne chemicals by humans. chem senses. 2016;41(1):3–14. 11. gunawan h, aditanoyo t. study of the effect of splaying wall to modify acoustic modes distribution in small room. j phys [serial on the internet]. 2018 april [cited 2018 aug 20];2018(6):[about 6p.]. available from: https://iopscience.iop.org/ article/10.088/1742-6596/1075/1/012049/ meta. 12. lusijarto tt, subekti ra, susanti v. economic analysis and energy consumption approaches for lighting improvement of government building facilities. proceeding of international conference on sustainable energy engineering and application; october 23 2017; jakarta. continuous improvement of sustainable energy for eco-mobility; 2018. 13. azis m, supriadi b, lesmono a. analisis pengaruh warna dan ukuran dinding ruangan terhadap intensitas pencahayaan. j pembelajaran fis. 2017;5(1):35–40. 14. apostolico a, cappetti n, d’oria c, naddeo a, sestri m. postural comfort evaluation: experimental identification of range of rest posture for human articular joints. int j interact des manuf. 2014;8(2):109–20. 15. mirbagheri ss, rahmani-rasa a, farmani f, amini p, nikoo mr. evaluating kyphosis and lordosis in students by using a flexible ruler and their relationship with severity and frequency of thoracic and lumbar pain. asian spine j. 2015;9(3):416–22. 16. chinyere n i. influence of workstation and work posture ergonomics on job satisfaction of librarians in the federal and state university libraries in southern nigeria. iosr j humanit soc sci. 2014;19(9):78–84. 17. chiasson me, imbeau d, major j, aubry k, delisle a. influence of musculoskeletal pain on workers’ ergonomic risk-factor assessments. appl ergon. 2015;49(1):1–7. 18. taifa iw, desai da. anthropometric measurements for ergonomic design of students’ furniture in india. eng sci technol int j. 2017;20(1):232–9. 19. collins jd, o’sullivan lw. musculoskeletal disorder prevalence and psychosocial risk exposures by age and gender in a cohort of office based employees in two academic institutions. int j ind ergon. 2015;46(1):85–97. 20. higgins dm, fenton bt, driscoll ma, heapy aa, kerns rd, bair mj, et al. gender differences in demographic and clinical correlates among veterans with musculoskeletal disorders. women’s heal issues. 2017;27(4):463–70. leonardo lubis, jesslyn christianningrum putri, et al. :16–25 48 international journal of integrated health sciences. 2019;7(1) acute and sub-chronic toxicity studies of combination of physalis angulata l. (cecendet) extract and methylprednisolone on animals introduction systemic lupus erythematosus (sle) is regarded as a chronic inflammatory disease with unknown etiology. the sle has various clinical manifestations, natural history of disease, and prognosis. the disease primarily affects women of childbearing age with high mortality rate.1 corticosteroid is one of the major drug therapies for sle as anti-inflammatory and immunosuppressant. one potential and recommended corticosteroid in indonesia for sle patient is methylprednisolone with various dosages, depending on the severity of the disease. the recommended low-dose corticosteroid for sle maintenance therapy is less than or equal to 7.5 mg of prednisone and gradually tapers off over several weeks to prevent withdrawal effect until the steroid can be stopped. thus, the dose should be reduced by 20–25% every week or longer.2 physalis angulata l., known as cecendet, is a herb with several characteristics such as 0.1–1 m of height, upright, and with strong branch. in java island, indonesia, it grows on lowland up to 1,200 m above the sea level. cecendet has been used by society through generations as antidiabetic, antibacterial, antiviral, anti-inflammatory, antioxidant, analgesic, diuretic, cough reliever, and antitumor.3 the laboratory studies proven that cecendet suppress immune system by decreasing t cell proliferation, lymphocytes function, and abstract objective: to evaluate the safety of combination of physalis angulata l. (cecendet) extract and methylprednisolone through a single dose in mice (acute toxicity) and repeated doses within 90 days in rats (subchronic toxicity). methods: : acute toxicity test was conducted to 2 groups of female mice by monitoring their behavior and death at 4 hours and 24 hours after cecendet adminstration. while subchronic toxicity test was conducted to 6 groups of rats as normal group, control group, and receive varoius cecendet dose. each group was combined with methylprednisolone 5 mg/kg b.w. at first month and gradually taperred to 3.2 mg/kg b.w. at third month. subchronic toxicity was evaluated by monitoring rats’ behavior, mortality, blood biochemistry, blood cell count, urinalysis, and organ macroscopic and histologic. results: the study showed cecendet extracts did not affect mice behavior in single dose therapy up to 5 g/kg b.w. and had ld50 of more than 5 g/ kg b.w., which was categorized as practically non-toxic. the sub-chronic toxicity study showed that up to 1 g/kg b.w. of cecendet extracts that was administered for 90 days did not cause death, was not organ toxic, did not affect blood biochemistries, blood cell count, and urinalysis. conclusions: cecendet extract and methylprednisolone combination was safe based on acute and sub-chronic toxicity data. keywords: acute toxicity, ld50, lupus, physalis angulata l, subchronic toxicity pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v7n1.1619 ijihs. 2019;7(1):48–55 received: february 26, 2019 revised: march 25, 2019 accepted: march 29, 2019 elin yulinah sukandar,1 shiane hanako sheba2 1school of pharmacy, bandung institute of technology 2research division of syamsi dhuha foundation correspondence: shiane hanako sheba, research division of syamsi dhuha foundation jl. ir. h. juanda no.369 comp ddk no.1 bandung, west java, indonesia e-mail: shianehanako2014@gmail.com :48–55 original article international journal of integrated health sciences. 2019;7(1) 49 effects on macrophage activation.4,5 cecendet has anti lupus effect to pristane-induced lupus animal model such as reducing proteinuria level and anti-inflammatory effect.4–8 based on the previous studies, cecendet has potential effect for supplementary therapy in lupus patients. therefore, its safety profile must be investigated through acute and subchronic toxicity studies. the preliminary study for acute toxicity showed that the cecendet alone has an ld50 of more than 5 g/kg b.w. and is categorized as practically non-toxic. sub-chronic toxicity of cecendet alone to rat did not affect blood biochemistry (glucose, total cholesterol, triglycerides, sgpt, sgot, creatinine, and urea); index of vital organs such as the liver, kidneys, and heart are not different from control; urinalysis parameter were not affected; and histology of the kidneys, liver, heart, spleen and lungs showed no abnormalities compare to control group. most sle patients need immunosuppressive agents, therefore toxicity study of cecendet extract and corticosteroid combination is needed. therefore, this study evaluated the safety of combination of cecendet extract and methylprednisolone through a single dose in mice with acute toxicity and repeated doses within 90 days in rats with subchronic toxicity. methods the material used was cecendet extract in amylum maydis (5:4 ratio). the extract was prepared by pt. phytochemindo reksa, a pharmaceutical manufacturing certified for good manufacturing practice for traditional medicine (certificate number: 0104/ cpotb/14.1/43/viii/2008) by national agency for drug dan food control of the republic of indonesia. methylprednisolone were obtained from marketplace as a generic brand of 4 mg tablet. female mice weighing 29–34 grams for acute toxicity study were obtained from animal laboratory, school of pharmacy, bandung institute of technology; while male table 1 group control 225 mg/kg b.w. 900 mg/ kg b.w. 1800 mg/ kg b.w satellite control satellite 1800 mg/ kg b.w. male liver 2.86±0.47 2.88±0.36 2.82±0.18 2.77±0.17 2.71±0.36 2.73±0.17 lungs 0.61±0.10 0.77±0.37 0.66±0.10 0.62±0.13 0.59±0.13 0.71±0.35 heart 0.31±0.05 0.36±0.03 0.37±0.04 0.37±0.06 0.33±0.04 0.40±0.06 spleen 0.19±0.019 0.19±0.025 0.20±0.027 0.18±0.028 0.20±0.025 0.19±0.052 kidney 0.59±0.10 0.62±0.05 0.62±0.05 0.65±0.04 0.56±0.05 0.64±0.06 adrenal glands 0.019±0.003 0.016±0.004 0.018±0.004 0.016±0.002 0.020±0.005 0.019±0.005 testis 0.91±0.13 1.00±0.07 0.98±0.12 0.99±0.09 0.93±0.16 0.99±0.23 seminal vesicles 0.50±0.08 0.43±0.06 0.42±0.08 0.51±0.11 0.48±0.13 0.47±0.11 female liver 3.00±0.22 3.22±0.21 3.17±0.35 3.02±0.35 2.95±0.49 2.97±0.36 lungs 0.60±0.06 0.71±0.08 0.75±0.12 0.80±0.27 0.65±0.11 0.80±0.24 heart 0.37±0.03 0.36±0.02 0.39±0.03 0.36±0.03 0.36±0.04 0.43±0.06 spleen 0.20±0.024 0.21±0.038 0.23±0.045 0.24±0.051 0.20±0.033 0.24±0.034 kidney 0.60±0.08 0.62±0.05 0.61±0.05 0.64±0.06 0.63±0.08 0.64±0.06 adrenal glands 0.027±0.007 0.033±0.007 0.032±0.006 0.031±0.007 0.033±0.007 0.040±0.006 ovarium 0.055±0.007 0.053±0.007 0.050±0.012 0.053±0.011 0.058±0.011 0.059±0.007 uterus 0.32±0.16 0.23±0.03 0.32±0.28 0.29±0.13 0.28±0.11 0.25±0.06 rats organ index after cecendet extract and methyprednisolon administration for 90 days elin yulinah sukandar, shiane hanako sheba :48–55 50 international journal of integrated health sciences. 2019;7(1) and female wistar rats weighing 200–210 grams for sub-chronic toxicity study were obtained from d’wistar laboratory animal suppliers, bandung. the procedure of this study was carried out based on guidelines for invivo nonclinic toxicity from national agency for drug dan food control (nadfc) of the republic of indonesia. acute toxicity test according to the fixed dose method of acute oral toxicity, while subchronic test according to the 90 days of oral subchronic toxicity test. all the procedures were approved by the health research ethic committee faculty of medicine universitas padjadjaran bandung with ethical approval no 262/un6.c1.3.2/kepk/pn/2061. ten female mice were acclimatized for 7 days prior to the study and fasted for 4 hours prior to test substance administration, while water was still provided. mice were randomly divided into 2 groups (each group consist of 5 mice): a dose group and a control group.9 cecendet dose of 5 g/kg b.w. (5000 mg/kg b.w.) was combined with methylprednisolone dose of 0.14 mg/20 g b.w. or 7.25 mg/kg b.w, which was converted from human dose of 56 mg/70 kg. mice received test preparation solution for 1 ml/20 g b.w. orally. they were also given methylprednisolone solution 0.5 ml/20 g b.w. 5 minutes afterwards. in the previous study, a limit test at one dose level of 5000 mg/kg did not show mortality and based on the guide line of nadfc further testing at the next lower level did not need to be carried out, therefore this dose was used in the combination test with methylprednisolon. both animal behavior and death were observed for 4 hours and then 24 hours after table 2 hematology profile after test preparation administration for 90 days group control 225 mg/kg b.w. 900 mg/ kg b.w. 1800 mg/ kg b.w satellite control satellite 1800 mg/ kg b.w. male hematocrit (%) 34.0±6.4 32.5±4.0 31.6±3.2 33.8±6.0 32.2±4.1 30.8±2.7 hemoglobin (g/dl) 13.5±0.9 13.1±1.0 13.3±0.8 13.1±1.6 13.3±1.2 13.3±1.2 ʃ thrombocyte (105/mm3) 1406.1± 276.9 1483.1± 194.6 1334.7± 153.0 1394.9± 163.0 1258.7± 92.6 1260.6± 325.8 ʃ leukocyte (103/mm3) 8.0± 2.6 5.4±0.8* 4.9±1.2* 4.0±1.0* 6.6±1.4 3.5±0.5 ʃ eryhtrocyte (106/mm3) 5.7±1.1 5.5±0.6 5.4±0.6 5.7±0.9 5.5±0.7 5.3±0.5 mch (pg/cell) 49.0±6.7 48.4±4.4 50.0±3.5 46.0±4.9 49.3±4.8 49.8±3.8 mchc (g/dl) 135.7±19.1 135.8±13.2 141.3±9.8 130.6±14.6 139.0±13.5 144.1±14.3 mcv (m3/cell) 36.1±1.1 35.7±0.5 35.4±0.7 35.3±0.9 35.5±0.5 34.7±1.8 female hematocrit (%) 32.0±4.1 38.8±9.1 34.9±2.9 33.6±4.0 37.2±5.8* 35.0±8.3 hemoglobin (g/dl) 12.5±1.1 13.0±1.6 12.1±0.8 12.7±1.2 13.8±1.3 12.5±0.8 ʃ thrombocyte (105/mm3) 1346.3± 186.8 1381.8± 298.0 1345.8± 297.8 1807.8± 582.5 1231.0± 133.6 1087.4± 163.8 ʃ leukocyte (103/mm3) 5.3±1.7 7.3±1.7* 4.9±0.9 5.6±2.0 4.7±0.8 5.2±1.3 ʃ eryhtrocyte (106/mm3) 5.7±1.1 6.4±1.5 5.9±0.5 5.7±0.7 6.3±1.0 5.9±1.4 mch (pg/cell) 45.2±6.8 41.2±5.2 41.4±4.4 46.0±3.3 44.5±4.5 43.9±6.8 mchc (g/dl) 131.2±13.6 114.0±15.0 116.7±13.0 127.1±9.0 125.2±12.7 122.3±19.1 mcv (m3/cell) 34.4±3.4 36.2±0.6 35.5±0.7 36.2±0.7 35.7±0.5 35.9±1.1 note: * p<0.05 compared to control acute and sub-chronic toxicity studies of combination of physalis angulata l. (cecendet) extract and methylprednisolone on animals :48–55 international journal of integrated health sciences. 2019;7(1) 51 administration. body weight were measured daily for 14 days along with observation of toxicity signs. at day fourteenth, all mice were sacrificed, macroscopic presentation of organs such as liver, kidneys, spleen, adrenal glands, heart, lungs, ovaries, testis and gastric mucosal were observed. the rats were acclimatized for 7 days prior to the study. rats were randomly divided into six groups, each consist of 10 male rats and 10 female rats per group, consisting test, control and satellite group. test group received 3 cecendet doses of 225 mg/kg b.w., 900 mg/ kg b.w., and 1800 mg/kg b.w. combined with methylprednisolone; and satellite group received cecendet dose of 1800 mg/ kg b.w. combined with methylprednisolone. methylprednisolone dose was tapered off consistently with the human dosage, for day 1st–30th was 5 mg/kg b.w, day 31st–60th was 4 mg/kg b.w, and day 61st-90th was 3.2 mg/kg b.w. behavior was observed prior to administration, on day 91st, and day 120th for satellite group. at the end of the experiment (test animal and control on day 91st; satellite group on day 120th) urinalysis was done by collecting urine approximately 16 hours to observe urine color, specific gravity, and ph.9 blood was collected from the tail to observe erythrocytes count, leucocytes count, hemoglobin, and hematocrit (volume of red blood cells compared to total blood volume). blood chemistry (alt, ast, and creatinine) examination was done by using spectrophotometer tool “tecno 168” with human reactor. all animals then were sacrificed to observe the organs (liver, spleen, kidneys, adrenal glands, heart, lungs, ovaries, testis and seminal vesicles) macroscopically. in this study, organ histology examination for liver, lungs, spleen, heart and kidneys were done to all groups.9 a b c mice body weight for 14 days after administration of cecendet extract (a), male rat body weight profile for 120 days (b), female rat body weight profile for 120 days (c) fig. 1 elin yulinah sukandar, shiane hanako sheba :48–55 52 international journal of integrated health sciences. 2019;7(1) results animal observation at 4 hours and 24 hours after administration of 5 g/kg b.w. of cecendet extract combined with methylprednisolone on acute toxicity test show no behavioral difference of test group compare to control group. the animal behaviors such as hanging, retablishment, flexion response, and haffner response were showed equal in both group and there were no dead animals was observed. there was no sign of toxicity such as straub reaction, vocalization, writhing, convulsion, tremor, lacrimation, salivation, piloerection, and ptosis on obaservation for 14 days after administration. body weight development profile for 14 days of control and test group were compared and described (fig. 1a). it showed that body weight gain in acute toxicity study from both control and test group are similar. all experimental animals of subchronis toxicity study were not affected by combination of cecendet extracts and methylprednisolone, all parameters were normal compared to control group. there were no toxicity signs of straub reaction, vocalization, writhing, convultion, tremor, lacrimation, salivation, piloerection, and ptosis. other behaviors such as hanging, retablishment were normally done, all rat group showed flexion response, haffner response, pineal and corneal reflexes. while defecation, urination, and grooming were equal in both group. body weight development profile of subchronic toxicity study for male rat groups and female rat groups were described (fig. 1b, c). the body weight increased in both male and female groups, and similar with control group. macroscopic observation on liver, heart, lung in both male and female rats showed no abnormalities in color and shape compared to control group. the ratio of organ to body weight after 90 days adminstration revealed that heart, liver, lung, spleen, kidney on male and female test group were not significantly different with control group (table 1). testis in male animals, ovaries and uterus in female table 3 clinical biochemistry profile after test preparation administration for 90 days group control 225 mg/kg b.w. 900 mg/ kg b.w. 1800 mg/ kg b.w satellite control satellite 1800 mg/ kg b.w. male alt (u/l) 38.6±5.9 36.0±4.7 41.6±4.4 41.5±5.6 47.0±13.1 38.6±3.1 ast (u/l) 135.0±28.3 123.0±11.0 118.1±11.8 123.7±11.4 125.3±11.4 124.3±8.9 creatinin (mg/dl) 0.45±0.09 0.42±0.15 0.38±0.16 0.47±0.15 0.42±0.13 0.35±0.12 glucose (mg/dl) 112.8±25.0 142.0±17.8 130.3±31.8* 106.9±16.4* 120.3±15.8 156.5±19.8 total cholestrol (mg/dl) 82.0±12.8 97.5±62.7 78.1±13.7 87.1±59.3* 88.4±31.4 91.7±12.9 trigliseride (mg/dl) 147.7±23.7 110.1±37.6 109.6±42.7 122.1±13.8* 127.2±22.1 113.0±22.3 urea (mg/dl) 27.9±2.8 29.2±5.6 38.7±3.7 38.6±9.0* 25.2±3.8 32.9±6.2 female alt (u/l) 34.1±5.5 36.1± 4.0 31.8±4.8 29.1±3.1 32.5±5.4 33.7±5.2 ast (u/l) 98.2±19.8 123.0±19.3 111.7±21.4 116.1±34.8 95.2±16.9 105.3±7.5 creatinin (mg/dl) 0.34±0.15 0.31±0.20 0.40±0.26 0.30±0.17 0.23±0.09 0.29±0.12 glucose (mg/dl) 169.3±32.6 161.6±51.2 159.6±41.3 119.3±24.3 179.9±24.5 161.1±17.8 total cholestrol (mg/dl) 85.9±12.5 106.8±43.6 115.8±26.9 118.1±57.6 110.8±59.7 91.4±11.2 trigliseride (mg/dl) 170.1±31.5 149.9±39.2 143.3±27.8 132.2±42.8* 187.6±74.9 149.0±55.3 urea (mg/dl) 39.9±8.4 39.2±7.5 38.4±10.3 37.9±19.8 38.8±7.2 47.9±9.2 note: * p<0.05 compared to control acute and sub-chronic toxicity studies of combination of physalis angulata l. (cecendet) extract and methylprednisolone on animals :48–55 international journal of integrated health sciences. 2019;7(1) 53 d e f animals were similar compared to control groups. blood parameter showed that there was no difference between test group and control group on both male and female groups (table 2). statistycal analysis with one way anova showed significance decerased of leukocytes number in male rat was in all doses (p<0.05). blood chemistries to examine combination of cecendet extract and methylprednisolone effects on heart, liver and kidneys were presented (table 3).10,11 the alt and ast in all dose groups did not show any differences compared to control group. similarly, blood creatinine level did not significantly differ between test and control group, both in male and female. there were significant changes in blood glucose level in comparison with control group, such as an increase blood glucose level in male group with cecendet dose of 900 mg/kg b.w. and satellite group, while a decrease blood glucose level in female group with cecendet dose of 1800mg/kg b.w. and satellite, but all of glucose level were within normal limit (80–300mg/dl). in group with cecendet dose of 225 mg/kg b.w., there was no difference in total cholesterol level compared to control group. nevertheless, in group with dose of 900 and 1800 mg/kg b.w., there were slight increase in total cholesterol level. triglycerides level decreased in both group with cecendet dose of 1800 mg/kg b.w. and satellite male group. urea level increased only in male group with cecendet dose of 900 and 1800 mg/kg b.w. from the results, group with cecendet dose of 225 mg/kg b.w. did not affect rats’ blood biochemistries. a b c liver histology in female rat after 90 days of cecendet extract administration (40x). (a) control group (b) extract dose of 225 mg/ kg b.w. and methylprednisolone (c) extract dose of 1800 mg/kg b.w. and methylprednisolone. kidney histology in female rats after 90 days of cecendet extract administration (40x). (d) control group (e) extract dose of 225 mg/ kg b.w. and methylprednisolone (f) extract dose of 1800 mg/kg b.w. and methylprednisolone fig. 2 elin yulinah sukandar, shiane hanako sheba :48–55 54 international journal of integrated health sciences. 2019;7(1) urinalysis parameter in this study, specific gravity and urine ph level showed no significant changes both in test and control group, therefore the test preparation was non-toxic to kidney (table 4). in liver and kidney observations, no differences were found microscopically both in test and control group. normal hepatocytes in liver histology, both in test and control groups, kuppfer cells were well distributed in female and male rats (fig. 2a–c). kidney histology showed normal glomerulus and bowman’s capsule in male and female rats both in test and control group (fig. 2d–f ). discussion the main hindrance to the use of natural or herbal as a supplement therapy for an illness is the lack of scientific data regarding its efficacy and safety. on the other hand, the use of traditional herbs has long been proven to have efficacy for several diseases. so, scientific research is needed to prove the safety of its herb, particularly those indicated to reduce the symptoms of a chronic disease. cecendet is a herb that has long been used as an antiinflammatory in rheumatic diseases and several previous studies have indicated that this cetendet has anti-inflammatory effect in the lupus animal model.3,6 in current study, acute and sub-chronic toxicity studies of cecendet combined with methylprednisolone were carried out, as a condition adapted to lupus patients who were taking methylprednisolone as the main drug for lupus. the result of an acute toxicity test of 5 g/kg b.w. cecendet extract combined with methylprednisolone showed no sign of toxicity and no animal dead. therefore, the cecendet extract has a lethal dose 50 (ld50) higher than 5 g/kg b.w. and according to hodge and sterner toxicity scale is categorized practically non-toxic.9 body weight development profile in acute and sub-chronic toxicity studies showed body weight increasing of all test animals, indicates that cecendet extract does not have general toxic effects and not reducing appetite.12 the liver plays key role in many metabolic process of the body, its inflammation and necrotic are identified by increasing of serum alanine aminotransferas (alt) and aspartate aminotransferas (ast) level. in this study, the results of alt and ast examination in all group of test animals did not show significant differences with control group, indicates that cecendet extract is not toxic to the liver.10,12 renal function test should be performed on blood sample to investigate major toxic affect of tested material to kidney by monitoring creatinine and urea level.11 the result of creatinine and urea level of all animal groups in this study were not difference compare to control group, it is indicate that cecendet extract is not affect the kidney function. in addition, in current study show the significance decerased of leukocytes number in male rat of all group compare to control group. generally, leukocytes is often associated with infection, as leukocytes number increase due to infection. antimicrobial effects of cecendet may have caused decrease in leukocytes number. in conclussion, this study demonstrated that administration of cecendet extract in table 4 urinalysis profile after test preparation administration for 90 days group control 225 mg/kg b.w. 900 mg/ kg b.w. 1800 mg/ kg b.w satellite control satellite 1800 mg/ kg b.w. male spesific gravity (g/ml) 1.19± 0.13 1.16± 0.02 1.05±0.08 1.11±0.01 1.17±0.04 1.12±0.11 ph 8.0±1.0 7.6±1.5 6.4±0.6 6.6±0.6 6.6±0.9 6.8±0.8 female spesific gravity (g/ml) 1.13±0.05 1.07± 0.01 1.05±0.06 1.08±0.03 1.21±0.04 1.16±0.07 ph 5.8±0.8 8.4±1.1 7.0±1.2 7.4±1.1 6.6±2.1 7.4±1.1 acute and sub-chronic toxicity studies of combination of physalis angulata l. (cecendet) extract and methylprednisolone on animals :48–55 international journal of integrated health sciences. 2019;7(1) 55 combination with methylprednisolone was safe both as single dose or repeated dose, based on acute and sub-chronic toxicity evaluation to mice and rats. cecendet extracts with methylprednisolone had ld50 more than 5 g/kg b.w. and is categorized as practically non-toxic. body weight profile, behavior, blood biochemistry, blood, urinalysis parameter, and body organs (both macroscopically and microscopically) were not affected by cecendet (225 mg/kg b.w.) in combination with methylprednisolone (5mg/kg b.w. for the first month, 4 mg/kg b.w. for the second month, and 3.2 mg/kg b.w. for the third month). references 1. pons gj, alarcón gs, lacie s. understanding the epidemiology and progression of systemic lupus erythematosus. semin arthritis rheum. 2010;39(4):257–68. 2. perhimpunan reumatologi indonesia. rekomendasi perhimpunan reumatologi indonesia untuk diagnosis dan pengelolaan lupus eritematosus sistemik. jakarta: perhimpunan reumatologi indonesia; 2011. 3. chaidir l, epi, taofik a. eksplorasi, identifikasi, dan perbanyakan tanaman ciplukan (physalis angulata) dengan menggunakan metode generatif dan vegetatif. j ilmu pertanian. 2015;9(1):82–90. 4. yang yj, yi l, wang q, xie bb, dong y, sha cw. anti-inflammatory effects of physalin e from physalis angulata on lipopolysaccharidestimulated raw 264.7 cells through inhibition of nf-κb pathway, immunopharmacol immunotoxicol. 2017;39(2):74–9. 5. sun l, liu j, liu p, yu y, ma l, hu l. immunosuppression effect of withangulatin a from physalis angulata via heme oxygenase 1-dependent pathways. process biochem 2011;46(2):482–8. 6. adnyana ik, sukandar ey, maeistuti n, setiawan f. evaluation of ethanolic extracts of mullaca (physallis angulata l.) herbs for treatment of lupus disease in mice induced pristane. procedia chemistry. 2014;13(2014);186–93. 7. sn vikasari, ab sutjiatmo, ey sukandar, s suryani, pa perdana. efek ekstrak etanol herba cecendet (physalis angulata l.) pada kadar proteinuria hewan model lupus eritematosus sistemik. kartika j ilmiah farm. 2014;2(1):15– 9. 8. wang zl, luo xf, li mt, xu d, zhou s, chen hz. resveratrol possesses protective effects in a pristane-induced lupus mouse model. plos one [serial on the internet]. 2014 dec [cited 2019 jan 17];9(12):[about 16p.]. available from: https://www.ncbi.nlm.nih.gov/pmc/ articles/pmc4263676/. 9. badan pengawas obat dan makanan. peraturan kepala badan pengawas obat dan makanan republik indonesia nomor 875 tahun 2014 tentang pedoman uji toksisitas nonklinik secara invivo. jakarta: badan pengawas obat dan makanan; 2014. 10. gowda s, desai pb, kulkarni ss, hull vv, math aa, vernekar sn. markers of renal function tests. n am j med sci. 2010;2(4):170–3. 11. sharma a, hirulkar nb, wadel p, das p. influence of hyperglycemia on renal function parameter in patients with diabetes mellitus. ijpba 2011;2(suppl 2):734–9. 12. arthur fkn, woode e, terlabi eo, larbie c. evaluation of acute and subchronic toxicity of annona muricata (linn.) aqueous extract in animals. eur j exp biol. 2011;1(suppl 4):115– 24. elin yulinah sukandar, shiane hanako sheba :48–55 volume 8 no 1 2020 v2.indd international journal of integrated health sciences 27 introduction chronic kidney disease (ckd) is an abnormal condition in the structure or function of the kidney, which occurs for more than three months, with health implications.1 ckd is classified according to decreased function of the glomerular filtration rate (gfr) and albuminuria levels.1 there are 11−12 new ckd cases per 1,000,000 children in europe with a prevalence of 55−60 cases per 1,000,000 children.2 the incidence continues to increase compared to previous years.3 the kidney disease outcomes quality initiative (kdoqi) divides the classification length of stay children hospitalized with chronic kidney disease based on etiology and stage in dr. hasan sadikin hospital bandung, indonesia correspondence: angelreika libowo, faculty of medicine universitas padjadjaran, indonesia e-mail: angelreika.libowo@yahoo.com angelreika libowo,1 ahmedz widiasta,2 dedi rachmadi2 1faculty of medicine universitas padjadjaran, indonesia 2department of child health, faculty of medicine universitas padjadjaran-dr. hasan sadikin general hospital bandung, indonesia abstract objectives: this study aims to describe the los children hospitalized with ckd based on the etiology and stage at dr. hasan sadikin general hospital, bandung in 2016–2018. methods: this was a retrospective study with a cross-sectional design from june–october 2019. the inclusion were all medical records of pediatric inpatient diagnosed with ckd and exclusion criteria were incomplete medical record data and hospital readmission patients. the variables studied were ckd etiology, ckd stage, and length of stay results: from 103 patients, the etiologies found were steroid-resistant nephrotic syndrome (srns) (58.25%), congenital anomalies of kidney and urinary tract (9.71%), urinary tract infection (5.83%), and chronic glomerulonephritis (21.36%). the mean los was 19 days. the longest los found in ckd stage 5 patients caused by srns (141 days). meanwhile, the shortest los was found in ckd stage 2 patients caused by chronic glomerulonephritis and ckd stage 5 patients were caused by srns who died (1 day). conclusion: pediatric patients with ckd stage 5 with srns has the potential to have a longer los than other etiologies. keywords: children, chronic kidney disease, etiology, length of stay, stages original article received: december 20, 2019 accepted: march 31, 2020 pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ ijihs.v8n1.1880 ijihs. 2020;8(1):27–31 of ckd into 5 stages. the stage of ckd is determined by the level of decline in kidney function, namely through gfr.4 gfr levels are categorized as normal if >90ml/min/1.73 m2. the lower the gfr levels, the higher the ckd stages. all individuals with gfr levels <60ml/ min/1.73 m2 for ≥3 months have been diagnosed with ckd, with or without kidney damage. the main causes of ckd in children are different from adults. in children, ckd is usually caused by congenital anomalies of the kidney and the urinary tract (cakut) (49.1%), steroid-resistant nephrotic syndrome (srns) (10.4%), chronic glomerulonephritis (e.g. lupus nephritis, alport’s syndrome) (8.1%) and renal ciliopathy (5.3%).2 some other causes of ckd in children are microangiopathic thrombosis, nephrolithiasis, wilms tumor, infection, and others. the etiology of ckd will determine the progression of ckd severity. in 28 international journal of integrated health sciences some ckd cases, continuous kidney structure damage can cause end stage renal disease (esrd).6 patients with esrd conditions require renal replacement therapy (rrt) in the form of hemodialysis, peritoneal dialysis, or transplantation to stay alive.6 patients with rrt require high costs of hospitalization.7 data obtained in 2015 showed that indonesian health insurance, badan penyelenggara jaminan sosial (bpjs), financing for kidney failure was idr 2.68 trillion.8 this was ranked the second largest financing after the heart disease.8 however, there are often differences in the calculation of hospital cost which the hospital fee rates are greater than the indonesia case base groups (ina-cbgs) rates.9 difference in rates may not be charged on patients (kemenkes ri, 2014). if this happens continuously, it will cause harm to the hospital. the long length of stay (los) will add up the financial burden of health services. identification of factors related to los in children with ckd, the etiology and stage of the ckd can help in determining interventions to reduce the los. this study aims to look at the differences of los in children with ckd based on their etiology and stage of disease. from this study, it is expected to be able to provide an overview data about the los in ckd patients. the data can help the hospital and bpjs in determining alternative treatments that are more effective and efficient of cost by considering the los of pediatric patients with ckd, as well as being the basic consideration for bpjs in determining ina-cbgs rates for children with ckd patients. methods this study was a retrospective study with a cross-sectional design, conducted from june to october 2019 using secondary data from the medical record database in dr. hasan sadikin general hospital, bandung, indonesia. the subjects of this study were pediatric patients who were hospitalized in hasan sadikin general hospital, bandung in 2016−2018. the inclusion criteria of this research were all medical records of children patients diagnosed with chronic kidney disease treated in dr. hasan sadikin general hospital bandung, indonesia and exclusion criteria were inaccessible or incomplete registry data and hospital readmission patients. data was taken from the patient’s medical record with total sampling method, and processed using microsoft excel 2010. data collection was carried out after obtaining ethical approval number 244/un6.c1.1/ dl/2019 by the research ethics committee of universitas padjajaran bandung, and research licensing letter issued by the research ethics committee of dr. hasan sadikin general hospital bandung (no. lb.02.01/x.2.2.1/10525/2019). the selected data will be presented in the table to illustrate the difference in los. results based on the list of names given from the medical record database, the total pediatric ckd patients who were hospitalized in dr. length of stay children hospitalized with chronic kidney disease based on etiology and stage in dr. hasan sadikin hospital bandung, indonesia children with ckd admitted to dr. hasan sadikin general hospital in 2016 – 2018 (n=139) exclusion criteria incomplete registry data patients who got readmitted to the hospital total sample used (n=103 ) data analysis fig. diagram of subject selection international journal of integrated health sciences 29 table 1 characteristics of children with ckd characteristics (n=103) % sex male female 56 47 54.37 45.63 age group 1–5 years 6–9 years 10–18 years 9 11 83 8.74 10.68 80.58 funding sources private bpjs non-pbi bpjs pbi hospital subsidy 7 55 34 7 6.80 53.40 33.01 6.80 tabel 3 length of stay of children with ckd based on stage characteristics ckd stages (n=103 ) stage 1 n (%) stage 2 n (%) stage 3 n (%) stage 4 n (%) stage 5 n (%) length of stay ≤7 days 8–14 days 15–21 days 22–28 days >28 days 6 (60.0) 0 (0.0) 3 (60.0) 0 (0.0) 1 (10.0) 1 (50.0) 1 (50.0) 0 (0.0) 0 (0.0) 0 (0.0) 2 (40.0) 1 (20.0) 1 (20.0) 1 (20.0) 0 (0.0) 1 (50.0) 1 (50.0) 0 (0.0) 0 (0.0) 0 (0.0) 21 (25.0) 18 (21.43) 14 (16.67) 10 (11.90) 21(25.0) hasan sadikin general hospital, bandung in the study period was 139 people, but there were 7 inaccessible data. there were 103 data meet the inclusion criteria from 132 data that have been collected. a total of 29 data were excluded because they were patients with readmission hospitalization. angelreika libowo, ahmedz widiasta, et al. table 2 length of stay of children with ckd based on etiology characteristics ckd stages (n=103) cakut n (%) srns n (%) chronic glomerulonephritis n (%) urinary tract infection n (%) others n (%) length of stay ≤7 days 8–14 days 15–21 days 22–28 days >28 days 2 (20.0) 4 (40.0) 1 (10.0) 1 (10.0) 2 (20.0) 18 (30.0) 10 (16.67) 7 (11.67) 8 (13.33) 17 (28.33) 9 (40.91) 3 (13.64) 7 (31.81) 1 (4.55) 2 (9.09) 1 (16.67) 1 (16.67) 3 (50.0) 1 (16.67) 0 (0.0) 1 (20.0) 3 (60.0) 0 (0.0) 0 (0.0) 1 (20.0) characteristics of pediatric ckd patients treated at dr. hasan sadikin general hospital can be seen in table 1. out of 103 patients, the majority of the patients were male (54.37%), adolescent (80.58%), and had funding sources from bpjs (86.41%), which includes bpjs nonpbi (53.40%) and pbi (33.01%). the oldest patient in this study was 18 years old and the youngest one was 1 year old with an average age of 12 years. in this study, the most frequent etiology was srns. the longest los in this group was 141 days with an average los of 22 days. patients with cakut were mostly hospitalized for 8–14 days (40.0%). while most of the patients with chronic glomerulonephritis were hospitalized for ≤7 days (40,91%). half of the patients with urinary tract infection (uti) had to be hospitalized for 15–21 days. patients with other etiology such as renal tuberculosis mostly had los in the 8–14 days group (60.0%). overall, the mean los in all patients was 19 days with the longest los was 141 days in patients with srns. the shortest los was found in patients with ckd stage 2 caused by chronic glomerulonephritis who got hospitalized for 1 day and patient with ckd 30 international journal of integrated health sciences stage 5 caused by srns who died. research data shows that from 103 patients, 84 of them suffered ckd stage 5. the majority of ckd patients have los in the category ≤7 days (60%). similarly, in patients with ckd stages 2, 3, and 4, the most los is ≤7 days which is 50%, 40%, and 50%, respectively. whereas patients with ckd stage 5 have an equivalent percentage in the ≤7 days and >28 days category, which is 25%. patients with ckd stage 5 have an average los of 21 days with the longest stay was 141 days. discussion in this study we found that children with ckd were more prevalent in males (54,35%). this finding is similar to the previous studies conducted by becherucci et al.2 this is due to the higher incidence of congenital disorders, one of the most common etiology of ckd in children, including obstructive uropathy and renal dysplasia in males than in females.10 similarly, the prevalence of esrd was more prevalent in males than females. this data is in accordance with a previous study which states that the progression of ckd in men is faster than in women.11,12 this is likely caused by estrogen hormone in female which act as a protective agent, while in men there is the testosterone hormone which is damaging to the kidneys.12 the incidence of ckd increases with age. 80,58% of the patients were in the 10–18 years age group with the most common etiology was srns. this is similar to the data obtained from 14 educational hospitals with children’s nephrology consultants (2017). in patients aged 1-5 years old, the most common etiology was cakut. this is in accordance with a study that has been done previously in tunisia.13 the etiologies of pediatric ckd patients in this study were srns, cakut complicated by uti, and chronic glomerulonephritis. srns patients need time for hemodynamic stabilization of the patient, diagnosis, and administration of chemotherapy.14 however, the process of finding the best therapy for patients with srns is individual, so the duration of los and the outcome of each patient can be different.14 the los of patients with cakut in this study were mostly in the 8–14 days category (40%). patients with congenital anomalies will undergo the correction procedure for these abnormalities.15 in patients with cakut who complicated by uti, patients need time to manage the uti that require a minimum of 10 days for antibiotics, and a minimum of 3–7 days to obtain urine culture results. imaging examinations (radiology) are also needed to establish the diagnosis and determine the next steps of management.15 as for patients with an initial etiology of uti, the bacterial culture will be performed on patients and then given antibiotics. chronic glomerulonephritis also requires a quite long hospitalization, but not requires chemotherapy or surgery. the los of children with stage 5 ckd is mostly in ≤7 days and> 28 days category. the difference was caused by the condition of some patients who experienced hemodynamic instability so the doctor must wait for the patient to return stable to start the treatment. in addition, the setting-up device for hemodialysis or peritoneal dialysis will take several days. this will complicate the treatment process and have an impact on the los of the patient. however, not all ckd stage 5 patients experience this condition so that the doctor can start kidney replacement therapy and send the patient home when his condition has improved. some of the patients with ckd stage 5 admitted because the doctors found other disorders, such as anemia and pulmonary edema during hemodialysis. in this condition, the patient needs to be hospitalized for a few days until the patient gets better. eighteen patients with ckd stage 5 died in this study, either by the progression of the disease or by the other comorbid the patients had. death is one of the factors that affect the los, which can reduce the duration of stay. the los in patients with ckd stage 2, 3, and 4 were not as long as patients with ckd stage 5. the majority of first-stage ckd patients were hospitalized for ≤7 days because generally, the patient is not in life-threatening condition, so patients can be discharged immediately after being treated. in those patients, clinical monitoring will be carried out in the form of vital signs and supporting examinations to determine the patient’s overall condition. if the patient is found contraindicated for treatment (anemia, leucopenia, thrombocytopenia), then the correction will be carried out first before starting therapy. in addition to the etiology and stage of the disease, there are other factors influence the los of patients with ckd in children. in this study, several patients went home before achieving recovery for various reasons both financial and family reasons. this is supported by nursalam’s study which states the reason for leaving a patient can affect the los of the patient. other studies also confirmed that length of stay children hospitalized with chronic kidney disease based on etiology and stage in dr. hasan sadikin hospital bandung, indonesia international journal of integrated health sciences 31 patient condition at discharge affected los.16 in the present study, the patient’s condition at discharge was unclear because it was not stated in the medical record, unless if the patient dies. this may affect the los of patients in this study. in the patient funding source data, the majority of patients pay with governmental insurance (bpjs), pbi and non-pbi. a study in iran states that the method of payment affects the los of patients with the results of patients who use health insurance have a longer stay than patients with independent payments.17,18 the limitation of this study is inaccessible registry data from the hospital system due to the transfer of paper-based data to paperless. besides, the limited time of the study also caused a reduction in the sample taken in this study, causing an uneven distribution of the number of members in each group of data. for further research it is recommended that the recording of data registers can be done more carefully. besides, further research is expected to increase the number of samples by extending the period so that the data collected can better present each group of data. a multicentre study in various regions is also needed to obtain data that better represents the los of pediatric ckd patients throughout indonesia. it can be concluded that from 103 patients with ckd at dr. hasan sadikin general hospital bandung in the 2016–2018 period, the majority of the patients are male, adolescent, and have sources of funding from bpjs, pbi and non-pbi. ckd with srns has the potential to prolong the los, so the patients will need greater costs. in patients with ckd stage 5, the duration of los is longer because most patients experience hemodynamic disorders that require stabilization before starting treatment. angelreika libowo, ahmedz widiasta, et al. 1. kdigo. clinical practice guideline update for the diagnosis, evaluation, prevention, and treatment of chronic kidney disease. kidney int suppl. 2017;7(3):e1. 2. becherucci f, roperto rm, materassi m, romagnani p. chronic kidney disease in children. clin kidney j. 2016;9(4):583–91. 3. wong cj, moxey-mims m, jerry-fluker j, warady ab, l. furth s. ckid (ckd in children). nih public access. 2013;60(6):1002–11. 4. initiative nkf (nkf) kdq. clinical practice guidelines. new york: national kidney foundation; 2002. 5. pardede so, chunnaedy s. penyakit ginjal kronik pada anak. sari pediatr. 2017;11(3):199. 6. couser wg, remuzzi g, mendis s, tonelli m. the contribution of chronic kidney disease to the global burden of major noncommunicable diseases. kidney int. 2011;80(12):1258–70. 7. el nahas am, bello ak. chronic kidney disease: the global challenge. lancet. 2005;365 (9456):331–40. 8. kemenkes ri. situasi penyakit ginjal kronis. pus data dan inf kementerian kesehatan ri. 2017. 9. azalea m, andayani tm. analisis biaya pengobatan penyakit ginjal kronis rawat inap dengan hemodialisis di rumah sakit. j manaj dan pelayanan farm. 2016;141–50. 10. warady ba, chadha v. chronic kidney disease in children: the global perspective. pediatr nephrol. 2007;22(12):1999–2009. 11. goldberg i, krause i. the role of gender in chronic kidney disease. eur med j. 2016;1(2):58–64. 12. carrero jj, hecking m, chesnaye nc, jager kj. sex and gender disparities in the epidemiology and outcomes of chronic kidney disease. nat publ gr. 2018; available from: http://dx.doi. org/10.1038/nrneph.2017.181 13. maalej b, louati h, guirat r, wali m, abid h, jallouli m, et al. childhood chronic kidney disease. imedpub journals. 2018;2(1);1–3. 14. nourbakhsh n, mak rh. steroid-resistant nephrotic syndrome: past and current perspectives. pediatric health med ther. 2017; 8:29–37. 15. sahay m. congenital anomalies of kidney and urinary tract. clin queries nephrol. 2013;2(4):156–65. 16. sepehri a, simpson w, sarma s. the influence of health insurance on hospital admission and length of stay-the case of vietnam. soc sci med. 2006;63(7):1757–70. 17. khosravizadeh o, vatankhah s, bastani p, kalhor r, alirezaei s, doosty f. factors affecting length of stay in teaching hospitals of a middle-income country. electron physician. 2016;8(10):30423047. 18. gohari m, vahabi n, moghadamifard z. semi-parametric cox regression for factors affecting hospitalization length. daneshvar pezeshki. 2012;19(99):23–30. references 70 international journal of integrated health sciences. 2017;5(2) original article intervertebral disc characteristic on progressive neurological deficit abstract objective: to examine the intervertebral disc characteristic on magnetic resonance imaging (mri) in lumbar herniated disc (lhd) patients with progressive neurological deficit. methods: patients were collected retrospectively from dr. hasan sadikin general hospital database from 2011–2013 with lhd, had neurological deficit such as radiculopathy and cauda equine syndrome for less than four weeks with a positive sign confirmed by neurological examination and confirmatory with mri examination. results: a total of 14 patients with lumbar herniated disc disease (10 males, 4 females) suffered from progressive neurological deficit with an average age of (52.07±10.9) years old. early disc height was 9.38±0.5 mm and progressive neurological deficit state disc height was 4.03±0.53 mm, which were significantly different statisticaly (p<0.01). symptoms of radiculopathy were seen in 11 patients and cauda equine syndrome in three patients. modic changes grade 1 was found in five patients, grade 2 in eight patients,grade 3 in one patient, pfirmman grade 2 in eleven patients and grade 3 in three patients. thecal sac compression 1/3 compression was seen in four patients and 2/3 compression in ten patients. conclusions: neurosurgeon should raise concerns on the characteristic changes of intervertebral disc in magnetic resonance imaging examination to avoid further neural injury in lumbar herniated disc patients. keywords: lumbar herniated disc, magnetic resonance imaging, progressive neurological deficit pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v5n2.1042 ijihs. 2017;5(2):70–4 introduction significant impacts of the implementation of the national health insurance scheme were seen in the annual increase of the incidence of low back pain (lbp) with a considerable loss of working time and socioeconomic burden. increased older age population and changes in the intervertebral disc characteristics that are associated with repetitive minor trauma at endplate can cause low back pain (lbp). although imaging studies showed that disc degeneration strongly correlate with lbp, not all of disc degeneration are symptomatic.1–7 intervertebral disc is a structure that has a viscoelastic and avascular nature which makes it possible for the degeneration process to change the anatomy of the disc. early phase noticeable by proteoglycan depletion and reduce of water content, changes osmotic pressure. therefore, early diagnosis of disc degeneration is critical for the success of any modality of treatment strategy.8,9 the etiologic factors of nocioceptive and disability caused by pathological disc is still currently debatable.2,10 a common belief is that changes the diffusion of water will result in structural changes in nucleus pulposus, annulus and end plate that are altered the internal disc stability.11,12 magnetic resonance imaging (mri) is highly accurate in detecting abnormality of the disc, but the relationship between findings on mri and clinical course farid yudoyono, rully hanafi dahlan, muhammad zafrullah arifin department of neurosurgery, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital, bandung correspondence: farid yudoyono, department of neurosurgery, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital jl. pasteur no. 38, bandung, indonesia e-mail: faridspine@gmail.com received: may 5, 2017 revised: july 31, 2017 accepted: august 28, 2017 :70–4 international journal of integrated health sciences. 2017;5(2) 71 remains controversial.5,6,13,14 methods ethical approval for the current study was granted by the ethics committee of the faculty of medicine, universitas padjadjaran. the patients were collected retrospectively from dr. hasan sadikin general hospital database for the period of 2011–2013 by including those with a diagnosis of lhd, a history of radiculopathy and cauda equine syndrome with progressive neurological deficit within less than four weeks with concomitant neurologic examination that correlated with the same nerve root being affected and a confirmatory cross-sectional imaging study demonstrating a herniated disc at the level and side corresponding to their symptoms. the exclusion criteria comprised of malignancy, significant deformity, prior back surgery and other established contraindications to elective surgery. lumbar spine mri were acquired using magnets operating at field strength of 1.5 tesla with axial and sagittal t1 weighted, t2 weighted. images were collected as printed films and then digitized using computer system. all images were identified for patient confidentiality. patients received either a standard open discectomy or decompression of the involved nerve. disc height was defined as the disc height measured as the distance between the inferior endplate to the superior endplate at middle vertebral body line performed by mri and plain lumbal radiograph for repeated examinations.15,16 the assessment included the followings: disc morphology, thecal sac modified compression by the disc fragment characterized as non, <1/3, 2/3, or >2/3 as a relative term for canal compromise secondary to disk herniation; disc degeneration described by pfirrmann; endplate marrow abnormality according to the modic classification in which modic 1 refers to edema-like signal intensity, modic 2 refers to fat-like signal intensity and modic 3 refers to sclerosis-like signal intensity (fig. 1 and 2).5,17–20 data analyses were performed using spss version 13 for windows (spss, inc, chicago, il, usa). data are presented as the number of subjects in each group or mean±sd. each independent variable was compared using the t test. :70–4 farid yudoyono, rully hanafi dahlan, et al. table 1 patients characteristics sex age level symptoms dh early (mm) dh prog (mm) bulging type modic pfirmman thecal sac m 64 l345 rad. 10 5.3 protruded 1 3 2/3 m 67 l345 rad. 9 4.3 protruded 1 3 2/3 f 32 l5s1 rad. 10 5.7 protruded 1 3 1/3 f 33 l5s1 rad. 9.5 4.4 prostruded 1 3 1/3 f 50 l5s1 ces 9.2 3.7 protruded 1 3 2/3 m 62 l345 rad. 10.3 3.4 extruded 2 3 2/3 m 62 l345 rad. 9.2 3.2 extruded 2 3 2/3 f 45 l45s1 ces 9 4.7 protruded 2 2 2/3 m 45 l45s1 rad. 8.9 4.5 extruded 2 2 1/3 m 56 l45 rad. 9 3.3 extruded 3 3 2/3 m 58 l45 rad. 10.3 4.8 protruded 2 2 2/3 m 59 l345 ces 9.2 3.2 extruded 2 3 2/3 m 47 l345 rad. 8.8 3.1 extruded 2 3 2/3 m 49 l23 rad. 9 2.9 extruded 2 3 2/3 notes: dh= disc height, f= female, m= male, l= lumbar; early= first radiological examination, prog= pregressive neurological deficit tim, rad.= radiculopathy, ces= cauda equina syndrome 72 international journal of integrated health sciences. 2017;5(2) intervertebral disc characteristic on progressive neurological deficit table 2 study results variables value patients 14 sex f=4/m=10 age (years old) 52.07± 10.9 level l23 1 l345 6 l45 2 l45s1 2 l5s1 3 symptom radiculopathy 11 cauda equina synd 3 dh early (mm) 9.38 ± 0.5 dh progressive (mm) 4.03 ± 0.53 bulging type protruded 7 extruded 7 modic grade 1 5 grade 2 8 grade 3 1 pfirmman grade 1 0 grade 2 11 grade 3 3 thecal sac compression normal 0 1/3 3 2/3 11 results a total 14 patients with lumbar herniated disc disease (10 males, 4 females) suffering from progressive neurological deficit with avarage age of (52.07±10.9) years old between january 2012 and december 2013 were evaluated retrospectively. early disc height of 9.38±0.5 mm and progressive disc height of 4.03±0.53 mm were found, which were significantly different (p<0.01). one, six, two, two and three patients had lhd at the l2-3,l3-4-5,l4-5,l45-s1,l5-s1 levels. symptoms of radiculopathy were found in 11 patients and cauda equine syndrome in three patients. protruded disc was seen in 7 patients and extruded type in 7 patients. modic changes grade 1 was revealed in five patients, grade 2 in eight patients and grade 3 in one patient. pfirmman grade 2 was found in eleven patients and grade 3 in three patients. thecal sac compression 1/3 compression was observed in three patients and 2/3 compression in eleven patients. discussion with the increasing size of aging population, a higher prevalence of clinical disability related to disc degeneration disease is seen. lumbar herniated disc was the most common cause of low back pain and it was observed as a major aspect of disc degeneration around the globe. advances in the development of neuroimaging technology allows an excellent noninvasive means of imaging for the entire lumbar spine. the contrast, sensitivity and also the multi planer images help clarifying the disc anatomy within or adjacent spine. intervertebral disc characteristic of the lumbar spine has been play important role in development of low back pain. recent studies have reported the usefulness of routine use of mri in evaluating of nerve root compression and relation with clinical symptoms.17 by gender, men were more prone to ldh, which is a warning for society. the findings of our study are consistent with those of other studies.5 this results showed that men are more susceptible to disc degeneration when compared to women, which is most likely due to increased mechanical stress and injury. in this study, the authors found the disc height reduced significantly before the surgery. this supports the hypothesis of the previous study.6 the previous study showed that more than 50% decrease disc height in painfull degenerative disc. a previous study found that a modic change includes segmental instability and strongly correlation with progression of neurological symptoms.18 however, another previous studies showed that modic changes in the degenerative process of disc in relation to back pain and associated with aggravation of neurological deficit.19 in this study, the authors found that grade 2 of modic changes were found in 57% of subjects, meaning a high number of increased modic changes as reactive bone and granulation tissue are found :70–4 international journal of integrated health sciences. 2017;5(2) 73:70–4 farid yudoyono, rully hanafi dahlan, et al. in early phase of degenerative process.20 a previous study has reported pfirmann grading use in assessing disc degeneration on mri, and it associated with increasing back pain.19 current findings of this study could support the extension of this hypothesis since the majority of participants had disc degeneration of pffirman grade 2, i.e. w11 patients (78%), which is similar to the results of the study by hansen et al.19 a previous study by albert et al.20 reported that mri change findings in the lumbar intervertebral disc have a significant association with age, indicating lbp. the study shows that the average age of lumbar herniated disc patients is more than 50 years old, i.e. 52.07±10.9 years old. people of that age seems to be vulnerable because of the decrease in the elasticity and water content of the nucleus with age. 3,15 our current study found that lumbar level 345 was observed in six patients (43%). this is due to the fact that lumbar spine carries most of the body weight. thecal sac compression or canal was found to be 2/3 compromised in 11 patients (71%), which is similar to what was revealed in the study by lurie et al.5 these consistent findings suggest that compromised canal may denote as the guide point of neurological deficit that is related to lhd perioperatively. in lumbar degenerative disc patients, the intervertebral disc has a wide range of presentations including changes in disc height, endplate, and within the disc, simoultaneously. in contrast, the current study shows that changes in the intervertebral disc morphology relates to progressive neurological deficit. there are several limitations to our study. although mri has become the gold standard for imaging of ldh due to its ability to capture vertebral bone and soft tissue pathology, it is quite expensive that the use is limited due to funding considerations. furthermore, the small sample size in this study may make the estimates for these subgroups imprecise. therefore, further studies specifically designed to evaluate these future are needed t. in conclusion, neurosurgeon should raise concerns on the characteristic changes of intervertebral disc in magnetic resonance imaging examination to avoid further neural injury in lumbar herniated disc patients. disc height measurement and modic changes b) thecal sac compression measurement 1/3 (asterix), 2/3 ( β ) and >2/3 (α) fig. 2lumbar herniated disc on sagittal t2 weighted image , a) axial t2 weighted image (red asterixs) fig. 1 references 1. le maitre cl, freemont aj, hoyland ja. accelerated cellular senescence in degenerate intervertebral discs: a possible role in the pathogenesis of intervertebral disc degeneration. arthritis res ther. 2007;9(3):1– 12. 2. peng b, fu x, pang x, li d, liu w, gao c, yang h. prospective clinical study on natural history of discogenic low back pain at 4 years of followup. pain physician. 2012;15(6):525–32. 3. kato f, yukawa y, suda k, yamagata m, ueta t. normal morphology, age-related changes and 74 international journal of integrated health sciences. 2017;5(2) intervertebral disc characteristic on progressive neurological deficit abnormal findings of the cervical spine. part ii: magnetic resonance imaging of over 1,200 asymptomatic subjects. eur spine j. 2012; 21(8):1499–507. 4. el barzouhi a, vleggeert-lankamp cl, lycklama à nijeholt gj, van der kallen bf, van den hout wb, jacobs wc, et al. magnetic resonance imaging in follow-up assessment of sciatica. n engl j med. 2013;368(11):999–1007. 5. lurie jd, moses ra, tosteson ana, tosteson td, carragee ej, carrino ja, et al. magnetic resonance imaging predictors of surgical outcome in patients with lumbar intervertebral disc herniation. spine (phila pa 1976). 2013;38(14):1216–25. 6. o’neill c, kurgansky m, kaiser j, lau w. accuracy of mri for diagnosis of discogenic pain. pain physician. 2008;11(3):311–26. 7. boyd lm, richardson wj, allen kd, flahiff c, jing l, li y, et al. early-onset degeneration of the intervertebral disc and vertebral end plate in mice deficient in type ix collagen. arthritis rheumatism. 2008;58(1):164–71. 8. cortes dh, magland jf, wright ac, elliott dm. the shear modulus of the nucleus pulposus measured using mr elastography: a potential biomarker for intervertebral disc degeneration. magn reson med. 2014;72(1): 211–9. 9. melrose j, smith sm, appleyard rc, little cb. aggrecan, versican and type vi collagen are components of annular translamellar crossbridges in the intervertebral disc. eur spine j. 2008;17(2):314–24. 10. schenk p, läubli t, hodler j, klipstein a. magnetic resonance imaging of the lumbar spine: findings in female subjects from administrative and nursing professions. spine (phila pa 1976). 2006;31(23):2701–6. 11. beattie pf, morgan ps, peters pd. diffusionweighted magnetic resonance imaging of normal and degenerative lumbar intervertebral discs: a new method to potentially quantify the physiologic effect of physical therapy intervention. j orthop sports phys ther. 2008;38(2):42–9. 12. abu-ghanem s, ohan n, abu-ghanem y, kitta m, shelef i. acute schmorl node in dorsal spine: an unusual cause of a sudden onset of severe back pain in a young female. asian spine j. 2013;7(2):131–5. 13. takashima h, takebayashi t, yoshimoto m, terashima y, tsuda h, ida k, yamashita t. correlation between t2 relaxation time and intervertebral disk degeneration. skeletal radiol. 2012;41(2):163–7. 14. sa n, juhasz i, komaromy h, pozsar k, zsigmond i, perlaki g, et al. a statistical model for intervertebral disc degeneration: determination of the optimal t2 cut-off values. clin neuroradiol. 2014;24(4):355–63. 15. ma dy, liang y, wang d, liu z, zhang w, ma t, et al. trend of the incidence of lumbar disc herniation: decreasing with aging in the elderly. clin interv aging. 2013;8:1047–50. 16. phan k, mobbs rj,. rao pj. foraminal height measurement techniques. j spine surg. 2015;1(1):35–43. 17. hilal k, sajjad z, sayani r, khan d. utility of limited protocol magnetic resonance imaging lumbar spine for nerve root compression in a developing country, is it accurate and cost effective? asian spine j. 2013;7(3):184–9. 18. zhang yh, zhao cq, jiang ls, chen xd, dai ly. modic changes: a systematic review of he literature. eur spine j. 2008;17(10):1289–99. 19. hansen bb, bendix t, grindsted j, bliddal h, christensen r, hansen p, et al. effect of lumbar disc degeneration and low-back pain on the lumbar lordosis in supine and standing: a cross-sectional mri study. spine. 2015;40(21):1690–6. 20. albert hb, kjaer p, jensen ts, sorensen js, bendix t, manniche c. modic changes, possible causes and relation to low back pain. medical hypotheses. 2008;70(2):361–8. :70–4 64 international journal of integrated health sciences. 2017;5(2) original article correspondence: thomas sintong pratama purba, department of physical medicine and rehabilitation, faculty of medicine, universitas padjajaran-dr. hasan sadikin general hospital jl. pasteur no. 38, bandung, indonesia e-mail: thomas.purba@gmail.com effect of quadriceps muscle strengthening exercise on quadriceps and hamstring muscle strength ratio in patients with osteoarthritis grade 2 and 3 abstract objective: to evaluate the effect of quadriceps muscle strengthening exercise on quadriceps and hamstring strength ratio in knee osteoarthritis (oa). methods: this was a quantitative study with quasi-experimental design. the subjects in the study were 16 female patients with knee oa grade 2 and 3. quadriceps muscle strengthening exercise was given to the subjects 3 times a week during 8 weeks. the study was conducted at the department of physical medicine and rehabilitation of the faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital in august–september 2015. results: it was revealed that the quadriceps muscles improved significantly. however, the hamstring muscles did not show significant improvement based on the comparison between before and after performing the exercise. the average right quadriceps muscle strength before exercise was 12.46 and after exercise was 18. the average left quadriceps muscle strength before and after exercise were 11.59 and 17.7, respectively. the average right hamstring muscle strength before and after exercise were 7.29 and 7.94, respectively. conclusions: there are quadriceps muscle strength improvements after practicing quadriceps muscle strengthening exercise. however, no significant hamstring muscle strength improvement is seen after practicing quadriceps muscle strengthening exercise. an improvement in quadriceps and hamstring muscle ratio is observed. keywords: osteoarthritis, quadriceps and hamstring muscle strength ratio, quadriceps muscle strengthening exercise pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v5n2.1041 ijihs. 2017;5(2):64–9 thomas sintong pratama purba, marina annette moeliono, sunaryo barki sastradimadja department of physical medicine and rehabilitation, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital, bandung introduction knee osteoarthritis (oa) is a joint disease that is commonly found in elderly. knee oa affects >40% europeans and americans, leading to disabilities.1 osteoarthritis is a disease that is characterized by a joint cartilage degradation followed by the degradation in the subchondral bone and synovial joint capsule.2 some of the oa factors are associated with the presence of mechanical loading and degenerative process. the clincal simptoms that are frequently found in oa patients include joint stiffness, joint range of motion (rom) reduction, quadriceps muscle weakness, and proprioception internal changes.3 knee as the largest joints providing support for the body weight is frequently affected by oa. knee oa patients find difficulties to do daily activities, especially those requiring mobilization as well as transference processes. muscle strengths plays a role in the oa knee pathogenesis. previous studies reported the correlation between muscle imbalance and muscle weakness in knee joints with several symptoms, e.g. decreases in functional ability, received: may 5, 2017 revised: june 22, 2017 accepted: august 28, 2017 :64–9 international journal of integrated health sciences. 2017;5(2) 65 the presence of pains, and fall risks.2–5 quadriceps and hamstrings are two largest muscles in the frontal plane. co-contraction from the quadriceps and hamstring muscles can increase joint compressive forces, leading to knee joint stabilization. dynamic stability in the frontal plane occurs due to quadriceps and hamstring abduction/aduction moment arm. correlation between quadriceps and hamstring muscle strengths have been investigated in several studies. a study by adogoke et al.6 described a lower quadriceps and hamstring muscle strength ratio in oa patients when compared to the healthy young population. another study described a correlation between quadriceps and hamstring muscle strength ratio and symptomatic knee oa after practicing typical quadriceps and hamstring muscle strengthening exercises.2 in such, quadriceps muscle weakness was stated as a primary cause to quadriceps and hamstring value changes in oa knee patients.6 several existing studies have reported that the hamstring muscles considerably influence the quadriceps and hamstring muscle strength rasio. strengthening exercise is applied to knee oa patients based on findings that quadriceps muscle weakness is regarded as a major factor in the deviation of quadriceps and hamstring ratio value.3–5 the muscle strengthening exercise that is recommended to knee oa patients includes quadriceps muscle strengthening exercise with no weight bearing. this exercise program can be performed because it can distinctively strengthen the specific muscles and is appropriate for patients who experience pain when practicing weight bearing exercise.7 therefore, this study aimed to analyze the effect of quadriceps muscle strengthening exercise to the quadriceps and hamstring muscle strength ratio. methods population in this study comprised of the knee oa patients who visited physical medicine and rehabilitation clinic, dr. hasan sadikin general hospital, bandung. the study was conducted in the period of august–september 2015. the subjects were members of the population who met the inclusion criteria and did not meet the exclusion criteria and were willing to participate in the study by signing the informed consent. the number of subjects was defined using consequtive sampling approach; thus, the knee oa patients who met the criteria were included in the study for a certain period until the total required samples were obtained. the total required sample size was calculated based on a previous study with 16 subjects as the minimal numbers. this study used the pre-post designs with 1 group consisted of 16 subjects. the subjects were then given information related to the examination and intervention procedures. participants who did not attend the exercise three times in a row are considered dropped out. inclusion criteria in this study were females aged 40–70 years, diagnosed with oa knee grade 2 and 3 in sub acute and chronic phases based on american college of rheumatologi (acr) and kellgren lawrence criteria, neutral alignment of knee joint, and able to walk with or without any gait aid. the exclusion criteria in the study were valgus-varus or recurvatum deformities, knee instabilities due to ligamentous laxity in cruciate ligament or collateral and meniscus injuries, stroke or certain neural system disorders, knee injury (fracture, ligament rupture or meniscus) or knee surgery, suffering from degenerative or metabolic diseases (arteriosclerosis, diabetes mellitus) or other inflammatory disorders, performing high intensity exercise (tennis, badminton) or attending other strengthening exercises in the last 6 months, and a numeric rating scale (nrs) >6. the research method used in the study was quantitative with quasi-experimental design while the study design was experimental with one group pretest-posttest design. data were calculated to analyze the effect of the treatment by using paired t test for normally distributed data or wilcoxon matched pairs test for nonnormally distributed data. the study analyzed the correlation between dependent and independent variables. the independent variable was quadriceps muscle strengthening exercise while the dependent variables were quadriceps muscle strength, hamstring muscle strength, and quadriceps and hamstring muscle strength ratio. the confounding variables were body mass index (bmi) and age. the subjects involved in the study were knee oa grade 2–3 patients given quadriceps muscle strengthening exercise. comparative examination between the quadriceps and hamstring muscles were performed before and after the intervention. subjects were asked to do quadriceps strengthening exercise for 8 weeks, 3 times a week. the exercise was conducted at the department of physical thomas sintong pratama purba, marina annette moeliono, et al. :64–9 66 international journal of integrated health sciences. 2017;5(2) quadriceps muscle strengthening exercise effect to quadriceps and hamstring muscle strength ratio in osteoarthritis grade 2 and 3 patients medicine and rehabilitation of the faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital. the quadriceps and hamstring muscle strength examinations were performed before and after the study to investigate the muscle comparison after the exercise. this study used several devices for clinical examinations, such as height and weight measuring instruments, blood pressure monitor device, push-pull dynamometer, and quadriceps exercise bench. quadriceps strengthening muscle exercise is regarded as the most suitable excercise for oa patients. the exercise can be done dynamically and isotonically due to the fact that quadriceps muscles contract concentrically while the hamstring muscles will contract eccentrically as quadriceps muscle co-contractor. as such, quadriceps muscle strengthening exercise can improve hamstring muscles (fig. 1).6 quadriceps muscle strengthening exercise is a resistance exercise with external torque resulted by gravitation through the body. when the knee extension tibia on femoral, lower extremities external moment arm increase from 90° to 0° when knee flexion. in contrary, when knee extension femoral on tibia, external moment arm upper body weight decreased 90° to 0° when knee flexion (fig. 2).2,6 the protocol applied for quadriceps muscle measurement was as follow: (a) the examiner held a dynameter with two hands, (b) the dynamometer was placed on the distal end of the tibia, (c) a muscle strength measurement were performed three time to obtain the average value as the measurement result. the subjects in the study should performed the exercise protocols i.e. (1) doing warmingup and stretching exercise in 10 minutes before starting the quadriceps muscle strengthening exercise, (2) sitting on quadriceps exercise bench with stabilization, (3) given an exercise load based on 1 repetition maximum (rm) measurement performed every week at 60% intensity of 1 rm, (4) performing 90° knee extension against the load during the full knee extension in 2 seconds and going back to the starting position with flexible movement, (5) doing 3 set of 10 repetition exercise, (6) performing cooling down and streching in rqbe rqae lqbe lqae rhbe rhae lhbe lhae age -0.31 -0.56 -0.19 -0.44 -0.24 -0.29 -0.16 -0.176 p=0.23 p=0.06 p=0.47 p=0.09 p=0.38 p=0.26 p=0.56 p=0.09 bmi 0.15 -0.18 0.33 0.05 -0.21 -0.18 -0.08 -0.18 p= 0.58 p=0.49 p=0.2 p=0.84 p=0.44 p=0.5 p=0.77 p=0.51 note: bmi= body mass index; lhae= left hamstring after exercise; lhbe= left hamstring before exercise; lqae= left quadriceps after exercise; lqbe= left quadriceps before exercise; rhae= right hamstring after exercise; rhbe= right hamstring before exercise; rqbe= right quadriceps before exercise; rqae= right quadriceps after exercise :64–9 table 2 correlation between confounding variable and quadriceps and hamstring muscle strengths table 1 subject basic characteristics characteristics mean/median minimun maximum sd age 57.875 40 70 10.7633 height 1.525 1.47 1.61 0.04661 weight 62 37 74 7.96633 bmi 26.399 16.015 31.203 3.241 note sd= standard deviation, bmi= body mass index international journal of integrated health sciences. 2017;5(2) 67 10 minutes after the exercise. this study was approved by the ethic committee, dr. hasan sadikin general hospital, bandung, indonesia. results the subjects in this study were 16 knee oa oa grade 2–3 patients aged 40–70 years. the subject basic characteristics show the average age was 57 years old, the average height was 1.525 m, minimum weight was 37 kg, maximum weight was 74 kg (median 62), minimum bmi was 16.015 and maximum bmi was 31.203 (median 26.399) (table 1). results shows that there was a correlation between confounding factor and the quadriceps and hamstring muscle strength, which is not considered as statistically significant (table 2). the average right quadriceps muscle strength before exercise was 12.46 and it became 18 after the exercise (table 3). the average pre-exercise left quadriceps muscle strength was 11.59 while the postexercise value was 17.7. the average right hamstring muscle strength before exercise was 7.29 while after practicing exercise was 7.94. the data distribution of left hamstring muscle strength before exercise was 7.5 while after practicing exercise did not show normal distributed data with a median of 7.5. the results revealed that minimum value was 5.83 and maximum value was 13.16 which did not show normal distributed data with median was 12.5. therefore, the minimum value was 6 and maximum value was 22.5. the statistical analyses applied were paired t test to analyze normal distributed data and paired wilcoxon to analyze the non-normally distributed data. the results showed that the right and left quadriceps muscle strengths improved significantly with a confidence interval (ci) of 95% (p=0.001). however, no significant improvement was found in left hamstring muscle strength. the right quadriceps and hamstring muscle strength ratio was 1.73 before exercise and became 2.3 after the exercise (table 4). left quadriceps and hamstring muscle strength ratio before exercise was 1.61 and 2.26 after the exercise. based on the paired t test statistical analysis, a significant improvement was found in quadriceps and hamstring muscle strength ratio of right and left feet. the results show improved quadriceps and hamstring muscle strength ratio after exercise in knee oa patients. the improvement was statistically significant. discussion muscle strength of the joint is considered as one of several factors which can worsen the condition of knee oa. muscle dysfunctions include inadequate quadriceps muscles and thomas sintong pratama purba, marina annette moeliono, et al. mean before exercise mean after exercise p value right quadriceps muscle strength 12.46 18 0.00 left quadriceps muscle strength 11.59 17.7 0.00 right hamstring muscle strength 7.29 7.94 0.19 left hamstring muscle strength 7.5 7.5 0.11 table 4 comparison between quadriceps and hamstring muscle strength ratio mean before exercise mean after exercise t p value right ratio 17.399 2.3366 -41.992 0.0008 left ratio 1.6195 2.2621 -66.116 0.0000 :64–9 table 3 comparison between quadriceps and hamstring muscle strength in before and after performing quadriceps muscle strengthening exercise 68 international journal of integrated health sciences. 2017;5(2) references 1. kingsbury sr, gross hj, isherwood g, conaghan pg. osteoarthritis in europe: impact on health status, work productivity and use of pharmacotherapies in five european countries. rheumatology. 2014;53(5):937–47. 2. hafez ar, al-johani ah, zakaria ar, al-ahaideb a, buragadda s, melam gr, et al. treatment of knee osteoarthritis in relation to hamstring and quadriceps strength. j phys ther sci. 2013;25(11):1401–5. 3. segal na, glass na, torner j, yang m, felson dt, sharma l, et al. quadriceps weakness predicts quadriceps and hamstring muscle strength ratio deviation which will lead to imbalance of knee joint muscles. this study included 16 knee oa grade 2–3 patients aged less than 70 years who visited dr. hasan sadikin general hospital and met the inclusion criteria. the subjects were given interventions in the form of quadriceps muscle strengthening isotonic exercise 24 times. the subject average age in this study is 57.87 and the standard deviation is 2.81. however, a previous study discovered that knee oa prevalence in >45 years old was 27.8% and >60 years old was 37%.8 the subjects who meet the inclusion criteria of this study relating to knee oa are females. epidemiology proposes that females show higher risks suffering from oa with acute condition than males.8,9 the subject bmi median in this study is 26.39 kg/m2, lower bmi category is 16.01 kg/m2, and higher bmi category is 31.2 kg/ m2. most of the subjects in the study are categorized as overweight (66.67%). the results show similarities to several studies which stated that majority of oa subjects are overweight. overweight subjects show 8.1 times higher of oa risk than normal bmi.10–13 this study reveals that there are significant quadriceps muscle strength improvements. the findings are similar to the previous studies which discover significant quadriceps muscle strength improvements after performing resistance exercise with 60% intensity of 1rm. resistance exercise intensities performed by the subjects were 80% and 60% which show the similar muscle strength improvements and adaptation in elder population with more repetition in lower intensity.14–16 high intensity exercises for oa patients are not allowed due to higher joint compression force which cause pain in knee. as the study included elder population with knee oa, the excercise intensity used was 60% of 1rm. the exercise frequency was 3 times a week, at which the intensity was regarded as more effective for strengthening exercise than others. the strengthening exercise program should be done in 8 weeks to accomodate neural and muscle adaptations.1 no significant hamstring muscle strength improvement was seen after the quadriceps muscle strengthening exercise in this sudy. this finding is caused by insufficient hamstring muscle construction when the quadriceps contraction occurs. several studies describe electromyography (emg) activities in hamstring muscle occured during the end of knee extension. however, this study is similar to a previous study which reveals that in open chained knee extension, hamstring muscle play a role to prevent knee anterior translation.18 quadriceps and hamstring muscle strength ratio improvements are discovered in this study. the results show that quadriceps muscle strength significantly improve after exercise while hamstring muscle strength does not increase significantly. therefore, the average ratio value is higher than healthy adults.6 knee stability in sagittal plane is influenced by two muscle groups, the quadriceps and the hamstring muscle groups. quadriceps and hamstring muscle strength imbalance will increase the risks of injury and nonnorrmal load distribution which stimulate knee oa progressivity. the therapy given to the oa patients should not only include quadriceps muscle strengthening exercise but also quadriceps and hamstring muscle strengths.19,20 the limitation in this study is attributed to the primary research design aimed to examine the quadriceps muscle strength through quadriceps muscle strengthening exercise. consequently, the study did not include the types and load positions as in correlation with hamstring muscles. a further study should be conducted to analyze the correlation between quadriceps and hamstring muscle strength ratio in normal population. an investigation on quadriceps and hamstring muscle strength ratio after quadriceps and hamstring muscle strengthening exercise can also be initiated to obtain accurate comparison. quadriceps muscle strengthening exercise effect to quadriceps and hamstring muscle strength ratio in osteoarthritis grade 2 and 3 patients :64–9 international journal of integrated health sciences. 2017;5(2) 69 risk for knee joint space narrowing in women in the most cohort. osteoarthritis cartilage. 2010;18(8):769–75. 4. brandt kd, dieppe p, radin e. etiopathogenesis of osteoarthritis. med clin north am. 2009;93(1):1–24. 5. palmieri-smith rm, mclean sg, ashton-miller ja, wojtys em. association of quadriceps and hamstrings cocontraction patterns with knee joint loading. j athl train. 2009;44(3):256–63. 6. adegoke boa, mordi el, akinpenlu oa, jaiyesimi ao. isotonic quadriceps-hamstring strength ratios of patients with knee osteoarthritis and apparently healthy controls. afr j biomed res. 2007;10(2):211–6. 7. bennell kl, hinman rs. a review of the clinical evidence for exercise in osteoarthritis of the hip and knee. j sci med sport. 2011;14(1):4–9. 8. zhang y, jordan j. epidemiology of osteoarthritis. clin geriatr med. 2010;26(3):355–69. 9. hämäläinen s, solovieva s, vehmas t, luoma k, leino-arjas p, hirvonen a. genetic influences on hand osteoarthritis in finnish women – a replication study of candidate genes. plos one [serial on the internet]. 2014 may [cited 2016 dec 12];9(5):[about 11p.]. available from: http://journals.plos.org/plosone/ article?id=10.1371/journal.pone.0097417. 10. hafez ar, alenazi am, kachanathu aj, alroumi am, mohamed es. knee osteoarthritis: a review of literature. phys med rehabil int [serial on the internet]. 2014 may [cited 2016 dec 12];1(5):[about 8p.]. available from: http://austinpublishinggroup.com/ physical-medicine/fulltext/pmr-v1-id1021. php#introduction. 11. blumenfeld o, williams fmk, hart dj, arden nk, spector td, livshits g. lower limbs composition and radiographic knee osteoarthritis (rkoa) in chingford sample—a longitudinal study. arch gerontol geriatr. 2012;56(1):148–54. 12. henriksen m, christensen r, danneskioldsamsøe b, bliddal h. changes in lower extremity muscle mass and muscular strength after weight loss in obese patients with knee osteoarthritis: a prospective cohort study. arthritis rheum. 2012;64(2):438–42. 13. lohmander ls, gerhardsson de verdier m, rollof j, nilsson pm, engström g. incidence of severe knee and hip osteoarthritis in relation to different measures of body mass: a populationbased prospective cohort study. ann rheum dis. 2009;68(4):490–6. 14. mayer f, scharhag-rosenberger f, carlsohn a, cassel m, müller s, scharhag j. the intensity and effects of strength training in the elderly. dtsch arztebl int. 2011;108(21):359–64. 15. aguiar gc, do nascimento mr, de miranda as, rocha np, teixeira al, scalzo pl. effects of an exercise therapy protocol on inflammatory markers, perception of pain, and physical performance in individuals with knee osteoarthritis. rheumatol int. 2015;35(3):525– 31. 16. bressel e, wing je, miller ai, dolny dg. highintensity interval training on an aquatic treadmill in adults with osteoarthritis: effect on pain, balance, function, and mobility. j strength cond res. 2014;28(8):2088–96. 17. kisner c, colby la. therapeutic exercise: foundations and techniques. 6th ed. philadelphia: f.a. davis; 2012. 18. kingma i, aalbersberg s, van dieen jh. are hamstrings activated to counteract shear forces during isometric knee extension efforts in healthy subjects? j electromyogr kinesiol. 2004;14(3):307–15. 19. hortobágyi t, westerkamp l, beam s, moody j, garry j, holbert d, et al. altered hamstringquadriceps muscle balance in patients with knee osteoarthritis. clin biomech (bristol, avon). 2005;20(1):97–104. 20. wang h, ji z, jiang g, liu w, jiao x. correlation among proprioception, muscular strength, and balance. j phys ther sci. 2016;28(12):3468– 72. thomas sintong pratama purba, marina annette moeliono, et al. :64–9 80 international journal of integrated health sciences. 2017;5(2) correlation between degree of gibbus angulation, neurological deficits, and pain in spondylitis tuberculosis patients introduction tuberculosis (tb) is an infectious disease that is caused by mycobacterium tuberculosis. tuberculosis primarily affects the lungs (pulmonary tb); however, it can also affect other organs (extra pulmonary tb).1 since 1993, the world health organization (who) has stated tb as a global emergency for humanity. it is estimated that a third of the world population is afflicted by tb.2 tuberculosis mostly affect people living in crowded areas with poor environmental and sanitation condition as well as malnourished patients. bone and joint tuberculosis comprise 35% of all extrapulmonary tb cases with the majority of the case affect the spine (spondylitis) which is about 50% of all bone and joint tb cases. spondylitis tb has higher prevalence in developing countries compared to the rest of the world. common symptoms of spondylitis tb include symptoms of chronic diseases and fatigue, sub-febrile fever especially during night time, nocturnal hyperhidrosis, anorexia, weight loss, tachycardia, and anemia. local symptoms caused by spondylitis tb include pain and stiffness of the back, which are also commonly the first symptoms to occur.3 the worst complications of tuberculosis of the spine are neurological deficits that may take the form of paraor tetraplegia, hemiplegia or monoplegia.4 these neurological deficits occur in 15–42.5% of patients with spondylitis tb.5 spondylitis tb is usually accompanied with a deformity of the spine, which occurs in 80% cases, along with the occurrence of gibbus abstract objective: to analyze the correlation between the degree of angulation and neurological deficits as well as pain in spondylitis tuberculosis (tb) patients. methods: this observational-analytic study included bivariate analysis on data collected from the medical records of patients with presented with spondylitis tb to dr. hasan sadikin general hospital, bandung outpatient clinic from january 2014 to december 2015. the variables were the degree of gibbus angulation, neurological deficits, and pain. results: the study showed significant positive correlation between gibbus angulation and sensory neurological deficits (r=0.375; p=0.009) and there was significant positive correlation between gibbus angulation and pain (r=0.638, p=0.000). the study showed an insignificant correlation between gibbus angulation and motoric neurological deficits (r=0.125; p=0.525). conclusions: there is a significant correlation between the degree of gibbus angulation and pain as well as sensory neurological deficits. meanwhile, no significant correlation is found between the degree of gibbus angulation and motoric neurological deficits. keywords: gibbus angulation, neurological deficits, pain, spondylitis tuberculosis pissn: 2302-1381; eissn: 2338-4506; http://doi.org/10.15850/ijihs.v5n2.1049 ijihs. 2017;5(2):80–3 received: july 10, 2017 revised: august 17, 2017 accepted: september 4, 2017 rizkiditia nugraha hadian,1 renaldi prasetia,2 ahmad faried3 1faculty of medicine, universitas padjadjaran 2department of orthopedics and traumatology, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital, bandung 3department of neurosurgery, faculty of medicine, universitas padjadjaran-dr. hasan sadikin general hospital, bandung correspondence: rizkiditia nugraha hadian, faculty of medicine, universitas padjadjaran jl. raya bandung-sumedang km 21 jatinangor, indonesia e-mail: rizkiditianugrahahadian@gmail.com :80–3 original article international journal of integrated health sciences. 2017;5(2) 81:80–3 rizkiditia nugraha hadian, renaldi prasetia, et al. angulation, that is a form of structural kyphosis where one or more adjacent vertebrae become wedged. the primary cause of the deformity of gibbus is unstable lesion and its progressive development.6 this study aimed to evaluate the correlation between the degree of gibbus angulation and neurological deficits as well as pain. methods this study was an analytical study to evaluate the relationship between the independent and dependent variables. the dependent variables were the motoric and sensoric neurological deficits while the independent variable was gibbus. ethical clearance was obtained from the health research ethics committee faculty of medicine universitas padjadjaran as stated in ethical exemption letter number 575/un6. c1.3.2/kepk/pn/2016. population in this study was all patients with spondylitis tb who received treatment in dr. hasan sadikin general hospital, bandung during 2014–2015. minimum sample size in this study was 48 patients. the subject selection was performed consecutively based on the fulfilment of the inclusion criteria. the inclusion criteria were patients diagnosed with spondylitis tb whom developed gibbus and received treatment at the outpatient clinic of the department of orthopedics and traumatology at dr. hasan sadikin general hospital, bandung. patients were excluded from the study if their medical records were not complete. there were 49 patients who fulfilled the criteria and evaluated in the study. this study used secondary data obtained from patient’s medical records. variables in this study were degree of gibbus angulation, neurological deficits and wong-baker faces pain rating scale for pain. the degree of gibbus angulation and neurological deficits was further classified into several groups. gibbus angulation were classified into: 1) severe, >60°; 2) moderate, 30–60°; and 3) mild, <30°.7 the gibbus was measured with cobb angle (the angle was made by drawing a line through the superior surface of the first normal vertebrae cephalad at upper-end plate to the lesion and a line through the inferior surface of the first normal caudal, lower end plate, to the lesion). perpendiculars were drawn from these line and cobb angle was measured at their section (fig.).8–10 neurological deficits were identified based on the assessment of the motoric and sensory functions. the results of the motoric function assessment were classified into: (1) 5 as full rom, able to move against gravity with full strength (normal), (2) 4 as full rom, able to move against gravity with moderate strength, (3) 3 as full rom, able to move against gravity only, (4) 2 as full rom, unable to move against gravity, (5) 1 as visible muscle contraction without joint movement, and (6) 0 as without muscle contraction. the sensory function assessment results were then classified into several groups: (1) normal, (2) hyperesthesia, (3) hypoesthesia, (4) anesthesia. wong-baker faces pain rating score scale were classified into: (1) severe, pain from 7–10, (2) moderate pain from 4–6, (3) mild pain from 1–3. after clustering, the data were analyzed using statistical analysis software to determine p and r value and the correlation between variables were observed. results total samples included in this study were 49 patients, which consisted of 18 male patients and 31 female patients. the characteristics of patients with spondylitis tb in dr. hasan sadikin general hospital, bandung were described based on the age, sex, neurological deficits and wong-baker faces pain rating scale (table 1). the results showed that there were more spondylitis tb patients who were >35 years old (51%); females (63%); with mild degree of gibbus angulation (67.3%); with normal motoric neurological functions (79.6%); with normal sensory neurological functions (87.8%), and with moderate wongbaker faces pain rating scale (65.3%). radiograph showing measurement of cobb angle fig. 82 international journal of integrated health sciences. 2017;5(2):80–3 correlation between the degree of gibbus angulation, neurological deficits and pain in spondylitis tuberculosis patients table 1 subject characteristics characteristics n % age (yrs.) <35 24 49 >35 25 51 gender male 18 37 female 31 63 degree of gibbus angulation mild 33 67 moderate 14 28 severe 2 4.1 neurological deficits motoric 39 79 normal 10 20 not normal sensory 43 88 normal 6 12 not normal wong-baker faces pain rating scale mild 12 24 moderate 32 65 severe 5 10 total 49 100 note: yrs.= years there was no correlation found between the degree of gibbus angulation and neurological deficits (motoric) based on lambda analysis method, with r value = 0.125 and p 0.525 (>0.05) (table 2). meanwhile, there were correlation between gibbus angulation and neurological deficits (sensory), also using lambda analysis method, with r value = 0.375 and p = 0.009 (p <0.05). there were also a correlation between gibbus angulation and wong-baker faces pain rating scale after analysis using spearman’s method; with r=0.638 and p=0.000 (<0.05). discussion distribution of the patients’ characteristics are described (table 1). there were 49 patients with spondylitis tb in dr. hasan sadikin general hospital, bandung during the period analyzed in this study with the majority of the patients aged 35 years old and older (51%). this disease seems to occur more often in women than in men (63%). the finding on age is in agreement with the result from a previous study on the prevalence of patients with spondylitis tb.11 however, in the previous study it is stated that spondylitis tb occur more frequently in men (62%). based on the degree of gibbus angulation that had been previously classified into mild, moderate, and severe, more patients suffered from mild gibbus angulation degree (67%). this agrees with the result from a previous study which stated that, on average, the preoperative spondylitis tb patients were still classified as mild. most patients still maintain the normal motoric and sensory functions. although neurological deficits are recognized as the complications of spondylitis tb, most patients in this study had not experienced complications.12 in this study, patients experiencing sensory neurologic deficits were assessed for their sensory function through the use of the light touch stimuli. the degree of gibbus angulation was found as having a significant positive correlation with sensory neurological deficits, correlation coefficient of r value = 0.375 and p value = 0.009 (p <0.05). this is in line with other study, which suggested that spondylitis tb patients experienced paraparesis with sensory neurological deficits.13 this is caused by compression due to cold abscess, resulting in vascular thrombosis.3 on the other hand, with motoric function assessment via the muscle strength assessment in patients, the correlation coefficient of r value was 0.125 and the p value was 0.525 (>0.05), resulting in no correlation between the degree of gibbus angulation and motoric neurological deficits.5 the finding is supported by the result table 2 correlation between dependent and independent variables variable r p value correlation between gibbus and neurological deficits (motoric) 0.125 0.525 (>0.05) correlation between gibbus and neurological deficits (sensory) 0.375 0.009 (<0.05) correlation between gibbus and vas score 0.638 0.000 (<0.05) international journal of integrated health sciences. 2017;5(2) 83 rizkiditia nugraha hadian, renaldi prasetia, et al. :80–3 1. world health organization. global tuberculosis report 2015: the effects of brief mindfulness intervention on acute pain experience: an examination of individual difference. bull who 2015;1(20):1689–99. 2. kementerian kesehatan republik indonesia. terobosan menuju akses universal: strategi nasional pengendalian tb di indonesia 2010– 2014. stop tb. 2011;(1):1–80. 3. sahputra re, munandar i. spondilitis tuberkulosa cervical. j kes andalas. 2015;4(2):639–48. 4. jain ak. tuberculosis of the spine. j bone joint surg. 2010;92(7):905–13. 5. ha k, kim y. late onset of progressive neurological deficits in severe angular kyphosis related to tuberculosis spondylitis. eur spine j. 2016;25(4):1039–46. 6. spiegel d, singh g, banskota a. tuberculosis of the musculoskeletal system. tech orthop. 2005;20(2):167–78. 7. gokce a, ozturkmen y, mutlu s, gokay n s, tonbul m, caniklioglu m. the role of debridement and reconstruction of sagittal balance in tuberculous spondylitis. indian j orthop. 2012;46(2):145–9. 8. shrestha op, sitoula p, hosalkar hs, banskota as, spiegel da. bone and joint tuberculosis. upoj. 2010;20(1):23–8. 9. jain ak, dhammi ik, jain s, mishra p. kyphosis in spinal tuberculosis – prevention and correction. indian j orthop. 2010;44(2):127–136. 10. soon-eok k, jae-hyuk s, ki-ho n, yoon-chung k, kee-yong h. kyphotic angle progression of thoracic and thoracolumbar tuberculous spondylitis after surgical treatment: comparison with predicted kyphosis outcome after conservative treatment. asian spine j. 2009;3(2):80–8. 11. babamahmoodi f, alikhani a, charati j, ghovvati a, ahangarkani f, delavarian l, et al. clinical epidemiology and paraclinical findings in tuberculosis patients in north of iran. biomed res int [serial on the internet]. 2015 jan [cited 2016 jan 12];2015(2015):[about 5p.]. available from: https://www.ncbi.nlm. nih.gov/pmc/articles/pmc4324112/. 12. issack s, boachie-adjei o. surgical correction of kyphotic deformity in spinal tuberculosis. int orthop. 2012;36(2):353–7. 13. jain k, kumar j. tuberculosis of spine: neurological deficit. eur spine j. 2013;22(suppl 4):s624–33. 14. garg r, somvanshi d. spinal tuberculosis: a review. j spinal cord med. 2011;34(5):440–54. references of a previous study stating that the lesion in patients with spondylitis tb developed slowly, thus causing spinal cord to gradually adapt with the progressive compression caused by tb lesion.13 due to this spinal cord adaptation, no correlation is found between degree of gibbus angulation and motoric neurological deficits. in this study, all patients who experienced pain, were evaluated for their facial expression when withholding pain. results of the data analysis show that degree of gibbus angulation correlates significantly with wong-baker faces pain rating scale, coefficient r value = 0.638 and p=0.000 (<0.05). these findings are in line with those of a previous study, which mentioned that a significant positive correlation is seen between wong-baker faces pain rating scale and the degree of gibbus angulation due to cold abscess as well as other inflammatory responses affecting spinal cord in patients infected with tb.14 a study limitation include a high number of incomplete medical records in terms of the data on the measurement of degree of gibbus angulation. patients’ examination data should be included completely in the medical record in the future because neat and complete medical records will improve the quality of the study. in summary, there is a correlation between the degree of gibbus angulation and sensory neurological deficits as well as pain. however, there is no correlation between the degree of gibbus angulation and motoric neurological deficits.