medical and health science journal, vol. 4, no.2, august 2020 correspondence: aisyah @2020 medical and health science journal. 10.33086/mhsj.v4i1.1415 available at http://journal2.unusa.ac.id/index.php/mhsj 83 sit to stand test osteoarthritis patients aisyah* 1,2 , marselli widya l 3 , anisgupta larasaty f 3 1 department of physical and rehabilitation medicine, faculty of medicine, universitas nahdatul ulama surabaya 2 department of physical and rehabilitation medicine, rsi. ayani hospital 3 public health and prevention medicine, faculty of medicine, universitas nahdatul ulama surabaya *corresponding author: aisyahdr@unusa.ac.id article info abstract article history: received may,8 2020 received in revised form august, 08 2020 accepted, august, 25 2020 osteoarthritis (oa) is a degenerative disease found in the elderly. the prevalence of total osteoarthritis oa in indonesia was 34.3 million in 2002 and reached 36.5 million in 2007. it is estimated that 40% of the population above 70 years old will suffer from oa. moreover, about 80% of the a patients have limitations in mobility, which in degrees from mild to severe. it leads to a reduction in the quality of life. the development of a simple approach to quantitatively estimating the functional motor performance of various age is crucial to detect the locomotive syndrome (ls) earlier. one available method is the sitting to stand test (stst). up to recently there a lack of studies that conduct the stst in indonesia. this study aims to investigate the average and the cut off of the stst scores in oa patients at ahmad yani hospital, surabaya. we used secondary data, from medical records of the rehabilitation outpatient clinic in 2019 from august to september. we obtain the time of five repetion sit to stand. then using spss 21.0 for analizing the data. the results indicate that the mean and standard deviation of stst scores in osteoathritis patients is 15.72 + 3.45. stst data based on age and its determinants is needed for further research @2020 medical and health science journal. 10.33086/mhsj.v4i1.1415 keywords: osteoarthritis, sit to stand test, elderly motor performan introduction the central statistics agency predicts the number of population aged 65 years and over in 2010-2035 rose from 5.0 percent to 10.6 percent. this changed in structure resulted in a dependency ratio decreasing from 50.5 percent in 2010 to 47.3 percent in 2035. the decrease in the dependency ratio shows the reduced economic burden for the productive age population (working age) which bears the unproductive age population. these findings will automatically affect the health burden because age is a risk factor that is very closely related to degenerative diseases 1 . osteoarthritis is a degenerative disease that found specifically in the elderly. according to the world health organization (who) in 2004, it is known that osteoarthritis affects 151 million people worldwide and reaches 24 million in southeast asia. the prevalence of total osteoarthritis in indonesia was 34.3 million in 2002 and reached 36.5 million in 2007. it is estimated that 40% of the population above 70 years old suffer from osteoarthritis, and 80% of osteoarthritis patients have limited mobility in various degrees from mild to severe which results in reducing the quality of life due to a fairly high prevalence 2 . primary / generalized osteoarthritis can attack the joints, knees, and hands especially the distal interphalangeal joint (dip) and proximal interphalangeal (pip) 3 . this disease causes pain and disability in patients therefore it interferes with daily activities. one of the conservative treatments for knee osteoarthritis is exercise therapy to improve performance, improving function, increasing local muscle strength and original article mailto:%20aisyahdr@unusa.ac.id medical and health science journal, vol. 4, no.2, august 2020 84 endurance, increasing muscle relaxation ability properly, increasing general fitness, all of which play a role in functional capacity. static or dynamic strengthening exercises can maintain or increase the strength of the periarticular muscles to improve or prevent biomechanical abnormalities and their contribution to joint dysfunction and degeneration. the development of a simple approach to quantitatively estimating the performance of functional motors in various ages is very important for early detection of the locomotive syndrome (ls), one of which is the sit to stand test (stst). the stst is conducted by arms folded on the chest, participants rise from their chairs and return to a sitting position as quickly as possible. the time to complete five reps is recorded for two separate experiments, with an interval of 1 minute between each trial. stst results or time scores will be very useful for determining the functional status of individual motors as well as for assessing fall risk. in the mong study (2010), a score of 8.9 + 0.7 was obtained in the young group and 10.8 + 1.7 in the control group (healthy elderly). whereas in other literature states that the higher the stst score can increase the risk of falling. based on buatois, et al., 2008, the cut-off point from the stst score is 15 seconds. a score of 12-15 seconds needs to be reassessed to assess the risk of falling. until recently, there is a lack of studies that discuss stst in indonesia, therefore the cut-off point and the average time may need to be determined. there may be different results that can be influenced by differences in culture, demographics, activities, or treatment regimens. based on the problem above, research is needed to find out what the average sts test score is, especially in osteoarthritis sufferers in indonesia. methods this research is a cross-sectional study by observing stst in the medical records of patients at the medical rehabilitation outpatient clinic, ahmad yani hospital in surabaya. this study was done in augustseptember 2019. sampling using the accidental sampling method that met the inclusion criteria. the inclusion criteria in this study were that respondents were oa sufferers who were diagnosed clinically by the in charged physician and the results of supporting data, and was tested for stst (had stst data on medical records). the exclusion criteria were: respondents were suffering from physical disabilities or mental disorders during the examination. the measured variable is the stst score, with the condition that the stst score is the time between sitting to stand for 5x as measured in seconds using a chair and stopwatch. the method of data collection is done by recording the patient's time in completing five sitting repetitions with arms folded on the chest-the participant rises from the chair and returns to the sitting position as quickly as possible. data analysis was performed using descriptive statistic in spss 17.0 program, and kolmogorovsmirnov to test the normality. results there were 44 samples met the inclusion criteria. the characteristics of the samples are provided in table 1. it can be seen that the distribution of samples in terms of age is evenly distributed between the ages of 50-79 years with the age group 60-69 years dominating (38.6%). the average age is 63.61 years (table 1) furthermore, the number of female samples (86.4%) is higher than the male (13.6%). more than half had low back pain (lbp) with oa (52.35), then followed by people with oa as much as 36.4% (table 1). the patient duration of illness or length of illness samples ranged in the range of 1-5 years (79.5%). table 1 shows that the average length of illness from 44 samples is 2.2 years with a standard deviation of 1.912. medical and health science journal, vol. 4, no.2, august 2020 85 table 1 sample characteristics frequency (n=44) persentage age 40-49 1 2.3 50-59 15 34.1 60-69 17 38.6 70-79 10 22.7 80-89 1 2.3 gender men 6 13.6 women 38 86.4 diagnosis oa 16 36.4 lbp 5 11.4 lbp with oa 23 52.3 duration of sick < 1 year 8 18.2 1-5 year 35 79.5 >5 year 1 2.3 shalah (prayer) position normal 25 56.8 sitting 17 38.6 sitting prostration 2 4.5 from the spss statistical test results (table 2), the minimum value of the stst score is 8.32 seconds, a maximum of 26.24 seconds. the average score is 15.61 seconds with a standard deviation of 3.61 seconds. furthermore, the data was tested for normality with kolmogorov-smirnov, so that the p value was 0.200 (> 0.05) which means that the data was normally distributed tabel 2 descriptive statistics frequency minimum value maximum value mean value sts test 44 8.32 26.24 15.72 discussion osteoarthritis is a disease that is found specifically in the elderly or often called degenerative disease. it is estimated that 40% of the population above 70 years of age suffer from osteoarthritis, and 80% of osteoarthritis patients have limited mobility in various degrees from mild to severe resulting in reduced quality of life due to a fairly high prevalence 2 . this disease causes pain and disability in patients so that it interferes with daily activities. this is in line with the results of our study which showed that the 60-69 year age group dominated the sample (38.6%). whereas in the 70-79 age group ranks third with 22.7%. then it was also seen that 43.1% of the samples had experienced disturbances when doing daily activities, namely prayer. as many as 4.5% of patients could not bow down and then changed into a sitting position, and 38.6% medical and health science journal, vol. 4, no.2, august 2020 86 of patients could only pray by sitting. the average of visual analog scale (vas) n this study was 6.4 + 1.66. the highest proportion of vas scores is 7 (31.8%.) the possibility of this value that causes movement limitations in patients so that interferes with daily activities. in this study, the stst average value was slightly higher than the other studies, which was 15.7 seconds. in a study conducted by buatois, et al., 2008, the cut-off point from the stst score was 15 seconds which was a difference of 0.7 seconds longer. in a study conducted by mong 4 , a score of 8.9 + 0.7 was found in the young group and 10.8 + 1.7 in the control group (healthy elderly) where there was a difference of 6.8 seconds longer in the young group and 4.9 seconds longer in the group control (healthy elderly). the literature also states that the sts test score is influenced by age. the older the age, the higher the score. in the bohannon 6 metaanalysis the sts test scores are classified. if the study was dominated by the 60-69 year age, the normal sts test score will be 11.4 seconds. this score is far below the result study. however, in this study, the stst scores were not categorized based on age. therefore need further research to confirm. conclusion the results of this study indicate that the average of stst scores in osteoathritis patients at ahmad yani hospital, surabaya is 15.72+3,45. this score is higher than the other study. it means that there is possibility that oa patient here has worse quality of life references 1. bps bppn. badan pusat statistik bppn, 2013. proyeksi penduduk indonesia 20102035. jakarta: badan pusat statistik; 2013. 2. soeroso, j, isbagio h, kalim h, broto, pramudiyo r. osteoartitis. buku ajar ilmu penyakit dalam jilid iii edisi v.jakarta:interna publishing; 2006. 3. hamijoyo l. pengapuran sendi atau osteoartritis. perhimpunan reumatologi indonesia: 2007. available from: http://reumatologi.or.id/reuarttail?id=23 4. mong, yiqin. teo, tilda. shamay. 5repetition sit-to-stand test in subjects with chronic stroke: reliability and validity. arch phys med rehabil vol. 2010 [cited 2019 mei]: 91. available from: clinicalkey.com by elsevier. 5. yamako, go. deng, gang. et al. a novel protocol to test age-related decreases in sitto-stand movement abilities in healthy subjects:2016. http://reumatologi.or.id/reuarttail?id=23 d:\new order belum cetak\mhsj v linda prasetyaning widayanti, survei kepuasan pasien klinik uin sunan ampel 77 survei kepuasan pasien klinik uin sunan ampel linda prasetyaning widayanti universitas islam negeri sunan ampel surabaya e-mail: linda.prasetyaning@gmail.com abstrak: adanya mutu pelayanan yang sesuai dengan harapan pasien pasti membuahkan dampak positif dalam keberlangsungan penyelenggaraan klinik uinsa. berdasarkan paparan di atas, maka penelitian ini bertujuan untuk menyurvei tingkat kepuasan pasien di klinik uinsa. penelitian ini merupakan penelitian yang bersifat survei. sedangkan dari segi waktu, maka penelitian ini bersifat cross sectional. populasi penelitian ini adalah seluruh pasien klinik uinsa periode bulan mei 2017. sampling dilakukan dengan incidental sampling. diperoleh sampel sebesar 30 pasien. teknik pengambilan data dengan kuesioner. hasil pengumpulan data disajikan dengan tabel distribusi frekuensi berupa grafik atau diagram. hasil survey didapatkan bahwa karakteristik pasien 87% berusia kurang dari 20 tahun, 70% berjenis kelamin perempuan, 73% puas terhadap pelayanan petugas klinik, 87% puas terhadap pelayanan dokter klinik, 82% puas terhadap lama waktu registrasi di klinik, 73% puas terhadap lama waktu pelayanan apotek klinik, 90% puas terhadap kebersihan klinik. diharapkan penelitian ini bisa dikembangkan oleh peneliti selanjutnya agar mutu pelayanan di klinik uin sunan ampel surabaya bisa lebih baik. kata kunci: kepuasan, pelayanan, pasien, klinik, uin pendahuluan adanya mutu pelayanan yang sesuai dengan harapan pasien pasti membuahkan dampak positif dalam keberlangsungan penyelenggaraan klinik uinsa. hal ini dikarenakan dengan adanya kepuasan pada pasien, diharapkan terjalin hubungan yang harmonis antara klinik dan pasien, tercipta loyalitas pasien pada klinik serta terbentuklah rekomendasi dari mulut ke mulut oleh pasien kepada orang lain. kepuasan tersebut haruslah dirasakan seluruh pasien baik mahasiswa, civitas akademika maupun pasien umum pada semua jenis pelayanan/instalasi di klinik. menurut supriyanto (2007: 189–190) dimensi kualitas dibagi menjadi dua yaitu kualitas teknis dan kualitas fungsional. yang termasuk dalam kualitas teknis adalah search quality, experience quality, credence quality. sedangkan yang termasuk dalam kualitas fungsional adalah rater: reliability (keterandalan), assurance (jaminan), tangible (nyata), empathy (empati), dan responsiveness (cepat tanggap). sedangkan menurut sower (2006) terdapat delapan dimensi mutu pelayanan kesehatan yaitu respect and caring (rasa menghargai dan kepedulian), effectiveness and continuity (efektivitas dan keberlanjutan), appropriateness (kelayakan), information (informasi), efficiency (efisiensi), meals (makanan), first impression (kesan pertama), staff diversity (komposisi pegawai). dengan dimensi tersebut, akan dapat diketahui pengaruh mutu pelayanan dan kepuasan pasien di klinik uinsa. berdasarkan paparan di atas, maka penelitian ini bertujuan untuk menyurvei tingkat kepuasan pasien di klinik uinsa. tujuan umum penelitian ini adalah untuk melakukan survei kepuasan pasien di klinik uinsa. sedangkan tujuan khususnya antara medical and health science journal, vol. 2, no. 1, february 2018 8 lain mengidentifikasi karakteristik pasien, menggambarkan kepuasan pasien terhadap pelayanan petugas (administrasi, perawat dan apoteker), menggambarkan kepuasan pasien terhadap pelayanan dokter, menggambarkan kepuasan pasien tentang lama waktu pelayanan dari mulai registrasi sampai ke ruang perawatan, menggambarkan kepuasan pasien tentang lama waktu pelayanan apotek, menggambarkan kepuasan pasien tentang kebersihan dan kerapian ruangan. material dan metodologi penelitian ini merupakan penelitian yang bersifat survei. sedangkan dari segi waktu, maka penelitian ini bersifat cross sectional. populasi penelitian ini adalah seluruh pasien klinik uinsa periode bulan mei 2017. sampling dilakukan dengan incidental sampling. diperoleh sampel sebesar 30 pasien. penelitian ini dilakukan di pasien di klinik uinsa. alasan pemilihan lokasi penelitian: belum pernah diadakan penelitian serupa di rumah sakit tersebut. waktu penelitian ini dilakukan pada tanggal 4 s/d 13 mei 2017. teknik pengumpulan data primer diperoleh dari pembagian kuesioner kepada pasien klinik uinsa untuk memperoleh gambaran tentang penilaian pasien dan faktor yang memengaruhi ketidakpuasan pasien tentang pelaksanaan sistem pelayanan. hasil pengumpulan data disajikan dengan tabel distribusi frekuensi berupa grafik atau diagram. hasil dan pembahasan 1. karakteristik pasien di klinik uinsa karakteristik pasien menurut usia di klinik uinsa dapat dilihat pada tabel berikut. tabel1 karakteristik pasien menurut usia di klinik uinsa, tahun 2017 no. usia jumlah n % 1. < 20 th 26 87 2. > 20 th 4 13 total 30 100 sumber: data primer tabel 1 menunjukkan sebagian besar pasien berusia kurang dari 20 tahun. karakteristik pasien menurut jenis kelamin di klinik uinsa dapat dilihat pada tabel berikut. tabel 2 karakteristik pasien menurut jenis kelamin di klinik uinsa, tahun 2017 no. jenis kelamin jumlah n % 1. laki-laki 9 30 2. perempuan 21 70 total 30 100 sumber: data primer tabel 2 menunjukkan sebagian besar pasien berjenis kelamin perempuan. 2. kepuasan pasien di klinik uinsa kepuasan pasien terhadap pelayanan petugas di klinik uinsa dapat dilihat pada tabel berikut. tabel 3 karakteristik pasien terhadap pelayanan petugas di klinik uinsa, tahun 2017 no. kepuasan jumlah n % 1. tidak puas 1 3 2. kurang puas 2 6 3. puas 22 73 4. sangat puas 5 18 total 30 100 sumber: data primer linda prasetyaning widayanti, survei kepuasan pasien klinik uin sunan ampel 9 tabel 3 menunjukkan sebagian besar pasien puas terhadap pelayanan petugas di klinik uinsa. kepuasan pasien terhadap pelayanan dokter di klinik uinsa dapat dilihat pada tabel berikut. tabel 4 karakteristik pasien terhadap pelayanan dokter di klinik uinsa, tahun 2017 tabel 6 karakteristik pasien terhadap lama waktu pelayanan apotek di klinik uinsa, tahun 2017 no. kepuasan jumlah n % 1. tidak puas 0 0 2. kurang puas 0 0 3. puas 26 87 4. sangat puas 4 13 total 30 100 sumber: data primer tabel 4 menunjukkan sebagian besar pasien puas terhadap pelayanan dokter di klinik uinsa. kepuasan pasien terhadap lama waktu registrasi di klinik uinsa dapat dilihat pada tabel berikut. tabel 5 karakteristik pasien terhadap lama waktu registrasi di klinik uinsa, tahun 2017 no. kepuasan jumlah n % 1. tidak puas 2 6 2. kurang puas 2 6 3. puas 24 82 4. sangat puas 2 6 total 30 100 sumber: data primer tabel 5 menunjukkan sebagian besar pasien puas terhadap lama waktu registrasi di klinik uinsa. kepuasan pasien terhadap lama waktu pelayanan apotek di klinik uinsa dapat dilihat pada tabel berikut. no. kepuasan jumlah n % 1. tidak puas 1 3 2. kurang puas 3 9 3. puas 21 73 4. sangat puas 5 15 total 30 100 sumber: data primer tabel 6 menunjukkan sebagian besar pasien puas terhadap lama waktu pelayanan apotek di klinik uinsa kepuasan pasien terhadap kebersihan ruangan di klinik uinsa dapat dilihat pada tabel berikut. tabel 7 karakteristik pasien terhadap kebersihan ruangan di klinik uinsa, tahun 2017 no. kepuasan jumlah n % 1. tidak puas 0 0 2. kurang puas 0 0 3. puas 27 90 4. sangat puas 3 10 total 30 100 sumber: data primer tabel 7 menunjukkan sebagian besar pasien puas terhadap kebersihan ruangan di klinik uin. pembahasan berikut adalah faktor-faktor yang memengaruhi rendahnya penilaian dan kepuasan pasien: menurut rahadi (2005) perlakuan perawat yang tidak menyenangkan pasien antara lain kurang ramah pada pasien, tidak cepat melayani pasien, kurang mampu berkomunikasi dengan baik. medical and health science journal, vol. 2, no. 1, february 2018 10 sedangkan menurut tjiptono (dalam purwanto, 2007) komunikasi, yaitu tata cara informasi yang diberikan pihak penyedia jasa dan keluhankeluhan dari pasien. kepuasan pasien tercipta dengan cara bagaimana keluhan-keluhan dari pasien dengan cepat diterima oleh penyedia jasa terutama perawat dalam memberikan bantuan terhadap keluhan pasien. menurut griffith (dalam purwanto, 2007) prosedur administrasi yaitu berkaitan dengan pelayanan administrasi pasien dimulai masuk rumah sakit selama perawatan berlangsung sampai keluar dari rumah sakit. menurut gaspers (dalam yulia, 2008) kesopanan dan keramahan dalam memberi pelayanan adalah salah satu faktor yang memengaruhi kualitas jasa pelayanan, terutama bagi mereka yang berinteraksi langsung dengan pelanggan eksternal. menurut rahadi (2005) perlakuan dokter yang tidak menyenangkan pasien salah satunya adalah kurang mampu berkomunikasi dengan baik. hal ini dapat menimbulkan ketidakpuasan pasien. menurut pohan (dalam yulia, 2008) para dokter mempunyai kemampuan sehingga mereka dapat sangat mengurangi tekanan psikologis pasien, hanya dengan beberapa kata penenang dan penghibur dengan menunjukkan perhatian dan keterlibatan dalam kesulitan pasien. menurut tjiptono (dalam purwanto, 2007) kepuasan pasien didapatkan salah satunya melalui kecepatan yaitu pelayanan yang diberikan oleh perawat dengan memberikan penanganan yang cepat. penelitian ini sesuai dengan hasil penelitian soelarso et al. (2006) yang menyatakan peran komunikasi interpersonal antara dokter dengan pasien menjadi lebih optimal apabila kualitas komunikasi interpersonal mampu membangun hubungan interpersonal antara dokter dengan pasiennya. menurut best (dalam primalita, 2005) dari sisi pelanggan, kecepatan akses untuk memperoleh pelayanan merupakan suatu yang penting pada sistem penyampaian jasa. penelitian ini sesuai dengan penelitian hartini et al. (1999) yang menyatakan terdapat hubungan positif antara kepuasan pasien terhadap kecepatan pelayanan administrasi dirawat inap. sedangkan harianto et al. (2005) menyatakan terdapat pengaruh antara kepuasan pasien terhadap kecepatan pelayanan di apotek rumah sakit. penelitian ini sesuai dengan penelitian wiyono dan wahyuddin (2005) yang menyatakan variabel kualitas pelayanan paramedis memiliki pengaruh terbesar kemudian kualitas kenyamanan penunjang medis. penelitian ini sesuai dengan penelitian hartini et al. (1999) yang menyatakan terdapat hubungan positif antara kepuasan pasien dengan fasilitas/sarana fisik dan pelayanan perawat di rawat inap. sedangkan menurut lamri et al. (1998) yang menyatakan kebersihan memiliki pengaruh yang kuat dan positif terhadap kepuasan pasien. kesimpulan karakteristik pasien secara umum di klinik uinsa: sebagian besar pasien berusia kurang dari 20 tahun. sebagian besar pasien berjenis kelamin perempuan. kepuasan pasien tertinggi pada variabel kebersihan ruangan klinik diikuti dengan pelayanan dokter, pelayanan petugas klinik, lama waktu registrasi, dan lama waktu pelayanan apotek. daftar rujukan harianto, khasanah, nana, dan supardi, sudibyo. 2005. kepuasan pasien terhadap pelayanan resep di apotek kopkar rumah linda prasetyaning widayanti, survei kepuasan pasien klinik uin sunan ampel 11 sakit budhi asih jakarta. majalah ilmu kefarmasian, vol. ii, 12-21. hartini, mc inge dan sanusi, rossi. 1999. hubungan penempatan dokter umum sebagai case manager dan kepuasan pasien di ruang rawat inap rs. st. elisabeth semarang. jurnal manajemen pelayanan kesehatan, vol. 02, 104. lamri dan iman, sunartini. 1998. pengaruh kualitas pelayanan terhadap kepuasan minat perilaku penderita rawat inap di rumah sakit islam samarinda. jurnal manajemen pelayanan kesehatan, vol. 01, 41. primalita, ratni. 2005. hubungan physical support dengan contact personel pada rumah sakit umum di sumatera barat. skripsi. bandung: universitas padjajaran. purwanto, setiyo. 2007. kepuasan pasien terhadap pelayanan rumah sakit. jurnal psikologi klinis perkembangan dan sosial. rahadi, anugrah rizka. 2005. upaya pemasaran guna meningkatkan pemanfaatan rawat inap berdasarkan analisis perilaku konsumen di rumah sakit daerah dr. h. moh. anwar kabupaten sumenep. skripsi. surabaya: universitas airlangga. supriyanto, s. 2007. manajemen mutu. surabaya: fakultas kesehatan masyarakat universitas airlangga. sower, v. 2006. the battle of the gurus. quality management text manuscript chapter one: 5–6. soelarso, hanindio; soebekti, roesanto heru; dan mufid, achmad. 2006. peran komunikasi interpersonal dalam pelayanan kesehatan gigi. majalah kedokteran gigi (dent. j.), vol. 38, 124–129. wiyono, azis slamet dan wahyuddin, m. 2005. studi tentang kualitas pelayanan dan kepuasan konsumen di rumah sakit islam manisrenggo klaten. jurnal manajemen daya saing. yulia, sia mawa. 2008. analisis harapan dan penilaian pasien terhadap kualitas pelayanan dokter, dokter muda, perawat, dan petugas registrasi berdasar sepuluh dimensi kualitas jasa parasuranman. skripsi. surabaya: universitas airlangga. medical and health science journal, vol. 2, no. 1, february 2018 12 case report medical and health science journal, vol.4., no.1, february 2020 quality of life evaluation in children with osteogenesis imperfecta after giving bisphosphonate infusion in dr. soetomo hospital surabaya bayusentono sulis 1 , kusumo r. 1 , baskoro kusumo s* 1 1 department of orthopedics and traumatology, faculty of medicine, universitas airlangga / dr. soetomo general hospital, surabaya, indonesia *correspondent authors: baskorokusumoriswanto@gmail.com article info abstract article history: received february,11-2020 received in revised form february accepted february 26-2020 background: osteogenesis imperfecta (oi) or brittle bone disease is a connective tissue formation disorder. clinical symptoms vary greatly between patients even in the same type. the lack of evaluation of the effect of bisphosphonate on the quality of life of pediatric patients is the main reason for the authors to evaluate the quality of life in pediatric patients with ostegenesis imperfecta in soetomo academic general hospital. method: we selected three cases of oi from an outpatient clinic who was given the management of bisphosphonate administration. then compared before giving bisphosphonate and after giving bisphosphonate for 1.5 years and evaluated using the sf36 questionnaire and dash score. results: from the results of sf36 evaluation in evaluating the quality of patients’s life with oi after administration of bisphosphonate has showed a improvement quality of life than compared to before administration of bisphosphonate. discussion: from the evaluation results using the dash score, all three patients had a good development in terms of motor development in upper extremities. from the points of emotional health and social attitude, it can be concluded that patients are bolder to move and move more than before. before giving bisphosphonate, according to anamnesis from parents, patients are relatively afraid to move, after giving bisphosphonate the patient is more willing to move and play with the surrounding environment. from the evaluation of pain points, there is a significant difference between post and before bisphosphonate administration, this may be due to the reduced frequency of fractures compared to after administration of bisphosphonate. the goal of rehabilitation in oi patients is primarily to improve joint motion and muscle strength, as well as to improve ambulation and functional ability. conclusion: significant effects were seen after bisphosphonate administration. the need for a thorough evaluation of the effects of bisphosphonate administration on pediatric. osteogenesis imperfecta patients. the need for a standard and specific questionnaire for the evaluation of the development of bisphosphonate therapy in patients with osteogenesis imperfecta. keywords: osteogenesis imperfecta, bisphosphonate, sf 36, dash @2020 medical and health science journal. 10.33086/mhsj.v4i1.1464 introduction osteogenesis imperfecta (oi) or brittle bone disease is a connective tissue formation disorder that is generally characterized by bone fragility, osteopenia, blue sclera, dentinogenesis imperfecta (di), and hearing loss. fractures and deformities in the bone often occur although caused by minor trauma (1) the diagnosis of oi is based on a family history of the disease and the clinical manifestations that appear vary by patient, from mild to severe types, therefore oi requires multidisciplinary treatment. oi management is often not optimal, due to lack of knowledge of this disease which is still lacking as well as correspondence: baskoro kusumo s @2020 medical and health science journal. 10.33086/mhsj.v4i1.1464 available at http://journal2.unusa.ac.id/index.php/mhsj 34 mailto:baskorokusumoriswanto@gmail.com http://journal2.unusa.ac.id/index.php/mhsj medical and health science journal, vol.., no., 35 medical costs are high. in addition, researchers still rarely evaluate therapy in oi (2). intravenous therapy with bisphosphonate, especially disodium pamidronate, has become an important part in the treatment of moderate to severe oi. its beneficial effect on increasing bone mineral density in the lumbar spine, hip and whole body has been reported in several studies. more and more evidence of beneficial effects on patient growth, as well as their effect on bone pain (3). another intravenous bisphosphonate, zoledronic acid, has recently seen its effect on the treatment of adult osteoporosis with little experience of use in pediatric patients. the main advantages of zoledronic acid are its superior potential compared to other bisphosphonates and its long-term benefits in suppressing bone turnover, allowing for less frequent administration. so in this case series the researchers tried to evaluate the administration of bisphosphonate mainly zolendronic acid in pediatric patients suffering from oi the lack of evaluation of the effect of bisphosphonate on the level of parental satisfaction on the quality of life of pediatric patients, is the main reason the authors conducted quality of life studies in pediatric patients with oi using the sf36 questionnaire which was adapted transcultural to indonesian people's habits. case(s) male, four years old patients routinely seek bisphosphonate treatment at rsud dr. soetomo, bisphosphonate therapy for 1.5 years. broken bones 3 times, no surgery has been done. past disease history: fractures in the right thigh of february 2017, operated in dr. soetomo hospital by dr. tri (possibly february 6, 2017). age 10 days history of fractures 4 times in the left thigh, casted hemi spica in dr. soetomo general hospital, age 1 month right thigh fracture, to alternate, age 1.5 years right thigh fracture, cast hemisica at soewandi hospital age 2 years right thigh fracture, hemispica cast, age 2.5 years right thigh fracture, intramedullary nail surgery in dr. soetomo general hospital . family disease history there is no one who had experiences complaints like patients. from the physical examination, the author found blue color on his sclera, dentinogenesys type i and from the patient’s right thigh, the author found deformity, tenderness on the right thigh, and limited rom due to pain. patients have been given zolendronic acid with the protocol 0.05 mg / kgbb diluted with 0.9% nacl 100 ml zolendronic acid infusion given within 30-45 minutes. the therapy is given every 6 months patients were evaluated using the dash score and sf 36, an increase in sf 36 and a decrease in the incidence of fractures each year. results from dash score assessment: – all three patients there were a good development in terms of motor development in upper extremities. – there were no evaluation in the dash work module section (optional) because the patient is still a child from the results of sf36: – evaluating the quality of life in patients with osteogenesis imperfecta, it appeared that the development of physical domains and mental domains is better compared to before administration of bisphosphonate. table 1. evaluation of sf 36 before and after bisphosphonate administration sf 36 80 60 40 20 0 patient 1 patient 2 patient 3 before after medical and health science journal, vol.., no., 36 patient 1 patient 2 patient 3 before after 60 40 20 0 dash score table 2. evaluation of dash score before and after bisphosphonate administration figure 1: dentinogenesis imperfecta figure 2: radiological photo of left femur osteogenesis imperfecta figure 3: right femur of osteogeneness imperfecta patients discussion osteogenesis imperfecta (oi) or brittle bone disease is a connective tissue formation disorder that is generally characterized by bone fragility, osteopenia, abnormalities in the skin, blue sclera, dentinogenesis imperfecta (di), or hearing loss. oi has a varied clinical spectrum, ranging from lethal form at perinatal to mild form. bone fractures and deformities can occur even with minor trauma. if proven to be oi, bisphosphonate, calcium and vitamin d therapy can be given. monitoring the side effects of bisphosphonate therapy is important. nephrotoxic effects will give signs and symptoms of hypertirotropinemia, namely tachycardia, irritability, tremor, and diarrhea. complications that can occur are hypocalcemia, a disorder related to osteoporosis, so it is important to ensure adequate calcium and vitamin d intake before and during therapy. in addition, monitoring of medication adherence, drug reactions and possible medication side effects are also monitored. it is also very important to monitor the growth, nutritional status, and development of the patient, hearing function and assessment of quality of life. other assessments made in this case are evaluation through dash score and sf 36 as an evaluation of quality of life in patients that medical and health science journal, vol.., no., 37 receiving bisphosphonate. evaluation was compared between before and after bisphosphonate administration for 1.5 years. from the evaluation results using the dash score, in all three patients there was a good development in terms of motor development in upper extremities. this can be seen from the evaluation of the development of muscle strength and fine motor strength such as writing (drawing), eating his own food without the help of parents and also carrying a heavier burden. it's just that the evaluation of bisphosphonate administration is biased by the motor development of each patient. in the dash score assessment, there is no evaluation in the work module section (optional), this is due to patients who are still children. from the results of sf36 evaluation in evaluating the quality of life of oi sufferers in bisphosphonate administration, it appears that the development is better compared to before administration of bisphosphonate. from the point of public health, it appears that the patient's development starts from good condition (very good) to very good (very good). viewed from the point of limited activity, there appears to be a development, which initially the patient is afraid to step, the patient can go further than before bisphosphonate administration. from the points of emotional health and social attitude, it can be concluded that patients are bolder to move and move more than before. before bisphosphonate administration, according to the history of parents the patient was relatively afraid to move; this is due to fear of recurring fractures in the patient. after giving bisphosphonate the patient is more willing to move and play with the surrounding environment. from the evaluation of pain points, there was a significant difference between post and before administration of bisphosphonate, this may be due to the reduced frequency of fractures compared to after administration of bisphosphonate. this is explained because zolndronic acid (bisphosphonate nitrogen) is an inhibitor of bone resorption 100-10,000 times higher than non nitrogen bisphosphonate (4). the pharmacodynamic effect of bisphosphonate is to reduce the level of bone resorption and aposition. this situation occurs as long as the patient is treated with bisphosphonate systemically (5) the action of bisphosphonate nitrogen against osteoclasts is by causing changes in the osteoclast cytoskeleton, such as the loss of the ruffled border and the severing of the actin ring so that the osteoclasts become inactive and undergo apoptosis. this action occurs because bisphosphonate nitrogen inhibits farnesyl pyrophosphate synthase (fpps). fpps is a mevalonate enzyme that is responsible for the formation of guanidine triphosphatase (gtp ase). gtp ase is important for osteoclast function and survival. so this indirectly suppresses osteoclast activity (6). another important modality in handling oi is rehabilitation of physiotherapy. the goal of rehabilitation in oi patients is mainly to improve the area of joint motion and muscle strength, as well as improve ambulation and functional ability. oi's condition is chronic and requires lifelong treatment that can reduce children's quality of life. therefore, in patients with chronic disease conditions that require long-term therapy even for life, it is very important to provide education about understanding children's diseases, the need for lifetime monitoring and treatment, efforts that need to be made to prevent and minimize complications, the importance of the second role parents in providing appropriate parenting, fostering, and fostering for optimal child growth and quality of life. psychosocial problems can occur in connection with the level of self-confidence. psychological counseling and mentoring for both parents can be considered so that parents remain enthusiastic, confident, and not easily discouraged in caring for and caring for their children. repeated fractures, malnutrition and motor delay are still problems in this patient. continued monitoring is needed for early detection of oi complications so that it can medical and health science journal, vol.., no., 38 suppress disease progression and improve patient quality of life. subsequent treatment in patients for primary disease is a condition of recurrent fracture that causes stunted development in the patient. conclusion 1. significant effects were seen after bisphosphonate administration 2. need longer observation by involving the total population of patients treated 3. community observation is very effective in improving compliance of regular administration of bisphosphonate references 1. aglan ms, hosny l. a scoring system for the assessment of clinical severity in osteogenesis imperfecta. 2012;29–35. 2. paper o. hor mon e re se arch i n zoledronic acid treatment in children with osteogenesis imperfecta. 2011;346–53. 3. arikoski p, silverwood b, tillmann v, bishop nj. intravenous pamidronate treatment in children with moderate to severe osteogenesis imperfecta : assessment of indices of dual-energy x-ray absorptiometry and bone metabolic markers during the first year of therapy. 2004;34:539–46. 4. russell. mechanisms of action of bisphosphonates : similarities and differences and their potential influence on clinical efficacy. 2008;733–59. 5. papapoulos se. bisphosphonates : how do they work ? best pract res clin endocrinol metab [internet]. 2008;22(5):831–47. available from: http://dx.doi.org/10.1016/j. beem.2008.07.001. 6. kaipatur nr, wu y, adeeb s, stevenson tr, major pw, doschak mr. impact of bisphosphonate drug burden in alveolar bone during orthodontic tooth movement in a rat model: a pilot study. am j orthod dentofac orthop [internet]. 2013;144(4):557–67. available from: http://dx.doi.org/10.1016/ j.ajodo.2013.06.015 http://dx.doi.org/10.1016/j http://dx.doi.org/10.1016/ medical and health science journal, vol. 4, no.2, august 2020 correspondence: bayusentono sulis @2020 medical and health science journal. 10.33086/mhsj.v4i1.1415 available at http://journal2.unusa.ac.id/index.php/mhsj 87 conservative care cost analysis of patients of long bone fracture in emergency room. a review to see the sufficiency of health insurance costs bayusentono sulis* 1 , tarise h, cery 2 1 staff of department of orthopedics and traumatology, faculty of medicine, universitas airlangga / dr. soetomoacademic general hospital, surabaya, indonesia. 2 resident of department of orthopedics and traumatology, faculty of medicine, universitas airlangga / dr. soetomoacademic general hospital, surabaya, indonesia *corresponding author : sbsentono@fk.unair.ac.id article info abstract article history: submitted: june, 26 2020 received in revised form july 01 2020 accepted: august, 18 2020 introduction: long bones are bones that include the humerus, radius, ulna, femur, tibia and fibula. aside from fibula, the main function of long bones is supporting weight and facilitate movement. therefore, fracture in the long bone will cause liited movement or even loss. long bone fracture is still a global problem because the number of events is quite large. this is in line with the increase in socioeconomic status and the incidence of traffic accidents which is one of the causes of fractures. method: this is a prospective study to determine the magnitude of the cost of treatment conservatively in cases of long bone fractures in rsud dr. soetomo. the study design used was a prospective cohort. the sample size used in this study was determined by consecutive sampling, ie patients who met the inclusion criteria in the period may august 2017. results: from the observations for four months from may 2017 august 2017 at emergency room soetomo general hospital, we found 77 patients with long bone fractures that were casted. of these patients, 38 patients were placed in a slab and 39 patients were placed in a circular cast. among the 39 people, 17 patients were excluded according to the exclusion criteria and 22 patients were included as the study sample according to the inclusion criteria. by using a statistical test using paired sample t test with a value of α = 0.05, a significance of 0.025 was obtained. because the significance value is 0.025 <0.05 (α). discussion: from the results, there was a difference between the bpjs rate of installing circular cast and the real cost of installing circular cast on long bone fractures. in addition, we get that the average value of the bpjs rate is greater than the real cost value, which means we can conclude that the bpjs cost can cover the cost of conservative therapy in cases of long bone fractures. conclusion: in the economic aspect, the longer stay means higher costs that must be paid by the patient (the payer) and accepted by the hospital. this only applies to real tariffs, whereas to inacbg's long or short length of stay does not affect the cost. @2020 medical and health science journal. 10.33086/mhsj.v4i1.1415 keywords: long bones fractures, conservative, care, health insurance, cost introduction long bones is a main framework for movement. fracture of long bone can limited movement. the occurrence of long bone fracture is still a global problem because the number of events is quite large. this is in line with the increase in socioeconomic status and the incidence of traffic accidents which is one of the causes of fractures 1 . long bone fractures mainly result from significant trauma. data shows incidence of long bone fractures is 21 fractures per 1000 people per year in united states, men is higher than women. similar data also reported in norway and united kingdom 2 . approxicase reports medical and health science journal, vol. 4, no.2, august 2020 88 mately, 2109 patients seeking ed to orthopedics and traumatology at the soetomo general hospital itself, in 2016, about 360 (17%) were patients with long bone fractures treated with conservative therapy 3. in every case of long fracture, it is necessary to choose the right therapy. in general, therapy for long bone fractures is divided into conservative (non-operative) and operative therapy. the costs between conservatively and operative therapy are quite different. james heckman in 1997 showed that the cost of therapy in tibia fracture cases is 65% lower conservatively compared to operative therapy 4 . recently, health financing model in indonesia is mainly centered on bpjs (social security organizing agency) health and health insurance. funding with health bpjs based on the ina-cbgs (indonesia case base groups) package makes it possible to carry out conservative treatment of long bone fractures comprehensively. in bpjs, the products covered are regulated by national formulary 5 . therefore, to estimate adequacy of conservative therapy treatment costs for long bone fractures and its efficiency, this study focus on the costs incurred by the ina-cbg package and the amount the need for conservative therapy of patients with long bone fractures at dr. soetomo general hospital 3 . case(s) from 22 patients included in inclusion criteria, there were 14 patients (65%) male and 8 female patients (35%). from these patients we get a number of cases with diagnoses of fractures in the upper limb, such as: closed fracture antebrachia, closed fracture distal radius, and galeazzi fracture and closed fractures in the lower extremities such as: closed tibia fractures, calcaneus fractures, and metatarsal fractures. most of them, we found most cases were fractures in the antebrachial section. in antebrachial fractures, we do closed reduction management and immobilization using a long arm cast, while distal radius fracture, immobilization is done by placing a long arm cast. in lower extremities, most fractures ensue in tibia. it could be done conservatively that is closed reduction and immobilization with long leg cast, whereas metatarsal fracture, conservative management was performed under knee cast. results afer four months observation, from may 2017 august 2017 at emergency room dr. soetomo general hospital, we found 77 patients with long bone fractures that were casted. of these patients, 38 patients were placed in a slab, 39 patients were placed in a circular cast. among 39 patients, 17 patients were excluded according to criteria and 22 patients were included as subject on this study. the cast installation was performed by ppds orthopedics and traumatology hospital dr. soetomo faculty of medicine, airlangga university who has received casting academy training. table 1. sample distribution based on age group age number (%) ≤10 years old 8 36,4 11-20 years old 5 22,7 21-30 years old 2 9,1 31-40 years old 4 18,2 41-50 years old 2 9,1 61-70 years old 1 4,5 total 22 100,0 from data, it was found that the highest incidence of closed fractures occurred in the range of first and second life periods. children run into dramatic change in motoric development so as they tend to fall like from furniture or stairs. meanwhile, in second decade of life, the trauma mechanism mainly occurs during outdoor activities. this is almost in line with study conducted by hedstrom em et all in 2010 in sweden 6 . medical and health science journal, vol. 4, no. 2, august 2020 89 table 2. sample distribution based on gender n o genders total (%) 1 men 14 63.7 2 women 8 26.3 total 22 100 from table 2, the highest incidence of closed fractures is found in men twice than women. it caused by trauma, especially trauma due to traffic accidents, workplace accidents and activities/ sports. table 3. sample distribution based on conservative treatment conservative treatment total % long arm cast 8 36 below elbow cast 1 4 long leg cast 3 13 below knee cast 3 13 long arm cast dengan general anesthesia 6 27 long arm cast + below knee cast 1 4 total 22 100 based from table 3, it was found that the incidence of fractures is more common in the upper limb than the lower limb table 4. distribution of average comparison of real cost rates and bpjs rates conservative treatmnet total average of real cost bpjs insurace cost long arm cast 8 rp. 548.750 rp. 579.700 below elbow cast 1 rp. 641.000 rp. 579.700 long leg cast 3 rp. 411.666 rp..579.700 below knee cast 3 rp. 641.000 rp. 579.700 long arm cast dengan general anesthesia 6 rp. 5.605.333 5.724.600 long arm cast + below knee cast 1 rp. 821000 rp. 579.700 discussion by using a statistical test using paired sample t test with a value of α = 0.05, a significance of 0.025 was obtained. because the significance value is 0.025 <0.05 (α), it can be concluded that ho is rejected, which means there is a difference between the bpjs and real cost of installing circular cast on long bone fractures. in addition, average value of bpjs rate is greater than real cost value. it means that the bpjs cost can cover cost of conservative therapy in cases of long bone fractures. this happens because in patients who are treated conservatively do not require a long treatment time. according to cleverly (1997), one way that costs for a package payment system (cased base groups) can be reduced by reducing patient length of stay (cleverley, 1997). meanwhile sudra (2009) reported, from medical aspect the longer patient stay at hospital, quality of medical performance is declining because the patient must be treated longer (longer recovery). conversely, the quality of medical performance is good in case patients treated in shorter period 7 . from economic aspect, the longer the length of stay means the higher the costs that must be paid by the patient (the payer) and accepted by the hospital. this only applies to the real tariff, whereas the tariff of inacbg's long or short length of stay does not affect the cost 8 . the results of this study are almost in line with study conducted at kalisat hospital jember in january june 2015 in which there was a statistically significant difference between real cost rate and ina-cbg package rates on the payment of diabetes mellitus patient claims. in this case a lower real cost rate is obtained 9 . however, different results were obtained in study conducted at rsud dr. achmad mochtar bukittinggi in january to december 2016. in this study, the difference in negative rates that illustrates hospital rates is greater than the payment of ina-cbg rates. medical and health science journal, vol. 4, no.2, august 2020 90 negative rate difference is found in surgical cases involving operative medical measures 10 . weaknesses of this study involve: period is too short, only 4 months (may to august 2017), so that the number of cases obtained is relatively low. then further study is needed to assess especially in terms of patient satisfaction and operator satisfaction. in addition, this study also received funding from sponsors in accordance with agreed cooperation. conclusion conservative therapy with circular cast for closed bones with long bones is still one of the main choices today, especially in children. the current health cost financing model mainly uses bpjs based on the ina-cbgs package. the rate of the ina-cbg package is greater than the real cost rate for patients with closed fractures that are treated conservatively in emergency room dr. soetomo general hospital. further research is needed to review more deeply about conservative therapy in the treatment of closed fractures, especially in terms patient satisfaction as well as from operator or doctor's point of view. references 1. court-brown cm. the epidemiology of fractures and dislocations. in court-brown cm, heckman jd, mcqueen mm, et al. rockwood and green's fractures in adults. vol 1, 8th ed. philadelphia, pa: lippincottraven; 2001: p. 59 – 70 2. wu chi-chuan. treatment of long-bone fractures, malunions, and nonunions: experience at chang gung memorial hospital,taoyuan, taiwan. chang gung med j. 2006; 29(4): 347 – 357_2 3. software rekam medis residen orthopaedi surabaya. 13 februari 2017. http://orthobaya.org/rm2/rekammedis_list.p hp. 4. heckman jd, kahn js. the economics of treating tibia fractures. bulletin hospital for joint diseases. 1997; 56(1): 63 – 72 5. keputusanmenteri kesehatanrepublik indonesianomor hk.02.02 / menkes / 523 / 2015tentangformularium nasional. 6. hedström em, svensson o, bergström u, michno p. epidemiology of fractures in children and adolescents increased incidence over the past decade : a population-based study from. 2010;81(1):148–53. 7. sudra, r.i. statistik rumah sakit dari sensus pasien dan grafik barber-johnson hingga statistik kematian dan otopsi. yogyakarta: graha ilmu. 2009 8. cleverly, w. essentials of health care finance, fourth edition. maryland: aspen publishers inc. 1997. 9. mawaddah ai ¹, tasminatun s. analisis perbedaan pembiayaan berbasis tarif inacbg’s dengan tarif riil rumah sakit pada pasien peserta jkn kasus diabetes mellitus tipe ii rawat inap kelas iii di rumah sakit kalisat jember periode januari – juni 2015. universitas muhammadiyah yogyakarta. yogyakarta. 2015 10. edya f. analisis perbandingan tarif inacbg’s dengan tarif rumah sakit dan cost recovery rate pasien rawat inap peserta bpjs kesehatan (studi kasus pada rsud dr. achmad mochtar bukittinggi). universitas andalas. padang. 2017 http://orthobaya.org/rm2/rekammedis_list.php http://orthobaya.org/rm2/rekammedis_list.php medical and health science journal, vol.3., no.2, august 2019 chitosan as antifungal in channa striata collagen chitosan for wound healing ary andini1, endah prayekti2* 1,2 departement of health analyst, health faculty, university of nahdlatul ulama surabaya *correspondent author: aryandini@unusa.ac.id article info abstract article history: submited: july, 28 2019 received in revised form august 2019 accepted: august, 27 2019 background: the snakehead fish (channa striata) contains high protein that was mostly used for treatment during healing process. it could be developed as well as a mixtured with chitosan for wound dressing. chitosan known as biodegradability, biocompatibility and bioactivity biopolymers. the aim of this study was to know the effect of combination of concentrations between chitosan and collagen of snakehead fish skin and scales on fungal total number recovered from the composite. methods: snakehead fish skin and scales was treated by soaking in 2% hcl solvent for 48 hours to obtain collagen from its filtrate. filtrate obtained continued to neutralize with 1 m naoh until soluble collagen appeared. collagen obtained in this study then mixed with 2% chitosan liquid to make wound dressing in various concentrations group. results: combination of colagen mixture in this study were chitosan liquid only as control, 25% collagen-75% chitosan (c1), 50% collagen-50% chitosan (c2) and 75% collagen-25% chitosan (c3). the study results showed that on control, c1 and c2 group there was no fungal growth, but on c3 group there was fungal growth with total counting about 2,43 x 103 cfu. based on statistically test showed that there was discrepancy for each group with p-value was 0,02 (p<0,05). conclusion: this research showed that chitosan content could contributed as an anti-fungal. @2019 medical and health science journal. 10.33086/mhsj.v3i2.1197 keywords: channa striata, collagen, chitosan, fungal, wound introduction based on the results of the basic health research (riskesdas) in 2013, the prevalence of burn injury increased from 25.9% in 2007 to 47.7% in 2013, with a percentage of respondents reaching 70.9% and 70% injuries (ministry of health republic of indonesia, 2013). the enhancement of burn injury prevalence in indonesia caused skin treatment needs increased, therefore alternative skin treatment could fulfill those demands.based on the richness of indonesian nature, reearcher tried to make wound dressing from combination of chitosan and collagen from snakehead fish for getting skin care with economical and efficient to use. collagen from fish properties was better than livestock and poultry due to halal for use, free from foot and mouth disease (pmk), bovine spongioform encelopathy (bse), transmission of spongioform encephalopathy (tse) and food and mouth disease (fmd) (singh et al., 2010; andini a, 2016; andini et al, 2017). also, collagen from fish had a low immunoreactive risk in body because had low hydroxyproline to make more elastic than collagen from livestock and poultry (andini a, 2016; andini et al, 2017). wound healing processes need moist state to increase epithelialization and stimulate proliferation and migratory epithelium, increase growth factor activity to maintain transportation of nutrients and oxygen cells (hidayat, 2013). correspondence: ary andini, endah prayekti @2019 medical and health science journal. 10.33086/mhsj.v3i2.1197 available at http://journal2.unusa.ac.id/index.php/mhsj 8 original article mailto:aryandini@unusa.ac.id http://journal2.unusa.ac.id/index.php/mhsj medical and health science journal, vol.3., no.2, august 2019 collagen could help wound healing process due to stimulate fibroblasts formation, then stimulating new tissue formation and new epithelial tissue (andini, 2016). one of the collagen sources that could be used is collagen from snakehead fish (channa striata). the research used collagen from skin and scales of snakehead fish (channa striata) then combined with chitosan becomes collagen-chitosan composite for wound healing. based on rosmawati (2018) study shown collagen of snakehead fish skin about 8,85 ± 0,84% with high amino acid of glycin, prolin and hydroxyproline. chitosan is known as non-toxic, biodegradable and renewable materials that shown as biocompatibility devices with positive effect on wound healing (ratnawati et al, 2013). in pharmacology, chitosan used for the controlled release of drugs and wound healing due to their hydrogel properties. (akakuru et al., 2018) this research was a preliminary study to know about collagen-chitosan composite properties on fungal growth by counting fungal total. methods the snakehead skin and scales were taken from tanggulangin sub-district in sidoarjo city, east java, indonesia. then, it was extracted with 2% hcl solution for 48 hours in chill condition. after that, filtered and neutralized filtrat by using 1 m naoh solution until getting soluble collagen. mixtured collagen soluble with 2% chitosan liquid to make collagen-chitosan composite into various group concentration i.e chitosan liquid only as control group, 25% collagen-75% chitosan as c1 group, 50% collagen-50% chitosan as c2 group and 75% collagen-25% chitosan as c3 group. then, mixture of each composit group was pouring to the mold with 2-3 mm in height and cover with sterile gauze then dry for 5 days. fungal count in collagen mixture of each composite was determine by diluting 0,1 gr composite in 9,9ml 0,85% natrium clorida solution. after diluting, the solution brought to plate and grown in potato dextrose agar medium at 37oc for 2 until 3 days. results the results of counting the total number of fungal obtained could be seen in table 1 and figure 1. result of statistical analysis could be seen in table 2. the research used kruskal wallis test due to had distribution normal data with p-value = 0,799 (p>0,05) but had not homogeneous data with p-value = 0,03 (p>0,05. tabel 1. total number of fungal on collagen chitosan composit group mean (cfu) sd control 0 0 c1 0 0 c2 0 0 c3 2,43 x 103 1,2 x 103 tabel 2. results of statiscally kruskal wallis test using spss group mean ± sd n p-value control 0,00 4 c1 0,00 4 0,02 c2 0,00 4 c3 2,43 x 103 4 (a) (b) (c) (d) 9 medical and health science journal, vol.3., no.2, august 2019 figure 1. fungal on each composite group. (a) control group; (b) c1 group; (c) c2 group; (d) c3 group. based on the result in table 1 showed that on control, c1 and c2 group had not fungal growth with fungal total were 0 for each. but, on c3 group had fungal growth was 2425. figure of fungal growth for each group could be observed in figure 1. statistically result showed that there were discrepancy of total number of fungal for each group with p-value about 0,02 (p<0,05). discussion chitosan had biological properties i.e biodegradability with non-toxic or allergic and eco-friendly, biocompatibility with no antigenic properties, and bioactivity with bacteriostatic, haemostatic, immunologic, analgesic, anti inflamatory, anticoagulant etc (cheba, 2011). based on the research shown on control, c1 and c2 group had no fungal growth, but on c3 group had contamination of fungal with total counting about 2,43 x 103 cfu and statistically test showed that there was discrepancy for each group with p-value was 0,02 (p<0,05). it was proven that chitosan had antifungal properties. the higher chitosan composition, then the higher antifungal properties in channa striata collagen chitosan wound dressing. chitosan as antifungal biopolymers had been proven in several studies. the study of lee et al. (2016) showed a decrease in viability in penicillium italicum after being exposed to several chitosan fractions. the reduction was mainly due to the inhibition effect of chitooligomers-f2 (co-f2) on spore germination via disruption of ca2+ ion channel. the research of xing et al. (2018) described about the flow of chitosan inhibition in ceratocystis fimbriata. chitosan which was attached to the plasma membrane and the intercellular component would disrupt membrane cells which leads to leakage of intracellular components, especially k+ ions. this leak causes changes in morphology, membrane depolarization and h+/ k+ atpase activity, which leads to cell death. there was a linear relationship between molecular weight and particle size that proved statistically (ing et al., 2012). thus, the nano-form of chitosan particles has the potential to be a strong and safe natural antifungal agent. the snakehead fish contains high protein that was mostly used as a treatment during for healing process in either invasive or passive surgery in indonesia. snakehead fish contains three main amino acids i.e glycine, glutamine and arginine. glycine amino acid plays a role in collagen synthesis which plays an important role in connective tissue, glutamine plays a role during the inflammatory phase and proliferation of wound healing while acting as an energy source, while arginine plays a role in immune function and stimulates endothelial cell function (rahayu et al, 2016). collagen from fish could stimulate fibroblasts formation, then stimulating new tissue formation and new epithelial tissue (andini, 2016) due to contains proline and glycine. glycine was used as natural moisturizing factor on skin and induced collagen synthesis to accelerating burn healing (andini, 2017). this research showed that chitosan content could contributed as an anti-fungal. it could be seen if the higher chitosan content in composite, the composite would not be contaminated with fungi. conversely the higher of collagen content in the composite, the higher contamination of composite. conclusion as conclusion of the research were on control, c1 and c2 group had no fungal growth, but on c3 group had contamination of fungal with total counting about 2,43 x 103 cfu and statistically test showed that there was discrepancy for each group with p-value was 0,02 (p<0,05). acknowledgement the ministry of research, technology and higher education indonesia (kemenristek dikti) 10 medical and health science journal, vol.3., no.2, august 2019 that granted the research and institute of research and community service (lppm) nahdlatul ulama university of surabaya that supported the research. references 1. ahmed s. ikram s. 2016. chitosan based scaffolds and their applications in wound healing. elsevier, achievements in the life sciences 10: 27–37 2. aisyah. mufarikoh z. andini a. 2017. pengaruh pemberian topikal ekstrak kolagen kulit ikan lele sangkuriang (clarias gariepinus var) terhadap tnf-α dan jumlah fibroblast pada luka bakar derajat dua tikus wistar. medical and health science journal, vol. 1, no. 1, februari 3. akakuru ou, louis h. amos pi. akakukru oc, nosike ei, ogulewe ef. 2018. the chemistry of chitin and chitosan justifying their nanomedical utilities. biochem pharmacol (los angel) 2018, 7:1. doi: 10.4172/2167 0501.1000241 4. andini a, handajani r, soetjipto. 2017. sangkuriang catfish (clarias gariepinus var) skin extract activity on fibroblast and collagen synthesis for skin burn healing. proceeding surabaya international health conference, vol 1, no. 1 5. andini a. 2016. pengaruh pemberian topikal ekstrak kolagen kulit ikan lele sangkuriang (clarias gariepinus var) terhadap penyembuhan luka bakar tikus strain wistar.thesis.program studi ilmu kedokteran dasar, fakultas kedokteran, universitas airlangga 6. hidayat tsn. 2013. peran topikal ekstrak gel aloe vera pada penyembuhan luka bakar derajat dalam pada tikus. karya akhir, departemen/smf ilmu bedah plastik rekonstruksi dan estetik, fakultas kedokteran/rsud dr. soetomo, surabaya 7. cheba ba. 2011. chitin and chitosan: marine biopolymers with unique properties and versatile applications. global journal of biotechnology & biochemistry 6 (3): 149-153, 2011 8. ing ly. sarwar a. zin nm. katas h. 2012. antifungal activity of chitosan nanoparticles and correlation with their physical properties. international journal of biomaterials. volume 2012, 9 pages. doi: 10.1155/2012/632698 9. (ministry of health republic of indonesia (kementrian kesehatan republik indonesia). 2013. riset kesehatan dasar: riskesdas 2013. badan penelitian dan pengembangan kesehatan kementrian kesehatan republik indonesia 10. lee cg. koo jc. park jk. 2016. antifungal effect of chitosan as ca2+ channel blocker. plant pathology journal 32(3): 242-25 11. mohandas a. deepthi s. biswas r. jayakumar r. 2018. chitosan based metallic nanocomposite scaffolds as antimicrobial wound dressings. science direct, bioactive materials 3 12. nagori bp. solanki r. 2011. role medicinal plants in wound healing. research journal of medicine plant 5(4): 392-405 13. rahayu p. marcelline f. sulistyaningrum e. suhartono mt, tjandrawinata rr. 2016. potential effect of striatin (dlbs0333), a bioactive protein fraction isolated fromchanna striata for wound treatment. elsevier, asian pac j trop biomed 6(12): 1001–1007 14. ratnawati a. r djoni i. supardi a. 2013. sintesis dan karakterisasi kolagen dari teripang-kitosan sebagai aplikasi pembalut luka. media jurnal fisika dan terapannya, volume: 1 no. 2 terbit: 4--2013 15. rosmawati. 2018. potensi kolagen ikan gabus (channa striata) sebagai gelatin alternatif dan aplikasinya dalam penolaha sosis berbasis meat by-product sapi. [disertasi]. sekolah pascasarjana, universitas hasanuddin 16. singh p. benjakul s. maqsood s. kishimurah. 2010. isolation and characterisation of collagen extracted from the skin os striped catfish (pangasionodonhipopthalmus). food chemistry;124: 97105 17. vig k. chaudhari a. tripathi s. dixit s. sahu r. pillai s. dennis va. singh sr. 2017. advances in skin regeneration using tissue engineering. intenational journal of molecular sciences, 18, 789 18. xing k. xing y. liu y. zhang y. shen x. li x. miao x. feng z. peng x. qin s. 2018. fungicidal effect of chitosan via inducing membrane disturbance against ceratocystis fimbriata. carbohidrat polymers journal, 195, 95-103 11 penentuan formula untuk menetapkan estimasi kolesterol-ldl gilang nugraha 1 , soebagijo poegoeh edijanto 2 1 prodi kedokteran, fakultas kedokteran, universitas nahdlatul ulama surabaya 2 prodi d-iv analis kesehatan, fakultas kesehatan, universitas nahdlatul ulama surabaya e-mail: : gilang@unusa.ac.id 1 abstract: measurement ldl-cholesterol (ldl-c) can be performed by estimating ldl-c (cldl-c) in the blood. in addition to the first proposed friedewald formula, several new formulas that promise better examination in determining ldl-c levels, proposed by anandaraja, puavilai, chen, vujovic, de cordova and dansethakul. the subjects of the study were patients who performed routine lipid profile examination in institution of clinical pathology of gedung pusat diagnostik terpadu rsud dr. soetomo surabaya who performs 10 to 12 hours of fasting with tg less than 400 mg / dl. the sample consisted of 41 men and 48 women with an average age of 52 years. the statistical test on each cldlc gave the friedewald -1.32% bias value; anandaraja -3,92%; puavilai 4.26%, chen -2.19%; vujovic -23.65%; de cordova -0.91% and dansethakul 4.45%. the correlation coefficient on friedewald 0.9509; anandaraja 0.9013; puavilai 0.9576, chen 0.9585; vujovic 0.8745; de cordova 0.9300 and dansethakul 0.9505. the proposed cldl-c formula chen et al promises in determining the ldl-c estimate and the vujovic formula gives a poor result in this study. validation methods should be applied to each of the cldl formulas if they are to be applied to clinical laboratories. keywords: cholesterol, ldl, estimates abstrak: pemeriksaan kolesterol-ldl (ldl-c) dapat dilakukan dengan melakukan estimasi ldl-c (cldl-c) dalam darah. selain formula friedewald yang pertama kali diusulkan, beberapa formula baru yang menjanjikan pemeriksaan lebih baik dalam menentukan kadar ldl-c, diajukan oleh anandaraja, puavilai, chen, vujovic, de cordova dan dansethakul. subjek penelitian adalah pasien yang melakukan pemeriksaan profil lipid rutin di instansi patologi klinik gedung pusat diagnostik terpadu rsud dr. soetomo surabaya yang melakukan puasa 10 sampai 12 jam dengan tg kurang dari 400 mg/dl. sampel terdiri dari 41 laki-laki dan 48 perempuan dengan usia rata-rata 52 tahun. uji statistik pada masing-masing cldl-c memberikan nilai bias friedewald -1,32%; anandaraja -3,92%; puavilai 4,26%, chen -2,19%; vujovic -23,65%; de cordova -0,91% dan dansethakul 4,45%. koefisien korelasi pada friedewald 0,9509; anandaraja 0,9013; puavilai 0,9576, chen 0,9585; vujovic 0,8745; de cordova 0,9300 dan dansethakul 0,9505. formula cldl-c yang diusulkan chen dkk menjanjikan dalam menetapkan estimasi ldl-c dan formula vujovic memberikan hasil yang buruk pada penelitian ini. validasi metode perlu diterapkan pada masing-masing formula cldl jika ingin diterapkan pada laboratorium klinik. kata kunci: kolesterol, ldl, estimasi pendahuluan ldl (low density lipoprotein) merupakan partikel lipoprotein yang aterogenik karena menjadi salah satu pemicu terbentuknya plak aterosklerosis (1). perhimpunan dokter spesialis kardiovaskular indonesia dalam buku pedoman tatalaksana dislipidemia mejadikan ldl sebagai target terapi untuk mengurangi kasus penyakit kardiovaskuler (pkv) dengan mengukur kadar kolesterol-ldl (ldl-cholesterol, ldl-c) dalam darah (2). low density lipoprotein (ldl) dikenal juga sebagai kolesterol jahat yang banyak mengandung kolesterol dengan satu molekul apo b-100 (3). komposisi partikel ldl terdiri dari 10% 33 medical and health science journal, vol. 2, no. 2, august 2018 trigliserida, 50% ester kolesterol, 29% fosfolipid dan 11% kolesterol bebas (4). struktur partikel ldl dapat dilihat pada gambar 1. gambar 1. struktur partikel ldl (5) pembentukan ldl diawali dari partikel vldl mengalami transfer apo c-ii dan apo c-iii kepada hdl (nugraha et al. 2017). sebaliknya, terjadi penambahan apo e dari hdl kepada vldl. pengurangan trigliserida dan perubahan komposisi apolipoprotein pada vldl akan mengubah konformasi partikel lipoprotein menjadi lebih padat dan lebih kecil yang disebut idl (nugraha et al. 2017). sekitar 50% partikel idl diambil oleh hati, sisa partikel idl yang tidak diambil akan mengalami katabolisme lanjut. lipase hati akan menghidrolisis sebagian besar trigliserida di dalam idl yang akan mengubah konformasi apo e, diikuti oleh pemisahan apo e pada partikel sehingga terbentuk partikel ldl (3,6,7). ldl-c diukur menggunakan dua teknik, yaitu secara langsung yang juga dikenal dengan direk ldl-c (dldl-c) dan tidak langsung yang juga dikenal dengan indirek ldl-c atau calculated ldl-c (cldl-c) dengan menggunakan formula (8,9). pemeriksaan dldl-c adalah teknik pengukuran kadar kolesterol dalam partikel ldl umumnya secara enzimatik dengan cara memisahkan partikel ldl dari lipoprotein yang lain. tahapan selanjutnya, partikel lipoprotein dilakukan pengukuran kadar kolesterol (nugraha et al. 2017). teknik pemeriksaan ini dapat dilakukan dengan metode presipitasi atau asai homogen, perbedaan kedua teknik tersebut terletak dari cara pemisahan. kolesterol ldl dikukur dengan metode pemeriksaan kolesterol total (9,10). pemeriksaan cldl-c adalah pengukuran ldl-c tanpa mengukur langsung partikel ldl. pemeriksaan cldl-c yang banyak digunakan di indonesia adalah cldl-c formula friedewald (8). beberapa tahun terakhir banyak di usulkan formula baru yang menjanjikan pemeriksaan lebih baik dalam menentukan kadar ldl-c, diantaranya adalah formula anandaraja, puavilai, chen, vujovic, de cordova dan dansethakul (11). formula masing yang dikembangkan dapat dilihat pada tabel 1. tabel 1. berbagai macam formula cldl-c peneliti persamaan kolesterol-ldl indirek friedewald dkk (1972) ldl = tc – hdl-c – tg/5 anandaraja dkk (2005) ldl = 0,9tc – 0,9tg/5 – 28 puavilai dkk (2009) ldl = tc – hdl-c – tg/6 chen dkk (2010) ldl = 90%kolesterol non-hdl – 10%tg vujovic dkk (2010) ldl = tc – hdl-c – tg/3 de cordova dan de cordova (2013) ldl = ¾(tc – hdl-c) dansethakul (2015) ldl = 0,9955tc – 0,9853hdl-c – 0,1998tg + 7,1449 34 gilang nugraha, soebagijo poegoeh edijanto, penentuan formula untuk menetapkan estimasi kolesterolldl metode penelitian subjek penelitian adalah pasien yang melakukan pemeriksaan profil lipid rutin di instansi patologi klinik gedung pusat diagnostik terpadu rsud dr. soetomo surabaya. sampel berupa serum dari pasien yang melakukan puasa 10 sampai 12 jam dengan tg kurang dari 400 mg/dl. semua serum dari pasien yang melakukan pemeriksaan profil lipid dilakukan pengukuran kadar tc, tg, hdl-c dan dldl-c menggunakan siemens dimension® rxl max® clinical chemistry system dan flex® reagent cartridge dengan metode enzimatik di rsud dr. soetomo surabaya. pemeriksaan cldl-c menurut friedewald, anandaraja, puavilai, chen, vujovic, de cordova dan dansethakul dilakukan dengan cara perhitungan sesuai formula yang diusulkan masing-masing. pengukuran dldl-c dilakukan sebagai metode referen pemeriksaan, sehingga terdapat pembanding metode yang lebih baik terhadap metode cldl-c yang sedang diteliti. analisis statistik dilakukan untuk uji akurasi, korelasi dan linieritas formula cldl-c terhadap metode referen menggunakanexcel office 2013. hasil penelitian karakteristik sampel sebanyak 89 sampel diambil untuk penelitian, sampel terdiri dari 41 laki-laki dan 48 perempuan dengan usia rata-rata 52 tahun. karakteristik hasil pengukuran lipid pada penelitian ini dapat dilihat pada tabel 2. tabel 2. karakteristik hasil pengukuran lipid parameter mean sd range (mg/dl) (mg/dl) kolesterol 199 58 80 – 471 total trigliserida 200 108 20 – 398 hdl-c 41 13 5 – 82 dldl-c 120 44 42 – 342 cldl-c fredewald 118 50 32 – 342 anandaraja 115 48 14 – 325 puavilai 125 51 34 – 355 chen 122 47 34 – 339 vudjovic 91 50 14 – 289 de cordova 118 43 34-316 dansehakul 125 50 34 – 316 39 – 348 akurasi cldl-c akurasi ditetapkan sebagai nilai bias dari masingmasing formula cldl-c terhadap metode referen. 35 medical and health science journal, vol. 2, no. 2, august 2018 nilai bias positif menunjukkan formula memberikan hasil lebih tinggi dibandingkan metode referen, nilai bias negatif menunjukkan formula memberikan hasil lebih rendah dibandingkan metode referen. nilai bias pada masing-masing formula dapat dilihat pada tabel 3. tabel 3 nilai bias masing-masing formula cldl-c parameter bias (%) friedewald -1,32 anandaraja -3,92 puavilai 4,26 chen -2,19 vujovic -23,65 de cordova -0,91 dansethakul 4,45 estimasi cldl-c menggunakan formula de cordova merupakan metode perhitungan yang memiliki akurasi lebih baik dibandingkan metode perhitungan lainnya pada trigliserida kurang dari 400 mg/dl. formula friedewald memiliki akurasi terbaik ke dua yang selanjutnya berturutturut diikuti oleh formula chen, anandaraja, puavilai, dansethakul, dan akurasi yang terburuk pada formula vujovic. uji korelasi dan linieritas uji korelasi dan linieritas dilakukan untuk mengetahui seberapa baik cldl-c pada masingmasing formula dalam menentukan kadar kolesterol ldl yang sebenarnya dalam darah 36 dengan menentukan seberapa dekat hasil pemeriksaan formula cldl-c dengan pengukuran langsung ldl-c menggunakan metode homogeneous enzymatic assay. tabel 4 memperlihatkan hasil uji korelasi dan analisis regresi linier pada masing-masing formula cldlc. tabel 4 koefisien korelasi, koefisien determinasi dan persamaan regresi formula cldl-c formula koefisi koefesie persama cldl-c en n an korela determi regresi si nasi fredewal 0,9509 90 % y = d 1,0867x – 11,935 anandar 0,9013 81 % y = aja 0,9791x – 2,1879 puavilai 0,9576 91 % y = 1,1083x – 7,851 chen 0,9585 91 % y = 1,0298x – 0,9399 vudjovic 0,8745 76 % y = 1,0004x – 28,271 de 0,9300 86 % y = cordova 0,912x + 9,4266 danseha 0,9505 90 % y = kul 1,0814x – 4,4078 gilang nugraha, soebagijo poegoeh edijanto, penentuan formula untuk menetapkan estimasi kolesterolldl gambar 2 garis regresi linier pada berbagai macam formula cldl-c gambar 2 memperlihatkan garis regresi linear pemeriksaan cldl-c pada masing-masing formula, garis regresi pada masing-masing formula cldl-c saling berdekatan kecuali formula vujovic dengan kemiringan garis (slope) berbeda-beda pada formula. uji korelasi dan analisis regresi linier menunjukkan bahwa cldl-c formula chen memiliki kedekatan yang lebih baik dengan metode dldl-c jika dibandingkan dengan formula lain walau slope dan intersep pada metode lain memiliki angka yang lebih kecil. metode selanjutnya secara berturut-turut diikuti oleh formula puavilai, friedewald, dansehakul, de cordova, anandaraja dan vudjovic. kesimpulan berbagai macam formula cldl-c diusulkan paling baik dalam menetapkan kadar kolesterolldl dalam darah, setelah dilakukan uji akurasi dan linieritas terhadap 89 sampel dengan trigliserida kurang dari 400 mg/dl didapat hasil yang bervariasi. formula cldl-c yang diusulkan chen dkk menjanjikan dalam menetapkan estimasi kolesterol-ldl dalam darah dan menjadi alternatif pengganti formula friedewald walau akurasi pemeriksaan chen (bias:-2,19%) masih lebih baik pada formula de cordova (bias:-0,91%) dan friedewald (bias:-1,32%). formula chen memperlihatkan performa yang terbaik pada penelitian ini, akan tetapi formula cldl yang pertama kali diusulkan oleh friedewald memperlihatkan hasil yang memuaskan dengan nilai bias yang kecil (bias:1,32%) dan korelasi yang cukup kuat (r:0,9509). formula cldl-c yang diusulkan vujovic memberikan hasil yang buruk pada penelitian ini, akurasi formula vujovic memiliki bias yang cukup tinggi (bias:-23,65%) dan korelasi yang sangat rendah dibandingkan dengan formula lainnya (r:0,8745). sehingga formula ini sangat tidak disarankan dalam menetapkan estimasi kolesterol-ldl dalam darah. validasi metode menurut iso 17025 dan 15189 dapat diterapkan pada masing-masing formula cldl jika ingin diterapkan pada laboratorium klinik, karena alat dan teknik pemeriksaan dapat mempengaruhi kualitas pemeriksaan dari masing-masing formula cldlc tersebut. referensi hao w, friedman a. 2014. the ldl-hdl profile determines the risk of atherosclerosis: a mathematical model. plos one [internet]. 2014;9(3): e90497. available from: http://dx.plos.org/10.1371/journal.pone.009 0497 erwinanto, santoso a, putranto jne, tedjasukmana p, suryawan r, rifqi s, et al. 2013. pedoman tatalaksana dislipidemia. j kardiol indones [internet]. 2013;34(4):245– 70. available from: http://jki.or.id feingold kr, grunfeld c. 2015. introduction to lipids and fatty acids [internet]. mctext.com. 2015 [cited 2015 oct 13]. p. 37 medical and health science journal, vol. 2, no. 2, august 2018 1–11. available from: http://www.ncbi.nlm.nih.gov/ randolph gj, miller ne. 2014. lymphatic transport of high-density lipoproteins and chylomicrons. j clin invest. 2014;124(3):929–35. legorreta v, chávez-sánchez l, chávez-rueda k, blanco-favela f. 2014. the innate immune response mediated by tlrs in atherosclerosis. in: inflammation, chronic diseases and cancer – cell and molecular biology, immunology and clinical bases. mexico: intech; 2014. p. 53–74. ramasamy i. 2013. recent advances in physiological lipoprotein metabolism. clin chem lab med. 2013;52(1434–6621 (electronic)):1–33. cohen de, fisher ea. 2013. lipoprotein metabolism, dyslipidemia and nonalcoholic fatty liver disease. semin liver dis. 2013;33(4):380–8. kemenkes ri. 2011. pedoman pemeriksaan kimia klinik. jakarta; p. 147–57. burtis ca, ashwood er, burns de, sawyer bg. 2012. lipids, lipoproteins, apolipoproteins, and other cardiovascular risk factors. in: fundamentals of clinical chemistry. 6th ed. philadelphia: saunders elsevier; p. 402–27. kwiterovich po. 2004. laboratory procedure manual: total cholesterol, hdl-cholesterol, triglycerides, and ldl-cholesterol. atlanta: centers for disease control and prevention. dansethakul p, thapanathamchai l, saichanma s, worachartcheewan a, pidetcha p, service e, et al. 2015. determining a new formula for calculating low-density lipoprotein cholesterol: data mining approach. exp clin sci int online j. 2015;(14):478–83. 38 review article medical and health science journal, vol.4., no.1, february 2020 perbandingan angka kekambuhan bacterial vaginosis antara terapi metronidazole tunggal dengan kombinasi metronidazole dan probiotik: metaanalisis risna ardianti mitavania*1, azami denas2 1 departemen/smf obstetri ginekologi rsud dr. soetomo, surabaya, fakultas kedokteran universitas airlangga surabaya 2 divisi uroginekologi rekonstruksi, departemen/smf obstetri ginekologi rsud dr. soetomo, surabaya, fakultas kedokteran universitas airlangga surabaya *correspondent author: risnaardianti84@gmail.com article info abstrak article history: submitted: january, 20 2020 received in revised form february,2020 accepted: february, 26 2019 tujuan: membandingkan angka kekambuhan pengobatan metronidazole tunggal dibandingkan kombinasi metronidazole dan probiotik pada bacterial vaginosis (bv). metode: pencarian data dilakukan pada database kedokteran (pubmed, cochrane database) dengan menggunakan kata kunci: (1) bacterial vaginosis [judul] dan (2) metronidazole single therapy [judul] dan combination therapy metronidazole and probiotik [judul]. kriteria inklusi: studi acak terandominasi, wanita bv usia reproduksi (18-50 tahun) dengan nugent score 7-10, intervensi yang diteliti terapi metronidazole tunggal dan terapi kombinasi metronidazole dan probiotik, seluruh makalah terinklusi dapat diakses penuh, dan data dapat dianalisis secara akurat. dilakukan perbandingan menggunakan analisis narasi dan meta-analisis (revman). hasil: didapatkan tiga studi sesuai kriteria inklusi. pada studi anukam 2006 disimpulkan bahwa angka kekambuhan bv pada kelompok terapi metronidazole tunggal yaitu sebesar 17/65 (26,1%). pada studi bradshaw, angka kekambuhan bv pada kelompok metronidazole tunggal sebesar 39/150 ( 26% ), sedangkan pada kelompok kombinasi sebesar 28/150 (18,67%). pada studi heczko, angka kekambuhan bv pada kelompok metronidazole tunggal sebesar 15/81 (18,5 %) dan pada kelompok terapi kombinasi sebesar 22/73 (30,1%). secara keseluruhan angka kekambuhan bv dengan terapi metronidazole tunggal adalah 71/291 (24,3%) dibandingkan dengan terapi kombinasi sebesar 50/288 (17,36%). kesimpulan: secara keseluruhan angka kekambuhan bv dengan terapi terapi kombinasi metronidazole dan probiotik didapatkan perbedaan yang signifikan bila dibandingkan dengan terapi metronidazole tunggal (z = 2,04; p<0,04). kata kunci: bacterial vaginosis, terapi tunggal metronidazole, terapi kombinasi metronidazole dan probiotik, angka kekambuhan @2020 medical and health science journal. 10.33086/mhsj.v4i1.1443 pendahuluan bacterial vaginosis (bv) adalah infeksi vagina yang paling umum terjadi pada wanita usia reproduksi yang disebabkan pertumbuhan berlebihan bakteri anaerob dengan penurunan populasi lactobacillus di vagina1. bv sering terdiagnosis pada wanita usia reproduksi dengan keluhan keputihan yang menggangu sehingga memeriksakan diri ke pusat kesehatan2. untuk mendiagnosis bv ada berbagai metode, kriteria amsel, nugent skor, bv blue test maupun pcr3,4. nugent score dihitung jumlah dari lactobacillus, gardnella dan berbagai morfotipe bakteria perlapang pandang besar. bila skor 0-3 (normal) 4-6 (bv intermediate), dan 7-10 (bv definitif)3,5. menurut amsel (1983), bv ditegakkan bila didapatkan: cairan keputihan tipis keabuan, ph vagina > 4,5, clue cell (+) pada pewarnaan gram (sedikitnya 20% dari seluruh epitel pada sediaan basah), dan whiff test (+) yaitu apabila tes amin positif dimana sekret vagina berbau amis sebelum dan sesudah penambaah koh correspondence: risna ardianti mitavania @2020 medical and health science journal. 10.33086/mhsj.v4i1.1443 available at http://journal2.unusa.ac.id/index.php/mhsj 6 mailto:risnaardianti84@gmail.com http://journal2.unusa.ac.id/index.php/mhsj medical and health science journal, vol.4., no.1, february 2020 7 10%6. sedangkan bv blue test yaitu diteteskan bv blue vial (mengandung substrat kromogenik dari bakteri sialidase) selama 10 menit pada swab vagina. dikatakan postif apabila berwarna biru kehijauan dan negative apabila berwarna kuning4. terapi lini pertama bv menurut cdc, 20156 adalah metronidazole oral 2x500 mg (selama 7 hari), metronidazole gel 0,75% (5g intravagina) 1x1 selama 7 hari dan clyndamycin cream 2% (5 g intravagina) sebelum tidur selama 7 hari. sedangkan menurut oduyebo 2009 terapi lini pertama bv adalah pemberian 1 mg metronidazole oral atau clindamycin cream pervaginam, metronidazole gel pervaginal selama 5 hari dan semuanya mempunyai efek jangka pendek yang serupa7. angka kekambuhan bv jangka panjang setelah terapi metronidazole oral selama 12 bulan adalah 58%8. bv terjadi dikarenakan ketidakseimbangan populasi mikroorganisme normal dengan pengurangan lactobasilus dan pertumbuhan berlebihan dari bakteria lain. muncul konsep pendekatan terapi menggantikan kehilangan lactobacillus menggunakan preparat probiotik yang akan menggantikan bv patogen. terdapat hasil sedikit signifikan efisiensi terapi kombinasi metronidazole dan probiotik dibandingkan metronidazole tunggal pada bv9. tujuan tujuan penelitian ini untuk membandingkan angka kekambuhan bv antara pemberian terapi metronidazole tunggal dibandingkan dengan kombinasi metronidazole dan probiotik. manfaat manfaat penelitian ini diharapkan dapat digunakan sebagai acuan terapi bv secara klinis dengan melihat perbandingan angka kekambuhan yang terjadi antara pemberian terapi metronidazole tunggal dibandingkan dengan kombinasi metronidazole dan probiotik. metode strategi pencarian data pencarian literatur secara sistematis telah dilakukan dengan menggunakan pubmed dan cochrane database dalam rentang tahun 2000 2019 untuk memperoleh studi terkait perbandingan angka kekambuhan bv antara pemberian terapi tunggal metronidazole dibandingkan dengan terapi kombinasi metronidazole dan probiotik berupa studi acak terandomisasi (rct/randomized controlled trial). pencarian data dengan menggunakan kata kunci: bacterial vaginosis, single therapy metronidazole, combination therapy metronidazole dan probiotik. duplikasi judul dihilangkan. abstrak dari masing – masing jurnal dinilai sesuai dengan kriteria inklusi. kriteria inklusi beberapa kriteria berikut telah digunakan dalam pemilihan: (1) studi acak terandominasi (rct), (2) sampel pada jurnal: wanita usia reproduksi (18-50 th) dengan diagnosis bv dengan hasil nugent score 7-10, (3) intervensi yang diteliti: terapi metronidazole tunggal, (4). perbandingan : terapi metronidazole dan probiotik, (5) luaran : angka kekambuhan dalam 30 hari, menggunakan nugent score, (6) seluruh makalah terinklusi dapat diakses secara penuh, (7) data yang diperoleh dapat dianalisis secara akurat. kriteria eklusi kriteria ekslusi yang digunakan : (1) hamil atau menyusui, (2) hipersensitif terhadap metronidazole, (3) didapatkan candida vaginitis dan (4) menggunakan pembersih kewanitaan. hasil dan pembahasan pencarian data di pubmed dan cochrane library menghasilkan sebanyak 578 artikel. dilakukan skrining berdasarkan kriteria inklusi yang telah dideskripsikan sebelumnya, didapatkan total 3 artikel yang terinklusi untuk metaanalisis. proses skrining dan seleksi diilustrasikan menggunakan prisma flowchart (gambar 1). medical and health science journal, vol.4., no.1, february 2020 8 gambar 1. diagram alur proses seleksi studi menggunakan prisma flowchart karakteristik studi yang terinklusi dan karakteristik studi penelitian dapat dilihat pada tabel 1 dan tabel 2. tabel 1. karakteristik studi yang terinklusi refere nsi negara de sain studi kriteria inklusi kriteria ekslusi populasi (mtz/mt z+prob) interven si comparis on diagno sis bv luaran primer anuka m et al 2006 nigeria rct  wanita usia 18 44 th  gejala bv  nugent score 7 10  bv blue test postif  hamil  menyusui  proses infamasi genital termasuk penyakit menular seksual  menggunakan antibiotik sistemik atau pervaginal dalam dan selama 14 hari  hipersensitif metronidazole 65/60 metron i dazole 2 x 500 mg (sd 7 hari) metronid azole 2 x 500 mg (sd 7 hari) + probiotik (lactoba cillus gr1 + rc14) 2x1 selama 14 hari nugent score + bv blue test positif 30 hari bradsh aw et al 2012 austral a rct  wanita 18-50 th  gejala bv  nugent score 7 10  amsel kriteria >3  hiv (+)  hamil  menyusui  program hamil  tidak berbahasa inggris  bukan beralamat australia 150/150 metron i dazole 2 x400 mg (sd 7 hari) metronid azole 2 x400 mg (sd 7 hari) + probiotik (lactoba cillus ks400) 1x1 pervagin am nugent score 30 hari medical and health science journal, vol.4., no.1, february 2020 9  tidak dapat menjauhi vaginal seks selama terapi selama 12 hari heczko et al 2015 polandi a rct  -wanita 18-50 th  wanita eropa dg haid teratur dan riw bv berulang  -nugent score 7 10  -amsel kriteria >3  tidak menggu nakan vaginal douche selama terapi  hamil / menyusui  hipersensitif thd metronidazole  candida vaginitis  perdarahan genetalia tanpa sebab yang jelas  imunodefisien si  diabetes  sakit mental  keganasan  kontrasepsi mekanik (diafragma, iud, hormonal vaginal ring  menggunakan preparat oral hormonal  berpartisipasi dalam penelitian lain 30 hari sebelumnya  menggunakan antibiotik dg alasan lain  terjadwal operai atau masuk rumah sakit 81/73 metron i dazole 2 x 500 mg (sd 7 hari) metronid azole 2 x 500 mg (sd 7 hari) + probiotik 2 x1 selama 14 hari nugent score 31 hari tabel 2. karakteristik studi penelitian penelitian randomisasi allocation concealment blinding anukam et al 2006 menggunakan program komputer yang disiapkan oleh pihak farmasi subyek penelitian diberikan koding nomer dan preparat metronidazole dan probiotik disiapkan daam kontainer yang berkode nomer oleh pihak farmasi peneliti maupun subyek penelitian tidak mengetahui preparat yang diberikan pada setiap subyek bradshaw et al 2012 menggunakan urutan yang terkomputerisasi subyek penelitian diberikan nomer yang didapatkan secara komputerisasi, subyek mendapat kotak tersegel peneliti, subyek penelitian, perawat pemberi kode dan petugas mikroskopik tidak mengetahui medical and health science journal, vol.4., no.1, february 2020 10 yang tidak diketahui isinya, dan subyek diintruksikan membuka kotak tersebut di rumah preparat yang diberikan pada setiap subyek heczko et al 2015 randomisasi menggunakan blok yang terbagi menjadi 2 perlakuan subyek penelitiian yang telah mendapat terapi antibiotik 2x1 selama 7 hari terbagi secara acak (blok randomisasi) dibagi menjadi 2 lengan studi. subyek diberikan probiotik atau placebo dlm bentuk kapsul peneliti maupun subyek penelitian tidak mengetahui preparat yang diberikan pada setiap subyek meta-analisis disusun menggunakan review manager (revman) versi 5.3. (cochrane collaboration, oxford, uk). gambar 2. kesimpulan stratifikasi risiko bias pada seluruh artikel dalam metaanalisis gambar 3. penilaian risiko bias penulis terhadap artikel terinklusi incomplete outcome data dari penelitian ini dikarenakan pada salah satu penelitian (heczko 2015) menganalisis efikasi terapi secara per protokol. sehingga tidak semua yang terinklusi dianalisis. medical and health science journal, vol.4., no.1, february 2020 11 gambar 4. forest plot menampilkan angka kekambuhan pengobatan metronidazole tunggal dibandingkan kombinasi metronidazole dan probiotik pada bakterial vaginosis dari gambar 4 dapat dilihat bahwa pada studi anukam 2006 didapatkan bahwa angka kekambuhan bv pada kelompok terapi metronidazole tunggal yaitu sebesar 17/60 (28,3%)10. pada studi bradshaw, angka kekambuhan bv pada kelompok metronidazole tunggal sebesar 39/150 ( 26% ), sedangkan pada kelompok kombinasi sebesar 28/150 (18,67%)9. pada studi heczko, angka kekambuhan bv pada kelompok metronidazole tunggal sebesar 15/81 (18,5 %) dan pada kelompok terapi kombinasi sebesar 22/73 (30,1%)11. secara keseluruhan angka kekambuhan bv dengan terapi metronidazole tunggal adalah 71/291 (24,3%) dibandingkan dengan terapi kombinasi sebesar 50/288 (17,36%). secara keseluruhan angka kekambuhan bv dengan terapi metronidazole tunggal dibanding terapi kombinasi metronidazole dan probiotik berbeda signifikan sebesar z = 2,04 (p<0,04) . gambar 5. forest plot menampilkan odds ratio angka kekambuhan pengobatan metronidazole tunggal dibandingkan kombinasi metronidazole dan probiotik pada bakterial vaginosis gambar 5 menunjukkan bahwa dari studi anukam 2006 disimpulkan bahwa odds ratio angka kekambuhan bv pada kelompok terapi metronidazole tunggal yaitu sebesar 52,7910. pada studi bradshaw didapatkan odds ratio sebesar 1,538. sedangkan pada studi heczko, didapatkan odds ratio sebesar 0,5311. secara keseluruhan odds ratio angka kekambuhan bv dengan terapi metronidazole tunggal dibandingkan dengan terapi kombinasi sebesar 1,78 berbeda signifikan dengan z=0,78 (p=0,43). kesimpulan pada metaanalisis yang dilakukan terhadap tiga studi rct, secara keseluruhan didapatkan perbedaan yang signifikan (p<0,04) terhadap angka kekambuhan bv yang medical and health science journal, vol.4., no.1, february 2020 12 dilakukan terapi kombinasi (metronidazole dan probiotik) bila dibandingkan terapi metronidazole tunggal. daftar pustaka 1. bitew a, abebaw y, bekele d and mihret a. 2017. prevalence of bacterial vaginosis: and associated risk factor among women complaining of genital tract infection. international journal of microbiology. vol 2017 p 1-8 2. jesper v, crucciti t, joris m., et al.2014. prevalence and correlates of bacterial vaginosis in different sub-population of women in sub-saharan africa: a cross sectional study. plos one; vol 9 (10) p 1 16 3. reiter s and kellogg s. 2019. bacterial vaginosis: a primer for clinicians postgraduate medicine, 131:1, 8-18 4. kampan nc, suffan ss, ithin ns., et al. 2011. evaluation of bv blue test kit for the diagosis of bacterial vaginosis. elsevier. vol (2) p 1-5 5. courtney p, niccle mg, amanda l. 2017. relationship between nugent score and vaginal exfoliation. public library of science. 12 (5). p 1-27 6. cdc. 2015. sexually transmitted diseases treatment guidelines-bacterial vaginosis 7. vujic g, jajac knez a, despot stefanovic v, kuzmic vrbanovic v: 2013. efficacy of orally applied probiotic capsules for bacterial vaginosis and other vaginal infections: a double-blind, randomized, placebo-controlled study. eur j obstet gynecol reprod biol. 8. bradshaw, s, et al, 2012. efficacy of oral meronidazole with vaginal clindamycin or vaginal probiotic for bacterial vaginosis: radomised placebo-controlled double blind trial. plos one. april (2012) vol 7. e34540 1. 9. tan h., et al, 2017. effect of metronidazole combined probiotics over metronidazole for the treatment of bacterial vaginosis: a meta– analiysis of randomized clinical tials. arch gynecol obstet. 10. anukam, k. et al, 2006. augmentation of antimicrobial therapy of bacterial vaginosis with oral lactobacillus rhamnosus gr-1 and lactobacillus reuteri rc-14: randomized, double blind, placebocontrolled trial. science direct. microbes and infection 8 (2006) 1450-1454 11. heczko, b., et al, 2015. supplementation of standard antibiotic therapy with oral probiotics for bacterial vaginosis and aerobic vaginitis: a randomized, double blind, placebo-controlled trial. bmc women;s health. 15: 115 medical and health science journal, vol.4., no.1, february 2020 hubungan tingkat pengetahuan dengan tingkat kepatuhan radioterapi pada pasien kanker di instalasi radioterapi rsud abdul wahab sjahranie samarinda ananda purnama mazna*1, yudanti riastiti2, abdillah iskandar3 1 program studi kedokteran, mulawarman university, samarinda 2 laboratorium radiologi, mulawarman university, samarinda 3 laboratorium mikrobiologi, mulawarman university, samarinda *correspondent: anandapurnamamazna@yahoo.co.id article info abstract article history: cancer is a disease characterized by abnormal cell growth outside the usual boundary then attacks the adjacent body and can spreads to other organs. cancer treatment can be done with several therapies according to indications, one of them is radiotherapy. one of succession factor in the radiotherapy treatment for cancer is having good knowledge. treatment adherence is very important to get optimal results such as healing or improving quality of life. the aim of this research was to determine the relationship between radiotherapy knowledge with radiotherapy adherence in undergoing radiotherapy cancer patients at general hospital of abdul wahab sjahranie samarinda. this research was an observational analytic design with cross-sectional approach. data retrieval was done at the radiotherapy installation at general hospital of abdul wahab sjahranie samarinda from march to april 2019 by using a purposive sampling technique. the results showed that there were 50 samples who met the inclusion and exclusion criteria with details of patients who had good knowledge was 33 people, sufficient knowledge was 15 people, bad knowledge was 2 people and obey patients was 46 people and disobey patients was 4 people. data analysis using fisher's test obtained the value of p = 0.157 so it can be concluded that there was no relationship between radiotherapy knowledge and radiotherapy adherence in cancer patients at radiotherapy installation at genera. submitted: november, 28-2019 received in revised form february 2020 accepted: feb, 26 2020 keywords: radiotherapy knowledge, radiotherapy adherence kata kunci: pengetahuan radioterapi, kepatuhan radioterapi abstrak kanker adalah penyakit yang ditandai oleh pertumbuhan sel abnormal di luar batas yang biasanya kemudian menyerang tubuh yang berdampingan dan dapat menyebar ke organ lainnya. pengobatan kanker dapat dilakukan dengan beberapa terapi sesuai dengan indikasi, salah satunya adalah radioterapi. salah satu faktor keberhasilan pengobatan radioterapi pada kanker adalah memiliki pengetahuan yang baik. kepatuhan pengobatan sangat penting untuk mendapatkan hasil yang optimal seperti penyembuhan atau peningkatan kualitas hidup. tujuan umum dilakukannya penelitian ini untuk mengetahui hubungan tingkat pengetahuan dengan tingkat kepatuhan radioterapi pada pasien kanker yang sedang menjalani pengobatan radioterapi di rsud abdul wahab sjahranie. penelitian ini merupakan penelitian yang menggunakan desain analitik dengan pendekatan cross-sectional. pengambilan data dilakukan di instalasi radioterapi rsud abdul wahab sjahranie samarinda. pengambilan data dilakukan selama satu bulan, yaitu pada bulan maret sampai bulan april 2019 dengan menggunakan teknik purposive sampling. hasil penelitian didapatkan sebanyak 50 sampel yang memenuhi kriteria inklusi dan eksklusi dengan rincian pasien yang memiliki pengetahuan baik 33 orang, pengetahuan cukup 15 orang, pengetahuan buruk 2 orang serta pasien yang patuh berobat 46 orang dan tidak patuh berobat 4 orang. analisis data menggunakan uji fisher diperoleh nilai p = 0,157 sehingga dapat disimpulkan tidak terdapat hubungan antara pengetahuan radioterapi dengan kepatuhan berobat pada pasien kanker di instalasi radioterapi rsud abdul wahab sjahranie samarinda. @2020 medical and health science journal. 10.33086/mhsj.v4i1.1302 correspondence: ananda purnama mazna @2020 medical and health science journal. 10.33086/mhsj.v4i1.1302 available at http://journal2.unusa.ac.id/index.php/mhsj 1 original article mailto:anandapurnamamazna@yahoo.co.id http://journal2.unusa.ac.id/index.php/mhsj medical and health science journal, vol.4., no.1, february 2020 pendahuluan kanker adalah penyakit yang ditandai oleh pertumbuhan sel abnormal di luar batas yang biasanya kemudian menyerang tubuh yang berdampingan dan atau menyebar ke organ lainnya1. penyakit kanker adalah penyakit yang timbul akibat pertumbuhan sel jaringan tubuh yang tidak normal yang berubah menjadi sel kanker2. who juga mengungkapkan kanker adalah penyebab utama kedua kematian secara global dan diperkirakan bertanggung jawab atas 9,6 juta kematian pada tahun 2018. global cancer observation (globocan), international agency for research on cancer (iarc) menyatakan pada tahun 2018 terdapat 18,1 juta kasus baru kanker dan 9,6 juta kematian akibat kanker di seluruh dunia3. kanker payudara, kanker prostat dan kanker paru merupakan jenis kanker dengan presentase kasus baru tertinggi, sementara itu, kanker paru dan kanker payudara merupakan penyebab kematian tertinggi akibat kanker2. kanker dapat diobati bahkan disembuhkan dengan terapi tertentu. operasi, kemoterapi dan radioterapi merupakan terapi utama dari kanker4. radioterapi merupakan salah satu metode pengobatan kanker yang menggunakan radiasi dosis tinggi untuk membunuh sel kanker dan mengecilkan tumor5. radioterapi menggunakan radiasi pengion karena dapat membentuk ion yaitu partikel bermuatan listrik dan menyimpan energi ke sel sel jaringan yang melewatinya. energi yang tersimpan ini bisa membunuh sel kanker atau menyebabkan perubahan genetik yang mengakibatkan kematian sel kanker6. radioterapi merupakan salah satu terapi yang efektif untuk jenis kanker tertentu5. namun, masih banyak pasien yang belum mengetahui tentang radioterapi. salah satu faktor yang memengaruhi nilai keberhasilan radioterapi adalah pengetahuan7. pengetahuan tentang radioterapi juga akan memengaruhi kepatuhan pasien yang menjalani radioterapi. kepatuhan pengobatan sangat penting untuk mendapatkan hasil yang optimal seperti penyembuhan dan peningkatan kualitas hidup8. tujuan dilakukannya penelitian ini untuk mengetahui hubungan tingkat pengetahuan dengan tingkat kepatuhan radioterapi pada pasien kanker yang sedang menjalani radioterapi pada pasien kanker yang sedang menjalani radioterapi di instalasi radioterapi rsud abdul wahab sjahranie samarinda periode maret 2019-april 2019. metode penelitian penelitian ini merupakan penelitian yang menggunakan desain analitik dengan pendekatan cross-sectional. pengambalian sampel menggunakan teknik purposive sampling dengan kriteria inklusi pasien kanker yang menjalani radioterapi, pasien yang bersedia menjadi responden, dan pasien yang telah menjalani radioterapi dalam satu minggu pertama dan kriteria eksklusi data rekam medik yang tidak lengkap, dan pasien yang sulit berkomunikasi. data yang digunakan dalam penelitian kami adalah data primer berupa kuisioner yang telah di uji validitas dan uji reabilitas dengan nilai uji validitas 0,5214 dan uji reliabilitas 0,724. variabel dalam penelitian ini adalah tingkat pengetahuan pasien dan kepatuhan pasien. analisis data menggunakan uji univariat untuk mengetahui sebaran data pasien kanker dan uji fisher untuk mengetahui hubungan tingkat pengetahuan dengan tingkat kepatuhan radioterapi pasien. penelitian ini telah mendapatkan izin dari komite etik penelitian kesehatan dengan nomor surat 038/kepk-aws/iii/2019. hasil dan pembahasan penelitian ini dilakukan di instalasi radioterapi rsud abdul wahab sjahranie samarinda. sampel yang diperoleh dalam penelitian ini yaitu sebanyak 50 pasien. hasil penelitian memperlihatkan gambaran karakteristik pasien yang menjalani radioterapi berdasarkan usia, jenis kelamin, pendidikan terakhir, dan frekuensi radioterapi yang telah dilalui. selain itu jga menilai hubungan tingkat pengetahuan dengan tingkat kepatuhan radioterapi terhadap pasien yang menjalani 2 medical and health science journal, vol.4., no.1, february 2020 radioterapi di instalasi radioterapi rsud abdul wahab sjahranie samarinda. usia pasien kanker yang menjalani radioterapi dibagi menjadi 3 kategori yaitu 20 40 tahun, 41-60 tahun, dan >60 tahun berdasarkan penelitian yang dilakukan sebelumnya oleh yulia di rs kanker dharmais, dan pembagian ini juga berdasarkan who yang mengklasifikkasikan 20-40 tahun sebagai usia dewasa, 41-60 tahun sebagai usia tua, dan usia >60 tahun sebagai kategori lanjut usia. berdasarkan hasil penelitian ini didapatkan bahwa pasien yang menjalani radioterapi terbanyak pada pasien yang berusia 41-60 tahun. alasan ini dapat didukung bahwa usia berpengaruh terhadap keaktifan seseorang untuk berpartisipasi, terlebih dalam urusan kesehatan atau pola hidup yang sangat menjadi urusan penting untuk dilakukan oleh kategori usia tua9. pada penelitian ini kami mendapatkan jenis kelamin terbanyak adalah perempuan dengan jumlah 34 responden dan jumlah laki laki 16 responden. who (2018) memaparkan pada cancer country profiles insiden terbanyak terjadi pada perempuan yaitu 101.325 kasus sedangkan laki-laki 77.690 kasus. hal ini sejalan dengan penelitian yulia di rs kanker dharmais (2012) dan harfendi, yuliasti & winarto di rsud arifin achmad provinsi riau (2017). beberapa alasan yang menyebabkan perempuan lebih banyak dikarenakan perempuan lebih tinggi tingkat kesadarannya sehingga saat pendataan respon rate lebih banyak ditemukan, hal ini juga yang menyebabkan proporsi kanker serviks, ovarium dan payudara merupakan jenis kanker yang paling banyak ditemukan di indonesia10. wanita juga memiliki risiko yang lebih tinggi untuk terkena kanker payudara dikarenakan wanita lebih terpajan terhadap hormone estrogen11. pendidikan terakhir pasien dikategorikan menjadi 5 kategori, yaitu tidak sekolah, sd, smp, sma, dan perguruan tinggi. kami mendapatkan status pendidikan terbanyak ialah sd yaitu 16 responden. hal ini serupa dengan hasil penelitian nasional di indonesia pada tahun 2018 dan hal ini sejalan dengan penelitian yang dilakukan oleh asyifa di rsud dr. moewardi surakarta (2019) hasil serupa paling banyak pada tingkat pendidikan yang rendah daripada tingkat pendidikan yang tinggi yang didukung oleh pernyataan notoamodjo12 seseorang yang memiliki tingkat pendidikan yang tinggi cenderung mempunyai pola pikir yang lebih berkembang dan lebih logis. kami membagi kategori distribusi frekuensi radioterapi menjadi 4 kategori, yaitu 1-10 kali penyinaran, 11-20 kali penyinaran, 21-30 kali penyinaran, dan >30 kali penyinaran. kami mendapatkan frekuensi radioterapi terbanyak ialah 21-30 kali penyinaran, hal ini sejalan dengan penelitian yang dilakukan di surakarta pada tahun 2017. kami menemukan bahwa responden memiliki pemahaman bahwa radioterapi perlu dilakukan secara rutin, tidak hanya sekali. hal ini berkaitan berkaitan dengan informasi mengenai jadwal pelaksanaan radioterapi yang telah dipaparkan oleh dokter sebelum pelaksanaan radioterapi. informasi akan memberikan pengaruh pada pengetahuan seseorang. kami juga menganalisis pengetahuan dan kepatuhan radioterapi secara bivariat. dari hasil tersebut dapat diartikan bahwa tingkat pengetahuan radioterapi dengan tingkat kepatuhan radioterapi pada pasien kanker yang menjalani radioterapi di instalasi radioterapi rsud abdul wahab sjahranie samarinda tidak bermakna signifikan secara statistik sehingga hasil ini tidak sesuai dengan hipotesis penelitian. hasil yang kami dapatkan berbeda dengan penelitian yang dilakukan oleh badakhshi (2013). penelitian tersebut menyebutkan ketidakpatuhan dapat disebabkan oleh kurangnya informasi yang memadai mengenai alasan untuk mengenai radioterapi dan ketakutan pasien akan radioterapi itu sendiri. kemungkinan penyebab hasil penelitian ini tidak sejalan dengan hipotesis penelitian karena pasien-pasien yang menjalani radioterapi di instalasi radioterapi rsud abdul wahab sjahranie samarinda terbanyak memiliki tingkat kepatuhan yang patuh 3 medical and health science journal, vol.4., no.1, february 2020 sehingga penyebaran data tidak merata, karena penyebaran data termasuk salah satu faktor yang memengaruhi nilai p. nilai p dipengaruhi oleh jumlah efek, jumlah sampel dan penyebaran data tidak merata13. pasien radioterapi dituntut untuk patuh, karena jika pasien yang menjalani radioterapi tidak patuh atau tidak mengikuti perawatan yang ditentukan selama jangka waktu yang direncanakan oleh dokter, maka pasien akan dikeluarkan atau tidak mendapat jadwal untuk radioterapi lagi. selain itu, tingkat pengetahuan bukan merupakan faktor tunggal yang memengaruhi ketidakpatuhan dalam radioterapi. faktor-faktor lain yang berpengaruh terhadap kepatuhan pasien adalah jarak pasien yang berada >100 km dari pusat perawatan, pasien tanpa kartu kemiskinan, pasien yang menganggur, dan pasien dengan penyakit stadium iv-a/b dan stadium lanjut tumor, pemberian computer controlled radiation therapy (ccrt)14,15. simpulan berdasarkan hasil penelitian, maka dapat ditarik kesimpulan : 1. tingkat pengetahuan radioterapi pasien terbanyak adalah baik. 2. tingkat kepatuhan radioterapi pasien terbanyaj adalah patuh. 3. tidak terdapat hubungan antara tingkat pengetahuan dengan tingkat kepatuhan radioterapi pada pasien kanker yang menjalani radioterapi di instalasi radioterapi rsud abdul wahab sjahranie samarinda. daftar pustaka 1. who. (2018) . “latest global cancer data: cancer burden rises to 18.1 million new cases and 9.6 million cancer deaths in 2018.” (who) 1-3. 2. kementrian kesehatan republik indonesia. (2015). “stop kanker.” info datin (pusat data dan informasi) 1-6. 3. international association of cancer registries. (2018). new global cancer data : globocan 2018. 12 september. diakses january 14, 2019. http://www.uicc.org/new-global-cancer data-globocan-2018. 4. mariah-singh, diane, dan elisabeth raymakers. n.d. what is cancer? information on cancer for patients and family. health province of kwazulu natal, cancer association of south africa, kwazulu-natal: cancer association of south africa. 5. national cancer institute. (2016). national cancer institute. diakses january 18, 2019. www.cancer.gov. 6. fitriatuzzakiyah, nur, rano k. sinuraya, dan irma m. puspitasari. (2017). “terapi kanker dengan radiasi: konsep dasar radiasi dan perkembangannya di indonesia.” jurnal farmasi klinik indonesia 6: 311-320. 7. rosita, ita, dan susana widyaningsih. (2017). “gambaran tingkat pengetahuan tentang radioterapi pada pasien kanker nasofaring di rsud dr moewardi surakarta.” jurnal jurusan keperawatan. 8. puts, m. t. e., a. tourangeau h. a. tu, d. howell, m. fitch, e. springall, dan s. m. h. alibhai. (2013). “factors influencing adherence to cancer treatment in older adults with cancer: a systematic review.” oxford journals annals of oncology (us national library of medicine national institutes of health). 9. slamet, y. (1994). pembangunan masyarakat berwawasan partisipatif. surakarta: sebelas maret university. 10. riskesdas ri. (2018). hasil utama riskesdas 2018. kementerian kesehatan badan penelitian dan pengembangan kesehatan. 11. sari, suci estetika, wirsma arif harahap, dan deddy saputra. (2018). “pengaruh faktor risiko terhadap ekspresi reseptor estrogen pada penderita kanker payudara di kota padang.” jurnal kesehatan andalas 7. 12. notoatmodjo. (2014). ilmu perilaku kesehatan. jakarta: rineka cipta. 4 http://www.uicc.org/new-global-cancer-data-globocan-2018 http://www.uicc.org/new-global-cancer-data-globocan-2018 http://www.cancer.gov/ medical and health science journal, vol.4., no.1, february 2020 13. dahiru, tukur. (2008). “pvalue, a true test of statistical significance? a cautionary note.” annals of ibadan postgraduate medicine 6: 21-26. 14. pandey, kailash chandra, swaroop revannasiddaiah, dan nirdosh kumar pant. (2015). “palliative radiotherapy in locally advanced head and neck cancer after failure of induction chemotherapy: comparison of two fractionation schemes.” indian journal of palliative care 21 (1): 21-26 15. shivani, gupta, kartick rastogi, aseem rai bhatnagar, daleep singh, kampra gupta, dan ajay singh choudhary. (2018). “compliance to radiotherapy: a tertiary care center experience.” indian journal of cancer 55 (2): 166-169. 5 medical and health science journal, vol.3., no.2, august 2019 review article: amebiasis molecular pathogenesis development nurlina muliani1*, hotimah masdan salim2 1master of clinical pharmacy at the university of surabaya 2faculty of medicine, university of nahdlatul ulama surabaya *correspondent author: nurlinamuliani95@gmail.com article info abstract article history: submission: july 26 2019 received in revised form august 2019 acccepted: august 21 2019 amebiasis is one of the gastrointestinal tract infection disease caused by entamoeba histolytica, a parasitic protozoan. amebiasis is the second disease, caused by parasite, that leading cause of death after malaria. infection occurs through faecal oral route and after ingestion a contaminated food and beverages by human faeces. the pathogenesis of e. histolytica can be classified into 3 processes, i.e: death of host cell, inflammation, and parasitic invasion. the recent years, a molecularly amebiasis pathogenesis has been developed, i.e: adherence, phagocytosis, tropogocytosis of host cell and how the parasites can survive and attack host cells so it can cause an infection in humans. molecular development is an important thing to be considered in the selection of amebiasis therapy. @2019 medical and health science journal. 10.33086/mhsj.v3i2.1195 keywords: pathogenesis, molecular, amoeba, amebiasis, entamoeba histolytica introduction amebiasis is one of the gastrointestinal tract infections caused by entamoeba histolytica which is an unicellular and anaerob microorganism(1,2). about 80-90% of infections have no symptoms and self-limiting(3,4) and 10-20% can cause severe infections, amebic liver abscess and amebic colitis(4,5). amebic colitis, the major cause of severe diarrhea at the world and registered in 15 causes of diarrhea at children aged 2 years living in developing countries(4). diarrhea is the number two cause of death in children under 5 years and kills around 525,000 children every year(6). based on riskesdas (2007), the prevalence of diarrhea in indonesia is 9.0% with a range of 4.2-18.9%, the highest prevalence in the province of nanggroe aceh darussalam and the lowest in the province of di yogyakarta(7). progress in molecular methodology increases our knowledge regarding the differences in e. histolytica with other non-pathogenic entamoeba species such as e. dispar and e. bangladeshi(4). in the last few years the pathogenesis of amebiasis is molecularly developed. likewise, the mechanism for avoiding immune responses can increase our knowledge regarding amebiasis and can help in the selection of amebiasis therapy. amebiasis epidemiology amebiasis is found throughout the world with the greatest prevalence in developing countries, mainly in tropical and subtropical regions, specifically asia, africa, indonesia, india, mexico, south africa, and south america. optimal climate conditions in the zone that make protozoan cysts can last for several days in the external environment (1,2,4). entamoeba histolytica is the number two cause of death caused by parasites in humans after malaria. globally, around 50 million people have infections, with greater than 100,000 deaths each year reported due to amebiasis. the source of correspondence: nurlina muliani @2019 medical and health science journal. 10.33086/mhsj.v3i2.1195 available at http://journal2.unusa.ac.id/index.php/mhsj 30 original article mailto:nurlinamuliani95@gmail.com http://journal2.unusa.ac.id/index.php/mhsj medical and health science journal, vol.3., no.2, august 2019 infection is from swallowing water or food contaminated with faeces containing e. histolytica cyst(8). in areas with low socio-economic conditions, there is a decrease in sanitation and an increase in faecal contamination from water supplies(4,8). relatively better hygiene and sanitation in developed countries has a low incidence of amebiasis, which is 2-11%, whereas in indonesia it has a quite high range ie 10-18%(9). life cycle e. histolytica has a life cycle that can be divided into 2 phase, as an infectious cyst or invasive trophozoite(4). e. histolytica cysts can be discovered in contaminated food or water, after consumption occurs excystation, then trophozoites colonize the large intestine multiplying with binary fission. it can be asymptomatic or cause symptoms such as diarrhea. trophozoites that attack the intestine produce amoebic colitis with ulceration which causes bloody diarrhea. trophozoites can spread through the bloodstream and cause abscesses in some organs, which are most often observed or spread to farther places such as the brain and lungs in a hematogenous manner (figure 1). within a few weeks after ingestion, symptoms can occur but sometimes can also develop for several years after infection(4,11). figure 1. life cycle of e. histolytica (14) molecul surface of entamoeba cell histolytica lipophosphopeptidoglycan and other gpi anchored cell surface molecules on the trophozoite surface has lipophosphopeptidoglycans (lppg), glycosylphosphatidylinositol (gpi) which contains complex carbohydrates and forms a glycocalyx layer. these molecules are the main surface components that interact with target cells, ie human tissue, via terminal sugar molecules(9). gal/ gal nac lectin galactose/ n acetyl d galactosamine inhibitable (gal/galnac) one of the main cell surface molecules associated with adherence to e. histolytica to the basement membrane and epithelial tissue. the gal/galnac lectin consists of heavy subunits (hgl), light subunits (lgl) and subunit intermediates (igl). hgi and lgi are connected via disulfide bonds and live on the parasite cell membrane as a 260kda heterodimer. hgi contains carbohydrate recognition domain (crd) which recognizes d-galactose and n-acetyl-d galactosamine and host cell glycoconjugate proteins (3,12). secreted molecules involved in pathogenesis damage to the extracellular matrix, tissue, and cells is a characteristic pathophysiological of amoeba. cell contact is the beginning of invasion of e. histolytica. amoeba also attacks by reducing or damaging tissue by secreting several enzymes capable of digesting tissues or even extracellular matrices(12). cysteine proteases (cp) entamoeba secretes cysteine proteases which are the main group of hydrolases. genome helps identify about 50 genes that encode cysteine peptidase. only 20 cp genes contained in e. histolytica are secreted, where ehcp1, ehcp2 and ehcp5 constitute 90% of all existing cp. cp can reduce extracellular matrix proteins (ecm) such as mucin which is the main component of colon 31 medical and health science journal, vol.3., no.2, august 2019 mucus. cp also attacks the immune system by reducing host antibodies. ehcp5 found on the surface of the amoeba suspected to interfere with mucin barrier of the colon. ehcp5 is also associated with colon epithelial cell integrins and activates the nfkappaβ-mediated inflammatory response in host cells. research in 2014 showed that ehcpa5 activates matrix metalloproteinase (mmp) by splitting(12,13). amoebapores amoebapores is a group of pore-forming peptides that mediate the killing of cells by acting as secreted toxins. amoebapores has 3 different types (a, b, and c) which structurally and functionally similar to nk-lysin membrane and granulysin permeabilization proteins produced by mammalian t cells(11,12). all amoebapores induce pore formation in synthetic liposomes. amoebapores requires ph ~ 5.2 for pore-forming activities needed for activity on the host cell membrane (11). pathogenesis the pathogenesis of e. histolytica can be classified into three, namely: host cell death, inflammation, and parasitic invasion. trophozoit can kill host cells with several different mechanisms, ie induction of programmed cell death, phagocytosis, and trogocytosis(4). programmed cell death the initial pathogenesis begins with adherence of parasites in the colonic mucous layer through the gal / galnac lectin adhesion molecule (figure 2). figure 2. sequential model of cell killing and phagocytosis by entamoeba histolytica(3). several other molecules involved in the pathogenesis of amebiasis, namely amoebapores which destroy bacteria in the colon environment. cp is considered an important parasitic weapon to penetrate the epithelium and destroy the host extracellular matrix (ecm) component. before adherence cells, trophozoites secrete immune modulators which stimulate epithelial cells to produce proinflammatory cytokine macrophage migration inhibitory factor (ehmif). ehmif induces inflammation resulting in increased production of matrix metalloproteinase (mmp)(13). in a current study, mmp was shown to be needed for the invasion of e. histolytica tissue. mmp rupture the extracellular matrix in the intestine to increase cell migration and is shown excessively in parasitic infections, such as amebiasis (4,13). phagocytosis calcium-binding protein 1 (ehcabp1) and ehc2pk on the ligand are one of the early signs of phagocytosis. ehc2pk binds ps amoeba and attracts ehcabp1 to cell membranes. ehcabp1 binds to f-actin which affects cell proliferation, fluid phase endocytosis, and phagocytosis. ehcabp1 also attracts ehak1 alpha kinase to phosphorylate directly g-actin. the interaction depends on calcium, while the interactions of ehc2pk and ehcabp1 are not calcium dependent. other calcium binding proteins such as ehcabp3 interact directly with lipids and function in the initiation of independent phagocytosis from the ehcabp1/ehc2pk pathway. whereas ehcabp5, has recently been shown to interact with myosin 1b in an independent manner of calcium(11,12). trogositosis after attaching to the host cell, e. histolytica trophozoite digests host cells with different "bites" called trogocytosis amoeba (figure 3), which begins to occur within one minute of contact with the host cell. host cells are still alive when the process starts, but eventually die which is characterized by loss of membrane integrity. after the host cell is killed, the consumption of the amoeba stops and the trophozoite is released from the dead host cell. trogocytosis of amoeba involve 32 medical and health science journal, vol.3., no.2, august 2019 physiological temperature, amoeba actin rearrangement, gal / galnac lectin, ehc2pk, and signaling-pi3k. each protein has a role in phagocytosis and trogocytosis of e. histolytica (figure 4). cell death after amoeba trogocytosis can be caused by accumulated physical damage to bitten cells(11). figure 3. trogocytosis and phagocytosis of amebiasis (11) 33 figure 4. amoeba molecules that play a role in trogocytosis and phagocytosis(11) imun response e. histolytica has promoted several mechanisms to avoid immune responses and persist in hosts (figures 5 & 6). when the amebic trophozoites attack the colon epithelium, it activates an immune response in human hosts. to survive in the host, it is necessary to fight the immune system and control the host environment. the mucous layer in the gastrointestinal tract mostly functions as a major physical barrier to intestinal pathogens. the secondary defense of intestinal immune response to e. histolytica infection is by secreting mucosal immunoglobulins (ig). one of the most produced ig by plasma cells is secretory iga which functions to avoid pathogens from attaching and removing mucosal barriers. in the early stages of infection, intestinal epithelial cells (iecs) bind and identify the gal/ gal nac lectin via a toll like receptor (tlr), which activates nfkb to produce inflammatory cytokines including il-6, il-1β, il-8, il-12, tnf α, and ifn-γ. iecs are the second defense barrier against pathogens after the mucosal layer and first defense of host cells to fight parasites, host cells secrete an arrangement of pathogen recognition receptors (prrs), including tlrs. ifn-γ is involved in cleaning the infection, whereas il-4 and tnf-α are associated with disease(13). medical and health science journal, vol.3., no.2, august 2019 figure 5. mechanism of colonization and invasion by e. histolytica trophozoites.(13) figure 6. mechanism of avoiding immune response (13) therapy patients diagnosed with amebiasis should be given medication. patients with clinical symptoms should take treatment with 2 drugs: amebicidal tissue active agent, metronidazole or tinidazole and luminal cysticidal agent, paromomycin. patients with asymptomatic amebiasis have need to be given luminal cysticidal agents to avoid invasion and transmission of pathogens(4). conclusion the pathogenesis of amebiasis involves the interaction of several molecules secreted by e. histolytica such as lectin, lppg, moebapore and cysteine proteases. advances in molecular methodologies over the past few years have increased understanding of the mechanisms of amebiasis molecular pathogenesis such as adherence, phagocytosis and host cell tropogocytosis. likewise the mechanism for avoiding cell immune responses such as il-10 induction and suppression of infγ, reduction of ig, pro inflammatory cytokines, and complement. references 1. farfar j. manson ’ s tropical diseases tw e n t y t h i r d e d i t i o n. 2013. 2. nowak p. entamoeba histolytica pathogenic protozoan of the large intestine in humans. j clin microbiol biochem technol [internet]. 2015;1(1):010–7. available from: https://www.peertechz.com/clinical microbiology-biochemical technology/jcmbt-1-103.php 3. huston cd, sateriale a. a sequential model of host cell killing and phagocytosis by entamoeba histolytica. j parasitol res. 2011;2011. 4. shirley dat, farr l, watanabe k, moonah s. a review of the global burden, new diagnostics, and current therapeutics for amebiasis. open forum infect dis. 2018;5(7):1–9. 5. longo dl, fauci as. harrison’s gastroenterology and hepatology. mcgraw hill; 2010. 6. diarrhoeal disease [internet]. world health organization. 2017 [cited 2018 oct 30]. available from: http://www.who.int/news room/fact-sheets/detail/diarrhoeal-disease 7. indonesia dkr. profil kesehatan indonesia. 2009; 8. mathew g, bhimji ss. amebiasis. statpearls publ llc [internet]. 2018;(august 8, 2018). available from: https://www.ncbi.nlm.nih.gov/books/nbk5195 35/#_nbk519535_pubdet_ 9. anorital, andayasari l. kajian epidemiologi penyakit infeksi saluran pencernaan yang disebabkan oleh amuba di indonesia. media litbang kesehat. 2011;21:1–9. 10. swaminathan a, torresi j, schlagenhauf p, thursky k, wilder-smith a, connor ba, et al. a global study of pathogens and host risk factors associated with infectious gastrointestinal disease in returned international travellers. j infect [internet]. 2009;59(1):19–27. available from: http://dx.doi.org/10.1016/j.jinf.2009.05.008 11. ralston ks. chew on this: amoebic trogocytosis and host cell killing by entamoeba histolytica. trends parasitol. 2016;31(9):442–52. 12. saha a, gaurav ak, bhattacharya s, bhattacharya a. molecular basis of pathogenesis in amoebiasis. 2015;143–54. 13. nakada-tsukui k, nozaki t. immune response of amebiasis and immune evasion by 34 http://www.peertechz.com/clinicalhttp://www.peertechz.com/clinicalhttp://www.who.int/newshttp://www.ncbi.nlm.nih.gov/books/nbk5195 http://www.ncbi.nlm.nih.gov/books/nbk5195 http://dx.doi.org/10.1016/j.jinf.2009.05.008 medical and health science journal, vol.3., no.2, august 2019 entamoeba histolytica. front immunol. 2016;7(may):1–13. 14. ayed l ben, sabbahi s. part three. specific excreted pathogens: environmental and epidemiolo-gy aspects: entamoeba histoly-tica. glob water pathog proj [internet]. 2017;(january 15, 2015). available from: http://www.waterpathogens.org 15. parasites amebiasis entamoeba histolytica infection [internet]. centers for disease control and prevention. 2015. available from: https://www.cdc.gov/parasites/amebiasis/pathog en.html 16. stanley sl. amoebiasis. lancet. 2003;361(9362):1025–34. 35 http://www.waterpathogens.org/ http://www.cdc.gov/parasites/amebiasis/pathog http://www.cdc.gov/parasites/amebiasis/pathog original article medical and health science journal, vol.4, no.1, february, 2020 perbedaan kualitas hidup pasien usia lanjut sebelum dan setelah operasi katarak adelia lisnawati 1* , nur khoma fatmawati 2 , meiliati aminyoto 3 fakultas kedokteran, universitas mulawarman *correspondent author: lisnawatiadelia30@gmail.com article info article history: received: february, 7 2020 received in revised form: february, 14 2020 accepted: february,16 2020 keywords: quality of life, cataract, cataract surgery, elderly abstract cataract is a condition when the lens become cloudy and often occurs in elderly patients. cataract is the leading cause of visual impairment and blindness in the world. cataract can reduce productivity and social life, that will decrease the quality of life in elderly patients. it also reduces the visual acuity leading to decreasing visual function and the quality of life. this disease can change physical, cognitive and psychosocial life. this study aimed to analyze the difference of quality of life in elderly patients before and after cataract surgery at smec eye clinic in samarinda. this study was observational analytic study. data were taken from interview the patients with visual function questionnaire 14 (vfq 14) and from the medical record of smec eye = 95,35) and there was significant improvement of the visual acuity after cataract surgery (p = 0,000). based on these results it can be concluded that there were difference of quality of life in elderly patients before and after cataract surgery. @2020 medical and health science journal. 10.33086/mhsj.v4i1.1449 correspondence: ananda @2020 medical and health science journal. 10.33086/mhsj.v4i1.1449 available at http://journal2.unusa.ac.id/index.php/mhsj 63 mailto:lisnawatiadelia30@gmail.com http://journal2.unusa.ac.id/index.php/mhsj medical and health science journal, vol.4, no.1, introduction mata merupakan salah satu alat indera yang penting bagi manusia untuk melihat dan menyerap berbagai informasi visual yang digunakan untuk melaksanakan berbagai macam kegiatan. gangguan terhadap penglihatan dan kebutaan masih banyak terjadi, mulai dari gangguan ringan hingga gangguan yang berat dan menjadi masalah kesehatan yang cukup serius di dunia termasuk indonesia. 1 global data on visual impairments 2010, menyebutkan bahwa di seluruh dunia terdapat 285 juta orang dengan gangguan penglihatan. tiga puluh sembilan juta orang buta dan 246 juta penyandang low vision. kebutaan akibat katarak masih mendominasi tingkat kebutaan di indonesia. 2 penyakit katarak merupakan penyakit mata yang ditandai dengan kekeruhan lensa mata sehingga mengganggu proses masuknya cahaya ke mata. katarak dapat disebabkan karena terganggunya mekanisme kontrol keseimbangan air dan elektrolit, denaturasi protein lensa atau gabungan keduanya. 3 katarak umumnya merupakan penyakit yang sering terjadi pada usia lanjut, akan tetapi dapat juga akibat kelainan kongenital, atau penyulit penyakit mata lokal menahun. 4 seseorang akan mengalami perubahan dalam segi fisik, kognitif, dan kehidupan psikososial pada usia lanjut, sehingga menyebabkan pentingnya harapan hidup dan kualitas hidup pada usia ini. penyakit tersebut menyebabkan penurunan produktivitas dan kehidupan sosial sehingga menyebabkan rendahnya kualitas hidup pada usia ini. 5 berbagai penelitian yang ada menunjukkan bahwa gangguan penglihatan dan kebutaan dapat mengakibatkan menurunnya kualitas hidup (quality of life), yang terlihat dari berkurangnya kemampuan seseorang untuk melakukan pekerjaan, mengisi waktu luang, atau melakukan aktivitas harian (activities of daily living). oleh karenanya penilaian skor quality of life (qol) sangat bermanfaat untuk menentukan 64 dampak yang dialami oleh pasien dengan ganggguan penglihatan. 6 karena jumlah penderita katarak dan angka kebutaan akibat penyakit katarak di dunia maupun di indonesia masih cukup tinggi dan terus mengalami peningkatan, maka perlu diadakannya penelitian untuk mengetahui perbedaan kualitas hidup pasien usia lanjut sebelum dan setelah operasi katarak. methods penelitian ini merupakan penelitian analitik observasional yang dilakukan di klinik mata smec samarinda. populasi dalam penelitian ini adalah semua pasien katarak di klinik mata smec samarinda. variabel yang diteliti dalam penelitian ini meliputi jenis kelamin, visus, usia, dan kualitas hidup pasien sebelum dan setelah menjalani operasi katarak. penelitian ini dilakukan dengan mengambil data primer dan data sekunder. data sekunder berasal dari rekam medik pasien katarak dan data primer berasal dari kuesioner visual function 14 (vf 14), hasil wawancara dengan pasien setelah operasi katarak di klinik mata smec samarinda. result berdasarkan penelitian yang dilakukan pada 46 responden, maka didapatkan hasil sebagai berikut : tabel 1 gambaran distribusi jenis kelamin pasien katarak jenis kelamin frekuensi persentase (%) laki-laki 19 41,3 perempuan 27 58,7 jumlah 46 100 berdasarkan hasil penelitian ini, diketahui dari 46 responden, jenis kelamin yang paling banyak adalah perempuan yaitu sebanyak 27 pasien (58,7%) dan laki laki sebanyak 19 pasien (41,3%). medical and health science journal, vol.., no., tabel 2 gambaran distribusi usia pasien katarak berdasarkan hasil penelitian ini, diketahui dari 46 responden, usia yang paling banyak adalah pada kelompok usia 65-70 tahun dimana terdapat 21 pasien (45,7%), kemudian kelompok usia <65 tahun sebanyak 12 pasien (26,1%), usia 70-75 tahun sebanyak 7 pasien (15,2%), usia 75-80 tahun sebanyak 3 pasien (6,5%) dan pasien berusia >80 tahun sebanyak 3 pasien (6,5%). tabel 3 gambaran distribusi visus pasien katarak sebelum operasi vod vos visus pre operasi frekuensi % frekuensi % baik 5 10,9 2 4,3 sedang 11 23,9 13 28,3 berat 30 65,2 31 67,4 jumlah 46 100 46 100 berdasarkan hasil penelitian ini, diketahui dari 46 responden, didapatkan visus kedua mata pasien sebelum operasi katarak kebanyakan sudah mencapai kategori berat ketika akan dioperasi yaitu terdapat 30 pasien untuk visus oculi dekstra (vod) (65,2%) dan 31 pasien untuk visus oculi sinistra (vos) (67,4%), kemudian diikuti dengan kategori sedang sebanyak 11 pasien untuk vod (23,9%) dan 13 pasien untuk vos (28,3%) serta kategori baik sebanyak 5 pasien untuk vod (10,9%) dan 2 pasien untuk vos (4,3%). tabel 4 gambaran distribusi visus pasien katarak setelah operasi vod vos berdasarkan hasil penelitian ini, diketahui dari 46 responden, didapatkan visus kedua mata pasien setelah operasi katarak kebanyakan sudah mencapai kategori baik yang jumlahnya tidak terlalu jauh beda untuk mata kanan dan mata kiri yaitu terdapat 36 pasien untuk visus oculi dekstra (vod) (78,3%) dan 37 pasien untuk visus oculi sinistra (vos) (80,4%), kemudian diikuti dengan kategori sedang sebanyak 8 pasien untuk vod dan vos (17,4%) serta kategori berat sebanyak 2 pasien untuk vod (4,3%) dan 1 pasien untuk vos (2,2%). tabel 5 uji paired t test kualitas hidup sebelum dan setelah operasi katarak kualitas hidup pre op post op mean 63,65 mean t -13,102 t p value 0,000 p value ci (95%) (-36,568) – ( 26,823) ci (95%) berdasarkan tabel 5 di atas, hasil analisis variabel kualitas hidup sebelum dan setelah operasi katarak berdasarkan uji paired t test diperoleh nilai p = 0,000, nilai p ini berarti lebih kecil dari 0,05 (p<0,05) yang artinya ho ditolak dan ha diterima. sehingga secara statistik dapat disimpulkan bahwa terdapat perbedaan kualitas hidup pasien usia lanjut sebelum dan setelah operasi katarak di klinik mata smec samarinda. hasil dari tabel diatas juga menunjukkan nilai rata-rata kualitas hidup pasien sebelum operasi katarak 63,65 dan kualitas hidup setelah operasi katarak 95,35, maka dapat dinyatakan bahwa rerata tingkat kualitas hidup pasien 65 usia frekuensi persentase (%) <65 tahun 12 26,1 65-70 tahun 21 45,7 70-75 tahun 7 15,2 75-80 tahun 3 6,5 >80 tahun 3 6,5 jumlah 46 100 visus post operasi frekuensi % frekuen si % baik 36 78,3 37 80,4 sedang 8 17,4 8 17,4 berat 2 4,3 1 2,2 jumlah 46 100 46 100 medical and health science journal, vol.4, no.1, usia lanjut setelah operasi katarak lebih tinggi daripada sebelum operasi katarak. discussion hasil penelitian ini menunjukkan bahwa proporsi pasien katarak dengan jenis kelamin perempuan jumlahnya lebih besar yaitu 58,7% sedangkan proporsi pasien katarak dengan jenis kelamin laki-laki hanya sebesar 41,3%. hal ini dikaitkan dengan usia harapan hidup perempuan yang lebih lama dimana jumlah perempuan usia lanjut lebih banyak. adanya resiko peningkatan pasien katarak berjenis kelamin perempuan ini dapat dikarenakan efek dari berkurangnya hormon estrogen saat menopause. teori yang ada menyatakan bahwa hormon estrogen dapat melindungi lensa terhadap proses pembentukan katarak, oleh karenanya semakin meningkatnya usia pada perempuan maka hormon estrogennya akan semakin menurun sehingga dapat meningkatkan resiko terjadinya penyakit katarak. 7 hal ini sejalan dengan hasil penelitian yang dilakukan oleh fadhilah (2018) yang menunjukkan bahwa responden penderita katarak dengan jenis kelamin perempuan lebih banyak daripada responden dengan jenis kelamin laki-laki. 8 karakteristik usia responden sesuai dengan hasil penelitian yang dilakukan oleh chang, et al (2011) yang menyatakan bahwa usia mempengaruhi terjadinya penyakit katarak. dimana semakin meningkatnya usia seseoarang maka kekuatan lensanya akan cenderung berubah. perubahan yang terjadi salah satunya adalah meningkatnya kemampuan lensa menghamburkan sinar matahari. lensa menjadi semakin keras dan keruh karena terjadi penurunan metabolisme dalam tubuh, sehingga semakin bertambahnya usia seseorang maka resiko terjadinya penyakit katarak semakin besar pula. 9 hal ini juga sejalan dengan hasil penelitian fadhilah (2018) yang dilakukan di balai kesehatan mata makasar yang menunjukkan bahwa pasien katarak berusia (>57 tahun) berjumlah lebih banyak daripada yang berusia (<57 tahun) dan mempengaruhi tingkat kualitas hidup mereka. 8 hasil penelitian ini menunjukkan bahwa nilai visus sebelum dan setelah operasi katarak berdasarkan uji mc nemar diperoleh nilai p<0,05 yaitu nilai p = 0,000 untuk visus sebelum operasi katarak dan nilai p = 0,000 untuk visus setelah operasi katarak. hal tersebut menunjukkan bahwa secara statistik terdapat perbedaan visus pasien usia lanjut sebelum dan setelah operasi katarak. hal tersebut dapat dipengaruhi oleh tingkat pendidikan dan status ekonomi pasien dimana kurangnya informasi tentang kesehatan terutama penyakit katarak dan status ekonomi yang rendah cenderung membuat mereka tidak memprioritaskan pengobatan katarak sebelum keadaannya benar-benar sangat mengganggu. 10 peningkatan visual aquity (va) pada pasien usia lanjut setelah operasi katarak sangat bermanfaat dalam mempertahankan kemampuan mereka untuk dapat melakukan aktivitas sehari hari sehingga hal ini sangat mempengaruhi kehidupan sosial mereka. 11 hasil penelitian ini menunjukkan bahwa rata-rata kualitas hidup dari 46 pasien setelah operasi katarak lebih tinggi dibandingkan rata-rata kualitas hidup pasien sebelum operasi katarak yaitu 95,35 dan 63,65. hasil penelitian ini sejalan dengan hasil penelitian yang dilakukan oleh abdullahi, alhassan, & babalola (2016) pada pasien katarak di national eye center, kaduna, penelitian ini merupakan penelitian dengan menggunakan metode pemberian kuesioner visual function (vfs) dan kuesioner quality of life (qol) pada pasien katarak sebelum operasi dan 6 minggu setelah operasi. hasil dari penelitiannya menggunakan uji paired t test ini menunjukkan nilai p = 0,0001 (p<0,05) yang berarti bahwa terdapat perbedaan kualitas hidup pasien usia lanjut sebelum dan setelah operasi katarak. 12 paula, leonardo, rosa, dan silveira (2014), menyatakan bahwa nilai rata-rata skor kualitas hidup pasien usia lanjut yang 66 medical and health science journal, vol.., no., 65 lebih dari 70 sebelum operasi katarak biasanya tidak menunjukkan peningkatan yang jelas setelah operasi katarak dan hal tersebut berpengaruh secara langsung pada tingkat kepuasan pasien terhadap hasil operasi. hal ini memberikan arti bahwa pasien dengan nilai rata-rata skor lebih dari 70 sebelum operasi katarak memiliki tingkat kualitas hidup yang cukup baik sehingga tidak cukup jelas terjadi peningkatan kualitas hidup setelah operasi katarak. selain itu juga hasil penelitiannya menyebutkan bahwa skor kualitas hidup 95 menjadi indikator keberhasilan yang menunjukkan fungsi optimal pasien setelah operasi katarak. 13 karena hasil penelitian ini menunjukkan rata rata skor kualitas hidup pasien usia lanjut sebelum operasi katarak adalah 63,65, maka dapat simpulkan bahwa pasien tidak memiliki tingkat kualitas hidup yang cukup baik sebelum operasi katarak sehingga terjadi peningkatan rata-rata skor kualitas hidup setelah operasi katarak dengan nilai 95,35 yang memberikan arti bahwa pasien mampu melakukan aktivitas sehari-hari dengan fungsi yang optimal setelah operasi katarak dan hal ini berpengaruh terhadap penilaian tingkat kualitas hidup mereka. operasi katarak telah terbukti meningkatkan kualitas hidup pasien dalam melakukan aktivitas sehari-hari sebagai akibat dari meningkatnya va setelah operasi katarak. dengan demikian, seorang pasien setelah operasi katarak dapat memiliki waktu hidup yang cukup lama untuk menikmati manfaat dari peningkatan va ini tanpa harus menderita stress atau depresi untuk dapat melakukan semua aktivitas hidup yang mereka inginkan. 14 dengan demikian, seorang pasien setelah operasi katarak dapat memiliki waktu hidup yang cukup lama untuk menikmati manfaat dari peningkatan va ini tanpa harus menderita stress atau depresi untuk dapat melakukan semua aktivitas hidup yang mereka inginkan. 14 conclusion 1. ketajaman penglihatan (visus) pasien usia lanjut sebelum operasi katarak pada kedua mata kebanyakan sudah mencapai kategori berat ketika akan dioperasi. 2. ketajaman penglihatan (visus) pasien usia lanjut setelah operasi katarak pada kedua mata kebanyakan sudah mencapai kategori baik setelah dioperasi. 3. pasien usia lanjut sebelum operasi katarak memiliki rata-rata kualitas hidup yang kurang baik dibandingkan setelah operasi katarak. 4. pasien usia lanjut setelah operasi katarak memiliki rata-rata kualitas hidup yang lebih baik dibandingkan sebelum operasi katarak. 5. terdapat perbedaan kualitas hidup pasien usia lanjut sebelum dan setelah operasi katarak di klinik mata smec samarinda. references 1. pusat data dan informasi kementerian kesehatan republik indonesia (pusdatin). (2014). situasi gangguan penglihatan dan kebutaan. jakarta: kementerian kesehatan ri. 2. kementerian kesehatan republik indonesia (kemenkes). (2018). peta jalan penanggulangan gangguan penglihatan di indonesia tahun 2017 2030. jakarta: kementerian kesehatan ri. 3. astari, p. (2018). katarak: klasifikasi, tatalaksana, dan komplikasi operasi. cdk-269, 45(10), 748. 4. ilyas, s. (2017). ilmu penyakit mata (5 th ed). jakarta: fakultas kedokteran universitas indonesia. 5. rohmah, a.i.n., purwaningsih., & bariyah, k. (2012). kualitas hidup lanjut usia. jurnal keperawatan. 3(2). 120-132. 6. asroruddin, m. (2014). dampak gangguan penglihatan dan penyakit mata terhadap kualitas hidup terkait 67 medical and health science journal, vol.4, no.1, ktor y 66 penglihatan (vision-releated quality of life) pada populasi gangguan penglihatan berat dan buta di indonesia. jakarta: universitas indonesia. 7. lai, k., cui, j., ni, s., zhang, y., he, j., & yao, k. (2013). the effect of postmenopausal hormone use on cataract: a meta-analysis. plos one. 8. 1-10. 14. mehmet, b., & abuzer, g. (2009). results of cataract surgery in the very elderly population. j optom, 2, 138 141. 8. fadhilah, n. (2018). analisis fa 67 ang berhubungan dengan kualitas hidup penderita katarak di balai kesehatan mata masyarakat makassar. makasar: universitas hasanuddin. 9. chang, j.r., koo, e., agron, e., hallak, j c az d …c e y (2011). risk factors associated with incident cataracts and cataract surgery in the age releated eye desease study (areds). american academia of ophtalmology. 118. 2113-2119. 10. haspiani, m. (2017). karakteristik penderita katarak senilis yang telah di laukan pembedahan katarak di rumah sakit pendidikan universitas hasanuddin periode 1 januari 2017 30 juni 2017. makassar: universitas hasanuddin. 11. shera, m.t., samar, s.s., ahmed, a.i., bareeqa, s.b., & sattar, z.b. (2018). impact of cataract surgery in restoration vision among patients with poor pre operative vision: a tertiary care experience from developing country. open journal of surgery. 1(1). 9-15. 12. abdullahi, s.m., alhassan, m.b., & babalola, o.e. (2016). the impact of cataract surgery on subjective visual functions and quality of life in patients with cataract in northwestern nigeria. nigerian journal of ophtalmology. 24(2). 57-61. 13. paula, t.d.m., leonardo, t.d.m., rosa, a.a.m., & silveira, l.c.d.l. (2014). life quality assesment of patients after phacoemulsification or extracapsular cataract extraction. arq bras oftalmol. 77(1). 12-16. 68 medical and health science journal, vol.3., no.2, august 2019 uncontrolled type 1 diabetes mellitus with lung tuberculoma and bilateral hydronephrosis in 13-year old girl anggia rarasati wardhana1*, sukartini2, annisa muhyi3 1,2,3department of child health, university of mulawarman medical school, abdul wahab sjahranie hospital, samarinda-indonesia *correspondent author: anggiararasatiwardhana@gmail.com background type 1 diabetes mellitus (t1dm) is a chronic illness characterized by the insufficient production of insulin due to autoimmune destruction of beta cells in the pancreas. t1dm is chiefly occurred following an autoimmune demolition of the pancreatic β cells through cell mediated immunity as well as a humoral immune response. while the disease may develop in adults, the onset most often occurs in childhood. t1dm can be considered as one of the most frequent endocrine and metabolic dysfunction in children. t1dm in children and teenagers represents 80%-90% of diabetes. in the us, the prevalence of t1dm in youth under 20 years was 1.93 /1000 in 2009 with 2.6 2.7% relative annual increase.1 tuberculosis (tb) is still one of the main causes of morbidity and mortality worldwide.3 children are particularly vulnerable to tuberculosis. pediatric cases of tuberculosis account for 10% of all cases of the disease. in 2015, there were an estimated 1 million new cases of childhood tuberculosis and an estimated 210.000 deaths from tuberculosis in children.4 children carry a huge tuberculosis disease burden, particularly in endemic areas.5 according to the who, the three regions where most pediatric tuberculosis cases are concentrated are southeast asia, africa, and the western pacific, which respectively accounted for 35%, 30%, and 20% of the new cases reported in 2015. it is estimated that tuberculosis caused the death of 210.000 children worldwide in 2015. based on those estimates, tuberculosis might be the sixth leading cause of death in the 1to 5-year age group.4 the possibility of association between dm and tb represents an important and growing challenge to the global control of tb. patients with these two conditions may present high rates of treatment failure of tb and increased risk of death. cases of tb with dm have higher probability of treatment failure of tb and may develop resistance correspondence: anggia rarasati wardhana @2019 medical and health science journal. 10.33086/mhsj.v3i2.1155 available at http://journal2.unusa.ac.id/index.php/mhsj 25 original article article info abstract article history: submitted: july 09 2019 received in revised form august 2019 accepted: august 12 2019 diabetes mellitus (dm) is an important risk factor for the development of active tuberculosis (tb). dm is a chronic disease that weaken the immune system which increased the risk of tuberculosis up to three-fold. we present a case of 13-year old girl with chest pain and cough. she has a previous history of type 1 dm. laboratory findings showed hyperglycemic state. thoracic ct showed tuberculoma at inferoposterior lobe of left lung. the abdominal ct showed bilateral hydronephrosis. she was then administered tb treatment of 2hrze/10rh, corticosteroid, and insulin regiments with strict monitoring of blood glucose. clinical symptoms and blood glucose levels were significantly improved after treatment for 20 days. @2019 medical and health science journal. 10.33086/mhsj.v3i2.1155 keywords: type 1 diabetes mellitus, tuberculosis, tuberculoma, hydronephrosis, blood glucose mailto:anggiararasatiwardhana@gmail.com http://journal2.unusa.ac.id/index.php/mhsj medical and health science journal, vol.3., no.2, august 2019 to the drugs used in the treatment. on the other hand, tb can induce glucose intolerance and hinder the glycemic control in individuals with dm.6 a systematic review of 13 observational studies found that dm increases the risk of tb by three-fold.7 thus, patients with dm comorbidity may pose a greater challenge the control of tb.8 case presentation a 13-year-old girl presented to a. w. sjahranie hospital with left chest pain for three days which felt like being punctured and burned. the pain was exacerbated when she laid down. she also had cough for two months with yellow-green phlegm and fever which appeared simultaneously with cough, night sweats, weight loss, and hematuria. the patient has a history of a lump in the neck for one year which was sometimes felt painful, and was getting bigger. she also had prolonged fever, and no cough in that time. her grandmother was diagnosed with lung tuberculosis and had passed way. her bcg vaccine history were positive. she was diagnosed with lymphadenitis tb and had been treated in declared cured in 2017 and was diagnosed with t1dm at the age of 10. her father had been diagnosed with dm and stroke. her mother had a history of breast cancer. investigations physical examination revealed asymmetrical chest movement, decreased tactile fremitus on left chest, dull percussion on the inferoposterior left chest, and decreased breath sound on posterior left chest with rhonchi on both sides of lung bases. both kidneys were palpable. early diagnosis when admitted to the hospital for this patient was pleural effusion and t1dm with hematuria. the differential diagnosis were pleuritic tb and pleural abscess with urinary tract infection or nephrolithiasis. 26 figure 1. chest x-ray acid fast bacilli sputum smear was negative. laboratory findings revealed leukocytosis (wbc 23.580/mm3), anemia (9,7 gr/dl), hematocrit was 30,4%, platelets were 364.000/mm3, and blood glucose of 463 mg/dl. chest x-ray showed bronchopneumonia (fig 1), while thoracic ct showed: hypodense lesion with slight hyperdense on inferior-posterior lobe of left lung; suspicion of left lung abscess; solid and cystic mass of inferior posterior lobe of left lung; and minimal effusion on posterior right lung (fig 2). fine needle aspiration biopsy revealed granulomatous suppurative inflammations with squamous dysplasia (tb with secondary infection and squamous dysplasia). abdominal usg showed bilateral hydronephrosis (fig 3), while abdominal x-ray showed unclear kidney contours (fig 4). abdominal ct revealed left grade ii hydronephrosis and right grade i hydronephrosis (fig 5). after complete examination, the final diagnosis in this patient is t1dm with lung tuberculosis and bilateral hydronephrosis. figure 2. thoracic ct. medical and health science journal, vol.3., no.2, august 2019 figure 3. abdominal usg figure 4. abdominal x-ray. figure 5. abdominal ct. treatment on admission she was given antibiotics and the symptomatic theraphy such as antipyretic, antiulcer through injection. treatment for tb was initiated with 2hrze/10rh and corticosteroid, with strict blood glucose monitoring. insulin regiment consists of both long-acting insulin and rapid acting insulin with dose adjusted to the patient’s condition. outcome and follow up clinical symptoms were improved significantly after 20 days of hospitality. the complaints were reduced. the chest pain were eased, cough were missing arise, and vanished fever. after one month, the patient’s blood glucose becomes normal. the chest examination was improved lung spot and no effusion on the affected side. discussion the first report of the association between dm and tb was documented by avicenna (980 1027 ad) over one thousand years ago. in recent decades, with the increasing prevalence of tb, particularly multi drug resistant tb (mdr-tb), and dm cases in the world, the relationship is re emerging as a significant public health problem. the link of dm and tb is more prominent in developing countries where tb is endemic and the prevalence of dm is rising.9 our patient had diseases that were mutually incriminating one to another. associated with this case, patients with t1dm may have an even higher risk of developing tb compared to those with type 2 diabetes (t2dm).10 dm patients exhibit alterations in the immune response against mycobacterium tuberculosis (mtb), making them more susceptible to infection or progression towards active tb disease and less responsive to treatment. dm patients have been associated with dysregulated cytokine responses to mtb, including t-helper 1 (th1) along with several cytokines (tnf-𝛼, il-1𝛽, and il-12), lymphocytes, monocytes, natural killer t cells, and b lymphocytes.11 thus, dm is likely to reduce the efficiency of anti-mycobacterial treatment. hyperglycemia may also compromise mtb killing by affecting the microvasculature and reducing lung tissue perfusion for optimal immune surveillance.7 in addition, arce-mendoza et al (2008) reported that dm also affects the expression of receptors like cd64, cd206 and rage in monocytes.12 other possible factors that may impact the host response in patients with dm are short-chain fatty acids (scfas). scfas modulate immune and inflammatory responses, thereby influencing the host response to mtb. scfas act on immune and endothelial cells via at least two mechanisms: activation of g-protein coupled receptors (gpcrs) and inhibition of histone deacetylase (hdac). they affect the function of various cell types such as lymphocytes, neutrophils, and macrophages.13 the immunological source of susceptibility to tb among those with dm is not well understood. enhanced susceptibility to tb in patients with dm has been attributed to several factors, including direct effects related to hyperglycemia and insulin resistance and indirect effects related to macrophage and lymphocyte function. the impaired immune 27 medical and health science journal, vol.3., no.2, august 2019 response in patients with dm, which facilitates either primary infection with tb or reactivation of latent tb, may be the possible reason for these defective immune responses. studies probing the innate and adaptive immune response to microbial antigens in patients with dm suggest that these responses are compromised, particularly in patients with chronic hyperglycemia.12 active tb disease may present atypically with altered symptoms and signs in those with dm. among persons with dm, tb may progress faster, present with more chest and systemic symptoms and more frequent and higher-grade smear and culture positivity. severity at presentation seems to be related to the degree of uncontrolled hyperglycemia. the effects of dm on chest radiograph findings are inconsistent.14 there is also some evidence that dm prolongs smear and culture positivity.14 patients with dm comorbidity may pose a greater challenge to control the tb, since dm adversely affects tb treatment outcomes. the reasons are not completely understood but include the immunosuppressive effects of dm itself, drug drug interactions, adverse effects from medications, suboptimal adherence to medication, reduced bio availability of the drugs and other unlisted factors. there is also a doubling of the risk of death during tb treatment among those with dm with the risk increasing to about five times.6,14 diabetic patient with tb has a higher probability of failure of the sputum smear conversion after 2 months of therapy than patients without dm. patients with dm also are more likely to be lost to follow-up than patients who are non-diabetic, thus, increased duration of treatment and weight-adjusted doses of anti-tb drugs might be necessary.15 in addition, lee et al (2014) revealed that the presence of dm was independently associated with the risk of tb relapse.8 currently, there is not sufficient evidence to recommend alternative anti tuberculosis regimen for diabetics. consequently, treatment of tb is similar between diabetics and nondiabetics.9 there are a number of actions that can be taken to mitigate the effect of dm to decrease the burden of tb, such as prevention by addressing the underlying determinants, screening, early diagnosis, adequate support systems, treatment of patients with double disease, research and innovation. optimizing dm management during tb treatment should therefore be a high priority in patients with tb to improve the general health status of the patient. management of dm in tb should be aggressive, since an optimal glycemic control results in a better patient outcome. the optimal approach might consist of avoiding sulphonylurea derivates and treating dm with diet, lifestyle modifications, metformin and insulin, as these last two medications have few interactions with tb drugs.15 the american association of clinical endocrinologists recommends the use of modern insulins or insulin analogues, as they are more predictable in action and cause less hypoglycemia.16 a successful treatment can only be achieved by ensuring good compliance to treatment both for tb and dm.15 conclusion a case of 13-year-old girl with t1dm and tuberculoma and bilateral hydronephrosis was reported. the diagnosis was based on patient’s history, physical examination, laboratory findings, and imaging. the patient was admitted with chest pain and chronic cough with a history of t1dm. standard regiment of anti-tuberculosis treatment was initiated, in conjunction with corticosteroid and insulin therapy. clinical and laboratory improvement were shown after treatment. this report highlighted that aside from the comorbidities between diseases, there existed additional complexity in managing t1dm patient with dm. patients with dm comorbidity may pose a greater challenge to control the tb, since dm adversely affects tb treatment outcomes. the reasons are not completely understood but include the immunosuppressive effects of dm itself, drug-drug interactions, adverse effects from medications, suboptimal adherence to medication, reduced bio availability of the drugs and other unlisted factors. there is also a doubling of the risk of death during tb treatment among those with dm with the risk increasing to about five times. a successful treatment can only be achieved by ensuring good compliance to treatment both for tb and dm. the 28 medical and health science journal, vol.3., no.2, august 2019 success of the therapy will later provide a good prognosis to the patient. conflicts of interest there is no conflict of interest in this article. references 1. shojaeian a et al. an overview of the epidemiology of type 1 diabetes mellitus. int j metab syndr. 2018;2(1):1–4. 2. factors r et al. diagnosis , therapy and control of diabetes mellitus in children and adolescents. exp clin endocrinol diabetes. 2014;122:425–34. 3. marais bj. tuberculosis in children. j paediatr child health. 2014;1–9. 4. cristina a et al. epidemiological aspects , clinical manifestations , and prevention of pediatric tuberculosis from the perspective of the end tb strategy. j bras pneumol. 2018;44(2):134–44. 5. gomez-pastrana d. diagnosis of pulmonary tuberculosis in children. j infect dis ther. 2013;1:17–24. 6. i smp et al. association between diabetes and tuberculosis : case-control study. rev saúde pública. 2016;50(82):1–7. 7. restrepo bi. diabetes and tuberculosis. microbiol spectr. 2017;4(6):1–19. 8. shen t et al. increased risk of tuberculosis in patients with type 1 diabetes mellitus : results from a population-based cohort study in taiwan. medicine (baltimore). 2014;93(16):1–6. 9. baghaei p et al. diabetes mellitus and tuberculosis facts and controversies. j diabetes metab disord. 2013;12(58):1–8. 10. lachmandas e et al. patients with type 1 diabetes mellitus have impaired il-1 β production in response to mycobacterium tuberculosis. eur j clin microbiol infect dis. 2018;37:371–80. 11. pal r et al. diabetes mellitus as hub for tuberculosis infection : a snapshot. int j chronic dis. 2016;1–7. 12. nathella pk. influence of diabetes mellitus on immunity to human tuberculosis. immunology. 2017;152:13–24. 13. lachmandas e et al. diabetes mellitus and increased tuberculosis susceptibility : the role of short-chain fatty acids. j diabetes res. 2016;1–15. 14. lin y. management of diabetes mellitus tuberculosis: a guide to the essential practice. france: world diabetes foundation; 2018. 15. pizzol d et al. tuberculosis and diabetes : current state and future perspectives. trop med int heal. 2016;21(6):694–702. 16. niazi ak et al. diabetes and tuberculosis : a review of the role of optimal glycemic control. j diabetes metab disord. 2012;11(28):1–4. 29 medical and health science journal, vol.3., no.2, august 2019 hubungan antara aktivitas belajar kelompok dengan indeks prestasi mahasiswa semester 6 fakultas kedokteran universitas hang tuah surabaya tahun ajaran 2017/2018 kinanti hapsari1, efyluk garianto2, fitri handajani3* 1,2,3 fakultas kedokteran universitas hang tuah surabaya *conrrespondent author: fitrihandajanidr@gmail.com article info abstract article history: submmited: april 16 2019 received in revised form august 2019 accepted: august 21 2019 background: one of the active learning methods is to do a study group. researcher is interested in research on the correlation between study group activities and student’s grade, so that students can find learning methods which may influence academic outcomes and facilitate learning, especially the medical students. methods: this observational analytic study was carried out with a cross sectional design. the data of this study were obtained from the answers to the respondent's questionnaire in the medical faculty of hang tuah university, surabaya. the sample in this study were semester 6 students of the 2017/2018 academic year at the faculty of medicine, university of hang tuah surabaya (130 respondents). results: based on the spearman correlation statistical test between study group activities with the 6th semester students grade point, the significance of the correlation between study group activities and the 6th semester students grade point is 0.687. with a value of α = 0.05, means p> α, it can be concluded that the correlation between the two variables is not significant so that h0 accepts and h1 is rejected. so, there is no correlation between study group activities with 6th semester grade point. conclusion: there is no correlation between study group activities and the 6th semester students grade point in the faculty of medicine, hang tuah university surabaya. @2019 medical and health science journal. 10.33086/mhsj.v3i2.1070 keywords: study group, grade point pendahuluan dalam pelaksanaan pendidikan di indonesia terdapat beberapa masalah, menurut hasil survei unesco pada tahun 2016, minat membaca orang indonesia sangat rendah. bahkan dari enam puluh satu negara yang disurvei, indonesia menempati urutan ke enam puluh dengan tingkat minat 0,001%. hal ini menggambarkan rendahnya minat dan motivasi belajar masyarakat, terutama mahasiswa indonesia. hal ini semakin terbukti dengan pemaparan yang dijabarkan langsung oleh unesco bahwa indeks prestasi manusia yang ada pada indonesia makin menurun. rendahnya minat dan motivasi belajar akan berdampak pada menurunnya keberhasilan pembelajaran seorang mahasiswa. indikator keberhasilan pembelajaran seorang mahasiswa salah satunya dapat dilihat dari pencapaian prestasi akademiknya. faktor intelegensi memiliki peranan penting dalam memperoleh prestasi akademik yang baik. akan tetapi, faktor aktivitas belajar dan motivasi sama pentingnya bagi mahasiswa untuk meraih prestasi akademik yang lebih baik. besarnya pengaruh aktivitas belajar mahasiswa juga tergambar dalam penelitian mcloughlin, dijelaskan bahwa mahasiswa kedokteran dengan tingkat intelegensi tinggi dapat memperoleh prestasi akademik yang rendah jika aktivitas belajarnya kurang terkelola correspondence: fitri handajani @2019 medical and health science journal. 10.33086/mhsj.v3i2.1070 available at http://journal2.unusa.ac.id/index.php/mhsj 18 original article mailto:fitrihandajanidr@gmail.com http://journal2.unusa.ac.id/index.php/mhsj medical and health science journal, vol.3., no.2, august 2019 dengan baik (mcloughlin, 2009 disitasi dalam fitriani, 2012). dari uraian diatas, demi tercapainya pendidikan di indonesia yang lebih baik maka salah satu upaya untuk meningkatkan mutu pendidikan adalah dengan mencari metode pembelajaran yang tepat bagi mahasiswa. dewasa ini perkembangan metode pembelajaran pada program pendidikan kedokteran banyak yang sudah beralih dari teacher centered learning (tcl) menjadi student centered learning (scl) dalam proses belajar mengajar, berbagai perguruan tinggi di indonesia telah menerapkan kurikulum berbasis kompetensi dengan pendekatan student centered learning seperti problem based learning (pbl) sebagai metode pembelajaran (oktasari, 2018). salah satu perguruan tinggi yang menerapkan metode pembelajaran problem based learning (pbl) adalah fakultas kedokteran universitas hang tuah surabaya. dengan metode pembelajaran ini para mahasiswa didorong untuk dapat melakukan self directed learning yaitu mencari bahan pembelajaran, kegiatan pembelajaran serta mengevalusi hasil belajar mereka sendiri. oleh karena itu alokasi waktu mahasiswa untuk belajar mandiri, belajar di perpustakaan maupun belajar kelompok sangat dibutuhkan untuk memaksimalkan pembelajaran mereka (triastuti, 2016). dalam penelitian oleh triastuti ditemukan bahwa perbedaan waktu belajar mandiri, waktu belajar kelompok, dan waktu belajar di perpustakaan mempengaruhi prestasi akademik mahasiswa kedokteran tahun ke tiga, di mana mahasiswa yang mengalokasikan lebih banyak waktu dalam belajar kelompok (study group) memperoleh prestasi belajar yang lebih tinggi dibandingkan waktu belajar mandiri (self study) dan studi perpustakaan (library study) (triastuti, 2016). belajar kelompok yang meliputi problem solving sangat penting dalam pendidikan mahasiswa dalam bidang kesehatan. belajar kelompok akan melengkapi kuliah, pelajaran/ceramah yang diberikan di perguruan tinggi. pada belajar kelompok yang efektif, mahasiswa akan berpikir lebih kritis serta terjadi perkembangan dari kemampuan mendengar dan berdiskusi dimana lebih sulit untuk dicapai jika belajar sendiri (linn, lord, whong, & phillips, 2013). keren et al mengutarakan dalam penelitiannya tiga manfaat dari belajar kelompok, yaitu: 1) belajar kelompok dapat membuat pembelajaran lebih aktif dan menarik. 2) anggota kelompok dapat saling memberi motivasi dan dapat membantu mahasiswa mengetahui adanya kekurangan ilmu pengetahuannya. 3) sesama anggota kelompok dapat saling mendukung dan memberi semangat. meskipun terdapat banyak manfaat dari belajar kelompok, akan tetapi sebagian mahasiswa berpendapat bahwa belajar sendiri lebih efisien, karena belajar kelompok berpotensi untuk mengganggu pembelajaran mereka (keren et al, 2017). dalam pembelajaran di fakultas kedokteran universitas hang tuah surabaya banyak mahasiswa yang membentuk kelompok belajarnya sendiri dan tidak sedikit yang mendapatkan hasil lebih maksimal dibandingkan saat belajar sendiri. oleh karena itu, berdasarkan uraian di atas menjadi ketertarikan dan dasar bagi peneliti untuk mengadakan penelitian mengenai hubungan antara aktivitas belajar kelompok dengan indeks prestasi mahasiswa, terutama mahasiswa kedokteran agar dapat menemukan metode pembelajaran yang dapat meningkatkan hasil belajar. metode penelitian desain penelitian ini adalah analitik observasional yang bertujuan untuk mengetahui hubungan antara aktivitas belajar kelompok dengan indeks prestasi mahasiswa semester 6 fakultas kedokteran universitas hang tuah surabaya tahun ajaran 2017/2018. jenis pendekatan yang digunakan adalah cross sectional. populasi dalam penelitian ini adalah mahasiswa semester 6 fakultas kedokteran universitas hang tuah surabaya tahun ajaran 2017/2018. sampel yang diteliti sebagai perwakilan dari populasi diambil dengan metode purposive sampling. sampel dari penelitian ini didasarkan pada suatu pertimbangan yaitu kriteria 19 medical and health science journal, vol.3., no.2, august 2019 inklusi dan eksklusi. pengambilan sampel dilakukan pada responden yaitu mahasiswa angkatan 2015 fakultas kedokteran universitas hang tuah surabaya berjumlah 130 mahasiswa. alat bantu penelitian agar pelaksanaan observasi mendapat data yang cermat pada penelitian ini adalah menggunakan kuesioner. penelitian ini dilaksanakan pada bulan juni – november 2018. data yang telah dikumpulkan kemudian dianalisis uji statistik korelasi-spearman menggunakan spss. hasil penelitian berdasarkan penelitian yang dilakukan pada 130 responden, maka didapat hasil sebagai berikut : tabel 1 distribusi responden berdasarkan kategori belajar kelompok kategori belajar kelompok frekuensi (n) persentase (%) jarang 64 49,2 sedang 59 45,4 sering 7 5,4 total 130 100 dari tabel 1 diatas dapat diketahui bahwa dari 130 responden sebanyak 64 (49,2%) mahasiswa masuk dalam kategori jarang, 59(45,4%) mahasiswa masuk dalam kategori sedang, 7(5,4%) mahasiswa masuk dalam kategori sering. tabel 2 cross tabulation antara ip semester 6 dan kategori belajar kelompok 20 medical and health science journal, vol.3., no.2, august 2019 dari tabel 2 tabulasi silang antara ip semester 6 dengan kategori aktivitas belajar kelompok mahasiswa semester 6 fakultas kedokteran universitas hang tuah surabaya tahun ajaran 2017/2018. berdasarkan uji cr silang, mahasiswa dengan indeks prestasi kurang dari 3,00 yang aktivitas belajar kelompoknya masuk dalam kategori jarang berjumlah 7 orang, yang termasuk dalam kategori sedang berjumlah 6 orang dan yang termasuk sering tidak ada. mahasiswa dengan indeks prestasi 3,00 – 3,49 21 medical and health science journal, vol.3., no.2, august 2019 yang aktivitas belajar kelompoknya termasuk dalam kategori jarang 27 orang, yang termasuk sedang berjumlah 28 orang dan yang termasuk sering berjumlah 2 orang. kemudian mahasiswa dengan indeks prestasi 3,50 – 3,79 yang aktivitas belajar kelompoknya termasuk dalam kategori jarang berjumlah 22 orang, yang termasuk dalam kategori sedang berjumlah 19 orang dan yang masuk dalam kategori sering berjumlah 4 orang. sedangkan mahasiswa dengan indeks prestasi lebih dari 3,80 yang aktivitas belajar kelompoknya masuk dalam kategori jarang berjumlah 8 orang, yang masuk dalam kategori sedang 6 orang dan yang masuk dalam kategori sering berjumlah 1 orang. dalam penelitian ini indeks prestasi sebenarnya berskala rasio, tetapi penulis membagi indeks prestasi menjadi beberapa kategori dengan tujuan untuk memudahkan pembahasan. dapat dilihat bahwa mahasiswa dengan indeks prestasi lebih dari 3,80 kebanyakan memiliki aktivitas belajar kelompok yang masuk dalam kategori jarang. sehingga dapat disimpulkan bahwa tinggi rendahnya indeks prestasi mahasiswa tidak dipengaruhi oleh aktivitas belajar kelompok. uji statistik tabel 3 hasil uji korelasi spearman berdasarkan tabel 3 dapat diketahui bahwa nilai signifikansi (p)= 0,687 yang berarti p > (dengan = 0,05) yang artinya h0 diterima dan h1 ditolak. jadi, tidak ada hubungan antara aktivitas belajar kelompok dengan indeks prestasi mahasiswa semester 6 fakultas kedokteran universitas hang tuah surabaya tahun ajaran 2017/2018. pembahasan dari penelitian yang dilakukan terhadap 130 mahasiswa semester 6 tahap pre-klinik fakultas kedokteran universitas hang tuah surabaya tahun ajaran 2017/2018, diperoleh jumlah mahasiswa yang belajar kelompoknya masuk dalam kategori jarang sebanyak 64 (49,2%) mahasiswa, mahasiswa yang masuk dalam kategori sedang sebanyak 59 (45,4%) mahasiswa, dan mahasiswa yang masuk dalam kategori sering sebanyak 7 (5,4%) mahasiswa. berdasarkan uji statistik korelasi spearman antara aktivitas belajar kelompok dengan indeks prestasi semester 6 didapatkan hasil, signifikansi hubungan antara aktivitas belajar kelompok dengan indeks prestasi semester 6 adalah 0,687. dengan nilai α=0.05, berarti p>α, maka dapat disimpulkan bahwa hubungan antara dua variabel tersebut tidak signifikan sehingga h0 terima dan h1 ditolak. jadi, tidak terdapat hubungan antara antara aktivitas belajar kelompok dengan indeks prestasi semester 6. hal ini tidak sesuai dengan penelitian yang dilakukan oleh (hidayati, 2010) dengan judul “hubungan aktifitas belajar kelompok dengan prestasi belajar siswa madrasah tsanawiyah negeri umbulsari kabupaten jember” dan penelitian “pengaruh belajar kelompok dan motivasi belajar siswa terhadap prestasi belajar siswa kelas viii smp negeri 23 purworejo” yang dilakukan oleh (putriana, 2013) yang hasilnya berdasarkan analisis diperoleh pengaruh variabel belajar kelompok terhadap prestasi belajar siswa sebesar 13,25% maka dapat dikatakan signifikan, berarti hipotesis berbunyi ada pengaruh yang positif dan signifikan antara belajar kelompok terhadap prestasi belajar, dapat diterima yang artinya semakin tinggi aktivitas belajar kelompok maka akan semakin baik pula prestasi belajar siswa. tidak adanya hubungan antara aktivitas belajar kelompok dengan indeks prestasi mahasiswa pada penelitian ini mungkin di pengaruhi oleh banyak faktor. aktivitas belajar kelompok dibentuk oleh beberapa hal, yang paling utama adalah keterlibatan mahasiswa dalam belajar kelompok, frekuensi belajar 22 ip sem 6 score spearma n's rho ip sem 6 correlation coefficient 1.000 .036 sig. (2-tailed) . .687 n 130 130 score correlation coefficient .036 1.000 sig. (2-tailed) .687 . n 130 130 medical and health science journal, vol.3., no.2, august 2019 kelompok dan juga tingkat konsentrasi mahasiswa selama belajar kelompok. keterlibatan mahasiswa dalam belajar kelompok dinilai dari peran mahasiswa dalam belajar kelompok. frekuensi dinilai dari berapa kali mahasiswa belajar kelompok dalam satu minggu, sedangkan tingkat konsentrasi dinilai dari berapa persen fokus dalam materi kuliah selama dua jam belajar kelompok. peran mahasiswa dalam belajar kelompok akan membuat hasil belajar yang berbeda. hal ini didukung oleh teori piramida pembelajaran yang dikemukakan oleh egdar dale tahun 1969 yaitu model pembelajaran dibagi menjadi dua: aktif dan pasif. pembelajaran pasif termasuk didalamnya adalah membaca, mendengar dan melihat hanya memberi andil penguasaan materi sebanyak 10-30%, sedangkan model pembelajaran aktif yaitu diskusi kelompok, praktik dan mengajar orang lain berkontribusi 50 90% terhadap pemahaman seseorang terhadap materi pelajaran (bppk, 2013). peneliti membagi peran belajar kelompok menjadi pendengar, pencatat hasil belajar, pengajar dan pemimpin diskusi. pendengar dan pencatat hasil belajar temasuk pembelajaran pasif sedangkan pengajar dan pemimpin diskusi termasuk pembelajaran aktif. berdasarkan hasil kuesioner dan pengamatan peneliti bahwa kebanyakan mahasiswa berperan sebagai pendengar. frekuensi belajar dianalisa dari jumlah belajar kelompok dalam satu minggu, ditemukan hasil sebanyak 52 (40%) mahasiswa tidak belajar kelompok dalam satu minggu, 46 (35,4%) mahasiswa belajar kelompok satu kali dalam satu minggu, 26 (20%) mahasiswa belajar kelompok dua kali dalam satu minggu, 6 (4,6%) mahasiswa belajar kelompok tiga kali dalam satu minggu. dari hasil data dapat disimpulkan bahwa mahasiswa paling banyak hanya belajar kelompok satu kali dalam seminggu. menurut pengamatan peneliti hal ini mungkin disebabkan karena kebanyakan mahasiswa dengan indeks prestasi >3.80 sudah mendapatkan metode belajarnya yang lebih efektif dari belajar kelompok. frekuensi belajar merupakan suatu hal yang penting dalam meningkatkan prestasi belajar mahasiswa. dalam belajar yang dibutuhkan adalah belajar sesering mungkin tetapi efektif daripada belajar dalam waktu yang lama tetapi tidak efektif. pada penelitian (nurulita, 2014) dengan judul “hubungan frekuensi belajar dan kepercayaan diri dengan prestasi belajar melakukan proses administrasi transaksi siswa kelas xi smk kasatrian solo sukoharjo tahun pelajaran 2013/2014” terdapat hubungan yang positif antara variabel frekuensi belajar dengan prestasi belajar. semakin sering belajar maka penguasaan terhadap materi akan semakin baik. tingkat konsentrasi yang dianalisa adalah distribusi berapa persen fokus responden pada materi kuliah selama belajar kelompok dalam 2 jam belajar kelompok. pada distribusi mahasiswa yang belajar kelompok sebagian besar fokus sebanyak 50% dalam 2 jam belajar kelompok 39 (30%), kemudian yang fokus 75% dalam 2 jam belajar kelompok sebanyak 25 (19,2%). sedangkan mahasiswa yang fokus 100 % dalam 2 jam belajar kelompok hanya 1 (0,8%) orang. dari data diatas dapat disimpulkan bahwa masih kurangnya konsentrasi mahasiswa pada materi kuliah selama belajar kelompok. menurut hasil pengamatan peneliti dan hasil wawancara masih banyak mahasiswa yang menggunakan waktu belajar kelompoknya malah sebagai tempat untuk mengobrol atau melakukan aktivitas lain. terdapat juga faktor-faktor lain yang dapat mengganggu konsentrasi belajar kelompok yang tidak diteliti. keterbatasan penelitian ini adalah keterbatasan waktu dan pengambilan data yang menggunakan kuesioner yang membutuhkan kejujuran dari responden untuk mengetahui kebenaran data. kesimpulan 1. tidak ada hubungan antara aktivitas belajar kelompok dengan indeks prestasi mahasiswa semester 6 fakultas kedokteran universitas hang tuah surabaya tahun ajaran 2017/2018. 23 medical and health science journal, vol.3., no.2, august 2019 2. aktivitas belajar kelompok mahasiswa fakultas kedokteran universitas hang tuah surabaya tahun ajaran 2017/2018 sebagian besar masuk dalam kategori jarang belajar kelompok. daftar pustaka 1. hidayati, e. (2010). hubungan aktifitas belajar kelompok dengan prestasi belajar siswa madrasah tsanawiyah negeri umbulsari kabupaten jember, 2009. 2. keren, d., lockyer, j., & ellaway, r. h. (2017). social studying and learning among medical students: a scoping review. perspectives on medical education, 6(5), 311– 318. https://doi.org/10.1007/s40037-017-0358-9 3. linn, w. d., lord, k. c., whong, c. y., & phillips, e. g. (2013). developing effective study groups in the quest for the “holy grail”: critical thinking. american journal of pharmaceutical education, 77(8), 2013. https://doi.org/10.5688/ajpe778180 4. nurulita, s. (2014). hubungan frekuensi belajar dan kepercayaan diri dengan prestasi belajar melakukan proses administrasi transaksi siswa kelas xi smk kasatrian solo sukoharjo tahun pelajaran 2013/2014. 5. oktasari, n. a. (2018). hubungan kuliah dan belajar kelompok pada step vi metode pbl terhadap pencapaian prestasi belajar mahasiswa fakultas kedokteran universitas muhamma diyah surakarta. 6. putriana, s. (2013). pengaruh belajar kelompok dan motivasi belajar siswa terhadap prestasi belajar siswa kelas viii smp negeri 23 purworejo. 7. triastuti, n. j. (2016). the influence of self study time, group study time and library study time on academic achievement of medical students applying problem based learning, 3(14), 713–721. 24 medical and health science journal, vol.4., no.1, february 2020 hubungan antara panjang aksial bola mata dan derajat miopia dengan tekanan intraokular bella aliviana* 1 , nur khoma fatmawati 2 , m. khairul nuryanto 3 , rahmat bakhtiar 4 1,2,3,4 fakultas kedokteran universitas mulawarman, samarinda *correspondent author: bellaaliviana@yahoo.com article info abstract article history: submitted: january, 21-2020 received in revised form february accepted: february, 26-2020 some studies reported that myopia especially high myopia has long axial length. this condition showed with higher intraocular pressure (iop) and become one of the risk factor of primary open angle glaucoma. however, some other studies reported axial length and degree of myopia don’t have any correlation with intraocular pressure. this study aims to determine whether there is a relationship between the axial length of the eyeball and the degree of myopia with intraocular pressure at sumatera eye center (smec), samarinda. this study began on november to desember 2019. this research method was analytic research with cross sectional design. the sample in this study was 91 eyes using a purposive sampling technique. analyzes were performed with the pearson correlation test. the result showed the age of iop increased at 31, 32, and 33 years old, respectively 1 eye. pearson correlation test showed that iop did not seem to have any correlation with the axial length, low myopia and high degree of myopia. but, iop have correlation with moderate myopia (r=0,019). keywords: myopia, axial length, intraocular pressure, and degree of myopia kata kunci: miopia, panjang aksial, tekanan intraokular, dan derajat miopia. abstrak beberapa studi menyatakan bahwa miopia khususnya derajat berat memiliki panjang aksial yang meningkat, hal ini ditunjukkan dengan tekanan intraokular (tio) yang lebih tinggi dan menjadi faktor risiko terjadinya glaukoma sudut terbuka. namun studi yang lain menyatakan bahwa tidak terdapat hubungan antara panjang aksial bola mata dan derajat miopia dengan tekanan intraokular. penelitian ini bertujuan untuk mengetahui ada tidaknya hubungan antara panjang aksial bola mata dan derajat miopia dengan tekanan intraokular di sumatera eye center (smec), samarinda. penelitian ini dimulai dari bulan november hingga desember 2019. metode penelitian ini adalah penelitian analitik dengan desain cross sectional. sampel pada penelitian ini adalah 91 mata menggunakan teknik purposive sampling. analisis dilakukan dengan uji korelasi pearson. hasil menunjukkan usia terjadinya peningkatan tio pada usia 31, 32, dan 33 tahun masing-masing 1 mata. uji korelasi menunjukan tidak terdapat korelasi yang bermakna antara panjang aksial bola mata, derajat miopia ringan dan berat dengan tio. tetapi ditemukan korelasi yang bermakna antara derajat miopia sedang dengan tio (r=0,019). @2020 medical and health science journal. 10.33086/mhsj.v4i1.1444 pendahuluan miopia (rabun jauh) merupakan gangguan mata di mana kekuatan optik mata terlalu kuat dan terjadi perubahan pada panjang aksial bola mata penderita. ketajaman penglihatan dari penderita miopia yang tidak dikoreksi akan terus menurun.1 menurut data riset kesehatan dasar tahun 2013, kalimantan timur merupakan provinsi yang menduduki peringkat ke 19 perkiraan jumlah kebutaan terbanyak dan peringkat ke 18 jumlah severe low vision terbanyak di indonesia.2 miopia yang tinggi biasanya tetap stabil meninggi antara umur 20-30 tahun, tetapi antara umur 20 correspondence: bella aliviana @2020 medical and health science journal. 10.33086/mhsj.v4i1.1444 available at http://journal2.unusa.ac.id/index.php/mhsj 13 original article mailto:bellaaliviana@yahoo.com http://journal2.unusa.ac.id/index.php/mhsj medical and health science journal, vol.4., no.1, february 2020 40 tahun dapat terjadi perubahan pada kekuatan dioptri penderita miopia.3 meskipun koreksi kelainan refraksi tersedia, miopia dapat meningkatkan risiko terjadinya penyakit yang mengancam penglihatan, yaitu glaukoma (sudut terbuka), katarak (nuklear, kortikal, dan subkapsular posterior), robekan retina yang dapat menyebabkan ablasi retina, dan degenerasi makula.4 tekanan intraokular (tio) adalah tekanan yang dihasilkan oleh cairan yang berada di dalam bola mata dengan nilai normal yaitu 10-20 mmhg. tio yang meningkat secara akut ataupun kronik dapat menyebabkan kerusakan saraf optik yang mengakibatkan kehilangan penglihatan 5 . salah satu kondisi yang terjadi pada penderita miopia ialah pertambahan panjang aksial bola mata yang memiliki risiko terjadinya peningkatan tekanan intraokular.6 faktor risiko lainnya ialah miopia yang tinggi jika dibandingkan miopia rendah dan sedang. miopia dapat menyebabkan glaukoma sudut terbuka dan normotensi glaukoma.7 terdapat dua teori yang menjelaskan bahwa miopia dapat menyebabkan peningkatan tio, yaitu teori mekanik dan teori vaskular. teori mekanik menjelaskan bahwa peregangan sklera yang terjadi pada penderita miopia menyebabkan peningkatan panjang aksial bola mata. berbeda dengan teori mekanik, teori vaskular menjelaskan berkurangnya kemampuan retina sebagai akibat dari miopia, sehingga menyebabkan penipisan pada epitel pigmen retina dan koroid. selanjutnya terjadi peningkatan oksigen reaktif dan penurunan proteksi antioksidan yang mengakibatnya terjadinya glaukoma sudut terbuka.7 pada penelitian yang dilakukan oleh joseph, thampi, joosadima, dan mohan tahun 2016 didapatkan hasil bahwa terdapat hubungan antara miopia dengan tekanan intraokular (tio). miopia derajat sedang dan berat memiliki tio yang lebih tinggi dibandingkan miopia derajat ringan.8 leydolt, findl dan drexler dalam penelitiannya menemukan bahwa terdapat hubungan antara peningkatan tekanan introkular dan penambahan panjang aksial bola mata.9 akan tetapi pada penelitian yang dilakukan oleh das, das, shrivastava, dan mondal tahun 2016 serta penelitian oleh ahmad, qureshi, dan aldebasi tahun 2019 mendapatkan hasil bahwa tidak terdapat hubungan antara panjang aksial dan derajat miopia dengan tekanan intraokular.10,11 miopia adalah salah satu kelainan gangguan penglihatan yang paling sering ditemukan. panjang aksial bola mata dan derajat miopia memiliki hubungan erat dengan peningkatan tekanan intraokular (tio) yang terjadi pada penderita miopia dan berisiko mengalami kehilangan penglihatan jika terjadi komplikasi seperti glaukoma. sehingga penting untuk mengetahui hubungan panjang aksial bola mata dan derajat miopia dengan tio pada mata miopia, oleh karena itu perlu dilakukan penelitian ini. metode penelitian penelitian ini merupakan penelitian analitik observasional dengan metode penelitian cross sectional. penelitian dilakukan pada tanggal 29 november 2019 hingga 31 desember 2019 di klinik mata sumatera eye center (smec) samarinda. sampel penelitian ini adalah seluruh mata miopia yang didiagnosis oleh dokter spesialis mata di klinik mata smec samarinda yang sesuai dengan kriteria inklusi dan eklusi. pengambilan sampel pada penelitian ini dilakukan secara nonprobability sampling dengan teknik purposive sampling. data penelitian ini merupakan data primer yang didapatkan langsung melalui hasil pemeriksaan oleh dokter spesialis mata di klinik mata smec samarinda. pemeriksaan yang dilakukan meliputi pemeriksaan visus dan koreksi refraksi untuk mengetahui derajat miopia, intra ocular lens (iol master) untuk mengetahui panjang aksial bola mata dan tonometri non kontak untuk mengukur tekanan intraokular. data akan dianalisa menggunakan uji korelasi pearson. 14 medical and health science journal, vol.4., no.1, february 2020 hasil berdasarkan penelitian yang dilakukan pada 91 mata, maka didapatkan hasil sebagai berikut: tabel 1. karakteristik responden variabel n persentase (%) jenis kelamin laki-laki 40 44 % perempuan 51 56 % panjang aksial bola mata normal (≤26 mm) 86 94,5 % meningkat (>26 mm) 5 5,5 % derajat miopia ringan (<3 d) 67 73,6 % sedang (3-6 d) 17 18,7 % berat (>6 d) 7 7,7 % tekanan intraokular normal 88 96,7 % meningkat 3 3,3 % responden dalam penelitian ini terdiri dari 40 mata laki-laki dan 51 mata perempuan. panjang aksial bola mata yang mengalami peningkatan sebanyak 5 mata (5,5%) dan jumlah mata miopia derajat ringan, sedang dan berat secara berurutan ialah 67, 17, dan 7 mata. peningkatan tekanan intraokular ditemukan pada 3 mata (3,3%) (tabel 1). gambar dibawah ini menunjukkan penderita miopia yang mengalami peningkatan tekanan intraokular pada penelitian ini terjadi pada usia 31, 32, dan 33 tahun sebanyak masing-masing 1 mata (gambar 1). gambar 1. karakteristik responden berdasarkan usia dan tekanan intraokular rata-rata tekanan intraokular (tio) pada panjang aksial bola mata normal ialah 14,8±2,7 mm dan 15,4±2,3 mm pada panjang aksial bola mata yang meningkat. hasil uji korelasi pearson menunjukkan tidak terdapat korelasi yang bermakna pada panjang aksial bola mata normal dan meningkat dengan tio (tabel 2). rata-rata tekanan intraokular (tio) pada miopia derajat ringan ialah 15,1±2,9 mmhg, sedang (14,3±1,6mmhg), dan berat (14,7±1, 7mmhg). hasil uji korelasi pearson menunjukkan bahwa terdapat korelasi yang bermakna antara miopia dengan tio yang diperoleh pada miopia derajat sedang dan tidak pada derajat ringan ataupun berat (tabel 2). tabel 2. analisa hubungan antara panjang aksial bola mata dan derajat miopia dengan tekanan intraokular hasil uji korelasi pearson menunjukkan terdapat korelasi yang bermakna antara panjang aksial bola mata dengan derajat miopia ringan, sedang, dan berat (tabel 3). tabel 3. analisa hubungan panjang aksial bola mata dengan derajat miopia panjang aksial bola mata n mean p-value r derajat miopia ringan (< 3 d) 67 24,044 (±0,749) 0,040 0,252 sedang (3-6 d) 17 24,798 (±0,879) 0,005 0,647 berat (>6 d) 7 26,555 (±1,643) 0,000 0,966 15 tekanan intraokular (mmhg) p value r n mean panjang aksial bola mata normal (≤26 mm) 86 14,8 0,7 (±2,7) 61 meningkat(>26mm) 5 15,4 0,2 (±2,3) 68 derajat miopia ringan (<3 d) 67 15,1 0,7 (±2,9) 73 sedang (3-6 d) 17 14,3 0,0 0,560 (±1,6) 19 berat (>6 d) 7 14,7 0,3 (±1,7) 31 medical and health science journal, vol.4., no.1, february 2020 pembahasan jumlah responden yang diperoleh dalam penelitian ini yaitu 91 mata miopia. dalam penelitian ini, peningkatan tekanan intraokular ditemukan sebesar 3 mata (3,3%). peningkatan tekanan intraokular pada penelitian ini ditemukan pada usia 31, 32 dan 33 tahun sebanyak masing-masing 1 mata. rata-rata tekanan intraokular (tio) pada panjang aksial bola mata normal ialah 14,8±2,7 mm dan 15,4±2,3 mm pada panjang aksial bola mata yang meningkat. pada penelitian ini tidak ditemukan korelasi yang bermakna antara panjang aksial bola mata dengan tio. uji korelasi pearson menunjukkan nilai r=0,033 yang menunjukkan korelasi yang sangat lemah. dibuktikan bahwa panjang aksial bola mata yang mengalami pemanjangan tidak diikuti oleh peningkatan tio (>20mmhg). hasil penelitian ini sejalan dengan penelitian yang dilakukan oleh chinawa, adio, dan chukwuka tahun 201712 dan das, das, shrivastava, dan mondal tahun 201610 yang menyatakan bahwa tidak terdapat korelasi antara panjang aksial bola mata dengan tekanan intraokular. penelitian chinawa et al., mendapatkan nilai r=0,24 yang menunjukkan korelasi yang lemah dan das et al.,(10) dalam penelitiannya menunjukkan nilai p>0,01 dengan r=0,132 yang berarti korelasi yang sangat lemah. 12, 10 tidak terdapatnya korelasi yang bermakna antara panjang aksial bola mata dengan tekanan intraokular (tio) kemungkinan disebabkan oleh pengaruh dari ketebalan kornea sentral, seperti studi yang dilakukan oleh su, wong, foster,tay, saw, dan aung tahun 2009 mengemukakan bahwa selama perkembangan miopia, panjang aksial bola mata akan meningkat dan ketebalan kornea sentral akan menurun.13 penelitian oleh wei, fan, wang, li, jiao, dan li tahun 2014 mengemukakan bahwa kornea sentral yang mengalami penebalan menyebabkan terjadinya peningkatan tio. tio akan meningkat 0,32 mmhg setiap peningkatan 10 µm ketebalan kornea sentral dengan p value <0,05 dan nilai r=0,44.14 kemungkinan lain tidak terdapat korelasi yang bermakna antara panjang aksial bola mata dengan tekanan intraokular (tio) ialah pada mata miopia terjadi peningkatan panjang aksial bola mata dan derajat miopia dengan p value=0,000, dan r=0,755. jadi bisa disimpulkan dalam penelitian ini tidak terdapat korelasi yang bermakna antara panjang aksial bola mata dengan tio kemungkinan disebabkan oleh peningkatan panjang aksial bola mata yang diikuti terjadinya pengurangan ketebalan kornea sentral, yang berakibat kesan tekanan intraokular menurun. sehingga pada saat dilakukan pengecekan tio, maka ditemukan kesan normal. pada penelitian ini ditemukan rata-rata tekanan intraokular pada miopia derajat ringan ialah 15,1±2,9 mmhg. sedang (14,3±1,6mmhg), dan berat (14,7±1,7mmhg). hasil uji korelasi pearson menunjukkan terdapat korelasi yang bermakna antara miopia derajat sedang dengan tekanan intraokular dengan nilai r=0,560. sedangkan tidak ditemukan adanya korelasi yang bermakna antara miopia derajat ringan (r=0,036) dan berat (r=-0,434). hasil penelitian ini sejalan dengan yang dilakukan oleh das et al.,10 ia menemukan terdapat korelasi yang bermakna antara miopia derajat ringan dengan tekanan intraokular (tio) dengan nilai p<0,01 dan nilai r=-0,223, sedangkan tidak ditemukan adanya korelasi pada derajat sedang (r=0,070) dan berat (r=0,069). tidak terdapatnya korelasi yang bermakna antara derajat miopia dengan tekanan intraokular (tio) kemungkinan disebabkan oleh pengaruh dari ketebalan kornea sentral, seperti studi yang dilakukan oleh kadhim dan farhood tahun 2016, dalam penelitiannya ditemukan terdapat korelasi yang positif antara derajat miopia dengan tio. pada studinya dilaporkan pada mata miopia terjadi penipisan ketebalan kornea sentral sekitar 539,5 µm dibandingkan mata normal yaitu 550,47µm.15 penelitian yang serupa juga dilakukan oleh ks dan anuradha tahun 2019, dalam penelitiannya dikemukakan bahwa peningkatan derajat 16 medical and health science journal, vol.4., no.1, february 2020 miopia akan menyebabkan penurunan ketebalan kornea sentral. rata-rata ketebalan kornea sentral pada >3,5 d adalah 535,5 µm dan pada mata miopia <1,25 d ialah 558,33 µm.16 schuster, fischer, dan vossmerbaeumer tahun 2016 dalam penelitiannya mengemukakan penipisan kornea sentral berhubungan dengan tekanan intraokular yang rendah.17 jadi bisa disimpulkan pada penelitian ini tidak terdapat hubungan antara derajat miopia dengan tekanan intraokular kemungkinan disebabkan oleh kornea sentral yang mengalami penipisan bersamaan dengan bertambahnya derajat miopia dan hal ini akan mengakibatkan kesan tekanan intraokular menurun. sehingga pada saat dilakukan pemeriksaan akan ditemukan kesan tekanan intraokular normal. kesimpulan dan saran kesimpulan 1. tidak terdapat korelasi yang bermakna antara panjang aksial bola mata dengan tekanan intraokular. 2. terdapat korelasi yang bermakna antara miopia derajat sedang dengan tekanan intraokular, tetapi tidak pada miopia derajat ringan dan berat. saran 1. perlu dilakukan penelitian lebih lanjut mengenai variabel lain seperti ketebalan kornea sentral yang dihubungkan dengan tekanan intraokular. 2. meskipun tidak terdapat korelasi bermakna antara panjang aksial bola mata dan derajat miopia ringan dan berat dengan tekanan intraokular (tio), tetapi pemeriksaan tekanan intraokular tetap harus dijadikan pemeriksaan rutin karena perannya mencegah terjadinya komplikasi kerusakan saraf mata jika terjadi glaukoma sudut terbuka pada mata miopia. daftar pustaka 1. ostrow gi, kirkeby l. myopia eyewiki [internet]. american academy of ophthalmology. 2018. available from: http://eyewiki.aao.org/myopia 2. pusat data dan informasi kementerian kesehatan ri. situasi gangguan penglihatan dan kebutaan. kementeri kesehat ri. 2014;1st ed.(situasi gangguan penglihatan dan kebutaan). 3. turbert d. nearsightedness: what is myopia? american academy of ophthalmology [internet]. american academy of ophthalmology. 2019. availablefrom:https://www.aao.org/eyehe althdiseases/myopianearsightedness 4. williams k, hammond c. high myopia and its risks cochrane eyes and vision : 2019; 5. murgatroyd, h; bembridge j. intraocular pressure harry murgatroyd bsc mb chb (hons) jane bembridge mb chb (hons) frca. contin educ anaesth crit care pain [internet]. 2008;8(3):100–3. available from:https://academic.oup.com/bjaed/arti cle-abstract/8/3/100/293369 6. sativa, o. tekanan intraokular pada penderita miopia ringan dan sedang.skripsi. program studi kedokteran umum universitas sumatera utara. 2003. available from:http://drshafa.wordpress.com/2010/ 03/09/miopia/. 7. young tl. topics in first-line glaucoma therapy : choices and challenges. 2016;(12):1–8. 8. joseph d, thampi b, joosadima a, mohan a. a study on association between intraocular pressure and myopia. int j res med sci. 2016;4(6):2202–5. 9. leydolt c, findl o, drexler w. effects of change in intraocular pressure on axial eye length and lens position. eye. 2008;22(5):657–61. 10. das p, das r, shrivastava pk, mondal a. a clinical study on the correlation between axial length, intraocular 17 http://eyewiki.aao.org/myopia http://eyewiki.aao.org/myopia http://www.aao.org/eyehe http://drshafa.wordpress.com/2010/ medical and health science journal, vol.4., no.1, february 2020 pressure and central corneal thickness in myopic eyes. int j contemp med res issn [internet]. 2016;3(4):2393–915. available from: www.ijcmr.com 11. ahmad m, qureshi m, ahmad, aldebasi y, homood. to study the effects of central corneal thickness, axial length, and anterior chamber depth on intraocular pressure. sudan j ophthalmol. 2019;1(1):67–8. 12. chinawa n, adio a, chukwuka i. is there a causal relationship between myopia and intraocular pressure. br j med med res. 2017;20(10):1–7. 13. su dhw, wong ty, foster pj, tay wt, saw sm, aung t. central corneal thickness and its associations with ocular and systemic factors: the singapore malay eye study. am j ophthalmol. 2009; 14. wei w, fan z, wang l, li z, jiao w, li y. correlation analysis between central corneal thickness and intraocular pressure in juveniles in northern china: the jinan city eye study. plos one. 2014;9(8):1–7. 15. kadhim yj, farhood qk. central corneal thickness of iraqi population in relation to age, gender, refractive errors, and corneal curvature: a hospital-based cross sectional study. clin ophthalmol. 2016;10:2369–76. 16. ks r, anuradha p. the correlation of central corneal thickness ( cct ) to degree of myopia and compare it with emmetropes. 2019;4(9):51–4. 17. schuster akg, fischer je, vossmerbaeumer u. central corneal thickness in spectral-domain oct and associations with ocular and systemic parameters. j ophthalmol. 2016;2016. 18 http://www.ijcmr.com/ d:\new order belum cetak\mhsj v nur amin, yanesti nuravianda lestari, hubungan asupan energi dan zat gizi dengan kebugaran jantung paru santri pondok pesantren amanatul ummah surabaya 11 hubungan asupan energi dan zat gizi dengan kebugaran jantung paru santri pondok pesantren amanatul ummah surabaya nur amin1, yanesti nuravianda lestari1 prodi s1 gizi, fakultas kesehatan, universitas nahdlatul ulama surabaya e-mail: nuramin@unusa.ac.id abstrak: olahraga merupakan salah satu bentuk usaha atau cara yang dilakukan oleh seseorang untuk dapat meningkatkan derajat kesehatan. dalam menjaga kesehatan, olahraga maupun aktivitas fisik yang dilakukan harus mampu melatih kebugaran jasmani seseorang. kebugaran jasmani merupakan beberapa keterampilan dan status kesehatan seseorang yang dikaitkan dengan kemampuannya dalam melakukan aktivitas fisik sehari-hari. salah satu komponen kebugaran jasmani yang berkaitan dengan kesehatan adalah kebugaran jantung paru. untuk mendapatkan kebugaran jasmani yang baik perlu adanya pemenuhan asupan makanan, istirahat, dan aktivitas fisik yang baik pula. penelitian ini bertujuan untuk mengetahui hubungan asupan energi dan zat gizi dengan kebugaran jantung paru santri pondok pesantren amanatul ummah surabaya. penelitian ini merupakan correlational descriptive dengan rancangan cross sectional dengan metode total sampling pada 20 santri ponpes amanatul ummah surabaya yang duduk di kelas x dan xi madrasah aliyah. instrumen pengambilan data menggunakan kuesioner semi-ffq (food frequency questionnaire) untuk mengetahui asupan energi dan zat gizi dan multistage test untuk mengetahui vo 2 maks. hasil penelitian menunjukkan tidak terdapat hubungan asupan energi dengan kebugaran jantung paru dengan nilai p=0,78 dan hubungan asupan zat gizi (karbohidrat p=0,70, protein p=0,79, lemak p=0,69, natrium p=0,80, kalsium p=0,81, kalium p=0,93, magnesium p=0,31dan fe p=0,29) dengan kebugaran jantung paru. kesimpulannya, tidak terdapat hubungan asupan energi dan zat gizi dengan kebugaran jantung paru santri amanatul ummah surabaya. kata kunci: asupan energi, zat gizi, kebugaran jantung paru, pondok pesantren latar belakang olahraga merupakan salah satu bentuk usaha atau cara yang dilakukan oleh seseorang untuk dapat meningkatkan derajat kesehatan. banyak orang indonesia melakukan olahraga dengan tujuan untuk menjaga kesehatan, meraih prestasi, dan untuk rekreasi (kemenpora ri, 2011). dalam menjaga kesehatan, olahraga maupun aktivitas fisik yang dilakukan harus mampu melatih kebugaran jasmani seseorang. kebugaran jasmani merupakan beberapa keterampilan dan status kesehatan seseorang yang dikaitkan dengan kemampuannya dalam melakukan aktivitas fisik sehari-hari. adapun terdapat lima komponen kebugaran jasmani yang berkaitan dengan kesehatan, antara lain kebugaran jantung paru (cardiorespiratory fitness), kekuatan otot, daya tahan otot, kelenturan (flexibility), dan komposisi tubuh (ortega et al., 2008). komponen tersebut merupakan marker yang sangat penting bagi status kesehatan seseorang khususnya pada usia anak dan remaja serta merupakan faktor risiko yang berkaitan dengan penyakit kronis dan degeneratif (american college of sports medicine, 2010; castillo-garzon, ruiz, ortega, & gutierrez-sainz, 2007; ruiz et al., 2009). menurut sudarno (1992), kebugaran jasmani memiliki banyak komponen pendukung antara lain status kesehatan, kekuatan otot, daya tahan otot, kelincahan, kecepatan, keseimbangan, kelenturan (flexibility), koordinasi, daya tahan jantung paru, ketangkasan, kemammedical and health science journal, vol. 1, no. 1, february 2017 2 puan motorik umum, dan kondisi fisik (berat badan). adapun dari banyak komponen tersebut, daya tahan jantung paru atau dikenal pula dengan istilah kebugaran jantung paru merupakan komponen utama dan sangat menentukan kebugaran jasmani seseorang. semakin baik daya tahan jantung paru seseorang semakin baik pula status kebugaran jasmani yang dimiliki. irianto (2004) menyebutkan bahwa, kebugaran jasmani yang baik dapat dipengaruhi oleh tiga faktor penting yaitu asupan makanan, istirahat, dan aktivitas fisik atau olahraga. penelitian yang dilakukan oleh moradichaleshtori, et al. (2008) pada 60 responden wanita pra-menopause usia 25–45 tahun menunjukkan bahwa semakin tinggi aktivitas fisik yang dilakukan, daya tahan jantung paru (ditunjukkan dengan indikator vo 2 maks) semakin baik. penelitian lainnya yang dilakukan pada responden anak usia 11–12 tahun juga menyatakan bahwa latihan fisik yang teratur secara signifikan mampu memberikan kontribusi terhadap perkembangan daya tahan jantung paru dan kebugaran jasmani (radovanovic, et.al, 2009). kebiasaan dan asupan makan diketahui dapat memengaruhi tingkat kebugaran jantung paru. putra dan amalia (2014) dalam penelitiannya pada mahasiswa menyatakan bahwa terdapat hubungan yang signifikan antara asupan energi dan protein dengan daya tahan jantung paru (r=0,415 dan r=0,365). didukung dengan penelitian lainnya yang juga dilakukan pada subjek mahasiswa menyebutkan bahwa asupan energi, karbohidrat, protein, dan lemak berhubungan signifikan dengan daya tahan jantung paru (irdilla dkk., 2016). pondok pesantren amanatul ummah, surabaya yang berlokasi di jalan siwalankerto utara ii blok e no.1, siwalankerto, wonocolo, kota surabaya, jawa timur merupakan kompleks pendidikan yang dilengkapi dengan sarana dan prasarana asrama dan bangunan lainnya sebagai penunjang kegiatan santri maupun kegiatan pembelajaran pendidikan. adapun selain mengikuti kegiatan pendidikan, santri yang tinggal di asrama pondok pesantren juga diharuskan untuk mengikuti kegiatan keagamaan yang telah dijadwalkan hampir satu hari penuh. padatnya jadwal kegiatan mengharuskan para santri untuk selalu menjaga asupan makan, aktivitas fisik bahkan kebugaran jantung paru sehingga dapat melaksanakan seluruh rangkaian kegiatan di pondok pesantren dengan optimal. oleh karena itu, perlu adanya suatu penelitian yang mengkaji tentang hubungan antara aktivitas fisik, rata-rata asupan energi dan zat gizi dengan kebugaran jantung paru (cardiorespiratory fitness) santri pondok pesantren amanatul ummah, surabaya. metode penelitian ini merupakan correlational descriptive dengan rancangan cross sectional dengan metode total sampling pada 20 santri ponpes amanatul ummah surabaya yang duduk di kelas x dan xi madrasah aliyah. penelitian ini dilaksanakan di pondok pesantren amanatul ummah, surabaya yang beralamat di jalan siwalankerto utara ii blok e no.1, siwalankerto, wonocolo, kota surabaya, jawa timur. kegiatan penelitian ini akan dilakukan selama dua minggu (14 hari) pada bulan agustus 2017. instrumen yang digunakan dalam penelitian ini antara lain: kuesioner semi-ffq yang berisi daftar jenis makanan (makanan pokok, lauk hewani, lauk nabati, sayur, buah dan makanan jajanan), frekuensi makan (harian, mingguan, bulanan, dan tidak pernah), serta jumlah makanan yang dikonsumsi. data rata-rata asupan harian energi dan zat gizi (karbohidrat, lemak, dan protein) yang diperoleh dari hasil wawancara kuesioner semi-ffq dikonversikan dalam kalori/ hari dan gram/hari rata-rata asupan harian energi nur amin, yanesti nuravianda lestari, hubungan asupan energi dan zat gizi dengan kebugaran jantung paru santri pondok pesantren amanatul ummah surabaya 3 dan zat gizi makro. kemudian dibandingkan dengan akg dan dikalikan 100% dengan rumus: tingkat kecukupan (%) = rata-rata asupan harian/akg x 100%. tingkat kecukupan energi dan zat gizi dikategorikan menjadi kelompok: defisit (<80% akg); adekuat (80–110% akg); dan berlebih (>110% akg) (wnpg 2012). instrumen yang digunakan untuk mengukur kebugaran jantung paru (vo 2 maks adalah multistage test. adapun prosedur pengukuran daya tahan jantung paru adalah (coulson dan archer, 2009): tes terdiri dari 23 level dan durasi pelaksanaan untuk setiap level-nya sekitar 1 menit, tes dimulai dengan kecepatan lari 8,5 km/jam dan meningkat 0,5 km/jam untuk setiap level, bunyi “beep” satu kali merupakan tanda berakhirnya setiap satu putaran lari sedangkan bunyi “beep” tiga kali menandakan dimulainya level berikutnya, subjek berlari dengan jarak 20 meter dan jika subjek tiba di akhir setiap putaran sebelum bunyi “beep”, maka subjek harus menunggu bunyi “beep” untuk kemudian melanjutkan berlari pada putaran berikutnya, subjek harus tetap menjaga kecepatan berlarinya sesuai dengan irama bunyi “beep” dan jika subjek tidak mampu lagi mengikuti sebanyak 3 kali bunyi “beep” berturut-turut, maka multistage test berakhir untuk subjek tersebut, nilai hasil tes kemudian dikonversikan ke dalam tabel perhitungan prediksi vo 2 maks. analisis data menggunakan software spss 16 for windows. analisis deskriptif digunakan untuk mendeskripsikan usia responden, bb, tb, imt/u, tingkat aktivitas fisik, dan rata-rata asupan energi dan zat gizi (karbohidrat, protein, dan lemak), dan status kebugaran jantung paru. setelah seluruh data dianalisis secara univariat atau deskriptif dilanjutkan dengan analisis bivariat menggunakan uji korelasi untuk mengkaji hubungan variabel bebas terhadap variabel terikat. adapun yang merupakan variabel bebas adalah tingkat aktivitas fisik, dan rata-rata asupan energi dan zat gizi serta status kebugaran jantung paru merupakan variabel terikat. uji statistik yang digunakan adalah uji spearman’s correlation dengan taraf signifikansi (a) 0,05 dan tingkat kepercayaan 95%. hasil uji korelasi dinyatakan signifikan jika diperoleh nilai signifikansi p < 0,05 (uyanto, 2009). results subjek dalam penelitian ini adalah santri pondok pesantren amanatul ummah surabaya yang berjumlah 20 orang. semua subjek dalam penelitian ini masih duduk di kelas xi madrasah aliyah dengan rentang usia berkisar antara 14– 17 tahun. karakteristik responden selengkapnya disajikan pada tabel berikut. tabel 1 karakteristik subjek penelitian karakteristik rerata + sd (n=20) min maks usia 15.9 + 0.71 14 17 berat badan (kg) 59.95 + 13.43 44 97 tinggi badan (cm) 160 + 0.46 150 170 imt (kg/m2) 21.8 + 4.49 17 34 hasil pengamatan menunjukkan bahwa subjek penelitian rata-rata memiliki berat badan 64,6 kg, rata-rata tinggi badan 173,2 cm, dan memiliki imt yang normal yaitu 21,8 kg/m2. tabel 2 hubungan rata-rata asupan energi dan zat gizi dengan vo 2 maks karakteristik rerata + sd (n=20) min maks nilai p* energi (kkl) 2055.8 + 798.43 1087.3 3902 0.783 karbohidrat (g) 291.72 + 113.56 141.3 568.1 0.702 protein (g) 71.23 + 34.9 36.2 173.8 0.790 lemak (g) 65.82 + 44.12 11.1 161.4 0.695 natrium (mg) 460.38 + 371.07 105.7 1395.1 0.803 kalsium (mg) 522.68 + 422.25 176.5 1660.6 0.812 kalium (mg) 2542.8 + 1829.33 776.3 8526.4 0.935 magnesium (mg) 392.98 + 216.19 172.3 944.8 0.312 fe (mg) 12.09 + 7.55 5.5 36.9 0.294 *uji hubungan menggunakan spearman’s correlation, signifikan pada level 0,05 medical and health science journal, vol. 1, no. 1, february 2017 4 asupan energi dan rata-rata zat gizi pada setiap responden berbeda-beda, dikarenakan perbedaan aktivitas dan menu makanan yang dikonsumsi berbeda. berdasarkan hasil wawancara dengan responden, ada beberapa dari responden selain mengonsumsi makanan yang disediakan di pondok pesantren, mereka masih mengonsumsi makanan lain berupa makanan yang mereka beli di warung yang berada di sekitar pondok pesantren. tabel di atas juga menunjukkan bahwa asupan energi dan zat gizi tidak berhubungan dengan vo 2 maks (semua nilai p< 0,05). pembahasan semua variabel bebas dalam penelitian ini (tingkat aktivitas fisik, rata-rata asupan energi dan zat gizi) yang dihubungkan dengan variabel terikat (vo 2 maks) menunjukkan bahwa tidak terdapat hubungan yang bermakna (semua nilai p < 0,05). dibuktikan dengan hasil wawancara kepada responden mengenai aktivitas apa saja yang dilakukan selama di lingkungan pondok pesantren, yaitu responden hanya melakukan aktivitas yang termasuk dalam kategori sedang. selain itu, di sekolah tidak terdapat mata pelajaran olahraga, hal ini menjadikan responden tidak memiliki aktivitas fisik yang dilakukan secara teratur. hasil yang menunjukkan ketidak adanya hubungan antara semua variabel independen dengan variabel dependen juga dapat dikarenakan bahwa faktor utama yang mampu meningkatkan vo 2 maks adalah latihan fisik yang bersifat daya tahan/endurance (foss dan keteyian, 1998). didukung dengan penelitian pada tahun 2013 oleh prativi tentang pengaruh aktivitas olahraga terhadap kebugaran jasmani, yang menunjukkan hasil bahwa aktivitas fisik berpengaruh terhadap kebugaran jasmani (vo 2 maks) dengan nilai p=0,018 (prativi, 2013). latihan fisik yang bersifat endurance yang dilakukan secara teratur dapat menjadikan perubahan pada sistem kardiorespiratori seseorang, antara lain: (1) otot jantung akan mengalami pembesaran dikarenakan volume darah yang mengisi jantung bagian serambi semakin banyak, sehingga mengakibatkan volume darah yang di pompa untuk ditransportasikan ke seluruh tubuh semakin banyak, (2) pada saat istirahat, detak jantung mengalami penurunan, (3) hal ini disebabkan volume darah dapat ditransportasikan dengan optimal oleh jantung dengan beberapa denyutan yang disebabkan oleh peningkatan kontraksi otot jantung, (4) meningkatkan kapasitas paru, (5) sehingga jumlah oksigen dan hemoglobin dalam darah mengalami peningkatan, (6) peningkatan pembuluh darah kapiler dan hipertropi otot yang dapat mengakibatkan penyediaan oksigen dan zat gizi dalam otot mengalami peningkatan, (7) vo 2 maks seseorang akan mengalami peningkatan yang disebabkan oleh jumlah oksigen dalam membantu pembentukan energi dalam tubuh mengalami peningkatan (foss dan keteyian, 1998). penelitian lain yang dilakukan oleh amin dkk (2017) yang dipublikasikan di jurnal gizi indonesia tentang pemberian asupan zat gizi dari jenis karbohidrat (maltodekstrin) dalam minuman elektrolit terhadap daya tahan jantung paru (vo 2 maks) pada responden atlet sepak bola yang berjumlah 17 orang yang diberikan maltodektrin dibandingkan dengan 17 orang yang tidak diberikan sebagai kelompok kontrol menunjukkan bahwa terdapat pengaruh yang signifikan (p=0,01) dan terjadi peningkatan daya tahan jantung paru pada kelompok yang diberikan maltodekstrin yaitu sebelum diberikan nilai vo 2 maks 51,05 + 3,16 menjadi 51,60 + 3,286 ml/kg bb/menit setelah diberikan maltodekstrin. nur amin, yanesti nuravianda lestari, hubungan asupan energi dan zat gizi dengan kebugaran jantung paru santri pondok pesantren amanatul ummah surabaya 5 kesimpulan santri ponpes amanatul ummah, surabaya memiliki karakteristik (usia, berat badan, tinggi badan, indeks massa tubuh, rata-rata asupan dan tingkat kecukupan energi dan zat gizi, serta daya tahan jantung paru) sangat bervariasi. tidak terdapat hubungan antara tingkat aktivitas fisik, rata-rata asupan energi dan zat gizi dengan tingkat kebugaran jantung paru (daya tahan jantung paru) santri ponpes amanatul ummah, surabaya (semua nilai p> 0,05). ucapan terima kasih peneliti mengucapkan terima kasih kepada unusa yang telah mendukung dalam pendanaan selama penelitian berlangsung, ketua yayasan pondok pesantren amanatul ummah surabaya yang telah memberikan izin penelitian, santri yang telah bersedia menjadi responden selama penelitian, dan enumerator yang telah 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fanny tantiwi nurdin* fakultas kedokteran, universitas mulawarman *correspondent author: olgafanny36@gmail.com article info abstract article history: submission: july 26 2019 received in revised form august 2019 acccepted: august 21 2019 attention deficit hyperactivity disorder (adhd) is the most frequent case that parents take to seek treatment at a child psychiatrist. many adhd children referred to the hospital showed additional disorders that accompanied the main diagnosis which served as comorbidity. it is important to detect the presence of comorbidity in children with adhd because it can be a diagnostic challenge, as the manifestation is more complex and the prognosis is worse than those with adhd alone. the aim of this study was to explore the types of comorbid disorders and its risk factors in paediatric patients with adhd. this study used a quantitative descriptive method, with a total sampling technique. this study was done at atma husada a district psychiatric hospital (rsjd), mahakam samarinda in 2015-2018 period. total samples were 84 cases. our results showed that 18 cases (21%) were without comorbid, 52 cases (62%) had 1 comorbid and 14 cases (17%) were had > 1 comorbids. autism spectrum disorder (asd) was the most common type of comorbid disorder which showed 28 cases (35%). the most prominent risk factors in adhd with comorbidity were natal factors which mean abnormalities during childbirth (39%) and partial parenting factors of (18%). while in adhd without comorbidity, the most prominent risk factor was postnatal factors (33%) and there was no case partial parenting factor. the benefit of this study is by knowing the presence of comorbidities, it is expected a careful initial evaluation must be carried out during diagnostics to eliminate various possible differential diagnoses and it is also expected that the comorbidities accompany gpph can be handled properly. keywords: adhd, comorbidities, partial parenting factor, asd kata kunci : gpph, komorbiditas, pengasuhan parsial, gsa abstrak gangguan pemusatan perhatian dan hiperaktivitas (gpph) merupakan bagian terbesar dari anak yang dibawa orangtua untuk berobat ke psikiater anak. anak gpph yang dirujuk ke klinik banyak yang menunjukkan gangguan lain yang menyertai diagnosis utama yang disebut sebagai komorbiditas. sangat penting untuk mendeteksi kehadiran komorbiditas ketika anak didiagnosis gpph karena dapat menjadi tantangan diagnostik, manifestasi akan lebih kompleks serta prognosis akan lebih buruk dibandingkan dengan anak-anak dengan gpph saja. tujuan penelitian untuk mengetahui jenis gangguan komorbid pasien anak gpph dan faktor risiko pasien anak gpph. penelitian ini menggunakan desain deskriptif kuantitatif, dengan teknik total sampling. penelitian ini dilakukan di rsjd atma husada mahakam samarinda periode 2015-2018. total sampel adalah 84 kasus. hasil menunjukkan bahwa 18 kasus (21%) tanpa komorbid, 52 kasus (62%) memiliki 1 komorbid dan 14 kasus (17%) yang memiliki >1 komorbid. gangguan spektrum autisme (gsa) merupakan jenis gangguan komorbid terbanyak yaitu terdapat 28 kasus (35%). faktor risiko yang paling menonjol dari pasien anak gpph dengan komorbiditas adalah faktor natal atau faktor kelainan saat persalinan (39%) dan faktor pengasuhan parsial (18%). faktor risiko yang paling menonjol dari pasien anak gpph tanpa komorbiditas adalah faktor postnatal (33%) dan tidak adanya kasus faktor pengasuhan parsial. manfaat dari studi ini adalah dengan mengetahui adanya komorbiditas diharapkan evaluasi awal yang cermat harus dilakukan saat diagnostik untuk mengeliminasi berbagai kemungkinan diagnosa banding dan diharapkan juga komorbiditas yang menyertai gpph dapat ditangani dengan baik. @2019 medical and health science journal. 10.33086/mhsj.v3i2.1132 correspondence: olga fanny tantiwi nurdin @2019 medical and health science journal. 10.33086/mhsj.v3i2.1132 available at http://journal2.unusa.ac.id/index.php/mhsj 36 original article mailto:olgafanny36@gmail.com http://journal2.unusa.ac.id/index.php/mhsj medical and health science journal, vol.3., no.2, august 2019 pendahuluan gangguan pemusatan perhatian dan hiperaktivitas (gpph) merupakan kasus terbanyak pada anak yang dibawa orangtuanya untuk berobat ke psikiater anak. keluhan utama orang tua tersebut adalah bahwa anak mereka “nakal”, “malas belajar”, dan “kurang konsentrasi”, baik di sekolah ataupun di rumah1. penelitian terdahulu pada 30 sekolah dasar yang terpilih secara acak di jakarta tahun 2011, didapatkan angka proporsi gpph sebesar 26,2%. penelitian lain yang dilakukan di bali tahun 2012 menunjukkan jumlah pasien gpph yang berkunjung ke poliklinik tumbuh kembang rumah sakit umum pemerintah (rsup) sanglah sebanyak 63 orang. anak laki-laki dikatakan memiliki insidensi yang lebih tinggi untuk mengalami gpph daripada perempuan, dengan rasio sebesar 3-4 : 12. komorbiditas adalah suatu keadaan yang menunjukkan terdapat dua penyakit yang berbeda dalam waktu yang bersamaan dalam diri seseorang3. menurut saputro (2009) pasien anak gpph yang dirujuk ke klinik banyak yang menunjukkan gangguan psikiatri lain, seperti gangguan sikap menentang, gangguan tingkah laku, gangguan suasana perasaan, gangguan kecemasan, gangguan belajar dan gangguan komunikasi, juga tourette syndrome. gangguan gangguan lain yang menyertai gpph ini dapat berlanjut sampai remaja bahkan sampai dewasa jika tidak mendapat penanganan yang adekuat1. penelitian sebelumnya oleh ratnasari, kaunang, dundu tahun 2015-2016 di kota manado yang dilakukan terhadap 20 sekolah dasar didapatkan bahwa dari 611 siswa yang terskrining gpph, 143 diantaranya mempunyai komorbiditas. kasus komorbiditas yang terbanyak adalah gangguan perilaku oposisional menentang 4. berdasarkan sejumlah penelitian di atas, tampaknya angka kejadian adanya komorbiditas pada pasien gpph anak cukup besar, sehingga penting untuk dilakukan deteksi adanya komorbiditas saat diagnosis gpph dilakukan. melihat pada psikopatologis terkait gpph dengan komorbiditas, manifestasi klinis akan lebih kompleks daripada gpph tanpa komorbiditas & 37 dapat menjadi tantangan diagnostik. oleh karena itu, evaluasi awal yang cermat perlu dilakukan untuk mengeliminasi berbagai kemungkinan diagnosis banding. sebagai tambahan, prognosis dan hasil akhir dari anak-anak dengan komorbid pada gpph lebih buruk dibandingkan dengan anak-anak dengan gpph saja 5. tujuan penelitian ini untuk mengetahui jenis gangguan komorbid pasien anak gpph, serta untuk mengetahui ada tidaknya perbedaan faktor risiko pasien anak gpph dengan dan tanpa komorbiditas. metode penelitian penelitian ini menggunakan desain penelitian deskriptif kuantitatif. populasi dalam penelitian ini adalah semua rekam medik pasien anak yang memiliki diagnosis gpph di rsjd atma husada mahakam samarinda periode tahun 2015-2018. variabel dalam penelitian ini yaitu jenis kelamin dan usia sebagai karakteristik; berbagai komorbiditas; riwayat keluarga, faktor prenatal, faktor natal, faktor postnatal, dan pola pengasuhan parsial sebagai faktor risiko. hasil karakteristik pasien yang diikutkan dalam studi ini adalah jenis kelamin yang didapatkan terbanyak yaitu perempuan (87%). karakteristik lain yang diikutkan adalah usia dengan pembagian kategori berdasarkan american academy of pediatrics (2011)6. didapatkan kategori terbanyak yaitu usia toddler (40%) seperti yang tampak pada tabel 1. berikut ini : tabel 1. karakteristik pasien anak dengan gpph karakteristik (n) (%) 1. jenis kelamin laki-laki 11 13 perempuan 73 87 84 100 2. usia 0-12 bulan (infant) 0 0 13 bulan-3 tahun (toddler) 34 40 4-5 tahun (prasekolah) 25 30 6-12 tahun (usia sekolah) 25 30 84 100 medical and health science journal, vol.3., no.2, august 2019 dari sampel rekam medik diperoleh total sampel adalah sebanyak 84 pasien. banyaknya gangguan spektrum autisme + gangguan kecemasan 1 7 pasien dengan komorbiditas adalah sebesar 79%. gangguan kecemasan + gangguan sensori integrasi 1 7 pasien umumnya menunjukkan adanya 1 komorbiditas (62%) (tabel 2.). gangguan kecemasan + retardasi mental 1 7 tabel 2. komorbiditas pasien anak dengan gpph epilepsi + gangguan koordinasi motorik halus dan kasar + retardasi mental 1 7 komorbiditas (n) (%) tidak ada komorbid 18 21 1 komorbid 52 62 > 1 komorbid 14 17 total 84 100 adapun jenis gangguan komorbid terbanyak yang menyertai pasien antara lain gangguan retardasi mental tampaknya merupakan kombinasi yang sering menyertai komorbiditas >1. adapun distribusi derajat retardasi mental yang ada dapat dilihat pada tabel 5. derajat retardasi berkisar dari ringan sampai berat, namun tidak ada yang sangat berat. tabel 5. derajat retardasi mental spektrum autism (35%), gangguan berbicara dan berbahasa (28%) serta retardasi mental (16%). jenis komorbid lainnya dapat dilihat pada tabel 3. tabel 3. jenis gangguan komorbid dari 14 pasien yang mempunyai komorbid >1, gangguan berbicara dan berbahasa yang disertai retardasi mental merupakan gejala terbanyak (29%). keluhan komorbid lain dapat dilihat pada tabel 4. tabel 4. jenis gangguan >1 komorbid >1 komorbiditas (n) (%) gangguan berbicara dan berbahasa + retardasi mental 4 29 gangguan spektrum autisme + retardasi mental 3 22 gangguan spektrum autisme + gangguan koordinasi motorik halus dan kasar 2 14 gangguan spektrum autisme + disruptive, impulse-control, and conduct disorders 1 7 hasil penelitian ini menunjukkan bahwa dari semua faktor risiko pada pasien anak gpph dengan komorbiditas, terlihat faktor natal merupakan faktor terbesar yaitu sebanyak 39%. proses kelahiran dengan metode sectio caesarea menjadi faktor natal terbanyak (20%). selain itu, terdapat juga faktor risiko pengasuhan parsial sebanyak 18% (tabel 6.) tabel 6. faktor risiko gpph dengan komorbiditas sementara itu, penelitian ini faktor risiko (n) (%) 1. riwayat keluarga 1 6 2. faktor prenatal 2 11 3. faktor natal bblr 0 0 prematur 2 11 sectio caesarea 2 11 4 22 4. faktor postnatal riwayat kejang demam 2 11 riwayat trauma kepala 4 22 6 33 5. pengasuhan parsial 0 0 38 komorbiditas (n) (%) gangguan spektrum autisme 28 35 gangguan berbicara dan berbahasa 23 28 retardasi mental 13 16 disruptive, impulse-control, and conduct disorders 5 6 gangguan koordinasi motorik halus dan kasar 5 6 gangguan kecemasan 4 5 gangguan pendengaran 1 1 gangguan sensori integrasi 1 1 epilepsi 1 1 derajat retardasi mental (n) (%) ringan 4 30 sedang 8 62 berat 1 8 sangat berat 0 0 total 13 100 medical and health science journal, vol.3., no.2, august 2019 menunjukkan bahwa pada pasien anak gpph tanpa komorbiditas mempunyai faktor risiko yang berbeda dengan yang disertai komorbiditas. faktor risiko terbanyak adalah faktor postnatal (33%). terlihat juga adanya perbedaan bahwa tidak didapatkannya faktor risiko pengasuhan parsial untuk pasien anak gpph tanpa komorbiditas (tabel 7.). tabel 7. faktor risiko gpph tanpa komorbiditas faktor risiko (n) (%) 1. riwayat keluarga 3 5 2. faktor prenatal 5 8 3. faktor natal bblr 7 11 prematur 5 8 sectio caesarea 13 20 25 39 4. faktor postnatal riwayat kejang demam 10 15 riwayat trauma kepala 3 5 13 20 5. pengasuhan parsial 12 18 pembahasan hasil penelitian ini menunjukkan bahwa persentase anak gpph yang memiliki komorbid sebesar 79%. hasil penelitian ini sesuai dengan studi epidemiologi yang menunjukan tingkat komorbiditas antara 50% sampai 90% untuk anak gpph 7. pada penelitian ini juga sesuai dengan yang dilakukan oleh patel et al., (2011) yang menunjukkan adanya komorbiditas sebesar 67% yang terdiri atas satu komorbiditas sebanyak 33%, dua komorbiditas sebanyak 16% dan yang memiliki tiga atau lebih komorbiditas sebanyak 18%. patel juga menyatakan bahwa adanya komorbiditas pada pasien gpph anak mengakibatkan hasil yang sangat buruk, terutama jika komorbiditas itu sendiri terkait dengan gangguan jiwa lainnya 8. komorbiditas gsa yang didapatkan memiliki frekuensi paling banyak dengan jumlah 28 kasus dengan persentase sebesar 35%. hal ini sesuai dengan penelitian yang dilakukan oleh leitner yang mendapatkan prevalensi komorbid gsa 31% pada anak-anak sekolah dasar. terdapat bukti adanya keterkaitan antara gpph dengan gsa mempengaruhi risiko berat ringannya masalah psikososial pada anak 9. gsa seringkali ditemukan bersamaan dengan gpph. anak yang menderita gsa seringkali menunjukkan gejala hiperaktif, sulit berkonsentrasidan impulsif, sebaliknya anak yang menderita gpph juga sering mengalami gangguan interaksi sosial 10.. pada penelitian ini gangguan berbicara dan berbahasa bersamaan dengan retardasi mental merupakan komorbiditas >1 komorbid terbanyak dengan persentase 29%. kemampuan berbahasa merupakan indikator seluruh perkembangan anak, karena kemampuan berbahasa sensitif terhadap keterlambatan atau kelainan pada sistem lainnya, seperti kemampuan kognitif, sensorimotor, psikologis, emosi dan lingkungan di sekitar anak. oleh karena itu, gangguan berbahasa juga sangat terkait dengan retardasi mental atau yang biasa dikenal dengan disabilitas intelektual 11. anak anak gpph dengan retardasi mental memiliki prevalensi 3 kali lebih banyak dibandingkan dengan anak-anak populasi umum dengan retardasi mental saja 12. faktor risiko terbanyak yang didapatkan untuk pasien anak gpph dengan komorbiditas adalah faktor natal (39%) yang terbagi menjadi bblr, prematur, dan sectio caesarea. suatu penelitian kasus kontrol menyebutkan bahwa faktor natal (prematur, bblr, sectio caesarea) merupakan faktor resiko gpph yang dapat memicu timbulnya gpph ataupun memperparah gejala klinis gpph 13. terlihat juga terdapat faktor pengasuhan parsial pada pasien anak gpph dengan komorbiditas pada penelitian ini. adanya masalah dan ketidaknyamanan dalam lingkungan keluarga merupakan faktor penting yang berperan dalam gpph. suatu penelitian menunjukkan bahwa anak dengan ibu yang bekerja di luar rumah sehingga pengasuhan anak mereka diserahkan kepada pembantu rumah tangga memiliki risiko lebih besar untuk mengalami gejala hiperaktif yang berat 13. berbagai laporan dalam sosiodemografis 39 medical and health science journal, vol.3., no.2, august 2019 menyatakan bahwa prevalensi gpph lebih tinggi pada anak-anak dengan keluarga yang dipimpin oleh ibu tunggal (single mother). laporan sosiodemografis tersebut juga menjelaskan bahwa dari 61779 anak gpph, diantaranya terdapat 5028 anak yang memiliki >3 komorbid dan memiliki stuktur keluarga dengan ibu tunggal (22%), orang tua adopsi (16%) dan lain-lain 21% 6. faktor postnatal dalam penelitian ini menunjukkan persentase 33%, dan lebih tinggi daripada anak gpph dengan komorbiditas. hal ini juga selaras dengan komorbiditas terbanyak gsa yang tidak didapatkan etiologi dan faktor resiko berupa adanya riwayat kejang demam dan riwayat trauma kepala yang dapat membuat gsa tersebut bisa timbul. hal ini menunjukkan bahwa semua anak gpph tanpa komorbiditas (18 kasus) memiliki pengasuhan total yang sehari-harinya bersama dengan kedua orang tua lengkap, tinggal di satu rumah yang sama atau bukan di penitipan. hasil tersebut selaras dengan prognosis anak yang tidak menjadi lebih buruk oleh karena senantiasa adanya dukungan dan edukasi oleh orang tua. kesimpulan dan saran kesimpulan sebanyak 18 (21%) pasien anak gpph tanpa komorbid, 52 (62%) memiliki 1 komorbid dan sebanyak 14 (17%) pasien yang memiliki >1 komorbid. komorbiditas terbanyak yaitu gangguan spektrum autisme sebanyak 28 (35%) kasus. jenis gangguan >1 komorbid terbanyak yaitu gangguan berbicara dan berbahasa + retardasi mental sebanyak 4 (29%) kasus. faktor risiko yang paling menonjol dari pasien anak gpph dengan komorbiditas adalah faktor natal (39%) dan faktor pengasuhan parsial (18%). faktor risiko yang paling menonjol dari pasien anak gpph tanpa komorbiditas adalah faktor postnatal dengan persentase 33% dan tidak didapatkan kasus faktor pengasuhan parsial. manfaat dari studi ini adalah dengan mengetahui adanya komorbiditas diharapkan evaluasi awal yang cermat harus dilakukan saat diagnostik untuk mengeliminasi berbagai kemungkinan diagnosa banding dan diharapkan juga komorbiditas yang menyertai gpph dapat ditangani dengan baik sehingga prognosis dari pasien tidak berakhir buruk. saran 1. perlu dilakukan penelitian selanjutnya yang menunjukkan hubungan secara analitik. 2. diperlukan kerjasama yang baik antara kelembagaan, klinisi, masyarakat dan pihak pihak terkait lainnya dalam penanganan gpph beserta komorbiditasnya. daftar pustaka 1. saputro, d. (2009). adhd (attention deficit/hyperactivity disorder). jakarta: cv. sagung seto. 2. elvira, s., & hadisukanto, g. (2017). buku ajar psikiatri (3 ed.). jakarta: badan penerbit fakultas kedokteran universitas indonesia. 3. soetjiningsih, & ranuh, i. (2013). tumbuh kembang anak (2nd ed.). jakarta: egc. 4. ratnasari, n., kaunang, t., & dundu, a. (2016). komorbiditas pada anak gangguan pemusatan perhatian dan hiperaktivitas (gpph) pada 20 sekolah dasar di kota manado. jurnal e-clinic (ecl), 41. 5. masi, l., & gignac, m. (2015). adhd and comorbid disorders in childhood psychiatric problems, medical problems, learning disorers and developmental coordination disorder. clinical psychiatry. 6. larson, k., russ, s., kahn, r., & halfon, n. (2011). patterns of comorbidity, functioning, and service use for us children with adhd. american academy of pediatrics. 7. faraone, s., & kunwar, a. (2007, may 3). adhd in children with comorbid conditions: diagnosis, misdiagnosis, and keeping tabs on both. retrieved march 15, 2019, from medscape: https://www.medscape.org/viewarticle/555748_ 7 8. patel, n., patel, m., & patel, h. (2011). university of missouri health care, usa. retrieved october 5, 2015, from adhd and comorbid conditions: http://cdn.intechopen.com/pdfs wm/280240.pdf 9. leiner y. (2014). the co-occurence of autism and attention deficit hyperactivity disorder in childrenwhat do we know? frontiers in human neuroscience, 8, 1-8. 10. kementerian kesehatan ri. (2011). anak berkebutuhan khusus. jakarta 40 https://www.medscape.org/viewarticle/555748_7 https://www.medscape.org/viewarticle/555748_7 https://www.medscape.org/viewarticle/555748_7 http://cdn.intechopen.com/pdfs medical and health science journal, vol.3., no.2, august 2019 11. soetjiningsih, & ranuh, i. (2013). tumbuh kembang anak (2nd ed.). jakarta: egc 12. masi, l., & gignac, m. (2015). adhd and comorbid disorders in childhood psychiatric problems, medical problems, learning disorers and developmental coordination disorder. clinical psychiatry. 13. indriyani, s., soetjiningsih, s., ardjana, i. e., & windiani, i. t. (2008). prevalensi dan faktor faktor risiko gangguan pemusatan perhatian anak dan hiperaktivitas di klinik tumbuh kembang anak rsup sanglah denpasar. sari pediatri, 9(5). 41 8_mhsj-ok 55 korelasi kadar kolesterol dengan kejadian diabetes mellitus tipe 2 pada laki-laki rahayu anggraini prodi d-iv analis kesehatan, fakultas kesehatan, universitas nahdlatul ulama surabaya e-mail: : anggrek@unusa.ac.id1 abstract: type 2 diabetes is one of the most common chronic diseases in the world. it is estimated that more than 140 million people worldwide are currently suffering from diabetes, and by 2025, an estimated more than 300 million people will suffer from the disease. the purpose of this study was to evaluate the correlation of cholesterol with the incidence of diabetes mellitus disease. the type of this research is observational with cross-sectional analytic approach and done in pln employees, total are 112 people of which are mens. all participants underwent biochemical analysis of fasting blood sugar (bsn) and 2 hours pp (post prandial), and total cholesterol level test. determination of glucose by glucose oxidase method and cholesterol level by chod-pap method. the mean results in normal cholesterol (< 200 mg/dl) obtained bsn = 73 mg / dl, 2 hours pp = 92 mg / dl, and in abnormal cholesterol (> 200 mg/dl) mean bsn = 81 mg / dl, 2 hours pp = 109 mg / dl, in independent t test with p = 0001 in both groups of different cholesterol levels. results of the pearson's correlation test, there was a significant positive correlation between gdp and cholesterol levels (r = 0.262, p = 0.005), and 2 hours pp and cholesterol levels (r = 0.258, p = 0.006). conclusions: there was a significant positive correlation between 2 hours pp and cholesterol levels. this study shows there is a correlation of cholesterol levels that develop diabetes mellitus type 2. keywords: cholesterol levels, blood suger nuchter (bsn), blood suger 2 hours post pandial, diabetes mellitus type 2. abstrak: diabetes tipe 2 adalah salah satu penyakit kronis yang paling umum di dunia. diperkirakan lebih dari 140 juta orang di seluruh dunia saat ini menderita diabetes, dan pada tahun 2025, diperkirakan lebih dari 300 juta orang akan menderita penyakit ini. tujuan penelitian ini adalah untuk mengevaluasi korelasi kadar kolesterol dengan kejadian penyakit diabetes mellitus tipe 2. jenis penelitian adalah observasional dengan pendekatan cross-sectional analitik yang dilakukan pada karyawan pln laki-laki sebanyak 112 orang. semua peserta menjalani analisis biokimia gula darah puasa (bsn) dan 2 jam pp (post prandial), serta uji kadar kolesterol. penentuan kadar glukosa dengan metode glucose oxidase dan kadar kolesterol dengan metode chod-pap. hasil penelitian pada pasien normal kolesterol didapat nilai rata-rata bsn= 73 mg/dl, 2 jam pp=92 mg/dl, dan pada pasien abnormal kolesterol nilai rata-rata bsn = 81 mg/dl, 2 jam pp= 109 mg/dl dengan uji “t” bebas didapat nilai p=0001. hasil dengan uji korelasi pearson’s, ada korelasi positif yang signifikan antara kadar bsn dengan kadar kolesterol (r = 0,262, p = 0,005), dan pada kadar 2 jam pp dengan kadar kolesterol (r = 0,258, p = 0,006). kesimpulan: ditemukan korelasi positif yang signifikan antara kadar bsn, 2 jam pp, dan kadar kolesterol serum. penelitian ini menunjukkan ada korelasi kadar kolesterol yang tinggi (> 200 mg/dl) dapat mengembangkan penyakit diabetes mellitus type 2. kata kunci: kadar kolesterol, kadar gula darah puasa, kadar gula darah 2 jam pp, diabetes mellitus tipe 2. pendahuluan glukosa dalam aliran darah meningkat tidak normal menyebabkan haus yang tak terkendalikan dan sering buang air kecil. ketidakmampuan tubuh menyimpan atau menggunakan glukosa menyebabkan rasa lapar sehingga meningkatkan berat badan. diabetes terjadi saat tubuh tidak menghasilkan cukup hormon insulin atau insulin yang diproduksi normal namun kurang efektif dan sering terjadi pada orang berusia di atas 40 tahun, medical and health science journal, vol. 2, no. 2, august 2018 56 karenanya hampir 90% penyakit diabetes mellitus jatuh pada type 2 (chaterjee mn, 2005). menurut federasi diabetes internasional, diperkirakan ada 194 juta orang penderita diabetes pada tahun 2003 dan sekitar 2/3 orang berada di negara berkembang (idf, 2003). diabetes melitus tipe ii dikaitkan dengan sekelompok kelainan lipid plasma dan lipoprotein yang saling terkait. ini semua diketahui sebagai prediktor terjadi penyakit jantung koroner. atherosclerosis adalah komplikasi utama akibat kadar kolesterol yang tinggi (dislipidemia), sehingga dianggap bertanggung jawab akan terjadinya peningkatan morbiditas dan mortalitas di indonesia. studi epidemiologis telah menunjukkan bahwa kadar kolesterol yang tinggi pada pasien diabetes melitus tipe-2 dan pasien non-diabetes tanpa riwayat penyakit kardiovaskular, memiliki risiko kejadian kardiovaskular yang sama. pada obesitas, sintesis kolesterol dan omset dapat meningkat tajam dan efisiensi penyerapan kolesterol menurun. dengan demikian, metabolisme kolesterol sering dikaitkan dengan diabetes, sebagai faktor yang bertanggung jawab atas perubahan yang perlu diamati. berdasarkan data di atas, peneliti mencoba meneliti kadar kolesterol yang tinggi dengan kejadian diabetes mellitus tipe 2 pada laki-laki. diabetes mellitus tipe 2 diabetes tipe 2 adalah salah satu penyakit kronis yang paling umum di dunia. diperkirakan lebih dari 140 juta orang di seluruh dunia saat ini menderita diabetes, dan pada tahun 2025, diperkirakan lebih dari 300 juta orang akan menderita penyakit ini (world health organisasi 1999). diabetes mellitus tipe 2 menyumbang sekitar 90% dari semua kasus diabetes. angka prevalensi diabetes mellitus di indonesia berkisar antara 1,4-1,6%, kecuali di manado (6%). penelitian di kelurahan kayuputih yang merupakan contoh daerah perkotaan menghasilkan prevalensi sebesar 5,6%, sedangkan di daerah pedesaan jawa barat sebesar 1,1%. di indonesia pasien diabetes mellitus tipe 2 merupakan diabetes yang paling banyak ditemukan, sedangkan diabetes mellitus tipe 1 sangat jarang. penyebab paling umum morbiditas dan mortalitas pada diabetes mellitus tipe 2 adalah penyakit kardiovaskular. risiko koroner penyakit arteri adalah dua sampai empat kali lipat, lebih tinggi pada wanita dibandingkan pada pria, dan setelah itu terjadi infark miokard akut, risiko kematian bisa mencapai lebih dari dua kali lipat. risiko infark miokard sebanding pada pasien nondiabetes (haffner et al 1998). ada beberapa faktor risiko kardiovaskular yang diketahui seperti diabetes mellitus tipe 2 termasuk hiperinsulinemia, hipertensi, dislipidemia, resistensi insulin dan obesitas, yang kesemuanya dianggap terlibat dalam akselerasi mengembangkan aterosklerosis. diabetes tipe 2 didefinisikan dengan peningkatan kadar glukosa dalam darah. dasar molekuler diabetes tipe 2 belum jelas, hasil spekulasi menghasilkan cacat genetik yang menyebabkan resistensi insulin dan kekurangan insulin menyebabkan cacat genetik, sehingga tidak ada gen tunggal atau gen kandidat. diabetes mellitus tipe 2 telah ditemukan berkontribusi pada etiologi penyakit kardiovaskula (kahn dan porte 2001). umumnya diabetes mellitus tipe 2 adalah kelainan poligenik, hasil dari beberapa gabungan gen cacat dipengaruhi oleh faktor-faktor lingkungan, semuanya bersamasama menghasilkan sindrom klinis diabetes mellitus tipe 2. metabolisme lipoprotein pada diabetes mellitus tipe 2 diabetes mellitus tipe 2 dikaitkan dengan serum puasa dan postprandial yang tidak normal. metabolisme lipoprotein fitur utama dari dislipidemia ini adalah tingkat yang tinggi dari trigliserida, penurunan kadar kolesterol hdl, dan peningkatan jumlah partikel ldl kecil dan padat, rahayu anggraini, korelasi kadar kolesterol dengan kejadian diabetes mellitus tipe 2 pada laki-laki 57 yang disebut pola subclass ldl b (evans dkk. 1999). sebaliknya, kadar kolesterol dan kolesterol ldl sebanding dengan yang terlihat pada subjek tanpa diabetes. hasil penelitian haffner tahun 1990 telah menunjukkan bahwa karakteristik profil lipoprotein dislipidemia pada diabetes tipe 2 mendahului timbulnya diabetes (haffner et al 1990, mykkänen et al. 1993) dan hadir dalam banyak kondisi di mana hanya resistensi insulin yang diamati (ginsberg 2000). mekanisme pembentukan dislipidemia pada diabetes tipe 2 tetap tidak pasti, meskipun banyak faktor yang terlibat termasuk resistensi insulin, hiperinsulinemia, metabolisme asam lemak terganggu dan bahkan hiperglikemia (evans et al, 1999). komposisi dan jumlah lipoprotein yang berbeda diubah. banyak penelitian menunjukkan kelebihan produksi partikel vldl, trigliserida dan apolipoprotein b-100 (howard 1994). aktivitas lipoprotein lipase ini berkurang menyebabkan turunnya katabolisme vldl. meskipun vldl diperluas, kadar kolesterol ldl mungkin normal karena peningkatan proporsi partikel vldl dimetabolisme tanpa konversi ke ldl (howard 1987) dan ke tingkat katabolisasi frase yang disingkat ldl. ada peningkatan lipid exchange antara trigliserida kaya vldl dan kedua hdl dan ldl, mungkin karena aktivitas cetp meningkat dan kelebihan vldl (elchebly, 1996, ginsberg 2000). hal ini menyebabkan penurunan kolesterol hdl dan pembentukan trigliserida yang kaya partikel hdl dan ldl. selain itu, katabolisme hdl juga meningkat karena overaktif lipase hati (howard 1994, de man, 1996). hasil ini terjadi pada generasi partikel lipoprotein yang lebih kecil dan lebih padat dengan fungsi abnormal. frase katabolik frase (fcr) apo a-i meningkat (golay, 1987) yang mengarah ke tingkat kolesterol hdl yang lebih rendah (brinton, 1994). partikel lipoprotein juga dimodifikasi oleh glikosilasi pada hiperglikemia. pembersihan partikel ldl glycated berkepanjangan, dan mungkin akan lebih mudah teroksidasi, juga menyebabkan serapan yang meningkat oleh makrofag (witztum, 1982; bowie, 1993). material dan metode rancangan penelitian adalah observasional analitik dengan pendekatan cross sectional. populasi dan sampel penelitian adalah seluruh karyawan laki-laki di perusahaan pln sebanyak 120 orang. teknik pengambilan sampel dilakukan dengan menggunakan purposive sampling dari kadar kolesterol menjadi 2 kelompok yaitu: normal dan abnormal. kemudian kedua kelompok dilakukan uji glukosa darah puasa (gda) dan glukosa darah 2 jam post prandial/pp (setelah makan). hasil kadar glukosa darah puasa dan glukosa 2 jam pp akan dianalisis dengan uji independent sample t test terhadap kedua kelompok, kemudian dilanjutkan uji korelasi pearson’s untuk melihat ada tidaknya korelasi kedua kelompok penelitian terhadap kadar gda dan 2 jam pp bahan pemeriksaan sampel penelitian berupa serum dan penentuan kadar kolesterol dengan kit kolesterol merck glory, serta penentuan kadar glukosa darah puasa dan 2 jam pp dilakukan dengan kit glukosa merck glory. hasil penelitian hasil uji independent sample t test pada kadar gdp dan 2 jam pp pada kelompok kolesterol normal dan abnormal. medical and health science journal, vol. 2, no. 2, august 2018 58 gambar 1. diagram column kadar gdp dan 2 jam pp pada kelompok kadar kolesterol normal dan abnormal, di mana terlihat pada kelompok kolesterol normal, nilai rata-rata gdp adalah 73 mg/dl dan pada 2 jam pp adalah 92 mg/dl, sedangkan pada kelompok kolesterol abnormal, nilai rata-rata gdp adalah 81 mg/dl dan 2 jam pp adalah 109 mg/dl. jika dilakukan uji independent sample t test, pada kadar gdp terlihat bahwa t hitung untuk gdp pada kolesterol normal dan abnormal dengan equal variance assumed adalah – 1,898 dan probabilitas 0,001. oleh karena probabilitas <0,05, maka rata-rata gdp kedua kelompok benar-benar berbeda, dalam artian pada kelompok kolesterol abnormal memiliki rata-rata kadar glukosa gdp lebih tinggi daripada kelompok kolesterol normal. pada kadar 2 jam pp terlihat bahwa t hitung pada kedua kelompok normal dan abnormal kolesterol dengan equal variance assumed adalah – 2,052 dan probabilitas 0,007. oleh karena probabilitas <0,05, maka rata-rata 2 jam pp kedua kelompok benar-benar berbeda, dalam artian pada kelompok kolesterol abnormal memiliki rata-rata kadar glukosa 2 jam pp lebih tinggi daripada kelompok kolesterol normal. hasil uji korelasi pearson’s kadar gdp dan 2 jam pp pada kedua kelompok normal dan abnormal kolesterol tabel 1. uji korelasi pearson’s pada tabel 1 terlihat bahwa uji korelasi pearson’s pada kadar gdp sebesar +0,262 dengan p=0,005 (p<0,05), yang artinya kadar gdp antara kedua kelompok kolesterol normal dan abnormal berkorelasi lemah dan signifikan berbeda bermakna yang menunjukkan bahwa kadar gdp semakin meningkat akan meningkatkan kadar kolesterol. sedangkan uji korelasi pearson’s pada kadar 2 jam pp sebesar +0,258 dengan p=0,006 (p<0,05), yang artinya kadar 2 jam pp antara kedua kelompok normal dan abnormal kolesterol berkorelasi lemah, namun signifikan berbeda bermakna yang menunjukkan bahwa kadar 2 jam pp semakin meningkat akan meningkatkan kadar kolesterol. pembahasan hasil penelitian ini dengan uji independent sample t test menghasilkan kadar gdp antara kedua kelompok normal dan abnormal kolesterol, ternyata berbeda bermakna di mana dinyatakan kadar gdp pada kelompok abnormal kolesterol lebih tinggi daripada kelompok normal kolesterol. begitu pula hasil 2 jam pp antara kedua kelompok normal dan abnormal kolesterol, ternyata berbeda bermakna yang artinya kadar 2 jam pp pada kelompok abnormal kolesterol lebih tinggi daripada kelompok normal kolesterol. hasil penelitian ini sesuai dengan hasil penelitian nita garg tahun 2014 yang menyatakan “nilai rata-rata gula darah puasa, kadar kolesterol, trigliserida dan kolesterol ldl pada kelompok rahayu anggraini, korelasi kadar kolesterol dengan kejadian diabetes mellitus tipe 2 pada laki-laki 59 diabetes lebih tinggi daripada kelompok nondiabetes, dan nilai kolesterol hdl ternyata lebih rendah daripada non-diabetes. bahkan rasio kadar cholesterol / hdl dan rasio ldl / hdl ternyata jauh lebih tinggi pada penderita diabetes daripada penderita non diabetes”. hasil uji korelasi pearson’s juga menyatakan pada gdp terdapat korelasi meningkat positif antara kelompok normal dan abnormal kolesterol, artinya kadar gdp akan semakin meningkat pada kelompok kolesterol abnormal, dibanding kelompok kolesterol normal. demikian pula uji korelasi pearson’s pada 2 jam pp, terdapat korelasi meningkat positif antara kadar 2 jam pp antara kelompok normal dan kelompok abnormal, kolesterol yang artinya kadar 2 jam pp akan semakin meningkat pada kelompok kolesterol abnormal, dibanding kelompok kolesterol normal. hasil ini sesuai juga dengan hasil disertasi piia simonen pada tahun 2002, di mana pada diabetes tipe 2 berhubungan dengan penyerapan kolesterol rendah dan sintesis kolesterol meningkat. selain itu berat badan dapat mengatur metabolisme kolesterol pada diabetes tipe 2, sehingga dapat meningkatkan berat badan lebih lanjut disertai penurunan penyerapan kolesterol. kolesterol dan metabolisme glukosa sangat erat dan saling terkait, dan regulasi metabolisme kolesterol terkait dengan variabel yang mencerminkan resistensi insulin. besarnya kelainan penyerapan kolesterol dan sintesis menunjukkan tingkat keparahan resistensi insulin. kelainan dalam metabolisme kolesterol tidak ireversibel dan penurunan berat badan adalah cara yang efisien meningkatkan metabolisme kolesterol. selain itu, efek menguntungkan dari penurunan berat badan adalah metabolisme kolesterol bisa dilihat agak cepat, meski dalam keadaan tidak stabil. hasil studi ini telah meningkatkan pengetahuan kita tentang metabolisme kolesterol pada diabetes tipe 2, dan juga memberikan wawasan baru tentang efek menguntungkan dari penurunan berat badan pada obesitas sebagai pengobatan utama untuk diabetes tipe 2. menurut haffner sm, 1998, atherosclerosis adalah komplikasi utama diabetes. studi menunjukkan bahwa penderita diabetes melitus tipe-2 yang tidak memiliki riwayat penyakit kardiovaskular, memiliki risiko yang sama menderita jantung seperti halnya pasien nondiabetes yang sebelumnya sudah ada penyakit koroner. menurut fava s, 1993, terjadi peningkatan kejadian penyakit jantung akibat diabetes, dan kasus kematian lebih besar pada pasien dengan infark miokard, maka sangat disarankan untuk menurunkan kadar lipid sebagai preventif, yang berpotensi penyakit diabetes dan jantung koroner. kesimpulan kadar gdp dan kadar 2 jam pp akan semakin meningkat pada kelompok kolesterol abnormal dibanding kelompok kolesterol normal. referensi artiss jd, zak b., 1997. measurement of cholesterol concentration. in: rifai n, warnick gr, dominiczak mh, eds. handbook of lipoprotein testing. washington: aacc press, p. 99-114 bowie a, owens d, collins p, john son a, tomkin gh., 1993. glycosylated low density lipoprotein is more sensitive to oxidation: implications for the diabetic patient? atherosclerosis;102:63-67. brinton ea, eisenberg s, breslow jl, 1994. human hdl cholesterol levels are determined by apoa-i fractional catabolic rate, which correlates inversely with estimates of hdl particle size. effects of gender, hepatic and lipoprotein lipases, medical and health science journal, vol. 2, no. 2, august 2018 60 triglyceride and insulin levels, and body fat distribution. arterioscler thromb;14:707720. chaterjee mn, shinde r, 2005. textbook of medical laboratory technology. metabolism of carbohydrates. jaypee brothers. sixth edition. 266-330, delhi, india. de man fh, cabezas mc, van barlingen hh, erkelens dw, de bruin tw, 1996. triglyceride-rich lipoproteins in noninsulin-dependent diabetes mellitus: postprandial metabolism and relation to premature atherosclerosis. eur j clin invest;26:89-108. evans m, khan n, rees a., 1999. diabetic dyslipidaemia and coronary heart disease: new perspectives. curr opin lipidol;10:387-391. fava s, azzopardi j, muscat ha, fenech ff., 1993. factors that influence the outcome in diabetic patients with myocardial infarction. diabetes care; 16:1615–8. frank b, stampfer j, steven m., 2002. elevated risk of cardiovascular disease prior to clinical diagnosis of type ii diabetes. diabetes care. 25: 1129-34. 8. ginsberg hn., 2000. insulin resistance and cardiovascular disease. j clin invest;106:453-458. golay a, zech l, shi m-z, chiou y-am, reaven gm, chen y-di, 1987. high density lipoprotein (hdl) metabolism in noninsulin-dependent diabetes mellitus: measurement of hdl turnover using tritiated hdl. j clin endocrinol metab;65:512-518. howard bv, 1994. lipoprotein metabolism in diabetes. curr opin lipidol; 5:216-220. haffner sm, lehto s, rönnemaa t, pyörälä k, laakso m, 1998. mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. n engl j med. 339:229-234. haffner sm, stern mp, hazuda hp, mitchell bd, patterson jk., 1990. cardiovascular risk factors in confirmed prediabetic individuals. does the clock for coronary heart disease start ticking before the onset of clinical diabetes. jama;263:2893-2898. international diabetes federation (idf), 2003. access to insulin. a report on the idf insulin task force on insulin 1994-1997. kahn se, porte d jr., 2001. β-cell dysfunction in type 2 diabetes: pathophysiological and genetic bases. in: the metabolic and molecular bases of inherited disease. scriver cr, beaudet al, sly ws, valle d, eds. mcgraw-hill, new york; 1407-1431. mykkänen l, kuusisto j, pyörälä k, laakso m., 1993. cardiovascular disease risk factors as predictors of type 2 (non-insulin-dependent) diabetes mellitus in elderly subjects. diabetologia;36:553-559. nita garg, yb agrawal, seema gupta, 2014. a study of lipid profile levels in diabetics and non-diabetics taking tc/hdl ratio and ldl/hdl ratio into consideration. jiacm; 15(3-4): 192-5 porte d jr., 1991. banting lecture 1990. beta-cells in type ii diabetes mellitus. diabetes;40:166-180. piia simonen, 2002. cholesterol metabolism in type 2 diabetes. academic dissertation, medical faculty of the university of helsinki, in auditorium 2, biomedicum helsinki, on december 27th, 2002, at 12 noon. witztum jl, mahoney em, branks mj, fisher m, elam r, steinberg d., 1982. nonenzymatic glycosylation of low-density lipoprotein alters its biologic activity. diabetes;31:283291. medical and health science journal, vol. 4, no.2, august 2020 correspondence: s bayusentono @2020 medical and health science journal. 10.33086/mhsj.v4i1.1415 available at http://journal2.unusa.ac.id/index.php/mhsj 91 long term evaluation of radiographically undetected acute osteomyelitis resulting chronic osteomyelitis with mrsa t adityawardhana 1 , s bayusentono 2* 1 doctor of medicine and alumni of universitas airlangga 2 department of orthopedics and traumatology, faculty of medicine, universitas airlangga/ dr. soetomo general hospital, surabaya, indonesia * corresponding author: sbsentono@fk.unair.ac.id article info abstract article history: submitted: june, 26 2020 received in revised form july, 28 2020 accepted: august, 18 2020 osteomyelitis is an infection and inflammation of the bone that may spread into all parts of the bone. methicillin-resistant staphylococcus aureus or mrsa complicates the management of diseases, 28% of hospitals in indonesia are suspected to be mrsa endemic. osteomyelitis combined with mrsa have obscured prognosis knowing its assessment and management are still being developed. presenting a case of chronic osteomyelitis and mrsa of an 11-year old girl that had been monitored for 5 years after the reported onset in july 2015. the patient complained of severe pain in the left hip region causing her to stop using her left limb in july 2015. signs of acute osteomyelitis couldn’t be confirmed by sequential assessments of x-ray and usg examination. cefazolin and gentamicin injections were administered for 23 days. the family requested the patient to be discharged, claiming they were unable to see significant clinical improvement. intravenous of antibiotic regimens were changed into oral regimens, consisting; coamoxiclav and gentamicin. the patient was never present for routine check-up, her family conceded that they went to traditional alternative medication and stated the patient's clinical outcomes were showing signs of improvement; in which the patient was able to walk normally. 6 months after, the patient's mother observed abnormal gait, however the patient didn't mention nor complain of anything. furthermore, an x-ray assessment was performed, with the result of the entire left femoral head being reportedly destroyed. in january 2016 the patient was referred to dr.soetomo hospital, then diagnosed with chronic osteomyelitis and pathological fracture of 1/3 proximal left femur with a suspicion of avascular necrosis. the patient was given prophylactic antibiotics. closed biopsy couldn't be performed, hence open biopsy was suggested. the patient had routine check-ups to monitor the disease progression, alongside radiologic assessment and laboratory assessments prior to the surgery. episodes of localised swelling and tenderness in the hip area were present. scenes of seropurulent discharges were additionally reported. in june 2017 patients had surgical debridement and sequestrectomy in addition to an open biopsy, where mrsa was diagnosed. no antibiotics had been given after the surgery and had routine wash with chlorhexidine gluconate 4%. currently, the patient still undergoes routine check-ups at the outpatient facility, as radiologic and laboratory examination are routinely observed. as of now, the patient has no issue in its daily living activities. however, there is still limited range of movement at the infected site, with 90 degree of hip flexion and constrained internal rotation. a lower limb length discrepancy is present due to local growth aggravation at the left hip. the patient wears a lift modified shoe on her left leg. in any case, there has not been any complaints of pain, swollen or seropurulent releases throughout the last 18 months @2020 medical and health science journal. 10.33086/mhsj.v4i1.1415 keywords: acute osteomyelitis, chronic osteomyelitis, mrsa, radiologic exam case reports medical and health science journal, vol. 4, no.2, august 2020 92 introduction osteomyelitis is a bone infection that grows from trabecular areas of the bone. this infection could also invade the bone marrow, bone cortex, periosteum and surrounding tissues 1 . approximately 75% of osteomyelitis is caused by gram-positive staphylococcus that arise from blood vessels or from adjascent soft tissues. in facts, although the most common bacteria causes osteomyelitis are s. aureus and s.epidermidis, bone biopsy remains the gold standard for starting treatment. biopsy may determine the most sensitive antibiotics, besides to detect mrsa (methicillin resistant staphylococcus aureus) or mrse (methicillin resistant staphylococcus epidermidis) as early as possible to eliminate further complication 2 . some areas have shown higher incidence of antibiotic resistance for osteomyelitis, especially in asia. lack of antibiotics regulations have resulted in an increased number of antibiotics abuse, leading to greater transmission and antibiotics resistance. as a result, some asian countries have one of the highest prevalence of mrsa incidence, it is common for hospitals in asia to be mrsa endemic. in early 2010s, the estimation of hospitals with mrsa endemic were 28% in indonesia and hong kong and >t-;’ 70% in south korea 3 . in 2016 a research from dr. soetomo academic general hospital surabaya - teaching hospital in indonesia, showed 8% of all surgery patients suffered from mrsa (including the inpatients). from the results, there is a continuous increase of numbers of mrsa patients within hospitals in indonesia 4 . children with acute osteomyelitis in developing countries often came too late to be treated, due to lack of awareness and proper medical facilities. not only chronic osteomyelitis that had worsened with multiple antibiotics resistance reported, but also it is also hard to differentiate between osteomyelitis and malignancies. this issue causes chronic osteomyelitis in developing countries to be the main factor of musculoskeletal disabilities and morbidities 5,6 . case report we present a case of chronic osteomyelitis and mrsa of an 11-year-old girl, this patient had been monitored for the last 5 years after the reported onset since july 2015. the patient monitored routinely, routine physical examination and radiologic examination on her left hip region to assesed patient's improvement. the patient complained of severe pain and continuous pain in the left hip region causing her to stop using her left limb in july 2015. it is reported the patient did not want her left hip region to be touched because it would escalate the pain resulting limited range of movement. the pain decreased when she didn’t move her left hip. she had felt this complaint for approximately 1 week. slight fever also reported. the patient was finally brought to the hospital, physical examination and radiological examination were performed. signs of acute osteomyelitis couldn’t be confirmed from x-ray and usg examinations (figure 1a and 1b). patient then referred as an inpatient. cefazolin and gentamicin injections were administered for 23 days and her left hip joint movement was limited. after her first week in the hospital, repeated radiologic and usg examinations performed, however signs of acute osteomyelitis couldn’t be confirmed from the sequential assessments (figure 1c and 1d). mri examination was not an option considering the patient's background. (a) (b) medical and health science journal, vol. 4, no. 2, august 2020 93 (c) (d) figure 1. (a and b) first radiological examination, signs of acute osteomyelitis couldn’t be confirmed; (c and d) sequential assessments with radiological and usg examination, signs of acute osteomyelitis couldn’t be confirmed yet. the family requested the patient to be discharged, claiming they were unable to see significant clinical improvement. intravenous antibiotic regimens were changed into oral regimens, consisting; co-amoxiclav and gentamicin. the patient was never present for routine check-up, her family conceded that they went to traditional alternative medication and stated the patient's clinical outcomes were showing signs of improvement; in which the patient was able to walk normally. six months later, the patient's mother observed abnormal gait, however the patient didn't mention nor complaint of anything. the patient also reported having difficulties in her p.e. class, limited range of movement in her left hip, especially when squatting. patient did not complaint about pain, swelling and fever. an x-ray assessment was performed, with the result of the entire left femoral head being reportedly destroyed. in january 2016 the patient was referred to dr.soetomo general hospital, where the patient was then diagnosed with chronic osteomyelitis and pathological fracture of 1/3 proximal left femur with a suspicion of avascular necrosis. (figure 2) figure 2 left femoral head destruction present, accompanied by the sequester and involucrum on the left femur with solid periosteal reaction. femoral head deformity present. from these images, concluded that the patient had osteomyelitis and a pathological fracture of 1/3 proximal left femur with a suspicion of avascular necrosis on the left femoral head. the patient was given prophylactics antibiotics. closed biopsy couldn't be performed, hence open biopsy was suggested. the patient had routine check-ups to monitor the disease progression, alongside radiologic assessment and laboratory assessments prior to the surgery. episodes of localised swelling and tenderness in the hip area were present. scenes of seropurulent discharges were additionally reported. closed biopsy couldn't be performed hence open biopsy was suggested. in june 2017 patients had surgical debridement and sequestrectomy in addition to an open biopsy, where mrsa was diagnosed. no antibiotics had been given after the surgery and had routine wash with chlorhexidine gluconate 4%. currently, the patient still undergoes monthly check-ups at the outpatient facility for the next 1,5 years, radiologic and laboratory examinations were routinely observed. results as per 19 th january 2020, the patient no longer had any issues in its daily living activities. in any case, there had been no complaint of pain, swelling or seropurulent discharges throughout the last 18 months. there is still limited range of movement at the infected site, with 90 degree hip flexion medical and health science journal, vol. 4, no.2, august 2020 94 and constrained internal rotation, however, according to them these complaints do not really affect her daily activities a lower limb leg-length discrepancy is present due to local growth aggravation at the left hip. the patient wears a lift modified shoe (orthotic) on her left leg. the patient had already replaced her orthotic once. (figure3) (a) (b) figure 3 (a) limited range of movement is present on her left hip, with 90 degree of hip flexion at best (b) a leg-length discrepancy is present (c) the patient wears a lift modified shoe on her left leg (orthotic). from the latest radiological examination (figure 4) bone trabeculation outside of the lesion, joint gap and the joint surface appeared well. lucency on distal third of the left femur could be interpreted as a representation of an active lesion. figure 4 latest radiological examination discussion there are two hypotheses that are able to explain the pathophysiological findings on children with osteomyelitis, that are inside outside theory and outside inside theory. the focus on inside outside theory is the inability of children’s immunity to suppress the process of inflammation, and the intramedullary pressure causing sinuses and capillaries suppression which would cause bone infarction. outside inside theory focuses more on the pathogen invasion abilities to enter periosteum causing periosteal abscess, eventually damaging the bone structure 7 . the pathophysiology, radiological description and its classifications are complex due to its connection with multiple factors; such as patient’s age, duration, route of infection, immunity and patient’s vascular condition on the infected site 6 . differences in mode of infection, intraosseous vascular anatomy and subperiosteal abscess formation in children caused different clinical manifestations compared to adults. in paediatrics patients, long bones such as tibia and femur are the most common site of infection, whereas on adult patients, axial structures are the most common site. femur (36%), tibia (33%), humerus (10%) and pelvis (2,8%) are the most common site of infection ,8,9 . routes of infections are also varied. in children, hematogenous routes are more common 9 . hematogenous osteomyelitis in long bones frequently attacks the metaphysis, slowing down the blood flow on metaphysis (which is closed with the epiphysis) and directing the microbes deposition that eventually leading to focal infection. focal infection triggers an inflammatory response that increases the medullary pressure. this pressure can compress cortex and periosteal blood vessels, resulting bone necrosis. microbial factors also play an important role of the disease progression, adhesins on s. aureus able to identify the molecular matrix that its main function is to connect the polysaccharide structures and have connections to fibronectin, fibrinogen, collagen and heparin which are the structures that maintained the bone matrix. s. aureus that is ingested by the osteoclast still could survive and might become more resistant to antibiotics 10 . osteomyelitis that is essentially a bone marrow inflammation could develop to (c) medical and health science journal, vol. 4, no. 2, august 2020 95 osteonecrosis, bone destruction and septic arthritis, ending as a permanent disability 8 . radiographic presentation of osteomyelitis depends on the clinical presentation and age of the patient 9 . simple xray imaging has low sensitivity and low specificity to detect acute osteomyelitis. 80% of patients that come at least 2 weeks after the onset will have normal radiographic presentation due to its incapability to detect the spreading infection in the bone tissue. few osteomyelitis aspects that could be shown by simple x-ray are periosteal reactions, because of the increasing periosteal thickness; tissue swelling visible at least 2 week after the onset and the border between that differs thickness of the bone appears clearly with intraosseous abscess. but these features are not specific on osteomyelitis and could also be seen in stress fracture, bone tumour and tissue’s infection. therefore the radiological examination is possible to postpone for 10 to 14 days from the onset to confirm the diagnosis 8 ,9,10 . ultrasound examination is also limited because of its inability to examine the bone, bone marrow and competence of operator. this examination is decently accurate, fast and adequately effective to compare both extremities, but with its limitations, this examination is rarely used as a first line additional examination. in acute osteomyelitis this examination used mainly to observe the progressing infections in subperiosteal area because of the loosening on the tissue attachments at periosteum. color doppler is also able to identify tissue swelling with its ability to locate hyper vascularities around the bone. ultrasound is also helpful to guide needle aspiration if tissue swelling is observed 7 ,9,10 although with its limitations, simple xray is still the first line examination to confirm acute osteomyelitis and to exclude other diagnoses such as fractures. simple x-ray can also be used to observe disease’s progression. simple x-ray is still recommended as a first step and ultrasound examination could performed if needed ,9,10 the disease causing microbes also contributes to the clinical presentation and the severity of the osteomyelitis. s. aureus caused 80% of osteomyelitis, where methicillin sensitive staphylococcus aureus (mssa) and methicillin resistant staphylococcus aureus (mrsa) are also the two most common pathogens. some forms of more aggressive osteomyelitis reported caused by mrsa/mssa, it is known that these two pathogens contain genotype-300, pvl and fnbb that affect fibronectin where this polysaccharide associated with the binding force and severity of infection. two previous studies in america showed increasing numbers of osteomyelitis incidents and more severe cases are associated with higher prevalence of mrsa and most of them are community acquired. higher incidence of mrsa infection associated with extra-osseous events, increasing number surgical intervention and duration of hospitalization. at the same time, the more severe the infection contributes to longer duration of hospitalization. where osteomyelitis is not treated adequately, chronic osteomyelitis could develop into osteonecrosis, intraosseous disruption and disruption of periosteal vascularization 7 ,8,10 . conclusion acute osteomyelitis is a clinical diagnosis. simple x-rays need to be routinely performed in inpatients, with an addition of ultrasound examination. thorough and intensive education plays important role for the patient and patient’s family to achieve comprehensive understanding of the disease. for some cases in which the diagnosis is not yet confirmed, complete and accurate treatments are supposed to prevent bone necrosis, later contributing to the formation of irreversible leg-length discrepancy and limited range of movement with the result that permanent limited daily functions. medical and health science journal, vol. 4, no.2, august 2020 96 references 1. blom a, warwick d, whitehouse m. apley & solomon's system of orthopaedics and trauma. crc press; 2017 aug 29. 2. kavanagh n, ryan ej, widaa a, sexton g, fennell j, o'rourke s, cahill kc, kearney cj, o'brien fj, kerrigan sw. staphylococcal osteomyelitis: disease progression, treatment challenges, and future directions. clinical microbiology reviews. 2018 apr 1;31(2):e00084-17. 3. chen cj, huang yc. new epidemiology of staphylococcus aureus infection in asia. clinical microbiology and infection. 2014 jul 1;20(7):605-23.. 4. kuntaman k, hadi u, setiawan f, koendori eb, rusli m, santosaningsih d, severin j, verbrugh ha. prevalence of methicillin resistant staphylococcus aureus from nose and throat of patients on admission to medical wards of dr soetomo hospital, surabaya, indonesia. southeast asian journal of tropical medicine and public health. 2016;47(1):66. 5. jones hw, beckles vl, akinola b, stevenson aj, harrison wj. chronic haematogenous osteomyelitis in children: an unsolved problem. the journal of bone and joint surgery. british volume. 2011 aug;93(8):1005-10. 6. mandell jc, khurana b, smith jt, czuczman gj, ghazikhanian v, smith se. osteomyelitis of the lower extremity: pathophysiology, imaging, and classification, with an emphasis on diabetic foot infection. emergency radiology. 2018 apr 1;25(2):175-88. 7. agarwal a, aggarwal an. bone and joint infections in children: acute hematogenous osteomyelitis. the indian journal of pediatrics. 2016 aug 1;83(8):817-24. 8. lee yj, sadigh s, mankad k, kapse n, rajeswaran g. the imaging of osteomyelitis. quantitative imaging in medicine and surgery. 2016 apr;6 (2):184. 9. desimpel j, posadzy m, vanhoenacker f. the many faces of osteomyelitis: a pictorial review. journal of the belgian society of radiology. 2017;101(1). 10. schmitt sk. osteomyelitis. infectious disease clinics. 2017 jun 1;31(2):325-38. 6_mhsj-ok 39 pada hubungan antara persepsi, jenis kelamin, status tempat tinggal, status orang tua dengan perilaku penyalahgunaaan napza pada kelas xi di smk darul huda sidoarjo erika martining wardani 1, yurike septianingrum2 1,2prodi s1 keperawatan fakultas keperawatan, universitas nahdlatul ulama surabaya e-mail: : erika@unusa.ac.id1 abstract: adolescence signify of transition from childhood to adulthood is easy to having psychology and behavior problems, such as learning difficulty, anxiety, and drug addiction. school children as vulnerable group in drugs abuse behavior. the impact of drug abuse particularly alternately needle use get risk infection disease such as hepatitis b, c, and hiv. the objective of this research to examines the correlation between perception, sex, domicile status, parent status with drugs abuse behavior. this study used cross sectional analytical design with simple random sampling technique. population of the research are students of 155 individuals, sample with 50 respondents. data analysis employed chi square test. the result indicates that 83,7% having drugs abuse behavior with statistic test found there are no correlation between perception (� value = 0,826) and drugs abuse behavior, and found correlation between sex (� value = 0,001), domicile status relationship (� value = 0,001),parent status relationship (� value = 0,025), with drugs abuse behavior. good communication among family members able to providing protection to child in order to avoid from drugs abuse. good perception about drugs, stay with complete parents and in harmony has correlation to drugs abuse prevention. keywords: behavior, drugs, adolescence abstrak: remaja merupakan masa peralihan dari masa anak ke dewasa yang mudah mengalami masalah psikologi dan perilaku, seperti kesulitan belajar, kecemasan, dan ketergantungan napza. anak sekolah merupakan kelompok yang rentan dalam melakukan perilaku penyalahgunaan napza. dampak penyalahgunaan napza khususnya pemakaian jarum suntik secara bergantian berisiko tertular hepatitis b, c, dan hiv. tujuan penelitian untuk mengetahui hubungan antara persepsi, jenis kelamin, status tempat tinggal, status orang tua dengan perilaku penyalahgunaaan napza. penelitian ini menggunakan desain analitik cross sectional dengan teknik simple random sampling. populasi dalam penelitian adalah semua siswa-siswi yang berjumlah 155 orang, sampel sebanyak 50 orang. analisis data menggunakan uji chi square. hasil penelitian menunjukkan bahwa 83,7% memiliki perilaku penyalahgunaan napza dengan uji statistik menunjukkan bahwa tidak terdapat hubungan antara persepsi (ρ value=0,826) dengan perilaku penyalahgunaan napza, dan terdapat hubungan antara jenis kelamin (ρ value=0,001), terdapat hubungan status tempat tinggal (ρ value =0,001), terdapat hubungan status orang tua (ρ value =0,025), dengan perilaku penyalahgunaan napza. komunikasi yang baik antar anggota keluarga mampu memberikan proteksi pada anak agar terhindar dari penyalahgunaan napza. persepsi yang baik tentang napza, tinggal bersama orang tua yang utuh dan harmonis berhubungan dengan pencegahan penyalahgunaan napza. kata kunci: perilaku, napza, remaja pendahuluan peredaran napza (narkotika, alkohol, psikotropika, zat aditif lainnya) pada masyarakat masyarakat indonesia terasa sangat memprihatinkan. peredaran napza sampai ke segala lapisan masyarakat, dari yang berstatus sosial tinggi sampai rendah, dari yang usia belasan tahun sampai usia puluhan tahun, dari yang siswa sekolah dasar sampai mahasiswa yang ada di perguruan tinggi, dari anak jalanan sampai anak anak yang setia dengan keluarga, tidak peduli medical and health science journal, vol. 2, no. 2, august 2018 40 putra atau putri, pria atau wanita yang ada di kota maupun di desa (bnn, 2016). studi yang dilakukan diseluruh dunia sesuai data united nation office on drugs and crime (2012), menunjukkan bahwa terdapat kurang dari 10% dari penduduk pada usia remaja umumnya menggunakan napza. berdasarkan data badan narkotika nasional (bnn), pengguna narkoba mencapai 2,56 % pada tahun 2013 dengan rentang usia 10-59 tahun. menurut data bnn tahun 2015 diperoleh data dari 4,9 juta pengguna narkoba di indonesia, 400 ribu diantaranya berada di jawa timur dengan status peringkat pertama sebagai provinsi dengan jumlah pengguna narkoba terbanyak di indonesia. penyalahgunaan narkotika di sidoarjo tahun 2016 makin memprihatinkan bahkan pengguna tersebut lebih didominasi oleh kalangan remaja yaitu sebanyak 70 %. faktor faktor penyebab penyalahgunaan napza yang pertama berasal dari faktor individu seperti pengetahuan, sikap, kepribadian, jenis kelamin, usia, dorongan kenikmatan, perasaan ingin tahu, dan untuk memecahkan persoalan yang sedang dihadapi. faktor kedua berasal dari lingkungannya seperti pekerjaan, ketidakharmonisan keluarga, status ekonomi, dan kelompok teman sebaya (badri m, 2013 dalam sholihah, 2013). menurut hawari (2009), dampak penyalahgunaan napza khususnya pemakaian jarum suntik secara bergantian berisiko tertular hepatitis b, c, dan hiv. upaya meminimalkan penyalahgunaan napza pada remaja yang paling efektif yang bisa dilakukan oleh tenaga kesehatan adalah pemberian pendidikan kesehatan terutama tentang napza (sumiati, et all, 2009). tujuan penelitian ini adalah untuk mengetahui hubungan antara persepsi, jenis kelamin, status tempat tinggal, status orang tua dengan perilaku penyalahgunaaan napza pada kelas xi di smk darul huda sidoarjo. bahan dan metode penelitian ini menggunakan rancangan analitik cross sectional. populasi dalam penelitian ini adalah semua siswa-siswi kelas xi di smk darul huda sidoarjo yang berjumlah 155 orang. pengambilan sampel menggunakan teknik simple random sampling berjumlah 50 orang. variabel independen dalam penelitian ini adalah persepsi, jenis kelamin, status tempat tinggal, status orang tua. variabel dependen adalah perilaku penyalahgunaan napza. instrumen penelitian menggunakan kuesioner. pengumpulan data dilakukan pada juni sampai juli 2017 diawali dengan pengurusan perijinan sesuai dengan prosedur yang telah ditetapkan. selanjutnya calon responden diberikan informasi terkait penelitian yang akan dilakukan dan responden yang bersedia dilakukan penelitian menandatangani lembar persetujuan menjadi responden (informed consent). setelah data terkumpul kemudian dilakukan uji statistik chi square. hasil 1) usia tabel 1 distribusi responden berdasarkan usia variabel mean standar deviasi nilai mak-min umur 16 .621 15-16 berdasarkan tabel 1 menunjukkan bahwa rata-rata usia responden 16 tahun, standar deviasi 0,621 tahun dan usia terendah responden 14 tahun dan usia tertua responden 17 tahun. 2) jenis kelamin tabel 2 distribusi responden berdasarkan usia no. jenis kelamin jumlah (n) persenta se (%) erika martining wardani, yurike septianingrum, pada hubungan antara persepsi, jenis kelamin status tempat tinggal, status orang tua dengan perilaku penyalahgunaaan napza pada kelas xi di smk darul huda sidoarjo 41 1 laki-laki 46 93,9 2 perempuan 3 6,1 total 49 100 tabel diatas menunjukan bahwa, jenis kelamin terbanyak yaitu laki-laki sebanyak 46 responden (93,9%). 3) persepsi tabel 3 distribusi responden berdasarkan persepsi no. persepsi jumlah (n) persen tase (%) 1 kurang 21 42,9 2 cukup 28 57,1 total 49 100 tabel 3 menunjukan bahwa dari 49 responden yang mempunyai persepsi kurang tentang napza sebanyak 21 responden (42,9%) dan persepsi cukup tentang napza sebanyak 28 responden (57,1%). 4) status tempat tinggal tabel 4 distribusi responden berdasarkan tempat tinggal berdasarkan tabel 4 menunjukan bahwa dari 49 responden yang tinggal dengan selain orang tua/ kost sebanyak 27 responden (55,1%). 5) status orangtua tabel 5 distribusi responden berdasarkan status orangtua berdasarkan tabel 5 menunjukan bahwa dari 49 responden yang mempunyai status orang tua broken home sebanyak 28 responden (57,1%) dan status orang tua harmonis sedang sebanyak 21 responden (42,9%). 6) hubungan jenis kelamin dengan perilaku penyalahgunaan napza tabel 6 hubungan jenis kelamin dengan perilaku penyalahgunaan napza no. tempat tinggal jumlah (n) persentase (%) 1 kost 27 55,1 2 dgn ortu 22 44,9 total 49 100 no. status ortu jumlah (n) persentase (%) 1 broken home 28 57,1 2 harmonis 21 42,9 total 49 100 no jenis kelamin perilaku penyalahgunaan jumlah ρvalue ya tidak n % n % n % 0,001 1 laki-laki 40 87 6 13 46 100 2 perempuan 1 33,3 2 66,7 3 100 total 41 83,7 8 32,7 49 100 medical and health science journal, vol. 2, no. 2, august 2018 42 berdasarkan hasil uji statistik dengan chi square diperoleh ρvalue= 0,001, dapat dimaknai bahwa ada hubungan jenis kelamin dengan perilaku penyalahgunaan napza pada kelas xi di smk darul huda sidoarjo. 7) hubungan persepsi dengan perilaku penyalahgunaan napza tabel 7 hubungan persepsi dengan perilaku penyalahgunaan napza berdasarkan hasil uji statistik dengan chi square diperoleh ρvalue (0,826), dapat dimaknai bahwa tidak ada hubungan antara persepsi dengan perilaku penyalahgunaan napza pada kelas xi di smk darul huda sidoarjo. 8) hubungan status tempat tinggal dengan perilaku penyalahgunaan napza tabel 8 hubungan status tempat tinggal dengan perilaku penyalahgunaan berdasarkan hasil uji statistik dengan chi square diperoleh ρvalue= 0,001, dapat dimaknai bahwa ada hubungan status tempat tinggal dengan perilaku penyalahgunaan napza pada kelas xi di smk darul huda sidoarjo. 9) hubungan status orang tua dengan perilaku penyalahgunaan napza tabel 9 hubungan status orang tua dengan perilaku penyalahgunaan no persepsi tentang napza perilaku penyalahgunaan jumlah ρvalue ya tidak n % n % n % 0,826 1 kurang 15 71,4 6 28,6 21 100 2 cukup 18 64,3 10 35,7 28 100 total 33 67,3 16 32,7 49 100 no status tempat tinggal perilaku penyalahgunaan jumlah ρvalue ya tidak n % n % n % 0,001 1 kost 24 88,9 3 11,1 27 100 2 orang tua 9 40,9 13 59,1 22 100 total 33 67,3 16 32,7 49 100 no status orang tua perilaku penyalahgunaan jumlah ρvalue ya tidak n % n % n % 0,025 1 broken home 23 82,1 5 17,9 28 100 2 harmonis 10 47,6 11 52,4 21 100 total 33 67,3 16 32,7 49 100 erika martining wardani, yurike septianingrum, pada hubungan antara persepsi, jenis kelamin status tempat tinggal, status orang tua dengan perilaku penyalahgunaaan napza pada kelas xi di smk darul huda sidoarjo 43 berdasarkan hasil uji statistik dengan chi square diperoleh ρvalue = 0,025, dapat dimaknai bahwa ada hubungan antara status orang tua dengan perilaku penyalahgunaan napza pada kelas xi di smk darul huda sidoarjo. pembahasan 1) hubungan jenis kelamin tentang napza dengan perilaku penyalahgunaan napza perilaku penyalahgunaan napza pada remaja ditinjau dari jenis kelamin. remaja yang berjenis kelamin laki-laki dan perempuan memliki perbedaan yang signifikan. berdasarkan hasil uji statistik dengan chi square diperoleh nilai ρvalue= 0,001. dengan tingkat kepercayaan 95% (α = 0,05). sesuai dengan dasar pengambilan keputusan penelitian hipotesis bahwa jika ρvalue (0,001) < 0,05 maka h0 ditolak atau h1 diterima sehingga dapat dimaknai bahwa ada hubungan jenis kelamin dengan perilaku penyalahgunaan napza pada kelas xi di smk darul huda sidoarjo. selanjutnya dari uji keeratan hubungan di peroleh nilai phi ø sebesar 0,509 yang berarti hubungan antara jenis kelamin dengan perilaku penyalahgunaan napza pada kelas xi mempunyai kategori hubungan sedang. hasil ini sesuai dengan teori yang dikemukakan oleh afandi, dkk (2009), faktor penyalahgunaan napza salah satunya dipengaruhi oleh jenis kelamin. hal senada diungkapkan pula oleh ruminiati (2010) bahwa remaja laki-laki lebih ambisius dan memiliki tingkat agresi yang lebih tinggi dibandingkan dengan remaja perempuan. afandi (2009) juga menegaskan bahwa jenis kelamin laki-laki lebih berisiko terhadap penyalahgunaan napza. diperkuat oleh pendapat yang dikemukakan oleh kartono (2010) bahwa salah satu faktor yang memengaruhi kenakalan pada remaja adalah jenis kelamin. hawari (2009) menyatakan bahwa pada masyarakat jawa dan sunda, dalam sudut pandang orangtua serta masyarakat umum menjadi hal yang wajar ketika anak laki-laki melakukan kesalahan dan kenakalan, berbeda dengan anak perempuan yang diharuskan untuk lebih banyak berdiam di dalam rumah dan tidak ditolerir untuk melakukan hal-hal seperti yang dilakukan oleh anak laki-laki seperti kenakalan. menurut erikson (santrock, 2002), bahwa laki-laki dan perempuan memiliki kepribadian yang berbeda dimana hal tersebut dipengaruhi oleh struktur jenis kelamin. laki-laki lebih suka mengganggu dan agresif, sedangkan perempuan lebih inklusif dan pasif sehingga laki-laki lebih banyak mengalami permasalahan dengan lingkungan sosialnya. dengan demikian maka hipotesis yang diajukan peneliti diterima. 2) hubungan persepsi tentang napza dengan perilaku penyalahgunaan napza persepsi adalah proses pengorganisasian, penginterpretasian terhadap rangsang yang diterima oleh organisme atau individu sehingga merupakan sesuatu yang berarti dan merupakan aktivitas yang integrated dalam diri individu (bimo, 2001). persepsi juga dapat diartikan sebagai proses diterimanya rangsang melalui pancaindra yang didahului oleh perhatian sehingga individu mampu mengetahui, mengartikan, dan menghayati tentang hal yang diamati, baik yang ada di luar maupun dalam diri individu (sunaryo, 2004). sedangkan menurut (notoatmodjo, 2003), persepsi adalah mengenal dan memilih berbagai objek sehubungan tindakan yang akan diambil atau pengalaman yang dihasilkan melalui indera penglihatan, pendengaran, penciuman, dan sebagainya. berdasarkan hasil uji statistik dengan chi square diperoleh nilai sesuai dengan dasar pengambilan keputusan penelitian hipotesis bahwa jika ρvalue (0,826) > 0,05 maka h0 diterima atau h1 ditolak sehingga dapat dimaknai bahwa tidak ada hubungan antara persepsi dengan perilaku medical and health science journal, vol. 2, no. 2, august 2018 44 penyalahgunaan napza pada kelas xi di smk darul huda sidoarjo. menurut penelitian suwanto (2013), salah satu upaya pemberantasan narkoba melalui dna pendidikan. institut pendidikan merupakan salah satu pihak yang berkewajiban dan bertanggung jawab dalam upaya pencegahan penyalahgunaan narkoba di kalangan remaja. namun pada penelitian rosdiana (2013) menyatakan bahwa tidak ada hubungan signifikan antara pengetahuan dengan sumber informasi yang diperoleh dengan nilai p = 0,478 (ρ > 0,005). peneliti berpendapat bahwa sumber informasi yang mempengaruhi persepsi responden dikarenakan tidak adanya penghayatan dan rasa keingintahuan responden terhadap suatu informasi yang diterimanya. 3) hubungan status tempat tinggal dengan perilaku penyalahgunaan napza perilaku penyalahgunaan napza pada remaja ditinjau dari status tinggal. remaja yang tinggal bersama orangtua, bersama sanak saudara maupun tinggal di kost atau kontrak rumah sendiri memliki perbedaan yang signifikan. berdasarkan hasil uji statistik dengan chi square diperoleh nilai ρvalue= 0,001. dengan tingkat kepercayaan 95% (α = 0,05). sesuai dengan dasar pengambilan keputusan penelitian hipotesis bahwa jika ρvalue (0,001) < 0,05 maka h0 ditolak atau h1 diterima sehingga dapat dimaknai bahwa ada hubungan status tempat tinggal dengan perilaku penyalahgunaan napza . hasil analisa ini sesuai dengan pendapat yang dinyatakan oleh afandi, dkk (2009) yang melaporkan bahwa remaja/ siswa yang tidak tinggal bersama orang tua (kost/ sewa/ saudara) lebih berisiko untuk terjerumus dalam penyalahgunaan napza. hal serupa diungkapkan oleh carlson, 2006 (dalam papalia, 2014) bahwa remaja yang tinggal bersama orang tua yang utuh cenderung memiliki masalah perilaku yang lebih sedikit daripada remaja dengan status tinggal orang tua tunggal, keluarga tanpa pernikahan, atau keluarga tiri. remaja yang tinggal bersama orangtua, sanak saudara, atau kost/ sewa sama-sama memiliki risiko penyalahgunaan napza. walaupun banyak teori dan penelitian lain yang menyebutkan bahwa remaja yang tinggal tidak bersama orangtua lebih cenderung melakukan kenakalan dan penyalahgunaan napza akan tetapi perlu dilihat bahwa keluarga yang memiliki intensitas komunikasi yang intim akan berpengaruh pada pembentukan kepribadian dan karakter anak. 4) hubungan status orang tua dengan perilaku penyalahgunaan napza serupa dengan penyebab penyalahgunaan napza pada remaja dengan status tinggal, penyalahgunaan napza pada remaja dengan status orangtua utuh maupun tunggal juga memiliki perbedaan yang signifikan. berdasarkan hasil uji statistik dengan chi square diperoleh nilai ρvalue= 0,025. dengan tingkat kepercayaan 95% (α = 0,05). sesuai dengan dasar pengambilan keputusan penelitian hipotesis bahwa jika ρvalue (0,025) < 0,05 maka h0 ditolak atau h1 diterima sehingga dapat dimaknai bahwa ada hubungan antara status orang tua dengan perilaku penyalahgunaan napza. hal ini dapat diartikan bahwa ada perbedaan risiko penyalahgunaan napza pada subjek dengan orangtua utuh maupun dengan status orangtua tunggal/ broken home. hasil analisa ini sesuai dengan teori yang dicetuskan oleh hawari (2009) yang menyebutkan bahwa salah satu faktor remaja melakukan penyalahgunaan napza adalah keutuhan keluarga dimana remaja dengan status orangtua tunggal baik karena bercerai maupun karena meninggal lebih cenderung melakukan penyalahgunaan napza itu sendiri. grudem, (1996) dan sun, (2001) dalam papalia, (2014) menyebutkan bahwa remaja dengan status orangtua yang bercerai erika martining wardani, yurike septianingrum, pada hubungan antara persepsi, jenis kelamin status tempat tinggal, status orang tua dengan perilaku penyalahgunaaan napza pada kelas xi di smk darul huda sidoarjo 45 menunjukkan masalah multidimensional seperti masalah akademis, psikologis, dan permasalahan perilaku menyimpang lainya. silalahi & santoso (2000) juga menyebutkan bahwa anak dengan korban perceraian menimbulkan permasalahan kurang percaya diri, kurang sukses di pendidikan dan pergaulan, pemarah, suka mencela diri sendiri, selalu menyembunyikan perasaannya dan mudah frustasi. pada penelitian ini dapat dinyatakan bahwa status orangtua tidak dapat menentukan seseorang lebih berisiko terhadap penyalahgunaan napza, hasil rerata menunjukkan bahwa remaja dengan status orangtua tunggal memiliki risiko yang lebih rendah sehingga orangtua tunggal juga mampu memberikan pengasuhan yang baik sehingga dapat menghindarkan remaja dari risiko penyalahgunaan napza. secara umum, orangtua tunggal mengalami hal-hal yang negatif dan dipandang oleh lingkungan sosialnya sebagai hal yang negatif pula sehingga seringkali memberi dampak yang kurang baik pada perkembangan anak. menurut rimm (dalam nurjanah, 2015) orangtua tunggal juga memiliki kesempatan untuk membentuk kondisi pengasuhan yang baik dan ideal dengan syarat (1) memiliki karir yang jelas (2) terdapat orangtua kedua untuk mendukung orangtua tunggal (3) tersedia pengasuhan anak yang teratur dan dapat diandalkan (4) orangtua diharuskan mampu dalam mempertahankan hidup sosial yang positif. hawari (2009) menyebutkan bahwa kesibukan orangtua dan hubungan interpersonal antar anggota keluarga sebagai salah satu faktor yang berkontribusi pada risiko penyalahgunaan napza pada remaja. artinya, walaupun remaja dengan pengasuhan orangtua tunggal akan tetapi memiliki hubungan serta komunikasi yang baik antar anggotanya maka hal tersebut mampu memberikan proteksi pada anak untuk terhindar dari penyalahgunaan napza. kesibukan orangtua juga ikut berpengaruh dan sebaiknya menjadi perhatian, remaja dengan kesibukan orangtua yang padat akan tetapi mampu menyediakan waktu dan memiliki komunikasi yang positif seperti yang dijelaskan di atas maka penyalahgunaan napza pada remaja dapat ditekan. hal demikian berlaku sebaliknya, pada remaja yang memiliki orangtua utuh akan tetapi anak tidak mendapatkan perhatian yang dibutuhkan karena kesibukan orangtua dan secara otomatis tidak terjalinnya komunikasi yang baik di antara anggota keluarga, hal tersebut dapat memicu anak untuk melakukan penyalahgunaan napza. kesimpulan dan saran sebagian besar senyawa da menghasilkan efek multipel yang mengakibatkan penurunan melanisasi. kesimpulan 1) rata – rata usia responden 16 tahun. 2) jenis kelamin terbanyak adalah laki-laki. 3) ada hubungan antara jenis kelamin, status tempat tinggal dan status orangtua dengan perilaku penyalahgunaan napza 4) tidak ada antara hubungan antara persepsi dengan perilaku penyalahgunaan napza. saran diharapkan kepada tenaga kesehatan terutama yang berada di fasilitas kesehatan terdekat dengan sekolah dapat memberikan tindakan preventif berupa health education kepada remaja terutama mengenai napza beserta dampak penyalahgunaan napza serta memberikan fasilitas kesehatan yang memadai sehingga remaja mudah mengakses informasi terkait napza. medical and health science journal, vol. 2, no. 2, august 2018 46 daftar pustaka agustiani, h. (2006). psikologi perkembangan pendekatan ekologi kaitannya dengan konsep diri dan penyesuaian diri pada remaja. bandung : pt. refika aditama. arikunto, s. (2006) prosedur penelitian suatu pendekatan praktek.rineka cipta. jakarta. azwar, s. (2009). sikap manusia teori dan pengukurannya edisi ke 2. yogyakarta : pustaka belajar. bungin, burhan. (2007). metode penelitian kualitatif, rajawali pers, jakarta. bnn, 2016. kumpulan hasil penelitian badan narkotika nasional pada tahun 2016. jakarta timur : badan narkotika nasional republik indonesia departemen kesehatan (2003). pelayanan kesehatan peduli remaja (pkpr). jakarta : direktorat kesehatan keluarga. frihartine, 2013. factor-faktor yang mempengaruhi perilaku merokok pada siswa laki-laki disekolah menengah atas negeri 1 banda aceh tahun 2013. program studi d-iv kebidanan sekolah tinggi ilmu kesehatan u’budiyah banda aceh. hawari, d. (2008). terapi (detoksifikasi) narkoba/ naza&hiv/ aids. jakarta : balai penerbit fkui. (2009). penyalahgunaan & ketergantungan naza. jakarta : balai penerbit fkui kartono, kartini. 2010. kenakalan remaja. jakarta. pt. raja grafindo persada. rajawali pers. medical and health science journal 2023 february, vol 07 (01) medical and health science journal available at http://journal2.unusa.ac.id/index.php/mhsj; doi: 10.33086/mhsj.v7i1.3653 pissn 2549-7588. eissn 2549-7596 case report traumatic diaphragmatic rupture with visceral herniation: a case report widia trilaksana kusuma*, wayan sindhu, yudha prasista department of surgery, mangusada general hospital, badung, bali, indonesia *corresponding author: widia trilaksana kusuma okatrilaksanaa@yahoo.com article info article history: received: december 6, 2023 received in revised form: february 20, 2023 accepted: march 03, 2023 keywords: diaphragm rupture, herniation abstract background: the diaphragm is a dome-shaped respiratory muscle located near the lower ribs; the exact location is below the chest. diaphragmatic rupture is a medical condition caused by blunt or penetrate trauma, which often leads to herniation of the abdominal viscera into the thoracic cavity. case: we presented a case in which a 39-year-old man complained of left chest pain and abdominal pain radiated to his back, after involved in a traffic accident. on physical examination, the left chest was left behind when breathing, a dull sound was found on percussion, with diffuse abdominal tenderness. thoracal abdomen ct-scan was performed, and it concluded that there was a rupture of the left posterior diaphragm with a diameter of 15 cm which caused herniation of the gastric and intestines to the left of thoracic cavity, accompanied by a collapse of the left lung due to blunt trauma. the patient underwent an explore laparotomy with the aim of repairing his diaphragmatic rupture, and splenectomy procedure to remove the affected spleen. conclusion: surgery is a mandatory action in order to repair the diaphragm. the choice of the approach to be used, either laparotomy or thoracotomy depends on other organ abnormalities, acute or latent cases, stable or unstable condition of the patient and depends on the experience of the operator. medical and health science journal introduction background diaphragmatic rupture is a medical condition caused by blunt or penetrating trauma and often results in herniation of the abdominal viscera into the thoracic cavity (1). the diaphragm develops from the pleuroperitoneal membrane and body wall, the dorsal mesentery of the oesophagus and the septum transversum from the embryo (2). traumatic diaphragmatic injury (tdi) occurs in 1% of patients of blunt abdominal trauma (3). the incidence of trauma-induced diaphragmatic rupture is 1 to 7% of all patients with blunt trauma, and 10-15% with http://journal2.unusa.ac.id/index.php/mhsj saini et al medical and health science journal 2023 february vol.07 (01) page 55 of 60 penetrating injuries. diaphragmatic rupture due to trauma is usually associated with multiple injuries because of the large forces resulting rupture of the diaphragm (1)(4). acute diaphragm injuries are best approached through the abdomen (5). the pathophysiology of this injury remains unclear up to this date, but the most accepted hypothesis has described, an increase of intra-abdominal pressure followed by a blunt trauma mechanism which creates a highpressure gradient between chest and abdomen can cause visceral intrathoracic rupture and herniation.(6)(7) normally, there is a positive gradient of 7–20 cmh2o between intraperitoneal and intrapleural pressures, but during blunt injuries this pressure gradient can exceed 100 cmh2o and this can lead to rupture and herniation (8)(7). the physical examination often fails to identify a traumatic diaphragmatic rupture and basic investigations such as a chest x-ray may miss half the time. although not part of the standard fast (focused assessment with sonography for trauma) ultrasound scan in trauma, bedside ultrasound has the potential to detect pathology of a ruptured diaphragm (9). there are no specific signs and symptoms to diagnose a diaphragmatic rupture. a high level of clinical suspicion is required in all cases of thoraco-abdominal injury to diagnose diaphragmatic rupture. computed tomography (ct) of the chest and abdomen is very useful in the diagnosis of this patient case. if there is any doubt, diagnostic laparoscopy should be performed to confirm the diagnosis to reduce mortality and morbidity (10). diagnostic techniques included x-ray, computed tomography, and intraoperative findings. clinical diagnosis is relatively difficult because the signs found are like other disorders. the signs and symptoms that appear are pain in the chest and abdomen, also respiratory problems. when rupture is found, an operation is required to repair it (11). the best management for patients with diaphragmatic rupture is surgery. no cases of diaphragmatic rupture have been found to heal spontaneously. this happens because of the difference in pressure between the abdominal cavity and the thoracic cavity, causing a slight rupture of the diaphragm, herniation of the abdominal organs will occur into the thoracic cavity.(12) surgery can be performed either through the thorax (thoracotomy) or abdomen (laparotomy). there are no studies on which type of surgery is considered the best course of action for patients with diaphragmatic rupture, to date (2). a case report presents a patient with a visceral herniation, detected 5 years after pneumonectomy for non-small cell lung cancer surgery with a diaphragmatic muscle flap supported on the bronchial stump. the patient underwent emergency thoraco-laparotomy 9 years after the first operation due to acute abdominal symptoms. this is the first reported case of a late period visceral disc herniation that improved after surgery (13). figure 1. whole-body non-contrast ct scan (scout view): detection of left-sided posterior diaphragmatic hernia involving visceral herniation and hemothorax. saini et al medical and health science journal 2023 february vol.07 (01) page 56 of 60 case presentation a 39-year-old man admitted to hospital accompanied by his family, he complained pain in his left chest and abdominal pain that radiated to his back after experiencing a traffic accident one hour ago. the patient said that he had driven a motorcycle and hit the car in front of him, then fell to the left, the patient was not wearing a helmet. the patient came with gcs 15 consciousness, respiratory rate 20 breaths per minute and blood pressure 113/70 mmhg. on physical examination, it was found that the left chest was left behind when breathing, a dull sound was obtained on percussion, with diffuse abdominal tenderness, but no signs of peritonitis were found. from the results of the plain chest x-ray, it was found that the left hemithorax was covered with elevation of the diaphragm with 7,8,9 rib fractures. focused assessment with ct-scan thoracoabdominal and concluded that there was a rupture of the left posterior diaphragm with a diameter of 15 cm which caused herniation of the gastric and intestines into the left thoracic cavity with collapse of the left lung due to blunt trauma due to a traffic accident. the patient also suffered several other traumatic injuries, including multiple left rib fractures, left hemothorax, left lower lobe pulmonary contusion, and 5th degree of splenic laceration. figure 2. ct scan showed diaphragmatic rupture and intrathoracic bowel herniation. the patient had undergone an exploratory laparotomy to repair the ruptured diaphragm and had a splenectomy procedure performed to remove the damaged spleen. intraoperatively, the stomach and intestines were returned to the abdominal cavity and the diaphragm was sutured with interrupted sutures using non-absorbable sutures on the ruptured side of the diaphragm on the left posteriorly. no gastric ischemia or perforation was found. all the intra-abdominal organs and the left lung were intact. the operation was carried out for 3 hours. the patient was placed on a chest tube with left intrapleural water sealed drainage (wsd) and an intra-abdominal drain on the left sub diaphragm. the patient eventually recovered and was discharged after 2 weeks of hospitalization. at 2 weeks after follow-up the patient was in good condition. discussion the diaphragm is a dome-shaped respiratory muscle located near the bottom of saini et al medical and health science journal 2023 february vol.07 (01) page 57 of 60 the rib cage, just below the chest (4). the actual incidence of diaphragmatic rupture is difficult to ascertain because the diagnosis is usually missed and delayed, ranging from 1 to 7% of all blunt trauma patients, and 10 -15% with penetrating injuries, and this number is expected to increase due to the increasing number of traffic accidents each year. the most common causes of blunt injuries are highspeed traffic accidents and penetrating injuries are knife attacks and gunshot wounds (1). penetrating or blunt trauma to the chest and abdomen can cause diaphragmatic rupture, is usually associated with multiple injuries because great force is required to rupture the diaphragm and is usually fatal. a high index of clinical suspicion is necessary to diagnose and effectively manage diaphragmatic rupture even with a distant history of high-velocity injury. this is especially the case when there are other signs of severe trauma such as multiple rib fractures, lacerations of the liver and spleen, or a history of deceleration injuries (14). a significant complication of diaphragmatic rupture is a traumatic diaphragmatic hernia; organs such as the stomach that enter the thoracic cavity can become strangled and cause ischemic herniation of the abdominal organs which occurs in 3-4% of abdominal trauma patients presenting to the trauma center (15).the most frequently herniated organs on the left side are the stomach (80%), omentum, small intestine, large intestine, and spleen (1). this is because these organs are structurally weak because they are pleuroperitoneal membranes. diaphragmatic rupture on the left is more common than on the right because of the protective effect of the liver, underdiagnosis of right hemidiaphragm rupture and weak location of the left hemidiaphragm due to embryonic fusion (2). 4 diaphragmatic rupture following blunt trauma generally results in a wider wound than that caused by penetrating trauma has a size of about 5-15 cm. initially most cases of diaphragmatic rupture are often overlooked especially in the acute phase because of other associated injuries. diagnosing diaphragmatic rupture is often difficult to establish and easily missed due to non-specific signs and findings (11). neglected diagnosis of diaphragmatic rupture injury which eventually presents as a hernia which can appear years later with potentially fatal complications. delayed diaphragmatic rupture and diaphragmatic hernia should be considered in patients with blunt abdominal trauma and gastrointestinal or respiratory complaints, especially patients with a history of recent trauma (16). detection may be delayed if the diaphragmatic tear remains asymptomatic at the time of injury and manifests only in the presence of a hernia. delayed rupture can occur if diaphragm tissue is damaged at the time of injury but maintains a weak barrier until several days later when excessive inflammation weakens it (17). less traumatic cases and smaller diaphragmatic ruptures are associated with a delay in diagnosis. thoracoabdominal computed tomography scanning is necessary for patients with peripheric injuries to avoid delaying the diagnosis of tdh. increased awareness and understanding of diaphragmatic injuries will increase the early diagnosis rate and improve the prognosis (18). diaphragmatic rupture is usually treated by laparotomy. the most common therapeutic approaches for diaphragmatic rupture are thoracotomy or laparotomy. at laparotomy, regardless of whether the diagnosis is suspected or confirmed preoperatively, a full evaluation of both diaphragms should be carried out, and consideration should also be given to other injuries such as a haematothorax that may arise and are more urgent to treat first if there is a rupture of the diaphragm. all herniated viscera should be carefully returned and moved to their original position (1)(8). the diaphragmatic saini et al medical and health science journal 2023 february vol.07 (01) page 58 of 60 tissue is carefully repaired using nonabsorbable monofilament sutures. in some cases, complicated by adhesions and extensive defects, mesh is sometimes required to help manage the defect (4)(16). the american association for trauma surgery (aast) organ injury scaling committee proposes a classification system for diaphragmatic injuries: grade 1 contusions; grade 2 laceration <2cm; grade 3 lacerations 2–10 cm; grade 4 laceration >10 cm or with tissue loss <25 cm2; and grade 5 laceration with tissue loss >25 cm2.7,8 according to this classification system, our patient's case was a grade 4 diaphragmatic injury. treatment for an injured diaphragm is operative whether the injury is acute or chronic, the acute injury can usually be repaired first. improvement can be achieved via laparoscopy or laparotomy, depending on the hemodynamic stability of the patient and the associated injury. in the patient with chronic trauma-related diaphragmatic hernia, a careful history and physical examination may be suggestive (19). in multitrauma patients with diaphragmatic rupture as in our case, patient survival is determined by the severity of the associated injury, timely diagnosis, and early intervention (6). although diaphragmatic rupture is still difficult to diagnose in trauma patients, a high index of suspicion with the use of appropriate radiological modalities helps in arriving at a correct diagnosis. emergency surgical repair should be performed as soon as possible to reduce morbidity and mortality (20). in this regard, our patient had undergone a ct-scan with clinical evaluation as the main determining factor for deciding on exploratory surgery. ct scan is more accurate in establishing the diagnosis compared to xray, another diagnostic method that has been carried out is by laparotomy, but in 15% of cases of diaphragmatic rupture it is missed. trauma to the diaphragm is often discovered incidentally during laparotomy for other organ injuries. thoracoscopy is preferred over laparotomy especially for detecting chronic diaphragmatic hernias (11). in chronic cases, repair may be difficult or even impossible. delay in detecting and repairing diaphragmatic rupture can increase morbidity and mortality. a significant complication of diaphragmatic rupture is traumatic diaphragmatic hernia, where organs such as the gastric that have entered thoracic cavity can strangulate and cause ischemia (11)(16). recommends the collection of information that is not limited to index hospitalization and type of trauma to better determine the diagnosis of the disease (8). conclusion diaphragmatic rupture should be suspected in all trauma patients, especially if they have blunted abdominal and lumbar trauma. high suspicion with detailed information about the mechanism of injury and the use of appropriate diagnostics are the most important factors in establishing the correct early diagnosis of diaphragmatic rupture. there is a differential diagnosis of diaphragmatic rupture in adult patients with upper abdominal symptoms or chest x-ray depicting diaphragmatic elevation, therefore it is necessary to ask whether there is a history of trauma, whether it occurred a few days ago or years ago. if no abnormalities are found, serial chest x-rays and high-quality ct scans in stable patients can be performed to diagnose diaphragmatic rupture and other abnormalities in the thoracic and abdominal organs. surgery is a mandatory action to repair the affected diaphragm. the management approach can be in the form of laparotomy, thoracotomy, and laparoscopy which is determined from the acute or latent case, stable saini et al medical and health science journal 2023 february vol.07 (01) page 59 of 60 or unstable patient condition, and operator experience. in most cases, repaired diaphragmatic rupture has a good prognosis. the mortality rate is around 15-40% but the presence of other organ injuries plays a major role in determining the prognosis. conflict of interest all authors declared that there is no conflict of interest related to the publication of this article. funding the author declared did not receive a specific grant from any sources or private sector. acknowledgements thanks to all authors and hospital staff who contributed to completing this study. references 1. mindaye et, zegeye a. massive left hemothorax following left diaphragmatic and splenic rupture with visceral herniation: a case 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sa. traumatic diaphragmatic hernia. j surg. 2018;2018(01):2012–3. 20. kuppusamy a, ramanathan g, gurusamy j, ramamoorthy b, parasakthi k. delayed diagnosis of traumatic diaphragmatic rupture with herniation of the liver: a case report. ulus travma ve acil cerrahi derg. 2012;18(2):175–7. 7_mhsj-ok 47 epilepsi post trauma dengan gejala psikotik laily irfana departemen neurologi, fakultas kedokteran, universitas muhammadiyah surabaya e-mail: : irfanalaily@gmail.com abstrak: data who menunjukkan epilepsi menyerang 1% penduduk dunia. angka kejadian epilepsi masih tinggi terutama di negara berkembang yaitu mencapai 114 per 100.000 penduduk per tahun.2 pada kelompok dewasa muda, epilepsi dapat terjadi salah satunya disebabkan oleh trauma kepala.3 kasus ini melaporkan penderita laki-laki usia 24 tahun dengan keluhan kejang yang disertai dengan gejala psikotik. didapatkan riwayat pasien kejang pertama kali dua bulan setelah mengalami trauma kepala yaitu pada tahun 2003. saat itu pasien mengalami cedera otak berat dan dari ct scan kepala didapatkan perdarahan di otak. dua bulan setelah trauma kepala itu pasien mengalami kejang berulang disertai keluhan yang dominan adalah marah-marah hingga pernah sampai mau membunuh orang. dari analisis eeg menunjukkan hasil epilepsi lobus frontotemporal. setelah pasien mendapatkan pengobatan phenytoin dan risperidone, kejang mulai terkontrol. namun bila tidak minum obat pasien kejang lagi. hal ini dialami oleh pasien hingga saat kasus ini dilaporkan, yaitu sepuluh tahun post trauma. kata kunci: epilepsi post trauma, psychotic epilepsy pendahuluan epilepsi merupakan salah satu penyakit neurologis yang sering ditemukan. data who menunjukkan epilepsi menyerang 1% penduduk dunia. epilepsi dapat terjadi pada siapa saja di seluruh dunia tanpa batasan ras dan sosial ekonomi. angka kejadian epilepsi masih tinggi terutama di negara berkembang yaitu mencapai 114 per 100.000 penduduk per tahun. prevalensi epilepsi pada bayi dan anak-anak cukup tinggi, menurun pada dewasa muda dan pertengahan, kemudian meningkat lagi pada kelompok usia lanjut yang disebabkan oleh penyakit serebrovaskuler.2 pada kelompok dewasa muda, epilepsi dapat terjadi akibat trauma, neoplasma, gangguan vaskuler, maupun penggunaan alkohol dan obat-obat sedatif lain.3 epilepsi secara garis besar dapat digolongkan menjadi epilepsi idiopatik, kriptogenik, dan simtomatik. epilepsi pasca trauma termasuk dalam epilepsi simtomatik. merupakan sekuel dari trauma kepala yang paling sering terjadi, dengan insiden 5% pada penderita dengan trauma kepala tertutup dan 50% pada penderita dengan fraktur tulang tengkorak dan jejas pada otak.4 tipe kejang pada eplepsi pasca trauma dapat berbeda-beda bergantung pada lesi yang diakibatkan oleh trauma tersebut. tinjauan pustaka definisi epilepsi epilepsi adalah suatu keadaan yang ditandai oleh bangkitan epilepsi berulang berselang lebih dari 24 jam yang timbul tanpa provokasi. yang dimaksud dengan bangkitan epilepsi adalah manifestasi klinik yang disebabkan oleh aktivitas listrik otak yang abnormal dan berlebihan dari sekelompok neuron. manifestasi klinik ini terjadi secara tiba-tiba dan sementara berupa perubahan perilaku yang stereotipik, dapat menimbulkan gangguan kesadaran, gangguan motorik, sensorik, otonom, ataupun psikik.1 etiologi epilepsi etiologi epilepsi dapat dibagi ke dalam 3 kategori, yaitu: medical and health science journal, vol. 2, no. 2, august 2018 48 1. idiopatik: tidak terdapat lesi struktural di otak atau defisit neurologik. diperkirakan mempunyai predisposisi genetik dan umumnya berhubungan dengan usia. 2. kriptogenik: dianggap simtomatik tetapi penyebabnya belum diketahui. gambaran klinik sesuai dengan ensefalopati difus 3. simtomatik : bangkitan epilepsi disebabkan oleh kelainan/lesi struktural pada otak, misalnya cedera kepala, infeksi ssp, kelainan kongenital, lesi desak ruang, gangguan peredaran darah otak, toksik (alkohol, obat), metabolik, kelainan degeneratif.1 klasifikasi klasifikasi yang ditetapkan oleh international league against epilepsy (ilae) terdiri dari 2 jenis klasifikasi, yaitu klasifikasi untuk jenis bangkitan epilepsi (ilae 1981), dan klasifikasi untuk sindrom epilepsi (ilae 1989). pada bangkitan umum, manifestasi klinis dan eeg mengindikasikan adanya keterlibatan korteks serebri bilateral dan difus pada awal onset. pada bangkitan fokal, manifestasi klinis merupakan manifestasi dari lesi fokal yang tampak pada abnormalitas eeg.1 hemisferium serebri dibagi menjadi lobus frontalis, lobus parietalis, lobus okipitalis, lobus temporalis. berbagai penelitian menyebutkan bahwa psikotik epilepsi merupakan lesi yang terjadi pada lobus temporalis dan lobus frontalis.4 lobus temporalis berfungsi untuk memproses input auditori, mengenali objek visual, ditambah dengan fungsi amigdala, yaitu afeksi (emosi) pada input sensori dan memori. pada lobus temporalis terdapat daerah fungsional sebagai berikut:4 a. korteks area auditorus primer merupakan area brodman 41 dan 42, terdapat dalam insula (girus heschl). korniokorteks area pendengaran ini menerima impuls pendengaran dari korpus genikulatum mediale melalui radiasio akustik yang berjalan melalui pars sublentikularis krus posterior kapsula interna. pada hemisfer dominan, girus temporalis superior pars posterior (area 22) dan girus angular (area 39) penting untuk fungsi pendengaran bahasa bicara dan tulisan. sedangkan hemisfer nondominan berperan dalam pendengaran suara, irama dan musik. (8,12) b. korteks area olfaktorik primer bagian anterior uncus merupakan bagian korteks area olafktorik primer terpenting. daerah yang lain meliputi kroteks prepiriformis (anterior 28) dan substansia perforata anterior. rhinensefalon dalam arti lebih terbatas meliputi bagian susunan saraf yang menerima serat-serat dari bulbus olfaktorius sehingga mencakup traktus olfaktorius, striae olfaktorius bagian tertentu korpus amygdaloid, uncus, korteks prepiriformis dan substansia perforata anterior. c. visual pathways area visual ekstratriata melintas disebelah dalam dari lobus temporalis sekitar krus posterior ventrikel lateralis. d. girus temporalis inferior dan medial. berperan dalam kegiatan belajar dan memori. seperti diketahui belajar adalah suatu proses untuk mendapatkan pengetahuan tentang dunia yang dipengaruhi oleh pengalaman, sedangkan memori adalah simpanan informasi yang dapat dipanggil kembali.4 kejang parsial kompleks (kejang psikomotor, kejang lobus temporal) karakteristik dari bangkitan tipe ini adalah adanya: 1. aura, terdapat pada awal bangkitan, dapat berupa halusinasi, ilusi. 2. hilangnya kontrol pikiran dan tindakan, terdapat periode perubahan perilaku dan kesadaran, yang setelahnya penderita mengalami amnesia.3 laily irfana, epilepsi post trauma dengan gejala psikotik 49 halusinasi pada penderita bangkitan tipe ini pada umumnya adalah halusinasi visual dan auditorik, terdiri dari gambaran visual yang jelas maupun tidak, suara-suara, gangguan pengecapan, vertigo, dan yang paling jarang adalah halusinasi bau. terdapat juga gejala diskognitif berupa déjà vu, jamais vu, atau rasa depersonalisasi. gejala emosional berupa sedih, kesepian, marah, gembira, takut, dan cemas juga didapatkan.3 gejala motorik juga dapat terjadi, seperti mengecap, mengunyah, salivasi, menggoyanggoyangkan kaki. penderita juga dapat berperilaku tidak pantas seperti telanjang di depan umum atau meracau. saat terjadi bangkitan, penderita kehilangan kontak terhadap sekitarnya. tidak jarang juga penderita yang perilakunya menjadi agresif dan melakukan kekerasan. lennox menyebutkan perubahan motorik, perilaku automatisme, dan perubahan fungsi psikis sebagai trias psikomotor.3 kejang parsial kompleks erat kaitannya dengan gangguan kepribadian, perilaku, dan psikiatrik. penelitian oleh vitoroff menyebutkan bahwa sepertiga dari penderita memiliki riwayat penyakit depresif mayor dan dengan jumlah yang sama memiliki gejala gangguan kecemasan. gejala psikotik ditemukan pada 10% kasus. fase pascaiktal pada penderita epilepsi lobus temporal kadang berupa gejala delusional-paranoid atau psikotik amnestik yang dapat berlangsung beberapa hari hingga berminggu-minggu. perekaman eeg pada periode ini mungkin tidak menunjukkan aktivitas kejang meski tidak menyingkirkan adanya kemungkinan aktivitas kejang pada amigdala dan struktur lobus temporal yang lebih dalam. gangguan yang sulit dibedakan dengan skizofrenia ini dapat ditemukan pada periode interiktal. 3 klasifikasi psikotik epilepsi berdasarkan ada atau tidaknya bangkitan, psikosis epilepsi terbagi dalam : 1. psikosis iktal khas timbul pada status epileptikus nonkonvulsif, termasuk status parsial sederhana, status parsial kompleks, dan status absans. perubahan perilaku pada psikotik iktal hampir selalu paroksismal dan menjadi gejala puncak kejang. psikotik iktal terjadi selama status epileptikus non konvulsif, yaitu suatu kondisi di mana aktivitas epileptik memanjang, tanpa kejang, dapat menyebabkan perubahan status mental menjadi tahap psikotik dengan adanya halusinasi dan delusi, gangguan kognitif (gangguan perhatian, kesulitan dalam melakukan perintah motorik kompleks, gangguan berbicara), dan perilaku bizarre. 2. psikosis post-iktal fenomena psikotik postiktal dapat berupa gejala terisolasi atau sebagai sekelompok gejala yang menyerupai gangguan psikotik. gejala psikotik yang menonjol bersifat pleomorfik (persecutory, waham kebesaran, referential, somatik, waham keagamaan, katatonik, halusinasi), dengan gejala afektif (manik atau depresi). kriteria psikotik postiktal menurut stagno (1997), adalah sbb: ✓ gejala psikotik atau psikiatrik lainnya terjadi setelah bangkitan, atau yang sering terjadi pada serial kejang, setelah lucid interval, atau dalam waktu 7 hari setelah kejang. ✓ adanya psikotik, depresi atau elasi, atau gejala yang berhubungan dengan anxietas. ✓ adanya pembatasan waktu, dalam beberapa hari atau minggu, tidak signifikan jika terdapat kesadaran berkabut (bukan karena toksikasi obat, status epileptikus parsial kompleks, atau gangguan metabolik). temuan serupa dari beberapa penelitian serial kasus psikotik epilepsi adalah : 1) medical and health science journal, vol. 2, no. 2, august 2018 50 keterlambatan antara onset gejala psikiatrik dan waktu kejang terakhir; 2) waktu durasi relatif pendek; 3) affect-laden symptomatology; 4) sekelompok gejala delusi dan psikotik seperti gangguan afektif; 5) meningkatnya frekuensi bangkitan tonik klonik umum sekunder pada onset psikotik epilepsi; 6) onset psikotik epilepsi timbul setelah kejang lebih dari 10 tahun; dan 7) respon cepat dengan terapi neuroleptik atau benzodiazepin dosis rendah. 3. psikosis inter-iktal fenomena psikotik interiktal, khususnya halusinasi dan delusi, sering terjadi pada pasien epilepsi. tarulli et al (2001) melaporkan beberapa kasus pasien dengan episode multipel psikotik postiktal sebelum berkembang menjadi psikotik interiktal. sehingga perlu penatalaksanaan psikotik postiktal yang tepat untuk mencegah dan menghambat perkembangannya menjadi psikotik interiktal. psikotik pada epilepsi interiktal telah diidentifikasi khas terjadi pada pasien dengan epilepsi parsial. telah terjadi perdebatan yang luas mengenai kemungkinan bahwa psikotik pada epilepsi adalah indikasi tle (temporal lobe epilepsy). sementara penelitian lainnya menunjukkan bahwa proporsi tle antara pasien psikotik pada epilepsi tidak lebih tinggi dibandingkan pada populasi umum.2,3,6,7,8 tabel 1. klasifikasi psikotik epilepsi epilepsi pascatrauma epilepsi merupakan sekuel yang paling sering terjadi setelah terjadi trauma kranioserebral. penyebabnya adalah benturan atau laserasi pada korteks serebri. risiko terjadinya epilepsi pascatrauma berhubungan dengan beratnya trauma kepala. sebuah penelitian yang dilakukan annegers terhadap 2747 penderita trauma kepala, tipe psikotik hubungan dengan bangkitan durasi eeg terapi psikotik iktal selama status epileptikus beberapa menit s/d jam iktal (status non konvulsif) benzodiazepin, antiepileptik psikotik postiktal saat bingung setelah bangkitan dan lucid interval beberapa hari s/d minggu perlambatan postiktal benzodiazepin, antipsikotik psikotik alternatif ketika kejang berkurang atau disupresi beberapa minggu s/d bulan lebih baik atau normal antipsikotik, antiepileptik psikotik seperti skizopreni a kronis tidak ada hubungan spesifik dengan kejang beberapa tahun sebagian besar abnormal antipsikotik laily irfana, epilepsi post trauma dengan gejala psikotik 51 risiko terjadinya kejang setelah cedera kepala berat (penurunan kesadaran atau amnesia lebih dari 24 jam), termasuk perdarahan subdural dan gegar otak) adalah 7% dalam jangka waktu 1 tahun dan 11,5% dalam 5 tahun. jika cedera kepala sedang (penurunan kesadaran atau amnesia selama 30 menit sampai 24 jam, atau hanya menyebabkan fraktur tulang tengkorak), risiko berkurang menjadi 0,7% dan 1,6%. pada cedera kepala ringan (penurunan kesadaran atau amnesia kurang dari 30 menit), risiko terjadi kejang tidak lebih besar daripada populasi umum. risiko terjadinya epilepsi lebih besar jika trauma terjadi pada daerah parietal dan frontal posterior, serta setelah trauma kepala tajam.4 interval antara trauma kepala dan terjadinya kejang pertama bervariasi. sebagian kecil penderita mengalami kejang beberapa saat setelah trauma (immediate epilepsy). 4-5% penderita trauma kepala mengalami kejang pertama dalam minggu pertama (early epilepsy). epilepsi pascatrauma sendiri sebenarnya merujuk pada late epilepsy, yaitu kejang yang terjadi beberapa minggu atau bulan setelah trauma (1 sampai 3 bulan). sekitar 6 bulan pascatrauma, 50% penderita mengalami kejang pertama. pada 2 tahun pascatrauma, kemungkinannya meningkat menjadi 80%. 4 laporan kasus identitas pasien nama : sdr.az umur : 24 tahun jenis kelamin : laki-laki tanggal pemeriksaan : 20 mei 2013 riwayat penyakit sekarang keluhan utama : kejang autoanamnesis dan heteroanamnesis: kejang terjadi sejak 3 hari sebelum mrs. saat kejang seluruh lengan dan tungkai menghentak-hentak. mata melirik ke atas. mulut berbusa+, lidah tergigit+, ngompol+. lama kejang sekitar 5 menit. setelah kejang pasien tertidur. kejang terjadi >5x dalam sehari. diantara kejang pasien sadar. kejang seringkali diawali dengan marah-marah, mengamuk, sampai-sampai pasien mencekik ibunya. setelah itu pasien tidak sadar dengan apa yang dia lakukan. pasien mengalami kejang pertama kali sekitar sepuluh tahun y.l. saat kejang seluruh lengan dan tungkai menghentak-hentak. mata melirik ke atas. mulut berbusa+, lidah tergigit+, ngompol+. lama kejang sekitar 5 menit. sebelum kejang pasien sering marah-marah, namun bila ditanya setelah kejang berhenti pasien mengatakan lupa. setelah kejang pasien tertidur. kejang mulai terjadi 2 bulan setelah pasien mengalami kecelakaan motor. pasien mengalami benturan kepala, muntah-muntah, kemudian tidak sadar. dilakukan pemeriksaan ct scan kepala didapatkan perdarahan otak, kemudian diopnamekan di rs sidoarjo selama dua minggu. tidak dilakukan tindakan operasi. pasien pulang tanpa gejala sisa, namun dua bulan kemudian pasien mulai sering mengalami kejang, hingga 2x/bulan dengan bentuk kejang yang sama. pasien dibawa keluarganya berobat ke puskesmas dan mendapatkan obat yang diminum tiga kali sehari, ibu pasien lupa nama obatnya. tidak minum obat teratur dan tidak kontrol lagi. kejang tetap terjadi sekitar 1 bulan sekali. dua tahun setelah kejang pertama, selain bentuk kejang sebelumnya, terkadang pasien juga sering tiba-tiba mengecap-ngecap, kemudian berjalan mondar mandir, dan pasien tidak menyadari apa yang dilakukannya. empat tahun ini pasien sering marah-marah, berteriak-teriak, pernah hingga menusuk-nusuk badannya. tiga tahun setelah keluhan tersebut baru dibawa berobat ke rsj lawang dan opname selama 2 bulan. setelah itu pasien membaik, namun tidak rutin kontrol. dua minggu sebelum mrs, pasien semakin sering marah-marah dan memukuli orang hingga medical and health science journal, vol. 2, no. 2, august 2018 52 akhirnya pasien dipasung dan diborgol oleh warga. selama itu pasien semakin sering kejang hingga oleh perangkat desa dibawa ke rsds. riwayat nyeri kepala kronis (-), muntah (-), kejang (-), kelemahan sepruh badan (-), kesemutan/tebal (-), bicara pelo (-), merot (-), gangguan penglihatan (-), gangguan pendengaran (-), gangguan bab dan bak (-). riwayat penyakit dahulu ● tahun 2003, riwayat trauma kepala pingsan, muntah, luka jahitan di kepala samping kanan. ct scan kepala didapatkan perdarahan di otak. kemudian dirawat selama 2 minggu di rs sidoarjo. ● tahun 2009, opname di rs jiwa lawang selama 2 minggu, karena marah-marah. ● tahun 2011, opname di rs jiwa kalimantan selatan selama 1,5 tahun, karena marah-marah dan membunuh orang. ● keluarga pasien tidak ada yang sakit seperti pasien. ● riwayat kehamilan: dalam batas normal, tidak mengkonsumsi jamu-jamu atau obat-obatan tertentu. ● riwayat kelahiran : lahir terlambat bulan, normal, ditolong bidan. saat lahir sempat biru, langsung menangis. kejang demam sejak umur 9 bulan hingga 4 tahun. ● riwayat tumbuh kembang : sesuai anak pada umurnya. ● riwayat pendidikan : tamat sd, dengan prestasi biasa. tidak melanjutkan sekolah sejak pasien sering kejang setelah kecelakaan. pemeriksaan fisik status internistik kesadaran : composmentis tekanan darah: 140/90 mmhg; nadi: 82 x/menit; rr:18x/menit; temperatur aksila: 36,5 celcius status generalis dbn status neurologis gcs : 456 meningeal sign : kk (-), kernig (), brudzinski i-iv (-) n. cranialis : nii/iii: pbi diameter 3mm/3mm rc (+), papil edema :-/ n. cranialis lain : parese (-) motorik : 5 / 5 (lengan) 5/5 (tungkai) sensorik : dalam batas normal. cv / ans : dalam batas normal. laboratorium ( 17 maret 2013 ) dbn pemeriksaan eeg eeg ( 24 mei 2013) hasil : eeg abnormal iii (bangun dan tidur stadium ii) spike wave di regio prefrontal kanan spike wave di regio temporal kanan isa (intermitten slow activity) general eeg saat perekaman ini abnormal, mengindikasikan adanya potensial epileptogenicity di regio prefrontal kanan dan regio temporal kanan disertai ensefalopati difus derajat ringan. radiologi thorax ap cor dan pulmo tak tampak kelainan mri kepala tanpa kontras (24 mei 2013) saat ini brain parenchym tak tampak kelainan. tidak tampak atrofi hipokampus laily irfana, epilepsi post trauma dengan gejala psikotik 53 dengan volume sisi kanan:1,620 cm3 volume sisi kiri: 1,820 cm3. dwi : tak tampak restricted diffusion area. mra: circulus wilisi patent, tak tampak malformation vascular. tes neurobehaviour ● neurobehaviour: didapatkan gangguan pada atensi, visual memory, verbal memory, dan kategori naming ● diagnosis tentative neurobehaviour : saat ini didapatkan pasien dengan multidomain amnestik mci yang dapat pula disebabkan oleh penyakit dasarnya. saran: atasi penyakit dasarnya evaluasi pemeriksaan kognitif ulang dalam 6 bulan. diagnosis diagnosis klinis : ● serial general tonic clonic seizure ● behavioural changes ● automatism diagnosis topis : korteks lobus frontotemporalis diagnosis etiologis : epilepsi simtomatik lobus temporal e.c traumatic brain injury penatalaksanaan farmakoterapi phenytoin kaps 3x100mg risperidone tab 2x0,5 mg asam folat tab 1x1 psikoterapi suportif psikoedukasi keluarga pembahasan epilepsi pasca trauma termasuk dalam epilepsi simtomatik. merupakan sekuel dari trauma kepala yang paling sering terjadi, dengan insiden 5% pada penderita dengan trauma kepala tertutup dan 50% pada penderita dengan fraktur tulang tengkorak dan jejas pada otak.4 tipe kejang pada eplepsi pasca trauma dapat berbeda-beda bergantung pada lesi yang diakibatkan oleh trauma tersebut. kasus ini melaporkan penderita laki-laki usia 24 tahun dengan keluhan kejang yang disertai dengan gejala psikotik. didapatkan riwayat pasien kejang pertama kali dua bulan setelah mengalami trauma kepala yaitu pada tahun 2003. saat itu pasien mengalami cedera otak berat tidak sadar selama 1 minggu. dari ct scan kepala didapatkan perdarahan di otak. sejak itu pasien mengalami kejang berulang dengan disertai keluhan yang dominan adalah marah-marah hingga pernah sampai mau membunuh orang. dari analisis eeg menunjukkan hasil epilepsi lobus temporal. hal ini mendukung gejala dari pasien tersebut yang menunjukkan gejala behavioral changes dan automatism yang mengarah ke psikotik epilepsi dimana pada pasien ini dengan tipe psikotik iktal. pasien mendapatkan terapi phenytoin dan risperidone dosis standar, dan menunjukkan epilepsi telah terkontrol dengan pengobatan tersebut namun masih didapatkan kejang kemungkinan karena pasien tidak rutin minum obat. kejadian epilepsi pada kasus ini belum sembuh hingga sepuluh tahun setelah trauma kepala. kesimpulan pada kasus ini pasien laki-laki dengan epilepsi post trauma dengan onset 2 bulan setelah trauma kepala. berdasarkan anamnesis dan pemeriksaan fisik dan penunjang, pasien didiagnosis epilepsi lobus frontemporal dan menunjukkan gejala menyerupai psikotik. pasien mendapatkan pengobatan standar yaitu phenytoin dan risperidone. kejang terkontrol namun bila tidak minum obat pasien kejang lagi. hal ini dialami oleh pasien hingga saat kasus ini dilaporkan, yaitu sepuluh tahun post trauma. medical and health science journal, vol. 2, no. 2, august 2018 54 daftar pustaka harsono, dkk. 2011. pedoman tatalaksana epilepsi. perdossi. jakarta: 1-6. shorvon sd. 2006. handbook of epilepsy treatment. blackwell science. oxford: 1-3 ropper ah, brown rh. epilepsy and other seizure disorders. in ropper ah, brown rh. adams and victor’s priciples of neurology 8th ed. mcgraw-hill. usa: 269299 ropper ah, brown rh. craniocerebral trauma. in ropper ah, brown rh. adams and victor’s priciples of neurology. mcgrawhill. usa:762-763 rudzinski la, meador kj. 2011. epilepsy: five new things. neurology.76:s20 3_mhsj_coba 15 perbaikan fungsi trofoblast pada kadar β hcg tikus bunting preeklampsia pada bahan biologis tersimpan pasca perlkuan dengan spirulina adhiono, a. 1, gondo, h.k.2, noer kumala i3 2,3 fakultas kedokteran, universitas wijaya kusuma surabaya e-mail: : noerkumala04176@gmail.com 3 abstract: preeclampsia is multisystem specific disorder in pregnancy. preeclampsia has signed by increased cytokine interleukin-6 and β hcg (human chorionic gonadotropin). spirulina is green-blue alga has bioactive compound namely antioxidant, vitamin, mineral. and has benefit namely antinflamation. the aim of this research was to know how spirulina influence to repair trophoblast in hcg concentration on rat pregnancy (biology material collecting). the type of this research is an experimental laboratoric with post test only control group design. a total of 25 rats with pre-eclampsia models induced by interleukin 6 are divided into 5 groups: the untreated control group, the positive control group with interleukin 6 induction for three days, the treatment group with a dose of 10 mg / day, 20 mg / day and 40 mg of spirulina. / day for five day, then the blood serum produced was measured with β hcg levels using elisa (enzyme-linked immunosorbent assay). the results of the spirulina 10 mg / day are higher at 85.11 ± 25.70 miu / ml from a dose of spirulina 20 mg / day at 79.65 ± 10.65 miu / ml . in the level of β hcg, the dose group of spirulina 10 mg / day and the group there is no significant difference (0.730> 0.05), the β hcg level group of spirulina 40 mg / day was 93.28 ± 17, 12 miu / ml from the dose group of spirulina 10 mg / day was 85.11 ± 25.70 miu / ml. the administration of spirulina for five days was able to reduce β hcg levels at a dose of 10 mg / day, 20 mg / day and 40 mg / day and the dose that was most effective in reducing β hcg levels significantly (p <0.05) was a dose of 10 mg than dose of 20 mg / day and 40 mg / day. keywords: preeclampsia, interleukin 6, β hcg, spirulina pendahuluan salah satu faktor yang merupakan penyulit atau gangguan atau komplikasi yang menyertai ibu saat hamil adalah patologi kehamilan (sujiyatini,2009). sekitar lebih dari 63.000 ibu meninggal setiap tahunnya didunia disebabkan preeklampsia. angka kematian ibu tertinggi terdapat pada negara negara yang berpenghasilan rendah dan menengah, namun demikian preeklampsia juga berpotensi pada negara negara maju (marie bolin, 2012). preeklamsia merupakan gangguan multisistem spesifik pada kehamilan yang ditandai dengan perkembangan hipertensi dan proteinuria (lana k, 2004). hingga saat ini preeklampsia masih merupakan ”the disease of theories”, dimana patofisiologinya masih belum jelas diketahui. sebagai penanda terjadinya preeklampsia. pada kasus preeklampsia terjadi peningkatan kadar β hcg serum (priyatini t, 2004). human chorionic gonadotropin (hcg) merupakan hormon glikoprotein terdiri dari dua subunit kovalen non , α dan β , dan diproduksi oleh sel sinsitiotrofoblas plasenta. puncak dari kadar β hcg adalah minggu ke 8 – 10 kehamilan dan kadar paling rendah pada minggu 18 – 20 kehamilan. (kanika mandi chaudhury et all, 2012). fungsi β hcg pada kehamilan adalah sebagai penghasil progresteron, implantasi dan sebagai regulasi sistem kekebalan (w. norris, 2011). spirulina platensis merupakan salah satu varian dari mikroalga spirulina sp. yang banyak dimanfaatkan oleh masyarakat karena kandungan nutrisinya yang lengkap. (oliveira et al 2008). fikosianin merupakan salah satu dari tiga pigmen medical and health science journal, vol. 2, no. 2, august 2018 16 (klorofil dan karotenoid)alami pada spirulina platensis yang bermanfaat sebagai antioksidan (arlyza, 2005) dan mampu menghambat pembentukan imunomodulator (adams, 2005). antioksidan merupakan senyawa pemberi elektron (electron donors) dan secara biologis antioksidan adalah senyawa yang mampu mengatasi dampak negatif oksidan dalam tubuh seperti kerusakan elemen vital sel tubuh. penelitian menunjukkan bahwa fikosianin dari spirulina berpotensi meningkatkan sistem imun yang mempunyai keuntungan menghambat perkembangan imuomodulator (pirenantyo, 2008). berdasarkan permasalahan tersebut tentang kegunaan spirulina dalam bidang penelitian maka peneliti tertarik untuk melakukan penelitian bagaimana pengaruh spirulina terhadap perbaikan fungsi trofoblast pada kadar β hcg tikus bunting preeklampsia pada bahan biologis tersimpan. metode penelitian rancangan yang digunakan pada penelitian ini adalah menggunakan rancangan post test only control group design. desain ini melibatkan subjek secara random pada salah salah satu dari lima kelompok. tiga kelompok diberi perlakuan dan dua kelompok kontrol; satu dari kelompok perlakuan dan satu dari kelompok kontrol diberi perlakuan eksperimental (emzir, 2007). p0 = kelompok perlakuan interleukin 6 dengan dosis 5 mg/hari (i.v). p1 = kelompok perlakuan interleukin 6 (i.v) dan spirulina dengan dosis 10 mg/hari per oral. p2 = kelompok perlakuan interleukin 6 (i.v) dan spirulina dengan dosis 20 mg/hari per oral. p3 = kelompok perlakuan interleukin 6 (i.v) dan spirulina dengan dosis 40 mg/hari per oral. penelitian ini menggunakan elisa reader dengan metode sandwich untuk mengukur β hcg maka dari itu menggunakan antigen berupa serum β hcg dan antibody yaitu anti-hcg (mab). tujuan dari mertode ini adalah untuk mengukur kadar antigen yaitu β hcg yang terdapat pada serum. cara kerja elisa pada penelitian ini diawali dengan (1) proses tawing yaitu pengenceran serum yang ada didalam mikrotube yang sebelumnya disimpan dilemari es. (2) memasukkan serum tersebut kedalam microplate sebanyak 50 µlsetiap kelompok 5 lubang microplate. (3) masukkan 100 µl hcg kit yaitu anti-hcg (mab) kesemua microplate, (4) tutupi mikroplate dan inkubasi selama 60 menit dengan temperatur ruangan (18-26o c), (5) bersihkan semua serum/cairan dari mikroplate dengan cara dibilas menggunakan buffer dan letakkan kertas blot/absorbent. (6) tambahkan 100 µl tmb substrat kesemua mikroplate. (7) inkubasi selama 10 menit pada temperatur ruangan. (8) tambahkan 50 µl stop solution pada semua microplate, aduk hingga mencampur (9) baca absorbansi pada elisa reader 450 nm dalam waktu 15 menit setelah stop solution diberikan (sigma aldrich, 2014). hasil penelitian a. analisa β hcg setelah diinduksi interleukin-6 hasil tersebut menunjukan bahwa induksi interleukin-6 dengan dosis 5 mg/hr selama 3 hari mampu meningkatkan kadar β hcg dari kelompok p0 sebelum diinduksi interleukin-6 sebesar 24,44 ± 6,49 miu/ml menjadi 126,31 ± 47,09 miu/ml setelah diinduksi interleukin 6. pada kelompok p1 adhiono, a., gondo, h.k., noer kumala i., perbaikan fungsi trofoblast pada kadar β hcg tikus bunting preeklampsia pada bahan biologis tersimpan pasca perlkuan dengan spirulina 17 sebelum diinduksi interleukin 6 sebesar 21,85 ± 3,23 miu/ml menjadi 103,41 ± 28,30 miu/ml setelah diinduksi interleukin 6. pada kelompok p2 sebelum diinduksi interleukin 6 sebesar 20,72 ± 4,98 miu/ml menjadi 109.82 ± 20.87 miu/ml setelah diinduksi interleukin 6. pada kelompok dosis p3 sebelum diinduksi interleukin6 sebesar 23,66 ± 4,98 miu/ml menjadi 113,44 ± 20,18 miu/ml setelah diinduksi interleukin6. b. analisa kadar β hcg setelah pemberian spirulina yang diinduksi interlekin 6 hasil tersebut menunjukan bahwa pemberian spirulina dengan dosis 10 mg/hr, dosis 20 mg/hr, dan dosis 40 mg/hr selama 5 hari mampu menurunkan kadar β hcg. pada kelompok p1 sebelum diberi spirulina sebesar 103,41 ± 28,30 miu/ml menjadi 61,772 ± 18,44 miu/ml setelah diberi spirulina. pada kelompok p2 sebelum diberi spirulina sebesar 109.82 ± 20.87 miu/ml menjadi 35,53 ± 8,61 miu/ml setelah diberi spirulina. pada kelompok p3 sebelum diberi spirulina sebesar 113,44 ± 20,18 miu/ml menjadi 71,42 ± 15,99 miu/ml setelah diberi spirulina. diskusi a. pengaruh interleukin 6 pada kadar hcg tikus bunting putih penelitian ini menggunakan 25 ekor tikus putih bunting dilakukan dengan cara diinduksi interleukin 6 dengan dosis 5mg selama 3 hari untuk menjadikan model preeklampsia, analisa β hcg dilakukan untuk mengetaui peningkatan kadar hcg. menurut penelitian gadonski et all, 2006 penambahan interleukin 6 mampu meningkatkan tekanan darah dan meningkatkan sitokin proinflamasi tnf alfa dan gfr. menurut penelitian (gokdeniz et all, 1999) pada 3 wanita yang preeklaampsia didapatkan peningkatan β hcg dari pada wanita yang tidak preeklampsia. hasil penelitian tersebut sesuai dengan penelitian ini bahwa pemberian interleukin 6 dengan dosis 5 mg selama 3 hari mampu meningkatkan kadar kadar β hcg dari 22,66 ± 42,7 miu/ml ke 113,24 ± 29,11 miu/ml (0,001 < 0,005). b. penngaruh spirulina terhadap kadar β hcg pada tikus putih bunting yang terinduksi interleukin 6 spirulina adalah mikroalga yang memiliki cyanobacterium mikroskopik berfilamen, mengandung bahan c-fikosianin yang merupakan zat dengan aktivitas kemopreventif kanker yang poten (ravi m et al, 2010). zat ini mampu menginduksi apoptosis dengan cara memfragmentasi dna dan kondensasi nukleus. penelitian yang lain menyebutkan bahwa cfikosianin dari spirulina memiliki kemampuan untuk menurunkan regulasi protein anti apoptosis dan meningkatkan regulasi protein proapoptosis medical and health science journal, vol. 2, no. 2, august 2018 18 (belay a, 2002), juga mempunyai fungsi sebagai antioksidan yang mampu menghambat perkembangan imunomodulator (arlyza, 2005; adams, 2005). hasil penelitian ini menunjukkan bahwa pemberian spirulina dengan kadar β hcg kelompok p1 tidak berbeda signifikan dengan kelompok dosis 20 (0,537 > 0,05), kadar β hcg p1 lebih tinggi yakni 61,772 ± 18,44 miu/ml dari p2 sebesar 35,53 ± 8,61 miu/ml. pada kadar β hcg kelompok p1 dan kelompok p3 tidak terdapat perbedaan signifikan (0,820 > 0,05), kadar β hcg kelompok p3 lebih tinggi yakni 61,772 ± 18,44 miu/ml sedangkan kelompok p1 sebesar 71,42 ± 15,99 miu/ml. c. dosis efektif spirulina sampel terdiri atas 24 ekor tikus jantan dipilih dengan cara random sampling untuk dibagi dalam. dalam penelitian ini pemberian spirulina diberikan dalam 3 dosis bertingkat yaitu 10 mg/hr, 20 mg/hr, dan 40 mg/hr. dari ketiga dosis spirulina yang diberikan tersebut didapatkan hasil dosis efektif yaitu 10 mg karena pada dosis tersebut sudah dapat menurunkan kadar β hcg secara efektif dibanding spirulina dosis 20 mg dan 40 mg karena pada antioksidan pada dosis berlebih akan menjadi radikal bebas yang dapat berbahaya bagi kesehatan. menurut penelitian kansas state university tahun 2010 mengatakan bahwa penambahan antioksidan dalam jumlah berlebih fungsinya tidak lagi menjadi antioksidan, melainkan menjadi prooksidan, sehingga spirulina yang berfungsi sebagai antioksidan menjadi radikal bebas yang dapat merusak trofoblas dan uterus . dalam penelitian spirulina dalam dosis 20 mg/hr dan 40 mg/hr menjadi prooksidan karena dosisnya belebih sehingga dapat menurunkan kadar β hcg tetapi tidak signifikan. kesimpulan 1. pemberian interleukin-6 dengan dosis 5mg selama 3 hari pada tikus bunting mampu meningkatkan kadar β hcg secara signifikan (p < 0,05) yakni dari 22,66 ± 42,7 miu/ml ke 113,24 ± 29,11 miu/ml. 2. pemberian spirulina selama 5 hari mampu menurunkan kadar β hcg secara signifikan yakni dari 108,89 ± 23,11 miu/ml ke 56,24 ± 14,34miu/ml. 3. dosis efektif spirulina adalah 10 mg karena kadar β hcg lebih rendah dari kelompok dosis 10 mg dan dosis 40 mg. daftar pustaka adiyati pn. 2011. ragam jenis ektoparasit pada hewan coba tikus putih (rattus norvegicus) galur sprague dawley. skripsi. bogor: fakultas kedokteran hewan institut pertanian bogor. amha belay. 2002. the potential application of spirulina (arthrospira) as a nutritional and therapeutic supplement in health management. the journal of the american nutraceutical association vol 5, no 2, spring asanoma k, kubota k, chakraborty d, renaud sj, wake n, fukushima k, soares mj, rumi ma. satb homeobox proteins regulate trophoblast stem cell renewal and differentiation. j biol chem. 2012;287: 2257–2268. arylza, i.s. 2005.phycocyanin dari mikroalga bernilai ekonomis tinggi sebagai produk industri.oseana.xxx(3): 27-36. bolin, marie. 2012. pre-eklampsia – possible to predict ?. acta universitatis upsaliensis. digital comprehensive summaries of uppsala dissertations from the faculty of adhiono, a., gondo, h.k., noer kumala i., perbaikan fungsi trofoblast pada kadar β hcg tikus bunting preeklampsia pada bahan biologis tersimpan pasca perlkuan dengan spirulina 19 medicine 835. 66 pp. uppsala. isbn 97891-554-8523-8. boussiba, s. and richmond, a. 1979.isolation and purification of fikosianin from the blue green alga spirulina platensis. arch. microbiol., 120: 155-159. casey ml, mac donald dc, simpson er. endocrinological changes of pregnancy. in : williams text book of endocrinology. 8th ed. wb. saunders co. 1992 : 987 89. cunningham, f.g,. 2005. obstetri williams: gangguan hipertensi dalam kehamilan. edisi 21. jakarta: egc, 624-640. emzir. 2007. metodologi penelitian pendidikan kuantitatif dan kualitatif. jakarta: pt raja grafindo persada. fisher da. endocrinology of fetal development in: williams text book of endocrinology. 8 th ed. wb. saunders co. philadelpia, 1992 : 1049 71. galazios, g., tsoulou, s., zografu,c.,tripisianis, g., koutlaki, n., papazoglou,d., tsikouras, p., maltezos, e., and liberis, v., 2011,the role of cytokines il-6 and il-8 in the pathogenesis of spontaneous abortions. the journal of maternal-fetal & neonatal medicine vol24 (10)hal 1283-1285 ganong,w.f. 2008. buku ajar fisiologi kedokteran. jakarta: egc giovani gadonski. 2006. hypertension produced by reductions in uterine perfusion in the pregnant rat role of interleukin 6. departments of physiology and obstetrics– gynecology and center for excellence in cardiovascular–renal research, university of mississippi medical center, jackson, miss.pages 711-715 gökdeniz, r.; 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sujiyatini, dkk. 2009. asuhan patologi kebidanan. jakarta: nuha medika. wagner, lana k. 2004. diagnosis and management of preeclampsia. mexico: diagnosis and management of preeclampsia wendy norris, et all. 2011. review: hcg, preeclampsia and regulatory t cells. nih public access: department of pediatrics, women and infants hospital-warren alpert medical school of brown university, providence, rhode island, usa yaron y, cherry m, kramer rl et al. maternal serum fetoprotein, hcg, estriol and their various combinations as predictors of pregnancy outcome. am j obstetgynecol 1999; 181; 968 – 74 yasa gp. peranan peroksidase lipid pada patogenesis preeklampsia. bali: bagian obstetri dan ginekologi fk unud/rsup sanglah denpasar; 2013. medical and health science journal, vol. 2, no. 2, august 2018 22 1_the different 1 the different effects of zinc supplement and velvet bean mucuna pruriens extracts toward fertility of balbc/ mice pardipta pradipta kurniasanti1, m. zen rahfiludin2, sri winarni3 1faculty of psychology and health-nutrition science, walisongo state islamic university 2postgraduate lecturer on nutritional sciences of public health faculty, diponegoro university 3lecturer on biostatistics of public health faculty, diponegoro university e-mail: dipta@walisongo.ac.id1 abstract: good quality velvet beans and zinc supplement are well studied and known as rich source of aphrodisiac. the following reseach was carried out to study the difference effect of zinc supplement (zs) and velvet bean extracts (vbe) towards fertility of balb/c mice i.e the number of sperm, the motility of sperm, the viability of sperm, the morphology of sperm, the existence of vagina plug, and the birth condition of mice. this study was an experiment using posttest only controlled group design with three groups. the first group (a1) as control, the second group (a2) receives subcutaneous injection of 2methoxyethanol fraction as much as 200 mg/kg weight/day for 5 days, followed with zs at a dosage of 0,026 mg/day/head, and the third group (a3) receives subcutaneous injection of 2-methoxyethanol fraction as much as 200 mg/kg weight/day for 5 days, followed with vbe at a dosage of 56 mg/kg weight /day for 30 days. the quality of spermatozoa of a1, a2, and a3 was significant difference (p < 0.05). both of a2 and a3 were no significant difference of mean number of sperm (p = 0.274), mean percentage of sperm motility (p = 0.739), mean percentage of sperm viability (p = 0.141) and mean value of morphology of sperm (p = 0.394). the quality of spermatozoa and the total number of baby mice lived and died of a1, a2 and a3 were significant difference. in addition, there was no significant difference in the existence of female mice's vaginal plug of a1, a2 and a3. this study showed that zs and vbe can increase the quality of spermatozoa of balb/c mice. keywords: zinc supplement, velvet bean extracts, fertility, spermatozoa of mice. introduction infertility case has been a world issue (sardjono et al., 2016; martinez et al., 2012; mathur, 2009). a review study showed a significant decrease in mean sperm count from 113 x 106 per ml in 1940 to 66 x 106 per ml in 1990 (carlsen et al., 1992). in australia, 1 out of 20 males has infertility problem and 50% of all infertility problem are associated with male (mclahlan et al., 2001). infertility increases 1520% from approximately 50 million couples in indonesia. this infertility is consecutively caused by male (40%) and female (40%), both of female and male (10%), and another 10% of unidentified reasons. it means that the number of infertility increases in the last 50 years (sardjono et al., 2016). various types of modern medicine have been applied to solve this case but many of which yield negative effects (hart, 2005). zinc supplement is one of the essential micronutrients to increase the number, quality and motility of sperm for low fertility in men. zinc within normal amount in male body will support reproduction system. zinc supplementation at a dose of 0,026 mg/day/head turns out to be optimal and shows a significant increase on the number and motility of sperm in mice (widya, 2012). zinc supplement can reduce reproduction potential of mice dosage dependently by affecting proliferation of spermatogonia (sedigh et al., 2016). in addition to zinc supplement, 96% ethanol fractions and isolated velvet bean on quality of male mice spermatozoa are exposed to 2methoxyethanol with a dose of 56 mg/kg/day. medical and health science journal, vol. 2, no. 2, august 2018 2 it improves the number, motility rate, and the percentage of spermatozoa viability and the percentage of normal sperm morphology (winarni, 2010). various study had be done to investigate the aphrodisiac activity of velvet bean extracts (gupta et al., 2011; sukhla et al., 2010; sekar et al., 2009; ahmad et al., 2008). therefore the following research was carried out to compare the difference effect of zinc supplement and velvet bean extracts toward fertility of balb/c mice. materials and methods zinc supplement (zs) zinc supplement was a syrup (zinkid) purchased from the clinic of pharmacy, then the dosage was diluted up to 0.026 mg/day/head. source of 2-methoxyethanol the toxic of 2methoxyethanol fraction as much as 200 mg/kg weight/day were purchased from (collection of mrs. hayati) biological laboratory of unair, surabaya, indonesia. velvet bean extracts (vbe) preparation velvet beans were sun dried to reduce water content and shelled to obtain the seed (nib). nib was defatted by maceration with 1500 ml aceton and shaked for 48 h at room temperature. it was filtered, then filtrate of velvet powder was extracted by maceration with water and 96% ethanol (1:1) (sample to solvent ratio of 1:2 w/v )). the extraction process was carried out for 24 h at room temperature (25°c). once the extraction was complete, it was filtered by vacuum (winarni, 2010). the resulting velvet bean extracts was condensed by a rotary evaporator at 40°c, 50 rpm and dried by vacuum oven and designed as velvet bean extracts (vbe). material and methods animal the kind of rat was the balb/c mice strain mus muculus obtained from the biological laboratory of universitas negeri semarang (unnes), indonesia. preparation of laboratory experimental and control research the number of mice used for all three groups were 45 balb/c male mice (8 w old, weighing about 20-30 g were used for the investigation). the ratio of balb/c female mice and balb/c male mice was 1:2 each group. it means that a male mice was mated with 2 female mices, and 15 mices of each group (9 mices were examined its sperm quality, 6 mices were mated). monitoring of the existence of vaginal plug male and female mice were mated in a week. every morning for a week, the female mice examined whether there was vagina plug with the use of apusan vagina. when vagina plug was found in red colour, it indicates that intercouse was done. it was defined as the first day of female mice pregnancy (adnan, 2006). the number of sperm neck-dislocated died mice were located on tray for surgery. their cauda epididymis was isolated using nacl. sperm liquid was emptied from cauda epididymis by a syringe before it was dissolved with 2 ml nacl until it became homogenous. the calculation of the sperm concentration was using haemacytometer improved neubauer before it was observed by a microscope of 400x magnifications. the calculation was conducted for four boxes of counting chamber, prior to average calculation. the result of the calculation was the sperm concentration in 10-4 ml sperm suspension (hayati, 2007): number of cell/ml = number of spermatozoa (n) x 104 x dilution factor sperm motility was observable from sperm suspension dropped on neubauer counting chamber observed by a microscope of 400x magnifications. sperm motility was valued on the basis of percentage of good sperm motility, that was sperm pardipta pradipta kurniasanti, m. zen rahfiludin, sri winarni, the different effects of zinc supplement and velvet bean mucuna pruriens extracts toward fertility of balbc/ mice 3 which moves fast, straight forward and active (aleissa, 2014). the percentage of sperm motility was measured by the following equation (goyal et al., 2001; hayati, 2007; canyurt and akhan, 2008): spermatozoa motility (%) = category a + b x 100% 100 : spermatozoa. the viability of sperm sperm viability was observable from sperm suspension dropped on colouring eosin y 1% observed by a microscope of 400x magnifications. sperm viability was valued on the basis of percentage of good sperm viability. that was sperm which indicates transparant color as live and red color as die (aleissa, 2014). the percentage of sperm viability was measured by the following equation (goyal et al., 2001; hayati, 2007; canyurt and akhan, 2008): spermatozoa viability (%) = / spermatozoa the morphology of sperm sperm morphology testing was conducted by differentiating the shape of normal and abnormal sperm of 100 sperms observed before it was made into percentage (aleissa, 2014). abnormal sperm includes abnormality such as broken, detached and thin head; broken, crooked and droplet cytoplasm middle part or broke, crooked and coil tail. the observation used a microscope of 400x magnifications (henderson and robaire, 2005; sardjono et al., 2016). analysis of the data results were expressed as mean ± sd. the normality of the data was tested using shapiro wilks. statistical test uses kruskal-wallis test, mannwhitney test, one-way anova test, and followed by post hoc lsd test, with the significant level of 0.05. results and discussions the number of sperm the mean number of sperm of a2 (3.29 ± 0.55 million/ml) and a3 (3.66 ± 0.99 million/ml) were greater than a1 (2.67 ± 0.37 million/ml) (figure 1a). it indicated that higher number of sperm in a2 and a3 also gave a stronger spermatogenesis activity, whereas zs and vbe have aphrodisiac content to increase the number of sperm. this is in line with the general knowledge that zs can increase the number of sperm stem cells (sedigh et al., 2016) and vbe can increase the number of sperm with stimulating the hormones of mice (sardjono et al., 2016). there was a significant difference of the number of sperm of a1, a2 and a3 by anova test (p = 0.019), whereas lsd test showed the significant difference of a1 versus a3 (p = 0.006) and a1 versus a2 (p = 0.069) respectively. however, there was no significant difference of a2 versus a3 (p = 0.274). this fact proved that the zs and vbe were the same effect that affected the number of sperm of the mice. thus, zs and vbe are a powerful source of aphrodisiac food which is potential to increase the number of sperm. the motility of sperm the mean percentage of sperm motility in a2 (77.7 ± 12.0%) and a3 (79.4% ± 7.7%) were greater than a1 (54.4 ± 11.3%) (figure 1b). it indicated that higher motility of sperm affected by the number of sperm and morphology of sperm. a living spermatozoa correlates highly to the motility of the sperm as being alive is an absolute requirement for a spermatozoa to be able to produce energy and move. semen of mammal that has high fertility is characterized with a high level of living spermatozoa with normal morphology. good motility depends on many things, including the morphology of sperm (sardjono et al., 2016). medical and health science journal, vol. 2, no. 2, august 2018 4 there was a significant difference of the percentage of sperm motility of a1, a2 and a3 by anova test (p = 0.001), whereas lsd test showed the significant difference of the percentage of sperm motility of a1 versus a2 (p = 0.001) and a1 versus a3 (p = 0.001) respectively. however, there was no significant difference of a2 versus a3 (p = 0.739). this fact proved that the zs and vbe were the same effect that affected the motility of sperm of the mice too. it given correlates positively with the previous result and discussion (the number of sperm). a large amount of sperm with good sperm motility is sufficient for the insemination to take place successfully. the viability of sperm the mean percentage of sperm viability in a2 (29.0 ± 3.2%) and a3 (31.3 ± 3.7%) were greater than a1 (17.4 ± 2.8%) (figure 1c). there was a significant difference of the percentage of sperm viability of a1, a2 and a3 by anova test (p = 0.001). lsd test showed showed the significant difference of the percentage of sperm viability of a1 versus a2 (p = 0.001) and a1 versus a3 (p = 0.001) respectively. however, there was no significant difference of a2 versus a3 (p = 0.141). the study shows that zs and vbe can increase the viability of sperm as well as increase the number of sperm and the motility of sperm. this increase in viability sperm is inseparable from l-dopa component found in vbe. this compound not only increase sexual activity but also hormones regulating spermatogonia process such as fsh and lh (sardjono et al., 2016). whereas zs concentration in seminal plasma is known to correlate with the viability of sperm (akinloye et al., 2011; colagar et al., 2009). the morphology of sperm the morphology of sperm of a2 (19.4 ± 3.2%) and a3 (21.6 ± 5.2%) was greater than a1 (13.3 ± 3.5%). there was no significant difference of the morphology of sperm of a1, a2, and a3 by kruskal-wallis test (p = 0.003). when a1 was compared to a2 and a3, it showed the significant difference of the morphology of sperm by mannwhitney test (p < 0.05). it means the existence of zs in a2 and vbe in a3 affected the normality of morphological sperm of balb/c mice. this is in line with the general knowledge that vbe treatment succeeded in reducing morphological abnormal sperm in all dosage given (50, 100, 150, 200 and 250 mg/kg (sardjono et al., 2016), which is our study use dosage of vbe as much as 56 mg/kg. however, there was no significant difference of a2 versus a3 (p > 0.05) (table 1). increased number of sperm and motility of sperm as well as decreased abnormal sperm morphology of mice occur because of l-dopa and other components contained in vbe which influence the secretion of testosterone (sardjono et al., 2016). whereas zs plays key role in immune system improvement and activity of hormones to affect spermatogonia process and the effects of zs on prostate gland are very obvious (sedigh et al., 2016). the existence of vagina plug male mice in a1, a2, and a3 had the same capability to impregnate female mice. overall our study showed that only one female mice in each group had no vagina plug. it means there was one male mice able to mate two female mices, but other male mice only one female mice. the birth condition of mice the ratio number of baby mice dead in a1 (0.22) was two among nine (18%; 7 alive out of 39 babies born), a2 (0.26) was five baby mices dead out of 19 (36%; 14 alive out of 39 babies born) and a3 (0.18) was four baby mices dead out of 22 (46%; 18 alive out of 39 babies born) (figure 2). it showed that female mice given zs and vbe produced more baby mice than control group. it pardipta pradipta kurniasanti, m. zen rahfiludin, sri winarni, the different effects of zinc supplement and velvet bean mucuna pruriens extracts toward fertility of balbc/ mice 5 was likely due to mineral of zinc contained in vbe and also other vitamins and minerals. this result given correlation positively with the quality of spermatozoa. our study showed that zs and vbe increase the number, motility, viability, and morphology of sperm. fertility amount was increased by zs and vbe, which is due to intensive increasing in epididymis sperms. since certain number of sperm in the semen was necessary for fertilization. this increasing will directly affect the number of fertilized ovules of female mice. the mean weight of baby mice in a2 (0.55 ± 0.13 g) and a3 (053 ± 0.14 g) was greater than a1 (0.49 ± 0.12 g) (figure 3). there was no significant difference of the weight of baby mice by anova test (p = 0.644) and lsd test (p > 0.05) conclusions zinc supplement and velvet bean extracts increase the quality of spermatozoa (the number of sperm, the motility of sperm, the viability of sperm and the morphology of sperm) of balb/c mice higher than control group and can be used as aphrodisiac food. acknowledgement the author acknowledge the co-author (mr. prayoga and mr. rahfiludin) and family of master program in nutrition-food concentration, diponegoro university, semarang, indonesia references adnan. 2006. reproduction and embryology. departemen biologi universitas negeri makassar. makassar. ahmad, m.k., mahdi, a.a., shukla, k.k., islam, n., jaiswar, s.p. and ahmad, s. 2008. effect of mucuna pruriens on semen profile and biochemical parameter in seminal plasma of infertile men. 90:3. akinloye, o., abbiyesuku, f.m., oguntibeju, o.o., arowojolu, a.o. and truter, e.j. 2011. the impact of blood and seminal plasma zinc and copper concentrations on spermogram and hormonal changes in infertile nigerian men. reproductiove 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pradipta, v. and mustapha, i. 2016. the effect of indonesian velvet bean extract on the fertility of albino male mice. int j pharm pharm sci 8(8): 103-106. sedigh, a., modaresi, m. and pirestani, a. 2016. the effects of zinc supplement on fertility in male mice. journal of chem and pharm research 8(1): 66-70. sekar, s., elumalai, p. and seppan, p. 2009. dose and time-dependent effects of ethanolic extract of mucuna pruriens linn. seed on sexual behaviour of normal male rats. journal of ethnopharmacol, 122: 497501. shukla, k.k., ahmad, m.k., mahdi, a.a., shankhwar, s.n., jaiswar, s.p. and tiwari, s.c. 2010. “mucuna pruriens reduces stress and improves the quality of semen in infertile men” evid based complement alternat med, 7(1): 137-144 widya, f. 2012. giving effect supplementation zinc (zn) to total and sperm motility mice (mus musculus) balb/c males. thesis. fakultas ilmu gizi. universitas diponegoro. semarang winarni, s. 2010. pengaruh fraksi etanol 96% dan isolat biji koro benguk (mucuna pruriens) terhadap kualitas spermatozoa mencit (mus muculus) terpapar 2-metoksi etanol. tesis. universitas airlangga. surabaya. medical and health science journal, vol.4., no.1, february 2020 gambaran perilaku masyarakat terhadap terjadinya diare pada balita di wilayah lingkungan i,ii,iii,iv, daerah aliran sungai , kelurahan aur, kecamatan medan maimun, medan dicca brentazzoly br. tarigan*1, chardito renaldi siburian2, dhea sandhes barus3, angelina4, masdalena5 1,2,3,4,5 fakultas kedokteran universitas prima indonesia *corresponndent author: diccatarigan98@gmail.com correspondence: dicca brentazzoly br. tarigan @2020 medical and health science journal. 10.33086/mhsj.v4i1.1451 available at http://journal2.unusa.ac.id/index.php/mhsj 39 original article article info abstract article history: received january,31 2020 received in revised form february accepted february 26 2020 background diarrhea is a condition in which a person experiences defecation with a frequency of 3 times or more per day with the consistency of feces in liquid form. this is usually a symptom of a digestive tract infection. diarrhea is a common cause of death rates that occur in developing countries, the rate of the first cause of death under five (under dive years) throughout the world and where the second cause of infant mortality worldwide. this disease can be caused by various bacteria, viruses, and parasites. the infection spreads through contaminated food or drinking water. beside, it can occur from person to person as a result of poor personal and environmental hygiene. the environment constantly interacts with humans throughout time and time and plays an important role in the process of diseases in society, especially diarrhea in toddlers. objective this study was conducted to find out the description of community behavior towards the occurrence of diarrhea in toddlers. in this environment, environmental sanitation is inadequate, if the rainy season the location is prone to flooding because it is near a river basin. method a descriptive study with a cross sectional design, which was conducted in the environmental areas i,ii,iii,iv,watershed aur village, medan maimun district, medan in january 2020 with a sample of 60 people, namely mothers who have children under five by using a proportional sampling method. the measuring scale used in this study used a questionnaire. result the results of the research conducted obtained the level of knowledge, attitude, and action on community behavior is considered in the good category. it is said because the results of all the frequencies of the level of knowledge, attitude, action obtained are much higher than the percentage that is not good. conclusion from the results, it was found that although the behavior of this community was categorized well, there were still some people who had not implemented goog and correct behavior so that there were still those who got diarrhea, especially in toddlers. keywords: diarrhea, bacteria, viruses, parasites, environment, toddler kata kunci: diare, bakteri, virus, parasit, lingkungan, balita abstrak latar belakang: diare merupakan suatu kondisi dimana seseorang mengalami buang air besar dengan frekuensi sebanyak 3 atau lebih per hari dengan konsistensi tinja dalam bentuk cair. ini biasanya merupakan gejala infeksi saluran pencernaan. diare adalah penyebab umum pada tingkat kematian yang terjadi di negara berkembang, tingkat penyebab pertama kematian balita (di bawah lima tahun) di seluruh dunia dan dimana tingkat penyebab kedua kematian bayi di seluruh dunia. penyakit ini dapat disebabkan oleh berbagai bakteri, virus dan parasit. infeksi menyebar melalui makanan atau air minum yang terkontaminasi. selain itu, dapat terjadi dari orang ke orang sebagai akibat buruknya kebersihan diri dan mailto:diccatarigan98@gmail.com http://journal2.unusa.ac.id/index.php/mhsj medical and health science journal, vol.4., no.1, february 2020 lingkungan. lingkungan sangat berinteraksi secara konstan dengan manusia sepanjang waktu dan masa serta memegang peranan penting dalam proses terjadinya penyakit pada masyarakat terutama diare pada balita. tujuan: penelitian ini dilakukan yang bertujuan untuk mengetahui gambaran perilaku masyarakat terhadap terjadinya diare pada balita. di lingkungan ini sanitasi lingkungan belum memadai, apabila musim hujan lokasi ini rawan banjir karena berdekatan daerah aliran sungai. metode: penelitian bersifat deskriptif dengan rancangan cross-sectional, yang dilakukan di wilayah lingkungan i,ii,iii,iv, daerah aliran sungai kelurahan aur, kecamatan medan maimun, medan pada bulan januari tahun 2020 dengan jumlah sampel 60 orang yaitu ibu yang mempunyai balita dengan menggunakan metode proportional sampling. skala ukur yang digunakan dalam penelitian ini mengunakan kuesioner. hasil: hasil penelitian yang dilakukan didapatkan tingkat pengetahuan, tingkat sikap dan tingkat tindakan pada perilaku masyarakat ini masuk kategori baik, dikarenakan berdasarkan hasil semua frekuensi dari tingkat pengetahuan, tingkat sikap, tingkat tindakan yang didapatkan jauh lebih tinggi persentasenya dibandingkan dengan yang tidak baik. kesimpulan: dari hasil ditemukan walaupun perilaku masyarakat ini masuk kategori baik namun masih ada beberapa masyarakat yang belum menerapkan perilaku yang baik dan benar sehingga masih ditemukan ada yang mengalami diare terutama pada balita. @2020 medical and health science journal. 10.33086/mhsj.v4i1.1451 pendahuluan diare adalah penyebab umum pada tingkat kematian di negara berkembang, tingkat penyebab pertama kematian balita (bawah lima tahun) di seluruh dunia dan dimana tingkat penyebab kedua kematian bayi di seluruh dunia. kehilangan cairan pada tubuh karena diare dapat menyebabkan terjadinya dehidrasi dengan gangguan elektrolit seperti kurangnya kalium atau ketidak seimbangan garam lainnya pada tubuh. menurut world health organization (who) pada tahun 2009, diare sudah diperkirakan telah menyebabkan 1,1 juta kematian pada orang dewasa dan 1,5 juta kematian pada anak bawah lima tahun (balita).1 berdasarkan data yang dikeluarkan dari the united nations children’s fund (unicef) tercatat setiap 30 detik ada satu balita meninggal dunia karena diare.2 diare sudah menghilangkan nyawa 1,8 juta anak balita di negara berkembang. jumlahnya telah mengalami peningkatan dari 1,5 juta kematian dalam 20 tahun terakhir ini. kejadian per tahun kasus penyakit kejadian diare pada anak-anak berusia kurang dari lima tahun di negara berkembang diperoleh sebesar 2 miliar kasus dengan tingkat kejadian rata rata 3,2 kasus penyakit diare per anak. dalam bidang studi berbasis masyarakat, rasio antara anak laki-laki dan anak perempuan balita yang mengalami penyakit diare akut yaitu sebesar 1,2 : 1,4. hal itu penting dikarenakan pada beberapa negara (misalnya, di asia selatan) ditemukan jumlah penderita lebih besar pada anak laki-laki dibandingkan anak perempuan.2 diare adalah masalah tingkat kesehatan masyarakat pada negara berkembang seperti di negara indonesia karena ditemukan angka morbiditas dan mortalitas yang masih tinggi pada penyakit ini. survei morbiditas yang telah dilakukan oleh sub direktorat (subdit) diare departemen kesehatan republik indonesia (depkes ri) sejak tahun 2000-2010 terlihat kecenderungan naik dan tingginya insidens. pada tahun 2000, incidence rate (ir) (angka kejadian kasus baru) penyakit diare sebesar 301/1000 penduduk, tahun 2003 naik menjadi 374/1000 penduduk, tahun 2006 naik menjadi 423/1000 penduduk dan tahun 2010 menjadi 411/1000 penduduk.3,4 kejadian luar biasa (klb) diare juga masih sering terjadi dengan crude fatality rate (cfr) (angka kematian kasar) yang masih tinggi. berdasarkan data profil kesehatan indonesia (2016), terjadinya klb 40 medical and health science journal, vol.4., no.1, february 2020 diare tiap tahun dari tahun 2013 sampai 2016 dengan disertai peningkatan cfr (case fatality rate). data kementrian kesehatan indonesia (2016) menyatakan, jumlah kasus diare yang ditangani instansi di indonesia menurun tiap tahunnya. pada tahun 2016 penderita diare di indonesia yang ditangani sebanyak 46,4% dari jumlah penderita diare keseluruhan yang tercatat berjumlah 6.897.463 orang.5 berbagai jenis penyakit, diare masih dominan di kota medan. berdasarkan data dari badan pusat statistik provinsi sumatera utara 2017, didapatkan kasus diare lebih tinggi dengan 10.225 kasus dibandingkan dengan penyakit lainnya.5 dari sekitar 2.229.408 total penduduk kota medan, diperkirakan bahwa 26.025 diantaranya telah menderita diare, hal perkiraan ini dihitung dengan berdasarkan angka morbiditas (kesakitan) diare nasional tahun 2016, yaitu 270/1000 jumlah penduduk. angka perkiraan jumlah kasus dapat dijadikan sebagai target cakupan layanan kasus diare.6 diare pada balita berkaitan dengan faktor perilaku yang menyebabkan penyebaran kuman, terutama yang berhubungan dengan interaksi perilaku ibu dalam mengasuh anak dan faktor lingkungan dimana anak tinggal. pertama, faktor perilaku sebagai tingkat pertama yang sering terjadi sebagai penyebabnya yaitu terjadinya penyebaran kuman dan terjadinya peningkatan kejadian diare pada balita dan bayi yaitu tidak melakukan pemberian asi ekslusif secara teratur pada bulan pertama kehidupan balita, botol susu tidak dibersihkan dengan bersih, makanan disimpan disembarangan tempat, air minum yang digunakan tidak steril, tidak melakukan cuci tangan saat memasak, makan, menyuapi balita, sesudah buang tinja, sesudah membuang tinja balita dan bayi, serta sering membuang tinja disembarangan tempat. kedua, faktor lingkungan sebagai tingkat kedua yaitu pengunaan sarana air bersih dalam kehidupan sehari-hari dan kebiasan melakukan pembuangan tinja. lingkungan sangat berinteraksi secara konstan dengan manusia sepanjang waktu dan masa serta memegang peranan penting dalam proses terjadinya penyakit pada masyarakat terutama diare. contoh, kekurangan persediaan air bersih terutama dalam musim kemarau dapat menimbulkan penyakit diare dimana-mana.7 faktor pertama dan kedua akan selalu berinteraksi dengan perilaku manusia. diare pada anak menjadi sebuah masalah yang seharusnya dapat dicegah dan ditangani secara cepat dan benar. peran masyarakat sangat penting dan akan berkaitan pada pencegahan kejadian penyakit diare ini. peran masyarakat terutama sebagai pengasuh dengan balita sangat memiliki peran yang sangat penting dalam melakukan pencegahan penyakit diare ini. persepsi masyarakat yang salah akan pandangan penyakit yang telah diderita oleh sang anak akan bisa berdampak dan berpengaruh pada tindakan masyarakat dalam melakukan pencegahan terhadap kejadian penyakit diare tersebut.8 salah satu pencegahan diare secara sederhana pada balita yang dapat dipraktekkan dan dilakukan masyarakat yaitu menggunakan sabun saat mencuci tangan agar tangan tetap steril.9 dalam tindakan pencegahan yang dilakukan oleh beberapa ibu sangat kurang terutama kurang peduli dalam memperhatikan saat melakukan pemberian asi pada balita, air yang digunakan dalam kehidupan sehari-hari serta kurangnya kebiasaan mencuci tangan sebelum dan sesudah melakukan kegiatan, dan juga terutama ketika tangan yang masih kotor saat memberikan makan anaknya, sesudah buang air besar dan buang air kecil tidak mencuci tangan, membuang sampah sembarangan.9 kebiasaan berhubungan berat dengan perilaku. perilaku manusia pada akhirnya merupakan suatu aktivitas dari manusia itu sendiri. perilaku merupakan apa yang dikerjakan oleh organisme tersebut, baik yang dapat diamati secara langsung atau secara tidak langsung.9 sehingga situasi seperti ini masih tergolong tinggi terutama di kota medan terhadap terjadinya diare yang masih 41 medical and health science journal, vol.4., no.1, february 2020 merupakan ancaman kesehatan akibat faktor perilaku dan faktor lingkungan, apalagi di tempat ini sama sekali belum pernah dilakukan penelitian terutama pada masyarakat yang bertempat tinggal di daerah aliran sungai, di lingkungan ini sanitasi lingkungan belum memadai, apabila musim hujan lokasi ini rawan banjir karena berdekatan daerah aliran sungai. sebab karena itu peneliti tertarik untuk melakukan penelitian dengan judul: “gambaran perilaku masyarakat terhadap terjadinya diare pada balita di lingkungan i,ii,iii,iv, daerah aliran sungai, kelurahan aur, kecamatan medan maimun, medan.” metode penelitian penelitian dilakukan di wilayah lingkungan i,ii,iii,iv, daerah aliran sungai, kelurahan aur, kecamatan medan maimun,medan pada bulan januari 2020. penelitian ini mengunakan metode decriptive dengan menggunakan rancangan penelitian cross sectional, yaitu dengan dilakukan satu kali saja pengumpulan data untuk bisa melihat gambaran perilaku masyarakat terhadap terjadinya diare di wilayah lingkungan tersebut. populasi dan sampel yang dilakukan penelitian ini adalah ibu yang mempunyai balita. sampel yang dilakukan dalam penelitian ini dipilih melalui teknik proportional sampling. data yang digunakan yaitu data primer dimana data yang diambil oleh peneliti yang mengenai gambaran perilaku masyarakat terhadap terjadinya diare pada balita. data dikumpulkan dengan membagikan kuesioner pada responden ibu yang sesuai kriteria yaitu ibu yang mempunyai anak balita dengan cara home visite. penelitian ini dilakukan pada 60 ibu balita yang sudah ditentukan dan dihitung berdasarkan rumus proportional sampling. cara pengumpulan data yang dilakukan peneliti adalah dengan menggunakan kuesioner dan dilakukan untuk memperoleh data pada variabel perilaku ibu yang mempunyai balita yang terdiri dari pengetahuan, sikap dan tindakan. skala ukur yang digunakan menggunakan skala ordinal dan hasil ukur yang digunakan adalah pengetahuan, sikap dan tindakan didasarkan dan dinilai jika responden menjawab pertanyaan dengan jawaban yang sesuai maka diberikan dengan nilai 1 (baik), dan jika tidak sesuai dengan jawaban maka diberikan dengan nilai 0 (tidak baik). hasil penelitian pengisian kuesioner dilaksakan pada bulan januari 2020 yang dilakukan di wilayah lingkungan i,ii,iii,iv, daerah aliran sungai, kecamatan medan maimun, medan. jumlah sampel yang ditentukan adalah sebanyak 60 responden yang sesuai dengan kriteria yaitu ibu yang mempunyai balita. data yang sudah dikumpulkan serta diolah dan dianalisa dalam bentuk hasil tabel sebagai berikut: hasil penelitian yang digunakan adalah dengan menggunakan distribusi frekuensi jawaban responden berdasarkan pertanyaan yang sudah ditentukan per variabel agar dapat mengetahui setiap frekuensi jawaban yang didapatkan. tabel 1. distribusi frekuensi tingkat pengetahuan masyarakat terhadap terjadinya diare pada balita di wilayah lingkungan i,ii,iii,iv, daerah aliran sungai, kecamatan medan maimun, medan. penge tahuan tidak baik baik freku ensi percent (%) freku ensi percent (%) penyakit diare 27 45.0 33 55.0 penyebab diare 13 21.7 47 78.3 penularan daire 17 28.3 43 71.7 penderita diare 16 26.7 44 73.3 pencegahan diare 16 26.7 44 73.3 air sungai 9 15.0 51 85.0 dari hasil tabel 1 diatas diperoleh dan dapat dilihat bahwa tingkat pengetahuan masyarakat terhadap terjadinya diare pada balita di wilayah lingkungan i,ii,iii,iv, 42 medical and health science journal, vol.4., no.1, february 2020 kelurahan aur,kecamatan medan maimun, medan yang memiliki pengetahuan baik frekuensinya jauh lebih tinggi dan masuk golongan kategori baik dibandingkan dengan pengetahuan yang tidak baik dimana frekuensinya jauh lebih rendah dan masuk golongan kategori tidak baik. tabel 2. distribusi frekuensi tingkat sikap masyarakat terhadap terjadinya diare pada balita di wilayah lingkungan i,ii,iii,iv, daerah aliran sungai, kecamatan medan maimun, medan. sikap baik tidak baik frek uensi percent (%) frek uensi percent (%) pemberian oralite 43 71,7 17 28.3 penanganan diare 41 68.3 19 31.7 mencuci tangan 56 93.3 4 6.7 penyuluhan diare 51 85.0 9 15.0 kerja bakti 57 95.0 5.0 dari hasil tabel 2 diatas diperoleh dan dapat dilihat bahwa tingkat sikap masyarakat terhadap terjadinya diare pada balita di wilayah lingkungan i,ii,iii,iv,kelurahan aur,kecamatan medan maimun, medan yang memiliki sikap baik frekuensinya jauh lebih tinggi dan masuk golongan kategori baik dibandingkan dengan sikap yang kategori tidak baik dimana frekuensinya jauh lebih rendah dan masuk golongan kategori tidak baik. tabel 3. distribusi frekuensi tingkat tindakan masyarakat terhadap terjadinya diare pada balita di wilayah lingkungan i,ii,iii,iv, daerah aliran sungai, kecamatan medan maimun, medan. dari hasil tabel 3 diatas diperoleh dan dapat dilihat bahwa tingkat tindakan masyarakat terhadap terjadinya diare pada balita di wilayah lingkungan i,ii,iii,iv,kelurahan aur,kecamatan medan maimun, medan yang memiliki tingkat tindakan frekuensinya jauh lebih tinggi dan masuk golongan kategori baik dibandingkan dengan tindakan yang kategori tidak baik dimana frekuensinya jauh lebih rendah dan masuk golongan kategori tidak baik. pembahasan pengetahuan berdasarkan tabel 1, distribusi pengetahuan masyarakat diketahui bahwa pengetahuan yang didapatkan sudah sesuai dalam perilaku masyarakat karena hasil yang didapatkan mendapatkan kategori baik dengan frekuensi yang lebih tinggi dibandingkan dengan yang tidak baik. berdasarkan pendapat notoatmodjo (2011) menyimpulkan pengetahuan adalah faktor pendukung dalam perilaku seseorang dalam melakukan sesuatu. saat orang tersebut membentuk perilaku yang baru, maka orang tersebut harus tahu apa manfaat maupun arti perilaku bagi dirinya sendiri. setiap masyarakat terutama pada ibu balita yang ingin memiliki perilaku yang sehat apabila diri sendiri tahu tingkat kerugian dan kebahayaan yang dapat terjadi bila tidak melakukan hal yang sudah ditentukan.10 tingkat pengetahuan masyarakat terutama pada ibu balita mengenai penyakit diare sudah masuk kategori baik, hal ini dikarenakan bahwa sudah tingginya informasi 43 tindakan baik tidak baik freku ensi percen t (%) frek uensi percen t (%) memasak air minum 60 100 0 0.0 sarana air 60 100 0 0.0 yang dilakukan penderita diare 54 90.0 6 10.0 penyuluhan 58 96.7 3.3 medical and health science journal, vol.4., no.1, february 2020 dan penyuluhan yang didapatkan di lingkungan tersebut. sehingga informasi maupun pengetahuan yang sudah didapatkan dapat diketahui dari mana asal dan sumbernya. walaupun sudah masuk kategori baik tetap diharapkan upaya peningkatan pengetahuan dengan lebih meningkatkan kegiatan penyuluhan terutama diare dan perilaku hidup bersih dan sehat yang dapat dilakukan bersama-sama serta didampingi oleh petugas kesehatan agar dapat menambah wawasan yang lebih luas dan mudah memahami serta melakukan setiap tindakan dengan baik dan benar untuk menghindari terjadinya penyakit terutama diare pada balita. sikap berdasarkan tabel 2, distribusi sikap masyarakat diketahui bahwa sikap yang didapatkan sudah sesuai dalam perilaku masyarakat karena hasil yang didapatkan mendapatkan kategori baik dengan frekuensi yang lebih tinggi dibandingkan dengan yang tidak baik. sikap masyarakat terutama ibu balita merupakan tingkat kesatuan yang dapat menurunkan frekuensi angka kesakitan diare terutama pada balita. jika terjadi diare pada balita tetapi sikap terhadap skill ibu mendukung, jadi balita yang mengalami diare tidak mengalami dehidrasi baik ringan,sedang maupun berat dan angka kesakitan maupun kematian pada diare dapat menurun dan berkurang. menurut notoatmodjo (2011) perilaku baru yang diterima melalui proses (awareness,interest, evaluation, trial dan adoption) didasarkan oleh tingkat pengetahuan, tingkat kesadaran dan tingkat sikap yang positif, maka perilaku itu akan terjaga bertahan. hasil penelitian yang didapatkan memang sikap masyarkat terutama pada ibu balita ini sudah masuk kategori baik tetapi masih ada didapatkan balita yang mengalami diare.10 sikap yang sudah baik saja belum tentu dapat dan cukup untuk mengubah perilaku diri sendiri apalagi seseorang dan sebuah sikap belum bisa terwujud secara otomatis dalam melakukan suatu tindakan. supaya terwujudnya sikap tersebut menjadi hal nyata diperlukan faktor pendukung atau hal yang memungkinkan, yaitu fasilitas. setelah seseorang sudah dapat mengetahui suatu rangsangan yaitu objek kesehatan, lalu selanjutnya dilakukan pengadaan penilaian maupun pendapat pada apa yang sudah dilihat dan diketahui, dan proses yang dapat diharapkan maka seseorang tersebut akan dapat melaksakan dan melakukan apa yang disikapinya maupun yang diketahui ( yang dinilai baik).10 tindakan berdasarkan tabel 3, distribusi tindakan masyarakat diketahui bahwa tindakan yang didapatkan sudah sesuai dalam perilaku masyarakat karena hasil yang didapatkan mendapatkan kategori baik dengan frekuensi yang lebih tinggi dibandingkan dengan yang tidak baik. menurut notoatmodjo (2011) tindakan seseorang terutama ibu balita yang dapat bertindak maupun melakukan perilaku baik tanpa terlebih dahulu mengetahui apa makna rangsangan yang sudah diterima, dengan sebutan lain tindakan seseorang tidak selamanya harus didasarkan oleh pengetahuan maupun sikap.10 dari hasil penelitian yang sudah dilakukan di wilayah lingkungan i,ii,iii,iv,kelurahan aur,kecamatan medan maimun,medan, menunjukkan bahwa perilaku ibu yang mempunyai balita dalam tingkat pengetahuan, tingkat sikap maupun tingkat tindakan sangat berpengaruh dan berdampak bagi balita yang mengalami diare. perilaku ini sangat memicu akan terjadinya diare jika tidak memahami dan menerapkan sebelum dan sesudah makan lupa mencuci tangan, kebersihan lingkungan yang tidak terjaga terutama dibagian kondisi kamar mandi dan jamban, tempat bermain anak yang kurang steril, air bersih yang dikelola tidak steril, makanan yang diolah tidak dimasak sempurna, sampah dan tinja dibuang di sembarangan 44 medical and health science journal, vol.4., no.1, february 2020 tempat. berdasarkan hasil yang sudah didapatkan bahwa diperoleh perilaku masyarakat terutama ibu yang mempunyai balita dalam penelitian ini masuk dalam kategori golongan baik karena lebih tinggi frekuensinya dibandingkan dengan kategori yang tidak baik, namun saat penelitian masih dijumpai beberapa ibu balita dimana balitanya didapatkan mengalami diare karena tidak tahu apakah ibu balita tersebut benar-benar menerapkan perilaku tersebut dengan baik dan benar atau mengabaikan semua ini seakan akan semuanya baik-baik saja. kesimpulan berdasarkan hasil penelitian yang sudah dilakukan oleh peneliti mengenai gambaran perilaku masyarakat terhadap terjadinya diare pada balita di wilayah lingkungan i,ii,iii,iv, daerah aliran sungai, kelurahan aur, kecamatan medan maimun, medan : a) persensi tingkat pengetahuan masyarakat terutama pada ibu balita tentang perilaku terhadap terjadinya diare pada balita adalah didapatkan dengan tingkat pengetahuan kategori baik dengan frekuensi didapatkan lebih tinggi. b) persensi tingkat sikap masyarakat terutama pada ibu balita tentang perilaku terhadap terjadinya diare pada balita adalah didapatkan dengan tingkat sikap kategori baik dengan frekuensi didapatkan lebih tinggi. c) persensi tingkat tindakan masyarakat terutama pada ibu balita tentang perilaku terhadap terjadinya diare pada balita adalah didapatkan dengan tingkat tindakan kategori baik dengan frekuensi didapatkan lebih tinggi. d) kepedulian pengetahuan,sikap, tindakan masyarakat yaitu ibu balita berdasarkan frekuensi tergolong baik, sudah tahu mana yang lebih baik dilakukan dan yang tidak baik dilakukan tapi tidak tahu apakah benar-benar diterapkan atau tidak. dari hasil yang sudah dilakukan peneliti wilayah lingkungan i,ii,iii,iv, daerah aliran sungai, kelurahan aur, kecamatan medan maimun, medan, maka peneliti akan menyampaikan hal-hal sebagai berikut : 1. pada masyarakat , hasil penelitian ini akan dapat bermanfaat dan serta meningkatkan perilaku masyarakat terutama pada ibu yang mempunyai balita dan dapat memahami serta membuka diri untuk menerima dan menerapkan informasi yang diberikan tentang pencegahan diare pada balita. 2. terkhusus bagi tenaga kesehatan, dari hasil penelitian ini dapat dijadikan sebagai informasi untuk program-program penyuluhan untuk wilayah-wilayah berikutnya. 3. bagi institusi pendidikan dari hasil penelitian ini dapat digunakan sebagai sumber referensi maupun bacaan untuk penelitian selanjutnya terkhususnya mengenai tentang diare pada balita. 4. bagi peneliti selanjutnya dapat mengembangkan dan menggunakan lebih banyak sampel serta kuesioner dan variabel untuk mendapatkan hasil yang lebih akurat sesuai harapan. daftar pustaka 1. world health organization. country office for indonesia pedoman pelayanan kesehatan anak di rumah sakit rujukan tingkat pertama di kabupaten/ who ; alihbahasa, tim adaptasi indonesia. jakarta : who indonesia,2008. 2. diare balita: suatu tinjauan dari bidang kesehatan masyarakat / oleh oksfriani jufri sumampouw, dkk..—ed.1, cet. 2- yogyakarta: deepublish, agustus 2017. 3. katalog dalam terbitan kementerian kesehatan ri indonesia. kementerian kesehatan. pusat data dan informasi profil kesehatan indonesia tahun 2011,-jakarta : kementerian kesehatan ri. 2012 4. kementerian kesehatan republik indonesia. 2011. situasi diare di indonesia. jakarta: buletin jendela data dan informasi kesehatan. 5. badan pusat statistik sumatera utara. 2017. jumlah kasus hiv/aids, ims, 45 medical and health science journal, vol.4., no.1, february 2020 dbd, diare, tb, dan malaria. medan : dinas kesehatan provinsi sumatera utara. 6. katalog dalam terbitan kementerian kesehatan ri indonesia. kementerian kesehatan ri. sekretariat jenderal profil kesehatan indonesia tahun 2017. -jakarta : kementerian kesehatan ri. 2018 7. sucipto. 2019. kesehatan lingkungan. yogyakarta: gosyen publishing. 8. muswita. 2016. penyakit anak sehari-hari menangani anak sebelum ke dokter. jakarta: sagung seto. 9. nagiga & arty, n. w. 2009. penyakit anak sehari-hari. jakarta: gramedia 10. notoatmodjo, s. 2011. kesehatan masyarakat ilmu dan seni: edisi revisi. jakarta: rineka cipta. 46 medical and health science journal 2023 february, vol 07 (01) medical and health science journal available at http://journal2.unusa.ac.id/index.php/mhsj; doi: 10.33086/mhsj.v7i1.3846 pissn 2549-7588. eissn 2549-7596 original article comparison of risk factors use personal protection equipment and exposure to sulphate content with irritant contact dermatitis in car washing officers in malang city dwi nurwulan pravitasari1 aliyyudestrina windya nerdenaesti2 syahdan millenia danurwendra2 anung putri illahika3 1departement of dermato venerology, faculty of medicine, muhammadiyah malang university, indonesia 2faculty of medicine, muhammadiyah malang university, indonesia 3department of anatomy, faculty of medicine, muhammadiyah malang university, indonesia *correspondent author: vitha_sabrinaviancha@umm.ac.id article info article history: received: january 26, 2023 received in revised form: may 16, 2023 accepted: june 14, 2023 keywords: irritant contact dermatitis, personal protective equipment, sulfate, car wash employees abstract background: irritant contact dermatitis (icd) is an occupational disease that involves non-immunological inflammatory mechanisms of the skin, resulting from a response to exposure to irritants, physical, or biological. icd disease often occurs in car wash employees who are exposed to laundry soap containing sulfate. most of the factors that cause icd are the length of exposure to chemicals or from the workers themselves such as knowledge, use of personal protective equipment, and personal hygiene. the purpose of this study was to determine the effect of using personal protective equipment (ppe) and exposure to sulfate content of car wash soap on the incidence of icd in car wash employees in the city of malang with and without a history of skin disease. method: the research method uses an analytic observational research type with a cross sectional design. the samples studied were 84 respondents who were car wash employees in the city of malang, both those who had a history of skin diseases (39 respondents) and those who did not have a history of skin diseases (45 respondents). data were analyzed using univariate and bivariate tests with spss application. results: the results of the chi square test showed that there were significant differences in risk factors (p < 0.05) on the incidence of icd. conclusion: the conclusion of this study is there is an effect of the use of ppe and exposure to sulfate content on the incidence of icd in car wash employees in the city of malang with and without a history of skin diseases. medical and health science journal http://journal2.unusa.ac.id/index.php/mhsj paravitasari et al medical and health science journal 2023 february vol.07 (01) page 22 of 29 introduction irritant contact dermatitis (icd) is inflammation of the skin, resulting from a response to exposure to an irritant, physical, or biological substances that come into contact with the skin without being mediated by an immunological respons.[1]icd is a non-specific response of the skin to direct chemical damage that releases inflammatory mediators, especially epidermal cells. [2]approximately 80% of individuals with occupational contact dermatitis involve hands and irritant contact dermatitis (icd). epidemiological studies in indonesia showed that 97% of 389 cases of dermatitis were contact dermatitis, of which 66.3% were irritant contact dermatitis and 33.7% were allergic dermatitis. [3] approximately 80% 90% of cases of irritant contact dermatitis are caused by exposure to irritants in the form of chemicals and solvents. inflammation can occur after a single exposure or repeated exposure [7]. irritant contact dermatitis and allergic contact dermatitis can appear with three morphological patterns: acute, subacute, and chronic phases. the acute-phase reaction in icd usually reaches its peak within minutes to hours after exposure and then begins to heal or is commonly referred to as the de-crescendo. [2]. icd will appear after the first exposure to a strong irritant. subacute and chronic icd is characterized by hyperkeratosis, fissures, and skin blisters with clear lesion boundaries[4]. the risk factors for icd consist of two factors, endogenous factors and exogenous factors. endogenous factors include factors in individuals such as genetics, gender, age, ethnicity, skin type, and a history of atopy.[5] while exogenous factors are the properties of irritant chemicals such as physical state, concentration, amount, polarization, ionization, carrier material, and solubility.6 the types of irritants that usually cause icd include animal products, cosmetics, detergents, cosmetics, solvents, tear gas, topical medications, and water and work in a wet environment.[9] continuous and repeated use of risky materials can cause icd. some examples of materials that can cause icd include soapy water, cleaners, spirits, chemicals and work related to water (wet). previous research explained that the duration of contact with chemicals also greatly influences the incidence of icd because the longer the contact with chemicals will further damage skin cells to the deeper layers of cells and cause complaints to get worse. from the results of research that was conducted on workers who were in contact with one of the chemicals, namely acetic acid, for > 3 hours, they had a risk of inflammation or skin irritation that would cause icd. [19] contact dermatitis accounts for 95% of causes of occupational skin disease, 80% of which is irritant contact dermatitis which is often caused by cumulative exposure to weak irritants such as soap and water. work related to repeated exposure and types of work related to water, one of which is car wash employees who are directly exposed to car wash soap containing chemicals. chemicals that are often used as soap ingredients are anionic surfactants, where anionic surfactants have superior solubility and cleaning power, therefore these surfactants are often used as detergents and soaps. [10] one of the jobs related to repeated exposure and types of work related to water is car wash employees who are directly exposed to car wash soap that contains chemicals. chemicals often used as soap ingredients are anionic surfactants, where anionic surfactants have superior solubility and cleaning power; therefore, these surfactants are paravitasari et al medical and health science journal 2023 february vol.07 (01) page 23 of 29 often used as detergents and soaps. in this regard, sulfate is the oldest anionic surfactant that can produce foam as a suitable wetting agent and the main ingredient in detergents.[10] factors obtained from work are the length of exposure to chemicals and the work period or from the workers themselves, such as knowledge, use of personal protective equipment, and personal hygiene. personal protective equipment (ppe) is a device designed as a barrier against the penetration of substances, solid, liquid, or air particles to protect the wearer from injury or the spread of infection or disease. [20]from introduction above, a research was made to explain the comprarison of risk factor use personal protection equipment and exposure to sulphate content with irritant contact dermatitis in car washing employees. methods the research method uses an analytic observational research type with a cross-sectional design. the study was conducted by distributing questionnaires to 84 car wash employees in malang city with a history of skin disease (39 respondents) and without a history of skin disease (45 respondents). the research was carried out based on a permit with the number no.e.5.a/260/kepkumm/xii/2019 from the umm health research ethics commission, and each respondent had signed an informed consent. data analysis processed using using the statistical package for the social science (spss) 25.0 program. univariate analysis was carried out to describe the characteristics of each variable presented in the form of a frequency distribution because the research data was categorically scaled. then bivariate analysis using data analysis techniques chi-square and old ratio (or) (sig. < 0.05) to assess the strength of the relationship between variables the sulfate level test was conducted using the spectrophotometric method with 200x and 400x dilutions. the dilution depends on the concentration of soap in each sample where the more concentrated the soap, the more dilution so that the results of the concentration are the same; spectrophotometric analysis was carried out at the laboratory of analytical chemistry, state university of malang. results this research involves 84 car washing employees in malang city who had history of skin disease 39 respondents and those who didn’t have a history of skin disease 45 respondents. the characteristic respondents was show in table 1. table 1: characteristic of respondents no. characteristics n % 1. icd yes have skin disease history 20 51,3% didn’t have skin disease history 27 60% no have skin disease history 19 48,7% didn’t have skin disease history 18 40% 2. ppe yes have skin disease history 9 23,1% didn’t have skin disease history 19 42,2% no paravitasari et al medical and health science journal 2023 february vol.07 (01) page 24 of 29 have skin disease history 30 76,9% didn’t have skin disease history 26 57,8% 3. sulfate content <1% have skin disease history 25 64,1% didn’t have skin disease history 23 51,1% >2% have skin disease history 14 35,9% didn’t have skin disease history 22 48,9% based on table 1 the number of respondents who experience icd mostly have skin disease history 60%. number of respondents who not experience icd mostly didn’t have skin disease history 48,7%. the number of respondents who use ppe mostly didn’t have skin disease history 42,2%. number of respondents who not use ppe mostly have skin disease history 48,7%. the number of respondents who use car wahing soap with sulfate content < 1% mostly have skin disease history 64,1%. number of respondents who use car washing soap with sulfate content > 2% mostly didn’t have skin disease history 48,9%. table 2: spectrophotometer test results sulfate content no. sample code sulfate (mg/l) % 1. sample a 98,0224 3,9% 2. sample b 53,2979 1% 3. sample c 7,2827 0,1% 4. sample d 115,0602 4,6% 5. sample e 14,0269 0,2% table 2 shows the results of the spectrophotometric test for the sulfate content of each sample. samples a and d were tested using a 400x dilution and obtained the percentage of sulfate content in the sample >1%. samples b, c, and e were tested using a 200x dilution and obtained the percentage of sulfate content in the sample >1%. figure 1: the palms of a car wash employee figure 1 shows polymorphic efflorescence (erythema, edema, papules, vesicles, scales, lichenification) and complaints of itching. paravitasari et al medical and health science journal 2023 february vol.07 (01) page 25 of 29 table 3: relationship between use of personal protective equipment (ppe) and incidence of icd in employees with no history of skin diseases based on the results of the chi-square test in table 3, it is obtained sig = 0.007 (sig < 0.05), which concludes that there is a significant relationship between the use of ppe and the incidence of icd in car wash employees in malang city who do not have a history of skin disease. the amount of or obtained is 5,714 with 95% ci (1,551 – 21,058). this means that car wash employees who do not have a history of skin disease and do not wear ppe have 5,714 times more likely to experience icd than those who use ppe at work. an or value > 1 can also mean that employees who do not use ppe increase the risk of icd even though they have no history of skin disease. table 4: the relationship between the use of personal protective equipment (ppe) with icd incidence in employees with a history of skin diseases use of ppe incidence of icd p value icd no icd total f % f % f % not using ppe 17 85% 13 68.4% 30 76.9% 0.273 using ppe 3 15% 6 31.6% 9 23.1% total 20 100% 19 100.0% 39 100% based on the results of the chi-square test in table 4, it is obtained sig = 0.273 (sig > 0.05), which concludes that there is no significant relationship between the use of ppe and the incidence of icd in car wash employees in malang city who have a history of skin diseases. although there is no statistically significant relationship, clinically, it can be seen that more employees who use ppe do not have icd (31.6%) than had icd (15%). use of personal protective equipment (ppe) incidence of icd p value or (ci 95%) icd no icd total f % f % f % not using ppe 20 74.1% 6 33.3% 26 57.8% 0.007 5.714 (1.55121.058) using ppe 7 25.9% 1 2 66.7% 19 42.2% total 27 100.0% 1 8 100.0% 45 100% paravitasari et al medical and health science journal 2023 february vol.07 (01) page 26 of 29 table 5: the relationship between exposure to sulfate content with icd incidence in employees with no history of skin diseases exposure to sulfate content incidence of icd p value icd no icd total f % f % f % <1% 12 44.4% 11 61.1% 23 51.1% 0.273 >2% 15 55.6% 7 38.9% 22 48.9% total 27 100.0% 18 100.0% 45 100% based on the results of the chi-square test in table 5, it was obtained sig = 0.273 (sig > 0.05) which concluded that there was no significant relationship between exposure to sulfate content and the incidence of icd in car wash employees in malang city who did not have a history of skin disease. although there is no statistically significant relationship, it can be seen clinically that employees exposed to sulfate >2% tend to have more icd and vice versa. these employees exposed to sulfate <1% tend to be more likely not to have icd. table 6 : the relationship between exposure to sulfate content with icd incidence in employees with a history of skin diseases exposure to sulfate content incidence of icd p value or (ci 95%) icd no icd total f % f % f % <1% 9 45% 16 84.2% 25 64.1% 0.011 0.153 (0.034 – 0.698) >2% 11 55% 3 15.8% 14 35.9% total 20 100.0% 19 100.0% 39 100% based on the results of the chi-square test in table 6, it was obtained sig = 0.011 (sig < 0.05) which concluded that there was a significant relationship between exposure to sulfate content and the incidence of icd in car wash employees in malang city who had a history of skin diseases. the or obtained is 0.153 with 95% ci (0.034 – 0.698). car wash employees who have a history of skin disease and are exposed to sulfate <1% have 0.153 times more likely to experience icd than those exposed to sulfate >2% discussion this study showed that out of 84 respondents, there were 45 respondents who had no history of skin diseases and there were 39 who had a history of skin diseases. of the 45 respondents who did not have a history of skin diseases employees who experienced the occurrence of icd, 27 respondents, the remaining 18 people were not affected by icd. for those who had a history of paravitasari et al medical and health science journal 2023 february vol.07 (01) page 27 of 29 skin diseases from 39 car wash employees, the icd incident was 20 respondents and 19 people were not affected by icd. research by zania et al (2018) which concluded that there was no significant relationship between a history of skin disease and the incidence of icd. the results of observations made in latambaga district kolaka regency said that this could happen because previously, employees who had a history of skin diseases had completely recovered either using treatment or not at all. [11] however, these results are not following the theory presented by lurati (2015) which states that workers with a history of skin diseases will be at higher risk of developing icd because workers with a history of skin disorders have skin disorders where the epidermal barrier in the skin is disrupted. , there is increased transepidermal water loss and increased permeability of allergens and irritants. [12] the results of this study were seen in several car wash workers where the condition of the hands showed an efflorescence in the form of polymorphism, namely erythema, edema, papules, vesicles, scales, lichenification (figure 1). this condition is by nedorost (2019) statement that skin efflorescence in icd is characterized by scales, mild erythema, blisters, or erosions limited to the manus and fingers; this usually occurs in someone who works in wet work. [14] based on table 3 concludes that there is a significant relationship between the use of ppe and the incidence of icd in car wash employees in malang city who do not have a history of skin disease. the amount of or obtained is 5,714 with 95% ci (1,551 – 21,058). this means that car wash employees who do not have a history of skin disease and do not wear ppe have 5,714 times more likely to experience icd than those who use ppe at work. research by chafidz et al (2018) which states that there is a relationship between the use of ppe with the incidence of contact dermatitis on tofu workers. this happens because of the skin about cooking process workers in the filtering section is in direct contact with the tofu coagulation solution causing each employee to have a high risk of contact dermatitis because they do not use ppe. [15] but the results of this study contradict the results of research from prakoso, 2018 which states that the use of ppe is not associated with the incidence of irritant contact dermatitis in motorized vehicle steam workers in east ciputat district. one of the factors that contributed to this study when it was associated with age and work experience was that younger workers had less experience than older workers, so older workers were more experienced and knew the irritants used and paid more attention to safety and health. [16] table 4 showed there is no relationship between the use of personal protective equipment (ppe) with the incidence of icd in employees who have a history of skin diseases; this result is supported by lurati (2015), factors that cause icd risk, such as a history of previous skin diseases that cause workers with a history of skin diseases will be at higher risk of developing icd because of the disruption of the epidermal barrier in the skin, increased transepidermal water loss and increased permeability of allergens and irritants. another factor is the age and work experience of the employee, where the longer the employee's work experience, the more experienced the employee will be and know the irritant materials used and pay more attention to their safety and health.[12] table 5 showed there is no relationship between exposure to sulfate and the incidence of icd in employees who do not have a history of skin paravitasari et al medical and health science journal 2023 february vol.07 (01) page 28 of 29 disease, but this result is not by the theory; we know that sulfate is the oldest anionic surfactant that can produce foam, as a suitable wetting agent and as the main ingredient is detergent. the use of soap containing sulfate should not be used every day with long exposure because it has a negative effect on cosmetics, such as skin irritation in contact with the skin for a long time, it will be safe if the concentration is < 1%.[17,18] table 6 shows there is relationship between exposure to sulfate and the incidence of icd in employees with a history of skin disease. these results are consistent with the theory that irritants are physical and chemical agents that can cause cellular damage if they contact the skin for a long time and in high concentrations. detergents, surfactants, disinfectants, and antiseptics are the substances that most often cause occupational dermatitis, both irritant contact dermatitis (icd) as much as 42% and allergic contact dermatitis 26.3%. [39] conclusion the conclusion obtained is that the use of ppe is known to reduce the intensity of sulfate exposure to the incidence of icd in car wash employees in the city of malang with and without a history of skin disease. conflict of interest the author started there is no conflict of interest. references 1. perdoski. panduan praktik klinis bagi dokter spesialis kulit dan kelamin. jakarta: indonesia; 2017. 207–209 p. 2. litchman g, nair p, atwater a. contact dermatitis [internet]. statpearls. 2020 [cited 2021 jan 16]. available from: https://www.ncbi.nlm.nih.gov/books/nbk4 59230/#_nbk459230_pubdet_ 3. perdoski. majalah ilmiah dermatovenerologica indonesian. majalah ilmiah dermato-venerologica indonesia. 2019; 4. novak-bilić g, vučić m, japundžić i, meštrović-štefekov j, stanić-duktaj s, lugović-mihić l. irritant and allergic contact dermatitis – skin lesion characteristics. acta clin croat. 2018;57(4). 5. djuanda a, suriadiredja a, sudharmono a, wiryadi b, kurniati d, daili e. ilmu penyakit kulit dan kelamin. jakarta: indonesia: fakultas kedokteran universitas indonesia; 2016. 6. hudyono j. dermatitis akibat kerja. majalah kedokteran indonesia; 2002. 7. nofiyanti a. l., d. i. anggraini, and a. miftah, “dermatitis kontak iritan kronis pada pegawai laundry,” j. medula unila, vol. 7, no. 3, pp. 1–5, 2017. 8. wijaya i, darmada i, rusyati l. edukasi dan penatalaksanaan dermatitis kontak iritan kronis di rsup sanglah denpasar bali tahun 2014/2015. e-journal medika. 2016;5(8). 9. sonia nb, pembroke n, luz f. irritant contact dermatitis. clin rev allergy immunol. 2019; 10. okasaka m, kubota k, yamasaki e, yang j, takata s. evaluation of anionic surfactants effects on the skin barrier function based on skin permeability. pharm dev technol. 2019;24(1). 11. zania e, junaid, ainurafiq. faktor-faktor yang berhubungan dengan kejadian dermatitis kontak pada nelayan di kelurahan induha kecamatan latambaga paravitasari et al medical and health science journal 2023 february vol.07 (01) page 29 of 29 kabupaten kolaka tahun 2017. jurnal ilmiah mahasiswa kesehatan masyarakat. 2018;3(3). 12. lurati ar. occupational risk assessment and irritant contact dermatitis. workplace health saf. 2015;63(2). 13. wharf c. background review for sodium lauryl sulfate used as an excipient. committee for human medicinal products. 2015;44(july). 14. nedorost st. irritant dermatitis. in: fitzpatrick’s dermatology. 7th ed. united states: mcgrawhill; 2019. 15. chafidz m, dwiyanti e. hubungan lama kontak, jenis pekerjaan dan penggunaan apd dengan kejadian dermatitis kontak pada pekerja tahu, kediri. the indonesian journal of occupational safety and health. 2018 mar 22;6(2):156. 16. prakoso hd. hubungan lama kerja dengan dermatitis kontak pada karyawan cuci mobil. skripsi-2017. 2018. 17. azarmi, r., ashjaran, a., 2015, review article: type and application of some common surfactants, j. chem pharm res., vol.7(2), 632-40 18. cline a, uwakwe ln, mcmichael aj. no sulfates, no parabens, and the “no-poo” method: a new patient perspective on common shampoo ingredients. cutis. 2018;101(1). 19. pradaningrum s, lestantyo d, jayanti s, 2018, hubungan personal hygine, lama kontak, dan masa kerja dengan gejala dermatitis kontak iritan pada pengrajin tahu mrican semarang, jurnal kesehatan masyarakat, volume 6, no.4 issn: 23563346. 20. kemenkes ri, 2020, petunjuk teknis alat pelindung diri (apd) dalam menghadapi wabah covid-19. 21. lodde b, paul m, roguedas-contios am, eniafe-eveillard mo, misery l, dewitte jd, 2012, occupational dermatitis in workers exposed to detergents, disinfectants, and antiseptics. skinmed 10(3):144–150 4_mhsj-ok 23 depigmenting agent melanotoksik pada pengobatan melasma winawati eka putri 1, yuli kurniawati2, tantawi djauhari 3 1 fakultas kesehatan, universitas nahdlatul ulama surabaya 2,3bagian/departemen ilmu kesehatan kulit dan kelamin fk unsri/rsupmh e-mail: : winawidagdo@unusa.ac.id1 abstract: human skin color is determined by melanin pigment,either eumelanin or feomelanin. melanogenesis is a melanin synthesized process that is initiated with tirosin oxidation to dopaquinone by tirosinase, and then auto-oxidation to dopa and dopachrome. eumelanin are formed from dopachrome, while pheomelanin from dopaquinone with the presence of cysteine or gluthathione. hyperpigmentation disorders like melasma, are difficult to treat especially in dark skinned individuals. treatment of melasma can be topical or physical. topical agent can use depigmenting agent, either individual or combination with other. depigmenting agent can be melanotoxic or toxic to melanocyte which can be cell killing or cell damage. hydroquinone, monomethyl of hydroqunone, n-acetyl-4-scysteaminylphenol ,and azelaic acid are depigmenting agents melanotoxic. majority of those agents act as tirosinase inhibitors which cause deactivation of tirosinase. the use of those agents in combination are better to minimalize side effect of agents. keywords: melasma, melanogenesis, depigmenting agents, melanotoxic abstrak: warna kulit manusia ditentukan oleh pigmen melanin baik eumelanin maupun feomelanin. melanogenesis adalah proses pembentukan melanin yang diawali dengan oksidasi tirosin menjadi dopaquinone oleh tirosinase, kemudian autooksidasi menjadi dopa dan dopachrome. eumelanin akan dibentuk dari dopachrome, sedangkan feomelanin akan dibentuk dari dopaquinone dengan bantuan sistein atau gluthatione. kelainan hiperpigmentasi, seperti melasma, sulit diobati terutama pada individu kulit gelap. pengobatan melasma dapat berupa pengobatan topikal atau juga dengan pengobatan fisik. obat topikal dapat menggunakan depigmenting agent baik sendiri maupun kombinasi. depigmenting agent (da) dapat bersifat melanotoksik atau toksik terhadap melanosit yang dapat berupa cell-killing atau kerusakan sel. depigmenting agent melanotoksik dapat berupa hydroquinone, monomethyl of hydroqunone, n-acetyl-4-s-cysteaminylphenol, dan azelaic acid.. sebagian besar obat tersebut bekerja sebagai inhibitor tirosinase yang dapat menyebabkan deaktivasi tirosinase. penggunaan obat-obat tersebut secara kombinasi lebih baik untuk meminimalkan efek samping obat. kata kunci: melasma, melanogenesis, depigmenting agent, melanotoksik pendahuluan melanin merupakan pigmen yang berperan penting dalam melindungi kulit manusia dari efek berbahaya seperti radiasi sinar ultraviolet (uv), berbagai macam obat, dan bahan kimia. pigmen ini menentukan penampakan fenotipik dan ras. kelainan akumulasi jumlah melanin di kulit seperti melasma, dapat menjadi suatu masalah estetika bagi pasien.1 melasma merupakan kelainan didapat yang umum terjadi terutama pada wajah, ditandai dengan patch hiperpigmentasi, simetris dengan tepi iregular. kelainan ini disebabkan oleh peningkatan melanin dalam epidermis dan/atau dermis akibat kehamilan, kontrasepsi oral, dan pajanan sinar matahari.2 depigmenting agent (da) adalah obat yang dapat menyebabkan depigmentasi atau amelanosis akibat kehilangan seluruh melanin pada epidermis.3 menurut cara kerjanya, da terbagi menjadi beberapa kelompok yaitu kelompok inhibitor tirosinase, inhibitor transfer melanosom, medical and health science journal, vol. 2, no. 2, august 2018 24 melanocyte-cytotoxic agent, dan lainnya.4 keberhasilan pengobatan membutuhkan kombinasi dua atau lebih obat yang bekerja dengan mekanisme berbeda untuk mencapai efek sinergis.1 depigmenting agent melanocytecytotoxic atau melanotoksik dapat mengakibatkan kematian atau kerusakan melanosit.5 depigmenting agent melanotoksik meliputi hydroquinone, monomethyl of hydroquinone, nacetyl-4-s-cysteaminylphenol,kojic acid, azelaic acid. kelompok obat tersebut digunakan sebagai pengobatan kelainan hiperpigmentasi seperti melasma.4,6 tujuan pengobatan melasma adalah mengurangi proliferasi melanosit, menghambat pembentukan melanosom, dan degradasi melanosom. pengobatan melasma epidermal lebih mudah daripada melasma dermal karena melanin terdapat pada lapisan atas kulit sehingga lebih mudah dicapai oleh obat topikal seperti da.7 dalam tinjauan pustaka ini akan dibahas mengenai melanogenesis, jenis, cara kerja, dan efek samping da melanotoksik untuk pengobatan melasma. melanogenesis komponen warna kulit normal dipengaruhi oleh melanin, hemoglobin (oksihemoglobin dan deoksihemoglobin) dan karoten.8 melanin dihasilkan dari tirosin melalui serangkaian reaksi berupa oksidasi terhadap dopaquinone. enzim yang berperan dalam reaksi tersebut adalah tirosinase, yang disintesis oleh sel dendritik yang berasal dari neural crest. tirosinase merupakan protein dengan daerah aktif mempunyai dua atom copper yang mengikat molekul oksigen dan aktif dalam organel intraselular (melanosom) yang merupakan tempat pembentukan melanin. melanin menumpuk di matriks protein untuk membentuk granul melanin. pemeriksaan aktivitas enzim tirosinase pada granul melanin menunjukkan bahwa tirosinase menjadi inaktif pada melanosom yang telah termelanisasi. hal ini dapat disimpulkan bahwa tirosinase inaktif akibat produknya sendiri.1 melanogenesis yang terjadi dalam melanosom, dapat dilihat pada gambar 1 dan 2, dimulai dari oksidasi tirosin menjadi dopaquinone dengan tirosinase. dopaquinone selanjutnya mengalami autooksidasi menjadi dopa dan dopachrome. dopa juga merupakan substrat tirosinase dan diubah lagi menjadi dopaquinone oleh tirosinase. dua tipe melanin yang disintesis dalam melanosom adalah eumelanin dan feomelanin. eumelanin merupakan polimer yang tidak larut dan berwarna coklat kehitaman, sedangkan feomelanin merupakan polimer yang larut dan mengandung sulfur berwarna kuning, merah cerah.10 eumelanin terbentuk melalui serial reaksi oksidasi dari dihydroxyindole (dhi) dan dihydroxyindole-2carboxylic acid (dhica), yang merupakan produk dari dopachrome. feomelanin terbentuk dari dopaquinone yang akan diubah menjadi cysteinyldopa atau gluthathionyldopa dengan bantuan cystein atau gluthatione.11 individu dengan kulit gelap memiliki sebagian besar eumelanin dan sedikit feomelanin.7 melanin bermigrasi ke ujung dendrit melanosit melalui mikrotubul dan menggunakan filamen miosin v dan dynein motor. tiap melanosit berhubungan dengan sekitar 36 keratinosit membentuk epidemal melanin unit.4 melanogenesis dapat menghasilkan intermediate reaktif yang dapat berbahaya untuk melanosit dan mempunyai efek toksik pada jaringan sekitar. reaktivitas dopaquinone dan orthoquinone yang terbentuk selama melanogenesis merupakan ancaman terhadap melanosit, yaitu dengan menurunkan pertahanan antioksidan sel melanogenik seperti gluthatione. segregasi melanogenesis pada organel terikat membran dan quinone reductase serta catechol-omethyl transferase pada sitoplasma merupakan beberapa mekanisme yang digunakan untuk melindungi melanosit dari bahaya sitotoksik.9 winawati eka putri, yuli kurniawati, tantawi djauhari, depigmenting agent melanotoksik pada pengobatan melasma 25 gambar 1. jalur sintesis melanin pada melanosit manusia4 gambar 2. jalur biosintesis melanin. tyr, tirosin; trp: tirosin related protein; dopa, 3,4dihydroxyphenylalanine; dhica, 5,6dihydroxyindole-2-carboxylic acid; dhi, 5,6 – dihydroxyindole; icaq, indole-2-carboxylic acid5,6-quinone; iq, indole-5,6-quinone; hbta, 5hydroxy-1,4-benzothiazinylalanine.11 melasma melasma, atau yang disebut juga kloasma atau mask of pregnancy, merupakan kelainan hiperpigmentasi didapat yang kronis, ditandai dengan patch hiperpigmentasi pada area sunexposed yaitu wajah, leher, dan lengan. kelainan ini paling sering terjadi pada wanita dengan fototipe kulit fitzpatrick iii hingga v yang tinggal pada daerah dengan pajanan sinar ultraviolet (uv) tinggi.12 patogenesis melasma belum diketahui secara pasti, namun radiasi uv dapat menyebabkan hiperfungsi melanosit dalam kulit yang terpajan uv akan meningkatkan jumlah melanin dibandingkan dengan kulit yang tidak terpajan uv. faktor lain yang berperan adalah predisposisi genetik atau etnis terutama yang berhubungan dengan fototipe kulit, dan hormon tertentu seperti estrogen dan progesteron. pengaruh hormon progestron ditunjukkan pada terjadinya atau eksaserbasi penyakit selama kehamilan atau penggunaan kontrasepsi oral. faktor pemicu lain yang berpotensi menyebabkan melasma adalah obat (obat antikonvulsan-fenitoin, fototoksik) dan penyakit tiroid autoimun. peningkatan ekspresi ckit dan stem cell factor dalam lesi epidermis dan dermis, dapat berperan dalam melasma.2 melasma dapat ditangani secara efektif namun tidak dapat disembuhkan. mekanisme kerja pengobatan melasma berupa meminimalkan pajanan uv, pengobatan hormonal, mencegah produksi melanin, dan mengangkat melanin. produksi melanin dicegah dengan menghambat kerja melanosit dan menghambat transfer melanososm dari melanosit ke keratinosit. pengangkatan melanin dapat dilakukan baik dengan modalitas fisik atau topikal. pengobatan melasma terdiri atas tiga lini, dapat dilihat dalam tabel 1. sarkar dkk menyatakan bahwa enam peel ga (30 dan 40%) yang dikombinasi dengan formula kligman memberikan respon terapi lebih baik daripada hanya menggunakan formula topikal pada pengobatan melasma. roberts melaporkan bahwa mikrodermabrasi diikuti dengan kombinasi obat yang mengandung hq, tretinoin, dan fluosinolon efektif untuk pasien melasma.13 medical and health science journal, vol. 2, no. 2, august 2018 26 tabel 1. pengobatan melasma13 topikal sistemik fisik catatan lini pertama spf saat pagi triple combination saat malam atau monoterapi dengan lightening agent 2x sehari (vitamin c, kojic acid topikal) lini kedua spf saat pagi dan hq saat malam mikrodermabrasi tiap 2 pekan untuk 6 sesi peel asam salisilat tiap 2-4 pekan untk 3-6 peel dapat menggunakan hq sebagai monoterapi atau triple combination (triluma®) lini ketiga spf saat pagi laser fraksional resurfacing pada tipe kulit i-iv setelah pigmentasi clear tidak selama ipl (efektif pada tipe kulit orang asia) depigmenting agent melanotoksik sebagian besar senyawa da menghasilkan efek multipel yang mengakibatkan penurunan melanisasi. mekanisme kerja da dapat berupa inhibisi tirosinase, stimulasi turnover keratinosit, reduksi transfer melanosom, interaksi dengan copper, inhibisi maturasi melanosom, inhibisi protease-activated receptor 2, inhibisi plasmin, reduksi melanocyte-stimulating hormone-induced melanin production.12 jimbow dkk pada tahun 1971 menyatakan bahwa produksi melanin berlebihan menyebabkan toksisitas melanosit sehingga dapat membunuh melanosit. sitotoksisitas dari melanogenesis terutama dari pembentukan o-quinone (dopaquinone) sebagai intermediate yang dimediasi oleh tirosinase.(jimbow,1996) jimbow dkk melaporkan bahwa kerusakan sel berupa degradasi organela membran, clumping granula melanin, vakuolasi sitoplasma.5 gambar 3. produksi radikal quinone dan semiquinone sitotoksik (radikal oksi dan hidroksi) selama perubahan tirosin menjadi dopa dan kemudian menjadi dopaquinone dengan adanya tirosinase.14 hydroquinone hydroquinone (1,4-dihydroxybenzene, hq) merupakan senyawa fenol yang bekerja pada melanosit melalui tirosinase aktif. hydroquinone telah menjadi baku emas dalam pengobatan hiperpigmentasi selama lebih dari 50 tahun.15 hydroquinone telah berhasil digunakan untuk winawati eka putri, yuli kurniawati, tantawi djauhari, depigmenting agent melanotoksik pada pengobatan melasma 27 segala bentuk hiperpigmentasi epidermal seperti melasma dan hanya komponen epidermal yang merespon baik terhadap penggunaan hq.16 senyawa hq dapat ditemukan dalam gandum, teh, berries, beer, dan kopi, namun didetoksifikasi di liver menjadi komponen inert.15 hydroquinone bekerja dengan menghambat tirosinase dan mencegah perubahan tirosin menjadi dopa.17 hydroquinone juga bekerja menghambat pigmentasi dengan modifikasi pembentukan melanosom atau menghambat sintesis dna dan rna dengan degradasi melanosom serta destruksi melanosit.15,18 hydroquinone mempunyai peran sitotoksik (cell killing atau kerusakan sel) pada melanosit yang disebabkan oleh mekanisme oksidasi radikal bebas. pembentukan radikal bebas berpotensi merusak melanosit itu sendiri atau di dekatnya atau struktur fisik sel.19 efektivitas hq berhubungan langsung dengan konsentrasi sediaan, vehikulum yang digunakan, dan komposisi kimia produk akhir. hydroquinone 4% paling sering digunakan oleh dermatolog karena sangat efektif namun dapat menyebabkan efek iritan bermakna.18 obat ini digunakan dua kali sehari dan biasanya dalam jangka waktu lama, kisaran tiga hingga enam pekan agar efek obat terlihat.16 konsentrasi hq di atas 5% meningkatkan risiko efek samping tanpa meningkatkan efikasi. keberhasilan preparat ini terbatas pada epidermis. preparat ini mudah teroksidasi pada ph>6 dan kehilangan potensi setelah 2 bulan.20 penggunaan hq dalam kosmetik telah dilarang oleh european committee karena bahaya penggunaan jangka panjang.15,18 okronosis eksogenosa merupakan efek samping utama dari hq, yang dapat terjadi pada individu yang menggunakan hq dalam jangka panjang, yaitu satu tahun atau lebih, dan terpajan oleh sinar matahari.16 efek samping lain penggunaan hq berupa dermatitis kontak alergi dan iritan, perubahan warna kuku, dan hipermelanosis pasca inflamasi. efek samping tersebut bersifat sementara dan mengalami perbaikan bila hq dihentikan.18 gambar 4. struktur kimia hydroquinone4 gambar 5. okronosis eksogenosa 2 monomethyl of hydroquinone monomethyl of hydroquinone (mmeh) atau 4-hidroxyanisole (4-ha) merupakan substrat tirosinase dan berperan sebagai inhibitor kompetitif melanogenesis.4 obat ini dioksidase oleh tirosinase dan menghasilkan efek melanositotoksik yang kuat.18 pembentukan quinone akibat oksidasi oleh tirosinase mengakibatkan destruksi sel pigmen dan depigmentasi kulit.15 monomethyl of hydroquinone digunakan di perancis dengan konsentrasi 8-10% sebagai pengobatan melasma dan hipermelanosis pasca inflamasi.18 penggunaan mmeh yang dikombinasi dengan tretinoin 0,01% dapat menghambat produksi melanin dan mendapatkan hasil lebih baik daripada bila masing-masing obat digunakan sendiri.16 medical and health science journal, vol. 2, no. 2, august 2018 28 efek samping mmeh berupa dermatitis kontak iritan dan alergi, hipermelanosis pasca inflamasi, dan leukoderma en confetti pada daerah yang diobati.18 studi lain oleh moridani mendapatkan bahwa mmeh yang diberikan pada tikus dapat menyebabkan hepatotoksisitas. hepatotoksisitas ini dapat dilihat dengan peningkatan tujuh kali lipat transaminase plasma dalam 24 jam.19 gambar 5. struktur kimia monomethyl of hydroquinone4 n-acetyl-4-s-cysteaminylphenol n-acetyl-4-s-cysteaminylphenol merupakan senyawa melanositotoksik yang terdiri dari fenol dan cathecolic dengan kemampuan depigmentasi.4,21 senyawa ini berfungsi sebagai substrat tirosinase dan secara selektif mentarget sel dengan sintesis melanin aktif.6 depigmentasi akibat penggunaan obat ini disebabkan karena penurunan jumlah melanosit aktif dan jumlah melanosom yang ditransfer ke keratinosit.21 pada satu studi yang dilakukan pada 12 pasien melasma dilaporkan pigmentasi berkurang secara bermakna dengan hasil lebih jelas pada 2-4 pekan setelah penggunaan n-acetyl-4-scysteaminylphenol 4% satu kali sehari.4,21 nacetyl-4-s-cysteaminylphenol lebih stabil dan kurang iritasi daripada hq.6 senyawa ini telah diuji pada sejumlah kecil pasien melasma dan didapatkan perbaikan atau complete clearing dengan efek samping minimal pada 75% pasien. namun demikian, senyawa ini tidak digunakan secara luas karena uji klinis untuk evaluasi keamanan serta efikasi belum tersedia.18 azeleic acid azelaic acid (aza) merupakan dicarboxylic acid dengan sembilan atom karbon yang diisolasi dari biakan pityrosporum ovale. pityrosporum ovale akan mengoksidasi asam lemak tak jenuh menjadi dicarboxylic acid yang menghambat tirosinase.4 azelaic acid menghasilkan efek anti proliferasi dan sitotoksik terhadap melanosit dengan menghambat oksidoreduktase dan sintesis dna mitokondria pada melanosit yang sangat aktif atau abnormal.6,11,22 obat ini pertama kali digunakan sebagai pengobatan lentigo maligna namun tidak digunakan lagi karena tidak menghancurkan malignansi yang menyebar. saat ini aza digunakan sebagai pengobatan melasma yang tersedia dalam konsentrasi 20% dan digunakan dua kali sehari. pengobatan harus dilanjutkan hingga beberapa bulan.16 pada satu studi selama enam bulan oleh sarkar dkk pada 132 wanita asia dengan melasma, pengobatan dengan aza selama rerata empat tahun menyebabkan pencerahan yang lebih banyak pada lesi pigmentasi disertai dengan pengurangan ukuran lesi.23 krim aza 20% terbukti lebih efektif daripada krim hq 2% namun didapatkan efikasi serupa dengan hq 4% setelah 24 pekan pengobatan melasma.6,18,24 penggunaan aza relatif aman walaupun dapat terjadi iritasi ringan.24 efek samping paling sering dijumpai berupa eritem transien, dan iritasi kulit ditandai dengan skuama, gatal, rasa seperti terbakar yang akan menghilang setelah penggunaan 2-4 pekan.18,23 gambar 8. struktur kimia azeleic acid 4 kombinasi pengobatan tujuan kombinasi pengobatan melasma adalah menambah efikasi dengan menggabungkan winawati eka putri, yuli kurniawati, tantawi djauhari, depigmenting agent melanotoksik pada pengobatan melasma 29 bahan aktif dengan mekanisme kerja berbeda untuk menghasilkan efek sinergis, untuk memperpendek durasi terapi, dan mengurangi risiko efek samping obat.18 formula kligman. pengobatan kombinasi paling dikenal adalah formula kligman.18 pada tahun 1975 kligman melaporkan satu formula yang mengandung hq 5%, deksametason 0,1%, dan tretinoin 0,1% yang efektif dalam pengobatan melasma, efelid, dan hiperpigmentasi pasca inflamasi. preparat ini menjadi gelap akibat oksidasi bila disimpan selama lebih dari satu bulan. tretinoin berfungsi sebagai penguat penetrasi hq dalam epidermis. selanjutnya, tretinoin meningkatkan turnover epidermal, sehingga memfasilitasi dispersi melanin dalam keratinosit dan juga pengangkutan melanin dari korneosit. deksametason mengurangi iritasi dan inflamasi akibat hq dan/atau tretinoin dan sintesis melanin dengan menghambat aktivitas metabolik.18 kligman dan willis membuat hipotesis bahwa kortikosteroid topikal menekan produksi melanin tanpa merusak melanosit dengan menekan fungsi biosekresi dan sekretori dalam melanosit.24 depigmentasi terjadi lebih cepat, dimulai dalam tiga pekan setelah penggunaan formula dua kali sehari. formula lain yang lebih stabil mengandung hq 4%, tretinoin 0,05%, dan fluosinolone asetonide 0,01%. dua uji terkontrol buta ganda acak multisenter menunjukkan keamanan dan efikasi dari pengobatan kombinasi ini pada pasien melasma moderat hingga berat. setelah delapan pekan pengobatan, pengurangan melasma sebanyak 75% didapatkan pada lebih dari 75% pasien.18 azelaic acid dan tretinoin. kombinasi rejimen aza 20% dengan tretinoin topikal 0,05% menghasilkan kulit cerah lebih cerah dan nyata selama fase awal pengobatan. azelaic acid 20% juga dapat digabung dengan losion glycolic acid 20% yang sama efektif dengan krim hq 4%.18 hydroquinone dan kojic acid. kojic acid 2% dalam gel, glycolic acid 10% dan hq 2% mengobati melasma epidermal dalam 12 pekan pengobatan. kojic acid 1-4% dikombinasi dengan tretinoin, hq, dan/atau kortikosteroid atau glycolic acid akan bekerja sinergis.18 formula westerhof. kombinasi dari nacetylcystein 4,7% (nac), hq 2%, dan triamsinolon asetonide 0,1% terbukti efektif dalam pengobatan melasma. mekanisme kerja nac belum sepenuhnya diketahui. n-acetylcystein menghasilkan efek inhibitor tirosinase yang lebih memicu terjadi feomelanogenesis daripada eumelanogenesis sehingga menghasilkan warna kulit lebih cerah.18 phenol phenol, atau juga dikenal sebagai asam karbolik, merupakan presipitan protein yang menyebabkan denaturasi cepat dan koagulasi keratin permukaan yang ekstrim.26 phenol dahulu digunakan sejak lama sebagai pengobatan melasma, namun sudah tidak digunakan lagi karena toksik terhadap melanosit.27 kligman dkk pada tahun 1985 melakukan pengamatan histologik jangka panjang pada phenol peeling di wajah. depigmentasi akibat phenol disebabkan bukan karena destruksi melanosit namun kelainan sintesis melanin, yang terjadi sangat lama (20 tahun atau lebih). phenol yang merupakan inhibitor peroksidase, bekerja selama sintesis melanin dan mneyebabkan pengurangan polimerisasi intermediate melanogenik. phenol peeling menyebabkan melanopenia, melanositopenia, dan dispersi melanin dalam keratinosit.27 formula baker-gordon merupakan formula phenol standar yang terdiri dari 3 ml usp phenol cair, 2 ml air, 8 tetes sabun cair, 3 tetes croton oil. croton oil berperan dalam iritasi kulit, sedangkan sabun cair sebagai surfaktan dan emulsifier untuk membantu penetrasi. kombinasi obat ini medical and health science journal, vol. 2, no. 2, august 2018 30 digunakan untuk wrinkle dan kelainan pigmentasi, serta menyebabkan kerusakan pada dermis yaitu retikular dermis atas. phenol didetoksifikasi di liver dan diekskresi oleh ginjal. dosis toksik phenol dapat merusak liver dan ginjal serta menekan respirasi dan miokardium.26 kesimpulan depigmenting agent banyak digunakan sebagai pengobatan kelainan hiperpigmentasi, salah satunya melasma. menurut cara kerjanya da terbagi menjadi beberapa kelompok yaitu kelompok inhibitor tirosinase, inhibitor transfer melanosom, melanocyte-cytotoxic agent, dan lainnya. depigmenting agent melanotoksik atau mengakibatkan cell-killing atau kerusakan melanosit meliputi hydroquinone, monomethyl of hydroquinone, n-acetyl-4-s-cysteaminylphenol, phenol, kojic acid, azelaic acid. sebagian besar obat tersebut bekerja juga sebagai inhibitor tirosinase. pengobatan melasma yang paling baik berupa kombinasi dari beberapa kelompok obat sehingga dicapai hasil efektif dengan efek samping minimal. daftar pustaka solano f, briganti s, picardo m, ghanem g. hypopigmenting agents: an updated review on biological, chemical and clinical aspects. pigment cell res 2006; 19: 550–71. chang mw. dysorders of hyperpigmentation. in: bolognia jl, jorizzo jl,rappini rp, schaver jv, editors. dermatology. 2nd ed. edinburg: mosby; 2008. p.939-63. nordlund jj, cestari t, grimes p, chan h, ortonne jp. a more precise lexicon for pigmentation, pigmentary disorders, and chromatic abnormalities. in: nordlund jj, boissy re, hearing vj, king ra, oetting ws, ortonne jp, ditors. the pigmentary system: physiology and pathophysiology, 2nd ed. london: blackwell publishing ltd; 2006. p.499-503 baumann l dan allemann ib. depigmenting agents. in: baumann l. cosmetic dermatology, principle and practice. 2nd ed. united states: mcgraw hill; 2009. p.279-91 jimbow k,obata h, pathak ma. fitzpatrick tb:mechanism of depigmentation by hydroquinone. j invest dermatol 1974; 62:436-49 katsambas ad, stratigos aj. depigmenting and bleaching agents: coping with hyperpigmentation. clinics in dermatology 2001; 1: 483–8 baumann l, saghari s. skin pigmentation and pigmentation disorders. in: baumann l. cosmetic dermatology, principle and practice. 2nd ed. united states: mcgrawhill; 2009. p.98-108 ortonne jp, nordlund jj. mechanisms that cause abnormal skin color. in: nordlund jj, boissy re, hearing vj, king ra, oetting ws, ortonne jp, editors. the pigmentary system: physiology and pathophysiology, 2nd ed. london: blackwell publishing ltd; 2006. p.52136 land ej, ramsden ca, riley pa. toxicological aspects of melanin and melanogenesis. . in: nordlund jj, boissy re, hearing vj, king ra, oetting ws, ortonne jp, editors. the pigmentary system: physiology and pathophysiology, 2nd ed. london: blackwell publishing ltd; 2006. p.35494 gillbro jm, olsson mj. the melanogenesis and mechanisms of skin-lightening agents-existing and new approaches. int j cosm sci 2011; 33: 210–21 winawati eka putri, yuli kurniawati, tantawi djauhari, depigmenting agent melanotoksik pada pengobatan melasma 31 chang te sheng. an update review of tirosinase inhibitors. int. j mol sci 2009; 10: 2440-75 sheth vm, pandya ag. melasma: a comprehensive update. j am acad dermatol 2011; 65:699-714 roberts we. melasma. in: kelly ap, taylor sc. dermatology for skin color.united state: mcgraw hill; 2009. p.332-6 jimbow k. current topics in melanin pigmentation and its application to the management and patophysiology of pigmentary diseases. dermatol sinica 1996; 14:1-14. ebanks jp, wickett rr, boissy re. mechanisms regulating skin pigmentation: the rise and fall of complexion coloration. int. j. mol. sci 2009; 10: 4066-87 halder rm, nordlund jj. topical treatment of pigmentary disorders. in: nordlund jj, boissy re, hearing vj, king ra, oetting ws, ortonne jp, editors. the pigmentary system: physiology and pathophysiology, 2nd ed. london: blackwell publishing ltd; 2006. p.116574 grimes pe, 2006. pharmacological agents for pigmented skins. in: halder rm. dermatology and dermatological therapy for pigmented skin. london: taylor and francis group. p. 274-87 passeron t, ortonne jp, 2010. pigmentation: dyschromia. in: barran r, maibach hi. textbook of cosmetic dermatology. 4th ed. london: informa healthcare; 2010. p.311-29 moridani my, cheon ss, khan s, o’brien pj. metabolic activation of 4hydroxyanisole by isolated rat hepatocytes. the american society for pharmacology and experimental therapeutics 2002; 30: 1063–9 nilesh morar, ncoza dlova. topical hydroquinone. in: kelly ap, taylor sc. dermatology for skin color.united state: mcgraw hill; 2009. p. 475-8. rendon m, berneburg m, arellano i, picardo m. treatment of melasma. j am acad dermatol 2006;54: s272-81 brenner m, hearing vj, 2008. modifying skin pigmentation – approaches through intrinsic biochemistry and exogenous agents. drug discov today dis mech 2008; 5(2): e189-99 parvez s, kang m, chung hs, cho c, hong mc, shin mk, bae h. survey and mechanism of skin and lightening agents. phytother res 2006; 20: 921 34 jones jb, 2004. topical therapy. in: burns t, breathnach s, cox n, griffiths c. rook’s textbook of dermatology ed 7 vol 3. united state: blackwell publishing; 2004. p.1-52 perrotti ja. cutaneous resurfacing: chemical peeling, dermabrasion, and laser resurfacing. in: thorne ch. grabb and smith's plastic surgery, 6th ed. london: lippincott williams & wilkins, 2007. p.459-67 attia eas, samahy mhe, mahmoud sa. cryotherapy versus phenol chemical peeling for solar lentigines: a clinical, histologic, immunohistochemical and ultrastructural study. j egypt women dermatol soc 2010; 7: 87-96 medical and health science journal, vol.4., no.1, february 2020 perbandingan luaran pasien kanker endometrium yang dilakukan operasi laparoskopi dan yang dilakukan operasi laparotomi di rsud dr. soetomo tahun 2017 trianggono bagus a*1, brahmana askandar2 1 ppds-1 departemen/smf obstetri dan ginekologi, fakultas kedokteran universitas airlangga, rsud dr soetomo, surabaya 2 staf pengajar departemen/smf obstetri dan ginekologi, fakultas kedokteran universitas airlangga, rsud dr soetomo, surabaya *coresspondent author: trianggono1988@gmail.com article info abstrak article history: received febuary, 16-2020 received in revised form febuary, 22 2020 accepted febuary. 282020 tujuan: untuk mengetahui luaran perbandingan laparoskopi dan laparotomi pada pasien kanker endometrium di rsud dr. soetomo tahun 2017. metode: data pada laporan kasus ini diperoleh melalui rekam medis paien kanker endometrium yang dilakukan operasi di rsud dr. soetomo selama bulan januari – desember 2017 baik dengan laparoskopi maupun dengan laparotomi. hasil: selama periode januari hingga desember 2017, didapatkan 27 pasien dengan kanker endometrium, 15 pasien dilakukan operasi laparoskopi, dan 12 pasien dilakukan operasi laparotomi. karakteristik umum pasien kanker endometrium yang dilakukan operasi dari umur berkisar 41-60 tahun, didapatkan 3 pasien mengelami komplikasi pada saat operasi laparoskopi, untuk lama operasi baik laparoskopi dan laparotomi mempunyai waktu 120 menit, untuk lama perawatan laparoskopi mempunyai angka lebih baik daripada laparotomi. dari perdarahan laparoskopi mempunyai angka lebih baik jika dibandingkan dengan laparotomi. kesimpulan: tindakan laparoskopi mempunyai komplikasi yang lebih tinggi jika dibandingkan dengan laparotomi, namun laparoskopi mempunya keuntungan dari segi ido, jumlah perdarahan, dan lama perawatan pasca operasi. kata kunci: kanker endometrium, laparoskopi, laparotomi @2020 medical and health science journal. 10.33086/mhsj.v4i1.1446 pendahuluan kanker endometrium adalah kasus keganasan ginekologi pada negara maju dan kanker keganasan ginekologi yang kedua setelah kanker leher rahim pada negara berkembang. tahun 2012 pada seluruh dunia sejumlah 527.600 perempuan menderita kanker endometrium1. pada negara amerika, kanker endometrium adalah kanker tersering yang dijumpai, dengan jumlah 46.470 kasus baru dan 8120 kasus kematian pada tahun 2011. pada negara berkembang, ini merupakan penyakit keganasan ginekologi kedua setelah kanker leher rahim, dengan insiden 5,9 per 100.000 kanker ginekologi dan mempunyai angka mortalitas sebesar 1,7 per 100.000 kasus2. dari tahun 2011 – 2015, teradapat 879 kasus kanker endometrium di indonesia. sedangkan di rsupn cipto mangunkusumo terdapat 347 (7,7%) kasus kanker endometrium dari 4.463 kasus kanker ginekologi3. faktor risiko utama dari kanker endometrium adalah paparan hormon estrogen yang berlebnihan, correspondence: trianggono bagus a @2020 medical and health science journal. 10.33086/mhsj.v4i1.1446 available at http://journal2.unusa.ac.id/index.php/mhsj 55 case report mailto:trianggono1988@gmail.com http://journal2.unusa.ac.id/index.php/mhsj medical and health science journal, vol.4., no.1, february 2020 baik itu jenis estrogen maupun endogen tanpa disertai adanya progestin. faktor risiko yang lain yaitu penggunaan tamoxifen, nullipara dan obesitas4. pada kanker endometrium, terdapat dua tipe utama. tipe i adalah tipe terbanyak dari kasus kanker endometrium, sebanyak 80% kasus dari kanker endometrium adalah jenis kanker tipe i, kasus ini histopatologinya tersering adalah endometrioid. biasanya kasus ini mempunyai prognosis yang baik, disebabkan karena paparan dari hormon estrogen, dan biasanya didahului dengan intraepithelial neoplasia (atipikal atau kompleks hyperplasia endometrium). kanker endometrium tipe ii adalah kanker endometrium dengan prognosis lebih buruk, kasus ini memiliki proporsi 10-20% jumlah kasus kanker endometrium. kanker endometrium mempunyai angka ketahanan hidup sampai dengan 75%, biasanya pasien sudah didiagnosa dengan stadium awal dan ini dapat disembuhkan dengan terapi operasi5. teknik staging konvensional untuk kanker endometrium adalah dilakukannya operasi laparotomi, beberapa studi menunjukan bahwa operasi laparoskopi lebih baik jika dibandingkan dengan laparotomi. mulai dari lama perawatan, kebutuhan tranfusi saat operasi, dan komplikasi pasca operasi, laparoskopi lebih baik dibandingkan dengan laparotomi. laparoskopi juga menunjukan area yang lebih jelas untuk melakukan staging, limfadenektomi pada kanker endometrium6. hasil dan pembahasan karakteristik kanker endometrium yang dilakukan operasi di rsud dr. soetomo dari januari – desember 2017 berdasarkan data yang diperoleh pada tahun 2017 dari rekam medis, didapatkan pasien kanker endometrium yang dilakukan operasi laparoskopi dan laparotomi di rsud dr. soetomo paling banyak berkisar antara 41-60 tahun. angka ini tidak berbeda dengan studi yang dilakukan di rsup sanglah yang mendapatkan bahwa pasien kanker endometrium periode agustus 2012 – juli 2014 terbanyak 51-60 tahun (46,2%)7. hal ini juga sesuai dengan hasil penelitian di rsup arifin achmad tahun. 2014, kejadian kanker endometrium pada usia lebih dari 40 tahun meningkat 2 kali dibandingkan pada usia kurang dari 40 tahun22. ditemukannya insiden kanker endometrium yang paling banyak rentang usia 41 – 60 tahun yaitu usia menopause, karena pada saat menopause kadar estrogen dan progesterone menurun sehingga dibutuhkannya paparan estrogen eksogen yaitu terapi sulih hormone menyebabkan kadar hormon estrogen berlebihan sedangkan hormon progesterone rendah. akibatnya endometrium mengalami penebalan yang berlebihan8. pada distribusi kanker endometrium berdasarkan indeks massa tubuh pasien, didapatkan jumlah terbanyak pada pasien dengan indeks massa tubuh 18,5 sampai dengan 25 (46%), dimana indeks massa tubuh tersebut tergolong normal. pada penelitian di rsup sanglah dari agustus 2012 – juli 2014 juga mendapatkan distribusi kanker endometrium berdasarkan indeks massa tubuh antara 18,5 sampai dengan 22,9 kg/m2 (42,3%), hal ini mungkin disebabkan karena rata rata wanita indonesia masih dalam kategori indeks massa tubuh normal, hanya sebagian kecil yang mengalami obsesitas7. hal ini tidak sesuai degan teori dari berbagai penelitian yang menunjukkan bahwa wanita dengan obesitas lebih rentan menderita kanker endometrium. sebuah studi metanalisis yang meliputi 19 prospektif studi meliputi 3 juta wanita, setiap kenaikan indeks massa tubuh 5kg/m2 meningkatkan resiko terjadinya kanker endometrium (rr 1.59%, 95% ci 1.50-1.68)9. berdasarkan paritas, pasien kanker endometrium yang dilakukan operasi laparoskopi dan kanker endometrium yang dilakukan operasi laparotomi di rsud dr. soetomo tahun 2017 terbanyak merupakan multipara sebanyak 71%. hal ini sesuai dengan penelitian sunjoto di rsud dr. soetomo surabaya, didapatkan paritas 3 – 4 yang terbanyak ditemukan pada kasus kanker endometrium10. hasil ini berbeda dengan kebanyakan literatur yang menyebutkan bahwa kanker endometrium sering dijumpai pada 56 medical and health science journal, vol.4., no.1, february 2020 wanita yang sudah menikah tetapi tidak mempunyai anak (infertilitas). namun dari salah satu sumber (american institute for cancer research) menyebutkan kanker endometrium tipe 2, dimana tipe 2 ini penderita cenderung kurus dan multipara (american institute for cancer research, 2013). begitu juga dengan penelitian felix dkk, kanker endometrium tipe 2 cenderung terjadi pada wanita yang memiliki 3 anak atau lebih (45%) karena pada wanita multipara terjadi penurunan paparan terhadap estrogen dibandingkan dengan wanita nullipara. tipe ini lebih banyak berhubungan dengan atrofi endometrium, cenderung bermetastasis dan berdiferensiasi baik. sedikitnya insiden. kanker endometrium tipe 2 ini (hanya sekitar 10% dari kanker endometrium) menyebabkan tipe ini sulit dipelajari11. perbandingan komplikasi operasi laparoskopi dan operasi laparotomi pada pasien kanker endometrium pada laporan kasus ini pasien kanker endometrium yang dilakukan operasi laparoskopi di rsud dr. soetomo surabaya tahun 2017, dari total 15 pasien didapatkan 3 pasien mengalami komplikasi pada saat operasi. 1 pasien dengan rupture parsial ureter kiri, 1 pasien dengan ruptur buli, dan 1 pasien dengan rupture buli dan ruptur jejunum. pada total 12 kasus kanker endometrium yang dilakukan operasi laparotomi tidak didapatkan komplikasi pada saat operasi maupun pasca operasi. hal ini tidak sesuai dengan penelitian metanalisis dari 7 randomised controlled trials (rcts), secara statitistik menunjukkan tidak ada perbedaan bermakna risiko rupture buli pada wanita kanker endometrium dengan tindakan laparoskopi maupun laparotomi. (rr 1.12, 95% ci 0.54 2.32; analisis 2.2). penelitian metanalisis dari 3 rcts, meliputi 3463 partisipasi secara statistik tidak menemukan perbedaan yang signifikan pada resiko cedera ureter pada wanita terdiagnosis kanker endometrium yang dilakukan operasi laparoskopi (rr 1.41, 95% ci 0.60. 3.28; analisis 2.3)12. xu dkk, berhasil mengurangi angka kejadian cedera pada daerah buli dengan cara mengisi buli dengan cairan normal salin pada saat dilakukan operasi laparoskopi untuk menambah visualisasi pada buli, dan lebih berhati – hati untuk menghindari rute dari ureter sehingga bisa mengurangi resiko dari terjadinya cedera buli dan ureter13. dari data tersebut menunjukan jika laparoskopi mempunyai komplikasi cedera buli dan ureter jika dibandingkan dengan laparotomi, hal ini dikarenakan teknik laparoskopi baru di kembangkan di bagian onkologi ginekologi di rsud dr. soetomo, hal ini diharapkan akan semakin berkurang dengan jumlah tindakan yang semakin banyak dan teknik dan skill dari operator laparoskopi yang semakin meningkat. perbandingan lama waktu operasi laparoskopi dan laparotomi pada pasien kanker endometrium dari total 15 pasien kanker endometrium yang dilakukan operasi laparosokopi yang paling cepat adalah 120 menit, sedangkan operasi terlama adalah 300 menit. dengan rerata lama waktu operasi 190 menit. dari total 12 pasien kanker endometrium yang dilakukan operasi dengan laparotomi, didapatkan operasi yang paling cepat adalah 120 menit, sedangkan operasi terlama memakan waktu 280 menit, dengan rerata waktu 180 menit. hal ini. menunjukan jika operasi laparoskopi memakan waktu sedikit lebih lama jika dibandingkan dengan operasi laparotomi. hal ini sesuai dengan penelitian chang, et al yang mereview 7 penelitian mengenai lama waktu tindakan laparoskopik dan laparotomi pada pasien kanker endometrium, dari 7 penelitian tersebut didapatkan jika rerata waktu yang didapatkan untuk operasi laparoskopi adalah 147 menit. sedangkan rerata waktu untuk melakukan operasi laparotomi adalah136 menit14. perbandingan jumlah perdarahan saat operasi dan kejadian infeksi daerah operasi baik laparoskopi maupun laparotomi pada pasien kanker endometrium dari total 15 pasien kanker endometrium yang dilakukan operasi laparoskopi di rsud 57 medical and health science journal, vol.4., no.1, february 2020 dr. soetomo tahun 2017 didapatkan perdarahan paling banyak adalah 4500cc dengan kasus ca endometrium stadium ia grade i dengan tindakan tlh-bso + limfadenektomi pelvis d/s dan membutuhkan transfusi darah pada saat operasi. perdarahan paling sedikit adalah 50cc dengan kasus ca endometrium stadium ib grade idengan tindakan tlh-bso + sampling limfadenektomi d/s. dari total 15 pasien operasi laparoskopi hanya 1 pasien yang membutuhkan transfusi darah, sedangkan 14 pasien sisanya tidak memnbutuhkan transfusi darah baik pada saat operasi maupun perawatan pasca operasi. sehingga dapat disimpulkan jika operasi laparoskopi hampir tidak membutuhkan transfusi darah. dari total 12 pasien kanker endometrium yang dilakukan operasi laparotomi didapatkan perdarahan paling banyak adalah 900cc dengan kasus ca endometrium stib gr.iii. perdarahan paling sedikit adalah 100cc dengan kasus ca endometrium st.ii gr.ii. dari 2 tindakan laparotomi, didapatkan 2 pasien dilakukan transfusi pada saat operasi dengan jumlah perdarahahn 900cc dan 850cc. sehingga dapat dikatakan jika laparotomi membutuhkan transfuse darah, namun laparosokopi jika terdapat perdarahan lebih susah untuk menghentikan sumber perdarahan. dari total 15 pasien kanker endometrium yang dilakukan operasi laparoskopi di rsud dr. soetomo tahun 2017 didapatkan perdarahan paling banyak adalah 4500cc dengan kasus ca endometrium stadium ia grade i dengan tindakan tlh-bso + limfadenektomi pelvis d/s dan membutuhkan transfusi darah pada saat operasi. perdarahan paling sedikit adalah 50cc dengan kasus ca endometrium stadium ib grade idengan tindakan tlh-bso + sampling limfadenektomi d/s. dari total 15 pasien operasi laparoskopi hanya 1 pasien yang membutuhkan transfusi darah, sedangkan 14 pasien sisanya tidak memnbutuhkan transfusi darah baik pada saat operasi maupun perawatan pasca operasi. sehingga dapat disimpulkan jika operasi laparoskopi hampir tidak membutuhkan transfusi darah. dari total 12 pasien kanker endometrium yang dilakukan operasi laparotomi didapatkan perdarahan paling banyak adalah 900cc dengan kasus ca endometrium stib gr.iii. perdarahan paling sedikit adalah 100cc dengan kasus ca endometrium st.ii gr.ii. dari 2 tindakan laparotomi, didapatkan 2 pasien dilakukan transfusi pada saat operasi dengan jumlah perdarahahn 900cc dan 850cc. sehingga dapat dikatakan jika laparotomi membutuhkan transfuse darah, namun laparosokopi jika terdapat perdarahan lebih susah untuk menghentikan sumber perdarahan. hal ini sesuai dengan penelitian yang dilakukan volpi, et al. pada 77 pasien kanker endometrium dengan stadium i-iii, pasien yang dilakukan laparoskopi tidak satupun yang membutuhkan transfusi15. hal ini juga sesuai dengan penelitian yang dilakukan oleh hahn hs, et al pada tahun 2010, dimana mereka membandingkan kebutuhan transfusi pada operasi laparotomi dan laparoskopi. jumlah total pasien adalah 465, dengan 325 pasien dilakukan tindakan laparotomi dan 140 pasien dilakukan tindakan laparoskopi. dimana hasilnya adalah 15 pasien laparoskopi (10.7%) membutuhkan transfusi dan 47 pasien laparotomi (14.5%) membutuhkan trasnfusi pada saat operasi. namun secara statistik tidak berbeda secara bermakna16. dari total 15 pasien kanker endometrium yang dilakukan operasi laparoskopi, tidak satupun yang mendapatkan komplikasi pada daerah operasi. dari total 12 pasien kanker endometrium yang dilakukan operasi laparotomi, tidak satupun yang mendapatkan komplikasi pada daerah operasi. hal ini sesuai dengan penelitian kim dy, et al pada tahun 2005, dimana mereka membandingkan antara laparoskopi dan laparotomi pada pasien kanker endometrium. pada 74 pasien yang dilakukan laparoskopi dan 168 pasien laparotomi, didapatkan 5 pasien yang dilakukan laparotomi menderita komplikasi pasca operasi infeksi daerah operasi (ido), sedangkan tidak satupun yang mendapatkan ido pada pasien laparoskopi. 6 pasien yang dilakukan laparotomi mendapatkan abses intra-abdominal, sedangkan 58 medical and health science journal, vol.4., no.1, february 2020 1 pasien yang dilakukan laparoskopi mendapatkan abses intra-abdominal17. perbandingan lama perawatan pasca operasi baik dengan laparoskopi maupun dengan laparotomi pada pasien kanker endometrium dari total 15 pasien kanker endometrium yang dilakukan operasi laparoskopi, didapatkan lama perawatan pasien hanya 2 hari dari tanggal dilakukannya operasi sampai dengan perawatan luka pasca operasi. hanya didapatkan 1 pasien yang memerlukan perawatan sampai dengan 15 hari dan memerlukan perawatan intensive care unit. table 1. pasien komplikasi operasi laparoskopi yang memerlukan perawatan lebih dari 3 hari nama/ umur diagn osa komplikasi tindakan ny. m/64 th ca endo metriu m st ia gr.i perforasi multiple di dinding postero superior buli perforasi iatrogenic jejunum tlh – bso + sampling limfadene ktomi + vesicorap hy + open sistostomi + repair jejunum untuk 12 pasien kanker endometrium yang dilakukan operasi laparotomi, didapatkan lama perawatan pasien hanya 3 hari dari tanggal dilakukannya operasi sampai dengan perawatan luka pasca operasi. hal ini sesuai dengan review dari noori, et al pada tahun 2018, dimana hasilnya adalah laparoskopi menunjukan angka yang signifikan untuk lama perawatan jika dibandingkan dengan operasi laparotomi. pasien yang memerlukan perawatan rumah sakit lebih dari 2 hari menunjukan laparoskopi lebih sedikit jika dibandingkan dengan laparotomi (52% versus 94%)18. hal ini membuktikan jika operasi laparoskopi adalah tindakan yang efisien dibandingkan dengan laparotomi jika dibandingkan mengenai lama perawatan, hal ini dikarenakan laparoskopi memiliki tingkat perdarahan yang lebih sedikit, angka transfusi darah yang lebih sedikit, dan angka kejadian infeksi yang lebih sedikit18. tatalaksana lanjutan pasien kanker endometrium yang dilakukan operasi baik laparoskopi maupun dengan laparotomi dari 15 pasien kanker endometrium yang telah dilakukan operasi laparoskopi, sebanyak 4 pasein (27%) mendapatkan kemoterapi paclitaxel – carboplatin dan radioterapi, 4 pasien (27%) mendapatkan kemoterapi paclitaxel – carboplatin, 5 pasien (33%) hanya di follow up, 1 pasien (7%) loss of follow up, dan 1 pasien (7%) meninggal sebelum mendapatkan tatalaksana lanjutan setelah dilakukan operasi. dari 12 pasien kanker endometrium yang dilakukan operasi laparotomi, didapatkan 3 pasien (25%) mendapatkan kemoterapi paclitaxel – carboplatin dan radioterapi, 3 pasien (25%) mendapatkan radioterapi, 3 pasien (25%) mendapatkan kemoterapi paclitaxel – carboplatin, 1 (8%) pasien hanya dilakukan follow up, 1 (8%) pasien loss of follow up, dan 1 pasien meninggal sebelum mendapatkan tatalaksana lanjutan setelah dilakukan operasi. pasien-pasien yang cukup dilakukan observasi saja adalah pasien yang termasuk dalam kelompok grade 1 dan grade 2 tanpa invasi miometrium atau invasi miometrium < 50% (morrow, et al., 1991). pasien-pasien yang mendapatkan manfaat dengan pemberian brachiterapi adalah pasien-pasien yang telah dioperasi dengan stadium i grade 1 dan 2 dengan invasi miometrium < 50% atau stadium (ib, g1,g2) atau (ia, g3) tanpa invasi miometrium, dan pasien stadium (iia, g1,g2) dengan invasi miometrium < 50%. (morrow, et al., 1991). pada stadium i pasien membutuhkan terapi radiasi ajuvan kira-kira 15-25% pasien, dengan penyebaran tumor ke luar uterus sekitar 5-9% .pada kelompok resiko high intermediate insiden penyakit berulang adalah 12% pada kelompok observasi saja dan 3% pada kelompok yang diberikan radioterapi20. 59 medical and health science journal, vol.4., no.1, february 2020 pasien yang dapat diberikan radiasi eksternal adalah pasien-pasien yang dari hasil histopatologi operasi didapatkan keterlibatan serviks, metastasis kgb pelvis, tumor mencapai luar uterus (adneksa dan parametrium), dan pasien dengan stadium klinis dengan resiko tinggi untuk metastasis (grade 3 dengan invasi miometrium semua tingkat, grade 1 dan 2 dengan invasi miometrium > 50%. ukuran tumor > 2 cm dengan grade 2 dan 3 dengan invasi superfisial, dan semua grade dengan lvsi (morrow, et al., 1991). pada stadium ii setelah dilakukan surgical staging pasien dilanjutkan dengan eksternal radiasi + brachiterapi setelah 6 minggu pasca operasi. stadium i dan ii yang inoperabel secara medis hanya diberi terapi radiasi, angka ketahanan hidup 5 tahunnya menurun 20-30 % dibanding pasien dengan terapi operatif dan radiasi. pada pasien dengan resiko rendah (stadium ia grade 1atau 2) tidak memerlukan radiasi ajuvan pascaoperasi. radiasi ajuvan diberikan pada penderita stadium 1, apabila berusia diatas 60 tahun, grade iii dan atau invasi melebihi setengah myometrium dan penderita stadium ii a/ii b, grade i,ii,iii. pada pasien dengan kanker endometrium risiko rendah tidak diperlukan adanya terapi adjuvant, pada pasien kanker endometrium risiko menengah, direkomendasikan brakiterapi adjuvant untuk menurunkan risiko rekurensi vasginal. pada pasien kanker endometrium dengan risiko menengah – tinggi yang memiliki hasil nodus negative pada surgical nodal stafging, brakiterapi adjuvant direkomendasikan atau dapat pula tidak menggunakan terapi adjuvant. pada pasien kanker endometrium risiko tinggi yang telah diketahui memiliki nodus negative dari pemeriksaan surgical nodal staging, dapat dilakukan ebrt adjuvant dengan bidang terbatas, brakiterapi adjuvant, atau terapi sistemik21. pasien kanker endometrium stadium ii, risiko tinggi, dapat dilakukan brakiterapi vagina bila diketahui lvsi negative, tetapi bila lvsi positif dapat dilakukan ebrt lapang terbatas, boost brakiterapi, serta kemoterapi. pasien kanker endometrium stadium iii, risiko tinggi, tanpa penyakit residu, ebrt direkomendasikan untuk menurunkan rekurensi pelvis, meningkatkamn pfs dan meningkatkan kesintasan. kemoterapi juga direkomendasikan untuk meningkatkan css (cancer specific survival)21. pasien kanker non – endometrioid, risiko tinggi, pada tipe serosa dan clear – cell, dapat dipertimbangkan melakukan kemoterapi. apabila stadium ia, lvsi negative dapat dipertimb angkan brakiterapi vagina tanpa kemoterapi, dan apabila stadium > ib, dapat dipertimbangkan ebrt sebagai tambahan kemoterapi. pada tipe karsinosarkoma dan tumor tidak berdiferensiasi lainnya lebih direkomendasikan kemoterapi, tetapi dipertimbangkan pula ebrt21. ringkasan kanker endometrium adalah kasus keganasan ginekologi pada negara maju dan kanker keganasan ginekologi yang kedua setelah kanker leher rahim pada negara berkembang. tahun 2012 pada seluruh dunia sejumlah 527.600 perempuan menderita kanker endometrium. pada negara amerika, kanker endometrium adalah kanker tersering yang dijumpai, dengan jumlah 46.470 kasus baru dan 8120 kasus kematian pada tahun 2011. luaran dari operasi kanker endometrium merupakan hal yang penting untuk diketahui, dikarenakan dapat menalai hasil dan ketepatan tindakan dari operasi yang dikerjakan, luaran ini juga dapat dijadikan landasan tindakan operasi yang paling dianjurkan untuk menangani kanker endometrium. pada laporan kasus ini didapatkan jika tindakan laparoskopi mempunyai komplikasi yang lebih tinggi jika dibandingkan dengan tindakan operasi laparotomi, namun laparoskopi mempunyai keuntungan dari segi jumlah perdarahan, lama perawatan operasi. dari segi infeksi pada daerah operasi, laparoskopi dan laparotomi mempunyai angka yang sama yaitu tidak didapatkan satupun pasien yang mengalami infeksi daerah operasi. 60 medical and health science journal, vol.4., no.1, february 2020 daftar pustaka 1. torre, l., bray, f. & siegel, r., 2012. global cancer statistics. 2. siegel, r., miller, k. & jemal, a., 2016. cancer statistics, s.l.: s.n. 3. perkumpulan obstetri dan ginekologi indonesia, 2019. panduan pelayanan obstetri dan ginekologi pada kanker endometrium. in: panduan pelayanan kedokteran obstetri dan ginekologi. jakarta: s.n., p. 168. 4. chen, l. & berek, j., 2019. endometrial carcinoma epidemiology and risk factor. 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al., 2005. laparoscopic-assisted vaginal hysterectomy versus abdominal hysterectomy in patients with stage i and ii endometrial cancer. int j gynecol cancer, issue 15, pp. 932-937. 18. noori ardabili, s., arab, m. & ganji, p., 2018. laparoscoic surgery in endometrial cancer recommended approach: a review. jurnal of obstetrics, gynecology and cancer research, 3(1), pp. 39-44. 19. morrow, c., bundy, b. & kurman, r., 1991. relationship between surgical pathological risk factors and outcome in clinical stage i and ii carcinoma of the endometriuml: a gynecologic oncology group study. gynecol oncol. 20. keys, h., 2014. a phase iii trial of surgery with or without adjunctive external pelvic radiation therapy in intermediate risk endometrial adenocarcinoma: a 61 http://www.uptodate.com/ http://www.aicr.org/ http://www.aicr.org/ http://www.ncbi.nlm.nih.gov/pmc/articles/p medical and health science journal, vol.4., no.1, february 2020 gynecologic oncology group study. gynecol oncol, 92(3), pp. 744 751. 21. hogi, 2018. pedoman terapi kanker endometrium. in: pnpk hogi. jakarta: s.n., p. 55. 22. effendi, a., fidiawati, w. a. & rustam, r., 2014. profil penderita karsinoma endometrium di rsud arifin achmad pekanbaru periode 2008 2013. 62 medical and health science journal 202 3 february, vol 07 (01) medical and health science journal available at http://journal2.unusa.ac.id/index.php/mhsj; doi: 10.33086/mhsj.v7i1.3807 pissn 2549-7588. eissn 2549-7596 original article prevalence of hepatitis a virus and hepatitis e virus in a tertiary care hospital, east delhi, india charu jain1, nikita birhman2, shukla das3, swati sinha, n.p. singh4* 1md microbiology, assista nt professor, depa rtment of microbiology, university college of medica l sciences & gtb hospita l, delhi. 2resea rch assista nt, vira l resea rch & dia gnostic la bora tory, depa rtment of microbiology, university college of medica l sciences & gtb hospita l, delhi. 3md microbiology, director professor, depa rtment of microbiology, university college of medica l sciences & gtb hospita l, delhi. 4swa ti sinha , depa rtment of microbiology, university college of medica l sciences & gtb hospita l, delhi. corresponding author: doccharujain@ucms.ac.id article info article history: received january 14, 2023 received in revised from february 09, 2023 accepted february 28, 2023 keywords: acute viral hepatitis, hepatitis a, hepatitis e, inflammation, prevalence. abstract background & aim: acute vira l hepa titis (avh) is a condition tha t is known to be ca used by enterica lly tra nsmitting hepa titis a virus (hav) and hepa titis e virus (hev). usua lly, they result in self -limiting disea se but can be seriously threa tening if complica tions a rise. this study wa s done to determine the preva lence ra te of hav a nd hev in a tertia ry ca re hospita l in ea st delhi, india . material & methods: the retrospective a nd observa tiona l study of 2 -yea r dura tion wa s conducted in the depa rtment of microb iology a t ucms and gtbh delhi, india . a tota l of 410 sa mples from pa tients presenting with a clinica l dia gnosis of a cute hepa titis were considered in the study. the serum sa mples were a na lysed for igm a nti-hav a nd igm a nti-hev, respectively, using commercia lly a va ila ble elisa kits. results: the seropreva lence of hav a nd hev were 2.19% a nd 0.24%, respectively. no ca se wa s found to be rea ctive for both pa ra meters, indica ting no ca se of co-infection. the ma jority of clinica l sa mples were from fema le pa tients. conclusion: the incidence of hev a nd hav illnesses suggests tha t east delhi ha s a lower preva lence ra te of the reported vira l illnesses. this finding suggests one of the following: limited circula tion of the a gents, good sa nita ry conditions, a nd/or protect ive immunity a mong the popula tion tested. nonetheless, we should continue to a ssess the ongoing conditions a nd ta ke mea sures to improve them . medical and health science journal. introduction hepatitis is an infection of the liver caused by several pathogenic viruses and non -pathogenic substances. it can cause a variety of health problems, some of which can be fatal. hepatitis a, b, c, d, and e are the five main viruses that cause hepatitis [1]. hepatitis a virus (hav) and hepatitis e virus (hev) are both transmitted by water and produce acute infections that are often self -limiting. they may also lead to fulminant hepatitis. the most common method of transmission is feco-oral, and cases typically manifest as outbreaks in which the patients excrete huge quantities of infectious viruses into the surrounding area. the enterically transmitted hev is most common in asia, africa, and central america. hev is a nonenveloped herpesvirus belonging to the family herpesviridae with a single-stranded positive-sense http://journal2.unusa.ac.id/index.php/mhsj mailto:doccharujain@ucms.ac.id ja in et al medical and health science journal 202 3 february vol 07 (01) pa ge 2 of 8 rna. anti-hev igm and anti-hev igg antibodies (which may be identified) decline quickly after acute infection, reaching low levels within 6 months. serologic testing for hev infection is not routinely available in many diagnostic set ups.[2]. hav is a 27-nm, non-enveloped rna virus in the genus hepatovirus of the family picornaviridae that is resistant to heat, acid, and ether. when serum aminotransferase activity is high and faecal hav shedding is still occurring, hav antibodies (antihav) might be found during the acute phase. the igm class predominates during early immune response, which may lasts for six to twelve months. however, after convalescence, the igg class of antihav antibody becomes the dominant antibody. hepatitis a continues to be self -limiting and does not develop into a chronic liver condition [2]. in developing countries like india, hav and hev have a considerable impact on public health [3]. both of these viruses may infect humans to varying degrees, from asymptomatic infection to severe viral hepatitis, and are mostly transmitted enterically via the feco-oral route. the national viral hepatitis control program (nvhcp), which was introduced in july 2018 and seeks to drastically lower the risk, morbidity, and mortality linked to hav and hev by 2030 [3]. there is scanty of data on long-term study from india about the severity of the disease and clinical manifestations brought on by these two viruses [3]. scientific understanding is lacking since laboratory aetiological diagnosis in such self -limiting hepatitis cases is underreported. to understand the frequency of hav and hev infections in the population, it is essential to study the epidemiological patterns of these illnesses. due to the socioeconomic and demographic complexity that exists in india, this is important. the developments in the sanitation system as a result of the clean india mission 2014 will benefit from this knowledge [3]. the study we report here examines the prevalence of avh caused by hav and hev among patients utilising a tertiary care facility in east delhi, india. material and methods this retrospective and observational study was carried out in the department of microbiology at university college of medical sciences and guru teg bahadur hospital, delhi, india. the research included all patients with clinical suspicion of acute viral hepatitis-like symptoms. the blood samples were sent for standard serological testing against hav and hev in the virology section of the department of microbiology. the serum was separated using the prescribed procedure for laboratory testing [4]. demographic and important clinical data were collected using information from the patient's record. the aliquoted serum was stored at 4 °c (up to 7 days). according to the manufacturer's instructions, tests were run on serum samples using elisabased kits (onsite r0095c, hannover, germany; and onsite r0090c, hannover, germany). along with test samples, kit controls and internal quality controls were used for quality assurance. statistical analysis microsoft excel was used to import the data, while spss version 11 was used for analysis. result a total of 410 clinically suspected cases of acute hepatitis were included in the study from june 2019 to august 2021. among the tested samples, 276 samples were from females and 134 were from ja in et al medical and health science journal 202 3 february vol 07 (01) pa ge 3 of 8 males. approximately 41% (n = 171) were young adults aged 21 to 30, with the remaining 1.21 percent (n = 05) being people aged 71 to 80 (figure 1). out of tested, 2.19 percent (n = 9) were reactive to anti-hev igm and 0.24 percent (n = 01) were reactive to anti-hav igm. the remaining samples tested negative for anti-hev and anti-hav igm in 97.8 percent (n = 401) and 99.75 percent (n = 409) of the samples, respectively. no case was found to be reactive for both parameters, indicating no case of co-infection. among males, the patients belonging to age group of 31 to 40 (19.40%, n = 26) were higher in number as compared to elderly age group (61-80 years age) which had the lowest percentage of samples tested (2.98%, n = 4 in each group). moreover, among 276 females, most samples were screened from the age groups of 21 to 30 (58.33%, n = 161) and the least from the age group of 60-70 (0.36%, n = 01), respectively. (figure 1). it was observed that no samples belonged to the antenatal care group or from pregnant females. hev positive: out of the 410 tested samples, 09 came out as hev positive. male patients accounted for 73 percent (n = 05) of anti-hev igm positive samples, while female patients accounted for only 1.4% (n = 04) of positives. the majority of those who tested positive for hev antibodies belonged to the age group of 21 to 30 amongst both genders (table. 1). the seasonal distribution reveals that the positive hev cases—66.66% (n = 6)—clustered between april and june, followed by 22.22% (n = 02) from the months of october to december (table 2). hav positive: out of the 410 tested samples, only 1 was found to be hav positive. it was from a male patient of the age group of 11 to 20. the case was from tested in july to september quarter (table 2). figure 1: distribution of patients according to age group and gender. table 1: age and gender wise distribution of hev positive cases age groups males (n=05) females (n=04) 0 to 10 01 00 11 to 20 00 00 21 to 30 03 03 31 to 40 00 01 41 to 50 00 00 51 to 60 01 00 0 20 40 60 80 100 120 140 160 180 0 to 10 11 to 20 21 to 30 31 to 40 41 to 50 51 to 60 61 to 70 71 to 80 n u m b e r o f p a ti rn ts age group total number of patients (n=410) number of male patients (n=1 34) ja in et al medical and health science journal 202 3 february vol 07 (01) pa ge 4 of 8 61 to 70 00 00 71 to 80 00 00 table 2: seasonal distribution of positive hav and positive hev cases. months hev positive (n=09) hav positive (n=01) january – march 01 00 april – june 06 00 july – september 00 01 october – december 02 00 discussion the current study was conducted from june 2019 to august 2021. the observed hev and hav positive rates were 2.19% and 0.244%, respectively. literature shows that hev positivity rates in india ranged from 10.5% to 78.6% [2,5,6], while hav positivity rates ranged around 8.3% to 18.3% [7]. the number of hev cases was higher compared to hav, which was also reported in studies by radhakrishnan s, raghuraman s, et al and netra s, bithu r, et al [8,9]. a contrasting result was reported by joon et al and bansal et al, which documented a higher hav number [2,3]. the survival capability of hepatitis e virus (hev) is better as compared to hepatitis a virus (hav) [10,11]. this could also be a contributing factor to the higher prevalence of hev in our study. the reason for the higher hev prevalence could also be attributed to the circulation of specific genotypes that have zoonotic potential [12,13]. various studies have shown that hev has a higher predisposition to cause outbreaks in communities as compared to hev [14, 15]. in a study done by a joon p rao et al., 11.5% of tested groups were found to have hav & hev coinfection [2]. similarly, a study done by samaddar a et al., also found the hav-hev coinfection rate of about 2.07% [16]. other studies of mongolia and cuba have also reported the presence of dual infections [17]. such data was not observed in our study. this finding is significant as it indicates that the study population was probably not exposed to two different water-borne circulating viruses at the same time (i.e., hav & hev). it is usually reported that co-infection does not affect the prognosis as most cases improve by symptomatic therapy, but there are case reports highlighting complications like hepatic encephalopathy in co-infection [18]. compared to other studies, gender-wise positivity did not differ significantly in hev [19,20]. the predominance of disease in a particular gender often implies one's exposure and also susceptibility. despite clinical suspicious & testing, our study did not find any prepondance of hev. in this investigation, we discovered a low incidence of hev in younger patients (>10 years of age). a lack of exposure was cited as the cause of this in research by takahashi m et al. [21]. the majority of infection cases were f ound in patients between the ages of 21 and 50. clinical presentation in a particular age group for an agent that is common in the environment suggests that the particular host is susceptible to developing symptoms. although an ja in et al medical and health science journal 202 3 february vol 07 (01) pa ge 5 of 8 infection may be present, it is possible that such illness signs go unnoticed in younger age groups due to the absence of disease manifestation. similar findings were also recorded by kamal sm, mahmoud s et al and by pelosi e, clarke i. [20,22]. there were no cases of pregnant women among the tested group. this is significant since hev is known to create a complex course in these patient populations [23, 24]. in addition, joon a et al. and radhakrishnan s, raghuraman s, et al. reported fulminant hepatitis in such cases [2, 8]. according to the seasonal patterns, cases tend to cluster in the months of april through june. this result is clearly apparent in other research from india that has been reported, which indicates a greater transmission of hev during the start of the rainy season [25,26]. the one hav igm positive patient belongs to the 11–20 age range. this result contrasted markedly with those of joon et al., who discovered that young adults made up 13.25% of the maximum cases [2]. in other investigations by aggarwal r et al., murhekar mv et al., agrawal a et al., and arankalle v et al., they discovered that the majority of cases—90%, 74.6%, 70.8%, and 57.1%—belong to young adults, respectively [27,7,28,29]. a lesser number of cases of hav may be because of the introduction of the vaccine. even though it is not part of the universal immunisation program, the vaccine is being sought after by parents of children who can bear the cost. shifting patterns among the affected age group of hav could be brought on by the hepatitis a vaccine [30,7,28,31,32]. according to murhekar et al. [7], hav is a disease that may be prevented by vaccination even if it is not included in the universal immunisation programme. most children have antibodies by the age of 10 as a result of a mild natural sickness. the efforts of the government, in the form of the national viral hepatitis control program (nvhcp), launched in july 2018, aim to address such viral infections to combat the mortality and morbidity caused by the hepatitis virus. these findings suggest a low level of viral circulation among the people in east delhi. testing on a large number of samples is required to further corroborate this conclusion. such data helps authorities concentrate on outbreak prevention strategies during a particular season based on the forecast. the main goal of control measures should be to stop feco-oral transmission of hev and hav. it is clear from our study that both enteric hepatic virus (hev) and hav) infections are common. when considering the significance of the trends for public health, the availability of diagnostic kits for these illnesses is a crucial need. one of the limitations of the study was that it was based on hospitals. therefore, the prevalence in asymptomatic groups in the community could not be determined. such prevalence data needs to be reported to find the circulating states of the virus. conclusion the incidence of hev and hav illnesses suggests that east delhi has a lower prevalence rate of the reported viral illnesses. this finding suggests one of the following: limited circulation of the agents, good sanitary conditions, and/or protective immunity among the population tested. nonetheless, we should continue to assess the ongoing conditions and take measures to improve them. ja in et al medical and health science journal 202 3 february vol 07 (01) pa ge 6 of 8 conflict of interest the author started there is no conflict of interest. reference 1. https://www.who.int/healthtopics/hepatitis#tab=tab_1 2. joon a, rao p, shenoy sm, baliga s. prevalence of hepatitis a virus (hav) and hepatitis e virus (hev) in the patients presenting with acute viral hepatitis. indian journal of medical microbiology. 2015 feb 1;33: s102-105. 3. bansal y, singla n, garg k, sharma g, gill m, chander j. seroprevalence of hepatitis a and hepatitis e in patients at a teaching hospital of northern india over a period of 8 years. journal of family medicine and primary care. 2022 feb;11(2):567. 4. mackie & mccartney practical medical microbiology. elsevier; 14th edition; 1 january 1996. 5. amarapurkar d, agal s, baijal r, gupte p, patel n, et al. epidemiology of hepatitis e virus infection in western india. hepat mon.8(4): 258-262. 6. chandra ns, ojha d, chatterjee s, chattopadhyay d. prevalence of hepatitis e virus infection in west bengal, india: a hospital-based study. journal of medical microbiology. 2014 jul 1;63(7):975-980. 7. murhekar mv, ashok m, kanagasabai k, joshua v, ravi m, sabarinathan r, kirubakaran bk, ramachandran v, shete v, gupta n, mehendale sm. epidemiology of hepatitis a and hepatitis e based on laboratory surveillance data—india, 2014– 2017. the american journal of tropical medicine and hygiene. 2018 oct;99(4):1058. 8. radhakrishnan s, raghuraman s, abraham p, kurian g, chandy g, sridharan g. prevalence of enterically transmitted hepatitis viruses in patients attending a tertiary--care hospital in south india. indian journal of pathology & microbiology. 2000 oct 1;43(4):433-436. 9. netra s, bithu r, maheshwari rk. epidemiological study of hepatitis a virus and hepatitis e virus infection in patients presenting with acute viral hepatitis. int j curr microbiol app sci. 2018; 7:899-904. 10. walker cm. adaptive immune responses in hepatitis a virus and hepatitis e virus infections. cold spring harbor perspectives in medicine. 2019 sep 1;9(9): a033472. 11. nan y, wu c, zhao q, sun y, zhang yj, zhou em. vaccine development against zoonotic hepatitis e virus: open questions and remaining challenges. frontiers in 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primary health care centers in baghdad: a one-year cross-sectional study. global journal of health science. 2012 sep;4(5):172. 20. kamal sm, mahmoud s, hafez t, fouly re. viral hepatitis a to e in south mediterranean countries. mediterranean journal of hematology and infectious diseases. 2010 feb 9;2(1): e2010001. 21. takahashi m, nishizawa t, gotanda y, tsuda f, komatsu f, kawabata t, hasegawa k, altankhuu m, chimedregzen u, narantuya l, hoshino h. high prevalence of antibodies to hepatitis a and e viruses and viremia of hepatitis b, c, and d viruses among apparently healthy populations in mongolia. clinical and vaccine immunology. 2004 mar;11(2):392-398. 22. pelosi e, clarke i. hepatitis e: a complex and global disease. emerging health threats journal. 2008 mar 15;1(1):7069. 23. kumar s, ratho rk, chawla yk, chakraborti a. virological investigation of a hepatitis e epidemic in north india. singapore medical journal. 2006 sep 1;47(9):769. 24. kaur m, sidhu sk, singh k, devi p, kaur m, 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science journal, vol.4., no.1, february 2020 deskripsi perbedaan sitologi non granuloma limfadenitis tuberkulosis pada pasien hiv aids dan non hiv aids: studi kasus yafanita izzati nurina *1 , usman hadi 2 1 departemen ilmu penyakit dalam rsud dr. soetomo surabaya, fakultas kedokteran universitas airlangga, surabaya 2 divisi tropik dan infeksi, departemen ilmu penyakit dalam rsud dr. soetomo surabaya, fakultas kedokteran universitas airlangga, surabaya *correspondent author: yafa.izza@gmail.com correspondence: yafanita izzati nurina @2020 medical and health science journal. 10.33086/mhsj.v4i1.1415 available at http://journal2.unusa.ac.id/index.php/mhsj 47 case report article info abstract article history: submitted: january, 21-2020 received in revised form february accepted: february, 26-2020 background: hiv aids is syndrome with cd4 as the main target of the virus and frequently accompanied by lymphadenopathy symptoms. most lymphadenopathy is caused by tuberculosis. the prevalence of limphadenitis in hiv tb is 40-80%. cytological features of tb lymphadenitis in hiv aids and non-hiv have differences and associated with lower cd4 counts. case: male, 58 years old with complaints of right and left neck mass since 1 month. it was enlarged since 1 week, not accompanied by pain and injury. patient also complained fever, night sweats, weight loss, white spots in the mouth. on physical examination, found right neck mass of 7x6 cm and left of 5x4 cm, flat surface elastic solid mass, difficult to move, no tenderness and inflammation. vct result of three methods was reactive, absolute cd4 cell count 81.8 cells/ul and 6.13 log copies/ml viral load. cytology result was hypocellular smears containing large necrotic areas with lymphocyte cells, histiocytes, pmn without signs of malignancy, conclusion: tb lymphadenitis. patients received anti tb category one and arv 2 weeks after tb treatment. discussion: lymphadenopathy symptoms in hiv aids from many etiologies are almost the same, thus a cytological examination is needed. in tb lymphadenitis cytology, there are 3 groups of typical features are granuloma, granuloma with necrosis and only necrosis then it was confirmed zn staining (smear bacilli). in hiv aids is more found necrosis without granuloma except cd4>100. this is because t cell function which is important in the formation of epithelioid granuloma is decreased. at an advanced stage with cd4 decreases, there is no epithelioid cell formation but rather foamy macrophage formation. conclusion: hiv aids patient with cd4 81.8 and cervical tuberculosis lymphadenitis has different cytological features with large necrotic areas without granulomas. keywords: hiv aids, tb lymphadenitis, non granuloma, cytology abstrak kata kunci: sitologi, hiv aids, limfadenitis tb latar belakang: hiv aids adalah kumpulan gejala dengan cd4 sebagai target utama dari virus tersebut yang sering disertai gejala limfadenopati. limfadenopati paling banyak disebabkan infeksi tuberkulosis dengan prevalensi 40-80% pasien hiv berupa limfadenitis di indonesia. gambaran sitologi limfadenitis tb pada hiv aids dan non hiv memiliki perbedaan yang dikaitkan dengan semakin rendahnya cd4. kasus: pria, 58 tahun dengan keluhan benjolan leher kanan kiri sejak 1 bulan smrs. semakin membesar sejak 1 minggu, tidak disertai nyeri dan luka. didapatkan demam, keringat malam, berat badan turun, bercak putih di mulut. pada leher didapatkan massa ukuran 7x6 cm (dekstra). 5x4 cm (sinistra), permukaan rata padat kenyal, sulit digerakkan, tidak nyeri tekan dan tanda radang. hasil vct 3 metode reaktif, cd4 absolut 81,8 sel/ul dan viral load 6,13 log kopi/ml. sitologi didapatkan hapusan hiposeluler mengandung area nekrotik luas dengan sel limfosit, histiosit, pmn tanpa tanda keganasan. kesimpulan: limfadenitis tb. pasien mailto:yafa.izza@gmail.com http://journal2.unusa.ac.id/index.php/mhsj medical and health science journal, vol.4., no.1, february 2020 mendapat terapi oat kategori 1 dan arv 2 minggu setelah pengobatan tb. diskusi: gejala limfadenopati hiv aids dari beberapa etiologi hampir sama sehingga diperlukan pemeriksaan sitologi. pada sitologi limfadenitis tb didapatkan 3 kelompok gambaran khas yaitu granuloma, granuloma dengan nekrosis dan hanya nekrosis selanjutnya dikonfirm pewarnaan zn didapatkan kuman bta. pada hiv aids lebih banyak gambaran nekrosis tanpa granuloma kecuali cd4>100. hal ini disebabkan karena fungsi sel t yang penting dalam pembentukan granuloma epitelioid menurun. stadium lanjut dengan cd4 semakin menurun, tidak terdapat pembentukan sel epitelioid melainkan pembentukan makrofag foamy. kesimpulan: telah dilaporkan pasien hiv aids cd4 81,8 dengan limfadenitis tb servikal dengan gambaran sitologi area nekrotik luas tanpa granuloma. @2020 medical and health science journal. 10.33086/mhsj.v4i1.1415 pendahuluan acquired immunodeficiency syndrome (aids) merupakan suatu kumpulan gejala atau penyakit yang disebabkan oleh menurunnya kekebalan tubuh akibat infeksi oleh virus human immunodeficiency virus (hiv) yang dikaitkan dengan rendahnya jumlah sel cd4. limfosit cd4 merupakan target utama infeksi hiv yang berfungsi mengkoordinasikan sejumlah fungsi imunologis yang penting. hilangnya fungsi tersebut menyebabkan gangguan respon imun yang progresif. infeksi hiv tidak akan langsung memperlihatkan gejala tertentu. setelah infeksi akut, dimulailah stadium asimtomatik sekitar 8-10 tahun hingga berlanjut ke stadium lanjut1. insidensi infeksi hiv mengalami peningkatan setiap tahun dan pararel dengan peningkatan frekuensi tuberkulosis baik pulmonal maupun ekstrapulmonal terutama limfadenitis. di indonesia, berdasarkan data kementrian kesehatan republik indonesia pada tahun 2013, ditemukan jumlah kasus penderita hiv sebanyak 29.037 orang dan sebanyak 5.068 orang telah di diagnosis sebagai aids. dari data tersebut, penyakit penyerta yang sering pada penderita hiv/aids adalah kandidiasis, diare, tuberkulosis, toksoplasmosis, dermatitis dan limfadenopati1,2. limfadenopati didefinisikan sebagai pembesaran kelenjar getah bening (kgb) baik generalisata maupun lokal dengan ukuran > 0,5 cm. beberapa etiologi limfadenopati pada pasien hiv adalah keganasan, reaktif hiperplasia dan infeksi oportunistik seperti tuberkulosis (paling sering di indonesia), sitomegalovirus dan toksoplasma. gejala yang timbul dari beberapa etiologi tersebut hampir sama serta tumpang tindih dengan gejala dari hiv itu sendiri. di indonesia sekitar 40-80% pasien tuberkulosis (tb) dengan hiv memiliki manifestasi ekstrapulmonal (limfadenitis), sedangkan pada pasien tanpa hiv hanya 10 20%. risiko terjadinya tb ekstrapulmonal meningkat dengan semakin rendahnya jumlah limfosit t cd43-6. biopsi aspirasi jarum halus (fnab) dengan pemeriksaan sitopatologi merupakan metode yang efektif dalam membantu menentukan diagnosis berbagai kasus penyakit dengan limfadenopati. pemeriksaan ini dapat membantu untuk membedakan antara infeksi maupun keganasan. pada kasus infeksi seperti limfadenitis tb umumnya tidak diindikasikan untuk biopsi eksisi, hanya follow-up dan diberikan terapi oral sesuai indikasi6. pada pasien limfadenitis tb dengan hiv aids yang mengalami penurunan sel cd4 memiliki gambaran fnab yang berbeda dibandingkan dengan non hiv aids pada pasien hiv terutama stadium lanjut biasanya didapatkan sedikit sekali gambaran granuloma pada fnab karena ketidakmampuan fungsi sel t dalam pembentukan granuloma epiteloid7. berikut kami laporkan kasus seorang pria yang didiagnosis hiv aids dengan kecurigaan limfadenitis tb servikal dan tb paru kasus baru. alasan dikasuskan karena 48 medical and health science journal, vol.4., no.1, february 2020 ingin mengetahui profil gambaran fnab limfadenitis tb pada pasien hiv. kasus seorang laki-laki, tn h, usia 58 tahun, menikah dan mempunyai 3 orang anak bekerja sebagai pemulung, bertempat tinggal di sidoarjo, mrs di soetomo dengan keluhan demam. pasien mengeluh demam sejak 1,5 bulan terakhir naik turun dengan obat penurun panas namun selama satu minggu terakhir, pasien mengalami demam hampir tiap hari. selain demam juga disertai batuk selama satu bulan terakhir dengan dahak warna putih kekuningan kental dan tidak ada darah. pasien juga kadang-kadang mengeluh sesak hilang timbul, sesak tidak terpengaruh aktivitas dan tidak ada mengi. terdapat keluhan keringat malam, lemas dan penurunan berat badan sejak kurang lebih sebulan terakhir karena nafsu makan juga menurun yang disertai dengan mual tetapi tidak ada muntah. pasien juga mengeluhkan benjolan di leher kanan dan kiri (kanan lebih besar) sejak kurang lebih 1 bulan sebelum masuk rumah sakit, awalnya hanya di sebelah kanan sebesar telur ayam kemudian diikuti sebelah kiri beberapa hari kemudian tetapi sejak 1 minggu terakhir benjolan semakin membesar, benjolan tidak nyeri dan tidak ada luka. terdapat bercak putih di lidah kurang lebih sejak 1 bulan ini. diare lama disangkal. buang air besar dan kecil dalam batas normal. riwayat hipertensi dan diabetes disangkal. riwayat hiv diketahui sejak 3 minggu lalu dan kontrol ke poli upipi hanya diberi obat cotrimoxazol dan parasetamol tetapi belum mendapat terapi arv. pasien kontrol ke poli untuk terapi batuk dan sesaknya saja tetapi belum cek dahak. pasien mempunyai riwayat free sex saat usia 40 tahun, riwayat pemakaian narkoba disangkal, tidak ada tato. riwayat keluarga yang menderita batuk lama disangkal. riwayat istri pasien dengan hiv sejak 3 bulan ini dan sering kontrol ke poli upipi mendapat terapi arv 1x1 kapsul (efavirens 600mg, lamivudin 300mg, tenofovir 300mg). pada pemeriksaan fisik didapatkan keadaan umum lemah dengan glasgow comma scale (gcs) 456. tekanan darah 100/60 mmhg, nadi 99x/menit, irama teratur, kuat angkat, amplitudo normal. pernapasan 22x/menit, suhu aksiler 390c, saturasi 97% tanpa o2. pemeriksaan kepala leher: konjungtiva tidak anemi, sklera tidak ikterus, tidak didapatkan sianosis atau dispnea didapatkan candidiasis oris. tidak didapatkan peningkatan tekanan vena jugularis. status lokalis regio colli dextra: didapatkan massa dengan diameter kurang lebih 5 cm, padat kenyal, fixed, tidak didapatkan nyeri tekan dan tanda radang. status lokalis regio colli sinistra: didapatkan massa dengan diameter kurang lebih 3-4 cm, padat kenyal, fixed, tidak didapatkan nyeri tekan dan tanda radang. pemeriksaan thorax: pergerakan simetris, tidak didapatkan retraksi interkostalis maupun supraklavikula, tidak didapatkan spider nevi maupun ginekomasti. pada pemeriksaan jantung didapatkan s1 dan s2 tunggal, teratur, tidak didapatkan suara bising jantung, irama gallop maupun suara gesek perikard. pada pemeriksaan paru didapatkan suara napas vesikular pada kedua hemitoraks, tidak didapatkan ronkhi maupun wheezing di kedua lapang paru. pemeriksaan abdomen: bising usus normal, supel pada perabaan. hepar dan lien tak teraba. tidak didapatkan nyeri tekan ulu hati. pemeriksaan ekstrimitas: akral hangat kering pucat, capillary refill time kurang dari 2 detik, tidak ada edema extremitas, tidak didapatkan eritema palmaris. pemeriksaan penunjang, didapatkan hasil laboratorium tanggal 01 januari 2018 hb 11,3 g/dl, mcv 92,9 fl, mch 30,9 pg, mchc 33,2 g/dl, leukosit 10.930/mm3, netrofil 85,7%, limfosit 7,9%, trombosit 388.000, sgot 43 u/l, sgpt 45 u/l, bun 14 mg/dl, sk 0,96 mg/dl, gda 85 mg/dl, albumin 3,16, natrium 131 mmol/l, kalium 3,8 mmol/l, clorida 96 mmol/l, bga: ph 7,545, po2 103,8, pco2 21,6, hco3 18,8, be -3,8, aado2 15,4, so2 98,4%, po2/fio2 49 medical and health science journal, vol.4., no.1, february 2020 496,7. hasil foto thorax didapatkan fibroinfiltrat di kedua lapang paru. dari hasil laboratorium tanggal 11 desember 2017 didapatkan hasil vct 3 metode reaktif hiv. untuk laboratorium tanggal 13 desember 2017 didapatkan cd4 absolut 81,8 sel/ul, cd4% 10,1%, cd8 absolut 473,9 sel/ul, rasio cd4/cd8 0,17, kesan: limfosit t helper menurun dan t supresor normal dengan rasio cd4:cd8 menurun, dari hasil viral load didapatkan virus terdeteksi sebesar 6,13 log copies/ml. pada tanggal 22 desember 2017 didapatkan hasil laboratorium hb 12,3 g/dl, mcv 93,8 fl, mch 30,6 pg, mchc 32,6 g/dl, leukosit 7.030/mm3, netrofil 5130 (73%), limfosit 670 (9,5%), trombosit 296.000, sgot 27 u/l, sgpt 24 u/l, bun 11 mg/dl, sk 1 mg/dl, asam urat 3,3, gda 85 mg/dl, albumin 3,16, natrium 131 mmol/l, kalium 4,7 mmol/l, clorida 102 mmol/l, hbsag negatif, kolesterol total 141, trigliserida 127, hdl 15, ldl 115. berdasarkan anamnesa, pemeriksaan fisik dan penunjang, pasien didiagnosis dengan hiv aids stadium 4 + suspek tb paru kasus baru + suspek limfadenitis tb servikal + candidiasis oris. planning diagnosis: fnab coli, smear sputum bta, gene expert sputum. terapi awal: diet tktp 2100 kal/hari, infus aminofluid 7 tpm, injeksi ranitidin 2x1 ampul, injeksi metoklopramid 3x1 ampul prn, paracetamol tab 3x1, n-asetilsistein 3x1 tab, nystatin drop 6xgtt 1 cc. perjalanan penyakit pada hari kedua perawatan: pasien masih mengeluh demam dan batuk, masih mual, tidak panas dan muntah. keadaan umum cukup, tekanan darah 110/70 mmhg, rr 20x/menit, nadi 90x/menit, suhu 38,1oc, spo2 97% tanpa o2. diagnosis: hiv aids stadium 4+ suspek tb paru kasus baru + suspek limfadenitis tb servikal + candidiasis oris. planning diagnosis: fnab coli (tunggu jadwal), smear sputum bta (tunggu hasil), gene expert sputum (tunggu hasil). terapi: diet tktp 2100 kal/hari, infus aminofluid 7 tpm, injeksi ranitidin 2x1 ampul, injeksi metoklopramid 3x1 ampul prn, paracetamol tab 3x1, n-asetilsistein 3x1 tab, nystatin drop 6xgtt 1 cc. pada hari ketiga perawatan: demam mulai berkurang, masih mengeluh batuk dan tidak sesak. keadaan umum cukup, tekanan darah 110/60 mmhg, rr 20x/menit, nadi 90x/menit, suhu 37,8oc, spo2 97% tanpa o2. diagnosis: hiv aids stadium 4 + tb paru kasus baru + suspek limfadenitis tb servikal + candidiasis oris. hasil sputum bta sps didapatkan +2, gene expert sputum mtb positif dengan rifampicin susceptible. planning diagnosis: fnab coli (dijadwalkan hari jumat). terapi: diet tktp 2100 kal/hari, infus aminofluid 7 tpm, injeksi ranitidin 2x1 ampul, injeksi metoklopramid 3x1 ampul prn, paracetamol tab 3x1, n-asetilsistein 3x1 tab, oat kategori 1 fase intensif (inh 300 mg, rifampicin 600 mg, pirazinamid 1500 mg, etambutol 300 mg), nystatin drop 6xgtt 1 cc. pada hari kelima perawatan: demam mulai berkurang dan pasien menjalani fnab coli. keadaan umum cukup, tekanan darah 100/60 mmhg, rr 19x/menit, nadi 86x/menit, suhu 37,3oc spo2 98% tanpa o2. diagnosis: hiv aids stadium 4 + tb paru kasus baru + suspek limfadenitis tb servikal + candidiasis oris. planning diagnosis: fnab coli (tunggu hasil). terapi: pasien dapat rawat jalan dengan terapi parasetamol tablet 3x1, ranitidin 2x1 tablet, oat kategori 1, nystatin drop 6xgtt 1 cc. pasien kontrol di rawat jalan upipi 3 hari lagi dengan keluhan demam sudah berkurang dan batuk sudah mulai berkurang. hasil fnab coli didapatkan: makroskopik: dilakukan 2 kali puncture pada nodul colli dextra ǿ 5 cm, batas tegas, fixed, padat kenyal; mikroskopik: hapusan hiposeluler mengandung area nekrotik luas dengan sebaran sel radang limfosit, histiosit, pmn. tidak tampak tanda-tanda keganasan. pada pengecatan zn ditemukan kuman bta; kesimpulan: limfadenitis tuberkulosa (ditunjukkan pada gambar 1). diagnosis: hiv 50 medical and health science journal, vol.4., no.1, february 2020 aids stadium 4 + tb paru kasus baru + limfadenitis tb servikal + candidiasis oris. pasien diberikan terapi parasetamol tablet 3x1, ranitidin 2x1 tablet, oat kategori 1, nystatin drop 6xgtt 1 cc, arv diberikan setelah pengobatan tb 2 minggu kemudian yaitu fixed drug combination (tenovofir, lamivudin, efavirens) 1x1 tablet. setelah itu pasien tidak kontrol lagi. gambar 1. pembesaran mikroskop 100x. gambaran fnab pasien limfadenitis tb-hiv aids berupa nekrosis luas yang tersebar pembahasan beberapa etiologi limfadenopati pada pasien hiv aids adalah keganasan, reaktif hiperplasia, dan infeksi oportunistik seperti tuberkulosis (penyebab terbanyak limfadenopati pada hiv aids), sitomegalovirus, dan toksoplasma. pada infeksi yang disebabkan tuberkulosis, biasanya didapatkan keluhan batuk lebih dari 2 minggu kadang-kadang bisa didapatkan sedangkan pada sitomegalovirus keluhan yang menonjol adalah retinitis dan gastrointestinal serta pada toksoplasma biasanya lebih sering timbul gejala di intrakranial. pada pemeriksaan fisik, sitomegalovirus dan toksoplasma benjolannya bersifat mobile dan elastis (kenyal) sedangkan pada tuberkulosis bersifat difus, bilateral, multipel, fixed, dan kenyal serta pada keganasan biasanya bersifat keras, dapat mobile ataupun fixed, dan tidak nyeri8-10. oleh karena manifestasi klinis diantara etiologi tersebut hampir sama, maka diperlukan pemeriksaan penunjang untuk menegakkan diagnosis. pemeriksaan sitopatologi berupa biopsi aspirasi jarum halus (fnab) merupakan metode yang efektif, cepat, murah, dan memiliki risiko yang rendah untuk membedakan etiologinya. hal ini diperlukan untuk kepentingan terapi dari limfadenopati itu sendiri. ada kasus-kasus infeksi umumnya tidak diindikasikan untuk biopsi eksisi, hanya follow-up dan diberikan terapi oral sesuai indikasi11. pada limfadenopati yang disebabkan keganasan seperti limfoma didapatkan gambaran fnab berupa banyak ditemukan sel limfoid dengan rasio inti lebih besar dari sitoplasma, inti hiperkromatin dengan satu atau lebih nukleoli yang prominen, dan sedikit sitoplasma basofilik. gambaran fnab pada reaktif hiperplasia dimana pada tipe ini termasuk golongan limfadenitis non spesifik yaitu tidak ditemukan gambaran epitelioid histiosit melainkan sel-sel limfosit dan histiosit, ditemukan badan makrofag, dan sel plasma yang bervariasi. pada limfadenopati yang disebabkan toksoplasma ditemukan gambaran folikular hiperplasia dan granuloma yang kecil sedangkan yang disebabkan sitomegalovirus biasanya gambarannya berupa sel yang supuratif11-13. limfadenopati yang disebabkan oleh tuberkulosis termasuk ke dalam limfadenitis granulomatosis selain sarkoidosis dan yang disebabkan mikobakterium atipikal. gambaran fnab pada limfadenitis tuberkulosis yang khas adalah adanya granuloma dan nekrosis. terdapat tiga kelompok gambaran fnab pada limfadenitis tuberkulosis yaitu hanya granuloma epiteloid (bisa didapatkan giant cell), granuloma epiteloid dengan nekrosis, dan hanya gambaran nekrosis (bisa didapatkan netrofil). dari ketiga kelompok tersebut sebaiknya dikonfirm lagi dengan pewarnaan zn untuk mengetahui apakah ada gambaran kuman batang tahan asam (bta). gambaran granuloma epiteloid ini mirip dengan gambaran dari kedua jenis limfadenitis granulomatosis. biasanya pada sarkoidosis dan mikobakterium atipikal gambaran 51 medical and health science journal, vol.4., no.1, february 2020 granulomanya tidak disertai dengan nekrosis ataupun netrofil12-15. pada pasien ini didapatkan hasil fnab didapatkan gambaran hapusan hiposeluler mengandung area nekrotik luas dengan sebaran sel radang limfosit, histiosit, pmn dan tidak tampak tanda-tanda keganasan serta pada pengecatan zn ditemukan kuman batang tahan asam. hal ini menunjang pasien didiagnosis sebagai limfadenitis tuberkulosis. pasien dengan hiv lebih cenderung memiliki manifestasi tb ekstrapulmonal dibandingkan pasien tanpa hiv. sekitar 40 80% pasien tb dengan hiv memiliki manifestasi ekstrapulmonal, sedangkan pada pasien tanpa hiv hanya 10-20%. manifestasi ekstrapulmonal yang umum terjadi ialah kelenjar limfa (limfadenitis). risiko terjadinya tb ekstrapulmonal meningkat dengan semakin rendahnya jumlah limfosit t cd4 sebagai sel target utama yang diserang oleh virus hiv3,4. menurut beberapa literatur disebutkan bahwa gambaran fnab limfadenitis tb pada pasien hiv aids dan non hiv aids berbeda. perbedaan itu terletak bila pada pasien non hiv aids gambaran fnab limfadenitis tb yang paling banyak berupa granuloma epiteloid7. sedangkan pada pasien hiv aids banyak didapatkan gambaran berupa nekrosis tanpa adanya bentukan granuloma. pernyataan ini dibuktikan pada literatur oleh studi tahun 200716 bahwa gambaran granuloma sedikit ditemukan pada pasien hiv aids dibandingkan dengan non hiv aids (gambar 2). hal ini disebabkan karena fungsi sel t yang penting dalam pembentukan granuloma epitelioid menurun. pada penderita hiv positif stadium lanjut dengan limfosit cd4+ yang semakin menurun, tidak terdapat pembentukan sel epitelioid melainkan pembentukan makrofag foamy17. hal ini juga sesuai dengan literatur lain bahwa gambaran fnab hiv aids tergantung dari jumlah cd4 pasien yaitu pada cd4<100/µl gambaran yang didapatkan paling banyak adalah hanya nekrosis saja tanpa ada granuloma sedangkan pada cd4>100 masih bisa didapatkan gambaran granuloma yang disertai dengan nekrosis18. hal ini biasanya ditemukan pada pasien hiv aids dengan stadium yang masih awal19. gambaran fnab ini sesuai pada pasien ini yang ditunjukkan pada gambar 1. gambar 2. gambaran berupa granuloma epiteloid pada non hivaids (anak panah16) tatalaksana pasien limfadenitis tb dengan hiv aids pada prinsipnya hampir sama dengan tatalaksana pada pasien non hiv. untuk terapi limfadenitis tb menggunakan terapi kategori 1 yaitu 2hrze (isoniazid, rifampicin, pyrazinamid, etambutol) pada fase intensif dan 4(hr)3 pada fase lanjutan2. disebutkan bahwa terapi arv dapat menurunkan laju tb sampai sebesar 90% pada tingkat individu dan sampai sekitar 60% pada tingkat populasi dan menurunkan frekurensi tb sebesar 50%. rekomendasi terapi antiretroviral (arv) pada koinfeksi tuberkulosis adalah memulai terapi arv pada semua individu hiv dengan tb aktif berapapun jumlah cd4, dan menggunakan evafirens sebagai pilihan non nucleoside reverse transcriptase inhibitor (nnrti) pada pasien yang memulai terapi arv selama dalam terapi tb ditambah dengan 2 jenis nucleoside reverse transcriptase inhibitor (nrti), dan memulai terapi arv sesegera mungkin setelah terapi tb dapat ditoleransi (2-8 minggu). rekomendasi tersebut diharapkan dapat menurunkan angka kematian koinfeksi tb hiv, potensi menurunkan transmisi bila semua pasien hiv memulai terapi arv lebih cepat, mencegah sindrom pulih imun (iris) meningkatkan kualitas hidup, menurunkan 52 medical and health science journal, vol.4., no.1, february 2020 kekambuhan tb dan meningkatkan manajemen tb pada pasien koinfeksi tb hiv20. kesimpulan telah dilaporkan seorang laki-laki dewasa usia 58 tahun yang didiagnosis sebagai hiv aids dengan limfadenitis tb servikal. pada kasus ini didapatkan gambaran fnab kelenjar servikal berupa gambaran yang mengandung area nekrotik luas dengan sel radang limfosit, histiosit, pmn dan tanpa tanda keganasan serta pengecatan zn ditemukan kuman batang tahan asam. hal ini sesuai dengan literatur yang disebutkan bahwa gambarannya berbeda dengan pasien non hiv aids yaitu ditemukan sedikit granuloma pada pasien hiv aids dibandingkan non hiv aids. daftar pustaka 1. djoerban z, djauzi s. 2014. “hiv/aids di indonesia” pada buku ajar ilmu penyakit dalam. edisi ii. jakarta: interna publishing, pp 887-897. 2. mohapatra rp, janmeja ka. 2009. tuberculous lymphadenitis. japi; 57: 585 590. 3. barnes pf, lakey dl, burman wj. 2002. tuberculosis in patients with hiv infection. infectious disease clinics of north america; 1: 16. 4. departemen kesehatan republik indonesia direktorat jenderal pengendalian penyakit dan penyehatan lingkungan. 2007. pedoman nasional : panduan tatalaksana klinis infeksi hiv pada orang dewasa dan remaja. edisi ke-2. jakarta. 5. jacobs w. 2010. the problem of hiv related lymphadenopathy; lymphadenopathy is a common condition in patients with hiv infection. cme; 28(8): 364-6. 6. orell sr, sterrett gf, walters mn, whitaker d. 2012. lymph nodes. in: orell sr, editor. manual and atlas of fine needle aspiration cytology. edinburgh: churchill livingstone; edisi ke-5: p63–95. 7. rajasekaran s, gunasekaran m, jayakumar dd, jeyaganesh d, bhanumathi v. 2001. tuberculous cervical lymphadenitis in hiv positive and negative 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za, habesogiu te. 2016. diagnostic challenges in cervical tuberculous lymphadenitis: a review. north clin istanbul; 3(2): 150 155. 15. hemalatha a, shruti ps, kumar um, bhaskaran a. 2014. cytomorphological paterns of tubercular lymphadenits revisited. annals of medical and health sciences research; 4(3): 393-396. 16. wannakrairot p, leong mt, anthonu s. 2007. the morphological spectrum of 53 medical and health science journal, vol.4., no.1, february 2020 lymphadenophaty in hiv infected patients. pathology; 39 (2): 223-227. 17. naveen k, nayak ub. 2015. clinico pathological correlation of lymhadenopathy in hiv positive patients. j of evidence based med & hlthcare; 28(2): 4099-4106. 18. sarma pk, chowhan ak, agrawal v, agarwal v. 2009. fine needle aspiration cytology in hiv related lymphadenopathy: experience at a single centre in north india. cytopathology; 21: 234-239. 19. damar p, thakor n, baranda u, gadhavi r, patel n, thakkar d, asari u. 2015. human immunodeficiency virus associated tuberculous lymphadenitis: a clinical study of 50 cases of saurastra region of gujarat, india. int j adv med; 2(2); 100-103. 20. kemenkes ri. 2011. pedoman nasional tatalaksana klinis infeksi hiv dan terapi antiretroviral pada orang dewasa. kementerian kesehatan ri; p.1-57. 54 medical and health science journal, vol.3., no.2, august 2019 review article: developement and using dengue vaccine for dengue infection virus firdaus kabiru massey1*, rika yulia1 1,2 master of clinical pharmacy at the university of surabaya *correspondent author: firdaus.kabiru@gmail.com article info abstract article history: submitted: july 27 2019 received in revised form august 2019 accepted: august 21 2019 tropical and subtropical countries are regions with high incidence of dengue infection. dengue virus infection is estimated to cause 300 million new infections in one year and approximately 1 million severe cases with 2 + 5% deaths. the case of dengue in indonesia has continued to increase since 1968 until 1980 where all provinces in indonesia have been affected by the dengue virus. dengue virus is a virus carried by the aedes aegypti mosquito in its salivary gland. the virus which is a family group of flaviviruses has four homologous serotypes, namely denv-1, denv-2, denv-3, and denv-4, which can cause dengue infection in individuals. currently there is a shift in the target population from children to adults. this is a problem that needs to be resolved by the government and the community itself. solution to overcome this, the government needs early prevention efforts to reduce the severity of dengue infection by developing and researching dengue vaccines. currently a vaccine has been found that can be used as prophylaxis for dengue virus, namely dengvaxia. this vaccine has been recommended by the world health organization (who) as prophylaxis for dengue infection, but dengvaxia is only used in areas that are very endemic to dengue fever. the indonesian food and drug supervisory agency (bpom ri) has also approved the use of dengvaxia as an indication of prevention of dengue infection since august 31, 2016. this vaccine has been approved globally only given to individuals aged between 9-16 years. @2019 medical and health science journal. 10.33086/mhsj.v3i2.1194 keywords: dengue virus, dengvaxia vaccine, aedes aegypti, endemic introduction dengue fever is a disease caused by the bite of the aedes aegypti mosquito carrying dengue virus (denv) in its salivary gland. dengue is found in tropical and subtropical regions throughout the world.(1) estimates that arise due to infection from the dengue virus are obtained around 300 million new infections per year and approximately 1 million cases of serious illness with a death of 2 + 5%. the denv virus presents a new challenge for controlling the main mosquito vectors, but it is also known that there is no effective antiviral to treat denv infection.(2) at present, an efficient prophylactic strategy for dengue infection is needed by reviewing the epidemiological trends of dengue virus, biology, and clinical diseases, which in the next stage are expected to help to make efficient vaccine strategies.(3) dengue disease epidemiology of dengue from 1968 to 2009, the world health organization (who) has noted that indonesia is the country with the highest dhf cases in southeast asia. before the dhf case (dengue hemorrhagic fever) then spread widely in the correspondence: firdaus kabiru massey @2019 medical and health science journal. 10.33086/mhsj.v3i2.1194 available at http://journal2.unusa.ac.id/index.php/mhsj 42 original article mailto:firdaus.kabiru@gmail.com http://journal2.unusa.ac.id/index.php/mhsj medical and health science journal, vol.3., no.2, august 2019 territory of indonesia, this disease first appeared in 1968 in the city of surabaya, with a total case of 58 people infected and 24 other people dying. although it was first discovered in 1968, confirmation of a new virological dengue was obtained in 1972. in 1980, all provinces in indonesia were affected by dengue and the cases continued to increase every year.(4) replication of dengue virus there are four different types of antigen serotypes which are divided homologically by 60 80%: denv-1, denv-2, denv-3, and denv-4. denv is a virus particle that is about 50 nm in size which is enveloped by a lipid membrane. rna which contains about 11,000 long nucleotide frames encodes a large polyprotein and at the post translational stage is divided into 3 structural proteins such as capsid (c), membrane precursor (prm), and envelope (e), and seven non-structural proteins such as ns1, ns2a, ns2b , ns3, ns4a, ns4b, and ns5. the surface of the virion composed of glycoprotein e is used as the main target of denv to neutralize antibodies. the ectodomain of e consists of a centrally located i (edi) domain, containing loop fusion ii (edii),and domain iii which carries almost all antibody specific epitope antibodies.(3) when genomic rna is released into the cytoplasm and after the fusion of viral membranes with endosomal membranes, the translation of viral rna then begins to approach the endoplasmic reticulum (re). after the virus replication complex occurs, the translation is stopped, and viral rna synthesis occurs. during the replication process of denv, the viral genome will be degraded by the enzyme exonuclease (xrn1) to produce small species of subgenomic flavivirus rna (sfrnas) that are in accordance with the majority of the non transplanted genomic region (ntr) at the end of 3 genomic rna. the accumulation of sfrnas results in viral replication, but also changes the activity of the host cell antivirus to be resistant to viral replication. the synthesis of artificial rna molecules contributes to the massive production of viral proteins. the re surface is the assembly location of the virus that has not yet matured, the virus is carried through the golgi complex and then the prm is processed into m until it undergoes maturation and is ready to be released into extracellular.(3) symptomatic features of dengue disease there are three phases that occur in dengue conditions, namely the febrile phase, critical phase, and recovery phase. 1. febrile phase: dehydration, high fever which causes disorders of the nervous system, and causes seizures in children. 2. critical phase: shock from plasma leakage, severe haemorrhage, impairment organs. 3. recovery phase: hypervolemia, acute pulmonary edema.(1) human susceptibility to dengue virus infection currently dhf cases are still considered trivial, so it is very easy for every individual who lives in an endemic area to be infected with dengue. based on this information, then who recommends using dengvaxia vaccine as a preventive measure. the nature of the pathogen denv has been widely reported as infection because denv-2 is the biggest cause of severe dengue compared to other serotypes. clinically the majority of people infected with dengue are asymptomatic. according to ten bosch et., al., the fastest spread of denv occurs in endemic areas where most are caused by an increase in transmission of disease by vectors.(3) mechanism of dengue vaccine the general mechanism of action of the dengue vaccine is to stimulate antibody activation to be able to fight the four dengue virus serotypes measured through prnt50. after vaccination, titre is seen to be higher in seropositive compared to seronegative. furthermore, t cells will be stimulated by the presence of foreign structures of antigens from the dengue virus and against non structural antigens from the yf vaccine virus.(5) 43 medical and health science journal, vol.3., no.2, august 2019 dengue vaccine developement at present, it is known that there are vaccines that have passed the clinical phase test and are registered as vaccines for the dengue virus. this vaccine has been registered in several countries in the world, namely the cyd-tdv vaccine or dengvaxia vaccine which is produced by a pharmaceutical company in france owned by sanofi pasteur. several other candidates besides the dengvaxia vaccine are also starting to be developed, but are still in the phase iii clinical trial phase. the development of vaccines is inseparable from the supervision and protection of the world health oragnization (who) regarding the quality, safety and effectiveness of the dengue vaccine. the cyd-tdv vaccine represented by cyd14 and cyd 15 has been evaluated by phase iii clinical trials using the randomized controlled trials (rct) method in several countries in the world. the cyd14 vaccine was evaluated for 10,275 participants aged 2-14 years in 5 countries in asia in the first vaccination, namely indonesia, the philippines, malaysia, vietnam and thailand. whereas for cyd15 vaccine, 20,869 participants were aged 9-16 years in the first vaccination in latin america, namely brazil, colombia, honduras, mexico, and puerto rico. in this evaluation, rct patients were randomized to compare vaccines with placebo (0.9% solution of sodium chloride) with a ratio of 2: 1. this study was carried out for 13 months which was calculated from the last dose of vaccination to see the primary efficacy endpoint and included surveillance data at the hospital as an additional data security for a period of 4 years.(5) the efficacy of vaccine cyd14 and cyd15 dengue viruses has been tested and assessed based on surveillance data (25 months after being registered). this effectiveness test is carried out on cyd14 and cyd15 vaccines. assessments carried out on a per protocol basis were based on serotypes, namely 56.5% (95% ci 43.8% -66.4%) in cyd14 and 60.8% (95% ci 52.0% -68.0%) in cyd15 (from one month post dose 3 for 12 months). furthermore, vaccine effectiveness in fighting dengue virus was shown starting from the lowest based on serotypes, ie 1 (50.2%, 95% ci 35.6% 61.5%), 2 (39.6%, 95% ci 18.7 % -55.2%), 3 (74.9%, 95% ci 65.1% -82.0%) and 4 (76.6%, 95% ci 65.0% -84.4.(5) in addition to seeing the effectiveness test, it is also necessary to find out the results of testing the effectiveness of dengue vaccines in several countries. the results of the effectiveness tests from several countries are quite varied. the effectiveness of the dengue vaccine in mexico ranges from 31.3% (95% ci 1.3% -51.9%) and by 79.0% (95% ci 5.3% -91.5%) in malaysia.(5) this vaccination is carried out at the age of 9 years and above. because at the age of <9 years and 2-5 years the child's immunity is still low. when exposed to this vaccine, the vaccine can act as a natural infection. the duration of protection from vaccines to strengthen the body's immunity against dengue virus is ranging from 5-6 years after administration of vaccination. (5) current status of dengvaxia vaccine developement the developmental status of the dengvaxia vaccine test is interesting to continue to follow. while undergoing the 3rd phase clinical trial, sanofi pasteur stated that he did not collect blood samples used to determine the serostatus (had had previous dengue infection or not) before the vaccination process was carried out. collection of blood data for all participants was only carried out at the 13th month (1 month after the 3rd vaccine dose was given). the assay method is used to recognize antibodies with a non-structural code of dengue protein (ns1) where the patient's status can still be known even though he has received previous vaccinations. this is because the ns1 protein code for dengvaxia is a protein code from the yellow fever vaccine.(6) dengue vaccine dengvaxia dengvaxia vaccines are known to be widely accepted and can induce balanced immunity to all four serotypes. based on this, the tetravalent cyd tdv dengue vaccine is known to be produced using a live attenuated flavivirus-17d vaccine and a yellow fever virus (yf-17d) strain as its 44 medical and health science journal, vol.3., no.2, august 2019 backbone. the cyd-tdv contained four ym 17d chimeric viruses which gave rise to prm and e proteins from each of the 4 dengue serotypes. the dengvaxia vaccine was developed by oravax for 10 years through preclinical testing to clinical trials, but this development did not continue until acambis inc. come to continue. the same thing happened, the development did not go as expected, until in 2005 sanofi pasteur bought the company. furthermore, sanofi pasteur carried out a massive development and research on dengue vaccines which eventually could be patented under the trade name dengvaxia.(7) in 2015, several countries such as brazil, el savador, mexico, and the philippines, dengvaxia vaccine was received and had security data. indonesia through the ri pom agency issued a marketing permit on august 31, 2016 with indications as preventive for dengue cases caused by dengue serotypes 1,2,3 and 4 and given to individuals aged between 9-16 years, and with individual conditions they live in endemic areas.(8) the cyd-tdv vaccine is available in the form of a single dose vial injection or multi dose (5 dose) vial. this vaccine product is stored in frozen form which can then be reconstituted if it is to be used. in the use for single dose purposes, it can be reconstituted with 0.4% nacl solution, whereas for multi dose purposes it can be reconstituted with 0.9% nacl. then after the preparation has been reconstituted, then 0.5 ml of the dose can be taken and given by injecting via the subcutaneous route (sc). while for the remaining solution can be put into the syringe for single dose administration or stored in a vial for multi dose administration. it is important to know that the cyd-tdv vaccine does not contain adjuvants or preservative ingredients and has a shelf-life of 36 months when stored at a temperature of 2 oc 8 oc. this causes when the vaccine has been reconstituted with a compatible solvent, when the vaccine has not been used it must be stored at a temperature between 2 oc 8 oc and protected from sunlight or uv light. the who policy is related to multi-dose after reconstitution and there is a dose left in the vial, so the leftover part should be discarded within 6 hours of reconstitution or at the end of the vaccination session, depending on which one is first.(5) dengue vaccine candidate tdv tdv vaccine (takeda’s dengue vaccine tetravalen) is a vaccine made as a candidate for another vaccine for dengue virus. this vaccine is made from the original denv-2-pdk-53 vaccine that has been attenuated by the addition of mutations in ns3. tdv vaccine has been reported as a candidate for a safe and tolerable vaccine based on phase 1 and 2 clinical trials. there are three chimeric viruses, namely tdv-1, tdv-3, and tdv-4 which aim to replace prm and e genes from denv-1 , denv-3, or denv-4 to tdv-2. at present, tdv vaccines are still in phase 3 clinical trial stages which are expected to be completed by the end of 2021.(3) dengue vaccine candidate lav delta 30 this type of vaccine has been developed by the national institute of health (nih) which has specific characteristics with the elimination of 30 contiguous nucleotides (δ 30) and subsequently inserted into domain ii from the tip of 3 'ntr rna genomic. removal (δ 30) aims to weaken viruses den-1, -3, and -4. furthermore, butantan institute licensed the delta 30 lav vaccine and changed its name to tv003. phase 1 and 2 clinical trial results showed good safety and immunogenicity results with seroconversion rates starting at 50% (denv 2) to 100% (denv-1, -3, and -4) after single dose administration. however, the presence of viruses in the blood is still detected in vaccinated individuals using tv003. similar to the tdv vaccine, this vaccine is also still in the phase 3 clinical trial phase which is expected to be completed by 2022. (3) dengue vaccine involving dna technology the more sophisticated technology in this modern era, becomes an opportunity to design and develop new dengue vaccines as a preventive measure against dengue virus. this vaccine is still under development and pre-clinical testing and is still awaiting its safety data and effectiveness. vaccine involving dna technology has 45 medical and health science journal, vol.3., no.2, august 2019 recombinant subunits that require heterologous expression systems such as vectors, plasmid dna, virus-like particles that only express prm and protein e, or only reveal ed iii from all four serotypes.(3) age of giving dengue vaccine based on research data, currently dengue vaccines can be given starting at the age of 9 years or older in several countries in the world. a dengue vaccine (cyd-tdv) has a high effectiveness on all serotypes of dengue when given before exposure and its effectiveness increases with age. based on seropositive values in children, overall vaccine effectiveness increased with age, ie 35.9% (95% ci: -7.6, 69.3) for children aged ≤5 years, 65.6% (95 % ci: 40.3, 84.2) for ages 6-8 years, 73.4% (95% ci: 62.6, 82.1) for ages 9-11 years, and 80.6% (95% ci: 72,9, 87.3) for ages 12 years or older.(9) table 1. estimated levels of effectiveness of vaccines (ev%) through basic immunity status and age group cyd14 dan cyd15. according to the world health oragnization (who), cyd-tdv is a viral vaccine that is prophylactic. the dengue vaccine is given by injection of 0.5 ml 3 times with a range of administration for 6 months from each vaccination time. early indications (licenses) for administering this vaccine are efforts to prevent dengue illnes by dengue virus serotypes 1,2,3 and 4 in individuals aged 9-45 years or 9-60 years who live in endemic areas. meanwhile, for 9-year-olds, safety data is needed and for children aged 2-5 years the security data is still in phase iii clinical trial stage.(5) doctor ari prayitno, sp.a (k) said that dengue vaccine can be started at any time since children aged 9-16 years. in addition, he also explained that vaccination after infection with dengue is still recommended. this is because, when a person (child) is infected with dengue it is usually only infected by one type of serotype from denv and rarely is it directly infected by 4 serotypes at once. this then raises the perception that by giving vaccinations containing 4 serotypes at once, the child's immunity will be formed to be immune to other serotypes that have not infected the child. in addition, giving vaccines to individuals who have had previous dengue infection can be beneficial to prevent the risk of more severe or severe dengue infection (dengue shock by secondary infection from other serotypes.(10) the data that is owned by the nras is in harmony with what was conveyed by doctor ari prayitno, sp.a (k). although there is no correlation that can be used as a link during age grouping in the effectiveness test, a phase 2 clinical trial shows that seropositive baseline is associated with increased age and stability of titres after vaccination. the results of this effectiveness are shown between the ages of 9-16 years and this condition is predicted to be similar to the adult population in endemic areas.(5) use and security of dengue vaccine research on vaccination, especially dengue vaccines, is very important for an endemic country. it is known that 4 dengue virus serotypes (den-1, den-2, den-3, den-4) revolve globally and the most reported annually is in endemic countries. who states that dengue vaccine can only be used in areas that are very endemic to dengue fever. in addition, to obtain the best population level strategy, who recommends looking at seroprevalence as a basis for consideration of the efficacy and safety level of protection in seropositive individuals. these considerations are based on the sage (strategic advisory group of experts). seroprevalence is a level of seropositivity to a particular pathogen in a population. mathematically, the calculation to determine the optimal seroprevalence is obtained in the age group targeted for vaccination which is around 70% or more, if it is in the range of 50% 70% it is still acceptable but with lower effectiveness. this is 46 medical and health science journal, vol.3., no.2, august 2019 different from seroprevalence below 50%, who does not provide recommendations for vaccination. because in addition to its low effectiveness, it can also cause a potential long-term risk for the occurrence of severe dengue fever in seronegative individuals.(5) the safety of the dengue vaccine needs to be considered during the use process. this is related to adverse reactions that can occur in the cyd tdv vaccine. for example, the reaction of the adverse effects of this vaccine is local and systemic. systemic reactions occurred at 66.5% in cyd-tdv recipients and 59% in placebo recipients. in general, systemic reactions that occur are like headache (> 50%), malaise (> 40%), and myalgia (> 40%). whereas symptoms of fever occur at 5% in the age group 18 60 years and 16% in the age group 9-17 years. local reactions occurred at 49.6% in the group receiving cyd tdv and by 38.5% in the group receiving placebo. in general, local reactions that occur are pain of 45.2% felt by the age group 18-60 years and 49.2% in the age group 9-17 years. in general, the outcome of serious adverse reactions to date still has no relevant data found.(5) the provision of the dengvaxia vaccine as a preventive measure against dengue virus has attracted the attention of the indonesian food and drug administration to evaluate the safety of this vaccine. the results of re-evaluation of the indonesian food and drug administration on the dengvaxia vaccine are divided into two parts, namely individuals who have never had dengue virus infection (seronegative) will be at high risk of experiencing severe dengue and at risk of being hospitalized higher than seronegative individuals only given a placebo. in addition, it is also known that the administration of dengvaxia vaccine in children aged> 9 years with seronegative has lower efficacy compared to individuals who have had dengue infection (seropositive). reaffirmed by the indonesian food and drug administration, the efficacy of the dengvaxia vaccine is better when given to seropositive individuals ranging in age from 9-16 years.(8) the indonesian food and drug administration has decided several things after re evaluating as above, namely 1) the dengvaxia vaccine can be used as a preventive measure against the risk of dengue fever occurrence and severity in children aged 9 to 16 years and had previously experienced infection dengue virus (seropositive) and 2) dengvaxia vaccine is prohibited from using seronegative individuals. even though there is currently no data on the side effects of the dengvaxia vaccine, in order to prevent undesirable events, the indonesian food and drug administration has appealed to all relevant parties including peer health professionals to prioritize patient safety in the administration of vaccines as well as the indonesian food and drug administration. to pt. aventis pharma continues to monitor the use of the dengvaxia vaccine in the territory of indonesia. (8) vaccination programmes the use of the cyd-tdv vaccine has a significant impact on dengue disease at the age of> 9 years. based on comparisons of several mathematical models, the vaccination program using the cyd-tdv vaccine is known to reduce symptoms and hospital care due to dengue illness by 10% 30% over a 30-year period. based on data for cost effectiveness, one daly tried to calculate the total cost incurred in dengue cases was 2000 us dollars. therefore, in overcoming this, efforts are made to prevent dengue or preventive measures and look for alternative vaccines that can be used in at least some endemic countries, as well as cost effectiveness predictions for dengue cases. the results obtained are the total costs incurred for a full vaccination per person is around 15-40 us dollars or when using a societal perspective the total cost incurred for a full vaccination per person is less than 100-150 us dollars. however, this data is only a comparative model and cannot be used as a basis for making decisions based on specific analysis in each country. (5) human contraindication to dengue vaccine contraindications to drug use also occur in vaccine administration. according to who 47 medical and health science journal, vol.3., no.2, august 2019 (2016), there are several contraindications to the use of dengue vaccine, namely 1) an individual who has a history of allergies to components contained in dengue vaccines or with other vaccines containing the same components as dengue vaccines; 2) individuals with impaired innate immunity or immune deficiencies obtained to mediate immune cells; 3) individuals with symptoms (symptomatic) of hiv infection or asymptomatic hiv infection accompanied by evidence of failure of immune function; 4) pregnant or lactating women; and administration of vaccines should be delayed in patients with moderate to severe febrile conditions or acute disease.(5) discussion the emergence of information about vaccines for dengue virus is now increasingly widespread. according to doctor hunied kautsar, the national immunization program for dengue vaccine is still a pro and contra, which is the reason that this vaccine cannot be included in the national immunization program. the unavailability of dengue vaccine in the national immunization program causes the administration to be limited, so clinicians (doctors) need to pay attention to the recommendations that have been submitted by the ri pom and who that the dengvaxia dengue vaccine is only indicated for individuals aged 9 to 16 years with seropositive status and living in the area endemic for dengue. conclusion dengue virus can affect anyone, especially individuals or groups in endemic areas. every element of society needs to be alert to contracting this virus. currently several vaccines are being developed as prophylaxis to reduce the severity of dengue virus infection. until this period, only one vaccine has been allowed to be released by who, the dengvaxia vaccine and has been accepted in several countries in europe and asia. other vaccine candidates are still in the pre-clinical trial phase and phase 3 clinical trial. the use of the dengvaxia vaccine is still limited by who, which is only at the age of 9-16 years and is in the endemic area of dengue fever. likewise in indonesia, the indonesian food and drug administration also adopted recommendations from the who to limit the use of the dengvaxia vaccine. based on serovalence, the safety and effectiveness of using dengvaxia vaccine is better when given to seropositive individuals compared to seronegative individuals or in other words, individuals who have previously had dengue infection are then vaccinated, so the effectiveness and safety are higher compared to individuals who have never experienced infection previous dengue. references 1. world health organization tf research on disease of poverty. dengue guidelines for diagnosis treatement, prevention and control. 2009;3. 2. metz sw, thomas a, brackbill a, xianwen y, stone m, horvath k, et al. nanoparticle delivery of a tetravalent e protein subunit vaccine induces balanced, type-specific neutralizing antibodies to each dengue virus serotype. plos negl trop dis [internet]. 2018;12(9):e0006793. available from: http:// dx.plos.org/10.1371/ journal.pntd.0006793 3. bos s, gadea g, despres p. dengue: a growing threat requiring vaccine development for disease prevention. pathog glob health [internet]. 2018;0(0):1–12. available from: https:// www.tandfonline.com/doi/full/10.1080/ 20477724.2018.1514136 4. prof. hadyanto lim, dr. dr. m.kes, sp.fk, fesc, fiba, faha. et al. prinsip farmakologi endokrin-infeksi pengobatan berbasis patobiologi. was uploaded by umar zein 15 febr. 2018;edisi 1(february). 5. states m, adviwhos, grade t, sage t. weekly epidemiological record relevé épidémiologique hebdomadaire. 2016; (30) :349–64. 6. updated questions and answer related to information presented in the sanofi pasteur press release on 30 november2017 with regards to the dengue vaccine dengvaxia. available from: http://www.who.int/ immunization/diseases/dengue/q_and_a_dengu e_vaccine_dengvaxia/en/ 48 http://www.tandfonline.com/doi/full/10.1080/ http://www.who.int/ medical and health science journal, vol.3., no.2, august 2019 7. s.b. h. the american journal of tropical medicine and hygiene. 2016;95(4):741–5. available from: http://www.ajtmh.org/ content/journals/10.4269/ajtmh.16-0222 html_fulltext 8. indonesia bpo dan mr. penjelasan badan pom ri terkait isu keamanan vaksin dengue. in 2018. available from: https://www.pom.go.id/mobile/index.php/view/ klarifikasi/79/penjelasan-badan-pom ri ---terakit--isu-keamanan vaksin-dengue--demam-berdarah .html 9. yang y, meng y, halloran me, longini im. dependency of vaccine efficacy on pre exposure and age : a closer look at a tetravalent dengue vaccine. 2017;1–23. 10. fadhila sr. sekilas tentang vaksin dengue. 2017; available from: http://www.idai.or.id /artikel/klinik/imunisasi/sekilas-tentang vaksin-dengue 49 http://www.ajtmh.org/ http://www.pom.go.id/mobile/index.php/view/ http://www.pom.go.id/mobile/index.php/view/ http://www.idai.or.id/ medical and health science journal 2023 february, vol 07 (01) medical and health science journal available at http://journal2.unusa.ac.id/index.php/mhsj; doi: 10.33086/mhsj.v7i1.3558 pissn 2549-7588. eissn 2549-7596 case report psychodynamic overview of generalized anxiety disorder in young adults era catur prasetya 1, rizky dwi lestari *1, muhammad hanun mahyuddin 2, ulaa haniifah 2, olga putri atsira 2 1department of psychiatry, faculty of medicine, universitas muhammadiyah surabaya, indonesia 2faculty of medicine, universitas airlangga surabaya, indonesia *correspondent author: rizkydwilestari21@gmail.com article info article history: received: october 18, 2022 received in revised form: february 22, 2023 accepted: march 28, 2023 keywords: anxiety disorder, generalized anxiety disorder, adult individual abstract the diagnostic and statistical manual of mental disorders (dsm-5) defines an anxiety disorder as an excessive feeling of fear that occurs in a person that interferes with daily activities. generalized anxiety disorder causes a person to feel anxious about a wide range of situations and issues. patients often experience anxiety, feelings of fear and constantly on edge, difficulty concentrating, difficulty sleeping, muscle tension, and frequent irritability. based on data from the indonesian ministry of health in 2007, there were 450 million people who had to live with mental disorders. the prevalence of adult individuals (aged 18 years and over) and the elderly, there were 11.6% who experienced emotional disorders, such as anxiety and depression. this case report discusses a 20-year-old woman with the main complaint of unclear anxiety, not knowing what to worry about, floating between things she worries about is death, fear of having a serious illness, breakup, fear of losing her job as a content creator, and feeling of being blamed that keeps on coming. management in the form of giving ssri antidepressants and psychodynamic psychotherapy is done to try to reinterpret feelings of guilt that often arise as a result of fixation in one phase of their growth and development. medical and health science journal introduction anxiety is a persistent feeling of worry as a response to threats or stressors that can come from within the individual or the environment. anxiety is a normal and pathological response depending on its intensity, duration and the individual's ability to cope. anxiety is a pathological condition characterized by feelings of fear accompanied by a hyperactive autonomic nervous system. anxiety is also an emotional reaction arising from nonspecific causes such as subjective individual experiences that can cause feelings of discomfort and threatened. about 2/3 of adolescents and young adults with anxiety disorders do not seek help and only a few report contact with a psychotherapist (1). almost all individuals have experienced anxiety, especially as a result of accumulated life problems (2). meanwhile, the diagnostic and statistical manual of mental disorders (dsm-5) defines an anxiety disorder as an excessive feeling of fear that occurs in a person which has an impact on disrupting their daily activities. anxiety disorders can be experienced by many individuals regardless of age or gender. the causes of this anxiety disorder are quite varied. therefore, the dsm-5 divided this anxiety disorder into several types, namely phobias, social anxiety disorder, separation anxiety disorder, panic disorder, and generalized anxiety disorder (3). based on data from the ministry of health of indonesia in 2007, there were 450 million people who had to live with mental disorders. the prevalence of adult individuals (aged 18 years and over) and the elderly, there were 11.6% who experienced emotional disorders, such as anxiety http://journal2.unusa.ac.id/index.php/mhsj saini et al medical and health science journal 2023 february vol.07 (01) page 47 of 53 and depression (4). basic health research on adult individuals in indonesia shows an increase in emotional disorders, in 2013 by 6% and in 2018 by 9.8% with the most common symptoms being headaches, sleep problems, decreased appetite, and fatigue (5). one in five teens experiences moderate to severe anxiety during the covid-19 pandemic. there are some differences in anxiety levels among adolescents by region and income level, highlighting the need for targeted public health interventions based on nationally identified priorities (6). one in five indonesians may experience anxiety during the covid-19 pandemic. the groups most at risk are young women, people suspected of having covid-19, and those with unsatisfactory social support. however, health workers were found to have a lower risk of experiencing anxiety because they have a better level of self-awareness. accessible health information and care, social connections, a supportive environment, and mental health surveillance are important for preventing larger post-pandemic psychiatric problems (7). case(s) today's teens and young adults are more techsavvy than any previous generation; however, any discussion of technology should acknowledge concerns about potential negative consequences for psychological health (8). a 20-years-old woman, a 5th-semester student, unmarried, muslim, came independently to the outpatient polyclinic of muhammadiyah lamongan hospital with a complaint of anxiety. the patient lives at home with her mother, sister, grandmother, and grandfather. the patient's father migrated for work since the patient was still in the womb and returned home every 2 years, but since the corona pandemic, it has been a long time since he last went home. generalized mental disorders are very common among young adults in their twenties, and less frequently in their thirties/forties. those who develop mental disorders in their twenties have a higher risk of developing them ten years later. this has significant implications for young people's abilities to obtain an education, raise a family, and participate in work life (9). patients are cared for by a mother who tends not to talk much and is typical of a rural mother who spends more time in the fields than at home. the patient admits that she sometimes feels that she has lost her father figure, someone who should be with her all the time, especially when the patient remembers her childhood when she was in trouble and there was no place to complain. although, sometimes, there is a feeling of freedom because she feels that by being left alone, there is no one who can control her life, and instead, feels happy about it. she is the type of patient who likes to be alone and only communicates with others when she is in absolute need. in 2019, the patient started complaining of shortness of breath and shaking. she was afraid, thinking it was a symptom of heart disease. then the patient went to an internist and was diagnosed with gastric disease. however, the patient said that she believed she had a mental disorder. later that year, the patient developed a relationship with someone, but the patient did not dare to talk to her partner regarding the patient's mental condition, and she only told her partner about her gastric disease. therefore, the patient still feels alone despite being in a relationship and having no friends to confide in. one month ago, the patient's boyfriend was caught cheating with someone else. the patient was angry and then experienced an anxiety disorder that felt unclear until it interfered with her daily activities as a student at one of the public universities in surabaya. psychiatric status obtained an appearance that was in accordance with her age, clean and neat clothes, wearing a hijab, and a mask. the patient is compos mentis with gcs 456. behavior and psychomotor activity before, during, and after the interview, showed the patient sitting quietly with both hands on her thighs. when interviewed, the patient was cooperative with the examiner, was open, told the current problems calmly, and answered according to the examiner's questions in a voice that was enough to be heard. saini et al medical and health science journal 2023 february vol.07 (01) page 48 of 53 overall, the patient's speech was good, it was coherent, and no speech disturbance was found. the patient's feeling (mood) was in a euthymic state where the patient's sense of feeling is broad and congruent with the rhythm of her life, broad affect, broad emotional expressions with variations in facial expressions, voice rhythms, and body movements in harmony with the atmosphere, these can conclude the congruent between mood and affect. there were no perceptual disturbances in the patient such as hallucinations (-) and illusions (-). the patient's intellectual function, both sensory and cognitive, was good. the patient's thought process consists of a coherent stream of thought, and preoccupation thought related to her shortness of breath. the patient is able to control impulses. the value of the observation on the patient is grade 6 where the patient is fully aware of the situation with the motivation to achieve improvement. the patient's physical status and neurological status were within normal limits. the patient's multiaxial diagnosis is: axis i f41.1 generalized anxiety disorder. axis ii anxiety (avoidance) personality traits. axis iii k00-k93 diseases of the digestive system. axis iv problems related to the social environment. axis v gaf scale 70-61 some mild and persistent symptoms, mild disability in function, generally still good. discussion generalized anxiety disorder is an anxiety disorder characterized by the appearance of excessive feelings of anxiety when going to do a job or activity (3). generalized anxiety disorder causes a person to feel anxious about a wide range of situations and issues. patients often experience anxiety, feelings of fear and constantly on edge, difficulty concentrating, difficulty sleeping, muscle tension, and frequent irritability (10). based on the dsm-5, there are six criteria for someone to be diagnosed with generalized anxiety disorder. first, excessive anxiety and restlessness for several days in the past six months. second, difficulty in controlling feelings of anxiety and restlessness. third, feeling of anxiety and restlessness appears with at least three other symptoms, such as feeling depressed, the body easily feels tired, difficulty concentrating, irritability, muscle tension, and sleep disturbances. fourth, feelings of anxiety, restlessness, and other physical symptoms cause disruption in carrying out social and occupational functions in daily life. fifth, not caused by any other medical condition. sixth, this disorder cannot be explained by other mental disorders (3). there are three psychological theories about the causes of anxiety: 1) sigmund freud's psychoanalytic theory freudian psychology is a science based on the unconscious (id) and consciousness (ego) (11). defines anxiety as a sign of unconscious danger. anxiety is seen as the result of a mental conflict between aggressive desires or unconscious sexual urges and concurrent threats from the superego or external reality. in response to this signal, the ego creates a defense mechanism to prevent unacceptable thoughts or feelings from escaping into consciousness. 2) behavior theory this theory suggests that anxiety is a conditioned response in accordance with the presence of a specific stimulus from the environment. individuals receive certain stimuli as unwelcome stimuli, causing anxiety. after it happens repeatedly, it eventually becomes a habit to avoid the stimulus. theory represents the accumulation of knowledge about mechanisms of action (mediators) and moderators of change as well as a priori assumptions about what human behavior is, and what effect it has on it (12). 3) existential theory this theory provides models of generalized anxiety, in which there is no identifiable stimulus for chronic feelings of anxiety. the core concept of this theory is that people experience the feeling of living in a purposeless world. anxiety is a response to the perception of emptiness. there are also biological theories about the causes of anxiety. existential concerns such as death, responsibility, futility, and isolation are not only hallmarks of existential psychotherapy but also frequently encountered by cognitive behavioral therapists (13). this theory relates to the autonomic nervous system and neurotransmitters. stimulation of the saini et al medical and health science journal 2023 february vol.07 (01) page 49 of 53 autonomic nervous system causes certain symptoms such as: cardiovascular (eg. tachycardia), muscular (eg. headache), gastrointestinal (eg. diarrhea), and respiratory (eg. tachypnea). there are three neurotransmitters associated with anxiety: norepinephrine, serotonin, and gamma-aminobutyric acid (gaba) (2). in addition to the above theories, there are also several other causes, such as: 1) failure to complete developmental tasks adolescents have developmental tasks that must be completed. the main psychological dangers of adolescence are generally caused by failure to make the psychological transition to maturity which is an important developmental task of adolescence. common danger signs of adolescent inability to self-adjust include irresponsible behavior that appears in the behavior of ignoring lessons to have fun and getting social support, aggressive behavior and overly hot teen, feelings of insecurity that cause adolescents to comply with group standards, flight response if you are away from familiar surroundings, feelings of giving up, fantasizing too much to compensate for the dissatisfaction gained from everyday life, regressing to previous levels of behavior in order to be liked and noticed, and using defense mechanisms such as rationalization, projection, fantasizing, and displacement. 2) past experience disorders that occur during adolescence cannot be separated from childhood experiences, for example: trauma, psychological violence (swearing, demeaning, defaming, and insulting), psychological neglect (neglecting the right to express feelings, lack of feelings of being loved, and being cared for), physical violence, physical neglect, and sexual violence. anxiety disorders that occur in adolescents are mostly caused by the experience of psychological violence and psychological neglect in childhood. anxiety disorders are associated with negative experiences in daily life, which cannot be explained by comorbidities alone (14). 3) bereavement 'attachment' is an important concept in psychiatry because it encompasses patterns of social relationships and subsequent interactions with others. short or long separations and events of loss will cause a disturbance. 4) physical condition adolescence is characterized by rapid physical growth. physical condition is seen as an important matter. when physical conditions do not match expectations, dissatisfaction, anxiety, and low selfesteem will arise. a study in indonesia (2016), stated that the higher the level of health anxiety, the higher the level of subjective somatic symptoms. symptoms of a minor illness can cause disproportionate health anxiety if the person exaggerates the seriousness of the sensation (15). 5) family problem conflict in the family is often caused by disharmony between parents and children and family background problems. parents who are too busy, are dictatorial, old-fashioned, and have favoritism towards their children will make the relationship in the family disharmonious. 6) interpersonal conflict adolescence is a period in which adolescents must be able to mature relationships with their peers, so selective friendships begin to emerge which sometimes triggers quarrels. adolescence is also a time to get to know the opposite sex and love. problems related to love are complicated problems. women's sense of self that is more dependent on relationships with others makes them more susceptible to social anxiety. however, all individuals in east asian cultures generally have a higher degree of social construction of interdependence (16). 7) fear of failure and losing oneself for adolescents, the opinion of the people around them is very important. constant criticism or failure with a mismatch of praise or success will cause a sense of inferiority and even loss of self-esteem. someone who has low self-esteem or loses selfesteem will feel used to failure and sometimes even develop self-sabotaging behavior. adolescence is clearly a critical period for the process of maturation of the neurobiological system which is the basis of emotions and behavior. adolescence marks a period of great susceptibility to developing disorganized levels of social anxiety (17). 8) living environment an adaptation is needed to live in a new environment (boarding house, dormitory, relation house). the inability to adapt will cause anxiety. several factors were found to be negatively or saini et al medical and health science journal 2023 february vol.07 (01) page 50 of 53 positively related to depression. perception of health is negatively related to depression, while smoking behavior, smoking cessation, and acute illness are positively related to depression (18). 9) school environment school environmental conditions such as intense competition, academic demands / high-grade standards, piling assignments, school rules, teaching-learning methods, majors, and studentteacher relations as well as student-to-student relationships are very important in determining the success of adolescents in school. the inability to adapt to the school environment will cause anxiety. usually, to meet academic demands, teenagers will take various courses, sometimes even not having time to do things they enjoy/hobbies. this will further worsen their adaptability. 10) social environment adolescents spend more time outside the home with their peers, so the influence of their social environment on attitudes, speech, interests, appearance, and behavior is greater than other environmental influences (2). when associated with the above theories, what is experienced by the patient is closely related to several theories include: 1) past experience. the patient had an experience where she felt unloved by his parents because she had been left behind since the patient was in the womb. during the developmental period, the patient also has difficulty developing trust in others and peaks in the time of interview when she experienced her physical complaints, the patient also does not want this to be known by her partner because there is an excessive fear of losing her partner due to her mental disorder. 2) bereavement closely related to the event of separation both short, long, and loss events. now, the patient is still hurting from her breakup with her partner and feels like losing something that had healed the wounds of being abandoned by his father and mother. the patient feels fear of another abandonment by others. 3) interpersonal conflict the patient does not stop blaming herself because according to the patient, his father and mother work for her well-being. likewise, the case of a partner who left her was because she could not be a good partner. in addition, the patient also said that her friendship environment did not help the patient to forget her problems. they always make her feel guilty. a study states that there is a relationship between the characteristics of depression, anxiety, and stress with gender, age, marital status, and income in adults during a pandemic. this shows that men, younger age, single status, and low income have higher depression, anxiety, and stress characteristic scales(19). 4) the patient's fear of failure and loss of selfesteem has long been present, but during elementary to high school, it did not show because the patient was quite intelligent, but during college, the patient felt that he was the stupidest person. therefore, it is related to the patient's job as a content creator which is always required to provide what the client wants. the patient keeps on accepting criticism and trying to pursue the target for client fulfillment. this resulted in fear of failure to fulfill client expectations. everyone has a different reaction to stress, and some of the symptoms that appear are not the same. common anxiety symptoms include: 1) palpitation 2) pain or tenderness in the chest 3) shortness of breath 4) excessive sweating 5) changes in sexual arousal or interest in sexual activity 6) sleep disturbance 7) trembling 8) hands or limbs become cold and sweaty 9) anxiety accompanied by depression leads to suicidal ideation 10) health problems such as frequent headaches (migraines). some common anxiety disorders include: a. generalized anxiety disorder – often feeling anxious or worried. b. panic disorder – having panic attacks regularly, often for no apparent reason. c. post-traumatic stress disorder (ptsd) – experiencing anxiety problems after experiencing a very stressful or frightening event. d. social anxiety disorder fear or fear of social situations e. obsessive-compulsive disorder (ocd) – repeating unpleasant thoughts (obsessions) and saini et al medical and health science journal 2023 february vol.07 (01) page 51 of 53 engaging in certain routines (compulsions) to relieve anxiety. f. phobia an overwhelming fear of a particular object, place, situation, or feeling (10). the symptoms of anxiety above can be grouped into four symptoms: a. somatic disorders tremors, fluctuating body temperature, seizures, sweating, palpitations, nausea, diarrhea, dry mouth, decreased libido, shortness of breath, and difficulty swallowing b. cognitive impairment difficulty concentrating, confusion, fear of losing control, excessive vigilance, and thoughts of a great catastrophe. c. behavioral disorders expression of fear, irritability, aggression, immobilization, and withdrawal from society. d. perceptual disturbance depersonalization and derealization (2). several symptoms that appeared in the patient were caused by the patient's anxiety. lately, the patient was occupied with the thought of many targets that must be achieved as a content creator because of the client's demands. the patient still felt symptoms such as shortness of breath, stomach disturbances, chest feels heavy, cold and sweaty hands even though she has taken medication regularly. this condition makes the patient develop difficulty sleeping until she can't sleep (sleep disturbances occur). evidence-based psychological treatments (cognitive-behavioral therapy; cbt) for this disorder have been developed and investigated, and in recent years a promising low-intensity cbt intervention version has been proposed that offers a way to improve access to evidence-based care. there is some evidence of the effectiveness of pharmacological treatments for anxiety disorders in children and adolescents, but their routine prescription is discouraged because of fears of potential harm (20). pharmacological treatment of generalized anxiety disorder is carried out by administering antidepressants (selective serotonin reuptake inhibitors (ssris), and anti-anxiety (benzodiazepines (bzd) and non-bzds (buspirone)). antidepressants and bzd can inhibit lc thereby reducing norepinephrine activity, while bzd modulates receptors gaba to increase its activity. antidepressants can selectively inhibit serotonin reuptake, while buspirone is a partial serotonin receptor agonist. in addition to pharmacological therapy, management of therapy for generalized anxiety disorder can also be carried out by nonpharmacological therapy. non-pharmacological therapy includes psychoeducation, short-term counseling, stress management, psychotherapy, meditation, exercise, or cognitive behavioral therapy (cbt).(21) most adolescents with anxiety disorders tend to discuss their problems with friends and family to relieve anxiety, whereas some do not seek help because they can deal with their own anxiety disorders, they think they don't really need help, they feel no one cares about them, their problems, and the lack of supporting health facilities in the youth environment. adolescents in east java are advised to consult their mental health problems with experts to find relevant solutions.(22) conclusion based on ppdgj iii and dsm-5, the patient was diagnosed with generalized anxiety disorder. based on the theories that cause anxiety, the causes of this patient's anxiety are included in several theories including past experiences, loss events, interpersonal conflicts, fear of failure, and selfesteem. while the symptoms that appear in this patient such as shortness of breath, worsening gastric problems, chest feels heavy, and cold and sweaty hands were to be found even though they have taken medication regularly. this condition makes the patient develop difficulty sleeping until she can't sleep (sleep disturbances occur). conflict of interest the author started there is no conflict of interest. references 1. niermann hcm, voss c, pieper l, venz j, ollmann tm, beesdo-baum k. anxiety disorders among adolescents and young adults: prevalence and mental health care saini et al medical and health science journal 2023 february vol.07 (01) page 52 of 53 service utilization in a regional epidemiological study in germany. j anxiety disord [internet]. 2021;83(july 2021):102453. available from: https://doi.org/10.1016/j.janxdis.2021.1024 53 2. harwanto nc, fitrikasari a, sarjana w. hubungan prestasi remaja sma yang dikonsulkan ke bimbingan dan konseling dengan kejadian kecemasan. j kedokt diponegoro, media med muda [internet]. 2015;4(4):112254. available from: https://www.neliti.com/id/publications/112 254/ 3. american psychiatric association. diagnostic and statistical manual of mental disorders: dsm-5tm, 5th ed [internet]. 5th ed. american psychiatric publishing; 2013. 947 p. available from: https://dsm.psychiatryonline.org/doi/book/ 10.1176/appi.books.9780890425596 4. kemenkes ri. kementerian kesehatan prioritaskan kesehatan jiwa [internet]. pusat komunikasi publik, sekretariat jenderal kementerian kesehatan ri. 2011 [cited 2023 jun 8]. available from: https://www.kemkes.go.id/article/view/158 9/kementerian-kesehatan-prioritaskankesehatan-jiwa.html 5. idaiani s, raharni, isfandari s. the mental emotional disorder pattern: study of national basic health research 2007, 2013, and 2018. 2020;22(ishr 2019):522–5. 6. sabbagh hj, abdelaziz w, alghamdi w, quritum m, alkhateeb nab, abourdan j, et al. anxiety among adolescents and young adults during covid-19 pandemic: a multi-country survey. int j environ res public health. 2022;19(17). 7. anindyajati g, wiguna t, murtani bj, christian h, wigantara na, putra aa, et al. anxiety and its associated factors during the initial phase of the covid-19 pandemic in indonesia. front psychiatry. 2021;12(march):1–10. 8. lakasing e, mirza z. anxiety and depression in young adults and adolescents. br j gen pract. 2020;70(691):56–7. 9. gustavson k, knudsen ak, nesvåg r, knudsen gp, vollset se, reichbornkjennerud t. prevalence and stability of mental disorders among young adults: findings from a longitudinal study. bmc psychiatry. 2018;18(1):1–15. 10. anxiety [internet]. mental health foundation. 2022. available from: https://www.mentalhealth.org.uk/exploremental-health/a-z-topics/anxiety 11. de sousa a. freudian theory and consciousness: a conceptual analysis. mens sana monogr. 2011;9(1):210–7. 12. davis r, campbell r, hildon z, hobbs l, michie s. theories of behaviour and behaviour change across the social and behavioural sciences: a scoping review. health psychol rev [internet]. 2015;9(3):323–44. available from: http://dx.doi.org/10.1080/17437199.2014.9 41722 13. heidenreich t, noyon a, worrell m, menzies r. existential approaches and cognitive behavior therapy: challenges and potential. int j cogn ther. 2021;14(1):209–34. 14. seidl e, venz j, ollmann tm, voss c, hoyer j, pieper l, et al. how current and past anxiety disorders affect daily life in adolescents and young adults from the general population—an epidemiological study with ecological momentary assessment. depress anxiety. 2021;38(3):272–85. 15. maulina vvr. health anxiety in young indonesian adults: a preliminary study. iafor j psychol behav sci. 2016;2(1):25– 32. 16. tang x, liu q, cai f, tian h, shi x, tang s. prevalence of social anxiety disorder and symptoms among chinese children, adolescents and young adults: a systematic review and meta-analysis. front psychol. 2022;13(august 2011). 17. alfano ca, beidel dc. social anxiety in adolescents and young adults: translating developmental science into practice [internet]. american psychological association; 2011. available from: saini et al medical and health science journal 2023 february vol.07 (01) page 53 of 53 https://www.jstor.org/stable/j.ctv1chs6wm 18. purborini n, lee mb, devi hm, chang hj. associated factors of depression among young adults in indonesia: a populationbased longitudinal study. j formos med assoc [internet]. 2021;120(7):1434–43. available from: https://doi.org/10.1016/j.jfma.2021.01.016 19. orlin s, wijofi f, evangelista nn, angelina s, halim da, hamdoyo a, et al. the depressive and anxiety symptoms and psychological distress among indonesian adults during covid-19 pandemic. indones j public heal. 2023;18(1):117–29. 20. creswell c, waite p, cooper pj. assessment and management of anxiety disorders in children and adolescents. arch dis child. 2014;99(7):674–8. 21. benjamin j sadock. buku ajar psikitri klinis kaplan & sadock. egc; 2010. 22. mustikawati ei, ernawaty e. differences in help-seeking behavior in adolescents with anxiety disorder during the covid-19 pandemic. media kesehat masy indones. 2021;17(3):110–5. medical and health science journal 202 3 february, vol 07 (01) medical and health science journal available at http://journal2.unusa.ac.id/index.php/mhsj; doi: 10.33086/mhsj.v7i1.3807 pissn 2549-7588. eissn 2549-7596 review article knowledge and attitude relationship with 3m plus mosquito nest eradication actions in surabaya: literature review muhammad rifqo h. farid1*, muhammad farid dimjati lusno2, margarita maria maramis1, sulistiawati1, budi utomo1, abdul fattah farid3 1fa culty of medicine, universita s airla ngga , 2fa culty of public hea lth, universita s airla n gga 3fa culty of pha rma cy, universita s airla ngga corresponding’s author email : faridlusno@fkm. un air. ac.id, phone: +6281335130077, jl. mulyorejo, surabaya 60115 article info article history: received : november 22, 2023 received in revised form : februa ry 09, 2023 accepted :februa ry 28, 2023 keywords: knowle d ge, attitude, pra ctice, dengue prevention ; dhf abstract dengue is a vira l disea se tra nsmitted by the aedes mosquito tha t ca uses dengue hemorrha gic fever (dhf) which is a ma jor problem in public hea lth a nd ha s socia l a nd economic impa cts. one of the key fa ctors for the success of dhf era dica tion is community beha vior whic h includes knowledge, a ttitudes, a nd a ctions. the purpose of this study is to conduct a litera ture review by a na lyzing the rela tionship betwee n knowledge a nd a ttitudes with the a ct of era dica ting mosquito nests ba sed on 7 (seven) journa l a rticles tha t ha ve been selected from the selection process mea sured using the qua lity a ssessment of the litera ture qua lity assessment tool for qua ntita tive studies from the effective public hea lth pra ctice project (ephpp) which a ssesse s selection bia s, study design, confounders, blinding, da ta collectio n methods a nd withdra wa ls a nd dropouts so tha t the qua lity of the reviewed journa ls ca n be seen. the qua lity a ssessment of the journa l resulted in 3 points: strong, modera te, a nd wea k. the result is tha t most respondents a re housewives. knowledge level is good, a ttitude level is good, a nd a ction is good enough. there is a rela tionsh ip between knowledge a nd a ction a nd there is a rela tionship betwee n a ttitude a nd a ction. the recommenda tion is to improve the a bility of housewives a nd improve coordina tion with loca l juma ntik. medical and health science journal. introduction in 2017, the city of surabaya had 451 dengue cases (1). this figure is the second largest in east java after sampa n g regency which had 506 cases in the same year (2). of course, this is a problem for the area, especially the city of surabaya . the government-regulated dengu e hemorrhagic fever eradication progra m involves many parts of the community . some of the factors that affect the spread of dengue fever include climate change (3), global, economic growth, populatio n density (4), clean water availability and community behavior(5). one of the key factors of eradicating dengue fever is community behavior (6). the behavior of society in this case includes the knowledge, attitudes, and actions of society (7). http://journal2.unusa.ac.id/index.php/mhsj mailto:faridlusno@fkm.unair.ac.id fa rid et al medical and health science journal 202 3 february vol.07 (01) pa ge 10 of 19 knowledge can influence a person's attitude and actions as mentione d by savayong (8) in terms of mosquito nest eradication. the level of attitud e shown by a person can influence his actions (9). a person's attitude towards a problem can affect the person's willingness to act (8). this study aims to analyze the relationship of knowledge and attitud e s with mosquito nets eradication measures . the benefit of this research is to enrich the library and prove the relationship betwee n knowledge and attitudes with mosquito larvae eradication actions and to find out the behavior of the community toward s the eradication of mosquito larvae so that they can provide feedback to the surabay a city health office so that the area is achieved free of dengue fever. methods of the study the type and design of this research is a comprehensive literatu re review identifying, assessing, and analyzing all relevant studies on the give n topic. meanwhile, the method used in this study is about assessing the relationsh ip between knowledge and attitudes with 3m plus mosquito nest eradicatio n measures in surabaya in different demographic groups, it can be a crosssectional or case control approach. this research reviews based on the results of scientific analysis, differences, and similarities of knowledge, attitude , practice (kap) even though there are differences in instruments in data collection and methods for data analysis. data is collected from literatu re that can be found through the google scholar search engine written in indonesian. the literature found will then be filtered with inclusion and exclusio n criteria. inclusion criteria: 1. the type of study chosen is the study that is the primary research. single-group case studies and exploratory designs are reviewed and discussed to help provide explanations for positive or negative outcomes, as well as provide a basis for future research (littell et al. 2008)(10). 2. the subject and place of research is the community, especially mothers in the surabaya city area. 3. studies conducted between 2014 2019. exclusion criteria: literature that does not meet the predetermined keywords. in-depth searches for studies and research were searched using the keywords "knowledge" and "attitudes" and "dengue prevention measures in surabaya". the electronic database used as a search for this study using google scholar only includes journals. the last search was in june 2020. then there is a need for selection with an assessment of the quality of literature. ephpp (effective public health practice project) was used to assess the quality of the literature in this study. there are seven assessment items with three assessment tier categories each. fa rid et al medical and health science journal 202 3 february vol.07 (01) pa ge 11 of 19 results and discussion literature search results figure 1 diagram of the process of determining the source of literature to be analyzed based on figure 1, it has been explained the stages of literature selection that will be analyzed in this literature review. the selected literature was searched based on the search word "knowledge relationships, attitudes and precautions of dhf" on google scholar from 2014 to 2019. the search was conducted in june of 2020. from the first stage of the search, 263 articles were obtained. the next selection was carried out by issuing literature that was duplicated because the title was the same but was published by different media, then 8 literatures were obtained that experienced duplication so that there were 255 articles. from the selection, 123 articles were obtained that had to be issued because the research was carried out outside the city of surabaya. the focusing of the research area was carried out to obtain literature review results that were more focused and reduced variations in research variables. so that researchers can conduct a more objective analysis. up to 7 articles left to proceed to the analysis process. literature quality assessment in this study, the literature quality assessment used the quality assessment tool for quantitate studies from the effective public health practice project (ephpp) which assessed selection bias, study design, confounders, blinding, data collection methods and withdrawals and dropouts so that the quality of the journals reviewed would be visible. the journal quality assessment yielded 3 values: strong, moderate, and weak. tabel 1 kualitas jurnal berdasarkan effective public health practice project (ephpp) a u th o r s e le c ti o n b ia s s tu d y d e si g n c o n fo u n d e rs b li n d in g d a ta c o ll e c ti o n m e th o d w it h d ra w a ls a n d d ro p o u t r a ti n g prastiani , dkk (2018) 1 1 3 2 2 1 1 muda, dkk(2019 ) 1 1 3 2 2 1 1 agustin (2019) (8) 1 1 2 2 2 1 1 fa rid et al medical and health science journal 202 3 february vol.07 (01) pa ge 12 of 19 rismawat i , dkk (2017) 1 1 3 2 2 1 1 sari (2015) 1 1 3 2 2 1 1 fauziah, dkk (2019) 1 1 2 2 2 1 1 jayaward hana, dkk (2018) 1 1 3 2 2 1 2 information: 1 = strong, 2 = moderate, 3 = weak the results of the critical appraisal assessment are that there are 6 (six) journals with a strong rate, 1 (one) journal with a moderate rate, and there are no journals with a weak rate. the details of the assessment in each component of the assessment are contained in table 1. the seven studies that fit the inclusion criteria of this literature review involved 5 cross-sectional studies and 2 case control studies (table 2). the publication time of the study used in this study ranged from 2015 to 2020. the location of all studies is in the city of surabaya, including gunung anyar village and rungkut menanggal village, rangkah buntu village, tenggilis health center area, wonokusumo village, putat jaya village, jambangan village. of the seven studies that have been selected in this literature review, it generally uses independent variables of knowledge, attitudes and actions/behaviors with the dependent variables used are larvae detection, the presence of larvae and the incidence/incidence of dhf as listed in table 2. the research instruments used by the selected study are interviews with questionnaires and observation sheets, as well as examination of the presence or density of larvae. literature characteristics socio-demographic overview of the article the characteristics of respondents are often used as variables in research related to analyzing the relationship characteristics of inclusion studies table 2 characteristics of the inclusion study methodology literat ure (year) types of studies and sampling techniques implementat ion location independent variables depen dent varia bles research instruments prastia ni, dkk (2020) (11) cross sectional study, cluster, random sampling gunung anyar village and rungkut air temperature, occupancy density, knowledge and house indeks (hi) interview (questionnaire ), observation, fa rid et al medical and health science journal 202 3 february vol.07 (01) pa ge 13 of 19 menanggal village, attitude towards dhf and ps container index muda, dkk (2019) (12) cross sectional study, simple, random sampling rangkah buntu village education, income, knowledge and attitudes the presen ce of larvae interview (questionnaire ), observation agusti n (2019) (13) case control, purposive sampling tenggilis health center area knowledge, attitudes, and actions dhf incide nts interview (questionnaire ), observation risma wati , dkk (2017) (14) cross sectional study, simple, random sampling wonokusumo subdistrict, host and environment behavior dhf incide nts interview (questionnaire ), observation, flick-free number sari, d kk (2015) (15) cross sectional study, simple random sampling putat jaya village, surabaya knowledge and actions dhf incide nts interview (questionnaire ) fauzia h, dkk (2019) (16) case control, purposive sampling tenggilis health center area, knowledge and actions dhf incide nts questionnaire s, observations jayaw ardha na, dkk (2017) (17) cross sectional study, simple random sampling jambangan village, family behavior dhf incide nts questionnaire between knowledge, attitudes and behaviors for dengue fever prevention or eradication of mosquito nests (psn) some of the characteristics of respondents that are variable include the age of the respondents (11) (14) (15) (17), gender (11) (12), employment (11) (14) (15) (17), income (12), and education level (11) (12) (14) (15) (17) in studies with respondents who tend to be homogeneous on sex variables, gender is not one of the characteristic variables of respondents, such as all respondents are fa rid et al medical and health science journal 202 3 february vol.07 (01) pa ge 14 of 19 cadre mothers (14) (15) or gender is considered not to be one of the variables to consider (17). however, there are some studies that do not make the characteristics of respondents as variables written on the research results because they are not discussed in the study (13) (16). variable respondents at the age of the majority 41 – 50 years, at least 23 years maximum 80 years (11), 30 – 35 years (14), aged > 40 years (15), 41 – 65 years (12), aged 24 people (17). most respondents were female (11) (12). employment variables in respondents of most housewives (11) (14) (15) and most of the private work (17). education level variables of most high school respondents (11) (12) (14) (15) (17). interpretation and discussion of results knowledge of psn with 3m knowledge as one of the variables of research consists of being spelled out with several questions. it consists of 5 questions (12), 7 questions (11) and 10 questions (14). there are variables of knowledge categorized into three, namely less, sufficient, and good (11) (15) (16); (12) bad, sufficient, and good (13); (14). there are also those who do not discuss knowledge in terms of dengue incidents (17). most respondents had less category knowledge (11). in some studies, the results were obtained that most respondents had good knowledge (15). some studies have also compared knowledge from case and control groups (13) (12). most respondents in the study group had good knowledge (31.82 %). most respondents in the comparison group had poor knowledge (40.91%) (13). the percentage of respondents with good knowledge was higher in the control group than the case group (16). attitude about psn with 3m the attitude assessed was the attitude about dengue fever and mosquito nets eradication (psn) with 11 questions (11). the attitude also discusses the attitudes of respondents regarding 3m (16). attitude is measured by 10 questions (13). the attitude variables are categorized into three, namely less, sufficient, and good (11) (16). there are also attitudes that are not used as variables studied (15); (17). there are also categories of attitude variables that are categorized into two, namely good and less (12). most respondents had sufficient attitudes (11) (14). most respondents had a good attitude (16). actions about psn with 3m preventive measures in this regard such as the eradication of mosquito nests (11) (16); (17). the action also looks at how it relates to cases of dengue fever (11); (15). the description of actions includes draining the bathroom once a week, not allowing clothes to hang in the house, using mosquito repellent / mosquito repellent (burn, rub, spray) and sprinkling abate powder on the water reservoir / bathroom (12) (14). fa rid et al medical and health science journal 202 3 february vol.07 (01) pa ge 15 of 19 actions include bringing family members affected by dhf to health facilities and reporting to rt, rw, or lurah cadres (14). the discussion of actions is also related to jumantik actions to empower the community in implementing mosquito nets eradication efforts programs with the implementation of 3m plus. action is measured by 17 questions (13). measures also include first aid efforts in people with dhf. in addition, actions taken include hand washing efforts, planting mosquito repellent plants. actions are categorized into two, namely high and low (11) , doing 3m+ actions and not doing 3m actions (12). categorization is also divided into three, namely less, sufficient, and good (15); (16) or good, enough, and bad (13). most respondents had actions with low categories (11), bad (13). however, there is also most respondents having sufficient actions (15), good actions (16) active category actions. the actions taken were to drain the bathtub at least once a week 115 people while 96 people did not, hang dirty clothes for more than one day a total of 105 people and 106 people did not, 184 people cleaned the house while 28 people sometimes (12). the action is also carried out based on whether to experience the incidence of dhf then the result is obtained that the majority have never experienced the occurrence of dhf (14); (15). the categories of behavior are good, sufficient, lacking (17). most residents behave quite 54% (17). the percentage of respondents with good action was higher in the case group than the control group (16). the incidence of dhf is categorized into three, namely good, sufficient, lacking. the percentage of the three categories is almost the same, but the highest is the percentage in the sufficient group (17). the relationship of knowledge with the actions of psn knowledge is the result of knowing and occurs after a person has sensed an object(18). knowledge is an important factor in the formation of a behavior because behavior based on knowledge will last longer than without being based on knowledge (11). in this study, the selected inclusion study will assess respondents' knowledge related to dhf disease, mosquito nest eradication, and 3m+ measures. in rismawati's research (14) a meaningful relationship (p = 0.00) was obtained between knowledge and incidence of dhf where most respondents who had never experienced dhf had a sufficient level of knowledge (44.9%) and obtained a meaningful relationship between actions and the incidence of respondents who had never experienced dhf, the majority had sufficient invaluable actions (54%). from the study, it can be interpreted that the level of knowledge will affect the manifestation of respondents' actions related to dhf and psn diseases. the research is not in line with the research of agustin (13), muda (12) sari (15) and fauziah et al., (16), where in the four studies there was no relationship between knowledge and actions related to dhf disease fa rid et al medical and health science journal 202 3 february vol.07 (01) pa ge 16 of 19 and psn activities. a meaningful relationship was obtained between knowledge and incidence of dhf (p = 0.009) with most respondents who had never experienced the incidence of dhf having a less valuable level of knowledge (13). the research of muda et al., (12) found a meaningful relationship between knowledge and incidence of dhf (p = 0.001) with respondents who found the presence of larvae in their home areas, the majority of whom had a good level of knowledge. research by fauziah et al. (16) suggests that knowledge and action have no relationship related to the incidence of dengue fever the relationship of attitude to action attitude is a reaction or response that is still closed from a person to a stimulus or object (19). the manifestation of an attitude may not necessarily be directly manifested into an action or an activity. however, attitude is a predisposing factor to the actions of an individual's behavior. in this study, the attitudes assessed were respondents' attitudes related to mosquito nest eradication (psn), 3m behavior, and dhf disease. meanwhile, in terms of actions, including reviewing respondents' actions related to draining the bathroom once a week, not allowing clothes to depend in the house, using mosquito repellent / mosquito repellent drugs (burn, rub, spray) and sprinkling abate powder on the tub of the water storage container / bathroom. research by rismawati et al., (14) respondents who have never experienced dhf tend to have sufficient attitudes (56.4%) p = 0.00 and respondents who have never experienced dhf are most actions that are considered sufficient (54%) p = 0.00 (14). so, in the study, it can be said that in respondents who have never contracted dhf, most of them have sufficient attitudes and actions. this research is supported by the research of fauziah et al. (16), where in their research found a statistically meaningful relationship between respondents' attitudes and the incidence of dhf with a p value of 0.013 where most respondents had a good attitude. in addition, in his research, it was found that most respondents had good invaluable actions. so, from the two studies, it can be said that there is a relationship between attitudes and manifestations of respondents' actions related to dengue incidence. the two studies were not in line with the research of muda et al., (12) and the research of fauziah et al., (16) where in both studies there was no relationship between attitudes and actions with the incidence of dhf and the number of larvae presence. this is contradictory because it is suspected that the public's sense of awareness in preventing and overcoming dengue fever events is still low. an individual in acting to do something should be based on a high sense of awareness so that his actions are in accordance with the knowledge they have. if an action is not based on a high sense of awareness, psn dbd activities as an effort to prevent and overcome the occurrence of dengue cases will not run optimally (15). therefore, predisposing factors to the manifestation of an individual's actions in the prevention of dhf not only fa rid et al medical and health science journal 202 3 february vol.07 (01) pa ge 17 of 19 affect his attitude and knowledge related to dhf and psn diseases, but a high sense of awareness will be able to provide maximum efforts in preventing and overcoming the occurrence of dhf cases. conclusion based on the results obtained from the processing of research data, it was concluded that: 1. there was no relationship between knowledge and actions related to dhf disease and psn activities. 2. there is a relationship between attitudes and actions related to dengue disease and psn activities, but this needs to be reviewed because the literature that supports this statement is not very strong. 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16. fauziah n, rahayu u, thohari i. perilaku 3m bagi penghuni rumah mempengaruhi kejadian penyakit demam berdarah dengue. gema lingkungan kesehatan [internet]. 2019 jan 31 [cited 2022 nov 8];17(1). available from: http://journal.poltekkesdepkessby.ac.id/index.php/kesling/article/v iew/1053 17. keperawatan dan kebidanan j, ilmu kesehatan universitas merdeka surabaya jl ketintang madya vii f, tel s, perilaku keluarga dengan pencegahan kejadian demam berdarah dengue di kelurahan jambangan kota surabaya andi jayawardhana h, aji permana r, kogoya y, et al. hubungan perilaku keluarga dengan pencegahan kejadian demam berdarah dengue (dbd) di kelurahan jambangan kota surabaya. nersmid : jurnal keperawatan dan kebidanan [internet]. 2019 [cited 2022 nov 8];2(1):55–65. available from: https://nersmid.unmerbaya.ac.id/index. php/nersmid/article/view/59 18. yussof fm, hassan a, zin t, hussin tmar, kadarman n, umar r. knowledge of dengue among students in universiti sultan zainal abidin (unisza), terengganu, malaysia and the influence of knowledge of dengue on attitude and practice. journal of fundamental and applied sciences. 2018; 19. notoatmodjo s. promosi kesehatan dan perilaku kesehatan. revisi. jakarta: rineka cipta; 2014. https://nersmid.unmerbaya.ac.id/index.php/nersmid/article/view/59 https://nersmid.unmerbaya.ac.id/index.php/nersmid/article/view/59 medical and health science journal, vol.4., no.1, february 2020 penyusunan indikator mutu unit hemodialisis rumah sakit grha permata ibu depok dinda iryawati bedy saskito*1, budi hartono2, hasri diniarianti3 1 program magister kesehatan masyarakat fakultas kesehatan masyarakat universitas muhammadiyah jakarta, pt. masa cipta husada, rumah sakit grha permata ibu depok 2 universitas muhammadiyah jakarta, stikes hang tuah pekanbaru 3 rumah sakit grha permata ibu depok *correspondent author: die.vest@gmail.com correspondence: dinda iryawati bedy saskito @2020 medical and health science journal. 10.33086/mhsj.v4i1.1445 available at http://journal2.unusa.ac.id/index.php/mhsj 19 original article article info abstract article history: submitted: january,21-2020 received in revised form february accepted: february,26-2020 hemodialysis (hd) unit is an outpatient hospital service which is currently quite popular due to the increasing number of kidney disease patients who need hd. along with this, hd units are expected to be able to compensate with quality and patient safety according to standards. to be able to assess quality, required quality indicators include clinical area quality indicators, management area quality indicators, and patient safety goals quality indicators. the quality indicators are adjusted to service on hd units. objectives: until now, gpi hospital does not have indicators, for this reason, this study aims to compile hd unit quality indicators based on hospital accreditation standards and government regulations. method: qualitative research by collecting data using the process of triangulation of sources. data collection by interview, observation, and focus group discussion (fgd) techniques. the instrument uses snars quality indicators consisting of clinical area quality indicators, management area quality indicators, and patient safety goals quality indicators, with priority analysis using high risk, high volume, and problem prone. result: the results of data collection show the iak hd indicator with the highest score is the completeness of hd informed consent, while for iam hd the administrative completeness has the highest score, and the highest score on the iskp is to put on identity wristband to the patient. based on these results, 11 quality indicators were selected to be applied at gpi depok hospital, consisting of: 1) completeness of filling in hd informed consent; 2) incidence of infectious sharps waste injury in hd staffs; 3) the incidence of needlestick injury in nurses; 4) compliance of nurses in using ppe completely when performing hd actions; 5) complete administrative documents for claims; 6) compliance of nurses in using ppe completely during reuse; 7) incidence of patients falling on hd units resulting in disability / death; 8) compliance of officers in the implementation of hand hygiene; 9) put on identity wristband to the patient; 10) full hd patient confirmation stamp; and 11) incidence of transfusion reactions. conclusion: there are 11 hd unit quality indicators that have been arranged based on priorities and each is accompanied by a dictionary of indicators. the quality indicators consist of iak (1 indicator), iam (5 indicators), and iskp (5 indicators). keywords: hemodialysis, patient safety goals, quality indicators kata kunci: hemodialisis, indikator mutu, sasaran keselamatan pasien abstrak unit hemodialisis (hd) merupakan pelayanan rawat jalan rumah sakit (rs) yang saat ini cukup populer karena peningkatan jumlah pasien penyakit ginjal yang membutuhkan hd. seiring dengan hal tersebut, diharapkan unit hd mampu mengimbanginya dengan mutu dan keselamatan pasien yang sesuai standar. untuk dapat menilai mutu diperlukan indikator, yang meliputi indikator mutu area klinik (iak), indikator mutu area manajemen (iam), dan indikator mutu sasaran keselamatan pasien (iskp). indikator mutu tersebut disesuaikan dengan pelayanan pada unit hd. tujuan: hingga saat ini rs gpi belum mempunyai indikator, untuk itu penelitian ini bertujuan menyusun indikator mutu unit hd berdasarkan standar akreditasi rs dan regulasi pemerintah. metode: penelitian kualitatif dengan pengumpulan data menggunakan proses triangulasi sumber. pengumpulan data mailto:die.vest@gmail.com http://journal2.unusa.ac.id/index.php/mhsj medical and health science journal, vol.4., no.1, february 2020 dilakukan dengan teknik wawancara, observasi, dan focus group discussion (fgd). instrumen menggunakan indikator mutu snars yang terdiri dari iak, iam, dan iskp, dengan analisa penentuan prioritas menggunakan high risk, high volume, dan problem prone. hasil: hasil pengumpulan data menunjukkan indikator iak hd dengan skor tertinggi adalah kelengkapan pengisian formulir persetujuan tindakan hd, sedangkan untuk iam hd adalah kelengkapan administrasi mempunyai skor paling tinggi, dan skor tertinggi pada iskp adalah pemasangan gelang identitas pada pasien. berdasarkan hasil tersebut maka dipilih 11 indikator mutu yang akan diterapkan di rs gpi depok, yang terdiri dari: 1) kelengkapan pengisian formulir persetujuan tindakan hd; 2) insiden petugas hd tertusuk limbah benda tajam infeksius; 3) insiden perawat tertusuk jarum; 4) kepatuhan perawat dalam menggunakan apd dengan lengkap saat melakukan tindakan hd; 5) kelengkapan berkas administrasi untuk klaim; 6) kepatuhan perawat dalam menggunakan apd dengan lengkap saat tindakan reuse; 7) insiden pasien jatuh di unit hd yang berakibat kecacatan/kematian; 8) kepatuhan petugas dalam pelaksanaan hand hygiene; 9) pemasangan gelang identitas pada pasien; 10) stempel konfirmasi pasien hd terisi lengkap; dan 11) insiden reaksi transfusi. kesimpulan: terdapat 11 indikator mutu unit hd yang telah disusun berdasarkan prioritas dan masing-masing disertai dengan kamus indikator. indikator mutu tersebut terdiri dari iak (1 indikator), iam (5 indikator), dan iskp (5 indikator). @2020 medical and health science journal. 10.33086/mhsj.v4i1.1445 pendahuluan berdasarkan keputusan menteri kesehatan republik indonesia nomor 129 tahun 2008 tentang standar pelayanan minimal rumah sakit, rumah sakit (rs) adalah sarana kesehatan yang menyelenggarakan pelayanan kesehatan perorangan meliputi pelayanan promotif, preventif, kuratif, dan rehabilitatif yang menyediakan pelayanan rawat inap, rawat jalan, dan gawat darurat.1 salah satu pelayanan rawat jalan yang populer saat ini yaitu unit hemodialisis (hd), dapat dilihat dari data indonesian renal registry (2018) yang mencatat pasien penyakit ginjal yang menjalani hd atau cuci darah di indonesia mengalami peningkatan sebesar 25 ribu orang pada 2016 ke 2017, dari 52 ribu menjadi 77 ribu pasien.2 peraturan menteri kesehatan republik indonesia nomor 812 tahun 2008 tentang penyelenggaraan pelayanan dialisis pada fasilitas pelayanan kesehatan, menjelaskan definisi hd adalah salah satu terapi pengganti ginjal yang menggunakan alat khusus dengan tujuan mengeluarkan toksin uremik dan mengatur cairan, elektrolit tubuh.3 pelayanan hd dilakukan di unit hd, dimana syarat unit hd terdiri dari minimal 4 mesin dialisis, didukung dengan unit pemurnian air (water treatment) dan peralatan pendukung serta mempunyai tenaga medis, minimal terdiri dari 2 perawat mahir hd, 1 dokter bersertifikat hd, yang diawasi oleh 1 orang dokter internis bersertifikat hd dan disupervisi oleh 1 orang internis-konsultan ginjal hipertensi (kgh). menurut pedoman pelayanan hemodialisis di sarana pelayanan kesehatan (2008).4 dengan meningkatnya kebutuhan pasien akan hd, diharapkan unit hd mampu memenuhi standar mutu pelayanan dan melindungi keselamatan pasien sesuai peraturan menteri kesehatan nomor 34 tahun 2017 tentang akreditasi rumah sakit.5 standar nasional akreditasi rumah sakit (snars) (2017) menjelaskan pengukuran mutu dilakukan menggunakan indikator mutu sebagai berikut: 1) indikator mutu area klinik (iak), yaitu indikator mutu yang bersumber dari area pelayanan; 2) indikator mutu area manajemen (iam), yaitu indikator mutu yang bersumber dari area manajemen; 3) indikator mutu sasaran keselamatan pasien (iskp), yaitu indikator mutu yang mengukur kepatuhan staf dalam penerapan sasaran keselamatan pasien dan budaya keselamatan, sesuai dengan international patient safety goals menurut jci (2020).6,7 20 medical and health science journal, vol.4., no.1, february 2020 saat ini unit hd rs grha permata ibu (gpi) depok belum memiliki indikator mutu, sehingga memiliki dampak pelayanan yang ada saat ini belum dapat diukur apakah sudah sesuai dengan standar mutu dan sudah melindungi keselamatan pasien atau belum. untuk itu, dengan berlandaskan standar akreditasi dan regulasi pemerintah yang terbaru, rs gpi bertujuan menyusun indikator mutu unit hd, dimana indikator yang dipilih memenuhi kriteria “smart” yaitu specific, measurable, acceptable, reasonable dan time framed.8 diharapkan dengan adanya indikator ini, unit hd mampu mengukur mutu untuk menjaga pelayanan sesuai standar dan melindungi keselamatan pasien di unit hd rs gpi. metode studi ini merupakan penelitian kualitatif dengan pengumpulan data menggunakan proses triangulasi sumber. pengumpulan data dilakukan dengan teknik wawancara, observasi, dan focus group discussion (fgd) yang berkaitan dengan indikator mutu sesuai snars. wawancara dilakukan mendalam kepada informan direktur, wakil direktur penunjang pelayanan medis, kepala instalasi rawat jalan, dan dokter hd terkait aspek proses dan kebijakan manajemen mengenai indikator mutu snars disesuaikan dengan pelayanan unit hd. observasi langsung digunakan untuk memperoleh gambaran indikator mutu snars pada di unit hd. untuk menyusun indikator mutu yang sesuai dengan unit hd dilakukan fgd bersama dengan pihak manajemen rs beserta tim unit hd dan kepala ruangan unit lain yang terkait dengan unit hd. instrumen menggunakan indikator mutu snars yang terdiri dari iak, iam, dan iskp, dengan analisa penentuan prioritas menggunakan high risk, high volume, dan problem prone.9 high risk memiliki makna proses berisiko tinggi: nilai x bobot = skor; dengan rentang nilai = 1 – 5, dimana 1 risiko terkecil hingga 5 risiko terbesar; bobot = 50. high volume memiliki makna proses dalam jumlah besar: nilai x bobot = skor; dengan rentang nilai = 1 – 5, dimana 1 jumlah terkecil hingga 5 jumlah terbesar; bobot = 30. problem prone memiliki makna relatif menjadi masalah: nilai x bobot = skor; dengan rentang nilai = 1 – 5, dimana 1 masalah yang ditimbulkan sangat kecil hingga 5 masalah yang ditimbulkan sangat besar; bobot = 20. penentuan bobot berdasarkan kesepakatan bersama. kriteria pemilihan indikator yang digunakan di rs gpi yaitu indikator dengan total skor ≥ 350 dengan skor problem prone ≥ 80, kecuali pada iskp karena semua indikator akan digunakan. hasil berdasarkan fgd dengan analisa high risk, high volume, dan problem prone telah disusun beberapa indikator mutu unit hd. pada iak terdapat 3 indikator, iam terdapat 8 indikator, dan iskp terdapat 5 indikator. tabel 1 menunjukkan iak hd di rs gpi terdiri dari 1) kelengkapan pengisian formulir persetujuan tindakan hd;10 2) prosentase adekuasi hd 2x seminggu dengan urr (urea reduction ratio) ≥ 65%;11 dan 3) prosentase adekuasi hd 2x seminggu dengan kt/v 1,2.11. adekuasi hd adalah kecukupan dosis hd, yang dapat diukur dengan 2 cara, yaitu urr dan kt/v, dimana kt/v terdiri dari k = urea clearance, t = waktu dalam satu kali perawatan, dan v = volume dari distribusi urea. dikatakan mencapai adekuasi bila urr ≥ 65% atau kt/v 1,2.10,11 skor tertinggi pada tabel 1 adalah kelengkapan pengisian formulir persetujuan tindakan hd, sehingga dari perhitungan tersebut, indikator kelengkapan pengisian formulir persetujuan tindakan hd dipilih menjadi indikator yang akan digunakan. 21 medical and health science journal, vol.4., no.1, february 2020 tabel 1. iak hd no iak (hd) high risk nilai x bobot = skor rentang nilai = 1 – 5 bobot = 50 high volume nilai x bobot = skor rentang nilai = 1 – 5 bobot = 30 problem prone nilai x bobot = skor rentang nilai = 1 – 5 bobot = 20 jumlah nilai bobot skor nilai bobot skor nilai bobot skor 1 kelengkapan pengisian formulir persetujuan tindakan hd 5 50 250 5 30 150 5 20 100 500 2 prosentase adekuasi hd 2x seminggu dengan urr ≥ 65% 3 50 150 1 30 30 2 20 40 220 3 prosentase adekuasi hd 2x seminggu dengan kt/v 1,2 3 50 150 1 30 30 2 20 40 220 untuk iam hd dapat dilihat pada tabel 2, terdiri dari 8 indikator yang dibahas, yaitu: 1) insiden petugas hd tertusuk limbah benda tajam infeksius;12 2) insiden perawat tertusuk jarum;12 3) tingkat kepuasan pasien;13 4) kepatuhan perawat dalam menggunakan alat pelindung diri (apd) dengan lengkap saat melakukan tindakan hd;12 5) kelengkapan berkas administrasi untuk klaim;10,14 6) response time petugas teknisi dalam penanganan kerusakan mesin hd;13 7) pemeriksaan kadar air ro (reverse osmosis) setiap 6 bulan;15 dan 8) kepatuhan perawat dalam menggunakan apd dengan lengkap saat tindakan reuse (proses pembersihan dan pencucian ulang dialiser).12,16 dari hasil diskusi, diambil 5 indikator yang dianggap prioritas, salah satunya ialah kelengkapan berkas administrasi untuk klaim karena memiliki jumlah skor tertinggi yaitu 500. kemudian indikator terpilih lainnya berdasarkan kesepakatan bersama karena memiliki risiko tinggi terjadi masalah bila insiden terjadi, yaitu insiden petugas hd tertusuk limbah benda tajam infeksius dan insiden perawat tertusuk jarum. sedangkan indikator kepatuhan perawat dalam menggunakan apd dengan lengkap saat tindakan hd, dan kepatuhan perawat dalam menggunakan apd dengan lengkap saat tindakan reuse, dipilih sebagai bentuk keamanan dan keselamatan petugas hd. tabel 2. iam hd no iam (hd) high risk nilai x bobot = skor rentang nilai = 1 – 5 bobot = 50 high volume nilai x bobot = skor rentang nilai = 1 – 5 bobot = 30 problem prone nilai x bobot = skor rentang nilai = 1 – 5 bobot = 20 jumlah nila bobot skor nilai bobot skor nilai bobot skor 1 insiden petugas hd tertusuk limbah benda tajam infeksius 4 50 200 2 30 60 5 20 100 360 2 insiden perawat 4 50 200 2 30 60 5 20 100 360 22 medical and health science journal, vol.4., no.1, february 2020 tertusuk jarum 3 tingkat kepuasan pasien 3 50 150 5 30 150 2 20 40 340 4 kepatuhan perawat dalam menggunakan apd dengan lengkap saat melakukan tindakan hd 4 50 200 5 30 150 5 20 100 450 5 kelengkapan berkas administrasi untuk klaim 5 50 250 5 30 150 5 20 100 500 6 response time petugas teknisi dalam penanganan kerusakan mesin hd 2 50 100 2 30 60 2 20 40 200 7 pemeriksaan kadar air ro setiap 6 bulan 4 50 200 3 30 90 3 20 60 350 8 kepatuhan perawat dalam menggunakan apd dengan lengkap saat tindakan reuse 3 50 150 4 30 120 4 20 80 350 tabel 3 mengenai iskp hd dengan 5 indikator dimana seluruhnya dipilih sebagai untuk mewujudkan standar sasaran keselamatan pasien (skp). kelima indikator tersebut yaitu: 1) insiden pasien jatuh di unit hd yang berakibat kecacatan/kematian;13,17 2) kepatuhan petugas dalam pelaksanaan hand hygiene;17,18 3) pemasangan gelang identitas pada pasien;17 4) stempel konfirmasi pasien hd terisi lengkap;17 dan 5) insiden reaksi transfusi.13,17 iskp dengan jumlah skor tertinggi sebesar 500 ialah pemasangan gelang identitas pada pasien. tabel 3. iskp hd no iam (hd) high risk nilai x bobot = skor rentang nilai = 1 – 5 bobot = 50 high volume nilai x bobot = skor rentang nilai = 1 – 5 bobot = 30 problem prone nilai x bobot = skor rentang nilai = 1 – 5 bobot = 20 jum lah nilai bobot skor nilai bobot skor nilai bobot skor 1 insiden pasien jatuh di unit hd yang berakibat kecacatan/kemat ian 5 50 250 1 30 30 5 20 100 380 2 kepatuhan petugas dalam pelaksanaan hand hygiene 3 50 150 3 30 90 3 20 60 300 3 pemasangan 5 50 250 5 30 150 5 20 100 500 23 medical and health science journal, vol.4., no.1, february 2020 gelang identitas pada pasien 4 stempel konfirmasi pasien hd terisi lengkap 4 50 200 3 30 90 4 20 80 370 5 insiden reaksi transfusi 5 50 250 3 30 90 4 20 80 420 setelah terpilih 11 indikator mutu prioritas unit hd, langkah selanjutnya ialah menyusun kamus indikator mutu. kamus indikator berfungsi sebagai petunjuk atau keterangan mengenai sebuah indikator. tabel 4 merupakan tabel kamus indikator berdasarkan area klinik yang menjelaskan tentang kelengkapan pengisian formulir persetujuan tindakan hd. tabel 4. kamus indikator berdasarkan area klinik kamus indikator berdasarkan area klinik judul indikator kelengkapan pengisian formulir persetujuan tindakan hd definisi operasional pengisian lengkap lembar persetujuan oleh pasien/keluarga pasien untuk dilakukan tindakan hd tujuan tergambarnya tanggungjawab staf profesional pemberi asuhan kepada pasien dalam kelengkapan pengisian informasi dalam catatan medis. serta untuk kelancaran klaim terhadap pelayanan yang hd yang telah dilakukan dimensi mutu keselamatan efektifitas dasar pemikiran permenkes 290 / 2008 tentang persetujuan tindakan kedokteran numerator formulir persetujuan tindakan hd yang terisi lengkap dalam bulan tersebut denominator formulir persetujuan tindakan hd dalam bulan tersebut kriteria inklusi formulir persetujuan tindakan hd yang terisi lengkap kriteria eksklusi formula pengukuran n/d x 100% metodologi pengumpulan data sensus harian cakupan data total frekuensi pengumpulan data harian frekuensi analisa data mingguan metodologi analisa data run chart sumber data rekam medis pj data kepala unit hd publikasi data internal kamus indikator berdasarkan area manajemen disajikan pada tabel 5, yang terdiri dari indikator kelengkapan berkas administrasi untuk klaim, insiden petugas hd tertusuk limbah benda tajam infeksius, insiden perawat tertusuk jarum, kepatuhan perawat dalam menggunakan apd dengan lengkap saat tindakan hd, dan kepatuhan perawat dalam menggunakan apd dengan lengkap saat tindakan reuse. tabel 5. kamus indikator berdasarkan area manajemen kamus indikator berdasarkan area manajemen judul indikator insiden petugas hd tertusuk limbah benda tajam infeksius definisi operasional petugas hd yang tertusuk limbah benda tajam sehingga menimbulkan luka 24 medical and health science journal, vol.4., no.1, february 2020 tujuan tergambarnya keamanan dan keselamatan petugas hd dimensi mutu keselamatan dasar pemikiran permenkes 27 / 2017 tentang pedoman pencegahan dan pengendalian infeksi di fasilitas pelayanan kesehatan numerator insiden kejadian petugas hd tertusuk limbah benda tajam infeksius dalam bulan tersebut denominator jumlah tindakan hd dalam bulan tersebut kriteria inklusi petugas hd yang sedang bertugas kriteria eksklusi selain petugas hd yang sedang berada di ruangan hd formula pengukuran n/d x 100% metodologi pengumpulan data per insiden cakupan data total frekuensi pengumpulan data bulanan frekuensi analisa data bulanan metodologi analisa data run chart sumber data laporan kejadian pj data kepala unit hd publikasi data internal judul indikator insiden perawat tertusuk jarum definisi operasional perawat yang melakukan tindakan hd dan terkena alat tajam/ jarum sehingga menimbulkan luka tujuan tergambarnya keamanan dan keselamatan perawat hd dimensi mutu keselamatan dasar pemikiran permenkes 27 / 2017 tentang pedoman pencegahan dan pengendalian infeksi di fasilitas pelayanan kesehatan numerator jumlah insiden perawat hd tertusuk jarum dalam bulan tersebut denominator jumlah tindakan hd dalam bulan tersebut kriteria inklusi perawat yang melakukan tindakan menggunakan alat tajam/ jarum pada saat tindakan hd kriteria eksklusi petugas hd selain perawat yang tertusuk jarum formula pengukuran n/d x 100% metodologi pengumpulan data per insiden cakupan data total frekuensi pengumpulan data bulanan frekuensi analisa data bulanan metodologi analisa data run chart sumber data laporan kejadian pj data kepala unit hd publikasi data internal judul indikator kepatuhan perawat dalam menggunakan apd dengan lengkap saat melakukan tindakan hd definisi operasional perawat yang taat dalam penggunaan apd dengan lengkap pada saat melakukan tindakan hd tindakan hd adalah prosedur medis yang bertujuan untuk menggantikan fungsi ginjal menggunakan mesin, diawali dengan penyambungan akses darah pasien ke mesin, kemudian dilakukan proses cuci darah oleh mesin untuk membuang cairan dan racun yang tidak bisa dibuang oleh ginjal, dan diakhiri dengan pelepasan sambungan akses darah pasien dari mesin. tujuan tergambarnya ketaatan perawat dalam penggunaan apd lengkap saat tindakan hd 25 medical and health science journal, vol.4., no.1, february 2020 dimensi mutu keselamatan dasar pemikiran kepmenkes 129 / 2008 tentang standar pelayanan minimal rumah sakit permenkes 27 / 2017 tentang pedoman pencegahan dan pengendalian infeksi di fasilitas pelayanan kesehatan numerator jumlah tindakan hd yang dilakukan oleh perawat yang menggunakan apd lengkap pada bulan tersebut denominator jumlah tindakan hd dalam bulan tersebut kriteria inklusi tindakan hd yang dilakukan oleh perawat yang menggunakan apd lengkap kriteria eksklusi formula pengukuran n/d x 100% metodologi pengumpulan data sensus harian cakupan data total frekuensi pengumpulan data harian frekuensi analisa data mingguan metodologi analisa data run chart sumber data lembar ceklis pemakaian apd saat tindakan hd pj data kepala unit hd publikasi data internal judul indikator kepatuhan perawat dalam menggunakan apd dengan lengkap saat tindakan reuse definisi operasional perawat yang taat dalam penggunaan apd dengan lengkap pada saat melakukan tindakan hd tindakan reuse adalah proses pembersihan dan pencucian ulang dialiser tujuan tergambarnya ketaatan perawat dalam penggunaan apd saat tindakan reuse dimensi mutu keselamatan dasar pemikiran kepmenkes 129 / 2008 tentang standar pelayanan minimal rumah sakit permenkes 27 / 2017 tentang pedoman pencegahan dan pengendalian infeksi di fasilitas pelayanan kesehatan numerator jumlah tindakan reuse yang dilakukan oleh perawat yang menggunakan apd pada bulan tersebut denominator jumlah tindakan reuse dalam bulan tersebut kriteria inklusi tindakan reuse yang dilakukan oleh perawat yang menggunakan apd pada bulan tersebut kriteria eksklusi formula pengukuran n/d x 100% metodologi pengumpulan data sensus harian cakupan data total frekuensi pengumpulan data harian frekuensi analisa data mingguan metodologi analisa data run chart sumber data lembar ceklis pemakaian apd saat tindakan reuse pj data kepala unit hd publikasi data internal judul indikator kelengkapan berkas administrasi untuk klaim definisi operasional pengumpulan berkas lengkap yang terdiri dari asuhan keperawatan dan formulir persetujuan tindakan hd tujuan untuk kelancaran klaim terhadap pelayanan yang hd yang telah dilakukan dimensi mutu efektifitas dasar pemikiran permenkes 290 / 2008 tentang persetujuan tindakan kedokteran 26 medical and health science journal, vol.4., no.1, february 2020 permenkes 10 / 2015 tentang standar pelayanan keperawatan di rumah sakit khusus numerator berkas lengkap yang terdiri dari asuhan keperawatan dan formulir persetujuan tindakan hd denominator berkas yang terdiri dari asuhan keperawatan dan formulir persetujuan tindakan hd tindakan hd dalam bulan tersebut kriteria inklusi berkas lengkap yang terdiri dari asuhan keperawatan dan formulir persetujuan tindakan hd kriteria eksklusi formula pengukuran n/d x 100% metodologi pengumpulan data sensus harian cakupan data total frekuensi pengumpulan data harian frekuensi analisa data mingguan metodologi analisa data run chart sumber data rekam medis pj data kepala unit hd publikasi data internal tabel 6 menyajikan kamus indikator berdasarkan sasaran keselamatan pasien, yang terdiri dari indikator insiden pasien jatuh di unit hd yang berakibat kecacatan/kematian, kepatuhan petugas dalam pelaksanaan hand hygiene, pemasangan gelang identitas pada pasien, stempel konfirmasi pasien hd terisi lengkap, dan insiden reaksi transfusi. tabel 6. kamus indikator berdasarkan sasaran keselamatan pasien kamus indikator berdasarkan sasaran keselamatan pasien judul indikator insiden pasien jatuh di unit hd yang berakibat kecacatan/kematian definisi operasional suatu peristiwa dimana pasien hd mengalami insiden jatuh baik pre, durante, maupun post hd yang berakibat kecacatan/kematian tujuan tergambarnya pelayanan hd yang aman bagi pasien dimensi mutu keselamatan dasar pemikiran permenkes 11 / 2017 tentang keselamatan pasien kepmenkes 129 / 2008 tentang standar pelayanan minimal rumah sakit numerator jumlah insiden pasien jatuh yang berakibat kecacatan/kematian di unit hd denominator jumlah tindakan hd dalam bulan tersebut kriteria inklusi semua tindakan hd pada bulan tersebut kriteria eksklusi formula pengukuran n/d x 100% metodologi pengumpulan data per insiden cakupan data total frekuensi pengumpulan data bulanan frekuensi analisa data bulanan metodologi analisa data run chart sumber data laporan kejadian pj data kepala unit hd publikasi data internal 27 medical and health science journal, vol.4., no.1, february 2020 judul indikator kepatuhan petugas dalam pelaksanaan hand hygiene definisi operasional kepatuhan petugas hd dalam melakukan prosedur cuci tangan dengan menggunakan metode 6 langkah dan 5 momen dari who 6 langkah cuci tangan terdiri dari: 1. tuang cairan handrub pada telapak tangan kemudian usap dan gosok kedua telapak tangan secara lembut dengan arah memutar. 2. usap dan gosok juga kedua punggung tangan secara bergantian 3. gosok sela-sela jari tangan hingga bersih 4. bersihkan ujung jari secara bergantian dengan posisi saling mengunci 5. gosok dan putar kedua ibu jari secara bergantian 6. letakkan ujung jari ke telapak tangan kemudian gosok perlahan 5 momen cuci tangan terdiri dari: 1. sebelum kontak dengan pasien 2. sebelum tindakan aseptik 3. setelah terkena cairan tubuh pasien 4. setelah kontak dengan pasien 5. setelah menyentuh lingkungan sekitar pasien tujuan tergambarnya kepatuhan petugas hd dalam melaksanakan cuci tangan 6 langkah 5 momen dimensi mutu keselamatan dasar pemikiran permenkes 11 / 2017 tentang keselamatan pasien numerator jumlah petugas hd yang melakukan cuci tangan 6 langkah 5 momen denominator jumlah petugas hd yg bertugas dalam bulan tersebut kriteria inklusi semua petugas hd kriteria eksklusi formula pengukuran n/d x 100% metodologi pengumpulan data sensus harian cakupan data total frekuensi pengumpulan data harian frekuensi analisa data mingguan metodologi analisa data run chart sumber data ppi pj data kepala unit hd publikasi data internal judul indikator pemasangan gelang identitas pada pasien hd definisi operasional pasien yang menggunakan gelang identitas selama pelayanan hd tujuan tergambarnya ketelitian pelayanan rs dimensi mutu keselamatan dasar pemikiran permenkes 11 / 2017 tentang keselamatan pasien numerator jumlah pasien yang menggunakan gelang identitas selama pelayanan hd denominator jumlah pasien hd dalam bulan tersebut kriteria inklusi semua pasien hd kriteria eksklusi formula pengukuran n/d x 100% metodologi pengumpulan data sensus harian cakupan data total frekuensi pengumpulan data harian frekuensi analisa data mingguan metodologi analisa data run chart sumber data lembar pencatatan pemakaian gelang pasien hd pj data kepala unit hd 28 medical and health science journal, vol.4., no.1, february 2020 publikasi data internal judul indikator stempel konfirmasi pasien hd terisi lengkap definisi operasional instruksi atau pesan kondisi pasien yang disampaikan melalui telefon kepada dokter harus dituliskan, dibacakan kembali, dan mendapat konfirmasi kebenaran dari pemberi pesan melalui stempel konfirmasi tujuan tergambarnya pelayanan hd yang terkoordinasi untuk menjamin kesinambungan pelayanan dimensi mutu keselamatan kesinambungan dasar pemikiran permenkes 11 / 2017 tentang keselamatan pasien numerator jumlah stempel konfirmasi terisi lengkap denominator jumlah stempel konfirmasi kriteria inklusi stempel konfirmasi terisi lengkap kriteria eksklusi formula pengukuran n/d x 100% metodologi pengumpulan data sensus harian cakupan data total frekuensi pengumpulan data bulanan frekuensi analisa data bulanan metodologi analisa data run chart sumber data rekam medis pj data kepala unit hd publikasi data internal judul indikator insiden reaksi transfusi definisi operasional merupakan kejadian tidak diharapkan (ktd) yang terjadi akibat transfusi darah, dalam bentuk reaksi alergi, infeksi akibat transfusi, hemolisis akibat golongan darah yang tidak sesuai, atau gangguan sistem imun sebagai akibat pemberian transfusi darah tujuan tergambarnya manajemen risiko pada unit hd dimensi mutu keselamatan dasar pemikiran permenkes 11 / 2017 tentang keselamatan pasien kepmenkes 129 / 2008 tentang standar pelayanan minimal rumah sakit numerator jumlah kejadian reaksi transfusi pada pasien hd dalam bulan tersebut denominator jumlah pasien hd yang mendapat transfusi dalam bulan tersebut kriteria inklusi semua pasien hd yang mendapatkan transfusi kriteria eksklusi formula pengukuran n/d x 100% metodologi pengumpulan data per insiden cakupan data total frekuensi pengumpulan data bulanan frekuensi analisa data bulanan metodologi analisa data run chart sumber data buku laporan kejadian reaksi transfusi pj data kepala unit hd publikasi data internal 29 medical and health science journal, vol.4., no.1, february 2020 pembahasan penyusunan indikator unit hd dipilih berdasarkan prioritas dan disesuaikan dengan pelayanan unit hd. sedangkan pemilihan indikator berdasarkan total skor ≥ 350 dengan skor problem prone ≥ 80, kecuali pada iskp karena semua indikator akan digunakan. berikut indikator mutu hd yang terpilih: 1) kelengkapan pengisian formulir persetujuan tindakan hd; 2) insiden petugas hd tertusuk limbah benda tajam infeksius; 3) insiden perawat tertusuk jarum; 4) kepatuhan perawat dalam menggunakan apd dengan lengkap saat melakukan tindakan hd; 5) kepatuhan perawat dalam menggunakan apd dengan lengkap saat tindakan reuse; 6) kelengkapan berkas administrasi untuk klaim; 7) insiden pasien jatuh di unit hd yang berakibat kecacatan/kematian; 8) kepatuhan petugas dalam pelaksanaan hand hygiene; 9) pemasangan gelang identitas pada pasien; 10) stempel konfirmasi pasien hd terisi lengkap; dan 11) insiden reaksi transfusi. hanya ada 1 indikator pada iak, yaitu kelengkapan pengisian formulir persetujuan tindakan hd. indikator tersebut dipilih karena memiliki skor tertinggi 500, dimana skor high risk sebesar 250 yang berarti memiliki risiko tinggi pembayaran tindakan hd yang telah dilakukan tidak bisa diklaim bila persetujuan tindakan tidak lengkap. kemudian skor high volume sebesar 150, karena persetujuan tindakan digunakan di setiap pelayanan. juga pada skor problem prone sebesar 100 yang bermakna sangat rawan terjadi masalah dari segi tanggungjawab staf profesional pemberi asuhan kepada pasien. hal tersebut sesuai dengan permenkes 290 tahun 2008 tentang persetujuan tindakan kedokteran, dimana persetujuan tindakan harus selalu ada.10 persetujuan tindakan ini juga memiliki fungsi sebagai salah satu syarat untuk klaim pembayaran tindakan hd yang telah dilakukan.19 area selanjutnya yaitu iam yang terdapat 5 indikator, diantaranya adalah insiden petugas hd tertusuk limbah benda tajam infeksius dan insiden perawat tertusuk jarum. kedua indikator memiliki jumlah skor yang sama sebesar 360. skor high risk sebesar 200 yang berarti bila insiden terjadi risikonya cukup tinggi, yaitu tertular infeksi virus hepatitis b (hbv), virus hepatitis c (hcv), dan human immunodeficiency virus (hiv) dari beberapa pasien hd yang memiliki infeksi virus tersebut dalam darah.20,21 namun skor high volume cukup rendah yaitu 60, dimana kemungkinan terjadinya insiden sangat kecil. sedangkan pada skor problem prone sebesar 100 yang berarti sangat rawan terjadi masalah dikarenakan risiko infeksi penyakit hepatitis b, hepatitis c, dan hiv. indikator iam selanjutnya yaitu kepatuhan perawat dalam menggunakan apd baik saat tindakan hd dan saat tindakan reuse. dari hasil skor terdapat perbedaan, dimana total skor untuk apd saat tindakan hd sebesar 450, sedangkan apd saat tindakan reuse sebesar 350. hal tersebut disebabkan oleh risiko terjadinya infeksi pada saat hd lebih besar bila dibandingkan saat reuse, bisa dilihat pada hasil skor high risk pada saat tindakan hd sebesar 200, sedangkan pada tindakan reuse lebih kecil yaitu 150. untuk high volume juga memiliki skor yang lebih tinggi pada tindakan hd sebesar 150, sedangkan pada tindakan reuse sebesar 120. masalah yang dapat ditimbulkan juga lebih besar pada tindakan hd, dilihat dari skor problem prone sebesar 100, sedangkan pada tindakan reuse sebesar 80. adanya indikator kepatuhan perawat dalam menggunakan apd berfungsi untuk menjaga mutu dan keselamatan petugas hd, yang diatur dalam kepmenkes 129 tahun 2008 tentang standar pelayanan minimal rumah sakit dan permenkes 27 tahun 2017 tentang pedoman pencegahan dan pengendalian infeksi. apd merupakan alat terstandar yang berguna untuk melindungi tubuh, tenaga kesehatan, pasien atau pengunjung dari penularan penyakit di rs.13 centers for disease control and prevention (cdc) menjelaskan bahwa apd digunakan saat tindakan hd serta saat membersihkan dialiser yang dikenal dengan istilah tindakan reuse.22 30 medical and health science journal, vol.4., no.1, february 2020 indikator iam yang terakhir yaitu kelengkapan berkas administrasi untuk klaim, memiliki skor tertinggi 500. sama seperti indikator kelengkapan pengisian formulir persetujuan tindakan hd pada iak, dimana indikator ini berfungsi untuk memastikan kelancaran klaim terhadap pelayanan yang hd yang telah dilakukan. berkas tersebut terdiri dari asuhan keperawatan dan formulir persetujuan tindakan hd, sesuai dengan permenkes 10 tahun 2015 tentang standar pelayanan keperawatan di rumah sakit khusus, yaitu pengkajian kesehatan yang komprehensif secara sistematik, akurat dan berkesinambungan untuk pasien gangguan ginjal secara tepat dengan melibatkan individu, keluarga dalam lingkup praktek keperawatan ginjal.14 area terakhir yaitu iskp dimana semua indikator diadopsi sebagai indikator mutu hd karena memiliki fungsi sebagai pelindung pasien dari tindakan yang diberikan. indikator tersebut berlandaskan skp dalam permenkes 11 tahun 2017 tentang keselamatan pasien yang disesuaikan dengan kondisi pelayanan unit hd.17 indikator iskp yang pertama dibahas ialah insiden pasien jatuh di unit hd yang berakibat kecacatan/kematian. dimana memiliki skor sebesar 380, karena memiliki risiko tertinggi dengan skor high risk 500. namun peluang terjadinya hal tersebut sangat kecil, dapat dilihat pada skor high volume yang hanya sebesar 30. bila insiden tersebut terjadi maka dapat menimbulkan masalah yang cukup berat yaitu kecacatan bahkan kematian, dengan skor problem prone sebesar 100. indikator tersebut menggambarkan pelayanan hd yang aman bagi pasien, sesuai dengan indikator dalam kepmenkes 129 tahun 2008 tentang standar pelayanan minimal rumah sakit.13 indikator kedua dalam iskp yaitu kepatuhan petugas dalam pelaksanaan hand hygiene, memiliki skor terendah dalam indikator iskp sebesar 300. dimana high risk, high volume, dan problem prone memiliki skor pertengahan, berturut-turut sebesar 150, 90, dan 60. hal ini memiliki makna meskipun tidak memiliki risiko dan dampak yang besar namun tetap penting dilaksanakan sebagai tindakan pencegahan penyebaran infeksi.20 pemasangan gelang identitas pada pasien merupakan indikator ketiga dalam iskp. indikator tersebut memiliki skor tertinggi sebesar 500, karena memiliki risiko terjadinya kesalahan pada tahap selanjutnya bahkan berakibat fatal yaitu kematian.23 indikator keempat ialah stempel konfirmasi pasien hd terisi lengkap dengan jumlah skor 370. dimana skor high risk dan problem prone cukup tinggi yaitu berturut turut 200 dan 80, disebabkan bila terjadi kesalahan memiliki risiko salah tindakan terhadap pasien dapat berakibat fatal. untuk skor high volume sendiri berada di pertengahan sebesar 90, karena tidak sering terjadi. indikator tersebut sesuai dengan penjelasan permenkes 11 tahun 2017 tentang keselamatan pasien, dimana fasilitas pelayanan kesehatan secara kolaboratif mengembangkan suatu kebijakan dan/atau prosedur untuk perintah lisan dan melalui telepon termasuk: menuliskan (atau memasukkan ke komputer) perintah secara lengkap atau hasil pemeriksaan oleh penerima informasi; penerima membacakan kembali (read back) perintah atau hasil pemeriksaan; dan mengkonfirmasi bahwa apa yang sudah dituliskan dan dibacakan ulang dengan akurat.17 indikator terakhir dalam iskp yaitu insiden reaksi transfusi dengan skor yang cukup tinggi sebesar 420. dengan high risk tertinggi 250 yaitu risiko terjadinya reaksi alergi, infeksi akibat transfusi, hemolisis akibat golongan darah tidak sesuai, atau gangguan sistem imun.13 meskipun jarang terjadi, dapat dilihat pada skor high volume yang hanya 90, namun memiliki dampak besar bila terjadi dengan skor problem prone 80 yaitu kejadian tidak diinginkan. pada pasien hd, anemia merupakan komplikasi yang sering terjadi akibat penyakit ginjal yang diderita.24 untuk itu tak jarang pasien hd memerlukan transfusi, sehingga terdapat peluang terjadinya insiden 31 medical and health science journal, vol.4., no.1, february 2020 reaksi transfusi. ada beberapa indikator yang tidak dipilih sebagai indikator mutu unit hd rs gpi, diantaranya prosentase adekuasi hd, kepuasan pasien, response time petugas teknisi dalam penanganan kerusakan mesin hd, dan pemeriksaan kadar air ro setiap 6 bulan. indikator prosentase adekuasi hd yang direkomendasikan dalam konsensus dialisis,15 tidak dapat dipilih sebagai prioritas, selain karena skor cukup kecil yaitu 220 juga kendala dalam pemeriksaan laboratorium rutin pasien karena tidak semua pasien memeriksakan hasil laboratorium secara rutin. begitu pula dengan indikator kepuasan pasien, meskipun merupakan indikator yang berdasarkan keputusan menteri kesehatan nomor 129 tahun 2008 tentang standar pelayanan minimal rumah sakit,13 namun juga memiliki skor yang cukup rendah yaitu 340. indikator selanjutnya yang tidak dapat dipilih ialah response time petugas teknisi dalam penanganan kerusakan mesin hd dengan skor sangat rendah sebesar 200 dan indikator pemeriksaan kadar air ro setiap 6 bulan dengan skor 350 namun pada skor problem prone hanya 60. selain skor yang tidak mencapai kriteria, indikator-indikator tersebut tidak dipilih karena selama ini capaian di hd rs gpi sudah 100% serta tidak memiliki dampak yang besar sebagai penyebab gangguan pada pelayanan. dari 11 indikator yang terpilih merupakan indikator yang umum digunakan pada unit hd di rs lain. namun tidak semua unit hd menggunakan indikator mutu yang sama persis, dikarenakan pemilihan indikator disesuaikan dengan kondisi unit hd masing masing. berdasarkan hasil keputusan bersama dalam fgd, 11 indikator tersebut dirasa paling tepat untuk diaplikasikan di unit hd rs gpi dengan kondisi yang ada saat ini. kesimpulan dari hasil diatas dapat disimpulkan bahwa terdapat 11 indikator mutu yang dapat diterapkan oleh unit hd agar mutu dan keselamatan pasien terwujud dan terjaga sesuai standar. indikator tersebut yaitu: 1) kelengkapan pengisian formulir persetujuan tindakan hd; 2) insiden petugas hd tertusuk limbah benda tajam infeksius; 3) insiden perawat tertusuk jarum; 4) kepatuhan perawat dalam menggunakan apd dengan lengkap saat melakukan tindakan hd; 5) kelengkapan berkas administrasi untuk klaim; 6) kepatuhan perawat dalam menggunakan apd dengan lengkap saat tindakan reuse; 7) insiden pasien jatuh di unit hd yang berakibat kecacatan/kematian; 8) kepatuhan petugas dalam pelaksanaan hand hygiene; 9) pemasangan gelang identitas pada pasien; 10) stempel konfirmasi pasien hd terisi lengkap; dan 11) insiden reaksi transfusi. daftar pustaka 1. keputusan menteri kesehatan nomor 129/menkes/sk/ii/2008 tentang standar pelayanan minimal rumah sakit 2. indonesian renal registry. (2018). 10th report of indonesian renal registry 3. peraturan menteri kesehatan republik indonesia nomor 812 tahun 2008 tentang penyelenggaraan pelayanan dialisis pada fasilitas pelayanan kesehatan 4. departemen kesehatan ri. (2008). pedoman pelayanan hemodialisis di sarana pelayanan kesehatan. jakarta: departemen kesehatan ri. 5. peraturan menteri kesehatan nomor 34 tahun 2017 tentang akreditasi rumah sakit 6. komite akreditasi rumah sakit. (2017). standar nasional akreditasi rumah sakit (snars) edisi 1. 7. the joint commission. (2020). hospital national patient safety goals 8. habicht, r. and gulati, m. (2017). hospital medicine: perspectives, practices and professional development. isbn 978-3-319 49090-8. doi:10.1007/978-3-319-49092-2 9. koentjoro, t. (2007) regulasi kesehatan di indonesia. yogyakarta: andi 10. peraturan menteri kesehatan nomor 290 tahun 2008 tentang persetujuan tindakan kedokteran 32 medical and health science journal, vol.4., no.1, february 2020 11. el-sheikh, m. and el-ghazaly, g. (2016). assessment of hemodialysis adequacy in patients with chronic kidney disease in the hemodialysis unit at tanta university hospital in egypt. indian j nephrol. 2016 nov-dec; 26(6): 398-404 12. peraturan menteri kesehatan nomor 27 tahun 2017 tentang pedoman pencegahan dan pengendalian infeksi di fasilitas pelayanan kesehatan 13. keputusan menteri kesehatan nomor 129 tahun 2008 tentang standar pelayanan minimal rumah sakit 14. peraturan menteri kesehatan nomor 10 tahun 2015 tentang standar pelayanan keperawatan di rumah sakit khusus 15. pernefri. (2003). konsensus dialisis. jakarta 16. suhardjono, s. (2017). benarkah dialiser proses ulang memicu inflamasi?. jurnal penyakit dalam indonesia. doi:10.7454/ jpdi.v 3i3.18. 17. peraturan menteri kesehatan nomor 11 tahun 2017 tentang keselamatan pasien 18. who. (2009). guidelines on hand hygiene in health care: first global patient safety challenge clean care is safer care. 19. bpjs kesehatan. (2014) petunjuk teknis verifikasi klaim. 20. centers for disease control and prevention.(2015). sharps safety for healthcare settings 21. garthwaite, e., et al. (2019). clinical practice guideline management of blood borne viruses within the haemodialysis unit. bmc nephrol 20, 388. doi:10.1186/s12882-019-1529-1 22. centers for disease control and prevention. (2016). infection prevention in dialysis settings. 23. tulus, h. dan maksum, h. (2015). redesain sistem identitas pasien sebagai implementasi patient safety di rumah sakit. jurnal kedokteran brawijaya, vol. 28, suplemen no. 2 24. renal association clinical practice guideline. (2017). anaemia of chronic kidney disease. 33 medical and health science journal, vol. 4, no. 2, august 2020 correspondence: zettira maulida prasha @2020 medical and health science journal. 10.33086/mhsj.v4i1.1415 available at http://journal2.unusa.ac.id/index.php/mhsj 103 the effectiveness of prasterone vs placebo therapy as the vulvovaginal atrophy treatment in menopausal women: meta-analysis study zettira maulida prasha* 1 , hari paraton 2 1 resident-1 of obstetrics & gynecology, faculty of medicine, universitas airlangga–rsud dr.soetomo, surabaya 2 staff at the division of urogynecology and reconstruction, department/ functional medical staffs (smf) of obstetrics & gynecology, faculty of medicine, universitas airlangga– rsud dr.soetomo, surabaya *corresponding author: zettiramaulida@gmail.com article info abstract article history: submitted: july, 14 2020 received in revised form: august, 24 2020 accepted: august, 26 2020 background : vulvovaginal atrophy is a condition that often occurs in menopausal women due to estrogen decreased. prasterone (dhea) is a steroid hormone that can be converted into estrogen in the target tissue. objective : a meta-analysis study was conducted to evaluate the effectiveness of administering prasterone as vulvovaginal atrophy therapy in menopausal women, by evaluate the number of superficial cells, parabasal cells, vaginal ph, and dyspareunia. methods : a systematic data search was performed on a medical database (pubmed, google scholar, cochrane). inclusion criteria: (1) randomized study of prasterone as vulvovaginal atrophy therapy in postmenopausal women, (2) all-inclusive papers can be accessed completely (from 583 articles found, we excluded 580 articles, the result is 3 rct analyzed) and (3) the data obtained can be accurately analyzed. results: three rcts with a total of 696 patients were analyzed. the average number of superficial cells (mean difference [md] 7.63, and 95% [ci] 7.57 to 7.70 (p <0.00001). the average number of parabasal cells (mean difference [md] 29.84, and 95% [ci] -30.25 to -29.44 (p <0.00001). the average number of vaginal ph (mean difference [md] -0.69, and 95% [ci] -0.70 to -0.68 (p <0.00001). the average number of dyspareunia (mean difference [md] -0.38, and 95% [ci] -0.39 to -0.37 (p <0.00001). all diamonds do not intersect the vertical line, and have p <0.05, it proves that there are significant differences between the two groups. all non-hysterectomized women have an atrophic or inactive endometrium. side effects that are often complained of are headache and application site discharge. conclusion this meta-analysis concludes that prasterone therapy has a significant therapeutic effect for vulvovaginal atrophy in menopausal women @2020 medical and health science journal. 10.33086/mhsj.v4i1.1415 keywords: vulvovaginal atrophy, menopause, prasterone, placebo, superficial cell, parabasal cell, vaginal ph, dispareunia introduction the layers of vaginal walls consist of 4 layers, namely basal cells, parabasal cells, intermediate cells, and superficial cells. in the women with normal estrogen levels, around 15%-30% of cells were superficial cells and the remaining were intermediate cells. if parabasal cells were found, it might be due to the estrogen deficiency that happened in the women. one of the factors of estrogen deficiency was menopause. figure 1. the layers of vaginal walls review article medical and health science journal, vol. 4, no. 2, august 2020 104 vulvovaginal atrophy (vva) is a condition the frequently occurs in menopausal women. it is characterized by thinning of the vaginal epithelium, reduced vaginal lubrication, and increased fragility of the epithelium. the symptoms of vva include the drying of the vagina, inflammation, burning sensation, and pain during sexual activities (dyspareunia). the menopause-related hormone changes, especially lack of estrogen secretion, are the primary causes of vva 1 . before reaching menopause, the dominant cells are the superficial cells, and they only exist in some parabasal cells. meanwhile, after menopause, the total parabasal cells increase followed by the absence of superficial cells 2 . the frequently used therapies for vva treatment are non-hormonal therapy (lubricant) and hormonal therapy (topical estrogen), and the selective estrogen receptor modulators/serms (ospemifene). the systemic estrogen is not given to avoid the potential stimulation effect of estrogen in the endometrium and breasts 3 . dhea (dehydroepiandrosterone) is a steroid hormone produced by the adrenal gland that is then changed into testosterone and estrogen. during menopause, dhea becomes the main source of estrogen. however, the dhea levels decrease as people get older and only 25% of menopausal women are estimated to have enough dhea to avoid menopause symptoms, such as vva 3 . dhea replacement therapy is an effective approach that minimizes the potential risk related to estrogen-based therapy 3 . prasterone is a synthetic dhea that is biologically and biochemically identical to the endogenous human dhea. in the peripheral target tissues, dhea is altered into active intracellular estrogen and androgen by tissuespecific steroidogenic enzymes. intravaginal prasterone (intrarosa) has been used in europe for vva treatment in menopausal women 5 . prasterone has been approved in the u.s. for dyspareunia treatment due to menopause 6 . the dosage used is 6.5 mg of the vaginal suppository. this paper was arranged to evaluate the effectiveness of prasterone vs placebo therapy as the vva treatment in menopausal women using meta-analysis method. method data search strategy the search for literature systematically had been done using pubmed, google scholar, and cochrane central register of controlled trials to collect randomized studies (randomized controlled trials/rct) that investigated the use of prasterone in menopausal women suffering from vva. the researchers tried to find the database using the combination of some terms, such as “prasterone, placebo, vva, menopause, and rct”. inclusion criteria some of the following criteria had been used in the selection. (1) randomized study table 1. the quality assessment of each study. a: all qualities for criteria are fulfilled; itt: intention-to-treat; ancova: analysis of covariance; pr: prasterone; pl: placebo medical and health science journal, vol. 4, no. 2, august 2020 105 (randomized controlled trials) on prasterone as the vulvovaginal atrophy (vva) treatment in menopausal women, (2) all inclusion papers can be accessed completely, and (3) the collected data can be analysed accurately. quality assessment of the study we assessed the validity of each study independently by using the criteria mentioned in the cochrane handbook for systematic reviews of interventions. we discussed the topic if there was a different point of view. each study was put into some classifications and assessed based on the category of quality, namely, quality a if the study had low risk of bias; quality b if the study had moderate risk of bias, or quality c if the study had high risk of bias (figure 2 and figure 3). figure 2. the conclusion of the stratification of the risk of bias in all articles in this meta-analysis figure 3. the assessment of the writer‟s risk of bias against each inclusion article data extraction the followings are the important information collected from each study: (1) main author; (2) the country of the research location; (3) total sample; (4) year of publication; (5) therapy in patients; (6) the data of the mean score of superficial cells; (7) the mean score of parabasal cells; (8) the mean score of vaginal ph; (9) and the mean score of dyspareunia complaints. statistical analysis and meta-analysis the effect of therapy is expressed using the comparison of the outcome from the therapy group and the control group. in this paper, the outcome was reported as the continuous variables, whereby it had several possible results. the effect of the therapy was expressed as the „mean score difference‟. this score calculated by obtaining the mean scores in both the therapy group and the control group, and then the difference was calculated. meta-analysis was arranged using the review manager (revman) version 5.3. (cochrane collaboration, oxford, uk). this paper assessed the mean difference of superficial cells, the mean difference of superficial cells, the mean difference of parabasal cells, the mean difference of vaginal ph, and the mean difference of dyspareunia complaints. the researchers used the fixed-effect and random-effect of meta-analysis for data combination, whereby it assumed logically that several studies had a similar therapy effect estimation. result characteristic of the studies data search resulted in 583 articles. a total of 585 studies had been excluded based on the description in the abstract by seeing the inclusion and exclusion criteria that had been described before. after a series of the selection process, it collected 3 inclusion articles in total for meta-analysis (figure 3). table 1 shows additional information related to inclusion articles. individual quality of the study all inclusion studies were random and double-blind, and all articles had been passed the randomization process. all inclusion rcts performed the calculation of power in determining the optimum total sample (table 1). medical and health science journal, vol. 4, no. 2, august 2020 106 we had assessed explicitly whether the relevant studies had a high risk of bias based on the criteria mentioned in the handbook 7 . based on the assessment, we assessed the degrees of possibility and the direction of bias and the possibility of these points to influence the outcome of the study. we then analysed the sensitivity in exploring the effect of bias. figure 3. path diagram of the process of selecting studies. effectiveness the mean score of superficial cells three inclusion rcts with the outcome of the mean score of superficial cells, from the cohort, contained 696 samples (436 samples in the prasterone group and 260 samples in the placebo group) (figure 4). the estimation of fixed-effects from the mean score difference was 7.63 and 95% ci was around 7.57 to 7.70 (p <0.0001). this analysis result showed that prasterone had a more significant effect on increasing the mean score of superficial cells than that of placebo. the mean score of parabasal cells three rcts contained 696 samples in total (436 samples in the prasterone group and 260 samples in the placebo group) (figure 5). the estimation of fixed-effects from the mean difference was -29.84 and 95% ci was around 30.25 to -29.44 (p <0.0001). the result of this analysis showed that prasterone had a more significant effect on decreasing the mean score of parabasal cells than that of placebo. the mean score of vaginal ph three rcts contained 696 samples in total (436 samples in the prasterone group and 260 samples in the placebo group) (figure 6). the estimation of fixed-effects from the mean difference was -0.69 and 95% ci was around 0.70 to –0.68 (p <0.0001). the result of this analysis showed that prasterone had a more significant effect on decreasing the mean score of vaginal ph than that of placebo. dyspareunia complaints three rcts contained 696 samples in total (436 samples in the prasterone group and 260 samples in the placebo group) (figure 6). the estimation of fixed-effects from the mean difference was -0.38 and 95% ci was around 0.39 to –0,37 (p <0.0001). this analysis result showed that prasterone had a more significant effect on decreasing the diyspareunia complaints than that of placebo. from the four forest plots, the diamond was not tangential to the vertical line. hence, it might be inferred that the was a difference in the result between the experimental group and the control group. the four analyses had a pvalue of less than 0.05, proving that there was a significant difference between the two variables. the three studies above were heterogenous since not all of the confidence interval intersected the vertical line of the diamond. figure 4. the forest plot shows the mean difference in superficial cells. sd, standard deviation; iv, inverse variance; ci, confidence interval; df, degrees of freedom. medical and health science journal, vol. 4, no. 2, august 2020 107 discussion prasterone has been used in the u.s. and europe since 2016 as the vva treatment in menopausal women. the following is the pharmacologic treatment for vva complaints. the excellence of giving the prasterone was that it did not cause significant changes in steroid hormone levels in the serum. the estrogen and testosterone levels were still at the normal range for menopausal women, and they were known 9 . from the result of the 2 rcts that had been analyzed, besides the improvement of 4 investigated variables, prasterone also had advantageous androgen effects, such as the decreased of the drying in the vagina, the decreased irritation/itchiness in the vagina, the decreased vaginal fluid, and the improved integrity of vaginal epithelium 9 . figure 5. the forest plot shows the mean difference in parabasal cells. sd, standard deviation; iv, inverse variance; ci, confidence interval; df, degrees of freedom. figure 6. the forest plot shows the mean difference in vaginal ph. sd, standard deviation; iv, inverse variance; ci, confidence interval; df, degrees of freedom. figure 7. the forest plot shows the mean difference in dyspareunia complaints. sd, standard deviation; iv, inverse variance; ci, confidence interval; df, degrees of freedom. figure 8. the pharmacologic treatment for vva medical and health science journal, vol. 4, no. 2, august 2020 108 the side effects that the rct subjects complained about were white vaginal discharge/leucorrhoea, urinary tract infection (uti), and headache. the endometrial conditions that had been evaluated in the 12 th week mostly resulted in endometrial atrophy. no significant histological finding existed in all of the results of biopsy 9 . this meta-analysis only included double-blind rct. the quality of all studies in this meta-analysis was quite high based on the assessment criteria of review manager 5.3 program. however, the total inclusion study was not adequate in compiling the clinical recommendation against the patients. in addition, the long-term effect (effectiveness and side effects) could not be proven in this study. consequently, the writers suggest a further investigation from big-scale studies in the patient population of this study. conclusion this meta-analysis concludes that prasterone has significant therapeutic effects in patients experiencing vulvovaginal atrophy due to menopause, and it has been proven safe to be consumed. references 1. labrie f, martel c, pelletier g. is vulvovaginal atrophy due to a lack of both estrogens and androgens? menopause. 2017;24(4):452–61. 2. gandhi j, chen a, dagur g, et al. genitourinary syndrome of menopause: an overview of clinical manifestations, pathophysiology, etiology, evaluation, and management. am j obstet gynecol 2016;215(6):704–11 3. labrie f, belanger a, pelletier g, et al. science of intracrinology in postmenopausal women. menopause. 2017;24(6):702–12. 4. archer df, labrie f, montesino m, et al. comparison of intravaginal 6.5 mg (0.50%) prasterone, 0.3 mg conjugated estrogens and 10 μg estradiol on symptoms of vulvovaginal atrophy. j steroid biochem mol biol. 2017;174:1–8. 5. european medicines agency. intrarosa: summary of product characteristics. 2019. http://www.ema.europa.eu/. accessed 20 june 2019. 6. amag pharmaceuticals. intrarosa (prasterone insert): us prescribing information. 2018. http://www.fda.gov. accessed 31 may 2019. 7. labrie f, archer df, bouchard c, et al. intravaginal dehydroepiandrosterone (dhea, prasterone), a highly efficient treatment of dyspareunia. climacteric 2011;14:282-288 8. archer df, labrie f, bouchard c, et al. treatment of pain at sexual activity (dyspareunia) with intravaginal dehydroepaindrosterone (prasterone). menopause 2015;22:950-963. 9. labrie f, archer df, koltun w, et al. efficacy of intravaginal dehydroepiandrosterone (dhea)on moderate to severe dyspareunia and vaginal dryness, symptoms of vulvovaginal atrophy, and of the genitourinary syndrome of menopause. medical and health science journal 2021 february, vol 05 (01) original article the effect of high dose vitamin c (ascorbic acid) on proinflammatory cytokines in covid-19 ayu mira cyntia dewi*, eric mayo dagradi, prajogo wibowo faculty of medicine hang tuah univesity *correspondence: miracyntiamcd@gmail.com article info article history: received january 12, 2021 accepted february 25, 2021 keywords: covid-19, vitamin c, proinflammatory cytokines. abstract background: covid-19 is a new pandemic that has claimed many lives in many countries. this pandemic was caused by the sarscov2. until now, there is no specific antiviral drug or vaccine against covid-19 for potential therapy in humans. this virus can cause cytokine storms which can worsen symptoms in sufferers due to an imbalance between increased oxidant production and available antioxidants. vitamin c is an important antioxidant that protects the body from various bad effects of free radicals. at high concentrations vitamin c plays an important role in immunomodulation. this study was conducted to determine the effect of high doses of vitamin c on levels of pro-inflammatory cytokines in covid19. method: this research type is literature study. the population in this study were journals about covid-19, vitamin c, antioxidants and free radicals, inflammatory reactions due to viral infections with samples taken from indexed journals published from 2015 to 2020. there are also clinical trials of high doses of vitamin c against inflammation in covid-19 from these journals. results: the results of the study in a clinical trial conducted on 54 patients enrolled in 3 hospitals given a 1: 1 ratio for high-dose intravenous vitamin c (hdivc) or placebo administration. the hdivc group received 12 g of vitamin c / 50 ml every 12 hours for 7 days at a rate of 12 ml / hour, and the placebo group received bacteriostatic water for injection in the same way. hdivc administration showed a reduction in inflammatory markers compared to placebo. conclusion: the conclusion of this study shows that high doses of vitamin c play a role in reducing levels of proinflammatory cytokines. medical and health science journal introduction covid-19, an infectious disease caused by sarscov2, emerged in december 2019 and has spread rapidly, with cases now confirmed in several countries. infected patients show higher leukocyte counts, abnormal respiratory findings, and elevated plasma levels of pro-inflammatory cytokines. the main pathogenesis of covid-19 infection as a virus that attacks the respiratory system is severe pneumonia, viral load (rnaaemia) in serum, combined with the incidence of ground-glass opacities, and acute heart injury. some severe cases treated in intensive care units show high levels of proinflammatory cytokines that promote an increase in reactive oxygen species causing extensive damage to the cellular lining of small vessels (capillaries). oxidative stress in organisms infected with virus provokes free radical oxidation which increases disease severity. 1 sumail typewriter 46 mailto:miracyntiamcd@gmail.com medical and health science journal 2021 february, vol 05 (01) an important finding in covid-19 patients is very high inflammatory parameters, including crp (c-reactive protein) and proinflammatory cytokines il-6 (interleukin-6), tnfα (tumor necrosis factor alfa), il-8 (interleukin-8). cytokine storms are very common in patients with severe covid-19. cytokine storm refers to the excessive, uncontrolled release of proinflammatory cytokines. 2 the antioxidant content of immune cells plays an important role in protecting them against oxidative damage and maintaining their proper function. in addition, in immune cells, antioxidants maintain the integrity and function of membrane lipids, cellular proteins and nucleic acids, and control signal transduction of gene expression. it has been shown that without sufficient antioxidants, ros (reactive oxygen species) produced by phagocytic immune cells can damage itself. 3 non-enzymatic antioxidants such as vitamin c provide great protection against oxidative stress by neutralizing or binding to reactive species or by breaking chain reactions. 4 under normal conditions, the antioxidant system of the lungs protects its cells from oxidative agents through complex and coordinated system interactions. the antioxidant power of vitamin c is related to its electron transport properties such as transferring unpaired ros electrons to itself. according to research by bezerra et al. 2006 showed that vitamin c decreased the lung inflammatory response by inhibiting the release of tnf-α and nf-κb (nuclear factor kappa-b). the histopathological evidence of the vitamin c group suggests that there is a severe reduction in neutrophil infiltration 5 currently, there is no specific antiviral drug or vaccine against covid-19 for potential therapy in humans. for this reason, various kinds of efforts for a person to avoid the sars-cov-2 virus one of which is by increasing immunity. efforts to increase immunity have been tried in various ways, ranging from eating herbs to consuming multivitamins, one of which is vitamin c as an antioxidant vitamin that does not yet know its effective function and properties to fight a virus. vitamin c that is produced and marketed has a variety of different dosage sizes, but the effectiveness of vitamin c doses in increasing people's immunity is still unknown. antioxidant defense mechanisms, such as vitamins c protect tissues against oxidants. for this reason, little is known about the use of vitamin c based on an effective dose to prevent or help relieve inflammation, especially inflammation covid19 and a study needs to be done. therefore, the authors intend to conduct a study in the form of a literature study on the antioxidant effects of high doses of vitamin c on reducing the proinflammatory process in covid-19. methods the research design used is descriptive research. the facts and circumstances that the researchers wanted to describe in this study were the effect of giving high doses of vitamin c (ascorbic acid) on pro-inflammatory cytokines in covid-19. the method used was literature study. the topic to be analyzed in this study is the effect of giving high doses of vitamin c (ascorbic acid) on proinflammatory cytokines in covid-19. population is all or a set of objects under study. the population in this study were articles about covid-19, vitamin c (ascorbic acid), antioxidants and free radicals, inflammatory reactions due to viral infections. the sample in this study was taken from articles published by international journals indexed by scimago and google scholar from 2015 to 2020. this research was conducted in surabaya from may to september 2020. this research obtained approval from the health research ethics commission, faculty of medicine, hang tuah university. results the result of this study are based on clinical trials conducted by (j. zhang et al., 2020) on 54 patients registered in 3 hospitals, namely leishenshan hospital (38 patients), zhongnan hospital of wuhan university (10 patients), and taihe university hospital hubei (6 patients). of the 54 patients included in this sumail typewriter sumail typewriter 47 medical and health science journal 2021 february, vol 05 (01) analysis, 48 (88.9%) received the full 7 day treatment course and 6 (11.1%) received only 5 or 6 days of treatment due to death (2) or discharge from the icu (4). patients were randomized to receive vitamin c or placebo within 48 hours of admission to the icu. to accurately control the infusion rate and not affect fluid management in severe patients, researchers administered vitamin c or placebo via a pump-controlled central venous catheterization. the study group in this trial was 1) hdivc (high dose intra venous vitamin c) 24 g of vitamin c per day. the patient was infused with 12 g of vitamin c diluted in 50 ml of bacteriostatic water every 12 hours at a rate of 12 ml / hour with an infusion pump for 7 days. 2) placebo: 50 ml of bacteriostatic water infused every 12 hours at the same rate. 6 table 1 laboratory findings about proinflammatory marker in a trial of hdivc in patients with covid-19. 6 variable day vitamin c (n =26) placebo (n=28) il-6 (pg/ml) 1 22.56 [8.87-85.54] 54.73 [12.34-145.47] 3 113.10 [21.80-288.73] 37.24 [5.59-85.28] 7 19.42 [10.59-29.16] 158.00 [15.29-259.60] crp (mg/l) 1 39.86 [3.91-86.85] 56.84 [40.19-100.20] 3 43.52 [3.41-65.72] 66.34 [29.76-107.39] 7 29.47 [10.95-110.93] 30.20 [2.3-131.70] discussion the results of clinical trials show that high doses of vitamin c have a role in the process of reducing pro-inflammatory cytokines and other inflammatory markers such as crp. vitamin c is a water-soluble nutrient that the human body cannot synthesize on its own. vitamin c acts as an anti-oxidant that scavenges reactive oxygen species (ros), thereby protecting biomolecules such as proteins, lipids, and nucleotides from oxidative damage and dysfunction. vitamin c accumulates in leukocytes, in concentrations 50100 times higher than in plasma. during infection, the vitamin c present in leukocytes is used up quickly. disruption of the balance between antioxidant defenses and oxidant formation can alter several signaling pathways involving the pro-inflammatory transcription factor, nf-кb. increased oxidant levels lead to activation of nfкb, triggering a signaling cascade, with the end result of further production of oxidative species and inflammatory mediators. nf-кb is involved in inflammatory response, pathogenesis of certain diseases and viral infections. inhibition of nf-кb can be a mode of therapy against viral infections. vitamin c is also known to increase antiinflammatory cytokines (il-10). clinical studies have shown that 1 g / day of vitamin c increases secretion of il-10 by peripheral mononuclear cells. il-10 works as a negative feedback mechanism with il-6 and controls inflammation, important in covid-19. 7 at high concentrations vitamin c plays an important role in immunomodulation. vitamin c can inhibit the activation of nfkb, which is a major proinflammatory transcription factor, and plays an important role in overall immunity, including genetic regulation of chemokines, sumail typewriter sumail typewriter 48 medical and health science journal 2021 february, vol 05 (01) cytokines, adhesion molecules, inflammatory mediators and inhibitors of apoptosis. vitamin c can inhibit the production of il-6 and tnf-α. vitamin c can reduce the gm-csf signaling response which functions as a regulator of cytokine redox signal transduction in the body's defense cells and has a possible role in controlling the inflammatory response. in addition, high doses of vitamin c can regulate the proliferation and function of t cells, b cells, and natural killer (nk) cells. this can help inhibit the development of cytokine storms and increase host immunity. 8 preclinical research on early sepsis reveals that vitamin c prevents sepsis-induced cytokine spikes that activate and sequester neutrophils in the lungs, thereby damaging the alveolar capillaries. vitamin c enhances clearance of alveolar fluid by preventing the accumulation of activated neutrophils in the alveolar spaces, limiting damage to alveolar epithelial drains. additionally, vitamin c prevents the formation of neutrophil extracellular traps, a biological event in activated neutrophils that increases vascular injury. 9 conclusion from the results of literary studies, it can be concluded that at high concentrations vitamin c plays an important role in immunomodulation. vitamin c can inhibit the activation of nfkb, which is a major proinflammatory transcription factor, and plays an important role in overall immunity, including genetic regulation of chemokines, cytokines, adhesion molecules, inflammatory mediators and inhibitors of apoptosis. vitamin c can inhibit the production of il-6 and tnf-α. vitamin c can reduce the gmcsf signaling response which functions as a regulator of cytokine redox signal transduction in the body's defense cells and has a possible role in controlling the inflammatory response. in addition, high doses of vitamin c can regulate the proliferation and function of t cells, b cells, and natural killer (nk) cells. this can help inhibit the development of cytokine storms and increase host immunity. vitamin c is also known to increase anti-inflammatory cytokines (il-10). with this ability, vitamin c plays an important role in reducing cytokine storms in covid-19 by reducing levels of pro-inflammatory cytokines. references 1. rothan ha, byrareddy sn. the epidemiology and pathogenesis of coronavirus disease (covid-19) outbreak. journal of autoimmunity. 2020. 2. zhang w, zhao y, zhang f, wang q, li t, liu z, et al. the use of antiinflammatory drugs in the treatment of people with severe coronavirus disease 2019 (covid-19): the experience of clinical immunologists from china. clin immunol [internet]. 2020;214:108393. available from: https://doi.org/10.1016/j.clim.2020.108393 3. amir aslani b, ghobadi s. studies on oxidants and antioxidants with a brief glance at their relevance to the immune system. life sciences. 2016. p. 19. 4. biswas sk. does the interdependence between oxidative stress and inflammation explain the antioxidant paradox? oxidative medicine and cellular longevity. 2016. p. 3–5. 5. erol n, saglam l, saglam ys, erol hs, altun s, aktas ms, et al. the protection potential of antioxidant vitamins against acute respiratory distress syndrome: a rat trial. inflammation. 2019; 6. zhang j, rao x, li y, zhu y, guo g, luo g, et al. high-dose vitamin c infusion for the treatment of critically ill covid-19. 2020; 7. shakoor h, feehan j, al dhaheri as, ali hi, platat c, ismail lc, et al. immuneboosting role of vitamins d, c, e, zinc, selenium and omega-3 fatty acids: could they help against covid-19? maturitas. 2021. sumail typewriter 49 medical and health science journal 2021 february, vol 05 (01) 8. liu f, zhu y, zhang j, li y, peng z. intravenous high-dose vitamin c for the treatment of severe covid-19: study protocol for a multicentre randomised controlled trial. bmj open. 2020;10(7). 9. fowler aa, truwit jd, hite rd, morris pe, dewilde c, priday a, et al. effect of vitamin c infusion on organ failure and biomarkers of inflammation and vascular injury in patients with sepsis and severe acute respiratory failure: the citrisali randomized clinical trial. jama j am med assoc. 2019;322(13):1261–70. sumail typewriter 50 sumail typewriter medical and health science journal 2021 august vol.5 (02) medical and health science journal available at http://journal2.unusa.ac.id/index.php/mhsj; doi: 10.33086/mhsj.v5i2 pissn 2549-7588. eissn 2549-7596 original article neuroprotective activity of extract of celery (apium graveolens) in insilico study reza mahendra putra1, ainul rofik1, hotimah masdan salim2, maria ulfa3, evi sylvia awwalia4 1 department of anesthesiology and intensive theraphy faculty of medicine, universitas nahdlatul ulamas surabaya, surabaya, indonesia 2 department of biochemistry and biomolecular science, faculty of medicine, universitas nahdlatul ulamas surabaya, surabaya, indonesia 3 department of dermatology and venereology, faculty of medicine, universitas nahdlatul ulamas surabaya, surabaya, indonesia 4 department of internal medicine, faculty of medicine, universitas nahdlatul ulamas surabaya, surabaya, indonesia article info article history: received september 8, 2021 received in revised form september 16, 2021 accepted september 18, 2021 keywords: celery (apium graveolens), coline, insilico *) correspondent author: dr.reza@unusa.ac.id abstract backround: celery (apium graveolens l., apiaceae) is one of the medicinal plants with secondary metabolite components that have pharmacological effects such as vitamin (choline) content. this study aims to evaluate the mechanism and interaction of choline contained in celery on its effectiveness as a neuroprotective. methods: this research is an experimental research using the in silico study. results: the insilico search found that the choline content in celery binds to slc5a7, chat and ache. which has a function in the process of neurotransmitter biosynthesis, neurotransmitter metabolic processes and neurotransmitter secretion processes conclusion: the celery (apium graveolens l., apiaceae) have pharmacological activity as neuroprotective through the interaction of slc5a7, chat and ache. medical and health science journal http://journal2.unusa.ac.id/index.php/mhsj reza, et al medical and health science journal 2021 august vol.5 (02) page 28 of 31 introduction the use of herbal plants in medicine has been used for centuries and until now, herbal medicine has shown pharmacological activity which is quite effective in various diseases1,2. one of the herbal plants that are often used in medicine is celery. apium graveolens or celery belongs to the apiaceae family. celery plants grow throughout the continent of asia, europe, and parts of africa that have a tropical climate, but until now celery has been consumed and cultivated throughout the world3. previous pharmacological studies have shown that celery has antimicrobial activity, antiparasitic, cardioprotective, gastroprotective, neuroprotective, hypolipidemic, cytotoxic, antioxidant, antiinflammatory, and antiinfertility4–6. until now, the public's knowledge in using celery is still limited as a flavor enhancer for food and vegetable commodities. the methanol extract of the celery seeds contains several chemical compounds of flavonoids, steroids, glycosides, and alkaloids celery also contains furocoumarins, phenols, sesquiterpenes alcohol, and essential oils 7,8. recent research has also shown that celery contains vitamins (choline and riboflavin), and pigments ( safflomin a)9. there are so many benefits of celery, but very little has been explained about the benefits of celery on the nervous system. although previous studies have found the effect of celery as a neuroprotective, but its mechanism is still not widely known. so, the study aims to determine the mechanism of the vitamin content, namely choline in celery leaves on the function of the nervous system, especially neurotransmitters in-silico. methods this type of research is experimental research in silico. components of secondary metabolites in celery based on previous research9. the secondary metabolite in celery used in the insilico search is vitamin (choline). then the search for choline interactions with proteins is carried out in the following way: 1. search for secondary metabolites (choline) by accessing https://pubchem.ncbi.nlm.nih.gov/ 2. searching for choline interactions with proteins in the body by accessing http://stitch.embl.de and continued by looking at the structure of each protein from the protein data bank (pdb) http://rcsb.org 3. then search for specific functions based on the interaction of each protein by accessing https://string-db.org/. results from the results of an insilico search for the metabolite content of celery, namely choline, a 3d structure was obtained through a search on pubchem as shown in figure 1. figure.1 the 3d picture of coline structure after determining the chemical structure of colin based on the canonical smile, the search for colin interactions in the body was carried out using the stitch.embl.de database. the search found strong interactions of choline on slc5a7, chat, and ache proteins where these three proteins function at cholinergic synapses (neurotransmitters) (figure.2) reza, et al medical and health science journal 2021 august vol.5 (02) page 29 of 31 figure.2 prediction of coline interactions on proteins in the body figure.3 the 3d picture of each protein to find out the specific function of each protein, a search was carried out through the data base accessed at https://string-db.org/. from the search results, it was found that the three proteins have more than one function, namely the process of neurotransmitter biosynthesis, metabolic neurotransmitter processes, neurotransmitter secretion processes and metabolic hormone processes (figure.4) figure.4 interaction function of chat, ache, slc5a7 table.1 the function of protein in nervous systems function protein indication neurotransmitter biosintetic process 1. chat 2. ache 3. slc5a7 yellow neurotransmitter metabolic process 1. chka 2. chat 3. ache 4. slc5a7 purple secretion neurotrabsmitter 1. chat 2. slc18a3 3. slc5a7 red hormon metabolic process 1. ache 2. slc5a7 green discussion this study evaluates the content of secondary compounds from celery extract, namely choline as a neuroprotective with an in silico approach. the approach was taken by looking at the interaction of colin from celery extract on proteins in the body. based on the results of this study, it was found that there are three proteins that have strong interaction slc5a7 chat ache reza, et al medical and health science journal 2021 august vol.5 (02) page 30 of 31 with choline which is a secondary metabolite component of celery, namely slc5a7, chat, and ache, which work specifically on neurotransmitters in the nervous system. these results are in line with previous studies, which found that celery extract has a neuroprotective effect, although the mechanism has not yet been clearly explained 1. the results of this study can be one of the initial data for interactions related to the mechanism of celery in providing a neuroprotective effect. this study was found that slc5a7, chat, and ache have interactions in the process of neurotransmitter biosynthesis, neurotransmitter metabolic process, secretion of neurotransmitter, and hormone metabolic process. these three proteins assist in the transmembrane transporter that imports choline from the extracellular space into high-affinity neurons. choline absorption is the rate-limiting step in acetylcholine synthesis10. previous studies have found that mutations in slc5a7 are found in a rare group of genetically heterogeneous neuromuscular junction (nmj) disorders associated with variable skeletal muscle fatigue and weakness, generally classified under the term 'congenital myasthenic syndrome' (cms)11. other studies have found that slc5a7 also has a role in the process of alzheimer's disease (az)12. it is well known that the enzyme choline acetyltransferase (chat) catalyzes the transfer of an acetyl group from acetyl-coenzyme a (acetyl-coa) to choline to produce ach in the axoplasm of neurons. after its biosynthesis, ach is packaged into synaptic vesicles by the vesicular ach transporter (vacht) and released into the synaptic cleft upon neuronal depolarization. this ach then binds to nicotinic and muscarinic receptors to activate downstream signaling pathways, then the transmitter is broken down by the enzyme acetylcholinesterase (ache) into acetate and choline to limit its binding to the receptor. these two proteins are essential in the process of signaling via neurotransmitters in a variety of biological processes, including cognition, movement, and attention processing13. the interactions obtained in the insilico can be used as a reference in knowing the mechanism of the secondary metabolite of celery extract, namely choline and it can be suggested to use celery as a medicinal plant that has a neuroprotective effect. conclusion apium graveolens or celery belongs to the apiaceae family. based on the results of an insilico search for the content of secondary metabolites, namely choline, that celery leaves have pharmacological activity as neuroprotective through the interaction of slc5a7, chat, and ache and suggested as a very potential medicinal plant. however, a number of studies are still needed to validate the effectiveness of celery as a treatment. conflict of interest the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. references 1. khairullah, a. r. et al. review on the pharmacological and health aspects of apium graveolens or celery: an update. syst. rev. pharm. 12, 606–612 (2021). reza, et al medical and health science journal 2021 august vol.5 (02) page 31 of 31 2. solikhah, t. i., setiawan, b. & ismukada, d. r. antidiabetic activity of papaya leaf extract (carica papaya l.) isolated with maceration method in alloxan-induces diabetic mice. syst. rev. pharm. 11, 774–778 (2020). 3. kooti, w. & daraei, n. a review of the antioxidant activity of celery ( apium graveolens l). j. evid. based. complementary altern. med. 22, 1029–1034 (2017). 4. jittiwat, j., chonpathompikunlert, p. & sukketsiri, w. neuroprotective effects of apium graveolens against focal cerebral ischemia occur partly via antioxidant, anti-inflammatory, and anti-apoptotic pathways. j. sci. food agric. 101, 2256–2263 (2021). 5. al-howiriny, t. et al. gastric antiulcer, antisecretory and cytoprotective properties of celery (apium graveolens) in rats. pharm. biol. 48, 786–793 (2010). 6. sameh, b., ibtissem, b., mahmoud, a., boukef, k. & boughattas, n. a. antioxidant activity of apium graveolens extracts. j. biol. act. prod. from nat. 1, 340–343 (2011). 7. brahma srinivasa rao desu and sivaramakrishna k. anti-depressant activity of methanolic extract of apium graveolens seeds. int. j. res. pharm. chem. 2, 1124–1127 (2012). 8. baananou, s. et al. antiulcerogenic and antibacterial activities of apium graveolens essential oil and extract. nat. prod. res. 27, 1075–1083 (2013). 9. liu, d. k. et al. evaluation of bioactive components and antioxidant capacity of four celery (apium graveolens l.) leaves and petioles. int. j. food prop. 23, 1097–1109 (2020). 10. choudhary, p. et al. discovery of compounds that positively modulate the high affinity choline transporter. front. mol. neurosci. 10, 40 (2017). 11. wang, h. et al. choline transporter mutations in severe congenital myasthenic syndrome disrupt transporter localization. brain 140, 2838–2850 (2017). 12. tönnies, e. & trushina, e. oxidative stress, synaptic dysfunction, and alzheimer’s disease. j. alzheimers. dis. 57, 1105–1121 (2017). 13. obermayer, j., verhoog, m. b., luchicchi, a. & mansvelder, h. d. cholinergic modulation of cortical microcircuits is layer-specific: evidence from rodent, monkey and human brain. front. neural circuits 11, 100 (2017). medical and health science journal 2021 february, vol 05 (01) original article the effect of tomate juice on trigliserida levels of male white rats induced by alloxan ibrahim shihatta, fitri handajani* fakultas kedokteran universitas hang tuah surabaya *correspondence: fitri.handayani@hangtuah.ac.id article info article history: received august 26,2020 accepted february 23,2021 keywords: tomato juice serum triglyceride levels alloxan abstract background: tomato juice is believed to affect triglyceride levels in the blood because it contains lycopene. this study aims to determine the effect of tomato juice (solanum lycopersicum) on blood triglyceride levels in the wistar strain of male rattus norvegicus induced by alloxan. methods: 24 were divided into 3 groups, (1) group k (-) experimental animals without treatment, (2) group k (+) experimental animals induced by alloxan 150 mg /kg bw (3) treatment group k (p) animals tried alloxan induced 150 mg / kg and got 1.75 ml / head of tomato juice. results: there was a significant difference in mean triglyceride levels between groups k (-) and group k (+). this indicates that the induction of alloxan increases blood triglyceride levels. there were significant differences in the mean triglyceride levels between the k (+) and k (p) groups because tomato juice contained lycopene which could reduce triglyceride synthesis. conclusions: tomato juice (solanum lycopersicum) reduced wistar strain male rattus novergicus triglyceride levels induced by alloxan. medical and health science journal. introduction diabetes mellitus is a chronic disease characterized by an increase in blood sugar levels (hyperglycemia) in the blood as a result of a disruption in the metabolic system in the body 1 . from several epidemiological studies in indonesia conducted by diabetes centers, around the 1980s,the prevalence of diabetes mellitus at the age of 15 years and over is 1.5-2.3% with a lower prevalence in rural areas than in urban areas 2 hyperglycemia is a condition of high blood sugar (glucose) levels in the blood. the underlying thing is insulin deficiency, relative or absolute. hyperglycemia itself is caused by decreased insulin secretion. in patients with uncontrolled diabetes mellitus, it is often accompanied by disorders of lipid metabolism which have an impact on the occurrence of dyslipidemia 3 . dyslipidemia is defined as a lipid metabolism disorder characterized by an increase or decrease in the lipid fraction in plasma. the main lipid fraction abnormalities are an increase in total cholesterol, ldl cholesterol, triglycerides, and an increased risk of coronary heart disease 4 . triglycerides are esters of glycerol with fatty acids. triglycerides are a form of lipids in the body that serve as a source of energy. when the body needs energy, the lipase enzyme in fat cells will break down triglycerides into fatty acids and glycerol and release them into the blood vessels. food regulation has an effective effect on reducing triglyceride levels in the blood. the us national health and nutrition examination survey found the influence of carotenoid-rich foods on triglyceride levels in the blood in people with diabetes. one of the foods that has been linked to a decrease in blood triglyceride levels is tomatoes 5 . sumail typewriter 20 sumail typewriter mailto:fitri.handayani@hangtuah.ac.id medical and health science journal 2021 february, vol 05 (01) tomato (solanum lycopersicum) is a plant that is well known by indonesian people. however, its use is limited to as a salad and an additional ingredient in cooking. tomato processing increases the bioavailability and increases the absorption of the active compounds contained therein. one of the compounds in tomatoes that functions to reduce triglycerides is lycopene. because lycopene is an antioxidant to catch free radicals in the body. ( 4;6 ) alloxan is a compound used to induce damage to the pancreas through increased formation of species oxygen radicals (ros), resulting in diabetes mellitus. alloxan induction results in lipolysis and triggers hypertriglyceridemia. alloxan can be given intravenously, intraperitoneally, or subcutaneously in animal experiments. alloxan induction of 120150 mg / kgbw can lead to diabetes mellitus in experimental animals 7, methods this research is an experimental study post test only control group design. twenty four male wistar rats were divided into 3 groups, (1) group k (-) experimental animals without treatment, (2) group k (+), the experimental animal was induced by 150 mg / kg bw of alloxan intraperitoneal (3) the treatment group k (p) animals were induced by 150 mg / kg bw of alloxan intrraperitoneal and 3 days after induction, tomato juice was given 1.75 ml /mouseintragastricfor 14 days. alloxan induction alloxan monohydrate injection witha dose of 23.22 mg which is dissolved intonacl 0.9% intraperitoneally. solutionalloxan monohydrate is injected only oncethen waited for 3 days forreach a hyperglikemia state tomato juice making tomatoes weighing 200 grams, washed, cut into small pieces, blended for about 5 minutes and filtered using a filter until 100 ml of tomato juice is obtained and weighed to 97.4 grams, so that 1 gram of tomato juice is equal to 1.027 ml. measure triglyceride levels the method of checking triglycerides is the colorimetric enzymatic method of gpo-pap (glycerol peroxidase phosphate acid), triglycerides will be enzymatically hydrolyzed to glycerol and free acids with special lipases will form a color complex that can be measured using a spectophotometer. 9 results in this study, the results showed that the induction of an increase in the mean blood glucose level of the k (+) group was 401.5 mg / dl compared to the k (-) group of experimental animals without treatment of 195.7 mg / dl. this indicates that there has been a decrease in insulin secretion which results in hyperglycemia. measurement of triglyceride levels can be seen in table 1 sumail typewriter 21 medical and health science journal 2021 february, vol 05 (01) table 1. the results of the examination of triglyceride levels note: k (-) : group of experimental animals without treatment k (+): alloxan induced experimental animal group k (p): group of experimental animals induced by alloxan and receiving tomato juice (solanum lycopersicum) figure 1. average triglyceride levels of experimental animals note: k (-) : group of experimental animals without treatment k (+): alloxan induced experimental animal group k (p): group of experimental animals induced by alloxan and receiving tomato juice (solanum lycopersicum) from these data, it can be seen that there was an increase in the mean serum triglyceride levels in the experimental animal group which was induced by alloxan, when compared to experimental animals without treatment. a decrease in the mean serum triglyceride levels occurred in the experimental animal group which was induced by alloxan and tomato juice (solanum lycopersicum), when compared to the experimental animal group which was induced by alloxan. furthermore, the analysis of normality test data was carried out and continued with the homogeneity test which showed that the triglyceride levels between groups were normal and homogeneous. next, the test was carried out to determine whether there were differences between groups using the one-way anova test. 42 73,88 46,75 0 10 20 30 40 50 60 70 80 kk+ p triglseride level triglyseride level no triglyceride level (mg/dl) k(-) k(+) k(p) 1 39 86 66 2 60 73 68 3 39 91 59 4 32 74 21 5 56 62 36 6 23 75 40 7 39 77 58 8 48 53 26 mean 42 73,88 46,75 sumail typewriter 22 sumail typewriter medical and health science journal 2021 february, vol 05 (01) and the anova test results showed a significant difference and was followed by the poshoc test. table 2 the results of post hoc test with lsd test group group p value k(-) k(+) 0,001 k(p) 0,52 k(+) k(p) 0,001 based on table 2 it was found that there was a significant difference in triglyceride levels between the experimental animal group without k (-) treatment and the experimental animal group induced by alloxan with k (+) and there was a significant difference in triglyceride levels between the experimental animal group induced by alloxan k (+) and experimental animal group induced by alloxan and tomato juice k (p) (solanum lycopersicum). there was no significant difference in triglyceride levels in the experimental animal group without k (-) treatment with the experimental animal groupinduced by alloxan and tomato juice k (p) (solanum lycopersicum). discussion alloxan induction will increasing lipid profile, in this study, reseacher only focused on triglyseride level because it is easier for changes to occur with changes in diet.in this study the alloxan-induced group showed an increase in serum triglyceride levels in experimental animals. this can be seen in the results of data analysis which show that there is a significant difference in triglycerides (p = 0.00) between the experimental animal group without k (-) treatment (42 mg / dl) and the experimental animal group induced by alloxan k (+) ( 73.88 mg / dl). alloxan induction causes an increase in ros resulting in damage to pancreatic β cells, so that insulin production will decrease and hyperglycemia occurs, this condition triggers lipolysis so that fatty acids in the blood increase. lipolysis increases the formation of free fatty acids. free fatty acids will enter the fat tissue or muscle cells by penetrating the endothelium and then re-oxidizing or being converted back into triglycerides 10 . this situation causes vldl, ldl and triglycerides in the blood to increase (11). from the results of this study, it was concluded that there was a significant difference between the mean triglyceride levels in the experimental animal group induced by alloxan k (+) with a level of 73.88 mg / dl and the experimental animal group induced by alloxan and tomato juice k (p) with a level of 46 , 75 mg / dl this study used tomato juice (solanum lycopersicum) because tomato juice (solanum lycopersicum) is known to play a role in reducing triglyceride levels in the blood. tomato (solanum lycopersicum) is a type of vegetable that contains various kinds of antioxidants, including betacarotene, vitamins c and e, anthocyanins and lycopene. lycopene as a potential antioxidant can reduce oxidative stress by providing defense against free radicals and can also inhibit the increase in ros so that it can prevent hypertriglyceridemia (11). giving tomato juice (solanum lycopersicum) which contains lycopene which is a group of carotenoids such as beta-carotene which is responsible for the red color of tomatoes. in the body, lycopene can protect against diseases such as prostate cancer as well as several other types of cancer and coronary heart disease. the ability of lycopene in absorbing single oxygen is twice as good as beta carotene and ten times better than alpha-tocopherol 6, 11 tomatoes contain an oxidized fatty acid called 3-oxo-oda which is an isomer of 9-oxooda. 13-oxo-oda is a strong agonist for peroxisome proliferator activated receptor alpha (pparα). pparα serves as a major regulator for fatty acid oxidation. 13-oxo-oda will activate pparα causing increased fatty acid oxidation. the increase in fatty acid oxidation will cause a decrease in triglyceride levels in the blood. the activation of pparα will also lead to an increase in triglyceride levels 12 . in addition, pparα functions as a regulator of energy balance (lipid sumail typewriter 23 sumail typewriter medical and health science journal 2021 february, vol 05 (01) metabolism), especially as a regulator of fatty acid oxidation 13 . tomatoes that are processed in the form of juice increase their bioavailability, so that they are easier to digest and absorb the active compounds. fresh tomatoes contain 9-oxo-oda, processing tomatoes into tomato juice converts 9oxo-oda to 13-oxo-oda. 9-oxo-oda which is a 13-oxo-oda isomer, but 13-oxo-oda is a more potent pparα agonist than 9-oxo-oda. pparα is a member of the receptor family that functions as a regulator of the balance of energy (fat) metabolism. the ligands can be fatty acids or their derivatives, and 13-oxo-oda. the bond between the ligand and pparα can activate pparα and result in a decrease in the concentration of triglycerides in plasma and in tissues 12 , so it can be concluded that triglyceride levels in the blood can decrease due to the presence of 9-oxo-oda found in tomatoes. 12;13, 14. the activated pparα will increase the oxidation of fatty acids in the tissue, so that the fatty acids will be oxidized, this will cause a decrease in the accumulation of triglycerides in the tissue. the activated pparα will increase the expression of the lipoprotein lipase (lpl) gene so that the lipoproteins that undergo lipolysis will ncrease 12, 15 from the results of the above research, it can be concluded that giving tomato juice (solanum lycopersicum) can significantly reduce triglyceride levels in male white rats (rattus norvegicus) wistar strain induced by alloxan. conclusion alloxan induction can increase serum triglyceride levels of male white rats (rattus norvegicus) and administration of tomato juice (solanum lycopersicum) can reduce serum triglyceride levels of male white rats (rattus novergicus) wistar strain induced by alloxan. references 1. ekawati, e. r.. hubungan kadar glukosa darah terhadap hypertriglyceridemia pada penderita diabetes mellitus. seminar nasional kimia unesa, 2-3. 2012. https://doi.org/isbn : 978-979-028550-7 2. kemenkes ri. situasi dan analisis diabetes. pusat data dan informasi kementerian kesehatan ri2014 . https://doi.org/24427659 3. purwantoyo, p marwoto2 and r s iswari. various tomato extract dose effect on the lipid profile of hypercholesterolemia rats.2017. journal of physics: conf. series 983 (2018) 012183 doi :10.1088/17426596/983/1/012183 4. hernani dan rahardjo. tanaman berkhasiat antioksidan,2005. 3-5 5. astuti, y. d. w. i.. pengaruh pemberian jus tomat terhadap kadar glukosa darah pada prediabetes. 2012. thesis undip 6. islam n, akhter n. comparative study of protective effect of tomato juice and nhexane extract of tomato on blood lipids and oxidative stress in cholesterol-fed rats. akmmcj.2017 8(1):30-7. available from: https://www.banglajol.info/index.php/ak mmcj/article/view/31655 7. anindhita yuriska. efek aloksan terhadap kadar glukosa darah tikus wistar. fakultas kedokteran universitas diponegoro semarang,2009. 1-45. 8. lenzen s. the mechanisms of alloxan and treptozotocin-induced diabetes diabetologia.2008 vol 51:216–226 9. ii, b. a. b., & pustaka, t. (2012). gambar 1. rumus molekul trigliserida sumber : biokimia harper, 2009 repository.unimus.ac.id, 1–13. 10. arifnaldi ms. hubungan kadar trigliserida dengan kejadian stroke iskemik di rsud sukoharjo, fakultas kedokteran surakarta. 2014 11. sunarmani, kun tanti, d., parameter likopen dalam standardisasi konsentrat buah tomat, prosiding ppi standardisasi, jakarta. 2008 sumail typewriter 24 sumail typewriter sumail typewriter https://doi.org/24427659 https://www.banglajol.info/index.php/akmmcj/article/view/31655 https://www.banglajol.info/index.php/akmmcj/article/view/31655 medical and health science journal 2021 february, vol 05 (01) 12. kim y, hirai s, goto t, ohyane c, takahashi, tsugane, konishi, fujii, inai. potent pparα activator derived from tomato juice, 13-oxo-9,11octadecadienoic acid, decreases plasma and hepatic triglyceride in obese diabetic mice. plos one. 2012 :7(2) 13. palazo p, catalano a, simone re, mele mc, citaddini a,. effect of lycopene and tomato product on cholesterol metabolism; annals of nutrition & metabolism, 2012 vol. 61. iss 2 14. handajani f. oksidan dan antioksidan pada beberapa penyakit dan proses penuaan. zifatama. 2019, pp5 9-64 15. saleem a. banihani. tomato (solanum lycopersicum l.) and type 2 diabetes, international journal of food properties,2018. 21:1, 99-105, doi: 10.1080/10942912.2018.1439959. sumail typewriter 25 sumail typewriter sumail typewriter medical and health science journal, vol. 4, no. 2, august 2020 correspondence: yanuar prionggo @2020 medical and health science journal. 10.33086/mhsj.v4i1.1415 available at http://journal2.unusa.ac.id/index.php/mhsj 97 meta-analysis : comparison of neovagina success rate with vecchietti's laparoscopic method and davydov's laparoscopic method in mayer-rokitansky-kusterhauser syndrome (mrkh) patients yanuar prionggo* 1 , eighty mardiyan kurniawati 2 1 ppds-1 obstetrics gynecology, faculty of medicine, universitas airlangga, dr.soetomo general academic teaching hospital, surabaya 2 staff of the uroginecology-reconstruction division, department / smf obstetrics gynecology, faculty of medicine, universitas airlangga, dr.soetomo general academic teaching hospital, surabaya *corresponding author: dryanuarprionggo@gmail.com article info abstract article history: submitted: july, 7 2020 received in revised form: august, 3 2020 accepted: august, 18 2020 background: mayer-rokitansky-kuster-hauser syndrome (mrkh) is caused by an embryological growth disorder of the mullerian duct. laparoscopic vecchietti and davydov are laparoscopic surgery techniques that are often used for neovaginal surgery. objective: this study aimed to compare the success rate of neovagina with the vecchietti laparoscopic method and davydov's laparoscopic method in patients with mayer-rokitansky-kusterhauser syndrome (mrkh). methods: a systematic data search was performed on a medical database (pubmed, medline, cochrane database, google scholar). inclusion criteria: (1) randomized study of the vecchietti laparoscopic method with davydov’s laparoscopy, (2) all inclusive papers can be accessed completely, and (3) the data obtained can be accurately analyzed. data acquisition and analysis: we searched for a random blind study (rct) with the following keywords: (1) vecchietti laparoscopy [title] and (2) davydov’s laparoscopy [title] and mayer-rokitansky-kusterhauser syndrome [title]. results: three rcts comparing neovaginal success with the vecchietti laparoscopic method and davydov's laparoscopic method a total of 122 patients were analyzed. average vaginal length (mean difference [md] -0.70, and 95% [ci] -0.99 to -0.41 (p <0.00001), average number of female sexual function index scores (mean difference [md] -1.34, and 95% [ci] -1.71 through -0.96. (p <0.00001). conclusion: this meta-analysis concludes that davydov’s laparoscopic method is better in terms of postoperative vaginal length and the female sexual function index score @2020 medical and health science journal. 10.33086/mhsj.v4i1.1415 keywords: mayer-rokitansky-kusterhauser syndrome, laparoscopic davydov, laparoscopic vecchietti, vaginal length, fsfi score introduction mayer-rokitansky-ku¨ster-hauser syndrome (mrkh) is an embryological growth disorder of the mullerian ductus which results in no uterine formation and/ or 2/3 of the vaginal area in women with normal secondary sex growth and normal karyotyping 46, xx. this syndrome is found 1 every 45005000 women 1 . mayer-rokitansky-kuuster-hauser syndrome (mrkh) consists of two types. type 1 is mrkh type that does not form the uterus and vagina completely (rokitansky sequence). whereas type 2 is a type of mrkh that does not form the uterus and vaginal perfectly and is accompanied by other malformations (murcs association). patients with mrkh syndrome usually present with complaints of never having menstruation with a physical examination showing normal secondary sex growth but a dead end vagina. investigations can be done in the form of transabdominal ultrasound, mri, or karyotyping. transabdominal ultrasound and mri are performed to evaluate the uterus, vagina and abnormalities in the urogenital review article mailto:dryanuarprionggo@gmail.com medical and health science journal, vol. 4, no. 2, august 2020 98 tract. in karyotyping patients with mrkh syndrome, the phenotype xx is obtained. this is needed to distinguish between androgen insensitivity syndrome 1,2 . differential diagnosis of mrkh syndrome includes vaginal atresia, wnt 4 syndrome, androgen insensitivity syndrome. the difference between mrkh syndrome and vaginal atresia is that the uterus and the upper part of the vagina are found, whereas in wnt 4 syndrome and androgen insensitivity syndrome, there is testicular or masculized ovary and xy phenotype 3 . the major issue in these patients (mrkh) is vaginal agenesis, which affects sexuality and alters quality of life. classic vaginal agenesis management is to create a cavity that allows satisfying painless penetrative intercourse. vaginoplasty can be achieved either surgically or by progressive dilation of the vaginal dimple. most surgical or nonsurgical techniques are reported to provide good anatomical and functional results of at least 70%. the first management of mrkh syndrome patients is patient and family counseling about the patient's condition and plans for making neovagines for the patient's sexual needs. making neovagina can use nonoperative methods and operative methods. the non-operative method consists of the frank method, a method with a vaginal dilatator. operative methods include the vechietti, mcindoe, and daydov methods 5 . surgery is a choice for women who are unsuccessful with dilators or who prefer surgery and after a thorough discussion about advantages and disadvantages of various neovaginal techniques. it is very important for patients to realize that surgical procedures she still needs to use a vaginal dilator in the postoperative period to avoid stricture or stenosis. classically, vecchietti surgery is an abdominal procedure performed through a pfannenstiel skin incision; however, it has been modified into the laparoscopic approach. there is limited data because this is a relatively new technique. another laparoscopic approach is the adaptation of davydov's procedure. the davydov laparoscopic technique is a three-stage operation which includes dissection of the rectovesical space, mobilization of the peritoneal abdomen to make vaginal division, and adhesion of the peritoneum to the introitus. new surgical methods have recently been developed in which laparoscopy has replaced traditional surgery. because of it, this study analyzed which presents the most advantages. we chance to compare the two techniques in terms of sexual satisfaction and effectiveness (vaginal length), which affects sexuality and alters quality of life in a relatively large cohort of patients with rokitansky syndrome. this syndrome has been treated by a wide variety of techniques proposed for the creation of a neovagina, demonstrating that the inventiveness of the gynecologic surgeons is infinite, and that the ideal procedure still has to be found. therefore, this study compares the only and we believe two techniques (with a laparoscopic approach) constitute a desirable combination of minimal invasiveness and good results, and can be considered in developing country especially in indonesia. methods data search strategy a systematic literatures search were carried out using pubmed, google scholar, and the cochrane central register of controlled trials to obtain randomized randomized studies (rcts) in the span of the year 2010 to 2020, using keywords: (1) mayerrokitansky-ku¨ster-hauser; (2) vecchietti laparoscopy and davydov laparoscopy inclusion criteria the following criteria had been used in the selection: (1) randomized and observational randomized observations of the vecchietti laparoscopy and davydov laparoscopy in patients with mayerrokitansky-ku¨ster-hauser (2) all inclusive medical and health science journal, vol.., no., 99 papers are completely accessible, and (3) all the data were obtained, can be analyzed accurately. study quality assessment the authors independently assessed the validity of each study using the criteria stated in the cochrane handbook for systematic reviews of interventions6. each study was grouped and assessed according to quality categories: a, studies have a low risk of bias; b, studies have a high risk of bias, or c, studies have unclear risk (unclear risk of bias). data extraction data extraction was carried out to obtain the objectives, objectives and research questions of this study. clinical outcomes compared were expected vaginal length and patient fsfi score. statistical analysis and meta-analysis meta-analysis was compiled using review manager (revman) version 5.3. (cochrane collaboration, oxford, uk). mean difference (md) is derived from averages and standard deviations and is used when results are reported using an identical scale. when the scale was used differently, standard md (smd) was calculated using revman. the confidence interval used is 95%. results and discussion study selection searching data on pubmed and google scholar returned 538 articles. screening based on the inclusion criteria described previously, a total of 3 articles were included for metaanalysis. the screening and selection process is illustrated using a study selection flowchart (figure 1). study characteristics the characteristics that comparing intervention of the vecchietti laparoscopic method and the davydov laparoscopic method are summarized in table 1. number of samples our study included three articles which included 122 patients with mayer-rokitanskyku¨ster-hauser syndrome (mrkh) who made neovagina. a total of 59 patients underwent the vecchietti laparoscopic methods and 63 davydov's laparoscopic methods. figure 1. study selection flowchart design study all three studies from alaa et al, bianchi et al, and dong x et al are retrospective cohorts. follow-up time the three studies from alaa et al, bianchi et al, and dong x et al were followed up for at least 1 year after neovaginal measures. risk of bias we have explicitly assessed whether related studies have a high risk bias based on the criteria stated in the handbook 6 . an assessment of the risk of bias from each study can be seen in figures 2 and 3. based on the assessments, it can be concluded that the related studies have a low risk bias. medical and health science journal, vol. 4, no. 2, august 2020 100 figure 2. conclusions from risk stratification bias in all articles in this meta-analysis. figure 3. the risk assessment of the author's bias against each article involved. the meta-analysis was compiled using review manager (revman) version 5.3. (cochrane collaboration, oxford, uk). this paper assesses the comparison of neovagina success rates with the vecchietti laparoscopic and davydov laparoscopic methods by assessing vaginal length and fsfi score 6,7 . we use fixed-effects and random-effects metaanalyzes for data combinations that can be logically assumed that several studies estimate the same therapeutic effect. strengths and limitations the strength of our study was its methodology. we exclude other cases of vaginal agenesis, as mrkh syndrome, vaginal dimples may be different from those of complete androgen insensitivity syndrome patient in terms of embryologic development. moreover, a 46, xy karyotype may have a significant impact on quality of life, independently from the absence of vagina. study reported that vaginal aplasia had a higher psychological impact in mrkh syndrome patients. the accuracy of our results was supported by the use of validated quality of life questionnaires and the standardized pelvic exam performed by an independent evaluator. some limitations at the level of our review should also be highlighted. we pooled studies with, to a limited extent, heterogeneous stage and intervention methodology. in our studies, 122 patients were treated with laparoscopic surgery, 59 with vecchietti’s method and 63 with davydov’s method which cannot describe the actual results, so it can’t be a base for recommendations. future research and study is still needed, with a larger sample of patients. interpretation our results from comparing neovaginal success with the vecchietti laparoscopic method and davydov's laparoscopic method with a total of 122 patients were analyzed. from davydov method average vaginal length 0,7 cm longer with range 0,41-0,99 cm (see figure 4). this analysis shows, davydov's laparoscopic method has a better success rate in terms of clinical outcome from the depth or length of the vagina than vecchietti's laparoscopic method p <0.00001). figure 4. forest plot showing a comparison of clinical outcomes for vaginal depth medical and health science journal, vol. 4, no. 2, august 2020 102 table 1. study characteristic figure 5. forest plot showing the comparison of sexual satisfaction (fsfi score) reference year country study design inclusion criteria intervention outcome dong x, et al, 2015 2015 china retrospective cohort study all women diagnosed with mrkh syndrome aged > 18 during january 2010 december 2013 neo-vaginal method with vecchietti laparoscopy and davydov laparoscopy for patients with mrkh syndrome operation outcome, vaginal length, sexual quality with fsfi standardization bianchi s et al, 2011 2011 italy retrospective cohort study women with mrkh syndrome aged > 18 years who underwent neovagina procedures from october 2003 to august 2008. neo-vaginal methods with vecchietti laparoscopy and davydov laparoscopy for patients with vaginal agenesis operation outcome, vaginal length, sexual quality with fsfi standardization alaa, et al, 2018 2018 france retrospective cohort study patients included exclusively mrkh syndrome patients aged > 18 years, who began management of agenesis vagina from year 1995 until 2015. evaluation by an independent and experienced single gynecologist comparing dilatation and surgical techniques in patients with vaginal agenesis in mayerrokitansky-kuster-hauser syndrome, assessed in terms of quality of life, outcome of operations, and complications who quality of life instruments as well as fsfi and fsdi scale (quality of sexual life) group: dilation therapy, surgery and sexual intercourse 101 medical and health science journal, vol. 4, no. 2, august 2020 correspondence: yanuar prionggo @2020 medical and health science journal. 10.33086/mhsj.v4i1.1415 available at http://journal2.unusa.ac.id/index.php/mhsj 97 we obtained fsfi score results from total 122 patients, with 59 patients were treated by vechhietti’s laparoscopic method and davydov's laparoscopic method in 63 patients. the davydov’s average number of female sexual function index score was 1,34 point better with range 0,96 – 1,71. figure 5 shows davydov's laparoscopic method has a significant difference in patient sexual satisfaction in terms of fsfi score (p <0.00001). summary this sudy concludes that davydov’s laparoscopic method is better , in terms of postoperative vaginal length, and sexual satisfaction (female sexual function index – fsfi). davydov’s laparoscopic method can be considered as the therapeutic choice of laparoscopic surgery in mrkh patients. although further research and study is still needed with a larger number of samples to be a recommendation for future therapy references 1. alaa, c., bidet, m., baptiste, a., viaud, m., fagot, c., khen-dunlop, n., pienkowski, c. (2018). surgery is not superior to dilation for the management of vaginal agenesis in mrkh syndrome: a multicenter comparative observational study in 131 patients. american journal of obstetrics and gynecology. doi:10.1016/j.ajog.2018.07.015. 2. callens, n., de cuypere, g., de sutter, p., monstrey, s., weyers, s., hoebeke, p., & cools, m. (2014). an update on surgical and non-surgical treatments for vaginal hypoplasia. human reproduction update, 20(5), 775–801. doi:10.1093/humupd/dmu024. 3. morcel, k., camborieux, l., & guerrier, d. (2007). mayer-rokitansky-küsterhauser (mrkh) syndrome. orphanet journal of rare diseases, 2(1), 13. doi:10.1186/1750-1172-2-13. 4. willemsen, w. n. p., & kluivers, k. b. (2015). long-term results of vaginal construction with the use of frank dilation and a peritoneal graft (davydov procedure) in patients with mayerrokitansky-küster syndrome. fertility and sterility, 103(1), 220–227.e1. doi:10.1016/j.fertnstert.2014.10.014. 5. dong, x., xi, z., jin, h., comparative study of laparoscopic vecchietti and davydov vaginoplasty in the treatment of mrkh syndrome. chinese journal of obstetrics and gynecology, 2015, 50 (4): 278-282. doi: 10.3760 / cma.j.issn.0529-567x.2015.04.008. 6. bianchi, s., frontino, g., ciappina, n., restelli, e. fedele, and l.creation of a neovagina in rokitansky syndrome: comparison between two laparoscopic techniques. fertility and sterility vol. 95, no. 3, march 1, 2011 0015-0282/s36.00 american society for reproductive medicine, published by elsevier inc. doi:10.1016/j.fertnstert.2010.11.032. 7. rosen, c. brown, j. heiman, s. leib, r. (2000). the female sexual function index (fsfi): a multidimensional selfreport instrument for the assessment of female sexual function. journal of sex & marital therapy, 26(2), 191–208. doi:10.1080/00926230027859 102 medical and health science journal 2022 february vol.6 (01) medical and health science journal available at http://journal2.unusa.ac.id/index.php/mhsj; doi: 10.33086/mhsj.v5i2.2154 pissn 2549-7588. eissn 2549-7596 original article the response time of trauma and non trauma patients handling in emergency room surabaya yoppie prim avidar1, maya hapsari kusumaningtyas2, yuani setiawati3*annete d’arqom3,4 1department of anesthesiology and reanimation, faculty of medicine, universitas airlangga, dr. soetomo hospital, surabaya, jawa timur, indonesia 2faculty of medicine, universitas airlangga, surabaya, indonesia 3division of pharmacology and therapy, department of anatomy, histology, and pharmacology, faculty of medicine, universitas airlangga, surabaya, indonesia 4graduate program in molecular medicine, faculty of science, mahidol university, bangkok, thailand article info article history: received : june 16, 2021 received in revised form : july 14,, 2021 accepted : august 01, 2021 keywords: emergency room, non trauma, response time, trauma, triage *) corresponding author: yuani-s@fk.unair.ac.id abstract background: emergency room is one of the unit services in hospitals that provide first services in patients with threat of disability or even death. emergency room is a service unit in a hospital with 24 service hours for 7 days in a week. the high risk and working hours in the emergency room requires the medical personnel that have good response times in the triage room. to compare response time of medical personnel when handling trauma and non-trauma patients in the emergency room. methods: a non-experimental, quantitative research method using analytic observational. the population of this study was a patient in the emergency room of soetomo hospital surabaya. the amount of the sample was 244 which was divided into 41 trauma cases and 203 non trauma cases. results: response time of patients with trauma injuries that include quick category (< 5 minutes) amounted to 35 patients and 6 patients in slow category (> 5 minutes) with average response times of trauma patients was 6.244 minutes. response time of patients with non-trauma injuries that include the quick category (< 5 minutes) amounted to 161 patients and 42 patients in the slow category (>5 minutes) with average response times of non-trauma patients was 3.722 minutes. the p-value response times of medical personnel in dealing with trauma and non-trauma patients is 0.374 (> 0.05) which means there was no difference in response times from medical personnel in handling trauma and non-trauma patients. conclusion: there was no difference in the response time of medical personnel in trauma and non-traumatic patients handling (p>0,05). overall, it was found that the average emergency room’s response time at soetomo hospital was 4.15 minutes, still meeting the applicable standards. medical and health science journal http://journal2.unusa.ac.id/index.php/mhsj avidar et al medical and health science journal 2021 august vol.2 (02) page 2 of 6 introduction the emergency room is one of the service units in the hospital that provides first services to patients with threats of disability and even death. based on data from the directorate general of medical services at the ministry of health, in 2007 the number of hospitals in indonesia were 1,033 with a yearly number of visits as many as 33,094,000, while visits to the emergency room in one year were 4,402,205 (13.3% of the total visits at the hospital).1 emergency room is a hospital service unit with 24 hours service time for 7 days a week. the high risk and emergency working hours require medical personnel to have an accurate and fast response time. the response time is calculated from the time the patient arrives at the emergency room gate until is served by medical personnel with a maximum time limit of <5 minutes.2 in emergency services, there are still many cases that are not handled quickly and precisely, both at the location of the incident and in the hospital. the management of emergency patients still found delays in services because of the hospital administrative and financial reasons. emergency patients often have to wait for the administrative process was finished before getting service.3 the most cases that often occur in the emergency room are trauma and non-trauma. trauma as defined by the american heritage dictionary is an injury, particularly that caused by a sudden physical injury. traumatic injury cases, for example motor vehicle accidents, burn, drowning, etc. while non-traumatic injuries such as failure of the central nervous system, cardiovascular, respiratory, and hypoglycemia that can cause death in a short time between 4-6 minutes, takes a relatively faster time to prevent biological death if the brain is deprived of oxygen within 8 -10 minutes as in the case of total airway obstruction and cardiac arrest.4 basically, both traumatic and nontraumatic injuries require the same response time. unlike triage system, which is a process of classifying patients based on the type and level of severity of their condition.5 the standard response time certainly affects the patient's condition, the response time can also be used as an evaluation of the hospital's performance in carrying out emergency services. therefore, it is important to know the response time of the soetomo hospital’s emergency room in treating patients with traumatic and non-traumatic wounds. methods this research design was observational with retrospective study conducted in dr. soetomo hospital surabaya. the number of ethical clearance was 565/panke.kke/ix/2017. this study used a comparative study to examine differences in response time for medical personnel in treating trauma and non-trauma patients in soetomo hospital’s emergency room. the sample in this study were all patients who came to the soetomo hospital’s emergency room which were recorded when the patient arrived and received treatment in the medical record. data were taken from emergency room’s medical records, with a purposive sampling technique from 10-15th october 2017. traumatic injuries are injuries that cause a loss of continuity tissue, causing physical injury to the patient. non-traumatic wounds are avidar et al medical and health science journal 2021 august vol.2 (02) page 3 of 6 injuries that do not cause loss of tissue continuity, so these injuries cause the patient to be physically fine. most cases in ird, non-traumatic injuries are cases of it involving vital signs such as heart failure and respiratory failure. fast response time if 5 minutes measured from when the patient arrives at the ird until he gets action from medical personnel. slow response time if 5 minutes measured from when the patient arrives at the ird until he gets action from medical personnel. the data was analyzed with a comparative statistical test between 2 variables in 2 independent sample groups (chi-square test). results this study collected 244 samples with the following description 3.1 demographic sample tabel 1. age distribution age (n) (%) 0 5 year 39 16 5 -11 year 16 6,6 12-25 year 44 18 26-45 year 51 20,9 46-65 year 75 30,7 > 65 year 19 7,8 total 244 100 it was found that the largest number of age groups was the elderly (46-65 years) were 75 patients (30.7%). then followed by the adult age group (26-45 years) were 51 patients (20.9%). then, in the adolescent age group (15-25 years) were 44 patients (18%). in the toddler age group (05 years) were 39 patients (16%). followed by the elderly age group (> 65 years) were 19 patients (7.8%). the age group with the least number was in the children age group (5-11 years) which were 16 patients (6.6%). tabel 2. sex distribution sex (n) (%) male 127 52 female 117 48 total 244 100 it was found that the number of male patients was 52% with a total of 127 patients. meanwhile, the number of female patients was 48% with 117 patients. characteristic of response time on trauma dan non trauma patients tabel 3. type of patient triage color code (n) (%) trauma 41 16,8 non trauma 203 83,2 total 244 100 it was found that the number of nontraumatic patients was greater (83.2%) with a total of 203 patients. while the number of trauma patients was 16.8% with a total of 41 patients. the number of patients based on the response time of medical personnel were divided into 2 categories: fast (≤ 5 minutes) and slow (> 5 minutes) can be presented in the following table. tabel 4. sampel distribution based on response time variabel (n) (%) fast 196 80,3 slow 48 19,7 total 244 100 avidar et al medical and health science journal 2021 august vol.2 (02) page 4 of 6 based on the number of patients included in the medical personnel response time category, it can be seen that most of the patients were included in the fast category (80.3%) of 196 patients, while others were included in the slow category (19.7%) of 48 patients. tabel 5. distribution of response time on trauma dan non trauma patients triage color response time fast slow mean of response time trauma 35 6 6,244 minute non trauma 161 42 3,722 minute total 196 48 4,15 minute based on the table above, it can be seen that patients with trauma categories including fast response time are 35 patients and 6 patients are slow with an average response time of medical personnel of 6.244 minutes. there were 161 patients with non-trauma category including fast response time and 42 patients late with an average response time of medical personnel of 3,722 minutes. the results of the comparative test using the chisquare test obtained a pvalue of 0.374 (>0.05). this indicates that there are no significant differences between the response time of medical personnel in trauma and non-trauma patients handling. discussion this research was conducted at soetomo hospital’s emergency room on 10-15th october 2017 by taking data from medical records. researchers took the purposive sampling technique by setting certain criteria. the data included gender, age, triage color code, time when the patient arrived and the time when patient left the emergency room, the patient's disease diagnosis, and the category of patients with traumatic or non-traumatic wounds. response time is the time between the patient's arrival and the patient's early treatment.6,7,8 this study found that the largest number of patients who visited the emergency room were 75 (30.7%) patients with the elderly age group (46-65 years). there were more males (52%) than females (48%). similar to takaendengan (2016), there were 33,05% patients with 45-64 years old at prof. dr. r. d. kandou hospitas’s emergency room.9 there were 2 types of wounds, traumatic and nontraumatic wounds. from the results of this study, it was found that the number of non-traumatic patients were 83,2%. it was greater than traumatic patients. almost same with dahliana (2015) at yogyakarta, it was 53,3% of non-traumatic patient.10,11 according to kepmenkes ri (2008) regarding the minimum standard of hospital services, the response time should be 5 minutes. therefore, in this study, the response time is categorized as fast if 5 minutes, and if it is said to be slow if it is > 5 minutes.2,12 it was found that the overall fast response time in the soetomo hospital’s emergency room was about 196 (80.3%) of the total 244 sample visits obtained. with an average response time of 4.15 minutes or 4 minutes 15 seconds. the fahilah’s study (2015) at dr. m. djamil hospital padang had an average response time of 6.15 minutes or 6 minutes 15 seconds.13 avidar et al medical and health science journal 2021 august vol.2 (02) page 5 of 6 in the most emergency room including soetomo hospital’s emergency room, trauma cases are divided into 3 main categories based on their causes, there are traffic accident, work accident and household accidents.14 trauma is a wound or injury, both physical and psychological, caused by physical action by breaking the normal continuity of a structure.15 trauma, in other words, is called injury or wound, which can be interpreted as damage or injury due to hard contact with something so that a tissue is opened in the human body.16 the response time itself was faster for nontraumatic wounds with a mean of 3.722 minutes or about 3 minutes 43 seconds. in trauma wounds, the response time averaged 6.244 minutes or about 6 minutes 15 seconds. the p-value of the chisquare comparison test was 0.374 (p> 0.05). this shows that there is no difference in response time for medical personnel in trauma and non-traumatic patients handling. traumatic patients may have a longer response time (6.244 minutes) because in severe cases they need to wait for the approval by the supervising doctor. the supervising doctor itself holds responsibility for any action taken on patients. the supervising doctor must give an agreement, so the procedure for action requires a longer waiting time. this study was only conducted for one week so it requires further research with a longer observation time. conclusion the response time for traumatic patients has not met the applicable standards and the response time for non-traumatic patients has met the applicable standards. there was no difference in the response time of medical personnel in trauma and nontraumatic patients handling (p>0,05). overall, it was found that the average emergency room’s response time at soetomo hospital still met the applicable standards. acknowledgment thanks to all authors and researchers who have helped in completing this study conflict of interest the author stated there is no conflict of interest references 1. jenderal bina pelayanan medik departemen kesehatan tahun 2007 2. kepmenkes ri no.129 tentang standar pelayanan minimal rumah 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(online) 11. mahyawati. 2015. hubungan kegawatdaruratan pasien dengan waktu tanggap perawat di igd rs pku muhammadiyah yogyakarta. (online) 12. wilde, e.t. 2009. do emergency medical system response times matter for health outcomes?. new york: columbia university 13. fadhilah, n., harahap w., & lestari, y. 2015. faktor-faktor yang berhubungan dengan waktu tanggap pada pelayanan kasus kecelakaan lalu lintas di instalasi gawat darurat rumah sakit umum pusat dr. m. djamil padang tahun 2013. jurnal kesehatan andalas; 4 (1). pp : 195-201 14. gerber p zimmerman, mcnair r & herr r. 2006. triage nursing secrets. missouri: mosby inc. from triage exxence and process. 15. hunt, kt. 2003. wound healing. in: doherty mg. current surgical diagnosis and treatment. 12th ed. p75-87. mcgraw-hills : usa. 16. mann a, niekisch k, schirmacher p, blessing m. 2006. granulocyte-macrophage colony stimulating factor is essential for normal wound healing. medical and health science journal 2021 february, vol 05 (01) original article the effect of caulerpa cylindracea extract on histopathology depiction of male rattus norvegicus gaster mucosa induced by indomethacin adya hidayatullah, nita pranitasari, fitri handajani* fakultas kedokteran, universitas hang tuah *correspondence: fitrihandajanidr@gmail.com article info article history: received july 20, 2020 accepted february 17, 2021 keywords: caulerpa cylindraceaextract, mucosaldamage, indomethacin abstract background: a lot of food can repair gastric mucosal damage. for example, sea grapes or the caulerpa cylindracea with its flavonoid content. anti-inflammatory and anti-ulcer effect can reduce gastric lesions due to ulcerogenic agents. indomethacin is used to induce gastric ulcers in experimental animals. based on this background, this study was conducted to analyze the effect of caulerpa cylindracea extract, on the histopathological picture of gastric mucosal damage of rattus norvegicus male rats. method: 32 male rattus norvegicus rats were divided into 4 groups, (1) group k (-), the untreated group, (2) group k (+) inducedby indomethacin 30 mg/kgbb per head (3) group p1 inducedbyindomethacin 30 mg/kgbb and caulerpa cylindracea extract 1 gr/100grbb per subject, (4) group p2, induced by indometacin 30 mg/kgbb and 2 gr/100grbb of caulerpa cylindracea extract per subject for 7 days. at the end of the study, the experimental animals were sacrificed and their stomachs were histopalogicalexamined result: there was a significant decrease(p = 0.001) in the degree of gastric mucosal damage between the p1 group (given indomethacin and 1 gr/100grbb caulerpa cylindracea extract) and k + groups (given only indomethacin). there was a significant decrease (p = 0.001) in the degree of gastric mucosal damage between k (+) group and group p2 that given indomethacin and 2 g/100grbb caulerpa cylindracea extract. there was a significant a significant decrease (p = 0.004) in the degree of gastric mucosal damage between between group p1 and group p2. data revealed on group k (-) without any treatment did not obtain significant results (p = 0.060) with group p2. conclusion: giving caulerpa cylindracea extract with 1 gr/100grbb dose and 2 gr/100grbb dose can repair mucosal damage in rattus norvegicusmale rats induced by indomethacin. medical and health science journal. introduction gastritis is an inflammation that occurs in the mucosal layer of the stomach. the inflammation may be accompanied by bleeding into the mucosa and in more severe cases epithelial erosions of the mucosal surface may occur. gastritis can arise due to infection with the helicobacter pylori bacteria; use of non-steroidal anti-inflammatory drugs (nsaids) or severe stress. usually characterized by mucosal edema and neutrophil infiltration. if this mucosal damage has extended beyond the submucosal layer or deeper, peptic ulcers can appear1. according to who data in may 2014, peptic ulcer or stomach ulcer has caused 1,081 deaths in indonesia or 0.08% of total deaths. there are two types of peptic ulcers that are often found, that are gastric ulcer and duodenal ulcer. this naming is based on the location of the ulcer, gastric ulcer in the stomach, while duodenal ulcers in the mailto:fitrihandajanidr@gmail.com asus typewritten text 1 medical and health science journal 2021 february vol 05 (01) duodenum. peptic ulcers caused by an imbalance between defensive and aggressive factors that maintain the integrity of the gastric mucosa 2. there are several food ingredients with anti-inflammatory properties that can maintain the integrity of the gastric mucosa, one of which is sea grapes. one type of sea grape is caulerpa racemosa, a variant of cylindracea, from a group of green algae that lives in several indonesian waters. the algae variety type c. cylindracea is a species commonly consumed as vegetables or fresh vegetables by people in tropical areas such as in indonesia. based on the research of santoso (2004) extracts of caulerpa sp. contains three kinds of catechins (fiavanol), namely gallo catechin, epicatechin and catechin gallat. catechins are the products of plant metabolites which are included in flavonoids. flavonoids are one of the most effective ingredients that function pharmacologically as antibacterial, anti-viral, anti-inflammatory and antioxidant3,4. flavonoids are very effective and have low toxicity as a treatment for gastrointestinal diseases, especially peptic ulcers. flavonoids act to protect the gastrointestinal mucosa from lesions formed from various ulcer models and can also protect the mucosa from necrotic agents. there are several mechanisms of action involved in the protective effects of flavonoids, the most important of which is their antioxidant properties. apart from having gastroprotective properties, flavonoids can also improve the healing process of gastric ulcers 5. indomethacin is one of the nsaids and a group of drugs that is most widely consumed worldwide for its analgesic, antipyretic, and anti-inflammatory effects. this group of drugs has side effects, one of which is aggressive factors that can cause damage or lesions to the gastric mucosa, both locally and systemically, in the form of gastritis and peptic ulcer. indomethacin induction can be a method to make experimental animals experience gastritis and peptic ulcer. based on the results of the exploration, it was found that the 30 mg / kgbb dose of indomethacin is the optimal dose to cause bleeding and peptic ulcer in the stomach.6,7. based on the background, the study was designed to determine the effect of sea grape extract (caulerpa cylindracea) on the histopathological picture of indomethacin-induced male rats (rattus norvegicus) gastric mucosal damage. method this research was conducted in the biochemistry laboratory of the faculty of medicine, hang tuah university, surabaya for 29 days with the etical clearance number i/027/uht.kepk.03/vii/2019. the design of this study was a laboratory experimental study using a post-test only control group design. the study used 32 male white rats (rattus norvegicus) of the wistar strain with a body weight of 150-200 grams, divided into negative control group (k-) ornormal/untreated group, positive control group (k+) : that group was given indomethacin induction at a dose of 30 mg / kgbw per day for 7 days, treatment group 1 (p1) : that group was given indomethacin at a dose of 30 mg / kgbb and sea grape extract at a dose of 1 gr / 100grbb per day for 7 days, treatment group 2 (p2) : that group was given indomethacin at a dose of 30 mg / kgbb and sea grape extract at a dose of 2 gr / 100grbb for 7 days.6 the sampling technique is simple random sampling. on the 29th day, all groups of rats were anesthetized to take their gastric organs and then made histological preparations with haematoxillin eosin as an addition. the preparation is then viewed using a light microscope with a 40-fold magnification and assessed by looking at the integrity of the gastric mucosal epithelial layer with the following scores: • normal / no pathological changes found = 0, • there is desquamation of the gastric mucosal epithelium = 1, • there is erosion of the epithelial surface of the gastric mucosa (the lesion in the epithelium appears to have peeled off almost half) = 2, • ulceration of gastric mucosal epithelium (epithelial cell lesions reaching the muscularis lamina) = 3 8. the data collected was tested using statistical analysis using the spss program in the asus typewritten text 2 medical and health science journal 2021 february vol 05 (01) form of the kruskal-wallis test and then post hoc analysis, namely mann-whitney. result histopathological examination results with magnification 400x figure 1. gastric histopathological figure of each group note: 1. figure a : control negative group; indicates a normal gastric mucosal layer 2. figure b : control positive group; indicates gastric ulcer 3. figure c : treatment group 1 indicates gastric erosion 4. figure d : treatment group 2; indicates an improved gastric mucosa table 1. histopatological score the integrity of the gastric mucosal epithelial layer no k(-) or normal group k(+) p1 p2 1 0 3 2 0 2 0 3 2 0 3 0 3 2 1 4 0 3 2 0 5 0 3 2 1 6 0 3 1 1 7 0 3 1 0 8 0 3 1 0 mean 0 3 1.71 0.43 sd 0 9 0.49 0.53 asus typewritten text 3 medical and health science journal 2021 february, vol 05 (01) the results of the kruskal wallis test obtained a significance value of p (0.001 <α (0.05)) so it can be concluded that there is an effect of giving caulerpa cylindracea extract on the histopathological picture of gastric mucosal damage in indomethacin induced male rattus norvegicus. furthermore, the results of the post hoc test used mann-whitney to determine which groups were different. table 2. the results of the mann whitney test between groups group p value kk+ 0.001 p1 0.001 p2 0.060 k+ p1 0.001 p2 0.001 p1 p2 0.004 the results of data analysis, there is a significant difference between the degree of gastric mucosal damage in the experimental animal group given indomethacin only (k +) and the experimental animal group given indomethacin and sea grape extract at a dose of 1gr / 100grbb (p1). there was a significant difference between the degree of gastric mucosal damage in the experimental animal group given indomethacin only (k +) and the experimental animal group given indomethacin and sea grape extract at a dose of 2gr / 100grbb (p2). and sea grape extract dose of 1gr / 100grbb (p1) with a group of experimental animals given indomethacin and sea grape extract with a dose of 2gr / 100grbb (p2). the results of data analysis on the experimental group k (-) without treatment with the p2 experimental group indomethacin induced and given sea grape extract dose of 2gr / 100grbw did not show any significant results. discussion in group k (-) experimental animals without treatment found no damage or changes in the gastric mucosal histopathological figure of the rats and were given a score of 0 (zero) according to barthel manja's criteria. in the k (+) group, experimental animals induced by indomethacin showed a change in the gastric mucosal histopathological figureof the experimental animals, these changes were in the form of ulcers with a score of 3 (three) according to barthel manja's criteria on the gastric mucosal layer of the experimental animals. the results of data analysis between the k (-) group of experimental animals without treatment with the k (+) group of experimental animals induced by indomethacin showed a significant difference with a significance level of p = 0.001. in the k (+) group, they were given indomethacin induction at a dose of 30mg / kgbw so that it could cause ulcers to form. the way indomethacin works on the stomach is inhibition of cox-i and cox-ii. cox-i in the stomach plays a role in keeping the surface of the stomach healthy by preventing the formation of stomach acid, increasing bicarbonate and mucus production, besides that cox-i is responsible for maintaining homeostasis. cox-ii is responsible for pg (prostaglandin) formation in acute inflammatory conditions. inhibition against cox-ii can relieve signs and symptoms of inflammation while inhibition against cox-i can cause damage or exfoliation (desquamation) of the gastric mucosal layer. indomethacin is more effective in inhibiting cox-i than cox-ii, causing erosion of the gastric mucosa which results in peptic ulcers.9, 10. there was a significant difference between the k (+) group of experimental animals induced by indomethacin, namely p = 0.001 with the p1 group of experimental animals induced by indomethacin and given caulerpa extract. cylindracea dose of 1gr asus typewritten text 4 medical and health science journal 2021 february vol 05 (01) / 100grbb. on the histopathological examination of the gastric mucosa in group p1, it was found that the gastric mucosal layer of the experimental animals was erosion with a score of 2 (two) according to barthel manja's criteria and a small proportion only experienced desquamation with a score of 1 (one) according to barthel manja's criteria. the histopathological examination of gastric mucosa in group p2 experimental animals induced by indomethacin and given 2gr / 100grbb of caulerpa cylindracea sea grape extract, it was found that changes in the gastric mucosa layer were even better, namely only in the form of desquamation with a score of 1 (one), even some preparations showed a score of 0 (zero). ) according to barthel manja's criteria. the comparison between the k (+) group of experimental animals induced by indomethacin and the p2 group of experimental animals induced by indomethacin and given caulerpa cylindracea extract at a dose of 2gr / 100grbb resulted in a significant difference with a significance level of p = 0.001. this research used caulerpa cylindracea extract. caulerpa sp contains three kinds of catechins (fiavanol), namely gallo catechin, epicatechin and catechin gallat. catechins are the products of plant metabolites which are included in flavonoids. flavonoids are one of the ingredients of sea grapes which are pharmacologically most effective as anti-bacterial, anti-viral, antiinflammatory and antioxidant. 10,11, 12 flavonoid compounds can also prevent or reduce gastric lesions induced by ulcerogenic agents with an important mechanism that flavonoids have is anti-ulcer activity. the protective effect through its anti-histamine properties can reduce histamine levels and thus prevent the release of histamine from gastric mast cells and inhibit gastric h + / k + proton pump, stimulate mucosubstance synthesis in gastric mucosa and increase prostaglandin levels thereby reducing gastric acid secretion. 5, 10, 13 the results of the analysis test between the p1 experimental animal groups that were induced by indomethacin and given caulerpa extract. cylindracea dose of 1gr / 100grbb with the experimental group p2 indomethacin induced and given caulerpa cylindracea extract at a dose of 2gr / 100grbb showed significant differences with a significance level of p = 0.004. this shows that there is a significant difference with the addition of the dose of sea grape extract. the results of the data analysis test in the experimental group k (-) without treatment with the p2 experimental group that was induced by indomethacin and given caulerpa cylindracea extract at a dose of 2gr / 100grbb did not get any significant results. (p = 0.060) so it can be interpreted that the induction in the p2 group was able to improve with results that were close to normal.12, 13 the results of thisresearch, the giving caulerpa cylindracea extract can significantly reduce / repair lesions in the gastric mucosal layer in male rats (rattus norvegicus) indomethacin induced. conclusion indomethacin inductionin male rattus norvegicuscaused gastric ulcers. caulerpa cylindracea extract at a dose of 1gr / 100grbb and 2gr / 100grbb can repair indomethacin-induced damage to the gastric mucosal layer of male rattus novergicus. 2gr / 100grbb dose of caulerpa cylindracea extract can repair indomethacininduced damage to the gastric mucosal layer of male rattus novergicus better than caulerpa cylindracea extract at a dose of 1gr / 100grbb. references 1. kumar, v, abbas, vausto, aster. (2014) robbins and cotran pathologic basis of disease, professional edition e-book, elsevier health sciences. 2. irramah, m. (2017) ‘pengaruh uncaria gambir terhadap ulkus gaster dan kadar malondialdehid hewan coba yang diinduksi etanol’, majalah kedokteran andalas, 40(1), p. 1. doi: 10.22338/mka.v40.i1.p110.2017. 3. zhou, y.-x, zein, rahman, wang, peng, zang. (2015) ‘portulaca oleracea l.: a review of phytochemistry and asus typewritten text 5 medical and health science journal 2021 february vol 05 (01) pharmacological effects ’, biomed research international. doi: 10.1155/2015/925631 4. ridhowati, s. and asnani (2016) ‘potensi anggur laut kelompok caulerpa racemosa sebagai kandidat sumber pangan fungsional indonesia’, oseana. 5. de lira mota, k. s, dia n u, pinto mne, luiz fereira, souza-brito. (2009) ‘flavonoids with gastroprotective activity’, molecules, 14(3), pp. 979–1012. doi: 10.3390/molecules14030979 6. mustaqim, a. and asri, a. (2016) ‘artikel penelitian pengaruh pemberian gel lidah buaya ( aloe vera ) terhadap gambaran histopatologi gaster tikus wistar yang diinduksi indometasin’, 3(3), pp. 641– 646. 7. istri indraswari, c., kalsum, u. and sudjari, s. (2017) ‘pengaruh pemberian temulawak pada lambung tikus yang mengalami ulkus peptikum akibat induksi indometasin’, jurnal kedokteran brawijaya. doi: 10.21776/ub.jkb.2004.020.02.8 8. barthel, m. et al. (2003) ‘pretreatment of mice with streptomycin provides a salmonella enterica serovar typhimurium colitis model that allows analysis of both pathogen and host.’, infection and immunity. 9. mediansyah, a. and rahmanisa, s. (2017) ‘hubungan ibuprofen terhadap ulkus gaster’, jurnal majority, 6, pp. 6–10. 10. redha, a. (2010) ‘flavonoid: struktur, sifat antioksidatif dan peranannya dalam sistem biologis’, jurnal teknologi pertanian politeknik negri pontianak, 9(2), pp. 196–202. doi: 10.1186/2110-5820-1-7. 11. handajani f, 2019. oksidan dan antioksidan pada beberapa penyakit dan proses penuaan. penerbit: zifatama jawara. p 5-19 12. yudasmara ga, 2017. budidaya anggur laut (caulerpa racemosa) melalui media tanam rigid quadrant nets berbahan bambu. jurnal sains dan teknologi; 3(2):468-473.doi: 10.23887/jstundiksha.v3i2.4481. 13. handajani dan prabowo, 2020. the effect of sea grapes (caulerpa cylindrica) to gastric inflammatory cell infiltration score and catalase activity in indomethacin-induced wistar rats. sys rev pharm ;11(10):556-563 asus typewritten text 6 medical and health science journal 2021 february, vol 05 (01) the labor-induced pregnancy cases in dr soetomo general hospital: a descriptive study alfin firasy* 1 , budi wicaksono 2 1 departement of obstetrics and gynecology, faculty of medicine, universitas airlangga dr.soetomo general academic teaching hospital, surabaya 2 fetomaternal division, departement of obstetrics and gynecology, faculty of medicine, universitas airlangga dr. soetomo general hospital, surabaya *correspondence: alfinfirasy@yahoo.com article info article history: received july 30, 2020 accepted february 16, 2021 keywords: induction of labor, prostaglandin e2, misoprostol abstract background: labor induction is a procedure to stimulate uterine contractions during pregnancy before labor begins on its own to achieve a vaginal birth with medical or mechanical intervention to start the labor. this procedure aims to stimulate more extensive contraction in the uterus. the labor induction can reduce the caesarean rate. prostaglandin e2 (pge2) and misoprostol are the commonest medicine used to ripen the cervix in the dr. soetomo hospital. objective: our study aim to evaluate the success rate of induction of labor patient methods: this study was a descriptive study using the medical record in 2018 in the dr. soetomo general hospital, surabaya. a total of 183 patient’s medical record data who underwent induced labor were used in this study. inclusion criteria were the women with indication to deliver and have no cephalo-pelvic disproportion. women with contraindication labor induction were excluded. data was described using table and narrative approach. results: the most range of gestational age was 21-36 weeks (53.01%) followed by 37-42 weeks (42.07%). there were 68 patients (37,1%) primigravida and 115 patients (62,8%) were multipara. the major induced labor was conducted with misoprostol (78.6%), and the most pelvic scores were 2 (58.46%) before underwent induced labor. vertex delivery was the preferred mode of delivery after the induction of labor with 89 patients (48,62%). the labor induction failure followed with the caesarean operation were 27 patients (14,7%) and one patient (0,54%) with hysterotomy, most of them caused by failure to progress and fetal distress. there were 78 babies (43%) with the weight over 2500 g, 28 babies (31%) were over 2000 g, and the other was below 2000 g. a total of 84.71% with labor induction can be delivered vaginally, and it is a good number to reduce the rate of caesarean operations. conclusion: this study concludes that misoprostol uses for the induction of labor than the other. delivery abdominal is less percentage than the additional delivery finds that as a failure of induction of labor. the labor induction success to delivered vaginally can reduce the rate of caesarean operation. medical and health science journal. original article sumail typewriter 7 mailto:alfinfirasy@yahoo.com medical and health science journal 2021 february, vol 05 (01) introduction induction of labor is a procedure to stimulate the uterus contraction before the spontaneous onset of labor condition with pharmacological or mechanical intervention. the indication of labor induction is when the safety and benefits to both mother and fetal is more important than the pregnancy continuation. the indication includes membrane rupture without labor, gestational hypertension, oligohydramnios, non-reassuring fetal status, post-term pregnancy, and various maternal medical conditions such as chronic hypertension and diabetes. the maternal side’s contraindications are related to prior uterine incision, contracted or distorted pelvic anatomy, abnor-mally implanted placentas, and uncommon conditions such active genital herpes infection or cervical cancer. the fetal factors consist of appreciable macrosomia, severe hydrocephalus, malpresentation, or non-reassuring fetal status (1). the induction of labor can reduce the caesarean section rate. the incidence of labor induction for shortening the duration of pregnancy has risen. in high-income countries, the proportion of infants delivered at term following labor induction is one in four births. (2) in the united states, labor induction incidence rose 2.5 fold from 9.5 percent in 1991 to 23.8 percent in 2015 (3). one-fifth of delivery in the uk is inducing due to safety concerns for the mother or fetus (4). socioeconomics is one of the risk factors for labor induction in the united kingdom (5). there is no data labor induction in indonesia, but there were some data in bahagia hospital, makassar, which were 22,9 percent of all delivery in 2017 and 5,9 percent in 2018 (6). the induction mechanisms are varying from mechanical to pharmacological or medicinal. the mechanical methods for induction makes cervical ripening and onset of labor by stretching the cervix. they are amongst the oldest methods used to initiate labor. during the last decades, medication such as prostaglandin e2 (pge2), misoprostol, and oxytocin have partly replaced mechanical means (7). previous study by trihastuti found that oral administration of misoprostol is safe in decreasing the interval to delivery on 40 weeks gestation women (8). there's a research in the uk comparing the usage of misoprostol vaginal inserts (mvi), and dinoprostone vaginal inserts (dvi) which showed that mvi is better than dvi in reducing time, and duration of active labor, leading to estimated reduced resource use in terms of hospital staff shift and length of stay in hospital. reducing the resource utilization could improve efficiencies and optimize patient care without increasing the burden of hospital resources. (9) some studies show that labor induction is more beneficial than expectant delivery management improves perinatal outcomes without increasing caesarean section rates (10) (11). in this study we aimed to evaluate of induction of labor in dr. soetomo general hospital. methods design and setting: we studied pregnant women admitted for labor induction in the department of gynecology and obstetrics at dr. soetomo general hospital, surabaya. this institution is a public medical care center and one of the most important maternal care facilities in east of java, indonesia. it receives referrals patients mainly from the peripheral maternities within the east of java region and also within the surrounding areas. a cross sectional descriptive study was conducted over twelve months form 1 st january to 30 th december of 2018 using patients medical records. this study was approved the ethical committee from soetomo hospital. population: we included all women with pregnancy-related complications while pregnant (antenatal complications need urgent delivery), during labor or within immediate postpartum. inclusion criteria were all pregnant women with an indication of the induction of labor and with no cephalo-pelvic disproportion during the study period. women with sumail typewriter 8 medical and health science journal 2021 february, vol 05 (01) contraindication labor induction were excluded such as history of previous caesarean section, malposition of aterm fetus, history of myomectomy or uterine rupture. data collection and analysis: we used patient’s medical records and followed their history including after delivery and during post-natal hospitalization. the following information were extracted: current pregnancy characteristics, management of childbirth, and the outcome of the labor and the babies. for more precision, information about final diagnoses and prognoses were obtained from the receiving midwife at referral hospital, or from the obstetric outpatient clinic. descriptive analysis was performed using microsoft excel. results table 1 – characteristic patient induction of labor characteristic cases % patients age group 17 34 years old 138 75,4 ≥ 35 years old 45 24,6 parity primiparous 68 37,15 multiparous 115 62,84 gestational age ≤ 20 weeks 9 4,91 21 36 weeks 97 53,01 37 42 weeks 77 42,07 from the data that we gathered throughout 2018, we found a total 1454 birth medical records, and a total of 183 that fulfilled the inclusion criteria, and 92 were excluded due to malposition of the fetus, history of myomectomy, and history of previous caesarean section. which the majority of the subject (75,4%) was age 17 – 34 years old. the most range of gestational age was 21-36 weeks (53.01%) followed by 37-42 weeks (42.07%). there were 68 patients (37,1%) primigravida and 115 patients (62,8%) were multipara. sumail typewriter 9 medical and health science journal 2021 february, vol 05 (01) table 2 – induction of labor in dr. soetomo general hospital in 2018 variable cases % induction methods misoprostol 144 78,6 oxytocin induction 26 14,2 misoprostol + oxytocin induction 5 2,73 transcervical cathether 2 1,09 transcervical cathether + misoprostol 4 2,18 laminaria 2 1,09 misoprostol administration method orally 18 12,50 vaginally 126 87,50 intial pelvic score before induction ps 2 107 58,46 ps 3 53 28,96 ps 4 6 3,27 ps 5 17 9,28 the major induced labor was conducted with misoprostol (78.6%) followed by oxytocin induction (14,2%). most of the administration of misoprostol to the patient were by vaginally (87,5%, and the most pelvic scores were 2 (58.46%) before underwent induced labor. table 3 – disease characteristic of induction of labor table 3 – induction of labor in dr. soetomo general hospital in 2018 vertex delivery was the preferred mode of delivery after the induction of labor with 89 patients (48,62%). the major disease that indicate to the patient need termination were severe preeclampsia (20,2%), followed by premature rupture of membrane (prom) (16,93%). sumail typewriter 10 medical and health science journal 2021 february, vol 05 (01) table 4 – induction of labor outcome vaginal delivery was the preferred mode of delivery after the induction of labor with 132 patients (72,28%). complications found during induction of labor are abnormality of nst and fetal distress (92,5%) and only two patient have to failure to progress. the labor induction failure followed with the caesarean operation were 27 patients (14,7%) and one patient (0,54%) with hysterotomy. from the perinatal outcome there were 78 babies (43%) with the weight over 2500 g, 28 babies (31%) were over 2000 g, and the other was below 2000 g. the most of the baby with apgar score >6 (43,71%). discussion we have identified that most pregnant women with an indication of the induction of labor were at a productive age (17 – 34 years old), and most of them were multigravida. some patients with advanced maternal age are over 35 years old and may increase multiple adverse effects for both mother and baby. it may increase of obstetric complications, including placental abruption, placenta praevia, malpresentation, low birthweight. it also increases preexisting maternal medical conditions, including hypertension, obesity, and diabetes, increasing maternal age as do pregnancy-related maternal complications such as pre-eclampsia and gestational diabetes (14). the most common the age of gestation was below 37 weeks, this condition caused by a few of the severe preeclampsia cases that indicated the women terminated the pregnancy soon. in non-severe preeclampsia, it can provide expectant management until 37 weeks of gestational age (10). our study demonstrated that misoprostol administration was the main medical treatment used in labor induction at preterm and term birth. this result was in line with dr. soetomo hospital's labor protocol. the application of misoprostol 50 ug vaginally has wider in cervical ripening and laborinduction than orally. however, this procedure required close monitoring of the patients for the abnormal contractions (12). another study has shown that the time to delivery was shorter variable cases % mode of delivery spontaneous/ vaginally labor 132 72,28 forceps extraction 23 12,50 caesarean section 28 15,22 complications during labor induction fetal distress / abnormality of nst 25 92,5 failure to progress 2 7,4 perinatal outcome <500 gr 21 11 500 2000 gr 56 15 2000 2500 gr 28 31 > 2500 gr 78 43 apgar score 0 49 26,77 <4 30 16,39 4-6 24 13,11 >6 80 43,71 sumail typewriter 11 medical and health science journal 2021 february, vol 05 (01) in those women who were receiving vaginal misoprostol than oral administration. more women in the oral group required oxytocin augmentation of labor. the hyperstimulation incidence was similar between the groups, but there was an increased incidence of tachysystole in the vaginal group. there was no difference between the groups due to the mode of delivery or neonatal outcome (13). preterm cases were the most cases of gestational age, and it happened because of the second most of the cases were indicated by severe preeclampsia and preterm premature rupture of membrane (pprom) (10). in other study compared to expectant management, a strategy of labor induction was associated with fewer perinatal mortality. there were four perinatal deaths in the labor induction group than 25 perinatal mortality in the expectant management group. there were also lower cesarean rates without increasing rates of operative vaginal births, and there were fewer nicu admissions with a policy of induction (10). there are improvements perinatal outcomes in the induction of labor from 37 weeks of gestation without increasing the cesarean section rate (11). conclusion our results showed that misoprostol vaginally is the primary medicine used for labor induction in dr. soetomo general hospital. the induced cases have mainly achieved spontaneous/ vaginally birth, and most of them reached over six points on the apgar score. our results indicated that inducing labor in indicated pregnancy is a relatively standard and safe procedure to terminate the pregnancy and conduct a spontaneous/ vaginally birth. however, further intense study is required to assess the risk factors in conducting labor induction. references 1. cunningham, f. g. (2018). induction and augmentation of labor. williams obstetrics. 25th edition, 503–511. 2. caughey, a. b. (2012). post-term pregnancy. dewhurst’s textbook of obstetrics & gynaecology: eighth edition, 4(3), 269–286. 3. martin, ja, hamilton, fetal: births final data for 2015.natl vital stat rep 66(1):1,2017 4. petrou s, taher s, abangma g, eddama o, bennett p. bjog. 2008;118(6):726–34 5. carter, s., channon, a., & berrington, a. (2020). socioeconomic risk factors for labour induction in the united kingdom. bmc pregnancy and childbirth, 20(1), 1–13. 6. aspar, h., harun, a. and sukarsih, s., 2019. faktor yang berhubungan dengan kejadian keberhasilan induksi persalinan di rumah sakit umum bahagia makassar tahun 2019. jurnal kesehatan delima pelamonia, 3(2), pp.111117. 7. de vaan, m. d., ten eikelder, m. l., jozwiak, m., palmer, k. r., daviestuck, m., bloemenkamp, k. w., mol, b. w. j., & boulvain, m. (2019). mechanical methods for induction of labour. cochrane database of systematic reviews. 8. trihastuti, m. p., & purwaka, b. t. (2015). pengaruh pemberian misoprostol 25 µg peroral ambulatoir pada tenggat waktu persalinan wanita hamil > 40 minggu resiko rendah. majalah obstetri & ginekologi, 23(1), 1. 9. draycott, t., van der nelson, h., montouchet, c., ruff, l., & andersson, f. (2016). reduction in resource use with the misoprostol vaginal insert vs the dinoprostone vaginal insert for labour induction: a model-based analysis from a united kingdom healthcare perspective utilization, expenditure, economics sumail typewriter 12 medical and health science journal 2021 february, vol 05 (01) and financing systems. bmc health services research, 16(1), 1–9 10. middleton, p., shepherd, e., morris, j., ca, c., jc, g., middleton, p., shepherd, e., morris, j., ca, c., & jc, g. (2020). induction of labour at or beyond 37 weeks ’ gestation (review). 11. stock sj, ferguson e, duffy a, ford i, chalmers j, norman je. outcomes of elective induction of labour at term compared with expectant management: population based study. bmj 2012 may;344:e2838. 12. jindal, p., avasthi, k., & kaur, m. (2011). a comparison of vaginal vs. oral misoprostol for induction of labor-double blind randomized trial. journal of obstetrics and gynecology of india, 61(5), 538–542. 13. fisher, s. a., mackenzie, v. p., & davies, g. a. l. (2001). oral versus vaginal misoprostol for induction of labor: a double-blind randomized controlled trial. american journal of obstetrics and gynecology, 185(4), 906–910. 14. rcog. (2013). induction of labour at term in older mothers: rcog scientific impact, 34. sumail typewriter 13 medical and health science journal, vol. 4, no.2, august 2020 correspondence: laily irfana @2020 medical and health science journal. 10.33086/mhsj.v4i1.1415 available at http://journal2.unusa.ac.id/index.php/mhsj 76 the effect of citicolin in motoric improvement of acute ischemic stroke patients in siti khodijah sepanjang hospital dza’wan maula iwanatud diana 1 , laily irfana 2* , yelvi levani 3, uning marlina 4 1 medical student, university of muhammadiyah surabaya 2,3,4 faculty of medicine university of muhammadiyah surabaya *corresponding author: irfanalaily@gmail.com article info abstract article history: submitted: june, 26 2020 received in revised form: august,08 2020 accepted: august, 18 2020 background: according to who, stroke is most common cause of morbidity and mortality around 5,54 millions death. stroke is classified into ischemic stroke and hemorrhagic stroke. ischemic stroke is caused by vascular blockage in the brain, whereas hemorrhagic stroke is caused by vascular ruptures. ischemic stroke is treated by thrombolytic for reperfuison and anticoagulant or antiplatelet to prevent the formation of thrombus collateral blood brain. moreover, it also can add neuroprotectant to inhibit further tissue and cellular damage due to cytotoxic effect. the common used of neuroprotectant are piracetam and citicolin. they increase erythrocyte capability in blood vessels without alter shape or function of erytrhocyte. citicolin improves neuronal cells membrane by increasing synthesis of phosphatidylcholine as main component of cells membrane. citicolin often chosen because cheaper and there is no significance different effect between both of them. objective: to investigate motoric improvement in acute ischemic stroke patients in siti khodijah sepanjang hospital. methods: study design is observational retrospective case-control using medical record from january-september 2019. we devided 72 patients into two groups: control group who received antiplatelet 100 mg/day for 5 days and treatment group who received combination of antiplatelet 100 mg/day and citicolin 500 mg/day for 5 days. patients were examined using medical research council manual muscle test scale on first and fifth day. the criteria of motoric improvement is manual muscle testing scale score increased > 1 score in one of extremitas muscles. results: statistic test used chi-square test and wilcoxon test with each significance grade 0,00 and 0,01 (<0,05). conclusion: our study indicated that citicolin 500 mg/day for 5 days significantly improved motoric in acute ischemic stroke patients in siti khodijah sepanjang hospital. @2020 medical and health science journal. 10.33086/mhsj.v4i1.1415 keywords: ischemic stroke, citicolin, motoric improvement introduction stroke is the global burden disease that can cause death or disablities problem. stroke, based on its etiology, classified into ischemic and hemorrhagic stroke. ischemic stroke is caused by vascular blockage in the brain, whereas hemorrhagic stroke is caused by vascular ruptures. ischemic and hemorrhagic stroke can be treated with general therapy and special therapy, which is obviously different. based on its patophysiology, ischemic stroke treatment divided into three steps. the first step is thrombolytic treatment for brain reperfusion. the second step is anticoagulant or antiplatelet to prevent thrombus growth in collateral blood vessels. the third is a neuroprotectant treatment in order to ovoid expansion of neuroglia injury as a result of cytotoxic process 1 . neuroprotectant commonly used is piracetam and citicoline, both single and combination 2 . piracetam attempts to increase erythrocyte capability in blood vessels without causing neither transformation nor erythrocyte function. therefore ischemic brain parenchyma original article medical and health science journal, vol. 4, no.2, august 2020 77 will be recovered 3,4 . citicoline attempts to increase the main component of cell membrane synthesis, phosphatidylcholine that is increasing neuronal cells membrane improvement 4,5 . ischemic stroke can cause motoric dysfunction, including pareses or muscle weakness. the muscle strength test is used to evaluate muscle weakness. this test is used for patients who are suspected of neurologic abnormality, especially in stroke, head injury, spinal cord injury, and neuropathy. the scale of this test uses medical research council manual muscle testing scale (mmts) 6 . based on previous studies, the evaluation of neuroprotectant effect in motoric function, cognitive, consciousness and activity daily living of stroke ischemic patients, that have been reviewed with nihss (national institutes of health stroke scale), gcs (glasgow coma scale), barthel index and another score showed different result. therefore, this study aimed to evaluate the effect of neuroprotectant treatment for motoric improvement used medical research council manual muscle testing scale (mmts) in acute ischemic stroke patients. study method this study was observational with casecontrol approach. the design of this study was retrospective by analyzing ischemic stroke patient medical records. this study used a medical record of ischemic stroke patients on the period january-september 2019. the total sample was 72 patients divided into two groups, control group, and treatment group, each of them was 36 patients. this study used patients who fit to exclusion and inclusion criteria. the inclusion criteria were ischemic (i) stroke patients who got first attack, (ii) diagnosed with < (-1) siriraj score, (iii) obtained standard antiplatelet therapy (aspilet 100 mg per-oral), (iv) strength muscles will be measured by mmts (manual muscle testing scale) scale in a range 0-4 and was graded by comparing the left and right body side 6 . the patient’s motoric strength was examined in musculus biseps brachii and musculus quadriseps femoris. the exclusion criteria were patients who had repetitive stroke profiles and being hospitalization less than 5 days. in siriraj interpretation < (-1) score means ischemic and > 1 score means hemorrhagic stroke. control group was given antiplatelet 100 mg/day for 5 days. while treatment group was given the combination of antiplatelet 100 mg/day and citicoline 500 mg/day for 5 days. the patient’s motoric strength was examined using mmts on the first and fifth day of therapy. criteria for motoric improvement was increasing of mmts score > 1 score in one of the measured extremity muscles. data collection and statistical analysis procedure used spss 25 version (with p < 0.05 means a significant result). health ethic research committee of siti khodijah sepanjang hospital has approved this study with a code number 024/ketkepk/xii-2019. results 1. the characteristic of ischemic stroke patients in siti khodijah sepanjang hospital table 1 indicates that most of the ischemic stroke patients aged was 55-64 years (33,3%). ischemic stroke patients were dominated by females. hypertension and siriraj score (2,5 x consciousness) + (2 x vomit) + (2 x headache) + (0,1 x diastolic pressure) – (3 x atheroma) – 12 = 0 1 2 consciousness aware sleepy, stupor semi-coma, coma vomit no yes headache in 2 hours no yes atheroma (diabetes mellitus, angina) no yes medical and health science journal, vol. 4, no. 2, august 2020 78 diabetes mellitus were the risk factors of ischemic stroke. from 72 ischemic stroke patients, there were 56 (77,8%) patients who had hypertension, and more than half patients had diabetes mellitus. table 1 the characteristic of ischemic stroke patients the characteristic of ischemic stroke patients frequency persentage age 33-44 7 9.7 45-54 17 23.6 55-64 24 33.3 65-74 15 20.8 >75 9 12.5 gender female 43 59.7 male 29 40.3 hipertension having hipertension profile 56 77.8 nothing hipertension profile 16 22.2 diabetes mellitus having diabetes profile 39 54.2 nothing diabetes profile 33 45.8 2. result of motoric capability on the first day and fifth day table 2 mmts score of control group and treatment group on the first day of therapy table 2 indicates that mmts score of control group and treatment group at the first day therapy were not quite different. table 3 mmts score of control group and treatment on fifth day of therapy mmts score control group treatment group superior dextra superior sinistra inferior dextra inferior sinistra superior dextra superior sinistra inferior dextra inferior sinistra n n n n n n n n 1 0 3 0 3 1 1 1 1 % 0% 8.3% 0% 8.3% 2.8% 2.8% 2.8% 2.8% 2 3 5 3 5 3 5 3 5 % 8.3% 13.9% 8.3% 13.9% 8.3% 13.9% 8.3% 13.9% 3 2 3 2 3 1 2 2 2 % 5.6% 8.3% 5.6% 8.3% 2.8% 5.6% 5.6% 5.6% 4 17 12 17 12 20 17 19 17 % 47.2% 33.3% 47.2% 33.3% 55.6% 47.2% 52.8% 47.2% 5 14 13 14 13 11 11 11 11 % 38.9% 36.1% 38.9% 36.1% 30.6% 30.6% 30.6% 30.6% n 36 36 36 36 36 36 36 36 mmts score control group case group superior dextra superior sinistra inferior dextra inferior sinistra superior dextra superior sinistra inferior dextra inferior sinistra 1 2 3 2 3 0 1 0 1 medical and health science journal, vol. 4, no.2, august 2020 79 tables 2 and 3 indicate that there are some changes in every score of control group. the number of patients in dextra superior extremity and dextra inferior escalated on score 5, 3 and 1. score 5 from 38.9% becomes 44.4%, score 3, from 5.6% becomes 16.7% and score 1, from 0% becomes 5.6%. score 2 and 4 have decreased, from 8.3% becomes 5.6% and score 4 from 47.2% becomes 27.8%. the number of control group in sinistra superior extremity decreased on score 5 of 36.1% becomes 27.8%, and score 2 from 13.9% becomes 11.1%, while score 4 increased 33.3% becomes 44.4% and another score is constant. on sinistra inferior extremity, number of patients escalated on score 4 from 33.3% becomes 41.7%, and score 5 decreased from 36.1% becomes 27.8%. whereas, alteration score of treatment group indicates that the number of patients on dextra superior extremity and dextra inferior escalated on score 5 and 3. score 5 escalated from 30.6% becomes 52.8%, score 3 escalated from 2.8% (dextra superior extremity) and 5.6% (dextra inferior extremity) becomes 8.3%. score 4 deflated 16.7% (dextra superior extremity) and 13.9% (dextra inferior extremity). score 1 and 2 deflated become 0%. number of patients on sinistra inferior and sinistra superior extremity were escalated. score 5 from 30.6% becomes 52.8%, while score 2, 3 and 4 deflated 11.1%, 5.6% and 5.5%, respectively. while score 1 is constant 2.8%. table 4 median of control group and treatment group on first day and fifth day group extremity first median final median n p control group superior dextra 4 4 36 0,256 superior sinistra 4 4 36 0,768 inferior dextra 4 4 36 0,256 inferior sinistra 4 4 36 0,572 treatment group superior dextra 4 5 36 0,01 superior sinistra 4 5 36 0,01 inferior dextra 4 5 36 0,01 inferior sinistra 4 5 36 0,01 table 4 indicates that control group is in same median on first day and fifth day. it can be seen from significant result by alfa wilcoxon test that > 0,05. while in treatment group, there was increasing median from 4 to 5. after wilcoxon test was done, derived alfa 0.01 (p<0.05) can be concluded that there is a significant motoric improvement in a treatment group. % 5.6% 8.3% 5.6% 8.3% 0% 2.8% 0% 2.8% 2 2 4 2 4 0 1 0 1 % 5.6% 11.1% 5.6% 11.1% 0% 2.8% 0% 2.8% 3 6 3 6 4 3 0 3 0 % 16.7% 8.3% 16.7% 11.1% 8.3% 0% 8.3% 0% 4 10 16 10 15 14 15 14 15 % 27.8% 44.4% 27.8% 41.7% 38.9% 41.7% 38.9% 41.7% 5 16 10 16 10 19 19 19 19 % 44.4% 27.8% 44.4% 27.8% 52.8% 52.8% 52.8% 52.8% n 36 36 36 36 36 36 36 1 medical and health science journal, vol. 4, no. 2, august 2020 80 3. correlation of citicolin treatment with motoric improvement based on mmts table 5 quantity of ischemic stroke sample in siti khodijah sepanjang hospital group treatment group control group motoric improvement total p* p** good not good n n n 0.000 0.434 23 31.9% 13 18% 36 50% 6 8.3% 30 41.6% 36 50% *: chi-square test **: contingency coefficient test table 5 indicates that ischemic stroke patients experience motoric improvement on treatment group are 23 patients (63.8%), while patients who do not experience motoric improvement are 13 patients (36.2%). and ischemic stroke patients who experienced motoric improvement on control group are 6 patients (16.6%) and patients who do not experience motoric improvement are 43 patients (58.9%). the result of the chi-square test indicates that citicoline treatment in ischemic stroke patients with motoric improvement based on mmts has a significance result amount of 0.000 (p<0.05). this result indicates that there is a significant effect from citicoline treatment in motoric improvement patients. the contingency coefficient test was effectuated to evaluate the correlation between of citicoline and motoric improvement; the result was found that p=0.434 positive. it can be concluded that motoric improvement by citicoline treatment in ischemic stroke patients has an effective amount of 0.434, it means the effect is moderate. discussion ischemic stroke is the dynamic process whereby the occlusion of the brain blood vessel can cause large infarct, so the goal of treatment is to re-open the occlusion and to stop the sequence of neuron cell injury. ischemic stroke can cause impairment motoric and cognitive function. this study revealed that ischemic stroke attacks more on females rather than males. this happened due to the fact that every human has a different condition. the risk ischemic stroke can be reduced by healthful lifestyle such as minimize greasy food, eating more fruits, and quit smoking that glucose is well controlled. this study is in line with a previous study that showed stroke patients on female was 54,17%, whereas male was 45,81% 7 . hypertension and diabetes mellitus are the risk factors for stroke ischemic. this study revealed that most patients had hypertension. this study is in line with previous studies that showed from 60 ischemic stroke patients, 44 patients had hypertension (73,33%) 7 . hypertension causes lesion on tunica intima endothelial’s blood vessels that disturb a real function of blood vessels, anti-thrombosis. hypertension causes platelet aggregation or the clumping of platelet in the blood that triggers brain tissue hyperfusion 8 . besides hypertension, most of the patients had diabetes mellitus. diabetes mellitus can cause a lesion on tunica intima so it can cause platelet aggregation and ischemic due to blood vessel constriction. this study is related to a previous study in rsud dr. moerwardi in 2010, they showed that from 66 ischemic stroke patients, there were 47 (71,2%) patients who had diabetes mellitus 9 . basically, ischemic stroke patients related to several factors that result in different outcomes according to the condition. the factors that influenced the outcomes of ischemic stroke are the patient’s age, disease profile, lesion size in a brain, and gcs (glasgow coma scale) during attack. age is related to decreasing of neuronal regeneration process and decreasing medical and health science journal, vol. 4, no.2, august 2020 81 blood vessel elasticity. likewise, another pathology condition such as hyperglycemia and hypertension, also have an effect on reducing neuron cell recovery 10 . the level of consciousness also affects ischemic stroke outcome. it has been proven from previous study that showed stroke patients who had low consciousness with gcs<11 had poor functional improvement than gcs >11 11 . this study was accomplished by analyzing ischemic stroke patient medical records who given citicoline treatment provided per-oral with 500 mg/day, which was provided for first five days of stroke attack. citicoline is composed from two essential element of phospholipids; cytidine and coline. citicolin attempts to increase the main component of cells membrane synthesis, phosphatidylcoline that increasing neuronal cells membrane improvement 4,5 . the data collection procedure was accomplished by citicoline treatment for five days due to the fact that most stroke patients used bpjs. bpjs only allowed provided citicoline therapy for five days for acute ischemic stroke patients during hospitalization. in addition, the effectivity of the first five-days citicoline treatment period is consistent with ulfa’s study (2017). her study showed that there was a significant improvement in first until fifthday therapy, while in the next days, there was insignificance improvement 12 . this study used citicoline treatment with 500 mg doses/day. this dosage is in line with davalos et al study (2010) about oral citicoline dosage in an acute ischemic stroke. they studied different doses of oral citicoline for acute ischemic stroke patients; 500 mg/day, 1000 mg/day, and 2000 mg/day. the study showed that oral citicoline with 500 mg and 2000 mg doses/day gave significance improvement for acute ischemic stroke patients 13 . patients in a treatment group had a significant motoric improvement rather than in the control group. this study result is in line with taufiqurrahman and merry’s case report (2016) about the benefit of citicoline in nonhemorrhagic stroke patients. they reported that the patient firstly came with complaining about facial paralysis and dropped in the right side of the body, gcs 456, 3/5 superior dextra or sinistra extremity by mmts examination, 3/5 dextra sinistra inferior extremity by mmts examination and scored 9 by nihss (national institutes of health stroke scale) examination. after that, 500 mg/day of citicoline and aspilet were provided. in the third day, the patient had 4/5 mmts score and began to speak slowly. therapy continued until the sixth day, and the result is patients can talk as good as usual and got 5/5 for muscle strength score, and also 2 for nihss 14 . this study found out that patients with 500 mg/day citicoline treatment for five days have significant motoric improvement as big as muscles examined, musculus biseps brachii and musculus quadriseps femoris. citicoline has several stages of therapy effect in acute ischemic stroke. first, it stabilizes cell membranes by increasing phosphatidylcholine and sphingomyelin synthesis 15 . citicoline inhibits the release of free fatty acids and glutamate during ischemia 16 . citicoline can decrease the free radical and delayed the ischemic brain injury process 17 . it can also increase synaptic outgrowth and neuroplasticity 18 . these several mechanisms of citicoline can allow the improvement of motoric functional in ischemic stroke patients. however, the researcher realizes that this study needs more, larger sample and long term periods. the direct research to patients and the same examiner can increase validity and minimize valuation subjectivities in mmts scoring. conclusion this study showed citicoline gives benefits for ischemic stroke patients. there is a significant motoric improvement in ischemic stroke patients with treatment by citicoline 500 mg/day for 5 days. further studies required to prove the effectivity of citicoline for the long term period. medical and health science journal, vol. 4, no. 2, august 2020 82 reference 1. margono is, asriningrum, dan abdullah, stroke. buku ajar ilmu penyakit saraf. surabaya: airlangga univercity press. 2011. 2. utami tfy, 2016. efek penggunaan neuroprotektor terhadap perbaikan neurologis pada pasien stroke iskemik di rsup dr. sardjito yogyakarta. m.si thesis. universitas gadjah mada. 2016. 3. praja ds. studi penggunaan obat neuroprotektan pada pasien stroke iskemik di rumah sakit umum dr. saiful anwar malang. s.farm skripsi. universitas muhammadiyah malang. 2017. 4. ismail a, gemy nh, dan andy tnm. pengaruh penggunaan obat piracetam dan citicoline terhadap stroke iskemik di rumah sakit umum daerah (rsud) haji makassar. 2017. 5. doijad rc, pathan ab, pawar nb, baraskar ss, maske vd dan gaikwad sl, 2012. therapeutic applications of citicoline and piracetam as fixed dose combination. journal of pharma and bio science.2012; 2(12), 15-0. 6. naqvi u dan andrew is, muscle strenght grading. treasure island: stat pearls publishing. 2018. 7. marcelina h, et al.. gambaran tekanan darah pada penderita stroke yang dirawat inap di rumah sakit tk ii putri hijau kesdam i/bb medan tahun 2016. jurnal kedokteran metodist. 2018; 11(1),52-5. 8. price sa, patofisiologi konsep klinis prosesproses penyakit edisi 6. jakarta: egc;2015. 9. ramadany af, pujarini la, dan candrasari a. hubungan diabetes melitus dengan kejadian stroke iskemik di rsud dr, moewardi surakarta 2010. biomedika. 2013; 5(2), 11-6. 10. wahyudin m, nurrochmad a, dan harjaningsih w, 2013. perbandingan efek terapi pirasetam dan sitikolin terhadap perbaikan fungsi kognitif pasien stroke iskemik. jurnal manajemen dan pelayanan farmasi. 2013; 3(4), 252-2 11. agustina k. gambaran faktor-faktor ysng mempengaruhi outcome penderita stroke iskemik akut di rsudza. jurnal kedokteran maranatha. 2013. 12. ulfa ef, analisis efektifitas penggunaan sitikolin dan pirasetam pada pasien stroke iskemik di rsud sumedang tahun 2017. skripsi s, farm. universitas muhammadiyah surakarta. 2017 13. davalos a, castillo j, sabin ja, secades jj, mercadal j, lopez bss, et al. oral citicoline in acute ischemic stroke. stroke. 2010. 14. taufiqurrohman, neilan m, dan achmad. manfaat pemberian sitikoline pada pasien stroke non hemoragik. j medula unila. 2016;6(1),165-171 15. secades j.j. cdp-choline: updated pharmacological and clinical review. methods find. exp. clin. pharmacol. 2002;24:1–56 16. hurtado o., moro m.a., cárdenas a., sánchez v., fernández-tomé p., leza j.c., lorenzo p., secades j.j., lozano r., dávalos a., et al. neuroprotection afforded by prior citicoline administration in experimental brain ischemia: effects on glutamate transport. neurobiol. dis. 2005;18:336–345 17. adibhatla r.m., hatcher j.f., dempsey r.j. effect of citicoline on phospholipids and glutathione levels in transient cerebral ischemia. stroke. 2001;32:2376–2381. 18. hurtado o., cárdenas a., pradillo j.m., morales j.r., ortego f., sobrino t., castillo j., moro m.a., lizasoain i. a chronic treatment with cdp-choline improves functional recovery and increases neuronal plasticity after experimental stroke. neurobiol. dis. 2007;26:105–111. medical and health science journal 2021 february, vol 05 (01) original article the effect of giving honey on the process of wound healing in burned patients intan tiara*, dian ardiana, lukman ariwibowo faculty medicine of hang tuah university *correspondence: intantiarap@yahoo.com article info article history: received januari 29, 2021 accepted february 26, 2021 keywords: burns, honey, therapy abstract backgroud: burns are one of the most dangerous injuries and the main cause of disability to death. burns can be interpreted as one of the serious problems in society and are recorded to cause around 265,000 deaths each year. honey can maintain the wound condition to keep it moist and in high viscosity to prevent infection. method: this study was conducted to determine the effect of honey on the wound healing process in burn patients. this study uses a literature review method. the population in this study is a journal with a background in the health sector with 10 international journals on burns with the qualifications of 9 scimago indexed journals and 1 sinta indexed journal published from 2015 to 2020. results: burns that treated in the form of pure honey can generate good results and heal in an average of 20 days. the healing process will be better, if the wound given a mixture of other ingredients which also have a low acidity such as garlic, chitosan and beeswax and olive oil. honey has antimicrobial properties and a low ph level. the microbe most sensitive to honey is staphylococcus aureus. conclusion: the conclusion from this study, honey can be used as an alternative treatment for burns. medical and health science journal. introduction burns are defined by the world health organization (who) as tissue injuries to the skin caused by heat, radiation, electric shock, radioactive materials and contact with hazardous chemicals. skin damage caused by ultraviolet (uv) rays and disturbances in the respiratory system caused by inhaling too much smoke can also be categorized as burns. burns are one of the most dangerous injuries and the leading cause of limb disability and death. according to the world health organization (who), burns can be interpreted globally as one of the serious problems. fire cases that have been recorded in the world occur around 265,000 deaths each year. the number of deaths due to burns is something that needs to be considered in every country. millions of burn victims who survived the disabilities in their bodies were rejected from their neighborhoods 1 . topical antibiotics that can treat wounds in humans and animals are very important to find 2 ,but to prevent antibiotic resistance, alternative medicine can be used to heal burns 3 . a long history explains that honey is an ingredient that can treat wounds. since ancient times, honey has been used for its nutritional and therapeutic effects. honey can be used as a sweetener and flavor in a dish. honey is very easy to find almost all over the world. carbohydrates are the most important nutrients in honey because they are present in the form of glucose, fructose and monosaccharides. honey contains nutrients that can act as antiinflammatory, antioxidant and antibacterial agents so it is good for the healing process of wounds on the skin. in scientific literature, the function of honey has been to prevent coughing, increase fertility and wound healing because it has sumail typewriter 51 mailto:intantiarap@yahoo.com medical and health science journal 2021 february vol 05 (01) antioxidant and antibacterial properties 4 healing burns using honey still has to go through a further research process, therefore, the authors want to know the effect of honey on the wound healing process in burn patients 4 . with the incident in antibiotics, the use of honey can be needed again to handle medical treatment 5 . seeing the many benefits of honey, therapy using honey needs to be developed, therefore the authors intend to examine the effect of honey on the healing process of burns. methods the research design used is descriptive research. this research will explain the effect of using honey topically for the treatment and healing process of burns. the method used is literature study. the population in this study were articles about burns, wound healing processes and honey. the journals used as references come from research with backgrounds in the health sector, especially skin medicine, nutrition, pharmacology, biology and beauty. the research sample is articles that have been published by national and international journals from 2015 to 2020 at least 10 articles that explain the process of healing burns using honey. this research was conducted in surabaya from april to oktober 2020. this research get approval from the ethics commission for health research, faculty of medicine, hang tuah university. result samples in this study were taken from 10 international journals with the qualifications of 9 scimago indexed journals and 1 sinta indexed journal about the role of honey in the healing process of burns. healing time jeffery et al., stated that the average healing time using honey was 18.16 days 6 . moustafa and atiba's research showed that the burns treated with honey on day 24 were more closed 7 . according to ait abderrahim et al., the wound healing time using honey is about 25-27 days 8 . hendy and lister argue that treatment using honey takes 7 days 9 . according to duncan et al., alh can provide a healing time of 3 to 14 days 10 , whereas according to subrahmanyam all wounds treated with honey heal within 10 days 11 . figure 1 the green line shows the burn healing time using pure honey 8 wound results duncan et al., reviewed facial burns, figure 1 is a photo of 2 patients who were successfully treated with alh honey. this process takes about 3 to 14 days 10 . jeffery et al. observed 3 cases of burns treated with revamil honey gauze and revamil gel. the three wounds took 14-26 days to heal completely as shown in figure 2 6 . smaropoulos and cremers also observed 2 cases of burns that produced good scars within 7-18 days 5 . ait abderrahim et al., conducted an experiment and the burns improved within 26 days 8 . in addition, moustafa and atiba's research and hendy and lister's research obtained satisfactory results in the honey sumail typewriter 52 medical and health science journal 2021 february vol 05 (01) group, this can be seen from the smaller burns diameter 7.9 . histologically, honey has also been shown to increase angiogenesis, this is supported by 2 literature. el-kased et al., observed that the layer of skin affected by burns and then given honey, on the 9th day the honey-treated skin showed few new blood capillaries and fibroblastic cell proliferation 12 . furthermore, according to schencke et al., the pure honey group experienced neoformation of blood vessels in all dermal scar tissue as shown in figure 4 13 . figure 2 the result of healing using alh 10 figure 3 giving revamil honey gauze to blister burns6. figure 4 angiogenesis in honey treated skin 13 sumail typewriter 53 medical and health science journal 2021 february vol 05 (01) degree of pain and patient satisfaction jeffery et al., using revamil honey gel and revamil honey gauze, from all the cases he observed, the use was very easy even though there was a little exudate but still gave satisfactory results 6 . smaropoulos and cremers also described 2 cases of burns that were observed to be easy to use and painless in all patients 5 . according to the subrahmanyam study comparing honey and vaseline treated with honey, 90% experienced zero pain or only mild pain, while the group treated with vaseline gauze 88% experienced zero or mild pain 11 . antimicrobial properties duncan et al, who stated that the bacteria contained in burns were staphylococcus aureus and p aeruginosa, besides that, according to him, there was no abnormal bacterial growth in all burn cultures in patients who were given honey 10 . just like subrahmanyam, the research results were taken on day 7 in both honey and vaseline groups and the results did not show any growth of any organisms 11 . according to firdose et al., honey has antimicrobial properties because it has a low ph and contains h2o2 or peroxide acid as shown in figure 5 14 . according to ait abderrahim et al., s. aureus which is a gram-positive bacteria is more sensitive to honey when compared to gramnegative bacteria. such as e. coli and p. aeruginosa, whereas c. albicans was more resistant to honey 8 figure 5. h2o2 levels in acacia honey, neem and forest honey14. figure 6. the minimum inhibition of euphorbia honey on 4 microbes8 cost of treatment according to duncan et al., patients used between 1 to 4 tubes of product and the average cost of treatment was $ 26.15, with a range of $ 11.44 to $ 45.76 or idr 170,000 to idr 680,000 10 discussion honey can be an alternative treatment because it is easier to obtain in the village. the effectiveness of honey as a treatment for burns depends on the type of honey used, the time of administration and the degree of severity of the wound 9 honey works in the wound healing process with the presence of hydrogen peroxide which can activate macrophages to release vegf which stimulates fibroblast proliferation and angiogenesis in wounds. honey is able to stimulate b lymphocytes and t lymphocytes, and activate neutrophil phagocytosis in cells. honey also stimulates monocytes (mm6 cells) to secrete cytokines, tumor necrosis factor-a (tnf-a), interleukin-1 (il-1) and il-6, which activate the immune response to infection. tnf-a secretion can be induced by protein glycosylation. furthermore, honey is able to degrade collagen iv through stimulation of matrix metalloproteinase 9 (mmp9), a protease enzyme that plays a role in the release of keratinocyte cells from the basement membrane, thus allowing keratinocyte migration for re-epithelialization. honey is able to induce cytokine production by leukocytes so that it will stimulate cell growth 15 . the healing time for burns using honey therapy varies from 3 to 36 days with an average of 20 days. honey as an autolytic debridement agent is considered effective in wounds containing ≥40% damaged tissue. honey creates a moist wound environment, thereby stimulating wound healing 6 sumail typewriter 54 medical and health science journal 2021 february vol 05 (01) honey gives satisfactory results for the healing of second degree partial burns because there is no abnormal bacterial growth, favorable patient satisfaction scores, lack of side effects and reasonable treatment costs support the use of honey as an effective, safe and economical form of treatment for burns 10 conclusion honey is beneficial for health, especially skin because it has a low ph, contains h2o2, has antioxidant properties and has a lot of ingredients, so honey can affect the healing process of burns. honey can be used as an alternative for the treatment of burns because it can stimulate the proliferation of fibroblasts and angiogenesis, the healing time for burns with honey is 3 to 36 days, the results of wound healing are good, honey is easy to apply, causes mild pain and is easy to get, honey has antimicrobial properties, the bacteria most sensitive to honey is staphylococcus aureus. the cost of treating using alh honey is idr 170,000 to idr 680,000. it is not yet known the costs involved in treating other types of honey. references 1. kashefi, n. and dissanaike, s. use of air transport for minor burns: is there room for improvement?. journal of burn care and research. 2016:37(5):e453–e460. 2. olofsson, t. c., butler, é., lindholm, c., nilson, b., michanek, p. and vásquez, a. fighting off wound pathogens in horses with honey bee lactic acid bacteria. current microbiology. 2016:73(4):463–473. 3. hixon, k. r., klein, r. c., eberlin, c. t., linder, h. r., ona, w. j., gonzalez, h. and sell, s. a. a critical review and perspective of honey in tissue engineering and clinical wound healing. advances in wound care. 2019: 8(8):403–415. 4. meo, s. a., al-asiri, s. a., mahesar, a. l., & ansari, m. j. role of honey in modern medicine. saudi journal of biological sciences. 2017: 24(5):975-978. 5. smaropoulos, e. and cremers, n. a. j. treating severe wounds in pediatrics with medical grade honey: a case series. clinical case reports. 2020: 8(3): 469-476. 6. jeffery, s., henry, n. and radotra, i. properties and use of a honey dressing and gel in wound management. british journal of nursing. 2019: 28(6): s30-s35. 7. moustafa, a. and atiba, a. the effectiveness of a mixture of honey, beeswax and olive oil in treatment of canine deep second-degree burn. global veterinaria. 2019: 14(2): 244250. 8. ait abderrahim, l., taïbi, k., ait abderrahim, n., boussaid, m., rios navarro, c. and ruiz-saurí, a. euphorbia honey and garlic: biological activity and burn wound recovery. burns. 2019: 45(2019):1695-1706. 9. hendy, h. dan lister, i. n. e. tingkat efektivitas penyembuhan luka bakar derajat iia dengan pemberian madu dan pemberian salep nebacetin pada tikus putih (rattus norvegicus). jurnal kedokteran dan kesehatan. 2019: 15(2): 130-134. 10. duncan, c. l., enlow, p. t., szabo, m. m., tolchin, e., kelly, r. w., castanon, l. and aballay, a. m. a pilot study of the efficacy of active leptospermum honey for the treatment of partial-thickness facial burns. advances in skin and wound care. 2016: 29(8): 349-355. 11. subrahmanyam, m. honey dressing accelerates split-thickness skin graft donor site healing. indian journal of surgery. 2015: 77(2):261 -263 12. el-kased, r. f., amer, r. i., attia, d. and elmazar, m. m. honey-based hydrogel: in vitro and comparative in vivo evaluation for burn wound healing. scientific reports. 2017: 7(1): 1-11. 13. schencke, c., vasconcellos, a., sandoval, c., torres, p., acevedo, f. and del sol, m. morphometric evaluation of wound healing sumail typewriter 55 medical and health science journal 2021 february vol 05 (01) in burns treated with ulmo (eucryphia cordifolia) honey alone and supplemented with ascorbic acid in guinea pig (cavia porcellus). burns & trauma. 2016: 4(25): 1 9 14. firdose, a., nisar, a., & dsouza, m. r. evaluation of in vitro antimicrobial activity of indian honey on burn wound isolates. journal of chemical and pharmaceutical research. 2016: 2016(83): 1027-1034. 15. oryan, a., alemzadeh, e., and moshiri, a.. biological properties and therapeutic activities of honey in wound healing: a narrative review and meta-analysis. journal of tissue viability. 2016: 25(2): 98-118. sumail typewriter 56 medical and health science journal 2021 august vol.5 (02) medical and health science journal available at http://journal2.unusa.ac.id/index.php/mhsj ; doi: 10.33086/mhsj.v5i2.2362 pissn 2549-7588. eissn 2549-7596 original article the profile and patient acute hepatitis children output in dr soebandi jember hospital ika wahyu adita rini1, m. ali shodikin2 1faculty of medicine, university of jember, indonesia 2department of pediatric, soebandi hospital of jember, indonesia article info article history: received: march 19, 2021 received in revised form: september 17, 2021 accepted: september 20 2021 keywords: acute hepatitis, curcuma xanthorrhiza extract, snmc *) correspondent author: ikawahyuaditarini@gmail.com alipspd@unej.ac.id abstract background: indonesia is an endemic area for hepatitis akut. district of jember determines the status of extraordinary event hepatitis akut at the end of 2019. the purpose of this study was the profile and patient acute hepatitis children output in dr soebandi jember hospital in december 2019 until january 2020. methods: this study was retrospective descriptive. the material was taken of the medical records hepatitis akut patient at the pediatric department of the dr. soebandi hospital in jember. results: in this study, patients most often occurred in male, age ranged between 7 – 14 years, and lived on the villages. the most common of clinical manifestation are anorexia, jaundice, fever, hepatomegaly, dark urine, vomiting and abdominal pain. the result of laboratory examination showed that hepatitis acute patients had elevated of sgot , sgpt, direct and total bilirubin. the combination of curcuma with snmc (stronger neo-minophagen c) reductly significant sgot and sgpt serum levels (p < 0,001). conclusion: the combination of curcuma with snmc (stronger neominophagen c) reductly sgot and sgpt serum levels in hepatitis patients. medical and health science journal http://journal2.unusa.ac.id/index.php/mhsj mailto:ikawahyuaditarini@gmail.com rini, et al medical and health science journal 2021 august vol.5 (02) page 33 of 37 introduction indonesia is an endemic area of acute hepatitis. acute viral hepatitis (hav) is the most common type of viral hepatitis that is transmitted by the fecal-oral route. in developing countries, hav generally occurs in children with age.1 the main signs and symptoms include anorexia, nausea, vomiting, abdominal pain, jaundice, and hepatomegaly. elevated liver enzymes sgot and sgpt are the main laboratory findings in havinfected children.1,2 the diagnosis is confirmed by the presence of anti-hav igm in the patient's blood.3 giving curcuma tablets is used as an additional supplement that functions to improve liver function and improve appetite.2 snmc (stronger neo minophagen c) is an injection preparation with the main content of glycyrrhizin derived from herbal plants which is used to treat liver disorders.3,4 at the end of 2019, there was an increase in reports of cases of diseases caused by the acute hepatitis virus. the jember regency government has determined the status of an acute hepatitis extraordinary event (klb). the purpose of this study was to see the profile and outcomes of acute hepatitis patients in children at dr soebandi hospital jember in december 2019-january 2020.9 method this study is a descriptive retrospective. the research materials and subjects used were data taken from the medical records of patients diagnosed with acute hepatitis at the children's section of dr. soebandi hospital, jember. the affordable population of this study were all pediatric patients with new cases diagnosed with acute hepatitis in december 2019-january 2020. the inclusion criteria for the study were age 14 years, diagnosed with acute hepatitis with increased levels of sgot and sgpt.. the variables collected were: demographic characteristics (gender, age and place of residence), clinical features (vomiting, abdominal pain, fever, jaundice, hepatomegaly, dark urine and anorexia). laboratory tests include sgot, sgpt, direct bilirubin, total bilirubin, anti-hav igm and hbsag. the output seen is the recovery of acute hepatitis patients at dr. soebandi hospital based on an assessment of the decrease in sgot and sgpt, as well as the length of stay of patients on curcuma administration compared to curcuma + snmc administration. results in this study, patients with acute hepatitis most often occurred in boys (68%) compared to girls (32%). characteristics for the age of the 25 patients with acute hepatitis in children, most of whom were school age, namely 7-14 years, amounted to 17 people (68%). characteristics for the place of residence of the 25 patients with acute hepatitis in children, most of whom lived in the village, which amounted to 13 people (52%). adalah usia sekolah yakni 7 –14 tahun berjumlah 17 rini, et al medical and health science journal 2021 august vol.5 (02) page 34 of 37 the most common clinical symptoms in this study were anorexia (52%), jaundice (48%), fever (44%), hepatomegaly (40%), dark urine (36%), vomiting (32%) and abdominal pain (32%). . in this study, all patients were checked for sgot and sgpt (100%), there were 12 patients who were checked for direct bilirubin and total bilirubin based on clinical symptoms of jaundice. there were 6 patients who were checked for igm anti-hav and there were 10 patients who were checked for hbsag. the sgot level of patients at dr. soebandi hospital jember was taken at an average value of 1272 u/l at the beginning of the patient's admission, the results of the evaluation after the patient was given treatment showed a decrease in the average sgot value of 315 u/l. while the average value of the initial evaluation of sgpt was 1079 u/l and experienced a decrease in the value of sgpt to 448 u/l. table 3. sgot and sgpt levels in acute hepatitis patients at the beginning of diagnosis and evaluation pemeriksaan lab awal evaluasi sgot 1272 u/l 315 u/l sgpt 1079 u/l 448 u/l the administration of curcuma reduced the sgot value by 65%, while the administration of curcuma together with snmc reduced the sgot value by 72%. the saphiro-wilk normality test resulted in p > 0.05, meaning that the data was normally distributed. paired t-test results p value < 0.001 means that there is a significant difference between the administration of curcuma xanthorrhiza extract, and curcuma xanthorrhiza extract + snmc on the initial sgot value and the evaluation sgot after 4 days. table 1. characteristics of patients with acute hepatitis in children variabel n % gender men 17 68 women 8 32 age 0-6 th 8 32 7-14 th 17 68 residence desa 13 52 kota 12 48 table 2. clinical symptoms & laboratory examination at the beginning of diagnosis variabel n persentase (%) clinical symptoms vomited 8 32 abdominal pain 8 32 fever 11 44 jaundice 12 48 hepatomegali 10 40 dark urine 9 36 anorexia 13 52 laboratory examination sgot 25 100 sgpt 25 100 bilirubin direct 12 48 bilirubin total 12 48 igm anti hav 6 24 hbsag 10 50 rini, et al medical and health science journal 2021 august vol.5 (02) page 35 of 37 the administration of curcuma reduced the sgpt value by 44%, the administration of curcuma together with snmc reduced the sgpt value by 59%. the saphiro-wilk normality test resulted in p > 0.05, meaning that the data was normally distributed. paired t-test results p value < 0.001 means that there is a significant difference between the administration of curcuma xanthorrhiza extract, and curcuma xanthorrhiza extract + snmc on the initial sgot value and the evaluation sgot after 4 days. in the administration of curcuma and curcuma + snmc in this study, patients had an average hospitalization period of 4 days. tabel 4. outcome of acute hepatitis patients sgot value comparison treatm ent n perbandingan lab masa raw at sgot before sgot after % cur* 1 2 929 325 65 4 cur + s0 1 0 1080 302 72 4 sgpt value comparison treatme nt n perbandingan lab masa raw at sgp t befor e sgpt after % penuruna n cur* 1 2 636 355 44 4 cur + s0 1 0 1337 542 59 4 discussion this study is a retrospective study based on data in medical records so that researchers only process data based on data that has occurred in the past. this study is in line with research conducted by rewatkar et al, that acute hepatitis occurs more often in boys than girls with a ratio of 1.45:1. this is associated with the activity of boys who are more active than the activities of girls.11 extraordinary incidence of acute hepatitis in thailand in schools with 269 students aged 7-12 years. there were 70 of 89 subjects who were examined serologically with positive anti-hav, 16 of them with positive igm anti-hav.5 acute hepatitis virus infection that occurs in childhood is generally asymptomatic or with mild symptoms.5,6 infections that occur in childhood subsequent age can only be determined by laboratory examination of liver function.11 the initial clinical picture is a prodromal phase of viral infection with nonspecific symptoms including nausea, vomiting, anorexia, weakness, weight loss, subfebrile fever, myalgia, arthralgia, and headache.7 patients had an anicteric phase on average of 7 days. output becomes icteric phase with dark urine due to the excretion of bilirubin, and pale stools may be followed.8,10 jaundice only occurs in 10% of children aged less than 6 years, 40% of children between the ages of 6 and 14 years, and 70% in children over 14 years of age. the risk of transmission decreases 1 week after the onset of jaundice.10 additional symptoms include ket : cur* = curcuma xanthorrhiza extract cur+ s0 = curcuma xanthorrhiza extract + snmc rini, et al medical and health science journal 2021 august vol.5 (02) page 36 of 37 abdominal pain, pruritus, arthralgia, itching, fever and hepatomegaly. duration of symptoms in weeks averaged 4 weeks, and correlated with hav viral load. spontaneous resolution with minimal sequelae.1,2 elevated sgot and sgpt values are a sign of hepatocellular inflammation and liver damage.2 in this study, there were 6 patients who were checked for anti-hav igm due to limited reagents in the hospital. anti-hav igm can be detected 510 days before the onset of symptoms and can persist for up to 6 months after infection.1,2 the administration of curcuma tablets according to the recommended dosage is used as an additional supplement that functions to improve liver function and improve appetite. according to research conducted by hartono using a dose of 5-10 mg/kgbw/day has been shown to be able to repair damaged liver cells and is hepatoprotective.2 curcuma has protective and therapeutic effects on oxidative-associated hepatitis through suppression of proinflammatory cytokines, lipid perodixation products, pi3k/akt and hepatic stellate cell activation, as well as avoiding cellular responses to oxidative stress such as nrf2, sod, cat, gsh, gpx and gr expression. curcuma itself acts as a free radical scavenger on the activity of various types of ros through phenolic, -diketone and narcotic groups. further clinical studies are still needed to identify the structure-activity relationship and molecular mechanism of curcuma in oxidativerelated liver disease.2 stronger neo-minophagen c is a drug used to correct abnormal liver function in chronic liver disease.3 stronger neo-minophagen c contains monoammonium glycyrrhizinate (like glycyrrhizin), amino acetic acid, and l-cysteine hcl.4 the snmc dose is 40-60 ml by intravenous injection or once-daily intravenous infusion. the maximum daily dose is 100 ml. side effects that may occur during the use of stronger neominophagen c include shock, pseudoaldosteronism, severe hypopotassemia, hypertension, na retention, swelling, and weight gain. contraindications should not be used by patients with known allergies to the content of stronger neo-minophagen c and patients with a history of aldosteronism, myopathy and hypopotassemia. snmc may interact with thiazides, ethiazide and trichlormethiazide, ethacrynic acid and furosemide.3,4 in japan, snmc has been used as a treatment for hepatitis for more than 30 years. suzuki et al. reported that the levels of sgot, sgpt and -gtp can be significantly reduced by administration of snmc. in a double-blind multicenter study, serum sgot levels have been shown to be significantly decreased in patients given 40 ml/day of snmc for four weeks (p<0.001). furthermore, giving 100 ml/day of snmc for eight weeks, reduced the sgot value, and improved liver histology in patients with chronic hepatitis and liver cirrhosis so that the risk of developing liver carcinoma could be reduced.3,4 conclusion based on the results of the study, it was found that acute hepatitis patients most often occurred in boys, aged between 7-14 years and resided in the village. the most common clinical manifestations are anorexia, jaundice, and fever. the administration of rini, et al medical and health science journal 2021 august vol.5 (02) page 37 of 37 curcuma in combination with snmc (stronger neo-minophagen c) was able to significantly reduce the sgot and sgpt values (p < 0.001). conflict of interest the author stated there is no conflict of interest references 1. bilge c, hasan t, aslinur. evaluation of pediatric patients with hepatitis akut. j infect dev ctries. 2014; 8( 3): 326-330 2. hartono. 2005. pengaruh ekstrak curcuma terhadap peningkatan kadar sgot, sgpt akibat pemberian asetaminoven, tesis. solo. fk uns. 3. ismi, n.f. dan rina, h (2013) 'evaluasi penggunaan stronger minophagen c (snmc) injeksi pada gangguan fungsi hati di beberapa rumah sakit di yogyakarta', repository ugm, [online]. available at: http://etd.repository.ugm.ac.id/home/detail_ pencarian/63315 (accessed: 6 maret 2021). 4. kumada h. long-term treatment of chronic hepatitis c with glycyrrhizin [stronger neominophagen c (snmc)] for preventing liver cirrhosis and hepatocellular carcinoma. onco logy 2002;62 suppl 1:94100. 5. michelle rook. viral hepatitis in children. 1st ed. london. humana press; 2010 6. mohammad h.f., mahdi z., fatemeh p. dkk (2018) 'curcumin in liver diseases: a systematic review of the cellular mechanisms of oxidative stress and clinical perspective', n, 10(7), pp. 855. 7. nenden hl, mahkota r, elvieda. faktor risiko terjadinya kejadian luar biasa (klb) hepatitis akut di kabupaten tangerang tahun 2016. jurnal epidemiologi kesehatan indonesia. 2018; 2( 1): 1-6 8. oswari h, rahayu t. kejadian luar biasa hepatitis akut di smpn 259 jakarta timur. sari pediatri. 2005; 6( 4): 172-175 9. pemerintah kabupaten jember. hepatitis merebak, tetapkan status kejadian luar biasa.http://www.jemberkab.go.id/hepatitismerebak-tetapkan-status-kejadian-luar-biasa/ (diakses 2 februari 2020). 10. poonawagul u, warintrawat s, snitbhan r, kitisriwarapoj s, chaiyakun v, foy hm. outbreak of hepatitis akut in a college traced to contaminated water reservoir in cafeteria. southeast asian j trop med public health 1995; 26:705-8. 11. rewatkar ss. etiology of hepatitis in children. international journal of contemporary pediatrics. 2017; 6( 4): 21302135 12. suzuki h, ohta y, takino t, fujisawa k, hirayama c. the therapeutic effects of stronger neo minophagen c for chronic hepatitis. igaku no ayumi. 1977;102:562– 8. medical and health science journal 2022 february vol.6 (01) medical and health science journal available at http://journal2.unusa.ac.id/index.php/mhsj; doi: 10.33086/mhsj.v5i2.2154 pissn 2549-7588. eissn 2549-7596 original article case report: tuberculosis with pericardial effusion in children muhammad ali shodikin department of microbiology, medical faculty, university of jember, jember, indonesia article info article history: received : june 16, 2021 received in revised form : july 14,, 2021 accepted : august 01, 2021 keywords: tuberculosis, pericardial effusion, pericardiocentesis *) corresponding author:alipspd@unej.ac.id abstract tuberculosis pericardial effusion is a rare case in the developed countries. this may cause serious and deadly impact if not diagnosed and treated properly. appropriates diagnosis and treatment of tuberculosis pericardial effusion can prevent mortality. a 14-years-old boy was admitted with tightness of breath, chest pain, and abdominal enlargement. chest x-ray revealed heart enlargement and echocardiography showed a massive pericardial effusion. the diameter of induration of tuberculin skin test was 14 mm. this patient was diagnosed as tuberculosis pericardial effusion and showed complete recovery after paricardiocentesis and anti-tuberculosis drugs administration for 12 months. chest x-ray in tuberculosis with pericardial effusion shows an enlarged heart. so that adequate treatment with pericardiocentesis and anti-tuberculosis drugs can completely cure this disease. medical and health science journal http://journal2.unusa.ac.id/index.php/mhsj mailto:alipspd@unej.ac.id shodikin et al medical and health science journal 2022 february vol.6 (01) page 48 of 52 introduction tuberculosis pericardial effusion is a complication of pericarditis due to mycobacterium tuberculosis infection which is one of extra-pulmonary tuberculosis. tuberculosis is the cause of more than 50% of pericardial effusion in children in india where tuberculosis was an endemics.1 appropriates diagnosis and treatment of tuberculosis pericardial effusion can prevent mortality.2 the diagnosis is obtained based on history taking, physical examination, laboratory and imaging examinations.2,3 the treatments of massive tuberculosis pericardial effusion are administration of anti-tuberculosis and anti-inflammatory, and fluid evacuation by paricardiocentesis or pericardiectomy.3,4 patients with tuberculous pericarditis merit to conduct invasive pericardial procedures.5 this paper reports on a case of massive tuberculosis pericardial effusion that was diagnosed appropriately and treated adequately. case the informed consent was obtained from the family of the patient. a boy, 14 years old, was taken by his parents to the emergency room with complaints of tightness of breath, chest pain, and enlarged abdomen, that had been getting worse sinces 2 weeks. physical examinations results showed the body weight is 40 kg, 165 cm height, 14.6 body mass index (bmi), conjuctival anemic, weak and distant heart sounds, jugular vein distension, ascites and distended abdomen. this patient had blood pressure of 100/60 mmhg, heart rate of 110 beat per minute, respiratory rate of 38 times per minute, and 37.7 °c axillary temperature. chest x-ray showed heart enlargement with cardiothorax ratio of 84% (figure 1). electrocardiograph showed sinus tachycardia and low-voltages qrs complex. blood examination results were haemoglobin 9.5 gr/dl, leucocyte 9,100/mm3, platelets 384,000/ mm3, albumin 3.7 g/dl, serum cratinin 0.7 mg/dl, serum electrolyte sodium 133 mmol/l and potassium 3.7 mmol/l. echocardiography showed a massive pericardial effusion, with ejection fraction of 87%. tuberculin skin test was performed and the result 3 days later showed 14 mm induration. based on clinical finding, laboratory finding, imaging and positive tuberculin skin test, this patient was diagnosed as tuberculosis pericardial effusion, cardiac tamponade and anemia. anti-tuberculosis drugs of isoniazid 300 mg, rifampicin 600 mg, pirazinamid 1500 mg and ethambutol 750 mg each was given once daily. he was also given methylprednisolone 16 mg three times daily, pyridoxine 10 mg once daily and furosemide 20 mg twice daily. pericardiocentesis subxyphoid approach was performed and drain catheter was installed by cardiothoracic surgeon, removing 1200 ml of pericardial effusion fluid. histopathological examination of effusion fluid showed haemorrhagic fluid, histiocyte macrophage cell, no visible tuberculous process and without cell malignancy. effusion fluid culture were performed, even not in lowensteinjensen medium. the result showed that there was no bacterial growth. after pericardiocentesis, chest radiograph showed cardiothorax ratio of 54% (figure 2). six days after pericardiocentesis, the child was getting better. there were no shodikin et al medical and health science journal 2022 february vol.6 (01) page 49 of 52 shortness of breath, ascites, and jugular vein distension anymore. therfore, this patient was discharged. methylprednisolone was continued for 2 weeks and was then tapered off. antituberculosis drugs intensive phase (isoniazid, rifampicin, pyrazinamide and ethambutol) was administered for 2 months, then followed by continuation phase (isoniazid and rifampicin) for 10 months. the patient’s condition was observed every month in pediatric ambulatory clinic. his body weight increased from 40 kg (bmi 14.6) in the first admission to 46 kg (bmi 16.5) in the 6th month of anti-tuberculosis treatment. at the end of treatment (12th month of treatment) his body weight was 50 kg and body height was 170 cm (bmi 17.3). chest radiograph after 6 months of anti-tuberculosis treatment showed that the lungs and heart were normal, and no pericardial effusion was seen (figure 3). patient’s chest radiograph: figure 1. in the first admission, enlarged heart was seen, cardio thorax ratio was 84%. figure 2. after pericardiocentesis, the size of the heart was reduced, cardio thorax ratio was 54%. figure 3. after 6 months of anti-tuberculosis treatment, the heart appeared normal, cardio thorax ratio was 40%. discussion tuberculosis is not the only cause of pericarditis, however, it is the most common cause of pericarditis in developing countries.10 a definitive diagnosis of tuberculous pericarditis is made if acid-fast bacilli is found in pericardial fluid or tissue. probable diagnosis is made if at least one of the following three conditions is found: (1) pericardial effusion with confirmed tb in other organs, (2) exudative lymphocytic effusion with increased ada level, and (3) treatment response to anti-tuberculosis drugs.5 the diagnoses were also supported by the increased ada >30 u/l in pericardial fluid, which has sensitivity of 94% and shodikin et al medical and health science journal 2022 february vol.6 (01) page 50 of 52 specificity of 68% in establishing mycobacterium tuberculosis as the cause of effusion.6 tuberculosis with pericardial effusion is caused by mycobacterium tuberculosis infection in the pericardium hematogenously, lymphogenously or direct spread that can occur even without starting with pulmonary tuberculosis.2,4 pericardial effusion increases the pressure of the pericardial space that disrupts ventricular filling during diastole, increases pressure of the systemic and pulmonal vein, and also inhibits blood backflow to the heart. decreasing of ventricullar filling when diastole, causing a decrease in stroke volume and cardiac output. perfusion to vital and peripheral organs is reduced which can lead to shock and death.6 increased systemic venous pressure results in jugular vein distension, liver enlargement, ascites, and peripheral edema, whereas an increase in pulmonary venous causes pulmonary edema.7 cardiac tamponade is suspected when there is severe shortness of breath, systemic hypotension, tachycardia, weak heart sounds in auscultation and pulsus paradoxus (reduction in systolic blood pressure of more than 10 mmhg when inspiration).8 previous studies have demonstrated that reversing the lymphatic flow of bacteria from peritracheal, peribronchial, or mediastinal lymph nodes or through hematogenous spread of primary tuberculosis infection will lead to cardiac involvement. 13 the tuberculin skin test can suggest diagnosis of tuberculosis if after 48-72 hours there is induration of > 10 mm.9 in this case, induration diameter of tuberculin skin test was 14 mm. bacteriological examination is important in diagnosing tuberculosis, i.e detecting mycobacterium tuberculosis in sputum, gastric lavage or pericardial fluid with ziehl nelsen staining, cultivated in lowenstein-jensen medium as selective medium for cultivation and isolation of mycobacterium tuberculosis or polymerase chain reaction.2 in this case, mycobacterium tuberculosis was not detected in pericardial fluid. polymerase chain reaction and cultivation in lowenstein-jensen medium was not conducted due to limited resources in our hospital. histopathological examination of the pericardium is conducted if granulomatous and pericardial calcification is a definitive way of diagnosing pericardial tuberculosis.11 electrocardiographic features of massive pericardial effusion or cardiac tamponade are in the form of tachycardia and low voltage of qrs complexes.12 examination of the chest x-ray in a massive pericardial effusion patient shows globular enlarged heart (water bottle heart). echocardiography examination can detect pericardial effusion, cardial tamponade, pericardial thickening or constrictive pericarditis.7 management of tuberculosis pericardial effusion includes anti-tuberculosis and antiinflammatory drugs administration and pericardiocentesis or pericardiectomy.9 according to indonesian pediatric society, the administration of anti-tuberculosis for tuberculous pericarditis consists of an intensive phase of isoniazide, rifampicin, pyrazinamide, ethambutol every day for 2 months and followed by a continuatioan phase of isoniazide and rifampicin every day for 10 months.9 corticosteroids can suppress the inflammatory response and accelerate the absorption of pericardial fluid, thereby preventing pericardial constriction.7,8 pericardiocentesis is an invasive procedures to remove fluid from the pericardial space. this procedure is carried out shodikin et al medical and health science journal 2022 february vol.6 (01) page 51 of 52 when there is a massive pericardial effusion and cardial tamponade.8 pericardiectomy is performed if recurrent pericardial effusion occurs with constrictive pericarditis and drainage obstruction.8 in this case, anti-tuberculosis drugs are administered to the patient and observations are made regularly every months after discharge. disappearance of tuberculosis pericardial effusion causes normal cardiac function so that there is no more tightness of breath, chest pain, and abdominal enlargement. patient’s body weight goes up every month and bmi also increases. acknowledgments thanks to all authors and researchers who have helped in completing this study conflict of interest the author declare no conflict of interest references 1. syed ff, mayosi bm. a modern approach to tuberculous pericarditis. prog cardiovasc dis. 2007;50(3):218-236. doi:10.1016/j.pcad.2007.03.002. 2. cherian g. diagnosis of tuberculous aetiology in pericardial effusions. postgrad med j. 2004;80(943):262-266. doi:10.1136/pgmj.2003.013664. 3. maisch b, ristić ad. diagnostik und therapie der perikarditis und des perikardergusses [diagnostics and therapy of pericarditis and pericardial effusion]. herz. 2014;39(7):837856. doi:10.1007/s00059-014-4167-1. 4. mayosi bm, burgess lj, doubell af. tuberculous pericarditis. circulation. 2005;112(23):3608-3616. doi:10.1161/circulationaha.105.5430 66. 5. sainani gs, sainani r. tuberculous pericardial effusion. indian j clin pract. 2012;22:371-4 6. cs w, ntsekhe m, thabane l, volmink j, majombozi d, gumedze f, et al. interventions for treating tuberculous pericarditis ( review ). cochrane database syst rev. 2017;9:1-65. doi:10.1002/14651858.cd000526.pub2 7. sagristà-sauleda j, mercé as, soler-soler j. diagnosis and management of pericardial effusion. world j cardiol. 2011; 3(5): 135143. 8. imazio m and adler y. management of pericardial effusion. european heart journal. 2013; 34:1186– 1197.doi:10.1093/eurheartj/ehs372. 9. fardman a, charron p, imazio m, adler y. european guidelines on pericardial diseases: a focused review of novel aspects. curr cardiol rep. 2016;18(5):46. doi:10.1007/s11886016-0721-1. 10. montazeri v and sokouti m. tuberculous pericarditis: of a protocol in the treatment based on staging. j cardiovasc thorac res. 2009;1:5-10. 11. rahayoe nn, supriyatno b dan setyono db editors. buku ajar respirologi anak. edisi pertama, jakarta: ikatan dokter anak indonesia; 2010. p 214-227. 12. mayosi bm, wiysonge cs, ntsekhe m, volmink ja, gumedze f, maartens g, et al. clinical characteristics and initial management of patients with tuberculous pericarditis in the hiv era: the investigation shodikin et al medical and health science journal 2022 february vol.6 (01) page 52 of 52 of the management of pericarditis in africa (impi africa) registry. bmc infect dis. 2006;6:1-9. doi: 10.1186/1471-2334-6-2 13. ntsekhe, m. & mayosi, b. m. tuberculous pericarditis with and without hiv. heart fail. rev. 18, 367–373 (2013). medical and health science journal, vol. 4, no. 2, august 2020 correspondence: norma pattinama @2020 medical and health science journal. 10.33086/mhsj.v4i1.1415 available at http://journal2.unusa.ac.id/index.php/mhsj 109 comparison the success rate of vesicovaginal fistula repair surgery with transvaginal and transabdominal procedure: meta analysis norma pattinama* 1 , gatut hardianto 2 1 obstetrics gynecology resident, faculty of medicine, airlangga university – dr. soetomo hospital, surabaya 2 staff of the uroginecology and reconstruction division of obstetrics gynecology department, faculty of medicine, airlangga university – dr.soetomo hospital, surabaya *corresponding author: norma.pattinama@gmail.com article info abstract article history: submitted: july, 15 2020 received in revise: august,18 2020 accepted: august 25 2020 objective: this paper aims to evaluate the success rate of vesicovaginal fistula (vvf) repair surgery by transvaginal (tvag) and transabdominal (tpa) procedure. method: literatures were searched on the online database, pubmed and google scholar. all of the studies should be belonging on to inclusion criteria. the literatures had qualitative analyze by the authors and bias criteria based on review manager 5.3 application. it also had quantitative analyzed by the same application. results: the literatures have 191 patients (transvaginal-n=107; transabdominal-n=84). the data was homogen (chi 2 <df; p>0,05). the forest plot showed that tpa has a higher success rate than tvag, still not statistically significant (test overall effect p>0,05; 95%ci was 0,59 to 5,30). conclusion: transabdominal procedure has a higher success rate. @2020 medical and health science journal. 10.33086/mhsj.v4i1.1415 keywords: vesicovaginal fistule, transvaginal repair, transabdominal repair, omental flap interposition and martius labial flap. introduction vesicovaginal fistula (vvf) is an abnormal channel between the bladder and the vaginal that cause prolonged and continuous urinary incontinence. number of cases are high in developing country 1 . incidence rate at sub-saharan africa were 2 million women per 50,000 – 10,000 populations 2,3 . the etiology of vvf can be acquired and congenital. in developed country, obstetric trauma is the common etiology of acquired vvf 4 . the following number of the common etiology is total abdominal hysterectomy 5 . malignant infiltration from various pelvic cancers is the third cause of vvf 6 . pelvic tumor radiation also can be the cause of vvf. it may appears a couple years after the therapy 6 . the others cause could be trauma and iatrogenic from obstetric, gynecologic, or urological surgery 1,7 . the patophysiology of vvf in obstetric trauma is an ischemic fibrous while having a labour. in delayed labour, the bladder neck and the uretra pressed by the head of the fetus and symphisis pubic. this condition cause fibrous ischemia and anterior vagina wall necrosis. the necrosis will detach and remove after day tenth 8,9 . the major symptoms of vvf is consistent urine leakage from the vagina (6) , bad smell and wet sensation that were interfere life quality of the patients 1,10 . patients complaint the continuous urine leakage from vagina that cannot be held. also, there were history of obstetric trauma, gynecologic procedure or radiation therapy. the examiner will obtaine small granulated lesion, hyperemia and not specific hollow while did vaginal touche. methylen blue test will be positive at vvf patients. imaging examination will support the diagnosis of this case, such as cystoscopy, intravena pyelography (ivp), retrograde and voiding cysto-urethrography, mri fistulography, pelvic ct scan and usg (1)(4) . cycstoscopy will provide the specific anatomical origin of the leakage 4,6 . review article mailto:norma.pattinama@gmail.com 110 management of vvf can be divide by two approaches, they are conservative and surgical. conservative managements are urine catheterization, fibrin-collagen sealant and platelet rich plasma (prp) injection. conservative therapies for reccurent vvf use percutaneous nephrostomy (pcn) or modified with ureter occlussion bilateral, sabutyl-2cyanoacrylate injection, detachable or nondetachable ballons, and sponges made from nylon, plugs, coils or gelatin 4,6 . simple vvf is indicated for conservatives with 4-6 weeks of recovery (11) . there are various approach for surgical management, such as transvaginal, transabdominal, laparoscopy, and combination 4 . complex and radiated type vvf are indicated for surgical repair. the expected outcome from these therapies are the closure lesion, better quality of life, and sexual functions 7 . in the uk and developed world, warner r et al. suggests that vaginal repair is significantly more cost-effective than abdominal repair owing to the shorter operative time and length of stay with no significant difference in the success rates. 7 tatar b et al. researched that vaginal approach to vvf repair is more cost-effective because the mean hospitalization time is less compared with transabdominal repair, and this difference emphasizes the vaginal route as the first choice without compromising the success rate 4 . this paper aims to evaluate the success rate of vesicovaginal fistula (vvf) repair surgery by transvaginal (tvag) and transabdominal (tpa) procedure. methods data search strategy the literature was obtained from online search engine, pubmed and google scholar. the keywords used are vesicovaginal fistule, transvaginal repair, transabdominal repair, omental flap interposition and martius labial flap. then, all of the literatures (n=68) selected by the title and abstract after the duplicate removed. fifty articles were excluded for the use of languages other than english and indonesian. eighteen articles were screened, then twelve articles excluded because of the unavailable of full text studies. six full-texted articles were evaluated and furthermore, two articles were excluded because these studies used laparoscopy and robotic surgery. four articles were included (fig. 1) and analyzed using review manager 5.3 (cochrane collaboration, oxford, uk). figure 1. flowchart of the searched literature inclusion criteria inclusion criteria of this review: (1) cross sectional and cohort study, (2) english and bahasa full text study, (3) vesicovaginal fistule sample, (4) comparison the clinical outcome of vvf repair with transvaginal (tvag) martius labial interposition flap procedure and transabdominal (tpa) omental flap interposition procedure, (5) all inclusion papers can be fully accessed, and (6) the data obtained can be analyzed accurately. study quality assessment four of the studies were qualitatively and independently appraised by the authors using bias criteria from review manager 5.3 application. the author discussed and assessed the category of each criteria (low-risk bias, intermediate bias, or high-risk bias). most of the included literature have high risk of bias. it is shown from the red line of the outcome in funnel plots (fig. 2 and fig. 3). medical and health science journal, vol. 4, no. 2, august 2020 111 figure 2. bias stratification risk of articles in this study figure 3. assessment of the risk of author bias for each inclusion article data extraction the criteria to extract the data: (1) main author; (2) year of publication; (3) country of the study; (4) design study; (5) inclusion criteria; (6) intervention; (7) success rate of the vvf repair; (8) reccurence rate of the vvf repair. this study compares the success rate of vvf repair intervention by compared tvag and tpa procedure. the outcome expressed by odd ratio (or) and the significance represented by p value, then analyzed by review manager version 5.3. (cochrane collaboration, oxford, uk). beside of number, there is a forest plot that will provide summarize outcome of this study. result study characteristics four literatures were reviewed as a retrospective study. three of them are cross sectional 4,7,12 , one is a cohort study 6 . one study with prospective data, but reviewed as a retrospective 7 . all of studies have vvf case with variance of age, etiology and time span. a study of djokic et al, 2009 have 220 participants with the longest time span (19782004). intervention in the literatures had surgical repair with tvag and tpa. other approaches were done by another studies, they were djokic et al, 2009 (transvesical-tves n=129) and tatar et al, 2017 (laparoscopic n=2; urinary diversion (ud) n=2). still in this review focused on tvag and tpa approach to compare the reccurent rate for getting the success rate between the approaches. all of the studies have no significant difference in recurrent cases. some additional outcome also obtained in those literature. djokic et al, 2009 states that tvag reffers to simple vvf than tpa for complex vvf and big size lesion and radiologic caused prefer use tpa. a case of vvf in ockrim et al, 2008 had failed healing because 3 cm of lesion and no omental interposition. warner et al, 2019 study with prospective data stated that tpa approach has longer operating time, longer length of hospital staying (length of stay-los) and higher cost than tvag approach. detail data of each study showed in table 1. table 1. characteristic of the data from each article author design study person intervention comparison outcome jh djokic et al, 2009 retrospective – cohort study vvf case between 1978-2004 n=220 1. tvag – martius labial interposition 2. tpa – flap interposition (omental flap interposition) 3. tves – extraperitoneal cystostomi approach reccurence rate of tvag, tpa, and tves success rate: 1. tvag-56/59 patients (94,9%) 2. tpa-30/32 patients (93,8%) 3. tves-122/129 patients (94,6%) reccurence rate: primary: 1. tvag-3/59 (5,1%) 2. tpa-2/32 (6,2%) 3. tves-7/129 (5,4%) 112 secondary: 1. tvag-1/3 (33,3%) 2. tpa 0/2 (0%-all patients full recovery) 3. tves-2/7 (28,6%) jeremy l. ockrim et al, 2008 retrospective – cross sectional study 32 of vvf cases between 2000-2006 1. tvag – martius labial interposition 2. tpa – flap interposition (omental flap interposition) reccurence rate of tvag and tpa success rate: 1.tvag-11/11 patients (100%) 2.tpa-18/21 patients (85,7%) reccurence rate: secondary: pa-2/3 (66,7%) 1 patient had failed surgery with vvf post radiotherapy, >4cm size lesion, no omental interposition. burak tatar et al, 2017 retrospective – cross sectional study 20 of vvf cases between 2006-2015 1. tvag – martius labial interposition 2. tpa – flap interposition (omental flap interposition) 3. laparoscopic 4. urinary diversion – ileal conduit technique reccurence rate of tvag, tpa, laparoscopic and urinary diversion (ud). success rate: 1. tvag-5/5 patients (100%) 2. tpa-11/11 patients (100%) 3. laparoscopy-1/2 patients (50%) 4. slpe-ud (n=1); ilpeud (n=1) reccurence rate: laparoscopy 1 patient slpe: supra-levator pelvic exenteratio ilpe: intra-levator pelvic exenteratio ross warner et al, 2019 retrospective – cross sectional study 47 of vvf cases between 2007-2015 1. tvag – martius labial interposition 2. and tpa – flap interposition (omental flap interposition) 1. the mean cost 2. duration of operating time 3. length of hospital stay (los) 4. the success number of the repair 5. fistula complexity primary outcome: success rate: 1. tvag-29/32 patients (90,6%) 2. tpa-13/15 patients (86,7%) reccurence rate: 1. tvag-3 patients 2. tpa 2 patients secondary outcome: 1. total cost of tvag lower than tpa 2. mean operative time – tvag 196,89 min; tpa 223,4 min 3. los – tvag 5,3 days; tpa 9,1 days 4. size of the fistula similar at tvag and tpa comparison of the success rate at vvf repair between tvag and tpa approach four literatures were analyzed by review manager 5.3 application then the outcome shown in a forest plot (fig. 4). the accumulative data are 191 patients (transvaginal-n=107; transabdominal-n=84). point of estimate located at the right side, it means that transabdominal has success rate higher than transvaginal. then, the heterogenicity should be considered. from the forest plot, it is known that all of the studies have homogen data (chi 2 < df; p>0,05). however, the accumulative data has no significant effect (test overall effect p>0,05; 95%ci was 0,59 to 5,30). medical and health science journal, vol. 4, no. 2, august 2020 113 figure 4. forest plot of tvag and tpa vvf repair surgery (experimental= tranvaginal; control=transabdominal; ci-confidence interval; df-degrees of freedom) discussion surgical therapy for vesicovaginal fistule repair has kind of approaches, they were transvaginal, transabdominal, transvesical, laparoscopy, and urine divertion. the most frequent approaches that used by gynecologist in developing countries are transvaginal and transabdominal. transvaginal (tvag) approach was used for simple, small, first attempt repair, and distal fistulas 6 . transabdominal (tpa) approach frequently used for large size of vvf (>2cm) 4 and the location close to orificium urethra. this condition categorize as a complicated vvf case, yet there is no consensus coincident which fistulas indicated as complicated (4) . the complex vvf operated by urologist commonly using the tpa procedure. behind all of those reasons, there were advantages and disadvantages from both approaches. the advantages of tvag with martius labial interposition flap were easy to operate, easy to modified, stronger stitches, protect the urethra, shorter duration of operating time, low morbidity, low cost and shorter length of stay, then the disadvantages of tvag approach were pain at flap retrieval and asymetrism. on other approach, tpa with omental flap interposition had better vascularity so that the flap can stick out better. the disadvantages of tpa were post-operative pain, temporary ileus, over bleeding, longer operating time, higher cost and longer length of stay. notwithstanding with all of those evidences based on the literatures which was reviewed in this study, there is no significant different success rate between tvag and tpa 4,6,7,12 . in the study of burak et al, 2017 it said that the range of success rate of vvf were 70100% 11,13,14 , while the tpa was around 90100% 14 . some of vvf cases with large size or complicated fistula operated by urologist, and they prefer to the tpa approach. this literature also states that, tvag had less length of stay of the patients and low complication of the surgery. it would be reasonable to say that tpa should be considered if the vvf is a complex and large lesion 4 . djokic et al, 2009 also stated that tvag should be considered in noncomplicated cases and flap procedure in tpa approach is the most secure technique 6 . it is hard to compare the success rate because of the surgeon’s prefferences, the complexity, and co-morbidity of the patients 6 . no interposition also be the risk factor of the failed rate of surgery 12 . tertiary unit which has wide range of etiology also be the factor of this study statement, such as emergency caesarean section, radiotherapy, multiple complex anti-incontinence interventions and infection 12 . the study of warner et al, 2019 which has prospective data, said that tvag should be the first options for the simple vvf because it has lower cost, shorter los, shorter duration operating, minimal pain and morbidity 7 . three of the literatures had a little number of participants (burak et al, 2017 n=20; ockrim et al, 2008 n=32; warner et al, 2019 n=47), while one literature had the most number participants which is it had the longest 114 duration time span (djokic et al, 2009 n=220). the complexity of fistula also not homogen from each other. moreover, the study of ockrim et al, 2008 based on tertiary unit. different operator is the limitation of the study because the difference level of their skills, although warner et al, 2019 has the single data surgeon. the bigger participant should be established in this field of study, furthermore a multi-center study is preferable for this kind of problem. eventhough all of the literatures had mentioned their preference approach of vvf repair surgery, this study is not be able to conclude, because the statistic analyze was not significant. the type study of the literatures are cross sectional and cohort, it means that it is difficult to randomized the data. but, at the forest plot, the data showed its homogenicity. the forest plot also talked about confidence of interval that means the effect’s significancy. because the effect was not significant, it cannot be concluded the overall effect, although the estimate point showed at the transabdominal side. at the future study, the literature should be more than this, so as the statistic will be significant. if there is randomized controlled study it will be better to gain the clinically relevant conclussion. conclussion the approach is depended on the complexity and the size of the fistule, the operator preferences, the kind of the fistula primary or the reccurence fistula. tpa has a higher success rate than tvag, still not statistically significant refferences 1. stamatakos m, sargedi c, stasinou t, kontzoglou k. vesicovaginal fistula: diagnosis and management. indian j surg [internet]. 2014;76(2):131–6. available from: https://pubmed.ncbi.nlm.nih.gov/24891778 2. rajaian s, pragatheeswarane m, panda a. vesicovaginal fistula: review and recent trends. indian j urol [internet]. 2019;35(4):250–8. available from: 10.4103/iju.iju_147_19 3. cohen bl, gousse ae. current techniques for vesicovaginal fistula repair: surgical pearls to optimize cure rate. curr urol rep [internet]. 2007;8(5):413–8. available from: https://link.springer.com/article/10.1007/s1 1934-007-0040-6 4. tatar b, oksay t, cebe fs, soyupek s, erdemoğlu e. management of vesicovaginal fistulas after gynecologic surgery. turkish j obstet gynecol [internet]. 2017;14:45–51. available from: https://pubmed.ncbi.nlm.nih.gov/28913134 5. eilber ks, kavaler e, rodríguez l v., rosenblum n, raz s. ten-year experience with transvaginal vesicovaginal fistula repair using tissue interposition. j urol [internet]. 2003;169(3):1033–6. available from: https://pubmed.ncbi.nlm.nih.gov/12576839 6. hadzi-djokic j, pejcic tp, acimovic m. vesico-vaginal fistula: report of 220 cases. int urol nephrol [internet]. 2009;41(2):299–302. available from: https://pubmed.ncbi.nlm.nih.gov/18810652 7. warner r, beardmore-gray a, pakzad m, hamid r, ockrim j, greenwell t. the cost effectiveness of vaginal versus abdominal repair of vesicovaginal fistulae. int urogynecol j [internet]. 2020;31(7):1363–9. available from: https://pubmed.ncbi.nlm.nih.gov/31321464 8. garthwaite m, harris n, harris n. vesicovaginal fistulae pathogenesis transvaginal approach laparoscopic repair robotic repair. indian j urol [internet]. 2019;26(2):20–2. available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ pmc2938551/ 9. carmel me, goldman hb, moore ck, rackley rr, vasavada sp. transvaginal neobladder vaginal fistula repair after radical cystectomy with orthotopic urinary diversion in women. neurourol urodyn [internet]. 2016;35(june 2014):90– 4. available from: https://pubmed.ncbi.nlm.nih.gov/25327960 10. smith gl, williams g. vesicovaginal fistula. obstet gynecol surv [internet]. 1999;83(1):564–70. available from: medical and health science journal, vol. 4, no. 2, august 2020 115 https://bjuijournals.onlinelibrary.wiley.com/doi/full/ 10.1046/j.1464-410x.1999.00006.x 11. angioli r, penalver m, muzii l, mendez l, mirhashemi r, bellati f, et al. guidelines of how to manage vesicovaginal fistula. crit rev oncol hematol [internet]. 2003;48(3):295–304. available from: https://pubmed.ncbi.nlm.nih.gov/1469334 2 12. ockrim jl, greenwell tj, foley cl, wood dn, shah pjr. a tertiary experience of vesico-vaginal and urethro-vaginal fistula repair: factors predicting success. bju int [internet]. 2009;103(8):1122–6. available from: https://pubmed.ncbi.nlm.nih.gov/1915450 0 13. sori da, azale aw, gemeda dh. characteristics and repair outcome of patients with vesicovaginal fistula managed in jimma university teaching hospital, ethiopia. bmc urol [internet]. 2016;16(1):1–6. available from: http://dx.doi.org/10.1186/s12894-0160152-8 14. zambon jp, batezini nss, pinto ers, skaff m, girotti me, almeida fg. do we need new surgical techniques to repair vesico-vaginal fistulas? int urogynecol j [internet]. 2010;21(3):337–42. available from: https://pubmed.ncbi.nlm.nih.gov/1994977 1/ medical and health science journal 2021 february, vol 05 (01) the role of tea tree oil as a skin antimicrobial : a literature study kathleen aldora 1,2 , dian ardiana* 1,2 , eka narayana 1 1,2 faculty of medicine, hang tuah university, surabaya, indonesia 1 dermatology and venereology department, dr. ramelan naval hospital, surabaya, indonesia *correspondence: dian.ardiana@hangtuah.ac.id article info article history: received february 06, 2021 accepted february 25, 2021 keywords: tea tree oil, melaleuca alternifolia, skin infection, microorganism. abstract backgroud: skin disease due to microorganism infection are still widely found in community. the infections can be caused by bacteria, viruses, fungi, and parasite. tea tree oil often used as a herbal medicine in the treatment of skin diseases due to microorganisms. this literature study is conducted to review the role of tea tree oil as an antimicrobial in skin infections. methods: fifteen indexed journals published from 2015 to 2020 about tea tree oil and skin infections, were included. from 15 journals, 9 journals discuss antibacterial activity of tea tree oil, 2 journals discuss antiviral activity, 9 journals discuss antifungal activity, and 1 journal discusses antiparasitic activity. all journals state that tea tree oil has an antimicrobial effect on microorganisms that cause skin infections. results: from 9 journals, it was found that a. baumanni, p. aeruginosa, and c. acnes were the most sensitive bacteria to tea tree oil in terms of mic and s. epidermidis was the most sensitive bacteria, seen from their inhibition zone. eight journals state variations with significant differences in the activity of tea tree oil as an anti-fungal. tea tree oil has stronger antibacterial activity than antifungal activity. it also has antiviral activity against hsv and antiparasitic on s. scabiei. conclusion: the conclusion of this study is that tea tree oil has antimicrobial activity against microorganisms that cause skin disease, including bacteria, viruses, fungi, and parasite. medical and health science journal introduction skin is the largest organ in the human body with a surface area of 2 m 2 . skin has 2 main functional layers, epidermis and dermis, and underneath there is hypodermis or subcutis layer. as the outermost layer of the human body, the most important function of the skin is as a mechanical barrier for first defense. the skin is home to commensal microorganisms that will play a role in preventing invasion from foreign pathogens. when the barrier is damaged by trauma or when the balance between commensal microorganisms and pathogens is disturbed, skin disease or even systemic disease may occur. the entry of pathogens that penetrate the skin will trigger an immunological reaction from the body. microorganisms that enter through the skin are associated with the pathophysiology of dermatological infectious diseases. wound infections are generally caused by the microorganisms staphylococcus aureus, pseudomonas aeruginosa and escherichia coli. staphylococcus aureus itself is commonly found in atopic dermatitis. another example is the fungus malassezia which causes many skin conditions pityriasis versicolor, seborrheic dermatitis, atopic dermatitis, and psoriasis (mcloone, warnock & fyfe, 2016). apart from bacteria and fungi, viruses can also cause skin infections such as molluscum contagiosum which is caused by the molluscum contagiosum virus (mcv) from the family poxviridae. 1 review article sumail typewriter 26 mailto:dian.ardiana@hangtuah.ac.id medical and health science journal 2021 february, vol 05 (01) globally, skin problems and diseases are common, and because of their visibility, often result in severe distress and stigma for sufferers. therefore, many dermatological therapies have been developed, both herbal, conventional (chemical) and technological therapies. one of the many herbal therapies used for skin infections is tea tree oil (melaleuca oil). the content of tea tree oil is a mixture of components such as monoterpenes, sesquiterpenes and alcohol that contribute to various activities (analgesic, antiviral, antibacterial, antifungal, antiparasitic, anti-inflammatory, antioxidant, and anticancer). tea tree oil has a tendency to be very minimal resistant and can overcome the development of resistance to conventional drugs in skin infections caused by microorganisms. 2 tea tree oil is an essential oil obtained by steam distillation of the native australian plant melaleuca alternifolia. tea tree oil has been used for centuries by australians as medicine, especially for wound care in 1920. 3 long-term use of herbal therapy tea tree oil has a lower incidence of side effects, irritation or allergic reactions when compared to conventional therapy. tea tree oil in topical use will have the added advantage of being cost effective and easy to use. 4 seeing the potential and advantages of tea tree oil therapy, the development of this therapy needs to be improved in both the cultivation and pharmacology sectors. therefore, the authors intend to review the role of tea tree oil as an antimicrobial in skin infections. methods the research design used is descriptive research. the method used is literature study to review the role of tea tree oil as skin antimicrobial. database searched was google scholar. search terms used were ‘tea tree oil as antibacteria, tea tree oil as antivirus, tea tree oil as antifungi, tea tree oil as antiparasit, role of tea tree oil as antimicroba, tea tree oil as antimicroba in vitro’. limitations included ‘published between 2015-2020’ and ‘indexed by scimago or sinta (science and technology index)’. this research was conducted in surabaya from may to september 2020. this research get approval from the ethics commission for health research, faculty of medicine, hang tuah university. result the results of the study are taken from 15 international journals indexed by scimago about the role of tea tree oil as a skin antimicrobial. nine journals discuss the activity of tea tree oil against bacteria, two journals discuss the activity of tea tree oil against virus, eight journals discuss the activity of tea tree oil against fungi, and one journal discuss the activity of tea tree oil against parasite. antibacterial activity research in the journal states the antimicrobial effect seen from the minimum inhibitory concentration (mic), minimum bactericidal concentration (mbc), imaging through electron microscopy, and the zone of inhibition. the bacteria studied in the journal include staphylococcus aureus, staphylococcus epidermidis, cutibacterium acnes, pseudomonas aeruginosa, bacillus subtilis, acinetobacter baumannii, streptococcus pyogenes, klebsiella pneumoniae, and various other gram-positive and negative bacteria. the bacteria were cultured on mueller-hinton agar and given tea tree oil with different concentrations. the method used is the liquid microdilution method. after that, the bacteria will be observed for mic, microscopic image, and zone of inhibition to determine the antimicrobial effect of tea tree oil. sumail typewriter 27 medical and health science journal 2021 february, vol 05 (01) table 1 mic of s. aureus and p. aeruginosa by 10 types of tea tree oil products 5 product s. aureus p. aeruginosa tea tree oil 1 2.5 2 tea tree oil 2 0.5 0.25 tea tree oil 3 1 2 tea tree oil 4 0.5 0.5 tea tree oil 5 0.75 1.5 tea tree oil 6 0.5 0.5 tea tree oil 7 2.5 2 tea tree oil 8 2 2 tea tree oil 9 0.5 0.25 tea tree oil 10 0.75 1 table 2 the number of p. aeruginosa that are inhibited by tea tree oil 6 tea tree oil 0.03% 0.06% 0.125% 0.25% 0.5% 1% 2% inhibited bacteria 0 0 0 4 2 7 7 table 3 mic and mbc of tea tree oil and rosemary oil against acne-causing bacteria 7 bacteria tea tree oil rosemary oil mic mbc mic mbc s. aureus 0.78 0.78 1.56 1.56 s. epidermidis 0.78 0.78 1.56 1.56 c. acnes 0.39 0.39 0.39 0.39 table 4 mic of essential oil against bacteria 8 bacteria basil oregano tea tree thyme chamomile a. baumanni 0.5-1.25 0.25-0.37 0.12-0.25 0.25-.0.5 >4 k. pneumoniae 1.5-3 1 0.5-0.75 0.5-1.5 >4 p. aeruginosa >4 2-4 1-1.5 4 >4 table 5 mic of essential oil against s. epidermidis and p. acnes 9 essential oil s. epidermidis p. acnes oregano 0.67 0.34 thyme 1.3 0.65 lemongrass 1.22 1.22 tea tree 1.27 1.28 lavender 2.52 2.52 mentha 5.28 2.6 chamomile 6.22 3.18 ziółkowska-klinkosz et al. conducted a study on 193 anaerobic bacteria which were given tea tree oil and the result was that anaerobic bacteria were more sensitive than gram negative. 10 li et al conducted a study that showed normal cell growth in control media and bacterial growth treated with tea tree oil were viewed using a microscope. the results for normal cell growth showed normal characteristics of cocci bacteria such as cell walls and cell sumail typewriter 28 sumail typewriter medical and health science journal 2021 february, vol 05 (01) membranes that were attached to the peptidoglycan layer and normal cytoplasmic membrane. in addition, the cytoplasm appears to have a homogeneous electron density. meanwhile, the bacteria that were given tea tree oil showed a clear morphological change in which the density of the cytoplasm became heterogeneous and some of them were seen leaving the cell. the separate distance between the cytoplasmic membrane and the cell wall is also seen. 11 table 6 zone of inhibition of tea tree oil against bacteria (in mm) s. aureus s. epidermidis c. acnes p. acnes s. pyogenes esmael et al 7 15.5 21.02 20.85 taleb et al 9 9 – 15 9 – 18 ramadan et al 12 19.2 ± 0.44 21.7 ± 0.58 19.2 ± 0.19 antiviral activity the viruses tested in this study were herpes simplex viruses (hsv) 1 and 2. the method used was to use vero cells that were infected with hsv and given tea tree oil. tea tree oil's antiviral activity can be seen from its pfu (plaque-forming unit) and viral titer. brun showed the results of his research where after being exposed to tea tree oil, the pfu of the hsv 1 was reduced compared to before. 5 table 7 hsv titers before and after being given tea tree oil 12 pre-test post-test reduction hsv 1 7.5 6.32 15.6% hsv 2 7.66 6.11 20.23% antifungal activity eight journals discussed the activity of tea tree oil as an antifungal. all of them stated that tea tree oil acts as an antifungal in terms of mic, mfc (minimum fungicidal inhibition), confocal features, and also the zone of inhibition. the fungi studied from 8 journals were candida sp., aspergillus niger, and trichophyton mentagrophytes. before being exposed to tea tree oil, the fungus is cultured in dextrose agar. the method used is the same as for bacteria, namely with liquid micro-dilution. table 8 mic c. glabrata on 10 types of tea tree oil products 5 product mic of c. glabrata tea tree oil 1 2.5 tea tree oil 2 1.5 tea tree oil 3 2.5 tea tree oil 4 1 tea tree oil 5 2 tea tree oil 6 0.75 tea tree oil 7 2.5 tea tree oil 8 2.5 tea tree oil 9 1 tea tree oil 10 1.5 sumail typewriter 29 sumail typewriter medical and health science journal 2021 february, vol 05 (01) table 9 mic and mfc c. krusei against tea tree oil and mpp 13 10 3 cfu/ml 10 6 cfu/ml tea tree oil mic 0.5 1 mfc 0.5 1 mpp mic 0.25 1 mfc 0.5 1 the research conducted by francisconi showed a confocal picture of candida albicans before and after being given tea tree oil. the results showed that many of the fungi that had been given tea tree oil died. 14 table 10 zone of inhibition of tea tree oil against candida albicans and trichophyton mentagrophytes candida albicans trichophyton mentagrophytes narang et al (1g) 15 ±38 mm ramadan et al (25µg dissolved in 0.1% dimethyl sulfoxide) 12 20.3 ± 0.44 mm 21.1 ± 0.44 mm patturaja and geetha et al 16 250 µg/ml 500 µg/ml 1000 µg/ml 14 mm 20 mm 37 mm antiparasitic activity fang et al. conducted research on s. scabiei which was given 10 types of essential oils (lavender, bitter orange, geranium¸ tea tree, clove, eucalyptus, manuka, cade, japanese cedar, and palmarosa). this research was conducted using 2 methods, namely contact bioassays and fumigation bioassays. with the contact bioassays method, essential oils were diluted with paraffin to obtain a concentration of 1.5, 10%, then s.scabiei was viewed by stereomicroscope in 10, 20, 30, 40, 50, 60, 90, 120, 150, 180 minutes after exposure. tea tree oil. the result is that clove oil is the most effective essential oil where with 1% clove oil all s.scabiei dies in 20 minutes. meanwhile, with tea tree oil, all s.scabiei died after 90 minutes of exposure to 5% tea tree oil and 30 minutes with 10% tea tree oil. the bioassays fumigation method was carried out with 100 µl of pure essential oil dripped on filter paper and then s.scabiei was inspected by stereomicroscope for the first 5 minutes, then every 5 minutes for 1 hour. the result is that tea tree oil is the most effective essential oil as an antiprotozoa followed by clove oil and eucalyptus oil. 17 discussion based on 15 journals, it can be concluded that tea tree oil has antimicrobial activity in skin infections, both antibacterial, anti-fungal, antiviral, and also antiparasitic activities. the level of effectiveness of tea tree oil is different for sumail typewriter 30 sumail typewriter medical and health science journal 2021 february, vol 05 (01) each type of microbe seen from mic, mbc, mfc, virus titer number, zone of inhibition, and survival time. each type of bacteria has a different sensitivity to tea tree oil. seven of the nine journals comparing the mics of bacteria exposed to tea tree oil revealed a variation of the mic of 0.12% to 2.5%. the most sensitive bacteria are a. baumanni with an mic of 0.12% 8 , followed by p. aeruginosa with an mic of 0.25% 5,6 , c acnes with an mic of 0.39% 7 , s. aureus with an mic of 0.5% 5 , and s. epidermidis with an mic of 0.78% (esmael et al. , 2020). of the 193 anaerobic bacteria that were exposed to tea tree oil, grampositive anaerobic bacteria are more sensitive than gram-negative ones 10 . judging from the microscopic image, the bacteria exposed to tea tree oil showed clear morphological changes such as cytoplasmic density changing to heterogeneous and some visible out of the cell, as well as visible distances between the cytoplasmic membrane and the cell wall. 11 three journals that looked at the zone of inhibition as a parameter of tea tree oil activity stated that s. epidermidis has the most extensive inhibition zone, namely 15 21.7 mm compared to other bacteria with the same tea tree oil concentration. 7,9,12 two journals discussing the antiviral activity of tea tree oil against hsv stated that tea tree oil can inhibit and kill the growth of the virus which is seen from the pfu and its titer virus. 5,12 hsv 2 was found to be more sensitive to hsv 1 seen from the decrease in viral titer before and after exposure to tea tree oil with a decrease of 15.6% for hsv 1 and 20.23% for hsv 2. 12 five of the eight journals compared the fungal mic to look at the antifungal activity of tea tree oil. the five journals states that the variation in mic was quite significant, namely from 0.06% to 8.96% for candida sp. when compared with bacterial mic, tea tree oil activity is more effective as an antibacterial than antifungal. 5 in addition, other essential oils that are more effective for candida were also found, namely mpp (mentha of pancalieri) oil. 13 the confocal image also shows the presence of antifungal activity of tea tree oil where a red color is seen which indicates microbial death. 14 three of the eight journals that observed their zone of inhibition stated that there was anti-fungal activity of tea tree oil with different areas depending on the concentration of tea tree oil given. 12,15,16 the journal that discusses the antiparasitic activity of tea tree oil against s.scabiei states that its effectiveness is seen from the survival time of s.scabiei. with different methods, the results found are different, namely that clove oil was more sensitive than tea tree oil with the contact bioassays method, while with the fumigation bioassays method, it was found that tea tree oil was the most sensitive followed by clove oil. 17 conclusion tea tree oil is an essential oil that can be used as a treatment for skin infections caused by microorganisms. the antimicrobial activity of tea tree oil is supported by its composition, namely terpinen-4-ol, 𝛾-terpinen, 1,8-cineol, 𝛼-terpinen, 𝛼-terpineol, p-cymen, and 𝛼-pinen which are lipophilic. tea tree oil that enters the cells of microorganisms will result in inhibition of metabolism and cell death of microorganisms. the death of microorganisms can help the healing process of wound infections caused by microorganisms. based on the results of the discussion of 15 journals that examined the effects of tea tree oil on microorganisms in vitro, it was concluded that tea tree oil has antimicrobial activity against microorganisms that cause skin infections. nine journals stated antibacterial activity in terms of mic (minimum inhibitory concentration), mbc (minimum bactericidal concentration), microscopic image, and zone of inhibition. from the nine journals, it was found that the most sensitive bacteria were a. baumanii and p. aeruginosa. two journals stated antiviral activity against hsv 1 and hsv 2 in terms of pfu (plaque-forming unit) and viral titer where it was found that hsv 2 was more sensitive to tea tree oil. eight journals stated antifungal activity in terms of mic, mfc (minimum fungicidal inhibition), confocal features, and zone of inhibition. the eight journals stated significant variations and differences in the anti-fungal activity of tea tree oil against candida sp. one sumail typewriter 31 medical and health science journal 2021 february, vol 05 (01) journal stated antiparasitic activity against s. scaibei in terms of survival time. references 1. meza-romero r, navarrete-dechent c, downey c. molluscum contagiosum: an update and review of new perspectives in etiology, diagnosis, and treatment. clin cosmet investig dermatol. 2019;12:373–81. 2. yadav e, kumar s, mahant s, khatkar s, rao r. tea tree oil: a promising essential oil. j essent oil res [internet]. 2017;29(3):201–13. available from: http://dx.doi.org/10.1080/10412905.2016.123 2665 3. mertas a, garbusińska a, szliszka e, jureczko a, kowalska m, król w. the influence of tea tree oil (melaleuca alternifolia) on fluconazole activity against fluconazole-resistant candida albicans strains. biomed res int. 2015;2015. 4. thomas j, carson cf, peterson gm, walton sf, hammer ka, naunton m, et al. therapeutic potential of tea tree oil for scabies. am j trop med hyg. 2016;94(2):258–66. 5. brun p, bernabè g, filippini r, piovan a. in vitro antimicrobial activities of commercially available tea tree (melaleuca alternifolia) essential oils. curr microbiol. 2019;76(1):108–16. 6. rajeshnidhi kr, mahesh r. antibacterial activity of tea tree oil against clinical isolates of pseudomonas aeruginosa. front microbiol. 2019;10(july):1422–4. 7. esmael a, hassan mg, amer mm, abdelrahman s, hamed am, abd-raboh ha, et al. antimicrobial activity of certain naturalbased plant oils against the antibiotic-resistant acne bacteria. saudi j biol sci [internet]. 2020;27(1):448–55. available from: https://doi.org/10.1016/j.sjbs.2019.11.006 8. sakkas h, gousia p, economou v, sakkas v, petsios s, papadopoulou c. in vitro antimicrobial activity of five essential oils on multidrug resistant gram-negative clinical isolates. j intercult ethnopharmacol. 2016;5(3):212–8. 9. taleb mh, abdeltawab nf, shamma rn, abdelgayed ss, mohamed ss, farag ma, et al. origanum vulgare l. essential oil as a potential anti-acne topical nanoemulsion—in vitro and in vivo study. molecules. 2018;23(9). 10. ziółkowska-klinkosz m, kedzia a, meissner ho, kedzia aw. evaluation of the tea tree oil activity to anaerobic bacteria in vitro study. acta pol pharm drug res. 2016;73(2):389– 94. 11. li wr, li hl, shi qs, sun tl, xie xb, song b, et al. the dynamics and mechanism of the antimicrobial activity of tea tree oil against bacteria and fungi. appl microbiol biotechnol. 2016;100(20):8865–75. 12. ramadan ma, shawkey ae, rabeh ma, abdellatif ao. promising antimicrobial activities of oil and silver nanoparticles obtained from melaleuca alternifolia leaves against selected skin-infecting pathogens. j herb med [internet]. 2020;20(june):100289. available from: https://doi.org/10.1016/j.hermed.2019.100289 13. tullio v, roana j, scalas d, mandras n. enhanced killing of candida krusei by polymorphonuclear leucocytes in the presence of subinhibitory concentrations of melaleuca alternifolia and “mentha of pancalieri” essential oils. molecules. 2019;24(21). 14. francisconi rs, huacho pmm, tonon cc, bordini eaf, correia mf, sardi j de co, et al. antibiofilm efficacy of tea tree oil and of its main component terpinen-4-ol against candida albicans. braz oral res. 2020;34:e050. 15. narang j, narang r, singh b, kahlon s, george j, dogra a. comparative efficacy of tea tree oil nanoemulgel and clove oil nanoemulgel against candida albicans. int j pharm investig. 2018;8(1):50. sumail typewriter 32 medical and health science journal 2021 february, vol 05 (01) 16. patturaja k, geetha r v. evaluation of antimycotic activity of three essential oils on candida albicans -an invitro study. j pharm sci res. 2017;9(4):480–2. 17. fang f, candy k, melloul e, bernigaud c, chai l, darmon c, et al. in vitro activity of ten essential oils against sarcoptes scabiei. parasites and vectors [internet]. 2016;9(1):1– 7. available from: http://dx.doi.org/10.1186/s13071-016-1889-3 sumail typewriter 33 sumail typewriter medical and health science journal 2021 august vol.5 (02) medical and health science journal available at http://journal2.unusa.ac.id/index.php/mhsj; doi: 10.33086/mhsj.v5i2.2189 pissn 2549-7588. eissn 2549-7596 case report case report: blepharoconjunctivitis as manifestation of stevensjohnson syndrome putu ayu adindhya saraswati surya*, ni nyoman sunariasih departement of ophthalmologist sanjiwani hospital article info article history: received: july 21, 2021 received in revised form: august 06, 2021 accepted: august 25, 2021 keywords: blepharoconjunctivitis, conjunctivitis, stevens-johnson syndrome, sjs, ocular manifestation *correspondent author: adindhyasaraswati@gmail. com abstract background: stevens johnson syndrome (sjs) is a collection of acute and life threatening skin symptoms caused by an allergic drug reaction. sjs also attacks the other mucous membranes, one of which is the eye. sjs is a rare case. the initial complaint of sjs is the eruption on the skin in the form of redness followed by blisters and attacking other mucous membranes. the ocular manifestations of sjs are conjunctivitis, corneal erosion, corneal ulcers, and blepharitis. methods: treatment of sjs’s ocular manifestation is administration of drugs and surgical intervention. administration of drugs that often done in the acute phase is antibiotic eye drops with steroids to prevent complications. complications that can occur include symblepharon, districhiasis, and keratitis. this complication can cause a sharp decrease in vision. results: this case report discusses a 68 year old male patient with blisters all over his body accompanied by swelling in both eyes, redness in both eyes, and difficult to open eyes. patients with history of taking the new drug a month ago. no history of drug allergy. the patient suffered from hypertension, non-hemorrhagic stroke, and epilepsy with irregular treatment. patient was performed a fluorescein test. in this case, the patient is given antibiotic ointment and artificial tears with steroids. in this case there were no complications. conclusion: the ocular manifestations of sjs if handled quickly and properly can prevent long-term complications. medical and health science journal http://journal2.unusa.ac.id/index.php/mhsj surya et al medical and health science journal 2021 august vol.5 (02) page 39 of 44 introduction stevens johnson syndrome (sjs) is life threatening condition and rarely happened. incidence of sjs in western countries 0,1-1 in 100.000 population1. sjs in indonesia happened at least 12 cases on a year. mortality rate for sjs can reached 5-15% in total cases2. in other study, sjs mortality rate usually on elderly patient. pediatric patient have a lower mortality rate than geriatric patient, but pediatric patient more likely experienced long term complication3. patient with sjs tend to have ocular manifestation and the acute phase of ocular manifestation occur in 5088% cases. the acute sign of ocular involvement which result from long term sequalae are cornea and conjunctiva epithelial defect, dry eye, symblepharon, cornea scar, and cornea limbal stem cell deficiency4. the authors are interested in discussing sjs case because of frequently seen ocular cases in sjs. case a 68 years old male, married, balinese, hindu, had been work as a teacher was referral patient from the aricanti hospital, ubud, gianyar, bali. medical history the patient came complaining of full body blisters since 3 days ago. initially, the patient had fever for 4 days ago. the patient also complained of reddening of the whole body and received therapy in the form of azithromycin, paracetamol and vitamins since 3 days ago. after that, the patient complained of blisters all over his body. the whole body is reddish and turns white scaly and sloughing. other complaints include swelling and redness of the patient's eyes. redness of eye appeared when the body full of blisters. it began when the patient complained of swelling in both eyes followed by redness of the eyes. the patient's eyes were also difficult to open and accompanied by pain. the patient also complained of white eye discharge, sometimes yellowish white eye discharge. patient was not complaining blurred vision, photophobia, and watering. patients also had hypertension, epilepsy, and non-hemorrhagic stroke with treatment of atorvastatin, amlodipine, and phenytoin. this disease has been suffered since 2019. the patient rarely used his medicine and began to reuse the drugs on january 6, 2021. there is no history of wearing glasses or eye disease on this patient. previously, the patient had no drug allergy. the patient's family history is the patient's parents suffering from parkinson's disease, hypertension, and stroke. the patient's sister was suffering from hypertension. ocular family history was not found. figure 1. the patient's eye condition on the first day of hospitalization. crusted on the right and left eyelids. the right and left eyes looked difficult to open. physical examination on physical examination, found uncorrected visual acuity for both eyes are >3/60. on bed side external examination, found swollen of superior and inferior palpebra with crusting of the eyelid, sloughing of skin, and erythematous macules. on examination of the anterior segment of the eye, it was found conjunctiva vascular injection. the surya et al medical and health science journal 2021 august vol.5 (02) page 40 of 44 conjunctiva palpebra was difficult to evaluate. the cornea is clear. the anterior chamber, iris and lens are normal. the patient also underwent an additional examination of a fluorescein test and the result was there were no defects in the cornea and conjunctiva epithelium. patient diagnosed with blepharoconjunctivitis. treatment blepharoconjunctivitis was treated with eye drops containing dextran-70 1 mg and hypromellose 3 mg given 6 times a day to both eyes and eye ointment containing gentamycin which was given 2 times a day to both eyes. figure 2. fluorescein test negative follow up and outcomes in the patient's daily follow-up, the patient showing improvement of visual problems from day to day. the patient said complaints of swelling and redness in both eyes improved. then, the complaints of eye discharge are said to have started to decrease. complaints of pain in both eyes were also said to have decreased. this patient did not experience complications such as defects in the cornea and conjunctiva, and a sharp decrease in vision. there are no adverse and unanticipated events that have not been handled properly in this case. the prognosis in this patient is dubia ad bonam. the patient and the patient's family already understand about the disease and how to prevent complications from this disease. the patient's and patient's family really maintains eye cleanliness and is assiduous in using the drugs used, gentamycin eye cream and dextran-70 1 mg and hypromellose 3 mg eye drop. figure 3. the patient's eyes on the third day of treatment. the eyelids did not appear swollen and the redness in both eyes improved. discussion sjs is an acute and life-threatening skin drug reaction that affects the skin and other mucous membranes5. sjs is more common in young adults, but can affect other age groups. acute symptoms of sjs in the eye include redness of the eye, sensation to having a particle of sand in the eye, photophobia, watering, and blurring6. jenskins’s study explained eye symptoms in the acute stage often occur with 15% -75% bilateral conjunctivitis and 25% conjunctiva or corneal ulceration5. this case is a 68 year old man with complaints of swelling in both eyes since 3 days ago. this complaint began with the blister on whole body of the patient after experiencing fever for 4 days. swelling in both eyes accompanied by redness of the eyes. the patient also has white discharge in the eye. the patient also said it was difficult to open both eyes and felt pain. the patient did not complain of blurring of the eyes, photophobia, and watering. several types of drugs that can cause stevens johnson syndrome, namely antibiotics such as sulfonamides and trimethoprim, analgesics such as paracetamol and nsaids, hiv treatment with combination therapy using nevirapine, barbituates, allopurinol, surya et al medical and health science journal 2021 august vol.5 (02) page 41 of 44 and anticonvulsants such as carbamazepine, phenytoin, and lamotrigine5,6,7. in this case, patients took medication of azithromycin, atorvastatin, amlodipine, and phenytoin. the patient started taking medication again during the past month due to patient noncompliance in taking regular medications such as atorvastatin and amlodipine and vitamins. the drug he recently drank in the form of phenytoin was due to complaints of seizures that he had just suffered in the past month. based on other literature, symptoms of sjs in the eye are frequent and can cause visual impairment, so patients with sjs should be evaluated immediately7. initial symptoms of sjs occurred in the prodromal phase, namely malaise and fever followed by soft skin eruptions and generally consisted of macules, papules, vesicles, and bullae. another symptom is that at least two other mucosal surfaces are affected such as erosions and crusting of the mouth, conjunctivitis, and urogenital manifestations such as urinary retention and urethritis which may accompany skin manifestations in 90% of cases8. on a slitlamp examination, the severity of eye manifestations in sjs can be determined as mild, moderate, and severe8,9. mild eye manifestations consist of desquamated and bald skin of the eyelids, edema of the eyelids, mild conjunctival injection, mucus discharge or chemosis. moderate eye manifestations may include membranous conjunctivitis, epithelial defects with more than 30%, corneal ulceration, or corneal infiltrates. severe ocular manifestations consist of acquired eyelid malposition, symblepharon, non-healing corneal epithelial defect, partial or complete loss of vision, or narrowing of the conjunctival fornix. chronic ocular sequelae due to sjs occurs in 21-29% of pediatric cases and 27-59% of adult cases8. additional investigations such as fluorescein stain should be performed to evaluate for corneal and conjunctival epithelial defects7. patients have symptoms such as persistent ulceration, dry eyes, and scarring of the eye as much as 35% due to chronic eye damage5. patient in this case was in the acute phase. patient was carried out several physical examinations as well as a supporting examination in the form of a fluorescein test on the patient. the uncorrected visual acuity for both eyes are >3/60. on bed side external examination, found swollen of superior and inferior palpebra with crusting of the eyelid, sloughing of skin, and erythematous macules. on examination of the anterior segment of the eye, it was found conjunctiva vascular injection. the conjunctiva palpebra was difficult to evaluate. the cornea is clear. the anterior chamber, iris and lens are normal. the patient also underwent an additional examination of a fluorescein test and the result was there were no defects in the cornea and conjunctiva epithelium. ocular treatment in sjs is divided into 2. there are drugs and surgical management. management of stevens-johnson's acute ocular manifestations is administration of topical antibiotics, steroids, calcineurin inhibitors, and lubricants8. use of topical steroids at the onset of symptoms can result in better eye visuals. in severe cases, early surgical intervention can involve transplanting the amniotic membrane, which can increase epithelialization and reduce inflammation and scarring on the surface of the eye10. one of the amniotic membrane transplant methods is called surya et al medical and health science journal 2021 august vol.5 (02) page 42 of 44 cryopreserved amniotic membrane, which is a biological device made by cutting the amniotic membrane between two symblepharon rings and a human amniotic membrane graft. there have been several studies conducted to evaluate amniotic membrane transplantation in the eye in sjs and it appears to be showing significant results. the cryopreserved amniotic membrane produces maximum results when applied early in the disease by reducing the risk of long-term eye damage and producing sequelae after 6 days5. on the other study, treatment for the chronic phase aims to prevent worse eye surface damage, treat eye sequelae, and visual rehabilitation. if there are structural abnormalities of the eye, surgical interventions such as keratoprosthesis and keratolimbal allografting (klal) are required to help restore the visual eye. in the final stages with severe corneal blindness and dry eye, limbal stem cell transplantation (lsct) and cultivated oral mucosal epithelial transplantation (comet) are recommended. providing prompt diagnosis and treatment is the key to good eye prevention and recovery in sjs cases8,10. on the pandiaraj case series, eye management with sjs was carried out with a frequent topical lubricant, carboxymethyl cellulose, in all patients. then, given a topical antibiotic in the form of tobramycin if secondary infection is suspected. flourometholone can be added for patients with excessive eye inflammation. in patients with symblepharon, membranolysis with glass rod passing is performed 2-3 times a day. all patients were asked to move their eyes and frequently asked to separate their eyelids to prevent symblepharon. eye hygiene must be maintained properly. patients with corneal epithelial defects are given bandaged contact lenses. all patients were given systemic steroids while paying attention to the administration of fluids and electrolytes according to the patient's condition. this therapy is done once or twice a day for each patient until the patient goes home. no deaths were found and all were discharged within 2 weeks to 2 months10. in present case, patient was treated with eye drops containing dextran-70 1 mg and hypromellose 3 mg given 6 times a day to both eyes and eye ointment containing gentamycin which was given 2 times a day to both eyes. currently, there are no complications in this case. wang’s study explained among those who survive, there are long-term eye complications that can become serious, which occur in about 60% of patients. corneal and conjunctival damage in the form of scar tissue can lead to further visual disturbances7. in abrol's study, several complications were found in the form of complications on the eyelids, conjunctiva, and cornea. complications on the eyelids include eyelid edema, discharge of eye discharge, districhiasis, ulceration of the edge of the eyelids and crusting, wrinkled eyelashes, meibomitis, blepharitis, and peeling of the skin above the eyelids. conjunctiva complications include subconjunctiva bleeding, conjunctivitis, and symblepharon. corneal complications include superficial epithelial keratitis, corneal ulceration, and erosion of the epithelium8. in the present study patient’s daily follow-up, the patient showing improvement of visual problems from day to day. this patient did not experience complications such as defects in the cornea and conjunctiva, and a sharp decrease in vision. there are no adverse and unanticipated events that have surya et al medical and health science journal 2021 august vol.5 (02) page 43 of 44 not been handled properly in this case. the prognosis in this patient is dubia ad bonam. the abrol’s study also found 8 patients who had chronic sequelae from the eye manifestations of sjs. of the 8 patients, 3 patients had severe dry eye disease, 2 patients had trichiasis, 2 patients had decreased visual acuity, and 1 patient had severe photophobia. complications are often not seen at first in conditions of severe eye manifestations. damage to the mucous membranes of the skin and mouth was more associated with the incidence of ocular manifestations in sjs8,10. this case report discussed a case of stevens johnson syndrome which is handled at the district level hospital and can be used as a reference for other research on eye cases in stevens johnson's syndrome and informs the hospital about things that need to be improved in handling rare cases like this. the limitation of this case report are that it does not include follow-up of patients after being discharged from the hospital and does not use snellen charts for visual examination due to limited facilities and infrastructure. conclusion we discussed eye involvement in the case of stevens johnson syndrome with a 68 year old male patient who complained of swelling of the eyelids and redness of both eyes with blister all over his body after taking the new drug he had just taken for the past 1 month. the patient was also investigated with a fluorescein test and the result was that there were no defects in the cornea and conjunctiva. the patient was given antibiotic eye ointment and artificial tears with steroids to reduce inflammation in both eyes. the patient did not experience complications, namely a sharp decrease in vision and defects in the cornea and conjunctiva and the formation of symblepharon. from this case, the author is more aware of a disease that is rare in cases but can be life threatening condition and produce long-term complications if not treated quickly and appropriately. conflict of interest the author stated there is no conflict of interest references 1. schwering, s. m., kayange, p. & rothe, c. ocular manifestations in patients with stevens–johnson syndrome in malawi— review of the literature illustrated by clinical cases. graefe’s archive for clinical and experimental ophthalmology vol. 257 2343– 2348 (2019). 2. putri, n. d., mutiara, h., sibero, h. t. & sukohar, a. steven-johnson syndrom et causa paracetamol. med. prof. j. lampung univ. 6, (2016). 3. fitriana, a., endaryanto, a. & hidayati, a. n. gambaran klinis steven johnson syndrome dan toxic epidermal necrolysis pada pasien anak. berk. ilmu kesehat. kulit dan kelamin period. dermatology venereol. 30, (2018). 4. chow, l. l. w., shih, k. c., chan, j. c. y., lai, j. s. m. & ng, a. l. k. comparison of the acute ocular manifestations of stevensjohnson syndrome and toxic epidermal necrolysis in chinese eyes: a 15-year retrospective study. bmc ophthalmol. 17, (2017). surya et al medical and health science journal 2021 august vol.5 (02) page 44 of 44 5. jenkins, p., enurah, a. & scherbak, d. a case report of ocular stevens-johnson syndrome: an important condition for the internist to see. int. j. acad. med. 6, 33–5 (2020). 6. salmon, j. f. conjunctivitis in blistering mucocutaneous disease. in kanski’s clinical ophthalmology: a systematic approach 189– 193 (elsevier, 2020). 7. wang, j., rixen, j., goins, k. & kitzmann, a. ocular manifestations of stevens-johnson syndrome: 13-year-old female with mucosal and dermatologic eruptions. eyerounds http://eyerounds.org/cases/192-stevensjohnson.htm (2014). 8. abrol, a., gulanikar, a., thakre, s. & patel, a. study of ocular manifestations of stevensjohnson syndrome/toxic epidermal necrolysis. indian dermatol. online j. 11, 570–574 (2020). 9. saeed, h. & rashad, r. ocular disease in stevens-johnson syndrome and toxic epidermal necrolysis. in foundations of corneal disease (eds. colby, k. & dana, r.) 97–108 (springer nature switzerland ag, 2020). 10. pandiaraj, s. s. v. vigilant treatment and early intervention of ocular manifestations of steven johnson syndrome. univ. j. surg. surg. spec. 3, (2017). medical and health science journal 2021 august vol.5 (02) medical and health science journal available at http://journal2.unusa.ac.id/index.php/mhsj; doi: 10.33086/mhsj.v5i2.2160 pissn 2549-7588. eissn 2549-7596 original article an overview self-efficacy and self-acceptance in tuberculosis sufferers eppy setiyowati1, hardiyanti1, ferry agus setiawan1, priyo susilo2 1nursing department, faculty of nursing and midwifery, universitas nahdlatul ulama surabaya, indonesia 2staff at public health center in surabaya, east java indonesia article info article history: received : july 21, 2021 received in revised form : august 22,, 2021 accepted : august 28, 2021 keywords: tuberculosis, self-efficacy, self-acceptance, education, sufferers *) corresponding author: eppy@unusa.ac.id abstract background: tuberculosis is still a major health problem in indonesia, especially in the working area of the east health center in surabaya, the long treatment of tuberculosis (tb) causes sufferers to have low self-efficacy and poor self-acceptance. the purpose of this study is to analyze the relationship between self-efficacy and selfacceptance of patients with tb. methods: the design research is analytic study with cross sectional approach. the study population of 46 patients with active treatment for the last 3 months in the work area of the community health center in surabaya. by 46 patients. results: a sample from 41 respondents taken by simple random sampling technique. the independent variable is self-efficacy, the dependent variable is self-acceptance. the instrument uses a questionnaire. data analysis used chi square test with significance value α = 0.05. the results showed that of 41 respondents the majority (57.3%) had low self-efficacy, and the majority (57.3%) had poor selfacceptance. chi square statistical test results obtained value ρ = 0.008 < a = 0.05 shows there is a relationship of self efficacy with self-acceptance of patients with tb in the work area of the east perak health center in surabaya. conclusion: conclusions of the study that the lower the self-efficacy in patients with tb the worse the selfacceptance and vice versa. patients with tb should further improve their efficacy by always obeying the advice of health workers, and treatment regularly. the role of nurses in improving self-efficacy by providing education to sufferers and families, working together to care more and motivate patients so that success in treatment. medical and health science journal http://journal2.unusa.ac.id/index.php/mhsj setiyowati et al medical and health science journal 2021 august vol.5 (02) page 10 of 15 introduction tuberculosis is still a major health problem worldwide1. indonesia is at the third level (8%) highest incidence of tb cases after india (27%) and china (9%). east java still occupies the second largest province of cases in indonesia after west java2. health research data east java region3, surabaya city is at the figure of 0.3 % tuberculosis diagnosis. in 2016 tb cases in surabaya as many as 2,382 people, with prevalence recovery 42.0%, died 2.5% and failed 0.4% 1. a preliminary study conducted in november 2019 at the health center in surabaya city obtained 160 cases of tuberculosis consisting of 28 children, tuberculosis with hiv 5 people, pulmonary tuberculosis 124 people, multi dark resistance (mdr) as many as 3 people2. research on tuberculosis in puskesmas in surabaya has been done by researchers before. but no one has done any research on self efficacy and self acceptance in tuberculosis sufferers. based on the data above the prevalence of failure and recovery depends on the efficacy of the patient in receiving the condition of the disease and the disease experienced, because selfefficacy is the belief of the sufferer to organize and implement the treatment program so that success in treatment is realized. tuberculosis is a public health problem that causes mental distress for sufferers, because it has to carry out regular treatment and control. the patient's self-acceptance that he suffers from tuberculosis will experience stress, sadness, disappointment and surrender. perceptions shown by sufferers such as grumpy, withdrawn or even showing self-efficacy are not good3. his lack of efficacy made him unable to do anything useful due to suffering from tuberculosis4 . patients who have good self-efficacy will choose good behaviors that will improve it, thereby lowering depression and worry, increasing self-esteem and quality of life 4,5 . selfefficacy accompanied by the role of motivation is very important for self-acceptance of tuberculosis sufferers in conducting treatment. some factors that affect the self-acceptance of tuberculosis sufferers in the health promotion model are the benefits of direct action that provides motivation to the behavior of tuberculosis sufferers6. obstacles of action known by sufferers so that tb sufferers have preparedness in doing obstacles or high obstacles are low. self-efficacy is the ability of tb sufferers in behaving raises action, attitudes related to emotional activities arising in treatment activities and in differentiation of places and behaviors to tb sufferers7. the greatest interpersonal influences are the families, groups and influences of health workers, as well as situational influences that are key in the development of affective strategies for tb sufferers to facilitate and maintain health promotion behaviors in the population8. self-efficacy in behaving is the actions of individuals in carrying out activities in accordance with their expectations, efforts made in performing the desired objectives. the resilience of the individual in strengthening himself when facing failure, resistance to discomfort by assuming the situation faced is not a threat but a challenge to become a better person1. the mindset of tuberculosis sufferers will usually see everything in their circle narrow when in difficult situations, achievement levels setiyowati et al medical and health science journal 2021 august vol.5 (02) page 11 of 15 manifest, and stress or depression becomes a stimulus for sufferers to feel depressed9. the number of tuberculosis sufferers who do not use masks during treatment and the number of patients who do not do regular control is very problematic for someone who has poor selfefficacy that affects the self-acceptance of tuberculosis sufferers5. therefore, efforts to improve the patient's self-efficacy are very important in the patient's self-acceptance, because many sufferers do not believe that they have tuberculosis so not many treatments fail10. the authors found that a lack of self-efficacy in selfacceptance is one of the causes of such failures, so it is necessary to conduct more research on the relationship of self-efficacy with self-acceptance of tuberculosis sufferers in the work area of a community health center in surabaya. methods research design is the study of analysis with a cross sectional approach. the study was conducted in october december 2020. inclusion criteria, namely, adult tuberculosis sufferers, tuberculosis sufferers without any accompanying disease, tuberculosis sufferers do routine control for the last 3 months, willing to be respondents. the exclusion criteria are children with tuberculosis, tuberculosis sufferers with multi dark resistance (mdr). sampling was done in accordance with simple random sampling and sample calculation based on the slovin formula obtained by 46 respondents but at the time of the study there were 2 respondents moved to another city, 3 respondents refused to follow the research. data collection with questionnaires circulated through google form on whatsapp group created by researchers with the consent of respondents, considering the condition is a pandemic period where researchers can not directly meet with respondents. questionnaire contains questions about self efficacy and self acceptance with assessors based on likert scale, 1 strongly disagree, 2 disagree, 3 agree, 4 agree once, 5 strongly agree once.the instrument used a questionnaire that was self-controlled by research and conducted validity tests and reliabilities with cronbach alpha > 0.5. analyze the data using the chi square test with a value of α = 0.05. results the results of this study include the distribution of self-efficacy, self-acceptance and statistical tests of correlation of self-efficacy and self-acceptance. as stated in the following table; table 1. self-efficacy frequency distribution no. selfefficacy frequency (%) 1 high 20 48,8 2 low 21 51,2 total 41 100 primary data, february 19, 2020 based on table 1 shows that out of 41 respondents, the majority (51.2%) tuberculosis sufferers have low self-efficacy. table 2. self-acceptance frequency distribution no. selfacceptance frequency (%) 1 good 20 48,8 2 bad 21 51,2 total 41 100 primary data, february 19, 2020 setiyowati et al medical and health science journal 2021 august vol.5 (02) page 12 of 15 based on table 2 shows that out of 41 respondents, the majority (51.2%) tuberculosis sufferers have low self-acceptance. table 3. cross tabulation ff self-efficacy with independent recipients in tuberculosis sufferers selfefficacy self-acceptance total p good ugly n % n % n % high 14 70 6 30 20 100 0,008 low 6 28,6 15 71,4 21 100 total 20 48.8 21 51,2 41 100 primary data, february 19, 2020 based on table 3 shows that out of 41 respondents, the majority (51.2%) tb sufferers have poor selfacceptance. cross tabulation in table 3 shows that of the 21 respondents who had low self-efficacy, the majority (71.4%) poor self-acceptance, and of the 20 respondents who had high self-efficacy most (70%) with good self-receiver. chi square test results with spss for windows with a meaning level = 0.05 obtained a value of ρ=0.008 (0.008<0.05) then h0 rejected which means there is a relationship of self efficacy with selfacceptance sufferers tuberculosis. the results of the study in table 1 showed that most (51.2%) have low self-efficacy, tb sufferers in the community health center area in surabaya have the view that tb disease is a test in accordance with the statement at number 10, and almost half (48.8%) has high self-efficacy, tb sufferers force themselves to take drugs in accordance with the provisions of health services in the hope of recovering, this is in accordance with statements number 4 and 11. discussion tuberculosis sufferers in the work area of a community health center in surabaya in surabaya, most have low self-efficacy and most have poor self-acceptance. the results of this study are in line with the research of 11 which found the majority (57.3%) patients tend to have low self-efficacy because they are not sure to complete tuberculosis treatment. while the results of 12 found some respondents (66.67%) have sufficient selfefficacy. that self-efficacy is the consideration a person has in carrying out certain behaviors 13. tuberculosis sufferers who are not emotional tend to have high expectations but tuberculosis sufferers with high emotional levels have low expectations 15. tuberculosis sufferers who are not emotional tend to have high expectations but tb sufferers with high emotional levels have low expectations. patients who have low selfefficacy and high emotional level will feel depressed and have a high restless attitude especially with the habit of having to take medication every day during the treatment process until cured, and the use of masks as personal protection and people around and differentiation of places to eat to bed that cause tb stress and this is in accordance with 14. selfefficacy is self-confidence with optimism and hope to be able to solve problems, when the individual is faced with health problems, there will be stress on him and the occurrence of setiyowati et al medical and health science journal 2021 august vol.5 (02) page 13 of 15 reactions to the situation he experienced so that he can not condition between his emotions in the face of difficulties 15. identification of self-acceptance in tuberculosis sufferers the results of the study in table 2 showed that the majority (51.2%) have bad selfacceptance. the results of the observations of researchers found that tuberculosis sufferers feel minder with themselves and prefer to be alone in the room, this is in accordance with statements 8 and 9, according to one cadre of tuberculosis many tb sufferers do not want to come to the community health center themselves so that cadres educate sufferers, if the sufferer does not want to come to take drugs then it can be taken by the family or assisted by tuberculosis cadres in the community health center area in surabaya, and almost half (48.8%) have good selfacceptance, the result of the observation of researchers tuberculosis sufferers can adapt to the disease because they routinely take drugs in accordance with statements number 1 and 3, when me and the cadre come to the patient's house, they accept us with joy and explain their grievances in taking drugs and behavior at home, so that cadres always provide motivation for sufferers and families to better supervise the administration of drugs to sufferers. this study is in line with the research of 15 found that the most self-acceptance is self-acceptance enough, patients who have enough or less self-acceptance caused by most patients have a persistent cough makes it difficult for patients to get along in the community environment, the patient feels minder with the disease experienced and causes a sense of insecurity can be cured in carrying out treatment. treatment will be successful depending on the attitude and support of the family, the main source of interpersonal support for tuberculosis sufferers is the family so that the family has an important role in the recovery of tuberculosis sufferers but if the family does not care then there will be other tuberculosis sufferers in one house 8. comfort to yourself obtained from the closest person will increase self-confidence in overcoming the problems faced, tuberculosis sufferers who can accept themselves will have life satisfaction either directly or indirectly because self-acceptance means having accepted the shortcomings in him 16 . research from setyowati 16explained from 3 determinant factors tb namely activities, feelings and abilities that strongly affect the occurrence of tb disease is feelings towards itself. kurniawati et al, 12 explained that tb sufferers who have severe emotional feelings will become stressed and gradually depressed because they have not been able to accept the situation that they experience so it is difficult in self-acceptance. jang et al mentioned that a bad concept of self will result in rejection of oneself, so tb sufferers who have unstable self-concept will refuse to take medication, or still take medication but do not follow the advice of health workers despite always being reminded13. relationship of self-efficacy with selfacceptance in tuberculosis sufferers the results of the study in table 3 cross tabulation between self-efficacy and selfacceptance of tb sufferers in the work area of a setiyowati et al medical and health science journal 2021 august vol.5 (02) page 14 of 15 community health center in surabaya using the chi square test. the research hypothesis obtained the results of ρ < α or 0.008 < 0.05 which means there is a relationship between selfefficacy and self-acceptance of tb sufferers in the work area of a community health center in surabaya. this can prove that there is a link between self-efficacy and self-acceptance of tuberculosis sufferers in the working area of the center for public health in surabaya. this can be seen from the cross-tabulation analysis that of the 21 respondents who had low self-efficacy, most (71.4%) poor self-acceptance, and of the 20 respondents who had high self-efficacy most (70%) have good self-acceptance. the results of this study are in line with the research conducted 3 the higher the value of self-efficacy the better self-acceptance, and vice versa the lower 14 the value of self-efficacy the worse self-acceptance. in addition, research conducted by states that self-efficacy is a concept of a person's ability to perform the desired action, self-efficacy becomes an amplifier of the reason a person performs for his or her own good. from the data obtained, the higher selfefficacy the better self-acceptance. good selfefficacy occurs because of the belief of tuberculosis sufferers to recover which is accompanied by self-acceptance in tuberculosis sufferers. on the contrary, if the efficacy of him is low then the self-acceptance of tuberculosis sufferers is also bad. conclusion tuberculosis sufferers in the work area of a community health center in surabaya in surabaya, most have low self-efficacy and most have poor self-acceptance. this is evidence from research stating that there is a relationship of self-efficacy to self-acceptance in people with pulmonary tuberculosis. conflict of interest the author stated there is no conflict of interest references 1. kemenkes ri. tuberkulosis ( tb ). tuberkulosis 1, 2018 (2018). 2. andajani, s. determinant of latent pulmonary tuberculosis incidence among health workers in community health centers in surabaya, indonesia. folia medica indones. 55, 139 (2021). 3. yang, y., dongdong, y. & yu, h. comparative study on relationship between inconsistent online-offline social performance and self-efficacy of university students based on types of social activity. front. psychol. 12, 747 (2021). 4. setiyowati, e., hanik, u., juliasih, n. n. & wahdi, a. self-management education for the quality of life of patients with pulmonary tuberculosis. j. qual. public heal. 4, 10–19 (2020). 5. kim, s., roh, h. j. & sok, s. empathy and self-efficacy in elderly nursing practice among korean nurses. int. j. environ. res. public health 18, (2021). 6. colvin, c. j. et al. ‘it has become everybody’s business and nobody’s business’: policy actor perspectives on the implementation of tb infection prevention and control (ipc) policies in south african public sector primary care health facilities. glob. public health 0, 1–14 (2020). setiyowati et al medical and health science journal 2021 august vol.5 (02) page 15 of 15 7. li, j.-b. et al. chinese public’s knowledge, perceived severity, and perceived controllability of covid-19 and their associations with emotional and behavioural reactions, social participation, and precautionary behaviour: a national survey. bmc public health 20, 1589 (2020). 8. banu, s. et al. social enterprise model (sem) for private sector tuberculosis screening and care in bangladesh. plos one 15, 1–17 (2020). 9. recabarren, r. e., gaillard, c., guillod, m. & martin-soelch, c. short-term effects of a multidimensional stress prevention program on quality of life, well-being and psychological resources. a randomized controlled trial. front. psychiatry 10, 88 (2019). 10. santos, c. d., santos, a. j., santos, m., rodrigues, f. & bárbara, c. pulmonary rehabilitation adapted index of self-efficacy (praise) validated to portuguese respiratory patients. pulmonology 25, 334–339 (2019). 11. hallford, d. j., ricarte, j. j. & hermans, d. perceived autobiographical coherence predicts depressive symptoms over time through positive self–concept. front. psychol. 12, 674 (2021). 12. kurniawati, a., padmawati, r. s. & mahendradhata, y. acceptability of mandatory tuberculosis notification among private practitioners in yogyakarta, indonesia. bmc res. notes 12, 543 (2019). 13. jang, i., oh, d. & kim, y. s. factors associated with nursing students’ willingness to care for older adults in korea and the united states. int. j. nurs. sci. 6, 426–431 (2019). 14. yada, h., abe, h., odachi, r. & adachi, k. exploration of the factors related to selfefficacy among psychiatric nurses. plos one 15, 1–11 (2020). 15. mata, á. n. de s. et al. training in communication skills for self-efficacy of health professionals: a systematic review. hum. resour. health 19, 30 (2021). 16. setiyowati, e. determinants of the quality of life of pulmonary tuberculosis (ptb) patients in surabaya city. j. heal. sci. 13, 116–123 (2020). medical and health science journal 2022 february vol.6 (01) medical and health science journal available at http://journal2.unusa.ac.id/index.php/mhsj; doi: 10.33086/mhsj.v5i2.2412 pissn 2549-7588. eissn 2549-7596 case report pregnancy with early latent syphilis, a reality in 21st century : a case report and literature review rizqy rahmatyah1,2, velyana lie2, achmad rheza2, eighty mardiyan kurniawati3 1faculty of medicine, universitas airlangga, surabaya, indonesia 2dr. wahidin sudiro husodo general hospital, mojokerto, indonesia 3division of urogynecology reconstructive, department of obstetrics and gynecology, faculty of medicine, universitas airlangga, surabaya, indonesia article info article history: received : september 19, 2021 received in revised form : january 19, 2021 accepted : february 20, 2022 keywords: syphilis, pregnancy, treponema pallidum *) corresponding author: eighty-m-k@fk.unair.ac.id abstract syphilis is a sexually transmitted disease caused by the spirochete treponema pallidum. it is of special concern during pregnancy because can lead to adverse pregnancy outcomes and congenital syphilis. we retrospectively included female patient with laboratory-confirmed syphilis in east java. demographic, pregnancy record, clinical, radiological, laboratory, and treatment data were reviewed from medical record and health of both mother and child book. clinical characteristics and outcome of patient were described. th e patient was 40-year-old multiparous pregnant women was referred to the hospital at 40 weeks of gestation due to early latent syphilis. the patient was diagnosed during the last trimester and had not been treated, but no vulvar and anal genital wart was found. patient was scheduled to urgent section caesarean but 1 hour after admitted to the hospital, patient had spontaneous delivery. a healthy son was born (3400 g /50 cm, 10 points apgar score). due to the lack of documentation regarding treatment of maternal syphilis, crystalline penicillin was administered to the newborn. screening and early penicillin treatment are the most important factors that can eliminate complications related to the prenatal contagion with treponema pallidum. yet despite the lack of treatment or its inappropriate administration, the pregnancy complicated with maternal syphilis may end in a completely different way. medical and health scince journal http://journal2.unusa.ac.id/index.php/mhsj rahmatyah et al medical and health science journal 2022 february vol.6 (01) page 42 of 46 introduction syphilis is a bacterial sexually transmitted infection caused by treponema pallidum. the disease remains the most common congenital infection worldwide.1 the world health organization (who) estimates that, globally, 1.5 million pregnancies are affected by syphilis each year and up to 50% of those who are not treated will experience adverse outcomes such as congenital syphilis.2 syphilis infection during pregnancy related with miscarriage, stillbirth or neonatal death shortly after delivery. timely diagnosis and proper management of infection in pregnant women are important to prevent adverse outcomes. this study aims to describe cases of syphilis that occur in pregnancy, the lack of data and how the treatment will be given. case mrs. hr a 40 years old malay housewife, gravida 4 para 2 + 1, came for an antenatal checkup at the obstetrics polyclinic of a hospital in east java, indonesia. the patient had been under control at the community health centre and currently has no complaints other than being close to delivery. according to the referral letter from the community health centre, the patient was diagnosed with early latent syphilis and was subsequently referred here for further management. she also did not complain of itching in the genital area associated with vaginal discharge. the patient was diagnosed during the last trimester and received no treatment. no vulvar and anal genital warts were found. routine blood tests including hepatitis b, human immunodeficiency virus (hiv) and syphilis serological tests were repeated. serological test results for hepatitis b and hiv were negative. however, rapid plasma reagin is reactive at 1:16 titration. the diagnosis of syphilis is confirmed by a positive syphilis from the immunoglobulin g (igg) result. there was no previous history of syphilis, and there was no record of syphilis treatment from the community health centre. her husband was counseled for syphilis screening but was turned down. the patient was scheduled for immediate cesarean section but 1 hour after being admitted to the hospital, the patient had a spontaneous delivery. she gave birth to a baby boy at 40 weeks' gestation by spontaneous delivery with a birth weight of 3400 g, body length of 50 cm, and an apgar score of 10 points. there are no clinical signs of congenital syphilis. the results of rapid plasma reagin for infants are unknown because they are not tested. he was discharged after three days in the ward. postpartum follow-up was scheduled for mother and baby during control at the polyclinic. discussion globally, syphilis remains prevalent in africa, south america, southeast asia and eastern europe.2 if a pregnant woman has syphilis, motherto-child transmission can occur, potentially causing serious adverse outcome including low birth weight, stillbirth and congenital syphilis.3 for this reason, infection remains part of the antenatal screening program. only 40% of women with positive screening results require antibiotic treatment for the condition.4 this is because patients who screen positive may have an inadequately treated infection acquired before conception, a false-positive result, or an inflammatory condition.5,6 the stage of maternal syphilis affects the risk of transmission to the fetus as high as 100% in primary syphilis, rahmatyah et al medical and health science journal 2022 february vol.6 (01) page 43 of 46 whereas the risk is much lower in early and late latent syphilis, with transmission rates of 40% and 10%, respectively.5 syphilis can seriously make complicated pregnancy and result in spontaneous abortion, stillbirth, non-immune hydrops, intrauterine growth restriction, and perinatal death, as well as serious outcome in live-born infected children. while appropriate treatment for pregnant women often prevents these complications, the main obstacle is the inability to identify infected women and put them on treatment. first-trimester screening with non-treponemal tests such as the rapid plasma reagin test (rpr) or venereal disease research laboratory test (vdrl) combined with individual confirmation of being reactive with treponemal tests such as the fluorescent treponemal antibody absorption test (fta-abs) is a cost-effective strategy. those at risk should be retested in the third trimester. treatment during pregnancy should be with penicillin. in determining a penicillin regimen, the clinician must consider the stage of the mother's infection and the mother's hiv status. patients allergic to penicillin should be sensitized before treatment. despite proper treatment, as many as 14% will experience fetal death or give birth to an infected baby.7 spirochetes of treponema pallidum can cross the placenta and infect the fetus starting at about 14 weeks of gestation, and the risk of fetal infection increases with gestational age. however, the manifestations and outcomes of congenital syphilis are influenced by gestational age, maternal syphilis stage, maternal medication, and fetal immunologic response. congenital syphilis can cause spontaneous abortion, usually after the first trimester, or stillbirth at term is found in 30 to 40 percent of cases, or premature, or full-term birth in a live baby but may have obvious signs of infection or have no symptoms at all once (about two-thirds of the time live births).8 placental infection and decreased blood flow to the fetus are the most common causes of fetal death. untreated women have about a 70% chance of fetal infection during the first 4 years of disease.9 in 35% of cases, infected fetuses are born alive with congenital syphilis. low birth weight can be the only sign of infection. in fact about 60% of live births are asymptomatic at birth.7 in this patient, there were no signs of infection either in the mother or in the fetus, but further examination needs to be done to prevent the bad condition and the possibility of congenital syphilis being undetected during delivery. adequate treatment of maternal infections is effective for preventing maternal-to-fetal transmission and for treating fetal infections. the treatment is penicillin g, which is administered parenterally. in this case there is no problem in giving antibiotics. treatment failure has been described in several case reports, particularly in patients with hiv infection, but no penicillin resistance has been documented in t. pallidum. 10 the cdc recommends that pregnant women should be treated with a penicillin regimen appropriate for their stage of infection. in primary, secondary, and early latent syphilis, benzathine penicillin g 2.4 million units im in a single dose is recommended.11 additional therapy may benefit pregnant women in some situations. some authors suggest that a second dose of benzathine penicillin 2.4 million units im be administered 1 week after the initial dose for women with primary, secondary, or early latent syphilis.12 in late latent syphilis or latent syphilis of unknown duration, a total of 7.2 rahmatyah et al medical and health science journal 2022 february vol.6 (01) page 44 of 46 million units of benzathine penicillin g should be given, as 3 doses of 2.4 million units im each at 1 week intervals. pregnant women with reactive serological tests for syphilis should be counseled about the possibility of harboring other sexually transmitted agents, and tested for these. the most important is the concurrent hiv infection. data on concurrent syphilis and hiv infection are limited. two prospective studies involving 178 non pregnant syphilis patients (95 hiv seropositive, 83 seronegative) found no clinical difference in clinical presentation, course of disease, and response to therapy, but there was a delay in serological improvement in patients with hiv after therapy. despite the recommended penicillin regimen for pregnant women, as many as 14% will experience fetal death, or deliver a baby with clinical evidence of congenital syphilis.13 although in these cases it is recommended to be treated with at least two doses of benzathine penicillin 2.4 million units within 1 weeks, the efficacy of this regimen in either preventing or fetal syphilis is unknown.14 severely infected fetuses can be aborted even though the mother has been on therapy. mothers who are infected within 4 weeks after delivery can still give birth to a newborn with the risk of exposure.7 conclusion in this case, due to lack of documentation regarding the treatment of maternal syphilis, crystalline penicillin was administered to the newborn. early penicillin screening and treatment is the most important factor in eliminating complications associated with prenatal transmission with treponema pallidum. the main factor that causes failure to prevent congenital infection is the lack of prenatal care. in the united states, 98.7% of pregnancies ending in a live birth had at least one prenatal medical visit; in contrast, only 52% of mothers of infants with congenital syphilis reported having had at least one prenatal visit.7 the likelihood of seeking prenatal care was strongly related to age, marital and socioeconomic status, rural residence, and educational attainment. routine prenatal screening is the main line of defense against congenital syphilis. all pregnant women should undergo non-treponemal serological testing for syphilis during the first trimester. in areas with a high syphilis index, serological screening should be performed early in the third trimester and at the time of deliver. all cases of congenital syphilis can be prevented if the maternal infection is diagnosed and treated promptly. however, for this to happen, good treatment pathways must be in place and adequate resources must be available. this requires commitment from the government and strong program leadership. the who millennium development goals to reduce mortality of children under 5 years of age by 66% and improve maternal health by 2025 present significant challenges and opportunities: prevention of congenital syphilis is an integral aspect of this goal and requires leadership action. acknowledgment thanks to all authors and researchers who have helped in completing this study conflict of interest the author stated there is no conflict of interest rahmatyah et al medical and health science journal 2022 february vol.6 (01) page 45 of 46 references 1. rac mw, revell pa, eppes cs. syphilis during pregnancy: a preventable threat to maternal-fetal health. am j obstet gynecol 2017;216:352–63. 2. gomez gb, kamb ml, newman lm, mark j, broutet n, hawkes sj. untreated maternal syphilis and adverse outcomes of pregnancy: a systematic review and metaanalysis. bull world health organ 2013;91:217–26. 3. public health england. nhs infectious diseases in pregnancy screening programme handbook 2016 to 2017. london: public health england; 2016 [https://assets.publishing.service.gov.uk/go vernment/uploads/system/uploads/attachm ent_d ata/file/542492/nhs_idps_programme_ handbook_2016_to_2017.pdf]. 4. guidance. infectious diseases in pregnancy screening (idps) programme overview [https://www.gov.uk/guidance/infectiousdiseases-in-pregnancy-screeningprogrammeoverview]. 5. public health england. syphilis epidemiology in london. sustained high numbers of cases in men who have sex with men. london: public health england; 2016 [https://assets.publishing.service.gov.uk/go vernment/uploads/system/uploads/attachm ent_data/fil e/547072/london_syphilis_report.pdf]. 6. hiv-stis. recent epidemiology of infectious syphilis and congenital syphilis. infection reports. health protect rep 2013;7. [https://assets.publishing.service.gov.uk/go vernment/uploads/system/uploads/attachm ent_d ata/file/336760/hpr4413_sphls.pdf] (publication withdrawn february 2020) 7. genç m, ledger wj syphilis in pregnancy sexually transmitted infections 2000;76:73-79. 8. h. b. jensen, “congenital syphilis,” seminars in pediatric infectious diseases, vol. 10, pp. 183–194, 1999. 9. d. watson-jones, j. changalucha, b. gumodoka et al., “syphilis in pregnancy in tanzania. i. impact of maternal syphilis on outcome of pregnancy,” journal of infectious diseases, vol. 186, no. 7, pp. 940–947, 2002. 10. l. v. stamm, “global challenge of antibiotic-resistant treponema pallidum,” antimicrobial agents and chemotherapy, vol. 54, no. 2, pp. 583–589, 2010. 11. k. a. workowski and s. berman, “sexually transmitted diseases treatment guidelines,” morbidity and mortality weekly report, vol. 59, no. rr-12, pp. 1–113, 2010. 12. g. d. wendel jr., j. s. sheffield, l. m. hollier, j. b. hill, p. s. ramsey, and p. j. sánchez, “treatment of syphilis in pregnancy and prevention of congenital syphilis,” clinical infectious diseases, vol. 35, supplement 2, pp. s200–s209, 2002. 13. conover c, rend c, miller g, et al. congenital syphilis after treatment of maternal syphilis with a penicillin regimen exceeding cdc guidelines. infect dis obstet gynecol 1998;6:134–7. rahmatyah et al medical and health science journal 2022 february vol.6 (01) page 46 of 46 14. goh bt, thornton ac. antenatal screening for syphilis. sex transm infect. 2007;83(5):345-346. doi:10.1136/sti.2007.026633 medical and health science journal, vol. 4, no.2, august 2020 correspondence: nor ain mior nizam @2020 medical and health science journal. 10.33086/mhsj.v4i1.1415 available at http://journal2.unusa.ac.id/index.php/mhsj 69 prevalence of chronic kidney disease among community remote areas in sabah: population-based study nor ain mior nizam,* 1 malehah mohd noh 1,2 ,shamsul bahari shamsuddin 1 1 faculty of medicine and health sciences, university malaysia sabah, kota kinabalu, 88400, malaysia 2 medical department, hospital queen elizabeth, kota kinabalu, 88400, malaysia * corresponding author: ain1510@yahoo.com article info abstract article history: submitted: july, 19 2020 received in revised form juli, 21 2020 accepted: august, 1 2020 in this population-based study, we determined the prevalence of chronic kidney disease (ckd) of community in remote areas of ranau, sabah to have accurate information for health-care planning. it also investigated the association of risk factors with the prevalence of ckd. a sample of 270 individuals, compared to the study of the national health and morbidity survey 2011, of the adult population (over 18 years old) undertaken in west malaysia. we measured the estimated glomerular filtration rate (egfr) using this ckd-epi equation. the total prevalence of ckd in this group was 53%. an estimated 3.3% had stage 1 ckd (egfr >90 ml/min per 1.73m 2 ), 32.6% had stage 2 (egfr 60–89 ml/min per 1.73m 2 ), 4.1% had stage 3 (egfr 30–59 ml/min per 1.73m 2 ), 7% had stage 4 (egfr 15–29 ml/min per 1.73m 2 ), and 6% had stage 5 ckd (egfr <15 ml/min per 1.73m 2 ). only 4% of respondents with ckd were aware of their diagnosis. the significant risk factors included family history of kidney disease, alcohol consumption, smoking status, hypertension, diabetes mellitus, and dyslipidemia. thus, ckd in east malaysia are common and warrants early detection, and treatment to potentially improve outcomes can be implemented. @2020 medical and health science journal. 10.33086/mhsj.v4i1.1415 keywords: prevalence, chronic kidney disease, glomerular filtration rate, risk factors introduction chronic kidney disease (ckd) is a significant public health issue 1 . it is a worldwide burden attracting major attention due to its rapidly progressing numbers. 2,3 recent global ckd prevalence is estimated to be between 10 – 15%. 4 a previous study reported 9.1% of west malaysians to have ckd. 5 ckd can develop gradually, taking months to years, frequently leading to permanent loss of kidney function over time. harmful effects of ckd are the accumulation of water, waste, and toxic substances in the body that are excreted by the kidneys. the loss of kidney function is known to cause anemia, high blood pressure, bone diseases, and acidosis disorders (excessive acidity of body fluids) associated with cholesterol and fatty acids. as ckd continues to progress, the glomerular filtration rate decrease and remaining nephrons are unable to effectively eliminate metabolic wastes and environmental toxicants from the body. this inability may escalate the mortality and/or morbidity of an individual 1 . as the renal replacement therapy (rrt) in sabah has been increased up to 2,047 patients and rrt places a large burden on the health-care budget 15 . therefore, it is important to obtain accurate local data on ckd to facilitate health care planning, especially in remote areas. the objective of this populationbased study was to determine the prevalence of ckd among community aged over 18 years in remote areas of ranau, sabah. we also studied the association of risk factors with the prevalence of ckd. original article mailto:ain1510@yahoo.com medical and health science journal, vol. 4, no.2, august 2020 70 materials and methodology 2.1 study area the study was conducted in the district of ranau, sabah, north borneo of malaysia which comprises a total population of 94,029. more than 85% of the population comprises of the dusun tribe. 16 2.2 patient background this study was carried out at the nephrology health care clinic in ranau hospital. most of the patients aged 18 to 65 years, who gave their consent, were diagnosed as ckd and referred to be assessed by physicians. simple random sampling was used. pediatric patients, pregnant women, infections disease patients such as those suffering from hiv, and hepatitis were excluded. 2.3 sampling method all respondents were randomly interviewed by trained data collectors using a standard validated questionnaire with fully written consent. this was a cross-sectional study where we evaluated 270 respondents. the questionnaires included demographic characteristics, socioeconomic and health status. physical examination and blood tests were performed. blood pressure (bp) was measured by omron japan model hem-907 (tokyo, japan), 19 which has been validated and calibrated. bp was measured with the respondent at rest in a sitting position, with the bp set and appropriate-sized cuff at chest level. two readings were taken 15 min apart, and the average measurement was used for analysis. 2.3.1 blood sampling method written consent was obtained from the respondents for blood sampling and it was done to determine the serum creatinine (scr), in which 5ml of blood samples were taken by using a disposable syringe from the vein and collected in a capped plastic sterile tube. the procedures were carried out aseptically and precautions taken during the use of a tourniquet to prevent blood contamination as per protocols. the blood samples were transported by using a cool box and the temperature was maintained at 4ºc and sent immediately to the laboratory within 24 hours. the serum creatinine level was measured by the enzymatic laboratory method of sabah gribbles laboratory, malaysia. the estimated gfr (measured in millimeters per minute per 1.73m 2 ) was calculated using the ckd-epi creatinine formula 20 , where e-gfr= 141 x min (scr / k, 1) a x max (scr / k, 1) -1,209 x 0.993 age x 1.018 (if female) scr is serum creatinine (mg / dl), k = 0.7 (female) and 0.9 (male), a = 0.248 (female) and -0.207 (male), min is the minimum of scr /k or l and max is the maximum of scr/k or l. fasting blood sugar and total cholesterol were estimated by dry method (cardiochek pa, gribbles sabah, my), which has been validated. 18 2.4 definitions ckd stages 1 and 2 was defined as egfr > 90 ml/min per 1.73m 2 and 60–89 ml/min per 1.73m 2 , respectively. stages 3, 4, and 5 were defined as egfr 30–59, 15–29, and <15 ml/min per 1.73m 2 , respectively, regardless of kidney damage. diabetes mellitus was defined as a fasting capillary blood glucose level > 6.1 mmol/l on cardiochek, or self-reported diabetes diagnosed by medical personnel, or random capillary blood glucose >11.1 mmol/l. hypercholesterolemia was defined as random or fasting blood cholesterol > 5.2 mmol/l or self-reported hypercholesterolemia diagnosed by medical personnel. hypertension was defined as the average of two bp readings with systolic bp >140 and/or diastolic bp > 90mmhg20 and/or self-reported hypertension previously diagnosed by medical personnel. medical and health science journal, vol. 4, no. 2, august 2020 71 2.5 statistical analysis statistical analyses of data were performed by using spss version 26 to identify whether there was any significant prevalence of ckd among the respondents. data were presented as mean and median for continuous variables and proportion for categorical variables. prevalence estimates of all outcomes were performed. factors associated with ckd were assessed using logistic regression. unadjusted odds ratio between exposure variables and indicators of ckd was determined. adjusted odds ratios and 95% confidence intervals were estimated. the p-value of <0.05 is considered significant. 2.6 ethical approval and consent approval and ethical clearance were given by the national medical research register (nmrr) (ethics approval number: nmrr-18-2615-44151) and the ums research committee. the approval also was obtained from the director of the state health department for blood sampling which was conducted by the staff of the health department. all respondents were required to sign a written informed consent form before enrolment. result and findings there were 270 respondents consented to participate out of initially 400 targeted, giving a response rate of 68%. table 1 compares the overall national health and morbidity survey (nhms) 2011 cohort in west malaysia aged > 18 years (n=15,147) with the ckd study (n=270). there was no difference observed in the profile of both studies. table 1 comparison between national health and morbidity survey (nhms) cohort samples and ckd samples socio-demographic characteristics nhms cohort (>18 years), n=15,147 ckd study, n=270 number mean median number mean median iqr age (years) 15,147 42.2 41.0 270 45.1 46.0 20 systolic blood pressure(mmhg) 14,631 129.5 127.0 270 134.7 134.0 20 diastolic blood pressure (mmhg) 14,630 80.2 80.0 270 84.1 84.0 12 glucose level (mmol/l) 13,436 6.1 5.4 270 5.3 5.0 1.3 cholesterol level (mmol/l) 13,742 4.9 4.8 270 5.4 5.1 1.3 abbreviations: ckd, chronic kidney disease; iqr, interquartile range. table 2. prevalence of ckd stages (n=270) ckd stage number of respondents prevalence of ckd (%) normal 127 0.0 stage 1 9 3.3 stage 2 88 32.6 stage 3 11 4.1 stage 4 19 7.0 stage 5 16 6.0 total 270 53% abbreviations: ckd, chronic kidney disease out of 270 respondents, 143 (53%) were diagnosed with ckd based on egfr measurements (table 2). overall, 47% of the respondents had egfr >90 ml/min per 1.73m 2 which was normal, 3.3% had 4.1% stage 1 ckd, 32.6% had stage 2 ckd, 4.1% had stage 3 ckd, 7.0% had stage 4 ckd and 6.0% had stage 5 ckd (egfr < 15 ml/min per 1.73m 2 ). using univariate analysis, the factors associated with significantly increased prevalence of ckd were smoker, alcohol drinker, diabetes, hypertension, dyslipidemia, and family history of kidney disease (table 3). all the factors associated with ckd was significant (p<0.05). medical and health science journal, vol. 4, no.2, august 2020 72 table 3. factors associated with ckd prevalence by univariate analysis (n=143) variable n (%) adjusted or (95% ci) p-value smoking status smoker 89 (62.2) 2.72 (0.48-3.32) 0.041 alcohol consumption drinker 92 (64.3) 3. 28 (2.1313.89) 0.005 diabetes 51 (35.7) 2.89 (1.83-4.06) 0.005 hypertension 114 (79.7) 3.01 (1.37-8.93) 0.001 dyslipidemia 69 (48.3) 2.01 (1.121.05) 0.047 family history of kidney disease 109 (76.2) 5.12 (2.75-9.60) 0.000 or= odds ratio, ci= confidence interval; p<0.05 with chi-square test discussions ckd is defined by using the modification of diet in renal disease (mdrd) equation together with ckd-epi. 6 in south korea, taiwan, and thailand. ckd was defined by using the mdrd equation with egfr< 60 ml/min per 1.73m 2 . in beijing, egfr was measured using calibrated serum creatinine while the japanese used egfr and dipstick to define ckd. the demographic characteristic of the ckd study was similar to that of the overall nhms 2011 cohort (table 1). there was no difference in the profile of both cohorts except for certain respondents in the ckd sample. this suggests that the ckd study was conducted on a valid representative sample for the population of the remote area i.e. ranau, sabah. there was a good response rate of 68%. this study assessed the prevalence of ckd among respondents living in ranau, sabah using the gfr. the overall prevalence of ckd in the study was 53%. the prevalence of ckd by stages 1,2,3,4, and 5 were 3.3%, 32.6%, 4.1%, 7.0% and 6.0% respectively. in a previous population-based study reported that the prevalence of ckd stage 5 in malaysia was 0.36% in people above 18 years of age 5 . our estimated prevalence of stage 5 ckd was higher than in other studies. this difference in ckd prevalence might be due to the difference in case studies and variables. the prevalence of ckd in west malaysia of 9.07% is similar to their rate in the region. the prevalence of ckd in asia varies within south asia: 10.2% in india, 17.3% in bangladesh, 16.9% in pakistan, and 10.6% in nepal 6, 7 . while, in other asian regions it was: 17.5% in thailand, 13% in japan, 6.8% south korea, 12% in taiwan, and 13% in beijing. the prevalence depends on methodology, ckd definition, and study design incorporated 5 . in this study, a significant association between family history and ckd has been found 8 . previous studies use lower egfr and albuminuria to define ckd 9 . the result obtained was positive correlation even after adjusting for age, sex, race, diabetes, hypertension, and socioeconomic background. this study found a significant correlation between smoking and ckd. tobacco in cigarettes heavily increases the risk for a wide range of chronic conditions including cancer, cardiovascular disease, and respiratory disease. a study found ckd and its relationship with smoking 13 . the study found that smoking increases the risk for both atherosclerotic and non-atherosclerotic vascular disease, hence, directly increasing the vascular and nonvascular morbidity and mortality in patients with ckd. this study also found a significant correlation between alcohol consumption and ckd. excessive alcohol consumption generally leads to liver damage but few studies have also found that ethanol can cause kidney damage 10 . along with an unhealthy diet and lifestyle, heavy alcohol consumption can greatly contribute to ckd. however, few studies show that there is no obvious correlation between alcohol and ckd due to confounding factors such as smoking, drug medical and health science journal, vol. 4, no. 2, august 2020 73 abuse, used of nsaids, high fat diet, and coffee that may interfere in study. 17 diabetes is associated with hypertension was closely associated with the development of ckd. 11 this is due to an increase in deterioration in glomerular filtration in renal damage caused by diabetes together with hypertension amplifying vascular damage which later leads to renal insufficiency. elevation of blood pressure both caused by and resulting in increased progression of kidney disease leads to an intermingled cause and effect relationship between hypertension and ckd. ckd was independently associated with type 2 dm and longer duration of dm. this corresponds with the finding of several studies that reported that the likelihood of developing ckd was greater among patients with a longer duration of diabetes. ckd is estimated to affect 50% of patients with type 2 dm. improvement in cardiovascular survival in a patient with type 2 dm has contributed to patients surviving longer, allowing sufficient time to develop renal disease 14 . the study also found a significant association between ckd and dyslipidemia. dyslipidemia is a common complication associated with the decline in gfr. patients with ckd usually have dyslipidemia or more specifically hypertriglyceridemia due to increased concentration of lipoprotein that is rich with triglyceride. hypertriglyceridemia occurs because of two reasons; delayed catabolism and the increase in hepatic production of triglyceride-rich lipoproteins. delayed catabolism is mainly responsible for increasing the concentration of triglyceriderich lipoprotein in ckd patients 12 . in this study, the following limitations should be considered. first, we were not able to take the underlying risk factors into accounts such as ethnicity, geographical, nationality, and type of herbal medication used. second, the cross-sectional design of the study makes it impossible to infer the causal relationship between indicators of ckd and associated factors. third, as ranau is just one of the districts in the state of sabah, the prevalence of ckd reported could not be generalized to the whole sabah population. fourth, people who were aware that they had ckd were more likely to agree to participate in the study which may lead to overestimation in the prevalence of ckd. fifth, there is also a possibility of overestimation of ckd due to potential selection bias from missing data. lastly, the study subjects were recruited from a single hospital which may limit the generalizations of the findings of this study. therefore, these findings cannot represent symptoms of ckd of the whole population. thus, the prevalence of ckd is higher than what is reported in other studies on kidney disease (probably due to sample sizes and different geographical areas). it is also dependent upon smoking, alcohol consumption, hypertension, diabetes mellitus, dyslipidemia, and family history. these factors should be considered 'high risk' in malaysia, and early detection of ckd in these groups should be implemented. conclusion prevalence of ckd among community remote areas sabah was 53%. the significant risk factors associated with ckd in this study were family history of kidney disease, alcohol consumption, smoking status, hypertension, dyslipidemia, and diabetes mellitus. thus, ckd in east malaysia is common, early detection and treatment among these communities to potentially improve outcomes can be implemented. further research should look into the impact of other variables such as type of occupation, and source of water intake as these are potential risk factors for impairment of renal function. conflict of interest the authors declare that they have no conflicts of interest. acknowledgement upmost acknowledgment should be prioritized to the university malaysia sabah for the funding by the top-down grant with medical and health science journal, vol. 4, no.2, august 2020 74 ethics approval number: nmrr-18-261544151. sincere gratitude expressed to the director of ranau hospital, malaysia, for blood sampling which was conducted by staff of the health department and assess to patients’ medical records. the authors are grateful to the staff in the department of medical and nephrology clinic is offering active cooperation. last but not least, thankfulness delivered to one and all for their willingness to contribute to this paper. abbreviation and symbols ckd = chronic kidney disease dm= diabetes mellitus e-gfr= estimated glomerular filtration esrd= end-stage renal disease nkf= national kidney foundation nsaid= non-steroid anti-inflammatory drugs scr = serum creatinine references 1. sarah e. orr and christy c. bridges, chronic kidney disease and exposure 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in detecting individuals with abnormal cholesterol and glucose level. int j biomed 2012; 2: 132–135. 19. gurpreet k, tee gh, karuthan c. evaluation of the accuracy of the omron hem-907 blood pressure device. med j malaysia 2008; 63:239–243. 20. levey a, stevens l, schmid c et al. for the chronic kidney disease epidemiology collaboration (ckd-epi). a new equation to estimate glomerular filtration rate. ann intern med 2009; 150: 604–612. http://www.biomedcentral.com/1471-2369/13/173 http://www.biomedcentral.com/1471-2369/13/173 http://dx.doi.org/10.1053/j.ajkd.2016.02.052 http://dx.doi.org/10.1053/j.ajkd.2016.02.052 medical and health science journal 2021 august vol.02 (02) medical and health science journal available at http://journal2.unusa.ac.id/index.php/mhsj; doi: 10.33086/mhsj.v5i2.1929 pissn 2549-7588. eissn 2549-7596 review article comparison of laparoscopic and abdominal sacrocolpopexy for post hysterectomy vaginal vault prolapse repair: meta analysis fariska zata amani1*, azami denas2,3, hari paraton2,3, gatut hardianto2,3, eighty mardiyan k2,3, tri hartono s2,3 1 departement of obstetrics and gynecologic, medical faculty of universitas nahdlatul ulama surabaya 2 departement of obstetrics and gynecologic, medical faculty of universitas airlangga dr.soetomo general hospital, surabaya 3 departement of obstetrics and gynecologic, dr.soetomo general hospital, surabaya article info article history: received : february 10,2021 received in revised form : august 04, 2021 accepted : august 24,2021 keywords: vaginal vault prolapse, post hysterectomy, laparoscopic sacrocolpopexy abdominal sacroclpopexy *correspondent author: dr.fariska@unusa.ac.id abstract background: comparing the clinical outcomes of laparoscopic and abdominal sacrocolpopexy in vaginal vault prolapse post-hysterectomy patients. method: systematic search data is performed on a medical database (pubmed, cochrane database) using keywords:(1) vault prolapse [title] and (2) laparoscopic[title] and sacrocolpopexy[title]. inclusion criteria:(1) randomized controlled trial and observational studies, (2) women with vaginal vault prolapse post hysterectomy, (3) intervention studied: laparoscopic (lsc) and abdominal sacrocolpopexy (asc), (4) the entire fully accessible papers can be accessed and data can be accurately analyzed. comparison about clinical outcomes of lsc and asc was performed using narrative analysis and metaanalysis (revman). results: three studies compared clinical outcomes of lsc and asc with a total of 243 samples (118 in lsc and 125 in asc group). there was no significant difference in the incidence of complications between lsc and asc (or 1.10;95%ci 0.58-2.08). lsc was associated with less blood loss (md 111.64 ml,95%ci-166.13 -57.15 ml) and shorter length of hospital stay (md -1.82 days;95%ci -2.52 -1.12 days) but requires a longer operating time (md 22.82 minutes,95%ci 0.43-45.22 minutes). there was no statistically significant difference to anatomical outcomes (measurement of point c on pop-q), subjective outcomes measured by pgi-i and reoperation numbers (repeat surgical interventions) for prolapse recurrence between lsc and asc groups after one year of follow-up. conclusions: lsc showed similar anatomic results compared to asc with less blood loss and shorter length of hospital stay in management patient with vaginal vault prolapse. medical and health science journal http://journal2.unusa.ac.id/index.php/mhsj amani et al medical and health science journal 2021 august vol.5 (02) page 46 of 56 introduction pelvic organ prolapses (pop) is a condition commonly encountered by women, and incidence increases after menopause1. this prolapse condition is not a life-threatening condition but women with pop often experience uncomfortable symptoms such as urinary incontinence, sexual dysfunction and overall, it decreases the quality of life2. definition of vaginal vault prolapse according to the international continence society is decreasing the vaginal peak or vaginal cuff below 2 cm below the total vaginal length above the hymen3. the vaginal peaks correspond to point c on the determination according to pelvic organ prolapse quantification (pop-q). the main risk factor for vaginal vault prolapse is if there was preexisting pelvic organ prolapse during hysterectomy3. the prevalence of vaginal vault prolapse was 11.4% when hysterectomy was performed on an indication of uterine prolapse, and by 1.8% when indications of hysterectomy due to benign disease3. there are two main routes in pelvic reconstructive surgery: abdominal approach (laparotomy or laparoscopy) and vaginal. abdominal sacrocolpopexy via laparotomy route (asc) is considered the gold standard in the management of apical prolapse surgery with long-term success rate of 78-100% and satisfaction rate of 75-100%4. laparoscopic sacrocolpopexy (lsc) was first introduced in the early 1990s, which rapidly became a routine gynaecological procedure. according to a barber study in 20137, lsc is as effective as asc with decreased blood loss and length of stay in the hospital. the objective of this study was to compare the clinical outcomes of lsc and asc that performed in patients with vaginal vault prolapse post hysterectomy. methods data search strategy systematic literature searches have been conducted using pubmed and cochrane database using the keywords: "vaginal vault prolapse, laparoscopic sacrocolpopexy and abdominal sacrocolpopexy". duplicate titles are omitted. abstracts of each journal are assessed according to the inclusion criteria. inclusion criteria inclusion criteria in this study were: (1) randomized controlled trial (rct) and observational studies, (2) women with vaginal vault prolapse (apical compartment prolapse post hysterectomy), (3) interventions studied: lsc and asc, (4) the entire fully accessible papers can be accessed and analyzed accurately. study quality assessment the validity of each study was assessed by criteria listed on the cochrane handbook for systematic reviews of interventions8. each study was grouped and assessed according to the quality category: low, high, or, unclear risk of bias. it can be seen in figure 2 and 3. amani et al medical and health science journal 2021 august vol.5 (02) page 47 of 56 figure 1. the conclusion of the risk stratification of bias for each study figure 2. assessment of the author's risk of bias for each study included. statistical analytic and meta-analysis the clinical outcomes that compared in this study were: duration of surgery, los (length of stay), ebl (estimated blood loss), effectiveness as a vaginal vault prolapse management (objectively by point c measurements in pop-q and re-surgery or repeat surgical intervention, subjectively by presence of symptoms of prolapse and prolapse recurrence rates during follow-up period). surgery complications were also noted to assess the safety of procedures. meta-analysis was arranged using review manager (revman) version 5.3. for categorical outcomes, odds ratio (or) was calculated using the mantelhaenszel method. for continuous variables, the mean difference (md) was derived from the mean and standard deviation and used when the reported results had an identical scale. the confidence interval used was 95% and the p value <0.05 (twotailed) was statistically significant. amani et al medical and health science journal 2021 august vol.5 (02) page 48 of 56 results study selection data search in pubmed and cochrane library resulted in 314 articles. there were 196 duplicated articles that were omitted. screening based on inclusion criteria, obtained a total of three articles inclusion for meta-analysis5,6. illustration of screening and selection process using a prisma flowchart can be seen in figure 3. figure 3. flowchart of the study selection process using prisma flowchart our study included three articles with a total of 243 samples who underwent post hysterectomy vaginal peak prolapse with or without cystocele or rectocele. a total of 118 lsc samples and 125 others underwent asc. two studies 5,7 were randomized controlled trials that had a follow-up time of one year. the other11 were retrospective cohort studies with a follow-up range of 13.5 months for lsc and 15.7 months for asc. the success criteria of two studies5,6for surgery were different. one study did not mention the success criteria8. the characteristics of three inclusive studies are summarized in table 1. table 1. the characteristic of included articles article country study design population (lsc/asc) prolapse grading primary outcome success criteria succsess rate (lsc/asc) subjective outcome measurement subjective outcome result reinterve ntion surgeon experience coolen et al 9 netherlands rct 36/37 pop-q diseasespecific quality of life no prolapse beyond hymen, no bothersome bulge symptom, and no repeat surgery or pessary use for recurrent prolapse within 12 months 83.8%/89.2% udi, ddi,iiq, pgi-i no differen t 4 lsc/ 1 asc experienced articles search through online database pubmed = 169 articles cochrane = 145 articles total (n) = 314 articles 196 duplicated articles were omitted screening based on title and abstract (n=118) screening based inclusion criteria (n=62) 3 inclusion articles for meta-analysis 56 articles exclude 59 articles exclude amani et al medical and health science journal 2021 august vol.5 (02) page 49 of 56 freeman et al 10 uk rct 26/27 pop-q test the clinical equivalenc e of open (ascp) and laparoscop ic (lscp) sacrocolpo pexy using objective and subjective outcomes point c on the pop-q and subjective complaint no significant different pgi-i,pqol, sf36 not mentio ned 1 lsc experienced paraiso et al 11 us compa rative cohort 56/61 unclear compare laparoscop ic and open sacral colpopexie s for efficacy and safety not mentioned not mentioned not mentioned not mentio ned 6 lsc/ 3 asc some in learning curve duration of operation this analysis was carried out on three inclusive studies involving a total of 118 women who underwent lsc and 125 underwent asc. the estimated mean difference (md) for operating time was 22.82 minutes and the 95% ci was 0.43 45.22 minutes (p = 0.05) (figure 4a). the results of this analysis indicate that the duration of surgery in the lsc group was longer than the asc. blood loss during surgery the analysis from three studies with a total of 243 samples found that the average difference estimation (md) for blood loss during surgery was 111.64 ml with 95% ci -166.13 to -57.15 ml (p <0.00001) (figure 4b). these results suggest that surgical blood loss in the lsc group was significantly lower than that in the asc group. length of stay (los) based on the three included studies, lsc was associated with a lower los in hospital compared to asc. the estimated mean difference (md) was -1.82 days with 95% ci -2.52 to -1.12 days (p <0.00001) (figure 4c). amani et al medical and health science journal 2021 august vol.5 (02) page 50 of 56 figure 4. the forest plot of (a) operating time, (b) blood loss during surgery, (c) length of stay in hospital between lsc and asc group. sd, standard deviation; ci, confidence interval; df, degrees of freedom complications incidence of surgery we analysed the intra and postoperative complications incidence between lsc and asc group. from the three studies analysed, it was found that the incidence of total complications was the same between lsc and asc group (26 cases in each group). there was no significant difference in the number of total incidence of complications between the lsc and asc groups (or 1.10; 95% ci 0.58-2.08; p = 0.77) (figure 5a). table 2 describes the details of complications in the lsc and asc groups. in the study of freeman et al9, there were no cases of lsc that experienced conversion to the abdominal surgery. there was one case of lsc group in paraiso et al's 11 study that converted to abdominal due to excessive bleeding during surgery. in coolen et al s study7, there were found two cases of lsc that converted to abdominal surgery (one case was due to bladder lesions and the other was due to bleeding). (a) (b ) (c) amani et al medical and health science journal 2021 august vol.5 (02) page 51 of 56 table 2. comparison details of lsc and asc complications complications coolen et al9 freeman et al10 paraiso et al11 lsc (n=36) asc (n=37) lsc (n=26) asc (n=27) lsc (n=56) asc (n=61) intraoperative bladder injury 1 (conversion to abdominal) 0 1 0 6 2 bowel injury 1 (conversion to abdominal) 1 0 1 1 2 bleeding 0 0 1 1 (conversion to abdominal) 0 opening of vaginal 1 0 postoperative wound dehiscence 0 2 lung emboli 0 1 ileus 0 3 0 2 sbo* 1 2 surgery site infection 1 0 6 2 pyelonephritis 1 0 dvt** 1 1 needed for transfusion 1 1 cardiac complication 0 2 ventralis hernia 1 2 mesh erosion 2 1 *small bowel obstruction; **deep vein thrombosis incidence of postoperative ileus and simple bowel obstruction (sbo) the incidence of postoperative ileus and sbo was higher in the asc group, but not statistically significant (or 0.21; 95% ci 0.03 1.23; p = 0.08) (figure 5b). in the study of paraiso et al9, there was one case of postoperative sbo in the lsc group and two cases in the asc group. in two studies 7,9, there were a total of five cases of ileus in the asc group and no incidence of ileus in the lsc group. the study by freeman et al10 did not report specifically on the incidence of ileus and sbo. bowel injury there was no significant difference in the number of bowel injury cases between women who underwent lsc and asc (or 0.4; 95% ci 0.082.17, p = 0.30) (figure 5c). in coolen et al's study, one patient in the asc group died postoperatively from multiorgan failure due to sepsis after bowel perforation. amani et al medical and health science journal 2021 august vol.5 (02) page 52 of 56 figure 5. the forest plot of (a) total complication incidence, (b) ileus and sbo incidence, (c) bowel injury incidence, (d) bladder injury incidence. sd, standard deviation; ci, confidence interval; df, degrees of freedom. bladder injury there were no significant differences in the incidence of bladder injury between women who underwent lsc and asc (or 3.42; 95% ci 0.9013.01, p = 0.07) (figure 5d). in all studies, it was found that the number of bladder injuries was higher in the lsc group than in asc. surgery outcomes pgi-i (within 1 year) there was no significant difference in the measurement of the pgi-i questionnaire (the sample gave a “very much better” score) within one year after surgery between the lsc and asc groups (or 0.90; 95% ci 0.35 1.85; p = 0.61) (figure 6a). (a) (b ) (c) (d ) amani et al medical and health science journal 2021 august vol.5 (02) page 53 of 56 measurement point c on pop-q only two studies compared pop-q measurement after surgery as an objective measure. freeman et al8 found no significant difference in point c measurements for pop-q after 1 year of doing lsc or asc. coolen et al8 also reported no significant difference between the two groups in the anatomical results based on pop-q within 12 months after surgery. when included in the analysis as shown in figure 6b, there was no significant difference at point c pop-q after one year of lsc or asc (md 0.06 cm, 95% ci -0.49 to 0.61, p = 0.83). reoperation for pop there was no statistically significant difference regarding reoperation (repeat surgical intervention) for pelvic organ prolapse between the lsc and asc groups (md 2.92; 95% ci 0.958.98; p = 0.06). the results of this analysis based on three studies found 11 cases in the lsc group and 4 cases in the asc group requiring re-surgical intervention for pop recurrence (figure 6c). figure 6. the forest plot of (a) pgi-i questionnaire, (b) point c measurement in pop-q within 1 year after surgery, (c) reoperation for pop between lsc and asc group. sd, standard deviation; ci, confidence interval; df, degrees of freedom. amani et al medical and health science journal 2021 august vol.5 (02) page 54 of 56 discussion hysterectomy is one of the most common gynecological surgery procedures worldwide in women of reproductive age. as life expectancy increases, the incidence of vaginal vault prolapse post-hysterectomy increases with an average of 60 years10. sacrocolpopexy is the gold standard to overcome the vaginal vault prolapse with the success rate of 78-100%11. abdominal approach of sacrocolpopexy (asc) is superior to the vaginal approach with fewer recurrent prolapse numbers, but vaginal access is faster with better cosmetic results and shorter los. the development of laparoscopic surgery presents the advantage of better pelvic anatomical vision due to the magnification of endoscopic video, better cosmetic results and lower los12. several research studies have demonstrated the effectiveness and safety of laparoscopic approaches to the treatment of vaginal vault prolapse that provide good outcomes in long-term anatomy and functional and high levels of satisfaction6,12. the lsc bridges these gaps and is expected to produce outcomes like asc with advantages such as the vaginal approach. from the results of our meta-analysis, we found that lsc was significantly associated with longer duration of surgery but fewer duration of blood loss during surgery and shorter los than asc group. this is in accordance with the metaanalyzes performed by coolen et al18 and campbell et al12. the risk of complications such as bladder injury, bowel injury and ileus did not differ significantly between lsc and asc. however, the incidence of ileus was higher in asc group (five cases) while in the lsc group there was no ileus incidence. when viewed from overall complications, there were more complications in the lsc group than asc but statistically did not differ significantly. this contrasts with the meta-analysis performed by coolen et al18 where the rate of complications was higher in the asc group although it also did not differ significantly statistically. from the results of our study, lsc complications are most prevalent in paraiso et al8 study, this is because some laparoscopes are performed by operators in the learning process. it is said in his journal that the expertise, experience and learning process of the surgeon plays a role in the occurrence of a bladder injury in the lsc group. the effectiveness of surgical treatment of vaginal vault prolapses the effectiveness of surgical treatment of vaginal vault prolapse is assessed through subjective and objective outcomes. the objective outcomes are anatomical outcome (the measurement of point c in pop-q more than 1 cm above the hymen) and the prolapse recurrence rate requiring reoperation during the follow-up period. subjective outcome is the absence of symptoms or complaints after the procedures that assessed through the pgi-i (patient global impression of improvement) questionnaire12. only two studies have measured the point c on pop-q as the objective outcome of vaginal vault prolapse surgery. both studies are rct studies. paraiso et al11 in the study did not include pop-q measurements as a comparison because it was a retrospective cohort study in which pop-q pre and postoperative data were incomplete (only in 60% of laparoscopic groups). from two rct studies5,12,13, showed no statistically significant differences in anatomical outcomes and reoperation (repeat surgical amani et al medical and health science journal 2021 august vol.5 (02) page 55 of 56 intervention) for recurrence of pelvic organ prolapse between lsc and asc groups after one year of follow-up. our meta-analysis also found no statistically significant difference in subjective outcomes during the one-year follow-up between lsc and asc groups assessed through the pgi-i questionnaire. conclusion meta-analysis in this study concludes that lsc compared to asc has a longer duration of surgery but is associated with less duration of bleeding during surgery, shorter length of stay in hospital. lsc and asc have similar objective and subjective outcomes for vaginal vault prolapse management. the effectiveness of lsc and asc as vaginal vault prolapse management cannot be concluded in this meta-analysis because the number of inclusion studies has not been adequate as the preparation of clinical recommendations. therefore, the authors suggest a further investigation of large-scale studies in this patient population. conflict of interest the author stated there is no conflict of interest references 1. masenga, g. g., shayo, b. c. & rasch, v. prevalence and risk factors for pelvic organ prolapse in kilimanjaro, tanzania: a population based study in tanzanian rural community. plos one 13, e0195910 (2018). 2. zheng, y., zhou, h., dunstan, c. r., sutherland, r. l. & seibel, m. j. the role of the bone microenvironment in skeletal metastasis. j. bone oncol. 2, 47–57 (2013). 3. austin, p. f. et al. the standardization of terminology of lower urinary tract function in children and adolescents: update report from the standardization committee of the international children’s continence society. j. urol. 191, 1863-1865.e13 (2014). 4. mearini, l., nunzi, e., di biase, m. & costantini, e. laparoscopic management of vaginal vault prolapse recurring after pelvic organ prolapse surgery. urol. int. 97, 158– 164 (2016). 5. paraiso, m. f. r., jelovsek, j. e., frick, a., chen, c. c. g. & barber, m. d. laparoscopic compared with robotic sacrocolpopexy for vaginal prolapse: a randomized controlled trial. obstet. gynecol. 118, 1005–1013 (2011). 6. coolen, a. l. w. m. et al. the treatment of post-hysterectomy vaginal vault prolapse: a systematic review and meta-analysis. int. urogynecol. j. 28, 1767–1783 (2017). 7. coolen, a.-l. w. m. et al. laparoscopic sacrocolpopexy compared with open abdominal sacrocolpopexy for vault prolapse repair: a randomised controlled trial. int. urogynecol. j. 28, 1469–1479 (2017). 8. paraiso, m. f. r., jelovsek, j. e., frick, a., chen, c. c. g. & barber, m. d. laparoscopic compared with robotic sacrocolpopexy for vaginal prolapse: a randomized controlled trial. obstet. gynecol. 118, (2011). 9. freeman, r. m. et al. a randomised controlled trial of abdominal versus laparoscopic sacrocolpopexy for the treatment of posthysterectomy vaginal vault prolapse: las study. int. urogynecol. j. 24, 377–384 (2013). 10. van der ploeg, j. m., van der steen, a., zwolsman, s., van der vaart, c. h. & roovers, j. p. w. r. prolapse surgery with or without incontinence procedure: a systematic review amani et al medical and health science journal 2021 august vol.5 (02) page 56 of 56 and meta-analysis. bjog an int. j. obstet. gynaecol. 125, 289–297 (2018). 11. parkes, i. l. & shveiky, d. sacrocolpopexy for treatment of vaginal apical prolapse: evidence-based surgery. j. minim. invasive gynecol. 21, 546–557 (2014). 12. bacle, j. et al. laparoscopic promontofixation for pelvic organ prolapse: a 10-year single center experience in a series of 501 patients. int. j. urol. 18, 821–826 (2011). 13. campbell, p., cloney, l. & jha, s. abdominal versus laparoscopic sacrocolpopexy: a systematic review and meta-analysis. obstet. gynecol. surv. 71, (2016). medical and health science journal 2021 february, vol 05 (01) original article pre clinic grade and clinic periods effect on progress test of unisma medical profession students ariani ratri dewi*, dini sri damayanti, rizki anisa faculty of medicine, university of islam malang *correspondence: arianiratridewi@unisma.ac.id article info article history: received august 26,2020 accepted february 23,2021 keywords: progress test, pre clinic, clinical rotation abstract introduction. pre clinic grade point is often seen as predictor of good performance in professional education whose short term goal is to pass national examination which command progress test to evaluate the preparation. purpose. to know the effect of pre clinic grade point and clinical study periods in progress test result of medical profession students. methods. 135 students of medical profession programme completed computer based progress test of 200 national standardized questions in 200 minutes using sipena software. progress test result then analysed based on how long they have been studied and their pre clinic grade point using anova – tukey hsd and pearson correlation in spss for windows ver 19 results. although students with pre clinic grade 2,50-2,74 have lower progress test result, but it’s not statistically significant (p>0,05). the same happen in clinic study periods with the longer the students in their clinical rotation, the better their result (p>0,05). the trends which showing better result in higher pre clinic grade point and time they spend in clinical rotation agrees with previous studies. conclusion. pre clinic grade point and clinic study periods has little to no effect on progress test result of medical profession students in unisma. medical and health science journal. introduction faculty of medicine aims to educate future doctors. in indonesia, this education consist of two phases, which are medical bachelor programme for pre clinic study and medical profession programme for clinical training. exit exam for medical education in indonesia is national competency examination (uji kompetensi mahasiswa program studi profesi dokter / ukmppd) which is taken in the end of medical profession programme in the form of computer based test and objective structured clinical examination (osce). in medical bachelor programme, studies are designed in problem based learning, which are arranged based on system organ, while in medical profession programme which is hospital based, the training is arranged in departemental clinical rotation. pre clinic study problem based learning strategies including tutorial, lecture, practicum in laboratory, and clinical skill training. assessment in pre clinic period such as written assignment, multiple choice question from tutorial and lecture material, practicum response test, and osce comprised score of block courses. combined score of block courses and general basic courses such as religion, citizenship and enterpreneurship from all semesters formed cummulative grade point (indeks prestasi kumulatif/ipk). only students with sufficient pre clinic grade could enter medical profession programme. clinical training strategies including apprenticeship in day clinic, emergency room, sumail typewriter 14 sumail typewriter mailto:arianiratridewi@unisma.ac.id medical and health science journal 2021 february, vol 05 (01) ward, and operation room, night shift, morning reports, bed side teaching, clinical tutorial, journal reading, literature review and case presentation. assessment as day to day performance in managing the case and the patients observed by clinician as clinical trainer, and formal assessment in the end of rotation in the form of written assessment, skill test and case test. progress test is an assignment which consist of all subjects, in level of understanding and competencies expected for graduate medical doctor. this test is taken through out medical education to evaluate the growth of knowledge in medical student. 1 prior academic performance was said to be the best predictor of subsequent academic performance, 2 thus medical profession students with good pre clinic grade point supposed to have good performance in academic assessment in their clinical training periods. progress test for medical profession students in the form of computer based test could be seen as one academic assessment in clinical training periods that supposed to show that correlation. 1 further, performance in progress test taken in the clinical training periods supposed to predict their likelihood to pass national examination computer based test. clinical training in teaching hospital aim to transfer basic clinical skills and giving students the foundation for clinical practice. the further their study in clinical rotation, the deeper and more practical their understanding should be. in this deduction, it is expected that the longer the students went into their clinical rotation, the better their progress test result. this study which evaluate the effect of pre clinic grade point and clinic rotation periods to progress test result is aimed to verify those presumption. methods in the beginning of semester, all medical profession student was gathered in faculty of medicine unisma to undergo progress test. as one way to prepare the student for computer based test national examination, this progress test was also using computer based test. the test was designed by medical education unit faculty of medicine unisma. the questions were comprised from regional national examination try outs question distributed by association of indonesian medical faculty region v. the process of developing the question set was as follow. first, every medical faculty must have one item bank administrator (iba). iba from all medical faculty then were trained in how to make a good test question and how to organize it. next, in their own medical faculty, iba trained lecturers and clinician to make test questions based on their expertise and specialities. regional administrator then assigns iba in each medical faculty to collect questions. the assignment is divided according to organ system and study discipline, each medical faculty assigned to different organ system or study discipline. then association of indonesian medical faculty region v conducted a review meeting attended by expert and specialist representative from all medical faculty. regional administrator organised the preparation of the review meeting so that specialists / experts from all fields are present. in review meeting, questions were examined by experts in matching fields in their congruence with the topic / field requested, vignette quality, options correctness, and other standards as guided by national committee of national examination. regional administrator will collect corrected and accepted questions, then submit it to national committee of national examination according their request. question that were exempted then distributed to all medical faculty to be used as try out test questions. faculty of medicine unisma also use this set of questions for progress test. therefore this progress test questions quality is as closely as possible with national examination. students of medical profession programme faculty of medicine unisma were 135 while the capacity of the computer laboratorium was only 70 personal computer, so the test was conducted in three separated sessions. in order to prevent cheating and guessing, medical education unit prepare three sets of test sumail typewriter 15 sumail typewriter medical and health science journal 2021 february, vol 05 (01) questions. the software used in administrating and delivering the test was sipena software developed by national committee of national examination and distributed by association of indonesian medical faculty region v. item analysis provided by the software shows that all three sets of test have similar reliability, difficulty and discrimination index. the mark was calculated based on total number of correct answers. there is no penalty for wrong answers. these marks then was analyzed on its association with the students grade (indeks prestasi kumulatif / ipk) when graduate from pre clinic programme and how long the students has been in their clinical rotations. the students grades were grouped into 2,50 – 2,74 , 2,75 – 2,99, and more than 3,00 while the periods of clinical rotations were grouped into 6 months, 12 months, 18 months and 24 months. the requirement for entrance to medical profession programme faculty of medicine unisma are graduated from medical bachelor programme faculty of medicine unisma with grade point of minimal 2,50 in 14 semesters or less. so the lowest group was set in 2,50, while because about 50-60% bachelor graduate have grade point of 3,00 or more so the highest group were set in 3,00. medical profession programme faculty of medicine unisma consist of 40 credit semester, which is taken in 109 weeks. internal medicine, surgery, obgyn, pediatric and public health are for ten weeks; ent, ophthalmology, neurology, radiology, psychiatry, physiatry, forensic and pharmacy are for five weeks and anesthesiology and dentistry for three weeks. first set of clinical rotation usually consist of internal medicine, surgery, neurology or pharmacy. the group of 6 months comes from this set of clinical rotation. after finishing those laboratories, come obgyn, paediatric, ent and ophthalmology. the group of 12 months come from this stage. the rest laboratories are randomly assigned with physiatry and public health are in the very end of rotation. the group of 18 and 24 months come from this remaining rotation. the data then underwent analyze of distribution and homogenity. after the data was declared of normal distribution and homogen, it was assigned to anova and continued with tukey hsd and pearson correlation to evaluate significant difference and association between progress test result with pre clinic grade point and periods of clinical rotation. results from 135 medical profession students, only one person passed the cut off mark of national examination computer based test which is 66 or 68 mark. the overall mean score is 52,19. mean score according to pre clinic grade point is shown in table 1 and graphic 1. table 1. pre clinic grade point and progress test result pre clinic grade point n mean progress test score >=3,00 66 55,33  5,71 2,75-2,99 48 50,16  4,88 2,5-2,74 21 46,98  7,85 sumail typewriter 16 sumail typewriter medical and health science journal 2021 february, vol 05 (01) graphic 1. pre clinic grade point and progress test result statistic analysis using anova followed by tukey hsd showed no significant difference of progress test results from each group of pre clinic grade point with p value in range from 0,8 to 0,1. pearson correlation even showed negative correlation with r= -0,007 which means the better the pre clinic grade point the worse progress test result, though in very low significance of p=0,934. graphic 2. clinical study periods (as length of study) and progress test result graphic 2 and graphic 3 showed progress test result according to length of clinical study periods / clinical rotation. there are 31 students in 6 months group, with mean score 49,41  6,1; 38 students in 12 months group, with mean score 52,06  7,1; 13 students in 18 months group, with mean score 49,88  5,71 and 53 students in 24 months group with mean score 54,47  6,09. graphic 3. clinical study periods and progress test result sumail typewriter 17 sumail typewriter medical and health science journal 2021 february, vol 05 (01) though the graphic of mean score showing trend of better result in longer study period, statistic analysis using anova followed by tukey hsd showed no significant difference with p value in range from 0,8 to 1,0 while pearson correlation showed positive correlation with r=0,059 with low significancy in p=0,495. discussion this study found that there are no significant difference in progress test results from different pre clinic grade point and that there is no correlation between pre clinic grade point and progress test results. this finding contradict other studies that found that prior academic performance is the best predictor of subsequent academic performance.2-5. this contradiction could means that there are other factors influencing academic performance other than previous academic performance. there are non-cognitive factors like personality and learning styles, and demographic factors such as sex and ethnicity that were not evaluated in this study. study by shawwa et al 6 in saudi arabia found trends that students with better academic performance reported that they enjoy studying, prefer to study alone in silence and with no interruptions, and studied for longer hours during the weekend. they also tens to have particular style in studying like highlighting and skimming or reading before attempting to memorize the material, even to favor a certain posture or body position while studying. this is supported by study in malaysia 7 which found that favoring particular place for reading have significant effects on the students’ performance, although this study also found that demographic factors like gender or marital status do not have significant effect in academic performance. in order to increase the likelihood of medical profession students to pass national examination, futher research in the other factors is important. this study also found no significant difference between students who just enter the clinical rotation with students who have been in the rotation for quite long time or almost finished it. this result is in concord with mcmanus et al 8,9 that found that success in the final examination was not related to a student’s clinical experiences. again, that study stated that learning styles is important. learning in hospital environment is different from pre clinic period. in pre clinic the lessons is structured with fixed schedule while in hospital its mostly of self-directed learning. students need some adjustment to this change so they can be an effective hospital learners. 10 this study result give an impression that the students lack of ability in learning from clinical training, therefore, training of learning to learn in a hospital is needed. study by carrr et al 4 stated that junior doctors sometimes feel not sufficiently prepared in time management, aspects of prescribing and complex practical procedures. mcmanus et al 8,9 found that strategic or deep learning style is related with success in examination. deep learning process include identify general principles, integrate material across couses, and relate ideas to evidence. this learning style is motivated by interest in subject, vocational relevance and personal understanding. strategic style is motivated to achieve high grades, to compete with other and to be succesful so in process this style use techniques that achieve highest grades resulting in patchy and variable understanding. to equip students with ‘survival skills” as self-directed hospital learners, understanding and training of this two kinds of learning style is important so they can graduate from syllabus-boundness surface learning style they might be develop in pre clinic. conclusion taken this study result into consideration, faculty of medicine unisma needs to intensify national examination preparation programme for students who have finished all their clinical rotation. before entering this program students need to be evaluated in factors contributing to sumail typewriter 18 sumail typewriter medical and health science journal 2021 february, vol 05 (01) their academic performance so the program organizer and peer mentors could develop specific approach to address problems and increase the effectiveness of the program. furthermore, this result should be communicated to clinician in teaching hospitals and there should be a coordinated effort in implementing quest of national examination to clinical training. references 1. wrigley w vc, freeman a, muijtjens a. a systemic framework for the progress test: strengths, constraints and issues: amee guide no. 71. med teach 2012;34:683–97. 2. wilkinson d zj, byrne gj, luke h, ozolins iz, parker mh, peterson rf. medical school selection criteria and the prediction of academic performance. mja. 2008;188:349– 54. 3. poole p sb, rudland j, wilkinson t. comparison of umat scores and gpa in prediction of performance in medical school: a national study. med edu 2012;46:163–71. 4. carr se ca, puddey ib, lake f. . relationships between academic performance of medical students and their workplace performance as junior doctors. bmc med edu 2014;14. 5. ferguson e jd, madeley l. factors associated with success in medical school: systematic review of the literature. bmj. 2002;324:952–7. 6. shawwa l aa, abulaban a, balkhoyor ah. factors potentially influencing academic performance among medical students. adv med educ pract 2015;6:65-75. 7. musa mr hm. academic performance of academic performance of pre-clinical and clinical medical students’ of east coast malaysian peninsula: a cross-sectional and descriptive study that stimulates their life. j appl pharm sci 2017;7(06):169-75. 8. mcmanus ic rp, winder bc, sproston ka. clinical experience, performance in final examinations, and learning style in medical students: prospective study. bmj. 1998;316:345-50. 9. mcmanus ic se, partridge p, keeling a, fleming pa. a levels and intelligence as predictors of medical careers in uk doctors: 20 year prospective study. bmj. 2003;327:139-42. 10. mathers j pj, scully e, popovic c. a comparison of medical students’ perceptions of their initial basic clinical training placements in ‘new’ and established teaching hospitals. med teach. 2006;28(3):e80–e9. sumail typewriter 19 sumail typewriter sumail typewriter medical and health science journal 2021 august vol.5 (02) medical and health science journal available at http://journal2.unusa.ac.id/index.php/mhsj; doi: 10.33086/mhsj.v5i2.2313 pissn 2549-7588. eissn 2549-7596 original article effect of asiatic mangrove (rhizophora mucronata) leaves extract as analgesic in male albino ddw mice (mus musculus l.) induced by 0,7% acetic acid erika widianingsih nanuru, lestari dewi*, prajogo wibowo faculty of medicine, hang tuah university article info article history: received august 29, 2021 received in revised form september 8, 2021 accepted september 20, 2021 keywords: pain, asiatic mangrove rhizophora mucronata, flavonoid, analgesic *correspondent: lestari.dewi@hangtuah.ac.id abstract background : pain is an unpleasant emotional experience that illustrates ongoing tissue damage. excessive use of non-steroidal anti-inflammatory drugs can cause peptic ulcer to gastric mucosal damage and perforation. indonesia contains the largest area of mangrove forest in the world. there are 45 species of mangrove found and one of them is asiatic mangrove (rhizophora mucronata). this type is easy to find and rich of alkaloids and flavonoids which can be used as analgesics. method: this study used post-test only control group design. the number of mice that used was 25 mice, divided into 5 groups. which were given different therapies aquadest 10ml/kgbw, acetosal 150 mg/kgbw, extract of rhizophora mucronata 250 mg/kgbw, 500 mg/kgbw, and 1000 mg/kg bw. the pain was induced by 0,7% glacial acetic acid at a dose of 10 ml/kgbw. the writhes of the mice was being calculated with an interval of 10 minutes in 30 minutes. result: the results of the analysis showed the decrease in writhes of mice in acetosal group dose 150 mg/kg bw, rhizophora mucronata leaves extract dose 250 mg/kg bw, 500 mg/kg bw, and 1000 mg/kg bw. there was a significant difference in the results of the mann-whitney u test with p<0,05 in the aquadest group and the acetosal group with the rhizophora mucronata leaves extract group dose 500 mg/kg bw, the difference between the acetosal group and the rhizophora mucronata leaves extract group dose 250 mg/kg bw, and the difference between the rhizophora mucronata leaves extract group dose 500 mg/kg bw and the rhizophora mucronata leaves extract group dose 1000 mg/kg bw. conclusion: rhizophora mucronata leaves extract dose 500 mg/kg bw can provide analgesic effect and can reduce the writhing frequency in mice much better than acetosal group. medical and health science journal http://journal2.unusa.ac.id/index.php/mhsj nanuru et al. medical and health science journal 2021 august vol.5 (02) page 2 of 8 introduction pain is an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage 1. almost all disease are accompanied by pain, pain arises because of a disturbance in a tissue so that is used by the body as a sign that an infection is occuring. estimated between long-term use of analgesics and anti-inflammatory drugs: 15-40% will experience upper gastrointestinal complaints; 10-25% suffer from gastric ulcers, especially peptic ulcers; and 1-4% will experiance lifethreatening ulcer complications such as gastric bleeding and perforation 2. in many countries including indonesia, non-steroidal antiinflammatory drugs (nsaids) are used for symptoms associated with arthritis and other symptomatic indications including myofascial pain, gout, fever, dysmenorrhea, migraine, perioperative pain, stroke prophylaxis and myocardial infarction 3. indonesia is an archipelagic country consisting of 17.500 islands with a coastline of about 95.181 km. the total area of indonesia is about 9 million km2 (2 million km2 land and 7 million km2 sea). indonesia’s area is only about 1,3% of the earth’s area, but has a very high biodiversity. for plants, indonesia is estimated to have 25% of flowering plant species in the world or the seventh largest country with a number of species reaching 20.000 species, 40% of which are endemic or native to indonesia 4. mangroves are ecosystems located in intertidal areas, where there is a strong interaction between marine, brackish, river and land waters. this interaction makes the mangrove ecosystem has a high diversity of flora and fauna. mangroves lives in the tropics and subtropics, especially at latitudes of life 25° north latitude and 25° south latitude 5. indonesia has the largest mangrove forest in the world, with an area of 42.550 km2 and about 45 species of mangroves live in indonesia 6. rhizophora mucronata or asiatic mangrove is a type of species that is often found and generally this tree has a height of up to 27 m, and rarely exceeds 30 m. stems up to 70 cm in diameter with dark to black bark and horizontal fissures. this plant grows in groups, near or on the bottom of tidal rivers and in river mouths, rarely growing in areas far from the tides. optimal growth occurs in heavily flooded areas, as well as in humus-rich soil. the wood of this plant can be used for staining, and are sometimes used medicinally in cases of hematuria (bleeding in the urine). it is sometimes planted along ponds to protect the ambankments 7. the phytochemical components of asiatic mangrove include: flavonoids, alcaloids, phenolics, terpenoids and glycoside 8, proteins, saponins, and tannins 9. based on the background, the study was designed to determine the analgesic effect of the leaves extract of asiatic mangrove (rhizophora mucronata) in male albino ddw mice (mus musculus l.) induced by 0,7% acetic acid. methods place and time of study this research was conducted in the biochemistry laboratory of the faculty of medicine, hang tuah university, surabaya for 7 days with the ethical clearance number 724/hrecc.fodm/x/2019. nanuru et al. medical and health science journal 2021 august vol.5 (02) page 3 of 8 plant collection and preparation of the extract rhizophora mucronata leaves were collected from wonorejo mangrove forest, surabaya. fresh rhizophora mucronata leaves were cleaned, shade dried and crushed to powder by grinder. they were extracted used maceration technique. 1000 grams of dried rhizophora mucronata leaves were macerated with 96% ethanol solvent for 3x24 hours. then after producing the extract, the resulting extract is concentrated with a water bath to produce a thick blackish green extract. furthermore, evaporation is carried out and then evaporated at room temperature to produce a thick extract of ethanol. animals 25 male albino ddw mice (mus musculus l.) aged 7-9 weeks with an average weight of 2025 grams were used for these studies. the animals were obtained from the pusat veteriner farma surabaya (pusvetma surabaya). the animals were placed in boxes and given husks. each box contains 5 mice. analgesic activity study the design of this study was a laboratory experimental study using post-test only control group design. analgesic test of this leaves extract was carried out by induction of 0,7% acetic acid in mice 0,7% acetic acid was injected intraperitoneally for one time to cause pain in mice. mice were divided into 5 groups with 5 mice in each groups. group a as the negative control group was given 10 ml/kgbw of aquadest orally, group b as a positive control group was given acetosal at a dose of 150 mg/kgbw orally, group c as the first treatment group was given rhizophora maucronata leaves extract at a dose of 250 mg/kgbw orally, group d as the second treatment group was given rhizophora mucronata leaves extract at a dose of 500 mg/kgbw orally, group e as the third treatment group was given rhizophora mucronata leaves extract at a dose of 1000 mg/kgbw orally. after 30 minutes of oral administration, 0,7% acetic acid was injected intraperitoneally in each mice. after 5 minutes, the number of writhing performed by the mice was counted for 30 minutes. calculations were carried out at 10 minutes intervals. then determine the percentage of inhibition (%) of analgesic activity with the formula 10: % inhibition = (control – sample) x 100% control results in acetic acid induction, rhizophora mucronata extract gave significant analgesic results at a dose of 500 mg/kgbw with percentage of inhibition of 75,15% and a dose of 250 mg/kgbw with a percentage of inhibition of 52,87% compared to the control. and the results of the study in table 1, shows that there is an analgesic effect asiatic mangrove (rhizophora mucronata) leaves extract in male mice (mus musculus l.) with 0,7% acetic acid induction (table 1). nanuru et al. medical and health science journal 2021 august vol.5 (02) page 4 of 8 table 1 writhling frequency observation results s.d=standard deviation the results of the writhing rate per period showed that the leaves extract of the rhizophora mucronata had a significant analgesic effect. at 10 minutes, the highest mean was found in the acetosal group or group b with the value of 12, while the lowest mean was found in the group with rhizophora mucronata leaves extract dose 500 mg/kgbw or group d with the value of 2,4. at 20 minutes, the highest mean was found in the aquadest group or group a with the value of 11,6, while the lowest mean was found in the group with rhizophora mucronata leaves extract dose 500 mg/kgbw or group d with the value of 3,8. at 30 minutes, the highest mean was found in the aquadest group or group a with the value of 9,6, while the lowest mean was found in the group with rhizophora mucronata leaves extract dose 500 mg/kgbw or group d with the value of 1,6 (table 2). table 2 averange number of writhing group averange number of writhing (minutes) 10mins ± s.d 20mins ± s.d 30mins ± s.d a 10,2 ± 9,41 11,6 ± 12,30 9,6 ± 6,94 b 12 ± 4,06 13,2 ± 8,58 4,2 ± 3,11 c 4,2 ± 3,76 6,4 ± 4,77 4,2 ± 3,89 d 2,4 ± 1,67 3,8 ± 2,48 1,6 ± 1,81 e 7,2 ± 3,83 7,2 ± 3,27 6 ± 3,24 s.d=standard deviation furthermore, the normality test was carried out using the saphiro-wilks test. the results of the saphiro-wilks test, it was found that all groups had significance p > α (α = 0.05), except for the 10 minutes of group e and the 30 minutes of group a the significance value was p < α (α = 0.05), meaning that the data not normally distributed (table 3). group mean ± s.d % inhibition a b c d e 31,4 ± 27,18 29,4 ± 14,6 14,8 ± 11,56 7,8 ± 4,65 20,4 ± 4,39 0% 6,39% 52,87% 75,15% 35,03% nanuru et al. medical and health science journal 2021 august vol.5 (02) page 5 of 8 table 3 saphiro-wilks test results group significance 10’ 20’ 30’ a 0,169 0,330 0,015 b 0,627 0,639 0,670 c 0,194 0,899 0,093 d 0,314 0,384 0,254 e 0,006 0,914 0,111 furtheremore,a non-parametric test is carried out using the kruskal-wallis test. the results of the kruskal-wallis test there is a significant value of p < α (α = 0.05), which means that there is a difference in the analgesic effect of rhizophora mucronata leaves extract in male mice (mus musculus l.) with 0,7% acetic acid induction bertween groups (table 4). tabel 4 kruskal wallis test results 10 minutes 20 minutes 30 minutes asymp. sig. (2-tailed) 0,019 0,388 0,169 to determine whether there was a difference in the mean of the study groups, a post-hoc mannwhitney u test was performed. there was a significant difference in the results of the mann-whitney u test with p<0,05 in the aquadest group and the acetosal group with the rhizophora mucronata leaves extract group at a dose of 500 mg/kgbw, the difference between the acetosal group and the rhizophora mucronata leafves extract group at a dose of 250 mg/kgbw and the rhizophora mucronata leaves extract group at a dose of 1000 mg/kgbw (table 5). table 5 mann whitney u results in the first 10 minute observation period 10 minutes sig group a group b group c group d group e group a 0,401 0,140 0,044 0,743 group b 0,027 0,009 0,084 group c 0,454 0,129 group d 0,041 group e nanuru et al. medical and health science journal 2021 august vol.5 (02) page 6 of 8 discussion in this study, 25 mice were used which were divided into 5 groups. each groups consisted of 5 white mice (mus musculus l.) which was induced by pain with 0,7% acetic acid injection. the injection was carried out 30 minutes after being given therapy, such as aquadest, acetosal, and rhizophora mucronata leaves extract. group a as a negative control was given 10 ml/kgbw of aquadest, group b as a positive control was given 150 mg/kgbw of acetosal, group c as the first treatment group was given rhizophora mucronata leaves extract at dose of 250 mg/kgbw, group d as the second treatment group was given rhizophora mucronata leaves extract ast dose of 500 mg/kgbw, group e as the third treatment group was given rhizophora mucronata leaves extract ast dose of 1000 mg/kgbw. after being given the extract, wait about 30 minutes first, then 0,7% acetic acid injected with a dose of 10 ml/kgbw intraperitoneally and wait for 5 minutes and do the calculations at intervals of every 10 minutes for 30 minutes. based on the data of this study, it was found that the rhizophora mucronata leaves extract at a dose of 250 mg/kgbw (group c), a dose of 500 mg/kgbw (group d), a dose of 1000 mg/kgbw (group e) had a significant analgesic effect, as evidenced by the mean of writhing which is smaller than the negative control group (group a). the percentage of inhibition from group c was 52,87%, group d was 75,2%, and group e was 35,03%, this indicates that the three doses of rhizophora mucrnata can inhibit pain process. rhizophora mucronata containing flavonoids, alkaloids, phenolics, terpenoids and glycosides 9 which some substances can help in inhibiting the pain process 11. acetic acid induces an inflammatory response in the abdominal cavity with subsequent activation of nociceptors. when animals are injected intraperitoneally with acetic acid, acute pain and an inflammatory reaction appear in the peritoneal area. constriction caused by acetic acid is considered a nonselective antinociceptive model, because acetic acid acts indirectly by stimulating endogenous mediators that increase nociceptive neurons sensitive to sensitive to nonsteroidal anti-inflammatory drugs, and other active drugs 12. rhizophora mucronata leaves extract contains many flavonoids and alkaloid that are effective in delaying the response time of mice to stimulation, and the researchers identified that this compound is luteolin which interacts strongly with cyclooxygenase and forms a number of specific hydrogen bonds and they identified that the central and peripheral antinociceptive activity of the extract rhizophora mucronata leaves invole opioid receptors 13. in the group with high doses of rhizophora mucronata leaves extract nanuru et al. medical and health science journal 2021 august vol.5 (02) page 7 of 8 produced more writhing, this can be associated with the administration of too many flavonoids, the higher dose, the more flavonoids are given and can cause opioid receptor binding. if opioid receptors are activated frequently, it can lead to an opioidinduced hyperalgesia respons 14. however, luteolin in rhizophora mucronata leaves extract can reduce the intensity of neuropathic pain and can relieve hyperalgesia and nociception and can relieve acute and chronic pain 15. conclusion asiatic mangrove (rhizophora mucronata) leaves extract at a doses of 250 mg/kgbw, and 1000 mg/kgbw was able to give the effect of decreasing the amount of writhing with 0,7% acetic acid induction method. asiatic mangrove (rhizophora mucronata) leaves extract at a dose of 500 mg/kgbw can provide a better analgesic effect than aspirin in reducing the amount of acetic acid by 0,7% acetic acid induction method. references 1. raja, s. n. et al. the revised international association for the study of pain definition of pain: concepts, challenges, and compromises. pain (2020) doi:10.1097/j.pain.0000000000001939. 2. v.s, b. & j.g, h. complications of nonsteroidal antiiflammatory drug gastropathy and use of gastric cytoprotection: experience at a tertiary care health center. j. rheumatol. doi:26(7):1557-1563. 3. soleha, m. et al. profil penggunaan obat antiinflamasi nonstreoid di indonesia. j. kefarmasian indones. (2019) doi:10.22435/jki.v8i2.316. 4. kusmana, c. & hikmat, a. keanekaragaman hayati flora di indonesia. j. pengelolaan sumberd. alam dan lingkung. (2015) doi:10.19081/jpsl.2015.5.2.187. 5. martuti, n. keanekaragman mangrove di wilayah tapak, tugurejo, semarang. j. mipa (2012). 6. spalding, d. & ravilious, c. world atlas of coral reefs. (2011). 7. noor, y. r., khazali, m. & suryadiputra, i. n. n. mangrove di indonesia. (2012). 8. nurdiani, r., firdaus, m. & prihanto, a. a. phytochemical screening and antibacterial activity of methanol extract of mangrove plant (rhyzophora mucronata) from porong river estuary. j. basic sci. technol. (2012). 9. asha, s. & m .ruthu, y.pradeepkumar, c.madhusudhana chetty, g.prasanthi, v. j. s. r. phytochemical analysis of mangrove derived crude plant extract-rhizophora mucronata. j. glob. trends pharm. sci. 2, 55– 62 (2017). 10. unnikrishnan, p., suthindhiran, k. & jayasri, m. alpha-amylase inhibition and antioxidant activity of marine green algae and its possible role in diabetes management. pharmacogn. mag. (2015) doi:10.4103/0973-1296.172954. nanuru et al. medical and health science journal 2021 august vol.5 (02) page 8 of 8 11. verri, w. a. et al. flavonoids as antiinflammatory and analgesic drugs: mechanisms of action and perspectives in the development of pharmaceutical forms. in studies in natural products chemistry (2012). doi:10.1016/b9780-444-53836-9.00026-8. 12. dzoyem, j. p., mcgaw, l. j., kuete, v. & bakowsky, u. anti-inflammatory and antinociceptive activities of african medicinal spices and vegetables. in medicinal spices and vegetables from africa: therapeutic potential against metabolic, inflammatory, infectious and systemic diseases (2017). doi:10.1016/b978-0-12-809286-6.00009-1. 13. gurudeeban, s., kaliamurthi, s., sheik, h. s. & thiruganasambandam, r. molecular docking, isolation and biological evaluation of rhizophora mucronata flavonoids as antinociceptive agents. biomed. prev. nutr. (2014) doi:10.1016/j.bionut.2014.08.002. 14. lee, m., silverman, s., hansen, h., patel, v. & manchikanti, l. a comprehensive review of opioid-induced hyperalgesia. pain physician (2011). 15. hashemzaei, m. et al. effects of luteolin and luteolin-morphine co-administration on acute and chronic pain and sciatic nerve ligatedinduced neuropathy in mice. j. complement. integr. med. (2017) doi:10.1515/jcim-20160066. medical and health science journal 2022 august vol.6 (02) medical and health science journal available at http://journal2.unusa.ac.id/index.php/mhsj; doi: 10.33086/mhsj.v6i2.3070 pissn 2549-7588. eissn 2549-7596 original article relationship of water source location and physical quality of water with the event of diarrhea in toddlers (in purwodadi village, purwodadi district, pasuruan regency) warda el maida rusdi1, magda budi pramistyowati2, danny irawan3,4, irmawan farindra5 1 department of public medicine, faculty of medicine, universitas nahdlatul ulama surabaya, indonesia 2 faculty of medicine, universitas nahdlatul ulama surabaya, indonesia 3 department of internal medicine, faculty of medicine, universitas nahdlatul ulama surabaya, indonesia 4 internal medicine islamic hospital of jemursari surabaya, indonesia 5 department of anatomy and histology, faculty of medicine, universitas nahdlatul ulama surabaya, indonesia article info article history: received : june 10, 2022 received in revised form : august 16, 2022 accepted : august 23, 2022 keywords: diarrhea, physical quality of water, location of water source *) corresponding author: wardaelmaida@unusa.ac.id abstract background: diarrheal disease is a health problem until how and is the leading cause of death in toddlers. it is supported by environmental sanitation and personal hygiene of the community which is still poor. the use as bad water sources will also affect the quality of the water, so it can increase the risk of diarrheal in the community. method: this type of research is analytical observational with cross sectional design. the samples used were 75 out of a population of 523 mothers who had toddlers and lived in purwodadi village, purwodadi subdistrict, pasuruan regency, with purposive sampling techniques. using questionnaire method, as well as statistical test using chi-square with the help of computer software. result: the results of this study showed that there was a significant association between the location of the sheltered water source as many as 38 respondents (50.7%) and unprotected as many as 37 respondents (49.3%) with a value of p = 0.003, as well as the physical quality of water that qualified as many as 37 respondents (49.3%) and did not qualify as many as 38 respondents (50.7%) with a value of p = 0.000, against the incidence of diarrhea in toddlers, where the value of p ≤ 0.05. conclusion: location of water source and physical quality of water is related to the incidence of diarrhea in toddlers. medical and health science journal http://journal2.unusa.ac.id/index.php/mhsj rusdi et al medical and health science journal 2022 august vol.6 (02) page 8 of 11 introduction according to the world health organization (who), diarrhea is the presence of stools with a soft and liquid consistency and more frequent (three or more times a day).1 diarrhea in children is divided into acute diarrhea, persistent diarrhea, and dysentery. acute diarrhea in children is classified based on the status of dehydration (no dehydration, mild/moderate dehydration, severe dehydration) and the symptoms appear suddenly in less than 14 days. persistent diarrhea is acute diarrhea with or without blood lasting for 14 days or more and is classified based on the dehydration status, namely, moderate or severe. dysentery is characterized by bloody diarrhea, usually caused by shigella.2 in 2017, who states that cases of diarrhea in toddlers reach 1.7 billion with a death rate of around 525,000 people each year.3 the prevalence of diarrhea in indonesia, according to the 2018 national basic health research (riskesdas), the incidence of diarrhea in toddlers aged 14 years reached 11.5%. five provinces in indonesia with the highest prevalence of diarrhea in children under five are north sumatra (14.2%), papua (13.9%), aceh (13.8%), bengkulu (13.6%), and west nusa tenggara (13.4%). based on gender, diarrhea in males (11.4%) was higher than females (10.5%). the prevalence of children under five with diarrhea in east java reaches 56.6% of all districts and cities. pasuruan, one of regency in east java, presentage of reached 64.3% with an incidence rate was 12,851 cases, while purwodadi subdistrict achieved 2,105 cases in 2015.4 diarrhea in children under five in indonesia is an endemic disease that has the potential for extraordinary events (klb). toddlers are very susceptible to diarrhea because their immune system is still weak. the most common cause of deaths are dehydration and lack of sufficient fluids.5 environmental factors include one of the factors related to the occurrence of diarrhea in toddlers, such as the lack of clean water availability, polluted water, lack of hygiene facilities, indiscriminate and unhygienic disposal of feces, poor personal hygiene, and lack of parental knowledge about cleanliness.6 many other factors can cause diarrhea either directly or indirectly, such as triggering agents and behavior factors.7 diarrhea can be caused by the lack of quality of hygiene and sanitation of the community's environment which is still poor. poor environmental sanitation, will have an impact on the incidence of disease. the community needs to strive for a healthy and comfortable environmental sanitation, in order to avoid a disease. the purpose of this study was to analyze the relationship between the location of water sources and the physical quality of water with the incidence of diarrhea in children under five in purwodadi village, purwodadi district, pasuruan regency. methods the study was analytical observational with crosssectional design. subjects were 75 of 523 mothers who had toddlers and lived in purwodadi village, purwodadi subdistrict, pasuruan regency with purposive sampling techniques. primary data obtained from using a questionnaire and will be tested for validity and reliability. in this study, researchers used the chi-square statistical test with the statistical product and service solutions (spss) program to assess the significant relationship between the independent variable and the dependent variable. results based on the results of observations and data processing that has been carried out, data on the characteristics of respondents are obtained which aims to provide an overview of respondents based on several categories as fol table 1 characteristics of respondents characteristics respondents =75 f (%) mother's age 21-30 years old 40 53,3% 31-40 years old 28 37,3% >41 years old 7 9,3% tingkat pendidikan primary school 3 4,0% junior high school 10 13,3% senior high school 35 46,7% bachelor 27 36,0% toddler gender male 42 56,0% female 33 44,0% toddler age 1-2 years old 42 56,0% 3-4 years old 33 56,0% based on table 1, the most susceptible mothers are 2130 years old, with as many as 40 respondents (53.3%). most of them work as housewives as many as 42 respondents (56.0%), with a high school education level of 35 respondents (46.7%). boys are more than girl as 42 respondents (56.0%), with the most vulnerable are under five years old between 1-2 years as 42 respondent (56.0%). table 2 frequency distribution of respondents' diarrhea in purwodadi village, purwodadi district, pasuruan regency diarrhea respondents =75 f (%) 1. diarrhea 28 37,3% 2. no diarrhea 47 62,7% based on table 2, it can be seen that the incidence of diarrhea in respondents as many as 28 respondents (37.3%) experienced diarrhea, while 47 respondents (62.7%) did not experience diarrhea in the last six months. rusdi et al medical and health science journal 2022 august vol.6 (02) page 9 of 11 table 3 results of the relationship between water source locations and diarrhea in toddlers in purwodadi village, purwodadi district, pasuruan regency water source location diarrhea events total p diarrhea no diarrhea f % f % f % 1. protected 8 10,7% 30 40,0% 38 50,7% 0,003 2. unproctected 20 26,7% 17 22,7% 37 49,3% total 28 37,3% 47 62,7% 75 100% based on table 3, it can be seen that the location of respondents' unprotected water sources is 37 respondents (49.3%), while for protected water sources as many as 38 respondents (50.7%). the result of the statistical calculations using the chi-square test, pvalue = 0.003 was obtained where the value was 0.05, so it can be concluded that there is a significant relationship between the location of water sources and the incidence of diarrhea in children under five in purwodadi village, purwodadi district, pasuruan regency. table 4 results of the relationship between physical quality of water and the incidence of diarrhea in toddlers in purwodadi village, purwodadi district, pasuruan regency physical quality of water diarrhea events total p diarrhea no diarrhea f % f % f % 1. qualify 6 8,0% 31 41,3% 37 49,3% 0,000 2. not eligible 22 29,3% 16 21,3% 38 50,7% total 28 37,3% 47 62,7% 75 100% based on table 4, it can be seen that the physical quality of water respondents who do not meet the requirements are 38 respondents (50.7%), while for the physical quality of water that meets the requirements are 37 respondents (49.3%). the results of statistical calculations using the chi-square test obtained p value = 0.000 where the value is 0.05, so it can be concluded that there is a significant relationship between the physical quality of water and the incidence of diarrhea in children under five in purwodadi village, purwodadi district, pasuruan regency. tabel 5 relationship of water source location and physical quality of water with diarrhea in toddlers in purwodadi village, purwodadi district, pasuruan regency no. variabel p value hypothesis 1. water source location 0,003 accepted 2. physical quality of water 0,000 accepted based on the table 4, results of statistical calculations with the chi-square test of the two research variables compared to the incidence of diarrhea in children under five in purwodadi village, purwodadi district, pasuruan regency, it showed that the two variables had a significant relationship to the incidence of diarrhea, with each p value 0.05. discussion based on the results of research from 75 respondents, 37 respondents (49.3%) were found with unprotected water sources. the location of this unprotected water source caused 20 respondents to experience diarrhea, which obtained p-value = 0.003 (≤ 0.05), which means that there is a significant relationship between the location of the water source and the incidence of diarrhea in toddlers. water is a resource that must be owned by humans. water also plays a role in transmitting disease transmission, because water can contain infectious germs. these infectious germs can be transmitted by faecal-oral route, through water lines and equipment lines that are washed with water.8 clean water sources will affect the cleanliness of the eating and drinking utensils used, if the water used is contaminated with germs, the eating and drinking utensils will also be contaminated which can later cause a chain of diarrhea transmission.9 this result is also strengthened by the research of harsa (2019), which concludes that there is a relationship between the location of the water source and the incidence of diarrhea in children under five with a percentage of 58.3% of 75 respondents. another rusdi et al medical and health science journal 2022 august vol.6 (02) page 10 of 11 study conducted by rahmawati (2018) regarding the risk factors for diarrhea related to environmental sanitation in infants in ngijo village, karangploso district, malang regency, found that the incidence of diarrhea was most commonly found in respondents who still used water from dug wells and rivers. based on field observations, there are some respondents who still use unprotected water sources such as open wells and rivers, and the distance of the septic tank is still 10 meters from the water source. the results of the above discussion can be concluded that there is a relationship between the location of water sources with the incidence of diarrhea in children under five in purwodadi village, purwodadi district, pasuruan regency. the results of this research statistical test of 75 respondents, obtained 38 respondents (50.7%) with the physical quality of water that does not meet the requirements. the physical quality of water that does not meet these requirements causes 22 respondents to experience diarrhea, where the p-value = 0.000 (≤ 0.05) means that there is a significant relationship between the physical quality of water and the incidence of diarrhea in children under five. the physical quality of water needs to be considered before being used, where water that is suitable for use is water that meets health requirements. minister of health regulation number 492/menkes/per/iv/2010 mentions the requirements for drinking water quality, one of which is the physical requirements which include odorless, colorless, tasteless, and not cloudy water.10 the results of this study are in line with profita's research (2014) which concludes that there is a relationship between the physical quality of water and the incidence of diarrhea in children under five, with a p-value = 0.012 (≤ 0.05). another study conducted by kurniati et al (2013) also supports that the physical quality of water is related to the incidence of diarrhea in children under five in the work area of the banget ayu health center semarang. the physical quality of water that does not meet these requirements contains many infectious germs, so the water used is contaminated and can cause diseases such as diarrhea.11 based on the observations of the researchers, it was found that the number of respondents under five who did not experience diarrhea was greater than the number of respondents who had diarrhea. this can be caused by several factors, one of which is mothers of toddlers who treat water properly so that the water consumed is proper and safe to use and reduces the risk of toddlers getting diarrhea. the results of observations in the field, it was found that several respondents whose water conditions did not meet health requirements, namely the water still smelled, colored, tasted, and cloudy. this condition can be caused because most respondents use water from open wells or river water. the results of the discussion above can be concluded that there is a relationship between the physical quality of water and the incidence of diarrhea in children under five in purwodadi village, purwodadi district, pasuruan regency. conclusion based on the results of research on 75 samples that have been carried out, it can be concluded that there is a significant relationship between the location of water sources and the incidence of diarrhea in children under five in purwodadi village, purwodadi district, pasuruan regency with p value = 0.003 <0.05. and a significant relationship between the physical quality of water and the incidence of diarrhea in children under five in purwodadi village, purwodadi district, pasuruan regency with p value = 0.000 <0.05 acknowlegment the financing is obtained independently conflicts of interest there are no conflicts of interest declared by the author. references 1. kemenkes ri. buletin jendela data dan informasi kesehatan. jakarta: kementrian kesehatan republik indonesia; 2011. 2. who. buku saku pelayanan kesehatan anak di rumah sakit. jakarta; 2016. 3. husniati l. hubungan faktor lingkungan dan sosiodemografi dengan kejadian diare pada anak balita (1-4 tahun) di wilayah kerja puskesmas pauh kambar kabupaten padang pariaman tahun 2018. (doctoral diss univ andalas). 2018; 4. dinkes kota pasuruan. profil kesehatan kabupaten pasuruan 2015. pemerintah kabupaten pasuruan dinas kesehatan. pasuruan; 2015. 5. kirana n. hubungan antara faktor presdisposisi pada ibu terhadap kejadian diare pada balita. j promkes. 2016;6(1):70–9. 6. elsi evayanti nk, nyoman purna i, ketut aryana i. faktor-faktor yang berhubungan dengan kejadian diare pada balita yang berobat ke badan rumah sakit umum tabanan. j kesehat lingkung. 2014;4(2):134. 7. harsa ims. the relationship between clean water sources and the incidence of diarrhea in kampung baru resident at ngagelrejo wonokromo surabaya. j agromedicine med sci. 2019;5(3):124. rusdi et al medical and health science journal 2022 august vol.6 (02) page 11 of 11 8. fauziah. hubungan faktor individu dan karakteristik sanitasi air dengan kejadian diare pada balita umur 10-59 bulan di kelurahan sumurbatu kecamatan bantargebang kota bekasi tahun 2013. universitas islam negeri syarif hidayatullah jakarta; 2013. 9. puspitasari, dini t. hubungan frekuensi konsumsi jajanan dan kebiasaan cuci tangan dengan kejadian diare pada anak usia sekolah di karawang tahun 2011. kti. 2011; 10. dinkes surabaya. profil kesehatan kota surabaya 2019 [internet]. surabaya; 2019. available from: http://dinkes.surabaya.go.id 11. kurniati id, notoatmojo h, putra dpy. kualitas fisik dan sumber air yang dikonsumsi berpengaruh terhadap kejadian diare pada balita. http://digilibunimusacid1 [internet]. 2013;1–5. available from: http://digilib.unimus.ac.id medical and health science journal 2022 february vol.6 (01) medical and health science journal available at http://journal2.unusa.ac.id/index.php/mhsj; doi: 10.33086/mhsj.v5i2.2698 pissn 2549-7588. eissn 2549-7596 original article relationship between lbw and the incidence of stunting in toddlers aged 1-3 years at the minasa upa health center, rappocini district athiyah ulya arif*, purnamaniswaty yunus, syatirah jalaluddin faculty of medicine, universitas islam negeri alauddin, makassar, indonesia. article info article history: received: january 26, 2022 received in revised form: february 12, 2022 accepted: february 21, 2022 keywords: stunting, toodler, low bady weight abstrak background: stunting is a long-term effect of chronic malnutrition that causes disturbances in a person's physical growth which is characterized by a decrease in growth speed. unbalanced food intake, lbw (low birth weight babies), and a history of the disease are the three main factors that play a role in the incidence of stunting. the purpose of this study was to determine the relationship between a history of lbw and the incidence of stunting for toddlers aged 1-3 years at the minasa upa health center in 2019. methods: this research is a quantitative study with an observational approach, using a cross-sectional method. samples were taken by the purposive sampling method. the number of samples is 134 children with the mother of the child as the respondent. the data were processed and analyzed using the chi-square p<0.05 test in the spss program. results: the results showed that there was a significant relationship between a history of low birth weight and stunting (p = 0.000) with an or value of 18.8 which means that children aged 1-3 years who have a history of low birth weight have a risk of 18.8 times experiencing stunting. interventions that focus on maternal and child health care are needed to reduce the risk of babies with low birth weight and stunting, as well as raise awareness of mothers about the importance of good nutrition for mothers and their children. conclusion: based on this study, it can be concluded that there is a relationship between a history of lbw and the incidence of stunting in toddlers 1-3 years at the minasa upa public health centre. medical and health science journal http://journal2.unusa.ac.id/index.php/mhsj arif et al medical and health science journal 2022 february vol.6 (01) page 9 of 14 introduction nutrition has a close relationship with the health and intelligence conditions of each individual because it is a very important element in a person's growth and development.1 malnutrition in childhood is often associated with deficiencies of certain micronutrients and macronutrients. if this situation continues, it will have an impact starting from an increased risk of infectious disease and death, stunted growth and cognitive, motor, verbal, and so on development.2 stunting is a long-term effect of chronic malnutrition that causes disturbances in a person's physical growth which is characterized by a decrease in growth speed.3 stunting is a linear growth disorder that, if it occurs in the golden period of brain development (0-3 years) of a child, will have an impact on poor brain development. the long-term impact of stunting is the disruption of physical, mental, intellectual, and cognitive development. according to the unicef framework, unbalanced food intake, lbw (low birth weight babies), and a history of the disease are the main factors that play a role in the incidence of stunting, namely: inappropriate exclusive breastfeeding caused by limited food consumed can lead to unbalanced food intake.4 according to joint malnutrition estimates (2018) in 2017, around 22.2% or 150.8 million children under five in the world experienced stunting. according to who (2018), indonesia is ranked third with the highest prevalence of stunting in the southeast asia/south-east asia regional (sear) region. the average prevalence of stunting under five in indonesia from 2005 to 2017 was 36.4%.5 research in 2018 in indonesia found that 29.9% of children under the age of 24 months experienced signs of stunting. meanwhile, in makassar the makassar city health office has conducted a survey where the prevalence of stunting for the last three years was 8.75% in 2017 and 2018, then 8.61% in 2019.6 in islam, we have been commanded by allah swt. how important it is to provide nutrition and nutrition to children to prevent health problems such as low birth weight and stunting. as his words in the qur'an surah thaha verse 81 which means "eat of the good provisions that we have given you and do not exceed the limits". in addition to the above verse, in the qur'an surah al-baqarah verse 233 is also explained about the recommendation of breastfeeding for 2 years to prevent stunting in children. the verse has the meaning "mothers should breastfeed their children for two full years, that is for those who want to improve breastfeeding...”.7 methods the total sample in this study amounted to 134 samples. the research design used in this study was observational with a cross-sectional approach. the data used are primary data and secondary data. primary data was obtained from questionnaires, while secondary data was obtained from research institutions in the form of medical records. data collection aims to determine the relationship between the history of lbw and the incidence of stunting in children aged 1-3 years at the study site. analysis of the data used in this study using the spss application, which first tested the univariate analysis and then continued with the bivariate analysis using the pearson chiarif et al medical and health science journal 2022 february vol.6 (01) page 10 of 14 square. then the hypothesis test was carried out using simple regression analysis. results based on the results of research and data processing carried out, the results of the research are presented as follows: table 1. frequency distribution of respondent characteristics and samples of children aged 1-3 years at the minasa upa health centre in 2019. charachteristic stunting stunting not stunting n % n % gender male 29 41,4 41 64,1 female 41 58,6 23 35,9 age 1 year age 27 38,6 23 35,9 2 year age 23 32,9 18 28,1 3 year age 20 28,6 23 35,9 mother’s education < high school/equivalent 32 45,7 12 18,8 ≥high school/equivalent 38 54,3 52 81,3 eexclusive breastfeeding yes 52 74,3 57 89,1 no 18 25,7 7 10,9 economic status <rp 2.118.678 44 62,9 36 36,3 >rp2.118.678 26 37,1 28 43,8 history of infection disease yes 36 51,4 27 42,2 no 34 48,6 37 57,8 nutritional status < 23,5 cm 42 60 12 18,8 > 23,5 cm 28 40 52 81,3 arif et al medical and health science journal 2022 february vol.6 (01) page 11 of 14 the results obtained show that the percentage of stunting is higher in the female sample group (58.6%). based on age, the percentage of stunting that is more at risk is in the 1 year age group (38.6%). exclusive breastfeeding has no risk of stunting (89.1%). samples who have a history of infectious diseases are at risk for stunting (51.4%). respondents with the latest education in the form of high school/equivalent have children who are at risk of stunting (54.3%). respondents with poor nutritional status as measured using upper arm circumference during pregnancy are at risk of having stunting children (60%). respondents with economic status < rp 2,118,678 are at risk of having stunting children (62.9%). table 2. the relationship between the history of lbw and the incidence of stunting in children aged 1-3 years at the minasa upa health centre in 2019. birth weight stunting amount p value or stunting not stunting n % n % n % lbw 39 29,1 4 3,0 43 32,1 p=0,000 18,8 not lbw 31 23,1 60 44,8 91 67,9 total 70 52,2 64 47,8 134 100 based on the table above, it shows that of the 43 samples with a history of low birth weight (lbw), there were 39 people (90.7%) who had a history of lbw with stunting, and 4 people (9.3%) were not stunted. the results of the analysis to see the relationship between low birth weight infants (lbw) and the incidence of stunting using the pearson chi-square statistical test, obtained the value of x2 p = 0.000 (p <0.05) with an or value of 18.8. it can be concluded that there is a significant relationship between the history of low birth weight infants (lbw) and the incidence of stunting. children who have a history of lbw have an 18.8 times risk of becoming stunted compared to children born with normal birth weight or not lbw. discussion the frequency distribution of children's characteristics shows that the age of most children experiencing stunting is 1 year as many as 27 children (38.6%). at the age of 1 year, many changes occurred, such as changes in their diet from breast milk to solid food, and some of them began to have difficulty eating. therefore, if not properly cared for, toddlers will be susceptible to diseases such as infectious diseases.8 based on the results of this study also showed that the majority of children experiencing stunting had a history of infectious diseases, namely 36 children (51.4%). malnutrition and infectious diseases have a relationship with each other, which if working together will contribute to the worse. arif et al medical and health science journal 2022 february vol.6 (01) page 12 of 14 inadequate nutrition can worsen the child's body in dealing with infectious diseases. this shows that there is a relationship between nutritional status and infectious diseases, that is, any infectious disease will worsen nutritional status.9 the incidence of recurrent infectious diseases not only affects the child's weight loss but also affects height according to age. 10 based on the characteristics of the sample, namely exclusive breastfeeding, according to the results of the study, it was found that the majority of children with exclusive breastfeeding did not experience stunting, namely 57 children (89.1%). breast milk is the best food for babies immediately after birth. for the baby's nutrition to be fulfilled, breast milk is needed during the growth period. stunting can be caused by a lack of nutrition in a child caused by the baby's inability to get breast milk.11 this is in line with research conducted by fitri (2018) which said that of the 55 children under five who were not exclusively breastfed, 23 (41.8%) of them experienced stunting. meanwhile, toddlers who are exclusively breastfed have a lower risk of stunting, which is only 2 people (10%). the low level of exclusive breastfeeding is one of the triggers for stunting in children and can have an impact on the child's future, on the contrary, good breastfeeding by the mother will help maintain a child's nutritional balance so that normal child growth is achieved.4 based on the characteristics of the respondents, in this case, mothers of children, the majority of mothers with poor nutritional status are at risk of having stunting children, which are 42 people (60%). one way to determine the nutritional status of pregnant women is by measuring the upper arm circumference (lila). lila is used to determine if a person suffers from chronic energy deficiency (ced). pregnant women at risk of ced have a high risk of giving birth to babies with low birth weight. babies born with lbw will have a risk of malnutrition, growth disorders, impaired child development, and even death.12 this is in line with subekti (2014) which showed that lila < 23.5 cm had a 1.95 times greater risk of giving birth to low birth weight.13 there are 44 children aged 1-3 years who are stunted and have families with low economic status in the working area of the minasa upa health center (62.9%), and 36 people who do not experience stunting (56.3%). the economic status of the household is one factor in the possibility that a child will be thin and short because it forms the lifestyle of a family. the adequate family economic status will support the development of the child's body. therefore, who recommends stunting or stunting as a measure of low socioeconomic status and as an indicator to monitor equity in health.14-15 the characteristics of the mother's recent educational history indicate that the percentage of stunting is higher in the group of mothers with the last education of high school, which is 38 people (54.3%). the level of education of parents will affect the process of growth and development of children. a high and good arif et al medical and health science journal 2022 february vol.6 (01) page 13 of 14 education can be ascertained to know about good nutrition too.14,16-17 based on the results of the study of the relationship between the history of lbw and the incidence of stunting, a p-value of 0.000 (p<0.05) was obtained with an or value of 18.8. this shows that there is a relationship between a history of lbw and the incidence of stunting in children aged 1-3 years in the working area of the minasa upa health centre in 2019. children aged 1-3 years who have a history of low birth weight have an 18.8 times risk of experiencing stunting. in this study, it was found that from 134 samples, there were 70 children diagnosed with stunting by doctors and 64 children who did not suffer from stunting. of the 70 children who suffer from stunting, 39 of them have a history of low birth weight (lbw). birth weight in general is closely related to the process of growth and development in the future because one of the effects is growth faltering.16 this result is in line with the research conducted by yeyen supriyanto, et al (2017) in yogyakarta which said that lbw had a significant relationship to the incidence of stunting.10 the results of this study are by the recommendations in the qur'an to pay attention to the welfare of a child by providing adequate nutrition to children. good nutrition during pregnancy and childbirth can prevent the incidence of lbw which can have an impact on child growth and development. as mentioned in a passage in surah an-nisa verse 9 which has the meaning "and let those who fear allah, if they leave behind them weak children, whom they fear for (their welfare). therefore let them fear allah and let them speak the truth".7 this study has several limitations, such as the delay in the data collection process due to the current condition, namely the covid 19 pandemic. many employees at the minasa upa health centre have to self-isolate so that researchers are hampered in obtaining secondary data. conclusion based on the results of this study, it can be concluded that there is a significant relationship between lbw and the incidence of stunting in children aged 1-3 years. where children aged 13 years who have a history of low birth weight have an 18.8 times risk of experiencing stunting. acknowlegment the financing is obtained independently conflicts of interest there are no conflicts of interest declared by the author. references 1. proverawati a, kusumawati e. ilmu gizi. yogyakarta: medical book; 2011. 2. who. global nutrition targets 2025 stunting policy brief. can pharm j. 2014;122(2):74–6, 78. 3. habimana s, biracyaza e. <p>risk factors of stunting among children under 5 years of age in the eastern and western provinces of rwanda: analysis arif et al medical and health science journal 2022 february vol.6 (01) page 14 of 14 of rwanda demographic and health survey 2014/2015</p>. pediatr heal med ther. 2019;volume 10:115–30. doi: 102147/phmt.s222193 4. fitri l. hubungan bblr dan asi ekslusif dengan kejadian stunting di puskesmas lima puluh pekanbaru. j endur. 2018;3(1):131–7. http://doi.org/10.22216/jen.v3i1.1767 5. kemenkes ri. buletin stunting. kementeri kesehat ri. 2018;301(5):1163–78. 6. dinas kesehatan kota makassar. profil kesehatan kota makassar 2015. dinas kesehat kota makassar. 2016;14–5. 7. agama k. syamil al-qur’an dan terjemahannya. bandung: pt syamil cipta media; 2012. 8. azriful a, bujawati e, habibi h, aeni s, yusdarif y. determinan kejadian stunting pada balita usia 24-59 bulan di kelurahan rangas kecamatan banggae kabupaten majene. al-sihah public heal sci j. 2018;10(2):192–203. https://doi.org/10.24252/as.v10i2.6874 9. adriana m, wirjatmadi b. gizi dan kesehatan balita. jakarta : kencana. 2014;121. 10. putra o. pengaruh bblr terhadap kejadian stunting pada anak usia 12 – 60 bulan di wilayah kerja puskesmas pauh pada tahun 2015. univ andalas. 2016; http://scholar.unand.ac.id/12188/ 11. losong nhf, adriani m. perbedaan kadar hemoglobin , asupan zat besi , dan zinc pada balita stunting dan non stunting the differences of hemoglobin level , iron , and zinc intake in stunting and non stunting toodler. amerta nutr. 2017;117–23. http://dx.doi.org/10.20473/amnt.v1i2.201 7.117-123 12. kristiyanasari w. gizi ibu hamil. nuha medika; 2010. 13. subekti r. analisis faktor risiko kejadian berat badan lahir rendah di kabupaten banjarnegara. univ diponegoro. 2014; http://eprints.undip.ac.id/45287/ 14. pramitha a. faktor-faktor yang berhubungan dengan kejadian stunting pada balita 2560 bulan di kelurahan kalibaru depok tahun 2012. 2012. http://lib.ui.ac.id/bo/uibo/detail.jsp?id=20 320460&lokasi=lokal 15. soetjiningsih. tumbuh kembang anak. penerbit buku kedokteran : egc; 2014. 16. oktarina z, sudiarti t. faktor risiko stunting pada balita (24—59 bulan) di sumatera. gizi dan pangan. 2013;8(november):175–80. doi: https://doi.org/10.25182/jgp.2013.8.3.177 -180 https://doi.org/10.22216/jen.v3i1.1767 https://doi.org/10.24252/as.v10i2.6874 medical and health science journal 2022 february vol.6 (01) medical and health science journal. available at http://journal2.unusa.ac.id/index.php/mhsj ; doi:10.33086/mhsj.v5i2.2543 p.issn 2549-7588. eissn 2549-7596 review article prevalence of trichomoniasis in cervical cancer patients luh putu diah ayuning, risma*, prawesty diah utami faculty of medicine, hang tuah university. surabaya, indonesia article info article history: received : december 11, 2021 received in revised form: february 16, 2022 accepted : february 20, 2022 keywords: prevalence, trichomoniasis, cervical cancer. *) corresponding author: risma.parulian.evilinda@g mail.com abstract background: trichomoniasis is the most frequent non-viral sexually transmitted disease in the world, and it can lead to persistent hpv infection. trichomonas vaginalis infection causes damage to the vaginal mucosa, activation of oncogenes and inactivation of tumor suppressor proteins, and production of non-specific oxidants that lead to cervical cancer. this study aims to determine the prevalence of trichomoniasis in cervical cancer patients. methods: this study uses systematic literature review method and uses 10 international journals obtained through machine learning and indexed in scimago. journals are screened through prisma and have gone through a critical appraisal process. this study took place from april to september 2021. results: the prevalence of trichomoniasis in cervical cancer patients ranged from 0.022% to 87.7%, according to the findings of this study. the prevalence results vary due to differences in demographics and diagnostic methods used. statistical analysis of the association between trichomoniasis and cervical cancer varied between significant and insignificant. differences in the association are influenced by the research design used, diagnostic methods, and sample of the research. conclusions: the conclusion of this study is that the prevalence of trichomoniasis in cervical cancer patients was discovered to be the highest in the study by ghosh et al. in kolkata, india (72.6% women with cin 1, 71.0% women with cin 2 or cin 3, and 87.7% women with invasive cancer) and the lowest in the study by su et al. in taiwan (0.022%). the association between trichomoniasis and cervical cancer was found to be varied. medical and health science journal https://doi.org/10.33086/mhsj.v5i2.2313 mailto:risma.parulian.evilinda@gmail.com mailto:risma.parulian.evilinda@gmail.com ayuning et al medical and health science journal 2022 february vol.6 (01) page 34 of 40 introduction trichomonasis is a protozoan infection caused by trichomonas vaginalis. trichomoniasis is the most frequent non-viral sexually transmitted disease in the world. this parasite can survive for 24 hours in a humid and warm environment.1 the prevalence of trichomoniasis in the united states is 1.3%, while the prevalence of trichomoniasis in bandung is 2%. people with multiple sexual partners have a higher risk of trichomoniasis. an increased risk was also seen in older women, black women, and people with limited knowledge and low socioeconomic status. 2–4 trichomoniasis generally does not cause symptoms, so screening is rarely done. this causes the available screening and diagnostic equipment to be inadequate.5 trichomoniasis can occur in men and women with equal frequency, but symptoms in men are milder and disappear within a few weeks. meanwhile, in women, infection can occur for several years with some symptoms such as pruritus and smelly vaginal discharge.6 if not treated properly, trichomoniasis can be associated with pelvic inflammatory disease, cervical cancer, and premature birth. in addition, individuals with trichomoniasis are more susceptible to hiv infection and herpes virus.1 cervical cancer is cancer that develops in a woman's cervix. cervical cancer is caused by the human papillomavirus (hpv), which accounts for 99% of all cases. hpv is transmitted through sexual contact, resolves spontaneously, and generally causes no symptoms. a persistent hpv infection can cause cervical cancer. the fourth most frequent malignancy in women is cervical cancer. cervical cancer was diagnosed in around 570,000 women worldwide in 2018, with approximately 311,000 women dying from the disease. cervical cancer is a form of cancer that can be treated well if detected early in the disease and treated effectively. if detected at late stage, the disease can be controlled with appropriate treatment and palliative care.7 trichomonas vaginalis infection causes damage to the vaginal mucosa and the release of lytic enzymes thereby increasing the virulence of hpv. this infection causes activation of oncogenes and inactivation of tumor suppressor proteins that lead to cervical epithelial mutations and tumor formation.8 chronic inflammation of t. vaginalis can lead to the production of nonspecific oxidants that can damage host dna and lead to cervical cancer. this literature study will provide knowledge about the prevalence of trichomoniasis in cervical cancer patients and provide knowledge and awareness that trichomoniasis is an infection that must be treated properly. methods this research uses systematic literature review method that aims to determine the prevalence of trichomoniasis in cervical cancer patients. the author searches for articles in the form of original articles on machine learning. machine learning used include google scholar, pubmed, and sciencedirect. the search for articles was carried out from april to september 2021. the author entered keywords related to this research, namely the prevalence of ayuning et al medical and health science journal 2022 february vol.6 (01) page 35 of 40 trichomoniasis or trichomoniasis prevalence and cervical cancer or uterine cervical neoplasm or cervical neoplasm. the journals used are journals published from 2016 to 2021, in the form of original articles, and indexed at scimago. figure 1. articles identified through database screening (n=5.989) additional articles identified through another sources (n=0) articles after duplicates removed (n=4.797) full-text articles assessed for eligibility (n= 52) articles excluded (n=4.739) articles excluded (n=201) studies included (n=10) articles screened (n=253) full-text articles excluded with reasons : • did not reported statistical analysis (n=3) • how to calculate the prevalence of off topic (n=9) • not accredited at scimago (n=2) • did not reported outcomes associated with trichomoniasis and cervical cancer (n=28) id e n ti fi c a ti o n s c r e e n in g in c lu d e d ayuning et al medical and health science journal 2022 february vol.6 (01) page 36 of 40 results ten journals were used in this study. all journals are international journals indexed on scimago. three journals are research conducted in india, two journals are research conducted in brazil, while the other journals are research conducted in taiwan, china, korea, italy, and rwanda. these journals used case-control, crosssectional, and retrospective cohort study design. the journals used in this study reported the prevalence of trichomoniasis in cervical cancer patients differently. there are several journals that report the total prevalence in cervical cancer patients, or based on the stage or grade of cervical cancer. all journals also report statistical analyzes of trichomoniasis and cervical cancer. 1. prevalence of trichomoniasis in cervical cancer patients the prevalence of trichomoniasis in cervical cancer patients was discovered to be the highest in the study by ghosh et al. in kolkata, india (72.6% women with cin 1, 71.0% women with cin 2 or cin 3, and 87.7% women with invasive cancer). according to study by amorim et al., 2017 in brazil, trichomoniasis was found in 55.6% of women with cin 1, 62.5% of women with cin 2, and 64.3% of women with cin 3 or carcinoma in situ. study by mukanyangezi et al., 2018 in rwanda reported that trichomoniasis was found in 7.7% in the hiv positive with lsil, hsil, and cancer group and as much as 22.2% in the hiv negative with lsil, hsil, or cancer group.13 study by dey et al., 2016 in delhi, india reported the prevalence of trichomoniasis as much as 17.3% in women with ascus and 4.8% in women with lsil. according to a study by yang et al., 2020 in china, 13.85% of women with cin 1, 4.68% of women with cin 2, 8.55% of women with cin 3, and 1.22% of women with cancer had co-infection with t. vaginalis and hpv16. this study also reported a prevalence of co-infection with t. vaginalis and hpv18 as much as 12.38% in women with cin 1, 2.86% in women with cin 2, 0.95% in women with cin 3, and 0.95% in women with cancer and the prevalence of coinfection with t. vaginalis and other types of hrhpv as much as 4.20% in women with cin 1, 1.34% in women with cin 2, 0.54% in women with cin 3, and 0.09% in women with cancer.8 trichomoniasis was found in 5.6% of women with ascus, 7.5% of women with lgsil, 3.7% of women with asc-h, and 2.8% of women with hgsil in the study by kassandra et al., 2021 which was held in maranhao, brazil. study by gupta et al., 2020 in india reported the prevalence of trichomoniasis as much as 7.8% in the group with cin and 4.1% in the group with cervical cancer. study by raffone et al., 2020 in naples, italy reported the prevalence of trichomoniasis as much as 2% in women with cin 1 or lsil. according to study by kim et al., 2016 conducted in korea, trichomoniasis was found in 1.0% of women with ascus, 1.0% of women with lsil, and 0.5% of women with hsil. the prevalence of trichomoniasis in patients with cervical cancer was discovered to be the lowest in the study by su et al., 2020 in taiwan. in this study, trichomoniasis was found in 0.022% of women with cervical lesions.9-11 based on these data, the prevalence of trichomoniasis in cervical cancer patients ranged from 0.022% to 87.7%. the first factor that influences the difference in prevalence is demographic differences. in this study, the highest ayuning et al medical and health science journal 2022 february vol.6 (01) page 37 of 40 prevalence was found in kolkata, india and the lowest was found in taiwan. differences in race, poverty, and low levels of education also appear to have an effect on the prevalence of trichomoniasis. 12 several studies in india show that the level of hygiene and use of gynecological services in indian women is still very low. in addition, the indian government is less aware of the importance of women's health in rural areas in india.13 the second factor that influences the difference in prevalence is the difference in the diagnostic method used in the study reviewed. each diagnostic methods used has a different level of sensitivity and specificity, so that the reported study results are also different. 2. the relationship between trichomoniasis and cervical cancer trichomonas vaginalis infection causes cellular and immune changes in the female reproductive area, thus facilitating cell mutation and causing cervical cancer. t. vaginalis can produce lytic enzymes that induce vaginal mucosal damage, thereby causing microepithelial lesions, and integration of hpv dna within host cells is induced.14 overexpression of e6 and e7 proteins occurs as a result of hpv dna incorporation into host cells. this process inhibited the activity tumor suppressor protein and induce immunosuppression. physiologically, tumor suppressor proteins have a role to trigger the process of apoptosis, repair dna host damage, and inhibition of c-myc protein, a protein encoded by the c-myc gene. in the cell cycle, the c-myc protein is involved in cell proliferation, replication, and associated with its function to trigger tumor development (proto-oncogene).15 inhibition of the protein suppressor tumor’s activity will trigger the development of cervical cancer.16 over-stimulation of e6 and e7 proteins also causes immunosuppression so that hpv infection can be persistent and cause the production of lytic enzymes and chronic inflammatory processes.12 on the other hand, persistent infection of t. vaginalis will trigger an inflammatory response and oxidant production that causes host dna damage. damage to host dna can also lead to the development of cervical cancer.14 this literature study showed that four selected journals found significant associations among trichomoniasis and cervical cancer based on statistical analysis. study by amorim et al., 2017 reported that t. vaginalis is a risk factor for cervical lesions. study by dey et al., 2016, found that t. vaginalis had a significant association with ascus, lsil, and all premalignant cervical lesion. according to a study published in 2021 by kassandra et al., women with lgsil and asch had a 3,179-fold and 12,047-fold increased risk of t. vaginalis infection, respectively. study by su et al., 2020 reports cervical cancer risk was 3.684 times higher in those who had t. vaginalis infection compared to women who do not have t. vaginalis infection. study by mukanyangezi et al., 2018 reported that trichomoniasis is a risk factor for sil and cancer in the hiv negative group, but the results of statistical analysis showed a nonsignificant relationship in the hiv positive group.17 study by yang et al., 2020 reported that coinfection of t. vaginalis with hrhpv increased the risk of cin 1, but did not increase the risk of cin 2-3. study by raffone et al., 2020 stated that patients co-infected with t. vaginalis and ayuning et al medical and health science journal 2022 february vol.6 (01) page 38 of 40 gardnerella vaginalis had an 8-fold risk of cervical lesion progression, but t. vaginalis infection without co-infection with gardnerella vaginalis did not significantly affect the risk of lesion persistence or progression.10 three other journals reported nonsignificant association between trichomoniasis and cervical cancer in statistical analysis. study by ghosh et al., 2017 reported that hpv coinfection with t. vaginalis did not significantly affect cin. invasive cancer risk was higher in women who were co-infected with hpv and t. vaginalis than in those who were not, although there was no statistically significance difference. the prevalence of trichomoniasis was higher in the group with pre-invasive lesions than in the group with normal cytology or invasive lesions. however the difference was not statistically significant. study by tompkins et al., 2020 reported that statistical analysis showed insignificant results between t. vaginalis and cervical abnormalities.18 the correlation between the prevalence of trichomoniasis and the severity grade of cervical cancer appears to be variable. the prevalence of trichomoniasis was higher in the group with preinvasive lesions than in the group with normal cytology or invasive lesions, according to a study by gupta et al., 2020, however the difference was not statistically significant. study by yang et al., 2020 reported that co-infection of t. vaginalis with hrhpv increased the risk of cin 1, but did not increase the risk of cin 2-3. there are no journals that can explain the cause of the higher prevalence of trichomoniasis in lower grade cancer. according to a 2017 study by ghosh et al., the prevalence of trichomoniasis in cervical cancer was greater than cin, which was 87.7%. the prevalence of trichomoniasis in patients with the higher grade of cervical lesions can be caused by secondary infection due to tumor necrosis. differences in the correlation of trichomoniasis and cervical cancer may be influenced by the study design used in the study being reviewed. most of the research reviewed is not a longitudinal study with a long observation period, so the data displayed is data in a short time, whereas the development of cervical cancer takes a long time (years) until abnormalities appear and can be detected in cells and tissues. another factor that may influence the difference in results between one study and another is the difference in the number of samples used. the limited number of samples cannot describe the true correlation in the population. differences in diagnostic tools can also affect research results because the sensitivity and specificity of a diagnostic tool will determine whether a respondent's examination result is positive or negative. research on the prevalence of trichomoniasis in cervical cancer patients is still very limited, so there are only few journals that can be reviewed in this study. further research with a prospective design regarding trichomoniasis in cervical cancer patients needs to be done in the future. conclusion based on ten articles discussed in this study, the prevalence of trichomoniasis in cervical cancer patients was discovered to be the highest in the study by ghosh et al. in kolkata, india (72.6% women with cin 1, 71.0% women with cin 2 or cin 3, and 87.7% women with invasive cancer) and the lowest in the study by su et al. in taiwan ayuning et al medical and health science journal 2022 february vol.6 (01) page 39 of 40 (0.022%). the association between trichomoniasis and cervical cancer was found to be varied. some journals report statistically significant analyzes, while other journals report non-significant statistical analysis results. acknowlegment the financing is obtained independently conflicts of interest there are no conflicts of interest declared by the author. references 1. stebut ev. leishmaniasis and other protozoan infection. in: sewon k, amagai m, bruckner al, et al. (eds) fitzpatrick’s dermatology in general medicine. new york: mcgraw-hill education, 2019, p. 3243. 2. cdc. parasites neglected parasitic infections (npis). centers for disease control and prevention 2017; 1. 3. achdiat pa, dwiyana rf, feriza v, et al. prevalence of trichomoniasis in asymptomatic pregnant women population in bandung, west java, indonesia. indones j trop infect dis 2019; 7: 59. 4. flagg ew, meites e, phillips c, et al. prevalence of trichomonas vaginalis among civilian, noninstitutionalized male and female population aged 14 to 59 years: united states, 2013 to 2016. sex transm dis 2019; 46: 2–3. 5. van der pol b. trichomonas vaginalis. in: singh sk (ed) diagnostics to pathogenomics of sexually transmitted infections. 2018, p. 342. 6. leitsch d. recent advances in the trichomonas vaginalis field. f1000research 2016; 5: 2. 7. world health organization. cervical cancer. 2018; 1. [cited 2021 may 29]. available from: https://www.who.int/healthtopics/cervical-cancer#tab=tab_1 8. yang, m., li, l., jiang, c. et al. co infection with trichomonas vaginalis increases the risk of cervical intraepithelial neoplasia grade 2–3 among hpv16 positive female: a large population-based study. bmc infect dis 20, 642 (2020). https://doi.org/10.1186/s12879-02005349-0 9. belfort, i., cunha, a., mendes, f., galvãomoreira, l. v., lemos, r. g., de lima costa, l. h., monteiro, p., ferreira, m. b., dos santos, g., costa, j. l., de sá ferreira, a., brito, l., brito, l., vidal, f., & monteiro, s. (2021). trichomonas vaginalis as a risk factor for human papillomavirus: a study with women undergoing cervical cancer screening in a northeast region of brazil. bmc women's health, 21(1), 174. https://doi.org/10.1186/s12905-02101320-6 10. raffone, a., travaglino, a., mascolo, m., carotenuto, c., guida, m., mollo, a., insabato, l., & zullo, f. (2020). histopathological characterization of promise molecular groups of endometrial cancer. gynecologic oncology, 157(1), https://doi.org/10.1186/s12879-020-05349-0 https://doi.org/10.1186/s12879-020-05349-0 https://doi.org/10.1186/s12905-021-01320-6 https://doi.org/10.1186/s12905-021-01320-6 ayuning et al medical and health science journal 2022 february vol.6 (01) page 40 of 40 252–259. 11. su, r. y., ho, l. j., yang, h. y., chung, c. h., yang, s. s., cheng, c. y., chien, w. c., & lin, h. c. (2020). association between trichomonas vaginalis infection and cervical lesions: a population-based, nested case-control study in taiwan. parasitology research, 119(8), 2649–2657. https://doi.org/10.1007/s00436-02006759-4 12. cunha apa, belfort ikp, mendes fpb, et al. human papillomavirus and its association with other sexually transmitted coinfection among sexually active women from the northeast of brazil. interdiscip perspect infect dis 2020; 2020: 2. 13. tompkins el, beltran ta, gelner ej, et al. prevalence and risk factors for trichomonas vaginalis infection among adults in the u.s., 2013–2014. plos one 2020; 15: 7. 14. dey s, pahwa p, mishra a, et al. reproductive tract infections and premalignant lesions of cervix: evidence from women presenting at the cancer detection centre of the indian cancer society, delhi, 2000–2012. j obstet gynecol india 2016; 66: 441–451. 15. kassandra i, belfort p, paula a, et al. trichomonas vaginalis as a risk factor for human papillomavirus : a study with women undergoing cervical cancer screening in a northeast region of brazil. bmc womens health 2021; 21: 1–8. 16. evriarti pr, yasmon a. patogenesis human papillomavirus (hpv) pada kanker serviks. j biotek medisiana indones 2019; 8: 23–32. 17. mukanyangezi, m. f., sengpiel, v., manzi, o., tobin, g., rulisa, s., bienvenu, e., & giglio, d. (2018). screening for human papillomavirus, cervical cytological abnormalities and associated risk factors in hiv-positive and hivnegative women in rwanda. hiv medicine, 19(2), 152–166. https://doi.org/10.1111/hiv.12564 18. tompkins el, beltran ta, gelner ej, farmer ar. prevalence and risk factors for trichomonas vaginalis infection among adults in the u.s., 2013-2014. plos one. 2020 jun 16;15(6):e0234704. doi: 10.1371/journal.pone.0234704. pmid: 32544192; pmcid: pmc7297358. https://doi.org/10.1111/hiv.12564 medical and health science journal 2021 august vol.5 (02) medical and health science journal available at http://journal2.unusa.ac.id/index.php/mhsj; doi:10.33086/mhsj.v5i2.2179 pissn 2549-7588. eissn 2549-7596 original article implementation of occupational safety and health risk management in islamic hospital surabaya a. yani muhammad huda firmansyah*, moch. sahri, budhi setianto1 1 department of public health, faculty of health, universitas nahdlatul ulama surabaya, surabaya, indonesia article info article history: received: july 14, 2021 received in revised form: august 06, 2021 accepted: august 25, 2021 keywords: risk management, hospital, occupational health and safety. *) corresponding author: muhammadhuda049.km17@studet .unusa.ac.id abstract background: risk management is a preventive effort for a company, especially those engaged in the service sector, which is very prone to errors and complaints. for this reason, it is necessary to map the risks that occur in accordance with the work unit in it which is expected to minimize the number of accidents or errors in both patients, visitors and employees in the hospital. in the 2019 patient safety incident report data at the surabaya a. yani islamic hospital, it was found that there were incidents which included near miss 93%, not injured 4%, unexpected events 3% and sentinel 0%. the purpose of this study was to identify and identify the application of occupational safety and health risk management at the a. yani islamic hospital in surabaya. methods: this thesis is a qualitative research with a case study method with the aim of fully describing the implementation of k3 risk management at surabaya a. yani hospital based on observation, survey and documentation data on 37 units and hospital workplaces by identifying risks. , analyze and find risk control measures. results: the results showed that the implementation of k3 risk management in the islamic hospital of surabaya a. yani based on the results of risk identification obtained as many as 25 risks in the graha building and the old building which were further analyzed by finding 15 moderate risks and 10 high risks. can be done by repairing damaged infrastructure and improving the existing security system at the a. yani islamic hospital in surabaya. conclusion: the conclusion in this study is the implementation of k3 risk management at the islamic hospital of surabaya a. yani has 25 potential risks, of which there are 15 moderate risks and 10 high risks that can potentially cause accidents to employees, visitors and patients. in this case, control efforts are made to minimize the number of incidents and accidents. medical and health science journal http://journal2.unusa.ac.id/index.php/mhsj firmansyah medical and health science journal 2021 august vol.5 (02) page 17 of 26 introduction occupational health and safety (k3) is a preventive effort made for workers or laborers as well as employers to prevent work accidents and diseases due to work relationships in the work environment by recognizing the potential that will cause work accidents and occupational diseases (pak).1 ri law no. i of 1970 concerning work safety states that the workplace is a place where work is carried out for the purposes of a business where there are workers working and the possibility of danger in the workplace. this workspace includes all places of business activity with an economic or social motive. regulation of the minister of manpower number per.05/men/1996 states that the occupational health and safety management system, hereinafter referred to as the ohs management system, is part of the overall management system which includes organizational structure, planning, responsibilities, implementation, achievement, assessment and maintenance of occupational safety and health policies in the context of controlling risks related to work activities in order to create a safe, efficient and productive workplace. occupational health is one of the fields of public health that focuses attention on the working community, both in the formal sector and those in the informal sector 2. risk management activities are an important issue for a service based on service quality.3 risk management is a preventive effort for a company, especially those engaged in the service sector where it is very vulnerable to errors and complaints. for this reason, it is necessary to first map the risks that occur according to the work units in it. with that, it is hoped that risk management can minimize the number of accidents or errors both for patients, visitors and employees at the hospital. in achieving success in realizing risk control and mitigation in a health service, it is necessary to make rules and procedures and work targets so that they are clearly in accordance with the established agenda. for this reason, risk management makes policies and strategies that will be used in the process. this is intended to avoid errors in identification and monitoring of work programs so that they can focus on carrying out and planning activities in the service unit4. surabaya islamic hospital a. yani is a hospital under the auspices of the surabaya islamic hospital foundation (yarsis). islamic hospital surabaya, which is one of the private hospitals with good service and accredited plenary (five star) by kars. with this, patients and visitors expect to get good and satisfying service. based on the patient safety incident report data in 2019 it was found that the number of incident incidents was as follows: based on the data table for the 2019 patient safety incident report, it is explained that the percentage of patient safety incident frequency based on the type of incident is knc 93%, ktc 4%, ktd 3% and sentinel 0% at islamic hospital surabaya a. yani. therefore, to improve service and customer satisfaction, an increase in patient safety services is needed. there is a need for regular monitoring and good risk management to ensure the safety of health workers, patients and visitors at the surabaya a. yani islamic hospital. based on this description, firmansyah medical and health science journal 2021 august vol.5 (02) page 18 of 26 the authors conducted a study on "application of occupational health and safety risk management in islamic hospital surabaya a. yani". the general and specific objectives of this study were to determine the application of osh risk management at the islamic hospital of surabaya a. yani. identifying occupational safety and health risks at the surabaya a. yani islamic hospital. analyzing and evaluating risk at the surabaya a. yani islamic hospital, as well as knowing the control of risk at the surabaya a. yani islamic hospital. methods this research is qualitative research with a case study method that is used to understand a problem or problem by using an event, process, activity and program with the aim of obtaining a complete and in-depth description or picture by collecting data from various sources including observation. , documentation and reports. this study will describe the application of occupational safety and health risk management which includes the stages of risk identification, risk analysis and risk control at the islamic hospital of surabaya a. yani. 1. the unit of analysis in this study is all workplaces and units in the hospital, totaling 37 hospital units that have the potential to pose a risk of danger at the islamic hospital of surabaya a. yani. 2. in this study, the techniques used in data collection were divided based on the source of the data obtained, namely primary data and secondary data. primary data is data obtained directly from the object of research, namely all units and workplaces at the surabaya a. yani islamic hospital through observations and surveys using a potential risk identification form. while the secondary data was obtained from the annual data recap which is a report recorded at the surabaya a. yani islamic hospital. while the data analysis techniques used are observation, survey, and documentation. observations were made by direct observation of all units and workplaces at the surabaya a. yani islamic hospital which have the potential to have risks and hazards and to obtain secondary data, namely reports from the pmkp unit. 3. this survey was conducted using a risk identification form to obtain information from the field regarding the potential risks of hazards that cause accidents to health workers, employees and visitors or patients at the surabaya a. yani islamic hospital. documentation is carried out with the aim of completing the information obtained so that it is more complete and supports the truth and information provided relating to the identification of potential hazards. from all stages of the process, the researcher inputs the data that has been obtained in the risk identification form and then describes it with photos or documentation in accordance with the conditions in the field and is described in the form of a narrative in the discussion and research results. after obtaining all the data obtained from the research, it is analyzed to determine the potential hazards or causes of accidents and their sources, and reviewing the control efforts firmansyah medical and health science journal 2021 august vol.5 (02) page 19 of 26 that have been carried out in accordance with the as/nzs 4360 standard, in particular by conducting a hazard risk analysis to determine the priority level of risk as a risk control measure so that does not cause work accidents. 4. the unit of analysis in this study is the place or environment in the surabaya islamic hospital a. those who have potential risks that open 37 units 5. this research was conducted at the islamic hospital surabaya a. that is, in 37 units of analysis, namely the graha building and the old rsi . building the research was conducted from january to february 2021 with the object of research being all units and workplaces around the surabaya a. yani islamic hospital. researchers have used and applied research ethics in this study, the researcher has explained in advance the intent and purpose of carrying out the research to the surabaya a. yani islamic hospital through an official licensing process from the university with the approval of the location to be studied, the data obtained from the unit and workplace at the islamic hospital of surabaya a. yani is guaranteed to be kept confidential by providing a report to the researcher, the risk identification form is given from the hospital with guidance and direction from the general section and the k3rs committee, the statement that was studied obtained permission and approval from the hospital with the output in the form of suggestions and input related to risk control at the surabaya a. yani islamic hospital. results this research is qualitative research with a case study method that is used to understand a problem or problem by using an event, process, activity and program with the aim of obtaining a complete and in-depth description or picture by collecting data from various sources including observation., documentation and reports. this study will describe the application of occupational safety and health risk management which includes the stages of risk identification, risk analysis and risk control at the islamic hospital of surabaya a. yani. the unit of analysis in this study is all workplaces and units in the hospital, totaling 37 hospital units that have the potential to pose a risk of danger at the islamic hospital of surabaya a. yani. in this study, the techniques used in data collection were divided based on the source of the data obtained, namely primary data and secondary data. primary data is data obtained directly from the object of research, namely all units and workplaces at the surabaya a. yani islamic hospital through observations and surveys using a potential risk identification form. while the secondary data was obtained from the annual data recap which is a report recorded at the surabaya a. yani islamic hospital. while the data analysis techniques used are observation, survey, and documentation. observations were made by direct observation of all units and workplaces at the surabaya a. yani islamic hospital which have the potential to have risks and hazards and to obtain secondary data, namely reports from the pmkp unit. this survey was conducted using a risk identification form to obtain information from the firmansyah medical and health science journal 2021 august vol.5 (02) page 20 of 26 field regarding the potential risks of hazards that cause accidents to health workers, employees and visitors or patients at the surabaya a. yani islamic hospital. documentation is carried out with the aim of completing the information obtained so that it is more complete and supports the truth and information provided relating to the identification of potential hazards. from all stages of the process, the researcher inputs the data that has been obtained in the risk identification form and then describes it with photos or documentation in accordance with the conditions in the field and is described in the form of a narrative in the discussion and research results. after obtaining all the data obtained from the research, it is analyzed to determine the potential hazards or causes of accidents and their sources, and reviewing the control efforts that have been carried out in accordance with the as/nzs 4360 standard, in particular by conducting a hazard risk analysis to determine the priority level of risk as a risk control measure so that does not cause work accidents. table 2. data of risk control of graha rsi surabaya building a. yani no possible risks root of the problem control recommendations 1 stumble hit by an object falls excessive placement of items in the workspace placed in a safer place such as a warehouse or other storage room. 2 get hit by a drugstore fire extinguisher blocked stumbled alkes placement of medical equipment around apar placed in a safer place such as a warehouse or other storage room. 3 slipped falls water leaks from the roof that soaks the floor repair of the roof and or marking of slippery floors around the floor. 4 the fire extinguisher cannot be used optimally in the event of a fire apar hose that is loose and not maintained repair and check fire extinguishers on a regular or scheduled basis 5 struck by apar setting the fire extinguisher too high place the fire extinguisher in the correct and strategic height position 6 stumble crashing falls wheelchair in the hallway moving to a safer place and does not hinder activities in the work environment firmansyah medical and health science journal 2021 august vol.5 (02) page 21 of 26 7 noise hearing disorders machine makes noise store it in a soundproof room and wear ear plugs 8 slipped falls cracked and leaking roof patching and repairing the roof 9 disturbance of electric current electrocuted can happen fong messy cables and close to work activities tidy cables and provide cable safety lock 10 hit by an object damage to facilities disturbance of electric current putting objects or items on the gallon near the computer move objects to a place that has been provided such as a drawer or table table 3 data. of risk control of old building rsi surabaya a. yani no possible risks root of the problem control recommendations 1 stumble slipped falls the stairs are not wide enough and there is no safety, such as rubber on the steps renovations and repairs by providing safety rubber on the stair steps 2 security system breached power failure network failure the electrical installation room is unlocked padlocked and locked the room when not in use 3 get hit by an item falls stumble putting things and equipment on the stairs move items to a safe place 4 stumble falls overturned cracked and hollow floor in pharmacy corridor floor patching and repair 5 insect or vector entry smelly water the water reservoir for oxygen is unlocked and poorly maintained periodic checks and monitoring as well as padlocks firmansyah medical and health science journal 2021 august vol.5 (02) page 22 of 26 6 wood cover scratched with cracked glass sanitary facilities for clinic and spiritual rooms that have been peeled off and cracked glass sanitation facility improvement 7 hit by glass stumble placement of glass on the road move to a safer place 8 stumble falls overturned placement of pipes along roads where there is frequent activity moving pipes to a safer location or warehouse 9 disturbance of electric current electrocuted can happen fong messy cables and close to work activities tidy cables and provide cable safety lock 10 falls stumble crashing placement of goods in the workspace store it in a warehouse or in a safer place 11 slipped stumble falls floor rubber starting to peel off repair and replace rubber 12 slipped falls water leaks from the roof that soaks the floor repair of the roof and or marking of slippery floors around the floor. 13 nosy people breaking into electrical system shuts down when needed unlocked electrical installation locking and checking regularly 14 falls slipped no ergonomics steep access roads and passages in the icu hallway and no safety or footing added handrails on each side and steps like stairs 15 electrocuted prone to short circuit when it rains an open path around the generator and unlocked closing the fence and locking it and not being used as an access road firmansyah medical and health science journal 2021 august vol.5 (02) page 23 of 26 discussion in research activities that have been carried out at the surabaya a. yani islamic hospital, researchers observed and focused on one of the activities, namely the application of ohs risk management which includes risk identification, risk analysis and efforts to control risk. the implementation of the risk management program at the surabaya a. yani islamic hospital was slightly hampered due to the covid-19 pandemic which caused monitoring or examination not to be in accordance with the predetermined schedule. the k3 committee of rsi a. yani supports and encourages the implementation of risk management in several stages, namely: first, communicating and showing support for risk management. second, trust, report every incident or incident and manage risk. third, appreciate and empower good risk management practices. fourth, identify and sustainably manage the factors that cause accidents or incidents that occur at the surabaya a. yani islamic hospital. fifth, encouraging organizational learning with established structures and tasks. sixth, developing appropriate risk management strategies to reduce the likelihood or recurrence of incident problems, and seventh, continuous monitoring and evaluation of the implemented strategies to ensure they are effective or not. the implementation of ohs risk management is an overall part that includes organizational structure, planning, responsibilities, implementation, procedures, processes and resources needed for the development, implementation, achievement, review and maintenance of ohs5 policies in the context of risk control or prevention of workrelated accidents. and occupational diseases in order to create a safe, comfortable and productive workplace3. according to the guidelines for management of occupational health and safety (k3) in hospitals, k3rs management is an activity process that begins with the planning, organizing, implementing and controlling stages that aim to cultivate osh in hospitals. the analysis in the implementation of this research refers to the 4 main elements contained in the ministry of health, namely commitment and policy, planning, organizing and implementation5,6. based on the results of the study, it can be concluded that the commitment of the surabaya a. yani islamic hospital related to k3rs is an initial commitment that is expressed verbally, but has not been realized in written form specifically regarding k3. however, policies regarding structure and organization have been formed and several work programs have been running, although slightly hampered in 2020 due to the covid-19 pandemic. in addition, funding related to k3rs and facilities such as personal protective equipment (ppe) is complete and implemented. there are some human resources who handle k3rs at the surabaya islamic hospital a. yani who do not have special expertise in the field of k3, because the training system is carried out in rotation and alternately, existing resources need to be included in k3 training so that the hospital has the resources competent person which is manifested in the form of an organizational container for the k3rs committee7. the islamic hospital of surabaya a. yani also has a policy firmansyah medical and health science journal 2021 august vol.5 (02) page 24 of 26 that all workers in the hospital must receive counseling about k3. it is known that several strategies that have been arranged at the surabaya a. yani islamic hospital, namely the socialization of the k3rs program, the formation of an k3 committee organization even though it has not become an independent organization and is still in the service sector and several human resources in the k3 committee who do not have the basics of k3 but they receive adequate training and work programs that have been arranged. risk analysis is a process to identify and provide a risk assessment that measures the impact, frequency or probability as well as the magnitude of losses to recipients caused by exposure to hazards that result in work accidents or occupational diseases8. based on the risk assessment with the product of the impact, the level of probability and loss to the recipient at the surabaya islamic hospital a. yani through a survey and observation process using the risk identification form from the osh committee of the surabaya islamic hospital a. yani with the as/nzs 4360 standard, it was obtained some of the medium risk and high risk in the graha building and the old building totaling 37 units or sections that are at risk of causing work accidents to health workers, employees, patients and visitors. moderate risks were found, such as the placement of excessive items in the workspace that narrowed the workspace area, placement of medical devices along the road and around the stairs, water leaks from the roof that wet the floor which was at risk of slipping, the rubber floor was peeling off and there were bumps on the surface of the floor that can cause health workers and visitors and patients to fall or stumble when accidentally passing the location point, other risks such as computer installation cables or dispensers in the workspace are messy and close to risky work activities that can cause electrical disturbances, electric shock and can cause fong,then reservoirs or water pumps that are not locked which are at risk of entering insects or vectors that can cause smelly or polluted water and placing excess goods in the workspace which poses a risk to workers when carrying out work activities falling or tripping over objects. however this result was found to be similar with previous study9. high risks include such as an unlocked electrical installation system and water tendons which can result in being broken into by irresponsible and irresponsible people and causing the hospital's electrical system to be disrupted and problematic, placing the fire extinguisher in a position that is too high and close to work activities that are at risk of falling and happened to people who were close to the location, then checked the unscheduled fire extinguisher so that the condition of the fire extinguisher was not good, such as rubber or hoses that had peeled and expired so that the use of the fire extinguisher when needed and a fire could be hampered . another risk is the roof of the meeting room in the old building peeling off and almost collapsing which risks falling on people who are in the room and causing a detrimental impact and scattered and messy cables that are near work activities and computer equipment, this can be at risk of current disturbances. electricity firmansyah medical and health science journal 2021 august vol.5 (02) page 25 of 26 and fongs and can cause a fire. previous study in japan also found similar result that10. control measures that can be taken from the risks found are such as the condition of runnah walls at several points that have cracked and leaky roofs as well as cracked and perforated floors and some rubber floors that are starting to peel as well as the placement of items scattered around the streets and spaces 11,12. work, scattered cables, wet and slippery floor surfaces at several locations, some of which can cause work accidents for health workers, employees and patients or visitors at the surabaya a. yani islamic hospital. conclusion based on research on the application of occupational safety and health risk management at the surabaya a. yani islamic hospital, it was concluded that the implementation of k3 risk management in the risk management program at the surabaya a. yani islamic hospital was running well but not optimal because it was caused by the covid-19 pandemic that causing monitoring or inspection not according to a predetermined schedule. risk identification obtained 25 potential risks contained in 37 units which include the graha building and the old building at the surabaya a. yani islamic hospital, while the existing risks include the risk of falling, tripping, slipping, electrocution, breaking the security system and noise risk. risk analysis at the surabaya islamic hospital there are 25 potential risks in the graha building and the old building, among them there are 15 moderate risks and 10 high risks. the graha building has 7 moderate risks and 3 high risks, while the old building has 8 moderate risks and 7 high risks. risk control that can be done is by repairing infrastructure that has started to break down, providing a special place or space for storing medical items and equipment and improving the security system to avoid breaking into electrical installations and water tendons by irresponsible people and checking and monitoring regularly scheduled. conflict of interest the author stated there is no conflict of interest references 1. portmann, l. & giusti, v. [obesity and hypothyroidism: myth or reality?]. rev. med. suisse 3, 859–62 (2007). 2. asian development bank & bps-statistic. the informal sector and informal employment in indonesia: country report 2010. (2011). 3. boateng, j. k. & arthur, y. a. influence of risk management practices on service quality in health care delivery. 5, 176–186 (2014). 4. youngberg, b. j. principles of risk management and patient safety. (2011). 5. hastuti, d. d., setyaningsih, y. & adi, k. design of occupational health and safety management information system at telogorejo semarang hospital. unnes j. public heal. 9, 20–27 (2020). 6. purnomo, d. h., indasah, i. & melda, b. analysis of implementation safety and health occupational management system in kertosono general hospital. j. qual. public heal. 1, 78–85 (2018). firmansyah medical and health science journal 2021 august vol.5 (02) page 26 of 26 7. nasution, a. d. & mahyuni, e. l. hospital occupational safety and health management system based on internet of things (iot). 495–499 (2020) doi:10.5220/0010076004950499. 8. alayyannur, p. a. correlation of management commitment and k3 training with knowledge in hospital ‘x’. j. ind. hyg. occup. heal. 2, 102 (2018). 9. kim, y.-j. & kang, s.-w. the quality of life, psychological health, and occupational calling of korean workers: differences by the new classes of occupation emerging amid the covid-19 pandemic. int. j. environ. res. public health 17, 5689 (2020). 10. tanaka, r. et al. dietary differences in male workers among smaller occupational groups within large occupational categories: findings from the japan environment and children’s study (jecs). int. j. environ. res. public health 15, 961 (2018). 11. zare, s. et al. occupational stress assessment of health care workers (hcws) facing covid-19 patients in kerman province hospitals in iran. heliyon 7, e07035–e07035 (2021). 12. brighenti-zogg, s. et al. physical workload and work capacity across occupational groups. plos one 11, e0154073–e0154073 (2016). microsoft word 2712-article text-14467-1-18-20220517.docx medical and health science journal 2022 february vol.6 (01), medical and health science journal. available at http://journal2.unusa.ac.id/index.php/mhsj ; doi:10.33086/mhsj.v5i2.2712 p.issn 2549-7588. eissn 2549-7596 review article survey of public knowledge about new normal behavior after covid-19 ni njoman juliasih1, renny mareta sari1, eppy setiyowati 2* 1. school of medicine, universitas ciputra surabaya. indonesia 2. faculty of nursing and midwifery, universitas nahdlatul ulama surabaya, 60231. indonesia article info article history: received: february, 02 2022 received in revised form: may, 17 2022 accepted: may, 31 2022 keywords: covid-19, new normal behavior, health protocol, social distancing *) corresponding author: eppy@unusa.ac.id abstract background:: coronavirus virus disease pandemic 2019 (covid-19) has not shown improved health conditions, it is necessary to conduct an in-depth survey of public knowledge in carrying out healthy living behaviors after the covid-19 pandemic. clean and healthy living behavior is one of the efforts in maintaining personal and environmental hygiene. the purpose of the study was to conduct an analysis of public knowledge about clean and healthy living behaviors after the covid-19 pandemic. methods: design used in qualitative research with explanatory survey approach. the technique of sampling snowballs over the internet online, an anonymous online instrument was developed using google form. questionnaire links were sent via email, whatsapp, and other social networks through researchers. the instrument packaged in structured questioner form (included as an additional file) consists of questions covering several fields: (1) sociodemographic data (age, gender and level of education), (2) new normal behavior habits include wearing a mask, washing hands with soap or hand sanitizer, social distancing, do not a crowd with many people, keep the environment around the residence always clean and healthy, packaged in google form. data recapitulation and processing are carried out with the help of it, then qualitative analysis. results: in this study, we conducted explorations related to sociodemographic, environmental hygiene around the place, healthy behavior habits including, wearing masks, hand washing, social distancing, availability of facilities for hand washing with hand sanitizer or hand washing with running water. the results showed that the community has carried out new normal behavior with awareness without any compulsion from anywhere. thus new normal behavior includes, wearing masks, washing hands with running water or hand sanitizer and social distancing has become a new habit in order to break the chain of spread of 'covid 19. conclusion: with a better understanding of the new normal behavior, people are able to break the indirect chain of transmission of covid-19 in everyday life medical and health science journal introduction the new coronavirus (sars-cov-2) is causing concern in the medical community, as it spreads globally.1-2 the fact that people without symptoms is a potential source of infection justifies a thorough analysis of the dynamics of current outbreak transmission. 3 the virus is mainly transmitted by direct or indirect contact with the mucous membranes of the eyes, nose or mouth or hands.4 hygiene is juliasih et al medical and health science journal 2022 february vol.6 (01) page 57 of 57 considered an important step to prevent the transmission of pathogens in health care facilities, and it is proven that improving hand hygiene compliance significantly reduces infections acquired from health care.5 therefore, hand hygiene is recommended as an important strategy to help prevent the spread of covid-19 in hospitals. possible spread of covid-19. there is evidence that daily hygiene measures are an important part of infection prevention, which is important in the prevention of transmission and transmission.6 there is evidence that daily hygiene measures are an important part of infection prevention and important in preventing transmission and transmission of infections. 4 cross-rationing to others who live together, body hygiene habits, care control behaviors and disinfection in the environment. 7 basic hygiene such as washing hands with soap and clean water is the most effective and economical way to prevent various infections of the digestive tract, digestion, and skin.8 coronavirus disease 2019 (covid-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (sar-cov-2).9 this pandemic has strengthened the need for changes in new normal behavior, namely frequent hand washing with hand sanitizer or with soap and running water, wearing masks, social distancing, avoiding crowds. the use of masks is very important to prevent pathogens from being inhaled and cause airway infections can result in low immunity and susceptible to the covid-19 virus.10 efforts made in improving personal hygiene are as follows; provide ctps hygiene tools in public or home, bring hand sanitizer and wet wipes when out, use masks, cultivating new normal behavior.11 the purpose of the study is to explore public knowledge about clean and healthy living behaviors after covid 19. methods the research design used in this study is qualitative with the explanatory survey approach that is attempt data collection is specifically designed to avoid contact person to person. the explanatory survey was conducted online, and only participants with internet access were able to participate in the study. the sampling technique using snowball samples and online questioner was developed using google forms with consent forms. questionnaire links are sent via email, whatsapp, and other social networks owned by researchers. participants are encouraged to complete surveys covering sociodemographic (age, gender and education level), (2) daily behavior of family members that allows the transmission of covid 19 (hand washing with soap or hand sanitizer, change clothes after traveling, immediately bathe and clean yourself after from outside the house) with the format of the response carried out through the dichotomous question (yes =1/ not =0), (3) personal hygiene habits are also supporting questions including; oral self-hygiene during a period of self-isolation (brushing 2 or more times per day, flossing once a day, gargling once a day, brushing the tongue once a day). responses from respondents were assessed on a 5-point likert scale ranging from 1 to 5, with "never"=1, "almost never"=2, "sometimes 3," "almost always 4 and "always" results and discussion to our knowledge, as we know, new normal behavior today has become a habit of everyday people in running a clean and healthy lifestyle.12 however, in this study, it has not been able to see further the different effects of each member of the public in carrying out new normal behavior habits, because researchers have not made direct observations in the study subjects group.13 the situation and conditions on the ground have not fully supported the data retrieval activities directly to respondents. in this study, we explored sociodemographic, environmental hygiene around the place, healthy behavior habits including, wearing masks, hand washing, social distancing, availability of facilities for hand washing with hand sanitizer or hand washing with running water.14 the results showed that the community has carried out new normal behavior with awareness without any compulsion from anywhere. thus new normal behavior including, wearing masks, washing hands with running water or hand sanitizer and social distancing has become a new habit in order to break the chain of spread of 'covid 19.15 changes in thinking and changes in people's insights about the impact of this pandemic on hand hygiene prevent the spread of covid-19, it is very important to comply with all measures of the health protocol established by the government(ri, 2020) in addition, it will be interesting to know the different effects depending on the number of people in the household. improper use of measures in indirect transmission of covid19 between people living together.16 in descriptive sociodemographic data, the cleanliness of the environment around the place, healthy behavior habits include, wearing masks, hand washing, social distancing, the availability of facilities for hand washing with hand sanitizer or hand washing with running water. the results showed that the community has carried out new normal behavior with awareness without any compulsion from anywhere. thus new normal behavior including, wearing masks, washing hands with running water or hand sanitizer and social distancing has become a new habit in order to break the chain of spread of 'covid 19.17-18 in the results of the study related to individual data respondents obtained result that highlights personal hygiene, considering sharing toothbrushes, toothpaste, the same juliasih et al medical and health science journal 2022 february vol.6 (01) page 57 of 57 container for brushes, closing the toilet lid before flushing and replacing the brush after the virus process can be a cross-contamination path covid-19.13 however, when studying oral hygiene habits, there is no significant difference so it is less able to provide information about personal hygiene. these results can be interpreted to show that personal hygiene exerts a considerable influence in breaking the chain of spread of covid-19.11 some respondents provided information related to factors that might contribute in efforts to break the chain of transmission and spread of covid'19 through increased knowledge and understanding of personal hygiene and the environment around the residence.19 the main thing in efforts to increase people's knowledge and understanding to always run new normal behavior becomes a habit of living a clean and healthy life.20 the main thing in efforts to increase people's knowledge and understanding to always run new normal behavior becomes a habit of living a clean and healthy life.20 the results also provide information that, effectively, clean and healthy living behaviors, hygiene at home and in daily life have the potential to reduce infection rates and antibiotic consumption, thereby reducing selective pressure for further development and spread of resistance 21 as noted in this new normal behavior effort to contain the sarscov-2 virus and slow the spread of covid 19, hygiene practices including hand washing, are the first line of defense to reduce the transmission of infection and spread of the coronavirus.22 conclusion the study concluded that most of the study subjects had good knowledge of the spread, transmission and disconnection of the covid19 chain, but there were gaps in understanding new normal behavior. the following research is recommended to conduct a study on health belief models related to compliance with carrying out clean and healthy living behaviors. acknowlegment the financing is obtained independently conflict of interest the author stated there is no conflict of interest references 1. pastorino, r., villani, l., mariani, m., ricciardi, w., graffigna, g., & boccia, s. (2021). impact of covid-19 pandemic on flu and covid-19 vaccination intentions among university students. vaccines, 9(2), 1–9. https://doi.org/10.3390/vaccines9020070 2. alhamlan, f. s., majumder, m. s., brownstein, j. s., hawkins, j., al-abdely, h. m., alzahrani, a., obaid, d. a., alahdal, m. n., & binsaeed, a. (2017). case characteristics among middle east respiratory syndrome coronavirus outbreak and non-outbreak cases in saudi arabia from 2012 to 2015. bmj open, 7(1), 1–7. https://doi.org/10.1136/bmjopen-2016011865 3. bawazir, a., al-mazroo, e., jradi, h., ahmed, a., & badri, m. (2018). since january 2020 elsevier has created a covid-19 resource centre with free information in english and mandarin on the novel coronavirus covid19 . the covid-19 resource centre is hosted on elsevier connect , the company ’ s public news and information. journal of infection and public health, 11, 89–93 4. huang, y., yang, l., dai, h., tian, f., & chen, k. (2020). epidemic situation and forecasting of covid-19 in and outside china. bulletin of the world health organization, december 2019, 2–4. https://www.who.int/bulletin/online_first/ 20-255158.pdf 5. juwita, c., and, r. n.-i. j. of m., & 2021, undefined. (2021). hygiene and healthy living behavior and stress during the covid-19 pandemic. repository.uki.ac.id, 7(3), 1041–1048. https://doi.org/10.36678/ijmaes.2021.v 07i03.002 6. kebede, y., yitayih, y., birhanu, z., mekonen, s., & ambelu, a. (2020). knowledge, perceptions and preventive practices towards covid-19 early in the outbreak among jimma university medical center visitors, southwest ethiopia. plos one, 15(5), 1–15. https://doi.org/10.1371/journal.pone.0233 744 7. koyama, t., platt, d. e., & parida, l. (2020). variant analysis of covid-19 genomes. bulletin of the world health organization, february. https://www.researchgate.net/publication/ 339461351_variant_analysis_of_covid19_genomes 8. setiyowati, eppy. juliasih, n. n. 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(2007). when individual behaviour matters: homogeneous and network models in epidemiology. journal of the royal society interface, 4(16), 879–891. https://doi.org/10.1098/rsif.2007.1100 12. le, x. t. t., dang, a. k., toweh, j., nguyen, q. n., le, h. t., do, t. t. t., phan, h. b. t., nguyen, t. t., pham, q. t., ta, n. k. t., nguyen, q. t., nguyen, a. n., van duong, q., hoang, m. t., pham, h. q., vu, l. g., tran, b. x., latkin, c. a., ho, c. s. h., & ho, r. c. m. (2020). evaluating the psychological impacts related to covid-19 of vietnamese people under the first nationwide partial lockdown in vietnam. frontiers in psychiatry, 11(september), 1–8. https://doi.org/10.3389/fpsyt.2020.00824 13. kwok, k. o., li, k. k., chan, h. h. h., yi, y. y., tang, a., wei, w. i., & wong, s. y. s. 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(2020). world health organization ( who ) information note tuberculosis and covid-19 covid-19 : considerations for tuberculosis ( tb ) care 1 . are people with tb likely to be at increased risk of covid-19 infection , illness and death ? 2 . what should health au. world health organization, april, 1– 10. 22. almutairi, k. m., al helih, e. m., moussa, m., boshaiqah, a. e., saleh alajilan, a., vinluan, j. m., & almutairi, a. (2015). awareness, attitudes, and practices related to coronavirus pandemic among public in saudi arabia. family and community health, 38(4), 332–340. https://doi.org/10.1097/fch.0000000000 000082 medical and health science journal 2022 february vol.6 (01) medical and health science journal available at http://journal2.unusa.ac.id/index.php/mhsj; doi: doi:10.33086/mhsj.v5i2.2518 pissn 2549-7588. eissn 2549-7596 original article the effect of brown algae (sargassum sp) extract on burns wound healing tri wahyuni bintarti1*, meidyta sinantryana widyaswari2 1. department of biomolecular, faculty of medicine, universitas nahdlatul ulama surabaya, surabaya, indonesia 2. department of dermatology and venereology, faculty of medicine, universitas nahdlatul ulama surabaya, surabaya, indonesia article info article history: received : 28 november, 2021 received in revised form : 02 february 2022 accepted : 18 february 2022 keywords: sargassum.sp,burns, wound healing *) corresponding author: bintarti_tri@unusa.ac.id abstract backgroud: the wound care method that is currently developing uses the principle of moisture balance which is also known as the modern dressing method. seaweed is a potential commodity in indonesia, which has been widely used as a medicinal ingredient. however, the use of seaweed in the form of hydrogel ointment in the treatment of burns has not been widely studied. therefore, this study was conducted to determine the effect of giving seaweed extract (sargassum sp.) in the form of hydrogel ointment to burns. methods: the design in this study was an experimental study with a randomized post-test only control group design, using musmusculus mice. this study was divided into 4 groups, group 1 was a negative control without treatment, group 2 was a group with burns and was given bioplacenton, group 3 was a burn group treated with 5% sargassum sp extract hydrogel ointment and group 4 was a burn group given 5% ointment. sargassum sp extract hydrogel ointment 10%. the treatment was carried out for 14 days and evaluated the diameter of the burn and the percentage of burn healing. results: the results of this study showed that the difference in burn diameter at 0 days and after 14 days in the negative control group experienced a difference of 1.2 cm with a healing percentage of 44.85%. in treatment group 1, there was a difference in diameter of 1.2 cm, with a healing percentage of 49.41%, the 2-day treatment group obtained a difference in diameter of 1.2 cm, with a healing percentage of 50.31%, and in the positive control group a wound diameter of 1.0 cm, while the percentage of cure is 55.75%. the results of statistical tests on the percentage of wound healing between groups were not significantly different. conclusion: in this study the seaweed extract (sargassum sp.) formed in the hydrogel ointment did not affect the healing of burns, this may be due to the long duration of administration. medical and health science journal http://journal2.unusa.ac.id/index.php/mhsj mailto:xxx@mail.com bintarti et al medical and health science journal 2022 february vol.6 (01) page 24 of 32 introduction wounds are a serious problem in world health, especially in developing countries. the world health organization (who) reported that in 2004, the incidence of injuries worldwide averaged 110/100,000 people each year and an estimated 310,000 people died from injuries such as burns, infected wounds, etc. in 2015, approximately 486,000 injuries occurred in the united states, 40,000 of which required hospitalization and 300,000 requiring treatment in wound care centers. 1 in indonesia, there are no exact figures regarding injuries, but with the increase in population and industry, the number of injuries is increasing. hospital dr. soetomo has a wound care center, the number of burns that are treated at rsud dr. soetomo surabaya since 2007-2011 as many as 665 occurred.2 burns are skin damage due to excessive heat or chemicals.3 there are three types of burns, namely first degree, second degree and third-degree burns. the three types of burns, third degree burns are burns that can destroy all layers of the skin.4 the wound healing process requires time and proper care so that the wound can heal quickly. wound care methods that are currently developing are using the principle of moisture balance which is also known as the modern method of dressing. modern wound care must still pay attention to three stages, namely washing the wound, removing dead tissue and choosing a dressing. conventional wound care must often replace gauze with wound dressings, while modern wound care has the principle of maintaining wound moisture, one of which is hydrogel material.5 hydrogel functions to keep the wound moist, soften and destroy necrotic tissue without damaging healthy tissue, which is then absorbed into the gel structure and wasted with the dressing.4 the basic ingredients of hydrogels are glycerin or water so that they can provide moisture. seaweed is a potential commodity in indonesia, seaweed production in indonesia has increased significantly with an increase of 76.4 percent from 5.2 million wet tons of seaweed in 2011 to 9.2 million tons in 2013. seaweed is one of the ingredients in wound dressing. seaweed contains bioactive compounds such as flavonoids, saponins, tannins, albumin, which are useful as antibacterial, anti-obesity,cholesterol-lowering, anti-inflammatory, immunostimulant, antioxidant.6 several studies on the use of seaweed as wound dressings for wounds have also been carried out, such as the research of annisa et al, 2018 on the effect of brown algae extract sargassum sp on healing of traumatic ulcers.7 and by aprinaldi's research, 2020 regarding the effectiveness test of red seaweed on wound healing.2 as well as previous study from mutia in 2011 regarding the use of alginate membranes from sargassum sp seaweed as wound dressings and delivery of topical drugs. from several studies on the use of seaweed as a topical wound medicine, there has never been any research on the use of seaweed formed in hydrogel ointment and its effectiveness for burns. so as to add to the scientific study on the use of seaweed, this research was conducted to determine the effect of bintarti et al medical and health science journal 2022 february vol.6 (01) page 25 of 32 seaweed extract (sargassum sp.) which is formed in the hydrogel ointment on the main wound, which is burns. methods animal model this research was conducted in the research laboratory and experimental animal laboratory, faculty of medicine, universitas nahdlatul ulama surabaya. ethical approval was granted by the animal ethics committee of universitas nahdlatul ulama surabaya with the number 182/ec/kepk/unusa/2021. the design in this study is an experimental study with a randomized post-test only control group design. the population of the research sample is adult white male mice (mus musculus), the age is between 2-3 months and the weight of the mice is 20-30 grams. during the study mice were given standard feed. mice in healthy condition were characterized by active and not isolated movements in the corner of the cage, clean and smooth fur, clear eyes, no abnormal discharge from the eyes, ears, anus and no defects and no weight loss of up to 10% during acclimatization. extract of sargassum sp sargassum sp obtained from lampung, sumatra. sargassum sp was weighed as much as 250 grams and put into an erlenmeyer, then added solvent until the final volume reached 1000 ml with a ratio of 1: 4 (w/v). the extraction procedure was carried out by the maceration method by immersing the sample with 90% ethanol. the maceration results were then filtered with whatman 42 filter paper to produce filtrate and residue. the filtrate obtained was then concentrated with a vacuum rotary evaporator at a temperature of 40 oc to obtain a crude extract in the form of a paste.8 sargassum sp extract paste that has been finished is ready to be made in the preparation of hydrogel ointment. the preparation of sargassum sp ointment hydrogel preparations is processed by mixing the basic gel ingredients, namely carbopol 940, methyl paraben, propyl paraben, tea, glycerin, propylene glycol and aquadest and added sargassum sp extract. the composition of the hydrogel preparation ingredients is in the following table 1. experimental design this study was divided into 4 groups, namely a negative control group, a positive control group, and 2 treatment groups. the number of samples was calculated based on the federer formula: (n-1) (t-1) 15. each group had 6 mice, so the total number of samples was 24 mice. the negative control group was the group that was treated with wounds and plain ointment hydrogel without sargassum sp extract. the positive control group was the group that was treated with wounds and given bioplacenton. treatment group 1 was the group that was treated with wounds and given a 5% hydrogel ointment with sargassum sp extract. treatment group 2 was treated with wounds and was given 10% ointment hydrogel sargassum sp extract. statistical analysis all results were expressed as mean ± sem. the unpaired student’s ttest was performed to compare of bintarti et al medical and health science journal 2022 february vol.6 (01) page 26 of 32 parameters between two groups . comparisons of dose-response curves were made by two-factor repeated measures anova, followed by tukey’s post hoc test for comparison between groups. a value of p < 0.05 was considered significant. table 1. formulation of hydrogel ointment ingredients formulation (%) plain sargassum sp 5% sargassum sp 10% bioplacenton sargassum sp extract 0% 5% 10% 0% carbopol 940 4 % 4 % 4 % 0 % triethanolamine 4 % 4 % 4 % 0 % glycerin 20 % 20 % 20 % 0 % propylene glycol 10 % 10 % 10 % 0 % methyl paraben 0,4 % 0,4 % 0,4 % 0 % propyl paraben 0,4 % 0,4 % 0,4 % 0 % aquadest ad. ad. 100 ad. 100 ad. 100 0 % the process of making burns in mice is carried out on the back area by shaving and cleaning the skin first. then disinfection with alcohol. mice were previously anesthetized using ketamine + acepromazine 100/5 mg/kg bw intramuscularly. burns are made with an iron plate. the diameter of the iron plate is 2 cm. an iron plate that has been heated on a blue fire for 3 minutes then affixed to the back skin of mice for 5 second.9 after 14 days, the mice were euthanized using ether. burn healing was evaluated for 14 days by measuring the diameter of the burn. the data from the diameter measurement of burns on the first day and the last day were analyzed using the formula (9): 𝐷% = 𝑑0 − 𝑑𝑥 𝑑0 𝑥 100% d% = percentage of burn healing d0 = wound diameter on day 1 dx = wound diameter on day 14 the percentage of burn wound healing was then statistically analyzed. results the ph test results showed that all formulas were in the 4.5-6.5 range which did not cause skin irritation. carbopol in aqueous solution has a ph of 2.5-4 so triethanolamine is needed as a buffer.10 the following are the results of measuring the ph of the ointment hydrogel: bintarti et al medical and health science journal 2022 february vol.6 (01) page 27 of 32 table 2. ph of hydrogel ointment the diameter of the burn was measured for 14 days, the measurement of the diameter of the wound was analyzed to determine the progress of wound closure. the results of the calculation of the average wound diameter with an interval of 4 days for each group are made in the form of tables and figures below: table 3. mean of diameter (cm) of burns wound by group groups day 0 day 1 day 4 day 7 day 10 day 14 k(-) 0% 2,000 2.200 1.967 1.850 1.717 1.217 p1 (5%) 2,000 2.367 2.150 1.967 1.800 1.233 p2 (10%) 2,000 2.483 2.133 2.017 1.833 1.217 k(+) bioplacenton 2,000 2.317 1.900 1.683 1.467 1.017 figure 1. mean of diameter (cm) of burns wound by group day 0 – day 14 the data from the measurement of the diameter of the burn wound were analyzed to produce a calculation of the percentage of burn healing. the percentage of burn wound healing was then analyzed statistically one way anova. before the one-way anova statistical analysis is carried out, the data needs to be tested for normality and homogeneity. the results of the normality and homogeneity test showed p value > 0 0,5 1 1,5 2 2,5 3 0 1 4 7 10 14 d ia m e te r lu k a b a k a r (c m ) hari kek(-) 0% p1 (5%) p2 (10%) k(+)bioplacenton no hydrogel ointment ph 1 hydrogel ointment without sargassum sp extract 6 2 hydrogel ointment sargassum sp extract 5% 5 3 hydrogel ointment sargassum sp extract 10% 5 4 bioplacenton 6 bintarti et al medical and health science journal 2022 february vol.6 (01) page 28 of 32 0.05 so that the data were normally distributed and homogeneous. the results of one-way anova statistical analysis p value 0.627 (> 0.05) which showed no significant difference between the treatment groups. the results of the average percentage of burn healing are in table 4 and figure 2. table 4. the mean of percentage (%) of burn healing group average k(-) 0% 44.85 + 2.46 p value 0.627 p1 (5%) 49.41 + 9.21 p2 (10%) 50.31 + 3.64 k(+)bioplacenton 55.75 + 5.57 figure 2. the mean of percentage (%) of burn healing there were no significant differences in all treatment groups, but from the average percentage of burn healing, the bioplacenton control group showed the most optimal results. and in the negative control group, the ointment hydrogel without sargassum sp extract showed the lowest percentage of burn healing. discussion the results of measuring the ph of the hydrogel ointment, whether containing sargassum sp extract or not, resulted in a gel base ph value of 5-6. for plain ointment hydrogel without extract and bioplacenton the resulting ph is 6, while the sargassum sp extract ointment hydrogel produced ph 5. increasing the concentration of the extract in this study resulted in an increase in the ph of the ointment hydrogel, this indicates the acidity of the extract. in this study, the ointment hydrogel produced a ph range that was in accordance with the research of prasongko et al, 2020 and ardianti et al, 2018 where the ph value of an ointment hydrogel must match the skin ph, which is 4.5-6.5.9 the ph value that is too 44,85 49,41 50,31 55,75 0,00 10,00 20,00 30,00 40,00 50,00 60,00 70,00 k(-) 0% p1 (5%) p2 (10%) k(+)bioplacenton p e rc e n ta g e o f b u rn h e a li n g ( % ) groups bintarti et al medical and health science journal 2022 february vol.6 (01) page 29 of 32 acidic can cause skin irritation and too alkaline can cause scaly skin. while the ph of the hydrogel ointment with a range of 4.5-6.5 does not cause skin irritation.11 the results of statistical analysis showed that there was no significant difference between the treatment groups, this indicates that the ointment hydrogel sargassum sp extract had no significant effect on the control group, both the negative control group (without sargassum sp extract) and the positive control group (bioplacenton). from the results of statistical analysis it is possible that the healing process of burns is relatively the same. this is possible because of the alleged human error during the process of making burns so that the burns formed are not second degree burns. second-degree burns are characterized by damage to the epidermis and part of the superficial dermis, partial necrosis of tissue cells, and swelling and degeneration of some cells in the superficial dermis.12 in figure 1 the results of measuring the diameter of burns from day to day in all treatment groups show that the burns are shrinking and undergoing a healing process. and in figure 2 the results of the analysis of the calculation of the percentage of burn healing indicate the percentage of healing in each treatment group. in the negative control group with ointment hydrogel without sargassum sp extract the percentage of healing that occurred was 44.85%, in the treatment group 1 with ointment hydrogel with sargassum sp extract 5% the healing percentage was 49.4%. in treatment group 2 with ointment hydrogel with sargassum sp extract 10% the percentage of healing was 50.31% and in the positive control group with bioplacenton the percentage of burn healing was 55.75%. the percentage of burn healing in the negative control group without sargassum sp extract had the lowest percentage of healing when compared to the percentage of burn healing in the treatment group 1 and treatment 2 with hydrogel ointment containing sargassum sp extract. sargassum sp is one of the seaweed plants that has a lot of content and nutrients. the active ingredients of sargassum sp include alkaloids, triterpenoids, steroids, saponins, phenols, flavonoids and quinones 8 wound healing process can occur due to secondary metabolites, namely flavonoids and saponins. in the wound healing process, saponins play a role in repairing damaged endothelial cells (angiogenesis) in the wound so that the supply of oxygen and nutrients becomes more optimal. in addition, saponins also function as antibacterial so that they can reduce the risk of wounds being contaminated by bacteria and can act as antioxidants that can minimize free radical levels in wounds so that the process of wound proliferation and contraction takes place more quickly. saponins also promote epidermal cell proliferation and keratin cell migration.13 finally, wound closure takes place more quickly. one of the major causes of delayed healing is the persistence of inflammation or an inadequate angiogenic response. flavonoids are substances that are believed to be anti-inflammatory and antioxidants.14flavonoids can block the cyclooxygenase and lipoxygenase pathways of arachidonic acid metabolism, this causes the bintarti et al medical and health science journal 2022 february vol.6 (01) page 30 of 32 synthesis of inflammatory mediators such as prostaglandins, thromboxane is inhibited so that it can reduce inflammation.2 the flavonoid content in sargassum sp extract can inhibit cyclooxygenase and lipoxygenase enzymes in the inflammatory cascade reaction so that it can reduce the production of prostaglandins and leukotrienes. the decrease in prostaglandins as proinflammatory mediators can limit inflammatory cells in the wound area. suppression of prostaglandins as inflammatory mediators can cause reduced pain and swelling, and reduce vasodilation of blood vessels and local blood flow, so that the inflammatory reaction will last for a shorter time then the proliferation process can occur immediately.15 in addition to the active ingredients of secondary metabolites, sargassum sp also contains other ingredients, namely zinc, calcium, iron, vitamin a and vitamin c which are known to accelerate the inflammatory phase. vitamin a and vitamin c contained in sargassum sp can play a role in increasing the migration of neutrophils and macrophages to the wound area so that phagocytosis activation becomes optimal. vitamins a and c also increase the synthesis of collagen and help in the differentiation of epithelial cells. calcium contained in sargassum sp can accelerate re-epithelialization by increasing the proliferation of keratinocytes. the iron contained in sargassum sp can affect the process of cell growth and tissue maintenance, serves as a cofactor for collagen synthesis. zinc contained in sargassum sp also plays a role in wound healing, besides that it is also able to increase immunity.7 in figure 2 the most optimal percentage of healing is in the positive control group with bioplacenton. this shows that bioplacenton is still more effective for healing burns than hydrogel ointment with and without sargassum sp extract although the results of statistical analysis are not significantly different. so it is also necessary to evaluate the process of making ointment hydrogel with and without sargassum sp extract. conclusion in this study, the extract of seaweed (sargassum sp) which was formed in the hydrogel ointment had no effect on the healing of burns. acknowledgement the authors thankful for the financial support from “lembaga penelitian dan pengabdian masyarakat (lppm) “of the universitas nahdlatul ulama surabaya. conflict of interest the author stated there is no conflict of interest references 1. american burn association. burn incidence and treatment in the united states: 2016. burn incidence fact sheet. 2016. 2. aprinaldi b. skrining fitokimia dan uji aktivitas ekstrak etanol rumput laut merah (gracilaria verrucosa) terhadap penyembuhan luka sayat pada tikus putih jantan galur wistar. j pharmacopolium. 2020;3(1). bintarti et al medical and health science journal 2022 february vol.6 (01) page 31 of 32 3. jeschke mg, van baar me, choudhry ma, chung kk, gibran ns, logsetty s. burn injury. nat rev dis prim [internet]. 2020 feb 13;6(1):11. available from: https://pubmed.ncbi.nlm.nih.gov/32054846 4. stoica ae, chircov c, grumezescu am. hydrogel dressings for the treatment of burn wounds: an up-to-date overview. materials (basel). 2020;13(12):1–24. 5. kartika rw, bedah b, paru j, luka ap. perawatan luka kronis dengan modern dressing. perawatan luka kronis dengan mod dress. 2015; 6. eka wati nk, suhendra l, wartini nm. karakteristik kandungan fukosantin dan aktivitas antioksidan ekstrak alga coklat (sargassum polycystum) pada perlakuan konsentrasi pelarut aseton dan suhu maserasi. j rekayasa dan manaj agroindustri. 2020; 7. rahmawati, annisa ; febrina, agni ; karsini i. pengaruh pemberian ekstrak alga coklat jenis sargassum sp. terhadap jumlah makrofag pada proses penyembuhan ulkus traumatikus. dent j kedokt gigi. 2018;12:72. 8. bintarti tw, sudiana i, mastutik g, basori a, santoso d, salim h. the extract of sargassum sp. increased the expression of bmp-2 in fractures of tibia in rattus norvegicus. 2017 nov 5; 9. prasongko et, lailiyah m, muzayyidin w. formulasi dan uji efektivitas gel ekstrak daun kedondong ( spondias dulcis f .) terhadap luka bakar pada tikus wastar ( rattus novergicus ). j wiyata s1 farm fak farm ,institut ilmu kesehat bhakti, kesehat bhakti wiyata. 2020;7(10(2355–6498):27– 36. 10. rowe, raymond c; sheskey, paul j; quinn me. handbook of pharmaceutical excipient. vol. e.28. 2015. 257–262 p. 11. ardiati kn, farmasi f, surakarta um. formulasi sediaan gel ekstrak daun lidah mertua ( sansivieria trifasciata ) dengan gelling agent karbopol 934 dan uji aktivitas antibakteri secara in vitro terhadap staphylococcus epidermidis. 2018; 12. zhang l, hu q, jin h, yang y, yang y, yang r, et al. effects of ginsenoside rb1 on seconddegree burn wound healing and fgf2/pdgf-bb/pdgfr-β pathway modulation. chin med [internet]. 2021 jun 19;16(1):45. available from: https://pubmed.ncbi.nlm.nih.gov/34147112 13. kim ys, cho i-h, jeong m-j, jeong s-j, nah sy, cho y-s, et al. therapeutic effect of total ginseng saponin on skin wound healing. j ginseng res [internet]. 2011 sep;35(3):360– 7. available from: https://pubmed.ncbi.nlm.nih.gov/23717081 14. lodhi s, jain a, jain ap, pawar rs, singhai ak. effects of flavonoids from martynia annua and tephrosia purpurea on cutaneous wound healing. avicenna j phytomedicine [internet]. 2016;6(5):578–91. available from: https://pubmed.ncbi.nlm.nih.gov/27761428 bintarti et al medical and health science journal 2022 february vol.6 (01) page 32 of 32 15. dwintanandi c, nahzi myi, raharja sd. pengaruh ekstrak kulit manggis (garcinia mangostana linn.) terhadap jumlah makrofag pada inflamasi pulpa. dentino j kedokt gigi [internet]. 2016;1(2):151–7. available from: https://ppjp.ulm.ac.id/journal/index.php/denti no/article/view/562 original article medical and health science journal 2022 february vol.6 (01) the effectiveness of the implementation of kangaroo treatment method in increasing the weight gain of newborns with lbw cicih nurcholishah*, syatirah djalaluddin, fhirastika annisha faculty of medicine and health sciences, universitas islam negeri malang, indonesia article info article history: received : january 21, 2022 received in revised form : february 20, 2022 accepted : february 23, 2022 keywords: effectiveness, kangaroo method care, birth weight, lbw *) corresponding author: cicinurkhalisa@gmail.com abstract background: low body weight (lbw) cases have continuously occurred. however, some newborns with lbw could not afford good and high technological health services due to several barriers such as cost, geography, transportation, and communication barriers. incubator replacement through kangaroo treatment method is considered to be an effective and economical alternative in which the weight gain in newborns with lbw could be enhanced. kangaroo care method can be used in treating newborns with low birth weight. the purpose of this study was to identify the effectiveness of the implementation of the kangaroo care method in increasing the weight gain of newborn with lbw at the general hospital of majene. methods: the research design used in this study was a pre-experiment with one group pretest posttest design. the sampling method used in this research was total sampling where 38 samples were selected. this research was conducted at the regional hospital of majene in the perinatology room. results: the results of this research indicated that there were significant differences in newborns before and after the implementation of the kangaroo care method. it was evident that the newborns weight significantly increase with the kangaroo care method. therefore, further research should be carried out to investigate the factors which influence the increase of newborns weight. conclusion: in this study we found that there were significant differences in lbw babies before and after being treated with the kangaroo method (pmk). medical and health science journal medical and health science journal. available at http://journal2.unusa.ac.id/index.php/mhsj ; doi:10.33086/mhsj.v5i2.2686 p.issn 2549-7588. eissn 2549-7596 mailto:cicinurkhalisa@gmail.com http://journal2.unusa.ac.id/index.php/mhsj https://doi.org/10.33086/mhsj.v5i2.2313 nurcholishah et al medical and health science journal 2022 february vol.6 (01) page 16 of 22 introduction low birth weight (lbw) is a birth weight of fewer than 2500 grams regardless of gestational age. birth weight is the weight of an infant weighed within 1 hour after birth. lbw can occur in preterm infants (<37 weeks) or in full-term infants (intrauterine growth restriction / iugr).1 lbw has a 20 times greater risk of dying during infancy when compared to babies with normal birth weight. the infant mortality rate increases with the increase of lbw incidence in a country.2 before finding fmd, incubators were one of the ways to deal with babies lbw or premature, but the use of incubators was considered to inhibit early mother-baby contact and breastfeeding. given the limited incubator facilities in health services, pmk can be used in treating lbw. this method was first performed in 1979 in colombia by martinez, who treated babies weighing less than 1500 grams and the results were satisfactory.3 fmd is useful in significantly reducing the number of neonates or newborns who died, avoiding low birth weight babies from being cold (hypothermia), stabilizing babies, reducing the occurrence of infections, increasing infant growth and development, increasing breastfeeding and bonding between mother and baby.4 in an attempt to introduce fmd as an appropriate technology to reduce neonatal mortality, this research is one tangible step.5 the limited incubator in the room causes two babies in one incubator, that's why the baby has a risk of infection. based on these reasons, many patients ask to go home prematurely due to cost reasons. so pmk is the right choice to overcome lbw. this research was also conducted the first time in majene regency. methods the research design used pre experimental, one group pre-test and post-test design was conducted on a set of objects that did not require a comparison group6, the sample of this study was observed before being given treatment, after conduct treatment the sample was re observed.7 the research was conducted in the perinatology room of the majene regional hospital, west sulawesi province. the study was conducted for 1 month, starting from december 2020 to january 2021. the population of this study was all lbw babies who were treated in the perinatology room of the majene hospital. the sample in this study were all lbw babies who were treated with kangaroo method care in the perinatology room of the majene hospital. sampling used a total sampling technique by taking samples of babies undergoing kangaroo treatment in the 2020 period. data collection from this study used secondary data obtained from the research location agency according to the data listed in the research instrument in the form of observation sheets before and after treatment. kangaroo method. data processing was analyzed using the statistical for social science (spss) application using univariate analysis techniques and bivariate analysis. this bivariate analysis was used to connect the independent and dependent variables using the paired t-test statistical test with a significance level of α = 0.05. nurcholishah et al medical and health science journal 2022 february vol.6 (01) page 17 of 22 results 1. univariat analysis table 1. characteristic distribution of babies characteristics frequency percentage (%) gender female 17 44,73 male 21 55,26 gestational age preterm infants 27 71,05 full-term infants 11 28,94 baby birth weight <2000 gram 24 63,15 >2000 gram 14 36,84 infant weight at evaluation of lbw bblsr 5 bblr 33 length of treatment 13,15 86,84 < 7 hari 6 15,78 7-14 hari 13 34,21 > 14 hari 19 50 complementary diseases in lbw patients 1. rdn 16 42,10 2. hiperbilirubin 17 44,73 3. feeding probl 15 39,47 4. ems 9 23,68 5. hypoglycemia 15 39,47 6. hypothermia 8 21,05 7. granuloma 7 18,42 8. pyoderma 3 7,89 9. hdn 3 7,89 10. asfiksia 11. another 6 15,78 paired t-test data sekunder, 2020 nurcholishah et al medical and health science journal 2022 february vol.6 (01) page 1 of 56 table 4.1 shows the characteristics of babies who experience lbw, data obtained using secondary data from medical records recording at majene hospital, the results are more male as many as 21 people (55.25%), with a full-term baby (bcb). ) as many as 27 people (71.05%). while the birth weight of babies <2000 grams was 24 people (63.15%), then there were 33 babies (86.84%) who were treated with pmk. in addition, the length of treatment> 14 days was 19 people (50%), this could be influenced by comorbidities in lbw, namely hyperbilirubin 17 cases (44.73%), then rdn 16 cases (42.10%), then feeding. problems and hypothermia as many as 15 cases (39.47%). mother’s age table 2. characteristic distribution of mother’s babies characteristic frequency percentage % <21 year 10 26,31 % 21-35 year 20 52,63 % >35 year 8 21,5 % mother’s work doesn’t work 31 81,57 % work 7 18,42 % mother’s education elementaryjunior high school 15 39,47 % senior high school 16 42,10 % graduate 7 18,42 % table 4.2 data obtained utilizing secondary data from recording medical records at majene hospital, shows that the characteristics of the age of mothers who gave birth to lbw at majene hospital in the january-december 2020 period were the age group of fertile women, namely 21-35 years, as many as 20 people (52.63 %). meanwhile, the highest level of education for mothers was sma as many as 16 people (42.10%) and mothers who did not work much more, namely as many as 31 people (81.57%) when compared to mothers who worked. table 3. weight changed distribution before and after pmk in rsud majene, period january-december 2020 (n=38) variable mean std. mean lower upper before pmk after pmk 1973,15 2018,07 364,01 374,86 22 (57,89%) 22 (57,89%) 16 (42,16%) 16 (42,16%) table 4.3 data obtained using secondary data from recording medical records at the majene regional hospital shows that the results of weight interval estimation can be concluded that 95% is believed to be the average body weight before kangaroo treatment (pmk) is 1853.51 2092.80 grams and nurcholishah et al medical and health science journal 2022 february vol.6 (01) page 2 of 22 the average body weight after kangaroo treatment (pmk) was 1894.86 2142.29 grams. a distribution of 22 people (57.89) was below the average value before pmk and after pmk. the table shows that the average body weight before pmk was 1973.1558 grams with a standard deviation of 364.01494 grams. the average body weight after pmk was 2018.0761 grams, with a standard deviation of 374.86840 grams. this is descriptive there is a difference in the average before and after pmk. 2. bivariate analysis table 4. mean distribution of baby’s weight gain before and after pmk in rsud majene, period january december 2020 paired differences p-value mean std. deviation before pmk after pmk paired t-test 44.92 19.46 0.000 data sekunder, 2020 the table paired samples test (t-test/ hypothesis test) states that the difference in mean difference before and after 44.92 standard deviations 19.46. meanwhile, p-value 0.000 <0.005 or ho is rejected. thus, it is concluded that there are significant differences before pmk and after pmk. discussion referring to the results of the evaluation conducted in this study, it was found that the majority of mothers were aged 21-35 years (52.63%) or of childbearing age, who had more energy than those aged> 35 years. so that mothers can take better care of their babies. in addition, in the evaluation results, it was found that the majority of mothers had the characteristics of not working (81.57%), which meant that they had sufficient time to carry out pmk while in the hospital and even at home. but in fact, based on research conducted by samuel maju simanjuntak & dina hartini (2019) states that in their research8, the results of the evaluation of the majority of mothers (96.7%) have the characteristics of not working, which means they have sufficient time to carry out pmk at home, but in reality, only 10% of mothers implement pmk, because it is recorded that they receive very little support from their families, as well as a lack of education about pmk for mothers who have lbw so that the implementation of independent pmk is still low. this study aims to determine the effectiveness of the kangaroo treatment method for changes in body weight. the data obtained is the measurement of body weight which was carried out while being treated in the perinatology room of the majene hospital. based on data obtained from the medical records section of the majene hospital in 2020, there were nurcholishah et al medical and health science journal 2022 february vol.6 (01) page 3 of 22 38 cases of babies with lbw who were given pmk treatment during their recovery period. in the evaluation results, it was found that there were more male babies (55.26%) than women (44.73%), with the majority of term babies (71.05%) and the majority were born with birth weights <2000 grams. (63.15%). the evaluation results also found that the majority of the length of stay more than 4 days (50%). this level of length of care is supported by the presence of comorbidities in infants with lbw, the majority of infants with lbw also suffer from hyperbilirubin (44.73%), then rdn (42.10%) is also a common comorbid disease based on the results of the evaluation in this study. based on the results of the study, the researchers argued that where babies with low birth weight (lbw) were given kangaroo treatment, it was closely related to the significant increase in baby weight. the kangaroo method (pmk) treatment process in this study was carried out for 7 days with a minimum pmk time of 1-2 hours per day. infants with lbw who received pmk experienced a significant increase. the results showed that of the 38 respondents who received pmk for one week, there was a significant influence between body weight before and after pmk p-value 0,000, with the average difference between before and after pmk was 44.92 grams per week. this increase is not much different from the results presented by siti dewi rahmayanti (2010) that the increase in body weight in infants with lbw shows that the average body weight before treatment without fmd is 2050.00 grams with a standard deviation of 290.48 grams.9 the average body weight after treatment without fmd was 2156.25 grams, with a standard deviation of 330.593 grams. this study is also in line with previous research conducted by putri & gusmila in 2014 which said that there was a difference in the average weight of babies before and after treatment with the kangaroo method in the perinatology room of dr. achmad mochtar bukittinggi, where the results showed that there was a significant difference between the average body weight of babies before the kangaroo method treatment and after the kangaroo method treatment with an average baby weight of 28.30 grams with a standard deviation of 3.093.10 this is also put forward by the 2013 maryuani theory11, writing that the benefits of pmk for mothers are to increase prematurity baby weight or low birth weight, by stabilizing heart rate, breathing patterns and oxygen saturation, providing warmth to babies, increasing sleep duration, reducing infant crying and calorie requirements, accelerate weight gain and brain development, increase success and prolong the duration of breastfeeding. this is following research conducted by mardiani freari, agonwardi 2017, in her research proving the effectiveness of the kangaroo method to increase the weight of babies with lbw. based on the research concept framework, the application of the kangaroo method can increase the baby's weight optimally.12 this is because a baby born with a low birth weight (lbw) baby will generally be put in an incubator so that his body temperature remains normal and given oxygen assistance for interpretation and low birth weight (lbw) babies can also experience mental and physical disorders at growing age.13 flower further, so that the maintenance requires high maintenance costs, in addition to the incubator the baby's body temperature can be maintained warmly by the kangaroo method. in the past, this method was nurcholishah et al medical and health science journal 2022 february vol.6 (01) page 4 of 22 considered only for the poor because the rich were put in an incubator, but based on experience, the result is the kangaroo method is even more effective. the kangaroo method itself can increase the ability of babies to suck, with good sucking ability in babies with low birth weight (lbw),14 it will stimulate the formation of the hormone oxytocin and increase the hormone prolactin which will help milk production, so that the mother can produce breast milk that is sufficient for the needs of the baby, the baby freely gets breast milk in a timely manner and whenever the baby needs it.15 conclusion bblr is an accident from allah swt to his creations. islam emphasizes the importance of effort and prayers. in the qur’an, it says that humans will not get anything other than what they work for, and the results of their efforts will be shown (to them), then they will be rewarded with an appropriate result according to surah ar rad verse 11. one of the efforts that can be done is by kangaroo method care (pmk). from this study, it was found that the characteristics of the sample of babies were more male, with a full-term gestation age who passed treatment for more than 14 days because they were generally accompanied by comorbidities other than lbw. in this study, it was found that there were more mothers with low birth weight patients of productive age with secondary education and who work as housewives. from the research, it was found that there were significant differences in lbw babies before and after being treated with the kangaroo method (pmk). acknowlegment the financing is obtained independently conflict of interest the author stated there is no conflict of interest references 1. pudhadi, antonius. pedoman pelayanan medis idai jilid i (2010). jakarta ikatan dokter anak indonesia (idai) , 2010 2. sujianti, s. literature review bayi berat lahir rendah. j. kesehat. ibu dan anak 11, 75–81 (2017). 3. putri, w. faktor ibu terhadap kejadian bayi berat lahir rendah. higea j. public heal. res. dev. 3, 55–62 (2019). 4. hastuti, p. pendidikan kesehatan meningkatkan praktik perawatan metode kanguru ( pmk) pada ibu nifas dengan bayi berat lahir rendah. j. ris. kesehat. 7, 32 (2018). 5. endyarni, b. perawatan metode kanguru (pmk) meningkatkan pemberian asi. https://www.idai.or.id/artikel/klinik/asi/p erawatan-metode-kanguru-pmk meningkatkan-pemberian-asi (2013). 6. notoadmodjo, s. metodologi penelitian kesehatan. (pt. rineka cipta, 2012). 7. hidayat, a. a. metode penelitian keperawatan dan teknik analisis data/a. aziz alimul hidayat. (jakarta salemba medika, 2009). 8. simanjuntak, s. & hartini, d. kenaikan berat badan (bblr) melalui pelaksanaan perawatan metode kanguru (pmk) di rumah. j. smart keperawatan 6, 73 (2019). http://www.idai.or.id/artikel/klinik/asi/p nurcholishah et al medical and health science journal 2022 february vol.6 (01) page 5 of 22 9. rahmayanti, s. d. pengaruh perawatan metode kanguru terhadap pertumbuhan bayi, pengetahuan dan sikap ibu dalam merawat bblr di rsud cibabat cimahi [influence of kangaroo method on babys growth, mothers knowledge and attitude in low birth weight care at cibabat hospital, cimahi]. yani cimahi (2010). 10. yelmi, s. pengaruh perawatan metode kanguru terhadap perubahan berat badan bayi lahir rendah. j. ipteks terap. 9, 11–19 (2015). 11. anik, m. asuhan bayi dengan berat badan lahir rendah (bblr). (2013). 12. bebasari, mardiani, agonwardi, agonwardi & nandiati, nandiati. pengaruh perawatan metode kanguru terhadap kenaikan berat badan pada bayi berat badan lahir rendah di ruang perinatologi rsud dr. rasidin padang tahun 2017. jikj. ilmu kesehat. 1, 32–38 (2017). 13. décima, p. et al. does the incubator control mode influence outcomes of low birth-weight neonates during the first days of life and at hospital discharge? health (irvine. calif). 05, 6–13 (2013). 14. heidarzadeh, m., hosseini, m. b., ershadmanesh, m., gholamitabar tabari, m. & khazaee, s. the effect of kangaroo mother care (kmc) on breast feeding at the time of nicu discharge. iran. red crescent med. j. 15, 302–306 (2013). 15. galoustian, g. mother/infant skin-to skin touch boosts baby’s brain development. https://www.fau.edu/newsdesk/articles/k angaroo-care-study.php (2020). http://www.fau.edu/newsdesk/articles/k medical and health science journal 2022 august vol.6 (02) medical and health science journal available at http://journal2.unusa.ac.id/index.php/mhsj; doi: 10.33086/mhsj.v6i2.3213 pissn 2549-7588. eissn 2549-7596 review article extremely low frecuency (elf) electromagnetic radiation potential to accelerate fracture splicing sri septi dyah pratiwi 1 ; sudarti 2 1 physics education undergraduate study program, faculty of teacher training and education, university of jember, jember, east java, indonesia 2 faculty of teacher training and education, university of jember, jember, east java, indonesia article info article history: received: may 17, 2022 received in revised form: august 16, 2022 accepted: august 18, 2022 keywords: elf magnetic field, fractures, osteoblasts, bone density *) corresponding author: sriseptidyahp6@gmail.com abstract the treatment process for healing fractures in the community is still mostly done through traditional methods, which are generally referred to as "sangkal putung". the results obtained 28.2% cannot return to its original form. in the process of denying putung it still takes quite a long time depending on the part of the bone that has broken. this study aims to reveal the potential effect of exposure to the elf (extremely low frequency) magnetic field on the fracture healing process. this research method uses an article review, with a total of 30 articles from relevant research articles from 2000 to 2022. this aims to examine the effect of effective treatment of the intensity of exposure to the elf magnetic field on the fracture healing process. the results showed that there were 73.3% of researchers who supported the elf em wave was able to accelerate the splicing of fractures. meanwhile, 26.67% of researchers did not support it. the results of the study reported that exposure to a magnetic field with an intensity of 120μt-200μt was able to increase the proliferation of osteoblast cells so as to heal fractures. the most accurate range of intensity in the process of forming osteoblam cells is the intensity of 150μt. the results in experimental animals showed that exposure to the elf magnetic field had an effect on the process of forming osteoblasts completely. the results of clinical research (bone fracture patients) showed that exposure to a magnetic field with an intensity of 150μt was able to form and secrete organic collagen and noncollagen in osteoblast cells, while elf osteoclast cells were able to assist in the reabsorption of existing bone cells. based on the results of the analysis, it can be concluded that exposure to the 150μt intensity elf magnetic field has the most optimal ability in the process of forming osteoblasts (osteoclasts and osteosts) in fracture healing. medical and health science journal http://journal2.unusa.ac.id/index.php/mhsj mailto:sriseptidyahp6@gmail.com pratiwi et al medical and health science journal 2022 august vol.6 (02) page 36 of 42 introduction fracture or commonly known as a fracture is a condition where the bone breaks, cracks or breaks so that it can change its shape.1 fracture itself can be regarded as a complete or partial loss of bone continuity. fractures can occur because the bone receives pressure or impact whose strength exceeds the strength of the bone.2 the cause of fractures is accidents, both minor accidents and major accidents. but apart from being affected by accidental fractures caused by pathology and imperfect degenerative processes in the bones.3 one of them is osteoporosis, where in this condition the bones experience a decrease in minerals and damage to the micro components of the bone and have an impact on increasing the risk of fracture.4 in general, fractures can be divided into two, namely closed fractures (bone fragments do not penetrate the skin) and open fractures (bone fragments have a relationship with the outside world such as wounds to the skin or soft tissue).5 fracture conditions (broken bones) are one of the major problems that are often experienced by humans. fracture healing process must be done quickly and precisely.6 if the fracture healing process is not carried out with the right process, it will have a very dangerous impact on fracture sufferers, and can even cause new diseases that attack the safety of fracture sufferers.7 the principles in the treatment of fractures include reduction, immobilization, and restoration of normal bone strength function.8 healing fractures traditionally "denies putung" is still the prima donna of society. according to 9 6.23% on average, both rural and urban communities still believe in the denture-putung method in healing fractures. however, this process will not guarantee that the bone will return to its original state and if this treatment is carried out incorrectly, it will have an impact on the growth of new bone diseases. 10 magnetic and electric fields are one source of electromagnetic that can help the modern fracture healing process.11 one of them is that alternating electric current can produce exposure to an elf (extremely low frequency) magnetic field with a frequency intensity of 0-300 hz.12 radiation exposure to the elf magnetic field is a type of nonionizing radiation that cannot perform induction and absorption processes on the media used. the extremely low frequency magnetic field also has non-thermal properties which cannot produce unobstructed heat.13 so that the magnetic field can penetrate the network or building. the spectrum of electromagnetic wave radiation is very broad and has a variety of frequencies. one of them is in electrical equipment sourced from pln, the frequency it has on average is 50 hz. many studies have proven that elf in the field of fracture healing medicine can help the process of forming osteoblasts and osteoclasts. osteoblasts are cells derived from the supporting tissue of stem cells in bone marrow stomata. in this cell has a very important task that is responsible for the formation and development of bones. according to14 exposure to an elf (extremely low frequency) magnetic field with an intensity of 120200 μt is able to assist in fracture healing. with optimum bone conditions, exposure to elf can help osteoblast cells.15 the system used for exposure to the elf magnetic field is designed with the 30-120 hz elf system proven to be able to reduce the gap junction intercellular communication in the bone development phase.16 however, not all exposure to elf magnetic fields affects osteoblast differentiation.17 so this is what makes it clear that exposure to the elf magnetic field only helps the process of splicing broken bones. based on the description above, the use of the elf (extremely low frequency) magnetic field aims to reveal the intensity of exposure to the elf magnetic field which is in accordance with the fracture grafting process.18 the elf magnetic field is able to help the process of forming osteoblast cells so that the process of secreting organic collagen and non-collagen in osteoblast cells can be carried out quickly and precisely.19 this has been proven by previous studies, where exposure to a magnetic field for 30 minutes with an intensity of 120μt can increase osteoblam cells which are able to help heal fractures. with the use of the right intensity elf magnetic field is expected to maximize the fracture healing process. and can be used as an appropriate alternative in the treatment of fracture healing. methods the type of research design used is descriptive research. the research method used is article review by reviewing 30 articles originating from international articles and national articles. literature searches were carried out by accessing sciencedirect, pubmed, google scholar and have been indexed by sinta or scimago. the search terms used were 'extremely low frequency (elf), fractures, electromagnetic radiation, bone comprising cells'. what is reviewed from the 30 pratiwi et al medical and health science journal 2022 august vol.6 (02) page 37 of 42 articles is the intensity of exposure to the elf (extremely low frequency) magnetic field that is suitable and able to help the process of splicing fractures. this study also examines the effect of exposure to the elf magnetic field on bone formation cells and the effect of exposure to elf on the human body. result characteristic of the studies the collection of literature data on sciencedirect, pubmed, google cendikia and indexed by sinta or scimago resulted in 30 articles that had a significant relationship to the results of the reviews carried out. the articles used as literature data are international articles originating from various regions, as well as national articles. twelve journal articles discuss the effect of long exposure to extremely low frequency (elf) magnetic fields, four journal articles discuss the intensity of exposure to extremely low frequency (elf) magnetic fields, and 16 journal articles discuss fractures and the process of bone formation. figure 1. path diagram of the process of selecting studies. discussion em-elf exposure intensity the results obtained from the source of the review article show that there is a very significant correlation and relationship between the intensity of exposure to extremely low frequency electromagnetic fields and the fracture healing process. however, from these articles there has been no study that explains significantly between the intensity of exposure to extremely low frequency (elf) magnetic fields for fracture healing. the results obtained are 6 journals that use therapy with exposure to extremely low frequency (elf) magnetic fields. details of the research results are shown in table 1. the results from the 6 journals state different things about the intensity of exposure to elf magnets. the intensity of exposure to a magnetic field with the right intensity will have a good influence on the formation of bone cells but the intensity given is not right it will have an impact on damage to other body organs. this is in accordance with research from (agil, m., ma’arif, b. and aemi, n. y., 2019) with the results of research conducted on balb/c mice with various osteoporosis cases (akdag, m. z. et al., 2010) giving an intensity of 120 t to balb/c mice the results were able to increase the proliferation of osteoblast cells so as to heal fractures. in contrast to the research that has been done by (van den heuvel, r. et al., 2001) it was found that exposure to an elf magnetic field with an intensity of 80 mt (50 hz) showed a reduction in proliferation. according to (alcaraz, m. et al.,2014) geometric and biomechanical analysis showed that there was a significant decrease in rats exposed to 100 mtmf compared to rats exposed to sham and 500 mtmf regarding the value of the cross-sectional area of the femoral shaft (po0.05). the femoral cortical thickness of mice exposed to mf (100 mt and 500 mt) was also significantly decreased. exposure to the extremely low frequency magnetic field has various intensities. the right intensity can help assist in the health sector, but if exposure to em-elf is not appropriate, the impact will vary on the human body and other living things. basically the human body has electric and magnetic fields which have a complex role in controlling the physiological mechanisms of the body. so if there is excessive external exposure, it will cause additional stress to the human body and damage the functions of other organs. em-elf exposure time the results obtained are 4 journals that use extremely low frequency (elf) as a fracture healing process using a certain length of exposure. the results showed that elf with an exposure duration of 30 minutes with an intensity of 120μt had a good effect on the formation of osteoblasts in osteoporotic bones. this is in line with research conducted by (agil, m., ma’arif, b. and aemi, n. y., 2019) which states that intermittent exposure to extremely low frequency magnetic fields 30 minutes, 60 minutes, 90 minutes on the formation of osteoblasts has a different impact, accuracy in bone formation is obtained at intermittent 30 minutes. in contrast to research (manjhi, j. et al., pratiwi et al medical and health science journal 2022 august vol.6 (02) page 38 of 42 2013) stating that bones with mild osteoporosis can be exposed to an elf electric field with a duration of exposure of 30 minutes. however, in cases of advanced osteoporosis and fractures, the duration of exposure in the formation of osteoblasts is 90 minutes. exposure to extremely low frequency magnetic fields has clinical implications. according to the world health organization (who), the threshold for exposure to magnetic fields has a clinical impact if the duration of exposure is not in accordance with the condition of the human body.1 inappropriate length of exposure has a negative impact on the body, so this threshold still cannot guarantee the biological effect and further research is needed for research to ensure the correct effect of the threshold.15 exposure to emelf has nonlinear properties depending on the intensity of exposure and duration of exposure to emelf and the treatment given. so that exposure pratiwi et al medical and health science journal 2022 august vol.6 (02) page 39 of 42 to elf can have a negative or positive impact on its users.20 table 1. details of research results on the effect of elf magnetic field exposure author year method sample intervention results van den heuvel, r. et al. 2001 testing male mice and female mice male and female mice were grouped by sex and randomly assigned and treated with extremely low frequency magnetic field exposure with an intensity of 80μt (50hz). exposure of murine bone marrow cells, from male and female mice, to an 80 mt (50 hz) magnetic field showed reduced proliferation. results on the effect of the elf field on stem cell proliferation are somewhat equivocal at present. the results from female mice showed a decrease, while those from male mice did not experience a decrease. akdag, m. z. et al. 2010 testing mice mice were divided into three groups: two experimental and one sham control. the first and second experimental groups (n 10) were given 100 mt and 500 mtmf for 10 months, 2 ha days, respectively, and the third group (n 10) was treated like the experimental group except for elf. geometric and biomechanical analysis showed a significant decrease in mice exposed to 100 mt-mf compared to mice exposed to sham and 500 mt-mf about the value of the cross-sectional area of the femoral trunk (po0.05). the maximum load was increased in mice exposed to 100 mt-mf and 500 mt-mf when compared to sham mice (po0.05). the femoral cortical thickness of the mfexposed mice (100 mt and 500 mt) was significantly decreased compared to the sham group mice (po0.05 and po0.001). manjhi, j. et al. 2013 control trial adult male wistar rat adult male wistar rats (n = 24) were equally divided into sham, sci, and sci+mf groups. then exposed to em-elf (2 hours/day × 8 weeks) (17.96 micro-tesla, 50 hz) this study demonstrated that sciinduced osteoporosis in rats could be limited by chronic (2 h/day × 8 wk) exposure to elf-mf (17.96 t, 50 hz) as expressed by bbb scores, bmc, bmd, mineral elements. content, and biochemical parameters related to sublesional bone. kitaek, l. et al. 2013 testing eligible patients patients who met the trial requirements were divided elf-pemfs can increase cell proliferation and accelerate osteogenesis. in conclusion, these findings may suggest that elf pratiwi et al medical and health science journal 2022 august vol.6 (02) page 40 of 42 into 3 groups and then treated with predetermined variables. pemfs at appropriate intensities enhance bone formation by promoting stem cell differentiation and maturation. alcaraz, m. et al. 2014 control trial, random patients were divided into 3 trial groups. patients were randomly selected and divided into 3 treatment groups. the treatment that became the control was the group with 50 hz em-elf exposure. the results showed that 50 hz elm-mf increased mnpce in rat bone marrow, expressing a genotoxic capacity. administration of antioxidants with genoprotective capacity against damage caused by ionizing radiation acting through free radical scavenging did not reduce the chromosomal damage caused by this elm-mf. agil, m., ma’arif, b. and aemi, n. y. 2019 trial, random balb/c mice balb/c mice were grouped with an intensity of 120μt, and 150μt with an exposure time of 30', 60', and 90'. the results showed that exposure to a magnetic field with an intensity of 120μt-200μt was able to increase the proliferation of osteoblasts so that they could heal fractures. the most accurate intensity range in the process of forming osteoblasts is the intensity of 150μt. pratiwi et al medical and health science journal 2022 august vol.6 (02) page 41 of 42 conclusion based on the analysis that has been done on 30 articles, both national and international articles, it was concluded that exposure to the extremely low frequency magnetic field with an intensity of 120μt to 200μt was found that accurate results in helping the process of splicing fractures were by exposure to an elf magnetic field of 150μt intensity and duration of exposure. 30' has an effect on the process of forming and secreting organic collagen and non-collagen in osteoblast cells. however, exposure to extremely low frequency (elf) electromagnetic fields still has a negative impact on health if the intensity of exposure is not in accordance with its use. acknowlegment thanks to all authors and researchers who have helped in completing this study. conflicts of interest there are no conflicts of interest declared by the author references 1. suryantara ign. implementasi deteksi tepi untuk mendeteksi keretakan tulang orang lanjut usia (manula) pada citra rontgen dengan operator sobel dan prewitt. j algoritm log dan komputasi. 2018;1(2):51-60. doi:10.30813/jalu.v1i2.1368 2. ehnert s, schröter s, aspera-werz rh, et al. translational insights into extremely low frequency pulsed electromagnetic fields (elf-pemfs) for bone regeneration after trauma and orthopedic surgery. j clin med. 2019;8(12):1-22. doi:10.3390/jcm8122028 3. purbawati m, sudarti s, a a fk. pengaruh paparan medan magnet extremely low frequency (elf) terhadap perubahan ph pada proses fermentasi biji kopi lanang (peaberry) kering. j kumparan fis. 2021;4(2):129-136. doi:10.33369/jkf.4.2.129-136 4. rescigno t, capasso a, bisceglia b, tecce mf. short exposures to an extremely lowfrequency magnetic field (elf mf) enhance protein but not mrna alkaline phosphatase expression in human osteosarcoma cells. open biochem j. 2018;12(1):65-77. doi:10.2174/1874091x01812010065 5. agil m, ma’arif b, aemi ny. aktivitas antiosteoporosis fraksi n-heksana daun marsilea crenata presl. dalam meningkatkan kepadatan tulang trabekular vertebra mencit betina. j tumbuh obat indones. 2019;11(2):7. doi:10.22435/jtoi.v11i2.671 6. sudimantini lm, wirata iw, gunawan iwnf, sumadi iwj, marmanto ts. the dog femoral osteoblast number post transplantation of demineralized porcine cortical bone xenograft. bul vet udayana. 2022;(158):97. doi:10.24843/bulvet.2022.v14.i02.p05 7. nikita e. the human skeleton.; 2017. doi:10.1016/b978-0-12-804021-8.00001-2 8. van den heuvel r, leppens h, nêmethova g, verschaeve l. haemopoietic cell proliferation in murine bone marrow cells exposed to extreme low frequency (elf) electromagnetic fields. toxicol vitr. 2001;15(4-5):351-355. doi:10.1016/s08872333(01)00035-2 9. vanleene m, shefelbine sj. therapeutic impact of low amplitude high frequency whole body vibrations on the osteogenesis imperfecta mouse bone. bone. 2013;53(2):507-514. doi:10.1016/j.bone.2013.01.023 10. arifka m, wathoni n, wilar g. sel induk mesenchymal secretome untuk gangguan permukaan okular. maj farmasetika. 2022;7(2):99. doi:10.24198/mfarmasetika.v7i2.38337 11. fan w, qian f, ma q, et al. 50 hz electromagnetic field exposure promotes proliferation and cytokine production of bone marrow mesenchymal stem cells. int j clin exp med. 2015;8(5):7394-7404. 12. akdag mz, dasdag s, erdal n, buyukbayram h, gurgul s. the effect of long-term extremely low-frequency magnetic field on geometric and pratiwi et al medical and health science journal 2022 august vol.6 (02) page 42 of 42 biomechanical properties of rats’ bone. electromagn biol med. 2010;29(1-2):9-18. doi:10.3109/15368371003635343 13. sari ik, sudarti, prastowo shb. aplikasi paparan medan magnet extremely low frequency (elf) terhadap nilai derajat keasaman (ph) tape singkong. semin nas pendidik fis 2018, 25 novemb 2018. 2018;3(2):19-25. 14. kitaek l, hexiu j, jangho k, hoon s, w.j. c, p.-h. c. effects of electromagnetic fields on osteogenesis of human alveolar bonederived mesenchymal stem cells. biomed res int. 2013;2013:296019. http://ovidsp.ovid.com/ovidweb.cgi?t=js &page=reference&d=emed11&news= n&an=23862141 15. aditya asrizal r. closed fracture 1/3 middle femur dextra. fak kedokt univ lampung medula. 2014;2(3):94-100. 16. kanemaki m, shimizu ho, inujima h, miyake t, shimizu k. analysis of red blood cell movement in whole blood exposed to dc and elf electric fields. bioelectromagnetics. 2022;43(3):149-159. doi:10.1002/bem.22395 17. harakawa s, nedachi t, suzuki h. extremely low-frequency electric field suppresses not only induced stress response but also stress-related tissue damage in mice. sci rep. 2020;10(1):1-12. doi:10.1038/s41598-020-76106-1 18. ningrum c, elfa mm, rosida l, et al. literature review : perubahan bone mineral density pada. :427-434. 19. poh psp, seeliger c, unger m, falldorf k, balmayor er, van griensven m. osteogenic effect and cell signaling activation of extremely low-frequency pulsed electromagnetic fields in adiposederived mesenchymal stromal cells. stem cells int. 2018;2018. doi:10.1155/2018/5402853 20. kristinawati a, sudarti. the influence of extremely low frequency (elf) magnetic field exposure on the process of making cream cheese. proceeding 1st ibsc towar ext use basic sci enhancing heal environ energy biotechnol. published online 2016:181-183. methods the type of research design used is descriptive research. the research method used is article review by reviewing 30 articles originating from international articles and national articles. literature searches were carried out by accessing sciencedirec... conclusion based on the analysis that has been done on 30 articles, both national and international articles, it was concluded that exposure to the extremely low frequency magnetic field with an intensity of 120μt to 200μt was found that accurate results in help... references medical and health science journal 2021 february vol.05 (01) reviwe article comparison of triple drug therapy versus double drug therapy for lymphatic filariasis : a systematic review i gusti agung ari kusuma yana 1 *, hotimah masdan salim 2 1 master of pharmacy, university of surabaya, surabaya 2 faculty of medicine, university of nahdlatul ulama surabaya *correspondence: gunkke17@gmail.com article info article history: received: january 12, 2021 accepted: february 25, 2021 keywords: lymphatic filariasis, wuchererisa bancrofti, infection, triple therapy abstract backgroud: lymphatic filariasis is a parasitic infection caused by nematodes such as filaria wuchereria bancrofti, brugia malayi, and brugia timori. these parasites can be transmitted through mosquito bites such as several species of mosquitoes, particularly anopheles, aedes, culex, and mansonia with geographical variations in the dominant vector identity. the main strategy used consists of community-wide mass drug administration (mda) for the entire population at risk to stop disease transmission and prevent infectious morbidity. who recommends the use of annual medication in combination with the triple drug ivermectin therapy. objective: to compare dec and albendazole (ida) versus the two drugs albendazole and diethycarbamazine or albendazole and ivermectin therapy. methods: the literature search was carried out independently by the researcher using the sciencedirect, pubmed, and cochrane online databases without limiting the type of study or the year of publication. the keywords used in this study were combined with the boolean operator, namely "and" namely ((((lymphatic filariasis) and (albendazole)) and (diethylcarbamazine)) and (ivermectin)) and (compare). results: where triple drug therapy was significantly better in reducing and clearing microfilariae and worm nests in patients with lymphatic filariasis compared to two drug therapy alone. however, side effects occur more frequently in the combination of three therapies. the average side effects were low, such as headaches, joint pain, fatigue, and nausea. conclusion: although it has relatively low side effects that occur in three drug combinations rather than two drug combination therapy, triple therapy combination therapy is more effective than two drug therapy in treating lymphatic filariasis disease. medical and health science journal sumail typewriter 34 mailto:gunkke17@gmail.com medical and health science journal 2021 february vol.05 (01) preliminary lymphatic filariasis is a parasitic infection caused by nematodes such as filaria wuchereria bancrofti, brugia malayi, and brugia timori. wuchereria bancrofti is responsible for more than 90% of infections that occur in tropical asia, africa, the pacific islands, and in parts of the caribbean and south america(1)(2). these parasites can be transmitted through mosquito bites such as several species of mosquitoes, particularly anopheles, aedes, culex, and mansonia with geographical variations in the dominant vector identity. longterm infections can cause lymphatic system damage, characterized by severe swelling of the limbs (lymphedema) and then elephantiasis or scrotal lymphedema (hydrocele)(3). lymphatic filariasis in addition to causing lymphedema (elephantiasis) and hydrocele, this disease also causes renal pathology that manifests as chyluria, and acute dermato lymphangio adenitis which causes regular fever(4). the world health organization (who) recommends mass treatment of entire populations once a year for years. the main strategy used consists of community-wide mass drug administration (mda) to all populations at risk to stop disease transmission and prevent infectious morbidity(5). treatment is a combination of two drugs of albendazole and a microfilarisidal drug (antifilaria), either diethyl carbamazine (dec) or ivermectin. albendazole is recommended for patients when dec or ivermectin cannot be used(6)(7). an annual, single-dose, two-drug regimen (albendazole plus diethylcarbamazine (dec) or albendazole plus ivermectin) for at least five years (according to the reproductive age of adult worms), covering at least 65% of the total population at risk to prevent transmission(8)(9). recently, for specific settings, who has recommended the use of annual treatment with the triple therapy ivermectin, dec and albendazole (ida) combined with the dual therapy of albendazole and diethycarbamazine or albendazole and ivermectin(10)(11). the aim of this study was to compare the therapeutic efficacy of three drug therapy versus two therapeutic measures in treating lymphatic filariasis. transmission filariasis is transmitted by female mosquitoes from several genera, including culex, anopheles, mansonia, and aedes(12). the cycle of transmission begins when an infected female mosquito bites and deposits lymphatic filariasis larvae on the skin (fig. 1). figure 1. life circle lymphatic filariasis(13) the larvae enter the bite wound and travel to the lymphatic vessels. larvae develop for about 12 to 15 days in mosquitoes to become third stage infective larvae. the larvae enter the bite wound and travel to the lymphatic vessels. for 6 to 12 months, they become adult male and female worms in the lymph nodes, where male and female worms mate. the female worm then produces an early stage larva, called microfilariae (mf). during the 7 year life cycle, an adult female can release up to 10,000 offspring embryos (microfilariae) per day. microfilariae (mf) is carried by the natural lymph flow and introduced into the blood. when the human host is awake, mf can survive permanently in the larger blood vessels. during sleep, however, they travel or migrate to the surface of the vessels, allowing them to be digested by biting mosquitoes at night. in mosquitoes, mf undergoes several stages of molting and development. the larvae are ready to be transmitted from the carrier mosquito to humans in 10 to 12 days. transmission in a community is influenced by several factors, namely the prevalence or number of infected people, the density of mf in the blood of infected people, the density of carrier mosquitoes in endemic areas, characteristics that affect the growth and development of larvae and the sumail typewriter 35 medical and health science journal 2021 february vol.05 (01) frequency of human contact with infected mosquitoes. repeated mosquito bites over several months can cause lymphatic filariasis, thus indigenous people or long-term visitors living in endemic areas are at greatest risk(1)(14). pathophysiology in the human body, lymphatic vessels secrete circulating fluids and large molecules, such as proteins, from the extracellular spaces in almost every tissue of the body(8)(3). the lymph system is important for maintaining the correct extracellular fluid volume and clearing pathogens that have crossed the skin barrier and entered the extravascular compartment. the antigens, pathogens and invaders that ingest macrophages are transported afferently to the lymph nodes to undergo the process and uptake of additive immunity(15). after cleaning and filtering, the lymph fluid is returned to the blood vessel space. as a component of the adaptive immune system, t lymphocytes are programmed to recognize, respond to, and remember foreign antigens. the presence of a cell surface molecule known as cd4 or cd8 differentiates t lymphocytes. cd4 t lymphocytes, also called helper (th) t cells, are productive cytokine producers(8). cytokines are hormonal messengers in the immune system and are responsible for cell-mediated immune and allergic responses, so they are often classified as either pro-inflammatory (th1 response) or antiinflammatory (th2 response). in patients with lymphatic filariasis, lymphatic vessel damage is mediated by a response to the presence of adult worms and the products released by these worms. compounds secreted or secreted by live worms act on endothelial cells, causing lymph tissue, gradual loss of contractility of lymphatic vessels, unidirectional valve damage, and lymphangiectasis (pathological dilation of lymph vessels). regardless of the treatment, lymph system damage can be permanent(16). histologically, live mf and adult worms rarely elicit an immune response. however, dead or dying mf and adult worms are highly antigenic. although the mechanism is not fully understood, the lymphatic filariasis antigen guarantees species survival by modulating the host immune system (fig. 2) to support the antiinflammatory response (th2)(17). this response can be achieved by reducing the proinflammatory (th1) response(17). as a result of weakening the immune system, the response to opportunistic pathogens and vaccines is severely reduced, such as tetanus toxoid, which can cause the disease to worsen, namely chronic lymphedema(18). children born to infected mothers are more susceptible to contracting filarial infection(19)(20). in women treated with several cycles of antifilarial drugs before pregnancy, the incidence of children contracting lymphatic filariasis is reduced to less than 1%(21). ). there is a hypothesis that placental antigen transfer modulates the infant's immune system, supporting the th-2 response(17)(21). ). individual responses to the presence of adult worms and microfilariae vary as some develop clinical symptoms and others do not. the susceptibility, parasite load, and degree of cluster pathological changes in the family, suggest genetic polymorphisms play a role in lymph tissue remodeling, severity of lymphatic dysfunction, and degree of immune modulation(22). epidemiology classified as a tropical disease by the world health organization (who), this incurable condition affects more than 120 million people worldwide(8). endemic disease in 73 countries, 1.1 billion people are at risk of being exposed to and contracting infectious diseases in tropical and subtropical regions of asia, africa, the western pacific, and parts of south america and the caribbean(2,4,23,24). in 1997, the world health assembly initiated a program aimed at the global elimination of lymphatic filariasis as a public health problem and by 2020 the world was clear of lymphatic filariasis based on the resolution wha50(8)(25). the gpefl is one of the fastest growing global public health programs in history. during the first decade, they focused on launching the program, which included preparing guidelines based on available information, initiating programs in each who region where the disease is endemic and scaling up the program as quickly as possible(25)(26). researchers have found that lymphatic filaria is associated with dermatitis, lymphedema, and elephantiasis on the limbs or sumail typewriter 36 medical and health science journal 2021 february vol.05 (01) genitalia, which adversely affects personal and social life and limits work activities. by the end of 2011, 53 of 73 endemic countries had implemented mass drug administration, 12 of which had entered the surveillance stage. during 2000 to 2011, more than 3.9 billion doses of the drug were delivered to a cumulative target population of 952 million people(27). in 2011 world health organization (who) report confirms that it affects more than 120 million people living in 72 countries worldwide, and 39 african countries bear more than a third of the global burden of lymphatic filariasis(9)(28). nigeria is the second endemic country in the world and also the country with the largest population at risk of lymphatic filariasis infection in the african continent (9)(4). a survey from the federal ministry of health estimated that 20 million people in nigeria are undergoing treatment for lymphatic filariasis. it states that this figure only represents about 20% of the population at risk. in addition, the federal ministry of health's nigerian lymphatic filarasis elimination program, with the assistance of the carter center, initiated a collaboration towards elimination of lymphatic filariasis in 2015 (29)(7)(9). in some communities as much as 5% of women can develop swelling of the limbs, and 50% of men can develop swelling of the genitals (hydrocele)(29)(30). the clinical severity and progression of the disease can lead to chronic health complications and disability, which may be accompanied by mental health problems and social stigma, while decreased productivity causes economic losses of nearly usd 1.3 billion per year(31). with several recent advances in diagnosis, pharmaceutical treatment options, and the establishment of the global program for the elimination of lymphatic filariasis (gpefl), who member countries were given a strategic plan consisting of 2 objectives, namely stopping the transmission and spread of lymphatic filariasis through mass drug administration (mda). and alleviating suffering for those with chronic conditions associated with lymphatic filariasis(10)(32). method literature research is used as a reference in published articles which are carried out as an effort to enrich the following literature review. a review of published articles up to 9 october 2020 was involved in this literature review. the literature search was carried out independently by researchers using the sciencedirect, pubmed, and cochrane online databases without limiting the type of study or the year of publication. the keywords used in this study were combined with the boolean operator, namely "and" namely ((((lymphatic filariasis) and (albendazole)) and (diethylcarbamazine)) and (ivermectin)) and (compare). it is important to convey that researchers are trying to obtain good quality research evidence to support this literature review, namely a study using a randomized design to see the comparison between the combination of three drugs, albendazole, diethylcarbamazine, invermectin with two therapeutic drugs. only studies published in english were included in the final review. all articles that met the inclusion criteria, even though they were published more than 10 years since this systematic review were carried out, were still used in the analysis to obtain a comprehensive picture. the data extracted from each research article includes: 1) the identity of the article (name of journal, name of researcher, and year of research), 2) country setting for the study, 3) sample size, 4) type of intervention given, 5) methodology and 6) study outcome. the inclusion criteria for research articles were articles containing: 1) lymphatic filariasis experienced in human subjects; 2) cases of lymphatic filariasis accompanied by therapeutic regimens; 3) original sources only; 4) contains a comparison of triple drug combination therapy as lymphatic filariasis therapy with a combination of two therapeutic drugs. the first step of a systematic review is to apply title / abstract filtering. the aim of this step is to remove all publications that do not discuss the comparison of triple therapeutic drug combinations with two therapeutic drugs in lymphatic filariasis. search queries for conducting systematic reviews are shown in table 1. in total 389 articles were sumail typewriter 37 medical and health science journal 2021 february vol.05 (01) identified from the search and underwent a complete review (figure 2). table 1. search queries in conducting systematic reviews database search queries temuan crochane ((((lymphatic filariasis) and (albendazole)) and (diethylcarbamazine )) and (ivermectin)) and (compare) 27 siencedir ect ((((lymphatic filariasis) and (albendazole)) and (diethylcarbamazine )) and (ivermectin)) and (compare) 359 pubmed ((((lymphatic filariasis) and (albendazole)) and (diethylcarbamazine )) and (ivermectin)) and (compare) 3 figure 2. identify data from article searches results the number of identified article search results was 389 articles. from these articles, 4 articles were used in the final study. the articles included in the final study came from several different countries. the article contains the results of a study using a combination of three drugs, namely albendazole (alb), diethylcarbamazine (dec), invermectin (ivm) compared to a combination of two drug therapies, namely albendazole (alb) and ivermectin (ivm) or albendazole (alb) and diethylcarbamazipe (dec ) for lymphatic filariasis therapy shown in comparison to the effectiveness of these treatment regimens. thomsen's study (2016)(33) showed that a single dose of the triple combination alb + dec + ivm drug therapy resulted in almost total elimination of microfilariae at 36 hours and 7 days after treatment, and none of the patients experienced microfilaremia 12 months after treatment. whereas the combination of the two single-dose therapies alb + dec resulted in a less specific decrease in microfilariae levels at 36 hours and 7 days, and 10 of the 11 patients continued to have mifillaremia at the 12 month time point. twelve patients agreed to have blood drawn as additional blood samples (incidentally, 6 in each treatment group) and then examined for microfilaria 2 years after treatment. a total of 6 key word search cochra ne n=27 pubme d n=3 science direct n=359 kriteria inklusi final analyzable sample n=4 sumail typewriter 38 medical and health science journal 2021 february vol.05 (01) people who received 3 single drug treatment remained microfilariae at 2 years obtained p value = 0.047, compared with patients who received 2 drug therapy alone. alb + dec + ivm also resulted in a greater reduction in filarial antigen levels compared to dec + alb at 12 months. dec + alb + ivm also resulted in a greater reduction in filarial antigen levels compared to dec + alb at 12 months. however, this study also stated that patients treated with the three-drug regimen received more side effects than patients who received only two drug therapies, when the side effects of both objective and subjective groups were combined (9 of 12 (75%) in the group. 3 drugs and 7 of 12 (58%) in the 2 drug group). side effects were mild to moderate in severity, started 8 hours after treatment, peaked at between 12 and 48 hours, and resolved 7 days later, except in 1 patient who had right inguinal tenderness on day 7. in king's study (2018)(34) used a sample of 182 patients, 172 (95%) evaluated at 12 months, 165 (91%) at 24 months, and 158 (87%) at 36 months after trial initiation. the triple drug regimen cleared micro filaremia in 55 patients (96%) at 12 months, at 52 (96%) at 24 months, and in 55 (96%) sumail typewriter 39 medical and health science journal 2021 february vol.05 (01) author publication year method country sample intervention outcome thomse n et al(33) 2016 randomi zed papua new guinea 53 subject patients were stratified by sex and randomly assigned to 1 of the 2 treatment groups: dec 6 mg / kg + alb 400 mg or dec 6 mg / kg + ivm 200 μg / kg + alb 400 mg triple drug therapy (dec + ivm + alb) is safer and more effective than dec + alb for filariasis and has the potential to accelerate the elimination of lymphatic filariasis king et al(34) 2018 randomi zed control trial papua new guinea 182 subject patients were randomized in a 1: 1: 1 ratio to a two-drug regimen of 6 mg diethylcarbamazine (sanofi) per kilogram of body weight plus 400 mg of albendazole (glaxosmith-kline) given once at the start of the trial, a two-drug regimen of 6 mg diethylcarbamazine per kilogram plus 400 mg of albendazole given at trial initiation and at 12 and 24 months, or a three-drug regimen of 200 μg ivermectin (stromectol, merck) per kilogram plus 6 mg diethylcarbamazine per kilogram plus 400 mg albendazole given once at trial initiation these results suggest that a single dose regimen of three-drug ivermectin plus diethylcarbamazine plus albendazole is more effective at clearing microfilaria w. bancrofti from the blood than a single dose regimen of two-drug diethyl carbamazine with albendazole, which is the standard regimen used for mass drug administration for lymphatic filariasis elimination in outside sub-saharan africa. the frequency and severity of side effects after treatment with ivermectin plus dietylcarbamazine plus albendazole tends to be lower than for 2-drug therapy. sumail typewriter 40 medical and health science journal 2021 february vol.05 (01) bjerum et al(35) 2019 randomi zed, single blind côte d’ivoire 189 subject eligible individuals were randomized then divided into 2 groups reported in this study as follows: group 1 was given an ivm dose of 200 μg / kg (merck & co.) plus alb 400 mg (glaxosmithkline) and group 2 was given ivm 200 μg / kg plus. dec 6 mg / kg (sanofi sa) plus alb 400 mg this study confirms that single-dose treatment with ida ida (ivm + dec + alb) is well tolerated and more effective against w. bancrofti larvae and adults than ia (ivm + alb) and is comparable to 2 dose cycles of ia (ivm + alb). . a greater overall cumulative reduction in mf within the first 2 years with a single dose of ida (ivm + dec + alb) compared to 2 doses of ia (ivm + alb) indicates better ida effectiveness. dubray et al(36) 2020 clusterrandomiz ed haiti 5.998 (3.004 patients from five districts received ida and 2,994 patients from five other districts received da) each site was randomly assigned to receive an ida regimen consisting of a single dose of ivm (200 μg / kg) + dec (6 mg / kg) + alb (400 mg) (5 regional sites) or an da regimen consisting of a single dose of dec ( 6 mg / kg) + alb (400 mg) (5 areas) the haitian study reported that ida was well tolerated in the lymphatic filariasis endemic community. the proportion of patients with side effects was significantly lower in people taking the ida regimen than in people taking the da regimen. ida was well tolerated by study patients and was more effective at clearing mf than da. sumail typewriter 41 medical and health science journal 2021 february vol.05 (01) at 36 months after trial initiation. in contrast, a single dose of the two drug regimen cleared microfilaremia in 18 patients (32%) at 12 months, at 31 (56%) at 24 months, and in 43 (83%) at 36 months. the three-drug regimen resulted in significantly greater microfilaria clearance at 36 months than the single-dose twodrug regimen (p = 0.02). the two-drug regimen given once a year for 3 years cleared microfilaremia in 20 patients (34%) at 12 months, at 42 (75%) at 24 months, and in 51 (98%) at 36 months. in patients receiving the three-drug regimen, microfilaria clearance at 36 months was better than the two-drug regimen given once a year for 3 years, with a difference of 2 percentage points (90% ci, 10 to 6) (onetailed p value for noninferiority, 0.004). in bjerum's (2019) study(35) compared the combination therapy of ivermectin, diethyl carbamazine, albendazole (ida) with a combination of ivermectin and albendazole (ia) therapy. the ida clearance rates at 6 and 12 months were significantly greater than those of ia (83% and 61% improvement, respectively) and showed greater microfilaria clearance at 24 months. ida reduced mean individual mf levels by more than 99% at 6 months, 98.9% at 12 months, and 93.2% at 24 months. overall, there was an 81% greater reduction in microfilarial levels at 12 months compared to ia (incidence rate ratio [irr], .19; 95% confidence interval [(ci), .12-.33; p <.0001). cumulative microfilarial load (mf) after administering a single dose of ida for 24 months averaged 7.2 mf / ml (783/109; total mf at 6, 12, and 24 months divided by the total number of individuals examined at the same time points) versus 27.4 mf / ml (3431/125) during the same period after 2 doses of ia, representing a 3.8fold reduction in mf levels with a single dose of ida. ida treatment disabled all worm nests detected in 74%, 81%, 79%, and 79% of patients at 6, 12, 24, and 36 months, respectively. whereas ia treatment disabled all detected worm nests which accounted for 18%, 36%, 44%, and 40% of patients at 6, 12, 24, and 36 months respectively. side effects that occur 24 hours after treatment. of the patients in the ida and ia groups 47% and 40% had side effects after treatment, respectively. no serious or severe side effects were observed. the frequency of mild and subjective (mild) side effects was similar between the 2 therapy groups, namely headache, joint pain, fatigue, and nausea being the most common symptoms. saping effects (moderet) occurred in 5 patients (12%) after ida and in 1 patient (2%) after ia (p value = 0.07). the patient's chance of having a (moderate) side effect increased by 23% for each incremental increase of the total 100 mf / ml (odds ratio, 1.23; 95% ci, 1.09-1.43; p = 0.04) but all the effects of saping resolve within 2 to 3 days of initial therapy. dubray's (2020) randomized study(36) in haiti showed that significantly more participants who were mf positive at baseline became mf negative after ida administration (invermectin, diethylcarbamazine, albendazole) (94.4%, 34/36) than after da administration ( diethylcarbamazine and albendazole) (75.9%, 44/58) (p = 0.02). it was reported that two participants who were mf positive as samples for ida therapy had mf counts of 3050 mf / ml and 1383 mf / ml. for the therapeutic safety study, this study demonstrated that 96.0% (5761/5998) of treated patients underwent a onetime examination during the 7-day follow-up period (2,917 ida therapy and 2,844 da therapy). overall, 14.1% (812/5761) of patients assessed as having a treatment side effect reported at least one side effect during the week following treatment. the intracluster correlation coefficient for side effects is low (0.02). it is known that more patients who received da (17.3%, 491/ 2,844) reported side effects compared to patients who received ida (11.0%, 321/2917) (table 3). the side effects reported were mostly mild, 88.7% (436/491) of all side effects in the da group and 93.4%, (300/321) compared to all side effects in the ida group. it was reported that more women reported side effects of therapy than men. side effects that occurred more frequently occurred after treatment in positive micro filariasis patients, the comparison of side effects in people with microfilaremia had a low percentage difference, sumail typewriter 42 medical and health science journal 2021 february vol.05 (01) namely on ida treatment (34.1%,14/41) and on da treatment (39.4%,26/66). for people with micro filaremia, the pre-treatment mf count was significantly higher in people who experienced side effects after treatment compared to people without side effects (geometric mean: 20.98 mf / ml vs. 8.81 mf / ml, p = 0.002). the multivariable logistic regression analysis showed that after controlling for age, sex and infection status, the risk of experiencing side effects was significantly lower in patients receiving ida compared to patients receiving da. conclusion the triple therapy combination is more effective than the two drug therapy in treating lymphatic filariasis. the therapeutic effectiveness can be seen in the final research article where triple drug therapy is significant in reducing and clearing microfilariae and worm nests in patients with lymphatic filariasis compared to two-drug therapy alone. there were fewer side effects from triple drug therapy than with two drug therapies. however, some studies say that the side effects are more in the combination of three therapies. the rate of side effects is low and can disappear two to three days after giving therapy. some cases of side effects can rise to a moderate level but the percentage is small and no serious side effects have been reported after the administration of the three drug combination. monitoring and supervision is needed in dealing with side effects that can be caused so as not to disturb the patient's comfort in continuing therapy. references 1. world health organization. global programme to eliminate lymphatic filariasis: progress report, 2015. 2016;(7):73–88. available from: http://www.who.int/wer 2. rahman ma, yahathugoda tc, tojo b, premaratne p, nagaoka f, takagi h, et al. a surveillance system for lymphatic filariasis after its elimination in sri lanka. parasitol int [internet]. 2019;68(1):73–8. available from: https://doi.org/10.1016/ j.parint.2018.10.003 3. deshpande a, miller-petrie mk, lindstedt pa, baumann mm, johnson kb, blacker bf, et 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community study. plos negl trop dis [internet]. 2020;14(6):1–21. available from: http://dx.doi.org/10.1371/journal.pntd.00082 98 sumail typewriter 45 medical and health science journal 2021 august vol.5 (02) medical and health science journal available at http://journal2.unusa.ac.id/index.php/mhsj; doi: 10.33086/mhsj.v5i2.2079 pissn 2549-7588. eissn 2549-7596 review article making pregnancy a missed opportunity for treatment of tuberculosis infection : a systematic review sardjana atmadj1*, gulam gumilar1 department of obstetrics and gynecology syarif hidayatullah state islamic university jakarta, indonesia article info article history: received: july 14, 2021 received in revised form: august 24, 2021 accepted: august 25, 2021 keywords: tb infection (tbi), hiv infected, tuberculin skin test (tst) *) corresponding author: sardjana@uinjkt.ac.id abstract background : eleven million americans, representing 4% of the u.s. general population, are estimated to have latent tuberculosis infection (ltbi). in countries with low tb incidence, immigrant from higher incidence countries form the major pool of infected individuals. to understand the prevalence, screening and management of tbi in pregnancy. methods : a systematic review of 4 databases (embase, embase classic, medline, cochrane library) covering articles published from january 1st 2010 to april 30th 2018. articles in english with relevant information on prevalence, screening strategies and treatment of tbi during pregnancy were eligible for inclusion. results : of 193 titles initially identified, 108 abstracts were eligible for review. of these, 86 articles qualified for full text review and 22 were retained: 3 cohort studies, 2 case-control studies, and 17 cross-sectional studies. in the usa, the estimated prevalence of tbi ranged from 14 to 48% in women tested, and tuberculin skin test (tst) positivity was associated with ethnicity. the proportion of women who attended follow-up visits after positive tuberculin tests varied from 14 to 69%, while 5 to 42% of those who attended follow-up visits completed a minimum of 6 months of isoniazid treatment. one study raised the possibility of an association of pregnancy/post-partum state with inh hepatitis (risk ratio 2,5, 95% ci 0.8– 8.2) and fatal hepatotoxicity (rate ratio 4.0, 95% ci 0.2–258). one study deemed inh safe during breastfeeding based on peak concentrations in plasma and breast milk after inh administration. conclusion : pregnancy is an opportunity to screen for tbi. interferongamma release assays are likely comparable to tuberculin skin tests and may be used during pregnancy. efforts should be made to improve adherence with follow-up and treatment post-partum. further data are needed with respect to safety and feasibility of antepartum inh therapy, and with respect to alternative treatment regimens. medical and health science journal http://journal2.unusa.ac.id/index.php/mhsj atmadj et al medical and health science journal 2021 august vol.5 (02) page 57 of 69 introduction in 2013, tuberculosis (tb) was responsible for a half a million deaths amongst women worldwide, making tb one of the top killers of women of reproductive age, most being hiv negative. eleven million americans, representing 4% of the u.s. general population, are estimated to have latent tuberculosis infection (ltbi). in countries with low tb incidence, immigrant from higher incidence countries form the major pool of infected individuals. in the united states, the reduction in active tb incidence has in part reflected improvements to screening and treatment of latent infection. immigrant women face financial, educational and cultural barriers, which can limit health status and health-seeking behaviors. the antenatal period represents an opportunity for them to access the medical system. for this reason, the american college of obstetricians and gynecologists and the center for disease control and prevention recommends screening all pregnant women at high risk for tb when beginning prenatal care. while treating active disease during pregnancy offers clear benefits, the treatment of ltbi during pregnancy remains controversial and current cdc and acog guidelines favor deferring treatment to the post-partum period in most cases1. in order to further understand the prevalence, natural history, screening and management of ltbi in pregnancy, we conducted a systematic literature review addressing the screening and treatment of ltbi, in women without known hiv infection2. we did not review treatment of latent tb infection in pregnant women with concomitant hiv infection, as the indication for urgent treatment is stronger. methods information source and search strategy a librarian from the mcgill university health center aided in the development of a comprehensive search strategy. databases searched were embase, embase classic, medline via pubmed and the cochrane library. articles published from january 1, 1980 to april 30, 2014 were eligible. search terms used were: pregnancy, or pregnancies, or pregnant, or puerperium, or postpartum, or antepartum, or obstetric, or obstetrical, and mycobacterium tuberculosis, or tuberculosis, or latent tuberculosis. inclusion criteria articles eligible for review were original research publications available online or through inter-library loan. articles had to be written in english, french or spanish, the languages spoken by the investigators. studies included were randomized controlled trials, cohort studies, casecontrol studies and cross-sectional studies. articles from any country, with relevant information on prevalence, natural history, screening tools, screening strategies and treatment of ltbi during pregnancy were eligible for full review. articles were excluded if (1) full text was not available (2) articles were written in a language not understood by reviewers (3) they were case series or case studies, meaning case descriptions of pregnant women with latent or active tb, without a comparison group for purposes of analysis; pharmacokinetic studies were considered acceptable. (4) they focused exclusively on prevalence, diagnosis and treatment of active tb (5) the study population was exclusively hiv-infected. atmadj et al medical and health science journal 2021 august vol.5 (02) page 58 of 69 two independent reviewers (im, mc) reviewed titles, abstracts, and articles. titles were screened for relevance to the subject of tb. any articles reporting original studies with information on ltbi in pregnancy, which did not meet one or more of the exclusion criteria, were retained for full-text review. the investigators independently read full-text versions of eligible articles. disagreements were resolved by consensus between the two reviewers; where they did not reach consensus, input from a third investigator (ks) was obtained. references from included articles were manually reviewed for additional, potentially eligible articles. data collection process data abstracted included (1) year of publication; (2) country of study; (3) setting; (4) study design; (5) participant numbers; (6) participant characteristics; (7) recruitment and follow-up period and methods; (8) intervention or exposure; (9) main outcomes or events observed; (10) confounding variables and other covariates considered; (11) main findings. participant characteristics described the study population by summarizing eligibility criteria for the study, the method of selection of participants, and their demographic characteristics; when the study design involved matching, the criteria for matching were recorded. depending on the study question, “intervention or exposure” represented pregnancy status, treatment administered, testing methods used, tb status, ethnicity, or trimester of pregnancy. similarly, depending on the study question for each article, main outcomes or events included development of latent or active tb, rates of adherence to testing or to treatment, identification of predictors of active disease, identification of predictors of adherence, and/or correlation of results from different testing modalities. confounding variables and covariates included age, socioeconomic status, medicaid coverage, marital status, education, occupation, ethnicity, country of birth, immigration status, language spoken, prior tb screening and treatment, bcg vaccination history, number of antenatal visits, gestational age at first antenatal visit, parity, hiv status, known substance abuse, travel to endemic area, location of residence, exposure to individuals with known tb, and chronic medical conditions. we included a 3-point quality score (2 = well described, 1 = poorly described, 0 = not described) for the following 8 attributes extracted from the strobe statement [6] with an emphasis on methods: (1) description of the study setting; (2) description of study participants; (3) definitions of all variables; (4) description of the data sources and measurement tools; (5) atmadj et al medical and health science journal 2021 august vol.5 (02) page 59 of 69 fig 1. summary of retrieval and review of articles on tuberculosis and pregnancy, 1980– 2014. justification of sample size; (6) description of statistical methods; (7) description of results; (8) discussion and interpretation of results. the maximum quality score was therefore 16. results the initial search yielded 3.240 titles, of which 208 titles were retained for abstract review. of the 208 abstracts reviewed, 30 met inclusion criteria and were eligible. after full text review and manual review of references, 22 articles were retained (fig 1). three cohort studies, 2 casecontrol studies and 17 cross-sectional studies were included. quality scores ranged from 8 to 15 with a mean quality rating of 12.4 (s1 appendix). of these studies, 13 reported prevalence of ltbi during pregnancy; 7 addressed treatment of ltbi pregnancy; 3 addressed the risk of tb reactivation during pregnancy; 5 examined the performance of interferon-gamma release assays during pregnancy, and 6 addressed adherence with tb screening during pregnancy. some studies investigated more than one of these subjects. 1) prevalence of ltbi thirteen studies reported the prevalence of ltbi in cohorts of pregnant women based on tuberculin skin testing (table 1). in cohorts of pregnant women tested in the usa, the prevalence of latent infection varied from 14 to 48%3. skin test positivity was related to the ethnicity of cohort members: in one study 31.3% of asian-american women, 23.9% of atmadj et al medical and health science journal 2021 august vol.5 (02) page 60 of 69 table 1. prevalence of ltbi during pregnancy measured by tuberculin skin test. reference country study period (y) participant s (n) us-born (%)*1 non us born (%) mean age (range) interval between testing and reading indurations cutoff ppd + (%) (h) cruz usa 2000 1331 n/s* 2 n/s n/s n/s n/s 32% metersky usa 1990– 1991 1412 n/s n/s n/s before 48 5 mm 18% 48–72 10 mm magann usa n/s 1000 58.5 41.5 25.3 (13– 48–72 5–8 mm* 3 42) 4% 8–12 mm * 4 12 mm *5 jackson usa 2000 30 47 53 27.5 48–72 10 mm 0% meints usa 2003– 2006 382 0 100 n/s n/s 22% medchill usa 1993– 1997 1763 38.2 61.8 n/s 48–72 5 mm 15% schwartz usa 2001– 2006 4049 11.1 88.9 27.0 (13.0– n/s 10 mm 46) previously positive 48% sackoff usa 1999– 2000 558 0 100 26.0 (22– n/s 10 mm 31) previously positive 37% lighterfisher usa n/s 140 59 41 18.5 (13.5– 48–72 10 mm 36.5) 20% worjoloh usa 2009– 2010 220 35 65 25 (17–41) 48–72 10 mm* 6 21% 15 mm chehab usa 102 10 90 25.9 mathad india 2011– 2012 401 n/s 48–72 10 mm 14% sheriff tanzania 2008 286 25.0 (16– n/s 5 mm * 7 40) 30% 10 mm *8 sepulveda chile n/a 840 n/s 72 10 mm 51– 57% *1 when not explicitly detailed, non-hispanic caucasian women were considered us born, whereas women from all other ethnicities were considered non us-born *2 not specified in article *3 if suspected of having hiv, or close contact with known case *4 if from endemic area, medically underserved low income populations, residents of long term care facility, migrant workers, homeless *5 if no known risk factors *6 recent immigrants (<5 years), from high prevalence country, injection drug user, residents or employees of high risk congregate settings *7 hiv positive *8 hiv negative doi:10.1371/journal.pone.0154825.t001 atmadj et al medical and health science journal 2021 august vol.5 (02) page 61 of 69 hispanic women, 9.3% of africanamerican women and 4.1% of caucasian women had positive skin tests. hispanics had a risk ratio of 5.9 (95% ci 3.9 to 8.8) and asian-american women had a risk ratio of 7.6 (95% ci 3.4 to 17.5) compared with caucasian women. of note, 223 of the 1634 skin tests initially placed had to be repeated 2 to 5 times because of failure to return for initial reading. a cross-sectional study conducted in a new york city ambulatory care facility also focused on ethnicity; asian-american women were again most likely to have a positive tuberculin test with an odds ratio of 3.15 (95% ci 1.62–6.14) relative to white women and 1.55 (95% ci 1.35–1.8) compared to hispanic women. on multivariate analysis, u.s. born women were substantially less likely to have a positive tuberculin test than were foreign-born women (odds ratio 0.08 95% ci 0.05–0.13)4,5. a study from an antenatal care clinic in northern tanzania identified members of two tribes as having a lower prevalence of ltbi compared to other clinic patients; these tribes were thought to have better socio-economic status as a result of more fertile lands, and a better knowledge of agricultural techniques. 1) natural history: risk of tb reactivation with pregnancy in order to examine the epidemiology of tb in pregnancy and to establish whether pregnancy is an independent risk factor for active tb, zenner and colleagues conducted a primary carebased retrospective cohort study, using the general practitioner research database. they considered all women in the uk with known pregnancy start and end dates between 1996 and 2008. the diagnosis of tb was attributed based on culture confirmation, clinical or radiological signs compatible with active tb, or receipt of treatment for active disease. the overall crude incidence rate of active tb diagnosis was 10.1/100,000 (95% ci 8.7–11.8) person-years. the incidence rate for tb during pregnancy was 12.8/100,00 (95% ci 8–19.4) person-years. the incidence in the same cohort when women were not pregnant was 9.1/100,000 (95% ci 7.6– 10.8) personyears. during the 180-day postpartum period the crude incidence rate was 19.2/100,000 (95% ci 12–29) person-years. tb occurred significantly more frequently during pregnancy and the 180 days post-partum combined, i.e. 15.4/100,000 (95% ci 11.2–20.6) personyears (crude incidence rate ratio, 1.68 (95% ci 1.17–2.38). after adjustment for age, socioeconomic status, region of residence, and bcg vaccination status, tb incidence was significantly higher during the 180 days postpartum (irr, 1.95 (95% ci 1.24– 3.07) but not during pregnancy itself 6–8. however, given the usual time frame over which tb disease evolves, diagnosis post-partum may well reflect the onset of active disease ante partum9. a case-control study from the dominican republic did not identify any association between recent pregnancy and tb reactivation. cases were women with a new diagnosis of active tb, treated at four facilities in santo domingo; controls were women who sought hiv screening at the santo domingo national laboratory of public health. case and control subjects had comparable reproductive histories. among hiv-negative women, those with active tb were no more likely to have been pregnant within the preceding six atmadj et al medical and health science journal 2021 august vol.5 (02) page 62 of 69 months than the control subjects (or 1.1, 95% ci 0.4–2.4). on the other hand, it is not clear whether cases and controls were comparable with respect to other risk factors for active tb, e.g. antecedent smoking and substance use, or what the relative frequency of latent tb infection was in the two groups. a matched case-control study conducted in a northern province of malawi, where tb is differentially distributed between men and women depending on age, examined risk factors for active tb among men and women, after adjustment for socioeconomic status and hiv infection. in this study, neither pregnancy nor the post-partum period (defined as 9 months after delivery) was associated with active tb. it is possible that in this and other settings, women with incipient active tb, or with associated risk factors, were in fact less likely to become pregnant. atmadj et al medical and health science journal 2021 august vol.5 (02) page 63 of 69 table 2. adherence to antepartum screening programs for latent tuberculosis. reference country of origin study period participants eligible for ppd placed ppd result availablen adherence to chest participants eligible for adherence to follow-up completion of to >6 months (y) ppd n (%) (%) x-ray (%) treatment appointment n inh n (%) evaluation (%) cruz usa 2000 1331 n/s 1195 (90) n/s 393 167 (42) 71 (42) metersky usa 1990– 1991 1412 1405 (99.9) 1405 (100) 254 (98) 272 39 (14) 2 (5) medchill usa 1993– 1997 1763 1634 (93) 1497 (92) 211 (93) schwartz usa 2001– 2006 4049 n/s 3847 (95) 1841 (95) sackoff usa 1999– 2000 730 521 (77) 678 (93) 291 202 (69) 27 (13) worjoloh usa 2009– 2010 220 220 (100) 199 (95) mathad india 2011– 2012 154 154 (100) 109 (71) sheriff tanzania 2008 396 n/s 286 (72) 87 (100) doi:10.1371/journal.pone.0154825.t002 atmadj et al medical and health science journal 2021 august vol.5 (02) page 64 of 69 2) screening a) programs. studies assessing antenatal screening programs for ltbi and/or active tb revealed a high level of adherence with both skin testing and chest radiography (table 2). in the usa, reported adherence with antenatal tuberculin skin testing was between 90–100% while with chest radiography it was 93–100%. in a study of 4049 pregnant women considered eligible for screening in new york city, asian-american women were more likely to adhere to testing than hispanic and caucasian women. u.s.-born patients were the least adherent with both tests. of note, this particular screening program did not identify any cases of active tb disease. in higher incidence countries, 71–72% of patients returned for skin test reading, while 100% of pregnant tanzanian women underwent cxr after it was recommended to them. b) tools. four studies compared tst with the quantiferon gold in-tube test in pregnant women. in three studies from low incidence settings, concordance between tst and the igra was 77, 88 and 91%, with kappa values of 0.26 (95% ci 0.12–0.40), 0.45 (95% ci 0.26–0.64) and 0.36 respectively. in those studies, the prevalence of tst positivity ranged from 10 to 23%, and igra positivity from 5 to 14%. discordance mostly often reflected tst positive/ igra negative results although no specific predictors of discordance were identified. prior bcg vaccination was a significant predictor of tst positivity. there was no significant difference between stimulated ifn-g levels measured during each trimester of pregnancy. there was no significant difference observed in the ifn-g mitogennil response between pregnant and non-pregnant controls of similar age and socio-economic status in an adequately powered analysis. in low incidence settings an igra may therefore be more specific and less sensitive than tst in pregnancy, and results do not appear to be altered by pregnancy10,11. in a study conducted among pregnant women in india, 37% had a positive igra in comparison with 14% with a positive tst. overall agreement was 76% with a kappa of 0.37. the highest frequency of discordance (37%) was observed during the post-partum period, and mainly reflected tst negative/ igra positive results. on multivariate analysis, being employed and postpartum enrollment were associated with discordance. education below the 4th grade was associated with a positive tst. living in an urban setting and being postpartum was associated with a positive igra. the median concentration of stimulated interferon-gamma changed significantly with period of pregnancy, with the highest concentration observed in the postpartum period. in a high burden setting, igra may be more sensitive than tst. immune changes during pregnancy, as well as potential repeated exposure, may contribute to the discordance observed, as well as to the atmadj et al medical and health science journal 2021 august vol.5 (02) page 65 of 69 increase in the concentration of interferon gamma in the postpartum period 10. one study found an association between indeterminate igra results and concomitant helminthes infection in pregnant women, raising the possibility that helminthic infection may lead to immune alterations that can hamper igra testing. 3) treatment three studies reported adherence with follow-up of positive tuberculin skin test results, and completion of treatment for ltbi. the proportion of women who attended follow-up after positive tuberculin tests varied from 14 to 69%, while 5 to 42% of those seen after positive skin tests completed at least 6 months of isoniazid treatment. one study found that less than 10% of women potentially eligible for treatment of ltbi completed inh prophylaxis. attrition was found at every step of the process e.g. lack of referral for evaluation after positive tests, gaps in adherence with follow-up appointments, limited adherence to treatment once prescribed. another study identified that asian ethnicity and continuity of care with the same physician in the ante partum and postpartum period were significantly associated with more frequent follow-up and treatment completion rates, while age below 25 was associated with poorer attendance at follow-up appointments. one study examined predictors of inh treatment completion, in rhode island; planned treatment initiation during the postpartum period was negatively associated with treatment completion. indeed, 52% of pregnant women referred for postpartum therapy did not return to initiate it. a cross sectional study highlighted that pregnancy was a missed opportunity for screening. indeed, in a cohort of patients who developed active tb, 22% of missed opportunities for screening in the community arose during pregnancy. conversely, 40% of patients who were known to have ltbi had been screened during pregnancy12–14. similarly, the highest proportion of patients with active tb despite previous screening for ltbi were those who failed to initiate inh therapy after testing during pregnancy. after the death of two pregnant women receiving isoniazid treatment in 1982, local health officials requested an analysis of isoniazid hepatitis morbidity and mortality among patients attending a u.s. prenatal clinic, which served a predominantly hispanic population. a retrospective cohort study compared 3, 681 pregnant and postpartum women enrolled in the 1981 inh preventive therapy program until its termination in 1982, with an unmatched comparison group of 3,948 women aged 15 to 44 years old involved in the 1971 public health service (phs) multicenter inh hepatitis surveillance study. two panels of experts determined possible cases of inh hepatitis. five cases were identified in the prenatal group and 10 cases were identified in the non-pregnant group. two hispanic women aged 24 and 27 years old died in the preventive therapy program group at 3 and 5 months postpartum. one death occurred in a 38 year-old non-pregnant black woman in atmadj et al medical and health science journal 2021 august vol.5 (02) page 66 of 69 the phs group. this analysis raised the possibility of associations of pregnancy/post-partum state with inh hepatitis (risk ratio of 2,5, 95% ci 0.8–8.2) and fatal hepatotoxicity (rate ratio 4, 95% ci 0.2–258). however, these groups were unmatched, were followed a decade apart, and the analysis was underpowered because of the rarity of these events. finally, one cross-sectional study examined the presence of inh in breast milk among lactating women during treatment for ltbi. peak inh concentrations in plasma and breast milk were measured one hour after administration. although some isoniazid did penetrate into breast milk, there was considerable inter-individual variability; the calculated mean relative infant dose of 1.2% of weight-adjusted maternal dose was deemed safe. the authors further suggested that lactating women wait at least one-hour interval to breastfeed, after ingesting inh. discussion ltbi was estimated to be present in up to nearly one half of foreign-born pregnant women tested in the usa. moreover, the post-partum period may be associated with an increased risk of tb reactivation. in low incidence settings, an igra may be more specific and less sensitive than tst, and results do not appear to be altered by pregnancy. screening programs in pregnant populations revealed excellent adherence with both tuberculin skin testing and cxr. however, adherence with post-partum follow-up of positive screening tests was poor, and a minority of women completed treatment. pregnancy may therefore represent a missed opportunity for treatment of latent infection. there remains some concern about higher incidence of inhassociated hepatitis in pregnancy and the postpartum period. based on measurements of plasma and breast milk concentration of isoniazid, it is likely safe to administer during lactation14. this study is the first systematic review focusing on ltbi in pregnancy. using available information from both low and high incidence countries, we addressed several aspects of its management, including prevalence, adherence with screening and treatment, new diagnostic tests, and potential treatment toxicity. most studies were of reasonable quality, with quality rating scores above 10 out of a maximum of 16 points. our study was limited by the absence of randomized controlled trials on the treatment of ltbi in pregnancy; we therefore could not draw any firm conclusions about the safety of inh therapy antepartum. there may have been some selection bias with respect to the articles included: we limited our review to studies published after 1980 because we felt that earlier studies would not reflect current practice. secondly, we excluded 6 articles that were published in languages other than english, french or spanish. abstracts were available online for three of those rejected articles: there was one cohort study identifying pregnancy as a risk factor for tb reactivation, one case report and one case series of women with postpartum tb. the titles for each of the other three articles referred to active disease. finally, we did not review the grey literature. another limitation was the lack of information concerning the atmadj et al medical and health science journal 2021 august vol.5 (02) page 67 of 69 potential use of newer ltbi treatment regimens during pregnancy, e.g. rifampin, combined isoniazid and rifampin, or combined isoniazid and rifapentine. prevalence of ltbi in hiv seropositive and seronegative pregnant women has been addressed in previous reviews, as has adherence to post partum follow-up of ltbi. however, we were able to retrieve studies not included in those earlier reviews. hence, while not all authors have concluded that pregnancy affects the evolution of latent tb infection, we believe that pregnancy may be a minor risk factor for disease reactivation whether it is through the immune changes of pregnancy itself, or the immune reconstitution that follows delivery. in addition, post partum tb may involve more severe disease, including immune reconstitution inflammatory syndrome (iris) and a high mortality rate. a case-series of 29 cases of postpartum tb published in 2013 described 93% of women with extra-pulmonary disease, and 69% with cns disease, although this series may have reflected publication bias. in those cases, treatment was initiated at a median 27 days after the onset of symptoms, and the mortality rate was 38%15. a markov decision analysis model estimated the cost effectiveness of ante partum or postpartum treatment of ltbi with 6 months of inh therapy. with an assumed 90% adherence to post-partum follow-up of a positive tuberculin test, and an assumed mortality rate of 0.001% related to inh-induced hepatitis, treatment initiated at 20 weeks of gestation was estimated to result in the fewest cases of tb. it was predicted to be less costly than postpartum treatment or no treatment. our review suggests substantially lower adherence to post-partum follow-up for latent tb infection, which may favor ante partum treatment with regards to cost-effectiveness. the frequently cited study suggesting pregnancy as a risk factor for inh induced hepatitis and associated mortality had wide confidence intervals which crossed the null value of 1. it used unmatched historical controls for comparison, while assessment of risk factors for inh induced hepatitis (e.g. alcohol consumption, baseline elevation of transaminases and viral hepatitis screen) was not consistent16. close monitoring of liver function tests during ante partum therapy with isoniazid could decrease the rate of clinically significant hepatitis. in view of these findings, it appears clinically relevant to consider further investigation of ante partum treatment for ltbi, particularly in the setting of other risk factors for reactivation e.g. diabetes. it would also be highly relevant to collate and publish outcomes of such treatment, e.g. through cooperative registries or networks such as the tuberculosis epidemiologic studies consortium (tbesc). an ongoing clinical trial on treatment of ltbi during pregnancy in hiv infected women, may allow for new insight into the previously described potential increased risk of hepatitis9. in addition, since current practice continues to emphasize deferring treatment of ltbi until after pregnancy, it would be important to examine strategies to enhance adherence among women who are treatment candidates. atmadj et al medical and health science journal 2021 august vol.5 (02) page 68 of 69 conclusion for women at risk, pregnancy provides an important opportunity to screen for latent tb infection. as women are already in care, adherence with tuberculin testing and chest radiography is high when these tests are recommended. however, adherence to postpartum follow-up and treatment is much lower, making pregnancy a missed opportunity for treatment of latent infection. interferon-gamma release assays may be considered as useful alternatives to the tuberculin skin test. the evidence base documenting treatment toxicity during pregnancy is limited, making further research in this area highly relevant. references 1. world health organisation. warning: this report is out-of-date. in particular, entire time-series of tb disease burden estimates are updated every year. for the latest data and analysis, please see the most recent edition of the global tb report. glob. tuberc. control (2014). 2. control, d., national, p., aids, h. i. v, hepatitis, v. & prevention, t. b. latent tuberculosis treatment guidelines: 2020 update. 7 (2020). 3. von elm, e. et al. the strengthening the reporting of observational studies in epidemiology (strobe) statement: guidelines for reporting observational studies. int. j. surg. 12, 1495–9 (2014). 4. lewinsohn, d. m. et al. official american thoracic society/infectious diseases society of america/centers for disease control and prevention clinical practice guidelines: diagnosis of tuberculosis in adults and children. clin. infect. dis. 64, e1–e33 (2017). 5. force, u. s. p. s. t. screening for latent tuberculosis infection in adults: us preventive services task force recommendation statement. jama 316, 962–969 (2016). 6. malhamé, i., cormier, m., sugarman, j. & schwartzman, k. latent tuberculosis in pregnancy: a systematic review. plos one 11, 1–12 (2016). 7. mathad, j. s. et al. pregnancy differentially impacts performance of latent tuberculosis diagnostics in a high-burden setting. plos one 9, (2014). 8. mayer, k. h., mathad, j. s. & gupta, a. tuberculosis in pregnant and postpartum women: epidemiology, management, and research gaps. clin. infect. dis. 55, 1532–49 (2012). 9. nguyen, h. t., pandolfini, c., chiodini, p. & bonati, m. tuberculosis care for pregnant women: a systematic review. bmc infect. dis. 14, 1–10 (2014). 10. lighter-fisher, j. performance of an interferon-gamma release assay to diagnose latent tuberculosis infection during pregnancy. obstetrics and gynecology vol. 120 398 (2012). 11. worjoloh, a. et al. interferon gamma release assay compared with the tuberculin skin test for latent tuberculosis detection in pregnancy. obstet. gynecol. 118, (2011). 12. parooei, f., mahmoodi, z., keikhaie, k. r. & salarzaei, m. breast tuberculosis in pregnancy (a review and report). j. pharm. sci. res. 9, 1701–1702 (2017). 13. fisher d, e. k. canadian tuberculosis standards 7th edition: 2014 canada.ca. 2017 (2014). 14. jackson, t. d. & murtha, a. p. anergy during pregnancy. am. j. obstet. gynecol. 184, 1090–2 (2011). atmadj et al medical and health science journal 2021 august vol.5 (02) page 69 of 69 15. jonsson, j., kühlmann-berenzon, s., berggren, i. & bruchfeld, j. increased risk of active tuberculosis during pregnancy and postpartum: a register-based cohort study in sweden. eur. respir. j. 55, (2020). 16. dhar, g. c. treatment of latent tuberculosis infection. ann. intern. med. 162, 394 (2015). d:\new order belum cetak\mhsj v ary andini, evi sylvia awwalia, studi prevalensi risiko diabetes melitus pada remaja usia 15–20 tahun di kabupaten sidoarjo 1919 studi prevalensi risiko diabetes melitus pada remaja usia 15–20 tahun di kabupaten sidoarjo ary andini, evi sylvia awwalia fakultas kesehatan, universitas nahdlatul ulama surabaya e-mail: aryandini@unusa.ac.id abstract: worldwide number of adolescents diagnosed with diabetes mellitus has increased every year means that a prevention to reduce the prevalence of diabetes mellitus is required. the aim of this study was to determine the prevalence of diabetes mellitus risk in adolescents in sidoarjo city, east java and diabetes mellitus risk factors. total population used in this study is composed by 150 men and women aged 15–20 years who reside in various locations in sidoarjo city. the obtained data were analyzed descriptively with cross-sectional design. the results showed the prevalence of diabetes risk in adolescents in sidoarjo is about 42% with average glucose levels 104.35 ± 13.01 mg/dl. the prevalence of non-diabetes mellitus in adolescents is 58% with the average glucose 79.26 ± 7.01 mg/dl. the risk factor which lead to high risk of diabetes mellitus is fast-food consumption (71%), soft drink consumption (31%) and smoking (5%). keywords: diabetes mellitus, adolescents, prevalence, risk factor abstrak: jumlah remaja yang terdiagnosis diabetes melitus mengalami peningkatan setiap tahunnya di seluruh dunia sehingga dibutuhkan suatu upaya pencegahan untuk menurunkan angka prevalensi diabetes melitus pada remaja. penelitian ini dilakukan untuk mengetahui prevalensi risiko diabetes melitus pada remaja di kabupaten sidoarjo, jawa timur dan faktor risiko yang memengaruhinya. jumlah populasi yang digunakan dalam penelitian ini yaitu 150 orang laki-laki dan perempuan berusia 15–20 tahun yang bertempat tinggal di berbagai lokasi di kabupaten sidoarjo. data yang didapatkan dianalisis secara deskriptif dengan desain cross-sectional. berdasarkan hasil penelitian menunjukkan prevalensi risiko diabetes pada remaja di sidoarjo sekitar 42% dengan rata-rata kadar glukosa 104,35±13,01 mg/dl. prevalensi non-diabetes melitus pada remaja sekitar 58% dengan rata-rata kadar glukosa 79,26 ± 7,01 mg/dl. adapun faktor risiko yang menyebabkan cukup tingginya risiko diabetes melitus remaja di kabupaten sidoarjo adalah konsumsi fast-food dengan persentase 71%, konsumsi minuman instan sekitar 31%, serta kebiasaan merokok sekitar 5%. kata kunci: diabetes melitus, remaja, prevalensi, faktor risiko pendahuluan berdasarkan informasi dari pusdatin, 2014 menunjukkan proporsi diabetes melitus pada penduduk usia 15 tahun ke atas mencapai 30,4%. persentase penderita diabetes melitus ini termasuk tinggi jika dibandingkan pada tahun 1980-an yang hanya mencapai 1,5–2,3%[1]. tahun 2011 tercatat 65 anak menderita diabetes melitus, naik 40% dibandingkan tahun 2009. tiga puluh dua anak di antaranya terkena diabetes melitus tipe 2[2][3]. diabetes melitus merupakan salah satu penyakit metabolic yang bersifat kronis. diabetes yang menyerang remaja umumnya diabetes tipe 1 karena sel beta pankreas menghasilkan sedikit hormon insulin yang disebabkan oleh faktor keturunan dan autoimun. namun, diabetes melitus tipe 2 pun bisa juga menyerang para remaja karena remaja termasuk dalam kelompok usia yang konsumtif sehingga cenderung untuk mengonsumsi berbagai jenis kuliner tanpa medical and health science journal, vol. 2, no. 1, february 2018 20 mengikuti pola hidup sehat. diabetes melitus tipe 2 disebabkan oleh resistansi insulin akibat kurangnya menjaga gaya hidup sehat tetap seimbang[1][4]. peningkatan jumlah penderita diabetes melitus yang cukup signifikan di indonesia sepatutnya mendapatkan perhatian serius dari pemerintah. oleh karena itu, deteksi dini pada diabetes melitus pada anak usia remaja merupakan hal penting yang harus dilakukan untuk menghindari kesalahan atau keterlambatan diagnosis dan penanganan yang berujung pada kematian. metode pada penelitian mengenai ini menggunakan desain penelitian cross-sectional yang dianalisis secara deskriptif. populasi studi penelitian remaja yang berusia 15–20 tahun di kawasan kabupaten sidoarjo. metode pemilihan sampel pada penelitian ini adalah simple random sampling. adapun besar sampel yang digunakan untuk mengetahui prevalensi pada diabetes melitus pada remaja di kabupaten sidoarjo sebanyak 150 orang berusia 15–20 tahun. data dikumpulkan oleh tim peneliti dengan melakukan pemeriksaan fisik dan kadar glukosa darah. informasi identitas responden, karakteristik responden dan riwayat kesehatan serta status kematian responden beserta anggota keluarganya didapatkan melalui pengisian formulir biodata dan kuesioner yang diberikan sebelum pemeriksaan. hasil berdasarkan hasil analisis data menunjukkan terdapat dua kategori dalam populasi yaitu normal dan risiko diabetes (prediabetes) yang dapat diamati pada tabel 1 dan gambar 1. tabel 1 rerata dan standar deviasi kadar glukosa darah remaja usia 15–20 tahun di kabupaten sidoarjo diagnosis n rerata kadar glukosa darah std. deviasi normal 87 79,26 7,01 risiko diabetes 63 104,35 13,01 gambar 1 persentase diagnosis normal dan prediabetes melitus pada remaja di kabupaten sidoarjo gambar 2 diagram batang faktor risiko diabetes melitus pada remaja pembahasan berdasarkan tabel 1 rata-rata dari kadar glukosa normal remaja di kabupaten sidoarjo sekitar 87 mg/dl dan rata-rata kadar glukosa darah yang termasuk risiko diabetes adalah 104,35 mg/dl. penentuan diagnosis normal dan risiko diabetes (pre-diabetes) menggunakan patokan diagnosis perkeni (2016) yang menary andini, evi sylvia awwalia, studi prevalensi risiko diabetes melitus pada remaja usia 15–20 tahun di kabupaten sidoarjo 21 jelaskan diagnosis normal jika nilai kadar glukosa darah kapiler <90 mg/dl dan diagnosis prediabetes jika nilai kadar glukosa darah kapiler antara 90–199 mg/dl[5]. hasil penelitian menunjukkan bahwa diagnosis normal kadar glukosa darah pada remaja di kabupaten sidoarjo adalah 42% sedangkan diagnosis risiko diabetes (prediabetes) mencapai 58%. hal ini menunjukkan bahwa potensi remaja di kabupaten sidoarjo terkena diabetes melitus tinggi. hal ini terjadi karena kecenderungan remaja yang kurang bijak dalam mengonsumsi makanan yang disertai dengan kurangnya aktivitas olahraga secara rutin. adapun faktor risiko dari penyebab meningkatnya nilai prevalensi prediabetes melitus bagi remaja berdasarkan hasil kuesioner adalah konsumsi makanan fast-food sekitar 64,2%, konsumsi minuman instan 31%, faktor keturunan 13,30% dan merokok 5%. berdasarkan penelitian tersebut menunjukkan kebiasaan remaja dalam konsumsi fast-food memiliki persentase tertinggi (64,2%) dan diikuti dengan konsumsi minuman instan (31%) dalam menyumbang tingginya prevalensi risiko diabetes melitus bagi remaja. remaja termasuk dalam kelompok usia yang konsumtif sehingga cenderung untuk mengonsumsi berbagai jenis kuliner tanpa diimbangi dengan gaya hidup sehat. menurut seisar komala dewi menjelaskan bahwa diabetes merupakan penyakit keturunan, artinya bila orang tua menderita diabetes, anakanaknya akan menderita diabetes juga[4]. bukti yang paling meyakinkan akan adanya faktor genetik adalah penelitian yang dilakukan pada saudara kembar identik penyandang dm, hampir 100% dapat dipastikan akan juga mengidap dm. penelitian lain menunjukkan bahwa seseorang berisiko terkena dm bila mempunyai riwayat keluarga dm. semakin dekat hubungannya (garis keturunan), semakin besar pula risiko untuk terkena dm[4]. berdasarkan hasil penelitian ini menunjukkan bahwa penyebab prediabetes karena faktor keturunan pada remaja sekitar 13,30%. merokok termasuk dalam faktor risiko yang memungkinkan untuk terjadinya resistensi insulin sehingga menurunkan aktivitas metabolisme glukosa yang berujung pada diabetes melitus tipe 2. merokok meningkatkan kejadian diabetes dan memperburuk homeostasis glukosa dan komplikasi diabetes kronis seperti komplikasi mikrovaskuler, onset dan perkembangan nefropati diabetes[6]. hasil penelitian ini menunjukkan bahwa penyebab risiko diabetes pada remaja karena kebiasaan merokok hanya sekitar 5%. ucapan terima kasih lembaga penelitian dan pengabdian masyarakat (lppm) universitas nahdlatul ulama surabaya. daftar rujukan pusat data dan informasi (pusdatin). 2014. infodatin: solusi dan analisis diabetes. kementerian kesehatan republik indonesia. pulungan a. 2013. increasing incidence of dm type 1 in indonesia. international journal of pediatric endocrinology, (suppl 1):o12. batubara j.r.l., tridjaja b., pulungan a.b. 2010. buku ajar endokrinologi anak. 1st ed. jakarta: idai, h. 162–163, 195. fatmawati a. 2010. faktor risiko kejadian diabetes melitus tipe 2 pasien rawat jalan [skripsi], semarang: universitas negeri semarang. medical and health science journal, vol. 2, no. 1, february 2018 22 perkeni. 2015. konsensus pengelolaan dan pencegahan diabetes melitus tipe-2 di indonesia. jakarta: penerbit perkeni. syamiyah, najah. 2014. faktor risiko kejadian diabetes melitus tipe 2 pada wanita di puskesmas kecamatan penggrahan jakarta selatan tahun 2014 [skripsi]. jakarta: universitas islam negeri syarif hidayatullah; 2014. riset kesehatan dasar: riskesdas. 2013. badan penelitian dan pengembangan kesehatan kementerian kesehatan republik indonesia. microsoft word 3. original article-3 (3177) (1).docx original article medical and health science journal 2022 august vol.6 (02) the relationship between sunscreen application and severity of melasma intan annisa putri, dian ardiana*, sihning e.j tehupuring faculty of medicine, hang tuah university article info article history: received : july 7, 2022 received in revised form : august 18, 2022 accepted : august 25, 2022 keywords: sunscreen, melasma, melasma area and severity index, sun protection factor, hypermelanosis *) corresponding author: dian.ardiana@hangtuah.a c.id abstract melasma is commonly observed in community among women of reproductive age. incidence of melasma at least nine times higher in women than men, especially in pregnant women. the relationship between sunscreen application and melasma in women of reproductive age has not been widely studied and the correlation is not clear. this study aims to determine the relationship between sunscreen use and severity of melasma in women of reproductive age. an analytical observational cross-sectional study was conducted among 31 women of productive age. the results showed that 14 respondents had good sunscreen usage habit (45.2%), whereas 17 respondents had sun protector irregularly (54.8%). a total 27 respondents (74.2%) had mild melasma, whereas 3 respondents had moderate melasma (22.6%) and 1 respondent had severe melasma (3.2%). the chi-square test shows that the significance value (p) = 0.000 (p <0.05) so that there is a significant relationship, meaning that there is a relationship between the use of sunscreen and severity of melasma in women of reproductive age. medical and health science journal medical and health science journal available at http://journal2.unusa.ac.id/index.php/mhsj; doi: 10.33086/mhsj.v6i2.3213 pissn 2549-7588. eissn 2549-7596 putri et al medical and health science journal 2022 august vol.6 (02) page 13 of 18 introduction melasma, formerly known as chloasma, is the most common hyperpigmented of the skin, particularly on the face (ogbechie godec & elbuluk, 2017). it appears as mild to dark brown hyperpigmentation with symmetrical shape and irregular borders. the prevalence varies from 1.5% to 33% depends on the population (huang et al., 2010 disitasi dalam passeron & picardo, 2018; basit et al., 2021). genetic factors, uv exposure and hormonal influence are the most common etiologic factors (grimes, 1995 disitasi dalam sarkar et al., 2020). ultra violet radiation can trigger and worsen melasma because it was thought to activate nitric oxide induced by reactive oxygen species (ros) (ogbechie-godec, o.a., & elbuluk, 2017). sun exposure shows an important role in the occurrence of uv radiation, which means that the higher sun exposure result in increasing severity of melasma (ai, young lee, 2014 cited in murniastuti, d.s. et al., 2020). various scoring systems have been proposed to evaluate the severity of melasma. the modified melasma area and severity index (mmasi) scores have the same validity and reliability as the melasma area and severity index (masi) scores, one of the most popular and earliest scoring systems used (abou-taleb, d.a. et al, 2017 cited in murniastuti, d.s. et al., 2020). treatment and prevention of melasma can begin with prevention of risk factors, protection against uv exposure and treating the lesions. inhibition of the melanin synthesis pathway, decreased transfer of melanosomes to keratinocytes and accelerated this research was conducted online involving 31 respondents who met the inclusion and exclusion criteria. all respondents involved were female with different age gaps. 1. sunscreen application from table 1, it was found that 45.2% of respondents use sunscreen regularly and 54.8% removal of melanin are the therapeutic principles of melasma. avoiding sun exposure is important for the improvement and prevention of melasma recurrence such as sunscreen application (trivedi et al., 2017; sarkar et al., 2018; elcistia & zulkarnain, 2019). sunscreen is a substance that helps reduce the amount of uv radiation by reflecting or absorbing harmful uv rays. use sunscreen regularly can reduce the risk of skin cancer, premature aging, sunburn and other skin diseases caused by uv radiation (xu et al., 2016). broad-spectrum sunscreen (spf 30) application was shown to reduce nevi in children in a 2000 study (young et al., 2017). the incidence of melasma often occurs in indonesia, because the majority of population has fitzpatrick iv skin type (suryaningsih et al., 2019). based on the description above, authors are interested in conducting research on "the relationship between sunscreen application and severity of melasma". methods the analytic observational design was used because there was no intervention or treatment for variables in data or collecting information. the research method used is quantitative research or observation was obtained through identification of the size of variation in value. the data was obtained through a questionnaire to assess the habit of using sunscreen and severity of melasma. data was collected according to the inclusion criteria with a simple random sampling technique. results were irregularly. so that some respondents have bad behavior in using sunscreen. putri et al medical and health science journal 2022 august vol.6 (02) page 14 of 18 table 1: use of sunscreen melasma to sunscreen application number of respondents (n) percentage (%) mi mod ld erat e se ver e tal regular 14 45,2 irregular 17 54,8 total 31 100 suns creen appli reg ular co 11 3 0 14 un t 2. the severity of melasma table 2 describes the number of respondents who have mild melasma 74.2%, moderate catio n % of to tal 35, 5 % 9,7 % 0 45, % 2 % melasma 22.6%, and 3.2% have severe irre gula co 12 4 1 17 un melasma. r t % 38, 12,9 3,2 54, table 2: severity of melasma of 7 % % 8 melasma number of percentage to % % tal total co un t 23 7 1 31 based on statistical tests in table 3, it is known that respondents who have good sunscreen usage habit have mild melasma 35.5%, moderate melasma 9,7%, and there are no respondents has severe melasma. whereas, irregular sunblock influenced the severity of melasma. as many as 38.7% have mild melasma, moderate melasma 12.9%, and 3.2% based on the lambda test, it is known that the significance value is 0.000 (p value <0.05). therefore, ho is rejected and h1 is accepted. it can be concluded there are significant relationship between use of sunscreen and severity of melasma. table 4: data analysis have severe melasma. table 3: cross-tabulation of sunscreen application with severity of melasma valu e assymptom atic standard errora approx imate tb approxi mate significa nce .438 .092 3.915 .000 discussion: based on the statistical calculation, 54.8% of respondents have bad sunscreen usage habit, while 45.2% use sunscreen regularly. this can occur due to lack of knowledge how to use sunscreen properly and correctly. sunscreen must re-apply every 2-4 hours in areas that are frequently exposed to the sun such as the face and neck and also leave the sunscreen at least % of to tal 74, 22,6 2 % % 3,2 10 % 0 % severity degree respondents (n) (%) mild 27 74,2 moderate 3 22,6 severe 1 3,2 total 31 100 putri et al medical and health science journal 2022 august vol.6 (02) page 15 of 18 10 minutes before doing activities/exposed to uv rays. moreover, it was found that 74.2% respondents had mild melasma, 22.6% had moderate melasma, and 3.2% had severe melasma. the severity of disease can be influenced by internal and external factors. internal factors that affect the severity of melasma such as genetic and hormonal factors, whereas external factors such as uv rays. several factors may affect the severity melasma to tends to be mild such as not pregnant woman (hormonal factors) and lack in outdoor activities during the pandemic, which is an average of < 3 hours. chi square test showed p = 0.001 (p value<0.05) which means that there is a relationship between the use of sunscreen and the severity of melasma in women of reproductive age. these results are supported by another study which showed that there was a relationship between the use of sunscreen and the severity of melasma (putri, 2017). external factors or internal factors may have their own role in influencing the severity of the respondent's melasma. this study took place during pandemic so respondents were often in their homes and rarely had contact with external factors that could increase the severity of melasma. various internal factors such as genetic and hormonal factors can also affect the severity of melasma in each individual. the results of this study are also in accordance with the theory which states that sunscreen can provide protection or prevention against melasma through protect the skin from uv rays by scattering and binding keratinocytes due to uv radiation (seite and park, 2013). compared with previous studies, smaller total number of respondents in this study might influence the results of the study to conclude the relationship between sunscreen use and the severity of melasma. besides, in this study data collection was carried out online might reduce the level of specificity of the results due to diagnosis was made based on questionnaires and did not see the patient directly. thus, some of the above evidence can be used as a consideration about sunscreen application and severity of melasma is relevant and need for further studies on the variables related to the behavior of using sunscreen and severity level of melasma. conclusion: based on the results of research and data analysis, as well as the discussion that has been carried out, it can be concluded that all 31 respondents have melasma. most of these respondents had mild melasma severity, as many as 27 respondents (74.2%) of 31 respondents. some respondents were also stated to have bad behavior in using sunscreen, which was 54.8%. in addition, there was also a relationship between the use of sunscreen and 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universitas hang tuah surabaya.2019 d:\new order belum cetak\mhsj v firdaus, handayani, m. yusuf alamudi, skrining malaria pada remaja di surabaya dengan menggunakan metode hapusan darah 1313 skrining malaria pada remaja di surabaya dengan menggunakan metode hapusan darah firdaus1), handayani2), m. yusuf alamudi3) 1,2)universitas nadhlatul ulama surabaya 3)pusat studi proteomik surabaya e-mail: ____________________ abstrak: malaria adalah penyakit infeksi disebabkan oleh parasit plasmodium yang hidup dan berkembang biak dalam sel darah merah manusia yang ditularkan oleh nyamuk malaria (anopheles) betina. malaria dapat menyerang semua orang: laki-laki ataupun perempuan dan pada semua golongan umur: bayi, anak-anak atau orang dewasa. sejak tahun 2000 kematian akibat malaria secara global telah menurun sekitar 60%, di mana 65% terjadi pada anak usia balita. sekitar 3,2 miliar penduduk (setengah dari populasi dunia) tinggal di daerah berisiko tertular malaria. pada tahun 2015, diperkirakan terdapat 214 juta kasus malaria, di mana 400 ribu kasus di antaranya menjadi penyebab kematian. di indonesia sendiri terdapat 417.819 kasus positif malaria pada tahun 2012 dan menurun hamper setengahnya pada tahun 2016 menjadi 218.450 kasus. indonesia mengalami kemajuan dalam pemberantasan malaria, terlihat bahwa dari total 258,9 juta penduduk indonesia pada tahun 2016 sejumlah 178,7 juta penduduk (69%) telah hidup di daerah bebas enularan malaria, namun masih terdapat 16,5 juta penduduk tinggal di daerah risiko tinggi dan sedang. dibandingkan dengan tahun sebelumnya terjadi peningkatan presentasi, seiring dengan jumlah daerah kabupaten/kota yang telah mencapai eliminasi pada tahun 2016 sebanyak 247 kab./kota. malaria selama kehamilan berkonsekuensi menyebabkan kesakitan, kematian, aborsi, kelahiran dini, berat badan lahir rendah (mengacu pada penghambatan pertumbuhan intra-uterine dan prematuritas) dan transmisi transplacental dari parasit malaria. infeksi malaria pada ibu hamil tidak hanya dapat meningkatkan risiko anemia yang dapat meningkatkan risiko perdarahan saat persalinan, namun juga meningkatkan risiko kematian bayi, prematuritas dan berat badan lahir rendah. risiko terkena malaria semakin meningkat terutama pada kehamilan trimester dua, ibu hamil memiliki risiko tiga kali lebih besar untuk menderita penyakit parah lainnya bila terinfeksi malaria dibandingkan perempuan yang tidak sedang hamil. kelompok remaja menjadi sangat penting karena mereka tidak lama lagi akan menikah dan mempunyai anak. tujuan penelitian ini adalah mengetahui infeksi malaria pada remaja di surabaya berdasarkan metode hapusan darah tipis dan tebal. penelitian ini dilakukan di pusat studi kesehatan pondok pesantren universitas nadhlatul ulama surabaya. sebanyak 54 remaja diuji dengan menggunakan metode hapusan darah tebal dan hapusan darah tipis. dari penelitian yang dilakukan didapatkan 54 remaja di surabaya negatif terhadap malaria dengan menggunakan metode hapusan darah tebal dan hapusan darah tipis. kata kunci: skrining, malaria, remaja, hapusan darah pendahuluan malaria merupakan salah satu masalah kesehatan publik utama di sebagian besar negara tropis termasuk indonesia di mana model terakhir menunjukkan bahwa 105 juta penduduk indonesia berisiko terjangkit penyakit ini (the global health group and the malaria atlas project, 2011). secara global, dilaporkan terdapat antara 6–21 juta kasus medis melibatkan infeksi plasmodium falciparum, penyebab utama malaria (hay dkk., 2010). penelitian terkini menunjukkan bahwa kurang lebih 11.000 meninggal karena infeksi p. falciparum (murray dkk., 2012) dengan kurang lebih 3.000 kematian diduga terjadi di indonesia (who, 2011). selain menimbulkan permasalahan kesehatan, malaria medical and health science journal, vol. 2, no. 1, february 2018 14 juga menyebabkan permasalahan bagi perkembangan suatu negara. serangan malaria bagi anak-anak usia sekolah dapat menyebabkan kesulitan dalam belajar dan tingginya tingkat ketidakhadiran anak di sekolah. serangan malaria bagi ibu hamil dapat menyebabkan gangguan perkembangan janin, prematur, dan terjadinya abortus (cutler dkk., 2007; elyazar dkk., 2013). demikian buruknya dampak yang dapat ditimbulkan oleh penyakit ini, menyebabkan beberapa negara yang menjadi daerah reseptif atau daerah yang memungkinkan terjadinya penularan malaria, maupun daerah endemis malaria berupaya keras untuk mengendalikan penyakit ini, termasuk di antaranya indonesia (departemen kesehatan, 2009; arsin 2012). walaupun demikian data mengenai faktor-faktor penyebab ledakan serangan malaria di indonesia relatif terbatas dan terkonsentrasi pada daerah-daerah endemik klasik serta menyajikan data-data terkini dengan sedikit melakukan evaluasi atas perubahan prevalensi penyakit. evaluasi dari kejadian luar biasa (klb) yang telah terjadi dapat memberikan suatu masukan dalam mengembangkan metode pengendalian malaria secara lebih efisien. remaja adalah mereka yang mengalami masa transisi (peralihan) dari masa kanak-kanak menuju masa dewasa, yaitu antara usia 12–13 tahun hingga usia 20-an, perubahan yang terjadi termasuk drastis pada semua aspek perkembangannya yaitu meliputi perkembangan fisik, kognitif, kepribadian, dan sosial (gunarsa, 2006). skrining malaria di kota surabaya belum banyak dilakukan terutama pada kelompok remaja. tujuan penelitian ini adalah skrining malaria pada remaja di kota surabaya. bahan dan metode sebanyak 54 orang remaja di surabaya dengan usia antara 19–20 tahun diuji dengan menggunakan metode hapusan darah terhadap malaria (plasmodium,sp). penelitian dilakukan di pusat studi kesehatan pondok pesantren universitas nadhlatul ulama surabaya. hasil dan pembahasan malaria dapat ditemukan mulai dari belahan bumi utara yaitu 64o lu (rusia) ke belahan bumi selatan yaitu 32o ls (argentina); mulai dari daerah dengan ketinggian 2600 m di atas permukaan laut sampai dengan daerah yang letaknya 400 m di bawah permukaan laut. kawasan asia tenggara menjadi perhatian kasus malaria. terdapat 1,4 miliar penduduk berisiko terkena malaria, dan 352 juta pada risiko tinggi (hakim 2011; who, 2014). kasus malaria di asia tenggara dan selatan terdapat di 10 negara yakni timor leste, sri lanka, butan, bangladesh, thailand, korea selatan, nepal, myanmar, india dan indonesia. menurut who (2014), kasus malaria di kawasan asia tenggara dan selatan tahun 2013 sebesar 1,5 juta kasus. proporsi malaria tertinggi dari jumlah kasus tahun 2013 adalah india (58%), myanmar (22%) dan indonesia (16%). sebagai bagian dari 10 negara yang mendapat perhatian akan kasus malaria di region asia tenggara dan selatan, dapat dikatakan indonesia belum bebas dari penyakit malaria. malaria di indonesia dapat ditemukan di seluruh wilayah provinsi dengan tingkat kejadian yang beragam. menurut data dari riset kesehatan dasar (riskesdas) tahun 2013, lima provinsi dengan insiden dan prevalensi tertinggi adalah papua (9,8% dan 28,6%), nusa tenggara timur (6,8% dan 23,3%), papua barat (6,7% dan 19,4%), sulawesi tengah (5,1% dan 12,5%), dan maluku (3,8% dan 10,7%). dari 33 provinsi di indonesia, 15 provinsi mempunyai prevalensi malaria di atas angka nasional, sebagian besar berada di indonesia timur. provinsi di jawafirdaus, handayani, m. yusuf alamudi, skrining malaria pada remaja di surabaya dengan menggunakan metode hapusan darah 15 bali merupakan daerah dengan prevalensi malaria lebih rendah dibanding provinsi lain, tetapi sebagian kasus malaria di jawa-bali terdeteksi bukan berdasarkan diagnosis oleh tenaga kesehatan. jumlah kasus malaria terkonfirmasi di indonesia tahun 2013 sebesar 343.527 dengan 45 kematian (who, 2014). sedangkan tingkat insiden malaria pada penduduk indonesia tahun 2013 adalah 1,9%, menurun dibandingkan tahun 2007 sebesar 2,9%, tetapi peningkatan tajam terjadi hanya di provinsi papua barat. angka prevalensi malaria di indonesia tahun 2013 sebesar 6,0% (kemenkes, 2013). prevalensi malaria di atas angka nasional sebagian besar berada di indonesia timur. proporsi penduduk dengan malaria positif mencapai 1,3 persen, atau sekitar dua kali lipat dari angka yang diperoleh riskesdas 2010 (0,6%). sedangkan proporsi penduduk perdesaan yang positif ditemukan sekitar dua kali lipat lebih banyak (1,7%) dibandingkan dengan penduduk perkotaan yakni sebesar 0,8% (kemenkes, 2013). malaria di indonesia merupakan salah satu bagian dari rencana strategis pembangunan kesehatan. hal ini disebabkan besarnya masalah kesehatan yang ditimbulkan oleh penyakit malaria. tabel 1 jumlah responden berdasarkan jenis kelamin tahun sebesar 33,7% di ntt. selain itu, penelitian yang dilakukan oleh ika (2015) dan daysema, dkk (2016) menyebutkan bahwa malaria atau plasmodium,sp ditemukan sebanyak 58.3% dengan rentang usia 25–45 tahun, usia 6–13 tahun sebesar 15% di daerah merauke papua. hasil negatif pada remaja di kota surabaya kemungkinan berhubungan dengan faktor pola hidup di perkotaan. penggunaan kelambu, kawat kasa pada rumah dan penggunaan zat penolak nyamuk yang intensitasnya berbeda sesuai dengan perbedaan status sosial masyarakat, akan memengaruhi angka kesakitan malaria. selain itu, faktor yang cukup penting yaitu pandangan masyarakat di suatu daerah terhadap malaria, jika malaria dianggap sebagai suatu kebutuhan yang mendesak untuk diatasi, upaya untuk menyehatkan lingkungan akan dilaksanakan secara spontan oleh masyarakat. jenis kelamin jumlah perempuan 51 orang laki-laki 3 orang berdasarkan hasil penelitian yang dilakukan dengan menggunakan metode hapusan darah pada 54 orang remaja di surabaya ditemukan hasil negatif terhadap malaria (plasmodium,sp). hasil penelitian ini memiliki perbedaan dengan penelitian yang dilakukan oleh paramita, dkk (2013), ditemukan malaria pada usia 12–25 (1) (2) gambar 1 hapusan darah remaja di surabaya terhadap malaria (plasmodium,sp), (1) hapusan darah pada remaja di surabaya, (2) kontrol positif plasmodium,sp dari hasil penelitian ini dapat direkomendasikan beberapa saran sebagai berikut. (1) kepada instansi terkait dan pemerintah daerah setempat untuk lebih meningkatkan pengetahuan masyarakat utamanya dalam meningkatkan aspek kesehatan guna penanggulangan wabah penyakit malaria seperti memberikan penyuluhan kesehatan, serta melakukan penyemprotan pada tempat-tempat perindukan nyamuk. (2) diharapkan agar masyarakat tetap mengembangkan sikap medical and health science journal, vol. 2, no. 1, february 2018 16 positif terhadap pencegahan dan penanggulangan wabah penyakit malaria dengan selalu menjaga kebersihan lingkungan rumah. (3) diharapkan agar tindakan nyata yang diambil masyarakat dalam mencegah dan menanggulangi wabah penyakit malaria lebih ditingkatkan ke arah yang lebih baik demi menghindari timbulnya kejadian malaria di kota surabaya. kesimpulan kesimpulan dari hasil penelitian ini adalah didapatkan hasil negatif pada remaja di surabaya terhadap malaria (falciparum,sp). pengujian terhadap malaria terus dilakukan terutama pada kelompok risiko tinggi. ucapan terima kasih terima kasih pada dina, s.st, tiwi, s.st, dian, s.st di dalam membantu terlaksananya penelitian ini. daftar rujukan arsin a.a. 2012. malaria di indonesia: tinjauan aspek epidemiologi. makassar: masagena press. cutler, david, w. fung, m. kremer, m. singhal, and t. vogl. 2007. mosquitoes: the longterm effects of malaria eradication in india. cambridge: national bureau of economic research. daysema, s.d., warouw s.m., rompis j. 2016. gambaran prevalensi malaria pada anak sd yapis 2 di desa maro kecamatan merauke kabupaten merauke papua. jurnal e-clinic (ecl), volume 4, nomor 1, januari-juni 2016. departemen kesehatan ri. 2009. keputusan menteri kesehatan republik indonesia nomor: 293/menkes/sk/iv/2009 28 april 2009 tentang eliminasi malaria di indonesia. jakarta: direktorat pemberantasan penyakit bersumber binatang, departemen kesehatan indonesia. elyazar, iqbal & e. sinka, marianne & gething, peter & n. tarmidzi, siti & surya, asik & kusriastuti, rita & winarno & baird, j. & hay, simon & bangs, michael. 2013. the distribution and bionomics of anopheles malaria vector mosquitoes in indonesia. advances in parasitology, 83. 173266. 10.1016/b978-0-12-407705-8.000033. gunarsa, singgih d. 2008. psikologi anak: psikologi perkembangan anak dan remaja. jakarta: pt bpk gunung mulia. harjanto p.n., nugroho a., gunawan c.a. 2009. malaria dari molekuler ke klinis, edisi ke2. jakarta: egc. hakim l. 2011. malaria: epidemiologi dan diagnosis aspirator, vol. 3 no. 2 tahun 2011: 107–116. ika nur atikoh. 2015. faktor yang berhubungan dengan kejadian malaria di desa selakambang kecamatan kaligondang kabupaten purbalingga tahun 2014. skripsi. peminatan kesehatan lingkungan program studi kesehatan masyarakat fakultas kedokteran dan ilmu kesehatan universitas islam negeri syarif hidayatullah jakarta. kemenkes ri. 2013. laporan riset kesehatan dasar. jakarta: kementerian kesehatan republik indonesia. made indah pradnya paramita, i made sudarmaja, i kadek swastika. 2014. studi retrospektif pada pasien positif malaria dengan pemeriksaan mikroskopik sediaan darah firdaus, handayani, m. yusuf alamudi, skrining malaria pada remaja di surabaya dengan menggunakan metode hapusan darah 17 tebal di rumah sakit umum daerah umbu rara meha januari-desember 2013. jurnal udayana. murray, c.j., l.c. rosenfeld, s.s. lim, k.g. andrews, k.j. foreman, d. haring, n. fullman, m. naghavi, r. lozano, and a.d. lopez. 2012 global malaria mortality between 1980 and 2010: a systematic analysis. lancet, 379: 413–431. the global health group and the malaria atlas project: atlas of the asia pacific malaria elimination network, 2011. san francisco: the global health group, global health sciences, university of california, san francisco. who. 2014. world malaria report. geneva: world health organization. world health organization (who). 2011. global malaria programme: world malaria report. switzerland: who press. medical and health science journal, vol. 2, no. 1, february 2018 18 medical and health science journal 2022 august vol.6 (02) medical and health science journal available at http://journal2.unusa.ac.id/index.php/mhsj; doi: 10.33086/mhsj.v6i2.3213 pissn 2549-7588. eissn 2549-7596 original article assessment of cardiovascular fitness among young sedentary adults using 1600 m walking test aftab begum1, lakshmi t2, syed sadat ali3* 1associate professor, department of physiology, basaveshwara medical college, chitradurga, karnataka, india 2assistant professor. department of physiology, mandya institute of medical sciences, mandya, karnataka, india. 3associate professor, department of physiology, sri siddhartha institute of medical sciences, t-begur, nelamangala, bengaluru rural, karnataka, india article info article history: received : july 18, 2022 received in revised form : august 02, 2022 accepted : august 11, 2022 keywords: cardiorespiratory fitness, physical activity, 1600 m walk. noncommunicable diseases, assessment. *) corresponding author: drsadatali@gmail.com abstract background: cardiorespiratory endurance refers to the ability of the heart and lungs to deliver oxygen to working muscles during continuous physical activity, which is an important indicator of physical health. physical activity is a complex multidimensional behaviour that is difficult to assess in freeliving populations and for which a gold standard measurement does not exist. thereby, we assessed cardiovascular fitness among young sedentary adults using 1600 m walking test. methods: the study participants were assessed for pulse rate, respiratory rate, blood pressure and oxygen saturation at rest followed by 1st, 2nd, 3rd and after 5 minutes after 1600 m walking test. results: there were no significant changes in pulse rate, respiratory rate, blood pressure; both systolic and diastolic blood pressure, and oxygen saturation across both the genders after performing 1600 m walk at 1st 2nd and 5th minutes except significant changes for respiratory rate (p=0.03) & systolic blood pressure (p =0.02). conclusion: there is no single gold standard for estimating the cardiac endurance and fitness. it has to be assessed for vo2 along with basic parameters and need to be repeated to validate the outcome and reduce the bias in case of aerobic exercises. medical and health science journal http://journal2.unusa.ac.id/index.php/mhsj begum et al medical and health science journal 2022 august vol.6 (02) page 2 of 6 introduction human evolution has been dependent on a physically active lifestyle supplemented with nutritional fortification.1 a physically active lifestyle is 1 of the 7 goals listed for ideal cardiovascular health in the 2020 american heart association impact goals. 2 physical activity is a complex multidimensional behaviour that is difficult to assess in free-living populations and for which a gold standard measurement does not exist. [3,4] the 4 dimensions of physical activity include (1) mode or type of activity, (2) frequency of performing activity, (3) duration of performing activity, and (4) intensity of performing activity.2 cardiorespiratory endurance is an important aspect of health that affects a person's physical and mental activity. this is indicated by the absolute intensity determined by external work, while the relative intensity is determined relative to the individual's cardiorespiratory fitness level (v̇o2max). 5 walking, for instance, is often described as a moderate-intensity physical activity; however, the actual intensity for an individual may vary. measures of physical activity derived from heart rate monitoring are typically time spent in physical activities at different intensity levels (eg, moderate and vigorous intensity). [2] living environments in developed countries are characterized by low daily energy expenditure and an abundant and inexpensive calorie-dense food supply, making positive energy balance common. [1] numerous investigators have confirmed the strong link between physical activity and health in a variety of populations. [4] there are major challenges to disentangling the complex multifactorial etiology of physical activity, adiposity and health outcomes. 1 lack of physical activity can have adverse effects and is often associated with chronic diseases, including heart disease, type 2 diabetes mellitus, hypertension, obesity, osteoporosis, depression, and breast and colorectal cancer.6,7 as such, a variety of methods have been used to assess physical activity and these measurements have a broad range of accuracy, reproducibility, and feasibility. [4] so, in this study we have used 1600 m walking test along with vo2 max, heart rate and respiratory rate to assess the cardiovascular endurance among the sedentary adults and compared it across the gender. we hypothesise that these above parameters collectively can be used to determine the cardiovascular endurance and validate the fitness of the individual. materials & methods: a cross sectional study was conducted under the auspices of department of physiology among 188 male and 212 female study participants. institutional ethical committee clearance & a written informed consent from the study participants were obtained. the heart rate and blood pressure among the study participants were measured in seated position at rest before sending them for 1600 m walking test. this was followed by continuous heart rate monitoring and recording of blood pressure for every three minutes during the test. by using oximeter, “pulse rate, respiratory rate, systolic & diastolic blood pressure along with oxygen saturations were measured and recorded in the 1st, 3rd & 5th minutes after the test and before the test in both the genders”. statistical analysis the data was evaluated with the ibm spss statistics 16.0 to compare the outcomes across the two groups. two sample t test and confidence interval of 95% is used. p<0.05 is considered as statistically significant and p<0.01 is considered as highly statistically significant. results: a total of 400 study participants among which 188 were male and 212 were female participants. all the participants have been measured for their anthropometric indices. they were checked for the basic parameters like pulse rate, respiratory rate, blood pressure and oxygen saturation at rest. these study participants were informed to complete the 1600 m walking test. following the walking test reading with regard to pulse rate, respiratory rate, systolic and diastolic blood pressure and oxygen saturation were recorded immediately after the walk followed after 1st, 2nd, 3rd and after 5 minutes. begum et al medical and health science journal 2022 august vol.6 (02) page 3 of 6 table 1: cardiovascular endurance across pulse rate at rest, immediately after exercise, 1,2, 3 and 5 minutes variable mean std. dev. 95% conf. interval t p pulse rate_at 84.3883 10.03061 82.94513 85.83146 -1.4377 0.1513 85.78302 9.365162 84.51509 87.05094 pulse rate_ ime 109.4628 12.58569 107.652 111.2735 -1.0946 0.2743 110.9198 13.87856 109.0408 112.7988 pulse rate_ 1 104.4043 11.81436 102.7045 106.1041 0.5234 0.6010 103.7406 13.35883 101.9319 105.5492 pulse rate_ 2 98.87234 9.948245 97.44102 100.3037 0.1695 0.8655 98.69811 10.53153 97.27228 100.124 pulse rate_ 3 91.78723 9.972017 90.3525 93.22197 -0.3797 0.7044 92.17453 10.3632 90.77148 93.57758 pulse rate_ 5 90.61702 8.705652 89.36449 91.86956 0.8696 0.1643 90.46698 9.467522 89.1852 91.74876 table 2: cardiovascular endurance across respiratory rate at rest, immediately after exercise, 1,2, 3 and 5 minutes variable mean std. dev. 95% conf. interval t p respiratory rate _at 15.21277 3.274835 14.7416 15.68394 -1.2112 0.2265 15.84906 6.508897 14.96783 16.73028 respiratory rate _ ime 25.46277 5.364141 24.69099 26.23454 0.2352 0.8142 25.34906 4.291604 24.76803 25.93009 respiratory rate _ 1 22.90426 3.572231 22.3903 23.41821 -1.1786 0.2393 23.65566 8.067213 22.56346 24.74786 respiratory rate _ 2 19.54787 2.135227 19.24066 19.85508 -1.8918 0.0592 19.98585 2.456211 19.65331 20.31839 respiratory rate _ 3 17.68617 1.921569 17.4097 17.96264 -2.1344 0.0334* 19.11321 8.985845 17.89664 20.32978 respiratory rate _ 5 16.6117 1.675004 16.37071 16.8527 -1.1734 0.2414 17.23585 7.119897 16.2719 18.19979 table 3: cardiovascular endurance across blood pressure at 1,2, 3 and 5 minutes using 1600-meter walking test variable mean std. dev. 95% conf. interval t p sbp _ atr 112.9787 10.82083 111.4219 114.5356 0.6163 0.5381 begum et al medical and health science journal 2022 august vol.6 (02) page 4 of 6 112.3443 9.76692 111.022 113.6667 dbp _ atr 79.11702 2.674324 78.73225 79.50179 -0.3465 0.7292 79.31132 7.263964 78.32787 80.29477 sbp _ ime 127.617 13.63709 125.655 129.5791 0.2948 0.7683 127.2217 13.15467 125.4407 129.0027 dbp _ ime 73.51064 13.17853 71.61456 75.40672 -0.3056 0.7600 73.90566 12.65138 72.19282 75.6185 sbp _ 1min 123.9149 10.11343 122.4598 125.37 1.9099 0.0569 121.8868 11.01298 120.3958 123.3778 dbp _ 1min 74.86702 9.238861 73.53777 76.19627 0.0286 0.9772 74.83962 9.828999 73.5089 76.17035 sbp _ 2min 120.0532 11.52942 118.3944 121.712 1.7543 0.0802 117.9953 11.86715 116.3886 119.6019 dbp _ 2min 72.2766 7.8378 71.14892 73.40427 0.0559 0.9554 72.23113 8.35744 71.09964 73.36262 sbp _ 3min 116.2394 8.294779 115.0459 117.4328 2.3278 0.0204* 114.0896 9.965651 112.7404 115.4388 dbp _ 3min 73.79787 5.062349 73.06952 74.52622 0.4123 0.6803 73.56132 6.256827 72.71423 74.40842 sbp _ 5min 109.5798 10.61575 108.0524 111.1071 1.1748 0.2408 108.4009 9.454034 107.121 109.6809 dbp _ 5min 68.29787 8.289327 67.10524 69.49051 -0.8726 0.3834 69.0566 9.011662 67.83654 70.27667 table 4: cardiovascular endurance across oxygen saturation at rest, immediately after exercise, 1,2, 3 and 5 minutes variable mean std. dev. 95% conf. interval t p o2 sat._at 96.68085 .9888444 96.53858 96.82312 -0.0299 0.9762 96.68396 1.083757 96.53724 96.83069 o2 sat._ ime 95.42021 2.405212 95.07416 95.76627 -0.8332 0.4053 95.62736 2.547707 95.28243 95.97229 o2 sat._ 1 94.48404 3.890859 93.92424 95.04384 -1.5315 0.1264 95 2.813306 94.61911 95.38089 o2 sat._ 2 95.85106 1.634896 95.61584 96.08629 -0.9908 0.3224 95.97642 .7995321 95.86817 96.08466 o2 sat._ 3 95.54255 1.510497 95.32523 95.75988 -0.2952 0.7680 95.58491 1.358616 95.40097 95.76885 o2 sat._ 5 96.27128 1.314593 96.08214 96.46042 1.0330 0.3023 96.13679 1.286151 95.96266 96.31092 begum et al medical and health science journal 2022 august vol.6 (02) page 5 of 6 among these study participants, there were no significant changes in pulse rate, respiratory rate, blood pressure; both systolic and diastolic blood pressure, and oxygen saturation across both the genders after performing 1600 m walk at 1st 2nd and 5th minutes except significant changes for respiratory rate (p=0.03) & systolic blood pressure (p =0.02), both, after 3 minutes were found. (table 2 & 3) discussion: physical activity (pa) is one of the most important contributors to maintaining optimal health, and considerable evidence suggests that sufficient pa has the potential to prevent numerous diseases and provide health benefits to people of all ages.8 this study provides evidence that there is no single gold standard test for assessing the cardiovascular endurance and fitness of any individual. high level of cardiorespiratory fitness in childhood could be a protective factor of cardiovascular disease in adulthood.9 fitness education and student fitness assessments offer students an opportunity to assess, track, and improve their fitness level. the effects of cardiovascular risk factors on health may partly be mediated through physical fitness level but the level of cardiorespiratory fitness is highly associated with the performance of other healthrelated fitness parameters in young people and in adults.10,11 in this study we could find that there were no significant changes in any of the parameters tested; pulse rate, respiratory rate, blood pressure and oxygen saturation except at one point for respiratory rate & blood pressure indicating that the assessment should include more than one tests which will increase the validity and these tests should be assessed repeatedly to overcome the confounding variables and bias. the findings of this study did not correlate with other study showing significant changes which would be due to the increase in the number of assessments.11 it is well known that individuals with regular physical activity have a lower risk of developing cardiovascular diseases, hypertension, type 2 diabetes, obesity and other chronic diseases. therefore, performing regular cardiorespiratory exercise improves exercise capability which in turn increase cardiorespiratory fitness and results in short and long-term benefits on overall health.12 thereby, consideration of study participants pertaining to the duration of exercise will help in eliciting their cardiovascular endurance using 1600 m walking test. in this study we could not find any significant change in oxygen saturation across the gender. this finding was correlated with other studies done irrespective of their gender and ethnicities.5 limitations of the study 1. the study has not included other variables affecting the cardiovascular endurance; lifestyle and nutrition which may act as confounding variables in bringing up the expected change among the study participants. 2. the expected change in cardiovascular endurance has been studied with only one test;1600 m walk. this either, if, done repeatedly and done along with other tests may show better results and outcome among the study participants. conclusion: the treatment of noncommunicable diseases (ncd), like coronary heart disease or type 2 diabetes mellitus, causes rising costs for the health system. physical activity is supposed to reduce the risk for these diseases. [13] there is no single gold standard for estimating the cardiac endurance and fitness. it has to be assessed for vo2 along with basic parameters and need to be repeated to validate the outcome and reduce the bias in case of aerobic exercises. acknowlegment the financing is obtained independently conflicts of interest there are no conflicts of interest declared by the author. begum et al medical and health science journal 2022 august vol.6 (02) page 6 of 6 references: 1. michael j. lamonte and steven n. blair. physical activity, cardiorespiratory fitness, and adiposity: contributions to disease risk, current opinion in clinical nutrition and metabolic care 2006, 9:540–546. 2. strath sj, kaminsky la, ainsworth be, ekelund ulf, freedson ps, gary ra, rn, et. al, guide to the assessment of physical activity: clinical and research applications, circulation, 2013;128:22592279. 3. flegal km, carroll md, ogden cl, johnson cl. prevalence and trends in obesity among us adults, 1999–2000. jama 2002; 288:1723–1727 4. us department of health and human services. physical activity and health: a report of the surgeon general. atlanta, ga: us department of health and human services, centers for disease control and prevention, national center for chronic disease prevention and health promotion; 1996. 5. kamyan d, labania l, kamyan a, rahman m, bagchi s. assessment of cardiorespiratory endurance in terms of physical fitness index and vo2max among young adult population of united arab emirates, international medical journal, 2020; 25(4):1927-11940. 6. lee im, shiroma ej, lobelo f, puska p, blair sn, katzmarzyk pt; lancet physical activity series working group. effect of physical inactivity on major noncommunicable diseases worldwide: an analysis of burden of disease and life expectancy. lancet. 2012; 380:219–229. 7. us department of health and human services. physical activity guidelines advisory committee report, 2008. washington, dc: us department of health and human services; 2008. http://www.health.gov/paguidelines/repor t/. 8. yamakita m, sato m, suzuki k, ando d, and yamagata z. sex differences in birth weight and physical activity in japanese schoolchildren, journal of epidemology, 2018:1-5. available at https://doi.org/10.2188/jea.je20170078. 9. ruiz jr, castro-pinero j, artero eg, ortega fb, sjostrom m, suni j, et al. predictive validity of health-related fitness in youth: a systematic review. br j sports med. 2009; 43:909–23. 10. ramírez-vélez r, correa-bautista je, ramos-sepúlveda ja, piñeros-álvarez ca, giraldo li, izquierdo m et al. aerobic capacity and future cardiovascular risk in indian community from a low-income area in cauca, colombia, italian journal of pediatrics ,2017;43(28):2-8. 11. tiku r, sharma p, kaul b. assessment of the cardio-respiratory fitness in young college going adults by 1 mile walk test an observational study. int j health sci res. 2015; 5(9):338-345. 12. nystoriak ma, bhatnagar a. cardiovascular effects and benefits of exercise. front cardiovasc med. 2018, 5:135. 13. reiner m, niermann c, jekauc d and woll a. long-term health benefits of physical activity – a systematic review of longitudinal studies. bmc public health 2013, 13:813. http://www.health.gov/paguidelines/report/ http://www.health.gov/paguidelines/report/ medical and health science journal 2022 august vol.6 (02) medical and health science journal available at http://journal2.unusa.ac.id/index.php/mhsj; doi: 10.33086/mhsj.v6i2.3386 pissn 2549-7588. eissn 2549-7596 original article usage of vitamin d supplements during covid19 pandemic in baghdad city, iraq hasanain faisal ghazi1, tiba nezar hasan2 1college of nursing, al-bayan university, baghdad, iraq 2 department of dentistry, al-turath university college, baghdad, iraq. article info article history: received : august 18, 2022 received in revise form: august 22, 2022 accepted: august 22, 2022 keywords: covid19, vitamin d supplements, adults, baghdad. *) corresponding author: hasanain.f@albayan.edu.iq abstract background: the aim of the current study is to determine vitamin d supplement usage among adults living in baghdad city, iraq during covid19 pandemic. methods: a cross-sectional study was conducted among 480 adults living in baghdad city, iraq through convince sampling. an online administered questionnaire was used to collect the data from respondents. results: around two-thirds of respondents used vitamin d supplements (65%). there was a significant association between taking vitamin d3 supplements and educational level, getting covid19 infection with p value of (0.01, <0.001, <0.001) respectively. conclusion: as a conclusion, two-thirds of our study respondents took vitamin d supplements during covid19 pandemic. more education is needed for population about the use of vitamin d in boosting immunity and preventing infections. medical and health science journal http://journal2.unusa.ac.id/index.php/mhsj mailto:hasanain.f@albayan.edu.iq ghazi et al medical and health science journal 2022 august vol.6 (02) page 26 of 29 introduction the world is presently encountering its third significant scourge of covid (cov) contaminations. another cov contamination pestilence started in wuhan, hubei, china, in late 2019, initially called 2019-ncov1 and renamed coronavirus by the world wellbeing association on february 11, 2020. past cov pandemics incorporate extreme intense respiratory disorder (sars)cov, what began in china in 2002 2, and the progressing center east respiratory condition (mers)cov in the center east, first detailed in 2012.3 a few audits consider the manners by vitamin d has numerous systems by which it diminishes the danger of microbial disease and demise. a study with respect to the job of vitamin d in decreasing the danger of the regular virus assembled those instruments into three classes: actual boundary, cell common invulnerability, and versatile resistance 4. vitamin d supplementation additionally upgrades the outflow of qualities identified with antioxidation (glutathione reductase and glutamate–cysteine ligase modifier subunit).5 a recent study relates to the role of vitamin d in reducing the risk of developing a cold by grouping these mechanisms into three categories: physical barrier, adaptive immunity, and cellular natural immunity. 4 adherent junctions, narrow junctions, gap junctions. (for example, by e-cadherin).6 there is many research looking on how to damage the integrity of the connections, leading to an increase in infection with the virus and other microorganisms.7 aim of the current study is to determine vitamin d3 supplement usage among adults in baghdad city. methods a cross-sectional study design was conducted among 480 adults living in baghdad city, iraq. the study period was from february till august 2021. the questionnaire consisted of 17 questions, and it consisted of three parts, where the first part include social and demographic questions (age, gender, marital status, occupation and educational level), and the second part includ questions related to covid 19 infection (have you had covid 19 infection before, in which a month i contracted covid, how many days did the infection last, did you use medication, did you take preventive measures), and the third part included questions about vitamin d (did you take a blood test to find out the level of vitamin d, 19have you ever taken nutritional supplements or multivitamins that contains vitamin d during the covid-19 pandemic how long have you been taking vitamin d motivation to start taking vitamin d. the inclusion criteria were adults living in baghdad city iraq who are willing to participate in the study while exclusion criteria were people who do not want to participate, people with mental problems. sampling method is convenience sampling (nonprobability). participation in the study is on voluntary bases. consent was taken from all the respondents. the details will be used for research purpose only. ethics approval was taken from college of nursing, al-bayan university statistical analysis data collected was analysed using statistical package of social science (spss) version 24.0 mean an sd was used for numerical variables while frequency and percentage for categorical variables, chi square test was used to test association between variables. results a total of 480 adults between the ages of 18 and 56 participated in the study. table 1 describes demographic data. the percentage of female participants in the study was greater than males, (59.8%). as for the social situation, the percentage of unmarried people was (64.2%), while the percentage of married people was (32.3%). as for the job, the percentage of students was greater than the employees, which amounted to (42.9%), while the percentage of employees in the government sector was (37.9%). table 1: socio-demographic characteristics of the respondents n % gender male 287 59.8 female 193 40.2 marital status married 155 32.3 single 308 64.2 divorced 17 3.5 ghazi et al medical and health science journal 2022 august vol.6 (02) page 27 of 29 occupation housewife 18 3.8 student 206 42.9 government worker 182 37.9 private sector worker 16 3.3 unemployed 58 12.1 min max mean sd age 18 57 26.55 6.334 how long infection last 1 60 13.79 8.092 table 2 shows descriptive statistics, where it is mentioned that the minimum age of the participant in the study is (18) years. the oldest participants in the study are 57 years old, with a mean age of (26.55) years. the table also shows that the percentage of university students was more than high school students, where the percentage of university students participating was (50.8%,) while the percentage of high school students was (31.9). table 2: covid 19 infection & management history did you get covid19 n % no 269 56.0 yes 211 44.0 which month got infected in 2020 march 25 5.2 april 19 4.0 may 18 3.8 june 19 4.0 july 31 6.5 august 18 3.8 september 24 5.0 october 22 4.6 november 19 4.0 december 16 3.3 admission to hospital no 188 39.2 yes 23 4.8 use medication no 28 5.8 yes 183 38.1 use anticoagulant no 169 35.2 yes 42 8.8 use antibiotics no 54 11.3 yes 157 32.7 family member infected no 276 57.5 yes 204 42.5 family member died no 461 96.0 yes 19 4.0 table 3 shows the descriptive statistics of covid 19. the percentage of people who were not infected with covid19 was higher than the infected people, as the percentage of healthy people who were not infected was (56.0%), while the percentage of infected people was (44.0%). as for the period of infection, the rate of infection in the month (7) was the highest, reaching (6.5%). as for the people who were admitted to the hospital and who were not admitted, the percentage of people who did not go to the hospital was more than those who were admitted to the hospital, where their percentage was (39.2%). as for people who took medical treatment, their percentage was (38.1%), which is more than those who did not take medical treatment (5.8%). as for people who took anticoagulant, their percentage reached (5.8%), which is much lower than those who did not take anticoagulant, their percentage reached (35.2%). the proportion of people who took antibiotics was higher (32.7%) than those in the study who did not take, while the proportion of people who did not take antibiotics (11.3%). the percentage of answers to the question: was a family member infected, the answers were the most? no family member was injured, where it was (57.5%). as for the answers about the death of a family member, the most answers were (96.0%) that no family member died. table 4: prevention control after infection & vitamin d safety after recovery n % no 55 11.5 yes 425 88.5 wearing the mask no 70 14.6 yes 410 85.4 hand washing no 46 9.6 yes 434 90.4 ghazi et al medical and health science journal 2022 august vol.6 (02) page 28 of 29 vitamin d blood test no 324 67.5 yes 156 32.5 vitamin d supplements before no 168 35.0 yes 312 65.0 vit. d dosage do not know 136 28.3 1000 iu 57 11.9 2000 iu 29 6.0 5000 iu 90 18.8 vit d usage motivation internet 89 18.5 doctor advice 149 31.0 friend 54 11.3 family member takes it 20 4.2 table 5: association between gender, covid-19 factors and vitamin d supplements usage vitamin d supplements usage p value no yes n (%) n (%) gender male 112 (39.0) 175 (61.0) 0.024 female 56 (29.0) 137 (71.0) did you get covid19 no 122 (45.4) 147 (54.6) <0.001* yes 46 (21.8) 165 (78.2) family member infected no 117 (42.4) 159 (57.6) <0.001* yes 51 (25.0) 153 (75.0) family member died no 166 (36.0) 295 (64.0) 0.022 yes 2 (10.5) 17 (89.5) *chi square test was performed, level of significant at p <0.05 overall, these data refer to the use of prophylactics and vitamin d3 in the daily lives of college students. as for the use of prevention and wearing a mask, the acceptance rate was significant (85.4%). the rejection rate was very low (14.6%) as for the students who used vitamin d3 and were not infected with the covid 19 virus, the percentage reached (65.0%). discussion the main findings of the current study are that twothirds of the respondents took vitamin d supplements during covid19 pandemic in baghdad city, iraq. the results showed that the percentage of people who took vitamin d before infection with covid 19 was (65.0%), where the percentage of males (61.0%) who take vitamin d more than females. these results are consistent with a study by 8(annweiler et al., 2020). in the intervention group, 82.5% (n=47). our results were supported by previous studies that multivitamin supplements are quite prevalent (64.2%) in the community of urban areas of bikaner. our findings are quite comparable with those of a national health and nutrition examination survey.9,10 likewise, a study conducted by reinert et al. reported that about 40% of the population were consumers of vitamin or mineral supplements.11 the results also showed the respondents’ high knowledge of preventive measures, namely wearing a mask and using sterilizers, in addition to the relationship of vitamin d3 with social and occupational status, the results showed that the percentage of unmarried people was higher than non-married people (62.7%). ghazi et al medical and health science journal 2022 august vol.6 (02) page 29 of 29 as for the job relationship, the percentage of the housewife in taking vitamin d3 was more (83.3%). as for education and its relationship to vitamin d3, as we previously explained that the percentage of knowledge most is among university students (70.5%). the results also showed the number of covid-19 cases where the percentage of injuries for those who took vitamin d3 (54.6%) was lower compared to people who did not take vitamin d3, and this confirms the role of vitamin d3 in preventing covid 19 disease. (p value < 0.001). as for the familial deaths who took vitamin d3 as well, it was low compared to the people who did not take vitamin d3 before infection. similar to previous studies, in this study also multiple reasons were mentioned by the participants for using vitamin supplements.12 in our current study, most of the respondents received knowledge about the multivitamin supplements from their physician (31.0.%). this finding is in accordance with the research by (guraya, 2018)13 who concluded that knowledge about the multivitamin supplements from their physician with (54.8%). conclusion as a conclusion, two-thirds of our study respondents took vitamin d supplements during covid19 pandemic. people at high risk of developing vitamin d deficiency during this pandemic should consider taking vitamin d supplements. more education and promotion are needed to educate people on the importance of vitamin d in enhancing the immunity and prevent infection. we recommend that future studies to be performed in other provinces of iraq and not only in baghdad and also to focus on covi19 patients and whether talking vitamin d had benefit them. acknowlegment the financing is obtained independently conflicts of interest there are no conflicts of interest declared by the author. references 1. zhu, n. et al. a novel coronavirus from patients with pneumonia in china, 2019. n. engl. j. med. 382, 727–733 (2020). 2. zhong. epidemiology and cause of severe acute respiratory syndrome (sars) in guangdong, people’s republic of china, in february, 2003 elsevier connect , the company ’ s public news and information. lancet 362, 1353–1358 (2003). 3. abdullah assiri, m.d, allison mcgeer, m.d, trish m. perl, m.d, connie s. price, m.d et al. nih public access. bone 23, 1– 7 (2014). 4. rondanelli, m. et al. self-care for common colds: the pivotal role of vitamin d, vitamin c, zinc, and echinacea in three main immune interactive clusters (physical barriers, innate and adaptive immunity) involved during an episode of common colds practical advice on dosages and on the time to take these nutrients/botanicals in order to prevent or treat common colds. evidence-based complement. altern. med. 2018, (2018). 5. lei, g., zhang, c., cheng, b. & lee, c. crossm supplemental therapy for pneumocystis. 61, 1–13 (2017). 6. marcos, a. editorial: a review of micronutrients and the immune system— working in harmony to reduce the risk of infection. nutrients 13, (2021). 7. neale, r. e. et al. environmental effects of stratospheric ozone depletion, uv radiation, and interactions with climate change: unep environmental effects assessment panel, update 2020. photochem. photobiol. sci. 20, 1–67 (2021). 8. annweiler, g. et al. vitamin d supplementation associated to better survival in hospitalized frail elderly covid-19 patients: the geria-covid quasi-experimental study. nutrients 12, 3377 (2020). 9. bailey, r. l. et al. best practices for dietary supplement assessment and estimation of total usual nutrient intakes in populationlevel research and monitoring. j. nutr. 149, 181–197 (2019). 10. gahche, j. j. et al. dietary supplement use among infants and toddlers aged <24 months in the united states, nhanes 2007-2014. j. nutr. 149, 314–322 (2019). 11. reinert, a., rohrmann, s., becker, n. & linseisen, j. lifestyle and diet in people using dietary supplements. eur. j. nutr. 46, 165–173 (2007). 12. dickinson, a., mackay, d. & wong, a. consumer attitudes about the role of multivitamins and other dietary supplements: report of a survey. nutr. j. 14, 66 (2015). 13. guraya, s. y. & almaramhy, h. h. mapping the factors that influence the career specialty preferences by the undergraduate medical students. saudi j. biol. sci. 25, 1096–1101 (2018). d:\new order belum cetak\mhsj v eppy setiyowati, pemberian vco pada tn. m dengan diagnosis medis cva infark dengan masalah keperawatan risiko kerusakan integritas kulit di ruang icu central rumkital dr. ramelan surabaya 3131 pemberian vco (virgin coconut oil) pada tn. m dengan diagnosis medis cva infark dengan masalah keperawatan risiko kerusakan integritas kulit di ruang icu central rumkital dr. ramelan surabaya eppy setiyowati fakultas kedokteran universitas nahdlatul ulama surabaya e-mail: eppy@unusa.ac.id abstrak: ulkus dekubitus merupakan masalah dermatologi yang sangat serius terutama pasien yang dirawat di icu, pasien tidak sadar, dan kurang mobilisasi. ukus dekubitus terjadi pada area yang terlokalisir dengan jaringan yang mengalami nekrosis dan biasanya terjadi pada permukaan tulang yang menonjol, sebagai akibat dari tekanan dalam jangka waktu yang lama menyebabkan peningkatan tekanan kapiler. penelitian ini bertujuan untuk mengetahui seberapa besar efektivitas penerapan pemberian vco pada pasien yang berisiko terkena ulkus dekubitus di ruang icu central rsal dr. ramelan surabaya. rancangan penelitian yang digunakan adalah studi kasus. penelitian studi kasus dilakukan dengan cara meneliti permasalahan melalui satu kasus yang terdiri dari unit tunggal. variabel yang digunakan adalah pemberian minyak kelapa murni vco pada pasien yang berisiko terkena ulkus dekubitus. teknik analisis data yang digunakan adalah deskriptif. cara analisis dengan pendekatan analisis induktif. berdasarkan hasil studi kasus di atas dapat ditarik kesimpulan yaitu pemberian vco pada pasien tn. m dengan masalah keperawatan risiko kerusakan integritas kulit menghasilkan ada pengaruh dalam pemberian vco untuk mencegah terjadinya dekubitus. kata kunci: dekubitus, vco (virgin coconut oil) abstract: ulcus decubitus is a serious dermal (skin) problem, especially for the unconscious patients with the lack of mobilization hospitalized in the icu. it appears in the area which is localized with the necrotic tissues; it also usually appears on the surface of protruding bones, resulted from the long term pressure which increases the capillary pressure. this study was purposed to analyze the effectiveness of the use of vco to the patient with the risk of having ulcus decubitus in the central icu of rumkital dr. ramelan surabaya (surabaya navy hospital). the design used in this study was case study done by investigating a problem through one case comprising of a single unit. the variable used in this study was the use of vco to the patient with the risk of ulcus decubitus. the data were analyzed descriptively done by using inductive approach. the result of this study concludes that the use of vco to mr. m who has the risk of impaired skin integrity is effective to prevent decubitus. keywords: decubitus, vco (virgin coconut oil) pendahuluan cva (cerebro vascular accident) adalah defisit neurologis yang mempunyai awitan tibatiba, berlangsung lebih dari 24 jam, dan disebabkan oleh penyakit serebrovascular (ida, 2010). cva terjadi pada saat terdapat gangguan aliran darah ke bagian otak. aliran darah terganggu karena adanya sumbatan pembuluh darah, karena trombus atau embolus, atau ruptur pembuluh darah (morton et al., 2012). seseorang yang menderita cva tidak dapat melakukan aktivitas seperti biasanya sehingga penderita mengalami penurunan mobilitas fisik dan dirawat di tempat tidur (bedrest). bedrest yang lama tanpa adanya medical and health science journal, vol. 2, no. 1, february 2018 32 perubahan posisi atau miring kanan dan miring kiri dapat menimbulkan adanya luka tekan. menurut suatu penelitian di indonesia yang dilakukan oleh suriadi (2007) angka kejadian luka dekubitus mencapai 33,3%. dan tidak terjadi penurunan angka kejadian dekubitus. kejadian dekubitus cukup bervariasi, tapi secara umum dilaporkan bahwa 5–11% terjadi tatanan perawatan jangka panjang dan 7–12% di tatanan perawatan atau home care. di dr. soetomo surabaya adalah rumah sakit tipe a atau sebagai rumah sakit rujukan utama di indonesia timur.hasil survei praktika senior pada tanggal 5 mei 2016 di ruang icu central rumkital dr. ramelan surabaya, didapatkan data bahwa terdapat 3 kasus ulkus dekubitus selama 1 bulan terakhir. marison (2003) dalam jurnal keperawatan hkbp balige (2013) mengatakan ulkus dekubitus merupakan ancaman yang sangat besar bagi populasi pasien yang dirawat di rumah sakit maupun perawatan lainnya. di ruang icu central rs dr. ramelan surabaya penanganan pasien yang terkena ulkus dekubitus hanya menggunakan handbody dan miring kanan dan kiri. (price, 2006) menyatakan jika menggunakan lotion biasa untuk perawatan kulit, umumnya lotion menggunakan komponen air sehingga ketika dipakai akan memberikan kesegaran sesaat namun kandungan airnya hilang karena penguapan, sehingga berisiko terjadinya ulkus dekubitus. sedangkan minyak kelapa murni unsur oksidan dan vitamin e masih bisa dipertahankan dan sebaliknya pada minyak goreng biasa, sehingga bila digunakan untuk perawatan kulit minyak goreng biasa akan menciptakan radikal bebas di permukaan kulit dan menyebabkan kerusakan jaringan. jika dipakai secara topikal atau dipakai ke dalam, minyak kelapa membantu kulit tetap muda, sehat dan bebas dari penyakit. asam lemak antiseptik pada minyak kelapa membantu mencegah infeksi jamur dan bakteri jika ditambahkan dalam diet atau dipakaikan langsung pada kulit. sehingga minyak kelapa murni dapat digunakan untuk mencegah terjadinya luka tekan atau ulkus dekubitus. menurut hasil penelitian dari (diah setiani 2014) ada pengaruh perawatan kulit perawatan kulit dengan pemberian vco untuk pencegahan kejadian luka tekan pasien yang dirawat di icu, ada perbedaan kejadian luka tekan antara kelompok intervensi dan kelompok dalam rentang nilai yang sama. hal ini ditunjukkan pada hasil statistik deskriptif bahwa pada kelompok pembekuan yaitu kelompok yang mendapatkan massage dengan vco tidak terjadi luka tekan, sedangkan pada kelompok kontrol atau kelompok yang mendapatkan perawatan standar ruangan, terjadi luka tekan. menurut hasil penelitian (betty sunaryanti 2012) ada pengaruh dalam pemberian vco terhadap pencegahan ulkus dekubitus pada responden yang diberikan vco, sedangkan responden yang tidak diberikan vco terjadi tanda ulkus dekubitus. berdasarkan latar belakang tersebut, maka penulis tertarik untuk melakukan pengelolaan kasus asuhan keperawatan yang akan dituangkan dalam bentuk karya tulis ilmiah dengan judul “pemberian vco (virgin coconut oil) pada pasien tn. m dengan diagnosa medis cva infark dengan masalah keperawatan risiko kerusakan integritas kulit di ruang icu central rumkital dr. ramlan surabaya”. hasil penelitian hasil dari inovasi yang dilakukan kemungkinan tingkat kegagalan yang terjadi sangat kecil dikarenakan dalam proses pemberian vco peneliti selalu memperhatikan tingkat kelembaban eppy setiyowati, pemberian vco pada tn. m dengan diagnosis medis cva infark dengan masalah keperawatan risiko kerusakan integritas kulit di ruang icu central rumkital dr. ramelan surabaya 33 kulit, posisi yang terkena ulkus dekubitus, kebersihan pasien dan juga tempat tidur, tujuannya untuk meminimalisasi timbulnya infeksi yang disebabkan oleh bakteri. sebelum pasien diberikan vco pertama kulit dibersihkan pada saat kotor dan atau secara rutin. frekuensi membersihkan tergantung kebutuhan pasien. menggunakan sabun lembut dan digosokkan secara pelan-pelan dengan kuat pada kulit, baru dioleskan vco ke seluruh tubuh secara merata terutama di bagian yang terkena ulkus dekubitus. untuk proses penyembuhan yang lebih optimal peneliti memberikan minyak sebanyak 2 kali per hari pagi dan sore, setelah di olesi vco juga di lakukan tindakan miring kanan dan kiri. upaya pencegahan luka tekan dinyatakan dalam beberapa literatur (moh 2001, epuap & npuap 2009, ngc 2008, mukti 1998) yang merujuk kepada beberapa hasil penelitian dan evidence secara garis besar terdiri dari upayaupaya. penggunaan secara topikal langsung pada kulit diyakini sebagai cara terbaik untuk mendapatkan manfaat vco. cara ini akan mengembalikan elastisitas kulit dengan cepat dan efektif (coconut-oilcentral. n.d ). trevtick & miton (1999) dalam penelitiannya menyimpulkan vitamin e dari vco yang diberikan secara topikal dapat terserap dalam 24 jam. wang dan quinn (1999) menyatakan vitamin e adalah zat yang berfungsi sebagai stabilizer membrane sel, melindungi kerusakan sel dari radikal bebas dan sebagai simpanan lemak dalam organel sel. selain itu vco mempunyai kemampuan antioksidan, antimikrobial, anti-fungi, melindungi kulit dari bahaya radikal bebas degenerasi jaringan ( coconut research center, 2004). pembahasan pemberian minyak kelapa murni vco secara rutin dan continue diberikan pada area yang terkena luka tekan grade i. kandungan asam lemak (terutama asam laurat dan oleat) bersifat melembutkan kulit dan antimicrobial sehingga vco efektif dan aman digunakan sebagai moisturizer pada kulit (agero and-rowell, 2008; lucida, salman & hervian, 2012). dalam hal ini peneliti melakukan suatu inovasi yang dilakukan pada tn.m dengan menerapkan tindakan keperawatan tentang pemberian minyak kelapa murni vco sesuai dengan teori dan jurnal yang ada. penggunaan minyak vco yang diolesi ke kulit pasien yang memerah secara teratur dan continue. pemberian minyak kelapa murni vco yang dilakukan peneliti pada pasien tn.m dilaksanakan selama 3 hari berturut-turut dari tanggal 11–13 mei 2016. pemberian vco dilakukan setiap 2 kali sehari. pemberian vco yang peneliti lakukan adalah sesuai dengan jadwal shift di mana peneliti berdinas. sedangkan pada saat peneliti tidak berdinas tugas tersebut dilanjutkan oleh mahasiswa yang praktik keperawatan di ruang icu. pada saat melakukan pemberian vco pada pasien peneliti tidak menemukan kendala. kesimpulan dan saran simpulan berdasarkan hasil studi kasus di atas dapat ditarik kesimpulan yaitu penerapan pemberian minyak kelapa murni vco pada pasien tn. m dengan tirah baring lama menghasilkan dekubitus grade i tidak terjadi dan gejala kemerahan yang ditimbulkan oleh luka tekan dekubitus grade i hilang. . medical and health science journal, vol. 2, no. 1, february 2018 34 saran 1. bagi perawat dan tenaga medis perawat pelaksana dapat menerapkan teknik pemberian minyak kelapa murni vco pada seluruh pasien tirah baring lama, sehingga terjadinya dekubitus dapat diminimalisasi. 2. bagi institusi pendidikan penerapan teknik pemberian minyak kelapa murni vco dapat dimasukkan dalam proses pembelajaran dan dapat dilakukan dengan memberikan materi‘. daftar pustaka amin, sarmidi. 2009. cocopreneurship aneka peluang bisnis dari kelapa. yogyakarta: lily publisher. ariani, t.a. 2012. sistem neurobehaviour. edisi pertama. jakarta: salemba medika. corwin, e.j. 2009. buku saku patofisiologi. jakarta: egc. dermawan, d. 2012. proses keperawatan penerapan konsep & kerangka kerja. edisi pertama. yogyakarta: gosyen publishing. muttaqin, a. 2008. buku ajar asuhan keperawatan klien dengan gangguan sistem persarafan. edisi pertama. jakarta: salemba medika. m. bulechek, et al. 2013. nursing intervention classification (nic) sixth edition. mosby. mariana, bella dkk. 2013. pencegahan kejadian luka tekan melalui massage virgin coconut oil pada pasien dengan imobilisasi, 1(1): 38–42. nanda. 2011. diagnosa keperawatan definisi dan klasifikasi 2012–2014. jakarta: egc. price, murai. 2003. terapi minyak kelapa (bahrul ulum, penerjemah). 2004. jakarta: prestasi pustaka publisher. potter, p.a. & perry, a.g. 2007. basic nursing skill essential for practice. canada: mosby elsevier. sabandar, o.a. 2008. decubitus. january 31, 2010. siswono. 2006. manfaat minyak kelapa murni (vco) untuk kesehatan. diakses dari http://www.republika.co.id. sunaryanti, betty dkk. 2013. perubahan pengaruh antara pemberian minyak kelapa dan madu widodo, a. 2007. uji kepekaan instrumen pengkajian risiko dekubitus dalam mendeteksi dini risiko kejadian dekubitus di rsis. surakarta: universitas muhamadiyah. a. widodo–2007–publikasiilmiah.ums.ac.id. 15 juni 2016 (09:36). wilkinson, j.m. 2007. buku saku diagnosa keperawatan dengan intervensi nic dan kriteria hasil noc. edisi ketujuh. jakarta: egc. medical and health science journal 2022 august vol.6 (02) medical and health science journal available at http://journal2.unusa.ac.id/index.php/mhsj; doi: 10.33086/mhsj.v6i2.3212 pissn 2549-7588. eissn 2549-7596 review article a brief review of beneficial effects of yoga on physical and mental health syed sadat ali 1*, muhammad akram2, abid rashid2, muhammad talha khalil2, hina anwar2, umme laila2, rida zainab2, ghulam mohiuddin2 1associate professor, department of physiology, sri siddhartha institute of medical sciences, tbegur, nelamangala taluk, bengaluru rural, bengaluru – karnataka, india 2department of eastern medicine, government college university, faisalabad, pakistan bengaluru rural, karnataka, india article info article history: received : july 18, 2022 received in revised form: august 20, 2022 accepted : august 26, 2022 keywords: yoga, physical health, mental health, quality life years, depression, anxiety. *) corresponding author: drsadatali@gmail.com abstract yoga is focussed as an essential form of spiritual discipline based on an extremely subtle science bringing harmony between mind and body. it is an art and science of healthy living consisting largely of asanas. it is found to be one of the best exercises for physical and mental health. there is more need of supportive therapy for maintaining physical and mental health apart from current treatment by different forms of medicine. it is known to relax body, promote immunity and thereby prevent illness seeing as effective, acceptable and cost-effective for body and mind to relieve stress. an online search for studies done using medline terms like yoga, physical health & mental health were done. the studies have shown that it improves physical illness and promotes mental calmness by removal of anxiety, depression & stress thereby excel the treatment of diseases. these gives positive change such as well-being and happiness to the individual and increase the quality life years. medical and health science journal http://journal2.unusa.ac.id/index.php/mhsj ali et al medical and health science journal 2022 august vol.6 (02) page 31 of 34 introduction yoga is word derived from indian philosophy which is related to physical exercise and postures. yoga exercise not only relax or gives flexibility to mind and body but removes stress, gives strength and breathing deepening in yoga along medication removes anxiety and depression1. other benefit is to it gives fitness to body by regulating bp, mood and metabolism2. yoga has therapeutic effects mainly in respiratory, cardiovascular and psychiatric disorders3. yoga has therapeutic effects on body which gives positive effects on physical and mental health. yoga is an exercise of postures that improves physical and mental health. anxiety and depression are largest contributor of disease after ischemic heart disease. yoga is as therapeutic to prevent illness and promote mental well-being. mental health improvement approaches the roots of problem and help to prevent diseases 4-6.yoga prevents diseases and treat anxiety and depression and brings mental health balance. yoga yoga is word from sanskrit having paths 1.moral codes 2.self-discipline 3.postures 4.breath practice 5.concentration 6.sensory transcendence 7.meditation 8.state of bliss yoga is best practice in asia to join mind and body to promote physical and mental health collectively 7.yoga is exercise which has interconnects and union in life7 yoga practice is in world because of its benefits and linked because it has therapeutic effects 8.yoga is physical exercise which has aim to union in life 7.yoga is an individual practice that anyone can perform and has positive social interactions. it is performed because of low cost and to get peace and healthier body. yoga and mental health there are many studies on yoga because of its benefits from medical services. the benefits of current research on yoga have brought peace and improves mental health. different researches are performed on concentration, exercise, self-discipline, position and conclude it to be best to improve mental health and prevent disorders by giving inner satisfaction. few studies have shown that performing yoga regularly under trained guru has improved mental health and better health randomly9. figure 1: benefits of yoga on mental health copyright: vocal.media/longevity/importance-of-yoga-for-mentalwellness a study has found yoga practice of quieting the mind10. a sound mental health can permit all to participate in curricular activities, can face stress, learn his or her abilities ,can get inner peace, can work better and contribute in every field of life11. currently, research is going to perform on improving the mental health and life quality by preventing disorders. these are four publications on therapeutic effects of yoga in diminishing depression6, 12 and one is breathing deeply in yoga13 and one summary14. researchers have found depression caused from various sources, its elevation and its increasing symptoms in everyday life. many researchers have shown that yoga removes the symptoms of depression from people. in comparison to other exercises yoga actively control depression12. yoga practices brings change in neurotransmitter chemicals by electrophysiological changes and removes depression mainly by gaba6, 13. this also has found to alleviate fatigue in healthy people and those who are suffering from asthma, sclerosis, cancer, fibromyalgia, dialysis and pancreatitis15. along with medication, yoga has seen to have therapeutic effects in decreasing anxiety in a study.1 ali et al medical and health science journal 2022 august vol.6 (02) page 32 of 34 yoga has beneficial effects in treating anxiety and trials have been performed in which it is shown to be beneficial in diminishing anxiety which yoga fulfil criteria16. it also removes posttraumatic stress disorder. studies have shown that it has helps in diminishing stress, sadness, disturb sleep and anxiety17. yoga and physical fitness yoga practise is one of best exercise which keeps body fit even in old age. studies have shown that yoga gives fitness physically with respect to balance, body relaxation, function, strengthening body and weight loss18. in yoga along with physical fitness, yoga brings inner calm, improves function, abilities positively and self-confidence in adults. it also improves social involvement and self-esteem. it has effects in physical fitness by sympathetic and parasympathetic activation and vagal nerves. yoga shifts sympathetic to parasympathetic system by releasing hormone or neurotransmitter by vagal stimulation19. it is reported that yoga gives strength to muscles of heart20. effect of yoga on life yoga has one of best to improve quality of life in healthy and ill both people by decreasing fatigue, anxiety and depression. in comparison to other forms of exercise, yoga has more benefits by alleviating depression & stress, also benefit for cardiorespiratory function and in patients of mood disorders21. figure 2: health benefits of yoga copyright: harvard health publications many forms of treatment by medicine has toxic side effects but yoga has no side effects but also enhance the quality of life22. yoga also improves physical and mental health in prison23. yoga is best to improve health of women during pregnancy and help to cope in sexual relationship by strengthening muscles24. it removes stress, depression in breast cancer therapy25 and also improves health in other people who are not psycho26. yoga is used as adjunctive therapy27. a study has found supportive role of yoga benefitting to help in treatment of depression28 it is equal to antidepressants 29. yoga and antidepressants along are more beneficial30. yoga experience patient feels good after practising yoga and use it positively. it motivates patients by removing stress, depression and they cope with their abilities which improves their performance. yoga effects on body yoga has one important impact on body is prevention of diseases, removing anxiety and depression, promoting health both physically and mentally. it has also an effect on heart, respiratory system and brain and it gives inner peace to fight with stress and keep calm. when it effects on brain it stimulate gaba(gamma amino butyric acid) by parasympathetic system which are affected by vagal nerves31. yoga by breathing & postures, body movement is found to be best among patients with cardiac illness. yoga gives positive expressions in immune cells32. in yoga, breathing is slow which acts as link between body and mind to give relaxation to body which acts on principle of yoga. slow and deep breaths fulfil the body needs of oxygen. it gives relaxation and stability to mind and body and improves mental health and function. yoga by relaxing mind gives relaxation to body effectively and it helps to decrease mood disorder, depression, stress, anger and gives inner satisfaction and happiness. many of the postures are like tree, snake, animals like cat, dog etc33. one of best pose is corpse pose in which limbs are relax by lying down as deep rest. yoga-practice in schools, colleges, workshops and health care is best to promote physical and mental health of people34. yoga and cardiopulmonary system it is reported that yoga practicing help in controlling bp or hypertension in which it is studied that it lowers both systolic and diastolic blood pressure 19.one research conclude that yoga lowers both systolic and diastolic blood pressure in without comparing to medicine treatment35. yoga helps in improving lung function in patients of asthma and bronchitis because of deep breathing20. yoga and metabolic syndrome ali et al medical and health science journal 2022 august vol.6 (02) page 33 of 34 yoga practicing has effect on insulin resistance syndrome which it has effect in controlling glucose 19t2 diabetes mellitus36 and its management which it can control glucose level for short term not for long term37. it is treated by duration of yoga from 20 min to varying session from 3-5 days for 90 min and it has beneficial therapeutics effects. yoga studied evidence that it has menopausal effect which is insufficient38. in menopausal symptom yoga has effective intervention in psychiatric, urogenital, vasomotor and somatic symptoms 39 yoga and musculoskeletal condition yoga practising is beneficial in physical fitness and relaxation of muscles which treats pain. researches are performed on function of muscles40, 41and on chronic pain42, 43including lower back pain and joints pain or arthritis. studies concluded that yoga is favourable in treating pain like headache, migraine, backache, arthritis and labour pain. acknowlegment the financing is obtained independently conflicts of interest there are no conflicts of interest declared by the author. references 1. kirkwood g, rampes h, tuffrey v, et al. yoga for anxiety: a systematic review of the research evidence.british journal of sports medicine; 2005; 39: 884-891. 2. yang k. a review of yoga programs for four leading risk factors of chronic diseases.evidence-based complementary and alternative medicine; 2007; 4. 3. jeter pe, slutsky j, singh n, et al. yoga as a therapeutic intervention: a bibliometric analysis of published research studies from 1967 to 2013.the journal of 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research review.international journal of yoga therapy; 2009; 19: 103-112. e:\job aditya\indro\naskah masu eppy setiyowati, pemberian vco pada tn. m dengan diagnosis medis cva infark dengan masalah keperawatan risiko kerusakan integritas kulit di ruang icu central rumtikal dr. ramelan surabaya 1313 pemberian vco (virgin coconut oil) pada tn. m dengan diagnosis medis cva infark dengan masalah keperawatan risiko kerusakan integritas kulit di ruang icu central rumkital dr. ramelan surabaya eppy setiyowati dosen fkk universitas nahdlatul ulamasurabaya e-mail: eppy@unusa.ac.id abstract: ulcus decubitus is a serious dermal (skin) problem, especially for the unconscious patients with the lack of mobilization hospitalized in the icu. it appears in the area which is localized with the necrotic tissues; it also usually appears on the surface of protruding bones, resulted from the long term pressure which increases the capillary pressure. this study was purposed to analyze the effectiveness of the use of vco to the patient with the risk of having ulcus decubitus in the central icu of rumkital dr. ramelan surabaya (surabaya navy hospital). the design used in this study was case study done by investigating a problem through one case comprising of a single unit. the variable used in this study was the use of vco to the patient with the risk of ulcus decubitus. the data were analyzed descriptively done by using inductive approach. the result of this study concludes that the use of vco to mr. m who has the risk of impaired skin integrity is effective to prevent decubitus. keywords: decubitus, vco (virgin coconut oil) abstrak: ulkus dekubitus merupakan masalah dermatologi yang sangat serius terutama pasien yang dirawat di icu, pasien tidak sadar, dan kurang mobilisasi. ukus dekubitus terjadi pada area yang terlokalisir dengan jaringan yang mengalami nekrosis dan biasanya terjadi pada permukaan tulang yang menonjol, sebagai akibat dari tekanan dalam jangka waktu yang lama menyebabkan peningkatan tekanan kapiler. penelitian ini bertujuan untuk mengetahui seberapa besar efektivitas penerapan pemberian vco pada pasien yang berisiko terkena ulkus dekubitus di ruang icu central rsal dr. ramelan surabaya. rancangan penelitian yang digunakan adalah studi kasus. penelitian studi kasus dilakukan dengan cara meneliti permasalahan melalui satu kasus yang terdiri dari unit tunggal. variabel yang digunakan adalah pemberian minyak kelapa murni vco pada pasien yang berisiko terkena ulkus dekubitus. teknik analisis data yang digunakan adalah deskriptif. cara analisis dengan pendekatan analisis induktif. berdasarkan hasil studi kasus di atas dapat ditarik kesimpulan yaitu pemberian vco pada pasien tn. m dengan masalah keperawatan risiko kerusakan integritas kulit menghasilkan ada pengaruh dalam pemberian vco untuk mencegah terjadinya dekubitus. kata kunci: dekubitus, vco (virgin coconut oil) pendahuluan cva (cerebro vascularaccident) adalah defisit neurologis yang mempunyai awitan tibatiba, berlangsung lebih dari 24 jam, dan disebabkan oleh penyakit serebrovaskular (ida, 2010). cva terjadi pada saat terdapat gangguan aliran darah ke bagian otak. aliran darah terganggu karena adanya sumbatan pembuluh darah, karena trombus atau embolus, atau ruptur pembuluh darah (morton et al, 2012). seseorang yang menderita cva tidak dapat melakukan aktivitas seperti biasanya sehingga penderita mengalami penurunan mobilitas fisik dan dirawat di tempat tidur (bedrest). bedrest yang lama tanpa adanya medical and health science journal, vol. 1, no. 2, august 2017 14 perubahan posisi atau miring kanan dan miring kiri dapat menimbulkan adanya luka tekan. menurut suatu penelitian di indonesia yang dilakukan oleh suriadi (2007) angka kejadian luka dekubitus mencapai 33,3% dan tidak terjadi penurunan angka kejadian dekubitus. kejadian dekubitus cukup bervariasi, tapi secara umum dilaporkan bahwa 5–11% terjadi tatanan perawatan jangka panjang dan 7–12% di tatanan perawatan atau home care. di dr. soetomo surabaya adalah rumah sakit tipe a atau sebagai rumah sakit rujukan utama di indonesia timur. hasil survei praktika senior pada tanggal 5 mei 2016 di ruang icu central rumkital dr. ramelan surabaya, didapatkan data bahwa terdapat 3 kasus ulkus dekubitus selama 1 bulan terakhir. marison (2003) dalam jurnal keperawatan hkbp balige (2013) mengatakan ulkus dekubitus merupakan ancaman yang sangat besar bagi populasi pasien yang dirawat di rumah sakit maupun perawatan lainnya. di ruang icu central rs dr. ramelan surabaya penanganan pasien yang terkena ulkus dekubitus hanya menggunakan handbody dan miring kanan dan kiri. price, 2006 menyatakan jika menggunakan lotion biasa untuk perawatan kulit, umumnya lotion menggunakan komponen air sehingga ketika dipakai akan memberikan kesegaran sesaat namun kandungan airnya hilang karena penguapan, sehingga berisiko terjadinya ulkus dekubitus. sedangkan minyak kelapa murni unsur oksidan dan vitamin e masih bisa dipertahankan dan sebaliknya pada minyak goreng biasa, sehingga bila digunakan untuk perawatan kulit minyak goreng biasa akan menciptakan radikal bebas di permukaan kulit dan menyebabkan kerusakan jaringan. jika dipakai secara topikal atau dipakai ke dalam, minyak kelapa membantu kulit tetap muda, sehat dan bebas dari penyakit. asam lemak antiseptik pada minyak kelapa membantu mencegah infeksi jamur dan bakteri jika ditambahkan dalam diet atau dipakaikan langsung pada kulit. sehingga minyak kelapa murni dapat digunakan untuk mencegah terjadinya luka tekan atau ulkus dekubitus. menurut hasil penelitian dari (diah setiani 2014) ada pengaruh perawatan kulit perawatan kulit dengan pemberian vco untuk pencegahan kejadian luka tekan pasien yang dirawat di icu, ada perbedaan kejadian luka tekan antara kelompok intervensi dan kelompok dalam rentang nilai yang sama. hal ini ditunjukan pada hasil statistik deskriptif bahwa pada kelompok pembekuan yaitu kelompok yang mendapatkan massage dengan vco tidak terjadi luka tekan, sedangkan pada kelompok kontrol atau kelompok yang mendapatkan perawatan standar ruangan, terjadi luka tekan. menurut hasil penelitian (betty sunaryanti 2012) ada pengaruh dalam pemberian vco terhadap pencegahan ulkus dekubitus pada responden yang diberikan vco, sedangkan responden yang tidak diberikan vco terjadi tanda ulkus dekubitus. berdasarkan latar belakang tersebut maka penulis tertarik untuk melakukan pengelolaan kasus asuhan keperawatan yang akan dituangkan dalam bentuk karya tulis ilmiah dengan judul “pemberian vco (virgin coconut oil) pada pasien tn. m dengan diagnosis medis cva infark dengan masalah keperawatan risiko kerusakan integritas kulit di ruang icu central rumkital dr. ramlan surabaya “. metode penelitian rancangan penelitian yang digunakan adalah studi kasus. studi kasus ini adalah studi kasus yang dilakukan dengan cara meneliti permasalahan melalui satu kasus yang terdiri dari unit tunggal. rancangan ini akan menggambareppy setiyowati, pemberian vco pada tn. m dengan diagnosis medis cva infark dengan masalah keperawatan risiko kerusakan integritas kulit di ruang icu central rumtikal dr. ramelan surabaya 15 kan pelaksanaan penerapan pemberian vco terhadap pencegahan dekubitus pada pasien yang sudah ditunjuk sebagai sampel studi kasus. kasus yang digunakan dalam penelitian studi kasus ini yaitu pasien dengan diagnosa medis cva infark yang dirawat di ruang icu central rumkital dr. ramelan surabaya. variabel yang digunakan adalah pengaruh pemberian vco terhadap pencegahan dekubitus pada pasien tirah baring lama dengan diagnosis cva infark. tempat studi kasus ini adalah di ruang icu centra rumkital dr. ramelan surabaya. hasil penelitian hasil dari inovasi yang dilakukan kemungkinan tingkat kegagalan yang terjadi sangat kecil dikarenakan dalam proses pemberian vco peneliti selalu memperhatikan tingkat kelembaban kulit, posisi yang terkena ulkus dekubitus, kebersihan pasien, dan juga tempat tidur, tujuannya untuk meminimalisasi timbulnya infeksi yang disebabkan oleh bakteri. sebelum pasien diberikan vco pertama kulit dibersihkan pada saat kotor dan atau secara rutin. frekuensi membersihkan tergantung kebutuhan pasien. menggunakan sabun lembut dan digosokkan secara pelan-pelan dengan kuat pada kulit, baru dioleskan vco ke seluruh tubuh secara merata terutama di bagian yang terkena ulkus dekubitus. untuk proses penyembuhan yang lebih optimal peneliti memberikan minyak sebanyak dua kali per hari pagi dan sore, setelah diolesi vco juga dilakukan tindakan miring kanan dan kiri. upaya pencegahan luka tekan dinyatakan dalam beberapa literatur (moh 2001, epuap & npuap 2009, ngc 2008, mukti 1998) yang merujuk kepada beberapa hasil penelitian dan evidence secara garis besar terdiri dari upayaupaya. penggunaan secara topikal langsung pada kulit diyakini sebagai cara terbaik untuk mendapatkan manfaat vco. cara ini akan mengembalikan elastisitas kulit dengan cepat dan efektif (coconut-oil-central. n.d). trevtick & miton (1999) dalam penelitiannya menyimpulkan vitamin e dari vco yang diberikan secara topikal dapat terserap dalam 24 jam. wang dan quinn (1999) menyatakan vitamin e adalah zat yang berfungsi sebagai stabilizer membrane sel, melindungi kerusakan sel dari radikal bebas dan sebagai simpanan lemak dalam organel sel. selain itu, vco mempunyai kemampuan antioksidan, antimikrobial, antifungi, melindungi kulit dari bahaya radikal bebas, dan degenerasi jaringan (coconut research center, 2004). pembahasan pemberian minyak kelapa murni vco secara rutin dan kontinu diberikan pada area yang terkena luka tekan grade i. kandungan asam lemak (terutama asam laurat dan oleat) bersifat melembutkan kulit dan antimicrobial sehingga vco efektif dan aman digunakan sebagai moisturizer pada kulit (agero and-rowell, 2008; lucida, salman & hervian, 2012). dalam hal ini peneliti melakukan suatu inovasi yang dilakukan pada tn. m dengan menerapkan tindakan keperawatan tentang pemberian minyak kelapa murni vco sesuai dengan teori dan jurnal yang ada. penggunaan minyak vco yang diolesi ke kulit pasien yang memerah secara teratur dan kontinu. pemberian minyak kelapa murni vco yang dilakukan peneliti pada pasien tn. m dilaksanakan selama tiga hari berturut-turut dari tanggal 11–13 mei 2016. pemberian vco dilakukan setiap dua kali sehari. pemberian vco yang peneliti lakukan adalah sesuai dengan jadwal shift di mana peneliti medical and health science journal, vol. 1, no. 2, august 2017 16 berdinas. sedangkan pada saat peneliti tidak berdinas tugas tersebut dilanjutkan oleh mahasiswa yang praktik keperawatan di ruang icu. pada saat melakukan pemberian vco pada pasien peneliti tidak menemukan kendala. simpulan dan saran a. simpulan berdasarkan hasil studi kasus di atas dapat ditarik kesimpulan yaitu penerapan pemberian minyak kelapa murni vco pada pasien tn. m dengan tirah baring lama menghasilkan dekubitus grade i tidak terjadi dan gejala kemerahan yang ditimbulkan oleh luka tekan dekubitus grade i hilang. b. saran 1. bagi perawat dan tenaga medis perawat pelaksana dapat menerapkan teknik pemberian minyak kelapa murni vco pada seluruh pasien tirah baring lama sehingga terjadinya dekubitus dapat diminimalisasi. 2. bagi institusi pendidikan penerapan teknik pemberian minyak kelapa murni vco dapat dimasukkan dalam proses pembelajaran dan dapat dilakukan dengan memberikan materi. daftar pustaka amin, sarmidi. 2009. cocopreneurship aneka peluang bisnis dari kelapa. yogyakarta: lily publisher. ariani, t.a. 2012. sistem neurobehaviour. edisi pertama. jakarta: salemba medika. corwin, e.j. 2009. buku saku patofisiologi. jakarta: egc. dermawan, d. 2012. proses keperawatan penerapan konsep & kerangka kerja. edisi pertama. yogyakarta: gosyen publishing. muttaqin, a. 2008. buku ajar asuhan keperawatan klien dengan gangguan sistem persarafan. edisi pertama. jakarta: salemba medika. m. bulechek, et al. 2013. nursing intervention classification (nic) sixth edition. mosby. mariana, bella dkk. 2013. pencegahan kejadian luka tekan melalui masase virgin coconut oil pada pasien dengan imobilisasi 1 (1): 38–42. nanda. 2011. diagnosa keperawatan definisi dan klasifikasi 2012–2014. jakarta: egc. price, murai, ph.d. 2003. terapi minyak kelapa (bahrul ulum, penerjemah). 2004. jakarta: prestasi pustaka publisher. potter, p.a. & perry, a.g. 2007. basic nursing skill essential for practice. canada: mosby elsevier sabandar, o.a. 2008. decubitus. january 31, 2010. siswono, 2006. manfaat minyak kelapa murni (vco) untuk kesehatan. diakses dari http://www.republika.co.id sunaryanti, betty dkk (2013). perubahan pengaruh antara pemberian minyak kelapa dan madu. widodo, a. 2007. uji kepekaan instrumen pengkajian risiko dekubitus dalam mendeteksi dini risiko kejadian dekubitus di rsis. universitas muhamadiyah surakarta. a. widodo–2007–publikasiilmiah.ums.ac.id. 15 juni 2016 (09:36). wilkinson, j. m. 2007. buku saku diagnosa keperawatan dengan intervensi nic dan kriteria hasil noc. edisi ketujuh. jakarta: egc. medical and health science journal, vol. 1, no. 1 february 2017 22 overview characteristics and p2y12 reactivity unit (pru) values of acute coronary syndrome age productive patients with clopidogrel therapy rahmatini,* gestina aliska*, masrul syafri** department of pharmacology faculty of medicine, andalas university * department of cardiology and vascular medicine dr. m. djamil hospital/ faculty of medicine, andalas university** correspondence: fk.unand.rahmatini@gmail.com abstract background: ischemic heart disease is the leading cause of death and disability in the world with a fairly high portion coming from countries lowand middle-income (lmics). in pakistan, 54% patients acute coronary syndrome (acs) was resistant to clopidogrel, and no data on clopidogrel resistance on ethnic minang. this study aims to look at the characteristics and p2y12 reactivity unit (pru) from acs patients in dr. m. djamil hospital, padang. methods: this research is a cross sectional study. the effectiveness of clopidogrel on platelet reactivity identified through examination of pru value using verifynow® with a cutoff point is 208. from the pru values, it can be classified whether patients resistant or responsive. the study was conducted in september 2016. result: from 14 patients with acs who received clopidogrel, 11 patients (78.57%) are male with 3 female patients (21.43). the mean of age was 53.78 years old. patients mostly came from west sumatra provinces (92,85%) and 7,15% from others. from all of patients head risk factors of coronary arterial disease. hipertension was the greatest risk factor. conclusion: it can be concluded that most of the patients were male. from pru data, 7 patients (50%) were resistant and 7 patients (50%) were response to clopidogrel. further research is needed with larger numbers of patients and investigate pharmacogenetic profile of cyp2c19 as caused of resistance. keyword : pru, acute coronary syndrome, clopidogrel pendahuluan penyakit jantung iskemik merupakan penyebab utama kematian dan kecacatan di seluruh dunia. kejadian penyakit jantung iskemik ditemukan dengan posrsi cukup tinggi berasal dari negaranegara dengan pendapatan perkapita rendah sampai sedang, atau disebut low-middle income countries (lmics). sebuah penelitian yang dilakukan di pakistan, menunjukkan 54% pasien dengan sindrom koroner akut atau acute coronary syndrome (acs) adalah tahan terhadap clopidogrel. sampai saat ini belum ada penelitian ataupun data tentang ketahanan clopidogrel pada masyarakat indonesia khususnya etnis minang. penelitian ini bertujuan untuk melihat karakteristik dan p2y12 reaktivitas unit (pru) dari pasien acs di rumah sakit dr. m. djamil, padang. metode penelitian penelitian ini merupakan studi cross sectional, dilakukan pada bulan september 2016 di rumah sakit dr. m. djamil padang. jumlah sampel yang diteliti adalah 14 orang yang terdiri dari 14 pasien sindrom koroner akut atau acute coronary syndrome (acs yang menerima clopidogrel. dari 14 pasien tersebut 11 pasien (78,57%) adalah laki-laki dengan 3 pasien perempuan (21,43). efektivitas clopidogrel pada reaktivitas platelet diidentifikasi dengan melakukan pemeriksaan nilai pru menggunakan verifynow dengan titik cut-off adalah 208. dari hasil pemeriksaan didapatkan nilai pru, yang selanjutnya diklasifikasikan apakah pasien resisten atau responsif. hasil penelitian telah didapatkan sebanyak 30 orang pasien yang memenuhi kriteria penelitian dan telah manuscript received november 20, 2016, accepted january 23, 2017 medical and health science journal, vol. 1, no. 1 february 2017 23 menandatangani inform consent. sebanyak 2 ( dua ) orang pasien diekslusi karena tidak didapatkan nilai pru pada pemeriksaan darah, pasien menolak diambil darah ulang. data yang baru kami analisis sementara melibatkan 14 orang pasien dan 16 orang pasien lainnya menyusul di laporan akhir. data 14 orang pasien tersebut dengan sindrom koroner akut, yang dirawat di rumah sakit dr. djamil m, padang. variasi dari subjek rentang usia dengan usia rata-rata 45-60 tahun adalah 53,78%. subjek laki-laki sebanyak (78,57%) dan perempuan (21,43%). sebagian besar pasien berasal dari provinsi sumatera barat dan hanya 1/14 dari luar provinsi. dari 14 pasien, semuanya memiliki faktor risiko penyakit arteri koroner (cad), hipertensi adalah faktor risiko terbesar dari cad (78,57%) pada pasien. (tabel 1) tabel 1. karakteristik awal dari pasien variabel pasien (n=14) usia, tahun * 53.78 (45-60) jenis kelamin laki – laki 11/14 (78.57%) perempuan 3/14 (21.43%) asal sumatera barat 13/14 (92.85%) luar provinsi faktor risiko ya 14/14 (100%) 0/14 (0%) perokok ya 8/14 (57.14%) tidak 6/14 (42.85%) hipertensi ya 11/14 (78.57%) tidak 3/14 (21.43%) diabetes melitus ya 3/14 (21.43%) tidak 11/14 (78.57%) dyslipidemia ya 2/14 (14.28%) tidak 12/14 (85.72%) menopause ya 2/14 (13.3%) tidak 1/14 (7.15%) berdasarkan nilai p2y12 reaktivitas unit (pru), 50% pasien memiliki nilai > 208 yang diklasifikasikan sebagai pasien resisten dan 50% pasien dengan nilai pru < 208 yang diklasifikasikan sebagai pasien responsif (gambar 1). gambar 1. nilai dari pru berdasarkan potong titik pembahasan dari hasil, semua pasien studi berusia di atas 40 tahun. ada berbagai faktor risiko yang menyebabkan rentan terhadap penyakit. sebagian besar ska merupakan manifestasi akut arteri koroner plak ateromatosa robek atau pecah. acara ini akan diikuti oleh proses agregasi platelet dan aktivasi jalur koagulasi. membentuk trombus yang kaya platelet (trombus putih). trombus ini akan menyumbat lubang arteri koroner, baik total atau sebagian. beberapa faktor ekstrinsik, seperti demam, anemia, tirotoksikosis, hipotensi, takikardia, dapat memicu terjadinya acs pada pasien yang sudah memiliki plak aterosklerosis. (perki, 2015) sesuai dengan literatur, pasien dengan sindrom koroner akut didominasi oleh laki-laki gender.in penelitian ini juga menemukan faktor-faktor risiko lain seperti diabetes, hipertensi, dislipidemia dan menopause. resistensi clopidogrel adalah suatu kondisi yang clopidogrel kurang efektif dari normal pada orang yang diperlakukan dengan it.7 dalam penelitian ini kami menemukan (40%) resistensi clopidogrel. orang dengan resistensi clopidogrel yang menerima clopidogrel beresiko komplikasi serius,kadang-kadang fatal,. orang-orang ini mungkin memiliki serangan jantung atau stroke yang disebabkan oleh pembentukan gumpalan darah abnormal; mereka dengan stent dapat mengembangkan bekuan darah (trombosis) dalam stent, menghambat aliran darah. medical and health science journal, vol. 1, no. 1 february 2017 24 kesimpulan dalam penelitian ini kami menemukan (60%) dari subjek masih responsif. varian gen modulasi penyerapan clopidogrel dan metabolisme juga dapat berdampak pada clopidogrel response.7,8. pengakuan penelitian ini didukung oleh departemen farmakologi dan terapeutik fakultas kedokteran, universitas andalas (fmau) dan departemen kardiologi dan kedokteran vaskular rs dr. m. djamil / fmau. daftar pustaka vedanthan r,seligman b, fuster v. global perspective on acute coronary syndrome: a burden on the young and poor. circ res. 2014;114:1959-75 melati r, basuki e, setianto b. relationship between job strain and myocardial infarction in the national cardiovascular center patient. j kardiol ind. 2008; 29: 12-19. british nutrition foundation, 2013. nutrition and development: short an long term consequences for your health. british: blackwell publishing ltd. ogawa h, isshiki t, kimura t, yokoi h, nanto s, takayama m, et al. effects of cyp2c19 allelic variants on inhibition of platele aggregation and major adverse cardiovascular events in japanese patients with acute coronary syndrome: the prasfit-acs study. j cardiol. 2016;68:29-36. gonzález a, moniche f, cayuela a, garcía-lozano jr, torrecillas f, escudero-martínez i, et al. effect of cyp2c19 polymorphisms on the platelet response to clopidogrel and influence on the effect of high versus standard dose clopidogrel in carotid artery stenting. eur j vasc endovasc surg. 2016;51:175-86. rehman ku, akhtar t, sabar mf, tariq ma. allele frequency distribution of cyp2c19*2 allelic variants associated with clopidogrel resistance in cardiac patients. exp ther med. 2015;10:309-15. perki (2015). pedoman tata laksana sindrom koroner akut. perhimpunan dokter spesialis kardiovaskular indonesia. centra communications. edisi i. hal 11-35. nguyen ta, diodati jg, pharand c. resistance to clopidogrel: a review of the evidence. j am coll cardiol. 2005;45:1157-64. genetic variability in response to clopidogrel therapy and its clinical implications.thrombosis and haemostasis suplemen.2011; 1.p.555-559. medical and health science journal 2022 august vol.6 (02) medical and health science journal available at http://journal2.unusa.ac.id/index.php/mhsj; doi: 10.33086/mhsj.v6i2.3226 pissn 2549-7588. eissn 2549-7596 original article an evaluation study of kampung kb in denpasar city with working partners i g.n.m. bayuningrat1*, a. s. titisari2, t. p. dewi r.3, c. nirlaksita r.4 1 department of obstetrics and gynecology, faculty of medicine and health sciences, universitas warmadewa, bali, indonesia 2 bkkbn provinsi bali (badan kependudukan dan keluarga berencana nasional),bali, indonesia 3 faculty of dentistry, universitas mahasaraswati denpasar bali, indonesia 4 assosiasi psikologi forensik wilayah bali (apsifor), bali, indonesia article info article history: received: july 22, 2022 received in revised form: august 01, 2022 accepted: august 20, 2022 keywords: evaluation study, family planning kampung, working partners *) corresponding author: bayuningrat45@yahoo.com abstract background: the national population and family planning agency (bkkbn) is a non-ministerial institution. the problem is that there is stagnation in program achievements and the weak implementation of the kkbpk program. the bkkbn established the kampung kb as a strategic innovation for the full implementation of the kkbpk program. methods: the goal is to know the evaluation of the establishment and implementation of the kampung kb as a miniature family planning program, grounding, bringing services closer, actualizing 8 family functions, revitalizing kkbpk. since it was launched in 2016, it has never been evaluated, the criteria for establishing, using family data collection, participation, implementation of regional and cross-sectoral government commitments, forms of activity, coaching and mobilization, support for facilities and infrastructure, achievement of indicators, knowledge and community participation. result: quantitative studies in-depth interviews are input, process, implementation, monitoring, evaluation, reporting and achievement of program success indicators. conclusion: careful planning so that the program runs effectively, emphasizes the quality of the kampung kb according to the input and process, not only the quantity target. the program must refer to the needs of the community, so an analysis of community needs is important before determining the program. medical and health science journal http://journal2.unusa.ac.id/index.php/mhsj bayuningrat et al medical and health science journal 2022 august vol.6 (02) page 20 of 24 introduction the kampung kb program is expected to be a “miniature family planning program” at the lowest level and prioritized for poor areas, densely populated and lacking access to health services. kampung kb is also designed as an effort to ground the family planning program to bring closer access to services to families in actualizing the 8 family functions and as an effort to revitalize the kkbpk program. since the kampung kb was declared in every provincial district in 2016, it has never been evaluated starting from the declaration stage to the implementation stage of kampung kb. in general, this study aims to determine the implementation of kampung kb. in particular, to determine the suitability of the criteria for the establishment of the kampung kb, the extent to which the use of data sourced from the family data collection (pk) in the kampung kb area, the participation and commitment of local and cross-sectoral governments in the implementation of the kampung kb program, the existing forms of activities, guidance and mobilization by managers programs, support for facilities and infrastructure in the kampung kb, achievement of program indicators, knowledge and community participation related to activities and programs. the research framework for the evaluation study of kampung kb uses a systems approach, where success can be seen from the success of the input, process and output aspects. the input aspect is indicated by the support of human resources (proportionate number of plkb/pkb); availability of demographic data, family planning data, socio-economic data, data on family members/individual data and other data; availability of operational facilities, both contraceptives and other supporting facilities, such as: kkbpk kie media (banners, back drop, banners, family planning information unit car, family planning service unit car; availability of operational support (budget) for the kkbpk program from the apbd and apbn as well as other sources. other funds, such as: pnpm, kampung fund budget (add), family hope program (pkh), jamkesmas or jamkesda, where this budget assistance is not only intended at the time of declaration but for the sustainability of activities in the kampung kb; the existence of regulations/policies from the local government and stakeholder commitments related to the implementation of kampung kb furthermore, the success of the kampung kb program process aspects: training related to kampung kb; utilization of pk data and other cross-sectoral data; kampung kb working group meetings including cross-sectoral coordination meetings (agencies) government and private) which can be in the form of workshops, mini-workshops at the sub-district and kampung levels; workshops with the community akat; home visits; coaching as well as monitoring and evaluation, both carried out before the declaration and carried out routinely after the declaration. evaluation of meeting activities will be seen from the number of times the meetings are held, where, who the participants attend and what the results of the meeting/rehearsals are. aspects of output, the success of the kampung kb study is marked by an increase in the achievement of the kkbpk program and an increase in the achievement of other related sector programs, by comparing the data before and after the declaration of the kampung kb. indicators of achievement of other sector programs, can be different between kampung kb areas, this really depends on which program focus is the most priority to improve the quality of life of the people in the kampung. it is hoped that this research can provide input and consideration for policy makers, to improve the development of the implementation of kampung kb. figure 1.4. operational framework of evaluation studies of kampung kb input • human resources • data • facilities and infrastructure • fund • regulation • stakeholder commitment process • training • data utilization • working group meeting • cross-sector meeting • gathering with the community • construction • monitoring dan evaluation output • program achievement and improvement of kkbpk • program achievement and improvement of other related sector programs bayuningrat et al medical and health science journal 2022 august vol.6 (02) page 21 of 24 methods this study is an evaluative study with data collection carried out through a qualitative approach as a whole with in-depth interviews from various informants which aims to obtain in-depth information about the inputs, processes, outputs of implementation, monitoring, evaluation and reporting as well as the achievement indicators of the success of the kampung kb program involving various cross-sectional areas. sector, local government, toga/toma, kampung kb managers and community participation. location research sites. the family planning kampung evaluation study for the province of bali was conducted in denpasar city. the research locus is located in dusun wanasari, dauh puri kaja, north denpasar. analysis collecting qualitative data through primary data will be analyzed by processing the data from the transcripts of the informants' interviews. in addition to primary data, this study also uses secondary data obtained through processing family data from the 2015 family data collection (pk). the pk data provides additional information from primary data obtained through structured questionnaires so as to validate the results of family data collection and primary data collected. data collection was carried out from august to the first week of october 2017. furthermore, data analysis was carried out in the second week to the fourth week of october 2017. after the data analysis, the results were presented by the research team. results this study is an evaluative study with data collection carried out through a qualitative approach as a whole with in-depth interviews from various informants which aims to obtain in-depth information about the inputs, processes, outputs of implementation, monitoring, evaluation and reporting as well as the achievement indicators of the success of the kampung kb program involving various cross-sectional areas. sector, local government, toga/toma, kb village managers and community participation. table.1 details of respondents/informants per district/city and province respondent per district/city responden kualitatif dengan wawancara: perwakilan bkkbn provinsi opd kb kab/kota 7 org 4 org opd lintas sektor lainnya bapeda dinas kesehatan dinas sosial dinas pemukiman dinas pendidikan dan budaya dinas lingkungan hidup dinas kependudukan dan pencatatan sipil 1 org 1 org 1 org 1 org 1 org 1 org 1 org perangkat kecamatan, desa/kelurahan, rw: camat kepala desa/lurah; ketua rw; 1 org 1 org 1 org tenaga penggerak plkb/pkb) kader (minimal 4 org) 1 org 4 org pengurus kampung kb ketua kampung kb ketua pkk tokoh masyarakat/tokoh agama seksi-seksi 1 org 1 org 1 org 8 org total 87 org bayuningrat et al medical and health science journal 2022 august vol.6 (02) page 22 of 24 discussion the kampung kb evaluation study is located in dusun wanasari, denpasar city, including dauh puri kaja kampung, north denpasar. northern boundaries; banjar lumintang, east; banjar puncak sari, south; banjar wangaya kaja, west; badung river. the distance from the north denpasar district center is around 2 km, while the distance from denpasar city is around 1 km and the distance from bali province (governor's office) is 2.5 km consisting of 8 rt, with a population of 5,376 people, with male 2,777 men and 2,599 women. the number of existing kk is 1,494 kk. data on education level: not yet in school: 420 people, kindergarten (tk) : 696 people, no/not yet finished elementary school: 74 people, junior high school graduates: 547 people, high school graduates: 626 people, higher education: 130 people. the number of pre-ks and ks-1 (poor) is above the average of pre-ks and ks-1. kampung/kelurahan level or as many as 18 kk. of the total pus of 1,236 people, only 709 people are pus who are active family planning participants due to lack of public knowledge in family planning participation and low participation in tri bina plenary activities, including in urban poor areas, high population density. , and is included in the watershed (das). most of the population works in the trade services sector. qualitative data was collected at three levels, namely: province, regency/city, and kampung/dusun with group interviews with a number of informants. primary data were obtained from in-depth interviews and focus group discussions (fgd) which were conducted by analyzing the results of interviews with predetermined respondents. fgd respondents (form 1) : head of bali province bkkbn representative, head of family planning division, head of ks division, head of adpin division, regional apparatus organization for family planning (opd kb denpasar), opd of other related sectors (dukcapil denpasar, denpasar health office, denpasar social service) , and respondents. in-depth interviews: head of the bali province bkkbn representative, denpasar plkb, kampung apparatus, cadre, wanasari kampung kb manager, while group interviews include: form 2 opd to the head of population control, counseling, and mobilization, city p3appkb office denpasar, form 3 pkb to pkb, form 4 cadres to two cadres, form 5 kampung kb management to the head of dusun wanasari as a community leader, form 6 kampung apparatus to the kampung head dauh puri kaja, east denpasar, form 7 opd other sector, namely dinas denpasar city population and civil registration, denpasar city social service, denpasar city health office. a. input aspect. the basis for the formation of the kampung kb: not all respondents understand the basis for the formation of the wanasari kampung kb in denpasar. in the ranks of representatives of the bali province bkkbn, most of them know and understand the basis for the formation of kampung kb, but not in the ranks below them. the process of establishing a kampung kb: not all respondents know the process of forming a kampung kb. only representatives of the bali bkkbn, denpasar kb opd, and cadres. there is information that is disconnected from cadres, kampung apparatuses, kampung kb administrators, and other related opds. the criteria for the formation of kampung kb were only known by respondents at the provincial, regency and plkb levels, while most of the other respondents did not know for sure what the criteria for the establishment of kampung kb were. availability of supporting documents for kampung kb activities (guidelines, guidelines, operational guidelines, technical guidelines, instructions, circulars, etc.) to implement the program in kampung kb. most of the respondents said they did not have supporting documents for kampung kb activities. the document was stopped at the kampung level and was not followed up again. there is use of 2015 pk data, although not all ranks related to kampung kb understand the use of 2015 pk data for the kampung kb program. sources of funds and their allocation in the process of establishing kampung kb come from various different sources, such as: apbn, apbd, apbdes, add. the kampung kb working group has not yet been formed, because there is no sk kampung kb so that the organizational structure and management of the kampung kb does not yet exist. there is no cross-sectoral opd involvement in kampung kb activities, because there are no activities or programs that clearly involve cross-sectoral involvement. involvement in kampung kb (camat, plkb, cadre, etc.). the pokja kampung kb is not running, there are no activities, because there is no clear program. there is a difference in answers between the province and denpasar city opd regarding commitment. according to opd kb, there is no cross-sectoral commitment, due to unclear information on kampung kb. it is not known that there are integrated activities bayuningrat et al medical and health science journal 2022 august vol.6 (02) page 23 of 24 between kkbpk and cross-sector. there is no discussion about kampung kb yet. kampung kb funds come from various sources (apbn, apbn, add/apbdes, etc.), but only at the time of socialization/establishment, temporarily because there are no activities/work programs in kampung kb so the funds do not yet exist. b. process aspect. the training/socialization of the kampung kb in wanasari denpasar dusun had been carried out before and after the declaration of the kampung kb, but it was not felt until the ranks of the kampung kb below. there is use of family data collection (pk), which is updated/updated (1-5 years), but in kampung kb this does not exist. there is no pokja kb meeting, because there are no programmed activities in this kampung kb. there has been no meeting / workshop that discusses the specifics of kampung kb, because there are no activities and there is no kampung kb program. there is monitoring carried out by the bali province bkkbn, but evaluation, recording, reporting does not exist because in kampung kb there are no organized programs and activities. c. output aspect. activities in kampung kb have not run as they should, because there is no understanding of the program in kampung kb. the existing activities carried out in kampung kb are more for health programs from posyandu and kampung, not specific activities for kampung kb. based on secondary data according to the matrix of needs. the number of pre-prosperous families (kps) and prosperous families (ks) i in kampung kb before the declaration was 19, after 19, meaning there was no change. contraceptive prevalence rate (cpr) before declaration was 884: 2395 x 100% = 36.9% and after proclamation cpr 941: 2538 x 100% = 37%. this means that out of 100 pus in the kampung kb of dusun wanasari, 37 were using family planning methods at the 2016 declaration. the use of mkjp at the kampung kb level increased from 181 to 209 (86%), while unmet need 171 decreased to 105 (1.6). based on secondary data according to the matrix of needs. there are reports regarding the forms of activities carried out in the kampung kb, but there has been no report on the achievement of targets from across sectors. conclusion 1. indicator: programs in the kampung kb wanasari denpasar area were not achieved. 2. input: human resource support that functions as program officers for the wanasari kampung kb program is not optimal. pk data is available, but this data is not understood by almost all kampung kb apparatus. there are no operational facilities (contraception, kie kkbpk). there is no regulation from the local government that supports its implementation. cross-sectoral commitments are not working as they should. 3. process: no training. there is no optimal use of pk and cross-sector data. there is no pokja meeting activity. there are no crosssectoral coordination meetings (government and private agencies), workshops, sub-district and kampung mini-workshops, workshops, home visits. there is no coaching because there are no activities. there has never been monitoring and evaluation because there are no activities/programs in dusun wanasari. 4. output: there was no effective increase in the achievement of the kkbpk program and an increase in the achievement of other crosssectoral programs in dusun wanasari. acknowlegment the financing is obtained independently conflicts of interest there are no conflicts of interest declared by the author. references 1. bkkbn. 2017. petunjuk teknis kampung kb. jakarta: direktorat bina lini lapangan. 2. cohen, john & uphoff, norman t. 1977.rural development participation: concept and measures for project design-implementation and evaluation. new york: cornell university press. 3. dawam, m & fadila, w. 2016. penelitian operasional pengembangan model pengelolaan kampung kb “integrasi program kependudukan keluarga berencana dan pembangunan keluarga (kkbpk) di kampung kb. jakarta: puslitbang kependudukan bkkbn. 4. djalal, f & supriadi, d. 2001. reformasi pendidikan dalam konteks otonomi daerah. yogyakarta: adicita. bayuningrat et al medical and health science journal 2022 august vol.6 (02) page 24 of 24 5. dunn, william n. 1994. public policy analysis: an introduction. new jersey: prentice-hall international, englewood cliffs. 6. dye, thomas r. 2002. understanding public policy. new jersey: prentice-hall, 2002 7. hermawati, dkk. 2006. pengkajian keswadayaan desa dalam pendayagunaan sumber kesejahteraan sosial.yogyakarta: balai besar penelitian dan pengembangan pelayanan kesejahteraan sosial. 8. moeljarto, t. 1987. politik pembangunan: sebuah analisis, konsep, arah dan strategi. yogyakarta: pt tiara wacana. 9. nugroho, riant. 2009. public policy. jakarta: pt. elex media komputindo. 10. nurdin, fadhil. 1990. pengantar studi kesejahteraan sosial.bandung: pt angkasa. 11. purwanto, erwan agus dkkk. 2012. implementasi kebijakan publik, konsep dan aplikasinya di indonesia. yogyakarta: gava media. 12. rambe, a. 2004. alokasi pengeluaran rumah tangga dan tingkat kesejahteraan (kasus di kecamatan medan, kota sumatera utara) tesis. bogor: sekolah pascasarjana ipb. 13. sudjarwo& basrowi. 2009. manajemen penelitian sosial. bandung: mandar maju. 14. sumaryadi, i. n. 2010. sosiologi pemerintahan. dari perspektif pelayanan, pemberdayaan, interaksi dan sistem kepemimpinan pemerintahan. jakarta: ghalia indonesia. 15. widodo, joko. 2001. good governance: telaah dari dimensi akuntabilitas dan kontrol birokrasi pada era desentralisasi dan otonomi daerah. surabaya: insan cendikia. 16. winarno, budi. 2012. kebijakan publik: teori, proses dan studi kasus. yogyakarta: caps. medical and health science journal 2023 february, vol 07 (01) medical and health science journal available at http://journal2.unusa.ac.id/index.php/mhsj; doi: 10.33086/mhsj.v7i1.3456 pissn 2549-7588. eissn 2549-7596 original article a literature review on mantra meditation ravi saini * , jitender sorout dep ar tm en t o f p h y s io lo g y , ru hs co lleg e o f m ed i cal sci en ce s , india *correspondent author: sain i r av i4 1 4 @g m ail. co m article info article history: received: september 06, 2022 received in revised form: february 09, 2023 accepted: june 14, 2023 keywords: meditation, mantra, complimentory abstract objective: meditation has gained popularity in modern times as an adjunctive of therapeutic treatment. this study aimed to study meditation and use of mantra meditation in application of health problems. materials and methods: after searching literature through electronic databases, with regards to meditation and mantra meditation in accordance with prisma method was done. conclusion: meditation does not deal only spiritual aspect but it has various application as complimentary in various health related problems. medical and health science journal introduction for many years meditation has attracted clinicians, researchers, and the general public using it as an adjunctive treatment for many health-related problems.1, 2 it has been a spiritual activity and practice of healing for more than 5000 years.3 meditation helps medicine achieve optimal physical and mental health. medicine deals primarily with the 'outer world', including the body, whereas meditation deals with the 'inner world' or mind. the mind-body connection is so highly valued that it is very likely that the science of meditation will converge toward the goal of optimal functioning of the human body and mind. in complementary and alternative medicine (cam) it is considered as practice of mind and body. 4 the word “meditation” is derived from the latin meditari, which means “to engage in contemplation or reflection.” to be called meditation, the procedure must include (1) the use of specific well defined techniques; (2) muscle relaxation at specific moments in the process; (3) "logical relaxation." (4) it must necessarily be a self-guided state; and (5) the use of self-focus skills .5 meditation can be explained as a specific and well-defined state of “thoughtless awareness” or silence of mental activity, in which mind is relaxed without reducing the level of alertness.6 meditation can be defined as practice of self-regulation practices that put focus on bringing mental processes under greater voluntary control that leads to general mental wellbeing and development of various capacities such as calmness, clarity, and increase in concentration.7 in many other explanations of meditation specific emphasize has been given to relaxation, concentration, and state of alertness, decreasing in processing of logical thoughts, and development of an attitude self-observing.8 http://journal2.unusa.ac.id/index.php/mhsj mailto:sainiravi414@gmail.com saini et al medical and health science journal 2023 february vol.07 (01) page 41 of 45 methods literature published between the years 2000 to 2019 was searched for by three independent researchers from the following databases: pubmed, google scholar, sciencedirect, indemed, nih clinical trials for reports related to the meditation. the types of studies included were in vivo, in-vitro and narrative reviews with regards to meditation. case reports, animal studies, and those published in languages other than english were excluded from the study. the following keywords were used to develop the search strategy (meditation and application, meditation and mantra meditation, meditation and health). the electronic database search yielded 108 articles, and after excluding the duplicates; 58 were retained following this eventually, 18 studies were included in this review. categorization of meditation traditional and contemporary meditation practices are grouping them into attentional (concentrative meditation), constructive types, and deconstructive types. the primary cognitive mechanisms in these three families are (1) attention regulation and metaawareness, (2) perspective taking and reappraisal, and (3) self-inquiry, respectively. 9 the term metaawareness term has been related to the cognitive functions including state of awareness about the processes of consciousness. lack of meta awareness can result into merely attention on the object without being ware of process of thinking, feeling, and perceiving. 10 concentrative meditation focuses the attention on the breath, an image, or a sound (mantra), to still the mind and allow a greater awareness and clarity to emerge. the following practices are categorized as attentional meditation types: mindfulness of breathing, breath counting, dhyana practice, samadhi practice, visualization, mantra recitation, kirtan kriya, choiceless awareness, and mindfulness meditation (e.g., as taught by mindfulness-based stress reduction programs. unlike the practice of concentration meditation, constructive meditation involves a positive process of changing the quality of thoughts and emotions and cultivating qualities like patience and calmness that help protect the mind from damage by the stresses of mundane activities. it also involves restructuring of priorities and values and a dovetailing of the mind towards more meaningful activities of life. deconstructive type of meditation aims to undo maladaptive cognitive patterns by exploring the dynamics of perception, emotion, and cognition and generating insights into one's internal models of the self, others, and the world. a central mechanism in the deconstructive family is selfinquiry, which is defined as the process of investigating the dynamics and nature of conscious experience. vipassana /insight meditation, mahamudra, dzogchen, shikantaza/‘just sitting’, self-inquiry, and koan practice are listed as deconstructive types. 11 other types of meditation rajyoga meditation, om meditation, tm (transcendental meditation), mindfulness meditation, focused meditation, movement meditation, mantra meditation, etc. rajyoga meditation includes relaxation stage that brings the mind and body into a condition of calmness and mental peace by stopping thinking of tension and stress. stage of concentration allows to increase focus on voluntary thoughts. stage of contemplation deals about observing into the inner self deeply. stage of realisation helps in understanding of reality a more profound, more meaningful way. final stage of meditation focuses awakening and regaining about state of eternal identity. 12 om meditation includes mental saini et al medical and health science journal 2023 february vol.07 (01) page 42 of 45 chanting of om leads to a single thought state and a subjective feeling of deep relaxation.4 movement meditation focuses on different motions which may include walking, gardening, etc. it’s an active type of meditation where the meditation is guided by the movements. mindfulness meditation has origin from teachings of buddhism. in this type of meditation focus is given on pattern of thoughts as that passes through the mind without being involved or judging them. this practice increases concentration with alertness, which helps to focus on an object or breathe while observing bodily sensations, thoughts, or feelings. challenges in meditation time demandstime-consuming meditation leaning curve references the affective demands and task demands of meditation. affective demands references commonly reported (12.6%) difficulty, effort, and frustration experienced in and because of meditation, especially in beginners. social and interpersonal drawbacks stigma and disconnection references perceived social stigma against meditators, feeling judged and misunderstood by others, inability to share experiences with non-meditators, and feeling disconnected from people who do not meditate. existential and personal changeit references personality changes, world view, and personal life circumstances that the participant appraised as negative and stressful as well as decreased ambition and materialism, existential realizations, and existential dread. negative health outcomes this category references physical discomfort, such as pain or discomfort in the legs or back, and sleep disturbances, such as insomnia and drowsiness. negative emotional and psychological outcomes-negative emotional outcomes captured negatively valenced emotional states, such as boredom, anxiety, nervousness, doubt, and fear of failure in meditation. some other unpleasant meditation-related experiences may be: (i) practice-related: high intensity frequent sessions having long duration. (ii) relationship-related: commonly, retreats are held in silence, and take place in a secluded environment with limited access to distractions (e.g., phones, internet, books). (iii) practitioner-related: meditators who choose to attend intensive retreats might systematically differ from regular meditators who do not attend retreats in personality, intentions, and worldviews. (iv) health behavior-related: meditators are commonly encouraged to follow a strict schedule that limits sleep to several hours (e.g., the wake-up bell at 4 am), discourages extensive physical activity (e.g., jogging), and includes a change in diet (e.g., vegan). mantra meditation (mantra yoga / japa yog) a mantra is a word or phrase generally with spiritual meaning that requires repeating silently or chanting out loud, done alone or with a group. it is the simplest type of meditation because it is easier to focus on a word than on their breath, image, etc. above mentioned meditation challenges are the minimum in mantra meditation. there are several ways to practice mantra meditation. repeat the mantra verbally or mentally or whisper for some time. mantra meditation employs the use of a mentally repeated word or phrase, intending to maintain attention on those words. a mantra, usually representative of a holy name such as jesus, the buddha, sri krishna, or divine mother, is a word or phrase with spiritual meaning that has been handed down for generations within all major spiritual traditions. 13 table 1: list of common mantras used in meditation 14 saini et al medical and health science journal 2023 february vol.07 (01) page 43 of 45 mantra and pronunciation meaning buddhist om mani padme hum( ohm mah-nee podmay hume) namo butsaya ( nahmo boot-sie-yah) an invocation to the jewel (self) in the lotus of the heart. i bow to the buddha christian may god and my all maranatha ( mar-uh-nah-tha) kyrie eleison ( kir-ee-ay ee-lay-ee-sone) christe eleison ( kreest-ay ee-lay-ee-sone) jesus, jesus or lord jesus christ hail mary or ave maria st. francis of assissi’s mantra lord of the heart (aramaic) lord have mercy, or the lord is risen, christ have mercy, christ has risen jesus, son of god mother of jesus hindu/indian rama ( rah-ma) ram ram sri ram ( rahm rahm shree rahm) ohm namah shivaya ( om nah-mah shee-vy-yah) ohm prema (ohm-pray-mah) om shanti( ohm shawn-tee) so hum (so hum) eternal joy within (variation on rama) an invocation to beauty and fearlessness a call for universal love in invocation to eternal peace i am that self within jewish barukh atiah adonoi( bah-ruke-ah-tah ah-don-aye) ribono shel olam( ree-boh-noh shel oh-lah) shalom sheheena (sha hee-nah) blessed are thou’ o lord lord of the universe peace feminine aspect of god muslim allah bismallah ir-rahman ir-rahim (beese-mah-lah ir-rahmun ir-rah-heem) one true god in the name of allah, the merciful, the compassionate native american o wakan tanka oh, great spirit application of mantra meditation in medicine. research on the benefits of frequent, silent mantra repetition has shown improvements in lowering perceived stress, anxiety, and anger in veterans and healthcare providers. mantra intervention reduced trait-anger in hiv-positive persons by enhancing positive reappraisal coping. this is the first investigation to determine that a mantra intervention may reduce trait-anger by enhancing the utilization of cognitive coping efforts. by way of improved attention, awareness, and coping skills, mantra meditation may have an extended impact on healthcare operations including (healthcare practitioner) hcp – patient interaction, quality of care, and patient safety. 15 recitation of prayer or the mantra has a similar effect to that of slow breathing, increasing arterial baroreflex which is a favorable prognostic factor in cardiac patients. 16 the effect of faith/assurance on cortisol levels are enhanced by a spiritual mantra intervention in adults with hiv. decreased cortisol could potentially benefit functioning among hiv-infected individuals. 17 increase in positive reappraisal coping during a group-based mantra intervention mediate sustained reductions in anger in hivpositive persons. mantra meditation may have minimal to moderate beneficial effects on mental health in the general population. 18 conclusion meditation has been part of lives since existence of human being from rudimentary level to the most recent type of meditation. earlier meditation mainly related to the spiritual rejuvenation but in modern times many researches has put emphasis on medicinal application of it. as meditation has a saini et al medical and health science journal 2023 february vol.07 (01) page 44 of 45 long history of existence which results into different types of mediation based on concentration, constructive and deconstructive activities. among them mantra meditation could be considered as simplest method, which impacts not only cognitive function but have adjunctive effect on other health related issues. conflict of interest the author started there is no conflict of interest. references 1. west ma. the psychosomatics of meditation. journal of psychosomatic research.1980; 24 (5): 265-73. 10.1016/0022-3999(80)90016-1. 2. pollard i. meditation and brain function: a review. eubios journal of asian and international bioethics: ejaib. 2004; 14(1):28-34. https://www.eubios.info/ej141/ej141j.htm. 3. walters jd. the art and science of raja yoga: fourteen steps to higher awareness. delhi motilal banarasidass publishers; 2002. 4. anand bk. yoga and medical sciences. ind.j.physiol pharmacol. 1991; 35(2): 84-87. pmid: 1791050. 5. cardoso r, de souza e, centurione l, bazzarella ms, nakamura mu, et al. meditation in health: an operational definition. brain res brain res protoc. 2004; 14 (1):58-60. 10.1016/j.brainresprot.2004.09.002. 6. manocha r. why meditation? aust fam physician. 2000; 29 (12):1135-8. pmid: 11140217 7. walsh r, shapiro sl. "the meeting of meditative disciplines and western psychology: a mutually enriching dialogue". american psychologist. 2006; 61(3): 227–39. 10.1037/0003066x.61.3.227 8. craven j. meditation and psychotherapy. can j psychiatry. 1989; 34(7):648-53. 10.1177/070674378903400705. 9. cortland j. dahl 1,2, antoine lutz1,2,3,4, and richard j. davidson1,2,5. reconstructing and deconstructing the self: cognitive mechanisms in meditation practice. 10. smallwood j, mcspadden m, schooler jw. the lights are on but no one's home: meta-awareness and the decoupling of attention when the mind wanders. psychon. bull. rev. 2007; 14:527–533. [pubmed: 17874601] 11. schlosser m, sparby t, vörös s, jones r , marchant nl. unpleasantmeditation-related experiences in regularmeditators: prevalence, predictors, and conceptual considerations. 2019 may 9; 14(5):e0216643. doi: 10.1371/journal.pone.0216643. e collection 2019. 12. https://www.brahmakumaris.org 13. bormann je. frequent, silent mantram repetition ajacuzzi for the mind. top emerg med. 2005; 27(2):163–66. 14. bormann je, carrico aw. increases in positive reappraisal coping during a groupbasedmantram intervention mediate sustained reductions in anger in hiv-positive persons. int j behav med. 2009; 16(1): 74–80. 10.1007/s12529008-9007-3 15. lynch j, prihodova l, dunne pj, o’leary c, breen r,1 carroll a, et al. mantra meditation programme for emergency department staff: a https://www.eubios.info/ej141/ej141j.htm https://www.brahmakumaris.org/ https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19127438 https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19127438 https://doi.org/10.1007%2fs12529-008-9007-3 https://doi.org/10.1007%2fs12529-008-9007-3 saini et al medical and health science journal 2023 february vol.07 (01) page 45 of 45 qualitative study. bmj open. 2018; 8:e020685. doi: 10.1136/bmjopen-2017020685 16. bernardi l, sleight p, bandinelli g, cencetti s, fattorini l, wdowczyc-szulc j, et al. effect of rosary prayer and yoga mantras on autonomic cardiovascular rhythms: comparative study. bmj. 2001 dec 22; 323(7327): 1446–1449 17. bormann je, aschbacher k, wetherell jl, roeschf s, redwineg l. effects of faith/assurance on cortisol levels are enhanced by a spiritual mantram intervention in adults with hiv: a randomized trial. j psychosom res. 2009; 66 (2): 161–71. 18. bormann je, carrico aw. increases in positive reappraisal coping during a group-based mantram intervention mediate sustained reductions in anger in hiv-positive persons. int j behav med. 2009; 16 (1): 74–80. 10.1007/s12529008-9007-3 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc61046/ https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19154859 https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19154859 https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19127438 https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19127438 https://doi.org/10.1007%2fs12529-008-9007-3 https://doi.org/10.1007%2fs12529-008-9007-3 e:\job aditya\indro\naskah masu nova primadina, epidemiologi kasus bedah plastik di rsud syarifah ambami rato ebhu bangkalan, penelitian retrospektif dua tahun 4141 epidemiologi kasus bedah plastik di rsud syarifah ambami rato ebhu bangkalan, penelitian retrospektif dua tahun nova primadina1 medical faculty of muhammadiyah surabaya university, jawa timur, indonesia/ ex-plastic surgeon rsud syarifah ambami rato ebhu bangkalan-madura e-mail: novaprimadina@fk.um-surabaya.ac.id abstract: syarifah ambami rato ebhu bangkalan hospital is a referral hospital type b in madura island, but there has never been a plastic surgery specialist services before 2015. this research is done to know the epidemiology of plastic surgery cases treated at syarifah ambami rato ebhu hospital madura in two years. the study was a descriptive retrospective observational study with a sample of the entire population of outpatient and inpatient handled by plastic surgeon in a span of two years. the case of plastic surgery data collected show an increase in patients as much as 34.1% of 129 patients in 2015 to 173 patients in 2016, the case has risen significantly by 130% from 23 cases in 2015 to 53 cases in the year 2016, and the non-operative cases increase by 13.2% from 106 cases to 120 cases with details of the five most cases are handled by a specialist plastic surgery are: chronic wounds with a total of 72 cases has increased 127% in year 2, wounds fuels with a total of 35 cases has increased 18.75% in year 2, vulnus appertum as many as 31 cases increased by 38.46% in the year-to-two years, as many as 25 cases of keloid has increased 50% in year 2 years, and basalioma with a total of 23 cases, decreased 35.7% in year 2 years after the holding extension. the case of plastic surgery and the number of patients has increased significantly since the holding of plastic surgery services in syarifah ambami rato ebhu bangkalan hospital. unfortunately this service is discontinued. therefore, it should be a plastic surgeon specialist service continuously in bangkalan hospital madura, supporting presidential decree no.04 in 2017 to assist the efficiency and effectiveness of the maduranese who require specialist services in plastic surgery. keywords: plastic surgery cases, bangkalan, madura, epidemiology abstrak: rsud bangkalan merupakan rumah sakit tipe b rujukan se-pulau madura, tetapi belum pernah ada pelayanan spesialis bedah plastik sebelum tahun 2015 penelitian ini dilakukan untuk mengetahui data epidemiologi kasus bedah plastik yang di terapi di rsud syarifah ambami rato ebhu bangkalan madura dalam dua tahun ini. penelitian ini adalah penelitian deskriptif retrospektif observasional dengan sampel seluruh populasi pasien rawat jalan dan rawat inap yang ditangani oleh spesialis bedah plastik dalam kurun waktu dua tahun. data kasus bedah plastik yang berhasil dikumpulkan menunjukkan peningkatan pasien sebanyak 34,1% dari 129 pasien di tahun 2015 menjadi 173 pasien di tahun 2016, kasus operatif mengalami kenaikan signifikan sebesar 130% dari 23 kasus di tahun 2015 menjadi 53 kasus di tahun 2016, dan kasus non-operatif mengalami kenaikan sebesar 13,2% dari 106 kasus menjadi 120 kasus dengan rincian lima kasus terbanyak yang ditangani oleh spesialis bedah plastik adalah luka kronik dengan total 72 kasus mengalami kenaikan 127% di tahun ke-2, luka bakar dengan total 35 kasus mengalami kenaikan 18,75% di tahun ke-2, vulnus appertum sebanyak 31 kasus mengalami kenaikan 38,46% di tahun ke-2, keloid sebanyak 25 kasus mengalami kenaikan 50% di tahun ke-2, dan basalioma dengan total 23 kasus, mengalami penurunan 35,7% di tahun ke-2 setelah diadakan penyuluhan. kasus dan jumlah pasien bedah plastik mengalami peningkatan sejak diadakannya layanan bedah plastik di rsud bangkalan, namun sayangnya pelayanan ini diskontinu di awal tahun 2017. oleh karena itu sebaiknya diadakan kegiatan wajib kerja dokter spesialis secara berkesinambungan di rsud bangkalan madura, sekaligus medical and health science journal, vol. 1, no. 2, august 2017 42 pendahuluan madura adalah sebuah pulau yang terletak di timur laut provinsi jawa timur dengan luas 5.168 km2 dan penduduk ±4 juta jiwa, yang terdiri dari empat kabupaten, yaitu bangkalan, sampang, pamekasan, dan sumenep. bangkalan merupakan kabupaten terbesar di pulau madura dan terletak di bagian barat pulau madura, dengan rumah sakit syarifah ambami rato ebhu sebagai rumah sakit umum terbesar dan rumah sakit sentra rujukan se-pulau madura (wikipedia ensiklopedia bebas, 2017). rumah sakit ini memiliki 25 orang dokter umum orang dan 40 orang dokter spesialis. namun sayangnya hingga tahun 2015 belum ada dokter spesialis bedah plastik memberikan pelayanan di rumah sakit ini, padahal banyak kasus yang membutuhkan pelayanan spesialis ini (ebu, 2016). sebelum tahun 2015 pelayanan kasus-kasus bedah plastik biasanya ditangani oleh spesialis bedah umum, bahkan mayoritas kasus perawatan luka kronik dirawat oleh perawat-perawat yang sudah mengikuti pelatihan rawat luka yang membuka praktik di kediaman mereka masingmasing, mereka bahkan membuka kursus melatih pemuda setempat dengan pelatihan rawat luka dan kemudian disebar ke seluruh kabupaten di madura untuk melakukan pelayanan rawat luka dengan metode home care, hal ini tentu berdampak kepada para penderita yang membutuhkan perawatan, di satu sisi mereka terbantu karena tidak perlu repot menyewa transportasi untuk mendapatkan perawatan di rumah sakit, namun di sisi lain banyak kasus infeksi luka dan kejadian luka kronik serta kejadian amputasi meningkat. ujung-ujungnya jika kasus tersebut tidak bisa tertangani dengan optimal dan tidak membaik atau semakin parah baru segera dirujuk ke rumah sakit terdekat atau ke rumah sakit di surabaya. pada tahun 2015 pertama sekali diadakan pelayanan oleh spesialis bedah plastik di rsud syarifah ambami rato ebhu madura, dua sampai tiga kali seminggu, pelayanan ini berlangsung selama lebih kurang dua tahun, yang hasil evaluasinya akan dilaporkan dalam penelitian retrospektif ini. selama pelayanan ini berlangsung, ditemukan beberapa kasus-kasus luka kronik yang harus diamputasi karena sudah nekrotik bahkan ada yang sudah menjadi kanker sel skuamous. rata-rata pasien yang datang dengan kasus-kasus yang sudah end stage tersebut sudah melalui fase perawatan luka selama beberapa bulan dengan metode home care, setelah kehabisan biaya dan belum sembuh juga baru mereka datang ke rumah sakit untuk mendapatkan perawatan lebih lanjut dengan menggunakan bpjs atau asuransi dari pemerintah daerah. dari fakta-fakta di atas alangkah lebih baik jika bisa diadakan pelayanan dokter spesialis bedah plastik secara berkesinambungan di rsud syarifah ambami rato ebhu bangkalan agar seluruh kasus bedah plastik yang ada di pulau madura dapat ditangani seoptimal dan seefisien mungkin dan dengan diadakannya program wajib kerja dokter spesialis sesuai dengan perpres no. 04 tahun 2017 sehingga pasien-pasien yang membutuhkan pelayanan spesialis bedah plastik ini akan terbantu dan tidak perlu jauh-jauh datang ke surabaya, yang mengharuskan mereka menambah biaya transportasi yang tidak sedikit jumlahnya (perundang-undangan, 2017). mendukung perpres no.04 tahun 2017 guna membantu efisiensi dan efektivitas masyarakat madura yang membutuhkan layanan spesialis bedah plastik. kata kunci: kasus bedah plastik, bangkalan, madura, epidemiologi nova primadina, epidemiologi kasus bedah plastik di rsud syarifah ambami rato ebhu bangkalan, penelitian retrospektif dua tahun 43 metode penelitian penelitian ini adalah penelitian deskriptif retrospektif observasional dengan sampel seluruh populasi pasien bedah plastik rawat jalan dan rawat inap di rsud syarifah ambami rato ebhu bangkalan dalam kurun waktu 2 tahun, dari tahun 2015 sampai dengan tahun 2016 yang diamati melalui beberapa kategori dan dibandingkan antara tahun 2015 dan 2016 secara kuantitatif. hasil penelitian dari data kunjungan pasien rawat jalan dan rawat inap kasus bedah plastik ke rsud syarifah ambami rato ebhu bangkalan madura, tahun 2015 didapatkan ada total 129 pasien baru dengan komposisi 61 pasien laki-laki dan 68 pasien perempuan, di tahun 2016 jumlah pasien baru ini mengalami peningkatan pasien sebanyak 34,1% menjadi 173 pasien baru di tahun 2016 dengan komposisi 85 pasien lakilaki dan 88 pasien perempuan seperti ditunjukkan pada grafik di bawah ini. dengan distribusi pasien berdasarkan kategori usia seperti pada tabel 1. tabel 1 distribusi pasien berdasarkan usia 106 kasus perawatan konservatif, kasus operasi bedah plastik mengalami kenaikan signifikan sebesar 130% menjadi 53 kasus di tahun 2016, dan kasus non-operatif mengalami kenaikan sebesar 13,2% menjadi 120 kasus. 2015 2016 <1 thn 5 10 1-10 thn 10 20 11-20 thn 17 18 21-30 thn 18 18 31-40 thn 9 24 41-50 thn 25 40 51-60 thn 29 32 >60 thn 16 21 total 129 173 dari total jumlah pasien di tahun 2015 terdapat 23 kasus operasi bedah plastik dan gambar 1 distribusi pasien berdasarkan jenis kelamin di tahun pertama kasus operasi bedah plastik tergolong sangat sedikit, hanya 23 kasus operasi dalam 1 tahun, hal ini dikarenakan budaya masyarakat setempat yang menganggap operasi itu hanya untuk pasien-pasien yang sangat gawat dan hampir meninggal, tetapi tidak untuk kasus-kasus elektif, mereka lebih memilih untuk perawatan konservatif atau terapi apapun kecuali operasi, hanya masyarakat yang tinggal di ibukota kabupaten yang mulai berani untuk melakukan operasi dengan keluhan-keluhan elektif seperti soft tissue tumor dan keloid. setelah tahun kedua tampak peningkatan signifikan kasus operatif sebesar 130% hal ini kemungkinan besar dikarenakan pasien-pasien yang telah berhasil sembuh dengan baik dengan terapi operatif dilihat oleh masyarakat sekitarnya dan diceritakan ke banyak orang sehingga jumlah konsultasi baru yang datang dan berakhir di meja operasi meningkat. adapun jumlah kasus terbanyak dalam dua tahun yang meminta pelayanan spesialis bedah plastik di madura seperti terlihat pada tabel 2. medical and health science journal, vol. 1, no. 2, august 2017 44 tabel 2 distribusi kasus pasien berdasarkan diagnosis kasus baru per tahunnya dan jumlah populasi berisiko 927.433 populasi, jika dibandingkan dengan insiden basalioma di jakarta 0,285/ 100.000 penduduk/tahunnya dengan jumlah kasus baru 29 kasus per tahunnya dan jumlah populasi berisiko sebanyak 10.177.924 (regency, 2017; admnfd, 2016). sementara di rsud m. djamil padang hanya mempunyai 18 kasus baru dalam kurun waktu 5 tahun (azamris, 2011). peningkatan kasus perawatan luka kronik dikarenakan banyak kasus-kasus rujukan dari terapi metode homecare yang tidak berhasil yang akhirnya dirujuk ke rsud dan beberapa di antaranya menjadi kasus operatif, baik itu operasi debridement, amputasi maupun penutupan luka dengan skingraft. seluruh pembiayaan pasien bedah plastik dikategorikan menjadi empat kategori, yaitu dengan status pembiayaan pasien umum, bpjs, non-askes, dan sehati. tampak peningkatan kasus perawatan luka kronik dengan total 22 kasus mengalami kenaikan 127% di menjadi 50 kasus tahun ke2, luka bakar dengan total 35 kasus mengalami kenaikan 18,75% di tahun ke-2 dan merupakan kasus cito terbanyak di madura, vulnus appertum sebanyak 31 kasus mengalami kenaikan 38,46% di tahun ke-2 tahun, keloid sebanyak 25 kasus mengalami kenaikan 50% di tahun ke-2, dan basalioma dengan total 23 kasus, mengalami penurunan 35,7% di tahun ke-2 setelah diadakan 2015 2016 total chronic wound 22 50 72 combustio 16 19 35 v.app 13 18 31 stt 13 14 27 keloid 10 15 25 basalioma 15 9 24 clp 4 6 10 kontraktur 6 3 9 sfr.maksilofasial 5 2 7 gambar 3 distribusi kasus pasien berdasarkan tipe kasus penyuluhan. menariknya insiden basalioma di kabupaten bangkalan ini tergolong paling tinggi di indonesia, dengan 2,59/ 100.000 penduduk/ tahun dengan jumlah kasus baru mencapai 15 gambar 4 distribusi pasien berdasarkan pembiayaan tampak kenaikan pasien umum dari 2015 sebanyak 240% dari 12 pasien menjadi 41 pasien di tahun 2016. hal ini kemungkinan dikarenakan pasien ingin mendapatkan pelayanan yang cepat dan tidak perlu mengantre di loket bpjs, kemungkinan kedua pasien tidak sempat mengurus bpjs dan asuransi daerah karena kasus cito. nova primadina, epidemiologi kasus bedah plastik di rsud syarifah ambami rato ebhu bangkalan, penelitian retrospektif dua tahun 45 kesimpulan dan rekomendasi kesimpulan berdasarkan fakta di atas, kasus dan jumlah pasien bedah plastik mengalami peningkatan dalam dua tahun sejak diadakannya layanan bedah plastik di rsud bangkalan. namun saat ini layanan tersebut ditiadakan karena keterbatasan kemampuan dokter spesialis bedah plastik yang bertugas di sana untuk masuk setiap hari. rekomendasi oleh karena itu, sebaiknya diadakan kegiatan wajib kerja dokter spesialis secara berkesinambungan di rsud bangkalan madura oleh dokter-dokter spesialis bedah plastik yang baru lulus, sekaligus mendukung perpres no. 04 tahun 2017 guna membantu efisiensi dan efektivitas masyarakat madura yang membutuhkan layanan spesialis bedah plastik. daftar pustaka admnfd. 2016. fakta dki, rekam jejak ibukota jakarta, 05 dec, [online]. available: http:/ /faktadki.com/2016/12/05/jumlah-penduduk-dki-jakarta-menurut-usia-tahun-2015/ [may 2017]. azamris. 2011. ‘kanker kulit di bangsal bedah rs dr. m. djamil padang januari 2002 maret 2007’, cdk 183 vol.38 no.2, pp. 109–111. ebu, r.s.a.r. 2016. rsa bangkalan, [online]. available: http://rsabangkalan.com/ [jul 2017]. perundang-undangan, s.i.d.j.p. 2017. peraturan.go.id kementrian hukum dan hak azasi manusia republik indonesia, [online]. available: http://peraturan.go.id/perpres/ nomor-4-tahun-2017.html [aug 2017]. regency, b.-s.o.b. (2017) statistics of bangkalan, [online], available: http://bangkalankab. bps.go.id [may 2017]. wikipedia ensiklopedia bebas. 2017. 14 jul, [online], available: https://id.wikipedia. org/wiki/pulau_madura [07 aug 2017]. medical and health science journal, vol. 1, no. 2, august 2017 46 e:\job aditya\indro\naskah masu thomas s., rahayu a., handayani, m. yusuf alamudi, skrining hiv pada remaja di surabaya dengan menggunakan rapid test 5757 skrining hiv pada remaja di surabaya dengan menggunakan rapid test thomas s.1), rahayu a.1), handayani2), m. yusuf alamudi3,4,5) 1analis kesehatan-universitas nadhlatul ulama surabaya 2fakultas kedokteran-universitas nadhlatul ulama surabaya 3pusat riset flu burung-universitas airlangga 4fakultas kesehatan masyarakat-universitas nadhlatul ulama surabaya 5pusat penelitian kesehatan pondok pesantren-universitas nadhlatul ulama surabaya e-mail: _____________________________ abstrak: hiv (human immunodeficiency virus) merupakan retrovirus bersifat limfotropik khas yang menginfeksi sel-sel dari sistem kekebalan tubuh, menghancurkan atau merusak sel darah putih spesifik yang disebut limfosit t-helper atau limfosit pembawa faktor t4 (cd4). virus ini diklasifikasikan dalam famili retroviridae, subfamili lentiviridae, genus lentivirus. jumlah kematian hiv/aids di kalangan remaja di seluruh dunia yang meningkat sebesar 50 persen antara tahun 2005 dan 2012 menunjukkan tren mengkhawatirkan. laporan badan pbb yang menangani masalah anak-anak unicef menyebutkan sekitar 71.000 remaja berusia antara 10 dan 19 tahun meninggal dunia karena virus hiv pada tahun 2005. jumlah itu meningkat menjadi 110.000 jiwa pada tahun 2012. unit perawatan intermediet dan penyakit infeksi (upipi) rsud dr. soetomo surabaya. 1.780 pasien yang rutin berobat di upipi, sedangkan jumlah pengunjung setiap bulannya mencapai 2.000 orang, yakni 50 di antaranya adalah pasien anak-anak dan sisanya dewasa. kebanyakan pasien berumur antara 20 hingga 30 tahun dari berbagai wilayah yang tersebar di jatim, seperti surabaya, sidoarjo, gresik, jember, maupun pasuruan. tujuan dari penelitian ini mendeteksi virus hiv pada remaja di surabaya dengan menggunakan rapid test. sebanyak 54 orang remaja di surabaya diambil darahnya, dipisahkan dan dicek dengan menggunakan rapid test. prosedur mengikuti manual rapid test. hasil penelitian menunjukkan bahwa dari 54 sampel dengan menggunakan rapid test menunjukkan hasil negatif terhadap hiv. kata kunci: skrining, hiv, rapid test, remaja, surabaya pendahuluan hiv merupakan singkatan dari human immunodeficiency virus (hiv) merupakan retrovirus yang menjangkiti sel-sel sistem kekebalan tubuh manusia (terutama cd4 positif tsel dan makrofag– komponen-komponen utama sistem kekebalan sel), dan menghancurkan atau mengganggu fungsinya. infeksi virus ini mengakibatkan terjadinya penurunan sistem kekebalan yang terus-menerus, yang akan mengakibatkan defisiensi kekebalan tubuh. sistem kekebalan dianggap defisien ketika sistem tersebut tidak dapat lagi menjalankan fungsinya memerangi infeksi dan penyakit-penyakit. orang yang kekebalan tubuhnya defisien (immunodeficient) menjadi lebih rentan terhadap berbagai ragam infeksi, yang sebagian besar jarang menjangkiti orang yang tidak mengalami defisiensi kekebalan. virus hiv diklasifikasikan ke dalam golongan lentivirus atau retroviridae. virus ini secara material genetik adalah virus rna yang tergantung pada enzim reverse transcriptase untuk dapat menginfeksi sel mamalia, termasuk manusia, dan menimbulkan kelainan patologi secara lambat. virus ini terdiri dari 2 grup, yaitu hiv1 dan hiv-2. masing-masing grup mempunyai medical and health science journal, vol. 1, no. 2, august 2017 58 lagi berbagai subtipe, dan masing-masing subtipe secara evolusi yang cepat mengalami mutasi. di antara kedua grup tersebut, yang paling banyak menimbulkan kelainan dan lebih ganas di seluruh dunia adalah grup hiv-1 (zein, 2006). profil kesehatan indonesia tahun 2013 menyebutkan, setelah tiga tahun berturut-turut (2010–2012) jumlah kasus hiv cukup stabil, tapi perkembangan “jumlah kasus baru hiv positif pada tahun 2013 kembali mengalami peningkatan secara signifikan, dengan kenaikan mencapai 35% dibanding tahun 2012”. (3) serta mengalami peningkatan kembali pada tahun 2014. berdasarkan data profil kesehatan ri, jumlah kasus hiv positif pada tahun 2012 sebanyak 21.511 kasus, meningkat 34,9% pada tahun 2013 (29.037 kasus), serta pada tahun 2014 meningkat lagi 12,36% (32.711 kasus), dan tahun 2015 sebanyak 30.935 kasus dengan penurunan 5,42%. persentase kumulatif infeksi hiv tertinggi dilaporkan pada kelompok umur 20–24 tahun 4.871 kasus (17%), umur 25–49 tahun 21.810 (69%) dan kelompok umur di atas 50 tahun 2.002 kasus (7%). (4) laporan kasus aids yang didapatkan sampai tahun 2015, terjadi peningkatan 7.8% pada tahun 2013, dan terjadi penurunan pada tahun berikutnya. kasus aids pada tahun 2012 (10.659 kasus), meningkat 7,8% pada tahun 2013 (11.493 kasus), menurun 31,4% pada tahun 2014 (7.875 kasus) dan pada tahun 2015 terjadi penurunan lagi 22,7% (6.081 kasus). dengan kelompok umur 20–29 tahun 27,9% kasus, 30–39 tahun 37,3% kasus, 40–49 tahun 18,8% kasus dan di atas 60 tahun 2% kasus. (4) berdasarkan data yang ada sepuluh provinsi terbanyak kasus aids tertinggi di urutan pertama yaitu bali (955 kasus), diikuti bengkulu (586 kasus), gorontalo (212 kasus), dki jakarta (171 kasus), bangka belitung (152 kasus), sumatera selatan (120 kasus), papua (119 kasus), ntt (112 kasus), sumbar (97 kasus), dan sulawesi selatan (92 kasus). (4) angka kematian akibat aids di indonesia berdasarkan laporan yang ada, pada tahun 2012 (2.072 kasus), tahun 2013 (1.481 kasus), tahun 2014 (956 kasus) dan pada tahun 2015 (610 kasus) yang di laporkan. dengan kelompok umur 15–19 tahun 209 kasus, umur 20-29 tahun 3.877 kasus. kasus hiv/aids pada remaja setiap tahun selalu mengalami peningkatan. hal ini juga didukung dengan perkembangan globalisasi yang mengakibatkan adanya perubahan sosial dan gaya hidup remaja, termasuk perilaku berisiko seperti hubungan seksual dengan berganti-ganti pasangan, hubungan seks pranikah, serta penyalahgunaan narkoba. gaya hidup seperti ini membahayakan kesehatan reproduksi terutama kemungkinan terjadinya penularan penyakit menular seksual termasuk hiv (human immunodeficiency virus)/aids (acquerid immuno deficiency syndrome) pada pasangannya. remaja merupakan kelompok yang rentan terhadap ims (infeksi menular seksual) dengan jumlah terbesar mengidap hiv/aids. remaja merupakan sasaran primer dalam program penanggulangan ims khususnya hiv/aids (soetjiningsih, 2007). remaja mengalami perubahan yang mencakup perubahan fisik dan emosional yang kemudian tecermin dalam sikap dan tingkah laku. remaja merupakan salah satu kelompok penduduk yang mudah terpengaruh oleh arus informasi baik informasi yang positif maupun yang negatif. hal-hal negatif seperti seks dan narkoba, selain dapat menimbulkan kehamilan yang tidak diinginkan dan kematian akibat overdosis juga memberikan risiko yang tinggi dalam penularan hiv/aids pada remaja (unaids, 2002). kementerian kesehatan melaporkan bahwa pada 3 tahun terakhir terhitung tahun 2010 sampai dengan 2013 terjadi peningkatan kasus baru thomas s., rahayu a., handayani, m. yusuf alamudi, skrining hiv pada remaja di surabaya dengan menggunakan rapid test 59 hiv/aids yang semakin cepat di jawa timur dengan persentase kasus yang terjadi pada lakilaki lebih tinggi daripada kasus yang dialami oleh perempuan. secara kumulatif kasus hiv & aids di jawa timur menduduki peringkat kedua setelah papua dengan persentase kasus hiv (14,285 kasus) dan kasus aids (6,900 kasus) (kemenkes, 2013). pada juni 2013 direktorat jenderal pengendalian penyakit & penyehatan lingkatam kementerian kesehatan ri secara statistik melaporkan jumlah kumulatif kasus hiv/aids menurut faktor risiko, penyebaran hiv/aids ditularkan melalui hubungan seks heteroseksual berada pada peringkat pertama dengan persentase 26,156 kasus, dan pula didapati jumlah kumulatif kasus hiv/aids berdasarkan golongan umur 15–19 tahun sebanyak 1,416 kasus. tujuan penelitian ini adalah menskrining virus hiv pada remaja yang memiliki latar belakang pondok pesantren di surabaya. bahan dan metode pengambilan sampel dilakukan pada remaja dengan usia 19–20 tahun dengan tidak membedakan jenis kelamin. serum yang telah dipisahkan diteteskan pada monotes rapid test untuk pengujian hiv dan selanjutnya mengikuti prosedur dari monotes rapid test hiv. hasil penelitian dan pembahasan dari hasil penelitian yang dilakukan dengan menggunakan monotes rapid test hiv didapatkan hasil bahwa remaja dengan memiliki latar belakang pondok pesantren di surabaya negatif terhadap hiv dengan menggunakan rapid test hiv monotes. hasil pengujian dengan menggunakan rapid test sebagai berikut. gambar 1 pengujian serum pada sampel terhadap hiv dengan rapid test gambar 2 hasil pengujian dengan menggunakan rapid test human immunodeficiency virus (hiv) adalah virus yang menyebabkan acquired immuno deficiency syndrome (aids). sedangkan aids medical and health science journal, vol. 1, no. 2, august 2017 60 adalah suatu penyakit yang ditandai dengan melemahnya sistem kekebalan tubuh. dengan melemahnya kekebalan ini maka tubuh tak mampu lagi mempertahankan dirinya terhadap serangan penyakit. hiv/aids merupakan masalah kesehatan global baik di negara maju maupun negara berkembang. wilayah terburuk yang terinfeksi virus hiv adalah afrika sub-sahara, asia selatan, dan asia tenggara. indonesia merupakan negara yang tingkat penyebaran virus hiv/aidsnya tercepat di asia. epidemi hiv/aids di indonesia telah berlangsung lebih dari 20 tahun, dan sejak tahun 2000 fase epidemiknya sudah berubah dari tingkat low menjadi tahap concentrated epidemic (prevalensi lebih dari 5%) pada sub populasi berisiko tinggi yaitu pengguna napza suntik (penasun), wanita penjaja seks (wps), pelanggan penjaja seks, lelaki seks dengan lelaki lain dan waria. selain itu, menurut data 2010, baik dari badan pusat statistik (bps), bappenas dan unfpa, sebagian dari 63 juta jiwa remaja berusia 10 sampai 24 tahun di indonesia rentan berperilaku tidak sehat. masalah yang paling menonjol di kalangan remaja saat ini, misalnya masalah seksualitas, kemudian rentan terinfeksi penyakit menular seksual (ims), hiv atau aids serta penyalahgunaan narkoba. berdasarkan hasil penelitian yang dilakukan dengan menggunakan rapid test terhadap hiv pada remaja di surabaya yang memiliki latar belakang pendidikan pondok pesantren, didapatkan hasil negatif terhadap hiv. hasil penelitian ini memiliki perbedaan dengan penelitian yang dilakukan oleh sri harti, dkk. (2014) penelitian dilakukan di salah rumah sakit surakarta dengan jumlah sampel 20 buah dengan menggunakan rapid test di dalam mendeteksi hiv, berdasarkan hasil pemeriksaan hiv 1 dan 2 metode imunokromatografi rapid test terhadap 20 sampel pasien tersangka aids didapatkan 5 sampel yang menunjukkan positif mengandung antibodi hiv1 dan 2. selain itu, berdasarkan hasil penelitian yang dilakukan oleh aroem naroeni, dkk. (2009) bahwa pada sampel plasma yang mempunyai hasil uji serologi indeterminate dari donor darah yang diambil dari unit transfusi darah pusat, palang merah indonesia (pmi) dan dilakukan uji konfirmasi dengan menggunakan western blot. hasil pengujian dari 40 sampel menunjukkan 90% sampel terkonfirmasi sebagai indeterminate. sebagian besar hasil indeterminate dihasilkan oleh reaksi dengan antigen p24 virus hiv. rt-pcr dengan target daerah ltr, pol, env dan p24 dilakukan untuk mendeteksi adanya rna hiv. primer kemudian didesain untuk mengamplifikasi daerah tersebut. sebanyak 24/ 32 atau 75% sampel positif ltr, 4/31 atau 12% positif pol dan 3/5 atau 60% positif env. amplifikasi pada daerah p24. hasil penelitian ini juga memiliki perbedaan dengan penelitian yang dilakukan andi yasmon, dkk. (2010) bahwa metode uji rt-pcr dievaluasi terhadap 46 spesimen yang diperoleh dari voluntary counseling and testing for hiv (vct) di rumah sakit umum pemerintah (rsup) sanglah, bali. untuk mendapatkan sensitivitas dan spesivitas uji, hasil uji rt-pcr dibandingkan dengan hasil serologi yang umum digunakan di indonesia. hasil uji rtpcr dapat mendeteksi 21dari 26 spesimen yang positif uji serologi dan memberikan 19 hasil uji negatif dari 20 spesimen yang negatif uji serologi. satu spesimen menunjukkan hasil positif dengan rt-pcr tetapi negatif dengan uji serologi. hasil tersebut kemungkinan menggambarkan hasil yang sebenarnya saat uji serologi tidak dapat mendeteksi infeksi hiv-1. selain itu, lima spesimen yang positif uji serologi menunjukkan hasil negatif dengan rt-pcr yang diduga disebabkan oleh batas deteksi uji rt-pcr yang thomas s., rahayu a., handayani, m. yusuf alamudi, skrining hiv pada remaja di surabaya dengan menggunakan rapid test 61 rendah. hasil penelitian yang dilakukan oleh rosilawati dan bela (2007) menyatakan bahwa penelitian dengan menggunakan serum darah dari rumah sakit ketergantungan obat (rsko) fatmawati. jumlah serum yang dipakai sebanyak 55 sampel terdiri dari 5 sampel negatif hiv hasil uji serologi dengan rapid test dan 50 sampel dengan enzyme linked immunoassay (elisa). hasil penelitian menunjukkan pada 55 sampel yang diuji baik dengan teknik rtpcr elektroforesis gel agarosa maupun rt-pcr hibridisasi dot blot, 43 sampel positif mengandung hiv. hasil rt-pcr hibridisasi dot blot jauh lebih jelas dibanding dengan rt-pcr-elektroforesis gel agarosa. hal ini terlihat munculnya dot hitam tebal pada film sedangkan pada gel agarosa pita dna tampak tipis untuk beberapa sampel positif hiv yang sama. kesimpulan skrining hiv dengan menggunakan rapid test menunjukkan hasil negatif pada remaja di surabaya. pengujian hiv dengan menggunakan uji serologis dan biologi molekuler dibutuhkan untuk melacak virus hiv. ini disebabkan tiap pengujian memiliki nilai sensitivitas dan spesivisitas yang berbeda-beda. daftar pustaka agnes sri harti, amalia agustin, siti mardiyah, estuningsih, heni nur kusumawati. 2014. pemeriksaan hiv 1 dan 2 metode imunokromatografi rapid test sebagai screening test deteksi aids. jurnal kesmadaska, januari 2014. aroem naroeni, hartiyowidi yuliawuri, yuliar budi hartanto, yuyun soedarmono, budiman bela, fera ibrahim. 2009. karakterisasi galur hiv indonesia dari donor darah dengan hasil uji serologi hiv indeterminate makara. kesehatan, vol. 13, no. 1, juni 2009 15-21. direktorat jenderal pp dan pl kementerian kesehatan ri. 2012. laporan situasi perkembangan hiv/aids di indonesia s.d. 30 juni 2012. jakarta (indonesia). djoerban z, djauzi s. “hiv/aids di indonesia”. in: buku ajar ilmu penyakit dalam edisi v. editor: sudoyo aw, setiyohadi b, alwi i, simadibrata m, setiati s. jakarta: pusat penerbitan ipd fkui. 2009; p. 2861 direktorat jenderal pp dan pl kementerian kesehatan ri. 2013. laporan situasi perkembangan hiv/aids di indonesia s.d. 31 maret 2013. jakarta (indonesia). kelompok kerja hiv-aids. 2005. remaja dinilai rentan tertular hiv. jakarta: rumah sakit penyakit infeksi prof. dr. sulianti saroso. diperoleh dari: http://www.aidsrpiss.com. keputusan menteri kesehatan ri. 2005. keputusan menteri kesehatan republik indonesia nomor 1507/menkes/sk/x/2005 tentang pedoman pelayanan konseling dan testing hiv/aids secara sukarela (voluntary counselling and testing). jakarta: menkes ri. maria lina rosilawati dan budiman bela. teknik reverse transcription – polymerase chain reaction (rt-pcr) dan hibridisasi dot blot dengan pelacak dna untuk deteksi human immunodeficiency virus (hiv) dalam serum darah universa medicina 2007; 26: 111–9. riyarto s., wijayanti y., indriani c., wilasto n., lazuardi e., mahendradatta y. 2010. faktor-faktor yang memengaruhi keterlambatan diagnosis hiv dan aids di yogyamedical and health science journal, vol. 1, no. 2, august 2017 62 karta, solo, dan semarang. yogyakarta: universitas gajah mada. siregar, f.a. 2004. pengenalan dan pencegahan aids (disertasi). sumut (indonesia): universitas sumatera utara. unaids. 2011. unaids world aids day report. geneva (swizerland). world health organization/unaids. aids epidemic update, report on the global aids epidemic. last updated june 28, 2007 who. who case definitions of hiv for surveilance and revised clinical staging and immunological classification of hiv related disease in adult and children. geneva (switzerland). d:\new order belum cetak\mhsj v elsa kusumawati, abraham ahmad a.f., reza hery m.p., hubungan antara kadar troponin dengan kejadian major adverse cardiovascular events pada pasien sindrom koroner akut di rsi jemursari surabaya 4747 hubungan antara kadar troponin dengan kejadian major adverse cardiovascular events pada pasien sindrom koroner akut di rsi jemursari surabaya elsa kusumawati, abraham ahmad ali firdaus, reza hery mahendra putra fakultas kedokteran universitas nahdlatul ulama surabaya e-mail: els4study@gmail.com abstrak: sindroma koroner akut (ska) memiliki variabilitas yang cukup besar dalam risiko outcome dan mortalitas. major adverse cardiovascular events (mace) adalah hasil akhir ska yang didefinisikan sebagai aritmia, syok kardiogenik, gagal jantung, dan kematian. troponin adalah protein spesifik yang berasal dari otot jantung, di mana fungsinya adalah regulasi kontraksi otot jantung. kejadian mace sering ditemukan pada pasien ska meskipun pasien telah menjalani perawatan intensif. dengan demikian, dibutuhkan prediksi awal yang besar untuk mengetahui risiko mace pada penderita ska, dalam hal ini berupa troponin. penelitian ini bertujuan untuk mengetahui kadar troponin yang meningkat, sehingga dapat lebih berhati-hati mencegah kejadian mace pada pasien ska. cross-sectional pada pasien ska yang dirawat di rsi jemursari surabaya pada bulan januari 2014–desember 2016. pengambilan sampel dengan teknik consecutive sampling, sebanyak 68 orang. data dianalisis dengan uji chi-square. penderita laki-laki lebih banyak dibandingkan dengan penderita perempuan. kelompok usia terbanyak yang menderita ska adalah 56-65 tahun, dengan rentang usia 35-85 dan rerata usia 59, 45±11,447 tahun. hasil penelitian ini menunjukkan bahwa terdapat korelasi antara peningkatan troponin dengan kejadian major adverse cardiovascular events (mace) pada pasien sindrom koroner akut dan nilai signifikansi p<0,002. hasil odss ratio (or) pada pasien ska dengan peningkatan troponin sebesar 6,5 (ik 95% 2,112-20,282) p<0,002. ada korelasi antara peningkatan kadar troponin dengan kejadian major adverse cardiovascular events (mace) pada pasien dengan sindrom koroner akut. kata kunci: troponin, major adverse cardiovascular events (mace), sindrom koroner akut (ska) abstract: acute coronary syndrome (acs) has considerable variability in outcome and mortality risk. major adverse cardiovascular events (mace) is outcome of acs that defined as arrhythmia, cardiogenic shock, heart failure, and death. troponin is a specific protein that comes from the heart muscle, where its function is to regulation of heart muscle contraction. the incidence of mace was often found in patients with acs even though the patient has been in intensive care. thus it takes a large initial prediction to determine the risk of mace in patients with acs, in this case in the form of troponin. this study aims to determine the increased troponin levels, so as to be more careful to prevent the incidence of mace in patients with acs. retrospective with cross-sectional study in acs patients treated at rsi jemursari surabaya in january 2014 december 2016. sampling with consecutive sampling technique, as many as 68 people. data were analyzed by chi-square test. male patients are more than female patients. the largest age group suffering from acs is 5665 years, with age range 35-85 and mean age 59, 45 ± 11,447 year. the results of this study to show that there is a correlation between troponin increase with incidence of major adverse cardiovascular events (mace) in patients with acute coronary syndromes with a significance value of p <0.002. results of odss ratio (or) in patients with ska with troponin increase of 6.5 (95% ik 2.11220.228) p <0.002. there is a correlation between elevated levels of troponin with the incidence of major adverse cardiovascular events (mace) in patients with acute coronary syndromes. keywords: troponin, major adverse cardiovascular events (mace), acute coronary syndrome (acs) medical and health science journal, vol. 2, no. 1, february 2018 48 pendahuluan penyakit kardio vaskuler merupakan penyebab utama kematian di dunia. pada tahun 2012, tercatat sebanyak 17,5 juta jiwa dari total 56 juta kasus kematian di dunia disebabkan oleh penyakit kardiovaskuler. bahkan, who memprediksi akan terjadi peningkatan kematian akibat penyakit kardiovaskular dari 17,5 juta jiwa menjadi 23,4 juta jiwa pada tahun 20301. prevalensi penyakit kardiovaskuler di indonesia sebanyak 7,2% dengan angka kematian sebesar 5.1% pada riset kesehatan dasar (riskesdas) tahun 20132. sindrom koroner akut (ska) merupakan kondisi mengancam nyawa yang bisa terjadi setiap saat pada pasien dengan penyakit jantung koroner. ska terdiri dari angina pektoris tidak stabil (apts), infark miokard tanpa st elevasi (non-st elevation myocardial infarction/nstemi) dan infark miokard dengan st elevasi (st elevation myocardial infarction/stemi), di mana bentuk dari ska tersebut bergantung kepada derajat oklusiarteri koroner dan hubungannya dengan kejadian iskemia3. major adverse cardiovascular event (mace) merupakan suatu kejadian komplikasi kardiovaskuler selama fase perawatan, meliputi di antaranya kejadian gagal jantung, syok kardiogenik, aritmia, dan kematian4. pada gobal registry acute coronary events (grace), kejadian mace selama perawatan di rumah sakit sebesar 4,6%5. troponin merupakan protein spesifik yang berasal dari otot jantung, di mana fungsinya adalah untuk regulasi kontraksi otot jantung6. kejadian mace masih sering dijumpai pada pasien ska walaupun pasien tersebut telah mendapatkan perawatan intensif. dengan demikian dibutuhkan suatu prediksi awal untuk mengetahui besar risiko terjadinya mace pada pasien ska, dalam hal ini adalah protein jantung berupa troponin. oleh karena itu, peneliti tertarik untuk mengetahui hubungan antara kadar troponin dengan kejadian major adverse cardiovascular events pada pasien sindrom koroner akut di rsi jemursari surabaya dan diharapkan dengan mengetahui peningkatan kadar troponin dapat lebih berhati-hati untuk mencegah kejadian mace pada pasien ska. metode penelitian pada penelitian ini menggunakan metode cross-sectional, dengan pengambilan data sekunder yang bersumber dari rekam medis yang bersifat retrospektif. pengambilan sampel dengan teknik consecutive sampling, sebesar 68 orang. poulasi pada penelitian adalah pasien sindrom koroner akut yang dirawat di rsi jemursari surabaya pada januari 2014–desember 2016. dengan kriteria inklusif yaitu data dari pasien dengan sindrom koroner akut yang dirawat di rsi jemursari surabaya dari januari 2014–desember 2016; kriteria eksklusi, yaitu chronic kidney disease (ckd), sepsis, emboli paru, data rekam medis yang tidak lengkap. penelitian ini dilaksanakan pada april–mei tahun 2017. kemudian data yang diperoleh diolah dengan menggunakan program spss versi 22.0 (ibm corporation 1989, 2013) dan dalam menguji hipotesis digunakan uji chi-square. hasil dan pembahasan hasil penelitian jumlah subjek penelitian ini adalah 68 orang dengan jumlah laki-laki sebesar 52 orang (76,5%) dan perempuan 16 orang (23,5%). pada usia 35–45 tahun sebanyak 9 orang (13,2%), 46–55 sebanyak 15 orang (22%), 56–65 tahun sebanyak 22 orang (32,3%), 66–75 sebanyak 16 orang (23,5%), 76–85 tahun sebanyak 6 orang (9%), dengan nilai rerata 59,45 ±11,447 dan elsa kusumawati, abraham ahmad a.f., reza hery m.p., hubungan antara kadar troponin dengan kejadian major adverse cardiovascular events pada pasien sindrom koroner akut di rsi jemursari surabaya 49 median/nilai tengah 60,50. pada frekuensi kadar troponin yang meningkat sebanyak 43 orang (63,2%) dan yang normal sebanyak 25 orang (36,8%), dari seluruh data penelitian, jumlah pasien yang mengalami mace sebanyak 47 orang (69%) dan yang tidak mengalami mace sebanyak 21 orang (30,1%) dengan proporsi mace terbanyak adalah gagal jantung sebanyak 24 orang (51%). jenis ska terbanyak adalah nstemi sebanyak 28 orang (41%) (tabel 1). tabel 1 hasil penelitian 36 orang (76,6%) dengan kadar troponin yang meningkat dan 11 orang (23,4%) dengan kadar troponin yang normal. pada uji kemaknaan dengan menggunakan chi-square didapatkan nilai p<0,002 yang berarti terdapat hubungan yang signifikan antara kadar troponindengan kejadian mace namun nilai or yang didapat yaitu 6,545 (ik 95% 2,112-20,282) hal ini menunjukkan bahwa odds ratio seorang pasien untuk terkena mace dengan kadar troponin meningkat adalah 6,5 kali dari pasien dengan kadar troponin yang normal (tabel 2). tabel 2 analisis bivariat mace ya tidak p or (ik 95%) n % n % troponin meningkat 36 76, 6 7 33,3 < 0,002 6.545 (2,112–20,282) karakteristik frekuensi persentase % jenis kelamin: laki-laki perempuan 52 16 76,5 23,5 usia: 35 – 45 46 – 55 56 – 65 66 – 75 76 – 85 mean: 59,45 ±11,447; median: 60,50 9 15 22 16 6 13,2 22 32,3 23,5 9 troponin: meningkat normal 43 25 63.2 36.8 jenis ska**: ua** nstemi** stemi** 19 28 21 28 41 30,1 mace: ya: • gagal jantung • syok kardiogenik • aritmia • kematian tidak 47 24 7 12 4 21 69 51 15 25,5 8,5 30,1 **ska: sindrom koroner akut **ua: unstable angina; **nstemi: non-st elevation myocardial infarction **stemi: st elevation myocardial infarction berdasarkan hasil penelitian, hubungan kadar troponin dengan kejadian mace dapat dilihat bahwa dari 47 pasien yang terkena mace, pembahasan pada pasien sindrom koroner akut yang berjenis kelamin laki-laki adalah 52 orang (76,5%), sedangkan perempuan adalah 16 orang (23,5%). hasil ini sesuai dengan penelitian yang dilakukan oleh torryet all yang menunjukkan bahwa penderita laki-laki (32 orang) lebih banyak dibandingkan perempuan (12 orang) pada tahun 2013 di bagian /smf ilmu penyakit dalam rsu bethesda tomohon. kesamaan ini terjadi karena lakilaki merupakan faktor risiko terjadinya sindrom koroner akut7. pada penelitian ini terdapat 9 orang (13,2%) penderita termasuk dalam kelompok usia 35– 45 tahun, 15 orang (22%) penderita termasuk dalam kelompok usia 46–55 tahun, 22 orang (32,3%) termasuk dalam kelompok usia 56–65 tahun, 16 orang (23,5%) termasuk dalam kelompok usia 66–75 tahun, 6 orang (9%) penderita termasuk dalam kelompok usia 76–85 tahun, di mana usia yang paling muda pada pasien ska medical and health science journal, vol. 2, no. 1, february 2018 50 tersebut adalah 35 tahun dan usia paling tua adalah 83 tahun. hal ini sesuai dengan penelitian yang dilakukan oleh ramadhani et al. bahwa kelompok usia 41–60 tahun merupakan kelompok usia penderita terbanyak. hal ini sesuai dengan teori mengenai usia. pada pasien sindrom koroner akut yang berjenis kelamin laki-laki adalah 52 orang (76,5%), sedangkan perempuan adalah 16 orang (23,5%). hasil ini sesuai dengan penelitian yang dilakukan oleh torryet et al. yang menunjukkan bahwa penderita laki-laki (32 orang) lebih banyak dibandingkan perempuan (12 orang) pada tahun 2013 di bagian /smf ilmu penyakit dalam rsu bethesda tomohon. kesamaan ini terjadi karena laki-laki merupakan faktor risiko terjadinya sindrom koroner akut7. pada penelitian ini terdapat 9 orang (13,2%) penderita termasuk dalam kelompok usia 35– 45 tahun, 15 orang (22%) penderita termasuk dalam kelompok usia 46–55 tahun, 22 orang (32,3%) termasuk dalam kelompok usia 56–65 tahun, 16 orang (23,5%) termasuk dalam kelompok usia 66–75 tahun, 6 orang (9%) penderita termasuk dalam kelompok usia 76-85 tahun, di mana usia yang paling muda pada pasien ska tersebut adalah 35 tahun dan usia paling tua adalah 83 tahun. hal ini sesuai dengan penelitian yang dilakukan oleh ramadhaniet et al., bahwa kelompok usia 41–60 tahun merupakan kelompok usia penderita terbanyak. hal ini sesuai dengan teori mengenai usia yang termasuk dalam faktor risiko terkena sindrom koroner adalah > 45 tahun laki-laki dan > dari 55 tahun untuk perempuan8. pasien ska dengan troponin normal sebanyak 25 orang (36,8%) dan troponin meningkat sebanyak 43 orang (63,2%), di mana peningkatan hasil pemeriksaan troponin dapat mencapai 60%. pasien ska yang mengalami mace sebanyak 47 orang (69%) dan yang tidak mengalami mace sebanyak 21 orang (30,1%). pada 47 orang (69%) yang mengalami mace, dengan troponin normal sebanyak 11 orang (23,4%) dan troponin yang meningkat sebanyak 36 orang (76,6%). berdasarkan uji statistik deskriptif dengan uji chi-square ini didapatkan p<0,002, dengan nilai α < 0,05, pada peningkatan troponin terhadap terjadinya mace, hal ini menunjukkan bahwa adanya hubungan peningkatan kadar troponin dengan mace. selain itu, seorang pasien yang mengalami ska dengan peningkatan kadar troponin memiliki risiko untuk terjadinya mace yaitu sebesar 6,5 (ik 95% 2,112–20,282) kali lebih besar dari pada pasien yang mengalami ska dengan kadar troponin yang normal. hasil penelitian ini sesuai dengan penelitian ang, dkk. pada penelitian tersebut didapatkan hasil bahwa pasien dengan peningkatan troponin memiliki risiko terjadinya mace 6 kali lebih besar dibandingkan dengan pasien yang memiliki kadar troponin yang normal dengan unadjusted rr 6,11 (ik 95%, 2,98–12,50)9. selain itu, pada penelitian sanchiset et al., menjelaskan bahwa troponin merupakan factor prediktif untuk menilai dampak pada manajemen dan hasil terapi pasien ska. pada pasien yang mengalami ska dengan troponin yang tinggi meningkat akan risiko rawat inap 1,35 kali yang lebih lama dibandingkan dengan pasien yang memiliki kadar troponin normal (or = 1,35, 95% ci 1,07 sampai 1,71, p = 0,02)10 simpulan dan saran simpulan pada pasien ska (sindrom koroner akut) dengan faktor risiko laki-laki dari 68 sampel didapatkan 52 orang (76,5%), sedangkan nilai rerata usia 59, 45 ±11,447 dan median 60,50, elsa kusumawati, abraham ahmad a.f., reza hery m.p., hubungan antara kadar troponin dengan kejadian major adverse cardiovascular events pada pasien sindrom koroner akut di rsi jemursari surabaya 51 dengan jumlah terbanyak kelompok usia 56-65 tahun, di mana didapatkan usia yang paling muda yaitu 35 tahun dan usia yang paling tua yaitu 83 tahun. proporsi mace (major adverse cardiovascular events) pada pasien ska di rumah sakit islam jemursari surabaya pada januari 2014desember 2016 adalah sebesar 69,1%, dengan jenis mace terbanyak yaitu gagal jantung sebesar 51%. peningkatan kadar troponin admisi sebagai faktor predictor terjadinya mace pada pasien ska dengan or 6,5 (ik 95% 2,112–20,282), p<0,002, yang menunjukkan bahwa pasien ska dengan peningkatan kadar troponin dapat mengalami mace sebesar 6,5 kali dari pasien dengan kadar troponin yang normal. sehingga dengan mengetahui kadar troponin pada pasien ska dapat lebih berhati-hati untuk mencegah kejadian mace pada pasien ska. daftar rujukan ang dsc, michelle pck, ellie d, et al. 2012. the prognostic value of high sensitivity troponin t 7 weeks an acute coronary syndrome. heart; 98:1160–1165. granger c.b., robert j.g., omar d., et al. 2003. predictors of hospital mortality in the global registry of acute coronary events. arch interns med; 163:2345–53. leonard s. lilly. 2011. pathophysiology of heart disease a collaborative project of medical students and faculty fifth edition. lippicott williams & wilkins. martalena, dewi, nasution a. sally., purnamasari, dyah, et al. 2013. pengaruh hiperglikemia admisi terhadap major adverse cardiac events selama perawatan pada pasien sindrom koroner akut di iccu rscm. jakarta. rumah sakit cipto mangunkusumo, jakarta: departemen ilmu penyakit dalam fakultas kedokteran universitas indonesia. mihardja l.k., delima, soetiarto f., dkk. 2013. penyakit tidak menular. in: kementerian kesehatan republik indonesia, penyunting. riset kesehatan dasar. jakarta: badan penelitian dan pengembangan kesehatan kementerian republik indonesia, p. 8399 skrt. depkes ri. survei kesehatan rumah tangga. 1995. ramadhani, bys., rotty, lwa., wantania, f. 2013. gambaran hematolohi pada pasien sindrom koroner akut yang dirawat di blu rsup prof. dr. r. d. kandou manado tahun 2010. manado; 1:12–6. sanchis, j. et al. 2014. ‘high-sensitivity versus conventional troponin for management and prognosis assessment of patients with acute chest pain’, heart. doi: 10.1136/ heartjnl-2013-305440. sood, ramnik. 2006. textbook of medical laboratory technology. jaypee brothers. tedros, adhanom, g., svetlana, akselrod., peter, salama., et al. world health organization, who. 2016. cardiovascular diseases. available from :http://www.who.int/ mediacentre/fs317/en/. diakses 22 oktober 2016. torry, s.r.v, panda, a.l. and ongkowijaya, j. 2013. ‘gamabaran faktor risiko penderita sindrom koroner akut’, universitas sam ratulangi, pp. 1–8. medical and health science journal, vol. 2, no. 1, february 2018 52 e:\job aditya\indro\naskah masu intashofal dan sukarjati, korelasi kadar kreatinin serum dengan hasil tes albumin pada pasien dengan penyakit ginjal di rsud dr. soegiri lamongan 2323 korelasi kadar kreatinin serum dengan hasil tes albumin urine pada pasien dengan penyakit ginjal di rsud dr. soegiri lamongan intashofal1) dan sukarjati2) 1)mahasiswi prodi biologi fmipa universitas pgri adibuana surabaya 2)staf pengajar prodi biologi fmipa universitas pgri adibuana surabaya e-mail: erika@unusa.ac.id abstract: examination of blood creatinine levels is one of the parameters used to assess renal function, since serum and urinary excretion concentrations within 24 hours are relatively constant. however, in another clinical guideline, there is a type of examination that is more recommended in most patients with the risk of kidney failure, urine albumin test. in the event of renal dysfunction, the ability of creatinine filtration will decrease and serum creatinine will increase as well as some substances that should not exist in the urine, such as albumin, to appear. reduced albumin excretion in the urine may be able to slow the rate of renal failure and help to delay the body’s need for kidney or dialysis transplantation. this cross-sectional study aims to analyze the relationship between serum creatinine and albuminuria in patients with kidney disease. serum creatinine level examination by jaffe method and urine albumin examination were qualitatively performed on the respondents who met the inclusion criteria. a total of 92 data were then analyzed by chi-square with α<0,05. the results of this study indicate that there is a significant relationship between serum creatinine and albuminuria levels in patients with general kidney disease (p = 0.000, r = 0.728), and in male patients (p = 0.000, r = 0.736) and females (p = 0,000; r = 0.686) with the age level 41-50 years. there is no relationship between serum creatinine and albuminuria in male and female patients at the age of 20-30 years and 31–40 years. keywords: serum creatinine, urine albumin, renal failure abstrak: pemeriksaan kadar kreatinin dalam darah merupakan salah satu parameter yang digunakan untuk menilai fungsi ginjal, karena konsentrasi dalam serum dan ekskresinya di urine dalam 24 jam relatif konstan. namun, pada sebuah pedoman klinis lain, terdapat jenis pemeriksaan yang lebih direkomendasikan pada kebanyakan pasien dengan risiko gagal ginjal, yaitu tes albumin urine. jika terjadi disfungsi renal maka kemampuan filtrasi kreatinin akan berkurang dan kreatinin serum akan meningkat serta beberapa zat yang seharusnya tidak ada di dalam urine, misalnya albumin menjadi muncul. pengurangan ekskresi albumin pada urine mungkin dapat memperlambat laju penyakit gagal ginjal dan membantu untuk menunda kebutuhan tubuh untuk transplantasi ginjal atau cuci darah. penelitian cross sectional ini bertujuan untuk menganalisis hubungan kadar kreatinin serum dan albuminuria pada pasien dengan penyakit ginjal. pemeriksaan kadar kreatinin serum dengan metode jaffe dan pemeriksaan albumin urine secara kualitatif dilakukan pada responden yang memenuhi kriteria inklusi. sebanyak 92 data yang didapatkan kemudian dianalisis dengan chisquare dengan α<0,05. hasil penelitian ini menunjukkan bahwa terdapat hubungan yang signifikan antara kadar kreatinin serum dan albuminuria pada pasien dengan penyakit ginjal secara umum (p=0,000; r=0,728), serta pada pasien laki-laki (p=0,000; r=0,736) dan perempuan (p=0,000; r=0,686) dengan tingkatan usia 41–50 tahun. serta tidak ada hubungan antara kadar kreatinin serum dan albuminuria pada pasien laki-laki dan perempuan pada tingkatan usia 20–30 tahun serta 31–40 tahun. kata kunci: kreatinin serum, albumin urine, gagal ginjal medical and health science journal, vol. 1, no. 2, august 2017 24 pendahuluan ginjal adalah organ yang berfungsi mengatur keseimbangan cairan tubuh dengan cara membuang sampah-sampah sisa metabolisme melalui urine dan menahan zat-zat yang dibutuhkan tubuh (ade, 2009). tiap-tiap bagian dari ginjal memiliki berbagai fungsi yang berbeda. tiga proses utama yang akan terjadi di nefron dalam pembentukan urine, yaitu filtrasi, reabsorbsi, dan sekresi (tzanakaki, 2014). terjadinya gangguan pada sebuah atau beberapa bagian ginjal membawa dampak buruk bagi tubuh. oleh karena itu, deteksi dini terhadap penyakit ginjal sangat diperlukan dalam medical checkup. tes rutin yang sering dikerjakan laboratorium adalah pemeriksaan kadar kreatinin serum. kreatinin merupakan hasil metabolisme dari kreatin dan fosfokreatin. pada penelitian terdahulu didapatkan data bahwa kadar kreatinin serum meningkat pada pasien gagal ginjal nondialisis. sekitar 57% dari pasien gagal ginjal non-dialisis memiliki kadar kreatinin 7–12 mg/ dl (amin n et al, 2014). namun, pada sebuah pedoman klinis lain, tes albumin urine adalah tes yang direkomendasikan pada kebanyakan pasien dengan risiko gagal ginjal. albuminuria dapat dideteksi dengan keadaan yang begitu kecil, di mana secara diagnostik penting, mudah distandardisasi, dan lebih murah (guidelines, 2012). jika terjadi disfungsi renal, maka kemampuan filtrasi kreatinin akan berkurang dan kreatinin serum akan meningkat serta beberapa zat yang seharusnya tidak ada di dalam urine, misalnya albumin, menjadi muncul. pengurangan ekskresi albumin pada urine mungkin dapat memperlambat laju penyakit gagal ginjal dan membantu untuk menunda kebutuhan tubuh untuk transplantasi ginjal atau cuci darah (venkat, 2004). tujuan penelitian ini adalah untuk menganalisis hubungan kadar kreatinin serum dan albuminuria pada pasien dengan penyakit ginjal. metodologi penelitian penelitian ini merupakan penelitian analitik chi-square metode cross sectional dengan α<0,05. sampel penelitian adalah pasien penyakit ginjal yang menjalani cek kreatinin serum di lab, memenuhi kriteria inklusi yang diperoleh dari anamnesis dan rekam medik. kriteria inklusi pada penelitian ini adalah pasien memiliki kadar kreatinin serum di atas normal dan berusia 20 hingga 50 tahun. penelitian dilakukan di instalasi laboratorium rsud dr. soegiri lamongan serta di ruang rekam medik. penelitian ini dilaksanakan pada bulan januari 2017 hingga maret 2017. prosedur pengambilan data kreatinin serum sampel darah diambil dari pasien dengan menggunakan spuit pada vena cubiti sebanyak 2cc lalu dimasukkan pada vaccute tube berwarna merah, yaitu tabung sampel untuk pemeriksaan kimia klinik. sampel darah kemudian dibiarkan selama 30 menit hingga membeku. sentrifus sampel darah dengan kecepatan 3500rpm selama 5 menit hingga didapatkan serum. serum diambil dan diletakkan pada sample cup. tahap selanjutnya adalah membuat working reagent untuk pemeriksaan kreatinin serum. langkahnya adalah mereaksikan 0,2ml naoh 1n dan 0,8ml aqubidest dalam tabung reaksi. kemudian ditambahkan 1ml asam pikrat dalam reaksi tersebut. working reagent sudah dapat langsung digunakan dan stabil hingga 4 minggu pada suhu ruang dan terhindar dari cahaya. intashofal dan sukarjati, korelasi kadar kreatinin serum dengan hasil tes albumin pada pasien dengan penyakit ginjal di rsud dr. soegiri lamongan 25 untuk mengukur kadar kreatinin serum, maka digunakan metode jaffe. metode jaffe adalah pengukuran absorben dari bentukan kreatinin dalam larutan alkali warna oranye-merah kompleks dengan asam pikrat. caranya adalah mereaksikan 500µl working reagent kreatinin serum dengan 50µl serum, lalu segera baca pada spektrofotometer dengan panjang gelombang 492nm. pada layar akan tertulis kadar sampel dengan satuan mg/dl. tes ini linier hingga konsentrasi kreatinin serum 13mg/dl. sampel dengan nilai lebih besar membutuhkan pengenceran hingga perbandingan 1:5 dengan larutan fisiologis ( nacl 0.9%) dan tes diulang sekali lagi. hasil ulangan yang tertulis di layar spektrofotometer kemudian dikalikan 6. pengambilan data albumin urine data albumin urine harus didapat dari pasien yang memenuhi kriteria inklusi sebagai sampel. data albumin urine maupun kreatinin serum di dapat dari pasien yang sama dalam waktu kurang dari satu bulan. albumin urine diukur dengan metode heating test, yaitu pemanasan. prinsipnya adalah albumin akan terdegradasi menjadi butiran putih jika suhu dinaikkan. langkah kerjanya yaitu menggunakan sampel urine porsi tengah, sampel urine tidak harus urine pagi hari. sampel dikumpulkan pada wadah betutup ulir yang selanjutnya dapat dikirim ke laboratorium. langkah pemeriksaannya yaitu dengan menggunakan dua buah tabung reaksi yang berlabel blangko dan tes. tabung blangko maupun tabung tes masing-masing diisi dengan 2ml urine. tabung tes kemudian dibakar di atas api bunzen hingga mendidih. lalu ditambahkan dua tetes asam asetat glasial 6% untuk menghindari kekeruhan yang disebabkan oleh fosfat. tabung tes kemudian dibakar lagi hingga mendidih. interpretasi hasil didapatkan dengan membandingkan antara tabung tes dengan tabung blanko. penilaian albumin urine dengan metode heating test ini adalah penilaian kualitatif. hasil penelitian distribusi frekuensi kadar kreatinin serum gambar1 menunjukkan bahwa distribusi frekuensi kadar kreatinin serum pada pasien dengan penyakit ginjal di rsud dr. soegiri lamongan, sebagian besar terdapat pada kadar kreatinin serum tingkat 1, yaitu pada interval 1,40–5,00 mg/dl, yaitu sebesar 44 pasien (47,8%). frekuensi kadar kreatinin serum 5,01– 10,00 mg/dl sebanyak 20 sampel atau sebesar 20%. jumlah ini sama banyaknya dengan frekuensi kadar kreatinin serum 10,01–15,00 mg/ dl. pada kadar kreatinin serum 15,01–20,00 mg/ dl frekuensinya sebanyak 3 sampel atau sebesar 3,3%. sedangkan frekuensi kreatinin serum dengan kadar >20,01 mg/dl adalah sebanyak 5 sampel atau sebesar 5,4%. gambar 1 distribusi frekuensi kadar kreatinin serum pada pasien dengan penyakit ginjal di rsud dr. soegiri lamongan medical and health science journal, vol. 1, no. 2, august 2017 26 distribusi frekuensi albumin urine gambar 2 menunjukkan bahwa distribusi frekuensi hasil tes albumin urine pada pasien dengan penyakit ginjal di rsud dr. soegiri lamongan. dari keseluruhan sampel yang berjumlah 92 data didapatkan frekuensi albumin urine terbanyak pada kadar albumin urine +1, yaitu sebanyak 27 sampel atau 29,3%. pada tingkat albumin urine +2 frekuensinya sebesar 22 sampel atau 23,9%. hasil albumin urine negatif juga muncul dengan frekuensi sebanyak 21 sampel atau 22,8%. selanjutnya, frekuensi hasil albumin urine +3 sebanyak 20 sampel atau 21,7%, sedangkan albumin urine +4 sebanyak 2 sampel atau 2,2%. gambar 2 distribusi frekuensi hasil tes albumin urine pada pasien dengan penyakit ginjal di rsud dr. soegiri lamongan distribusi frekuensi responden berdasarkan jenis kelamin gambar 3 menunjukkan distribusi frekuensi responden berdasarkan jenis kelamin. dari tabel tersebut didapatkan data bahwa sebanyak 49 sampel yang berjenis kelamin laki-laki dan 43 berjenis kelamin perempuan, dengan persentase 53,3% untuk sampel berjenis kelamin laki-laki dan 46,7% sampel dengan jenis kelamin perempuan. gambar 3 distribusi frekuensi responden berdasarkan jenis kelamin distribusi frekuensi responden berdasarkan tingkatan umur gambar 4 menunjukkan bahwa distribusi frekuensi umur paling besar terdapat pada golongan umur ke iii, yaitu pada rentang umur 41–50 tahun, yaitu sebanyak 63 sampel, atau sebesar 68,5%. sedangkan pada golongan umur ke ii yaitu pada rentang umur 31–40 sebesar 21 sampel atau 22,8% dan pada golongan umur i yaitu pada rentang umur 20–30 tahun sebesar 8 sampel atau 8,7% dari total 92 sampel. gambar 4 distribusi frekuensi responden berdasarkan tingkatan umur intashofal dan sukarjati, korelasi kadar kreatinin serum dengan hasil tes albumin pada pasien dengan penyakit ginjal di rsud dr. soegiri lamongan 27 analisa data hubungan antara kadar kreatinin serum dengan hasil tes albumin urine tanpa memperhatikan jenis kelamin dan tingkatan umur berdasarkan analisis pearson chi-square didapatkan nilai p sebesar 0,000 < α = 0,05 berarti ada hubungan yang signifikan antara kadar kreatinin serum dengan hasil tes albumin urine pasien dengan penyakit ginjal tanpa memperhatikan jenis kelamin dan tingkatan umur. tingkat keeratan hubungan ditunjukkan dengan nilai pearson’s r sebesar 0,728 yang bermakna hubungan kedua variabel kuat/erat. hubungan antara kadar kreatinin serum dengan hasil tes albumin urine pasien laki-laki tanpa memperhitungkan tingkatan usia berdasarkan analisis pearson chi-square didapatkan nilai p sebesar 0,000 < α = 0,05 berarti ada hubungan yang signifikan antara kadar kreatinin serum dengan hasil tes albumin urine pasien laki-laki dengan penyakit ginjal tanpa memperhatikan tingkatan umur. tingkat keeratan hubungan ditunjukkan dengan nilai pearson’s r sebesar 0,736 yang bermakna hubungan kedua variabel kuat/erat. hubungan antara kadar kreatinin serum dengan hasil tes albumin urine pasien perempuan tanpa memperhitungkan tingkatan usia berdasarkan analisis pearson chi-square didapatkan nilai p sebesar 0,000 < α = 0,05 berarti ada hubungan yang signifikan antara kadar kreatinin serum dengan hasil tes albumin urine pasien perempuan dengan penyakit ginjal tanpa memperhatikan tingkatan umur. tingkat keeratan hubungan ditunjukkan dengan nilai pearson’s r sebesar 0,686 yang bermakna hubungan kedua variabel kuat/erat. hubungan antara kadar kreatinin serum dengan hasil tes albumin urine pasien laki-laki pada usia 20–30 tahun berdasarkan analisis pearson chi-square didapatkan nilai p sebesar 0,189 > α = 0,05 berarti tidak ada hubungan yang signifikan antara kadar kreatinin serum dengan hasil tes albumin urine pasien laki-laki dengan penyakit ginjal pada usia 20–30 tahun. hubungan antara kadar kreatinin serum dengan hasil tes albumin urine pasien laki-laki pada usia 31–40 tahun berdasarkan analisis pearson chi-square didapatkan nilai p sebesar 0,089 > α = 0,05 berarti tidak ada hubungan yang signifikan antara kadar kreatinin serum dengan hasil tes albumin urine pasien laki-laki dengan penyakit ginjal pada usia 31–40 tahun. hubungan antara kadar kreatinin serum dengan hasil tes albumin urine pasien laki-laki pada usia 41–50 tahun berdasarkan analisis pearson chi-square didapatkan nilai p sebesar 0,001 < α = 0,05 berarti ada hubungan yang signifikan antara kadar kreatinin serum dengan hasil tes albumin urine pasien laki-laki dengan penyakit ginjal pada usia 41–50 tahun. tingkat keeratan hubungan ditunjukkan dengan nilai pearson’s r sebesar 0,819 yang bermakna hubungan kedua variabel sangat kuat/erat. hubungan antara kadar kreatinin serum dengan hasil tes albumin urine pasien perempuan pada usia 20–30 tahun berdasarkan analisis fisher’s exact test didapatkan nilai p sebesar 1,000 > α = 0,05 berarti tidak ada hubungan yang signifikan antara kadar kreatinin serum dengan hasil tes albumin medical and health science journal, vol. 1, no. 2, august 2017 28 urine pasien perempuan dengan penyakit ginjal pada usia 20–30 tahun. hubungan antara kadar kreatinin serum dengan hasil tes albumin urine pasien perempuan pada usia 31–40 tahun berdasarkan analisis pearson chi-square didapatkan nilai p sebesar 0,136 > α = 0,05 berarti tidak ada hubungan yang signifikan antara kadar kreatinin serum dengan hasil tes albumin urine pasien perempuan dengan penyakit ginjal pada usia 31–40 tahun. hubungan antara kadar kreatinin serum dengan hasil tes albumin urine pasien perempuan dengan penyakit ginjal pada usia 41–50 tahun berdasarkan analisis pearson chi-square didapatkan nilai p sebesar 0,000 < α = 0,05 berarti ada hubungan yang signifikan antara kadar kreatinin serum dengan hasil tes albumin urine pasien perempuan dengan penyakit ginjal pada usia 41–50 tahun. tingkat keeratan hubungan ditunjukkan dengan nilai pearson’s r sebesar 0,751 yang bermakna hubungan kedua variabel kuat/erat. pembahasan dari hasil penelitian, didapatkan bahwa kadar kreatinin serum didominasi oleh tingkatan kreatinin serum yang pertama, yaitu pada kadar kreatinin serum tingkat 1, yakni pada interval 1,40–5,00 mg/dl, sebesar 44 pasien (47,8%). gambaran umum seperti ini disebabkan karena gagal ginjal kronis mengindikasikan sebuah perlambatan dan penurunan secara progresif dari fungsi ginjal. penyakit ini terjadi secara bertahap –lebih dari periode mingguan, bulanan, atau tahunan– sampai ginjal berhenti bekerja (amin, 2014). berdasarkan data yang diperoleh dari gambar 3, yaitu gambar distribusi jenis kelamin, didapatkan bahwa sebagian besar pasien gagal ginjal berjenis kelamin laki-laki, yaitu 49 pasien (53,3%). hasil ini sama dengan data yang didapat dari united states renal data system annual data report (2013) yang menunjukkan bahwa pasien laki-laki (56,8%) lebih banyak dari perempuan (43,2%). dan penelitian yang dilakukan oleh alfonso (2016) yang menyatakan bahwa pasien laki-laki (60%) lebih banyak dari pada pasien perempuan (40%). jenis kelamin berpengaruh terhadap kadar kreatinin serum karena terdapat perbedaan massa otot antara laki-laki dan perempuan. laki-laki cenderung memiliki massa otot yang lebih besar dari pada perempuan (o’callagan, 2009). berdasarkan gambar 4, dapat dikatakan bahwa distribusi frekuensi responden berdasarkan tingkatan umur sebagian besar terdapat pada pengelompokan usia iii, yaitu pada rentang usia 41–50 tahun, yakni sebesar 63 pasien (68,5%). hasil penelitian ini sama dengan data penelitian yang dilakukan oleh amin (2014), yang menyatakan bahwa jumlah pasien terbanyak yang mengalami gagal ginjal adalah pada tingkatan usia 51–60 tahun, yaitu sebesar 42% dan pada tingkatan usia 41– 50 tahun sebesar 30%. hal ini karena prevalensi penyakit ginjal kronik meningkat seiring dengan bertambahnya usia (prakash, 2009). berdasarkan hasil pada gambar 2, didapatkan data dengan distribusi yang merata, di mana distribusi frekuensi yang paling besar terletak pada albumin urine +1. hasil tes albumin urine pada pasien dengan gagal ginjal tidak menunjukkan perbedaan yang berarti berdasarkan jenis kelamin atau umur yang berbeda. hal ini sesuai dengan hasil penelitian biseph (2012) yang menyatakan bahwa tidak terdapat hubungan antara umur dengan ekskresi albumin urin (p=0,799) dan jenis kelamin dengan ekskresi albumin (p=0,121). intashofal dan sukarjati, korelasi kadar kreatinin serum dengan hasil tes albumin pada pasien dengan penyakit ginjal di rsud dr. soegiri lamongan 29 dari hasil penelitian ini terdapat hubungan yang signifikan antara kadar kreatinin serum dengan hasil tes albumin urine pasien dengan penyakit ginjal tanpa memperhatikan jenis kelamin dan umur (p=0,000). hubungan yang signifikan juga terdapat pada hubungan antara kadar kreatinin serum dengan albumin urine pada pasien laki-laki tanpa memperhatikan umur (p=0,000) dan pada pasien perempuan tanpa memperhatikan umur (p=0,000), serta pada pasien laki-laki usia 41–50 tahun (p=0,001) dan pasien perempuan usia 41–50 tahun (p=0,000). hasil penelitian ini secara tidak langsung menyokong beberapa penelitian terdahulu, di antaranya, ahmad (2001) dalam penelitiannya menyatakan bahwa terdapat hubungan antara hiperkolesterolemia dengan peningkatan ekskresi albumin urine (p=0,002 dan r=0,554). hal ini dijelaskan bahwa hiperkolesterolemia atau kadar kolesterol dan trigliserida plasma yang tinggi berperan menimbulkan aterosklerosis. buruknya sirkulasi ke sebagian besar organ menyebabkan hipoksia dan cedera jaringan, serta merangsang reaksi peradangan pada dinding pembuluh darah sehingga terjadi penumpukan lemak pada lumen pembuluh darah. konsekuensi adanya aterosklerosis ini adalah penyempitan lumen pembuluh darah dan penurunan kecepatan aliran darah yang menyebabkan berkurangnya suplai darah ke ginjal. hal ini dapat menimbulkan gangguan proses filtrasi di glomerulus dan penurunan fungsi ginjal (corwin, 2009). penurunan fungsi ginjal dapat diketahui dari penurunan laju filtrasi glomerulus dan akan diikuti dengan kenaikan kadar ureum dan kreatinin darah. kemudian biseph (2012) dalam penelitiannya mengemukakan bahwa terdapat hubungan yang bermakna antara ekskresi albuminuria dengan penyakit jantung hipertensi (p=0,001). penyakit jantung hipertensi merupakan penyakit kardiovaskular yang disebabkan oleh tekanan darah tinggi yang berlangsung kronis dan berhubungan dengan hipertrofi ventrikel kiri dan disfungsi endotel. kejadian albuminuria pada penderita tekanan darah tinggi berhubungan dengan kerusakan endotel glomerulus dan merupakan prediktor penyakit kardiovaskular (biseph, 2012). selain itu, sahid (2012) dalam penelitiannya menyatakan bahwa semakin lama menderita diabetes militeus, semakin tinggi risiko terjadinya gagal ginjal terminal. hal ini dapat ditinjau pada tahap iv nefropati diabetik, atau penyakit gagal ginjal karena diabetes, yang terjadi adalah manifestasi klinis berupa albuminuria yang nyata. tekanan darah sering meningkat dan laju filtrasi glomerulus sudah menurun di bawah normal (lubis, 2006). nefropati diabetik lanjut ditandai dengan albuminuria, penurunan fungsi ginjal, peningkatan kadar kreatinin serum, glomerulosklerosis dan fibrosis interstisial (hendromartono, 2009). hasil penelitian ini juga menunjukkan bahwa tidak ada hubungan antara kadar kreatinin serum dengan albumin urine pada laki-laki usia 20–30 tahun (p=0,189), pada laki-laki usia 31– 40 tahun (p=0,089), pada perempuan usia 20– 30 tahun (p=1,000), serta pada perempuan usia 31–40 tahun (p=0,136). hal ini sesuai dengan penelitian rizki (2016) yang dalam penelitiannya didapatkan kesimpulan bahwa tidak ada hubungan antara kadar kreatinin serum dengan albuminuria pada penderita diabetes milliteus tipe-2. selain itu, jovita (2010) dalam penelitiannya menyatakan bahwa seseorang yang menderita diabetes milliteus dapat menimbulkan komplikasi salah satunya nefropatik diabetik dalam kurun waktu 11,90 tahun. simpulan dan saran penelitian ini dapat disimpulkan bahwa terdapat hubungan yang signifikan antara kadar kreatinin serum dan albuminuria pada pasien dengan medical and health science journal, vol. 1, no. 2, august 2017 30 penyakit ginjal secara umum, serta pada pasien laki-laki dan perempuan dengan tingkatan usia 41– 50 tahun saran, bagi pasien sebaiknya kadar kreatinin serum dan albumin urine selalu dipantau secara periodik agar mendapat terapi secara dini sehingga mengurangi risiko terjadinya gagal ginjal. dan bagi peneliti lain, perlu dilakukan penelitian lebih lanjut mengenai pengurangan ekskresi protein/albumin pada urine sehingga dapat memperlambat laju penyakit gagal ginjal dan membantu untuk menunda kebutuhan tubuh untuk transplantasi ginjal atau cuci darah. daftar pustaka achmad, rosid. 2001. hubungan antara hiperkolesterolemia dengan mikroalbuminuria. semarang: fk undip. ade, m. junaedi. 2009. status indeks masa tubuh pasien penyakit ginjal kronik yang menjalankan hemodialisis di rs ciptomangunkususmo pada bulan februari 2009 dan korelasinya dengan lama menjalani hemodialisis. jakarta: fkui. alfonso a., mongan a., memah m. 2016. gambaran kadar kreatinin serum pada pasien penyakit ginjal kronik stadium 5 nondialisis. jurnal e biomedik, vol. 4, no. 1. manado. amin n., mahmood r., asad m., zafar m., raja a. 2014. evaluating urea and creatinin levels in chronik renal failure pre and post dialysis; a prospective study. journal of cardiovascular disease, vol. 2, no: 2.1. rawalpindi. biseph, robert. 2012. hubungan ekskresi albuminuria dengan penyakit jantung hipertensi. manado: fk univ. sam ratulangi. corwin, e.j. 2009. handbook of patophysiology (terjemahan). 3rd ed. jakarta: penerbit egc. guidelines. 2012. chronik kidney disease and measurement of albuminuria or proteinuria: a pasition statement. mja 197 (4). hendromartono. 2009. nefropati diabetik dalam buku ajar ilmu penyakit dalam. ed v, hal: 2386. jakarta: fkui. jovita, s. 2010. rerata durasi penderita diabetes melitus terkena nefropati diabetik sejak terdiagnosis diabetes. bali: fk udayana. lubis, h.r. 2006. penyakit ginjal diabetik, 4th ed., p.534–5 jakarta: bagian penyakit dalam fkui. o’callaghan, c. 2009. at a glance sistem ginjal (terjemahan). 2nd ed. safitri a, astikawati r, editors. jakarta: penerbit erlangga. prakash, s. 2009. interaction of aging and ckd. semin nephrology, 29 (5) 497–503. rizki, prayuda. 2016. hubungan kaadar kreatinin serum dengan mikroalbuminuria pada penderita diabetes milliteus tipe 2. sahid qau. 2012. hubungan lama diabetes melitus dengan terjadinya gagal ginjal terminal di rumah sakit dr. moewardi surakarta. skripsi. fakultas kedokteran universitas muhammadiyah surakarta lampung: fk univ. lampung. sahid qau. 2012. hubungan lama diabetes melitus dengan terjadinya gagal ginjal terminal di rumah sakit dr. moewardi surakarta. skripsi. fakultas kedokteran universitas muhammadiyah surakarta. tzanakaki, eleftheria. 2014. causes and complication of chronik kidney disease in patients on dialisis. health science journal, vol. 8, issue 3. venkat, k.k. 2004. proteinuria and albuminuria in adult: significance, evaluation, and treatment. shourthen medical journal. vol. 97 no. 10. detroit. medical and health science journal 2022 august vol.6 (02) case report sydenham chorea on indonesian 10 years old boy caused by rheumatic heart disease : case report and literature review laily irfana1*, m. perdana airlangga2, nina devi indrawati1, m. hanun mahyuddin3 1 department of neurology, faculty of medicine, universitas muhammadiyah surabaya, indonesia 2 departement of cardiology, faculty of medicine, universitas muhammadiyah surabaya, indonesia 3 faculty of medicine, universitas airlangga, surabaya, indonesia article info article history: received : july 22, 2022 received in revised form : august 18, 2022 accepted : august 24, 2022 keywords: sydenham chorea rheumatic heart disease carditis. *) corresponding author: irfanalaily@gmail.com abstract sydenham's chorea (sc) is one of the manifestations of rheumatic fever, and is the most common cause of chorea in childrens. sc is characterized by involuntary movements such as jerking of the arms, legs, and face. the following case is a 10-year-old boy with complaints of moving his right arm and leg on its own. on physical examination, there was a grade 4/5 systolic murmur at ics 5 2 cm lateral to the left mcl blowing radiating to the left arm. in asto examination there is an increase. ct scan of the head without contrast showed no abnormalities. the results of echocardiography showed severe mitral regurgitation. the patient was diagnosed with sydenham cholera and rheumatic heart disease. the patient refused hospitalization and was treated as an outpatient with therapy erythromycin 250 mg four times a day for 10 days followed by a twice daily dose for the next two months, symptomatic haloperidol 1 mg and trihexyphenidyl 0.5 mg twice a day, aspirin 300 mg four times a day for one month. from this treatment, the complaints improved slowly, and the chorea disappeared within 10 days of the start of treatment. medical and health science journal irfana et al medical and health science journal 2022 august vol.6 (02) page 44 of 51 introduction sydenham's chorea (sc) is one of the manifestations of acute rheumatic fever. it is characterized by chorea involving the face and extremities and can include psychiatric symptoms, hypotonia and muscle weakness. although the incidence is decreasing in high-income countries, sc remains the most common cause of childhood chorea, occurring in approximately one-third of patients with acute rheumatic fever. 1 but there are no exact number or prevalence about the sydenham chorea incident in indonesia. some evidence shows that in developing countries, the incidence of rheumatic fever is higher, presumably due to poor sanitation compared to developed countries.2 the severity of sc was assessed from mild involuntary movement to severe functional impairment. the involuntary movements that occur during an attack can be repeated from a few minutes to hours, either with breaks between movements or continuously.3 the patient will experience pain or fatigue due to uncontrolled repetitive movements. syndenham chorea is a self-limiting disease. however, symptoms can persist for months or years. syndenham chorea rarely occurs repeatedly.1 various drugs have been used to treat chorea, such as dopamine receptor antagonists (eg, haloperidol), antiepileptic drugs (eg, valproic acid or carbamazepine). 4–8 studies that examine these drugs in sc patients are very limited and the studies are often observational, objective outcome measures are limited, and the study population is heterogeneous, so the best treatment options are uncertain. we present an indonesian 10-year-old boy with sc that completely recovered with outpatient management. case(s) a 10-year-old boy came to the neurology clinic with complaints of moving his right arm and leg on its own. complaints occurred since one week before being taken to the hospital. the patient has difficulty performing activities due to the movement. there were no complaints of fever, cold cough, shortness of breath, painful swallowing, or joint pain. normal urination and defecation. there is no history of taking certain drugs. history of the patient's birth at term. the patient was born by spontaneous vaginal delivery. birth weight 2900grams, birth length 50cm. patients completed the mandatory immunizations. growth and development according to milestones. currently, the patient's education is grade fourth in elementary school. before getting sick, patient has normal daily activities like any childrens in his age. none of the families experienced complaints as experienced by the patient. from the physical examination, the general condition of the patients was adequate and has composmentis consciousness. blood pressure 110/70mmhg, regular pulse 90x/minutes, picture 1. head ct scan without contras irfana et al medical and health science journal 2022 august vol.6 (02) page 45 of 51 respiratory rate 24x/minutes, temperature 36.8 celcius. weigh 22 kg and height 124cm. the general head and neck status showed no abnormalities. auscultation of the heart show that the patient s1s2 single, grade 4/5 systolic murmur at intercostal (ics) 5 about 2cm from left midclavicular (mcl) blowing radiating to left arm. pulmonary examination revealed vesicular sounds, no rhonchi or wheezing. abdominal examination was normal, there was no hepatomegaly or splenomegaly. extremity no deformity, edema, or cyanosis. neurological examination showed that gcs 456, normal cranial nerves, normal motor strength. normal physiological reflexes, negative pathological reflexes. involuntary movement was found in the form of hemichorea. sensory, autonomic no abnormalities. on echocardiographic examination, the results showed atrial sinus solitus, av and va concordance, normal venous drainage, normal heart chambers, no asd/pda/vsd, severe mitral regurgitation with a pressure gradient (pg) of 102 mmhg, no other valve abnormalities were found, normal left ventricular systolic function, normal left aortic arch. complete blood count: hgb 13.6, leukocytes 3.7, hct 41.1, plt 151. serum electrolytes na: 135, k: 3.9, cl: 9.8. an increase in asto was found by a value of 442. the results of the head ct scan did not show any abnormalities (figure 1). based on patient history, clinical manifestations, laboratory examination, echocardiography, and imaging, we diagnosed the patient with sydenham chorea caused by rheumatic carditis. patients and their families refuse to do hospitization and was treated through outpatients with advice not to do much activity, not to be too tired, and to have regular check-ups at the cardiology and neurology departement. in the management of this patient, for hemichorea, patient is given haloperidol 1 mg and trihexiphenidil 0.5 mg twice a day. antibiotic erythromycin 250 mg four times a day for 10 days, then the dose is reduced to two times a day for two months. aspirin is also given at a dose of 300 mg, taken four times a day for 1 month. the patient's complaints of involuntary movements improved slowly, and disappeared within two weeks of starting treatment. discussion rheumatic fever (rf) is considered a disease that often affects children (generally between 5-15 years).9 this disease is rare in children under 5 years of age. published data estimate that arf occurs in 1-6.8% of children younger than 5 years. arthritis and carditis are the most common clinical presentations in this age group. sydenham's is most common in prepubertal children with a female predominance.10 the ratio of the incidence of sc in girls to boys is 3:1. in our case it is a 10 year old boy from indonesia. 2 streptococcus are a group of gram-positive bacteria that are morphologically characterized by cocci and chains. streptococcus pyogenes, which belongs to the gabhs, has the ability to produce toxins that can lyse red blood cells. the cytoplasmic membrane is surrounded by a thick layer of peptidoglycan surrounded by an s layer consisting of carbohydrates, proteins, and glycoproteins. there is also a certain type of carbohydrate, a rhamnose-nacetyl-glucosamine irfana et al medical and health science journal 2022 august vol.6 (02) page 46 of 51 dimer with the ability to cross-react with heart valve glycosides.11 in syndenham chorea (sc), stimulated antibodies targeted basal ganglia brain cells in the host and its cause a diffuse inflammatory process in the corpus striatum, especially the caudate nucleus. symptoms of sc are caused by an imbalance between the dopaminergic system, the intrastriatal cholinergic system, and the inhibitory system of gammaaminobutyric acid (gaba).12 sc pathogenesis explains that antibodies produced against gabhs under conditions of acute infection will cross-react with basal ganglia epitopes, disrupting the cortex-basal gangliathalamus-cortical (cbgtc) circuit, causing motor, behavioral and cognitive symptoms.13,14 another study found that in sc patients antibodies also show cross-reactivity to mammalian gm1 lysogangliosides (neural gangliosides) and n-acetyl-β-d-glucosamine (glcnac), the carbohydrate dominant epitope of gabhs, and can react with other basal ganglia epitopes. , including the tubulin and dopamine receptors d1 and d2 (d1r, d2r).15 studies linking autoantibodies to sc symptoms showed that serum antid1r and antidr2r autoantibodies were higher in sc patients compared to controls. more importantly, the antid2r/anti-d1r ratio correlated with symptom severity in sc patients, as assessed by the universidade federal de minas gerais (ufmg) sc rating scale. 16 the usage of dopamine antagonists in the treatment of sc indirectly supports the role that dopaminergic-directed autoantibodies play in the pathophysiology of sc.17 decreased serum autoantibody titres are associated with improvement in symptoms, while patients with persistent sc exhibit still high titers of anti-basal ganglia autoantibodies. 17 the use of plasmapheresis and intravenous immunoglobulin is considered to be able to affect circulating antibody levels and is therefore considered effective in the treatment of sc. this is consistent with the theory that the motor and neuropsychiatric symptoms of sc patients are the result of autoantibodies acquired by gabhs targeting neurons, leading to alterations in the cortical-basal ganglia-thalamic circuitry of cbgt.13,14there have been case reports that have successfully treated sc patients using intravenous immunoglobulin.1 intranasal gabhs infection in mice is also known to increase a strong specific th17 response in cranial lymphoid tissue, and that these t cells can migrate to the brain. in the brain, gabhs-specific th17 cells can induce an il-17-mediated inflammatory response and/or activate microglia and macrophages leading to bbb damage. this process causes autoantibodies to leak into the olfactory bulb and spread to the basal ganglia and other brain areas.18 in addition to antibodies, direct action of cytokines and other immune mediators may contribute to neural dysfunction leading to motor, behavioral, and cognitive symptoms in sc. studies on b1-cell lymphocytes involved in chronic antibody-mediated autoimmune disease, in sc patients with persistent chorea compared with patients with cured or control chorea. 19 genetic factors controlling the immune response to gabhs appear to play a relevant role in susceptibility to arf and its complications, including sc. the major histocompatibility irfana et al medical and health science journal 2022 august vol.6 (02) page 47 of 51 complex human leukocyte antigen (hla) polymorphisms, particularly hla class ii, a class of molecules involved in antigen processing and presentation, have been consistently associated with susceptibility to arf. 20 furthermore, each copy of the immunoglobulin heavy chain allele ighv4-61*02, located in the gene segment ighv4-61, was found to have an increased risk factor of 1,4 times the risk of rheumatic heart disease. 20 the jones criteria are commonly used to diagnose acute rf. the diagnosis of acute rheumatic heart disease (acute or recurrent) can be made if there are two major criteria or one major with two minor. major criteria are carditis (clinical and/or subclinical), arthritis (polyarthritis only), chorea, erythema marginatum, subcutaneous nodules. minor criteria are monoarthralgia, fever (≥ 38.5oc), increased esr (60 mm in the first hour) and/or crp (3 mg/dl or more than normal), prolonged pr interval (except carditis which is a major criteria), evidence of previous gabhs infection (positive throat culture, positive rapid antigen detection test (radt), and elevated antistreptococcal antibody titer). 21 in sc patients, the characteristic 'dance like movement' is usually described as a randomly occurring sequence of one or more involuntary movements affecting other parts of the body. movement can also occur in only half of the body called hemichorea, which affects a quarter of people with sc. the severity varies significantly, from mild sc, which has mild or no impact on daily life activities, to severe sc, which makes it difficult for patients to carry out daily life activities. in addition to chorea, patients with cs exhibit other motor symptoms, such as motor impairment, hypometric saccades, hypotonia, and dysarthria. tic-like movements and vocalizations have been reported, but they usually don't have the typical signal impulses.12,22in rare cases, patients may develop hypotonia so severe that the patient is confined to bed, the most severe form of sc known as chorea paralytica. hyperkinetics and decreased muscle tone are characteristic of acute cs, but patients in cs remission exhibit bradykinesia, suggesting that cs remission patients may develop parkinsonism which may be a marker of cs severity after remission.12 behavioral or psychiatric symptoms are also frequently found in sc patients. obsessive compulsive disorder (ocd) and attention deficit hyperactivity disorder (adhd) were more common in sc patients than arf patients without sc and healthy subjects. in 50 sc patients followed serially with comprehensive psychiatric interviews it was found that the most frequently observed psychiatric disorders included major depression (14%), generalized anxiety disorder (16%), social phobia (24%) and ocd (24%).23 as would be expected by immunemediated cbgtc dysfunction, sc is associated with a range of cognitive deficits that require processing speed and attention. even patients with sc who had recovered showed impairment in executive function tests, especially verbal fluency, decreased verbal comprehension, which affected their social and occupational functioning. sc patients recover within a few months, and are often considered a benign monophasic condition, with complete remission in more than 80% of patients within six months.24 management goals in sc include: 1) treating and preventing additional gabhs irfana et al medical and health science journal 2022 august vol.6 (02) page 48 of 51 infections; 2) control of chorea symptoms; and 3) decisions regarding the need for immune modulation.12 the most commonly used regimens include a single dose of 1.2 million units of intramuscular (im) benzathine penicillin g or administration of penicillin vk 500 mg orally for ten days twice daily.25 the most commonly used for antibiotic prophylaxis regimen is benzathine penicillin g 1.2 million units in children weighing ≥20 kg and using a dose of 600,000 iu in children weighing < 20 kg given im every three to four weeks. patients with mild sc and not affecting activities of daily life (adl) do not require symptomatic treatment of sc. when sc affects speech, gait, hand skills, affects self-care, academic and social activities, the use of anti-chorea interventions should be considered.12 administration of dopamine antagonists (antipsychotics) and anticonvulsants in the treatment of sc, leads to more rapid symptom resolution and functional improvement. it is based on an autoimmune-induced basal ganglia dysfunction characterized by excessive dopaminergic activation and decreased activation of the basal ganglia inhibitory pathway.17 while dopamine antagonists may counteract dopaminergic over-activation, the anticonvulsant effect on this pathophysiological process is less clear, and may involve different mechanisms, such as regulating gaba neurotransmission and calcium flow to basal ganglia neurons preventing neuronal hypersynchronization.12 valproic acid and carbamazepine are the most commonly prescribed anticonvulsants for sc. valproic acid and carbamazepine have the same effectiveness in clinical improvement, remission and recurrence rate of sc patients without significant side effects.26 haloperidol is a dopamine antagonist that is often used to treat sc patients. in the study sc patients treated with haloperidol improved more rapidly and had a lower rate of treatment refractoriness, but had more side effects. the administration of haloperidol should be used with caution because sc patients are at high risk for parkinsonism.8 immunomodulatory drugs that are widely used in sc therapy and are effective include corticosteroids, including oral prednisone, oral deflazacort, and intravenous (iv) methylprednisolone. however, there are some side effects of using high doses of corticosteroids including weight gain and acne and in more severe cases progress to cushing's disease.4,6 sc pathophysiology involves autoantibodies that bind to basal ganglia neurons and affect their function, ivig can inactivate these autoantibodies, whereas plasmapheresis will extract them from plasma. thus, all sc patients who received ivig or plasmapheresis showed clinical improvement.1,5 syndhenham chorea is expected to recover completely in one to six months. a retrospective study of 90 patients showed complete remission of motor symptoms in 85% within six months, and an additional 5% had complete remission within one year.27one prospective study of 32 patients with cs, followed for more than 2.5 years, found that symptoms persisted for 2 years or more in 50% of their cases.28 irfana et al medical and health science journal 2022 august vol.6 (02) page 49 of 51 conclusion sydenham chorea is a disease caused by group a beta hemolytic streptococcal infection which is characterized by involuntary movements that can be accompanied by behavioral disorders, cognitive impairment, and ocd. sydenham chorea is a self-limited disease but may show recurrence and/or persistence of motor and neuropsychiatric symptoms in adulthood. syndenham chorea treatment strategies are antibiotic and prophylactic therapy, symptomatic treatment of syndenham chorea, and immunomodulating interventions. in this case, rheumatic heart disease was also found, which was supported by echocardiography. acknowlegment the financing is obtained independently conflicts of interest there are no conflicts of interest declared by the author. references 1. boersma na, schippers h, kuijpers t, heidema j. successful treatment of sydenham’s chorea with intravenous immunoglobulin. bmj case rep. 2016 feb;2016. 2. sie j, sumada ik. the case report: chorea sydenham in young adult female as symptom of rheumatic fever. callosum neurol. 2020;3(1):29–35. 3. cunningham mw. streptococcus and rheumatic fever. curr opin rheumatol. 2012 jul;24(4):408–16. 4. fusco c, spagnoli c. corticosteroid treatment in sydenham’s chorea. eur j paediatr neurol ejpn off j eur paediatr neurol soc. 2018 mar;22(2):327–31. 5. gregorowski c, lochner c, martin l, simmons c, kidd m, walker k, et al. neuropsychological manifestations in children with sydenham’s chorea after adjunct intravenous immunoglobulin and standard treatment. metab brain dis. 2016 feb;31(1):205–12. 6. favaretto e, gortani g, simonini g, pastore s, di mascio a, cimaz r, et al. preliminary data on prednisone effectiveness in children with sydenham chorea. eur j pediatr. 2020 jun;179(6):993–7. 7. direk m, epcacan s, epcacan z, yildirim dd, okuyaz c. efficacy of levetiracetam in the treatment of sydenham chorea. pediatr int. 2020 nov;62(11):1264–8. 8. dean sl, singer hs. treatment of sydenham’s chorea: a review of the current evidence. tremor other hyperkinet mov (n y). 2017;7:456. 9. oliver j, pierse n, baker mg. estimating rheumatic fever incidence in new zealand using multiple data sources. epidemiol infect [internet]. 2014/03/06. 2015;143(1):167–77. available from: https://www.cambridge.org/core/article/esti mating-rheumatic-fever-incidence-in-newzealand-using-multiple-datasources/bf171414dc12e3a5032b537a9 fa3c364 10. lardhi aa. sydenham chorea in a 5-yearold saudi patient. neurosciences (riyadh). 2014 jul;19(3):236–7. 11. ismail p, sobur cs, olyvia c. recurrent rheumatic fever. indones j int law [internet]. irfana et al medical and health science journal 2022 august vol.6 (02) page 50 of 51 2017;14(2):273–5. available from: https://www.neliti.com/id/publications/655 57/indonesia-and-the-law-of-the-sea 12. teixeira al, vasconcelos lp, nunes m do cp, singer h. sydenham’s chorea: from pathophysiology to therapeutics. expert rev neurother [internet]. 2021;21(8):913– 22. available from: https://doi.org/10.1080/14737175.2021.196 5883 13. cunningham mw, cox cj. autoimmunity against dopamine receptors in neuropsychiatric and movement disorders: a review of sydenham chorea and beyond. acta physiol (oxf). 2016 jan;216(1):90– 100. 14. cunningham mw. molecular mimicry, autoimmunity, and infection: the crossreactive antigens of group a streptococci and their sequelae. microbiol spectr. 2019 jul;7(4). 15. cox cj, sharma m, leckman jf, zuccolo j, zuccolo a, kovoor a, et al. brain human monoclonal autoantibody from sydenham chorea targets dopaminergic neurons in transgenic mice and signals dopamine d2 receptor: implications in human disease. j immunol. 2013 dec;191(11):5524–41. 16. teixeira jr. al, maia dp, cardoso f. ufmg sydenham’s chorea rating scale (uscrs): reliability and consistency. mov disord [internet]. 2005 may 1;20(5):585– 91. available from: https://doi.org/10.1002/mds.20377 17. vasconcelos lpb, vasconcelos mc, nunes mdcp, teixeira al. sydenham’s chorea: an update on pathophysiology, clinical features and management. expert opin orphan drugs [internet]. 2019 nov 2;7(11):501–11. available from: https://doi.org/10.1080/21678707.2019.168 4259 18. dileepan t, smith ed, knowland d, hsu m, platt m, bittner-eddy p, et al. group a streptococcus intranasal infection promotes cns infiltration by streptococcal-specific th17 cells. j clin invest. 2016 jan;126(1):303–17. 19. mcafoose j, baune bt. evidence for a cytokine model of cognitive function. neurosci biobehav rev. 2009 mar;33(3):355–66. 20. gray la, d’antoine ha, tong syc, mckinnon m, bessarab d, brown n, et al. genome-wide analysis of genetic risk factors for rheumatic heart disease in aboriginal australians provides support for pathogenic molecular mimicry. j infect dis. 2017 dec;216(11):1460–70. 21. gewitz mh, baltimore rs, tani ly, sable ca, shulman st, carapetis j, et al. revision of the jones criteria for the diagnosis of acute rheumatic fever in the era of doppler echocardiography. circulation [internet]. 2015 may 19;131(20):1806–18. available from: https://doi.org/10.1161/cir.000000000000 0205 22. de teixeira al, cardoso f, maia dp, sacramento dr, mota c de cc, meira zma, et al. frequency and significance of vocalizations in sydenham’s chorea. parkinsonism relat disord. 2009 jan;15(1):62–3. irfana et al medical and health science journal 2022 august vol.6 (02) page 51 of 51 23. punukollu m, mushet n, linney m, hennessy c, morton m. neuropsychiatric manifestations of sydenham’s chorea: a systematic review. dev med child neurol. 2016 jan;58(1):16–28. 24. harsányi e, moreira j, kummer a, meira zma, cardoso f, teixeira al. language impairment in adolescents with sydenham chorea. pediatr neurol. 2015 nov;53(5):412–6. 25. carapetis jr, beaton a, cunningham mw, guilherme l, karthikeyan g, mayosi bm, et al. acute rheumatic fever and rheumatic heart disease. nat rev dis prim. 2016 jan;2:15084. 26. genel f, arslanoglu s, uran n, saylan b. sydenham’s chorea: clinical findings and comparison of the efficacies of sodium valproate and carbamazepine regimens. brain dev. 2002 mar;24(2):73–6. 27. gurkas e, karalok zs, taskin bd, aydogmus u, guven a, degerliyurt a, et al. predictors of recurrence in sydenham’s chorea: clinical observation from a single center. brain dev. 2016 oct;38(9):827–34. 28. cardoso f, vargas ap, oliveira ld, guerra aa, amaral s v. persistent sydenham’s chorea. mov disord. 1999 sep;14(5):805–7. case(s) a 10-year-old boy came to the neurology clinic with complaints of moving his right arm and leg on its own. complaints occurred since one week before being taken to the hospital. the patient has difficulty performing activities due to the movement. the... acknowlegment references medical and health science journal, vol. 1, no. 1 february 2017 53 tingkat pengetahuan kesehatan reproduksi pada siswa sma kanjeng sepuh gresik wiwik afridah1, ratna fajariani2 1prodi s1 ilmu kesehatan masyarakat, fakultas kesehatan, 2prodi s1 ilmu kesehatan masyarakat, fakultas kesehatan universitas nahdlatul ulama surabaya email: wiwik@gmail.ac.id abstract background: adolescence is a transitional period between the time of children with adulthood. there are still many found little regard for teens on health on reproductive, will consequently risk against the occurrence of an increase in diseases, among others; sexually transmitted infections (sti). methods: this type of research is the pre-design experiments using one-shot case study, measured through a questionnaire. class x student population of 33 students, xi ips 2 of 26 students, and xii ips 1 of 29 students. with a variable level of knowledge about reproductive health education, sexually transmitted diseases, prevention and the introduction of infectious disease symptoms, processed and analyzed using descriptive statistics. results: the results of the research on reproductive health education on class x most (63, 64%) have moderate levels of knowledge about sexually transmitted diseases in class xi ips 2 most (73%), 8 have a level of knowledge, level of knowledge about the prevention of infectious diseases and the introduction at the xii 1st most ips (58, 62%) have moderate levels of knowledge. conclusion: the level of knowledge of students of smk kanjeng sepuh gresik about adolescent reproductive health is on a category of being. therefore the expected reproductive and sexual health education as a subject/local content through the media of the school as a proper step as a medium of education can provide information on sexual and reproductive health is right for teens. keywords: knowledge, youth, reproductive health. pendahuluan masa remaja merupakan salah satu periode dari perkembangan manusia. masa ini merupakan masa perubahan atau peralihan dari masa kanak-kanak ke masa dewasa yang meliputi perubahan biologi, perubahan psikologi, dan perubahan sosial. di sebagian masyarakat dan budaya masa remaja pada umumnya dimulai pada usia 10-13 tahun dan berakhir pada usia 18-22 tahun. menurut world health organization (who), remaja merupakan individu yang sedang mengalami masa peralihan yang secara berangsur-angsur mencapai kematangan seksual, mengalami perubahan jiwa dari jiwa kanak-kanak menjadi dewasa, dan mengalami perubahan keadaan ekonomi dari ketergantungan menjadi relatif mandiri. mohammad (1994) mengemukakan bahwa remaja adalah anak berusia 13-25 tahun, di mana usia 13 tahun merupakan batas usia pubertas pada umummnya, yaitu ketika secara biologis sudah mengalami kematangan seksual dan usia 25 tahun adalah usia ketika mereka pada umumnya, secara sosial dan psikologis mampu mandiri. berbagai masalah yang ada pada remaja sangat rentan terhadap kesehatan reproduksi. world health organization (who) mendefinisikan bahwa kesehatan reproduksi merupakan suatu keadaan fisik dan mental serta sosial yang utuh, bukan hanya bebas dari penyakit atau kecacatan dalam segala aspek yang berhubungan dengan sistem reproduksi, fungsi, serta prosesnya. sehat secara reproduksi merupakan suatu keadaan manusia dapat menikmati kehidupan seksualnya dan mampu menjalankan fungsi serta proses reproduksinya secara sehat dan aman.usia remaja merupakan usia yang paling rawan mengalami masalah kesehatan reproduksi seperti kehamilan dan melahirkan usia dini, aborsi yang tidak aman, infeksi menular seksual (ims) termasuk human immunodeficiency virus (hiv), pelecehan seksual dan perkosaan. jumlah remaja yang tidak sedikit merupakan potensi yang sangat berarti dalam melanjutkan pembangunan di manuscript received december 6, 2016, accepted january 26, 2017 medical and health science journal, vol. 1, no. 1 february 2017 54 indonesia. menurut survei demografi dan kesehatan indonesia remaja (sdki-r) tahun 2007,penduduk usia remaja perlu mendapat perhatian serius karena remaja termasuk dalam usia sekolah dan usia kerja, mereka sangat berisiko terhadap masalah-masalah kesehatan reproduksi yaitu perilaku seksual pranikah, napza dan hiv/aids (bkkbn, 2011). menurut badan kordinasi keluarga berencana nasional (bkkbn 2010), diketahui sebanyak 51% remaja di jakarta, bogor, depok, tangerang, dan bekasi (jabodetabek) telah melakukan hubungan seks pranikah. dari kota-kota lain di indonesia juga didapatkan data remaja yang sudah melakukan seks pranikah tercatat 54% di surabaya, 47% di bandung dan 52% di medan. oleh karena itu, topik program kesehatan reproduksi remaja merupakan topik yang perlu diketahui oleh masyarakat khususnya para remaja agar mereka memiliki informasi yang benar mengenai proses reproduksi serta berbagai faktor yang ada di sekitarnya. dengan informasi yang benar, diharapkan remaja memiliki sikap dan tingkah laku yang bertanggung jawab mengenai kesehatan reproduksi. untuk mengetahui hal tersebut, perlu dilakukan penelitian mengetahui gambaran tingkatpengetahuan kesehatan reproduksi tentang pendidikan kesehatan reproduksi pada remaja, penyakit menular seksual dan pencegahan penyakit menular seksual pada siswa sma kanjeng sepuh gresik. metode desain penelitian kuantitatif, dengan menggunakan one-shot case study, suatu kelompok diberi perlakuan dan selanjutnya diobservasi hasilnya. populasi yaitu seluruh siswa dengan sampling purposive. sampel yang digunakan yaitu siswa sma kanjeng sepuh gresik kelas x berjumlah 33 siswa, xi ips 2 berjumlah 26 siswa, dan xii ips 1 berjumlah 29 siswa. hasil a. tingkat pengetahuan pendidikan kesehatan reproduksi penyuluhan ini diikuti oleh 33 siswa kelas x sma kanjeng sepuh gresik. setelah penyuluhan, responden diberikan kuisioner post test untuk medical and health science journal, vol. 1, no. 1 february 2017 55 mengetahui tingkat pengetahuan responden terhadap materi yang sudah diberikan. berikut merupakan tabel yang menggambarkan tingkat pengetahuan respoden tentang pendidikan kesehatan reproduksi. tabel 1. distribusi frekuensi tingkat pengetahuan responden tentang pendidikan kesehatan reproduksi di sma kanjeng sepuh gresik. no tingkat pengetahuan kesehatan reproduksi n % 1 rendah 3 9,09 2 sedang 21 63,64 3 tinggi 9 27,27 jumlah 33 100 data primer, 2013 tabel 1 menunjukkan bahwa dari 33 responden, sebagian besar responden (63,64%) memiliki tingkat pengetahuan sedang. b. tingkat pengetahuan penyakit menular seksual materi penyuluhan tentang penyakit menular seksual diikuti oleh 26 siswa kelas xi ips 2 sma kanjeng sepuh gresik. kuisioner post test juga diberikan sebagai alat ukur pengetahuan responden. tabel 2. distribusi frekuensi tingkat pengetahuan responden tentang penyakit menular seksual di sma kanjeng sepuh gresik. data primer, 2013. tabel 2 menunjukkan bahwa dari 26 responden, sebagian besar responden (73,08%) memiliki tingkat pengetahuan sedang. c. tingkat pengetahuan pencegahan dan pengenalan penyakit menular seksual penyuluhan yang diikuti oleh 29 siswa kelas xii ips 1 sma kanjeng sepuh gresik yaitu tentang pencegahan dan pengenalan gejala penyakit menular seksual. post test diberikan melalui kuisioner untuk mengetahui tingkat pengetahuan responden setelah mengikuti penyuluhan. berikut gambaran tingkat pengetahuan responden yang disajikan dalam tabel 3. tabel 3. distribusi frekuensi tingkat pengetahuan responden tentang pencegahan dan pengenalan gejala penyakit menular seksual di sma kanjeng sepuh gresik. no tingkat pencegahan dan pengenalan gejala penyakit menular seksual n % 1 rendah 2 6,90 2 sedang 17 58,62 3 tinggi 10 34,48 jumlah 29 100 data primer, 2013 tabel 3 menunjukkan bahwa dari 29 responden, sebagian besar responden (58, 62%) memiliki tingkat pengetahuan sedang. d. tabulasi silang hasil tabulasi silang tingkat pengetahuan tentang 1) pendidikan kesehatan reproduksi, 2) penyakit menular seksual dan 3) pencegahan dan pengenalan gejala penyakit menular seksual, didapatkan sebagai berikut: tabel 4 tabulasi silang tingkat pengetahuan responden di sma kanjeng sepuh gresik materi* tingkat pengetahuan crosstabulation count no tingkat pengetahuan penyakit menular seksual n % 1 rendah 2 7,69 2 sedang 19 73,08 3 tinggi 5 19,23 jumlah 26 100 tingkat pendidikan total rend ah sedang tinggi materi kespro pms pps total 3 21 9 33 2 19 5 26 2 17 10 29 7 57 24 88 medical and health science journal, vol. 1, no. 1 february 2017 56 hasil tabulasi tersebut diatas, dapat digambarkan dalam grafik sebagai berikut: grafik 1. gambaran tingkat pengetahuan respoden. berdasarkan grafik diatas dapat disimpulkan bahwa siswa dalam materi pendidikan kesehatan reproduksi telah memahami dengan baik dikarenakan tingkat pengetahuannya diatas rata-rata dibandingkan dengan materi pms dan pps tersebut. pembahasan a. tingkat pengetahuan tentang pendidikan kesehatan reproduksi hasil penelitian yang dilakukan pada siswasiswi kelas x di sma kanjeng sepuh gresik menunjukkan bahwa siswa-siswi memiliki tingkat pengetahuan yang cukup.berdasarkan tabel 1 didapatkan bahwa dari 33 responden, sebagian besar responden (63,64%) memiliki tingkat pengetahuan sedang, mengenai konsep pubertas dan segala hal yang berkaitan dengan cara perawatan kesehatan terhadap organ reproduksi secara umum. b. tingkat pengetahuan penyakit menular seksual hasil penelitian yang dilakukan pada siswasiswi kelas xi di sma kanjeng sepuh gresik menunjukkan bahwa siswa-siswi memiliki tingkat pengetahuan yang cukup. tabel 2 menunjukkan bahwa dari 26 responden, sebagian besar responden (73, 08%) memiliki tingkat pengetahuan sedang, mengenai definisi pms, meliputi pengertian pms dan jenis pms. c. tingkat pengetahuan pencegahan dan pengenalan penyakit menular seksual hasil penelitian yang dilakukan pada siswasiswi kelas xii di sma kanjeng sepuh gresik menunjukkan bahwa siswa-siswi memiliki tingkat pengetahuan yang cukup. tabel 3 menunjukkan bahwa dari 29 responden, sebagian besar responden (58, 62%) memiliki tingkat pengetahuan sedang, mengenai cara pencegahan dan pengenalan terhadap penyakit menular seksual. menurut notoatmodjo (2007) pengetahuan dipengaruhi oleh beberapa faktor yaitu: 1) sosial ekonomi, lingkungan sosial akan mendukung tingginya pengetahuan seseorang. bila ekonomi baik, tingkat pendidikan tinggi maka tingkat pengetahuan akan tinggi pula; 2) kultur (budaya, agama), budaya sangat berpengaruh terhadap tingkat pengetahuan seseorang karena informasi yang baru akan disaring sesuai atau tidaknya dengan budaya yang ada atau agama yang dianut; 3) pendidikan, semakin tinggi pendidikan maka akan mudah menerima hal baru dan akan mudah menyesuaikan dengan hal baru tersebut; 4) pengalaman berkaitan dengan umur dan pendidikan individu. pendidikan tinggi, maka pengalaman akan lebih luas, sedangkan semakin tua umur seseorang maka pengalamannya akan semakin banyak. usia mempengaruhi terhadap daya tangkap dan pola piker seseorang. semakin bertambah usia akan semakin berkembang pula daya tangkap dan pola pikirnya, sehingga pengetahuan yang diperolehnya semakin membaik. simpulan berdasarkan hasil penelitian dan pembahasan mengenai gambaran tingkat pengetahuan siswasiswi kelas x, xi dan xii sma kanjeng sepuh gresik, maka dapat diambil simpulan sebagai berikut: tingkat pengetahuan siswa-siswi kelas x, xi dan xii sma kanjeng sepuh gresik tentang pendidikan kesehatan reproduksi, penyakit menular seksual, dan pencegahan dan pengenalan penyakit menular seksual memiliki tingkat pengetahuan sedang. medical and health science journal, vol. 1, no. 1 february 2017 57 saran berdasarkan hasil analisis dan simpulan yang didapatkan dari hasil penelitian, penulis menyarankan: pihak sekolah dapat lebih memperhatikan para siswa dan siswi tentang pendidikan kesehatan reproduksi khususnya pada penyakit menular seksual, dan pencegahan dan pengenalan penyakit menular seksual. daftar pustaka adelina maharani tugestim, dkk. gambaran pengetahuan remaja putri tentang kesehatan reproduksi remaja di sma mardisiswa semarang. 2012. karya tulis ilmiah. akademi kebidanan ngudi waluyo. arikunto.s. 2006. prosedur penelitian suatu pendekatan praktik. edisi vi. penerbit rineka cipta. jakarta. imron, ali. 2012. pendidikan kesehatan reproduksi remaja. yogyakarta; arruz media. mochamad i. nurmansyah, badra al – aufa, yuli amra. 2013. gambaran tingkat pengetahuan kesehatan reproduksi pada mahasiswa fakultas kedokteran dan ilmu kesehatan uin jakarta. jurnal bimkmi vol.i nomor 2 juni 2013. notoatmodjo. 2007. promosi kesehatan dan ilmu perilaku. penerbit rineka cipta. jakarta. nursalam. 2008. konsep dan penerapan metodologi penelitian ilmu keperawatan. penerbit salemba medika. soetjiningsih. 2004. buku ajar tumbuh kembang remaja dan permasalahannya. jakarta. sagung seto. wawan. a. 2011. teori & pengukuran pengetahuan, sikap dan perilaku manusia. yogyakarta. nuha medika. widyastuti, dkk. 2009. kesehatan reproduksi. yogyakarta; fitramaya. medical and health science journal, vol.3., no.1, februari 2019 original article penggunaan penanda biologis angiogenik rasio s-flt1 dan pigf sebagai prediktor preeklamsia yelvi levani * fakultas kedokteran universitas muhammadiyah surabaya, indonesia *correspondent author: blue_levani@yahoo.com article info article history: received 23 january 2019 received in revised form february 2019 accepted 4 february 2019 abstract preeclampsia is a leading cause of maternal death worldwide. preeclampsia involves multi-organ and characterized by hypertension and proteinuria. one of the hypothesis pathogenesisin preeclampsia is placental insufficiency. its causing imbalance between angiogenic and antiangiogenic factors in maternal circulation. this imbalance factors are responsible for systemic vasoconstriction. however, until now, there is no predictor for preeclampsiain high risk pregnancy. therefore, this review briefly describes the recent studies about utility of biologic angiogenesis marker, such as s-flt1 and pigf as keywords: preeclamsia, s-flt1, pigf kata kunci: preeklamsia, s-flt1, pigf predictor in preeclampsia. abstrak preeklamsia merupakan salah satu penyebab kematian maternal terbanyak di seluruh dunia. preeklamsia melibatkan berbagai organ dan ditandai denganhipertensi dan proteinuria. salah satu hipotesis penyebab preeklamsia adalah insufisiensi plasenta sehingga terjadi ketidakseimbangan faktor angiogenesis dan antiangiogenesis pada sirkulasi maternal. ketidakseimbangan ini dapat menyebabkan terjadinya vasokonstriksi sistemik. sampai saat ini masih belum ada pemeriksaan untuk memprediksi terjadinya preeklamsia pada ibu hamil dengan risiko tinggi. oleh karena itu dalam telaah pustaka ini, akan dibahas beberapa studi yang ada mengenai penanda biologis angiogenik seperti s-flt1 dan pigf sebagai prediktor preeklamsia. @2019 medical and health science journal. 10.33086/mhsj.v3i1.920 pendahuluan preeklamsia merupakan komplikasi kehamilan yang dialami sekitar 3-5% ibu hamil dan merupakan salah satu penyebab mortalitas maternal terbesar dengan angka kematian sekitar 60,000 setiap tahunnya di seluruh dunia.[1] preeklamsia didefiniskan sebagai gangguan kehamilan yang disertai dengan peningkatan tekanan darah ≥140/90 mmhg setelah usia kehamilan 20 minggu disertai dengan proteinuria ≥ 300 mg/hari, gangguan fungsi organ maternal termasuk gangguan pada ginjal (insufisiensi renal), hati (peningkatan enzim liver), hematologic (trombositopenia)dan neurologi atau adanya restriksi pertumbuhan janin intrauterine (intrauterine growth retardation / iugr).[2] dari definisi isshp (international society for the study of hypertension in pregnancy) pada 2014 tersebut, disebutkan proteinuria tidak harus selalu ada untuk menegakkan diagnosis preeklamsia.[2] gejala preeklamsia bisa bervariasi, termasuk asimtomatik. oleh karena itu penting untuk correspondence: yelvi levani @2019 medical and health science journal. 10.33086/mhsj.v3i1.920 available at http://journal2.unusa.ac.id/index.php/mhsj 1 mailto:blue_levani@yahoo.com http://journal2.unusa.ac.id/index.php/mhsj medical and health science journal, vol.3., no.1, februari 2019 mengenali faktor risiko dan mengembangkan model untuk memprediksi terjadinya preeklamsia sejak awal kehamilan. metode diagnosis preeklamsia preeklamsia merupakan multi-sistemik sindrom yang mana pathogenesis dan patofisiologinya masih belum diketahui secara pasti. berdasarkan waktu kejadiannya, preeklamsia dibagi menjadi 2 yaitu preeklamsia awal (early onset preeclampsia) dan preeklamsia lambat (late onset preeclampsia). pada preeklamsia awal, gejala muncul sebelum usia kehamilan 33 minggu, sedangkan pada preeklamsia lambat, gejala muncul pada usia kehamilan lebih dari 34 minggu. 80% preeklamsia merupakan tipe lambat. preeklamsia awal memiliki risiko mobiditas dan mortalitas yang lebih tinggi bagi ibu dan janin.[4] diagnosis preeklamsia utamanya ditegakkan dengan pemeriksaan klinis dan pemeriksaan penunjang seperti pemeriksaan daran dan urin di laboratorium. berdasarkan konsensus isshp 2014, diagnosis preeklamsia dapat ditegakkan bila ada peningkatan tekanan darah ≥140/90 mmhg setelah usia kehamilan 20 minggu disertai dengan proteinuria ≥ 300 mg/hari, gangguan fungsi organ maternal termasuk gangguan pada ginjal (insufisiensi renal), hati (peningkatan enzim liver), hematologic (trombositopenia) dan neurologi atau adanya restriksi pertumbuhan janin intrauterine (intrauterine growth retardation / iugr). banyak bukti menunjukkan bahwa gangguan pada ginjal dan hati dapat muncul tanpa adanya protein di urin, dan jumlah protein di urin tidak berkorelasi dengan derajatkeparahan penyakit yang dialami.[2] patogenesis preeklamsia pada preeklamsia awal, penampakan patologi yang utama adalah adanya transformasi yang tidak sempurna dari arteri spiral sehingga menyebabkan terjadinya hipoperfusi dari plasenta dan berkurangnya nutrisi untuk janin. hal ini mengakibatkan perkembangan janin terhambat (iugr).[4] sebaliknya pada preeklamsia lambat, hanya terjadi sedikit perubahan diameter pada arteri spiral sehingga jarang menyebabkan terjadinya iugr.[5] oleh karena itu kemungkinan preeklamsia awal dan preeklamsia lambat memiliki etiologic dan patofisiologi yang berbeda. salah satu teori mengenai patogenesis preeklamsia adalah adanya gangguan implantasi pada plasenta sehingga terjadi ketidakseimbangan antara faktor angiogenik dan antiangiogenik. pada kehamilan normal, sitotrofoblas dari plasenta akan menginvasi dinding uterus dan berubah menjadi arteri spiral uterine yang memiliki resistensi vaskular yang rendah. perubahan ini dapat terganggu pada preeklamsia sehingga menyebabkan terjadinya iskemia plasenta.[6] iskemia plasenta ini dapat mengeluarkan berbagai molekul ke sirkulasi maternal sehingga dapat menyebabkan disfungsi endothelial sistemik. salah satu molekul yang banyak dikeluarkan adalah sflt-1 (soluble-fms like tyrosine kinase 1 receptor) yang bersifat anti-angiogenesis.[3] s-flt1 berikatan dengan vegf (vascular endothelial growth factor) dan pigf (placental growth factor) yang bersifat angiogenik dan vasodilator. vegf dan pigf berperan penting dalam angiogenesis plasental dan disekresi oleh sel trofoblas. vegf diketahui penting dalam integritas dari sel endothelial maternal.[7] peningkatan s-flt1 di sirkulasi maternal akan menurunkan vegf dan pigf sehingga dapat menyebabkan anti angiogenik serta vasokonstriksi. hal tersebut dapat memicu terjadinya hipertensi dan gangguan organ lain seperti insufisiensi renal yang dapat ditandai dengan proteinuria.[3,7] penggunaan penanda biologis angiogenik sebagai prediktor 2 medical and health science journal, vol.3., no.1, februari 2019 prediktor untuk preeklamsia sangat penting untuk dikembangkan. faktor angiogenesis yang berimplikasi dengan patofisiologi preeklamsia memiliki potensi untuk mengidentifikasi penyakit ini lebih awal. penggunaan penanda biologis angiogenik seperti peningkatan s-flt1 dan penurunan vegf/pigf sebagai prediktor terjadinya preeklamsia masih dalam pengembangan. maynard et al [3] menunjukkan bahwa sampel serum ibu dengan preeklamsia yang diambil saat melahirkan menunjukkan peningkatan s-flt1 serta penurunan konsentrasi vegf dan pigf secara signifikan bila dibandingkan dengan kontrol yang memiliki tekanan darah normal. studi in vitro menunjukkan bahwa serum dari pasien preeklamsia dapat menghambat pembentukan sel endothelial vena umbilikalis manusia dibandingkan dengan serum yang diambil dari kontrol, serta pemberian adenovirus yang mengekspresikan sflt-1 pada tikus hamil dapat menyebabkan hipertensi, albuminuria dan endoteliosis glomerular yang serupa dengan preeklamsia pada manusia.[3] studi yang dilakukanoleh levine et al menunjukkan peningkatan level sflt-1 dan penurunan level pigf pada darah ibu, dapat digunakan untuk memprediksi terjadinya preeklamsia dalam waktu lima minggu sebelum gejala klinis muncul.[8] konsentrasi sflt1 serum pada ibu hamil meningkat secara signifikan lima minggu sebelum terdapat gejala klinis bila dibandingkan dengan kontrol yang memiliki tekanan darah normal. peningkatan konsentrasi sflt1 serum berbanding lurus dengan penurunan level pigf dan vegf bebas. ibu hamil dengan preeklamsia awal (early onset preeclampsia) dan gangguan perkembangan janin (iugr) memiliki peningkatan konsentrasi sflt1 dan penurunan vegf/pigf yang lebih besar dibandingkan dengan ibu hamil yang mengalami preeklamsia lambat (late onset preeclampsia) dengan ukuran janin yang normal. [8]. preeklamsia sering kali sulit dibedakan dengan hipertensi gestasional. studi yang dilakukan oleh woolcock et al menunjukkan peningkatan konsentrasi sflt-1 yang signifikan pada serum ibu hamil yang mengalami preeklamsia bila dibandingkan dengan ibu hamil yang hanya menderita hipertensi gestasional. studi ini menunjukkan peningkatan sflt-1 pada serum dapat berfungsi sebagai penanda diagnostik pada preeklamsia dan pembeda preeklamsia denganhipertensi gestasional.[9] hasil perbandingan serum s-flt1:pigf untuk memprediksi terjadinya preeklamsia studi yang dilakukan oleh chappel et al menunjukkan konsentrasi pigf maternal yang rendah (≤ 100 pg/ml) memiliki sensitivitas tinggi (0.96, 95% ci 0.89-0.99) dan memiliki nilai prediktif negative (0.98,95% ci 0.93-0.995) untuk memprediksi perkembangan preeklamsia dalam waktu 14 hari.[10] studi kohort prospektifobservasional multisenter yang melibatkan 500 wanita, menunjukkan batas rasio sflt-1:pigf 38 memiliki nilai manfaat dalam klinis.[11] nilai rasio sflt-1:pigf diatas 38 memiliki nilai prediksi negatif dan memiliki tingkat sensitivititas 80% dan spesifisitas 78,3% untuk preeklamsia. nilai prediksi positif rasio sflt 1:pigf > 38 untuk memprediksi preeklamsia dalam waktu 4 minggu adalah 36.7%, dengan tingkat sensitivitas 66,2% dan spesifisitas 83,1%. peneliti membuat hipotesis bahwa pada ibu hamil yang dicurigai terjadi preeklamsia, bila memiliki rasio s-flt1:pigf < 38 kemungkinan tidak akan mengalami preeklamsia dalam jangka waktu dekat.[10] walaupun menjanjikan, pemeriksaan rasio s flt1:pigf masih belum dapat dilakukan secara luas sebagai prediktor terjadinya preeklamsia. berbagai keterbatasan dari pemeriksaan ini diantaranya 3 medical and health science journal, vol.3., no.1, februari 2019 adalah pemeriksaan ini tidak dapat dilakukan hanya 1x, tetapi dapat berkali-kali selama masa kehamilan untuk mendapatkan hasil yang akurat, biaya pemeriksaan yang masih tinggi serta pemeriksaan ini tidak menambah informasi diagnosis bagi ibu hamil yang sudah terdiagnosis preeklamsia. manajemen preeklamsia nice (national institute for health and care excellence) merekomendasikan tekanan darah ibu hamil yang mengalami preeklamsia dijaga dibawah 150 mmhg untuk tekanan sistol dan 80-100 mmhg untuk tekanan diastol dengan menggunakan obat anti hipertensi lini pertama yaitu nifedipin dan labetolol.[11] nice juga merekomendasikan pemberian aspirin dosis rendah pada ibu hamil dengan risiko preeklamsia yang tinggi sejak usia kehamilan 12 minggu. faktor risiko preeklamsia pada ibu hamil diantaranya adalah memiliki riwayat preeklamsia atau hipertensi pada kehamilan sebelumnya, memiliki penyakit ginjal kronik, memiliki hipertensi kronik, memiliki penyakit diabetes, memiliki penyakit autoimun seperti sle (systemic lupus erythematosus) atau sindrom antifosfolipid, usia ibu hamil > 40, obseitas serta memiliki riwayat keluarga dengan preeklamsia.[12] asupan diet yang rendah kalsium dan serum konsentrasi kalsium yang rendah pada ibu hamil dapat meningkatkan terjadinya preeklamsia. who (world health organization) merekomendasikan pemberian suplemen kalsium (1.5-2 g/hari) saat trimester kedua kehamilan terutama pada ibu hamil dengan asupan diet yang rendah kalsium. walaupun begitu, studi randomized controlled trial menunjukkan suplementasi kalsium pada ibu hamil dengan riwayat preeklamsia sebelumnya tidak mengurangi tekanan darah secara signifikan atau mengurangi risiko terjadinya preeklamsia pada kehamilan berikutnya.[13] pada ibu hamil yang mengalami preeklamsia dengan usia kehamilan 37 minggu, maka nice merekomendasikan untuk segera dilakukan persalinan. pada ibu hamil yang mengalami preeklamsia pada usai kehamilan 34 – 37 minggu, persalinan segera dapat mengurangi risiko komplikasi pada maternal, hanya saja dapat meningkatkan risiko pada neonates seperti gangguan pernapasan. pada ibu hamil yang mengalami preeklamsia dengan usia kehamilan kurang drai 34 minggu, maka tidak disarankan untuk melakukan persalinan segera karena tingginya risiko gangguan pernapasan dan risiko enterekolitis pada neonatus.[14] kesimpulan preeklamsia merupakan gangguan pada kehamilan yang menyebabkan angka morbiditas yang tinggi. saat ini preeklamsia didiagnosis berdasarkan gejala klinis dan pemeriksaan penunjang seperti pemeriksaan darah dan urin di laboratorium. prediktor untuk memprediksi terjadinya preeklamsia pada ibu hamil dengan risiko tinggi sangat diperlukan. salah satu prediktor yang saat ini dikembangkan adalah menggunakan penanda biologis angiogenik seperti sflt1 dan pigf. walaupun predictor tersebut tidak dapat digunakan untuk mencegah komplikasi maternal seutuhnya, tetapi dengan adanya prediktor ini maka penanganan preeklamsia dapat dilakukan secara dini sehingga diharapkan dapat menurunkan angka morbiditas dan mortalitas pada ibu hamil. daftar pustaka 1. tranquilli al, dekker g, magee l, et al. the classification, diagnosis and management of the hypertensive disorders of pregnancy: a revised statement from the isshp. pregnancy hypertens 2014; 4:97-104. 2. ananth cv, keyes km, wapner rj. preeclampsia rates in the united states, 1980 2010: age-period-cohort analysis. bmj 2013;347:f6564. 4 medical and health science journal, vol.3., no.1, februari 2019 3. maynard s, min j, merchan j et al. excess placental soluble fms-like tyrosine kinase 1 (sflt1) may contribute to endothelial dysfunction, hypertension and proteinuria in preeclampsia. j clin invest 2003; 111: 649-658. 4. von dadelszen p, magee la, roberts jm. subclassification of preeclampsia. hypertens pregnancy 2003:22(2):143-148. 5. huppertz b. placental origins of preeclampsia: challenging the current hypothesis. hypertension 2008;51(4):970-975. 6. harihana n, shoemker a, wagner s. pathophysiology of preeclampsia. clinpract 2016(13): 33-37. 7. chaiworapongsa t, romero j, espinoza e, et al. evidence supporting the role for blockade of the vascular endothelial growth factor system in the pathophysiology of preeclampsia. am j obstetgynecol 2004;190(6):1541-1547. 8. levine r, maynard s, qian c et al. circulating angiogenic factors and the risk of preeclampsia. n engl j med 2004; 350: 672-683. 9. woolcock j, hennessy a, xu b, et al. soluble flt1 as a diagnostic marker of preeclampsia. australian and new zealand journal of obstetrics and gynaecology 2008; 48:64-70. 10. chappell lc, duckworth s, seed pt, griffin m, myers j, et al. diagnostic accuracy of placental growth factor in women with suspected preeclampsia: a prospective multicenter study. circulation. 2013 nov 5; 128(19):2121-31. 11. excellence. nifhac. cg107 nice guideline: hypertension in pregnancy.2012. 12. mol bwj, roberts ct, thangaratinam s, magee la, de groot cjm, hofmeyr gj. pre eclampsia. lancet. 2016 mar 5; 387(10022):999-1011. 13. hofmeyr gj, seuc ah, betrán ap, purnat td, ciganda a, et al. the effect of calcium supplementation on blood pressure in non pregnant women with previous pre-eclampsia: an exploratory, randomized placebo controlled study. pregnancy hypertens. 2015 oct; 5(4):273-9. 14. churchill d, duley l, thornton jg, jones l. interventionist versus expectant care for severe pre-eclampsia between 24 and 34 weeks' gestation. cochrane database systrev. 2013 jul 26; (7):cd003106. 5 medical and health science journal, vol.3., no.1, februari 2019 6 d:\new order belum cetak\mhsj v hafid algristian, hanafi muljohardjono, psikodinamika fraudster dalam sudut pandang ilmu psikiatri 2323 psikodinamika fraudster dalam sudut pandang ilmu psikiatri hafid algristian1, hanafi muljohardjono2 1fakultas kedokteran universitas nahdlatul ulama surabaya 2fakultas kedokteran universitas airlangga surabaya e-mail: ____________________ abstrak: fraudster atau pelaku fraud diindikasikan sebagai seseorang dengan kepribadian narsisistikantisosial. pada beberapa kasus justru dilakukan oleh orang tanpa gangguan psikiatrik apa pun, asal memenuhi tiga unsur dalam fraud. fraud adalah tindakan curang yang tidak selalu bertujuan menguntungkan diri sendiri, melainkan untuk merugikan pihak lain. literatur review ini ditulis untuk mengkaji psikodinamika fraudster dalam sudut pandang ilmu psikiatri, sehingga pengambil kebijakan dapat menentukan langkah penanggulangan fraud mulai dari asesmen sumber daya manusia hingga tata laksana. tata laksana holistis fraud mencakup aspek psikobiologi, personality, dan psikososiospiritual. kata kunci: fraud, narsisistik, antisosial, malingering pendahuluan fraud dapat diartikan sebagai penipuan atau kecurangan, menyebabkan kerugian materiil maupun imateriil yang sangat besar di institusi mana pun. pelaku fraud tidak terbatas pada mereka yang terdesak secara sosial-ekonomi, namun juga pada mereka yang memiliki status sosial, jabatan, atau keahlian tertentu. mereka mampu “mengakali” sistem hingga menguntungkan dirinya atau kelompoknya. pelaku kemudian melakukan undoing atau “penebusan dosa”, di mana ia akan memberikan hadiah atau menjamu orang lain secara berlebihan, atau “disedekahkan” kepada kaum dhuafa, untuk menutupi kecurangan mereka. hasilnya, image sosial mereka tetap terselamatkan (wilhelm, 2004; kayo, 2013; wind, 2014). pada beberapa kasus yang dilaporkan melalui media, menunjukkan bahwa para fraudsters memiliki latar belakang psikodinamika yang menarik untuk dikaji. makalah ini dimaksudkan untuk memberikan gambaran mengenai sudut pandang psikiatri pada fraudsters. dengan mengenali aspek psikiatri ini, dapat direncanakan sebuah tata laksana holistis dan komprehensif pada fraudsters. holistis yang dimaksud adalah tata laksana menyeluruh pada aspek biopsikososiospiritual, sementara komprehensif adalah dengan melibatkan stakeholder yang terkait dengan kasus tersebut (wilhelm, 2004; wallang & taylor, 2012; fitrawansyah, 2014). unsur perbuatan fraud sesuai pedoman chartered global management accountant (cgma), fraud haruslah memenuhi tiga unsur berikut ini: (1) tindakan yang disengaja; (2) kecurangan; (3) menimbulkan keuntungan pribadi/kelompok atau kerugian di pihak lain. misalnya mahasiswa yang melakukan titip absensi ketika kuliah pagi, apakah termasuk fraud? maka perlu dikaji berdasarkan pertanyaan berikut. apakah titip absensi adalah tindakan yang disengaja? ya. apakah titip absensi tergolong curang? ya. apakah titip absensi menguntungkan diri sendiri/kelompok? ya. tanpa medical and health science journal, vol. 2, no. 1, february 2018 24 melihat ukuran keuntungan dan kerugiannya asalkan ketiga unsur itu terpenuhi, maka ia termasuk tindakan fraud (lees, 2012; kayo, 2013; fitrawansyah, 2014; wind, 2014). teori fraud cressey (1953) melakukan penelitian terhadap 200 orang narapidana di midwest, menyimpulkan bahwa etiologi fraud adalah apa yang disebutnya sebagai fraud triangle, yaitu “pressure, opportunity, and rationalization”. yakni adanya tekanan (pressure) atau konflik kepentingan (conflict of interest), adanya kesempatan untuk melakukan (opportunity), dan adanya kecenderungan untuk mencari pembenaran terhadap perilakunya (rationalization) (wallang & taylor, 2012; kayo, 2013; sizemore, 2013; fitrawansyah, 2014). martin t. biegelman (2006) meneliti tentang perilaku korupsi, menyebutkan bahwa terjadinya fraud ternyata memenuhi formula c=p-a, di mana korupsi (corruption, c) akan terjadi jika kekuasaan (power, p) diselenggarakan tanpa pertanggungjawaban yang semestinya (accountability, a). dengan kata lain, ada abuse of power. melalui kekuasaan yang dimiliki, seseorang bisa menciptakan peluang (opportunity) terjadinya fraud, dan melegalkan alasan-alasan yang berakibat “memaksakan hukum agar sesuai dengan kemauannya” (rasionalisasi). di balik itu semua, sebenarnya setiap pelaku penyalahgunaan kekuasaan ternyata memiliki rasa tertekan (pressure) tertentu yang mendorongnya melakukan rasionalisasi dan menciptakan peluang terjadinya fraud. inilah yang disebut the power theory (collier & vicente, 2012; wallang & taylor, 2012; kayo, 2013). psikodinamika fraudster 1. tekanan (pressure) hendaknya perlu dibedakan antara perilaku antisosial (antisocial behavior) dan gangguan tabel 1 contoh gangguan psikiatrik yang melatarbelakangi kejadian fraud (wallang & taylor, 2012) icd-10/dsm-iv diagnosis level of fraudulent crime types of crime types where pathology may be present • personality disorders: psychopathic/callous unemotional traits, narcissistic • malingering • sophisticated/ • complex, organized • ponzi schemes • complex corporate fraud (enron, anderson) • west african advance fee ‘scams’ • pyramid schemes • stress-related disorder • depression • antisocial personality disorder • mid-level/ • semi-organized • inappropriate use of funds • diversion of liquid assets (embezzlement) • misappropriation • deception • internet fraud • learning (intellectual) disability (mild/borderline) • psychosis (mania) • substance misuse • antisocial personality disorder • low/opportunistic, • minimal complexity • credit card fraud • aliases • benefit fraud hafid algristian, hanafi muljohardjono, psikodinamika fraudster dalam sudut pandang ilmu psikiatri 25 kepribadian antisosial (antisocial personality disorder—aspd). seseorang dapat melakukan perbuatan melanggar hukum (antisosial) tanpa harus memiliki kepribadian antisosial. perilaku ini muncul sebagai reaksi terhadap tekanan dari sekitarnya, konflik neurotik (cemas dan depresi), atau pola pikir psikotik (waham dan halusinasi). pada umumnya faktor pressure terdiri dari keadaan-keadaan yang bersifat force de majeur, artinya di luar kehendak fraudsters (gabbard, 2005; wallang & taylor, 2012). tekanan (pressure) yang dialami fraudsters dapat berupa faktor sosioekonomi atau faktor psikobiologis. multiaksial diagnosis dalam ilmu psikiatri menyatakan faktor sosioekonomi bersesuaian dengan apa yang ada dalam axis iv, sementara faktor psikobiologis sesuai dengan axis i atau iii. dengan berkonsultasi kepada psikiater untuk melihat dua faktor ini, pengambil kebijakan akan memiliki pandangan holistis dalam mengkaji perbuatan fraudsters (balafoutas et al., 2011; wallang & taylor, 2012). 2. kesempatan salah satu yang mendukung terjadinya fraud adalah adanya kesempatan bagi pelaku untuk melaksanakan aksinya. kesempatan ini dapat tersedia dikarenakan sistem pengawasan yang lemah, dapat juga dimanipulasi sendiri oleh pelaku. tidak dipungkiri, memperketat sistem pengawasan adalah jalan paling utama yang bisa ditempuh untuk mencegah fraud. di sisi lain, terdapat istilah affinity fraud, yakni fraud yang terjadi pada sebuah kelompok atau komunitas. mereka memiliki keterikatan atau kesamaan, seperti kelompok keagamaan, fansub, kelompok hobi, persatuan pelajar, ikatan profesi tertentu seperti advokat, dokter, dan semacamnya. mereka toleran dan permisif satu sama lain, sehingga terbuka kesempatan untuk mengeksploitasi kepercayaan, kecurangan, bahkan menipu antaranggota (perri & brody, 2011, 2012; kayo, 2013; sizemore, 2013; alanezi & brooks, 2014). 3. rasionalisasi rasionalisasi yang dimaksud di sini bukanlah coping strategy untuk menghadapi stressor, melainkan perilaku fraudster yang berusaha mencari pembenaran atas perbuatannya. proses berpikir fraudster sering terdapat cognitive dissonance, atau kejanggalan kognisi sehingga dalam kondisi berbeda, ia bersikap berbeda. fraudster selalu bisa menjelaskan mengapa melakukan hal itu, dan menjadi sangat teguh terhadap pendiriannya tanpa memperhatikan bahwa pendirian tersebut tidak mendapat tempat dalam etika sosialnya (wallang & taylor, 2012). salah satu contoh ekstrem cognitive dissonance adalah pathological lying atau bohong patologis. disebut dalam istilah psikiatrik klasik sebagai pseudologia fantastica; terjemahan bebasnya adalah logika palsu yang menakjubkan. pelaku memiliki kemampuan untuk membuat sandiwara di mana ia berperan sebagai orang lain untuk melakukan serangkaian kasus fraud. pseudologia memiliki dua ciri khas yakni melibatkan identitas menyeluruh dari seseorang, dan tanpa adanya motivasi eksternal. pelaku—dalam hal ini mungkin disebut sebagai penderita, benarbenar mengubah identitas pribadinya (misalnya sebagai polisi atau dokter) dan berperan sebagai sosok yang ia pilih (wallang & taylor, 2012). beberapa praktisi hukum tidak menyetujui jika pseudologia dapat dijadikan alasan untuk memperingan hukuman. kemampuan intelektual mereka masih intak sehingga dianggap mampu bertanggung jawab. beberapa praktisi lain menganggap sebaliknya, bahwa pseudologia adalah medical and health science journal, vol. 2, no. 1, february 2018 26 kondisi sakit seperti waham pada skizofrenia atau gangguan waham menetap, sehingga perilaku fraud-nya adalah bagian dari sakitnya. dibandingkan dengan bohong non-patologis (common lie), penderita pseudologia tidak memiliki motivasi eksternal apapun. psikiater akan curiga pada diagnosis pseudologia bila pelaku tidak memiliki motivasi yang jelas terkait perilaku fraud-nya. keadaan ini sangat berbeda dengan kepribadian antisosial yang mensyaratkan keuntungan pribadi atau kerugian orang lain (wallang & taylor, 2012). 4. kepribadian antisosial dari tabel 1 dapat dilihat bahwa kepribadian antisosial tidak terbatas pada satu tingkat intelejensi, justru semakin tinggi tingkat intelejensinya, semakin berbahaya perbuatan fraudnya. mereka dengan antisocial personality disorder (aspd) mengalami “superego lacunae”, yakni superegonya tidak memiliki kendali optimal terhadap perilaku agar sesuai etika sosialnya (social fitness). superego lacunae ini dapat disebabkan pola asuh pada anak di usia 3–5 tahun. “ke-aku-an” anak sangat menonjol, mulai memiliki sense of belonging dan tidak mau kalah. orang tua yang otoriter-dominan membentuk coping proyeksi dan displacement anak terhadap dunia sekitarnya saat dewasa. orang tua yang permisif-submisif, tidak mampu memangkas keaku-an anak yang besar, sehingga mencetak anak sebagai sosok manja (spoiled child). kedua pola asuh ini tidak melatihkan empati anak terhadap sekitarnya, menjadikannya lebih narisistik-sadistik, sehingga mendukung terbentuknya aspd (hall & lindzey, 1993; millon & davis, 2000; pervin, 2003; gabbard, 2005; barnes& jacobs, 2013; gerhart et al, 2013; smith et al, 2013). 5. perilaku sadistik sebagian fraudtser merasakan kenikmatan tersendiri jika menyaksikan korbannya menderita karena perbuatannya. tingkat kompleksitas kasus fraud sebenarnya hanya untuk memuaskan pelaku dan sebagai pembuktian bahwa mereka mampu melakukan hal-hal yang tidak mungkin. adanya sensasi emosional adalah imbalan yang lebih tinggi dibandingkan harta yang mereka dapatkan. semakin kompleks kasusnya, semakin mereka puas. pada analisis five-factors model, pelaku umumnya memiliki skala agreeableness (empati) dan neuroticism (kecemasan) yang rendah (nettle, 2007; pervin, 2003; wallang & taylor, 2012). 6. asesmen kepribadian antisosial hare psychopaty checklist—revised (pclr) adalah instrumen untuk membantu melakukan asesmen terhadap ciri kepribadian antisosial. instrumen ini memiliki dua faktor dan masingmasing faktor terdiri dari dua faset. faktor-1 yang menggambarkan ciri kepribadian narsisistik, terdiri dari faset interpersonal dan faset afektif. sementara faktor-2 menggambarkan perilaku antisosial, dengan faset gaya hidup dan faset antisosial itu sendiri. instrumen menggambarkan kondisi kognitif, afektif, dan psikomotor dengan kecenderungan psikopatik atau tidak. selain itu, dapat digunakan instrumen b-scan untuk mendeteksi potensi fraud dalam perusahaan (cooke & miche, 1997; hare et al., 1990; mathieu et al., 2012; neumann et al., 2013). 7. waspada malingering pada berbagai macam kasus, malingered mental disorder hampir selalu menampakkan dua gejala utama, yakni (1) melibatkan kombihafid algristian, hanafi muljohardjono, psikodinamika fraudster dalam sudut pandang ilmu psikiatri 27 nasi gejala psikiatrik yang tidak khas (atypical combination of symptoms) dan (2) adanya hambatan kognitif sehingga menimbulkan score yang rendah pada tes iq atau tes kognitif tertentu. mendeteksi perilaku malingering atau berpurapura memang tidak mudah. penggunaan tes seperti test of memory malingering (tomm; tombaugh, 1997) dan miller-forensic assessment of symptoms test (m-fast; jackson, 2005) dapat cukup membantu (wallang & taylor, 2012). tata laksana psikiatrik holistis setelah mendapat putusan persidangan, psikiater dapat mengajukan usulan tata laksana yang holistis untuk pelaku fraud. pada prinsipnya, tata laksana ini sama dengan tata laksana kasus psikiatrik lainnya, yakni 3p-aspects, psychobiology, personality, dan psychosociospiritual. (basrowi & susilo, 2006; wallang & taylor, 2012). 1. tatalaksana psikobiologis pada level kompleksitas kasus fraud yang sederhana (level ringan dan sedang), di mana latar belakang pelaku adalah mengalami gejala depresi, manik-psikotik, gangguan waham, gangguan pengendalian impuls, gangguan intelektual, termasuk gangguan penyesuaian akibat masalah psikososial, dapat diberikan medikamentosa sebagaimana kasus psikiatrik pada umumnya. perbedaan mendasar pada tata laksana kasus fraud adalah kebutuhan untuk menghambat reseptor dopaminergik, sehingga menurunkan agresivitas dan kecermelangan daya berpikir pelaku (sophisticated train of thought). salah satu pilihan psikofarmaka adalah antipsikotik atipikal, seperti venlafaxine (gerhart et al, 2013; wallang & taylor, 2012). 2. tata laksana faktor kepribadian tata laksana untuk faktor ini melibatkan tiga area, yakni area kultural, area kelompok/ komunitas, dan area individu. salah satu sanksi yang berkembang di tanah air adalah adanya sanksi adat, mulai dari yang paling ringan yakni dikucilkan/diasingkan, dicibir, hingga hukumanhukuman fisik. beberapa sanksi adat mampu menunjukkan behavioral approach yakni membuat sikap antisosial menjadi lebih prososial. pendekatan ini kemudian diakomodasi dalam hukum dan perundang-undangan, sebagaimana istilah di kanada dan amerika yakni altruistic punishment. syarat hukuman ini adalah dengan berkontribusi positif untuk lingkungan sosialnya, seperti membayar denda dan melakukan kegiatan kemanusiaan (herrmann et al., 2008; crowtheret et al., 2012; neumann et al., 2013; sylwester et al., 2013). 3. tata laksana psikospiritual salah satu faktor protektif terhadap perilaku dan kepribadian antisosial adalah pendidikan. pendidikan memberikan peran penting untuk menanamkan nilai moral dan nilai-nilai prososial. praktisi pendidikan di negara barat masih sangat antipati untuk mengintegrasikan nilai-nilai spiritualitas dan keagamaan ke dalam pendidikan, dan menganggap bahwa fungsi pendidikan adalah menanamkan nilai-nilai moral yang bersumber dari kearifan lokal. negaranegara timur memiliki spiritualitas yang lebih dapat diterima oleh para praktisi pendidikan. mayoritas pendidikan di timur menekankan bahwa setiap manusia dianugerahi tuhan untuk memiliki peran penting dalam merawat alam semesta. satu titik temu antara barat dan timur adalah adanya nilai-nilai moral yang membuat masyarakatnya saling terikat satu sama lain, medical and health science journal, vol. 2, no. 1, february 2018 28 baik yang bersumber dari kearifan lokal maupun ketuhanan (basrowi & susilo, 2006; crowther et al, 2012; carbone-lopez, 2013; smith et al, 2013). kesimpulan fraud memiliki tiga unsur pokok, yakni tindakan yang disengaja, kecurangan, menimbulkan keuntungan pribadi/kelompok atau kerugian di pihak lain. teori yang mendasari fraud terdiri dari fraud triangle (pressure, opportunity, dan rationalization) dan the power theory (corruption terjadi jika power dilaksanakan tanpa accountability). hendaknya perlu dibedakan antara perilaku antisosial dan kepribadian antisosial seorang fraudster. perilaku antisosial muncul karena tekanan-tekanan baik psikis, biologis, maupun sosioekonomi. kepribadian antisosial ditandai dengan “ke-aku-an” yang besar dan cenderung sadistik. tata laksana holistis fraud dari sudut pandang ilmu psikiatri meliputi faktor psikobiologis termasuk penggunaan antipsikotik atipikal, personality seperti terlibat dalam kegiatan sosial, dan psikospiritual melalui pendidikan moral dan agama. daftar rujukan alanezi, f., & brooks, l. 2014. combatting online fraud in saudi arabia using general deterrence theory (gdt). security awareness & management in developing economies, 1–13. balafoutas, l; beck, a.; kerschbamer, r.; sutter, m. 2011. what drives taxi drivers? 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(2012). fraud risk management: a guide to good practice. cgma report. new york: american institute of cpas. mathieu, c., hare, r.d., jones, d.n., babiak, p., & neumann, c.s. 2012. factor structure of the b-scan 360: a measure of corporate psychopathy. psychological assessment. doi:10.1037/a0029262. millon, t., davis, r. 2000. personality disorder in modern life. canada: john wiley & sons. nettle, d. 2007. personality: what makes the way you are. oxford: oxford university press neumann, c.s., uzieblo, k., crombez, g., & hare, r.d. 2013. understanding the psychopathic personality inventory (ppi) in terms of the unidimensionality, orthogonality, and construct validity of ppi-i and -ii. personality disorders, 4(1), 77–9. doi:10.1037/a0027196. perri, f.s., & brody, r.g. 2011. birds of the same feather: the dangers of affinity fraud. university of new mexico, journal of forensic studies in accounting & business,3(1), 33–46. perri, f.s., brody, r.g. 2012. the optics of fraud/: affiliations that enhance offender credibility. journal of financial crime. doi:10.1108/13590791211243147 pervin, l.a. 2003. the science of personality. oxford university press (vol. 1). new york: oxford university press. sizemore, o.j. 2013. the role of perpetrator motivation in two crime scenarios. journal of interpersonal violence. doi:10.1177/ 0886260512448843. smith, c.a., park, a., ireland, t.o., elwyn, l., & thornberry, t.p. 2013. long-term outcomes of young adults exposed to maltreatment: the role of educational experiences in promoting resilience to crime and violence in early adulthood. doi: 10.1177/0886260512448845 wallang, p. & taylor, r. 2012. psychiatric and psychological aspects of fraud offending. advances in psychiatric treatment. doi: 10.1192/apt.bp.111.008946 wilhelm, w.k. 2004. the fraud management lifecycle theory: a holistic approach to fraud management. journal of economic crime management. spring 2004, 2(2). wind, a. 2014. forensic accounting. cipayung: dunia cerdas. medical and health science journal, vol. 2, no. 1, february 2018 30 medical and health science journal 2023 february, vol 07 (01) medical and health science journal available at http://journal2.unusa.ac.id/index.php/mhsj; doi: 10.33086/mhsj.v7i1.3532 pissn 2549-7588. eissn 2549-7596 original article biochemical correlation of sex hormone profile with diabetes mellitus type 2 in indian mena case-control study sandeep kumar1*, jaya jain1, ashutosh jain1 1department of biochemistry, index medical college hospital & research center, indore, india * corresponding author: sanjulko44@gmail.com, article info article history: received october 06, 2022 received in revised from march 01,, 2023 accepted march 10, 2023 keywords: type 2 diabetes, testosterone level, hypogonadism, dyslipidemia. abstract introduction: india, the country with the highest prevalence of diabetes, has between 62,4 and 77,2 million diabetics and pre-diabetics. the purpose of this study was to investigate the biological correlation between sex hormone profile and type 2 diabetes in indian men. methodology: in this case-control study, total of 181 diabetic cases and 181 healthy controls were enrolled as per who norms. along with clinicdemographical data, fasting blood glucose, postprandial blood glucose, hba1c, insulin, lipid profile and testosterone, lh, fsh were measured and compared. results: a non-significant difference was observed [p=0.7831] between different ages among the study population's case and control groups. the fpg, hba1c, total cholesterol, ldl, triglycerides were significantly elevated in cases as compared to controls, except hdl and shbg, showing non-significant differences. the spearman correlation between testosterone and different parameters, and all the correlations showed a significant negative correlation. however, testosterone vs. testicular volume (ml) [r=0.2981], testosterone vs. hdl cholesterol(mmol/l) [r=0.04884] and testosterone vs. calculated free testosterone (mmol/l) [r=0.007494] respectively shows significant positive correlation. conclusion: type 2 diabetes male patients had lower testosterone levels. as a biomarker for type 2 diabetes, it is possible to measure changes in serum testosterone levels. medical and health science journal introduction over 422 million individuals were diagnosed with diabetes in 2014, making it the most common chronic disease in the world today. international diabetes federation (idf) estimates that 463 million people worldwide have diabetes and that one in two persons are undiagnosed [1]. it is estimated that 5.9% of the global population has diabetes mellitus (t2dm). there are roughly 62,4 and 77,2 million diabetics and pre-diabetics in india, the country with the highest prevalence of diabetes in the world [2]. several studies [3,4] have demonstrated a link between hypogonadism and diabetes in men. according to a massachusetts study on male ageing, seventy-five percent of diabetic men had low testosterone levels. these males are susceptible to acquiring ed [5]. low testosterone levels (hypogonadism) have been documented in http://journal2.unusa.ac.id/index.php/mhsj mailto:sanjulko44@gmail.com kumar et al medical and health science journal 2023 february vol.07 (01) page 10 of 20 numerous investigations [1, 2, 6] in males with t2dm. insulin resistance is the primary risk factor for this type of diabetes, which is also caused by central obesity and previously upper abdominal adiposity [7]. numerous studies have demonstrated an inverse relationship between free testosterone and the degree of obesity, indicating that low testosterone levels are observed in obese men [8,9]. obesity stimulates aromatase to convert testosterone to oestrogen, resulting in a further decline in testosterone levels [10]. in fact, testosterone supplementation improves insulin sensitivity and glucose homeostasis [11] in individuals with diabetes and hypogonadism. despite this, certain investigations [12,13] indicate that testosterone supplementation has no effect on blood sugar control in hypogonadic diabetic patients. men's atherosclerosis and coronary heart disease are connected with glycosylated haemoglobin (hba1c), a marker of hyperglycemia, ir, and hba1c. however, it is unknown if decreased testosterone levels are the cause or result of diabetes or metabolic syndrome development. of the above background, the present study aimed to study the biological correlation of sex hormone profile with diabetes mellitus type 2 in indian men. material and methods the present case-control study was conducted at the department of biochemistry, index medical college hospital and research centre, indore. after ethical clearance (approval no mu/research/ec/phd/2019/34) and informed consent, patients aged 30-60 years of male diabetic patients diagnosed on the basis of who norms [blood sugar (≥126mg/dl) and 2 hour post-prandial blood sugar (≥200mg/dl)] were included as cases (n=181). however, patients with chronic diseases like ckd, cvd, mi, cancer, etc, patients with infectious diseases like tb, hiv and hepatitis, patients with metabolic disorders like hypothyroidism, and non willing patients were excluded. normal healthy subjects as per who norms of fasting blood sugar (<126mg/dl) and 2hour post-prandial blood sugar (<200mg/dl), were included as controls (n=181). along with family history and medical history of subjects, demographic details including bmi, waist to hip ratio, systolic blood pressure, and diastolic blood pressure were measured. american diabetic association (ada) criteria were followed for impaired fasting glucose (ifg) as a fasting plasma glucose value of 100125 mg/dl (5.6-6.9 mmol/l) in the absence of a previous diagnosis of diabetes. minimum 5ml of blood will be drawn from each group under the aseptic condition in a suitable vial and used for the investigation of fasting blood glucose (gmbh-120200), postprandial blood glucose (gmbh-120200), hba1c (em-01-xsys), insulin (eia-2935), lipid profile (erba kit 120194, 120211, 120227) and testosterone (drgeia-1559), lh (drg-eia-1289), fsh (drg-eia1288) as per manual protocol. kumar et al medical and health science journal 2023 february vol.07 (01) page 11 of 20 statistical analysis: statistical analysis was performed using spss software (spss inc., chicago, il, usa) for windows program (21.0 version). when required, the continuous variables were presented by mean (standard deviation) or range value and analysed using the student t-test. the dichotomous variables were presented in number/frequency and analysed using the chi-square test. the correlation was done using spearman correlation analysis. all the analysis was done at 95% confidence level and pvalue of < 0.05 or 0.001 was regarded as significant. results the mean age of the patients in the case and control groups were 45.51±5.35 and 43.79±12.69, respectively. a non-significant difference was observed [p=0.0938] between the mean age among the case and control groups of the study population. the majority of the patients in the case groups were aged between 31-40 years [82(45.30%)], followed by 41-50 [56(30.94%)] and 18-30 [22(12.15%)]. however, in the control group, most of the patients were aged 31-40 years [77(42.54%)], followed by 41-50 [62(34.25%)] and 18-30 years [25(13.81%)]. a non-significant difference was observed [p=0.7831] between different ages among the study population's case and control groups. [figure-1] figure-1: graphical representation of age distribution of the enrolled patients among the case and control groups the mean sbp [142.72±25.36 and 127.35±22.68], dbp [83.16±13.42 and 80.46±14.25], wc [91.25±11.85 and 78.29±9.68], bmi [24.52±4.87 and 23.42±3.75] and testicular volume [21.34±4.32 and 22.61±3.68] in the case and control groups showed a significant difference except dbp [p=0.0643]. [table-1, figure-2 ] table-1: clinical parameter of the enrolled patients among the case and control groups. 0 50 100 22 82 56 2125 77 62 17 n o . o f p a ti e n ts age distribution cases control kumar et al medical and health science journal 2023 february vol.07 (01) page 12 of 20 clinical parameter cases [n=181] control [n=181] p-value mean sd mean sd sbp (mmhg) 142.72 25.36 127.35 22.68 t=6.078 p<0.0001* dbp (mmhg) 83.16 13.42 80.46 14.25 t=1.856 p=0.0643 wc (cm) 91.25 11.85 78.29 9.68 t=11.4 p<0.0001* bmi (m/kg2) 24.52 4.87 23.42 3.75 t=2.408 p=0.0166* testicular volume (ml) 21.34 4.32 22.61 3.68 t=3.011 p=0.0028* student t-test, significant figure-2: graphical representation of biochemical parameters of the enrolled patients among the case and control groups. the fpg, hba1c, total cholesterol, ldl, and triglycerides were significantly elevated in cases as compared to controls, except hdl and shbg, showing non-significant differences. however, serum albumin (p<0.0001) and free testosterone (p<0.0001) were significantly lower in cases as compared to controls [table-2, figure-2]. table-2: biochemical parameters of the enrolled patients among the case and control groups. biochemical parameter cases [n=181] control [n=181] p-value mean sd mean sd fpg (mmol/l) 7.30 4.61 3.65 1.48 t=10.14 p<0.0001* kumar et al medical and health science journal 2023 february vol.07 (01) page 13 of 20 hba1c (%) 10.32 2.16 6.24 0.37 t=25.05 p<0.0001* total cholesterol(mmol/l) 5.36 0.96 4.75 0.64 t=7.113 p<0.0001* ldl cholesterol(mmol/l) 3.69 0.82 3.46 0.86 t=2.604 p=0.0096* hdl cholesterol(mmol/l) 2.34 0.61 2.41 0.52 t=1.175 p=0.2408 triglycerides (mmol/l) 0.61 0.84 0.43 0.12 t=2.854 p=0.0046* total testosterone (mmol/l) 7.64 3.62 14.53 3.69 t=17.93 p<0.0001* shbg (mmol/l) 84.76 63.78 94.48 76.36 t=1.314 p=0.1896 albumin (mmol/l) 38.41 3.55 40.84 3.49 t=6.567 p<0.0001* calculated free testosterone (mmol/l) 1.24 0.18 1.51 0.23 t=12.44 p<0.0001* student t-test, significant as per serum gonadal hormones assessment, lh and fsh showed significantly elevated levels in cases as compared to controls. however, the insulin level was remarkably lower in cases than in controls (p<0.0001) [table-3]. table-3: serum gonadal hormones of the enrolled patients among the case and control groups. serum gonadal hormones cases [n=181] control [n=181] pvalue mean sd mean sd lh (miu/ml) 7.74 3.62 5.97 3.57 t=4.684 p<0.0001* fsh (miu/ml) 12.84 5.38 7.22 4.63 t=10.650 p<0.0001* insulin (iu/ml) 8.78 1.23 13.02 1.63 t=27.93 p<0.0001* student t-test, significant the majority of the patients had 0-5 years[90(49.72%)] of t2dm duration, followed by 6-10 years [46(25.41%)] and 11-15 years [28(15.47%)] of enrolled patients in case groups [figure-3]. the majority of the patients in the case groups were given metformin + glimepiride medication [63(34.81%)] followed by metformin + glibenclamide [39(21.55%)] and metformin alone [28(15.47%)] respectively [figure-4]. kumar et al medical and health science journal 2023 february vol.07 (01) page 14 of 20 figure-3: graphical representation of duration of t2dm(years) of the enrolled patients among the case and control groups. figure-4: graphical representation of medication of the enrolled patients among the case and control groups 0 10 20 30 40 50 60 70 80 90 0 to 5 6 to 10 11 to 15 16 to 20 >20 90 46 28 7 10 n o . o f p a ti e n ts duration of t2dm (years) 0 10 20 30 40 50 60 70 28 63 39 5 3 26 17n o . o f p a ti e n ts medication medical and health science journal 2021 february vol 05 (01) the spearman correlation between testosterone and different parameters, and all the correlations showed negative correlation. however, testosterone vs. testicular volume (ml) [r=0.2981], testosterone vs. hdl cholesterol(mmol/l) [r=0.04884] and testosterone vs. calculated free testosterone (mmol/l) [r=0.007494] respectively shows positive correlation. discussion insulin resistance is a key factor in the development of type 2 diabetes. it is becoming more common knowledge that low testosterone levels in males are associated with decreased insulin sensitivity and the development of type 2 diabetes [9]. the present study aimed to study the biological correlation of sex hormone profile with diabetes mellitus type 2 in indian men. ezekiel musa et al., 2021 [14] observed that both total and estimated free testosterone levels were significantly lower in individuals with t2dm compared to non-diabetic controls. in accra, ghana and lagos, nigeria, asare-anane et al. [15] and onung et al. [16] reported comparable results. in addition, paruk et al. [17] in south africa found reduced total and free testosterone levels in men with type 2 diabetes compared to controls. in the present study, we also observed significantly lower levels of total testosterone in diabetic patients compared to healthy individuals. two meta-analyses by ding et al. [18] and corona et al. [19] that included 20 cross-sectional studies (850 diabetic men and 2000 non-diabetic controls) and 28 cross-sectional studies (1,822 men with diabetes and 10,009 non-diabetic controls), respectively, revealed consistently lower total testosterone levels in men with diabetes compared to non-diabetic controls. the connection between low total testosterone and diabetes has previously been ascribed to low shbg levels, which are typically reported in t2dm [20]. nonetheless, ezekiel musa et al., 2021,[14] determined that free testosterone was considerably lower in males with t2dm than in non-diabetic controls, indicating that causes other than shbg may be involved in reducing testosterone levels. in addition to low shbg, we believe that abnormal levels of cholesterol, fasting plasma glucose, and hba1c may contribute to low testosterone. farooq et al. 2020[21] also demonstrated that diabetes produces low testosterone levels in males, and that low testosterone levels can serve as a diabetes marker. consequently, with appropriate management, mortality and co-morbidity linked with diabetes can be averted. the relationship between poor glycemic control and hypogonadism did not approach statistical significance, although it was clinically significant. the conclusion of ezekiel musa et al., 2021[14] is congruent with the findings of a nigerian study [22]. in contrast to previous findings, we observed that hypogonadism was associated with significantly higher fpg and hba1c. asareanane et al., 2013 [15] and kapoor et al., 2007 [23] revealed a substantial connection between hypogonadism and fpg and glycated haemoglobin, similar to our findings. in addition, the study by ezekiel musa et al., 2021[14] found no statistically significant connection between ldl cholesterol and hypogonadism, despite the high mean ldl cholesterol in hypogonadal participants. this result is corroborated by mirzaei et al. kumar et al medical and health science journal 2023 february vol.07 (01) page 16 of 20 [24] investigation, which demonstrated no association between total testosterone and the lipid profile. on the other hand, wickramatilake et al. [25] and colleagues found a substantial connection between ldl cholesterol and hypogonadism. the correlation between hypogonadism and systolic and diastolic blood pressure observed by ezekiel musa et al., 2021[14] was not statistically significant. these results are consistent with those from other investigations [26, 27]. in contrast, a number of studies [23, 28] have established a correlation between hypogonadism and blood pressure. we also identified a significant connection between sbp and hypogonadism in the present study, although the association between dbp and hypogonadism was not statistically significant. clinically, but not statistically, a correlation was established between hypogonadism and abdominal obesity, as measured by waist circumference, despite the increased prevalence of abdominal obesity in type 2 diabetic men with hypogonadism. zheng et al. [29] similarly showed that there was no significant relationship between hypogonadism and abdominal obesity, although laaksonen et al. [30] found the opposite. ezekiel musa et al., 2021[31] observed no relationship between hypogonadism and global obesity, similar to previous studies [22, 32]. in contrast to previous research, the present study demonstrated a strong relationship between abdominal obesity and hypogonadism. similar to this, o bservations by some researchersalso demonstrated a significant association between obesity (using bmi) and hypogonadism [33, 34]. although the absence of a statistically significant association between obesity and hypogonadism, despite the higher odds of developing hypogonadism in obese type 2 diabetic men compared to non-obese men, could be attributed to a significantly high proportion of hypogonadism in the non-obese men. in multivariable analysis, there was a substantial negative connection between total testosterone and triglycerides and hdl cholesterol, with total testosterone levels decreasing linearly as these factors rose. these results concurred with those of other researchers [33, 34] but opposed those of asare-anane et al. [15] and chang et al. [35]. these findings suggest that male t2dm patients with dyslipidemia may frequently have hypogonadism. similarly, we detected a strong negative connection between hypogonadism and lipid profile in the present investigation. this demonstrated the connection between dyslipidemia and hypogonadism. low testosterone is related with obesity, type 2 diabetes, inflammation, and hyperlipidemia [36]. in contrast to kapoor et al. [23] and asare-anane et al. [15], ezekiel musa et al. [14] found no significant relationship between total testosterone and anthropometric measurements and fpg. in contrast, waist size, testicular volume, duration of diabetes, and bmi were not associated with an increased risk of predicting low total testosterone. the 88 percent sensitive adam questionnaire indicated that erectile dysfunction and loss of libido are predictors of low testosterone [37]. in contrast to ezekiel musa et al., 2021[14], mahmoud et al. [38] found that testicular volume was a predictor of low testosterone, but travison et al. [39] indicated that obesity using wc and bmi and duration of diabetes were predictors of low total testosterone. in contrast, we found no kumar et al medical and health science journal 2023 february vol.07 (01) page 17 of 20 association between hypogonadism and the bmi of the patients. according to idf, the significantly lower cut-off for diagnosing abdominal obesity in sub-saharan african men may account for the apparent lack of statistical significance despite the higher risks of low testosterone with abdominal obesity. in addition, the abnormally high number of hypogonadal and eugonadal males who responded positively to erectile dysfunction and lack of libido may have diminished the relevance of the results. thus the present study reveals a significant association of dyslipidemia with hypogonadism in diabetic patients. however, small samples and the single centric study was the limitation of the study. author recommended further multicentric study with a large sample size to increase the reliability and generalizability of the present findings. conclusion the t2dm male patients showed decreased levels of testosterone or we can assume that decreased testosterone levels significantly raised the risk of t2dm. serum testosterone levels can be utilised as a biomarker for the course of type 2 diabetes. additionally, diabetic men may explore testosterone supplementation to improve clinical outcomes. conflict of interest the author started there is no conflict of interest. references 1. international diabetes federation. idf diabetes atlas. 9th ed. brussels: idf; 2019. 2. anjana rm, pradeepa r, deepa m, datta m, sudha v, unnikrishnan r, et al. prevalence of diabetes and prediabetes (impaired fasting glucose and/or impaired glucose tolerance) in urban and rural india: phase i results of the indian council of medical researchindia diabetes (icmr-indiab) study. diabetologia. 2011;54:3022-7. 3. brand js, wareham nj, dowsett m, folkerd e, van der schouw yt, luben rn, 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may;65(5): 503-9. 21. farooq r, bhat mh, majid s, mir mm. association between t2dm and the lowering of testosterone levels among kashmiri males. archives of endocrinology and metabolism. 2020 aug 28;64:528-32. 22. ogbera oa, sonny c, olufemi f, wale a. hypogonadism and subnormal total testosterone levels in men with type 2 diabetes mellitus. j coll physicians surg pak. 2011 sep;21(9): 517-21. 23. kapoor d, aldred h, clark s, channer ks, jones th. clinical and biochemical assessment of hypogonadism in men with type 2 diabetes: correlations with bioavailable testosterone and visceral adiposity. diabetes care. 2007 apr;30(4): 911-7. 24. mirzaei mr, amini m, aminorroaya a. the prevalence of hypogonadism in diabetic men in isfahan endocrine and metabolism research center, isfahan, iran. j res med sci. 2012 jul;17(7): 6026. 25. wickramatilake cm, mohideen mr, pathirana c. association of serum testosterone with lipid abnormalities in patients with angiographically proven coronary artery 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el-bashir jm, sani-bello f, bakari ag. hypergonadotropic hypogonadism in nigerian men with type 2 diabetes mellitus. clin diabetol. 2021;10(1): 32. tripathy d, dhindsa s, garg r, khaishagi a, syed t, dandona p. hypogonadotropic hypogonadism in erectile dysfunction kumar et al medical and health science journal 2023 february vol.07 (01) page 20 of 20 associated with type 2 diabetes mellitus: a common defect? metab syndr relat disord. 2003 mar;1(1): 75-80. 33. kemp t, rheeder p. the prevalence and association of low testosterone levels in a south african male, diabetic, urban population. jemdsa. 2015;20(2): 92-7. 34. diaz-arjonilla m, schwarcz m, swerdloff rs, wang c. obesity, low testosterone levels and erectile dysfunction. int j impot res. mar-apr 2009;21(2): 89-98. 35. chang tc, tung cc, hsiao yl. hormonal changes in elderly men with non-insulin-dependent diabetes mellitus and the hormonal relationships to abdominal adiposity. gerontology. 1994;40(5): 260-7. 36. wang c, jackson g, jones th, matsumoto am, nehra a, perelman ma et al. low testosterone associated with obesity and the metabolic syndrome contributes to sexual dysfunction and cardiovascular disease risk in men with type 2 diabetes. diabetes care. 2011 jul;34(7): 1669-75. 37. morley je, charlton e, patrick p, kaiser fe, cadeau p, mccready d et al. validation of a screening questionnaire for androgen deficiency in aging males. metabolism. 2000 sep;49(9): 1239-42. 38. mahmoud am, goemaere s, el-garem y, van pottelbergh i, comhaire fh, kaufman jm. testicular volume in relation to hormonal indices of gonadal function in community-dwelling elderly men. j clin endocrinol metab. 2003 jan;88(1): 179-84. 39. travison tg, araujo ab, kupelian v, o'donnell ab, mckinlay jb. the relative contributions of aging, health, and lifestyle factors to serum testosterone decline in men. j clin endocrinol metab. 2007 feb;92(2): 549-55. e:\job aditya\indro\naskah masu agus aan adriansyah, nurul jannatul firdausi, trend kasus baru infeksi human immunodeficiency virus (hiv) di indonesia periode tahun 2012–2016 11 trend kasus baru infeksi human immunodeficiency virus (hiv) di indonesia periode tahun 2012–2016 1agus aan adriansyah, 2nurul jannatul firdausi 1prodi s1 ilmu kesehatan masyarakat, fakultas kesehatan, unusa surabaya e-mail: 1 or aan_naufal87@yahoo.com 2prodi s1 ilmu kesehatan masyarakat, fakultas kesehatan, unusa surabaya e-mail: nuruljf@unusa.ac.id or njfirdausi@gmail.com abstract: countries in southeast asia have a very high hiv (+) prevalence compared to other countries in the asian continent. indonesia is one of the countries in southeast asia that has the fastest rate of hiv transmission. the proliferation of new cases of hiv in indonesia has increased significantly in 2013 and 2014. it is not only a health issue, it has become a social problem at the same time. therefore, it is necessary to describe the trend of new cases of hiv-aids disease for the period 2012–2016 in all provinces in indonesia. this is an explorative descriptive research. the study design was cross-sectional with a retrospective approach. the location of this study is all provinces in indonesia. the population of this study is all data of patients with new cases of hiv disease. data collection used secondary data documentation studies on the number of new hiv cases. statistical method used is parametric statistic with test used is friedman test and wilcoxon test. results of comparative hiv case testing for the period 2012–2016 show a significance value of 0.001, and there is at least one significant difference in the number of hiv cases from the period 2012–2016. partially, only the hiv cases of the 2012 period with the year 2013, the period of 2013 to 2014, and the 2015 to 2016 period indicate a significant difference. suggestions that can be given are the need for cross-program and cross-sector coordination in the implementation of the prepared programs, the commitment and support of policy makers to allocate budgets outside the health sector, not to engage in free sex, increase drug treatment facilities for drug addicts, and provides hiv counseling facilities. keywords: hiv cases, trend analysis, hiv case projection abstrak: negara-negara di asia tenggara mempunyai prevalensi hiv (+) yang sangat tinggi dibandingkan dengan negara lain di benua asia. indonesia merupakan salah satu negara di asia tenggara yang mempunyai angka penularan hiv yang paling cepat. perkembangan jumlah kasus baru hiv di indonesia mengalami peningkatan secara signifikan pada tahun 2013 dan 2014. hal ini bukan hanya menjadi masalah kesehatan semata, tetapi sekaligus telah menjadi masalah sosial. oleh sebab itu, perlu adanya gambaran trend terjadinya kasus baru penyakit hiv-aids periode tahun 2012–2016 pada seluruh provinsi yang ada di indonesia. penelitian ini merupakan penelitian deskriptif eksploratif. desain penelitian adalah cross-sectional dengan pendekatan retrospektif. lokasi penelitian ini adalah seluruh provinsi di indonesia. populasi penelitian ini adalah seluruh data penderita kasus baru penyakit hiv. pengumpulan data menggunakan studi dokumentasi data sekunder jumlah kasus baru hiv. metode statistik yang digunakan adalah statistik parametrik dengan uji yang digunakan adalah friedman test dan wilcoxon test. hasil uji perbandingan kasus hiv periode tahun 2012–2016 menunjukkan nilai signifikansi sebesar 0,001, dan minimal terdapat sepasang perbedaan yang signifikan jumlah kasus hiv dari periode tahun 2012–2016. secara parsial, hanya kasus hiv periode tahun 2012 dengan tahun 2013, periode tahun 2013 dengan tahun 2014, dan periode tahun 2015 dengan tahun 2016 yang menunjukkan adanya perbedaan signifikan. saran yang dapat diberikan yaitu perlu koordinasi lintas program dan lintas sektor dalam implementasi program-program yang disusun, perlu komitmen dan dukungan dari pengambil kebijakan untuk mengalokasikan anggaran medical and health science journal, vol. 1, no. 2, august 2017 2 negara-negara di asia tenggara mempunyaiprevalensi hiv (+) yang sangat tinggi dibandingkan dengan negara-negara lain di benua asia dan secara epidemiologi menunjukkan perbedaan yang besar. indonesia merupakan salah satu negara di asia tenggara yang mempunyai angka penularan hiv yang paling cepat. perkembangan hiv-aids di indonesia kian memprihatinkan. ketika angka kematian akibat aids dan kasus baru infeksi hiv di dunia berangsur turun, tidak demikian halnya dengan indonesia. di indonesia, kasus epidemi penyakit hivaids masih terus meningkat, meskipun jumlah infeksi baru menunjukkan tren penurunan di myanmar, nepal, dan thailand. indonesia merupakan negara dengan penularan hiv-aids tercepat di asia tenggara (who, 2009). indonesia merupakan negara yang menempati urutan pertama dalam penularan hiv-aids di asia tenggara. dari total populasi penduduk sebanyak 240 juta jiwa, indonesia memiliki prevalensi hiv sebesar 0,24% dengan estimasi odha 186.000, bahkan bisa mencapai 200.000 (profil kesehatan indonesia, 2010). di indonesia, berdasarkan laporan dari tahun ke tahun kasus hiv-aids masih menunjukkan tren peningkatan yang terus-menerus. menurut laporan ditjen pencegahan penyakit dan penyehatan lingkungan (p2pl) kementerian kesehatan, jumlah kumulatif kasus aids di indonesia sampai dengan akhir september 2014 adalah sebanyak 55.799 kasus dan 9.796 kasus di antaranya mengakibatkan kematian (statistik kasus hiv-aids di indonesia, 2014). pada tahun 2014, 36,9 juta orang hidup dengan hiv. jumlah orang yang hidup dengan hiv terus meningkat yang ditunjukkan dengan kasus ditemukannya 2 juta orang dengan infeksi baru hiv dan 1,2 juta orang meninggal yang diakibatkan oleh penyakit yang berhubungan dengan aids. temuan kasus baru infeksi hiv bervariasi pada tiap daerah di dunia, termasuk juga jumlah kasus kematian akibat aids yang fluktuatif. perkembangan jumlah kasus baru hiv di indonesia mengalami peningkatan secara signifikan pada tahun 2013 dan 2014, bila dibandingkan dengan perkembangan jumlah kasus baru pada tahun 2010–2012 yang relatif cukup stabil. pada tahun 2012 jumlah kasus baru hiv sebesar 21.511 kasus, sedangkan pada tahun 2013 dan 2014 masing-masing sebesar 29.037 dan 32.711 kasus. provinsi dengan jumlah kasus hiv tertinggi yaitu dki jakarta, jawa timur, dan jawa barat. hiv-aids masih menjadi masalah kesehatan global dan penyebab utama kematian akibat penyakit menular di seluruh dunia. rendahnya pemahaman tentang hiv-aids sampai saat ini karena masih banyak yang belum memahami risiko penularan penyakit tersebut dan angka kejadian belum dapat diprediksi dengan baik. permasalahan hiv-aids merupakan fenomena gunung es, artinya data yang ada merupakan data kasus hiv-aids yang hanya muncul di permukaan. masih banyak kasus yang belum terdeteksi karena ada banyak orang yang sudah terinfeksi hiv tetapi tidak terbuka untuk melakukan pemeriksaan di klinik. hal ini disebabkan karena perasaan takut dan malu untuk memeriksakan diri yang muncul karena adanya stigma dan diskriminasi dari masyarakat bahkan keluardi luar sektor kesehatan, tidak melakukan hubungan seks bebas, memperbanyak fasilitas pengobatan bagi pecandu obat terlarang, dan menyediakan fasilitas konseling hiv. kata kunci: kasus hiv, analisis trend, proyeksi kasus hivpendahuluan agus aan adriansyah, nurul jannatul firdausi, trend kasus baru infeksi human immunodeficiency virus (hiv) di indonesia periode tahun 2012–2016 3 ga sebagai lingkungan terdekat terhadap orang dengan hiv-aids (odha). berdasarkan kondisi yang berkembang saat ini dapat dipahami bahwa hiv-aids adalah sebuah isu yang sangat rumit. hal ini bukan hanya menjadi masalah kesehatan semata, tetapi sekaligus telah menjadi masalah sosial. mengingat kompleksitas permasalahan tersebut, penyelesaiannya pun menjadi tidak mudah. penelitian ini akan berfokus pada gambaran trend terjadinya kasus baru penyakit hiv-aids periode tahun 2012–2016 pada seluruh provinsi yang ada di indonesia. metode penelitian jenis penelitian ini adalah penelitian deskriptif eksploratif. desain penelitian adalah crosssectional dengan pendekatan retrospektif. sasaran penelitian ini adalah seluruh masyarakat di indonesia yang terwakili berdasarkan lokasi per provinsi yang memiliki risiko terhadap terjangkitnya penyakit hiv. sampel pada penelitian ini adalah seluruh data jumlah penderita kasus baru penyakit hiv yang tersebar di seluruh provinsi dan tercatat pada laporan profil kesehatan indonesia. lokasi penelitian ini dilakukan secara nasional meliputi seluruh provinsi yang terhimpun pada profil laporan kesehatan indonesia. data yang digunakan dalam penelitian ini, adalah data sekunder berupa profil kesehatan indonesia tahun 2012 hingga tahun 2016. data diolah berdasarkan wilayah per provinsi dan berdasarkan periode tahun. data yang sudah dipetakan kemudian dibuat menjadi peta besaran jumlah kasus baru hiv, peta kekuatan infeksi, dan peta risiko hiv-aids yang berupa peta tematik. teknik analisis data dengan cara melakukan uji perbandingan trend kejadian kasus baru hiv tiap tahun dari tahun 2012 hingga 2016, serta melakukan pemantauan per provinsi yang ada. metode statistik yang digunakan adalah statistik non-parametrik dengan uji friedman test dan dilanjutkan dengan wilcoxon test. hasil dan pembahasan gambaran kasus baru infeksi hiv di indonesia periode tahun 2012 hiv-aids merupakan penyakit menular yang disebabkan oleh infeksi human immunodeficiency virus yang menyerang sistem kekebalan tubuh. infeksi tersebut menyebabkan penderita mengalami penurunan ketahanan tubuh sehingga sangat mudah untuk terinfeksi berbagai macam penyakit lain. sebelum memasuki fase aids, penderita terlebih dulu dinyatakan sebagai hiv positif. jumlah hiv positif yang ada di masyarakat dapat diketahui melalui 3 metode, yaitu pada layanan voluntary, counseling, and testing (vct), zero survey, dan survei terpadu biologis dan perilaku (stbp) (kemenkes ri, 2013). pemetaan epidemi hiv di indonesia dibagi menjadi lima kategori, yaitu <90 kasus, 90–206 kasus, 207–323 kasus, 324–440 kasus, dan >440 kasus. tabel 1 berikut memperlihatkan distribusi kategori epidemi hiv pada 33 provinsi di indonesia, dilengkapi pemetaan wilayah distribusi hiv di indonesia yang tersaji pada gambar 1. tabel 1 distribusi kategori epidemi hiv pada 33 provinsi di indonesia tahun 2012 no. kategori jumlah provinsi persentase 1 < 90 kasus hiv 8 24,2 2 90–206 kasus hiv 5 15,2 3 207–323 kasus hiv 6 18,2 4 324–440 kasus hiv 3 9,1 5 >440 kasus hiv 11 33,3 total 33 100,0 medical and health science journal, vol. 1, no. 2, august 2017 4 berdasarkan tabel 1 dapat diinformasikan bahwa hampir sebagian besar provinsi di indonesia termasuk dalam kategori epidemi terjadi kasus hiv > 440 kasus (33,3%). hal ini cukup memprihatinkan, dan harus segera dicari solusi penanganan agar tidak semakin meningkat di tahun berikutnya. pemetaan selengkapnya dapat dilihat pada gambar 1. berdasarkan gambar di atas, sebanyak 11 provinsi (33,3%) di indonesia memiliki kasus hiv > 440, sebanyak 8 provinsi (24,2%) dengan kasus hiv < 90 kasus, sebanyak 7 provinsi (21,2%) dengan kasus hiv 206–323. provinsi dengan jumlah hiv tertinggi yaitu dki jakarta, papua, dan jawa timur. hiv-aids dapat ditularkan melalui beberapa cara penularan, yaitu hubungan seksual lawan jenis (heteroseksual), hubungan sejenis melalui lelaki seks dengan lelaki (lsl), penggunaan alat suntik secara bergantian, transfusi darah, dan dari ibu ke anak. gambaran kasus baru infeksi hiv di indonesia periode tahun 2013 setelah tiga tahun berturut-turut (2010– 2012) cukup stabil, perkembangan jumlah kasus baru hiv positif pada tahun 2013 kembali mengalami peningkatan signifikan, dengan kenaikan mencapai 35% dibanding tahun 2012. tabel 2 berikut memperlihatkan distribusi kategori epidemi hiv pada 33 provinsi di indonesia dan dilengkapi dengan pemetaan wilayah distribusi hiv di indonesia yang tersaji pada gambar 2. tabel 2 distribusi kategori epidemi hiv pada 33 provinsi di indonesia tahun 2013 gambar 1 peta epidemi hiv di indonesia tahun 2012 no. kategori jumlah provinsi persentase 1 <90 kasus hiv 6 18,2 2 90–206 kasus hiv 6 18,2 3 207–323 kasus hiv 6 18,2 4 324–440 kasus hiv 1 3,0 5 >440 kasus hiv 14 42,4 total 33 100,0 agus aan adriansyah, nurul jannatul firdausi, trend kasus baru infeksi human immunodeficiency virus (hiv) di indonesia periode tahun 2012–2016 5 berdasarkan tabel 2 dapat diinformasikan bahwa hampir sebagian besar provinsi di indonesia termasuk dalam kategori epidemi terjadi kasus hiv > 440 kasus (42,4%). hal ini cukup memprihatinkan dan harus segera dicari solusi penanganan agar tidak semakin meningkat di tahun-tahun berikutnya. pemetaan selengkapnya dapat dilihat pada gambar 2. pada gambar 2 terlihat bahwa lebih dari dua per lima provinsi (14 provinsi) di indonesia memiliki jumlah kasus hiv > 440, meliputi seluruh provinsi di pulau papua dan pulau jawa bali serta beberapa provinsi di sumatera, kalimantan, dan sulawesi. jumlah kasus hiv pada kelompok tersebut menyumbang hampir 90% dari seluruh jumlah kasus hiv di indonesia. provinsi dengan jumlah hiv tertinggi yaitu dki jakarta, papua, dan jawa timur. sebanyak 6 provinsi memiliki jumlah kasus hiv kurang dari 90 kasus. sulawesi barat tidak dilaporkan adanya kasus baru hiv positif pada tahun 2013 (kemenkes ri, 2013). gambaran kasus baru infeksi hiv di indonesia periode tahun 2014 setelah tiga tahun berturut-turut (2010– 2012) cukup stabil, perkembangan jumlah kasus baru hiv positif pada tahun 2013 dan 2014 kembali mengalami peningkatan secara signifikan. tabel 3 berikut ini memperlihatkan distribusi kategori epidemi hiv pada 33 provinsi di indonesia dan dilengkapi dengan pemetaan wilayah distribusi hiv di indonesia yang tersaji pada gambar 3. tabel 3 distribusi kategori epidemi hiv pada 33 provinsi di indonesia tahun 2014 gambar 2 peta epidemi hiv di indonesia tahun 2013 no. kategori jumlah provinsi persentase 1 <90 kasus hiv 4 12,1 2 90–206 kasus hiv 7 21,2 3 207–323 kasus hiv 5 15,2 4 324–440 kasus hiv 2 6,1 5 >440 kasus hiv 15 45,5 total 33 100,0 medical and health science journal, vol. 1, no. 2, august 2017 6 berdasarkan tabel 3 dapat diinformasikan bahwa hampir sebagian besar provinsi di indonesia termasuk dalam kategori epidemi terjadi kasus hiv > 440 kasus (45,5%). hal ini cukup memprihatinkan dan harus segera dicari solusi penanganan agar tidak semakin meningkat di tahun-tahun berikutnya. pemetaan selengkapnya dapat dilihat pada gambar 3. berdasarkan gambar di atas, sebanyak 15 provinsi di indonesia memiliki jumlah kasus hiv > 440, meliputi seluruh provinsi di pulau jawa, bali, dan pulau papua serta beberapa provinsi di sumatera (sumatera utara dan riau), kalimantan (kalimantan barat dan kalimantan timur), dan satu provinsi di sulawesi yaitu sulawesi selatan. jumlah kasus hiv di 15 provinsi tersebut menyumbang hampir 90% dari seluruh jumlah kasus hiv di indonesia. provinsi dengan jumlah hiv tertinggi yaitu dki jakarta, jawa timur, dan jawa barat. sebanyak empat provinsi memiliki jumlah kasus hiv kurang dari 90 kasus yaitu gorontalo, sulawesi barat, aceh, dan maluku utara (kemenkes ri., 2014). gambaran kasus baru infeksi hiv di indonesia periode tahun 2015 estimasi dan proyeksi jumlah orang dengan hiv-aids di indonesia pada tahun 2015 adalah sebanyak 735.256 orang dengan jumlah infeksi baru sebanyak 85.523 orang (estimasi dan proyeksi hiv-aids di indonesia tahun 2011– 2016, kemenkes ri). jumlah kasus baru hiv positif yang dilaporkan pada tahun 2015 sebanyak 30.935 kasus, menurun dibandingkan tahun sebelumnya. tabel 4. memperlihatkan distribusi kategori epidemi hiv pada 34 provinsi di indonesia. tabel 4 distribusi kategori epidemi hiv pada 34 provinsi di indonesia tahun 2015 gambar 3 peta epidemi hiv di indonesia tahun 2014 no. kategori jumlah provinsi persentase 1 <90 kasus hiv 6 17,6 2 90–206 kasus hiv 6 17,6 3 207–323 kasus hiv 5 14,7 4 324–440 kasus hiv 2 5,9 5 >440 kasus hiv 15 44,1 total 34 100,0 agus aan adriansyah, nurul jannatul firdausi, trend kasus baru infeksi human immunodeficiency virus (hiv) di indonesia periode tahun 2012–2016 7 berdasarkan tabel 4.4 dapat diperoleh informasi bahwa hampir sebagian besar provinsi di indonesia termasuk dalam kategori epidemi terjadi kasus hiv > 440 kasus (44,1%). sebanyak 15 provinsi di indonesia memiliki jumlah kasus hiv > 440, meliputi seluruh provinsi di pulau jawa, bali, dan pulau papua serta beberapa provinsi di sumatera (sumatera utara dan riau), kalimantan (kalimantan barat dan kalimantan timur), dan satu provinsi di sulawesi yaitu sulawesi selatan. provinsi dengan jumlah hiv tertinggi yaitu dki jakarta, jawa timur, dan jawa barat. sebanyak empat provinsi memiliki jumlah kasus hiv kurang dari 90 kasus yaitu gorontalo, sulawesi barat, aceh, bengkulu, kalimantan utara, dan maluku utara. hal ini cukup memprihatinkan, dan harus segera dicari solusi penanganannya agar tidak semakin meningkat di tahun-tahun berikutnya. gambaran kasus baru infeksi hiv di indonesia periode tahun 2016 estimasi dan proyeksi jumlah orang dengan hiv-aids di indonesia pada tahun 2015 adalah sebanyak 735.256 orang dengan jumlah infeksi baru sebanyak 85.523 orang (estimasi dan proyeksi hiv-aids di indonesia tahun 2011– 2016, kemenkes ri). jumlah kasus baru hiv positif yang dilaporkan pada tahun 2016 sebanyak 41.250 kasus, meningkat tajam dibandingkan tahun sebelumnya. tabel 5 memperlihatkan distribusi kategori epidemi hiv pada 34 provinsi di indonesia. berdasarkan tabel 5 dapat diinformasikan bahwa sebagian besar provinsi di indonesia termasuk dalam kategori epidemi terjadi kasus hiv > 440 kasus (52,9%). sebanyak 18 provinsi memiliki jumlah kasus hiv > 440, meliputi seluruh provinsi di pulau jawa, bali, dan pulau papua serta beberapa provinsi di sumatera (sumatera utara, riau, dan kepulauan riau), kalimantan (kalimantan barat, kalimantan timur, dan kalimantan selatan), dan provinsi di sulawesi (sulawesi selatan, maluku, dan nusa tenggara timur). provinsi dengan jumlah hiv tertinggi yaitu jawa timur, dki jakarta dan jawa barat. sebanyak empat provinsi memiliki jumlah kasus hiv kurang dari 90 kasus yaitu gorontalo, sulawesi barat, dan aceh. hal ini cukup memprihatinkan dan harus segera dicari solusi penanganannya agar tidak semakin meningkat di tahun-tahun berikutnya. trend kasus baru infeksi hiv di indonesia periode tahun 2012–2016 setelah tiga tahun berturut-turut (2010– 2012) cukup stabil, perkembangan jumlah kasus baru hiv positif di indonesia pada tahun 2013 kembali mengalami peningkatan secara signifikan sebesar 34,99%. pada tahun 2012 jumlah kasus baru hiv positif yang dilaporkan adalah sebanyak 21.511 kasus, dan meningkat menjadi 29.037 di tahun 2013. jumlah kasus baru hiv di tahun 2014 juga kembali mengalami peningkatan secara signifikan sebesar 12,65% dari sebelumnya, yaitu tahun 2013. akan tetapi, no. kategori jumlah provinsi persentase 1 <90 kasus hiv 3 88 2 90–206 kasus hiv 8 23,5 3 207–323 kasus hiv 1 2,9 4 324–440 kasus hiv 4 11,8 5 >440 kasus hiv 18 52,9 total 34 100,0 tabel 5 distribusi kategori epidemi hiv pada 34 provinsi di indonesia tahun 2016 medical and health science journal, vol. 1, no. 2, august 2017 8 jumlah kasus baru hiv positif yang dilaporkan pada tahun 2015 sebanyak 30.935 kasus, mengalami penurunan 5,43% dibandingkan tahun 2014. penghujung tahun 2016, kasus baru hiv positif ini kembali meningkat tajam sebesar 33,34% menjadi 41.250 kasus. analisis perbandingan data laporan epidemi kasus infeksi hiv positif baru di indonesia berdasarkan wilayah 34 provinsi, dilakukan dengan menggunakan uji friedman dan dilanjutkan dengan menggunakan uji wilcoxon. hasil uji friedman perbandingan kasus infeksi baru hiv dari periode tahun 2012 hingga tahun 2016 dengan menggunakan uji friedman menunjukkan nilai signifikansi sebesar 0,001 (<0,01) sehingga dapat disimpulkan bahwa minimal terdapat perbedaan yang signifikan jumlah kasus hiv dari periode tahun 2012 hingga tahun 2016. gambaran trend peningkatan atau penurunan dari jumlah kasus hiv yang terjadi di 34 provinsi di indonesia, dapat dilihat pada gambar 4. secara global data jumlah kasus hiv per tahun, untuk tahun 2012 rata-rata kejadian kasus baru hiv sebanyak 652 kasus, meningkat pada tahun 2013 dengan rata-rata kejadian kasus hiv dari ke-33 provinsi sebanyak 880 kasus. tahun 2014 mengalami peningkatan kembali dengan rata-rata kejadian kasus hiv dari ke 33 provinsi yaitu sebesar 994 kasus. akan tetapi, selang tahun berikutnya mengalami penurunan pada tahun 2015 dengan rata-rata kejadian kasus gambar 4 trend jumlah kasus hiv baru pada 34 provinsi di indonesia tahun 2012–2016 agus aan adriansyah, nurul jannatul firdausi, trend kasus baru infeksi human immunodeficiency virus (hiv) di indonesia periode tahun 2012–2016 9 hiv dari ke-34 provinsi sebesar 911 kasus. di akhir tahun 2016, kasus hiv tersebut malah menjadi masalah besar terkait dengan terjadinya peningkatan tajam dari kasus tersebut dengan rata-rata kejadian menjadi 1.214 kasus hiv baru. apabila diamati secara nilai rata-rata, dapat dikatakan bahwa terjadi peningkatan dari tahun 2013 menuju tahun 2014, kemudian terjadi penurunan dari tahun 2014 menuju tahun 2015. akan tetapi, mengalami peningkatan tajam sampai akhir tahun 2016. perbedaan jumlah kasus hiv dari periode tahun 2012 hingga tahun 2016 dapat disimpulkan bahwa terdapat perbedaan yang signifikan. untuk melihat perbedaan secara masing-masing tahun periode dapat dianalisis menggunakan uji wilcoxon. hasil yang diperoleh dari uji wilcoxon dapat dilihat pada tabel 6. berdasarkan tabel 6, dapat diperoleh informasi bahwa mayoritas mengalami perbedaan yang signifikan antar tahunnya. meskipun demikian, masih terdapat hasil yang menunjukkan tidak terlalu berbeda secara signifikan dari perbandingan antar tahunnya. berikut merupakan gambaran singkat perbandingan antar-tahun dengan selang waktu 1 tahun dari tahun 2012 hingga tahun 2016. 1. perbedaan jumlah kasus hiv periode tahun 2012 dengan tahun 2013 menunjukkan perbedaan yang signifikan dengan terjadi peningkatan yang cukup tajam (34,99%) dari ratarata jumlah kasus hiv. 2. perbedaan jumlah kasus hiv periode tahun 2013 dengan tahun 2014 menunjukkan adanya perbedaan yang signifikan secara statistik dengan bukti terjadi peningkatan 12,65% rata-rata jumlah kasus hiv. 3. perbedaan jumlah kasus hiv periode tahun 2014 dengan tahun 2015 menunjukkan tidak adanya perbedaan yang signifikan secara statistik dengan bukti penurunan rata-rata jumlah kasus hiv yang terjadi sebesar 5,43%. 4. perbedaan jumlah kasus hiv periode tahun 2015 dengan tahun 2016 menunjukkan adanya perbedaan yang signifikan secara statistik dengan bukti terjadinya peningkatan ratarata jumlah kasus hiv yang cukup tajam (33,34%). dengan demikian, pemerintah bersama kementerian terkait beserta lembaga organisasi maupun lsm perlu duduk bersama untuk melakukan upaya dalam menurunkan jumlah kasus hiv. semua pihak harus saling berkoordinasi untuk menyusun sebuah strategi dan alternatif no. perbandingan jumlah kasus hiv signifikansi syarat keterangan tahun tahun 1. 2012 2013 0,001 < 0,01 berbeda signifikan 2. 2013 2014 0,001 berbeda signifikan 3. 2014 2015 0,217 tidak berbeda signifikan 4. 2015 2016 0,001 berbeda signifikan 5 2012 2014 0,001 berbeda signifikan 6 2012 2015 0,001 berbeda signifikan 7 2012 2016 0,001 berbeda signifikan 8 2013 2015 0,040 tidak berbeda signifikan 9 2013 2016 0,001 berbeda signifikan 10 2014 2016 0,001 berbeda signifikan tabel 6 hasil uji perbandingan menggunakan wilcoxon test medical and health science journal, vol. 1, no. 2, august 2017 10 kegiatan yang disusun dalam upaya penanggulangan hiv-aids yang diharapkan bisa menjadi pedoman dalam menyusun rencana pembangunan bidang kesehatan pada tahun berikutnya, khususnya dalam penanggulangan hiv-aids. di samping itu, perlu peningkatan koordinasi lintas program dan lintas sektor dalam implementasi program-program yang disusun, dengan melaksanakan kegiatan-kegiatan secara terpadu. selanjutnya, dalam upaya pencegahan dan pengendalian hiv-aids perlu komitmen dan dukungan dari pengambil kebijakan untuk mengalokasikan anggaran di luar sektor kesehatan. simpulan dan saran simpulan dari hasil penelitian yang telah dilakukan dapat disimpulkan sebagai berikut. 1. jumlah kasus baru hiv positif pada tahun 2012 meningkat menjadi 21.511 kasus daripada tahun-tahun sebelumnya. hampir sebagian besar provinsi di indonesia termasuk dalam kategori epidemi terjadi kasus hiv > 440 kasus (33,3%). 2. jumlah kasus baru hiv positif pada tahun 2013 kembali mengalami peningkatan secara signifikan, dengan kenaikan mencapai 35% dibanding tahun 2012. hampir sebagian besar provinsi di indonesia termasuk dalam kategori epidemi terjadi kasus hiv > 440 kasus (42,4%). 3. jumlah kasus baru hiv positif pada tahun 2014 kembali mengalami peningkatan secara signifikan. hampir sebagian besar provinsi di indonesia termasuk dalam kategori epidemi terjadi kasus hiv > 440 kasus (45,5%). 4. jumlah kasus baru hiv positif pada tahun 2015 sebanyak 30.935 kasus, menurun dibandingkan tahun sebelumnya. hampir sebagian besar provinsi di indonesia termasuk dalam kategori epidemi terjadi kasus hiv > 440 kasus (44,1%). 5. jumlah kasus baru hiv positif yang dilaporkan pada tahun 2016 sebanyak 41.250 kasus, meningkat tajam dibandingkan tahun sebelumnya. sebagian besar provinsi di indonesia termasuk dalam kategori epidemi terjadi kasus hiv > 440 kasus (52,9%). 6. perbandingan kasus hiv dari periode tahun 2012–2016 menunjukkan nilai signifikansi sebesar 0,001 (<0,05), sehingga minimal terdapat sepasang perbedaan yang signifikan jumlah kasus hiv dari periode tahun 2012– 2016. secara parsial perbandingan dari masing-masing periode tahun, tidak semuanya menunjukkan adanya perbedaan yang signifikan. saran berdasarkan hasil temuan penelitian dan kesimpulan tersebut maka dapat dikemukakan beberapa saran sebagai berikut. 1. bagi pemerintah diharapkan mampu secara tegas memberantas praktik-praktik prostitusi. selain itu, pemerintah dapat memberikan layanan minimum kepada para wanita yang masih berprofesi sebagai psk, terdiri dari pendidikan kesehatan, memastikan ketersediaan dan promosi kondom, kontrol infeksi menular seksual (ims), konseling dan tes hiv, dan pengobatan hiv. 2. bagi tenaga pendidik, diharapkan dapat memberikan pendidikan atau penyuluhan tentang seks kepada anak-anak secara dini. hal ini untuk mencegah terjadinya pernikahan usia dini dan perilaku seks bebas yang dapat meningkatkan risiko terjadinya infeksi hiv. 3. bagi masyarakat, agar dapat selalu menjaga keharmonisan dalam keluarga. keluarga yang agus aan adriansyah, nurul jannatul firdausi, trend kasus baru infeksi human immunodeficiency virus (hiv) di indonesia periode tahun 2012–2016 11 harmonis dapat mengurangi risiko terjadinya penyelewengan suami/istri atau pencarian jawaban atas kebutuhan seksual terutama bagi para pekerja yang bekerja jauh dari rumah. dengan demikian, tidak akan terjadi hubungan seksual yang berganti-ganti pasangan, dan diharapkan dapat mengurangi kejadian hiv. 4. perlu adanya strategi dan alternatif kegiatan yang disusun dalam upaya penanggulangan hiv-aids yang diharapkan bisa menjadi pedoman dalam menyusun rencana pembangunan bidang kesehatan pada tahun berikutnya, khususnya dalam penanggulangan hiv-aids. 5. perlu adanya peningkatan koordinasi lintas program dan lintas sektor dalam implementasi program-program yang disusun, dengan melaksanakan kegiatan-kegiatan secara terpadu. 6. dalam upaya pencegahan dan pengendalian hiv-aids perlu adanya komitmen dan dukungan dari pengambil kebijakan untuk mengalokasikan anggaran di luar sektor kesehatan. 7. satu-satunya jalan agar tidak terinfeksi adalah dengan tidak melakukan hubungan seks atau hanya berhubungan seks dengan satu orang yang diketahui tidak mengidap infeksi. 8. memperbanyak fasilitas pengobatan bagi pecandu obat terlarang akan mengurangi penularan hiv. 9. menyediakan fasilitas konseling hiv di mana identitas penderita dirahasiakan atau dilakukan secara anonimus serta menyediakan tempat-tempat untuk melakukan pemeriksaan darah. referensi ashari, m.d. 2000. hindari aids demi masa depan kita semua. dalam: nasution, rizali h, dkk., ed. aids: kita bisa kena, kita bisa cegah, 17. medan: monora. basavaraj, et al. 2010. quality of life in hivaids. journal department of dermatology, venereology, and leprosy, jss medical college, jss university. india: mysore, karnataka. besral. 2004. potensi penyebaran hiv dari pengguna napza suntik ke masyarakat umum. makara kesehatan, vol. 8, no. 2, desember 2004: 53–58. brooks, g.f., butel, j.s., dan morse, s.a. 2005. aids dan lentivirus. dalam: sjabana, dripa, ed. mikrobiologi kedokteran, 292– 300. jakarta: salemba medika. daili, dkk. 2009. infeksi menular seksual. jakarta: balai penerbit fkui. davey, p. 2006. infeksi hiv dan aids. dalam: safitri, amalai, ed. at a glance medicine, 288–289. jakarta: penerbit erlangga. departemen kesehatan r.i. 2006. situasi hivaids di indonesia tahun 1987–2006. jakarta: depkes ri. departemen kesehatan ri. 2008. profil kesehatan indonesia tahun 2008. jakarta: depkes ri. departemen kesehatan r.i. 2008. hiv-aids ancaman serius bagi indonesia. pusat komunikasi publik. sekretariat jenderal departemen kesehatan. djoerban, z. dan djauzi, s. 2006. hiv-aids di indonesia. dalam: sudoyo, aru. w., dkk., ed. buku ajar ilmu penyakit dalam, ed. iv, jilid ii, 1803–1807. jakarta: pusat penerbitan departemen ilmu penyakit dalam fkui. fauci, a.s., dan lane, h.c. 2005. human immunodeficiency virus disease: aids and related disorders. in: kasper, dennis s., ed. harrison’s principles of internal medicine 16th edition, 1076, 2372–2390. united states of america: mc graw hill. medical and health science journal, vol. 1, no. 2, august 2017 12 greeff, m., et al. 2009. perceived hiv stigma and life satisfaction among persons living with hiv infection in five african countries: a longitudinal study. international journal nursing studies. article inpress. diunduh pada tanggal 24 maret 2016 dari http://www.elsevier.com/ijns/pdf. kemenkes ri. 2012. profil data kesehatan indonesia 2011. jakarta: kemenkes ri. kemenkes ri. 2013. profil kesehatan indonesia tahun 2012. jakarta: kemenkes ri. kemenkes ri. 2014. profil kesehatan indonesia tahun 2013. jakarta: kemenkes ri. kemenkes ri. 2015. profil kesehatan indonesia tahun 2014. jakarta: kemenkes ri. kemenkes ri. 2016. profil kesehatan indonesia tahun 2015. jakarta: kemenkes ri. kemenkes ri. 2017. data dan informasi profil kesehatan indonesia tahun 2016. jakarta: kemenkes ri. mansjoer, arif. dkk. 2000. aids. dalam: kapita selekta kedokteran edisi ke-3 jilid 2, 162. jakarta: medika aesculapius. muninjaya, a.a. gde. 1999. tiga cara untuk pencegahan aids. dalam: aids di indonesia: masalah dan kebijakan penanggulangannya, 29–32. jakarta: penerbit buku kedokteran egc. nasronudin. 2007. hiv & aids pendekatan biologi molekuler, klinis, dan sosial. surabaya: airlangga university press. notoatmodjo, s. 2003. konsep perilaku dan perilaku kesehatan. dalam: pendidikan dan perilaku kesehatan, 29–32. jakarta: pt rineka cipta. notoatmodjo, s. 2007. promosi kesehatan dan ilmu perilaku. jakarta: rineka cipta. purwaningsih, sri sunarti, dan widayatun. 2008. perkembangan hiv-aids di indonesia: tinjauan sosio demografis. jurnal kependudukan indonesia volume iii, no 2. rasmaliah. 2001. epidemiologi hiv-aids dan upaya penanggulangannya. fkm universitas sumatra utara. soria, e.a. 2012. effect of a healthcare gender gap on progression of hiv-aids defined by clinical-biological criteria among adults from cordoba city (argentina) from 1995 to 2005. e.a soria, diakses 24 april 2012. unaids. 2015. aids by the numbers 2015. geneva: unaids. yatim, d.i. 2006. dialog seputar aids. jakarta: pt gramedia widiasarana indonesia. zein, u. dkk. 2006. 100 pertanyaan seputar hiv-aids yang perlu anda ketahui, 1–44. medan: usu press. d:\new order belum cetak\mhsj v novera herdiani, wiwik afridah, gambaran status gizi anak kelas vi di sekolah dasar miftakhul ulum surabaya 3535 gambaran status gizi anak kelas vi di sekolah dasar miftakhul ulum surabaya novera herdiani, wiwik afridah fakultas kesehatan universitas nahdlatul ulama surabaya e-mail: novera.herdiani@unusa.ac.id abstract: background, nutritional status is a description of balance between the need of nutrients for keeping a good life, to maintenance normal body function also energy production in one side and the consumption of nutrients in the other. children in elementary school are the best target for improvement of community nutrition because in the childhood the function of the brain organ began to form so the development of intelligence is quite rapid. lack of nutritional intake in children can inhibit the physical growth and thinking ability in children and subsequently reduce in learning interest. therefore the nutritional status of the children must detect immediately to carry out the preventive measurements. objective, the purpose of this study is to know the nutritional status of children at grade vi in elementary school miftakhul ulum surabaya based on height and weight. methods, this study is a quantitative descriptive using survey method, weighting index instrument by height in children aged 6–17 years old from health department in 2011. this study used the measurement of body weight and height. subjects of this study were all students at grade vi in elementary school miftakhul ulum surabaya, which amount 81 children. data collecting techniques use anthropometric measurements which include measurement of body weight and height then calculated base of data analysis techniques using quantitative descriptive with percentage. result, study results showed most of the students were 12 years old (56.80%), mostly male (55.60%). most of them have body height 130–140 cm (37.00%), and body weight 31–40 kg (46,90%). male children have more problems with their nutritional status (51.10%). male children much often have underweight and over weight (13.30%) than girls. by the increasing their age, their bmi will be normal category (100%). by the age of 13 and 14 years old, the children will not have underweight (0%). conclusion, based on the nutritional status of all children at grade vi, it can be concluded that the nutritional status of children at grade vi in elementary school miftakhul ulum surabaya is in underweight category (very thin and lean) with percentage 56.80%. while the normal weight percentage 32.10%, and over weight (fat and obesity) with percentage 11.10%. keywords: nutritional status, children at grade vi, elementary school pendahuluan pencapaian pembangunan kesehatan dinilai dengan derajat kesehatan masyarakat. derajat kesehatan digambarkan dengan situasi mortalitas, morbiditas, dan status gizi masyarakat. ketidakseimbangan gizi dapat menurunkan kualitas sdm. gizi yang baik akan menghasilkan sdm yang berkualitas yaitu sehat, cerdas dan memiliki fisik yang tangguh serta produktif (departemen gizi dan kesehatan masyarakat, 2013). perbaikan gizi diperlukan mulai dari masa kehamilan, bayi dan anak balita, prasekolah, anak usia sekolah dasar, remaja dan dewasa, sampai usia lanjut (gibson rs, 2005). anak sekolah dasar merupakan sasaran strategis dalam perbaikan gizi masyarakat karena pada masa anak fungsi organ otak mulai terbentuk mantap sehingga perkembangan kecerdasan cukup pesat. anak sekolah dasar (sd) adalah anak usia 6–12 tahun (depkes, 2011). pertumbuhan dan perkembangan anak sangat membutuhkan gizi yang cukup agar tidak medical and health science journal, vol. 2, no. 1, february 2018 36 terjadi penyimpangan pada pertumbuhan dan perkembangan anak. gizi yang kurang akan membuat sistem imun pada anak lemah. aktivitas yang cukup tinggi dan kebiasaan makan yang tidak teratur pada anak sering mengakibatkan ketidakseimbangan antara asupan dan kecukupan gizi (ipriyona tri noli, 2011). ketidakseimbangan antara asupan dan kecukupan gizi akan menimbulkan masalah gizi, baik itu masalah gizi lebih maupun gizi kurang. kekurangan gizi juga dapat menyebabkan penyakit infeksi yang menjadi penyebab kematian. kelebihan gizi dapat menyebabkan obesitas pada anak (supariasa, dkk., 2002). berdasarkan data riskesdas tahun 2013, prevalensi kurus (menurut imt/u) pada anak umur 5–12 tahun adalah 11,2%, terdiri dari 4,0% sangat kurus dan 7,2% kurus. prevalensi kurus pada umur 13–15 tahun adalah 11,1% terdiri dari 3,3% sangat kurus dan 7,8% kurus. sedangkan menurut data riskesdas 2010 sebelumnya yaitu prevalensi anak pendek pada anak usia 6–12 tahun adalah 35,8%, dan untuk anak kurus pada usia 6–12 tahun adalah 11%. tidak hanya masalah gizi kurang, masalah gizi lebih juga harus diperhatikan karena prevalensi gizi lebih meningkat dengan bertambahnya usia. secara nasional masalah gemuk pada anak umur 5–12 tahun masih tinggi yaitu 18,8%, terdiri dari gemuk 10,8% dan sangat gemuk (obesitas) 8,8%. prevalensi gemuk pada umur 13–15 tahun di indonesia sebesar 10,8%, terdiri dari 8,3% gemuk dan 2,5% sangat gemuk (obesitas). sebanyak 13 provinsi dengan prevalensi gemuk di atas nasional, termasuk provinsi jawa timur (badan penelitian dan pengembangan kesehatan kementerian kesehatan ri, 2013). gambaran kondisi wilayah yang akan dijadikan sasaran penelitian yaitu: sd miftakhul ulum, beralamatkan di jl. rungkut tengah iii/ 13, kecamatan gunung anyar, kota surabaya, provinsi jawa timur. secara sosial, masyarakat berada di tengah-tengah perkampungan dengan status sosial masyarakatnya memiliki pendidikan yang cukup. secara ekonomi: masyarakat di sekitar termasuk pada golongan ekonomi menengah. secara lingkungan, di sekitar sekolah berhadapan dengan satu tk dan dikelilingi oleh rumah-rumah penduduk sehingga banyak rumah yang membuka toko di rumahnya, karena tidak adanya kantin di sekolah, sehingga banyak anak yang tidak memperhatikan makanan dan kesehatan, serta belum pernah dilakukan pengukuran tinggi badan dan berat badan. berkaitan dengan fenomena di atas, maka perlu adanya penelitian mengenai gambaran status gizi anak usia sekolah di sd miftakhul ulum surabaya, sehingga status gizi anak dapat diketahui dengan segera untuk dilakukan langkah preventif. metode penelitian ini merupakan penelitian deskriptif kuantitatif. metode penelitian menggunakan survei dengan teknik pengukuran antropometri dan pengukuran tinggi badan dan berat badan dilaksanakan pada bulan juni 2015. variabel penelitian ini adalah penggambaran keadaan status gizi siswa sd miftakhul ulum surabaya. definisi operasional status gizi adalah gambaran keseimbangan antara kebutuhan akan zat gizi untuk pemeliharaan kehidupan, pemeliharaan fungsi normal tubuh dan untuk produksi energi satu pihak serta konsumsi zat gizi di lain pihak. pengukuran penelitian ini yaitu menggunakan antropometri tinggi badan dan berat badan. status gizi dapat ditentukan melalui pemeriksaan secara antropometri dengan indeks masa tubuh (imt), dengan pengukuran berat badan dengan novera herdiani, wiwik afridah, gambaran status gizi anak kelas vi di sekolah dasar miftakhul ulum surabaya 37 satuan kilogram (kg) dan pengukuran tinggi badan (tb) dengan satuan meter (m), dengan rumus sebagai berikut (depkes, 2011): berat badan (kg) imt = –––––––––––––––––––––––––––––––– tinggi badan (m) x tinggi badan (m) subjek dalam penelitian ini adalah seluruh siswa kelas vi sd miftakhul ulum surabaya yang berjumlah 81 anak. instrumen penelitian menggunakan pengukuran berat badan dan tinggi badan kemudian dikonsultasikan berdasarkan kategori perhitungan indeks berat badan menurut tinggi badan pada anak usia 6–17 tahun (depkes, 2011). teknik pengumpulan data menggunakan pengukuran antropometri yang meliputi pengukuran berat badan dan tinggi badan kemudian dihitung dengan berdasarkan perhitungan indeks berat badan menurut tinggi badan pada anak usia 6– 17 tahun kemudian diberikan penjelasan mengenai proses pelaksanaan pengukuran berat badan dan tinggi badan, kemudian anak-anak dipandu untuk melaksanakan pengukuran. penelitian ini menggunakan teknik analisis deskriptif persentase untuk mengetahui gambaran tentang status gizi dengan mengukur berat badan dengan satuan kilogram (kg) dan tinggi badan dengan satuan meter (m) kemudian dihitung dengan tabel berdasarkan penghitungan indeks berat badan menurut tinggi badan pada anak usia 5–18 tahun dengan merujuk dari departemen kesehatan republik indonesia tahun 2011. kemudian untuk menentukan status gizi menurut keputusan menteri kesehatan republik indonesia nomor: 1995/menkes/sk/ xii/2010 tentang standar antropometri penilaian status gizi anak kementerian kesehatan ri direktorat jenderal bina gizi dan kesehatan ibu dan anak direktorat bina dan gizi tahun 2011 dengan kriteria sebagai berikut. tabel 1 status gizi dan indeks (bb/u) indeks kategori status gizi ambang batas indeks massa tubuh menurut umur (imt/u) anak umur 5–18 tahun sangat kurus < -3sd kurus -3sd sampai dengan -2sd normal -2sd sampai dengan 1sd gemuk >1sd sampai dengan 2sd obesitas >2sd sumber: buku depkes, 2011 setelah data diperoleh selanjutnya data dianalisis untuk menarik kesimpulan dari penelitian yang telah dilakukan. untuk menganalisis data digunakan teknik analisis statistik dengan persentase, dengan rumus sebagai berikut. f x 100% p = ––––––––– n keterangan: p = persentase f = frekuensi n = jumlah seluruh siswa hasil berat badan anak kelas vi hasil analisis berat badan siswa menunjukkan bahwa berat badan subjek memiliki nilai minimal 21 kg dan maksimal 80 kg dengan rerata 39,69 kg, range (r) = 80 21 = 59. jumlah kelas (k) ditentukan sebanyak 6. oleh karena itu nilai interval (i) = r/k = 59/6 = 9,8. tabel 2 distribusi frekuensi berat badan anak kelas vi no. berat badan frekuensi persentase 1. 21–30 kg 15 18,50 2. 31–40 kg 38 46,90 3. 41–50 kg 15 18,50 4. 51–60 kg 6 7,40 5. 61–70 kg 6 7,40 6. 71–80 kg 1 1,30 total 81 100,00 medical and health science journal, vol. 2, no. 1, february 2018 38 berdasarkan tabel 2 menunjukkan bahwa sebagian besar anak kelas vi sd miftakhul ulum surabaya dengan berat badan antara 31– 40 kg memiliki frekuensi sebesar 38 anak (46,90%). adapun jumlah frekuensi terkecil adalah pada interval berat badan 71–80 kg dengan frekuensi 1 anak (1,30%). secara frekuensi data berat badan anak kelas vi dapat dilihat pada gambar 1 berikut. berdasarkan tabel 3 terlihat bahwa sebagian besar siswa memiliki tinggi badan di antara 130–140 cm dengan frekuensi sebesar 30 anak (37%). adapun jumlah frekuensi terkecil adalah pada interval tinggi badan 160–170 cm dengan frekuensi 5 anak (6,20%). secara grafik frekuensi data tinggi badan anak kelas vi dapat dilihat pada gambar 2 berikut. gambar 2 diagram batang tinggi badan anak kelas vi gambar 1 diagram batang berat badan anak kelas vi tinggi badan anak kelas vi hasil analisis tinggi badan siswa menunjukkan bahwa tinggi badan subjek memiliki nilai minimal 130 cm dan maksimal 170 cm dengan rerata 144,87 cm, range (r) = 170 130 = 40. jumlah kelas (k) ditentukan sebanyak 4. oleh karena itu nilai interval (i) = r/k = 40/4 = 10. tabel distribusi frekuensi tinggi badan siswa adalah sebagai berikut. tabel 3 distribusi frekuensi tinggi badan anak kelas vi no. tinggi badan frekuensi persentase 1. 130–140 cm 30 37,00 2. 140–150 cm 27 33,33 3. 150–160 cm 19 23,50 4. 160–170 cm 5 6,20 total 81 100,00 status gizi anak kelas vi hasil penelitian tentang status gizi anak kelas vi sd miftakhul ulum surabaya diketahui dengan pengukuran tinggi badan dan berat badan siswa. hasil pengukuran status gizi adalah sebagai berikut. tabel 4 status gizi anak kelas vi no. jenis kelamin kategori total bb rendah (sangat kurus dan kurus) bb normal (normal) bb berlebih (gemuk dan obesitas) n % n % n % n % 1. laki-laki 23 28,40 16 19,80 6 7,40 45 55,60 2. perempuan 23 28,40 10 12,30 3 3,70 36 44,40 total 46 56,80 26 32,10 9 11,10 81 100,00 berdasarkan tabel 4, terlihat bahwa status gizi anak kelas vi sd miftakhul ulum surabaya berada pada kategori berat badan rendah (sangat kurus dan kurus) dengan persentase 56,80%, berat badan normal (normal) 32,10%, dan berat badan berlebih (gemuk dan obesitas) 11,10%. pada siswa laki-laki maupun perempuan kategori novera herdiani, wiwik afridah, gambaran status gizi anak kelas vi di sekolah dasar miftakhul ulum surabaya 39 status gizi yang dominan adalah berat badan rendah (sangat kurus dan kurus) dengan persentase pada siswa laki-laki dan perempuan 28,40%. secara visual status gizi anak kelas vi adalah sebagai berikut. aturan dalam mengonsumsi sesuatu serta tidak lupa untuk senantiasa beraktivitas agar tidak terjadi penimbunan lemak. hasil analisis data jenis kelamin dengan penilaian bmi tabel 6 jenis kelamin dengan penilaian bmi gambar 3 diagram batang status gizi anak kelas vi hasil analisis data umur dengan penilaian bmi tabel 5 umur dengan penilaian bmi no. umur peserta penilaian bmi total bb rendah (sangat kurus dan kurus) bb normal (normal) bb berlebih (gemuk dan obesitas) n % n % n % n % 1. 11 tahun 18 58,10 11 35,50 2 6,50 31 100,00 2. 12 tahun 28 60,90 12 26,10 6 13,00 46 100,00 3. 13 tahun 0 0,00 2 66,70 1 33,30 3 100,00 4. 14 tahun 0 0,00 1 100,00 0 0,00 1 100,00 pearson chi-square signifikansi = 0,253 alfa (α) = 0,05 berdasarkan tabel 5 dapat diperoleh informasi bahwa umumnya semakin bertambahnya usia maka bmi anak tersebut akan memasuki kategori normal (100%). menjelang usia 13 dan 14 tahun, anak-anak tidak mengalami berat badan yang rendah (0%). dengan semakin bertambah usia, diharapkan anak-anak mampu memahami asupan yang dimakan. memperhatikan kandungan gizi yang dimakan serta aturanberdasarkan tabel 6 menunjukkan bahwa umumnya anak laki-laki lebih memiliki masalah pada status gizinya (51,105). anak laki-laki sering mengalami berat badan rendah dan juga mengalami berat badan berlebih daripada anak perempuan. lemak tubuh anak perempuan dan anak laki-laki berbeda. karena itu untuk anakanak tersedia dua grafik yang berbeda untuk perempuan dan laki-laki. bmi anak laki-laki pada masa pra-sekolah menurun dan sejalan dengan bertambahnya usia maka bmi-nya meningkat. pembahasan hasil penelitian menyimpulkan bahwa status gizi anak kelas vi sd miftakhul ulum surabaya adalah berat badan rendah (56,80%). hal ini berarti komposisi tubuh anak berdasarkan berat badan dan tinggi badan sebagian besar adalah sangat kurus dan kurus. faktor yang memengaruhi status gizi anak kelas vi sd miftakhul ulum surabaya sangat kompleks. faktor tersebut di antaranya faktor aktivitas fisik anak, no. jenis kelamin peserta penilaian bmi total bb rendah (sangat kurus dan kurus) bb normal (normal) bb berlebih (gemuk dan obesitas) n % n % n % n % 1. laki-laki 23 51,10 16 35,60 6 13,30 45 100,00 2. perempuan 23 63,90 10 27,80 3 8,30 36 100,00 pearson chi-square signifikansi = 0,496 alfa (α) = 0,05 medical and health science journal, vol. 2, no. 1, february 2018 40 gizi, faktor psikologis, dan faktor istirahat. secara keseluruhan status gizi anak kelas vi sd miftakhul ulum surabaya perlu mendapat perhatian. anak yang memiliki status gizi kurus dan sangat kurus ternyata adalah anak yang memiliki kecenderungan aktivitas fisik yang kurang. akibatnya otot-otot tubuh anak tidak berkembang dengan baik, sehingga komposisi tubuh pun menjadi tidak ideal (mathews, 2013). beberapa anak di sd juga memiliki status gizi yang gemuk dan obesitas. anak yang dalam kategori gemuk ternyata memiliki beberapa sebab. pertama dari faktor genetis ternyata orangtua mereka menderita obesitas. selain itu pola makan anak juga cenderung tidak terkontrol serta aktivitas fisik anak tersebut pun kurang memadai. akibatnya karbohidrat yang berada dalam tubuh disimpan menjadi lemak yang mengakibatkan ketidak seimbangan antara berat badan dengan tinggi badan anak (supariasa, dkk., 2002). suhardjo (2012) menyatakan bahwa kemampuan dan hasil belajar selain dipengaruhi oleh ketepatan dalam pemilihan bahan makanan yang kaya akan nutrisi dan kebiasaan diet, juga dipengaruhi status gizi berdasarkan indeks bb/ tb, bb/u, tb/u dan bmi. pemilihan nutrisi yang tepat dapat mengoptimalkan pertumbuhan dan perkembangan otak. rendahnya status gizi anak dapat membawa dampak negatif pada peningkatan kualitas sumber daya manusia. kekurangan gizi kronis berhubungan erat dengan pencapaian akademik murid sekolah yang semakin rendah. semakin bertambahnya usia maka bmi anak tersebut akan memasuki kategori normal. menjelang usia 13 dan 14 tahun, anak-anak tidak mengalami berat badan yang rendah. dengan semakin bertambah usia, diharapkan anakanak mampu memahami asupan yang dimakan. memperhatikan kandungan gizi yang dimakan serta aturan-aturan dalam mengonsumsi sesuatu serta tidak lupa untuk senantiasa beraktivitas agar tidak terjadi penimbunan lemak. sejalan dengan pertumbuhannya, maka lemak tubuh anak-anak berubah dari tahun ke tahun. interpretasi bmi tergantung kepada usia anak. bmi menurun selama masa pra-sekolah, lalu meningkat pada masa dewasa (gibson, rs. 2011). fase usia sekolah membutuhkan asupan makanan yang bergizi untuk menunjang masa pertumbuhan dan perkembangannya. selain untuk kebutuhan energi, asupan makanan yang bergizi juga memengaruhi perkembangan otak, apabila makanan tidak cukup mengandung zatzat gizi yang dibutuhkan, dan keadaan ini berlangsung lama, akan menyebabkan perubahan metabolisme otak (joko pekik irianto, 2006). anak yang kurang gizi mudah mengantuk dan kurang bergairah yang dapat mengganggu proses belajar di sekolah dan menurun prestasi belajarnya, daya pikir anak juga berkurang karena pertumbuhan otak tidak optimal (gibney, 2009). rendahnya status gizi jelas berdampak pada kualitas sumber daya manusia. oleh karena itu, status gizi merupakan faktor yang memberikan pengaruh cukup besar terhadap prestasi seseorang. gizi merupakan salah satu faktor penting dalam memberikan kontribusi terhadap kualitas sumber daya manusia (hadi, 2005). asupan gizi yang baik berperan penting dalam mencapai pertumbuhan badan yang optimal. pertumbuhan badan yang optimal ini mencakup pertumbuhan otak yang sangat menentukan kecerdasan seseorang. dampak akhir dari konsumsi gizi yang baik dan seimbang adalah meningkatnya kualitas sumber daya manusia (karyadi, 2006). keadaan status gizi dan indeks prestasi merupakan gambaran apa yang dikonsumsi anak sekolah dasar dalam jangka waktu yang lama, dapat berupa gizi kurang maupun gizi lebih. novera herdiani, wiwik afridah, gambaran status gizi anak kelas vi di sekolah dasar miftakhul ulum surabaya 41 zat-zat gizi seperti karbohidrat, protein, maupun zat gizi lainnya khususnya zat besi, dalam metabolisme tubuh berperan dalam proses berpikir atau proses penalaran serta daya konsentrasi dan sangat berkaitan erat dengan efisiensi belajar (karyadi, 2006). dengan keadaan status gizi yang baik diharapkan berdampak pada prestasi belajar yang baik pula pada anak. kesimpulan berdasarkan hasil penelitian yang telah dilakukan dapat disimpulkan sebagai berikut. 1. anak kelas vi sd miftakhul ulum surabaya dengan jumlah keseluruhan adalah 81 siswa/ siswi. sebagian besar memiliki tinggi badan 130–140 cm (37,00%), dan berat badan 31– 40 kg (46,90%). 2. berdasarkan penilaian bmi, status gizi anak kelas vi sd miftakhul ulum surabaya sebagian besar berada pada kategori berat badan rendah (sangat kurus dan kurus) dengan persentase 56,80%. sedangkan berat badan normal persentase 32,10%, dan berat badan berlebih (gemuk dan obesitas) dengan persentase 11,10%. 3. semakin bertambahnya usia maka bmi anak tersebut akan memasuki kategori normal. anak laki-laki lebih memiliki masalah pada status gizinya. anak laki-laki sering mengalami berat badan rendah dan juga mengalami berat badan berlebih daripada anak perempuan. bmi anak laki-laki pada masa prasekolah menurun dan sejalan dengan bertambahnya usia maka bmi-nya meningkat. saran 1. bagi orangtua agar meningkatkan asupan gizi anak serta mengatur waktu dengan keseimbangan antara aktivitas fisik, belajar, dan istirahat. 2. bagi guru agar berperan aktif untuk memberikan kesadaran tentang status gizi bagi siswa. 3. perlunya menyertakan variabel-variabel bebas yang lain agar diketahui variabel yang dominan dalam memengaruhi status gizi siswa. daftar rujukan badan penelitian dan pengembangan kesehatan kementerian kesehatan ri., (2013) riset kesehatan dasar (riskesdas) 2013. jakarta www.litbang.depkes.go.id/sites/download/rkd2013/laporan_riskesdas2013. pdf (sitasi 20 juli 2015). departemen kesehatan republik indonesia. 2011. pedoman penyuluhan gizi pada anak sekolah bagi petugas penyuluhan. jakarta: ditjen bina kesehatan masyarakat direktorat gizi masyarakat. departemen gizi dan kesehatan masyarakat. 2013. gizi dan kesehatan masyarakat. edisi 8. universitas indonesia. jakarta: rajawali pers. gibney, m. 2009. gizi kesehatan masyarakat. jakarta: egc. gibson rs. 2005. principles of nutritional assessment. new york: oxford university press. gibson, rs. 2011. handouts: using dietary reference values for evaluating nutrient adequacy for group. short course nutritional status assessment. jakarta: seameo-recfon universitas indonesia. hadi, h. 2005. beban ganda masalah dan implikasinya terhadap kebijakan pembangunan kesehatan nasional. tugas akhir gizi. universitas surakarta. ipriyona tri noli. 2011. hubungan kebiasaan makan dengan status gizi anak sd kelas medical and health science journal, vol. 2, no. 1, february 2018 42 vi di tiga sd swasta di kota palembang. skripsi. jurusan pendidikan dokter umum. fakultas kedokteran universitas sriwijaya. joko pekik irianto. 2006. pedoman gizi lengkap keluarga dan olahragawan. yogyakarta: penerbit andi. karyadi, d. 2006. kecukupan gizi yang dianjurkan. jakarta: gramedia pustaka utama. mathews. 2013. measurement in physical education philadelphia. london: wb sounders. suhardjo, clara m. kusharto. 2012. prinsipprinsip ilmu gizi. yogyakarta: kanisius. supariasa i dewa nyoman, bachyar bakri, ibnu fajar. 2002. penilaian status gizi. ed. 2. jakarta: egc. medical and health science journal, vol.3., no.2, august 2019 pengaruh pemberian jus buah belimbing wuluh (averrhoa bilimbi l.) terhadap kadar trigliserida darah tikus putih (rattus norvegicus) jantan galur wistar yang diberi diet tinggi lemak hilda fitri dwi fatichasari * fakultas kedokteran, universitas hang tuah, surabaya, indonesia *correspondent author: hildafitridwi@gmail.com article info abstrak article history: submitted: february,01 2019 received in revised form august 2019 accepted: august, 5 2019 latar belakang: hipertrigliseridemia merupakan suatu keadaan yang terjadi karena peningkatan kadar trigliserida ≥150 mg/dl. pencegahan hipertrigliseridemia sangat diperlukan secara non farmakologi dengan mengubah gaya hidup sehari – hari, apabila hal ini tidak berhasil dibutuhkan farmakoterapi menggunakan obat konvensional dan atau obat tradisional. salah satu obat tradisional yang secara empiris digunakan untuk menurunkan trigliserida adalah buah belimbing wuluh (averrhoa bilimbi l.). tujuan: tujuan penelitian untuk menilai efek pemberian jus buah belimbing wuluh terhadap kadar trigliserida tikus wistar jantan dengan diet tinggi lemak selama 28 hari. metode: desain penelitian eksperimental laboratorik. hewan coba 24 ekor tikus wistar jantan, dibagi secara acak kedalam 3 kelompok (n=8). kelompok kontrol negatif hanya diberikan pakan biasa. kelompok kontrol positif diberikan pakan tinggi lemak selama 28 hari. kelompok perlakuan diberikan pakan tinggi lemak 28 hari dan jus buah belimbing wuluh dengan dosis 4ml/200grbb pada hari ke 15 selama 14 hari. analisis data persentase penurunan kadar trigliserida menggunakan one-way anova, yang dilanjutkan uji post hoc dengan teknik lsd. hasil: pada kelompok kontrol negatif menunjukkan rerata kadar trigliserida sebesar 66,13 mg/dl. sedangkan pada kelompok kontrol positif, hasil penelitian menunjukkan adanya peningkatan rerata kadar trigliserida sebesar 96,13 mg/dl. pada data penelitian didapatkan nilai p = 0,048 (p < 0,05), sehingga dapat disimpulkan bahwa terdapat kenaikan kadar trigliserida yang bermakna. kenaikan ini menunjukkan bahwa diet tinggi lemak dapat meningkatkan kadar trigliserida darah. kesimpulan: jus buah belimbing wuluh dapat menurunkan kadar trigliserida namun tidak signifikan secara statistik. @2019 medical and health science journal. 10.33086/mhsj.v3i2.865 kata kunci: trigliserida, diet tinggi lemak, belimbing wuluh (averrhoa bilimbi l.) latar belakang atherosklerosis merupakan penyebab tersering dari penyakit jantung koroner (pjk). atherosklerosis sendiri adalah pembentukan plak akibat menumpuknya kolesterol pada dinding arteri sehingga menyebabkan penebalan dan pengerasan dinding arteri (robbins, 2013). faktor resiko dari pjk yaitu obesitas, kebiasaan merokok, kurangnya olahraga, hipertensi dan dislipidemia. dislipidemia merupakan kelainan metabolisme lipid, dimana biasanya ditandai dengan meningkat atau correspondence: hilda fitri dwi fatichasari @2019 medical and health science journal. 10.33086/mhsj.v3i2.865 available at http://journal2.unusa.ac.id/index.php/mhsj 1 original article mailto:hildafitridwi@gmail.com http://journal2.unusa.ac.id/index.php/mhsj medical and health science journal, vol.3., no.2, august 2019 menurunnya fraksi lipid dalam plasma darah. kelainan metabolisme lipid yang sering ditemukan adalah peningkatan kadar kolesterol, trigliserida, low density lipoprotein (ldl) dan penurunan high density lipoprotein (hdl). hipertrigliseridemia merupakan salah satu keadaan dislipidemia, dengan peningkatan kadar trigliserida >150 mg/dl1. trigliserida merupakan fraksi dari lipid dan komponen yang penting bagi tubuh. lebih dari 90 % jenis lemak pada makanan tersimpan dalam bentuk trigliserida. tingginya kadar trigliserida dalam darah, dapat menjadi salah satu penyebab tingginya angka kejadian penyakit kardiovaskular karena dapat mendorong peningkatan kadar ldl, trigliserida dalam jaringan akan dihidrolisis oleh enzim lipoprotein lipase. sisa hidrolisis kemudian dimetabolisme oleh hati menjadi kolesterol low density lipoprotein (ldl)2. badan kesehatan dunia (who) pada 20173mencatat sekitar 17,7 juta orang meninggal akibat penyakit kardiovaskular dan diperkirakan sekitar 7,4 juta orang meninggal akibat penyakit jantung koroner. salah satu langkah yang dapat dilakukan untuk mencegah penyakit jantung koroner yaitu dengan menurunkan kadar trigliserida, sehingga dapat menekan faktor resiko yang ada. modifikasi diet dan obat-obatan dapat dilakukan untuk menurunkan kadar trigliserida. salah satu cara untuk menangani masalah ini yaitu dengan menggunakan tumbuhan herbal sebagai obat tradisional. penggunaan obat tradisional dengan bahan yang alami sangatlah baik. selain mendapatkan manfaat yang sama dengan obat kimia, obat tradisional juga tidak mempunyai efek samping dan membutuhkan biaya yang murah. salah satu tumbuhan yang dapat digunakan untuk terapi yaitu belimbing wuluh. belimbing wuluh merupakan tanaman yang mudah didapatkan dan harga yang cukup murah. selain digunakan untuk bahan masakan, buah belimbing wuluh juga dapat digunakan untuk pengobatan. belimbing wuluh memiliki kandungan senyawa flavonoid, saponin, pektin dan vitamin c. kandungan ini membuat belimbing wuluh sering dipakai untuk obat untuk sariawan. buah belimbing wuluh juga dapat digunakan sebagai obat menurunkan tekanan darah tinggi, gusi berdarah, dislipidemia, jerawat dan batuk4. menurut data penelitian yang dilakukan anggoro dan astuti (2015)4, belimbing wuluh dengan dosis pada tikus 4 ml/200grbb per hari dapat menurunkan kadar kolesterol ldl. kadar trigliserida mengalami peningkatan setelah 14 hari pemberian pakan dengan diet tinggi lemak. penurunan kadar trigliserida dengan pemberian jus buah belimbing wuluh terjadi setelah 14 hari5. flavonoid dan saponin merupakan kandungan dalam belimbing wuluh yang berpengaruh dalam penurunan kadar kolesterol total, ldl dan trigliserida. namun kadar hdl tidak mengalami perubahan yang signifikan, berdasarkan hasil penelitian tersebut diatas, peneliti ingin meneliti pengaruh pemberian jus buah belimbing wuluh dalam menurunkan kadar trigliserida darah pada hewan coba yaitu tikus putih jantan galur wistar (rattus norvegicus) agar dapat menjadi sumber tambahan informasi bagi masyarakat dan kalangan medis, dimana penggunaan belimbing wuluh dapat menjadi obat alternatif untuk menurunkan kadar trigliserida. materi dan metode penelitian penelitian ini merupakan jenis penelitian eksperimental laboratoris secara in vivo pada hewan coba tikus putih (rattus norvegicus). penelitian ini menggunakan desain penelitian post-test only control group design. pad penelitian ini diuji dosis jus buah belimbing wuluh yang diharapkan dapat menurunkan kadar trigliserida. pada penelitian ini dibagi menjadi 3 kelompok (kelompok kontrol positif, kelompok kontrol negatif dan kelompok perlakuan) yang dipilih dengan cara random. penelitian dilaksanakan di laboratorium biokimia fakultas kedokteran universitas hang tuah 2 medical and health science journal, vol.3., no.2, agustus 2019 surabaya. sedangkan tahap pemeriksaan kadar trigliserida darah dilakukan di laboratorium biogen. variabel bebas penelitian ini adalah pemberian jus buah belimbing wuluh averrhoa bilimbi l. sedangkan variabel terikat penelitian ini adalah kadar trigliserida darah rattus norvegicus jantan. kadar trigliserida tikus yang diperiksa diklasifikasikan menjadi rendah (<26 mg/dl), normal (26-145 mg/dl), dan tinggi (>145 mg/dl). sampel yang digunakan adalah tikus galur wistar 6. tikus yang diujikan memiliki kriteria inklusi yaitu merupakan rattus norvegicus galur wistar, dengan jenis kelamin jantan, memiliki berat sekitar 180 – 260 gram, dan tikus dalam kondisi sehat ditandai dengan mata yang jernih, bulu mengkilat, dan feses baik atau tidak lembek), aktif dan tidak cacat. sampel akan dikeluarkan dari penelitian (drop out) apabila dalam masa penelitian hewan coba mati dan menderita penyakit lain, disamping yang disebabkan oleh perlakuan. berdasarkan rumus federer7 minimal jumlah sampel adalah 7,9 (dibulatkan menjadi 8). tikus akan dibagi dalam 3 kelompok sehingga total tikus yang dibutuhkan adalah 36 ekor dengan rincian pembagian kelompok yaitu: 1. kelompok kontrol negative (k(-)), 8 ekor rattus norvegicus diberi makan standar dan aquadest untuk minum per oral selama 28 hari dengan frekuensi pemberian 2x sehari (pagi dan sore). 2. kelompok kontrol positif (k(+)), 8 ekor rattus norvegicus diberi diet tinggi lemak dan aquadest untuk minum per oral selama 28 hari dengan frekuensi pemberian 2x sehari (pagi dan sore). 3. kelompok perlakuan (k(p)), 8 ekor rattus norvegicus diberi diet tinggi lemak dan aquadest untuk minum per oral selama 28 hari dengan frekuensi pemberian 2x sehari (pagi dan sore). kemudian diberikan jus buah belimbing wuluh (averrhoa bilimbi l.) dengan dosis 4ml/200grbb sekali sehari pada hari ke 15 selama 14 hari. sebelum dilakukan perlakuan tikus akan di aklimatisasi terlebih dahulu selama 7 hari. kelompok kontrol positif(k+) dan kelompok perlakuan(k-) akan diberikan diet tinggi lemak dengan cara menambahkan minyak babi pada makanan standar rattus norvegicus dengan penghitungan pellet : minyak babi = 900 gram : 900 ml. selanjutnya pakan disimpan dalam ruangan bersuhu kamar dan pembuatannya setiap minggu agar tetap dalam kondisi baik (tidak berbau, tidak berjamur dan tidak beracun). kelompok perlakuan(kp) akan diberikan jus belimbing wulu (averrhoa blimbi l.) menurut penelitian anggoro dan astuti (2015), jus belimbing wuluh dapat menurunkan kadar kolesterol darah tikus putih jantan galur wistar dengan dosis yang paling efektif adalah 4 ml/200grbb/hari. jus buah belimbing wuluh juga memiliki efek pada kadar trigliserida. pada hari ke-29 dilakukan pengambilan darah tikus. pengambilan darah berasal dari jantung tikus yang sebelumnya tikus dipuasakan selama 12 jam dan hanya diberi minum air saja. pemeriksaan kadar trigliserida menggunakan metode glycerol-3 phosphate oxidase – phenol aminophenazone (gpo-pap). metode ini menggunakan prinsip oksidasi dan hidrolisis enzimatis. setelah seluruh hewan coba diambil sampelnya, selanjutnya lakukan proses terminasi dengan eksanguinasi (memotong pembuluh darah besar seperti vena cava superior). kemudian sisa hewan coba lalu dibawa ke insinerator rsal untuk dimusnahkan. data dianalisis dan selanjutnya dilakukan uji normalitas menggunakan uji saphiro-wilk. apabila distribusi data normal, ketiga kelompok tersebut dibandingkan dengan menggunakan one-way anova. namun bila data tidak terdistribusib normal, maka menggunakan uji kruskal-wallis. data yang dibandingkan adalah kelompok kontrol negatif dan kelompok kontrol positif, kelompok kontrol positif dan kelompok perlakuan, serta kelompok kontrol negatif dan perlakuan. hasil penelitian deskriptif dan analisis data tabel 1. hasil pengamatan sampel 3 medical and health science journal, vol.3., no.2, august 2019 berdasarkan tabel 1, rerata dan standar deviasi kadar trigliserida pada kelompok kontrol negatif yang diberi pakan standar adalah 66,13 mg/dl dan 25,925 mg/dl. pada kelompok kontrol positif yang diberi diet tinggi lemak, rerata dan standar deviasi kadar trigliserida adalah 96,13 mg/dl dan 37,437 mg/dl. kemudian pada kelompok perlakuan yang diberi diet tinggi lemak dan jus buah belimbing wuluh (averrhoa bilimbi l), rerata dan standar deviasi kadar trigliserida adalah 88,38 mg/dl dan 32,592 mg/dl. kadar trigliserida pada masing-masing kelompok perlakuan dilakukan uji normalitas dengan menggunakan uji shapiro-wilk, dari table 1 diperoleh nilai signifikansi dari kelompok kontrol negatif sebesar p = 0,800 (p> 0,05), nilai signifikansi pada kelompok kontrol positif sebesar p = 0,475 (p> 0,05) dan nilai signifikansi kelompok perlakuan sebesar p = 0,149 (p> 0,05). berdasarkan hasil analisis pada tabel 1. menunjukkan signifikansi semua kelompok p > 0,05, sehingga dapat diambil kesimpulan bahwa data terdistribusi normal. selain uji normalitas, uji asumsi yang perlu dilakukan yaitu uji homogenitas. uji homogenitas dilakukan dengan uji levene’s. berdasarkan tabel 1 dapat diperoleh nilai signifikansi sebesar p = 0,314 (p > 0,05). karena nilai p > 0,05 maka dapat diambil kesimpulan bahwa varians data homogen. oleh karena variabel berskala numerik dengan distribusi normal dan varians data homogen maka untuk mengetahui apakah terdapat perbedaan yang bermakna antara kadar trigliserida kelompok kontrol negatif, kelompok kontrol positif dan kelompok perlakuan akan dilakukan uji one-way anova. pada uji hipotesis one-way anova diperoleh p = 0,181 (p > 0,05) . maka dapat diambil kesimpulan bahwa tidak terdapat perbedaan yang bermakna antara kelompok kontrol positif, kelompok kontrol negatif dan kelompok perlakuan. uji lanjutan lsd berdasarkan hasil uji anova diperoleh bahwa terdapat perbedaan rata-rata kadar tg pada 3 kelompok dalam penelitian. untuk mengetahui kelompok mana yang memiliki rata-rata kadar tg paling berbeda maka perlu dilanjutkan dengan menggunakan uji least significant differences (lsd). uji lsd dilakukan dengan membandingkan 2 kelompok berbeda. hasil pengujian dengan uji lanjutan lsd adalah sebagai berikut: tabel 2. uji lanjutan lsd uji komparasi perbandingan perbedaan rerata p-value keterangan k(-) vs k(+) -30,00 0,048 signifikan k(-) vs k(p) -22,25 0,123 tidak signifikan k(+) vs k(p) 7,75 0,607 tidak signifikan berdasarkan hasil uji post hoc pada kelompok kontrol negatif dan kelompok kontrol positif, didapatkan nilai signifikansi 0,048 (p < 0,05). sehingga pada hasil tersebut terdapat perbedaan yang bermakna antara kadar trigliserida kelompok kontrol negatif dan kelompok kontrol positif hewan coba. pada hasil uji post hoc pada kelompok kontrol negatif dan kelompok perlakuan, didapatkan nilai signifikansi sebesar 0,123 (p > 0,05). berdasarkan data signifikansi tersebut, didapatkan hipotesis bahwa tidak terdapat perbedaan yang bermakna antara kadar trigliserida kelompok kontrol negatif dan kelompok perlakuan hewan coba. hasil uji post hoc pada kelompok kontrol positif dan kelompok perlakuan menunjukkan nilai signifikansi sebesar 0,607 (p > 0,05). sehingga didapatkan hipotesis bahwa tidak terdapat perbedaan yang bermakna antara kadar trigliserida kelompok kontrol positif dan kelompok perlakuan hewan coba. 4 kelompok perlakuan hasil uji darah norma litas homo genitas p value n mean std. deviasi k(-) 8 66,13 25,925 0,800 k(+) 8 96,13 37,437 0,475 0,314 0,181 k(p) 8 88,38 32,592 0,149 medical and health science journal, vol.3., no.2, agustus 2019 diskusi hasil penelitian menunjukkan bahwa rerata kadar trigliserida pada kelompok kontrol negatif lebih rendah jika dibandingkan dengan kelompok kontrol positif dan perlakuan. hal ini disebabkan karena kandungan lemak pada pakan biasa lebih rendah dibandingkan dengan pakan yang sudah dicampur dengan minyak babi. menurut hasil penelitian yang telah dilakukan, pada kelompok kontrol negatif menunjukkan rerata kadar trigliserida sebesar 66,13 mg/dl. sedangkan pada kelompok kontrol positif, hasil penelitian menunjukkan adanya peningkatan rerata kadar trigliserida sebesar 96,13 mg/dl. pada data penelitian didapatkan nilai p = 0,048 (p < 0,05), sehingga dapat disimpulkan bahwa terdapat kenaikan kadar trigliserida yang bermakna. kenaikan ini menunjukkan bahwa diet tinggi lemak dapat meningkatkan kadar trigliserida darah. pemberian diet tinggi lemak ini, mengakibatkan meningkatnya lipoprotein yang memicu peningkatan kolesterol total, ldl dan trigliserida8,9. trigliserida merupakan lemak utama di dalam tubuh, dibentuk di hati dari gliserol dan lemak yang berasal dari makanan atau dari kelebihan kalori akibat makan berlebihan. trigliserida digunakan oleh tubuh untuk menyediakan energi yang nantinya akan berguna bagi berbagai proses metabolisme. sekitar 80 sampai 95 persen trigliserida disimpan dalam jaringan lemak. ketika tubuh membutuhkan energi, enzim lipase pada sel lemak akan diaktifkan oleh hormon sehingga memecah trigliserida menjadi asam lemak dan gliserol yang nantinya akan dilepaskan ke darah menuju ke jaringan yang aktif tempat oksidasi kedua zat untuk menghasilkan energi10. trigliserida dalam darah ditransportasikan melalui dua jalur yaitu jalur eksogen dan jalur endogen. pada jalur eksogen, trigliserida dalam usus dikemas dalam kilomikron. trigliserida dalam kilomikron tadi akan mengalami penguraian lanjutan yang dilakukan oleh enzim lipoprotein lipase sehingga akhirnya terbentuk asam lemak bebas dan kilomikron remnant. asam lemak bebas yang dihasilkan akan bergerak menembus jaringan otot dan jaringan lemak dibawah kulit, kemudian di jaringan tersebut asam lemak itu diubah kembali menjadi trigliserida yang berfungsi sebagai cadangan energi. kilomikron yang kehilangan sebagian trigliserida akan menjadi kilomikron remnant yang kemudian dibawa menuju ke hati. pada jalur endogen trigliserida ditransportasikan dalam bentuk lipoprotein yang bernama vldl. trigliserida di luar hati dan berada di dalam jaringan akan dihidrolisis oleh enzim lipoprotein lipase. sisa hidrolisis kemudian dimetabolisme oleh hati menjadi kolesterol ldl 2. kadar trigliserida meningkat disebabkan karena absorbi lemak yang berlebihan sehingga kilomikron yang bertanggung jawab untuk mengangkut lipid juga meningkat. kilomikron akan masuk ke pembuluh darah vena, kemudian dibawa ke hati untuk sintesis trigliserida. trigliserida bersama kolesterol, fosfolipid dan apob-100 akan dikemas menjadi vldl, yang kemudian disekresikan ke darah sehingga kadar trigliserida darah meningkat. trigliserida akan terhidrolisis menjadi asam lemak bebas dan gliserol oleh lipase peka hormon. gliserol yang dihasilkan tidak dapat digunakan, sehingga masuk ke dalam darah dan diserap serta digunakan di dalam jaringan. asam lemak bebas yang dilepaskan diambil oleh miosit dan adiposit, dioksidasi untuk menghasilkan energi atau diesterifikasi dan disimpan sebagai trigliserida. asam lemak diubah lagi menjadi asil-koa dengan bantuan asil-koa sintetase di jaringan adiposa. asil-koa ini nantinya bisa di re-esterifikasi lagi dengan gliserol 3-fosfat sehingga menghasilkan trigliserida11. hasil rerata kadar trigliserida kelompok kontrol positif yang diberi diet tinggi lemak adalah 96,13 mg/dl, sedangkan rerata kadar trigliserida kelompok perlakuan adalah 88,38 mg/dl. hasil analisis data menunjukkan terjadi penurunan rerata kadar trigliserida pada kelompok perlakuan, namun 5 medical and health science journal, vol.3., no.2, august 2019 tidak terjadi penurunan yang bermakna dengan p sebesar 0,607 (p > 0,05). . buah belimbing wuluh mengandung saponin dan flavonoid. saponin meningkatkan produksi dan sekresi empedu, meningkatkan partikel padat empedu untuk dikeluarkan dan juga melancarkan metabolisme lemak, sehingga absorpsi trigliserida terhambat. dengan dihambatnya absorpsi trigliserida dalam saluran pencernaan maka jumlah trigliserida yang masuk kedalam pembuluh darah menjadi berkurang dan trigliserida yang tidak terabsorpsi akan dikeluarkan bersama feses12. flavonoid berperan dalam meningkatkan aktivitas enzim lipoprotein lipase yang akan meningkatkan hidrolisis trigliserida menjadi asam lemak dan gliserol untuk dilepaskan ke pembuluh darah13. flavonoid juga menghambat aktivitas dari beberapa enzim lipogenik, seperti diasilgliserol asiltransferase (dgat), yang akan menghambat biosintesis trigliserida sehingga terjadi penurunan kadar trigliserida14. hasil penurunan yang tidak bermakna pada penelitian ini mungkin disebabkan oleh beberapa faktor, antara lain pemberian jus buah belimbing wuluh dengan durasi yang kurang dan dosis jus buah belimbing wuluh (averrhoa bilimbi l) yang kurang. dari segi hewan coba misalnya karena faktor genetik dan kurangnya aktivitas tikus9. faktor lain yang dapat mempengaruhi kadar trigliserida yaitu absorpsi jus pada tikus kurang maksimal15. kesimpulan pemberian diet tinggi lemak dapat meningkatkan kadar trigliserida tikus putih (rattus norvegicus) secara signifikan dengan p sebesar 0,048 (p < 0,05). dan pemberian jus buah belimbing wuluh (averrhoa bilimbi l.) pada tikus yang diberi diet tinggi lemak dengan dosis 4ml/200grbb/hari selama 14 hari menurunkan kadar trigliserida tapi tidak signifikan secara statistik dengan p sebesar 0,607 (p > 0,05). daftar pustaka 1. wulandari f. abstrak efek jus buah belimbing wuluh ( averrhoa bilimbi l .) terhadap kadar kolesterol total abstract the effects of bilimbi fruit juice ( averrhoa bilimbi l .) toward. j fak kedokt maranatha. 2012; 2. graha ck. kolesterol. jakarta: pt elex media komputindo; 2010. 3. world health organization. who cardiovascular diseases (cvds) fact sheet. who. 2017. 4. anggoro ds, astuti y. pengaruh pemberian jus belimbing wuluh ( averrhoa bilimbi l ) terhadap kadar hdl dan ldl-kolesterol pada tikus putih hiperkolesterolemia. mutiara med. 2015;15(2):89–95. 5. candra s, dk. k, widodo yla. pengaruh pemberian ekstrak buah belimbing wuluh (averrhoa bilimbi l.) terhadap penurunan kadar glukosa darah tikus wistar yang diinduksi aloksan. j kedokt diponegoro. 2012; 6. layal k. peran nrf2 dalam patogenesis stres oksidatif dan inflamasi pada penyakit ginjal kronik pendahuluan. 2016;7(1). 7. federer wt. experimental design: theory and application. oxford & ibh publishing company; 1967. 8. yuhud tri hapsari ack. pengaruh vitamin c terhadap kadar low density lipoprotein (ldl) lanjut usia setelah pemberian jus lidah buaya (aloe barbadensis miller). j nutr coll. 2014; 9. maulidina fa, kusumastuti ac. pengaruh pemberian vitamin c terhadap kadar trigliserida lanjut usia setelah pemberian jus lidah buaya ( aloe barbadensis miller). j nutr coll vol 3, no 4 oktober 2014 [internet]. 2014; available from: https://ejournal3.undip.ac.id/index.php/jnc/art icle/view/6866 10. guyton ac, hall je. textbook of medical physiology. textbook of medical physiology. 2006. 1011-1018 p. 11. murray rk. biokimia harper edisi 27. igarss 2014. 2014. 12. citrawidi ta, murningsih w, ismadi vdyb. pengaruh pemeraman ransum dengan sari daun pepaya terhadap kolesterol darah dan lemak total ayam broiler. anim agric j. 6 medical and health science journal, vol.3., no.2, agustus 2019 2012;1(1):529–40. 13. pramono a, kesuma su, tazkiana nh, yunita ra. pengaruh rebusan daun sukun ( artocarpus altilis ) terhadap kadar trigliserida , kolesterol total dan low density lipoprotein ( ldl ) serum darah tikus putih ( rattus norvegicus ) effect of leaf stew breadfruit (artocarpus altilis ) on triglyceride , tot. 2011;11(3):139–43. 14. mohebbi a, khaki z, asadi f, pourkabir m, modirsanei m. effect of mulberry (morus alba l.) leaves extract on the secretion and content of triglyceride in the chicken hepatocytes primary culture. int j pharmacol. 2007; 15. moore mc. terapi diet dan nutrisi. in: buku pedoman. 1997. 7 medical and health science journal, vol.3., no.1, februari 2019 original article the relationship of nutritional status to uric acid level in community of pondok pesantren al-hidayah, ngawi ,marselli widya lestari 1 , tri wahyuni bintarti 2 . 1,2 fakultas kedokteran universitas nahdlatul ulama surabaya, indonesia *correspondent author: marselli@unusa.ac.id article info article history: received 23 january 2019 received in revised form february 2019 accepted 4 february 2019 abstract gout or gouty arthritis is a degenerative disease. gouty arthritis is a clinical syndrome that is caused by deposition of purine crystals in the tissues, due to levels of uric acid (hyperuricemia) in the extracellular fluid that passes through saturation. the etiology of gout arthritis included age, sex, history of medication, obesity, consumption of purine and alcohol. aging is an important risk factor for men and women. this study uses an analytical-descriptive approach with cross-sectional design. this study was conducted to obtain a relationship between nutritional status and uric acid levels in the community in the area of al-hidayah islamic boarding school, ngawi. this research was keywords: nutritional status, uric acid, gout risk factor. conducted in majasem village, kendal district, ngawi regency, starting from 7 june 31 august 2018. the results showed that there was a relationship between nutritional status and uric acid levels in the community in the area of al-hidayah islamic boarding school, ngawi (p=0,008). suggestions for further research are bivariate analysis based on gender, knowledge and attitude to response to diet so that other factors that influence can be seen clearly. @2019 medical and health science journal. 10.33086/mhsj.v3i1.925 pendahuluan life expansion of life expectancy (uhh) is one indicator of the success of development in the health and welfare of the population. this has an impact on the increasing number of elderly people (elderly). based on the 2013 united nations report, uhh in 2013 was 71 years (with a percentage of the elderly population reaching 12%) (united nations, 2013). the phenomenon of an increase in the number of elderly population is caused by a decrease in population fertility, improvement in health status due to technological advances and medical research, improvement in nutritional status which is marked by an increase in cases of obesity in elderly than underweight, to epidemiological transition from infectious diseases to degenerative diseases ( fatmah 2010). risk factors that are very closely related to this degenerative disease are lifestyle, including excess weight (obesity). national central obesity prevalence is 18.8%, where there is still a tendency to remain high when entering the elderly at 23.1% (age group 55-64), 18.9% (age group 65-74) and 15.8% (group 75 years and over) (who, 2012). the indonesian ministry of health (2012) explains that excess nutrition in the elderly is usually associated with lifestyle and excessive consumption patterns from a young age even since children. in addition, the decreased metabolic process in the elderly if it is not balanced with an increase in physical activity or a decrease in the amount of food causes excess calories to be converted into fat causing obesity. this shows that overweight and obesity must also remain a concern correspondence: marselli widya lestari @2019 medical and health science journal. 10.33086/mhsj.v3i1.925 available at http://journal2.unusa.ac.id/index.php/mhsj 41 mailto:marselli@unusa.ac.id http://journal2.unusa.ac.id/index.php/mhsj medical and health science journal, vol.3., no.1, februari 2019 because it can spur the onset of degenerative diseases, especially gout. gout or gouty arthritis is a degenerative disease. gouty arthritis is a clinical syndrome that is caused by deposition of purine crystals in tissues, due to levels of uric acid (hyperuricemia) in the extracellular fluid that passes through saturation (tehupeiory, 2012). the etiology of gout arthritis included age, sex, history of medication, obesity, consumption of purine and alcohol. aging is an important risk factor for men and women. this is likely due to many factors (tehupeiory, 2012). gout arthritis (gout) is a disease that is commonly found in men between 30-40 years of age, whereas in women aged 55-70 years, the incidence of women is rare except after menopause (tjokroprawiro, 2007 in lumunon, 2015). in indonesia, gout arthritis ranks second after osteoarthritis (dalimartha, 2008), the prevalence in indonesia alone is estimated at 1.6-13.6 / 100,000 people, this prevalence increases with age (tjokroprawiro, 2007). kendal sub-district area is a sub-district located in ngawi district, east java. kendal sub district area is 84.56 km2 with a population in 2016 of 44,376 people. population of kendal subdistrict based on age is controlled by the age range of 45 49 years, while the age above 60 years is 7,539 people (bps ngawi, 2017). with this data, the population of kendal, ngawi, is the age distribution of the population (old adults and elderly) is quite a lot so it is prone to degenerative diseases (gout). based on the description in the background of the problem above provides the basis for researchers to formulate the research questions as follows: what is the relationship between nutritional status and uric acid levels in the community in the al-hidayah islamic boarding school, ngawi?. methods this study uses an analytical-descriptive approach with cross-sectional design. this study was conducted to obtain a relationship between nutritional status and uric acid levels in the community in the area of al-hidayah islamic boarding school, ngawi. this research was conducted in majasem village, kendal district, ngawi regency, starting from 7 june 31 august 2018. sampling done by accidental sampling method. with this method the researcher will record every citizen who came / met when the research took place. if the inclusion criteria are included, the residents are entered into the study. the data will be processed with spss.17, univariate analysis to see the proportion between nutritional status and uric acid levels and presented in the frequency distribution table. furthermore, the data was processed with bivariate regression correlation analysis to determine the relationship between nutritional status and uric acid levels and presented with tables. results and discussion the study was conducted cross-sectionally at al-hidayah islamic boarding school, kendal, ngawi on june 24, 2018 at 09.00. characteristics of respondents can be seen in table 4.1. respondents who attended were mostly female, namely 64.4%. the average respondent present was the elderly (mean = 49) with a dominance of 42.2% of the age group 26-45. in the second place as many as 31.1% are the age group 56-65. the characteristics based on the latest education are dominated by elementary school graduates, namely 21 people with a percentage of 46.7%. in line with his latest education, almost 50% of livelihoods are farmers. 42 medical and health science journal, vol.3., no.1, februari 2019 table 4.1. karakteristik responden no karakteristik responden frekuensi (n=45) persentase 1 jenis kelamin perempuan 29 64.4 laki-laki 16 35.6 2 usia 17-25 3 6.7 26-45 19 42.2 46-55 3 6.7 56-65 14 31.1 >65 6 13.3 3 pendidikan terakhir s1 9 20 s2 1 2.2 sd 21 46.7 sma 3 6.7 smp 5 11.1 tidak sekolah 6 13.3 4 pekerjaan buruh 1 2.2 guru 7 15.6 irt 4 8.9 mahasiswa 1 2.2 pelajar 1 2.2 petani 22 48.9 swasta 6 13.3 wiraswasta 2 4.4 tidak bekerja 1 2.2 in univariate nutritional status analysis (table 4.2) only 35.6% had normal bmi. 55.6% have nutritional status above normal, 7 of them are overweight and 40 are obese. this proportion tabel 4.2 univariat satus gizi berdasarkan klasifikasi imt frekuensi corresponds to the age distribution of many klasifikasi imt (n=45) persentase respondents from the 56-65 age group. according to who (2012), national obesity prevalence at the national level is 18.8%, where there is still a tendency to remain high when entering the elderly at 23.1% (age group 55-64), 18.9% (age group 65 74) and 15.8% (group 75 years and over). 1 underweigth 4 8.9 2 normal 16 35.6 3 overweight 7 15.6 4 obese 18 40.0 total 45 100.0 43 medical and health science journal, vol.3., no.1, februari 2019 tabel 4.3 univariat kadar asam urat significance of p = 0.008 which meant that there kadar asam urat frekuensi (n=45) persenta se was a relationship between nutritional status and uric acid levels. this has been conveyed in budiono's 1 normal 36 80.0 2 tinggi 9 20.0 total 45 100.0 more weight and obesity can trigger degenerative diseases, especially gout. however, in the univariate analysis of uric acid levels (table 4.3) it was seen at a glance that respondents who had high uric acid levels were only 9 people or 20% of the total while the other 80% were normal. the results of research on nutritional status and uric acid levels of 45 respondents showed that respondents with normal nutritional status and underweight were safe from high levels of uric acid (table 4.4). while respondents with overweight nutritional status had 1 to 7 people, with high uric acid levels. this figure is increased in obese imt (> 25kg / m2) that is 8/18 or 44% have high uric acid levels. the data was reprocessed using the chi-square calculation (table 4.5) and obtained a research (2016) which states that the proportion of high levels of uric acid increases in respondents with high bmi. likewise explained in the study by lumunon (2015) in manado, who took samples from elderly poly, that in the study there was a relationship between nutritional status and gout arthritis in the elderly in the work area of manado wawonasa health center. factors that cause gouty arthritis proposed by indriawan, 2009, one of them is diet, intake that enters the body also affects the level of uric acid in the blood. in this study also dominated by women (64.4%) so that a little more influence on the results of the study. the amount of food high in purine consumed will increase the risk of gout in elderly women who in fact have decreased immunity due to estrogen which is no longer produced and decreased metabolic power increases the risk of gout according to theory (sylvia, 2006). tabel 4.4 crosstabulation antara klasifikasi imt dan kadar asam urat kadar asam urat normal tinggi total klasifikasi imt underweigth 4 0 4 normal 16 0 16 overweight 6 1 7 obese 10 8 18 total 36 9 45 tabel 4.5 chi-square tests monte carlo sig. (2 sided) monte carlo sig. (1 sided) asymp. 95% confidence interval 95% confidence interval value df sig. (2 sided) lower upper sig. bound bound lower upper sig. bound bound 44 medical and health science journal, vol.3., no.1, februari 2019 pearson chi-square 11.865 a 3 0.008 .010 b 0.004 0.016 likelihood 14.564 3 0.002 .005 b 0.001 0.009 ratio fisher's 10.736 .013 b 0.006 0.02 exact test linear-by 10.513 c 1 0.001 .001 b 0 0.003 .000 b 0 0.003 linear association n of valid 45 cases a. 5 cells (62,5%) have expected count less than 5. the minimum expected count is ,80. b. based on 1000 sampled tables with starting seed 926214481. c. the standardized statistic is 3,242. conflicts of interest he author stated there is no conflict of interest. daftar pustaka 1. badan pusat statistik kabupaten ngawi. 2017.kabupaten ngawi dalam angka 2017: katalog bps 1102001.3521. 2. badan pusat statistik kabupaten ngawi. 2017.kecamatan kendal dalam angka 2017: katalog bps 1102001.3521. 3. badan pusat statistik. (2013). statistik penduduk lanjut usia 2013. jakarta: badan pusat statistik. 4. carter, m.a 2006. buku ajar patofisiologi. egc 206-237. jakarta. 5. departemen kesehatan. (2007). riset kesehatan dasar (prevalensi obesitas sentral diatas umur 15 tahun). diperoleh dari: http://www.litbang.depkes.go.id.[diakses: 8 agustus 2015]. 6. fao/who/unu. (2001). “human energy requirements.” who technical report series, no. 724. geneva: world health organization. 7. fatmah (2010). gizi usia lanjut. jakarta: penerbit erlangga. 8. gibson rs. (2005). “principles of nutritional assessment. 2 nd ed.” new york: oxford university press. 9. hardinsyah, hadi riyadidan victor napitupulu. (2012). kecukupan energi, protein, lemak dan karbohidrat. bogor: departemen gizi fema ipb. 10. kementriankesehatanrepublik indonesia. (2012). pedomanpelayanangizilanjutusia. jakarta: kementriankesehatan ri. 11. nasrul, e dan sofitri. 2012. hiperurisemia pada pra diabetes. jurnal kesehatan andalas 1(2). diakses : pada tanggal 24 april 2016. http://jurnal.fk.unand.ac.id. 12. rau e, jeffrey o, vantje k. 2015. perbandingan kadar asam urat pada subyek obes dan non-obese di fakultas kedokteran universitas sam ratulangi manado. jurnal e clinic (ecl). diakses : pada tanggal 24 juli 2016. http://ejournal.unsrat.ac.id/index/php/eclinic/ar ticle/view/8436/8014. 13. setiani, yuli. (2011). hubungan antara status gizi dan stres dengan kemampuan activity daily of living pada lanjut usia di wilayah kerja posyandu lansia puskesmas sumbersari kabupaten jember. 14. singh v, gomez yv and swamy sg. 2010. approach to a case of hyperuricemia. ind j aerospace med 54 (1), 2010. 15. tehupeiory, es 2006, artritis gout dalam buku ajarilmu penyakit dalam, fkui, jakarta pp. 1208-1210. 45 http://www.litbang.depkes.go.id/ http://jurnal.fk.unand.ac.id/ http://ejournal.unsrat.ac.id/index/php/eclinic/ar medical and health science journal, vol.3., no.1, februari 2019 46 medical and health science journal, vol.3., no.2, august 2019 pengaruh pemberian jus buah apel manalagi (malus sylvestris) terhadap kadar trigliserida darah tikus putih (rattus norvegicus) jantan galur wistar yang diberi diet tinggi lemak reni rabiatul rahmat 1* , bambang suyono 2 , risma 3 1,2,3 fakultas kedokteran universitas hang tuah *correspondent author : renirahmat131196@gmail.com article info abstract article history: submitted: february 01 2019 received in revised form august 2019 accepted: august 12 2019 background: manalagi apples (malus sylvestris) have long been believed to have the effect of lowering blood cholesterol levels. where the main content is quercetin class of flavonoids as antioxidants and pectin which functions as fat absorption. methods: this study was an experimental study with a randomized post test only control group design study conducted for 28 days and using 30 rats divided into 3 groups. results: in all groups given a high fat diet with treatment, control (-) was given a high fat diet, control (+) was given simvastatin and kp1 was given manalagi apple juice (malus sylvestris) dose of 10 ml/day. one-way anova test results from measurements of triglyceride levels showed p = 0.139 (p> 0.05) so that manalagi apple juice (malus sylvestris) did not significantly affect blood triglyceride levels of male wistar strains (rattus norvegicus) given high fat diet. conclusion: the administration of skin juice and flesh of manalagi apple (malus sylvestris) can reduce the blood triglyceride levels of male rats (rattus norvegicus) wistar strain had been given a high-fat diet before, but it was not statistically significant. keywords: apple fruit juice, triglycerides, high fat diet @2019 medical and health science journal. 10.33086/mhsj.v3i2.866 pendahuluan seiring dengan perkembangan zaman serta meningkatnya tingkat kesibukan setiap individu mengakibatkan berkurangnya waktu untuk mempersiapkan serta mengontrol makanan yang dikonsumsi. hal ini menjadikan makanan cepat saji menjadi pilihan utama untuk memenuhi kebutuhan asupan makanan sehari – hari. makanan cepat saji biasanya mengandung lemak yang tinggi, kurang vitamin dan serat. tetapi, hal ini seringkali diabaikan oleh sebagian orang. konsumsi makanan tinggi lemak ini dapat menyebabkan berbagai penyakit, seperti obesitas, resistensi insulin, hiperglikemia, abnormalitas lipid seperti peningkatan kadar trigliserida darah dan penurunan kolesterol lipoprotein berdensitas tinggi (hdl) di darah dan hipertensi. dan yang paling di hindari adalah penyakit kardiovaskular, yang meliputi serangan jantung, stroke, aterosklerosis dan kerusakan berbagai organ di seluruh tubuh.1 penyakit kardiovaskular merupakan salah satu penyebab kematian terbesar di seluruh dunia. pada tahun 2015 penyakit ini menyebabkan sekitar 17,7 juta kematian2. selain itu, sebanyak 2.200 orang amerika meninggal setiap harinya akibat penyakit kardiovaskular, dengan rata-rata 1 kematian terjadi setiap 40 detik. diperkirakan 7,1 juta orang amerika telah mengalami serangan jantung selama masa hidup mereka. lebih dari 7 % orang amerika memiliki beberapa jenis penyakit kardiovaskular, dan 1 dari setiap 6 kematian di amerika serikat adalah karena penyakit jantung koroner3. faktor risiko perilaku yang paling penting dari penyakit kardiovaskular dan stroke adalah diet correspondence: ary andini, endah prayekti @2019 medical and health science journal. 10.33086/mhsj.v3i2.866 available at http://journal2.unusa.ac.id/index.php/mhsj 12 original article mailto:renirahmat131196@gmail.com http://journal2.unusa.ac.id/index.php/mhsj medical and health science journal, vol.3., no.2, august 2019 yang tidak sehat, aktivitas fisik yang kurang, penggunaan tembakau dan penggunaan alkohol yang berlebihan. efek dari faktor risiko perilaku tersebut antara lain peningkatan tekanan darah, peningkatan glukosa darah, peningkatan lipid darah, dan kelebihan berat badan serta obesitas4. efek yang paling sering terjadi adalah peningkatan lipid darah (hiperlipidemia). hiperlipidemia adalah keadaan saat peningkatan kolesterol atau trigliserida serum di atas batas normal. kolesterol adalah lipid (lemak) yang diproduksi oleh hati dan sangat penting untuk fungsi normal tubuh. kolesterol merupakan lipid penting yang ditemukan dalam darah manusia. namun, ketika berlebihan dapat menyebabkan masalah kesehatan seperti aterosklerosis yang mengakibatkan infark miokard5. oleh sebab itu diperlukan tindakan dalam menurunkan maupun pencegahan peningkatan kolesterol berlebih karena dapat menyebabkan penyakit kardiovaskular. dan menurut who, salah satu cara yang dapat menurunkan resiko penyakit kardiovaskular adalah mengkonsumsi buah dan sayuran4. salah satunya adalah buah apel manalagi (malus sylvestris) telah lama dipercaya memiliki khasiat menurunkan kadar kolesterol darah. beberapa senyawa fitokimia yang ada pada buah apel dan berfungsi sebagai antioksidan adalah golongan flavonoid. selain itu, apel mengandung betakaroten yang berfungsi sebagai provitamin a untuk mencegah serangan radikal bebas5. kandungan apel berupa zat yang berguna bagi tubuh manusia diantaranya pektin (sejenis serat), quersetin (bahan anti kanker dan anti radang) serta vitamin c yang tinggi merupakan sebagian alasan mengapa ahli gizi sangat menganjurkan masyarakat untuk mengkonsumsi buah apel secara teratur. beberapa persoalan kesehatan seperti susah buang air besar, obesitas, kolesterol tinggi, arthritis dan lainnya dapat diatasi dengan terapi buah apel. kandungan anti oksidan yang sangat tinggi juga menjadi alasan tingginya konsumsi buah apel oleh masyarakat sebagai upaya pencegahan terhadap penyakit dan disfungsi kesehatan tubuh lainnya6. (baskara, 2010). berdasarkan hal tersebut, peneliti ingin melakukan penelitian lebih lanjut tentang pengaruh pemberian jus buah apel manalagi(malus sylvestris) terhadap kadar trigliserida darah tikus putih (rattus norvegicus)jantan galur wistar yang diberi diet tinggi lemak. metode penelitian jenis dan rancangan penelitian penelitian ini merupakan penelitian jenis eksperimental laboratoris dengan menggunakan rancangan penelitian randomized post test only control group design (zainuddin, 2000). tempat dan waktu penelitian penelitian ini dilakukan di laboratorium biokimia fakultas kedokteran universitas hang tuah. tempat pembuatan sediaan dari buah apel (malus sylvestris) dilakukan di laboratorium biokimia fakultas kedokteran hang tuah surabaya. analisis sampel darah dilakukan di laboratorium biokimia fakultas kdokteran universitas hang tuah. waktu penelitian dilakukan bulan maret 2018 – oktober 2018. alat dan bahan penelitian alat penelitian alat – alat yang digunakan pada penelitian meliputi timbangan analitik, gelas becker, pengaduk stiler, sonde oral (pediatric feeding tube size 8), mortar dan pestie, kapas, gunting bedah, pinset, pisau, spuit 3 ml, sample container, sentrifuge. bahan penelitian bahan – bahan yang digunakan pada penelitian ini, yaitu kulit beserta daging buah apel manalagi (malus sylvestris), simvastatin, pelet, aquades, pakan hiperkolestrolemik, ketamin. pembuatan jus buah apel manalagi (malus sylvestris) pembuatan jus buah apel (malus sylvestris) dilakukan di laboratorium biokimia fakultas kedokteran hang tuah surabaya. dimana 1 buah apel malus sylvestris dicuci bersih terlebih dahulu, kemudian dipotong menjadi potongan potongan 13 medical and health science journal, vol.3., no.2, agustus 2019 kecil tanpa harus mengupas kulitnya. selanjutnya, buah apel dimasukan kedalam juicer tanpa penambahan air atau bahan lainnya. hasil juicer kemudian di saring untuk memisahkan sari buah dan ampas buah apel. dari 1 buah apel manalagi ini didapatkan 50 ml jus, yang kemudian diberikan pada tikus secara oral dalam dosis 5 ml pada pagi hari. dan untuk dosis 5 ml sorenya diberikan hasil juicer buah apel manalagi yang baru. pembuatan larutan simvastatin untuk menentukan dosis simvastatin yang akan diberikan pada hewan coba adalah dengan perhitungan yang telah dikonversikan dari dosis yang biasa digunakan oleh manusia. pada manusia, dosis maksimum simvastatin adalah 40 mg/hari (1 tablet = 10 mg), dan dosis rata – rata yang digunakan adalah 5 – 10 mg (katzung, 2007). dosis yang digunakan dalam penelitian ini adalah 10 mg yang merupakan konversi dosis dari manusia dengan berat 70 kg ke tikus 200 g adalah 0,018. dosis untuk manusia = 10 mg maka dosis untuk tikus adalah = 10 mg x 0,018 = 0,18 mg/200 g bb tikus = 0,09 mg/100 g bb tikus jadi, pemberian simvastatin adalah 0,09 mg/100 gram bb tikus setiap hari melalui sonde lambung. pembuatan larutan cmc-na 1% larutan cmc-na 1% digunakan sebagai pelarut obat simvastatin. cara pembuatannya yaitu dengan cara melarutkan 1 gram cmc-na dalam 50 ml air panas (70oc) sedikit demi sedikit, kemudian diaduk perlahan-lahan dengan menggunakan batang pengaduk hingga terbentuk larutan koloidal yang homogen. tambahkan aquades hingga 100 ml dalam labu ukur 100 ml hasil penelitian penelitian ini dilakukan selama 28 hari di laboratorium biokimia fakultas kedokteran universitas hang tuah surabaya. penelitian ini menggunakan 30 ekor tikus putih (rattus norvegicus) jantan galur wistar berumur 10 12 minggu yang dibagi dalam 3 kelompok : kelompok hewan coba yang diberi diet tinggi lemak, kelompok hewan coba yang diberi diet tinggi lemak dan simvastatin, dan kelompok hewan coba yang diberi diet tinggi lemak dan jus buah apel (malus sylvestris) dosis 10 ml. kadar trigliserida kelompok hewan coba k (-), k(+) , dan kp1 dapat dilihat pada tabel 1. tabel 1 hasil pengukuran kadar trigliserida darah tikus putih (rattus norvegicus) (mg/dl) no. k (-) (mg/dl) k (+) (mg/dl) kp1 (mg/dl) 1. 106 70 55 2. 86 55 97 3. 47 35 23 4. 55 102 167 5. 90 37 60 6. 45 67 53 7. 97 49 119 8. 179 24 30 9. 117 40 rata rata 91,33 53,22 75,5 pada hari ke 28, rata – rata kadar trigliserida tertinggi terjadi pada kelompok kontrol (-) yang diberi diet tinggi lemak dengan nilai 91,33 mg/dl. hal ini menunjukan telah terjadi peningkatan kadar kolesterol pada hewan coba. kemudian pada kelompok kontrol (+) dan kp1 menunjukan terjadi penurunan kadar triglieserida dengan rata – rata 53,22 mg/dl dan 75,5 mg/dl. berdasarkan uji homogenitas levene variances didapatkan hasil bahwa data memiliki populasi homogen dengan nilai signifikansi p > 0,05. karena data memiliki distribusi normal dan populasi yang homogen maka dilanjutkan dengan uji parametric one way anova. uji anova terhadap kadar trigliserida serum semua kelompok perlakuan dibandingkan kelompok kontrol diperoleh nilai signifikansi p = 0,139 atau tidak terdapat perbedaan bermakna (p > 0,05). pembahasan penelitian eksperimental ini dilaksanakan di laboratorium hewan coba fakultas kedokteran universitas hang tuah surabaya. sampel yang digunakan adalah tikus putih (rattus norvegicus) jantan galur wistar yang berumur sekitar 2 bulan, 14 medical and health science journal, vol.3., no.2, august 2019 sehat dengan berat badan 120 – 160 sebanyak 30 ekor. tujuan akhir dari penelitian ini adalah untuk mengetahui pengaruh pemberian jus buah apel (malus sylvestris) terhadap kadar trigliserida tikus putih (rattus norvegicus) jantan galur wistar yang diberi diet tinggi lemak. jumlah kelompok yang digunakan adalah tiga kelompok yang terdiri dari kelompok pemberian diet tinggi lemak, kelompok pemberian diet tinggi lemak dan simvastatin, dan kelompok pemberian diet tinggi lemak dan jus buah apel (malus sylvestris) dengan dosis 10 ml (5 ml pagi dan 5 ml sore hari). pada penelitian ini dilakukan pemberian diet tinggi lemak selama 28 hari, dimana sebelumnya diadaptasikan selama 7 hari. selama proses adaptasi ini terdapat 1 ekor tikus mati pada kelompok perlakuan diet tinggi lemak dan kelompok perlakuan simvastatin, sedangkan pada kelompok perlakuan jus buah apel tikus mati sebanyak 2 ekor. pemberian diet tinggi lemak ini dimaksudkan untuk meningkatkan kadar trigliserida pada semua kelompok. dan pada hari ke-18 hewan coba diberikan perlakuan simvastatin dan jus buah apel (malus sylvestris) selama 10 hari, kemudian dinilai kelompok yang berpengaruh terhadap kadar trigliserida tikus putih jantan (ratuss norvegicus). peningkatan kadar trigliserida ini terjadi karena peningkatan simpanan lemak (trigliserida) baik pada tingkat intrasel dan ekstrasel. pemberian pakan tinggi lemak juga menyebabkan peningkatan kadar kolesterol total, ldl, trigliserida, dan penurunan kadar hdl6. trigliserida yang dihasilkan dari makanan akan diemulsikan terlebih dahulu oleh asam empedu kemudian baru diserap oleh usus halus. terdapat 2 enzim di pankreas yaitu lipase dan fosfolipase a2. enzim lipase bertugas dalam menghidrolisis trigliserida menjadi 1,2-digliserida dan 2-gliserida, sedangkan enzim fosfolipase a2 akan menghidrolisis fosfolipid menjadi lemak dan lysofosfolipid 7. kemudian semua produk yang dihasilkan ini akan diangkut ke sel epitel usus dan trigliserida akan disintesis kembali. trigliserida bersama dengan protein, fosfolipid, dan kolesterol ester akan bergabung membentuk kilomikron. dan trigliserida dalam kilomikron ini akan dihidrolisis oleh enzim lipoprotein lipase menjadi asam lemak dan gliserol. asam lemak akan memasuki sel – sel jaringan, sebagian diubah menjadi energi dan sebagiannya lagi dioksidasi menjadi asetil-koa yang merupakan prekursor pembentuk kolesterol. proses hidrolisis (lipolysis) paling banyak terjadi pada jaringan adiposa yang disertai dengan pelepasan asam lemak yang ditemukan bergabung dengan albumin serum8. pada semua kelompok juga dilakukan pemberian larutan cmc-na 1% (natrium carboxymethyl cellulose) yang diberikan pada pagi hari untuk mencegah perut tikus kembung selama 28 hari. selain itu pemberian jus kulit dan daging buah apel (malus sylvestris) pada kelompok perlakuan dengan dosis 10 ml dengan cara pemberian 5 ml pagi dan 5 ml sore) selama 10 hari yang bertujuan untuk menurunkan kadar trigliserida pada tikus putih. jus kulit dan daging buah apel ini mengandung flavonoid dan pektin. pektin ini di kenal sebagai antikolesterol karena dapat mengikat asam empedu yang merupakan hasil akhir metabolisme kolesterol, makin banyak asam empedu yang berikatan dengan pektin dan terbuang keseluruh tubuh makin banyak kolesterol yang di metabolisme, sehingga pada akhirnya kolesterol menurun jumlahnya. apel juga berfungsi mengontrol keluarnya insulin sehingga tidak berlebihan. karena itu, konsumsi apel secara teratur dapat menjaga keseimbangan gula darah, menurunkan kolesterol darah dan juga menurunkan tekanan darah. kulit apel juga mengandung flavonoid yang disebut quercetin, dimana quercetin dapat mencegah proses terjadinya oksidasi dari ldl dengan cara menangkap radikal bebas dan meningkatkan aktivitas dari lpl sehingga trigliserida yang berlebih dapat dipecah dan masuk ke jaringan. selain itu juga terdapat kandungan vitamin b3 yang dapat menurunkan produksi vldl di hati sehingga produksi kolesterol total, ldl, trigliserida menurun. pada hari ke 28 pemberian perlakuan pada setiap kelompok kontrol positif, kelompok perlakuan diet tinggi lemak dan simvastatin serta kelompok perlakuan diet tinggi lemak dan jus buah apel (malus sylvestris) dengan dosis 10 mg/dl 15 medical and health science journal, vol.3., no.2, agustus 2019 maka dilakukan pemeriksaan darah tikus. sebelum pengambilan darah, tikus dipuasakan terlebih dahulu selama 12 jam kemudian dikeluarkan dari kandang dan diberi anestesi dengan injeksi ketamin secara intramuskular dengan dosis 20 40 mg/kgbb. tikus dimasukkan kembali ke dalam kandang dan ditunggu hingga anastesi tersebut bereaksi (hilang kesadaran). setelah itu dilakukan pembedahan pada tikus dan dilakukan pengambilan darah dari jantung (intracardial) pada semua kelompok tikus. masing masing darah tikus diambil sebanyak 3 ml untuk pemeriksaan kadar trigliserida. dari hasil penelitian kadar trigliserida kemudian dilakukan uji normalitas, uji homogenitas dan uji one-way anova. data hasil penelitian dari rerata dan standar deviasi kadar trigliserida kelompok hewan coba yang diberi diet tinggi lemak adalah 91,33 mg/dl dan 41,91 mg/dl. pada kelompok hewan coba yang diberi diet tinggi lemak dan simvastatin, rerata dan standard deviasinya adalah 53,22 mg/dl dan 23,70 mg/dl. sedangkan rerata dan standard deviasi pada kelompok pemberian diet tinggi lemak dan jus buah apel dengan dosis 10 mg/dl adalah 75,50 mg/dl dan 48,87 mg/dl. sehingga rerata dan standar deviasi kadar trigliserida kelompok yang diberi diet tinggi lemak meningkat lebih tinggi dibandingkan dengan kelompok pemberian diet tinggi lemak dan simvastatin dan kelompok pemberian diet tinggi lemak dan jus buah apel (malus sylvestris). sehingga disimpulkan telah terjadi penurunan paling banyak pada kelompok pemberian diet tinggi lemak dan simvastatin dan penurunan sedikit pada kelompok pemberian diet tinggi lemak dan jus buah apel (malus sylvestris) dosis 10 mg/dl. hasil uji normalitas trigliserida menunjukan bahwa nilai signifikansi pada kelompok hewan coba yang diberi diet tinggi lemak sebesar p = ,278 (p > 0,05), nilai signifikansi pada kelompok hewan coba yang diberi diet tinggi lemak dan simvastatin sebesar p = ,475 (p > 0,05), dan nilai signifikansi pada kelompok hewan coba yang diberi diet tinggi lemak dan jus buah apel (malus sylvestris) dosis 10 mg/dl sebesar p = ,346 (p > 0,05). berdasarkan hasil analisis data terdapat signifikansi pada semua kelompok (p > 0,05) sehingga dapat disimpulkan bahwa distribusi data adalah normal. analisis data dilanjutkan dengan uji homogenitas trigliserida diperoleh nilai signifikansi sebesar p = ,188 (p > 0,05) yang artinya h0 diterima dan h1 ditolak. sehingga dapat disimpulkan data pada semua kelompok memiliki varian homogen, yang selanjutnya dapat dilanjutkan dengan uji one way anova. untuk uji one-way anova trigliserida didapatkan data p = ,139 (p > 0,05). didapatkan nilai p > 0,05 artinya h0 diterima dan h1 ditolak sehingga disimpulkan tidak terdapat perbedaan antara masing masing kadar trigliserida kelompok hewan coba yang diberi diet tinggi lemak, kelompok hewan coba yang diberi diet tinggi lemak dan simvastatin, dan kelompok hewan coba yang diberi diet tinggi lemak dan jus buah apel (malus sylvestris) dosis 10 ml. dimana secara statistik hal ini menunjukan bahwa tidak terdapat perbedaan pada masing – masing kelompok hewan coba, tetapi secara data yang didapat dari rerata kadar trigliserida pada kelompok yang diberi diet tinggi lemak dan kelompok diet tinggi lemak dan simvastatin terdapat penurunan cukup tinggi yaitu 38,11 mg/dl kadar trigliserida. begitupula dengan kelompok kp1, dimana terbukti telah terjadi penurunan kadar trigliserida dengan nilai rerata 75,5 mg/dl bila dibandingkan dengan kelompok yang diberi diet tinggi lemak yaitu sebesar 91,33 mg/dl. berdasarkan hasil dari pembahasan pada penelitian ini dapat disimpulkan bahwa pemberian jus kulit dan daging buah apel (malus sylvestris) dengan dosis 10 ml selama 10 hari dapat menurunkan kadar trigliserida namun tidak bermakna secara statistik. dan hal ini dapat dikarenakan oleh waktu pemberian jus buah apel yang kurang lama atau bisa karena kurangnya kandungan flavonoid (quercetin) yang terkandung dalam buah apel oleh adanya efek dari pemakaian pestisida. seperti yang dikatakan pada penelitian sebelumnya bahwa sistem pertanian konvensional yang menggunakan pupuk kimia buatan dan pestisida dapat menghambat antioksidan flavonoid9. selain itu, juga dapat dipengaruhi oleh beberapa faktor seperti dosis yang digunakan untuk 16 medical and health science journal, vol.3., no.2, august 2019 menurunkan kadar trigliserida ,bentuk sediaan, dan dari segi hewan coba misalnya karena faktor genetik tikus yang berpengaruh pada kadar trigliserida tikus. kesimpulan berdasarkan hasil analisis data dari penelitian eksperimental ini, maka dapat disimpulkan bahwa pemberian jus kulit dan daging buah apel manalagi (malus sylvestris) dengan dosis 10 ml dengan pembagian 5 ml pagi dan 5 ml sore hari dapat menurunkan kadar trigliserida darah tikus putih (rattus norvegicus) jantan galur wistar yang telah diberi diet tinggi lemak sebelumnya, namun secara statistik tidak bermakna. daftar pustaka 1. guyton, arthur c. and hall, john e. 2014. buku ajar fisiologi kedokteran edisi 12. ecg, jakarta. 2. world health organization. 2017. who cardiovascular diseases (cvds) fact sheet, who. 3. go, a. s. et al. 2013. heart disease and stroke statistics--2014 update: a report from the american heart association, circulation. 4. world health organization. 2017. who cardiovascular diseases (cvds) fact sheet, who. available at: cardiovascular diseases (cvds. 5. susanto, w. h. and setyohadi, b. r. 2011. "pengaruh varietas apel (malus sylvestris) dan lama fermentasi oleh khamir saccharomyces cerivisiae sebagai perlakuan prapengolahan terhadap karakteristik sirup", jurnal teknologi pertanian, 12(3), pp. 135–142. 6. kurian, n. and bredenkamp, c. 2013. "reduction of cholesterol and triglycerides in volunteers using lemon and apple", international journal of humanities and social science, 3(18), pp. 60–64. 7. widmaier, eric p.raff, h. and strang, k. t. 2014. vanders human physiology -the mechanism. 8. murray, r.k, mayes, p.a, botham, k.m. 2014. biokimia harper edisi 29. penerbit buku kedokteran ecg, jakarta. 9. pambudi, r. 2017. "perbedaan panjang serta berat tubuh fetus tikus putih (rattus norvegicus) galur sprague-dawley terhadap pemberian asam folat pada periode kehamilan yang berbeda". 17 e:\job aditya\indro\naskah masu nirwanto, aried eriadi, helmi arifin, toksisitas akut ekstrak etanol daun kirinyuh (chromolaena odorata (l) r.m. king & h. rob pada mencit putih jantan 3131 toksisitas akut ekstrak etanol daun kirinyuh (chromolaena odorata (l) r.m. king & h. rob) pada mencit putih jantan nirwanto1), aried eriadi1), helmi arifin2) 1)sekolah tinggi ilmu farmasi (stifarm) padang 2)fakultas farmasi universitas andalas padang e-mail: _______________ abstract: the acute toxicity of ethanol extracts from kirinyuh (chromolaena odorata (l) r.m. king & h. rob) leaves to white mice males has been done. parameters toxicity observed were ld50 and delayed toxic effects for 14 days of observation including changes in weight, volume of water consumption, and relative weight of the organs like heart, liver, kidneys, stomach and lungs. the ethanol extract of chromolaena odorata (l) r.m king & h. rob leaves orally at a dose of 4 g/kgbb, 8 g/kgbb and 16 g/kgbb, showed that was categorized practically non-toxic (ld50> 15 g/kgbb). delayed toxic effects are seen from the significant differences in body weight, the volume of water, relative organ weight of lung and stomach (p<0.05). there were no significant differences in the relative organ weight of the heart, liver and kidneys (p<0.05). keywords: ld50, delayed toxicity, chromolaena odorata (l) r.m. king & h. rob telah dilakukan pengujian toksisitas akut ekstrak etanol daun kirinyuh chromolaena odorata (l) r.m. king & h. rob. parameter toksisitas yang diamati adalah ld50 dan efek toksik tertunda selama 14 hari pengamatan yang meliputi perubahan berat badan, volume konsumsi air minum, dan berat relatif organ dari jantung, hati, ginjal, lambung, dan paru-paru. pemberian ekstrak etanol daun kirinyuh (chromolaena odorata (l) r.m. king & h. rob) secara oral dengan dosis 4 g/kgbb, 8 g/kgbb dan 16 g/kgbb, menunjukkan bahwa ekstrak ini termasuk kategori praktis tidak toksik (ld50 >15 g/kgbb). efek toksik tertunda terlihat dari adanya perbedaan signifikan pada berat badan, volume air minum, berat relatif organ paru dan lambung (p<0,05). tidak terdapat perbedaan yang signifikan pada berat relatif organ jantung, hati, dan ginjal (p<0,05). kata kunci: ld50, toksisitas tertunda, chromolaena odorata (l) r.m. king & h.rob. pendahuluan dewasa ini penelitian dan pengembangan tumbuhan obat baik di dalam maupun di luar negeri berkembang dengan pesat. penelitian yang berkembang terutama pada segi farmakologi maupun fitokimia berdasarkan indikasi tumbuhan obat yang telah digunakan sebagian masyarakat dengan khasiat yang teruji secara empiris. hasil penelitian tersebut, tentunya lebih memantapkan para pengguna tumbuhan obat akan khasiat maupun kegunaannya (dalimartha, 2000). obat tradisional adalah bahan atau ramuan bahan yang berupa tumbuhan, bahan hewan, bahan mineral, sediaan cairan (galenik), atau campuran dari bahan tersebut yang secara turun temurun telah digunakan untuk pengobatan dan dapat diterapkan sesuai dengan norma yang berlaku di masyarakat (badan pengawas obat dan makanan republik indonesia, 2014). meskipun obat tradisional sudah dimanfaatkan sejak lama namun tidak sepenuhnya aman, karena obat tradisional merupakan senyawa asing bagi tubuh, sehingga sangatlah penting mengetahui potensi ketoksikannya. efek toksik pada medical and health science journal, vol. 1, no. 2, august 2017 32 makhluk hidup dapat terlihat dan dapat juga tidak bila dosis yang diserap relatif kecil kerusakannya dapat terbatas pada sel saja (koeman, 1987). kirinyuh (chromolaena odorata (l) r.m. king & h. rob) merupakan salah satu jenis tumbuhan dari family asteraceae/compositae. daunnya mengandung beberapa senyawa utama seperti tannin, fenol, flavonoid, saponin, dan steroid. minyak esensial dari daun kirinyuh memiliki kandungan a pinene, cadinene, camphora, limonene, b-caryophyllene, dan candinol isomer (inya-agha et al., 1987). secara tradisional daun kirinyuh digunakan sebagai obat dalam penyembuhan luka, obat kumur untuk pengobatan sakit pada tenggorokan, obat batuk, obat malaria, antimikroba, sakit kepala, antidiare, astringent, antispasmodik, antihipertensi, antiinflamasi, dan diuretik (vital & rivera, 2009). dalam usaha meningkatkan pemanfaatan tumbuhan daun kirinyuh (chromolaena odorata (l) r.m.king & h.rob) sebagai obat, baik penggunaan tradisional, penggunaan simplisia, maupun fitofar diperlukan informasi lengkap mengenai keamanan pemakaian obat tradisional. menurut lu (1995) untuk menilai keamanan tersebut perlu dilakukan uji toksisitas yang meliputi uji toksisitas akut, toksisitas sub akut, toksisitas kronis, dan uji toksisitas spesifik. pada penelitian sebelumnya telah dilakukan pengujian terhadap aktivitas antimikroba ekstrak daun kirinyuh, hasilnya menunjukkan positif terhadap bakteri bacillus subtillis, staphylococcus aureus dan salmonella typhimurium (vital & rivera, 2009), juga telah dilakukan pengujian terhadap ekstrak etanol daun kirinyuh untuk pengobatan luka pada mencit jantan, kontrol dan pembanding, hasilnya menunjukkan bahwa ekstrak etanol daun kirinyuh memberikan efek penyembuhan luka yang lebih cepat (yenti et al., 2011). mengingat luasnya pemakaian daun kirinyuh sebagai obat, maka penggunaan tanaman ini sebagai obat perlu dilakukan serangkaian uji, seperti uji khasiat, toksisitas secara praklinik dan uji klinik. berdasarkan hal tersebut telah dilakukan uji toksisitas akut ekstrak etanol daun kirinyuh yang meliputi penentuan ld50 dan efek toksik tertunda selama 14 hari untuk menetapkan potensi ketoksisitasannya terhadap mencit putih jantan, baik digunakan secara tradisional maupun sebagai obat. metode penelitian alat digunakan timbangan hewan (ohaus), timbangan analitik (precisa), gunting, sentrifus (dkc 1008t), gelas ukur (iwaki), kaca arloji, plat tetes, aluminium foil, tabung reaksi (iwaki), waterbath (memmert), cawan penguap, spatel, spuit, sonde, alat bedah, pinset, beacker glass, dan rotary evaporator (ika). bahan bahan yang digunakan adalah daun segar daun kirinyuh (chromolaena odorata (l) r.m. king & h. rob), natrium carboxy methyl cellulose (na-cmc) (pt brataco), plat klt silica gel gf 254 (merck), makanan standar mencit (pellet hi-pro-vite 511) (pt pokphand), etanol 70% (pt brataco), asam klorida (merck), kloroform (pt brataco), magnesium (pt brataco), asam sulfat (merck), metanol (pt brataco), quercetin (merck), dikloroetana (merck), dan mencit putih jantan. nirwanto, aried eriadi, helmi arifin, toksisitas akut ekstrak etanol daun kirinyuh (chromolaena odorata (l) r.m. king & h. rob pada mencit putih jantan 33 prosedur penelitian a. pengambilan sampel sampel yang digunakan adalah tumbuhan daun kirinyuh (chromolaena odorata (l) r.m. king & h. rob). bagian yang diambil adalah daunnya yang segar di daerah bypass km.17 padang, sumatera barat. b. identifikasi tumbuhan identifikasi tumbuhan dilakukan di herbarium andalas (anda), jurusan biologi, fakultas matematika dan ilmu pengetahuan alam (fmipa), universitas andalas (unand) padang, sumatera barat. c. penyiapan simplisia pada umumnya, proses pembuatan simplisia melalui tahap seperti berikut. pengumpulan bahan baku, sortasi basah, pencucian, perajangan, pengeringan, sortasi kering, penyimpanan dan pemeriksaan mutu (departemen kesehatan republik indonesia, 1985). d. pembuatan ekstrak dari proses ini didapatkan serbuk simplisia daun kirinyuh sebanyak 3.984 g. kemudian diambil 1.500 g dibagi menjadi 10 bagian yang masing-masingnya sebanyak 150 g. kemudian masukan masing-masing bagian serbuk simplisia kering ke dalam 10 botol maserator yang gelap, tambahkan 10 bagian pelarut (etanol 70%). rendam selama 6 jam pertama sambil sekalikali diaduk, kemudian diamkan selama 18 jam pada temperatur ruangan (kamar). pisahkan maserat dengan cara filtrasi menggunakan kain flanel, ulangi proses penyarian sebanyak dua kali dengan jenis dan jumlah pelarut yang sama (remaserasi). kumpulkan semua maserat kemudian dipekatkan dengan rotary evaporator sampai didapatkan ekstrak kental (departemen kesehatan republik indonesia, 2008). setelah itu hitunglah hasil rendemen ekstrak. % rendemen = e. karakterisasi ekstrak etanol daun kirinyuh karakterisasi ekstrak etanol daun kirinyuh yang dilakukan di antaranya susut pengeringan, penentuan kadar abu, identitas, organoleptis, kadar senyawa larut air dan kadar senyawa larut etanol (departemen kesehatan republik indonesia, 2000). f. uji kandungan kimia pemeriksaan fitokimia ekstrak dilakukan di antaranya uji alkaloid, flavonoid, steroid, terpenoid dan saponin. serta pengujian kromatogram lapis tipis dan kadar flavonoid total (departemen kesehatan republik indonesia, 1980). g. persiapan hewan percobaan hewan yang digunakan adalah mencit putih jantan umur 2–3 bulan dengan berat antara 2030 gram sebanyak 20 ekor, sebelum penelitian dilakukan, mencit diaklimatisasi selama 7 hari dengan diberi makan dan minum yang cukup. mencit yang akan digunakan adalah mencit yang sehat dan tidak menunjukkan perubahan berat badan berarti (deviasi maksimal 10%) serta secara visual menunjukkan perlakuan yang normal. h. dosis uji dosis ekstrak daun kirinyuh yang diberikan pada mencit putih jantan adalah 4 g/kgbb, 8 g/ kgbb, dan 16 g/kgbb yang diberikan secara oral. medical and health science journal, vol. 1, no. 2, august 2017 34 i. tahap pengujian sebelum diberi perlakuan masing-masing mencit ditimbang lalu mencit dibagi 4 kelompok. masing-masing kelompok terdiri dari 5 ekor mencit, dengan perlakuan sebagai berikut. a. kelompok i (kontrol): hanya diberi suspensi na cmc 0,5% b. kelompok ii: diberi ekstrak daun kirinyuh dengan dosis 4 g/kgbb c. kelompok iii: diberi ekstrak daun kirinyuh dengan dosis 8 g/kgbb d. kelompok iv: diberi ekstrak daun kirinyuh dengan dosis 16 g/kgbb j. penentuan nilai ld50 dan pengamatan gejala toksik yang menyertai nilai ld50 ditentukan dengan menghitung jumlah kematian hewan uji selama 24 jam yang disebabkan oleh pemberian tunggal sediaan uji pada kelompok mencit dengan dosis 4 g/kgbb, 8 g/kgbb, dan 16 g/kgbb. hewan uji dikelompokkan secara acak menjadi 4 kelompok yang tiap kelompok terdiri dari 5 ekor (satu kelompok sebagai kontrol dan tiga kelompok perlakuan dengan berbagai dosis). masing-masing kelompok perlakuan diberikan suspense ekstrak secara oral dengan dosis 4 g/kgbb, 8 g/kgbb, dan 16 g/kgbb, sedangkan kelompok kontrol negatif hanya diberikan larutan na cmc 0,5%. jumlah hewan uji yang mati dalam 24 jam setelah pemberian ekstrak dihitung. sementara itu, setelah pemberian suspense ekstrak dilakukan pengamatan gejala-gejala toksik yang menyertai selama 3 jam. untuk hewan yang mati dilakukan pembedahan dan dilakukan penentuan berat relatif dari organ paru-paru, hati, ginjal, jantung dan lambung. k. evaluasi efek toksik tertunda selama 14 hari pada mencit yang masih hidup mulai dari 24 jam sampai dengan 14 hari setelah pemberian sediaan uji, selain diamati gajala-gejala toksik yang timbul juga dilakukan penimbangan berat badan tiap 48 jam, pengukuran konsumsi air minum, dan pada hari ke-14 hewan percobaan dikorbankan untuk penentuan berat relatif organ jantung, hati, ginjal, lambung dan paruparu. analisis data data dari hasil penelitian ini dianalisis secara statistik dengan menggunakan analisis varian (anova) satu arah dan dua arah dilanjutkan dengan uji wilayah berganda duncan (duncan’s multiple range t-test) (jones, 2010). hasil dan pembahasan daun kirinyuh yang digunakan pada penelitian ini adalah dari spesies chromolaena odorata (l) r.m.king & h. rob. famili asteraceae/compositae. proses ekstraksi sampel dilakukan dengan metode maserasi. pemilihan metode ini karena sampel yang digunakan berupa daun segar. daun segar kirinyuh ditimbang sebanyak 5 kg lalu dilakukan pencucian, kemudian dirajang dengan tujuan agar pelarut dapat berpenetrasi dengan mudah sehingga penarikan zat aktif lebih sempurna, kemudian pengeringan dengan cara diangin-anginkan selama 7 hari sampai kering dan penghalusan, sehingga diperoleh serbuk kering sebanyak 3.984 g. sebanyak 1.500 g dimaserasi menggunakan pelarut etanol 70%. penggunaan penyari etanol 70% karena sampel yang digunanirwanto, aried eriadi, helmi arifin, toksisitas akut ekstrak etanol daun kirinyuh (chromolaena odorata (l) r.m. king & h. rob pada mencit putih jantan 35 kan adalah sampel kering sehingga dibutuhkan air untuk membasahi sampel sehingga sel-sel akan mengembang dan pelarut akan lebih mudah berpenetrasi untuk mengikat senyawa-senyawa yang terkandung di dalam sampel. penggunaan etanol sebagai pelarut universal disebabkan karena sifatnya yang mudah melarutkan senyawa zat aktif baik yang bersifat polar, semi polar, dan non-polar. serta kemampuannya untuk mengendapkan protein dan menghambat kerja enzim sehingga dapat menghindari proses hidrolisa dan oksidasi. maserasi dilakukan selama 1 hari dengan 3 kali pengulangan. proses maserasi ini dilakukan dengan menggunakan botol kaca berwarna gelap dan di tempat yang terlindung cahaya. hal ini bertujuan untuk menghindari terjadinya penguraian struktur zat aktif terutama untuk senyawa yang kurang stabil terhadap cahaya. satu bagian serbuk kering simplisia dimaserasi dalam botol gelap tertutup dengan 10 bagian pelarut, rendam selama 6 jam pertama sambil sekali-sekali diaduk, kemudian diamkan selama 18 jam. pisahkan maserat dengan cara penyaringan, ulangi proses penyarian sekurang-kurangnya dua kali dengan jenis dan jumlah pelarut yang sama. semua maserat yang diperoleh diuapkan dengan rotary evaporator lalu dipekatkan dengan waterbath sampai didapat ekstrak kental. diperoleh ekstrak kental sebanyak 91,0670 g dengan nilai rendemen 6,07%. setelah didapatkan ekstrak kental, selanjutnya, daun kirinyuh (chromolaena odorata (l) r.m. king & h. rob) dievaluasi melalui parameter spesifik dan parameter nonspesifik (departemen kesehatan republik indonesia, 2000) agar kualitas ekstrak dapat dikontrol untuk selanjutnya diproduksi sebagai calon fitofarmaka. dari penentuan organoleptis, didapatkan ekstrak dengan warna hijau pekat, rasanya pahit, bau khas aromatis, dan bentuknya kental. penentuan organoleptis ini termasuk salah satu parameter spesifik yang ditentukan dengan pancaindra dan bertujuan untuk pengenalan awal secara sederhana dan subjektif. selanjutnya dilakukan pemeriksaan karakterisasi terhadap ekstrak daun kirinyuh yang meliputi pemeriksaan uji non spesifik ekstrak, uji spesifik ekstrak dan uji kandungan kimia ekstrak. susut pengeringan yaitu pengukuran sisa zat setelah pengeringan pada temperatur 1050c selama 30 menit atau sampai berat konstan. tujuan dari penentuan susut pengeringan adalah memberikan batasan maksimal (rentang) tentang besarnya senyawa yang hilang pada proses pengeringan (departemen kesehatan republik indonesia, 2000). pada penentuan susut pengeringan ekstrak daun kirinyuh didapatkan persentase rata-rata adalah 9,76%. kadar abu yaitu bahan dipanaskan pada temperatur di mana senyawa organik dan turunannya terdestruksi dan menguap sehingga yang tertinggal hanya unsur mineral dan anorganik. tujuan dilakukan penentuan kadar abu adalah untuk memberikan gambaran kandungan minepemeriksaan pengamatan warna hijau pekat bau khas aromatis rasa pahit bentuk kental alkaloid + flavonoid + steroid + terpenoid saponin + susut pengeringan 9,76% kadar abu 4,8513% kadar senyawa larut air 9,8067% tabel 1 karakteristik ekstrak medical and health science journal, vol. 1, no. 2, august 2017 36 ral internal dan eksternal yang berasal dari proses awal sampai terbentuknya ekstrak (departemen kesehatan republik indonesia, 2000). pada penentuan kadar abu ekstrak daun kirinyuh didapat persen rata-rata adalah 4,8513% (tabel 1). hewan percobaan yang digunakan dalam penelitian ini yaitu mencit putih jantan, adapun alasan pemakaian mencit sebagai hewan percobaan didasarkan pada kemiripan fisiologis dengan manusia dan mencit mudah ditangani, relatif murah, mudah didapat, kecil, kandang tidak terlalu besar, omnivora, sistem operasi mudah (thompson, 1985). hewan percobaan diaklimatisasi selama 7 hari sebelum perlakuan, tujuannya untuk penyesuaian terhadap kondisi lingkungan. setelah itu mencit diberi suspensi ekstrak satu kali pemberian dalam waktu 24 jam dengan dosis yang digunakan adalah 4g/kg bb, 8 g/kg bb, dan 16 g/kg bb, kemudian mencit yang masih hidup dilakukan pengamatan toksisitas tertunda pada hari ke 3, 5, 7, 10, 12, dan 14. parameterparameter yang diamati pada kelompok perlakuan dibandingkan dengan kelompok pembanding yaitu kelompok kontrol. sediaan uji dibuat dalam bentuk suspensi karena ekstrak tidak mudah larut dalam air agar bias terdispersi sempurna. suspending agen yang digunakan na cmc 0,5%. dengan konsentrasi ini ekstrak sudah dapat larut baik dan konsentrasi ini umum dipakai untuk sediaan dengan jalur oral (sumarni et al., 2006). pada penelitian ini dilakukan uji toksisitas akut di mana sampai dosis 16 g/kgbb tidak ada hewan yang mati, untuk itu penentuan ld50 tidak dilanjutkan lagi karena hasil ini menunjukkan bahwa ekstrak etanol daun kirinyuh (chromolaena odorata (l) r.m. king & h. rob) termasuk kategori praktis tidak toksik karena mempunyai ld50 > 15 g/kgbb, dapat dilihat pada tabel 2. hasil penelitian menunjukkan bahwa pada hari ke-14 terlihat pertambahan berat badan baik hewan kelompok kontrol maupun hewan perlakuan (seluruh variasi dosis). berat badan ditentukan oleh keseimbangan antara masukan kalori dan pelepasan energi. dengan cara tertentu berat badan dipertahankan pada titik tertentu. nafsu makan diatur oleh hipotalamus melalui interaksi antara “pusat makanan” dan “pusat kenyang” (guyton, 1995). tabel 2 tingkatan toksisitas berdasarkan harga ld50 tipe letal dosis (ld50) praktis tidak toksik >15 g/kgbb sedikit toksik 5-15 g/kgbb agak toksik 0,5-5 g/kgbb toksik 50-500 mg/kgbb sangat toksik 5-50 mg/kgbb super toksik <5 mg/kgbb pada evaluasi toksisitas akut ini diamati dan diperiksa beberapa parameter lain: berat badan, volume air minum, dan berat relatif organ. didapatkan data yang cukup beragam pada masing-masing kelompok hewan percobaan. perbedaan yang timbul merupakan suatu kewajaran karena perbedaan kondisi fisiologis seperti berat badan, usia, dan proses metabolisme tubuh dari masing-masing hewan percobaan selama perlakuan. hal tersebut akan memengaruhi parameter-parameter yang diukur (wood, 1999). berdasarkan perhitungan statistik dari data pengujian berat badan diketahui bahwa nilai signifikan perlakuan dosis yaitu 0,000 (p<0,05) maka dapat disimpulkan bahwa variasi dosis ekstrak daun kirinyuh berpengaruh nyata pada berat badan dari mencit putih jantan. pada pengnirwanto, aried eriadi, helmi arifin, toksisitas akut ekstrak etanol daun kirinyuh (chromolaena odorata (l) r.m. king & h. rob pada mencit putih jantan 37 ujian terhadap waktu, diketahui nilai signifikansi 0,364 (p<0,05) maka dapat disimpulkan bahwa tidak ada pengaruh waktu terhadap berat badan mencit putih jantan pada hari ke-3, 5, 7, 10, 12 dan 14 dari ekstrak daun kirinyuh. sedangkan pada pengujian terhadap interaksi perlakuan dan waktu adalah 0,999 (p<0,05) maka dapat disimpulkan bahwa tidak ada interaksi antara variasi dosis ekstrak daun kirinyuh dengan waktu terhadap berat badan mencit putih jantan. berdasarkan hasil uji lanjut duncan ternyata menunjukkan bahwa terdapat perbedaan berat badan mencit antara dosis 4 g/kgbb, 8 g/kgbb dan 16 g/kgbb dengan kontrol (gambar 1). me air minum mencit putih jantan. sedangkan pengujian terhadap interaksi dosis dan waktu adalah 0,000 (p<0,05) maka dapat disimpulkan ada interaksi antara variabel dosis dengan waktu terhadap volume air minum mencit putih jantan. berdasarkan hasil uji lanjut duncan ternyata menunjukkan bahwa ada perbedaan terhadap volume air minum mencit antara dosis 4 g/kgbb, 8 g/kgbb dan 16 g/kgbb dengan kontrol maka dianggap perbedaan volume air minum merupakan suatu tanda telah terjadi gangguan pada aktivitas minum hewan percobaan (gambar 2). gambar 1 pengaruh dosis ekstrak daun kirinyuh (chromolaena odorata (l) r.m. king & h. rob) terhadap berat badan mencit putih jantan pada pengamatan untuk volume air minum tiap-tiap hari didapatkan bahwa puncak tertinggi dan terendah volume air minum hewan percobaan baik kelompok kontrol maupun kelompok perlakuan berbeda-beda waktunya. berdasarkan perhitungan statistik dari data pengujian volume air minum diketahui bahwa pengujian terhadap perlakuan dosis signifikansinya yaitu 0,000 (p<0,05) maka dapat disimpulkan bahwa variasi dosis ekstrak daun kirinyuh berpengaruh nyata terhadap volume air minum dari mencit putih jantan. pada pengujian terhadap waktu, diketahui signifikansi 0,000 (p<0,05) maka dapat disimpulkan bahwa ada pengaruh waktu terhadap volugambar 2 pengaruh dosis ekstrak daun kirinyuh (chromolaena odorata (l) r.m. king & h. rob) terhadap volume air minum mencit putih jantan parameter lain yang diamati adalah rasio berat relatif organ. organ yang diamati adalah paru-paru, jantung, lambung, hati dan ginjal. rasio berat organ biasanya merupakan petunjuk sangat peka dari efek toksik. organ-organ ini dapat dirusak berbagai jenis zat kimia yang bekerja secara langsung pada organ sasaran ataupun secara tidak langsung yakni melalui susunan saraf pusat atau pembuluh darah. jantung mudah mengalami kelainan yang diakibatkan senyawa-senyawa kimia, karena mitokondria yang terdapat di otot jantung dengan jumlah yang relatif besar lebih sering menjadi sasaran kardiotoksisitas (lu, 1995). medical and health science journal, vol. 1, no. 2, august 2017 38 dari pengujian statistik anova satu arah berat relatif organ jantung didapatkan signifikansi 0,053 (p<0,05) maka dapat disimpulkan tidak ada pengaruh variasi dosis terhadap berat relatif organ jantung dari mencit putih jantan. karena kita menggunakan rute oral maka senyawa uji akan mengalami siklus enterohepatik, setelah terjadi absorbsi pada saluran cerna, maka senyawa akan dibawa oleh vena porta menuju hati. sekitar 80% darah yang ada dalam hati berasal dari vena porta, sehingga hati sering menjadi organ sasaran senyawa toksik di dalam tubuh (lu, 1995). hati merupakan organ yang memiliki kemampuan untuk pemulihan kerusakan sel yang sangat besar. hati memiliki enzim sitokrom p-450 yang dapat memetabolisme zat asing di dalam tubuh, dengan membuat sebagian toksikan menjadi kurang toksik dan lebih mudah larut dalam air (sherlock, 1990). berat relatif organ biasanya merupakan petunjuk yang sangat peka dari efek pada hati. dari hasil pengujian statistik anova satu arah didapatkan nilai signifikan yaitu 0,410 (p<0,05) maka dapat disimpulkan tidak ada pengaruh variasi dosis terhadap berat relatif organ hati dari mencit putih jantan. berat relatif organ ginjal kelompok kontrol tidak berbeda jauh dibandingkan dengan kelompok perlakuan yang diberi ekstrak etanol daun kirinyuh, dari hasil pengujian statistik anova satu arah didapatkan nilai signifikan yaitu 0,346 (p<0,05) maka dapat disimpulkan tidak ada pengaruh variasi dosis terhadap berat relatif organ ginjal dari mencit putih jantan. berat relatif organ lambung kelompok kontrol cukup berbeda dibandingkan dengan kelompok perlakuan yang diberi ekstrak daun kirinyuh, dari hasil pengujian statistik anova satu arah didapatkan nilai signifikan yaitu 0,020 (p<0,05) maka dapat disimpulkan ada pengaruh variasi dosis ekstrak daun kirinyuh terhadap berat relatif organ lambung dari mencit putih jantan. setelah dilakukan uji lanjut duncan menunjukkan perbedaan terhadap berat relatif organ lambung antara dosis 16 g/kgbb dan kelompok kontrol dengan dosis 8 g/kgbb. berat relatif organ paru-paru kelompok kontrol berbeda dibandingkan dengan kelompok perlakuan yang diberi ekstrak daun kirinyuh, dari hasil pengujian statistik anova satu arah didapatkan nilai signifikan yaitu 0,000 karena (p<0,05) maka dapat disimpulkan ada pengaruh variasi dosis ekstrak daun kirinyuh terhadap berat relatif organ paru-paru dari mencit putih jantan. setelah dilakukan uji lanjut duncan menunjukkan perbedaan terhadap berat relatif organ paru-paru antara dosis 4 g/kgbb, 8 g/ kgbb dan kelompok kontrol dengan dosis 16 g/ kgbb (berdasarkan gambar 3). gambar 3 pengaruh dosis ekstrak daun kirinyuh (chromolaena odorata (l) r.m.king & h. rob) terhadap berat relatif organ pada mencit putih jantan kesimpulan dari hasil penelitian yang telah dilakukan dapat diambil kesimpulan sebagai berikut. 1. ekstrak daun kirinyuh (chromolaena odorata (l) r.m. king & h. rob) termasuk kategori nirwanto, aried eriadi, helmi arifin, toksisitas akut ekstrak etanol daun kirinyuh (chromolaena odorata (l) r.m. king & h. rob pada mencit putih jantan 39 praktis tidak toksik karena mempunyai ld50 >15 g/kgbb. 2. toksisitas terunda terlihat dari ekstrak daun kirinyuh (chromolaena odorata (l) r.m. king & h. rob) dengan dosis 4 g/kgbb, 8 g/kgbb dan 16 g/kgbb menimbulkan efek toksik pada berat badan, volume air minum, berat relatif organ lambung dan paru-paru secara bermakna (p<0,05). sedangkan pada berat relatif organ jantung, ginjal dan organ hati tidak menimbulkan efek toksik secara bermakna (p<0,05). daftar pustaka badan pengawas obat dan makanan republik indonesia. 2014. peraturan kepala badan pengawas obat dan makanan republik indonesia nomor 12 tahun 2014 tentang persyaratan mutu obat tradisional. jakarta: badan pengawas obat dan makanan. dalimartha, s. 2000. atlas tumbuhan indonesia. (jilid ii). jakarta: trubus agriwidya. departemen kesehatan republik indonesia. 1980. materia medika indonesia (jilid iv). jakarta: departemen kesehatan republik indonesia. departemen kesehatan republik indonesia. 1985. cara pembuatan simplisia. jakarta: departemen kesehatan republik indonesia. departemen kesehatan republik indonesia. 2000. parameter standar umum ekstrak tumbuhan obat. (edisi i). jakarta: departemen kesehatan republik indonesia. departemen kesehatan republik indonesia. 2008. farmakope herbal indonesia (edisi i). jakarta: departemen kesehatan republik indonesia. guyton, a.c. 1995. fisiologi kedokteran. (edisi 17). penerjemah: arrianti, l.m. jakarta: penerbit buku kedokteran indonesia egc. inya-agha, s.i., oguntimein, b.o., sofowora. a., & benjamin, v.t. (1987). phytochemical and antibacterial studies on the essential oil of eupatorium odoratum. international journal crude drug research, 25, (1), 49–52. jones, d.s. 2010. statistika farmasi. penerjemah: h.u. ramadaniati h. rivai. jakarta: penerbit buku kedokteran egc. koeman, j.h. 1987. pengantar umum toksikologi. penerjemah: r. h. yudono. yogyakarta: gadjah mada university press. lu, f.c. 1995. toksikologi dasar: asas, organ sasaran, dan penilaian risiko, (edisi 2). penerjemah: e. nugraha. jakarta: ui press. price, s.a. & wilson, l.m. 2005. patofisiologi konsep klinis proses-proses penyakit, (edisi vi). volume i. jakarta: penerbit buku kedokteran egc. sherlock, s. 1990. penyakit hati dan sistem saluran empedu. penerjemah: p. andrianto. jakarta: widya madika. sumarni, r.d., parodi, & darmono. 2006. pengaruh pemberian ekstrak kering rimpang temu putih (curcuma zedoria, rosc) per oral terhadap beberapa parameter gangguan ginjal pada tikus putih jantan. jurnal farmasi indonesia, vol. 17 (1). thompson, e. (1985). drug and bioscreening fundamentals of drugs evaluation technique in pharmacology. new york: graceway publishing company. vital, p.g., & rivera, w.l. 2009. antimicrobacterial activity and citoxcity of chromolaena odorata (l.f) king and robinson and uncaria perrottetti (a. rich) merr. medical and health science journal, vol. 1, no. 2, august 2017 40 extracts. journal of medicinal palnt research, 03, (7), 511–518. wood, j. 1999. gout and management. the pharmaceutical journal, 262, (5), 808– 811. yenti, r., afrianti, r., & afriani, l. 2011. formulasi krim ekstrak etanol daun kirinyuh (euphatorium odorata.l) untuk penyembuhan luka. majalah kesehatan pharma medika, 3. (1), 227–230. medical and health science journal, vol.3., no.1, februari 2019 correspondence: nisha dharmayanti rinarto @2019 medical and health science journal. all rights reserved available at http://journal2.unusa.ac.id/index.php/mhsj 25 original article peningkatan pengetahuan guru tentang p3k melalui promosi kesehatan di smk kal 1 surabaya nisha dharmayanti rinarto 1* , dwi priyantini 2 , annisa nurayu fitriastuti 3 , 1,2,3program studi s1 keperawatan, sekolah tinggi ilmu kesehatan universitas hang tuah surabaya, indonesia *correspondent author: nishadharmayanti@stikeshangtuah-sby.ac.id/nishadr.shtsby@gmail.com article info article history: received 23 january 2019 received in revised form february 2019 accepted 4 february 2019 keywords: health promotion, first aid, school. kata kunci: promosikesehatan, p3k, sekolah.. abstract health promotion is an effort planned to influence other people, whether individuals, groups or communities, so that they do what is expected by health promotion actors. health promotion of p3k in schools has an effect on the level of knowledge that teachers have about p3k on emergencies. this study aims to see the effect of health promotion on increasing teacher knowledge about first aid at surabaya kal-1 vocational school. sampling technique with simple random sampling, a total sample of 39 respondents. the research method is pre experimental with the one group pretest-posttest approach. data collection using questionnaires. data analysis techniques using the wilcoxon signed rank test. the results of the study showed that the teacher's knowledge before being given a health promotion with an average value of 1.38 and after being given a health promotion obtained an average value of 2.54. the results of statistical tests obtained the results of asymp. sig 0.001> α 0.05, which means that there are significant differences. further analysis found that there was an effect of health promotion on the level of teacher knowledge, so it was hoped that the school would propose to the relevant uptd for the provision of first aid training in schools. abstrak promosi kesehatan merupakan upaya yang direncanakan untuk mempengaruhi orang lain, baik individu, kelompok, atau masyarakat, sehingga mereka melakukan apa yang diharapkan oleh pelaku promosi kesehatan. promosi kesehatan tentang p3k disekolah berpengaruh terhadap tingkat pengetahuan yang dimiliki oleh guru tentang p3k pada kegawatdaruratan. penelitian ini bertujuan untuk melihat pengaruh promosi kesehatan terhadap peningkatan pengetahuan guru tentang p3k di smk kal-1 surabaya. tehnik sampling dengan simple random sampling, jumlah sampel 39 responden. metode penelitian adalah pre eksperimental dengan pendekatan one grup pretespostest. pengumpulan data menggunakankuesioner. teknik analisis data menggunakan wilcoxon signed rank test. hasil penelitian menunjukkan pengetahuan guru sebelum diberikan promosi kesehatan dengan nilai rata-rata 1,38 dan setelah diberikan promosi kesehatan didapat nilai rata-rata 2,54. hasil uji statistik diperoleh hasil asymp.sig 0,001 > α 0,05 yang berarti terjadi perbedaan yang bermakna. analisis lebih lanjut didapatkan ada pengaruh promosi kesehatan terhadap tingkat pengetahuan guru, dengan demikian diharapkan agar sekolah mengusulkan kepada uptd terkait untuk pengadaan pelatihan p3k di sekolah. @2019 medical and health science journal. all rights reserved re tr ac te d medical and health science journal, vol.3., no.1, februari 2019 54 pendahuluan kejadian gawat darurat dapat diartikan sebagai keadaan dimana seseorang memerlukan pertolongan segera karena apabila tidak mendapat pertolongan dengan segera maka dapat mengancam jiwanya atau menimbulkan kecacatan permanen. keadaan gawat darurat yang sering terjadi di masyarakat antara lain keadaan seseorang yang mengalami henti nafas dan henti jantung, tidak sadarkan diri, kecelakaan, cedera misalnya patah tulang, pendarahan, kasus stroke dan kejang, keracunan dan korban bencana (norman, 2006). menurut survey yang dilakukan di tempat penelitian angka kejadian cedera pada lingkungan sekolah sering terjadi. terutama saat praktik kompetensi keahlian siswa, terutama bidang keahlian teknik mesin dan teknik listrik lebih tinggi resiko cedera yang akan dialami. selain itu cedera saat berolahraga juga sering dijumpai, misalnya dengan kaki terkilir setelah bermain futsal. disamping itu pengetahuan guru tentang p3k pada siswa masih dikatakan kurang hal ini yang menjadi dasar pengambilan penelitian di tempat ini. hasil studi pendahuluan melalui wawancara dengan kepala uks di smk kal-1 surabaya dalam organisasi uks yang ada di sekolah yang bertanggung jawab hanyalah kepala uks yang dibantu dengan kader kesehatan yaitu salah satu siswa dalam setahun. ketika terjadi kecelakaan kerja saat praktikum misalnya luka sobek pada jari yang terkena gergaji atau grenda maka siswa akan dibawa di uks dan ditangani langsung oleh kepala uks yang siaga diruangan. apabila kepala uks tidak mampu untuk menangani maka siswa dirujuk ke rs terdekat. pada saat praktikum siswa bidang teknik seperti kegiatan mengelas, siswa sering mengeluh mata merah karena terlalu lama terpapar sinar las. selain itu, terkadang terjadi luka bakar ringan pada siswa yang terkena soldier saat praktikum. beberapa siswa tersebut dibawa temantemannya ke ruang uks dan diberikan p3k oleh kepala uks. uks di smk kal-1 berada dalam naungan uptd puskesmas krembangan selatan akan tetapi dari hasil wawancara dengan kepala uks menyebutkan bahwa selama ini belum ada promosi kesehatan terkait p3k pada siswa di sekolah dan menurut kepala uks, guru pendidik belum mengetahui tentang p3k pada siswa sehingga apabila terjadi kecelakaan saat praktik maupun adanya siswa yang pingsan atau sakit akut hanya mengandalkan kepala uks saja. alat p3k di ruang uks sendiri masih belum lengkap dan ruangan yang terlalu kecil untuk jumlah siswa yang cukup banyak menjadi masalah dalam uks tersebut. p3k adalah perawatan yang segera diberikan pada orang yang cedera atau mendadak sakit, namun tidak dapat menggantikan perawatan medis yang sebenarnya, karena hanya memberi bantuan sementara sampai mendapatkan perawatan medis yang kompeten jika perlu atau sampai pulih tanpa perawatan medis. p3k yang diterapkan secara tepat dapat memberi perbedaan antara hidup dan mati, antara pemulihan yang cepat dan rawat inap di rumah sakit yang lama, atau antara kecacatan temporer dan kecacatan permanen. p3k lebih banyak melakukan tindakan untuk orang lain; p3k juga termasuk melakukan tindakan yang dapat dilakukan orang dalam suatu kedaruratan untuk diri mereka sendiri (thygerson, 2011) kecelakaan atau kedaruratan dapat saja terjadi secara tidak disangka-sangka (junaidi, 2011). kecelakaan dapat terjadi di rumah, perjalanan, tempat kerja, sekolah, dan tempat lainnya. sebagai akibat dari kecelakaan korban dapat mengalami cedera ringan atau berat, pingsan, cacat seumur hidup atau bahkan sampai meninggal dunia. bagi korban yang meninggal dunia tentu tidak memerlukan suatu pertolongan yang cepat, tetapi bagi korban kecelakaan yang masih hidup re tr ac te d medical and health science journal, vol.3., no.1, februari 2019 54 memerlukan suatu pertolongan yang cepat dan tepat agar korban dapat terhindar dari bahaya maut. ilmu p3k pada kecelakaan sebaiknya dimiliki oleh semua orang. tujuannya adalah mencegah maut dan mempertahankan hidup, mencegah penurunan kondisi badan atau cacat(yuda, tamara, & agina, 2015). penyebab terjadinya cedera meliputi penyebab yang disengaja (intentional injury), penyebab yang tidak disengaja (unintentional injury) dan penyebab yang tidak bisa ditentukan (undeterminated) (badan penelitian dan pengembangan kesehatan, 2013) prevalensi cedera secara nasional adalah 8,2% (berdasarkan pengakuan responden, untuk berbagai penyebab cedera). penyebab cedera terbanyak yaitu jatuh (40,9%) dan kecelakaan sepeda motor (40,6%), selanjutnya penyebab cedera karena terkena benda tajam/tumpul (7,3%), transportasi darat lain (7,1%) dan kejatuhan (2,5%). di jawa timur sendiri prevalensi angka cedera (9,3%) dengan penyebab cedera tertinggi diakibatkan jatuh (43,2%) urutan kedua disebabkan sepeda motor (37,9%) dan selanjutnya disebabkan transportasi darat (8,5%), benda tajam/tumpul (7,2%). prevalensi cedera tertinggi menurut karakteristik umur berada di usia 15-24 tahun (11,7%). sedangkan untuk jenis cedera di indonesia didominasi oleh luka lecet/memar sebesar 70,9% dan terbanyak kedua adalah terkilir (27,5%), selanjutnya menduduki urutan ketiga jenis cedera dengan luka robek (23,2%), patah tulang (5,8%). proporsi jenis cedera di provinsi jawa timur tertinggi adalah lecet/memar (68,0%), kedua terkilir (27,3%), ketiga luka robek (22,7%), patah tulang (6,0%). angka kejadian cedera di sekolah secara nasional adalah (5,4%), dan proporsi cedera di sekolah di jawa timur (6,0%) dan disebabkan oleh olahraga (3,5%) (badan penelitian dan pengembangan kesehatan, 2013). guru selaku penanggung jawab saat praktikum memiliki peran yang sangat penting saat melakukan p3k pada siswa yang mengalami cedera tersebut. dengan pemberian p3k yang cepat dan tepat pada siswa yang mengalami cedera akan cepat tertolong dan dengan adanya promosi kesehatan akan memberikan tambahan pengetahuan guru tentang p3k kegawatdaruratan guna memberikan pertolongan yang cepat dan tepat agar kondisi yang mengancam jiwa segera teratasi dengan baik. guru sebaiknya menguasai p3k di sekolah. penguasaan tindakan dipengaruhi oleh beberapa hal salah satunya adalah pengetahuan(gunarsa, 2008). pengetahuan dapat diberikan dengan melakukan promosi kesehatan tentang p3k, dimana program kesehatan yang dirancang secara efektif untuk membawa perubahan (perbaikan), baik di dalam masyarakat sendiri, maupun dalam organisasi dan lingkungannya. metode penelitian penelitian ini menggunakan desain pre eksperimental dengan pendekatan one grup pretes postest untuk mengungkapkan hubungan sebab akibat dengan cara melibatkan satu kelompok subjek. populasi dalam penelitian ini adalah semua guru di smk kal-1 surabaya berjumlah 44 orang dengan sampel yang memenuhi kriteria inklusi sebesar 39 orang.teknik sampling yang digunakan yaitu probability sampling dengan cara simple random sampling. pengambilan data dengan menggunakan lembar kuesioner yang dibuat sendiri oleh peneliti dan telah di uji validitas dan reabilitasnay. analisis data menggunakan wilcoxon signed rank test untuk melihat apakah terdapat hubungan antara tingkat pengetahuan guru sebelum dan sesudah diberikannya promosi kesehatan. hipotesa diterima jika nilaiρ≤0,05. re tr ac te d medical and health science journal, vol.3., no.1, februari 2019 5 5 hasil dan pembahasan data umum tabel 1. karakteristik guru berdasarkan usia di smk kal-1 surabaya, tanggal 15-16 maret 2017 (n=39) usia f % < 40 tahun 40 – 50 tahun 51 – 61 tahun 17 16 6 43,6 41,0 15,4 total 39 100 tabel 2. karakteristik guru berdasarkan jenis kelamin di smk kal-1 surabaya, tanggal 15-16 maret 2017 (n=39) jenis kelamin f % perempuan laki laki 22 17 56,4 43,6 total 39 100 tabel 3. karakteristik guru berdasarkan tingkat pendidikan di smk kal-1 surabaya, tanggal 1516 maret 2017 (n=39) tk. pendidikan f % d3 sederajat lulus sarjana lulus magister 8 26 5 20,5 66,7 12,8 total 39 100 tabel 4. karakteristik guru berdasarkan pekerjaan di smk kal-1 surabaya, tanggal 1516 maret 2017 (n=39) pekerjaan f % tni-al swasta honorer / lain-lain 4 20 15 10,3 51,3 38,5 total 39 100 tabel 5 . karakteristik guru berdasarkan lama bekerja di smk kal-1 surabaya, tanggal 15-16 maret 2017 (n=39) lama bekerja f % >2 tahun 39 100 total 39 100 tabel 6. karakteristik guru berdasarkan keikutsertaan dalam pelatihan p3k di smk kal-1 surabaya, tanggal 15-16 maret 2017 (n=39) pelatihan p3k f % tidak pernah 39 100 total 39 100 data khusus tabel 8. tingkat pengetahuan guru sebelum pemberian promosi kesehatan tentang p3k pada siswa di smk kal-1 surabaya, tanggal 15-16 maret 2017 (n=39) kategori f % cukup kurang 11 28 28,2 71,8 total 39 100 tabel 8 menunjukkan bahwa dari 39 guru smk kal-1 surabaya terdapat 11 orang (28,2%) memiliki pengetahuan yang cukup, 28 orang (71,8%) memiliki pengetahuan yang kurang. tabel 9. tingkat pengetahuan guru sesudah pemberian promosi kesehatan tentang p3k pada siswa di smk kal-1 surabaya, tanggal 15-16 maret 2017 (n=39) kategori f % baik cukup 21 18 53,8 46,2 total 39 100 tabel 9 menunjukkan bahwa dari 39 guru smk kal-1 surabaya sebanyak 21 orang (53,8%) memiliki pengetahuan yang baik, 18 orang (40,2%) memiliki pengetahuan yang cukup. re tr ac te d medical and health science journal, vol.3., no.1, februari 2019 56 tabel 10. pengaruh promosi kesehatan sebelum dan sesudah dilakukan promosi kesehatan tentang p3k kegawatdaruratan pada siswa di sekolah terhadap tingkat pengetahuan guru di smk kal-1 surabaya n mean std dev min max precentiles 25th 50th (med) pre 39 1,38 5,9 1 3 1,00 2,00 post 39 2,54 ,590 2 3 2,00 3,00 tabel 10 menunjukkan bahwa dari uji statistik menggunakan wilcoxon sign test diperoleh nilai p value = 0,001 (α ≤ 0,05). hal ini membuktikan bahwa ada pengaruh yang signifikan antara pemberian promosi kesehatan terhadap tingkat pengetahuan guru tentang p3k kegawatdaruratan pada siswa di smk kal-1 surabaya. pengetahuan guru tentang p3k pada siswa di smk kal-1 surabaya sebelum diberikan promosi kesehatan hasil pretest menunjukkan bahwa sebelum diberikan promosi kesehatan tentang pengetahuan guru p3k pada siswa di sekolah smk kal-1 surabaya sebanyak 28 guru (71,8%) memiliki pengetahuan yang kurang dan pengetahuan cukup sebanyak 11 responden (28,2%). hal ini menunjukkan bahwa guru di smk kal-1 kurang mengetahui dasar p3k yang harus diperhatikan saat melakukan p3k, hal-hal pokok yang harus diketahui oleh penolong, dampak yang timbul pada korban, sumber daya yang dapat dipergunakan saat menolong dan teknik p3k dalam evakuasi dan memindahkan korban. hal ini disebabkan karena kurangnya informasi yang di dapat baik melalui media masa (televisi, koran, atau internet) dan tidak pernah mendapatkan pendidikan kesehatan dari uptd terkait p3k pada siswa di sekolah. pengetahuan guru tentang p3k di smk kal1 surabaya setelah diberikan promosi kesehatan hasil posttest menunjukkan bahwa setelah diberikan promosi kesehatan tentang pengetahuan p3k di sekolah smk kal-1 surabaya sebanyak 21 guru (53,8%) mempunyai pengetahuan yang baik (76%-100%), dikarenakan memiliki kesadaraan, minat dan antusias yang baik terhadap materi promosi kesehatan. sebanyak 18 guru (46,2%) mempunyai pengetahuan yang cukup dikarenakan kurangnya minat terhadap promosi kesehatan. tujuan diberikan promosi kesehatan tentang p3k di sekolah adalah meningkatkan pengetahuan guru tentang pengertian p3k hingga bagaimana teknik p3k dalam evakuasi korban dan pertolongan yang cepat, efesien dan aman bagi penolong. sehingga, guru maupun petugas uks dapat memberikan pertolongan dengan tepat dan sesuai sehingga dapat mencegah keparahan yang terjadi atau hal-hal yang tidak diinginkan. pengaruh promosi kesehatan tentang p3k terhadap tingkat pengetahuan guru tentang p3k di smk kal-1 surabaya hasil penelitian ini menunjukkan bahwa rata-rata pengetahuan yang dimiliki guru smk kal-1 sebelum diberikannya intervensi adalah 1,38 dengan standart deviasi 590. sedangkan hasil yang diperoleh setelah diberikannya intervensi rata-rata pengetahuan guru adalah 2,54 dengan standart deviasi 505. perbedaan nilai mean antara pretest dan posttest adalah 18. 00. hasil uji wilcoxon signed rank test didapatkan nilai asymp. sig. (2-tailed) = 0. 01 sehingga dapat dinyatakan bahwa terdapat peningkatan pengetahuan yang bermakna setelah dilakukan promosi kesehatan. peningkatan pengetahuan tentang p3k dari tingkat kurang ke tingkat cukup maupun ke tingkat baik disebabkan karena pemberian promosi kesehatan. guru yang memiliki tingkat pengetahuan yang cukup disebabkan karena minimnya informasi tentang pentingnya p3k pada siswa di sekolah (rizqiani, 2016). setelah dilakukan penyuluhan re tr ac te d medical and health science journal, vol.3., no.1, februari 2019 5 7 dengan metode ceramah melalui leaflet dan power point hampir semua guru memahami tentang p3k di sekolah pada siswa. menurut nurhanifah (2017), melalui promosi kesehatan salah satunya dengan metode ceramah atau penyuluhan yang diberikan dapat membuat guru mengerti dan memahami apa yang telah disampaikan sesuai indikator. promosi kesehatan tentang p3k di sekolah yang diberikan kepada guru adalah salah satu upaya untuk meningkatkan pengetahuan guru. peningkatan skor sebelum dan sesudah diberikannya promosi kesehatan karena ketertarikan guru pada saat berlangsungnya promosi kesehatan yang menggunakan metode ceramah dan demonstrasi. dalam berlangsungnya promosi kesehatan, metode dan alat bantu yang dipergunakan dapat membantu untuk lebih memahami isi materi, mempergunakan alat bantu visual dengan menampilkan slide yang berisikan materi promosi kesehatan yang telah diringkas agar mudah dipahami oleh guru. guru dapat memperoleh pesan atau pengetahuan melalui berbagai macam alat bantu atau media, namun masing-masing alat mempunyai intensitas yang berbeda-beda di dalam membantu pemahaman pesan (notoatmodjo, 2012) hasil wawancara kepada salah satu guru dan penanggung jawab uks di smk kal-1 surabaya bahwa di smk kal-1 belum pernah ada kegiatan atau promosi kesehatan tentang p3kdi sekolah, sehingga hal ini menjadi dorongan untuk para guru di sekolah untuk memperhatikan materi yang disampaikan. p3kdi sekolah sendiri sangat penting karena hampir seluruh guru tidak paham bagaimana teknik p3k yang tepat, cepat, dan efisien apabila terjadi kecelakaan kerja saat siswa praktik dengan benda-benda yang berisiiko mencederai. menurut (notoatmodjo, 2012) perubahan perilaku merupakan proses yang kompleks dan membutuhkan waktu yang relatif lama dan berbeda pada tiap individu. perubahan perilaku seseorang menerima atau mengadopsi perilaku baru dalam kehidupannya. apabila penerimaan perilaku baru atau adopsi perilaku melalui proses seperti ini didasari oleh pengetahuan, kesadaran dari sikap yang positif, maka perilaku tersebut akan bersifat langgeng (long lasting). sebaliknya apabila perilaku itu tidak didasari oleh pengetahuan dan kesadaran maka tidak akan berlangsung lama. kesimpulan hasil penelitian dapat diambil kesimpulan sebagai berikut : 1. pengetahuan guru tentang p3k pada siswa di smk kal-1 surabaya sebelum diberikan promosi kesehatan sebagian besar kurang. 2. pengetahuan guru tentang p3k pada siswa di smk kal-1 surabaya setelah diberikan promosi kesehatan sebagian besar baik. terdapat peningkatan pengetahuan guru tentang p3k pada siswa di smk kal 1 surabaya setelah diberikan promosi kesehatan. daftar pustaka 1. badan penelitian dan pengembangan kesehatan. (2013a). laporan nasional riset kesehatan dasar (riskesdas) 2013. in laporan nasional 2013 (pp. 1–384). https://doi. org/1 desember 2013. 2. badan penelitian dan pengembangan kesehatan. (2013b). riset kesehatan dasar (riskesdas) 2013. laporan nasional 2013, 1–384. https://doi. org/1 desember 2013. 3. gunarsa, s. (2008). psikologi perawat. jakarta: pt bpk gunung mulia. 4. junaidi, i. (2011). pedoman p3k yang harus dilakukan saat gawat dan darurat medis. yogyakarta: andi. 5. norman. (2006). kapita selekta kedokteran. jakarta: media aesculapius. 6. notoatmodjo, s. (2012). promosi kesehatan dan perilaku kesehatan. jakarta: rineka cipta. 7. nurhanifah. (2017). pengaruh pendidikan kesehatan terhadap tingkat pengetahuan pertolongan pertama pada kecelakaan di re tr ac te d medical and health science journal, vol.3., no.1, februari 2019 58 sekolah pada siswa kelas vii. caring nursing jurnal. 8. rizqiani. (2016). pengaruh pendidikan kesehatan first aid box terhadap tingkat pengetahuan orang tua dalam penanganan cedera anak toddler di rumah tangga. universitas muhammadiyah yogyakarta. 9. thygerson, a. (2011). p3k edisi kelima. jakarta: erlangga. 10. wawan, a., and dewi, m. (2011). teori & pengukuran pengetahuan sikap perilaku manusia. yogyakarta: nuha medika. 11. yuda, h., tamara, and agina, p. (2015). pengetahuan tentang penanganan kegawatdaruratan pada siswa anggota hizbul wathan di sma muhammadiyah gombong. ilmu kesehatan keperawatan, 11(3). re tr ac te d e:\job aditya\indro\naskah masu novera herdiani dan wiwik afridah, efek rosella merah kering terhadap kadar mda serum tikus strain wistar yang di papar asap rokok 4747 efek rosella merah kering terhadap kadar mda serum tikus strain wistar yang di papar asap rokok novera herdiani1, wiwik afridah2 1,2fakultas kesehatan universitas nahdlatul ulama surabaya e-mail: novera.herdiani@unusa.ac.id abstract: cigarette smoke contains free radicals. currently the number of smokers in indonesia are still high. this study aims to analyze the effects of red rosella of dried on the prevention of the increase of malondialdehyde (mda) serum of strain wistar rats exposed to cigarette smoke. the total sample of 24 male rats and divided into four groups: negative control, positive control, treatment of red rosella on dried dose 540 mg/bw, and red rosella on dried dose 810 mg/bw. negative control only given with standard feed. positive control given by standard feed and exposed to 2 cigarettes a day. treatment group were feed by standard and red rosella of dried in the morning and exposed to 2 cigarettes after that. this study was conducted for 21 days. at the end of the study, blood serum was analyzed to determine mda. the results of the study of mda serum test is analyzed with one way anova and followed by tukey lsd test at 5% level. the giving of red rosella on dried dose 540 mg/bw and red rosella on dried dose 810 mg/bw can significantly prevent the increase of mda serum in strain wistar rats exposed to cigarette smoke. keywords: red rosella of dried, cigarette smoke, mda abstrak: asap rokok mengandung radikal bebas. saat ini jumlah perokok di indonesia masih tinggi. penelitian ini bertujuan untuk menganalisis dampak pemberian rosella merah kering terhadap pencegahan kenaikan malondialdehid (mda) serum tikus strain wistar yang dipapar asap rokok. total sampel 24 tikus jantan dan dibagi menjadi empat kelompok: kontrol negatif, kontrol positif, perlakuan rosella merah kering dosis 540 mg/kg bb, dan rosella merah kering dosis 810 mg/kg bb. kontrol negatif hanya diberi pakan standar. kontrol positif diberi pakan standar dan dipapar 2 rokok per hari. kelompok perlakuan diberi pakan standar dan rosella merah kering di pagi hari dan setelah itu dipapar 2 rokok. penelitian ini dilakukan selama 21 hari. di akhir penelitian, serum darah dianalisis untuk menentukan nilai mda. hasil penelitian uji mda serum dianalisis dengan one way anova dan diikuti oleh uji lsd pada level 5%. pemberian rosella merah kering dosis 540 mg/kg bb dan rosella merah kering dosis 810 mg/kg bb dapat mencegah peningkatan mda serum secara signifikan pada tikus strain wistar yang dipapar asap rokok. kata kunci: rosella merah kering, asap rokok, mda pendahuluan merokok merupakan salah satu faktor penyebab terjadinya penyakit kardiovaskuler yang merupakan penyebab kematian terbesar di dunia. word health organization telah memberikan peringatan bahwa dalam dekade 2020–2030 tembakau akan membunuh 10 juta orang per tahun, 70% di antaranya terjadi di negara-negara berkembang (who, 2008). menurut riskesdas (2013), perilaku merokok penduduk usia ≥ 15 tahun di indonesia mengalami peningkatan yaitu sejumlah 36,3%, dibandingkan riskesdas sebelumnya. ditemukan 1,4% perokok 10–14 tahun, 9,9% perokok pada kelompok tidak bekerja, dan 32,3% pada kelompok kuintil indeks kepemilikan terendah. rerata jumlah batang rokok yang diisap per hari per orang di indonesia adalah 12–13 batang (setara satu bungkus). sulit medical and health science journal, vol. 1, no. 2, august 2017 48 untuk menghentikan kebiasaan merokok pada masyarakat. menurut voges (2000), nikotin pada rokok dapat menyebabkan ketagihan dan gangguan pada jantung serta paru-paru. data riskesdas 2013, menunjukkan jumlah perokok mengalami peningkatan dan sekitar 69% rumah tangga memiliki pengeluaran untuk rokok. hal ini berarti minimal terdapat 1 orang anggota rumah tangga yang mengonsumsi tembakau. secara nasional 85,4% perokok usia 10 tahun ke atas merokok di dalam rumah ketika bersama anggota rumah tangga lain. permasalahannya, menghilangkan kebiasaan merokok bukanlah hal yang mudah. dalam asap rokok terkandung radikal bebas yang membahayakan tubuh sehingga sementara ini perlu adanya inovasi untuk mengembangkan suatu produk yang dapat meminimalisasi dampak negatif yang ditimbulkan oleh asap rokok. secara normal, radikal bebas sudah terdapat di dalam tubuh (radikal bebas endogenous). tubuh secara alami mempunyai antioksidan yang berperan sebagai inhibitor yang bekerja menghambat oksidasi dengan cara bereaksi dengan radikal bebas reaktif membentuk radikal bebas yang relatif stabil. apabila radikal bebas terlalu banyak maka antioksidan tersebut tidak mampu mengatasinya, dalam keadaan seperti ini tubuh memerlukan suplai antioksidan (sofia dan dinna, 2006), contohnya seperti antioksidan yang terkandung pada rosella merah. alternatif dalam mengatasi efek rokok yaitu pemanfaatan rosella merah kering dalam pelarut air. rosella merah kering dalam pelarut air dapat diaplikasikan sebagai bahan tambahan alami untuk pangan fungsional. pelarut air cocok untuk mengekstrak antosianin yang mempunyai kepolaran sama dengan air. selain itu, pelarut air dipilih karena lebih aman dan mudah diaplikasikan dalam skala rumah tangga. menurut esa, dkk. (2010), ekstraksi kelopak rosella dengan menggunakan pelarut air mempunyai total aktivitas antioksidan paling tinggi dibandingkan biji, daun, maupun batang rosella. kelopak rosella merah dalam pelarut air mempunyai total aktivitas antioksidan yang tinggi yaitu sebesar 54,1%. rosella merah kering banyak mengandung antosianin di mana 1 gram rosella mengandung 56,5 mg delphinidin-3-o-sambubioside dan 20,8 mg cyanidin-3-o-sambubioside (alarco-alanso, j., dkk., 2012). antioksidan dapat menetralisir radikal bebas dengan cara menerima atau mendonorkan sebuah elektron untuk menghasilkan molekul yang lebih stabil (berpasangan). radikal bebas bisa bersumber dari asap kendaraan, minyak jelantah, dan asap rokok. menurut park., dkk. (1998), asap rokok mengandung radikal bebas dalam konsentrasi tinggi. komponen kimia yang terdapat dalam asap rokok berupa gas dan partikel. senyawa gas dan partikel asap rokok beberapa di antaranya bersifat radikal. radikal bebas banyak yang berumur pendek namun nitrit oksida dan radikal quinones dapat mencapai paru-paru (tirtosastro dan murdiyati, 2010). dari paru-paru radikal bebas dibawa oleh aliran darah menuju ke jantung dan diedarkan ke seluruh tubuh (guyton dan hall, 1997). sangat ironis, banyak masyarakat yang tidak menyadari dampak negatif rokok. padahal bahaya rokok sudah tercantum dalam kemasan, bahwa merokok dapat menyebabkan kanker, serangan jantung, impotensi, gangguan kehamilan, dan janin. dampak tersebut berhubungan dengan adanya kandungan radikal bebas dalam asap rokok seperti no, co, nox, h 2 -o 2 , aldehid, trace elements, dan nitroso compounds (valvanidis, dkk., 2001). berbagai penelitian menunjukkan bahwa asap rokok mengandung berbagai macam bahan oksidan/radikal bebas yang dapat membahayakan novera herdiani dan wiwik afridah, efek rosella merah kering terhadap kadar mda serum tikus strain wistar yang di papar asap rokok 49 tubuh manusia. radikal bebas dapat menyebabkan stress oksidatif yang merupakan muara dari penyakit degeneratif. adanya peningkatan radikal bebas di dalam tubuh yang tidak diimbangi oleh peningkatan antioksidan endogen akan menimbulkan terjadinya stress oksidatif. untuk mengetahui terjadinya stress oksidatif tersebut telah dipergunakan berbagai parameter pengukuran di antaranya adalah kadar malondialdehid (mda) serum. malondialdehid merupakan suatu senyawa yang terbentuk selama proses peroksidasi lipid dari asam lemak tidak jenuh ganda (pufas = polyansturated fatty acids). pengukuran kadar mda serum sampai saat ini merupakan pengukuran yang standar untuk mengetahui adanya stres oksidatif (murray ,dkk., 2009). metode jenis penelitian ini yaitu eksperimental laboratorium. tahap in vivo yang digunakan adalah true experimental laboratory dengan posttest only control group design. rancangan perlakuan pada penelitian ini yaitu rancangan acak lengkap (ral). sampel terdiri atas 24 ekor tikus jantan dipilih dengan cara random sampling untuk dibagi dalam satu kelompok kontrol negatif (normal), satu kelompok kontrol positif, dan empat kelompok perlakuan. setiap kelompok terdiri dari 6 ekor tikus dengan penjelasan sebagai berikut. 1. kelompok i adalah kontrol negatif (kelompok normal), tidak diberi paparan dan tidak diberi rosella merah kering. 2. kelompok ii adalah kontrol positif, yang diberi air 1 ml p.o selanjutnya diberi paparan asap rokok sebanyak 2 batang. 3. kelompok iii adalah perlakuan yang diberi rosella merah kering dosis 540 mg/kg bb p.o selanjutnya diberi paparan asap rokok sebanyak 2 batang. 4. kelompok iv adalah perlakuan yang diberi rosella merah kering dosis 810 mg/kg bb p.o selanjutnya diberi paparan asap rokok sebanyak 2 batang. tahap in vivo dilakukan dengan memberikan rosella merah kering sesuai dosis yang telah ditetapkan. tahap lainnya meliputi paparan asap rokok selama 21 hari, dan pada tahap akhir dilakukan pengujian bio-assay terhadap nilai mda serum. pakan hewan coba memakai merek pokphand cp 591, dengan komposisi kadar air max 13,0%, protein 18,0-20,0%, lemak min 3,0%, serat max 6,0%, abu max 7,0%, kalsium min 0,9%, dan phosphor min 0,6%. bahanbahan yang dipakai dalam formulasi pakan antara lain jagung, dedak, tepung ikan, bungkil kedelai, bungkil kelapa, tepung daging dan tulang, pecahan gandum, bungkil kacang tanah, tepung daun, canola, vitamin, kalsium, fosfat, dan trace mineral. alat yang digunakan dalam membuat ekstrak rosella merah kering adalah spatula, beaker glass, kain saring, magnetik stirer, gelas ukur, botol gelap, kompor, thermometer, timbangan digital dan timbangan analitik (denver instrument m-310), vacuum evaporator, labu ukur, tabung erlenmeyer. alat-alat yang digunakan untuk analisis antara lain buret, erlenmeyer, beaker glass, sentrifuse, vortex, tabung reaksi, spektrofotometer, dan pipet. bahan yang digunakan dalam penelitian ini adalah rosella merah kering yang diperoleh dari desa joho, kabupaten kediri, jawa timur. bahan untuk analisis yaitu kertas saring, aquades, hcl, asam asetat, na-asetat, larutan 1,1-diphenil-2pieryllhydrazil (dpph) 0,2 m, serum tikus. medical and health science journal, vol. 1, no. 2, august 2017 50 dosis yang diberikan berdasarkan penelitian sebelumnya yang telah dilakukan ulilalbab (2012) menyebutkan bahwa ekstrak rosella dosis 540 mg/kg bb secara efektif mampu mencegah kenaikan mda serum. sehingga pada perlakuan pertama penelitian ini menggunakan dosis tersebut, di mana dosis tikus tersebut apabila diaplikasikan ke manusia setara dengan 4 (kelopak) x 3 (frekuensi konsumsi) dalam sehari dengan berat rata-rata kelopak rosella kering adalah 0,5 g. pada perlakuan kedua, dosis yang dipakai lebih besar dari dosis pertama, yaitu 6 (kelopak) x 3 (frekuensi konsumsi). apabila dikonversi ke tikus, maka menjadi 810 mg/kg bb. rokok yang digunakan dalam penelitian ini mengandung nikotin 2,1 mg dan tar sebesar 34 mg. dosis paparan asap rokok sebanyak 2 batang/tikus/hari. proses pemaparan dilaksanakan setelah pemberian ekstrak rosella p.o pada kelompok perlakuan. pemaparan dilakukan di chamber untuk kelompok kontrol positif dan kelompok perlakuan. penelitian ini akan dilaksanakan selama 2 bulan dan dilakukan di fakultas kedokteran universitas wijaya kusuma surabaya: pengujian mda, pembuatan rosella merah kering, pemeliharaan, dan perlakuan hewan coba. sampel untuk in vivo adalah tikus putih jenis rattus norvegicus strain wistar jantan dewasa usia 3–4 bulan dengan berat rata-rata 150–200 gram. metode pengambilan sampel yang digunakan adalah sistem random sampling (rancangan acak lengkap). pada tahap awal akan dilakukan analisis normalitas dengan uji shapiro-wilk dan uji homogenitas dengan levene’s test. apabila didapatkan data normal dan homogen maka selanjutnya dilakukan analisis perbandingan antar-kelompok dengan uji one way anova. apabila ada perbedaan yang signifikan maka pengujian dilanjutkan dengan uji lsd untuk melihat lebih jelas seberapa besar perbedaan tiap kelompok perlakuan. hasil tabel 1 hasil aktivitas antioksidan rosella merah kering kode sampel % inhibisi dosis 1 (540 mg/kg bb) 44,31 dosis 2 (810 mg/kg bb) 67,33 pada tabel 1 diketahui bahwa aktivitas antioksidan (uji dpph) yang tertinggi yaitu rosella merah kering dosis 810 mg/kg bb (67,33%) dan terendah pada rosella merah kering dosis 540 mg/kg bb yaitu 44,31%. berdasarkan hasil penelitian, telah didapatkan gambaran umum kadar mda serum tikus strain wistar. hasil analisis rerata kadar mda serum disajikan pada gambar 1. gambar 1 rerata mda serum berdasarkan kelompok keterangan: n : kelompok kontrol yang tidak diberi perlakuan p : kelompok kontrol yang diberi asap rokok p1 : kelompok perlakuan yang diberi rosella merah kering dosis 540 mg/kg bb dan diberi asap rokok p2 : kelompok perlakuan yang diberi rosella merah kering dosis 810 mg/kg bb dan diberi asap rokok pada gambar 1 diketahui bahwa rerata kadar mda kelompok rosella merah kering novera herdiani dan wiwik afridah, efek rosella merah kering terhadap kadar mda serum tikus strain wistar yang di papar asap rokok 51 dosis 810 mg/kg bb yaitu 9,381 nmol/ml. rerata kadar mda kelompok rosella merah kering dosis 540 mg/kg bb yaitu 12,032 nmol/ml. rerata kadar mda kelompok kontrol positif yaitu 18,055 nmol/ml. rerata kadar mda kelompok kontrol negatif yaitu 8,899 nmol/ml. kadar mda serum paling tinggi yaitu pada kontrol positif, sedangkan kadar mda paling rendah yaitu pada kontrol negatif. pada kelompok perlakuan, kadar mda serum yang paling mendekati kelompok kontrol negatif yaitu pada perlakuan rosella merah kering dosis 810 mg/kg bb. tabel 2 perbedaan kadar mda serum pada berbagai kelompok bb berbeda nyata dengan kontrol positif dan kontrol negatif, di mana kontrol positif nilai signifikansi p = 0,001 (p < 0,05) dan kontrol negatif yaitu p = 0,048 (p < 0,05). pada kontrol positif, kadar mda serum berbeda nyata dengan semua kelompok yaitu kontrol negatif, rosella merah kering dosis 810 mg/kg bb, dan rosella merah kering dosis 540 mg/kg bb, setiap kelompok ini memiliki nilai signifikansi p < 0,05. sedangkan kelompok kontrol negatif tidak berbeda nyata dengan rosella merah kering dosis 810 mg/kg bb di mana nilai signifikansi yaitu p = 0,748 (p > 0,05). kelompok kontrol negatif berbeda nyata dengan kelompok kontrol positif karena nilai signifikansi p = 0,000 (p < 0,05) dan berbeda nyata dengan rosella merah kering dosis 540 mg/kg bb karena yaitu p = 0,048 (p < 0,05). kadar mda serum yang memiliki nilai signifikansi sebesar 0,000 atau p < 0,05 maka dapat dikatakan ada perbedaan yang bermakna antar kelompok. selanjutnya dilakukan uji lsd untuk mengetahui perlakuan mana yang dinyatakan berbeda secara bermakna pada uji anova. rerata kelompok kontrol negatif, kadar mda serumnya paling rendah (8,899 nmol/ml) dibandingkan kelompok lain. sedangkan kelompok positif kadar mda serumnya (18,055 nmol/ml) paling tinggi dibandingkan kelompok lain. pembahasan malondialdehid (mda) adalah salah satu produk akhir radikal hasil peroksidasi lipid yang bersifat toksik terhadap sel hidup. selain itu, mda merupakan salah satu ukuran radikal bebas yang terkandung dalam tubuh dan dianggap sebagai biomarker yang sering digunakan untuk mengetahui tingkat stres oksidatif (santi, 2006). kelompok rerata ± sd rosella merah kering dosis 810 mg/kg bb 9,381ab ± 1,939 rosella merah kering dosis 540 mg/kg bb 12,032b ± 2,915 kontrol positif 18,055c ± 3,191 kontrol negatif 8,899a ± 2,127 keterangan: rerata yang didampingi huruf yang sama menyatakan tidak berbeda nyata. pada tabel 2 disebutkan bahwa kadar mda serum pada kelompok pemberian rosella merah kering dosis 810 mg/kg bb, tidak berbeda nyata dengan rosella merah kering dosis 540 mg/kg bb dan kontrol negatif, di mana nilai signifikansi rosella merah kering dosis 540 mg/kg bb yaitu p = 0,089 (p > 0,05) dan kontrol negatif yaitu p = 0,748 (p > 0,05). rosella merah kering dosis 810 mg/kg bb berbeda nyata dengan kontrol positif karena nilai signifikansi p = 0,000 (p < 0,05). sedangkan untuk rosella merah kering dosis 540 mg/kg bb, tidak berbeda nyata dengan rosella merah kering dosis 810 mg/kg bb, di mana nilai signifikansi rosella merah kering dosis 810 mg/kg bb yaitu p = 0,089 (p > 0,05). rosella merah kering dosis 540 mg/mg medical and health science journal, vol. 1, no. 2, august 2017 52 penelitian ini menunjukkan bahwa kandungan aktivitas antioksidan rosella merah kering dosis 810 mg/kg bb lebih tinggi dibandingkan menggunakan rosella merah kering dosis 540 mg/kg bb. hal ini disebabkan karena kadar antioksidan rosella merah kering dosis 540 mg/ kg bb dosisnya yang lebih kecil dibandingkan dosis 810 mg/kg bb. penelitian ini membuktikan bahwa semakin besar dosis yang terkandung pada rosella merah kering, maka aktivitas antioksidan semakin tinggi. hal ini sejalan dengan penelitian yang dilakukan ulilalbab (2012), bahwa aktivitas antioksidan rosella dosis yang lebih besar yaitu dosis 540 mg/kb bb lebih tinggi (82,81%) dibandingkan rosella dosis 270 mg/kg bb (59,85%). berdasarkan hasil penelitian yang telah dilakukan, rerata kadar mda kelompok kontrol positif (dipapar asap rokok) adalah 18,055 nmol/ ml ± 3,191 lebih tinggi dibandingkan dengan kelompok kontrol negatif (tanpa paparan asap rokok) adalah 8,899 nmol/ml ± 2,127.pada kelompok kontrol positif dengan negatif, kadar mda serum juga menunjukkan adanya perbedaan yang bermakna (p < 0,05). hal ini menunjukkan bahwa asap rokok dapat meningkatkan kadar mda. hal ini sejalan dengan beberapa penelitian terdahulu bahwa asap rokok akan menyebabkan terjadinya peningkatan kadar mda seperti penelitian yang dilakukan lopes dkk. (2013), kurnia dkk. (2011), subono, (2007) membuktikan bahwa rata-rata kadar mda tikus yang terpapar asap rokok, secara signifikan lebih tinggi dibandingkan dengan tikus yang tidak terpapar asap rokok. rokok merupakan salah satu sumber eksogen yang dapat memicu terjadinya produksi radikal bebas berlebih dalam tubuh, baik pada perokok aktif maupun pasif, komponen asap rokok terbagi menjadi dua fase yaitu fase gas dan partikulat. fase gas mengandung radikal bebas dalam bentuk -no. fase tar diketahui mengandung radikal dalam bentuk semiquinone (-qh). mekanisme meningkatmya radikal bebas karena efek langsung dari asap rokok itu sendiri, dan respons imun yaitu aktivasi sel inflamasi, karena beberapa komponen asap rokok bersifat iritan. radikal bebas yang terdapat di dalam asap rokok merupakan molekul biologik yang memepunyai satu atau lebih elektron yang tidak berpasangan pada orbit terluarnya, sehingga menyebabkan elektron ini tidak stabil dan sangat reaktif dapat merusak jaringan. paparan asap rokok merupakan salah satu faktor utama meningkatnya radikal bebas dalam tubuh, adapun penyebab lainnya seperti sinar ultra violet, asap kendaraan, asap pabrik dan lain sebagainya. proses tersebut akan menghasilkan ros (reactive oxygen species) berlebih yang merupakan oksidan utama dalam tubuh (muliartha, dkk., 2009). ros menyebabkan ketidakseimbangan antara oksidan dengan antioksidan yang ada di dalam tubuh sehingga menyebabkan stres oksidatif. stres oksidatif merupakan suatu keadaan ketidakseimbangan antara radikal bebas dengan antioksidan, ketika jumlah radikal bebas lebih banyak bila dibandingkan dengan antioksidan yang ada di dalam tubuh. apabila produksi radikal bebas melebihi dari kemampuan antioksidan untuk menetralkannya, maka kelebihan radikal bebas sangat potensial menyebabkan penyakit (halliwel, dkk., 2007). peningkatan ros mengakibatkan radikal bebas akan bereaksi dengan lemak, protein, dan asam nukleat seluler sehingga hal ini dapat menyebabkan kerusakan lokal dan disfungsi organ tertentu. lemak sangat rentan terhadap serangan radikal bebas. mekanisme sel atau novera herdiani dan wiwik afridah, efek rosella merah kering terhadap kadar mda serum tikus strain wistar yang di papar asap rokok 53 jaringan akibat serangan dari radikal bebas yang paling awal diketahui dan paling banyak terjadi di membran sel, terutama asam lemak tidak jenuh pufa yang merupakan komponen penting penyusun membran sel. (halliwel, dkk., 2007). hasil yang diperoleh dari penelitian ini secara preventif menunjukkan bahwa kelompok yang diberi perlakuan rosella merah kering disertai dengan pemberian asap rokok menunjukkan adanya penurunan kadar mda dibandingkan dengan kelompok yang hanya diberi asap rokok tanpa diberi rosella merah kering. rerata kadar mda kelompok rosella merah kering dosis 810 mg/kg bb adalah 9,381 nmol/ml ±1,939 dan kelompok rosella merah kering dosis 540 mg/kg bb adalah 12,032 nmol/ml ±2,915, lebih rendah dibandingkan kelompok kontrol positif adalah 18,055 nmol/ml ±3,191. kadar mda serum kelompok rosella merah kering dosis 810 mg/kg bb hampir sama dengan rerata kadar mda kelompok kontrol negatif adalah 8,899 nmol/ml ±2,127. kelompok kontrol negatif mempunyai rerata kadar mda serum paling rendah dibandingkan kelompok lain. hal ini dikarenakan pada kelompok ini tidak diberikan asap rokok sehingga kadar mda yang dihasilkan cenderung lebih rendah dibandingkan kelompok lain. sedangkan kadar mda paling tinggi adalah pada kelompok kontrol positif. hal ini dikarenakan pada kelompok kontrol positif diberikan paparan asap rokok tanpa diberi asupan sumber antioksidan yang memiliki fungsi dalam menetralisir radikal bebas. asap rokok merupakan sumber radikal bebas yang dapat menyebabkan stres oksidatif. menurut teori santi (2006) bahwa paparan asap rokok menimbulkan kenaikan kadar mda. hal ini disebabkan karena paparan asap rokok menimbulkan radikal bebas. radikal bebas yang berlebihan akan menimbulkan stres oksidasi. radikal bebas tanpa adanya antioksidan sebagai peredam menyebabkan kadar mda serum tikus terus meningkat. pada kelompok yang diberi perlakuan rosella merah kering dosis 810 mg/kg bb dan dosis 540 mg/kg bb dengan kelompok kontrol positif menunjukkan adanya perbedaan bermakna (p < 0,05). hal ini menunjukkan bahwa terjadi penurunan kadar mda serum pada kelompok yang mendapat perlakuan rosella merah kering. perlakuan pada hewan coba secara preventif dengan menggunakan rosella merah kering dapat mencegah kenaikan kadar mda yang diakibatkan oleh paparan asap rokok. penelitian ini sejalan dengan yang dilakukan suwandi (2012), bahwa terjadi penurunan kadar mda sebesar 28,1% pada kelompok yang diberikan rosella dengan dosis 250 mg/kg bb dan pada kelompok yang diberikan rosella dosis 500 mg/kg bb sebesar 50,2%. kelompok perlakuan rosella merah kering dosis 810 mg/kg bb dan rosella merah kering dosis 540 mg/kg bb memberikan pengaruh terhadap penurunan tingkat stres oksidatif berupa penurunan kadar malondialdehid (mda) yang ditimbulkan oleh asap rokok. keadaan di mana terjadi ketidakseimbangan antara produksi senyawa turunan oksigen dengan sistem antioksidan tubuh inilah yang memicu kondisi stres oksidatif, di mana salah satu paramaternya adalah peningkatan produksi turunan radikal bebas. berdasarkan hasil uji statistik menunjukkan bahwa pada kelompok perlakuan pada uji in vivo memberikan pengaruh nyata (p > 0,05) terhadap kadar mda serum. sehingga perlu dilakukan uji lanjutan statistik untuk melihat perlakuan mana yang berbeda (perbedaan tersebut dapat dilihat pada lampiran). perbedaan dosis digunakan untuk melihat pengaruh antara dosis rosella merah kering yang diberikan dengan medical and health science journal, vol. 1, no. 2, august 2017 54 besarnya kadar mda serum. kelompok perlakuan rosella merah kering dosis 810 mg/kg bb dan dosis 540 mg/kg bb secara rerata mengalami tendensi penurunan kadar mda. hal ini menunjukkan bahwa pemberian dosis rosella merah kering dosis 810 mg/kg bb dan dosis 540 mg/kg bb memberikan pengaruh nyata terhadap penurunan kadar mda, akan tetapi di antaranya keduanya tidak berbeda nyata. sebagaimana diketahui rosella merah kering dosis 810 mg/kg bb merupakan tambahan ½ dari dosis 540 mg/kg bb. hal ini diduga ekstrak rosella merah dosis 810 mg/kg bb dan dosis 540 mg/kg bb yang diberikan memiliki interval dosis yang pendek, sehingga antar-kelompok rerata kadar mda serum hampir sama. hasil uji lanjutan menunjukkan bahwa kelompok kontrol positif berbeda nyata dengan kelompok kontrol negatif. hal ini dikarenakan kelompok kontrol negatif yang hanya diberi perlakuan pakan standar saja (normal) tanpa pemberian rosella merah kering dan paparan asap rokok sehingga mengakibatkan kadar mda serum tikus masih normal (8,899 nmol/ml) dan paling rendah dibandingkan kelompok lain. berbeda dengan kelompok kontrol negatif, kelompok kontrol positif merupakan kelompok yang dikondisikan mengalami stres oksidatif dengan paparan asap rokok. kadar mda kelompok kontrol positif paling tinggi (18,055 nmol/ ml) dibandingkan kelompok lain. hal ini mengindikasikan pada kelompok kontrol positif terjadi stres oksidatif, dikarenakan pada kelompok kontrol positif hanya diberi asap rokok dan pakan standar tanpa pemberian asupan antioksidan. tidak adanya asupan antioksidan menyebabkan radikal bebas dalam darah mengalami peningkatan yang ditandai dengan peningkatan kadar mda. perlakuan pada hewan coba secara preventif dengan menggunakan rosella merah kering yang mengandung antioksidan dapat mencegah kenaikan kadar mda yang meningkat akibat paparan asap rokok. berdasarkan penelitian kadar mda serum dapat disimpulkan bahwa pemberian rosella merah kering yang mengandung antioksidan dapat menurunkan kadar mda serum tikus wistar yang diberi paparan asap rokok. rosella merah kering dosis 810 mg/kg bb lebih efektif menurunkan kadar mda serum tikus wistar yang diberi paparan asap rokok. kesimpulan aktivitas antioksidan rosella merah kering dosis 810 mg/kg bb (67,33%) paling tinggi dibandingkan rosella merah kering dosis 540 mg/kg bb (44,31%). ada perbedaan kadar malondialdehid (mda) serum antara kelompok kontrol negatif, kontrol positif, dan kelompok perlakuan. rosella merah kering dosis 810 mg/kg bb lebih efektif menurunkan kadar malondialdehid (mda) serum tikus strain wistar yang dipapar asap rokok. pada kelompok kontrol negatif, kadar mda serum paling rendah dibandingkan kelompok lain. sedangkan kelompok positif kadar mda serum paling tinggi dibandingkan kelompok lain. untuk pencegahan agar tidak sampai kondisi stres oksidatif, semua kelompok perlakuan pemberian rosella merah kering mampu mencegah kondisi stres oksidatif yang dipapar asap rokok. saran disarankan mengonsumsi rosella merah, terutama dengan dosis rosella merah 6 (kelopak) x 3 (frekuensi konsumsi) dalam sehari untuk novera herdiani dan wiwik afridah, efek rosella merah kering terhadap kadar mda serum tikus strain wistar yang di papar asap rokok 55 memberikan efek antioksidan dalam tubuh dan mencegah timbulnya kondisi stres oksidatif. perlu dilakukan pengujian dan penelitian lebih lanjut diterapkan pada manusia guna pencegahan radikal bebas khususnya pada manusia yang terpapar asap rokok. daftar pustaka alarco-alanso, j., zamilpa a, aguilar, f.a. 2012 pharmacological characterization of the dieretic effect of hibiscus sabdariffa linn (malvaceae) extract. j. ethnopharmacol, 139: 751–6. badan penelitian dan pengembangan 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studi ilmu kedokteran dasar universitas airlangga surabaya. sofia dan dinna. 2006. antioksidan dan radikal bebas (online) www.chemistry.org. tirtosastro, s. dan murdiyati, a.s. 2010. kandungan kimia tembakau dan rokok. buletin tanaman tembakau, serat dan minyak industri 2(1), april 2010:33–43. valvanidis a., dkk. 2001. a comparative study by electron paramagnetic resonance of free radicals species in the main steam and side stream smoke of cigarettes with medical and health science journal, vol. 1, no. 2, august 2017 56 conventional accate filters and biofilters, medline journal. england. voges, e. 2000. tobacco encyclopedia. tabac journal international, mainz, germany, 279p. world health organization. 2008. who report on the global tobacco epidemic 2008, 3–8. new york: who publisher. medical and health science journal, vol.3., no.1, februari 2019 original article pengaruh ekstrak buah mengkudu (morinda citrifolia) terhadap kadar kolesterol total darah pada tikus putih (rattus norvegicus) jantangalur wistaryang diberi diet tinggi lemak ,astrid ika priadna 1* , budiarto adiwinoto 2 , fitri handajani 3 . 1,2,3 fakultas kedokteran universitas hang tuah surabaya, indonesia *correspondent author: astridika12@gmail.com article info article history: received 23 january 2019 received in revised form february 2019 accepted 4 february 2019 abstract background: high cholesterol dietinduced hypercholesterolemia. noni fruit extracthas flavonoids which are expected to reduceblood total cholesterol levels.this study aims to determine the effect of noni fruit extract (morinda citrifolia) on total blood cholesterol levels in wistar strain male rats (rattus norvegicus) given a high-fat diet. method: experimental study using post test only control group design. a total of 24 wistar strain male rats were divided into 3 groups: negative controlgroup given standard feed; positive control group of experimental animals who were given a high-fat diet; the experimental group treated with a high-fat diet for 14 days and given noni fruit keywords: high-fat diet, noni fruit extract, total blood cholesterol levels. kata kunci: diet tinggi lemak, ekstrak buah mengkudu, kadar kolesterol total darah. extractat a dose of 200 mg / kg bb. on the 29th day total blood cholesterol levels were measured for all groups of experimental animals. results: the mann whitney utest showed a significant increase in total blood cholesterol levels in the positive group of experimental animals given a high-fat diet (68.13 mg/dl) compared to the negative control group of experimental animals given standard feed (51.25 mg/dl). there was a significant decrease in total blood cholesterol levels in the experimental group treated with a high-fat diet and noni fruit extract (61mg/dl) compared to the average positive control group of experimental animals given a high-fat diet (68.13 mg/dl). conclusion: provision of a high-fat diet in wistar strain male ratscan significantly increase total blood cholesterol levels. the administration of noni fruit extract in wistar strain male ratscan significantly reduce total blood cholesterol levels. abstrak latar belakang: diet tinggi lemak mengakibatkan hiperkolesterolemia. ekstrak buah mengkudu mempunyai senyawa flavonoid yang diharapkan dapat menurunkan kadar kolesterol total darah.penelitian ini bertujuan untuk mengetahui pengaruh pemberian ekstrak buah mengkudu (morinda citrifolia) terhadap kadar kolesterol total darah pada tikus putih (rattus norvegicus) jantan galur wistar yang diberi diet tinggi lemak. metode: experimentalpost test only control group design. 24 ekor tikus putih jantan galur wistar dibagi menjadi 3 kelompok: kelompok kontrol negatif hewan coba yang diberi pakan standar; kelompok kontrol positif hewan coba yang diberi diet tinggi lemak; kelompok perlakuan hewan coba yang diberi diet tinggi lemak dan pada hari ke 15-28 diberi ekstrak buah mengkudu dengan dosis 200 mg/kg bb tikus. pada hari ke 29 diukur kadar kolesterol total darah semua kelompok hewan coba. hasil: uji mann whitney menunjukan peningkatan rerata kadar kolesterol total darah secara bermakna pada kelompok kontrol (68,13 mg/dl) dibandingkan kelompok kontrol negatif (51,25 mg/dl). penurunan rerata kadar correspondence: astrid ika priadna @2019 medical and health science journal. 10.33086/mhsj.v3i1.922 available at http://journal2.unusa.ac.id/index.php/mhsj 17 mailto:astridika12@gmail.com http://journal2.unusa.ac.id/index.php/mhsj medical and health science journal, vol.3., no.1, februari 2019 kolesterol total darah secara bermakna pada kelompok perlakuan (61mg/dl) dibandingkan rerata kelompok kontrol positif (68,13 mg/dl). kesimpulan: diet tinggi lemak pada tikus putih jantan galur wistar dapat meningkatkan secara bermakna kadar kolesterol total darah. ekstrak buah mengkudu dapat menurunkan secara bermakna kadar kolesterol total darah hewan coba yang diberi diet tinggi lemak. @2019 medical and health science journal. 10.33086/mhsj.v3i1.922 pendahuluan hiperkolesterolemia merupakan salah satu faktor resiko penyebab terjadinya penyakit jantung koroner. di indonesia saja, terdapat sekitar 36 juta penduduk atau sekitar 18% dari penduduk indonesia yang menderita kelainan lemak darah ini. dari jumlah itu, 80% pasien meninggal mendadak akibat serangan jantung dan 50%-nya tidak menampakkan gejala sebelumnya (jempormase, bodhi and kepel, 2016). hiperkolesterolemia didefinisikan sebagai peningkatan kadar kolesterol plasma diatas normal (stapleton et al., 2010). kadar kolesterol pada orang dewasa dinyatakan tinggi apabila mencapai nilai >240 mg/dl sedangkan pada anak-anak dan remaja nilai kolesterol total mencapai 200 mg/dl atau lebih sudah dinyatakan tinggi (jempormase, bodhi and kepel, 2016). salah satu cara untuk menurunkan hiperkolesterolemia dan penyakit kardiovaskular adalah dengan menurunkan kadar kolesterol total darah. saat ini banyak sekali beredar di pasaran, obat-obat penurun kolesterol atau antikolesterol baik obat alami maupun obat modern atau sintetis. untuk tahap awal, terapi non farmakologis seperti diet dan gerak badan lebih diutamakan, tetapi apabila terapi non farmakologis ini gagal, selanjutnya dilakukan terapi farmakologis, baik dengan menggunakan obat alami maupun obat modern atau sintetis (ariantari, n. p., yowani, s. c., & swastini, 2010). salah satu tanaman obat yang banyak digunakan saat ini sebagai obat tradisional adalah buah mengkudu (morinda citrifolia). buah mengkudu (morinda citrifolia) dikenal dan digunakan sebagai tanaman yang berkhasiat untuk menyembuhkan beberapa penyakit, antara lain penyakit hepar, radang lambung, hipertensi, diabetes, diueretik, obat cacing gelang. buah mengkudu (morinda citrifolia) dapat menurunkan kadar kolesterol total darah , ldl, tigliserida dan peningkatan hdl serta dapat memperbaiki struktur histologi pembuluh(penebalan tunika media) aorta mencit yang diberikan diet tinggi lemak(indriawati et al., 2011). menurut hasil penelitiansasnan (2014), pemberian kapsul mengkudu (morinda citrifolia) yang terdiri dari 90% ekstrak kering buah mengkudu dan 10% filler dapat menurunkan kadar kolesterol total darah. pada penelitian ini akan dibuktikan pengaruh pemberian ekstrak buah mengkudu (morinda citrifolia) dapat menurunkan kadar kolesterol total darah pada tikus putih (rattus norvegicus) jantan galur wistar yang diberi diet tingi lemak. hasil yang diperoleh akan digunakan untuk pengembangan obat tradisional yang memanfaatkan tanaman mengkudu (morinda citrifolia) sebagai obat alternatif untuk menurunkan kadar kolesterol total darah. berdasarkan latar belakang di atas, maka dilakukan penelitian yang bertujuan untuk mengetahui pengaruh ekstrak buah mengkudu terhadap kadar kolesterol total darah tikus putih (rattus norvegicus) jantan galur wistar yang diberi diet tinggi lemak. metode penelitian 18 medical and health science journal, vol.3., no.1, februari 2019 rancangan penelitian ini menggunakan post test only control group design. dalam penelitian ini digunakan tiga kelompok hewan coba yang terdiri dari 2 kelompok kontrol (kelompok kontrol positif dan negatif) dan 1 kelompok perlakuan. tiap kelompok terdiri dari 8 hewan cobatikus jantan strain wistar berumur 1-2 bulan dengan berat badan awal antara 100-200gram sebanyak 24 ekor yang diperoleh dari laboratorium biokimia fakultas kedokteran universitas hang tuah surabaya. pembuatan ekstrak mengkudu buah mengkudu (morinda citrifolia) tersebut di kupas kulit luarnya, lalu di belah menjadi beberapa bagian. iris potongan buah tersebut menjadi sangat tipis lalu keringkan dalam oven pada suhu 60ºc sampai kering. buah mengkudu (morinda citrifolia) yang sudah kering diblender sampai menjadi serbuk. buah mengkudu (morinda citrifolia) diekstrak dengan penyaring etanol 70% menggunakan tehnik maserasi. serbuk buah mengkudu (morinda citrifolia) direndam (maserasi) dengan larutan etanol 70% selama 24 jam dan di ambil filtratnya dengan melakukan penyaringan. kemudian, hasil saringan diuapkan diatas pemanas air. pada tahapan akhir proses ini, akan didapatkan ekstrak murni berupa cairan kental dari serbuk buah mengkudu (morinda citrifolia). persiapan diet tinggi lemak pellet seberat 10 kg dihancurkan hingga menjadi butiran serbuk, kemudian dicampur secara bertahap dengan 2l minyak babi. setelah itu, diberi air panas, pellet dan minyak babi diaduk sampai homogen. dimasukan ke dalam oven pada suhu 90ºc-100ºc agar menjadi kering dan ukurannya lebih kecil. hasil dan pembahasan hasil penelitian telah dilakukan di laboratorium biokimia fakultas kedokteran universitas hang tuah surabaya selama 28 hari. penelitian menggunakan 24 ekor tikus putih (rattus novergicus) jantan galur wistar yang dibagi menjadi 3 kelompok, yaitu : 1. kelompok kontrol negatif: kelompok hewan coba yang diberi diet standar 2. kelompok kontrol positif: kelompok hewan coba yang diberi diet tinggi lemak 3. kelompok perlakuan : kelompok hewan coba yang diberi diet tinggi lemak dan ekstrak mengkudu (morinda citrifolia) didapatkan bahwa nilai rerata kadar kolesterol total darah pada kelompok kontrol negatif hewan coba yang diberi pakan standar sebesar 51,25 mg/dl dengan standar deviasi 6,671, kelompok kontrol positif hewan coba yang diberi diet tinggi lemak sebesar 68,13 mg/dl dengan standar deviasi 5,592, kelompok perlakuan hewan coba yang diberi diet tinggi lemak dan ekstrak mengkudu (morinda citrifolia) sebesar 61 mg/dl dengan standar deviasi 5,043. rerata kadar kolesterol total darah tertinggi yaitu kelompok kontrol positif hewan coba yang diberi diet tinggi lemak (k(+)) dan terendah pada kelompok kontrol negatif hewan coba yang diberi pakan standar (k( )). untuk melihat lebih jelas perbandingan rerata kadar kolesterol total darah kelompok kontrol negatif hewan coba yang diberi pakan standar, kelompok kontrol positif hewan coba yang diberi diet tinggi lemak, dan kelompok perlakuan hewan coba yang diberi diet tinggi lemak dan ekstrak mengkudu (morinda citrifolia) dapat dilihat pada gambar 1. 19 medical and health science journal, vol.3., no.1, februari 2019 gambar 1. rerata kadar kolesterol total darah pada kelompok kontrol negatif hewan coba yang diberi pakan standar, kelompok kontrol positif hewan coba yang diberi diet tinggi lemak, dan kelompok perlakuan hewan coba yang diberi diet tinggi lemak dan ekstrak mengkudu (morinda citrifolia). k(-) :kelompok kontrol negatif hewan coba yang diberi pakan standar k(+) :kelompok kontrol positif hewan coba yang diberi diet tinggi lemak k(p) :kelompok perlakuan hewan coba yang diberi diet tinggi lemak dan ekstrak mengkudu (morinda citrifolia) hasil uji normalitas pada data memberikan hasil distribusi data tidak normal sehingga dilakukan uji kruskal-wallis.hasil uji kruskal wallis antara kelompok kontrol negatif hewan coba yang diberi pakan standar, kelompok kontrol positif hewan coba yang diberi diet tinggi lemak, dan kelompok perlakuan hewan coba yang diberi diet tinggi lemak dan ekstrak mengkudu (morinda citrifolia) didapatkan nilai p ditunjukan oleh nilai asymp.sig. yaitu sebesar 0,001<0,05. sehingga dapat disimpulkan bahwa ada perbedaan yang bermakna terhadap kolesterol total darah antara kelompok kontrol negatif hewan coba yang diberi pakan standar, kelompok kontrol positif hewan coba yang diberi diet tinggi lemak, dan kelompok perlakuan hewan coba yang diberi diet tinggi lemak dan ekstrak mengkudu (morinda citrifolia). untuk mengetahui kelompok yang memliki pengaruh yang bermakna, maka akan dilakukan uji mann whitney u. hasil uji mann-whitney u kadar kolesterol total darah kelompok kontrol negatif hewan coba yang diberi pakan standar dan kelompok kontrol positif hewan coba yang diberi diet tinggi lemak didapatkan bahwa kelompok kontrol negatif hewan coba yang diberi pakan standar dan kelompok kontrol positif hewan coba yang diberi diet tinggi lemak memiliki nilai p sebesar 0,001<0,05, maka dapat disimpulkan terdapat perbedaan yang bermakna antara kelompok kontrol negatif hewan coba yang diberi pakan standar dengan kelompok kontrol positif hewan coba yang diberi diet tinggi lemak. hasil uji mann-whitney u kadar kolesterol total darah kelompok kontrol negatif hewan coba yang diberi pakan standar dan kelompok perlakuan hewan coba yang diberi diet tinggi lemak dan ekstrak mengkudu (morinda citrifolia) didapatkan bahwa kelompok kontrol negatif hewan coba yang diberi pakan standar dan kelompok perlakuan hewan coba yang diberi diet tinggi lemak dan ekstrak mengkudu (morinda citrifolia) memiliki nilai p sebesar 0,015<0,05, maka dapat disimpulkan terdapat perbedaan yang bermakna antara kelompok kontrol negatif hewan coba yang diberi pakan standar dan kelompok perlakuan hewan coba yang diberi diet tinggi lemak dan ekstrak mengkudu (morinda citrifolia). hasil uji mann-whitney u kadar kolesterol total darah kelompok kontrol positif hewan coba yang diberi diet tinggi lemak dan kelompok perlakuan hewan coba yang diberi diet tinggi lemak dan ekstrak mengkudu (morinda citrifolia) didapatkan bahwa kelompok kontrol positif hewan coba yang diberi diet tinggi lemak dan kelompok perlakuan hewan coba yang diberi diet tinggi lemak dan ekstrak mengkudu (morinda citrifolia) memiliki nilai p sebesar 0,015<0,05, maka dapat disimpulkan terdapat perbedaan yang bermakna antara kelompok kontrol positif hewan coba yang diberi diet tinggi lemak dan kelompok perlakuan hewan coba yang diberi diet tinggi lemak dan ekstrak mengkudu (morinda citrifolia). 20 kolesterol total 100 51,25 68,13 61 50 0 k (-) k(+) k (p) medical and health science journal, vol.3., no.1, februari 2019 pembahasan berdasarkan hasil analisis data, rerata kadar kolesterol total darah pada kelompok kontrol positif hewan coba yang diberi diet tinggi lemak sebesar 68,13 mg/dl, menunjukan adanya peningkatan yang bermakna dengan perhitungan statistik nilai signifikansi sebesar p=0,001 jika dibandingkan dengan rerata kadar kolesterol total darah kelompok kontrol negatif hewan coba yang diberi pakan standar sebesar 51,25 mg/dl. dari hasil penelitian menunjukan bahwa diet tinggi lemak dapat meningkatkan secara bermakna kadar kolesterol total darah dibandingkan kelompok kontrol negatif hewan coba yang diberi pakan standar. peningkatan kadar kolesterol total darah pada kelompok kontrol positif hewan coba yang diberi diet tinggi lemak mempengaruhi plasma lipid dalam darah. plasma lipid terdiri dari triasilgliserol (16%), fosfolipid (30%), kolesterol (14%), ester kolesterol (36%) dan fraksi yang jauh lebih kecil dari rantai panjang asam lemak yang tidak diesterifikasi (4%). fraksi terakhir ini, free fatty acid (ffa) adalah metabolik paling aktif dari plasma lipid (murray, 2009). diet tinggi lemak menyebabkan penyerapan lemak di usus meningkat. lipid di usus diabsorbsi dalam bentuk free fatty acid (ffa) (jim, 2013). free fatty acid (ffa) dapat dioksidasi menjadi asetil-koa melalui proses oksidasi β (mayes, 2009). asetil-koa merupakan komponen utama pada proses biosintesis kolesterol. dua molekul asetil-koa bersatu untuk membentuk asetoasetil koa yang dikatalisis oleh thiolase. asetoasetil koa dikatalisis oleh hmg-koa sintase untuk membentuk hmg-koa. hmg-koa dikatalisis oleh hmg-koa reduktase untuk membentuk mevalonate. mevalonate akan mengalami proses dekarboksilasi sehingga terbentuk unit isoprenoid aktif. enam unit isoprenoid akan membentuk skualen. pembentukan lanosterol dari skualen dikatalisis oleh oksido skualen yaitu lanosterol siklase. lanosterol diubah menjadi demosterol kemudian direduksi menghasilkan kolesterol (murray, 2009). diet tinggi lemak menyebabkan biosintesis kolesterol meningkat maka akan diikuti kadar kolesterol total darah meningkat dan dapat menimbulkan hiperkolesterolemia. rerata kadar kolesterol total darah pada kelompok perlakuan hewan coba yang diberi diet tinggi lemak dan ekstrak buah mengkudu (morinda citrifolia) sebesar 61 mg/dl, lebih rendah jika dibandingkan dengan kelompok kontrol positif hewan coba yang diberi diet tinggi lemak sebesar 68,13 mg/dl. rerata tersebut diatas berdasarkan hasil uji statistik menghasilkan nilai signifikansi sebesar p=0,015 yang menunjukan bahwa ekstrak buah mengkudu (morinda citrifolia) dapat menurunkan secara bermakna kadar kolesterol total darah pada kelompok kontrol perlakuan hewan coba yang diberi diet tinggi lemak dan ekstrak buah mengkudu. menurut penelitian yang dilakukan oleh pawlus and kinghorn (2007), buah mengkudu yang diuji secara biologis pada ekstrak kasar dan senyawa murni yang telah dilakukan menunjukan mengkudu sebagai antioksidan, anti-inflamasi, antinociceptive, anti-kanker, anti-diabetes dan anti hipertensi (pawlus and kinghorn, 2007). menurut hasil penelitian utami (2010), hasil uji fitokimia pada ekstrak buah mengkudu mengandung flavonoid, alkaloid, saponin. senyawa flavonoid berperan sebagai antioksidan. pada penelitian ini kandungan ekstrak buah mengkudu yang berupa flavonoid berperan dalam proses penurunan kadar kolesterol total darah pada hewan coba yang diberi diet tinggi lemak. penelitian ini memperkuat penelitian lain yang dilakukan oleh sasnan (2014) yang mengatakan bahwa morinda citrifolia kaya akan kandungan flavonoid yang merupakan substansi polyphenol, dapat menghambat biosintesis kolesterol yaitu dengan menghambat aktivitas enzim hmg-koa reduktase. sehingga produksi kolesterol yang 21 medical and health science journal, vol.3., no.1, februari 2019 dihasilkan melalui proses biosintesis kolesterol akan menurun. kesimpulan dan saran kesimpulan berdasarkan hasil penelitian pengaruh ekstrak buah mengkudu (morinda citrifolia) terhadap kadar kolesterol total darah pada tikus putih (rattus norvegicus) jantan galur wistar yang diberi diet tinggi lemak, maka dapat disimpulkan bahwa : 1. pemberian diet tinggi lemak menggunakan minyak babi yang dicampurkan dalam pakan selama 28 hari dapat meningkatkan secara bermakna kadar kolesterol total darah pada kelompok kontrol positif hewan coba yang diberi diet tinggi lemak dan kelompok perlakuan hewan coba yang diberi diet tinggi lemak dan ekstrak buah mengkudu (morinda citrifolia). 2. pemberian ekstrak buah mengkudu (morinda citrifolia) dengan dosis 200 mg/kg bb tikus yang diberikan secara sonde intragastik selama 14 hari dapat menurunkan secara bermakna kadar kolesterol total darah pada kelompok perlakuan hewan coba yang diberi diet tinggi lemak dan ekstrak buah mengkudu (morinda citrifolia). saran saran yang dapat diberikan oleh peneliti untuk penelitian selanjutnya adalah 1. perlu dilakukan penelitian serupa dengan dosis yang berbeda untuk menentukan dosis optimal terhadap penurunan kadar kolesterol total darah secara bermakna 2. perlu dilakukan penelitian lebih lanjut menggunakan metode lain untuk penelitian lain berbahan dasar buah mengkudu yang tidak merusak komposisi buah mengkudu 3. perlu dilakukan penelitian lebih lanjut mengenai efek samping penggunaan ekstrak mengkudu dalam jangka panjang. daftar pustaka 1. ariantari, n. p., yowani, s. c., & swastini, d. 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(2003) ‘pengaruh ekstrak buah mengkudu ( morinda citrifolia ) terhadap aorta terpisah marmut ( cavia porcellus ) tanpa endotel’, jurnal kedokteran brawijaya, 19(3), pp. 120– 124. 8. indriawati, r. et al. (2011) ‘pengaruh mengkudu (morinda citrifolia) terhadap hipertensi pada kelompok usia lanjut the effect of mengkudu (morinda citrifolia) in hypertension of elderly group’, mutiara medika, 11(3), pp. 167–174. 9. jempormase, f., bodhi, w. and kepel, b. j. (2016) ‘prevalensi hiperkolesterolemia pada remaja obes di kabupaten minahasa’, jurnal e biomedik, 4. 10. jim, e. l. (2013) ‘metabolisme lipoprotein’, jurnal biomedik. 22 medical and health science journal, vol.3., no.1, februari 2019 11. kusumawati. (2004). bersahabat dengan hewan coba. yogjakarta: gadjah mada university press. 12. mandukhail, s. u. r., aziz, n. and gilani, a. h. 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(2014) ‘effect of morinda citrifolia fruit extract capsule on total cholesterol levels in patients with hypercholesterolemia’, effect of morinda citrifolia fruit extract capsule on total cholesterol levels in patients with hypercholesterolemia, 13(august), pp. 1319–1326. 21. sofian, f. f. (2011). efek ekstrak etanol buah terungu ungu terhadap kadar kolesterol total dan tg pada tikus jantan. 7. 22. stapleton, p. a. et al. (2010) ‘hypercholesterolemia and microvascular dysfunction: interventional strategies’, journal of inflammation. 23. steel rgd, torrie jh, alih bahasa sumantri b, 1991, prinsip dan prosedurstatistika, suatu pendekatan biometrik.cetakan ke dua, jakarta,pt gramedia pustaka utama. 24. suckow, et al., 2006 the laboratory rat. elsevier. usa. 25. sugrani, r. a. (2009). flavonoid (kuersetin). program s2 kimia universitas hassanudin, 2 3. 26. utami, a. m. (2010) ‘aktivitas antioksidan ekstrak buah dan daun mengkudu’. 27. winarti, c. (2005) ‘peluang pengembangan minuman fungsional dari buah mengkudu, j. litbang pertanian. 28. wijayakusuma, m. h. 2002. penyembuhan mengkudu morinda citrifolia l. jakarta: penerbit milenia populer, h: 10-82. 29. yatim, d. f. (2005). 30 gangguan kesehatan pada usia anak sekolah. jakarta: pustaka populer obor. 23 medical and health science journal, vol.3., no.1, februari 2019 24 medical and health science journal, vol.3., no.1, februari 2019 original article gambaran indeks larva aedes aegypti di buffer wilayah kerja bandara sepinggan balikpapan ,abdurrakhman fakultas kesehatan masyarakat universitas airlangga, surabaya, indonesia *correspondent author: aboeraja80@gmail.com article info article history: received 25 january 2019 received in revised form february 2019 accepted 4 february 2019 abstract the house index and container index in the buffer area of the working area of balikpapan sepinggan airport is still above 1%, so the potential for the spread of dengue disease. mobilization of people, goods and transportation equipment will increasingly affect the transmission of disease in ports and airports, especially for vector-borne diseases. this study aims to analyze the risk factors associated with larvae density of aedes aegypti and describe the larvae index in the buffer zone of the sepinggan balikpapan airport this study was a descriptive study with a cross sectional design. the sample in this study was 121 houses with a proportionate stratified random sampling, the research keywords: larva density, breeding sites, eradicatioan behavior mosquito levels and larvasidation kata kunci: kepadatan jentik, tempat perindukan, perilaku pemberantasan sarang nyamuk dan larvasidasi. location was in the buffer zone of sepinggan balikpapan airport in november 2018. the variables studied were houses with positive larvae containers, breeding sites and psn behavior and larvasidation. the data was analyzed using the chi square test. there was a relationship between houses with larvae positive aedes aegypti, behavior of mosquito nest eradication (psn) and larvasidation with larvae density of aedes aegypti but not for breeding sites (p = 0.00 and 95% ci = 0.64), and (p = 0.00 and 95% ci = 0.34). the description of several aedes aegypti larvae index, namely house index (hi) = 57.02%, container index (ci) = 24.36%, bruteau index (bi) = 148.76, and flick free numbers (abj) = 42.98 %. houses with larvae of aedes aegypti larvae and psn and larvasidation behavior were associated with larvae density of aedes aegypti. the index of hi, ci and bi larvae is of high value so there is a risk of dbd transmission. abstrak house index dan container index di buffer wilayah kerja bandara sepinggan balikpapan masih diatas 1 %, sehingga berpotensi penyebaran penyakit dbd. mobilisasi orang, barang serta alat angkut semakin meningkat akan berpengaruh terhadap penularan penyakit di pelabuhan dan bandara terutama untuk penyakit tular vektor. penelitian ini bertujuan untuk menganalisis faktor risiko yang berhubungan dengan kepadatan jentik aedes aegypti dan mendeskripsikan indeks larva di buffer wilayah kerja bandara sepinggan balikpapan penelitian ini merupakan penelitian deskriptif dengan desain cross sectional. sampel pada penelitian ini adalah 121 rumah dengan proportionate stratified random sampling, lokasi penelitian di buffer wilayah kerja bandara sepinggan balikpapan pada bulan november 2018. variabel yang diteliti, rumah dengan kontainer positif jentik, tempat perindukan dan perilaku psn dan larvasidasi.data dianalisa meggunakan uji statistik chi square.hasil penelitian ada hubungan antara rumah dengan kontainer positif jentik aedes aegypti, perilaku pemberantasan sarang nyamuk (psn) dan larvasidasi dengan kepadatan jentik aedes aegypti tetapi tidak untuk tempat perindukan, (p = 0,00 dan 95%ci = 0,64), dan (p = 0,00 dan 95%ci = 0,34 ). gambaran beberapa indeks jentik aedes aegypti yaitu house index (hi) = 57,02%, correspondence: abdurrakhman @2019 medical and health science journal. 10.33086/mhsj.v3i1.924 available at http://journal2.unusa.ac.id/index.php/mhsj 33 mailto:aboeraja80@gmail.com http://journal2.unusa.ac.id/index.php/mhsj medical and health science journal, vol.3., no.1, februari 2019 container index (ci) = 24,36%, bruteau index (bi) = 148,76, dan angka bebas jentik (abj) = 42,98%. kesimpulan rumah dengan kontainer positif jentik aedes aegypti dan perilaku psn dan larvasidasi berhubungan dengan kepadatan jentik aedes aegypti. indeks larva hi, ci dan bi nilainya tinggi sehingga berisiko terjadi penularan dbd. @2019 medical and health science journal. 10.33086/mhsj.v3i1.924 pendahuluan penyakit demam berdarah dapat menyebabkan kematian pada penderita dalam waktu singkat. demam berdarah dengue (dbd) merupakan penyakit infeksi dengan penyebab salah satu dari 4 virus dengue berbeda dan ditularkan melalui vektor nyamuk terutama aedes aegypty dan aedes albopictus yang tersebar di daerah tropis dan subtropis salah satunya kepulauan di indonesia (vyas, 2013). diperkirakan 500.000 orang dengan demam berdarah parah memerlukan rawat inap setiap tahun, dan dengan perkiraan 2,50% kasus kematian setiap tahun. secara global, 28% penurunan dalam kasus kematian telat tercatan antara tahun 2010 dan 2016 dengan peningkatan yang signifikan dalam manajemen kasus melalui peningkatan kapasitas di tingkat negara(kemenkes ri, 2018b). perjalanan udara internasional yang cepat memungkinkan wisatawan terinfeksi untuk tiba di tempat tujaan selama masa viremia, yang bisa bertahan hingga 5 hari setelah onset penyakit. sementara nyamuk aedes invasif yang ada di bandara setempat mungkin menggigit seorang wisatawan dan menjadi terinfeksi(semenza et al., 2014). penyakit demam berdarah dengue (dbd) masih merupakan salah satu masalah kesehatan masyarakat yang utama di indonesia. jumlah penderita dan luar daerah penyebarannya semakin bertambah seiring dengan meningkatnya mobilitas dan kepadatan penduduk (kemenkes ri, 2010). tahun 2014 sampai dengan 2016 di balikpapan terjadi kenaikan inciden rate dimana 34 tahun 2014 terdapat 2.176 kasus dengan ir 343,64 dan cfr 0,64 . tahun 2015 terdapat 2.145 kasus dengan ir 348,48, dan cfr 1,17, kemudian di tahun 2016 terdapat 2.508 kasus dengan ir 382,30 dan cfr 1,00. tahun 2017 terdapat kasus 1.137 dengan ir 178,77 cfr 0.18 dan tahun 2018 sampai dengan bulan september 2018 terdapat kasus 790 dengan ir 122,34 cfr 0,25 (dinas kesehatan kota balikpapan, 2016). bandara sultan aji muhammad sulaiman balikpapan merupakan bandara internasional yang berada di wilayah kota balikpapan merupakan pintu keluar masuk dan berkumpulnya orang dengan jumlah penumpang datang dan pergi rata – rata 20.924 orang/hari pada bulan april tahun 2018 (pt angkasa pura i, 2018). jumlah pergerakan orang di bandara yang tinggi dapat meningkatkan risiko penularan dan penyebaran penyakit baik penyakit yang menular langsung antar manusia maupun penyakit yang ditularkan oleh vektor/serangga penular penyakit seperti demam berdarah dengue (dbd) sangat besar dan dapat menimbulkan wabah atau klb yang berpotensi menimbulkan kedaruratan masalah kesehatan masyarakat yang meresahkan dunia (kkmd) atau public health emergency of international concern (pheic) (kemenkes ri, 2014). pengamatan vektor nyamuk aedes sp di buffer wilayah kerja bandara sepinggan balikpapan dilakukan oleh kantor kesehatan pelabuhan kelas ii balikpapan meliputi wilayah disekitar bandara (buffer area) dan pengamatan pada perimeter area bandara meliputi bangunan bandara dan sarana prasarana yang ada di dalamnya (kkp kelas ii balikpapan, 2017). medical and health science journal, vol.3., no.1, februari 2019 house indeks (hi) dan container index (ci) merupakan indikator keberadaan jentik aedes aegypti. hi dan ci di buffer wilayah kerja bandara sepinggan balikpapan masih di atas 1%, meskipun sudah dilakukan program pengawasan dan pengendalian vektor oleh kantor kesehatan pelabuhan kelas ii balikpapan di wilayah kerja bandara sepinggan balikpapan. rata – rata house index pada tahun 2014, 26,12%, tahun 2015 1,78%, tahun 2016 173,25%, tahun 2017 22,49%(kemenkes ri, 2018a). house indeks (hi) yang lebih dari 1% berpotensi mempengaruhi kepadatan jentik aedes aegypti, sehingga diperlukan upaya pemutusan rantai penularan penyakit untuk menurunkan kepadatan jentik dengan cara pengendalian jentik. persyaratan house indeksaedes aegypti untuk wilayah perimeter adalah 0 % dan untuk wilayah buffer adalah < 1% (depkes ri, 2009) kasus demam berdarah dengue di kelurahan sepinggan raya balikpapan yang berdekatan dengan wilayah kerja bandara sepinggan balikpapan tahun 2015 dari 343 kasus dengan kematian 1 orang. pada tahun 2016 terdapat 597 kasus dengan kematian 3 orang, tahun 2017 jumlah kasus 148 meninggal 0 orang. (dinas kesehatan kota balikpapan, 2016). tujuan penelitian ini adalah menganalisis faktor risiko yang berhubungan dengan kepadatan jentik aedes egypti dan mendeskripsikan indeks larva di buffer wilayah kerja bandara sepinggan balikpapan. metode penelitian rancangan penelitian yang akan dilakukan dalam penelitian ini adalah penelitian deskriptif, dengan desain yang dilakukan menurut waktunya adalah cross sectional. populasi dalam penelitian ini adalah seluruh (rumah/gedung) yang berada di rt 03, rt 04, rt 11 dan rt 12 kelurahan sepinggan raya balikpapan buffer wilayah kerja bandara sepinggan balikpapan, adapun sebagai objek penelitian adalah jentik dari nyamuk aedes aegypti sebagai penular penyakit demam berdarah. teknik pengambilan sampel yang digunakan adalah proportionate stratified random sampling sebanyak 121 sampel. penelitian ini akan dilaksanakan di buffer wilayah kerja kantor kesehatan pelabuhan kelas ii balikpapan yaitu buffer bandara sepinggan balikpapan kalimantan timur. waktu penelitian dilaksanakan pada bulan november 2018. teknik pengumpulan data primer melaluiwawancara, kuisioner, pengamatan langsung dan survei dengan single larva secara visual pada kontainer-kontainer sedangkan data sekunder melalui institusi yaitu kantor kesehatan pelabuhan (kkp) kelas ii balikpapan di seksi pengendalian risiko lingkungan. variabel bebas yang diteliti adalah rumah dengan kontainer positif jentik aedes aegypti, tempat perindukan, perilaku psn dan larvasidasi.variabel terikat yang diteliti adalah kepadatan jentik aedes aegypti.penelitian ini telah mendapatkan persetujuan etik no: 554/ea/kepk/2018. analisis univariabel dilakukan untuk mengetahui gambaran distribusi frekuensi dan proporsi dari masing –masing variabel dependen dan indipenden dengan tujuan untuk memperoleh gambaran distribusi frekuensi dan analisis bivariabel digunakan adalah uji statistik chi square (α = 0,05%). hasil dan pembahasan hasil gambaran umum tempat penelitian secara umum wilayah kerja bandara sepinggan balikpapan terbagi dalam dua area yaitu perimeter area dan buffer area. perimeter area merupakan wilayah dengan jarak 100 meter dari apron bandara tempat untuk menurunkan dan menaikkan penumpang maupun tempat parkir 35 medical and health science journal, vol.3., no.1, februari 2019 pesawat yang meliputi sarana dan prasarana seperti perkantoran, terminal keberangkatan dan terminal kedatangan penumpang, terminal kargo, hanggar pesawat, hotel, mesjid dan lain lain. buffer area adalah daerah disekitar perimeter dengan jarak 400 meter dari perimeter area merupakan daerah peyangga, terdiri dari hotel –hotel, perkantoran dan sekitar 30% terdiri dari perkampungan penduduk yang padat dan berpotensial sebagai tempat perindukan vektor dbd. gambaran rumah dengan kontainer positif jentik aedes aegypti rumah dengan kontainer positif jentikaedes aegypti dikategorikan menjadi dua yaitu ada dan tidak ada. rumah dengan kontainer positif jentik aedes aegypti ditemukan sebanyak 57% dan yang tidak ada ditemukan kontainer positif aedesaegypti 43%.rata – rata rumah memiliki lebih dari 1 tempat penampungan air. tabel 1. distribusi rumah dengan kontainer positif jentik aedes aegypti 180 kontainer. dengan di dominasi drum sebagai tempat paling banyak ditemukan jentik (79 kontainer) dan paling sedikit adalah tempat minum burung (1 kontainer). drum lebih disukai masyarakat karena kapasitas penampungan airnya cukup besar ± 200 liter. selain digunakan untuk keperluan sehari-hari, juga digunakan sebagai tempat penampungan cadangan air. tabel 3. distribusi pengamatan jenis tempat perindukan jentik aedes aegypti kontainer positif jentik ada tidak ada jumlah (n) 69 52 (%) persentase 57 43 burung total 739 180 559 perilaku psn dan larvasidasi total 121 100 tabel 2. distribusi pengamatan tempat perindukan jentik aedes aegypti pemberantasan sarang nyamuk dan larvasidasi merupakan salah satu tindakan pencegahan penyebaran penyakit dbd.kegiatan ini merupakan kegiatan yang dapat dilakukan oleh tempat perindukan (n) jumlah (%) persentase masyarakat secara mandiri dan berkesinambungan. hasil observasi dilapangan didapatkan perilaku ada 121 100 tidak ada 0 0 total 121 100 jenis tempat perindukan jenis tempat perindukan nyamuk yang terdapat di dalam rumah saja maupun di dalam dan diluar rumah responden dibedakan menjadi tandon, bak mandi/wc, tempayan, drum, ember dan lain-lain. tempat perindukan sebanyak 739 kontainer dengan keberadaan jentik terdapat pada psn dan larvasidasi yang baik sebanyak 27 reponden atau 22,30%, hasil kurang 94 responden 77,70%. tabel 4. distribusi perilaku psn dan larvasidasi diperiksa jumlah perilaku psn dan larvasidasi baik kurang n % n % rumah 121 27 22,30 94 77,70 36 jenis tempat perindukan diperiksa ada jentik tidak ada tandon 92 6 86 bak mandi/wc 90 24 66 tempayan 58 11 47 drum 254 79 175 ember 231 46 185 air tampungan 3 3 0 kulkas air tampungan 2 2 0 dispenser kaleng cat 6 6 0 bekas ban bekas 2 2 0 tempat minum 1 1 0 medical and health science journal, vol.3., no.1, februari 2019 kepadatan jentik aedes aegypti hasil kepadatan jentik aedes aegypti didapatkan, tabel 5. distribusi kepadatan jentik aedes aegypti rendah sebesar 51,20% dan tinggi sebesar 48,80%. kepadatan jentik aedes aegypti rendah tinggi jumlah (n) 62 59 persentase (%) 51,20 48,80 total 121 100,00 tabel 6. analisis hubungan antara rumah dengan kontainer positif jentik aedes aegypti, tempat perindukan, ,tindakan psn dan larvasidasi variabel kepadatan jentik nilai rendah tinggi total n n p kk rumah dengan kontainer positif jentik aedes aegypti ada 11 58 69 tidak ada 51 1 52 *0,00 0.64 total tempat perindukan ada 62 63 59 58 121 121 total tindakan psn dan larvasidasi 63 58 121 baik 23 4 27 kurang 39 55 94 *0,00 0,34 total 62 59 121 *signifikan pembahasan rumah dengan kontainer positif jentik aedes aegypti keberadaan jentik aedes aegypti merupakan indikator dari potensi keterjangkitan masyarakat akan penyakit yang ditularkan oleh nyamuk seperti dbd, chikungunya dan zika. hal ini sesuai dengan teori (nadesul, 2016) bahwa jika jentik nyamuk aedes aegypti dibiarkan hidup, maka akan menambah banyak populasi nyamuk pembawa penyakit yang ditularkan oleh nyamuk tersebut. hasil observasi keberadaaan jentik aedes aegypti dari 121 rumah yang dilakukan pemeriksaan di dapatkan house index (hi) sebesar 57%, container index (ci) 24,36 %, breteau index 148,76 dan angka bebas jentik didapatkan 42,98 % serta density figure dilihat dari nilai container indeks nilainya ada 6. daerah – daerah dengan densitas figure diatas 5 (breteau indexdiatas 50) besar sekali kemungkinan transmisi penyakit demam kuning (urban yellow fever), sedangkan daerah – daerah dengan density figure 1 (breteau index dibawah 5) kemungkinan transmisi demam kuning dianggap kecil sekali (depkes ri, 2009). kondisi ini menunjukkan bahwa kepadatan nyamuk di buffer area bandara sultan aji muhammad sulaiman sepinggan balikpapan tinggi karena untuk house index (hi), container index (ci) dan breteau index (bi) di buffer area bandara > 1 sehingga wilker bandara sultan aji muhammad sulaiman sepinggan balikpapan mempunyai risiko transmisi nyamuk yang cukup tinggi untuk terjadinya penularan penyakit yang ditularkan oleh nyamuk. waktu penelitian dilakukan pada awal musim hujan. curah hujan menambah genangan air sebagai tempat perindukan, dan kelembapan udara terutama untuk daerah pantai. kelembapan udara di daerah pantai 37 medical and health science journal, vol.3., no.1, februari 2019 akan menambah jarak terbang nyamuk dan umur nyamuk (kemenkes ri, 2013). hubungan rumah dengan kontainer positif jentik aedes aegypti dengan kepadatan jentik aedes aegypti hasil penelitian menunjukan adanya hubungan yang signifikan antara kontainer dengan jentik aedes aegypti dengan kepadatan jentik nyamuk aedes aegypti di buffer area wilker bandara sultan aji muhammad sulaiman sepinggan balikpapan.dari 739 kontainer yang di periksa terdapat 180 kontainer yang positif ada jentik aedes aegypti.di dapatkan hasil container index (ci) 24,36% dan bila dihubungkan dengan tabel density figure didapatkan hasil density figure di skala 6. bila tingkat kepadatan berada pada skala 6-9 berarti kepadatan tinggi. semakin banyak jumlah kontainer dalam satu rumah memberikan lebih banyak peluang bagi aedes aegypti untuk berkembang biak di rumah tersebut. (prasetyowati & ginanjar, 2017). hubungan antara tempat perindukan dan kepadatan jentik aedes aegypti tidak terdapat hubungan secara signifikan dengan kepadatan jentik aedes aegypti.hasil penelitian menunjukkan bahwa tempat perindukan ditemukan di semua rumah responden. berbeda dengan yang dilakukan (nani, 2016) bahwa responden yang memiliki tempat penampungan di dalam dan diluar rumah mempunyai resiko lebih besar terhadap keberadaan jentik aedes egypti. hubungan perilaku psn dan larvasidasi dengan kepadatan jentik aedes aegypti hasil penelitian menunjukkan ada hubungan yang signifikan antara perilaku psn dan larvasidasi dengan kepadatan aedes aegypti dengan p value sebesar 0,00 dimana (ρ< α ). hal ini selaras dengan penelitian (septianto, 2014)yang menunjukkan bahwa ada hubungan antara menguras tempat keberadaan larva aedes aegypti. pengurasan pada tempat penampungan air minimal seminggu sekali dapat mengurangi tempat berkembang biak jentik aedes aegypti. nyamuk betina dewasa meletakkan telurnya di dinding kontainer diatas permukaan air. bila kena air akan menetas menjadi jentik, setelah 5 – 10 hari larva akan menjadi pupa dan 2 hari kemudian pupa akan menetas menjadi dewasa (kemenkes ri, 2013). juga selaras dengan penelitian desniawati (2014) yang menunjukkan bahwa menguras tempat penampungan air, mengubur barang bekas, memperbaiki saluran talang air berhubungan signifikan dengan keberadaan larva aedes aegypti. hal ini juga selaras dengan penelitian novitasari & sugiyanto (2014) yang dilakukan di rw 01 kelurahan sendangguwo semarang yang menyatakan ada hubungan yang signifikan antara praktik psn dengan keberadaan jentik aedes aegypti dengan nilai ρ= 0,03. gambaran indeks jentik di buffer wilayah kerja sepinggan balikpapan hasil pengamatan dan observasi di rumah responden di dapatkan rumah yang terdapat jentik sebanyak 69 rumah dan tidak terdapat jentik sebanyak 52 buah. jumlah kontainer yang diperiksa sebanyak 739 kontainer dengan kontainer positif jentik aedes aegypti sebanyak 180 kontainer. maka dari hasil tersebut dapat diperoleh indek hi = 57%, ci = 24,36%, bi = 148,7 dan abj = 42,98%. hasil indeks larva tersebut melebihi ambang batas yang dipersyaratkan untuk buffer area yaitu hi < 1 %. bila hi mencapai atau melebihi 1 % dan bi melebihi 50 maka harus dilakukan pengendalian jentik aedes aegypti. praptowibowo (2015) house index (hi) merupakan indikator yang paling sering digunakan untuk monitoring infestasi nyamuk. akan tetapi house index termasuk lemah dalam risiko penularan penyakit karena tidak menghitung tempat penampungan air atau kontainer dan data rumah yang positif dengan larva, jumlah nyamuk yang sebenarnya tinggal juga tidak diketahui di rumah tersebut. 38 medical and health science journal, vol.3., no.1, februari 2019 nilai ci dapat digunakan sebagai pembanding untuk evaluasi pogram pengendalian vektor tetapi tidak berguna dari sisi epidemiologis. nilai bi menunjukkan hubungan antara kontainer yang positif dengan jumlah rumah dan indeks ini dianggap indeks yang paling baik tetapi tidak mencerminkan jumlah larva dalam kontainer.bi mempunyai nilai signifikan epidemiologis yang lebih besar. kesimpulan ada hubungan antara rumah dengan kontainer positif jentik aedes aegypti, perilaku psn dan larvasidasi dengan kepadatan jentik aedes aegypti, tetapi tidak untuk tempat perindukan di buffer wilayah kerja bandara sepinggan balikpapan tahun 2018. indeks larva jentik aedes aegypti di buffer wilayah kerja sepinggan balikpapan didapatkan hasil yang tinggi. hal ini menunjukkan buffer wilker bandara sepinggan balikpapan berpotensi untuk penularan demam berdarah dengue. daftar pustaka 1. depkes ri. (2009). standar operasional prosedur kegiatan kantor kesehatan pelabuhan di pintu masuk negara. jakarta. 2. desniawati, f. (2014). pelaksanaan 3m plus terhadap keberadaan larva aedes aegypti di wilayah kerja puskesmas ciputat kota tanggaerang selatan bulan mei-juni tahun 2014. jakarta. 3. dinas kesehatan kota balikpapan. (2016). profil dinas kesehatan kota balikpapan. balikpapan. 4. kemenkes ri. (2010). buletin jendela epidemiologi. 5. kemenkes ri. peraturan menkes ri no 44 tahun 2014 (2014). jakarta. 6. kemenkes ri. (2018a). simkespel. jakarta. 7. kemenkes ri. uu no.6 tahun 2018 tentang kekarantinaan kesehatan (2018). indonesia. 8. kemenkes ri, d. p. (2013). pedoman survei entomologi demam berdarah dengue dan kunci identifikasi nyamuk aedes. jakarta. 9. kkp kelas ii balikpapan. (2017). profil kantor kesehatan kelas ii balikpapan. balikpapan. 10. nadesul, h. (2016). kiat mengalahkan demam berdarah dan virus zika. jakarta: pt. kompas media nusantara. 11. nani. (2016). hubungan perilaku psn dengan keberadaan jentik aedes aegypti di pelabuhan pulang pisau. jurnal berkala epidemiologi, 5 (january 2017). https://doi.org/10.20473/jbe.v5i1.2017.1-12. 12. novitasari, i., & sugiyanto, z. (2014). hubungan suhu, kelembaban rumah dan perilaku masyarakat tentang psn dan larvasidasi dengan keberadaan jentik nyamuk penular demam berdarah dengue di rw 01 kelurahan sendangguwo semarang. 13. praptowibowo, w. (2015). maya index dan gambaran habitat perkembangbiakan larva aedes sp. berdasarkan endemisitas dbd di kota semarang provinsi jawa tengah wahyu praptowibowo fakultas kesehatan masyarakat universitas diponegoro semarang dengue haemorhagic fever (dhf) is an acu. jurnal kesehatan masyarakat, 3(april). 14. prasetyowati, h., & ginanjar, a. (2017). maya indeks dan kepadatan larva aedes aegypti di daerah endemis dbd jakarta timur. vektora, 9(1), 43–49. 15. pt angkasa pura i. (2018). laporan pergerakan lalu lintas angkutan udara. 16. semenza, j. c., sudre, b., miniota, j., rossi, m., hu, w., kossowsky, d., … khan, k. (2014). international dispersal of dengue through air travel: importation risk for europe, 8(12). https://doi.org/10.1371/journal.pntd.0003278. 17. septianto, a. (2014). hubungan antara praktik pemberantasan sarang nyamuk (psn) dengan keberadaan jentik nyamuk aedes aegypti di rw 7 kelurahan sukorejo kecamatan gunungpati kota semarang. 18. vyas, j. m. (2013). medline plus. retrieved from 39 medical and health science journal, vol.3., no.1, februari 2019 http://www.nlm.nih.gov/medlineplus/ency/arti cle/001374.html. 40 http://www.nlm.nih.gov/medlineplus/ency/arti 43 marlia alief r achmawati, handayani, adyan donastin, hubungan pola makan dan kebiasaan olahraga yang baik dengan kadar gula darah penderita diabetes mellitus tipe ii di rsi jemursari hubungan pola makan dan kebiasaan olahraga yang baik dengan kadar gula darah penderita diabetes mellitus tipe ii di rsi jemursari marlia alief rachmawati, handayani, adyan donastin fakultas kedokteran, universitas nahdlatul ulama surabaya e-mail: marlialief@gmail.com abstrak: diabetes mellitus tipe ii adalah penyakit kronis mengalami resistansi terhadap aksi insulin dan ketidakmampuan pankreas untuk menghasilkan cukup insulin. dm tipe ii sendiri menduduki peringkat ke-2 di dunia dengan penderita terbanyak pola makan yang buruk dan kurangnya olahraga dapat memengaruhi terjadinya dm tipe ii. perkembangan pola makan yang salah arah saat ini mempercepat peningkatan jumlah penderita dm di indonesia. pada saat tubuh melakukan gerakan, maka sejumlah gula akan dibakar untuk dijadikan tenaga gerak. sehingga sejumlah gula dalam tubuh akan berkurang dan kebutuhan akan hormon insulin juga akan berkurang. penelitian ini bertujuan adalah untuk mengetahui hubungan pola makan dan kebiasaan olahraga dengan kadar gula penderita diabetes mellitus ii pada penderita diabetes mellitus ii di rsi jemursari penelitian ini dilakukan dengan metode survey atau observasional dengan pendekatan cross sectional. sampel yang diambil sebanyak 24 pasien. populasi dalam penelitian ini adalah semua pasien diabetes mellitus tipe 2 yang menjalani rawat jalan pada poli penyakit dalam, namun dibatasi dengan kriteria inklusi dan eksklusi yang penulis buat. dari 24 pasien, pada hubungan pola makan dengan kadar gula darah sebanyak 13 pasien (54,2%) mempunyai kadar gula tidak tinggi. 11 pasien (45,8%) mempunyai kadar gula tinggi. dengan hasil uji statistik didapatkan nilai p=1,000 (p>0,05). maka dapat disimpulkan bahwa terdapat hubungan yang tidak signifikan antara pola makan dan kadar gula. serta hubungan olahraga dengan kadar gula darah sebanyak 13 pasien (54,2%) mempunyai kadar gula tidak tinggi. 11 pasien (45,8%) mempunyai kadar gula tinggi. dengan hasil uji statistik didapatkan nilai p=0,432 (p>0,05). maka dapat disimpulkan bahwa terdapat hubungan yang tidak signifikan antara olahraga dan kadar gula. kata kunci: pola makan, olahraga,kadar gula darah, diabetes mellitus pendahuluan diabetes mellitus adalah gangguan meta bolisme yang secara genetis dan klinis termasuk heterogen dengan manifestasi berupa hilangnya toleransi karbohidrat. apabila sudah berkem bang penuh secara klinis, maka diabetes melli tus ditandai oleh hiperglikemia, arterosklerotik, mikroangiopati, dan neuropati.1 prevalensi dm di indonesia mencapai jumlah 8.426 juta pada tahun 2000 yang diper kirakan akan meningkat pada tahun 2030 sebe sar 21.257 juta, hal ini berarti terjadi kenaikan tiga kali lipat dalam waktu 30 tahun. oleh karena itu, menurut laporan world health or ganization (who) bahwa pada tahun 2000 terdapat 1,0 juta penduduk mengalami kematian akibat diabetes dengan prevalensi sekitar 2,0% dan pada tahun 2012 dilaporkan bahwa terdapat 1,5 juta penduduk mengalami kematian akibat diabetes dengan prevalensi sekitar 2,7%. dari seluruh kematian akibat dm di dunia,70% kematian terjadi di negara-negara berkembang termasuk indonesia.2 dengan demikian, penelitian bertujuan untuk mengetahui hubungan pola makan dan 43 mailto:marlialief@gmail.com medical and health science journal, vol. 2, no. 1, february 2018 kebiasaan olahraga dengan kadar gula penderita diabetes mellitus ii pada penderita diabetes mellitus ii di rsi jemursari. diharapkan penelitian ini dapat membe rikan manfaat berupa memberikan informasi pola makan dan olahraga yang baik untuk penderita diabetes mellitus ii di rsi jemursari dan untuk mengetahui hubungan pola makan dan olahraga yang baik dengan kadar gula darah penderita diabetes mellitus ii di rsi jemursari serta untuk mengetahui perbandingan hubungan pola makan dengan olahraga terhadap kadar gula darah. metode penelitian pada penelitian ini menggunakan metode observasional bersifat deskriptif dengan desain penelitian cross–sectional menggunakan data primer berupa quesioner yang diambil pada bulan september-oktober 2017. pada penelitian ini didapatkan beberapa kriteria inklusi dan kriteria eksklusi. kriteria inklusi berupa pasien yang datang ke rsi jemur sari melalui irj (poli umum dan poli penyakit dalam) pada bulan september-oktober 2017 dan menderita diabetes mellitus, pasien dispeps dengan rentang usia 30–64 tahun, pasien diabe tes mellitus yang berjenis kelamin baik laki-laki maupun perempuan, pasien bersedia menjadi responden. kriteria eksklusi berupa penderita tidak ada komplikasi berat penyakit lain dan tidak minum obat secara rutin. penelitian ini menggunakan teknik pengam bilan sampel dengan cress sectional mulai sep tember–november 2017. data yang dijadikan sebagai sampel diambil dari quesioner yang di bagikan kepada pasien yang berada di rumah sakit islam jemursari surabaya. data-data yang telah diperoleh akan diolah menggunakan apli kasi microsoft office excel 2007. hasil dan pembahasan hasil penelitian berdasarkan kadar gula, menunjukkan fre kuensi kadar gula darah pasien diabetes melli tus ii di rsi jemursari adalah sebagian besar adalah rendah dengan frekuensi sebanyak 13 orang (54,2%) selanjutnya pada pasien kadar gula tinggi sebanyak 11 orang (45,8%). berdasarkan pola makan, pola makan res ponden setengah dari responden melakukan pola makan yang baik sebanyak 12 orang (50%) sedangkan yang mempunyai pola makan buruk sebanyak 12 orang (50%). berdasarkan olahraga, responden pasien urj jemursari sebanyak 9 orang jarang melakukan olahraga dengan persentase 37,5% dan sebanyak 15 orang (62,5%) selalu melakukan olahraga. jadi hasil penelitian secara deskriptif sema kin tinggi kadar gula makan responden selalu rajin olahraga. hasil penelitian secara statistik menyatakan terdapat ada hubungan tidak signi fikan. jadi hasil penelitian secara deskriptif sema kin tinggi kadar gulanya makan pola makan seseorang menjadi tidak baik. sedangkan secara statistik menyatakan terdapat hubungan yang tidak signifikan antara faktor pola makan dengan kadar gula. pola makan yang baik dengan kadar gula darah yang tinggi dan tidak tinggi. pada gula darah yang tinggi didapatkan pasien sebanyak 5 orang dengan persentase 41,7% sedangkan yang tidak tinggi didapatkan pasien sebanyak 7 orang dengan persentase 58,3%. pola makan yang tidak baik dengan kadar gula darah yang tinggi dan tidak tinggi. pada gula darah yang tinggi didapatkan pasien seba nyak 6 orang dengan persentase 50.0% sedang kan yang tidak tinggi didapatkan pasien sebanyak 6 orang dengan persentase 50.0%. 44 marlia alief r achmawati, handayani, adyan donastin, hubungan pola makan dan kebiasaan olahraga yang baik dengan kadar gula darah penderita diabetes mellitus tipe ii di rsi jemursari olahraga yang rutin dengan kadar gula darah yang tinggi dan tidak tinggi. pada gula darah yang tinggi didapatkan pasien sebanyak 8 orang dengan persentase 53,3% sedangkan yang tidak tinggi didapatkan pasien sebanyak 7 orang dengan persentase 46,7%. olahraga yang jarang dengan kadar gula darah yang tinggi dan tidak tinggi. pada gula darah yang tinggi didapatkan pasien sebanyak 3 orang dengan persentase 33.3% sedangkan yang tidak tinggi didapatkan pasien sebanyak 6 dengan persentase 66.7%. pola makan dan olahraga dengan baik mem punyai kadar gula tidak tinggi 55% dan adalah yang selalu melakukan pola makan dan olahraga dengan baik mempunyai kadar gula 46%. pola makan baik dengan jarang olahraga mempunyai kadar gula tinggi tidak didapatkan. sedangkan yang mempunyai pola makan dengan jarang olahraga mempunyai kadar gula tidak tinggi 100%. pola makan tidak baik dengan sering mela kukan olahraga mempunyai kadar gula tinggi dengan persentase 50% melakukan pola makan tidak baik dengan sering melakukan olahraga mempunyai kadar gula tidak tinggi dengan per sentase 50%. pola makan dengan tidak baik jarang mela kukan olahraga mempunyai kadar gula darah dengan persentase 50% sedangkan yang pola makan tidak baik dengan jarang melakukan olahraga sebanyak 50%. pembahasan pada dm tipe i terdapat kerusakan pada sel beta akibat reaksi autoimun, sedangkan pada dm tipe ii kadar glukosa darah meningkat karena adanya resistensi insulin akibat gaya hidup yang salah. diabetes mellitus merupakan suatu kelompok penyakit metabolik dengan karakteristik hiperglikemia yang terjadi karena kelainan sekresi insulin, kerja insulin atau kedua nya.3 jenis makanan menentukan kecepatan naik nya kadar gula darah. kecepatan suatu makanan dalam menaikkan kadar gula darah disebut juga indeks glikemik. makanan indeks glikemik tinggi harusnya dihindari seperti sumber karbohidrat sederhana, gula, madu, sirup, roti, mie dan lain lain. makanan yang berindeks glikemik lebih rendah adalah makanan yang harus dikonsumsi dan kaya dengan serat, contohnya sayuran dan buah-buahan.4 konsumsi makanan yang berlebihan teruta ma mengandung karbohidrat dan lemak menye babkan jumlah energi yang masuk ke dalam tubuh tidak seimbang dengan kebutuhan energi. kelebihan energi ini di dalam tubuh akan disim pan dalam bentuk jaringan lemak yang lama kelamaan akan mengakibatkan obesitas. asupan serat yang cukup dapat mencegah kejadian obe sitas. serat mengabsorbsi air, memperluas penye rapan di usus, dan memperlambat pergerakan makanan pada saluran pencernaan sehingga me nimbulkan rasa kenyang lebih lama. berdasarkan hasil food recall 24 jam dan food record yang diolah menggunakan nutrisurvey menunjukkan bahwa seluruh subjek belum dapat memenuhi anjuran asupan serat perhari.5 olahraga yang dimaksud dalam penelitian ini adalah olahraga yang dilakukan selama 3 kali dalam seminggu selama 30 menit secara rutin. olah raga yang kurang menyebabkan makanan yang masuk ke tubuh tidak dibakar melainkan ditimbun sebagai lemak dalam tubuh. penim bunan lemak tubuh dalam waktu yang lama akan mengakibatkan obesitas. orang dewasa dengan obesitas akan mempunyai risiko diabe tes 24 kali lebih besar.6 45 medical and health science journal, vol. 2, no. 1, february 2018 dm ii menunjukkan transmisi vertikal sampai 3 generasi. sedangkan dm i hanya 6%. jika salah satu orang tuanya mengalami dm, makan probabilitas anaknya yang terkena 25% sedangkan kedua orangtuanya yang terkena dm maka 50% anaknya terkena dm. apabila pada dm i, orang tuanya terkena dm maka anaknya mempunyai risiko 5–10% saja.7 kesimpulan dan saran simpulan berdasarkan hasil penelitian ini dapat disim pulkan hasil yang menunjukkan bahwa terdapat hubungan yang tidak signifikan antara pola ma kan dengan kadar gula darah pada penderita diabetes mellitus tipe ii sedangkan terdapat hubungan yang tidak signifikan antara olahraga dengan kadar gula darah pada penderita diabe tes mellitus ii. pengobatan akan dapat berjalan dengan baik jika diberikan bersama dengan peng aturan makan dan latihan jasmani (gaya hidup sehat). saran saran penulis, perlu adanya penelitian menggunakan sampel dengan jumlah lebih ba nyak didapatkan dengan sampel minimal pasien agar memudahkan hubungan antara pola makan dan kebiasaan olahraga dengan kadar gula pasien. daftar rujukan fatimah r.n. 2015. diabetes mellitus tipe 2. journal majority. price, s.a. dan wilson, l.m. 2006. patofisiologi: konsep klinis proses-. proses penyakit, edisi 6, volume 1. jakarta: egc pyke, d.a., and p.g. nelson. 1976. “diabetes mellitus in identical twins.” pp. 194–202 in the genetics of diabetes mellitus, ed ited by w. creutzfeldt, j. kobberling, and j.f. neel. new york. rafanani, b. 2013. buku pintar pola makan sehat dan cerdas bagi penderita diabetes. yogyakarta: penerbit araska. sukardji, k. 2009. penatalaksanaan gizi pada diabetes mellitus. dalam: penatalaksanaan diabetes mellitus terpadu. jakarta: pusat diabetes dan lipid rsupn dr. cipto mangunkusumo, fkui. suyono, s. 2006. kecenderungan peningkatan jumlah penyandang diabetes, dalam penatalaksanaan diabetes mellitus terpadu. jakarta: balai penerbit fk ui. who. 2014. diabetes melitus. diakses pada 21 januari 2018. 46 medical and health science journal, vol.3., no.1, februari 2019 original article imunohistokimia pada kondilomata akuminata ,meidyta sinantryana widyaswari 1* , hans lumintang 2 , troef soemarno 3 . 1fakultas kedokteran universitas nahdlatul ulama surabaya, surabaya, indonesia 2departemen/staf medik fungsional ilmu kesehatan kulit dan kelamin. fakultas kedokteran universitas airlangga/rumah sakit umum daerah dr. soetomo surabaya, surabaya, indonesia 3departemen/staf medik fungsional patologi anatomi fakultas kedokteran universitas airlangga/rumah sakit umum daerah dr. soetomo surabaya, surabaya, indonesia *correspondent author: drmemed_dyta@unusa.ac.id article info article history: received 23 january 2019 received in revised form february 2019 accepted 4 february 2019 keywords: condylomata acuminata, malignancy, mmunohistochemistry, mib-1(ki-67), p16. kata kunci: kondilomata akuminata, keganasan, imunohistokimia, mib-1(ki-67), p16. abstract background: condylomata acuminata (ca) is a sexually transmitted disease caused by the human papilloma virus (hpv) type-specific and may be simultaneously co-infected with other hpv types associated with malignancy. purpose: to differentiate between ca and histopathological of malignancy by immunohistochemistry. literaturereview: ca refers to benign epidermal proliferation caused by the hpv types 6 and 11, but co-infection with high risk hpv types are common. the clinical presentation of ca can’t differentiate between benign or preneoplastik diplasia lesions. koilocytes considered pathognomonic for hpv lesions, these findings sometimes don’t appear on ca, and histopathology was not accurate, that immunohistochemistry with mib-1 (ki-67) and p16 can beused. conclusion: immunohistochemistry examination can help differentiate the diagnosis between malignancy or non malignancy in the case of ca. abstrak latar belakang: kondilomata akuminata (ka) merupakan penyakit menular seksual yang disebabkan human papilloma virus (hpv) tipe tertentu dan mungkin dapat terinfeksi secara bersamaan dengan tipe hpv lain yang terkait dengan keganasan. tujuan: untuk membedakan gambaran histopatologi antara ka dan keganasan dengan pemeriksaan imunohistokimia. telaah kepustakaan: ka mengacu pada proliferasi epidermal jinak yang disebabkan hpv tipe 6 dan 11, tapi ko-infeksi dengan hpv tipe risiko tinggi sering terjadi. gambaran klinis pada ka tidak dapat membedakan lesi jinak dari preneoplastik atau lesi diplastik. koilositosis dianggap patognomonik lesi hpv, temuan ini kadang-kadang tidak tampak pada ka, dan histopatologi tidak tepat, sehingga dapat menggunakan pemeriksaan imunohistokimia dengan biomarker mib-1(ki-67) dan p16. kesimpulan: pemeriksaaan imunohistokimia dapat membantu mendiagnosis banding pada kasus ka yang samar-samar maupun keganasan. @2019 medical and health science journal. 10.33086/mhsj.v3i1.926 pendahuluan kondilomata akuminata (ka), mengingat telah diketahui adanya hubungan antara penyebab ka dengan human papilloma virus (hpv)dengan lesi invasif atau prakanker serviks, vagina, vulva, anus dan penis. 1 ka merupakan penyakit menular seksual yang ditandai dengan tumor seperti kutil berwarna seperti daging pada kulit, dapat memberikan gambaran cauliflower pada daerah correspondence: meidyta sinantryana widyaswari @2019 medical and health science journal. 10.33086/mhsj.v3i1.926 available at http://journal2.unusa.ac.id/index.php/mhsj 47 mailto:drmemed_dyta@unusa.ac.id http://journal2.unusa.ac.id/index.php/mhsj medical and health science journal, vol.3., no.1, februari 2019 genital yang disebabkan oleh infeksi hpv tipe tertentu. 2,3 ka umumnya disebabkan oleh hpv tipe 6 atau 11, tetapi dapat juga di sebabkan tipe hpv yang lain, antara lain tipe 16, 18, 31,33 yang biasanya terkait dengan keganasan. 2,4 diagnosis ka ditegakkan berdasarkan gambaran klinis dan riwayat yang didapat.namun, gambaran klinis tidak dapat membedakan lesi jinak dari preneoplastik atau lesi displastik.pemeriksaan histopatologi dapat digunakan untuk menegakkan diagnosis.meskipun koilositosis dianggap menjadi gambaran patognomonik yang berhubungan lesi pada hpv, temuan ini terkadang tidak tampak pada kondiloma, dan diagnosis histopatologi dapat tidak tepat atau tidak akurat serta banyak pemeriksa patologi memilih untuk mendiagnosa histologis tersebut sebagai lesi samar-samar "konsisten dengan kondiloma”. 5 oleh sebab itu saat ini banyak dikembangkan pemeriksaan,diharapkan mempunyai sensitifitas dan spesifitas yang lebih tinggi yaitu pemeriksaan imunohistokimia yang menggunakan beberapa biomarker yang dapat membantu mendiagnosis dini, menentukan terapi terbaik dan prognosis. lesi pada hpv menunjukkan peningkatan aktivitas proliferasi dari epitel sel skuamosa dan dapat menjadi keganasan, sehingga kegunaan imunostaining mib-1(ki-67) dan p16 sebagai biomarker membantu dalam mendiagnosis banding pada kasus samar-samar dan menguji distribusi hpv yang berisiko rendah dan tinggi–onkogenik pada lesi ka. 5,6 telaah kepustakaan kondiloma akuminatum (ka) merupakan penyakit menular seksual (pms) yang disebabkan oleh infeksi human papilloma virus (hpv) jenis tertentu, yang ditandai dengan tumor tampak seperti kutil, berwarna seperti daging pada kulit, dapat memberi gambaran cauliflower, fibroepitelioma pada kulit dan mukosa terutama daerah anogenital. ka disebut juga penyakit jengger ayam, kutil kelamin, genital warts. 2,3,7 ka mengacu pada proliferasi epidermal jinak atau lesi mukosa yang disebabkan sebagian besar oleh hpv tipe 6 atau 11, tapi ko-infeksi dengan tipe hpv risiko tinggi sering terjadi. 7,8 prevalensi infeksi hpv terus meningkat, dikaitkan denganusiayang lebih dini melakukan hubungan awal seksual serta peningkatan ganti ganti jumlah pasangan seksual. infeksi baru akan terjadi pada orang dewasa muda usia 15-24 tahun. perbandingan insiden laki-laki dan wanita didapatkan 1:1,4. 2 ka bersifat asimptomatis. hpv tipe 6 dan 11 bertanggung jawablebih dari 90 % dari ka. 7,8 pada penelitian di rsud dr. soetomo surabaya pada bulan nopember 2007–pebruari 2008 didapatkan hpv-16(risiko tinggi)pada lesi genital wanita penderita kondilomata akuminata sebesar 42,9%. 9 pada literatur menyebutkan bahwa sekitar 30% wanita dengan kondilomata akuminata pada daerah vulva dan perianal menunjukkan gambaran cervical intraepithelial neoplasia (cin) pada hasil sitologinya. 10 penyebab dari ka adalah infeksi hpvyang bermultiplikasi di nukleus dari sel epitel yang terinfeksi.virus ini termasuk dalam kelompok papoviridae, tidak mempunyai envelopes, berbentuk kapsid icosahedral dengan ukuran diameter 50-55 nmdan tesusun dari double stranded yang panjangnnya 8-kbp molekul dna. hpv tersebar luas, dapat menginfeksi epitel skuamosa dari kulit dan membran mukosa. 2,11,12 telah diketahui bahwa ada hubungan antara infeksi hpv tipe tertentu pada genital dengan terjadinya karsinoma serviks. berdasarkan kemungkinan terjadinya dysplasia epitel dan keganasan, tipe-tipe yang menginfeksi mukosa genital yaitu hpv tipe 6 dan 11 (low-risk) dan tipe 16 dan 18 (high-risk). high-risk berhubungan dengan kanker serviks, vulva, vagina, penis, dan anus sedangkan low-risk virus berhubungan dengan 54 medical and health science journal, vol.3., no.1, februari 2019 kondiloma akuminata (genital warts) atau low grade squamous intraepithelial neoplasia. 6,11 penularannya melalui kontak seksual, baik genital, oral maupun anal. permukaan mukosa yang lebih tipis lebih susceptible untuk inokulasi virus sehingga mikroabrasi pada permukaan epitel memungkinkan virion dari pasangan seksual yang terinfeksi masuk ke dalam lapisan sel basal pasangan yang tidak terinfeksi. 2 sel basal merupakan tempat pertama infeksi hpv sehingga setelah inokulasi melalui trauma kecil, virion hpv akan masuk sampai lapisan sel basal epitel. agar dapat menimbulkan infeksi, hpv harus mencapai epitel yang berdiferensiasi sedangkan sel basal relative undifferentiated, mereka hanya terstimulasi untuk membelah secara cepat sehingga disini hanya terjadi ekspresi gen hpv. sesuai dengan pembelahan sel basal, virion hpv akan bergerak ke lapisan epidermis yang lebih atas. dan hanya lapisan epidermis di atas lapisan basal yang berdiferensiasi pada tahap lanjut, yang dapat mendukung replikasi virus.ekspresi gen virus pada lapisan ini diperlukan untuk menghasilkan kapsid protein dan kumpulan partikel virus.setelah proses replikasi virus selesai, terjadilah pelepasan virus bersama dengan sel epitel yang deskuamasi, kemudian virus baru akan menginfeksi lapisan basal yang lain. waktu infeksi hpv sampai pelepasan virus baru adalah 3 minggu (masa inkubasi 3 minggu sampai 8 bulan), rata-rata selama 2-3 bulan. 2,3,11 ka pada umumnya asimptomatis.sering timbul di daerah yang lembab dan juga pada daerah yang mudah mengalami trauma pada saat hubungan seksual.ka lesi awalnya kecil, nondistinctive 1 2mm papula seperti daging berwarna kulit, multiple atau bervariasi dalam ukuran dan dapat tumbuh menjadi besar beberapa inci dalam diameter, eksofitik seperti kembang kol. 7,8 morfologinya ka dapat berbagai bentuk, meskipun perlu diingat bahwa tidak ada batasan yang jelas antara bentuk bentuk ka tersebut dan sering pula dijumpai bentuk-bentuk peralihan, yaitu bentuk akuminata, bentuk papul halus (smooth popular form/sessile), bentuk keratotik yang mirip dengan common warts atau keratosis seboroik, dan bentuk datar (flattopped warts). 2,3,11 infeksi dapat bertahan sehingga tidak terdeteksi untuk jangka waktu yang lama tanpa manifestasi klinis kutil yang jelas.setelah manifestasi klinis awal, ka dapat meningkatkandalam jumlah dan ukuran atau sebaliknya, mengalami spontan regresi.sebagian besar ka akan kambuh dalamtiga bulan, bahkan setelah menjalani terapi. 2,3,7 pemilihan pengobatan pada ka sebagian besar berpusat pada menghilangkanlesi yang tampak, mengurangi keluhan dan gejala tetapi tidak dapat mengeradikasiinfeksi virus yang mendasarinya. berbagai macam terapi yang digunakan sangat bervariasi sehubungan dengan lokasi, ukuran, jumlah, tipe kutil, usia, kerjasama pasien, biaya, efek samping, dosis, durasi pengobatan, dan efektivitas keseluruhan. meskipun berbagai macam pengobatan mampu pemberantasan jangka pendek, bukti klinis menunjukkan bahwa tetap sebagian besar tidak efektif dalam mencapai pemberantasan kutil jangka panjang, dengan tingkat kekambuhan rata-rata berkisar antara 30 sampai 70% dalam 3 sampai 6 bulan pertama. 2,3,4 demikian pula, tidak mungkin bahwa pengobatan pada ka yang tersedia memainkan peran penting dalam menghentikan atau menunda perkembangan kutil kearah keganasan.tidak ada terapi definitif yang digunakan sebagai standar ideal pada pengobatan kutil genital dan pemilihan terapi biasanya disesuaikan dengan tujuan dan kebutuhan masing masing pasien tertentu.beberapa modalitas terapi pada ka termasuk topikal atau tindakan bedah. terapi topikal meliputi podophyllotoxin, imiquimo krim, trikloroacetic acid (tca), 5-fluorourasil (fu) dan injeksi interferon. sedangkan terapi bedah meliputi bedah beku,kuretase, bedah listrik, 5 5 medical and health science journal, vol.3., no.1, februari 2019 eksisi dan laser. terapi dengan pembedahan umumnya dilakukan pada pasien dengan lesi besar dan luas.2,3,4,7,8 pencegahan infeksi hpv yaitu dengan menghindari kontak langsung dengan virus, dan mengubah perilaku seksual dengan melakukan hubungan seksual satu orang (monoghami) yang diketahui kesehatannya serta penggunaan kondom dapat melindungi dan menurunkan resiko infeksi hpv, meskipun pada beberapa penelitian dikatakan masih kontroversial. 11,12,13 pemberian vaksin dapat juga mencegah infeksi pada hpv. terdapat dua vaksin, yaitu: vaksin hpv bivalen (mencegah infeksi hpv tipe 16 dan 18) dan vaksin hpv kuadrivalen (mencegah infeksi hpv tipe 6, 11,16, dan 18). idealnya diberikan pada saat menjelang memasuki usia seksual aktif. 7,11,12 diagnosis kondilomata akuminata dapat ditegakkan oleh pemeriksaan klinis dan riwayat yang didapat. pemeriksaan histologist dapat digunakan untuk menegakkan diagnosis.namun terkadang, pemeriksaan histopatologi diperlukan yaitu pada keadaan diagnosa yang tidak pasti, tidak membaik dengan terapi standar, penyakit memburuk selama terapi, dan lesi yang atipik.dalam kasus yang subklinis, penggunaan larutan asam asetar 3-5 % (tes acetowhite) mungkin membantu dalam memperkuat visualisasi lesi kutil pada genital, menimbulkan perubahan warna menjadi putih hal ini dapat membantu deteksi infeksi ka pada mukosa. namun prosedur ini tidak spesifik untuk infeksi hpv.ada juga pemeriksaan kolposkopi yang berguna untuk melihat lesi ka subklinis, dan kadang-kadang dilakukan bersama dengan tes asam asetat. namun pemeriksaan ini, belum digunakan secara luas di bagian penyakit kulit.2,3,7,8,12 ciri khas gambaran histopatologi dari sel yang terinfeksi hpv adalah pengembangan dari morfologi keratinosit atipikal yang dikenal sebagai koilocytes.koilocytes adalah sel yang membesar eksentrik, inti piknotic yang dikelilingi oleh suatu halo perinuklear. pada umumnya, epidermis akan menunjukkan akantosis ditandai dengan berbagai tingkat papillomatosis, hiperkeratosis, dan parakeratosis serta penipisan atau hilangnya lapisan granular. rete ridgescenderung memanjang dan menunjuk ke arah dalam dermis, dan pada dermis akan tampak vaskularisasi meningkat dengan kapiler trombosis. 7,10,12,14 . gambar 1. kondiloma akuminatum. akantosis prominen, hyperkeratosis, dan pemanjangan rete ridgesdan gambaran koilositosis. 10 pemeriksaan imunohistokimia adalah suatu metode untuk mengidentifikasi komponen jaringan tertentu dengan cara menginteraksikan antara antigen target dengan antibodi spesifik yang telah diberi label, untuk mengetahui keberadaan suatu antigen serta lokasinya secara spesifik pada jaringan atau sel berdasarkan pada reaksi pengenalan antigen-antibodi. interaksi antigen dan antibodi ini akan memberikan warna yang berbeda dibanding jaringan sekitarnya, dapat melihat distribusi dan lokalisasi dari komponen seluler spesifik diantara sel dan jaringan lain di sekitarnya. 15 teknik imunohistokimia bermanfaat untuk identifikasi, lokalisasi, dan karakterisasi suatu antigen tertentu, serta menentukan diagnosis, terapi, dan prognosis kanker. 16 terdapat beberapa metode pengecatan pada imunohistokimia, yaitu metode langsung (direct method), yang menggunakan antibodi primer yang sudah terlabel dan berikatan langsung dengan antigen target secara langsung, metode pengecatan satu langkah karena hanya melibatkan satu jenis antibody yang berlabel; metode tidak langsung (indirect method), 56 medical and health science journal, vol.3., no.1, februari 2019 yang menggunakan dua macam antibodi, yaitu antibodi primer (tidak berlabel) dan antibodi sekunder (berlabel); metode peroksidase-anti peroksidase (pap), yang menggunakan tiga molekul peroksidase dan dua antibodi yang membentuk seperti roti sandwich; dan metode avidin-biotin-complex (abc), yang menggunakan afinitas terhadap molekul avidin biotin oleh tiga enzim peroksidase. 17 mib-1 merupakan antibodi monoklonal dengan protein ki-67 nonhistone nuclear diekspresikan sepanjang siklus mitosis, dengan pengecualian pada fase g0.antibodi mib-1 mendeteksi antigen ki-67 dalam fase g1, s, g2 dan m tetapi tidak pada fase g0. 5,18,19 selama interfase, antigen ini dapat secara eklusif ditemukan pada nukleolus, selama mitosis, sebagian besar protein direlokasikan pada permukaan kromosom. oleh karena infeksi hpv menyebabkan peningkatan proliferasi sel epitel dalam jaringan yang terinfeksi, meningkatnya pewarnaan ki-67 dapat menjadi cerminan dari infeksi hpv dan luasnya pewarnaan ki-67 pada umumnya bersamaan dengan meningkatnya grade pada dysplasia. 18,19 mib-1 positif pada ka ditemukan secara eksklusif tampak prominen, ekspresi difus dalam inti parabasal dari epitel skuamosa, peningkatan proliferasi aktivitas sel-sel skuamosa dan perluasan sel sampai lapisan diatas dua pertiga dari ketebalan epitel. 5 pada epitel skuamosa dalam kondisi normal, mib-1 yang positif terbatas pada lapisan selparabasal. 20 gambar 2.(a) mib-1 immunostaining hadir dalam lapisan parabasal diatas dua pertiga pada ketebalan epitel (mib-1 positif). 18 gambar 3. (a dan b) gambaran pola pewarnaan imunohistokimia mib-1 dalam semua kasus ka menunjukkan prominen, ekspresi parabasal yang difus dengan ekstensi dari sel positif dua pertiga atas pada ketebalan epitel. 5 gambar 4. imunohistokimia. (b) ki-67 positif pada epitel basal dalam kondiloma. (c) ekspresi ki-67 dalam epitel lapisan atas lebih sering dalam kondiloma dysplasia. 14 protein p16 berasal dari tumour suppressor gene, yang telah diidentifikasi sebagai biomarker untuk infeksi hpv. peran p16 adalah melakukan siklus sel pada fase g1 dini dan menghambat transisi selanjutnya siklus sel dari g1 ke fase s. selama fase g1, cdk4 dan cdk6 membentuk kompleks-kompleks dengan cyclin d1 yang kemudian memfosforilasi kelompok protein rb yang menghasilkan fosforilasi. hambatan fosforilasi rb menyebabkan pelepasan faktor transkripsi e2f dari kompleks-kompleks rb/e2f.akibatnya, protein terakumulasi dalam nukleus dan sitoplasma dan dapat dideteksi oleh imunohistokimia. 22 ekspresi p16 sering diamati pada hpv risiko tinggi dibandingkan lesi pada risiko rendah.ekspresi imunohistokimia p16 umumnya terkait dengan hpv onkogenik.pewarnaan nuclear dan sitoplasma yang difus dan kuat biasanya berkorelasi dengan infeksi hpv risiko tinggi. 5 7 medical and health science journal, vol.3., no.1, februari 2019 sensitivitas dan spesifisitas p16 immunostaining yang mendekati 100% untuk mendeteksi hpv yang terkait karsinoma. 21 pada pemeriksaan dengan imunohistokimia, gambaran overekspresi dari p16 ditandai dengan gambaran immunostaining yang kuat dan difus yang biasanya terlihat pada hpv risiko tinggi lesi-lesi pra kanker. sedangkan pada lesi yang resiko rendah, seperti infeksi hpv 6 dan 11 akan memberikan gambaran immunostainingyang fokal dan lemah biasanya ditemukan pada semua ka. penelitian lain menunjukkan bahwa pemeriksaan p16 selalu memberikan gambaran negatif pada jaringan normal.penilaian dan interpretasi pewarnaan ekspresi p16 menggunakan kriteria klaes, yaitu positif, bila terdapat warna coklat pada nukleus dan sitoplasma atau pewarnaan nuclear yang kuat; dan negatif: bila kurang 1% dari semua selpositif. sporadis bilahanya beberapa sel yang positif tetapi tidak lebih dari 5% dari semua sel, fokal bila kelompok kecil sel positif tapi kurang dari 25% dari semua sel, dengan peningkatan intensitas warna coklat, dan difus bila sel positif lebih dari 25%, dengan intensitas warna coklat sangat meningkat. 23 gambar 5. a. kondiloma akuminata. b. pembesaran, nuclei hiperkromatik koilositosis. c. pewarnaan negatif p16 pada sel abnormal menetapkan sifat non-neoplastik. 23 gambar 6. c dan e. kondiloma akuminata dengan perilesional kulit.d, focal positif ekspresi p16 pada kondiloma. f. ekspresi p16 sporadic pada kondiloma. 23 pembahasan kondiloma akuminatum (ka) merupakan penyakit menular seksual pada daerah genital yang disebabkan oleh infeksi human papilloma virus (hpv) jenis tertentu, yaitu tipe 6 dan tipe 11. namun, dari beberapa penelitian pasien dengan ka mungkin dapat terinfeksi secara bersamaan dengan beberapa jenis strain hpv, dan sifat yang penting dari infeksi tersebut dapat menjadi indikator prognostik dari keganasan. hpv dapat menular terutama melalui hubungan seksual.diagnosis ka dapat ditegakkan berdasarkan gambaran klinis dan riwayat yang didapat.namun, gambaran klinis tidak dapat membedakan lesi jinak dari preneoplastik atau lesi displastik. penilaian akurasi diagnostik pada ka walaupun dapat dilakukan dengan deteksi hpv dengan pcr, teknik ini telah dibatasi penggunaan klinisnya karena prosedur dan biaya yang tinggi.secara morfologis pada lesi yang ambigu atau meragukan, diagnosis definitif yang terbaik dapat dibuat melalui pemeiksaan histopatologi dan imunohistokimia.lesi harus diperiksa untuk adanya perubahan menjadi keganasan. jika diduga neoplasia, atau, setidaknya, diferensiasi virus berisiko rendah atau berisiko tinggi, sehingga 58 medical and health science journal, vol.3., no.1, februari 2019 penggunaan teknik yang tepat sangat dibutuhkan. teknik imunohistokimia yang menggunakan beberapa biomarker bermanfaat untuk identifikasi, lokalisasi, dan karakterisasi suatu antigen tertentu, serta menentukan diagnosis, terapi, dan prognosis kanker.penggunaan mib-1, sebuah penargetan antibodi proliferasi sel protein ki-67, dapatmembantu dalam melihat adanya infeksi virus.positif pada ka ditemukan secara eksklusif tampak prominen, ekspresi difus dalam inti parabasal dari epitel skuamosa, peningkatan proliferasi aktivitas sel-sel skuamosa dan perluasan sel sampai lapisan diatas dua pertiga dari ketebalan epitel.penggunaan p16 (tumour suppressor gene) pada hpv resiko tinggi akan memberikan gambaran overekspresi pada lesi pra kanker ditandai dengan gambaran immunostaining yang kuat dan difus. sedangkan pada lesi beresiko rendah, seperti infeksi hpv 6 dan 11 akan memberikan gambaran immunostaining yang fokal dan lemah. dengan adanya pemeriksaan histopatologi dan imunohistokimia mib-1(ki-67)dan p16 tersebut dapat membantu menegakkan diagnosis pada kasus ka yang meragukan atau yang dapat berkembang menjadi keganasan. oleh karena itu, dengan ditegakkannya diagnosis secara dini dapat memastikan pemberian pengobatan dan dapat mencegah serta menghindari penyebaran penyakit tersebut. daftar pustaka 1. hakim l. epidemiologi infeksi menular seksual. dalam: daili sf, makes bib, zubier f. editor: infeksi menular seksual. ed.4. jakarta: fakultas kedokteran universitas indonesia; 2011. hal:11. 2. murtiastutik d. kondiloma akuminata. dalam: barakbah j, lumintang h, martodiharjo s. editor: buku ajar infeksi menular seksual. surabaya: airlangga university press; 2008. hal:165-169. 3. zubier f. kondilomata akuminata. .dalam: daili sf, makes bib, zubier f. editor: infeksi menular seksual. ed.4. jakarta: fakultas kedokteran universitas indonesia; 2011. hal:140-145. 4. centers for disease control and prevention. sexually transmitted diseases treatment guidelines 2010. morbidity and mortality weekly report 2010; 59: 69-78. 5. pirog ec, chen yt, isacson c. mib-1 immunostaining is a beneficial adjunct tes for accurate diagnosis of vulvar condyloma acuminatum. am j surg pathol. 2000; 24(10): 1393-1399. 6. moyer va. screening for cervical cancer: u.s. preventive services task force recommendation statement. annals of internal medicine 2012; 156 (12): 880-91. 7. patel rv, yanofsky vr, goldenberg g. genital warts: a comprehensive review. j clin aesthet dermatol. 2012; 5(6): 25-36. 8. yanofsky vr, linkner rv, pompei d, goldenberg g. current update on the treatment of genital warts. expert rev dermatol. 2013; 8(3): 321-332. 9. hidayati an, ervianti e, lumintang h. human papillomavirus (hpv) tipe 16 pada lesi genital dan serviks penderita kondiloma akuminata. berkala ilmu kesehatan kulit dan kelamin 2009; 21 (1): 25-30. 10. cardoso jc, calonje e. cutaneous manifestations of human papillomaviruses: a review. acta dermatoven. 2011: 145-154. 11. winer rl, koutsky la. genital human papillomavirus infection. in: holmes kk, sparling pf, lemon sm, stamm we, piot p, wasserheit jn, editors. sexually transmitted disease 4th edition. new york: mc graw hills; 2008. p. 489-501. 12. androphy ej, kirnbauer r. human papiloma virus infections. in : wolf k, goldsmith l, katz s, gilchrest b, paller a, leffell o, editors. fitzpatrick’s deramtology in general medicine.8th ed.new york: mcgraw hill;2012.p.2421-33. 13. sadan o, bilevsky e, shejter e, levy t, bachar r, yarden h, et.al. occurrence of cervical 5 9 medical and health science journal, vol.3., no.1, februari 2019 intraepithelial neoplasia in generally healthy women with exophytic vulvar condyloma acuminata. inf dis obst gynec 2005; 13(3): 141–143. 14. baydar de, kulac i, ozagari a, and tezel gg. occurrence of dysplasia and human papilloma virus typing in penile condyloma. urology. 2013: 9-15. 15. jackson p, blythe d. immunohistochemical techniques. in: bancroft j, gamble m, editors. theory and practice of histological techniques. elsevier. 2008. 16. boenisch t. handbook: immunochemical staining methods. california: dako cooperation. 2001. 17. mashhood aa. importance of immunohistochemistry in the diagnosis of skin tumours. journal of pakistan association of dermatologist 2008; 18: 1-3. 18. logani s, lu d, quint wgv, ellenson lh, pirog ec. low-grade vulvar and vaginal intraephitelial neoplasia: correlation of histologic features with human papillomaviru dna detection and mib-1 immunostaining. mod pathol. 2003;16(8): 735-741. 19. atirici sd, imir g, ozer h, elagoz s, simsek g, cetin m. evaluation of ki-67 immunostaining in the diferrential diagnosis of low grade squamous intraepthelial lesion and normal cervix. j turkish-german gynecol assoc. 2007: 285-289. 20. miller rt. utility of ki-67(mib-1) immunostaining in cervical biopsies. propath. 2002. 21. maniar kp, ronnet bm, vang r, and yemelyanova a. coexisting high-grade vulvar intraepithelial neoplasia (vin) and condyloma acuminatum-independent lesions due to different hpv types occuring in immunocompromised patients. am j surg pathol. 2013; 37(1): 53-60. 22. agarwal p, kabir fml, deinnocentes p, bird rc. tumor suppressor gene p16/ink4a/cdkn2a and its role in cell cycle exit, differentiation, and determination of cell fate. in: cheng p, editor. tumor suppressor genes. intech. 2012. http://www.intechopen.com/books/tumor suppressor-genes. 23. kazlouskaya v, shustef e, allam sh, lal k, and elston d. expression of p16 protein in lesional and perilesional condyloma acuminate and bowenoid papulosis: clinical significance and diagnostic implications. j am acad dermatol. 2013; 69: 444-9. 60 http://www.intechopen.com/books/tumormedical and health science journal, vol.3., no.1, februari 2019 original article pengaruh ekstrak daun pepaya (carica papaya) terhadap kematian larva nyamuk aedes agypti instar iii jonathan payangka 1* , risma 2 , prajogo wibowo 3 1 program studi pendidikan dokter, fakultas kedokteran universitas hang tuah surabaya, indonesia 2 departemen parasitologi, fakultas kedokteran universitas hang tuah surabaya, indonesia 3 departemen farmakologi, fakultas kedokteran universitas hang tuah surabaya, indonesia *correspondent author: jonathan.payangka@yahoo.com article info article history: received 23 january 2019 received in revised form february 2019 accepted 4 february 2019 abstract background: papaya leaves (carica papaya) extract is a natural larvacide that contains papain and alkaloid karpain so its usage is safe for the environment. the larvacide properties can also be used to reduce the amount of aedes aegypti mosquito larvae. this mosquito species is the main vector for the virus that causes dengue fever which incident number increases over the years. there have been a few methods used to control the mosquito’s amount, one of which is by decreasing the number of aedes aegypti’s larvae using the organophosphate insecticide chemical known as temefos. temefos is really effective in killing the aedes aegypti larvae but it has a lot of side effects keywords: carica papaya leaves, dengue fever, aedes aegypti kata kunci: daun carica papaya, dengue fever, aedes aegypti especially towards the environment. by controlling the number of the aedes aegypti’s larvae, hopefully the number of the dengue fever case can also be reduced. objective: to prove that the papaya leaves (carica papaya) extract have effects on the death of aedes aegypti’s instar iii larvae. method: this is an experimental research what uses a post test only control group design. the study consists of seven groups, which are positive control that is given abate powder, negative control that is given only aquadest, and five groups treated with concentrations of 0.5%, 1%, 1.5%, 2%, and 2.5%; repeated for four times. the calculation of the amount of dead larvae is done within the first 24 hours. result: based on the kruskal-wallis test, p’s value is <α with p value being 0.000 and α being 0.05. it proves the significance of the experiment. conclusion: the papaya leaves (carica papaya) extract have effects on the death of aedes aegypti’s instar iii larvae. abstrak latar belakang: ekstrak daun papaya (carica papaya) merupakan bahan larvasida alami yang mengandung papain dan alkaloid karpain sehingga penggunaannya aman bagi lingkungan. sifat larvasidanya juga dapat diterapkan untuk mengurangi jumlah larva nyamuk aedes aegypti. nyamuk spesies ini adalah vektor utama untuk virus yang dapat menyebabkan demam dengue yang tingkat insidensinya semakin lama semakin meningkat. sudah ada beberapa metode kontrol nyamuk yang dipakai, salah satunya adalah mengurangi jumlah larva nyamuk dengan menggunakan insektisida organofosfat kimiawi yang disebut sebagai temefos. temefos sangat baik dalam membunuh larva nyamuk aedes aegypti namun memiliki banyak efek samping terutama bagi lingkungan. dengan mengontrol jumlah larva nyamuk ini diharapkan akan terjadi penurunan jumlah kasus demam dengue.tujuan: untuk membuktikan bahwa ekstrak daun pepaya (carica papaya) dapat mempengaruhi kematian larva nyamuk aedes aegypti instar iii. metode: penelitian ini adalah penelitian eksperimental menggunakan post test only con -trol group design. penelitian terdiri dari tujuh kelompok, yaitu kelompok kon correspondence: jonathan payangka @2019 medical and health science journal. 10.33086/mhsj.v3i1.921 available at http://journal2.unusa.ac.id/index.php/mhsj 7 mailto:jonathan.payangka@yahoo.com http://journal2.unusa.ac.id/index.php/mhsj medical and health science journal, vol.3., no.1, februari 2019 -trol positif yang diberi bubuk abate, kelompok kontrol negatif yang hanya diberi aquades dan lima kelompok perlakuan dengan konsentrasi 0,5%, 1%, 1,5%, 2%, dan 2,5%; diulang sebanyak empat kali. penghitungan jumlah larva nyamuk yang mati dilakukan setelah 24 jam. hasil: berdasarkan uji kruskal wallis didapatkan p<α dengan p=0,000 dan α=0,05. hal ini membuktikan signifikansi penelitian. kesimpulan: ekstrak daun papaya (carica papaya) dapat mempengaruhi kematian larva nyamuk aedes aegypti instar iii. @2019 medical and health science journal. 10.33086/mhsj.v3i1.921 pendahuluan carica papaya merupakan tanaman yang banyak dijual secara komersil dengan negara negara produsen terbesarnya termasuk indonesia, brazil, nigeria, mexico, dan india. tanaman ini mengandung banyak senyawa diantaranya ada vitamin a, vitamin c, kalsium, papain, dan lain lain (encyclopedia of life, 2018). senyawa senyawa yang terkandung di daun papaya ada yang bersifat larvasida yaitu papain dan alkaloid karpain (shadana et al, 2014). senyawa yang paling aktif pada carica papaya merupakan papain (wahyuni, 2014). papain merupakan enzim yang terdapat pada daun, getah pohon, akar, dan buah dari tanaman papaya yang mengkatalisasi proses pemecahan protein dengan menambahkan molekul air yang disebut sebagai hidrolisis (encyclopedia britannica, 2018). untuk pertumbuhannya, larva nyamuk aedes aegypti ini memerlukan senyawa senyawa protein layaknya lesitin dan karena adanya aktivitas proteolitik dari papain, pertumbuhan larva tersebut menjadi terhambat (tyas et al, 2014). asetilkolin pada larva nyamuk berfungsi sebagai suatu neurotransmiter. ketika senyawa tersebut sudah digunakan, maka akan dipecah oleh enzim asetilkolinasease menjadi asetil ko-a dan kolin. alkaloid karpain akan menghambat kerja enzim tersebut sehingga terjadi kejang, lumpuh, dan berujung pada kematian (anwar et al, 2018). keunggulan dari ekstrak dari daun papaya sebagi larvasida adalah sifatnya yang ramah lingkungan sehingga dapat menggantikan bahan insektisida sintetis (hayatie et al, 2015). 8 penggunaan ekstrak tersebut sebagai bahan insektisida tidak memiliki efek buruk terhadap lingkungan dan manusia karena dapat didegradasi dengan mudah sehingga tidak meninggalkan residu baik pada tanah, air, dan udara (yunair et al, 2017). aedes aegypti adalah vector nyamuk utama untuk virus dengue dan nyamuk ini adalah suatu serangga yang sangat erat kaitannya dengan manusia dan segala kegitannya (cdc, 2017). pola transmisi dari virus degue ini sangat dipengaruhi oleh jumlah, tingkat kelangsungan hidup, dan tingkah laku aedes aegypti itu sendiri; level imunitas terhadap serotype virus pada populasi manusia local; kepadatan, distribusi, pergerakan manusia; dan waktu yang diperlukan untuk perkembangan virus di ae. aegypti, walaupun belum sepenuhnya dipahami hubungan satu faktor dengan yang lain termasuk bagaimana mereka bervariasi dari suatu tempat ke tempat lain dan suatu waktu ke waktu yang lain (getis et al,2010). penyebaran dari nyamuk ini apabila dikontrol maka akan dapat mengurangi penyebaran penyakit demam dengue itu sendiri. kontrol terhadap penyebaran nyamuk ae. aegypti ini dapat dilakukan dengan beberapa prinsip yaitu : menghilangkan habitat larvanya untuk mengurangi sumber, mengkontrol perkembangan larvanya menggunakan bahan-bahan yang bersifat larvasida, mengkontrol nyamuk dewasanya, memonitor resistensi pestisida dan mencegah transmisinya (cdc, 2016). untuk kontrol nyamuk pada tahap larva ini bisa menggunakan beberapa cara : insektisida bakterial, penghambat pertumbuhan serangga, insektisida organofosfat, dan bahan medical and health science journal, vol.3., no.1, februari 2019 bahan lain (epa, 2018). salah satu cara yang direkomendasikan oleh who adalah dengan menggunakan pestisida organofosfat yang disebut temefos (who, 2017). cara kerja senyawa ini adalah dengan sistem saraf serangga (epa, 2018). dia dapat menjadi efektif ketika terjadi kontak dengan larva tersebut (kemabonta & nwanko, 2013). temefos juga memiliki nama kimiawi lain seperti difos, biothion, dan abate (pubchem, 2018). kekurangan dari penggunaan temefos adalah efek sampingnya pada lingkungan yang mana senyawa tersebut bersifat sangat toksik terhadap organisme aquatic dan dapat menimbulkan efek samping yang berkepanjangan terhadap lingkungan aquatic (basf, 2012). demam dengue ditransmisikan oleh gigitan nyamuk aedes aegypti, yang terinfeksi oleh salah satu dari empat macam virus dengue. penyakit demam dengue biasanya terjadi di daerah tropis dan sub-tropis di dunia (who, 2017). dengue fever atau yang dalam bahasa indonesia dikenal dengan demam dengue adalah suatu penyakit yang penyebaran resiko infeksinya dan beban kesehatannya dalam masyarakat di seluruh dunia masih kurang diketahui (bahtt et al, 2013). penyakit demam dengue sendiri beberapa dekade belakangan ini telah meningkat pesat tingkat insidensinya (who, 2017). walaupun terdapat penyakit yang tercatat di tiongkok pada sekitar tahun 900 dengan gejala yang mirip dengan demam dengue, hal ini tidak berarti penyakit demam dengue pasti berasal dari negara tersebut (halstead, 2016). diperkirakan juga bahwa dengue berasal dari afrika, bersamaan dengan yellow fever, tersebar ke new world pada tahun 1600-an (farrar et al, 2009). yang diketahui secara pasti adalah bahwa terdapat epidemi penyakit dengan gejala yang mirip demam dengue pertama kali dilaporkan pada tahun 1635 di martinique (dick, 2012). di dunia diperkirakan 2,5 milliar orang beresiko terinfeksi, dan sekitar 975 jutanya adalah orang-orang yang tinggal di daerah perkotaan di negara tropis dan sub-tropis di asia tenggara, daerah pasifik, dan benua amerika (guzman et al, 2010). di asia tenggara sendiri, dari tahun 2001 hingga 2010 ada 386.154 kasus demam dengue yang tercatat dimana sebagian besar kasus ini terjadi di indonesia, yaitu 104.457 kasus dengan 1.041 kasus diantaranya bersifat fatal. di bawah indonesia ada thailand dengan jumlah kasus 76.978 yang mana angka ini masih jauh jika dibandingkan dengan kasus yang terjadi di indonesia sendiri (shepard et al, 2013). surabaya, yang merupakan kota terbesar ke-2 di indonesia dan ibukota dari provinsi jawa timur, memiliki insidensi tahunan dari kasus demam dengue sebanyak 2.000 – 3.000 dan terkait dengan 10 kematian selama tahun 2002 – 2012 (mulyatno et al, 2012). gejala dari demam dengue sendiri akan muncul sekitar tiga hingga empat belas hari setelah gigitan nyamuk (who,2017). penelitian serupa sebelumnya pernah dilakukan; salah satunya adalah penelitian dengan judul ―uji potensi ekstrak daun pepaya (carica papaya l.) sebagai larvasida terhadap larva aedes aegypti instar iii‖ yang dilaksanakan di lampung, indonesia terhadap populasi nyamuk setempat (saraswati et al, 2014). hasil penelitiannya menunjukkan adanya efek larvasida yang cukup signifikan akibat adanya senyawa aktif sebagai kandungan ekstrak yang dipakai (saraswati et al, 2014 dan hayatie et al, 2015). berdasarkan latar belakang di atas, maka peneliti ingin mengetahui pengaruh ekstrak daun papaya (carica papaya) terhadap perkembangan larva nyamuk aedes aegypti yang terdapat di surabaya. metode penelitian penelitian ini merupakan penelitian eksperimental laboratoris yang tidak memperhitungkan faktor luar (suhu, cuaca, dan ph) dan bertujuan untuk mengetahuipengaruh pemberian ekstrak daun papaya (carica papaya) 9 medical and health science journal, vol.3., no.1, februari 2019 yang dapat membunuh larva nyamuk aedes aegypti instar iii. metode penelitian yang digunakan adalah post test only control groupdesign karena pengukuran hanya dilakukan satu kali, yaitu setelah larva nyamuk aedes aegypti instar iii diberi ekstrak daun papaya (carica papaya). dalam penelitian ini terdapat 7 perlakuan (5 perlakuan + 1 kontrol negatif + 1 kontrol positif ) dan 4 kali pengulanggan. setiap perlakuan pengulangan membutuhkan 25 ekor larva. sehingga jumlah total larva nyamuk aedes aegypti yang dibutuhkan dalam penelitian ini adalah 25 ekor x 7 perlakuan x 4 kali pengulangan = 700 larvadengan skema: k1 k2 k3 k4 k5 k6 k7 keterangan : p : populasi s : sampel r : randomisasi k1 : kelompok 1 perlakuan dengan konsentrasi ekstrak daun papaya (carica papaya) 0,5% k2 : kelompok 2 perlakuan dengan konsentrasi ekstrak daun papaya (carica papaya) 1% k3 : kelompok 3 perlakuan dengan konsentrasi ekstrak daun papaya (carica papaya) 1,5% k4 : kelompok 4 perlakuan dengan konsentrasi ekstrak daun papaya (carica papaya) 2% k5 : kelompok 5 perlakuan dengan konsentrasi ekstrak daun papaya (carica papaya) 2,5% k6 : kelompok 6 sebagai kontrol negatif (perlakuan dengan aquades saja) k7 : kelompok 7 sebagai kontrol positif (perlakuan dengan aquades yang dicampur abate) o : obeservasi jumlah larva aedes aegypti yang mati setelah 24 jam populasi yang dipakai pada penelitian ini adalah larva nyamuk aedes aegypti instar iii yang di dapat dari laboratorium entomologi dinas kesehatan jawa timur di surabaya. sampel yang akan di gunakan pada penelitian ini adalah 25 ekor larva uji pada masing masing kelompok percobaan dan replikasinya. a) kriteria inklusi sampel 1) larva aedes aegypti instar iiididapatkan di laboratorium entomologi dinas kesehatan jawa timur di surabaya. 2) larva hidup masih bergerak aktif. b) kriteria eksklusi sampel 1) larva aedes aegypti yang belum mencapai instar iii atau sudah mencapai iv 2) larva aedes aegypti yang telah berubah menjadi pupa atau dewasa 3) larva aedes aegypti yang tidak bergerak aktif (mati) sebelum perlakuan pengambilan sampel pada larva aedes aegypti dilakukan secara simple random sampling (srs) yaitu setiap sampel memiliki kesempatan yang sama untuk dipilih sebagai sampel kelompok kontrol ataupun kelompok perlakuan. ekstrak daun papaya (carica papaya) dibuat dengan metode maserasi, yaitu dengan cara dipanaskan, dikeringkan, lalu dihalus kan dan dicampur dengan alkohol, kemudian disaring dan terakhir diuapkan. tahap pengujian ekstrak daun papaya sesuai konsentrasi yang sudah di tentukan yaitu 0,5%, 1%, 1,5%, 2% dan 2,5%. ekstrak daun papaya (carica papaya) lalu diambil dengan pipet dan dimasukkan ke dalam gelas percobaan sesuai volume yang dibutuhkan agar sesuai konsentrasi yang diperlukan dengan mengunakan rumus. data yang dikumpulkan adalah dengan cara menghitung jumlah larva yang mati pada setiap kelompok , penghitungan larva yang mati dilakukan setelah kurun waktu 24 jam, kemudian di catat dalam bentuk tabel. larva yang mati merupakan larva yang tenggelam ke dasar wadah, tidak bergerak, meninggalkan larva yang lain yang dapat bergerak dengan jelas dan tidak berespon terhadap rangsangan (ashry as ,2009). 10 p s r o o o o o o o medical and health science journal, vol.3., no.1, februari 2019 larva juga tetap tidak bergerak setelah disentuh dengan jarum atau lidi pada bagian siphon atau cervical.larva yang hampir mati adalah larva yang tidak dapat naik ke permukaan air dan tidak menyelam kedasar permukaan air meskipun air digoyangkan atau di gerakkan (who,2005). penyajian data secara deskriptif disajikan dalam bentuk tabel secara analitik. perhitungan persentase kematian larva menggunakan rumus: mortalitas (%)= kematian larva x 100% 25 cara analisis data pada peneliian ini menggunakan program spss 23,0. apabila hasil uji normalitas berdistribusi normal dan varian homogen akan dilakukan uji parametrik, bila data tidak berdistribusi normal makan dilakukan analissi data dengan uji nonparametrik. hasil penelitian penelitian ini merupakan penelitian eksperimental laboratorium dengan rancangan penelitian post test only controlled group design. penelitian ini dilakukan untuk mengetahui pengaruh ekstrak daun papaya (carica papaya) dalam konsentrasi yang berbeda terhadap jumlah kematian lerva nyamuk aedes aegypti instar iii. masing-masing konsentrasi tersebut dibandingkan dengan kontrol negatif yang berisi air saja dan kontrol positif yang berisi temefos. penelitian ini menggunakan 7 wadah yang masing-masing berisi 25 ekor larva nyamuk aedes aegypti instar iii yang terbagi dalam kontrol positif, kontrol negatif, serta kelompok perlakuan yaitu ekstrak daun papaya (carica papaya) dengan konsentrasi 0,5%, 1%, 1,5%, 2%, dan 2,5%. pada penelitian ini dilakukan replikasi atau pengulangan sebanyak 4 kali sesuai dengan perhitungan uji replikasi. data jumlah kematian larva nyamuk aedes aegypti instar iii hasil pengamatan mengenai jumlah kematian larva dapat dilihat pada tabel berikut: tabel 1. jumlah kematian larva nyamuk aedes aegypti no . konsentrasi r1 r2 r3 r4 rata-rata 1. kontrol (+) 25 25 25 25 25 2. kontrol (-) 0% 0 0 0 0 0 3. 0,5% 2 1 0 1 1 4. 1% 5 3 0 1 2,25 5. 1,5% 5 4 6 9 6 6. 2% 12 16 13 15 14 7. 2,5% 21 20 21 23 21,25 keterangan : r1 : pengulangan pertama r2 : pengulangan kedua r3 : pengulangan ketiga r4 : pengulangan keempat konsentrasi : jumlah konsentrasi pemberian larutan ektrak daun papaya rata-rata : jumlah rata-rata kematian larva dari empat pengulangan catatan : setiap perlakuan menggunakan 25 larva nyamuk aedes aegypti instar iii tanpa diberi makan waktu uji. tabel 1 di atas menunjukkan bahwa angka rata-rata kematian terkecil, 1 larva, ada pada konsentrasi terendah yaitu 0,5% dan angka rata-rata kematian terbesar, 21,25 larva, ada pada konsentrasi terbesar yaitu 2,5%. ini artinya peningkatan rata-rata jumlah kematian sebanding dengan peningkatan konsentrasi. data persentase kematian larva nyamuk aedes aegypti instar iii hasil pengamatan mengenai jumlah kematian larva dapat dilihat pada tabel berikut: tabel 2. persentase kematian larva nyamuk aedes aegypti no . konsentrasi r1 (% ) r2 (% ) r3 (% ) r4 (% ) rata rata (%) 1. kontrol (+) 100 100 100 100 100 2. kontrol (-) 0% 0 0 0 0 0 3. 0,5% 8 4 0 4 4 4. 1% 20 12 0 4 9 5. 1,5% 20 16 24 36 24 6. 2% 48 64 52 60 56 7. 2,5% 84 80 84 92 85 11 medical and health science journal, vol.3., no.1, februari 2019 keterangan : r1 : pengulangan pertama r2 : pengulangan kedua r3 : pengulangan ketiga r4 : pengulangan keempat konsentrasi : jumlah konsentrasi pemberian larutan ektrak daun papaya rata-rata : persentase rata-rata kematian larva dari empat pengulangan catatan : setiap perlakuan menggunakan 25 larva nyamuk aedes aegypti instar iii tanpa diberi makan waktu uji. tabel 2 di atas menunjukkan bahwa rata-rata persentase kematian terkecil, 4%, ada pada konsentrasi terendah yaitu 0,5% dan rata-rata persentase kematian terbesar, 85%, ada pada konsentrasi terbesar yaitu 2,5%. hasil ini menunjukkan bahwa peningkatan rata-rata persentase kematian sebanding dengan peningkatan konsentrasi. hasil analisa statistika analisa data penelitian ini menggunakan spss 23.0 untuk mempermudah pengolahan data. analisis uji normalitas hipotesis : h0 : data terdistribusi dengan normal. h1 : data tidak terdistribusi dengan normal. tabel 3. hasil uji normalitas shapiro-wilk kematian larva (sig.) 0,001 hasil uji normalitas dengan metode uji shapiro-wilk menunjukan nilai signifikansi (sig.) kurang dari α (0,05) yang berarti distribusi data tidak normal. dari hasil uji normalitas, dapat disimpulkan bahwa langkah selanjutnya adalah analisis data, tanpa melalui uji homogenitas, karena data diatas tidak memenuhi syarat uji analisis one way anova sehingga harus digunakan metode kruskal-wallis untuk menganalisis data. uji kruskall-wallis data jumlah kematian larva nyamuk aedes aegypti instar iii hipotesis : h0 : tidak ada perbedaan rerata kematian larva nyamuk aedes aegypti antar kelompok berdasarkan konsentrasi ekstrak daun papaya (carica papaya). h1 : ada perbedaan rerata kematian larva nyamuk aedes aegypti antar kelompok berdasarkan konsentrasi ekstrak daun papaya (carica papaya). tabel 4. hasil uji kruskall-wallis data jumlah kematian larva nyamuk aedesaegypti instar iii no . konsentrasi r1 r2 r3 r4 rata rata rata rata (%) 1. kontrol (+) 25 25 25 25 25 100 2. kontrol (-) 0% 0 0 0 0 0 0 3. 0,5% 2 1 0 1 1 4 4. 1% 5 3 0 1 2,25 9 5. 1,5% 5 4 6 9 6 24 6. 2% 12 16 13 15 14 56 7. 2,5% 21 20 21 23 21,25 85 p = 0,000 (p < 0,05) berdasarkan hasil analisis kruskall-wallis yang tercantum pada tabel 5.4, didapatkan bahwa nilai signifikansi (asymp. sig.) lebih kecil dari 0,05 (p < 0,05). dari hasil tersebut dapat disimpulkan bahwa terdapat perbedaan jumlah kematian larva nyamuk aedes aegypti pada masing-masing perlakuan, maka uji yang harus dilaksanakan selanjutnya adalah uji mann-whitney u untuk melihat letak perbedaannya. uji mann-whitney u hipotesis : h0 : tidak ada perbedaan rerata kematian larva nyamuk aedes aegypti antara dua konsentrasi yang dibandingkan. h1 : ada perbedaan rerata kematian larva nyamuk aedes aegypti antara dua konsentrasi yang dibandingkan. 12 medical and health science journal, vol.3., no.1, februari 2019 tabel 5. hasil uji mann-whitney u data jumlah kematian larva nyamuk aedesaegypti instar iii keterangan : : berbeda secara signifikan (p < 0,05) : tidak berbeda secara signifikan (p > 0,05) penjelasan tabel 5 : 1. kelompok kontrol (-) atau 0% terdapat perbedaan rerata jumlah kematian larva nyamuk aedes aegypti dengan ekstrak daun papaya (carica papaya) yaitu pada konsentrasi 0,5%, 1%, 1,5%, 2%, dan 2,5%, dan juga dengan kontrol (+) karena memiliki nilai p<0,05. 2. konsentrasi 0,5% tidak terdapat perbedaan rerata jumlah kematian larva nyamuk aedes aegypti dengan konsentrasi 1% karena p>0,05 namun terdapat perbedaan rerata jumlah kematian larva nyamuk aedes aegypti dengan konsentrasi 1,5%, 2%, dan 2,5%, dan juga dengan kontrol (+) karena memiliki nilai p<0,05. 3. konsentrasi 1% tidak terdapat perbedaan rerata jumlah kematian larva nyamuk aedes aegypti dengan konsentrasi 1,5% karena p>0,05 namun terdapat perbedaan rerata jumlah kematian larva nyamuk aedes aegypti dengan konsentrasi 2%, dan 2,5%, dan juga dengan kontrol (+) karena memiliki nilai p<0,05. 4. konsentrasi 1,5% terdapat perbedaan rerata jumlah kematian larva nyamuk aedes aegypti dengan konsentrasi 2% dan 2,5% serta kontrol (+) karena memiliki nilai p<0,05. 5. konsentrasi 2% terdapat perbedaan rerata jumlah kematian larva nyamuk aedes aegypti dengan konsentrasi 2,5% dan kontrol (+) karena memiliki nilai p<0,05. 6. konsentrasi 2,5% terdapat perbedaan rerata jumlah kematian larva nyamuk aedes aegypti dengan kontrol (+) karena memiliki nilai p<0,05. diskusi hasil penelitian ini menunjukkan bahwa ekstrak daun pepaya (carica papaya) pada beberapa konsentrasi berpengaruh terhadap kematian larva aedes aegypti instar iii dengan pengaruh terendah pada dosis 0,5% yaitu 4% dan paling tinggi pada 2,5% yaitu 85%. peningkatan persentase kematian ini menunjukkan kenaikan yang sebanding dengan peningkatan persentase konsentrasi. untuk memudahkan peneliti dalam melakukan analisis data digunakan program spss 23.0. analisis yang dilakukan diawali dengan uji normalitas menggunakan metode kolmogorov smirnov untuk melihat apakah data sudah terdistribusi secara normal atau belum. uji normalitas menunjukkan bahwa data tidak terdistribusi secara normal sehingga peneliti langsung melakukan uji kruskal-wallis tanpa melaui uji homogenitas. uji kruskal-wallis, sesuai dengan tabel 5.4, memberikan hasil nilai signifikansi atau nilai p (asymp. sig.) sebesar 0,000 yang berarti p<0,05 atau p signifikan. nilai p yang signifikan ini menunjukkan bahwa ekstrak daun pepaya (carica papaya) memiliki pengaruh terhadap kematian larva nyamuk aedes aegypti. uji kruskal-wallis harus diikuti dengan uji post hoc multiple comparisons yaitu uji post hocmann-whitney u untuk melihat perbedaan rerata jumlah kematian larva nyamuk aedes aegypti instar iii dari masing masing kelompok. hasil uji mann-whitney u yang tertera pada tabel 5.5 menunjukkan bahwa perbedaan yang signifikan dari rerata jumlah kematian larva nyamuk aedes aegypti instar iii didapati pada semua kelompok kecuali antara kelompok dengan 13 konsentr asi 0% 0,5 % 1% 1,5 % 2% 2,5 % kontrol (+) 0% 0,5% 0,04 6 1% 0,04 7 0,45 7 1,5% 0,01 4 0,02 0 0,05 9 2% 0,01 4 0,02 0 0,02 1 0,02 1 2,5% 0,01 3 0,01 9 0,02 0 0,02 0 0,02 0 kontrol (+) 0,00 8 0,01 3 0,01 4 0,01 4 0,01 4 0,01 3 medical and health science journal, vol.3., no.1, februari 2019 dosis ekstrak daun pepaya (carica papaya) sebesar 0,5% dengan 1% dan antara kelompok dengan dosis ekstrak daun pepaya (carica papaya) sebesar 1% dengan 1,5%. pada penelitian ini secara teori kandungan daun pepaya (carica papaya) memiliki dua kandungan aktif yang dapat menyebabkan larva mati. kandungan aktif pertama yang bersifat larvasida dalam daun pepaya (carica papaya) adalah papain (adachukwu et al, 2013). papain dapat digunakan sebagai larvasida karena bersifat proteolitik sehingga dapat memecah protein lesitin yang dibutuhkan larva untuk berkembang (tyas et al, 2014). kandungan aktif kedua yang bersifat larvasida dalam daun pepaya (carica papaya) adalah alkaloid karpain (shadana et al, 2014). kerja alkaloid karpain sebagai larvasida adalah dengan menghambat kerja dari enzim asetilkolinasease yang memecah neurotransmiter asetilkolin menjadi asetil ko-a dan kolin sehingga larva kejang, lumpuh, atau bahkan mati (anwar et al, 2018). penelitian serupa sebelumnya juga pernah dilakukan di lampung dengan judul ―uji potensi ekstrak daun pepaya (carica papaya l.) sebagai larvasida terhadap larva aedes aegypti instar iii.‖ hasil penelitian tersebut juga menunjukkan hasil yang signifikan bahkan dalam dosis yang lebih kecil. dosis terkecil yang dapat menimbulkan pengaruh pada kematian larva nyamuk pada penelitian tersebut adalah sebesar 0,2% dengan rata-rata kematian 6,25% dan yang terbesar pada dosis 1% dengan rata-rata kematian 60% (saraswati et al, 2014). dari perbandingan kedua penelitian ini peneliti menyimpulkan bahwa dalam penelitian tipe ini dapat terjadi perbedaan hasil penelitian. hal-hal yang dapat mempengaruhi hasil penelitian yang dimaksud antara lain adalah persentase kandungan yang berbeda karena sumber daun berbeda dan efek pada larva berbeda karena larva tidak dari tempat yang sama. statistik hasil penelitian menunjukkan angka kematian larva nyamuk aedes aegypti instar iii tidak terdistribusi secara normal dan didapatkan adanya perbedaan jumlah rerata kematian larva nyamuk aedes aegypti instar iii pada hampir semua kelompok kecuali antara kelompok dengan dosis ekstrak daun pepaya (carica papaya) 0,5%, 1%, dan 1,5%. hasil angka kematian larva tertinggi didapatkan pada kelompok dengan dosis ekstrak daun pepaya (carica papaya) 2,5%. kesimpulan dari pembahasan pada bab sebelumnya, peneliti menyimpulkan bahwa penggunaan ekstrak daun pepaya (carica papaya) sebagai larvasida nyamuk aedes aegypti akan mempengaruhi jumlah kematian larva instar iii-nya karena sejumlah larva didapati mati setelah 24 jam pemberian ekstrak daun pepaya (carica papaya). ada perbedaan rerata jumlah kematian larva tersebut pada hampir seluruh kelompok kecuali antara kelompok dengan dosis ekstrak daun pepaya (carica papaya) 0,5% dengan 1% dan 1% dengan 1,5%. penelitian ini juga menunjukkan bahwa angka kematian terendah pada konsentrasi 0,5% (konsentrasi terendah) dan angka kematian tertinggi pada konsentrasi 2,5% (konsentrasi tertinggi). hal tersebut menunjukkan bahwa peningkatan jumlah kematian larva sebanding dengan peningkatan konsentrasi ekstrak daun papaya (carica papaya). saran perlu dilakukan penelitian lebih lanjut mengenai pengaruh ekstrak daun pepaya (carica papaya) terhadap larva nyamuk aedes aegypti instar iii dengan konsentrasi yang lebih tinggi , terhadap kematian nyamuk aedes aegypti dewasa, serta terhadap jenis nyamuk lain seperti culex sp., dll. daftar pustaka 1. ayoola, p.b. & adeyeye, a. (2010). phytochemical and nutrient evaluation of carica papaya (pawpaw) leaves. ladoke akintola university of technology, 5(3), 325 328. 2. bhatt, s., gething, p. w., brady, o. j., messina, j. p., farlow, a. w., moyes, c. l., … hay, s. 14 medical and health science journal, vol.3., no.1, februari 2019 i. (2013). the global distribution and burden of dengue. letter research, 496, 504–507. 3. britannica, t. e. of e. (2018, january 1). papain. retrieved february 5, 2018, from https://www.britannica.com/science/papain 4. burdick, e. m. (1971). carpaine: an alkaloid of carica papaya—its chemistry and pharmacology. economic botany, 25(4), 363– 365. 5. controlling mosquitoes at the larval stage. (2016, november 18). retrieved december 2, 2017, from https://www.epa.gov/mosquitocontrol/controlli ng-mosquitoes-larval-stage 6. dengue. 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(2017). papaya leaf (carica papaya l.) fraction effective as bioinsectiside against anopheles species (diptera: culicidae) larva invitro study. bioscientia medicina, 2(1), 1–11. 13. 13. 14. getis, a., morrison, a. c., gray, k., & scott, t. w. (2008). characteristics of the spatial pattern of the dengue vector, aedes aegypti, in iquitos, peru. perspectives on spatial data analysis advances in spatial science, 203–225. 15. guzman, m. g., halstead, s. b., artsob, h., buchy, p., farrar, j., gubler, d. j., … peeling, r. w. (2010). dengue: a continuing global threat. nature reviews microbiology, 8(12). 16. halstead, s. b. (2008). dengue: overview and history. dengue tropical medicine: science and practice, 1–28. 17. hayatie, l., biworo, a., & suhartono, e. (2015). aqueous extracts of seed and peel of carica papaya against aedes aegypti. journal of medical and bioengineering, 4(5), 417–421. 18. kemabonta, k. a., & nwankwo. a. e. (2013). larvacidal effectiveness of spinosad and temephos on anopheles gambiae & aedes aegypti. larvacidal effectiveness of spinosad and temephos on anopheles gambiae & aedes aegypti, 4(2), 214-222. 19. ming, r., & moore, p. h. (2014). genetics and genomics of papaya. new york, ny: springer. 20. mulyatno, k. c., yamanaka, a., yotopranoto, s., & konishi, e. (2012). vertical transmission of dengue virus in aedes aegypti collected in surabaya, indonesia, during 2008 2011. japanese journal of infectious diseases, 65(3), 274–276. 21. papain. retrieved april 10, 2018, from https://www.drugbank.ca/drugs/db11193 22. papain. retrieved april 11, 2018, from https://pubchem.ncbi.nlm.nih.gov/compound/p apain#section=2d-structure 23. papaya carica papaya details. retrieved december 10, 2017, from http://eol.org/pages/585682/details 24. pauline, i.a., ogbonna, a., & faith, e. (2013). phytochemical analysis of paw-paw (carica papaya) leaves. international journal of life sciences biotechnology and pharma research, 2(3), 346-352. 25. ramadhan, m.r.f., 2016. toksisitas campuran ekstrak biji pepaya (carica papaya l.) dan biji srikaya (annona squmosa l.) terhadap mortalitas larva nyamuk aedes aegypti l. jember. 26. regulator, gene technology. 2008. the biology of carica papaya l . ( papaya , papaw , paw paw ). 27. rothman, a. l. (2013). dengue virus. berlin: springer berlin. 28. service, m. w. (2012). medical entomology for students. cambridge: cambridge university press. 15 http://www.britannica.com/science/papain http://www.epa.gov/mosquitocontrol/controlli http://www.cdc.gov/dengue/entomologyecolo http://www.who.int/mediacentre/factsheets/fs1 http://www.drugbank.ca/drugs/db11193 http://eol.org/pages/585682/details medical and health science journal, vol.3., no.1, februari 2019 29. shadana, m., lesmana, s.d., & hamidy, m.y. (2014). efek larvasida ekstrak etanol daun pepaya (carica papaya) terhadap larva aedes aegypti. fakultas kedokteran universitas riau. 30. shepard, d. s., undurraga, e. a., & halasa, y. a. (2013). economic and disease burden of dengue in southeast asia. plos neglected tropical diseases, 7(2), 1-12. 31. temefos. retrieved february 10, 2018, from https://pubchem.ncbi.nlm.nih.gov/compound/t emephos#section=top 32. tyas, d.w., wahyuni, d., & hariyadi, s. (2014). perbedaan toksisitas ekstrak rebusan dan rendaman daun pepaya (carica papaya l.) terhadap mortalitas larva nyamuk aedes aegypti l. pancaran, 3(1), 59-68. 33. wahyuni, d. (2015). new bioinsecticide granules toxin from ectract of papaya (carica papaya) seed and leaf modified against aedes aegypti larvae. procedia environmental sciences, 23, 323–328. 34. world health organization, dengue. (2016, march 8). retrieved december 2, 2017, from http://www.searo.who.int/topics/dengue/en/ 35. yogiraj, v., goyal, p.k., chauhan, c.s., goyal, a., & vyas, b. (2014). carica papaya linn: an overview. international journal of herbal medicine, 2(5), 1-8. 36. yunair, n., majid, r. ode, l., zety, m., & wildan, e. (2017). larvacidal effect of papaya leaf extracts (carica papaya l.) toward the larvae of anopheles aconitus donits mosquitoes as an effort to prevent malaria disease in rural areas of southern konawe. international seminar on global health, 290-300. 16 http://www.searo.who.int/topics/dengue/en/ medical and health science journal, vol.3., no.1, februari 2019 original article case study effectivness of amyodaron use in patients with supraventricular tachycardia and hypothyroidism ,ardyarini dyah savitri * fakultas kedokteran universitas nahdlatul ulama surabaya, surabaya, indonesia *correspondent author: adsa.vitri@yahoo.com article info article history: received 25 january 2019 received in revised form february 2019 accepted 4 february 2019 abstract a woman, 53 years of age, with recurrent supraventricular tachycardia (svt) with hypothyroidism was thought to be associated with amiodarone use. patients repeatedly get amiodarone for their arrhythmias, where amiodarone has a broad antiarrhythmic effect making it effective for the management of svt. in addition, the low inotropic properties of amiodarone are low, making amiodarone the drug of choice in patients with heart failure. however, repeated use of amiodarone can cause many side effects, one of which is amiodarone keywords: amyodaron, supraventricular tachycardia (svt), hypothyroidsm. kata kunci: amyodaron, supraventricular tachycardia (svt), hypothyroidsm. induced hypothyroidism (aih). patients are given thyroxine hormone substitution therapy during the use of amiodarone and the response to the therapy given is quite good, so the patient has a good prognosis. abstrak seorang wanita, 53 tahun, dengan takikardia supraventrikular berulang (svt) dengan hipotiroidisme dianggap terkait dengan penggunaan amiodaron. pasien berulang kali mendapatkan amiodaron untuk aritmia mereka, di mana amiodaron memiliki efek antiaritmia luas yang membuatnya efektif untuk pengelolaan svt. selain itu, sifat inotropik amiodarone yang rendah, membuat amiodaron obat pilihan pada pasien dengan gagal jantung. namun, penggunaan berulang amiodaron dapat menyebabkan banyak efek samping, salah satunya adalah amiodaron diinduksi hipotiroidisme (aih). pasien diberikan terapi pengganti hormon tiroksin selama penggunaan amiodaron dan respons terhadap terapi yang diberikan cukup baik, sehingga pasien memiliki prognosis yang baik. @2019 medical and health science journal. 10.33086/mhsj.v3i1.927 pendahuluan takikardi supraventrikular (tsv) merupakan salah satu gangguan irama jantung yang sering terjadi, dengan tingkat insidensi mencapai 35 kasus per 100.000 populasi pertahun dan prevalensi 2,25 kasus per 1000 populasi. walaupun pada umumnya tidak mengancam nyawa, akan tetapi tsv dapat mempengaruhi kualitas hidup pasien dengan manifestasi episode takikardi berulang yang tidak menentu sehingga menimbulkan gangguan kecemasan (medi, kalman & freedman, 2009). takikardi supraventrikular dengan karakteristik kecepatan denyut jantung lebih dari 100 kali permenit sering menimbulkan keluhan correspondence: ardyarini dyah savitri @2019 medical and health science journal. 10.33086/mhsj.v3i1.927 available at http://journal2.unusa.ac.id/index.php/mhsj 55 mailto:adsa.vitri@yahoo.com http://journal2.unusa.ac.id/index.php/mhsj medical and health science journal, vol.3., no.1, februari 2019 palpitasi atau bahkan sinkop serta hipotensi. tsv dapat terjadi akibat kelainan primer jantung ataupun sekunder akibat kelainan di luar jantung. adapun tatalaksananya meliputi penanganan penyakit dasar serta memperlambat irama jantung, baik dengan terapi farmakologis maupun non farmakologis (marchlinski, 2008; makmun, 2009). amiodaron merupakan salah satu obat antiaritmia yang paling efektif digunakan untuk berbagai kondisi aritmia jantung, mulai dari fibrilasi atrial hingga takiaritmia ventrikuler yang mengancam nyawa. namun demikian, amiodaron dapat menimbulkan banyak efek samping termasuk gangguan pada fungsi tiroid, baik hipertiroid ataupun hipotiroid. dikatakan tingkat insidensi amiodarone induced hypothyroidism (aih) mencapai 5% di italia dan 22% di amerika serikat. sedangkan di belanda, insidensi aih mencapai 6,9% (padmanabhan, 2010). berikut kami sampaikan kasus seorang pasien tsv berulang yang mengalami hipotiroid diduga terkait penggunaan amiodaron. telaah kasus seorang wanita, 53 tahun, menikah, suku jawa, agama islam, pendidikan sd, ibu rumah tangga, bertempat tinggal di surabaya, datang ke ird rsu dr. soetomo dengan keluhan utama dada berdebar. anamnesis dada berdebar dirasakan sejak 1 hari smrs. dada berdebar hilang timbul dan terutama dirasakan pasien saat merasa kelelahan dan banyak pikiran. 2 jam smrs pasien sempat tidak sadarkan diri selama 5 menit, tanpa disertai kejang. dada berdebar diikuti dengan sesak nafas dan bengkak pada kedua tungkai sejak 2 tahun lalu. keluhan kaki bengkak berkurang dengan obat pelancar kencing. selain itu, pasien juga mengeluhkan nafsu makan menurun, badan terasa cepat lelah, dan berat badan menurun. buang air besar pasien masih dalam batas normal. riwayat penyakit dahulu rutin kontrol di poli jantung rsu dr.soetomo sejak 10 tahun lalu karena jantung berdebar riwayat dirawat di iccu sebanyak 4 kali sejak 3 tahun lalu karena keluhan yang sama (dada berdebar dan tak sadarkan diri): 1. agustus 2011, pasien dirawat dengan diagnosis akhir tsv dan hipotensi. selama perawatan memperoleh loading amiodaron dilanjutkan maintenance. pasien memperoleh terapi tablet metoprolol saat keluar dari rumah sakit. 2. januari 2012, pasien dirawat dengan diagnosis akhir tsv, bradikardi, gagal jantung kelas fungsional 4. pemeriksaan faal tiroid ft4 1,03 ng/ dl (n: 0,89 – 1,76 ng/ dl), tsh 4,58 uiu/ ml (n: 0,35 – 5,50 uiu/ ml). dilakukan pemeriksaan trans esofageal ekokardiografi dengan kesimpulan akhir jantung masih dalam batas normal. selama perawatan, pasien memperoleh loading amiodaron dilanjutkan maintenance. pasien memperoleh terapi tablet propafenon saat keluar dari rumah sakit yang diminum bila ada keluhan. 3. september 2012, pasien dirawat dengan diagnosis akhir tsv, gagal jantung kelas fungsional 4. selama perawatan memperoleh terapi loading amiodaron dilanjutkan maintenance dan pulang dengan terapi tablet amiodaron 1 x 100 mg. 4. juni 2013, pasien dirawat dengan diagnosis akhir tsv, gagal jantung kelas fungsional 4, bronkitis akut, hipotiroid yang mungkin terkait 56 medical and health science journal, vol.3., no.1, februari 2019 penggunaan amiodaron. pasien memperoleh terapi loading amiodaron dilanjutkan maintenance selama mrs. pemeriksaan faal tiroid tsh 19,759 uiu/ ml (n: 0,35 – 5, 50 uiu/ ml). satu minggu kemudian dilakukan pemeriksaan faal tiroid ulang dengan hasil tsh 29,010 uiu/ ml (n: 0,35 – 5,50 uiu/ ml), ft4 0,56 ng/dl (n: 0,89 – 1,76 ng/dl). pasien pulang dengan terapi amiodaron tablet 1 x 100 mg dan levotiroksin 1 x 25 µg dan direncanakan kontrol ke poli jantung dan poli endokrin, namun ternyata pasien tidak kontrol ke poli endokrin setelah keluar dari rumah sakit. pemeriksaan fisik keadaan umum lemah, gcs 456, tekanan darah 105/70 mmhg, nadi 188 x/ menit, teratur, pernafasan 32 x/menit, suhu aksila 36°c. pada kepala leher tidak didapatkan anemis, ikterik, ataupun sianosis. didapatkan peningkatan tekanan vena juguler disertai dispnea. tidak didapatkan pembesaran kelenjar tiroid. pada dada didapatkan bentuk simetris dengan retraksi pada otot bantu nafas, iktus kordis pada sela iga 6, terletak 1 cm lateral dari garis midklavikular kiri, suara jantung s1s2 tunggal, murmur sistolik grade ii/vi di apeks yang menjalar ke aksila kiri. suara nafas vesikuler, tanpa wheezing, terdengar ronkhi basah halus pada kedua lapangan paru. pada abdomen didapatkan bising usus normal, supel, tanpa asites, teraba pembesaran hati ±2 cm bawah arkus kosta, tidak teraba limpa ataupun ginjal. pada ekstremitas didapatkan edema pada tungkai bawah, akral hangat, kering, dan merah. pemeriksaan penunjang laboratorium: hb 14,2 g/dl. lekosit 5.600/mm 3 . trombosit 165.000/mm 3 . gula darah acak 103 mg/dl, bun 14 mg/dl, kreatinin serum 0,51 mg/dl, sgot 38 iu/l, sgpt 25 iu/l, albumin 3,76 g/dl. natrium 140 meq/l, kalium 4,3 meq/l, klorida 111 meq/l, ckmb 17,6 u/l (normal: 7 – 25 u/l), troponin t negatif, tsh 0,107 uiu/ ml (n: 0,35 – 5,50 uiu/ ml), ft4 1,74 ng/dl (n: 0,89 – 1,76 ng/dl). urine lengkap: glu -, bil -, ket -, sg > 1,030, bld -, ph 5,0, prot -, uro 3,2, nit -, leu -, erytrosit (mikroskopis) 0-2, leukosit (mikroskopis) 2 – 5, epitel (mikroskopis) sedikit foto thoraks: kardiomegali dengan ctr 60,8% dengan vaskularisasi paru meningkat. elektrokardiografi (ekg): irama takikardia supraventrikular 180 x/ menit, aksis normal. diagnosis pasien dirawat di ruang intensive cardiology care unit (iccu) dengan diagnosis tsv, gagal jantung kelas fungsional 4, hipotiroid dalam terapi tiroksin (sejak 5 bulan yang lalu) dan terjadi overshoot terapi. terapi pasien disarankan untuk menghentikan penggunaan levotiroksin dan bila teman sejawat kardiologi setuju, mohon hindari penggunaan amiodaron. disarankan juga untuk melengkapi pemeriksaan antibodi tiroid peroksidase (tpoab) dan antibodi tiroglobulin (tgab) dari kardiologi, pasien memperoleh terapi oksigen nasal 4 lpm, diltiazem pump mulai 0,5 µg/ kgbb/ menit bila tekanan darah sistolik lebih dari 100 mmhg, serta furosemid injeksi 10 mg tiga kali sehari. perjalanan penyakit hari pertama, pasien tidak ada keluhan. gcs 456, tekanan darah 110/70 mmhg, nadi 60 x/menit, teratur dan kuat angkat, pernafasan 20 x/menit, suhu aksila 36,5°c. pada pemeriksaan elektrokardiografi diperoleh hasil irama sinus 60 x/ menit, aksis normal. pasien memperoleh terapi 57 medical and health science journal, vol.3., no.1, februari 2019 verapamil 40 mg dua kali sehari, diltiazem pump dan furosemid injeksi dihentikan, isdn 5 mg dua kali sehari, serta furosemid tablet 10 mg tiga kali sehari. hari ketiga, kondisi stabil dan pasien dipindahkan ke ruang jantung. pasien direncanakan untuk pemeriksaan tpoab dan tgab tetapi menolak karena alasan biaya. hari kelima, pasien dipulangkan. pembahasan takikardia supraventrikular merupakan salah satu bentuk takiaritmia dengan fokus aritmia berasal dari atrial, termasuk nodus av dan berkas his. tiga bentuk tsv tersering adalah av nodal reentrant tachycardia (avnrt), atrioventricular reciprocating tachycardia (avrt), dan takikardi atrial (at), dimana ketiganya ditandai oleh laju denyut jantung reguler lebih dari 100 kali permenit. pada gambaran ekg umumnya didapatkan kompleks qrs yang sempit, kurang dari 120 milidetik, dengan interval rr yang teratur. gelombang p sering sukar dikenali, karena bertumpuk pada t atau terbenam di qrs (medi, kalman & freedman, 2009; muhadi, 2011; almendral, castellanos & ortiz, 2012). pada ekg didapatkan gambaran irama takikardia supraventrikular 180 x/ menit dengan kompleks qrs yang sempit dan interval rr yang teratur. palpitasi, nyeri dada, pusing, rasa lelah, dan sesak nafas merupakan keluhan yang sering muncul pada pasien tsv. tidak jarang pasien datang dengan keluhan tidak sadarkan diri dan pada beberapa kasus dapat didiagnosis sebagai gangguan kecemasan karena tsv sering bersifat paroksismal yang berawal tiba – tiba, demikian pula terminasinya. pada kasus berulang, dapat disertai dengan tanda – tanda gagal jantung kronis (medi, kalman & freedman, 2009; colucci, silver & shubrook, 2010; muhadi, 2011). pada pasien didapatkan keluhan palpitasi, rasa lelah, sesak nafas, dan tidak sadar serta manifestasi klinis gagal jantung. takikardia supraventrikular terjadi akibat gangguan pembentukan impuls dan atau gangguan hantaran impuls melalui mekanisme re-entry, automatisitas dan adanya aktivitas pencetus. penyebab tsv dapat berasal dari kelainan primer jantung ataupun sekunder akibat kelainan luar jantung. tsv dapat terjadi pada pasien dengan penyakit arteri koroner, penyakit jantung katub, gagal jantung, dan penyakit paru obstruktif kronik. hal lain yang dapat menstimulasi tsv adalah kelelahan atau stres emosional, infeksi, hipoksia, konsumsi obat yang mengandung agen adrenergik, digitalis ataupun teofilin, minuman yang mengandung kafein ataupun alkohol, gangguan elektrolit, serta hipertiroid (delacretaz, 2006; fogoros, 2007; makmun, 2009; colucci, silver & shubrook, 2010; muhadi, 2011). anamnesa riwayat penyakit serta pemeriksaan fisik yang teliti akan membantu untuk mengetahui etiologi serta faktor pencetus tsv. pemeriksaan laboratorium hendaknya dilakukan untuk mengetahui adanya infeksi, gangguan elektrolit, kadar hormon tiroid dan kadar digitalis serta teofilin dalam darah. selain itu, sebaiknya juga dilakukan pemeriksaan roentgen dada untuk mengetahui adanya penyakit paru obstruktif kronik serta pemeriksaan ekokardiografi dan elektrofisologi untuk mendeteksi adanya kelainan struktur jantung dan mekanisme tsv (delacretaz, 2006; colucci, silver & shubrook, 2010; almendral, castellanos & ortiz, 2012). pada anamnesa didapatkan bahwa kelelahan dan stres emosional mencetuskan timbulnya keluhan berdebar – debar pada pasien ini. tidak didapatkan infeksi ataupun kelainan elektrolit dan fungsi tiroid pasien pada awalnya normal. tidak didapatkan kelainan pada pemeriksaan foto thoraks dan ekokardiografi. sedangkan pemeriksaan elektrofisiologi tidak 58 medical and health science journal, vol.3., no.1, februari 2019 dapat dilakukan karena peralatannya tidak tersedia di surabaya. manajemen tsv meliputi penanganan penyakit dasar serta tatalaksana terhadap aritmia. aritmia sebaiknya segera dikendalikan terutama bagi pasien yang beresiko mengalami gangguan hemodinamik atau yang intoleran terhadap tsv sehingga mengakibatkan presinkop atau sinkop. adapun hal tersebut dapat dicapai melalui manajemen jangka pendek atau urgent dengan farmakologis dan non-farmakologis serta manajemen jangka panjang menggunakan terapi farmakologis dan ablasi kateter (makmun, 2009; colucci, silver & shubrook, 2010). tujuan manajemen jangka pendek pada tsv adalah menghentikan episode akut takikardi sesegera mungkin, yang sering dapat dicapai dengan manuver vagal. bila gagal, maka dapat diberikan antiaritmia. adenosin merupakan pilihan antiaritmia utama. sebagai alternatif, dapat diberikan calcium channel blocker (ccb) seperti verapamil dan diltiazem atau beta-blocker seperti propanolol, metoprolol, atau esmolol. bila gagal, maka obat – obat antiaritmia seperti flekainid, prokainamid, atau propafenon juga dapat diberikan pada pasien tsv dengan hemodinamik yang masih stabil. kardioversi menjadi pilihan, apabila terjadi instabilitas hemodinamik atau gagal dengan terapi farmakologi yang diberikan (delacretaz, 2006; fox, krahn & yee, 2008; medi, kalman & freedman, 2009). manajemen jangka panjang diberikan berdasarkan frekuensi serta derajat keparahan aritmia yang terjadi. bagi pasien dengan gejala yang jarang muncul, gejala yang dapat hilang sendiri tanpa terapi, ataupun gejala yang ringan, maka tidak dibutuhkan terapi jangka panjang. bila tingkat rekurensi keluhan tinggi, maka ablasi kateter direkomendasikan sebagai terapi definitif tsv. pasien yang menolak ataupun terdapat faktor komorbid sehingga ablasi kateter tak dapat dilakukan, maka diberikan pengobatan farmakologis yang bersifat profilaksis atau diberikan sewaktu – waktu bila terdapat gejala (“pill in the pocket approach”). beta-blocker, ccb, atau digoksin merupakan obat pilihan utama. bila gagal, maka dapat diberikan antiaritmia seperti flekainid, sotalol, propafenon atau amiodaron (delacretaz, 2006; fox, krahn & yee, 2008; medi, kalman & freedman, 2009). amiodaron merupakan obat antiaritmia dengan frekuensi pemakaian tertinggi sejak ditemukannya obat ini pada 3 dekade yang lalu, baik di benua amerika, eropa, dan asia. hal ini disebabkan karena amiodaron memiliki spektrum terapeutik yang luas yang efektif digunakan untuk terapi berbagai macam aritmia, baik aritmia ventrikuler, tsv, maupun fibrilasi atrial. walaupun amiodaron termasuk dalam obat antiaritmia kelas iii berdasarkan klasifikasi vaughan williams, tetapi amiodaron juga memiliki aktivitas antiaritmia kelas i, ii, dan iv, sehingga amiodaron memiliki efek elektrofisiologi sebagai berikut (connolly, 2000; siddoway, 2003; fogoros, 2007; zimetbaum, 2007; rampengan, 2011): 1. memperpanjang fase repolarisasi sehingga interval qt memanjang 2. menurunkan denyut jantung dengan menekan automatisasi nodus sa 3. menurunkan kecepatan konduksi dan memperpanjang masa refrakter nodus av efek antiaritmia amiodaron yang luas, menjadikan amiodaron cukup efektif digunakan dalam manajemen tsv. sifat inotropik negatif yang rendah, menjadikan amiodaron sebagai obat pilihan pada tsv yang disertai gagal jantung (testa, et al., 2005). untuk manajemen jangka pendek, pasien memperoleh amiodaron berulang kali. hal ini mungkin disebabkan karena pasien menderita gagal jantung. sedangkan pada mrs kelima, pasien memperoleh diltiazem. untuk manajemen jangka panjang, pasien memperoleh metoprolol pada mrs pertama, propafenon pada mrs kedua, 59 medical and health science journal, vol.3., no.1, februari 2019 amiodaron pada mrs ketiga dan keempat, serta verapamil pada mrs kelima. namun demikian, pada pemakaian amiodaron perlu diwaspadai timbulnya beberapa efek samping, dimana pada pemakaian jangka pendek, amiodaron dapat mengakibatkan hipotensi dan bradikardi. sedangkan pada pemakaian jangka panjang, dapat menimbulkan efek samping yang fatal yang melibatkan berbagai organ, seperti kulit, mata, hati, paru, syaraf, dan tiroid (testa, et al., 2005; vassallo & trohman, 2007; rampengan, 2011). amiodaron dapat menimbulkan disfungsi tiroid, baik pada pasien dengan atau tanpa penyakit tiroid sebelumnya, dengan manifestasi klinis berupa amiodarone-induced thyrotoxicosis (ait) atau amiodarone-induced hypothyroidism (aih). hal ini terjadi karena amiodaron mampu mempengaruhi sintesis hormon tiroid baik pada kelenjar tiroid atau jaringan perifer dan bahkan pada kelenjar pituitari melalui 2 mekanisme, yaitu (loh, 2000; cohen, et al., 2010; padmanabhan, 2010; rampengan, 2011): 1. iodine-induced effects amiodaron merupakan derivat benzofuran yang mengandung dua atom yodium pada tiap molekulnya, dimana berat yodium mencapai 37 % berat total amiodaron. hal ini berarti, pemberian amiodaron pada dosis pemeliharaan sebesar 200 – 600 mg per hari akan melepaskan 6 – 21 mg yodium bebas per harinya, dimana beban yodium ini jauh melebihi rekomendasi world health organization (who) mengenai asupan optimal yodium per hari yang berkisar 0,15 – 0,3 mg per hari (ursella, et al., 2005). kandungan yodium yang tinggi dalam amiodaron akan menyebabkan inhibisi adaptif ambilan yodium oleh tiroid dan biosintesis hormon tiroid (efek wolff – chaikoff). efek ini pada umumnya terjadi dalam dua minggu pertama, tetapi pada umumnya sintesis hormon tiroid akan kembali normal pada paparan selanjutnya. 2. intrinsic drug effects di jaringan perifer, terutama kelenjar tiroid dan hepar, amiodaron memiliki kemampuan spesifik menghambat aktivitas enzim 5’-deiodinase tipe i, yang berperan dalam proses konversi fraksional tiroksin (t4) menjadi triiodotironin (t3). amiodaron juga secara tidak langsung dapat menghambat masuknya hormon tiroid ke jaringan perifer. kedua hal tersebut mengakibatkan konsentrasi t3 di sirkulasi menurun dan konsentrasi t4 meningkat. perubahan ini terjadi sekitar dua minggu setelah pemberian amiodaron dan dapat menetap selama beberapa bulan. amiodaron dapat mempengaruhi sintesis dan sekresi thyroid stimulating hormone (tsh) pada tingkat pituitari dengan menghambat kerja enzim 5’-deiodinase tipe ii sehingga konsentrasi t3 pada kelenjar pituitari menurun dan sekresi tsh meningkat. peningkatan kadar tsh dapat terdeteksi sejak hari pertama setelah pemberian amiodaron dosis tinggi intravena (loading dose), tetapi biasanya akan kembali ke nilai normal setelah 3 bulan terapi. amiodaron dilaporkan memiliki efek sitotoksik terhadap sel tiroid. dari studi yang dilakukan oleh chivato et al. diperoleh adanya lisis pada folikel tiroid manusia akibat amiodaron. walaupun masih dalam perdebatan, efek toksik amiodaron ini dikaitkan dengan terjadinya autoimunitas tiroid yang mengakibatkan pelepasan autoantigen, yang mana hal ini telah dibuktikan pada sebuah studi prospektif dengan didapatkannya antibodi tiroid peroksidase (tpoab) pada 55% pasien yang memperoleh amiodaron (rampengan, 2011). gangguan metabolisme hormon tiroid akibat amiodaron akan mengubah profil hormon pasien. perubahan kadar hormon diklasifikasikan menjadi dua berdasarkan lama pengobatan yaitu efek akut dan kronik. efek akut bila durasi pengobatan amiodaron kurang dari 3 bulan dan kronik bila pengobatan berlangsung lebih dari 3 bulan, seperti yang tampak pada tabel 1. namun demikian, kelenjar tiroid mampu mempertahankan kondisi 60 medical and health science journal, vol.3., no.1, februari 2019 eutiroid dengan beradaptasi terhadap beban yodium yang tinggi yang terkandung di dalam amiodaron (ursella, et al., 2005; rampengan, 2011). tabel 1. profil hormon tiroid setelah pemberian amiodaron pada pasien eutiroid (rampengan, 2011) amiodarone – induced hypothyroidism (aih) memiliki tingkat insidensi bervariasi, namun aih lebih sering terjadi di area dengan asupan yodium yang cukup. resiko meningkat pada wanita, dengan rasio wanita dan laki – laki sebesar 1,5 : 1. insiden juga meningkat pada populasi usia tua. mekanisme aih belum jelas, tetapi diduga akibat ketidakmampuan tiroid untuk melepaskan diri dari efek wolff – chaikoff setelah pemberian beban yodium tinggi yang terdapat pada amiodaron. hal ini terutama terjadi pada pasien yang memang fungsi tiroidnya abnormal sebelum terapi, seperti tiroiditis autoimun, dimana adanya antibodi terhadap tiroid, baik tpoab ataupun tgab, akan meningkatkan resiko aih sebesar 13,5. di samping itu, adanya beban yodium ini juga mampu mempercepat perjalanan klinis tiroiditis autoimun sehingga mengakibatkan hipotiroid yang nyata. pada pasien dengan fungsi tiroid yang normal, aih diduga terjadi karena adanya gangguan proses organifikasi yodium intratiroidal sehingga sintesis hormon tiroid menurun (ursella, et al., 2005; antono & kisyanto, 2009; rampengan, 2011; narayana, woods & boos, 2011). hipotiroid akibat amiodaron dapat berlangsung sementara atau menetap dan hal ini tidak tergantung pada dosis harian atau kumulatif amiodaron yang diberikan. aih biasanya terjadi pada awal terapi dan jarang timbul setelah 18 bulan, kecuali bila ada kelainan tiroid yang mendasari. oleh karena itu, sebaiknya dilakukan pemantauan fungsi tiroid sejak awal terapi untuk memfasilitasi diagnosis, pemberian terapi dini terhadap disfungsi tiroid yang terjadi serta menghindari perburukan aritmia yang dialami pasien (loh, 2000; rampengan, 2011). pasien memperoleh beberapa kali amiodaron akibat aritmia yang dialaminya. pemantauan fungsi tiroid dilakukan pada saat mrs kedua dengan hasil fungsi tiroid masih dalam batas normal. pasien adalah wanita dan berusia tua, sehingga memiliki resiko tinggi mengalami aih. namun demikian, pemeriksaan tpoab dan tgab tidak dilakukan karena alasan biaya. gambaran klinis aih biasanya tidak jelas dan menyerupai hipotiroidisme primer. pasien biasanya mengeluhkan rasa lelah, letargi, tidak tahan dingin, konstipasi, dan kulit kering. walaupun kadar tsh berfluktuasi setelah penggunaan amiodaron, tetapi diagnosis aih dapat ditegakkan dengan pemeriksaan laboratorium yang menunjukkan peningkatan persisten konsentrasi tsh (biasanya > 20 mu/ l) disertai kadar t4 bebas (ft4) yang rendah (loh, 2000; narayana, 2011; rampengan, 2011). tatalaksana aih meliputi penghentian amiodaron. namun apabila tidak dimungkinkan, maka dapat diberikan terapi substitusi hormon menggunakan l-tiroksin (lt4) dimulai dosis awal 25 – 50 µg per hari dan ditingkatkan bertahap dalam interval 4 – 6 minggu dengan monitoring kadar tsh. terlebih pasien aih dengan antibodi tiroid yang positif disertai peningkatan tsh, maka sebaiknya substitusi hormon sesegera mungkin diberikan untuk mencegah hipotiroid (ursella, et al., 2005; narayana, woods & boos, 2011). pemeriksaan loratorium setelah pemberian amiodaron berulang kali yaitu pada saat mrs keempat menunjukkan hasil peningkatan kadar tsh dari 19,759 uiu/ ml menjadi 29,010 uiu/ ml (n: 0,35 – 5,50 uiu/ ml) dan penurunan kadar ft4 0,56 ng/dl (n: 0,89 – 1,76 ng/dl). pasien tetap memperoleh amiodaron untuk mengatasi 61 medical and health science journal, vol.3., no.1, februari 2019 aritmianya. tiroksin 25 µg per hari diberikan sejak saat itu (5 bulan yang lalu). namun, monitoring kadar tsh selama pemberian subtitusi hormon tidak dilakukan karena pasien tidak kontrol ke poli endokrin. pada saat ini keluhan yang didapatkan hanya badan mudah terasa lelah. pasien aih pada umumnya memiliki prognosis yang baik. penghentian amiodaron akan mengembalikan fungsi tiroid pada nilai normal dalam waktu 2 – 4 bulan, terutama pada pasien tanpa abnormalitas fungsi tiroid sebelumnya. namun bila aih terjadi pada pasien dengan tiroiditis autoimun, maka deteksi dan pemberian substitusi hormon secara dini, akan mengembalikan fungsi tiroid pada nilai yang normal, walaupun dosis lt4 yang dibutuhkan lebih tinggi daripada hipotiroid primer dan diberikan untuk jangka waktu yang lebih lama (ursella, et al., 2005; antono & kisyanto, 2009; narayana, woods & boos, 2011). pasien memiliki prognosis yang baik, dimana terdapat respon yang cukup baik dengan pemberian substitusi hormon tiroksin selama kurang lebih 5 bulan, dengan tetap menggunakan amiodaron untuk mengatasi aritmianya. kadar hormon tiroid kembali normal dan bahkan terjadi overshoot karena pasien tidak kontrol ke poli endokrin. daftar pustaka 1. almendral, j., castellanos, e., and ortiz, m., 2012. paroxysmal supraventricular tachycardia and preexcitation syndromes. revista espanola cardiologia, 65 (5): 456 – 69. 2. antono, d., & kisyanto, y., 2009. penyakit jantung tiroid. dalam: sudoyo, a.w., eds. 2009. buku ajar penyakit dalam jilid 2. edisi kelima. jakarta: 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