A LT H EA M EDIC A L JOUR NA L

Volume 3, Number 1 March, 2016 e-ISSN 2337-4330 Original Articles Roles of Microwave Oven in Preparation of Microbiological Growth Media Christian Prijana, Yanti Mulyana, Basuki Hidayat Distribution of Pubertal Age among Male School Students in Jatinangor District from April to June 2013 Karthik Yogaswaran, Anggraini Widjajakusuma, Juliati Association of Body Mass Index to Onset of Puberty in Male Jeevithaambigai A/P Subramaniam, Yulia Sofiatin, R.M Ryadi Fadil Hypertension Treatment and Control in Older Adult at Tanjung Sari Public Health Center Rahmi Fauziah, Enny Rohmawaty, Lazuardhi Dwipa Durian Consumption Effect on Plasma Malondialdehyde Level as Biomarker of Stress Oxidative in Rats Anugrah Aulia Ulil Amri, Ani Melani Maskoen, Syarief Hidayat Relation between Preinfarction Angina and Coronary Collateral Circulation in Patients with Acute Myocardial Infarction Achmad Shidiq, Syarief Hidayat, Januarsih Iwan A. Rachman. Relationship between Short Term Memory and Cardiopulmonary Fitness of Administrative Officers at Universitas Padjadjaran Iswaran Ampalakan, Ambrosius Purba, Sunaryo B. Sastradimaja

Vo l um e 3 Nu m b e r 1 Ye a r 2 016

Impact of Near Work Activity on Visual Acuity among Junior High School Students Raisha Pratiwi Indrawati, Reni Farenia, Mayasari Wahyu K. Frequency and Clinical Characteristics of Tympanic Membrane Perforation Outpatients at Dr. Hasan Sadikin General Hospital in 2011–2013 Veronika Ratih M, Sally Mahdiani, Fenny Dwiyatnaningrum Characteristics of Thyroiditis Patients in Dr.Hasan Sadikin General Hospital in 2009–2013 Sri Maryanti, Hasrayati Agustina, Miftahurachman Clinical and Histopathological Characteristic of Salivary Gland Carcinoma in Dr. Hasan Sadikin General Hospital in 2009–2012 Fatimah Lidya Andriani, Ismet Muchtar Nur, Sally Mahdiani Effect of Midnight Prayer on Sympathetic Tone Hadiyatussalamah Pusfa Kencanasari, Achmad Fauzi Yahya, Setiawan Streptococcus pneumoniae Drugs Resistance in Acute Rhinosinusitis Chong Jie Hao, Chrysanti Murad, Trias Nugrahadi Detection of Streptococcus pyogenes from Throat Swab in Acute Pharyngitis Patients Ibnu Tsabit Maulana, Imam Megantara, Ike Rostikawati Husen Knowledge and Attitude of Senior High School Students toward Human Immunodeficiency Virus/Acquired Immunodeficiency

Syndrome Arnova Reswari, Kuswandewi Mutyara, Lynna Lidyana Association between Exclusive Breastfeeding and Child Development Ghaniyyatul Khudri, Eddy Fadlyana, Nova Sylviana Knowledge, Attitude, and Practice Survey among Nurses in Dr. Hasan Sadikin General Hospital toward Tuberculosis-Human Immunodeficiency Virus Collaboration Program Helen Oktavia Sutiono, Arto Yuwono Soeroto, Bony Wiem Lestari Association of Ascariasis with Nutritional and Anemic Status in Early School-Age Students Chin Annrie Eidwina, Lia Faridah, Yudith Setiati Ermaya, Dida Akhmad Gurnida Visual Acuity of Patients after Neodymium:Yttrium-AluminiumGarnet Laser at Cicendo Eye Hospital in 2013-2014 Lee Pei Yie, Budiman, Ihrul Prianza Prajitno Characteristics of Older Adult with Balance Disorder in Rehabilitation Clinic of Dr. Hasan Sadikin General Hospital 2014 Ku Shi Yun, Irma Ruslina Defi, Lazuardhi Dwipa Success Rate of Trabeculectomy in Primary Glaucoma at Cicendo Eye Hospital on January–December 2013 Erva Monica Saputro, Maula Rifada, RB. Soeherman Knowledge of Housewives Regarding Non Steroid Anti Inflammatory Drug Use on Joint Pain in Hegarmanah Village Jatinangor Adi Mulyono Gondopurwanto, Kuswinarti, Yusuf Wibisono Knowledge and Intention to Use Personal Protective Equipment among Health Care Workers to Prevent Tuberculosis Hasanah, Elsa Pudji Setiawati, Lika Apriani Functional Status of Stroke Patients at Neurologic Outpatient Clinic Dr. Hasan Sadikin General Hospital Lee Shok Chen, Marina A. Moeliono, Lisda Amalia Clinical and Cerebrospinal Fluid Abnormalities as Diagnostic Tools of Tuberculous Meningitis Fiona Lestari, Sofiati Dian, Ida Parwati Profile of Anemia on Lung Tuberculosis at Dr. Hasan Sadikin General Hospital and Community Lung Health Center Bandung Marizka Adzani, Nadjwa Zamalek Dalimoenthe, Indra Wijaya Anesthesia Technique Selection Pattern in Patients Undergoing Lower Extremities Surgery at Dr. Hasan Sadikin General Hospital from January–June 2013 Keshia Amalia Mivina Mudia, Ezra Oktaliansah, Ihrul Prianza Prajitno

Advisory Board Budi Setiabudiawan Yoni Fuadah Syukriani

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Executive Editors Diba Artsiyanti Ediyana Putri Basar Henni Djuhaeni Irma Ruslina Defi Kemala I. Mantilidewi Nur Melani Sari Poppy Siti Chaerani Rd. Reni Ghrahani Electronic Production Engineer Devi Fabiola Syahfitri Site Administrator Ati Sulastri Layout Editor Ati Sulastri

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Volume 3, Number 1 March, 2016 e-ISSN 2337-4330 Original articles Roles of Microwave Oven in Preparation of Microbiological Growth Media

1

Distribution of Pubertal Age among Male School Students in Jatinangor District from April to June 2013

6

Christian Prijana, Yanti Mulyana, Basuki Hidayat

Karthik Yogaswaran, Anggraini Widjajakusuma, Juliati

Association of Body Mass Index to Onset of Puberty in Male 12

Jeevithaambigai A/P Subramaniam, Yulia Sofiatin, R.M Ryadi Fadil

Hypertension Treatment and Control in Older Adult at Tanjung Sari Public 17 Health Center Rahmi Fauziah, Enny Rohmawaty, Lazuardhi Dwipa

Durian Consumption Effect on Plasma Malondialdehyde Level as Biomarker of 22 Stress Oxidative in Rats Anugrah Aulia Ulil Amri, Ani Melani Maskoen, Syarief Hidayat

Relation between Preinfarction Angina and Coronary Collateral Circulation in 29 Patients with Acute Myocardial Infarction Achmad Shidiq, Syarief Hidayat, Januarsih Iwan A. Rachman

Relationship between Short Term Memory and Cardiopulmonary Fitness of 34 Administrative Officers at Universitas Padjadjaran Iswaran Ampalakan, Ambrosius Purba, Sunaryo B. Sastradimaja

Impact of Near Work Activity on Visual Acuity among Junior High School 38 Students Raisha Pratiwi Indrawati, Reni Farenia, Mayasari Wahyu K.

Frequency and Clinical Characteristics of Tympanic Membrane Perforation 43 Outpatients at Dr. Hasan Sadikin General Hospital in 2011–2013 Veronika Ratih M, Sally Mahdiani, Fenny Dwiyatnaningrum

Characteristics of Thyroiditis Patients in Dr.Hasan Sadikin General Hospital in 49 2009–2013 Sri Maryanti, Hasrayati Agustina, Miftahurachman

Clinical and Histopathological Characteristic of Salivary Gland Carcinoma in Dr. Hasan Sadikin General Hospital in 2009–2012

54

Effect of Midnight Prayer on Sympathetic Tone

59

Streptococcus pneumoniae Drugs Resistance in Acute Rhinosinusitis

64

Detection of Streptococcus pyogenes from Throat Swab in Acute Pharyngitis Patients

69

Knowledge and Attitude of Senior High School Students toward Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome

73

Association between Exclusive Breastfeeding and Child Development

79

Knowledge, Attitude, and Practice Survey among Nurses in Dr. Hasan Sadikin General Hospital toward Tuberculosis-Human Immunodeficiency Virus Collaboration Program

85

Association of Ascariasis with Nutritional and Anemic Status in Early SchoolAge Students

93

Visual Acuity of Patients after Neodymium:Yttrium-Aluminium-Garnet Laser at Cicendo Eye Hospital in 2013-2014

99

Fatimah Lidya Andriani, Ismet Muchtar Nur, Sally Mahdiani

Hadiyatussalamah Pusfa Kencanasari, Achmad Fauzi Yahya, Setiawan Chong Jie Hao, Chrysanti Murad, Trias Nugrahadi

Ibnu Tsabit Maulana, Imam Megantara, Ike Rostikawati Husen

Arnova Reswari, Kuswandewi Mutyara, Lynna Lidyana Ghaniyyatul Khudri, Eddy Fadlyana, Nova Sylviana

Helen Oktavia Sutiono, Arto Yuwono Soeroto, Bony Wiem Lestari

Chin Annrie Eidwina, Lia Faridah, Yudith Setiati Ermaya, Dida Akhmad Gurnida

Lee Pei Yie, Budiman, Ihrul Prianza Prajitno

Characteristics of Older Adult with Balance Disorder in Rehabilitation Clinic of 103 Dr. Hasan Sadikin General Hospital 2014 Ku Shi Yun, Irma Ruslina Defi, Lazuardhi Dwipa

Success Rate of Trabeculectomy in Primary Glaucoma at Cicendo Eye Hospital on January–December 2013 110 Erva Monica Saputro, Maula Rifada, RB. Soeherman

Knowledge of Housewives Regarding Non Steroid Anti Inflammatory Drug Use 115 on Joint Pain in Hegarmanah Village Jatinangor Adi Mulyono Gondopurwanto, Kuswinarti, Yusuf Wibisono

Knowledge and Intention to Use Personal Protective Equipment among Health 120 Care Workers to Prevent Tuberculosis Hasanah, Elsa Pudji Setiawati, Lika Apriani

Functional Status of Stroke Patients at Neurologic Outpatient Clinic Dr. Hasan 126 Sadikin General Hospital Lee Shok Chen, Marina A. Moeliono, Lisda Amalia

Clinical and Cerebrospinal Fluid Abnormalities as Diagnostic Tools of 132 Tuberculous Meningitis Fiona Lestari, Sofiati Dian, Ida Parwati

Profile of Anemia on Lung Tuberculosis at Dr. Hasan Sadikin General Hospital 137 and Community Lung Health Center Bandung Marizka Adzani, Nadjwa Zamalek Dalimoenthe, Indra Wijaya

Anesthesia Technique Selection Pattern in Patients Undergoing Lower 141 Extremities Surgery at Dr. Hasan Sadikin General Hospital from January–June 2013 Keshia Amalia Mivina Mudia, Ezra Oktaliansah, Ihrul Prianza Prajitno

Upper Lower Segment Ratio Comparison between Obese and Normal Children 147 Aged 7 to 10 Years Old Muhammad Zulfikar Azhar, RM. Ryadi Fadil, Edhyana K. Sahiratmadja

Correlation between Oxygen Saturation and Hemoglobin and Hematokrit 152 Levels in Tetralogy of Fallot Patients Farhatul Inayah Adiputri, Armijn Firman, Arifin Soenggono

Age at Menarche and Eating Pattern among High School Students in Jatinangor 156 in 2013 Fani Fitrya Nafisah, Insi Farisa Desy Arya, Eppy Darmadi Achmad

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No author given Mental care and relief support for victims of the earthquake occurred in eastern part of Japan. Seishin Shinkeigaku Zasshi. 2011;113(9):825–44. Volume with supplement Rushton L, Hutchings SJ, Fortunato L, Young C, Evans GS, Brown T, et al. Occupational cancer burden in Great Britain. Br J Cancer. 2012;107 (Suppl1):S3–7.

Edition with suplement North CS, Pollio DE, Smith RP, King RV, Pandya A, Suris Am, et al. Trauma exposure and posttraumatic stress disorder among employees of New York City companies affected by the September 11, 2001 attacks on the World Trade Center. Disaster Med Public Health Prep. 2011;(5 Suppl 2):S205– 13. Books and Other Monographs Personal author(s) Sax PE, Cohen CJ, Kuritzkes DR. HIV essentials 2012. 2nd ed. Burlington: World Headquarters; 2012.

Editor(s)as the author Baxter R, editor. A cellular dermal matrices in breast surgery, an issue of clinics in plastic surgery. Mountlake Terrace: Saunders; 2012. Organization as the author UNAIDS. Meeting the investment challenge tipping the dependency. Geneva: WHO Library Cataloguing Data; 2012.

Chapter in a book Pignone M, Salazar R. Disease prevention and health promotion. In: Diedrich C, Lebowitz H, Holton B, editors. 2012 current medical diagnosis and treatment. 51sted. New York: The McGraw-Hill companies; 2012. p. 1–21.

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Conference paper Tirilly P, Lu K, Mu X. Predicting modality from text quiries for medical image retrieval. In: Cao Y, Kalpathy-Cramer J, Unay D, editors. MM 11. Proceeding of The 2011 International ACM Workshop on Medical Multimedia Analysis and Retrieval; 2011 Nov 28–Dec 01; Arizona, USA. New York: ACM; 2011. p. 7–12. Dissertation Rohim S. Kontruksi diri dan perilaku komunikasi gelandangan di kota Jakarta (Studi fenomenologi terhadap julukan gelandangan “manusia gerobak”) [dissertation]. Bandung: Universitas Padjadjaran; 2012.

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1

Roles of Microwave Oven in Preparation of Microbiological Growth Media Christian Prijana,1 Yanti Mulyana,2 Basuki Hidayat3 Faculty of Medicine Universitas Padjadjaran, 2Department of Microbiology and Parasitology Faculty of Medicine Universitas Padjadjaran, 3Department of Nuclear Medicine Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung

1

Abstract Background: Sterilization of a growth medium before being utilized is a very important step in a microbiology laboratory. The common method for this purpose is by using the autoclave. However, autoclaving takes more time. To overcome this limitation, we tried to use the microwave oven. The aim of this study was to evaluate the ability of microwave oven in preparing the growth media. Methods: This was a laboratory experimental study conducted at Microbiology Laboratory, Faculty of Medicine, Universitas Padjadjaran, from October to November 2014. The growth media used were: MacConkey agar, in petri dishes, inoculated with Escherichia coli; Sabouraud agar, in petri dishes, inoculated with Candida albicans; Kligler iron agar (KIA), in reaction tubes, inoculated with Escherichia coli and Salmonella Typhi; Simmons citrate agar, in reaction tubes, inoculated with Klebsiella pneumoniae; MuellerHinton (M-H) broth, in reaction tubes, inoculated with Escherichia coli; and Motility Indole Urea (MIU) semisolid agar, in reaction tubes, inoculated with Proteus sp.The media would be heated by microwave for 1, 2, and 3 minutes. Results: From the total 54 dishes/tubes of various microwave-sterilized media, contaminations were only seen at 5 dishes/tubes. Most of the media, except the one-minute-heated Mueller-Hinton broth, were sterilized more than half dishes/tubes. The identification function of all media in this study was performed well. Conclusions: The utilization of microwave oven as an alternative sterilizing apparatus for microbiological growth media is very potential, particularly for two and three minutes duration of heating. [AMJ.2016;3(1):1– 5] Keywords: growth media , microbiology, microwave, sterilization

Introduction Sterilize the growth medium before used is very important in the microbiology. The process of growth medium sterilization is commonly performed by using an apparatus named autoclave.1 There are two kinds of growth media sterilization process in between the microbiology laboratory; they are the sterilization of about-to-used-media, as well as the sterilization of the utilized media in order to decontaminate the media from the infectious contaminants. The disadvantage of autoclave sterilization process is taking a long period of time. During the autoclaving process,

the temperature is 121oC and the pressure is 2 atm, for 15 minutes. Sterilized objects are placed in an apparatus after heated around 1 hour. After the sterilization process, it still needs several hours to wait until the pressure inside the apparatus drops again up to 1 atm to permit opening the apparatus.2 The alternative sterilizing apparatus which will be tested in this study is the microwave oven. Microwave oven operates by transmitting a very short invisible wave, named microwave. That will be immediately absorbed evenly by water, carbohydrates, and lipids. The microwave will excitate the atoms of the molecules which absorb wave and produce heat.3 A 600–750 W microwave oven which

Correspondence: Christian Prijana, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km.21, Jatinangor, Sumedang, Indonesia, Phone: +628551100188, Email: [email protected] Althea Medical Journal. 2016;3(1)

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AMJ March 2016

identification function of media. The growth media used in this study were: MacConkey agar, in petri dishes, inoculated with Escherichia coli; Sabouraud agar, in petri dishes, inoculated with Candida albicans; Kligler iron agar (KIA), in reaction tubes, inoculated with Escherichia coli and Salmonella Typhi; Simmons citrate agar, in reaction tubes, inoculated with Klebsiella pneumoniae; Mueller-Hinton (MH) broth, in reaction tubes, inoculated with Escherichia coli; and Motility Indole Urea (MIU) semisolid agar, in reaction tubes, inoculated with Proteus sp.

is used at 100% power level will generate approximately 218–260oC of temperature. The heat produced by the microwave will at last denaturize the protein.4 The advantage of using microwave oven is the shorter time needed to produce heat. The objective of this study was to evaluate the ability of microwave oven in sterilizing growth media in different durations as well as the identification function of the microwave-sterilized growth media.

Methods

Results

This was a laboratory experimental study. The study was conducted at Microbiology Laboratory, Faculty of Medicine, Universitas Padjadjaran, from October to November 2014. This study was approved by Health Research Ethics Committee of Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia . The media would be heated by microwave for 1, 2, and 3 minutes; each of which consisted of two dishes/tubes, except Kligler Iron Agar with three tubes, and then incubated for 1x24 hours in the temperature of 37oC. Afterwards, one of the dishes/tubes would be kept for 7x24 hours in the refrigerator in with temperature between 2–8oC to subsequently observe if there were contaminant growth on the media. Rest of the media would be inoculated with certain microbes to subsequently observe the identification function of the microwavesterilized growth media, compared to the autoclaved media as control. The role of microwave oven was called potential in preparing a medium in certain duration if it could sterilize more than half of the dishes/tubes as well as preserving the

Most media were still sterile after being kept in the incubator for 24 hours and then in the refrigerator for seven days (Table 1). Contaminations were just seen in 5 out of 54 dishes/tubes, four of which were seen on Mueller-Hinton Broth and one of which was seen on KIA. All contaminations were found after 24 hours incubation, no other contaminations seen during the 7 days period in the refrigerator. In the first experiment , one tube of one-minute-heated Kligler iron agar was contaminated. In the second experiment , one tube of one-minute-heated Mueller-Hinton broth was contaminated. Meanwhile, in the third experiment, four tubes of MuellerHinton broth, one tube of one-minute-heated media, one tube of two-minute-heated media, and two tubes of three-minute-heated media were contaminated. The two minute duration of microwave heating succeed to sterilize all the media more than half of the dishes/tubes. The three

Table 1 Result of Recapitulation after Sterilizing Growth Media Using Microwave Oven and Keeping in the Refrigerator for 7 Days Type of Medium MacConkey Sabouraud KIA

Citrate Simmons MH Broth MIU

Total

One Minute Sterilization

Two Minute Sterilization

Three Minute Sterilization

Sterile

Contami nated

Sterile

Contami nated

Sterile

3

0

3

0

3

3

2

3

1

3

15

0

1

0

2

0

3

3

3

3

2

3

17

0

0

0

1

0

1

Contami nated

3

0

3

0

3

2

3

17

0

0

1

0

1

Sterile 9

9

8

9

5

9

49

Total

Contami nated 0

0

1

0

4

0 5

Althea Medical Journal. 2016;3(1)

Christian Prijana, Yanti Mulyana, Basuki Hidayat: Roles of Microwave Oven in Preparation of Microbiological Growth Media

Figure 1 Inoculation Results of S. Typhi to Kligler Iron Agar (KIA) From left to right: one minute microwave-heated medium; two minutes microwave heated medium; three minutes microwave-heated medium; and autoclaved medium as control.

minute duration of microwave heating succeed to sterilize all the media more than half of the dishes/tubes as well. The one minute duration of microwave heating failed to sterilize more than half of the Mueller-Hinton broth tubes; however, it succeed to sterilize the other five media more than half of the dishes/tubes. Since both tubes of the three-minute-heated Mueller-Hinton broth got contaminated after 24 hours of incubation, inoculation of E. coli for the three-minute-heated Mueller-Hinton broth could not be performed. One of the tubes was kept in the refrigerator for seven days. Inoculation of microbes to the microwaveheated media generated similar changes with the autoclaved-media. Apart from that, there was another phenomenon seen in this study. The microwave-sterilized media tended to have brighter or more transparent color than the autoclaved media.

Discussion

Table 1 showed that microwave oven succeed to sterilize most of the media. From the total 54 dishes/tubes of various microwavesterilized media, contaminations were only seen at 5 dishes/tubes. The results of Althea Medical Journal. 2016;3(1)

3

this study is in accordance with the study conducted by Bhattacharjee, et al. 5 which stated that the microwave is able to sterilize the microbiological growth media quickly. All contaminations in this study were found in tubes, no contamination was found on the petri dish. This result might be due to difficulties of burner’s heat in reaching the whole depth of a tube during the aseptic technique. The heat also probably failed to sterilize the tube because it was absorbed by hand while holding the tube. Inoculation performed to microwavesterilized media generated similar changes to the autoclaved growth media. It indicated that the identification function of the media in this study was still performed well. E. coli fermented lactose that changed the color of MacConkey agar into red. C. albicans produced cream-like colonies on Sabouraud agar. KIA turned into yellow at both the butt and slant as the result of glucose and lactose fermentation, meanwhile S. Typhi fermented only glucose but not lactose, so that it changed the color of the butt only. S. Typhi also generated black color near the site of inoculation due to the production of H2S. Simmons citrate agar turned into blue due to the utilization of citrate by K. pneumoniae. E. coli colony generated turbidity

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AMJ March 2016

at the Mueller-Hinton broth. The motility of Proteus produced swarming around the site of inoculation, the utilization of urea decreased the pH and changed the color of media into pink.6,7 Even though the temperature inside the microwave oven can destruct the identification component of a medium, the identification function of the media in this study was still performed well. This was probably due to the ability of microwave oven to excite the molecules contained in the media.8 The media immediately converts the microwave into heat energy that increases the temperature inside the microwave oven in such a short time, so that it is not long enough to destruct the identification component of growth media. Based on study conducted by Kothari, et al.9 microwave-sterilized liquid growth media is more fertile than the autoclaved media. In that study, various media were heated by microwave oven for 10 minutes. Various bacteria and yeast inoculate to the microwavesterilized media generated higher cellular density and growth velocity than the bacteria, and yeast inoculates to the autoclaved.9 There were differences in color between the microwave-sterilized media and the autoclaved media. Similar results were also stated by Geczi et al.10 The study showed that liquid food treated with microwave have different color with untreated control and traditional-heated samples. They arecaused by the Maillard reaction which occured during autoclaving.11 Maillard reactions are group of various complicated non-enzymatic reactions between free amino groups of protein, usually the ε-amino groups of protein, and carbonyl groups of reducing sugars.12 This reaction results in the darkening of the autoclaved media’s color due to the production of melanoidines, the final products of the reaction.13 This study has some limitations. The temperature in the microwave oven, as well as in the refrigerator, could not be measured precisely but could only be estimated around 218–260oC for microwave oven and 2–8oC for the refrigerator. The longest duration of microwave heating in this study is only three minutes. Even though there are still more sterile than contaminated Mueller-Hinton broth, the results of sterilizing the Mueller-Hinton broth generated some recommendations for further studies. There should be further studies in microwave-sterilizing the liquid media using more tubes and variations of heating duration. From this study, it can be concluded that

the utilization of microwave oven, particularly with two and three minute duration of microwave heating, as an alternative sterilizing apparatus for microbiological growth media is very potential. The most potential heating durations are two and three minutes since they are able to sterilize more than half dishes/ tubes of all media in this study.

References

1. Neumann O, Feronti C, Neumann AD, Dong A, Schell K, Lu B, et al. Compact solar autoclave based on steam generation using broadband light-harvesting nanoparticles. Proc Natl Acad Sci U S A. 2013;110(29):11677–81. 2. Bhowmik G. Introduction to the laboratory. In: Bhowmik G, editor. Analytical techniques in biotechnology. New Delhi: Tata McGraw-Hill Education; 2011. p. 27– 8. 3. Brace CL. Microwave tissue ablation: biophysics, technology, and applications. Crit Rev Biomed Eng. 2010;38(1):65–78. 4. Chen L, Wang N, Li L. Development of microwave-assisted acid hydrolysis of proteins using a commercial microwave reactor and its combination with LC-MS for protein full-sequence analysis. Talanta. 2014;129:290–5. 5. Bhattacharjee MK, Delsol JK. Does microwave sterilization of growth media involve any non-thermal effect? J Microbiol Meth. 2014;96:70–2. 6. Carroll KC. Bacteriology. In: Brooks G, Carroll KC, Butel J, Morse S, editors. Jawetz Melnick & Adelbergs Medical Microbiology. 26 ed. New York: Mcgraw-Hill; 2012. p. 149–406. 7. Mitchell TG. Mycology. In: Brooks G, Carroll KC, Butel J, Morse S, editors. Jawetz Melnick & Adelbergs Medical Microbiology. 26th ed. New York: Mcgraw-Hill; 2012. p. 671– 714. 8. Mani D, Arunan E. Rotational spectra of propargyl alcohol dimer: a dimer bound with three different types of hydrogen bonds. J Chem Phys. 2014;141(16):164311. 9. Kothari V, Patadia M, Trivedi N. Microwave sterilized media supports better microbial growth than autoclaved media. Res Biotechnol. 2011;2(5):63–72. 10. Geczi G, Horvath M, Kaszab T, Alemany GG. No major differences found between the effects of microwave-based and conventional heat treatment methods on two different liquid fodds. Plos One. Althea Medical Journal. 2016;3(1)

Christian Prijana, Yanti Mulyana, Basuki Hidayat: Roles of Microwave Oven in Preparation of Microbiological Growth Media

2013;8(1):1–12. 11. Bhattacharjee MK, Sugawara K, Ayandeji OT. Microwave sterilization of growth medium alleviates inhibition of Aggregatibacter actinomycetemcomitans by Maillard reaction products. J Microbiol Meth. 2009;78(2):227–30. 12. Teodorowicz M, Fiedorowicz E, Kostyra H, Wichers H, Kostyra E. Effect of Maillard reaction on biochemical properties of peanut 7S globulin (Ara h 1) and its

Althea Medical Journal. 2016;3(1)

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interaction with a human colon cancer cell line (Caco-2). Eur J Nutr. 2013;52(8):1927– 38. 13. Mohajjemzadeh F, Hassanzadeh D, Valizadeh H, Siahi-Shadbad MR, Mojarrad JS, Robertson T, et al. Assesment of feasibility of Maillard reaction between baclofen and lactose by liquid chromatography and tandem mass spectrometry, application to pre formulation studies. AAPS Pharm Sci Tech. 2009;10(2):649–59.

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The Distribution of Pubertal Age among Male School Students in Jatinangor District from April to June 2013 Karthik Yogaswaran,1 Anggraini Widjajakusuma,2 Juliati3 Faculty of Medicine Universitas Padjadjaran, 2Department of Epidemiology and Biostatistics Faculty of Medicine Universitas Padjadjaran, 3Department of Physiology Faculty of Medicine Universitas Padjadjaran

1

Abstract

Background: Puberty is important and exciting lifetime changes in an individual. Many new changes are experienced during puberty, such as physically, mentally, and emotionally. Currently, young males worldwide have different onset of pubertal age. Many factors may result in this change of pubertal age. The exact pubertal age was still unknown due to less study conducted previously. Therefore, the aim of this study was to identify the distribution of pubertal age among male school students in Jatinangor. Methods: A descriptive study was conducted from April to June 2013. A secondary data were obtained from the Jatinangor Cohort Study, from the Department of Epidemiology and Biostatistics, Faculty of Medicine, Universitas Padjadjaran. The samples were taken via cluster random sampling from 48 schools around Jatinangor. Randomization was conducted and a total of 219 male students were finally obtained from the overall data which had at least single onset of pubertal changes. This presents a response rate of 82.33%. Results: The earliest onset of pubertal age was identified as 9 years old and the oldest onset was 18 years old. The majority onset of pubertal age ranged from 12 to 15 years old with average mean of 13 years. Voice changes were identified as the early sign of puberty among males. Conclusions: Majority of the students undergo puberty at age 13 which is earlier compared to previous studies. Thus, this study indicates decreasing in onset of pubertal age among male school students in Jatinangor. [AMJ.2016;3(1):6–11] Keywords: Jatinangor, male school students, pubertal age, puberty

Introduction Changing trends occurring between childhood and adulthood, in the transitional phase of growth and development varies in every individual. This period is known as pubertal phase.1 The development of physical growth is known as adolescence stage which roughly ranges from 11–19 years old.2 According to American Academy of Pediatrics (AAP), currently, young males start puberty much more earlier compared to previous decades.1 Now, males begin puberty six months to two years earlier. Some males undergo precocious puberty (PP), as the development of pubertal changes, at an age younger than the accepted lower limits for age of onset of puberty.3 Thus, United State boys reach puberty between ages of 9–10, compared to 25 years ago where the first sign of puberty occurs at

ages of 11 years or more.4 Black American boys start showing pubertal changes around age 9.1 years while white and Hispanic boys undergo changes just after turning 10.5 Similar trends towards earlier puberty in boys have been seen in studies in Europe.4 However, in Asian countries, the mean age for pubertal among males is 15 years old.6 Several studies conducted stated that fewer data are available on the age and pattern of pubertal development in boys. This reflects less cultural awareness of male pubertal development.7 Besides, the current reducing in the pubertal age is still left unknown and the exact time period of male puberty is not clearly stated. Therefore, the aim of this study was to determine the pubertal age among male school students in Jatinangor in order to give a hint what intervention should be given.

Correspondence: Karthik Yogaswaran, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km.21, Jatinangor, Sumedang, Indonesia, Phone: +6283821350838, Email: [email protected] Althea Medical Journal. 2016;3(1)

Karthik Yogaswaran, Anggraini Widjajakusuma, Juliati: Distribution of Pubertal Age among Male School Students in Jatinangor District from April to June 2013

Methods The type of study conducted was descriptive study. This study was carried out from April to June 2013. A secondary data were obtained from the Jatinangor Cohort Study from the Department of Epidemiology and Biostatistics, Faculty of Medicine, Universitas Padjadjaran. Jatinangor Cohort Study comprised of reproductive health among school students in Jatinangor District and was approved by Health Research Ethics Committee. The samples were taken via cluster random sampling from 48 Elementary School (Sekolah Dasar, SD), Junior High School (Sekolah Menengah Pertama, SMP) and Senior High School (Sekolah Menengah Atas, SMA) around Jatinangor, which made up a total of 7542 male students. The six schools selected were SD Negeri Cibeusi, SD Negeri Cikopo II, SMP Al-Masoem, SMP PGRI, SMA PGRI and SMA Negeri Jatinangor which had a total of 1250 male students. Randomization was conducted by the Jatinangor Cohort Study team by only selecting Class IV–VI male students from Elementary School, Class VII–IX male students from Junior High School and Class X–XII male students from Senior High School which had a total of 266 male students. These students were given an informed consent form to be filled by their parents or guardians. Questionnaire forms which comprises of onset of pubertal age measured by secondary sexual characteristics were given to the students. The questionnaire

was validated by the Jatinangor Cohort team. A total of 219 male students were finally obtained from the whole data which had at least single onset of pubertal changes. This presents a response rate of 82.33%. All the data collected from the questionnaires were composed into Statistical Product and Service Solutions (SPSS) software version 15. The distribution of pubertal age among male students was analyzed. All the results were presented in suitable graphs.

Results

A total of 219 male students with onset of pubertal changes were divided according to their level of education. The highest number of onset of pubertal agewas experienced among Junior High School students while the lowest number was from Elementary School students (Figure 1). The earliest age for voice changes among male students was at age 9 years old with a total of 6 students and the oldest occurs at age 18 with only 1 student. The highest number experiencing onset of voice changes was 53 students at age 12 years old. The age range for majority voice changes was 12–14 years old (Figure 2). The onset of wet dream occurrence among male students began at age 9 years with a total of 4 students. There are 3 students with onset at age 16 years, while the highest number experiencing onset of wet dream as 66

Figure 1 Total Male Student with Pubertal Changes according to Level of Education Althea Medical Journal. 2016;3(1)

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Figure 2 Number of Students with Onset of Voice Changes according to Age students at age 13 years old. The age range for majority wet dream occurrence was at 12–14 years old (Figure 3). Moustache and pubic hair showed earlier onset of growth at age 10 years old, while beard and axillary hair started growing at age

12 years. The highest onset of hair growth varied. The highest number experiencing onset of pubic hair growth was 56 students at age 13 years old. Meanwhile, for onset of moustache and axillary hair growth, the highest number experiencing was at age 15 years, with 34

Figure 3 Number of Students with Onset of Wet Dream Occurrence according to Age Althea Medical Journal. 2016;3(1)

Karthik Yogaswaran, Anggraini Widjajakusuma, Juliati: Distribution of Pubertal Age among Male School Students in Jatinangor District from April to June 2013

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Figure 4 Number of Students with Onset of Sexual Hair Growth according to Age students and 25 students respectively. Onset of beard growth had the highest number at age 16 years with 27 students. Thus, the majority age range for sexual hair growth among Jatinangor boys was 12–15 years (Figure 4).

The earliest age for penis, scrotal, and testes enlargement among male students was at age 9 years old. Penis and testes enlargement had the same highest number experiencing its onset which was at age 13 with 47 students

Figure 5 Number of Students with Onset of Sexual Organ Enlargements according to Age Althea Medical Journal. 2016;3(1)

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and 22 students respectively. Meanwhile, the highest number experiencing onset of scrotal enlargementwas 19 students at age 15 years old. The majority age range for the enlargement was 12–15 years old (Figure 5).

Discussion

The study to find the distribution of pubertal age among the 219 students was conducted. The students were divided according to the onset of pubertal age corresponding with their pubertal changes. The pubertal changes that were taken in count were voice changes, moustache growth, beard growth, axillary hair growth, pubic hair growth, penis enlargement, scrotal enlargement, testes enlargement, and occurrence of wet dream. The range of pubertal age was based on the earliest onset of pubertal changes and the latest onset. The majority age range was also identified from this study. The result showed that the earliest onset of pubertal changes was at age 9 years old and the oldest onset occured at age 18 years old. This showed a wide range of pubertal onset among Jatinangor males. In Elementary School, there were 25 students with onset of pubertal changes and among them, the highest onset was seen in occurrence of wet dreams. Fourteen students experienced these changes, while voice changes took second highest with 11 students experiencing it. Meanwhile, among Junior High School students, pubertal changes occured in 100 students. Wet dreams occured mostly in all students, followed by voice changes and pubic hair growth. Finally, there were 94 students obtained from Senior High Schools with onset of pubertal changes. Wet dreams, voice changes, and pubic hair growth still remained the most frequent secondary sexual changes with onset of puberty. However, more students experienced voice changes prior to wet dream occurrence, resulting in voice changes as early sign of puberty in Jatinangor male school students. The majority onset of pubertal changes occured at age 12–15 years old. This showed a clear decrease in the onset of pubertal age. Previous study showed that the onset of puberty among Asian males is 15 years old.6 Now, males began puberty six months to two years earlier. Similar trends towards earlier puberty in boys have been seen in studies in Europe. United State boys reach puberty between ages of 9–10, compared to previous years where average boys undergo the first sign of puberty around 11 years old or more.4,7

Voice changes had the highest number of students experiencing earlier onset which is at age 12 years old. Study showed that generally aboy’s voice starts to change somewhere between ages of 11–15 years.2 Thus, for males in Jatinangor, the voice changed at age 12–14 years old. Voice changes is a result of hormonal changes, the increase of testosterone level during puberty.6 The secondary sexual characteristic is due to the result from the stimulation of gonads by pituitary gonadotropin. Testes enlargement are relatively constant untill age 11 years then the testicular enlargement begins.8 Similar trend was seen among males in Jatinangor. This sudden increment could be the result of the hormonal changes that takes place in the male students.2 Therefore, certain studies classify the increase in testicular size as a definite sign of puberty.8,9 The distribution of hair growth is also similar to other secondary sexual characteristics. The majority age range for onset of hair growth is also 12–15 years old. Pubic hair has the earliest growth at age 12 just after increase in the testicular volume. This showed the change in testosterone production in a male undergoing pubertal age.8 Occurrence of wet dreams is also strongly related to change in body hormonal level. The factor that causes this decreasing trend of pubertal age is still unknown. Although puberty is mostly due to the change in body hormonal level, but current lifestyle and environmental factor could be causes of early onset of puberty among younger generations.10 Current lifestyle which includes the dietary pattern on an individual might be a predisposing factor to the decrease in onset of puberty in males. Huge amount of fat intake is said to fasten the body metabolism to result in an early onset of puberty.4 The study proves that the distribution of pubertal age is at age 12–15 years old. However, the number of participants in this study was based on the data obtained from Department of Epidemiology and Biostatistics Faculty of Medicine, Universitas Padjadjaran. Thus, limited information was obtained from the data. Additional information on the pubertal age could not be obtained as the data was collected prior to the study. For the upcoming study, other criteria of concluding the onset of puberty among males, such as Tanner Staging can be conducted with proper procedures to obtain a better result. Tanner Staging will give a more precise result on what stage of pubertal development does that the individual is going through. Althea Medical Journal. 2016;3(1)

Karthik Yogaswaran, Anggraini Widjajakusuma, Juliati: Distribution of Pubertal Age among Male School Students in Jatinangor District from April to June 2013

In conclusion, the pubertal age in Jatinangor is around age 9–18 years old with the majority age range of 12–15 years old. The overall mean age for onset of puberty is 13 years old. The sign of puberty that appears early is voice changes followed by wet dreams and pubic hair growth.

References

1. Abbassi V. Growth and normal puberty. Pediatrics.1998;102(2 Pt 3):507–11. 2. Elizabeth ARE, Seth D. Pubertal development: correspondence between hormonal and physical development. Child Dev. 2009;80(2):327–37. 3. Carel JC, Leger J. Precocious puberty. N Engl J Med. 2008;358:2366–77. 4. Herman-Giddens ME, Steffes J, Harris D, Slora E, Hussey M, Dowshen SA, et al. Secondary sexual characteristics in boys: data from the Pediatric Research in Office Settings Network. Pediatrics. 2012;130(5):e1058–68.

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5. Harris P. Boys are reaching puberty earlier. New York: The Guardian; 2012 [cited 2012 October 20]; Available from: http://www. guardian.co.uk. 6. Xenos P, Sulistinah A, Lin HS, Luis PK, Podhisita C, Raymundo C, et al. Delayed Asian transitions to adulthood: a perspective from national youth surveys. Asian Population Studies. 2006;2(2):149– 83. 7. Euling SY, Lee PA, Selevan SG, Juul A, Sorensen T, Dunkel L, et al. Examination of US puberty-timing data from 1940 to 1994 for secular trends. Pediatrics. 2008;121 Suppl 3:S172–91. 8. Fujienda K. Pubertal development in Japanese boys. Clin Pediatr Endocrinol. 1993;2(Suppl 3):7–14. 9. Okuno A. Physical growth and hormonal changes in late childhood and early adolescence. Clin Pediatr Endocrinol. 1993;2(Suppl 3):1–6. 10. Louis GM, Marcus M, Ojeda SR, Pescovitz O, Selma FW, Wolfgang S, et al. Environmental factors and puberty timing. Pediatrics. 2008;121 Suppl 3:S192–207.

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Association of Body Mass Index to Onset of Puberty in Male Jeevithaambigai A/P Subramaniam,1 Yulia Sofiatin,2 R.M Ryadi Fadil3 Faculty of Medicine Universitas Padjadjaran, 2Department of Epidemiology and Biostatistics Faculty of Medicine Universitas Padjadjaran, 3Department of Child Health Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung 1

Abstract Background: Puberty is the period where the developmental process takes place, marks the transition from childhood to adulthood with physical and physiological changes. This study was conducted to discover association between body mass index (BMI) and onset of puberty in male. Methods: A cross-sectional study was conducted from May to November 2013 using simple random sampling which was part of bigger research study by Nutrition and Metabolism Working Group on Jatinangor Cohort, especially Puberty Survey in Jatinangor, by Department of Epidemiology and Biostatistics Faculty of Medicine Universitas Padjadjaran. Respondents were 286 males, 9–15 years old from Elementary School (Sekolah Dasar/SD) and Junior High School (Sekolah Menengah Pertama/SMP). Inclusion criteria were students who are healthy at the time and do did not have obvious disease, attained puberty within 1 year or did not yet attained it, and voluntarily followed the study procedure. The questionnaire was provided after getting informed consent from the respondents. The data analysis was done conducted using Pearson Correlation. Results: The magnitude of association of BMI to the onset of puberty in male among school students in Jatinangor was 0.243 which showed there was positive correlation coefficient between BMI to onset of puberty in male. Test results with the t-test showed t-value of 2.683 with p-value of 0.008. Conclusions: There is association of BMI to the onset of puberty in male among school students in Jatinangor. Positive correlation indicates that the higher the BMI, the faster the onset of puberty in male. [AMJ.2016;3(1):12–16] Keywords: Body mass index, male students, nutritional status, onset of puberty

Introduction The time of dramatic transformation in human lifecycle is termed as puberty.1,2 This is the period where there is the biologic transition between immature and adult reproductive function.3 The changes are not only in terms psychologically, but also rapid changes in size, shape, and composition which are sexually dimorphic.4 Due to the changes, it is required to understand the physical changes that occur during puberty in order to evaluate and treat the aberrations of pubertal development.5 Prospective studies for male puberty frequently use pubic and facial hair growth, voice change , and genital growth such as testicles and penis, but these changes can be unreliable and may be poorly recalled.6 These

studies have disregarded such measures and examined self-perception of pubertal onset.6 For males, it is recommended to use first sexual attraction, first nocturnal emission or termed as wet dream and first masturbation as assessment for onset of puberty.6 There are a number of factors that acts independently to influence the growth and maturation. More recently nutrition status by assessing the body mass index (BMI) on the timing or onset of puberty in male has become topic of interest.7 Leptin or fat cells and estradiol are the factors that will alter the onset of puberty in male if BMI is taken into account.7 There is a relatively extensive literature demonstrating or showing an inverse association between body fat and age at pubertal onset in girls, that is higher BMI leading to earlier age of menarche but the

Correspondence: Jeevithaambigai A/P Subramaniam, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya BandungSumedang Km.21, Jatinangor, Sumedang, Indonesia, Phone: +6281312354379 Email: [email protected] Althea Medical Journal. 2016;3(1)

Jeevithaambigai A/P Subramaniam, Yulia Sofiatin, R.M Ryadi Fadil: Association of Body Mass Index to Onset 13 of Puberty in Male

similar studies in male are still lacking.7 So this study enables to understand whether there is any association or correlation between BMI and the onset of puberty in male and how it is correlated.

Methods

This cross sectional type of study was conducted from May to November 2013 in schools that were included in bigger study conducted by Nutrition and Metabolism Working Group in Jatinangor Cohort, especially Puberty Survey in Jatinangor, by Department of Epidemiology and Biostatics Faculty of Medicine Universitas Padjadjaran which collected data from all grade 7 and 8 students from several Junior High School (Sekolah Menengah Pertama, SMP) and all grade 4 and 5 students from several Elementary School (Sekolah Dasar, SD) in Kecamatan Jatinangor. The study was conducted after getting clearance from the Health Research Ethics Committee Faculty of Medicine Universitas Padjadjaran. Validated and reliable questionnaires were provided to students after getting permission from the head of the school. The sampling method used was simple random method. The subjects were comprised of male school students aged 9‒15 years old. The total of 286 respondents were given questionnaires with their consent. The onset of puberty was accessed through the age of onset of wet dream and the BMI was measured by taking height and weight using stadiometer and weighing scale. The subject of the study were included if they were healthy at the time and did not have obvious illness, attained puberty in one year and voluntarily followed the research procedure. The subjects were excluded from the study if they did not attend the school when the survey was conducted and who refused to answer the questionnaires. In order to measure the height and weight for detecting BMI, it is essential to know the correct and reliable procedure or method to prevent error during recording. To measure height, the following procedure was followed. Firstly, the procedure was started by asking the students identity such as name, age, school, and the students were asked to take off their shoes before the measurement, and to stand with their back against the board (part of the body touches the board such as heel, buttock, back of the body, and head), body weight was evenly distributed on both feet, arm hung freely by the sides of the body, palms faced the thighs, legs were placed together, brought knees or Althea Medical Journal. 2016;3(1)

ankles together, the student stood erect; heads was up and faced straight ahead, verified the body position front and left by the examiner, positioned head in Frankfort Horizontal Plane. The students were asked to inhale deeply and held their breath without moving head or body, brought headpiece down onto the upper most point on the head; compressed the hair, asked them to exhale, then height was recorded to the nearest 0.1 cm (or appropriate unit for the stadiometer) and the examiner had to convert into meter later. The standardized method to measure weight was shown below. The scale was adjusted to “zero” by examiner and if the scale was accurate and there was no any zero error, the assessment had begun. The students were asked to remove extra layers of clothing, and any heavy items in their pockets, the child is asked to stand in the scale to ensure that the body weight is evenly distributed between both feet, arms is hang freely by the sides of the body, palms toward thighs, head is up and facing straight ahead, weight is recorded to nearest 0.1 kg (or appropriate unit for the scale). After finding the average height and weight, the BMI was calculated using the formula weight (kg) over height (m2), so it can be categorized into underweight (<18.5 kg/m2), normal (18.5‒24.99 kg/m2), obese (25‒29.99 kg/m2) and finally obese (≥30 kg/ m2) to find the correlation of fat mass to the onset of puberty.8 The respondents were included only if the difference of age of onset of wet dream and the current age of the student was less than or equal to 1 year, students were healthy at the time and did not have obvious illness, and respondents voluntarily followed the research procedure. Only students with difference of age of onset of wet dream and the current age less than or equal to 1 year were included because male with difference of age more than 1 year would attain the pubertal growth spurt which may alter the BMI measurement. From these criteria, 117 students were included in the study and the rest were excluded. The association of BMI and onset of puberty was found through correlation studies of bivariate variable using Pearson method that was analyzed through Statistical Package for the Service Solutions (SPSS) programm. Statistically, significant result was considered when p<0.05.

Results

There were 117 subjects included in the big study and were assessed according to the

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Table 1 Respondent Characteristic Respondent Characteristics

Frequency (n=117)

Percentage (%)

NA

NA

Onset of puberty Early

Normal Late

93

79.49

50

42.74

24

BMI

Underweight Normal

20.51

59

Overweight

50.43

8

Obese

6.84

0

Note: NA=Not Available

characteristics of the subjects which were BMI and age of wet dreams, which signified duration of puberty. The BMI assessment was according to World Health Organization (WHO) classification. The age of wet dreams or the duration of puberty was classified into 3 categories; early onset (<9 years), normal onset (9‒13 years old) and late onset (≥14 years). The BMI average of the respondent was 19.41 and standard deviation of BMI of the respondent was small enough which was equal to 2.64. Students with late onset of puberty were far less if compared to normal onset of puberty. Half of the students belonged to the BMI classification normal (Table 1). Those with normal onset of puberty, who were most of the students, were classified into normal BMI. The least number of students

0

were from late onset of puberty with BMI classification obese (Table 2). The magnitude of BMI association to the onset of puberty in male among school students in Jatinangor analyzed by Pearson correlation was 0.243. Test results with the t-test showed t-value of 2.683 with p value of 0.008. If compared to significance level α=5%, the p value was worth less.

Discussions

A tumor is an abnormal growth of tissue, Based on the onset of wet dreams, there were about 93 students, 79.49% with normal onset of puberty in between 9‒13 years, whereas only 24 students which is 20.51% with late onset of puberty (≥14 years). There was no data available for early onset of puberty which

Table 2 Cross Tabulation of BMI and Onset of Puberty BMI Underweight

Onset Early

Normal

Late

NA

43

7

%

0.00

36.75

Overweight

NA

3

Normal % %

Obese %

Total

%

Note: NA=Not Available

NA

0.00 0.00 NA

0.00 NA

0.00

47

42.74

5

8

12

10.26

0

0

0.00 93

79.49

50

5.98

40.17 2.56

Total

4.27 0.00 24

20.51

59

50.43 6.83 0

0.00 117

100

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Jeevithaambigai A/P Subramaniam, Yulia Sofiatin, R.M Ryadi Fadil: Association of Body Mass Index to Onset 15 of Puberty in Male

was <9 years old. This is because the study population did not comprise students aged <9 years old. The mean age of attaining puberty based on the study was 12.72 years. The students who earliest attain puberty were at the age of 9 years and those who latest reach puberty were at the age of 15 years. According to Jaruratanasirikul and colleague in Thailand9, the youngest boy who attains earliest onset of puberty is 8.2 and 9.2 years and the range of mean is around 10.8–12.4 years if assessed according to Tanner 2 testicular enlargement and Tanner 2 pubic hair. Compared to the result in Thailand9, onset of puberty in Jatinangor is latter because the criteria used to assess onset of puberty was wet dreams. The onset of puberty according to Tanner is faster than wet dreams. The mean of BMI was 19.41 with standard deviation of 2.64. Around half of the subjects which is 59 students (50.43%) had normal range The data showed that there were big number of students who were underweight with a frequency of 50 students and a small number of students who were overweight. Therefore, it can be concluded that half of the students in the population had poor nutritional status. A study conducted by Rajeev10 in India showed that the mean of BMI is 17.36 (3.08%) in 2005. Compared to that result, the BMI of Jatinangor adolescence were higher than Indians.10 Based on the study, there was association between BMI and onset of puberty. The result signified positive correlation that high BMI correlated with early onset of puberty. This study result is similar to the longitudinal prospective study conducted by Lee et al.7 on BMI and timing of pubertal initiation in male. Study by Lee et al.7 showed that there is strong association between BMI and onset of puberty in male. However, instead of using questionnaire, this particular study used Tanner genitalia staging as main outcome measure to detect onset of puberty, even the reliability and validity of this method has been questioned. On the other hand, other similar studies by Tremblay and Lariviere11 found that there was no significant association in male. This study used validated questionnaire as an instrument and included 569 boys total aged between 9, 13, 16 years. The samples were taken as randomized stratified samples. Besides that, this study used other environmental factors which may alter BMI such as peer influence during the study. There are several limitations in this study Althea Medical Journal. 2016;3(1)

that may interrogate the variables that have been measured. Instead of showing negative correlation, this study, showed positive association which high BMI had early onset of puberty. This correlation theoretically against the current proposed hypothesis. This study only measured the BMI after attaining the growth spurt because the BMI was not assessed during the onset of puberty, but within 1 year after attaining, the onset of wet dreams as the consequence the BMI may be altered by the growth spurt during the 1 year period of puberty. So, to overcome this problem, it is highly recommended to conduct cohort study embedded to Usaha Kesehatan Sekolah (UKS), the health monitoring in schools so the method will be effective in measuring the BMI on the onset and at the same time, the reproductive health education can be reached among school students. Besides that, by selfanswering question, the respondents may feel uncomfortable which may alter the finding of the study. Instead of self-answering monitored by the researcher, online questionnaire could be more reliable and effective. Besides that, this study used secondary data to detect age of the onset of puberty where it may have recall bias. The school students probably faced difficulty in recalling the exact year at the first time they had wet dreams. Furthermore, in order to get more accurate date of the onset of puberty it is required to educate male student on the importance of reproductive health. Finally, the population samples of this study contained limited number of obese students. Therefore, the BMI of the population were not normally distributed and mostly comprised of underweight and normal BMI. To overcome this problem, the study can be conducted in different setting with more obese male students or it is recommended to conduct cohort study. In conclusion, there is association of BMI to the onset of puberty in male among students in Jatinangor Sub District. Positive correlation coefficient indicates that the higher the BMI, the faster the onset of puberty in male will be. It adds the controversies on the correlation of nutritional status and onset of puberty. Further study with better design and measurement method is needed and it will be better to embed this study into established program such as UKS.

References

1. Mendle J, Ferrero J. Detrimental psychological outcomes associated with pubertal timing in adolescent boys. Dev

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Rev. 2012;32(1):49–66. 2. Bond L, Clements J, Bertalli N, EvansWhipp T, McMorris BJ, Patton GC, et al. A comparison of self-reported puberty using the Pubertal Development Scale and the Sexual Maturation Scale in a schoolbased epidemiologic survey. J Adolesc. 2006;29(5):709–20. 3. Speroff L, Fritz MA. Clinical gynecologic endocrinology & infertility. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. 4. Rogol AD, Roemmich JN, Clark PA. Growth at puberty. J Adolesc Health. 2002;31(6):192–200. 5. Berek JS. Berek & Novak’s gynecology. 14th ed. California: Lippincott Will & Wilkin; 2007. 6. Downing J, Bellis MA. Early pubertal onset and its relationship with sexual taking, substance use and anti-social behaviour: a preliminary cross-sectional study. BMC

Public Health. 2009;9(1):446. 7. Lee JM, Kaciroti N, Appugliese D, Corwyn RF, Bradley RH, Lumeng JC. Body mass index and timing of pubertal initiation in boys. Arch Pediatr Adolesc Med. 2010;164(2):139–44. 8. Gardner D, Dolores S. Greenspan’s basic & clinical endocrinology. 8th ed. San Francisco: McGraw-Hill; 2007. 9. Jaruratanasirikul S, Yuenyongwiwat S, Kreetapirom P, Sriplung H. Age of onset of pubertal maturation of Thai boys. J Pediatr Endocrinol Metab. 2014;27(3–4):215–20. 10. Rajeev A. Correlation of body mass index and total body fat with physical activity pattern in adolescents. Int J Diabetes Dev Ctries. 2009;29(3):139–42. 11. Tremblay L, Lariviere M. The influence of puberty onset, body mass index, and pressure to be thin on disordered eating behaviors in children and adolescents. Eat Behav. 2009;10(2):75–83.

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Hypertension Treatment and Control in Older Adult at Tanjung Sari Public Health Center

1

Rahmi Fauziah,1 Enny Rohmawaty,2 Lazuardhi Dwipa,3 Faculty of Medicine Universitas Padjadjaran 2Department of Pharmacology and Therapy Faculty of Medicine Universitas Padjadjaran, 3Department of Internal MedicineFaculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung

Abstract Background: Hypertension is considered as a major health problem in Indonesia, especially in older adult population because of its prevalence increases by age. Treatment strategy and control management of hypertension in Public Health Center (Pusat Kesehatan Masyarakat, Puskesmas) as primary health care should be enhanced to overcome this issue. This study aimed to describe the pattern of antihypertensive agent in older adults. Methods: This was a descriptive study with total sampling method for data collection. Data were collected from medical record of older adult patients with diagnosis of hypertension at Puskesmas Tanjung Sari from January to December 2013. The variables observed were gender, number of visits, the degree of hypertension, types of antihypertensive drug, combinations of antihypertensive drugs, and blood pressure control. Results: The number of older adults with hypertension was 180 people. Some of which, 120 women (66.7%) participated, 152 (84.4%) had hypertension stage 2, 100 (55.6%) had just one visit, and 80 (44.4%) had more than one visit. Among 80 participants with more than one visit, 8 had achieved target blood pressure. There were 166 participants (92.2%) who received single antihypertensive agent (captopril was given the most), and 14 participants (7.8%) who received the combination of two antihypertensive agent (combination of captopril and HCT (hydrochlorothiazide)) were given the most). Conclusions: More than 75% of older adult with hypertension have stage 2 hypertension and are treated by single antihypertensive agent. Ninety percent of the patient have uncontrolled blood pressure. [AMJ.2016;3(1):17–21] Keywords: Antihypertensive agent, hypertension, older adult, public health center

Introduction Increased life expectancy in few past century causes a continued increase of older adult population.1 The population of older adult in the world will increase from the estimated 810 million in 2012 to 2 billion in 2020.1 The population of older adult in Indonesia is also expected to increase from 9% in 2012 to 25% in 2050.1 Most of the causes of death in older adult in Indonesia are non-communicable diseases such as heart disease, stroke, and diabetes.2 Hypertension is a disease that increases the risk of heart disease, stroke, and kidney disease and its prevalence increases by age.3,4 Hypertension causes death of 8 million people worldwide each year and is included as

one of the 10 major causes of death in the older adult in Indonesia.2,3The percentage of older adult who are treated in Public Health Center (Pusat Kesehatan Masyarakat, Puskesmas) is 29.31% in 2012.2 The Ministry of Health made a policy aimed for Puskesmas as a primary health care to improve control and treatment management of hypertension in Indonesia.5 The characteristics of older adults include multi morbidity and physiological changes in various organs that can affect the pharmacokinetics and pharmacodynamics of drugs, hence, older adults are at high risk of drug accumulation.6-8 It contributes to the modification and influence the selection of drugs in the older adults.8 Since the hypertension is one of the 10 major causes

Correspondence: Rahmi Fauziah, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km.21, Jatinangor, Sumedang, Indonesia, Phone: +6285864622002 Email: [email protected] Althea Medical Journal. 2016;3(1)

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of death in the older adults in Indonesia, the control and treatment strategy become very important. In accordance with the background above, this study aimed to determine the treatment and control of hypertension in older adults in Puskesmas.

Methods

This study used descriptive study conducted at Puskesmas Tanjung Sari with total sampling method for data collection. The subject used in this study was medical record of older adult patients with diagnosis of hypertension at Puskesmas Tanjung Sari from January 1st to December 31st 2013. The instruments of this study used secondary data in the form of medical records at Puskesmas Tanjung Sari. The minimum total sample was obtained by using descriptive categorical formula with a precision of 10% which is equal to 73 samples. The distribution of frequencies and percentages were calculated using Microsoft Excel. This study was conducted after obtaining permission from The Health Research Ethics Committee Faculty of Medicine Universitas Padjadjaran Bandung. Inclusion criteria of the objects in this study were older adult patients aged ≥ 60 years who were treated at Puskesmas Tanjung Sari from January 1st to December 31st2013, with diagnosis of hypertension according to Joint National Committee 7 (JNC 7) criteria. The criteria are the results of measurement of systolic blood pressure ≥140 mmHg or Table 1 Patient Characteristics Patient Characteristics Gender Male

diastolic blood pressure ≥90 mmHg, whether or not accompanied by other diseases and are given antihypertensive drug. Exclusion criteria of the objects in this study were patients with uncompleted medical records in the first visit. Study variables observed in this study were gender, number of visits, the degree of hypertension, types of antihypertensive drug, combinations of antihypertensive drugs, and blood pressure control. Gender of the patients was classified as male and female. The number of visits was defined as how many times the patient went to the Puskesmas to control blood pressure, and was divided into only one visit and more than one visit. The degrees of hypertension were classified based on JNC 7 criteria (normal: <120/80, prehypertension: 120–139/80–89, stage 1 hypertension: 140– 159/90–99, stage 2 hypertension: ≥ 160/100) and were taken in the first visit.9 Types of antihypertensive drug and combinations of antihypertensive drugs used were taken in the first visit. Blood pressure control was taken in the last visit of the patients who had more than one visit and used the NICE clinical guideline criteria of hypertension in 2011 (age <80 years: <140/90 and age ≥80 years: <150/90).10

Results

During the study period from January 1st to December 31st2013, there were 41,205 patients treated at the Puskesmas Tanjung Sari according to the data obtained from the Summary Report Visit at Puskesmas Tanjung Total (n=180) 60 (33.3 %)

Female

120 (66.7 %)

> 1 visit

80 (44.4%)

Number of Visits Only 1 visit

Degrees of Hypertension Prehypertension

Stage 1 Hypertension Stage 2 Hypertension

Types of Antihypertensive Agent Single

Combination

100 (55.6 %) 3 (1.7 %)

25 (13.9 %)

152 (84.4 %) 166 (92.2 %) 14 (7.8 %)

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Rahmi Fauziah, Enny Rohmawaty, Lazuardhi Dwipa: Hypertension Treatment and Control in Older Adult at Tanjung Sari Public Health Center

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Table 2 Distribution of Single Antihypertensive Agent Types of drug

Total (n=166)

HCT (Hydrochlorothiazide)

7 (4.2%)

Reserpine

24 (14.5%)

Amlodipine

3 (1.8%)

Captopril

132 (79.5%)

Table 3 Distribution of Combination of 2 Antihypertensive Agent Types of drug

Total (n=14)

Captopril + HCT

11

Captopril + Reserpine

1

Reserpine + HCT

Sari. Among 41,205 patients, there were 180 older adult patients with hypertension who met the inclusion and exclusion criteria that have been determined. Based on the distribution of gender, older adult patients with hypertension treated at the Puskesmas Tanjung Sari were mostly women compared to men with a ratio 2:1, who visited only one time to control the blood pressure, and had stage 2 hypertension (Table 1). The use of a single antihypertensive agent in the first visit was higher than a combinations of two antihypertensive agents. These results indicated that more than 75% of patients had stage 2 hypertension and were treated by a single antihypertensive agent. Based on the distribution of a single antihypertensive agent in the first visit (Table 2), the majority of older adult patients received captopril followed sequentially by reserpine, HCT, and amlodipine. Most of the older adult patients received combination of captopril and HCT, followed by a combination of reserpine and HCT, and the combination of captopril and reserpine (Table 3). Based on the distribution of controlled blood pressure, the result indicated that 90% of patients who had more than one visit had uncontrolled blood pressure (Table 4).

2

Discussion The results of this study showed that women were the most of the older adults with hypertension. Several factors that cause hypertension in older women who had menopause (postmenopausal) are genetic factors, environmental and the decrease of estrogen levels that can induce endothelial dysfunction, obesity, activation of the ReninAngiotensin-Aldosterone System (RAAS), and oxidative stress. These factors contribute to the increase of renal vasoconstriction leading to hypertension.11 The number of older adult patients who had only one visit were more than patients who had more than one visit. The results of this study may indicate the low awareness of older adult patients to control their blood pressure. This is consistent with the study by Brindel Pauline et al.12 that showed that the frequency of visit in older adult patients with hypertension is associated with a high percentage of awareness, treatment and control of blood pressure. But things such as the patient visit which is not recorded at the medical record, the patient changes to private doctors or other health facilities and lack of education about the importance of controlled blood pressure, can cause the likelihood of the

Table 4 Distribution of Controlled Blood Pressure Blood Pressure Controlled

Uncontrolled

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Total (n=80) 8 (10%)

72 (90 %)

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higher number of patient with only one visit. The majority of patients who received antihypertensive agent in the first visit had stage 2 hypertension. The results are in accordance with the recommendation of 2013 European Society of Hypertension (ESH)/European Society of Cardiology (ESC) guidelines for the Management of Arterial Hypertension that the initiation of antihypertensive drug administration in the older adult is recommended at stage 2 hypertension.13 In this study, older adult patients with hypertension mostly received a single antihypertensive agent in their first visit. This is in accordance with AHA 2011 Expert Consensus Document on Hypertension in the Elderly that initiation of antihypertensive drug treatment in the older adult begins with a single drug administration with the lowest dose. The dose gradually increases until it reaches the maximum dose that can be tolerated depending on the response of the patient’s blood pressure. However, if the blood pressure is more than 20 or 10 mmHg above the target blood pressure, the treatment should be initiated with two antihypertensive agents.14 The results of this study showed that a single antihypertensive agent most often given in older adult was captopril. According to the 2013 European Society of Hypertension (ESH)/European Society of Cardiology (ESC) guidelines for the Management of Arterial Hypertension, all antihypertensive drugs recommended and can be used by the older adult, although diuretics and calcium antagonist is recommended in older adult patients with isolated systolic hypertension.13 Based on the interview with the doctor on duty at Puskesmas Tanjung Sari, captopril administration was most often because the availability of other antihypertensive drugs at Puskesmas Tanjung Sari was limited in 2013, while after the National Health Coverage (JKN), the availability of antihypertensive agent at Puskesmas Tanjung Sari is amlodipine (calcium antagonists). The combination of two antihypertensive drugs most frequently used in the older adults was captopril and HCT. Several studies have shown that the combination of ACE-I (Angiotensin Converting Enzyme Inhibitors) and diuretics can lower systolic blood pressure in patients with transient ischemic attack or previous stroke, diabetes, and hypertension patients aged 80 years and over.13

Older adult patients with hypertension who achieved target blood pressure in the last visit were 90% with more than one visit. The low number of controlled blood pressure can be caused by the poor compliance.15,16 In this study, poor compliance to antihypertensive drugs is likely affected by the lack of patient’s knowledge about the importance of blood pressure control, lack of education, long term and continuous treatment. In addition, based on the data from patients’ medical record who listed the number of antihypertensive drugs that were given, it can be concluded that the duration of captopril administration as antihypertensive drugs were most often given in 3 or 5 days. Antihypertensive drugs that were given in small numbers caused the patient must often come back to the Puskesmas in order to get an antihypertensive drug again, hence, it may affect patients’ compliance. This is consistent with other studies that the factors that contribute to poor adherence to antihypertensive agent include lack of patient understanding of the importance of achieving blood pressure control, lack of education to the patient, access to health facilities, drug adverse effects, drug cost, and low socioeconomic status.17-19 The conclusion of this study is more than 75% of older adults with hypertension have hypertension stage 2 and are treated by single antihypertensive agent (captopril), and ninety percent of the patients with more than one visit have uncontrolled blood pressure. The limitation in this study is incomplete data recorded in the medical record at Puskesmas Tanjung Sari, in the form of blood pressure data, diagnosis, and antihypertensive drugs given. Moreover, the medical recordkeeping system at Puskesmas Tanjung Sari is not good enough, so it took times when that patients’ data were not recorded in the medical record. It is suggested that the completeness of data in the medical record and medical record-keeping system should be improved in order to ease the monitoring and reporting of treatment and medication at Puskesmas Tanjung Sari. In addition, a primary health care providers and physicians who work in Puskesmas are expected to improve the treatment management of hypertension, especially in the older adults. Suggestion for further study is about factors that influence the number of visits and blood pressure control in older adult patients with hypertension at the Puskesmas Tanjung Sari should be conducted. Althea Medical Journal. 2016;3(1)

Rahmi Fauziah, Enny Rohmawaty, Lazuardhi Dwipa: Hypertension Treatment and Control in Older Adult at Tanjung Sari Public Health Center

References 1. Departement of Economic and Social Affairs. Population ageing and development 2012. New York: United Nations; 2012. 2. Pusat Data dan Informasi. Buletin lansia. Jakarta: Departemen Kesehatan Republik Indonesia; 2013. 3. Lawes CM, Hoorn SV, Rodgers A. Global burden of blood pressure related disease, 2001. Lancet. 2008;371(9623):1513–8. 4. Rahajeng E, Tuminah S. Prevalence of hypertension and its determinants in Indonesia. Maj Kedok Indon. 2009;59(12):580–7. 5. Departemen Kesehatan Republik Indonesia. Masalah hipertensi di Indonesia. Jakarta: 2012 [cited 2014 March 2]; Available from: http://www.depkes.go.id/ article/view/1909/masalah-hipertensidi-indonesia.html. 6. Shi S, Mörike K, Klotz U. The clinical implications of ageing for rational drug therapy. Eur J Clin Pharmacol. 2008;64(2):183–99. 7. Hilmer SN, McLachlan AJ, Le Couteur DG. Clinical pharmacology in the geriatric patient. Fund Clin Pharmacol. 2007;21(3):217–30. 8. McLean AJ, Le Couteur DG. Aging biology and geriatric clinical pharmacology. Pharmacol Rev. 2004;56(2):163–84. 9. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo Jr JL, et al. The seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report. JAMA. 2003;289(19):2560–71. 10. Krause T, Lovibond K, Caulfield M, McCormack T, Williams B. Management of hypertension: summary of NICE guidance. BMJ. 2011;343:d4891. 11. Coylewright M, Reckelhoff JF, Ouyang P. Menopause and hypertension:an age-old debate. Hypertension. 2008;51(4):952–9. 12. Brindel P, Hanon O, Dartigues J-Fo, Ritchie

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K, Lacombe J-M, Ducimetière P, et al. Prevalence, awareness, treatment, and control of hypertension in the elderly: the Three City study. J Hypertens. 2006;24(1):51–8. 13. Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Böhm M, et al. 2013 ESH/ ESC guidelines for the management of arterial hypertension the task force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013;34(28):2159–219. 14. Aronow WS, Fleg JL, Pepine CJ, Artinian NT, Bakris G, Brown AS, et al. ACCF/ AHA 2011 expert consensus document on hypertension in the elderly: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol. 2011;57(20):2037–114. 15. Bramley TJ, Gerbino P, Nightengale B, Frech-Tamas F. Relationship of blood pressure control to adherence with antihypertensive monotherapy in 13 managed care organizations. J Manag Care Pharm. 2006;12(3):239–45. 16. Yiannakopoulou EC, Papadopulos JS, Cokkinos DV, Mountokalakis TD. Adherence to antihypertensive treatment: a critical factor for blood pressure control. Eur J Prev Cardiol. 2005;12(3):243–9. 17. Krousel-Wood M, Thomas S, Muntner P, Morisky D. Medication adherence: a key factor in achieving blood pressure control and good clinical outcomes in hypertensive patients. Curr Opin Cardiol. 2004;19(4):357–62. 18. Roumie CL, Elasy TA, Greevy R, Griffin MR, Liu X, Stone WJ, et al. Improving blood pressure control through provider education, provider alerts, and patient education: a cluster randomized trial. Ann Intern Med. 2006;145(3):165–75. 19. Baroletti S, Dell’Orfano H. Medication adherence in cardiovascular disease. Circulation. 2010;121(12):1455–8.

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Durian Consumption Effect on Plasma Malondialdehyde Level as Biomarker of Stress Oxidative in Rats Anugrah Aulia Ulil Amri1, Ani Melani Maskoen2, Syarief Hidayat3 Faculty of Medicine Universitas Padjadjaran, 2Department of Biochemistry and Molecular Biology, Faculty of Medicine Universitas Padjadjaran, 3Department of Cardiology and Vascular Medicine Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung 1

Abstract

Background: Excessive consumption of durian (Durio zibethinus Murray) in Indonesia is often connected with its effect on health. This study aims to understand the effect of durian consumption to malondialdehyde (MDA) in plasma as oxidative stress biomarker. Methods: The study used an experimental research design on animal models, in the Biochemistry and Molecular Biology Department, Faculty of Medicine, Universitas Indonesia, July–August 2012. Thirty two Sprague-Dawley rats were used, divided into four groups: control, treatment week 1, 2, and 3. Each treatment group was given 20 gram durian fruit diluted with water until 20 ml volume per oral, divided into two doses (10 ml each) with 4 hours interlude between doses for 1 week, 2 weeks, and 3 weeks. All groups got normal diet and water ad libitum. Plasma MDA level was measured by TBARS method, then analyzed using KurskalWallis and Mann-Whitney tests. Results: Seventeen samples were successfully decapitated (5 for control; 6 for week 1; 3 for week 2; 3 for week 3). Average plasma MDA level for control treatment week 1, 2 and 3 groups were 0.707 nmol/ml, 0.432 nmol/ml, 0.312 nmol/ml, and 0.746 nmol/ml respectively. Data was significant (p<0.05) with p=0.02. Compared with control group, a significant increase occurred in week 1 and 2 groups with p=0.028 and p=0.025 respectively. Conclusions: Results of durian consumption show MDA level significantly decreases in week 1 and 2. However, MDA level dramatically increases exceeding control group level in week 3. [AMJ.2016;3(1):22–8] Keywords: Durian, malondialdehyde, oxidative stress

Introduction

Durian is a fruit unique in Indonesia and other countries in Southeast Asia. With its unique taste and strong penetrating odor, durian is widely known and consumed in the society. However, there are rumours saying that the durian has an effect on health. People believe that the consumption of an inappropriate amount of durian may cause miscarriage in pregnant women, increase the cholesterol level and increase blood pressure or hypertension. In contrast, currently the durian fruit is popular in daily utilization because of its health promoting compounds. The importance of durian is mostly connected with its composition of antioxidant properties, flavanoid, flavanol, ascorbic acid and tannin.1-6 Antioxidant is an important compound found in both human and nature which act as scavengers of free radicals

and reduce the oxygen toxicity. The imbalance between antioxidant and the reactive oxygen species (ROS) may result in oxidative stress. The ROS are free radicals and peroxides that are derived from the oxygen metabolism and present in all aerobic organisms. These include superoxide radical (O2•-), peroxyl radical (HOO•), hydroxyl radical (OH•) and hydrogen peroxyde (H2O2). The ROS play a significant role in many biological processes. The oxidative stress may affect molecules thus causing cell injuries which may lead to pathological processes in human.7 There are plenty methods of ROS which can cause oxidative stress in cells. One of which is by attacking the membrane cells which have phospholipid bilayer properties. A lipid peroxidation reaction will then occur once the ROS attack the polyunsaturated fatty acid (PUFA) in the phospholipid bilayer of membrane cells causing a series of chain reaction. The

Correspondence: Anugrah Aulia Ulil Amri, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km.21, Jatinangor, Sumedang, Indonesia, Phone: +6282111838844 Email: [email protected] Althea Medical Journal. 2016;3(1)

Anugrah Aulia Ulil Amri, Ani Melani Maskoen, Syarief Hidayat: Durian Consumption Effect on Plasma Malondialdehyde Level as Biomarker of Stress Oxidative in Rats

reactions form plenty of radicals including alkyl radical, peroxyl and alkoxyil. As the more stable product, lipid peroxidation produces many aldehydes including saturated aldehydes (propanal, butanal, hexanal, octanal, decanal), 2,3-trans-unsaturated-aldehydes (hexenal, octenal, nonenal, decenal and undecenal), and a series of 4-hydroxylated,2,3-transunsaturated aldehydes (4-hydroxyundecenal, and 4-hydroxinonenal (HNE)). Among the

Figure 1 Theoretical Framework Althea Medical Journal. 2016;3(1)

23

metabolites produced, malonyldialdehyde (MDA) was considered for a long time as the most important lipid peroxidation metabolite.8 The products of lipid peroxidation can be used as biomarkers of stress oxidative (Figure 1).9 The purpose of this experiment was to measure the oxidative stress caused by the durian compounds antioxidant properties by studying rats which were fed with excessive amount of durian and observed the effect of

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the treatment on plasma MDA level.

Methods

An experimental research design was conducted on animal models. The experiment waserformed in rats to investigate the effect of durian consumption on blood ROS level detected as plasma MDA level. This study was conducted r five weeks starting from July 2012 to August 2012. The data were collected based on the results of the experiment. The study took place in the Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia. The rats were divided into four different groups i.e. the control group for rats that did not consume durian; the group of week 1 for rats that consumed durian for 1 week, the group of week 2 for rats that consumed durian for 2 weeks, and the group of week 3 for rats that consumed durian for 3 weeks. In order to obtain maximum validity, the experiment should be repeated several times. While to estimate the number of observations for each variable the Federer’s formula was used and resulted in 24 samples (Figure 2). Furthermore, the rats used in the experiment weighted between 100 and 200 gram. The rats were male young adult aged 7 week-old before adaptation with the type of Sprague Dawley rats. The rats were bought in Bogor, Jawa Barat, Indonesia, while the durian fruit used in the experiment was purchased from a local market in Pramuka Street, Jakarta. All rats received a normal diet and ad libitum daily. Group of week 1, week 2, and week 3 were also given 20 mg of durian that has been diluted to 20 ml of volume with distilled water. Then, it given twice daily with each of 10 ml dilution and manually using a gastric tube. All methods were already approved by the Health Research Ethics Comittee. At the end of each observation period, every survived rat was sacrificed under deep ether anesthesia. Next, the blood of each rat was collected directly by heart puncture and put in a heparinized tube. The plasma

Figure 2 Federer’s Formula

Note: n= Minimum number of repetition needed for each treatment, minimum repetition for this study is 6 x 4(treatments)= 24 samples, In the samples, it was added 10% for drop out criteria 24 + (10% x 24) = 27 rats

was obtained after separating the red blood cells by centrifugation at 3000 rpm for 15 minutes. All plasma were placed in -20oC until the MDA measurement. The plasma MDA was assayed using the Thiobarbituric Acid Reactive Substances (TBARS) assay.10 The assay measures 2-TBARS which were naturally present in tissues and reported in MDA equivalents. The TBARS assay were based on the reaction of a chromogenic reagent, 2-thiobarbituric acid, with MDA at 25°C and pH 2-3.This reaction showed a pink-chromogen color which has a λ(max) of 532 nm that was able to be counted by the spectrophotometry. The plasma MDA level was analyzed using a computerized analysis of the Kurskall-Wallis non-parametrical test and Post-Hoc analysis of Mann-Whitney test.

Results

Table 1 Number of Samples and the Percentage Sample Group Control Week 1

Week 2

Week 3

Total

The study was initially conducted using 32 rats, and out of them, 15 rats were omitted and only 17 rats were successfully decapitated (Table 1 and 2). In order to establish the MDA concentration

Initial Number

Final Number

Percentage

5

5

100%

3

33%

9

9

9

32

6

3

17

67%

33%

53.1%

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Anugrah Aulia Ulil Amri, Ani Melani Maskoen, Syarief Hidayat: Durian Consumption Effect on Plasma Malondialdehyde Level as Biomarker of Stress Oxidative in Rats

25

Table 2 Body Weight of Rats Group Sample Group

Initial Body Weight (gram)

Final Body Weight (gram)

Control

163.3

188

Week 3

195

Week 1 Week 2

Average

based on the absorption rate of sample plasma, the function of MDA standard curve is needed (Figure 3). The plasma MDA level of rats established from the standard curve formula which was compared afterwards (Table 3 and 4). Generally, the average of MDA concentration data is significant according to the KurskalWallis non-parametrical test. The p value was less than 0.05 (p=0.02). Compared to the control group, the MDA concentration is decrease in the 1 week treatment group. This data was significant according to the Post-Hoc test using the Mann-Whitney test with p=0.028. Similarly, the 2 week treatment group was also showed significantly decrease compared to the control group with p=0.025. Moreover, the week 3 treatment group was rather increase compared to the control group

Figure 3 MDA Standard Curve Althea Medical Journal. 2016;3(1)

141

131.7

162.3

169.5

150

143.3 215

(p=0.655).

Discussion Malondialdhyde (CH2(CHO)2) is a routinely identified product of lipid peroxide chain reaction. Lipid peroxidation occurs in both plants and animals. It involves a complex process, mainly described as initiation, propagation and termination, targeting methylene (RH) bridge in PUFA. The double bond has a weak C-H bond which will make the hydrogen abstraction more susceptible in this condition.8 After the hydrogen abstraction, the carbon will have unpaired electron which will combine with oxygen to form a peroxyl radical (ROOH). The peroxyl radical is capable of abstracting a hydrogen atom from adjacent

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Table 3 Plasma MDA Level of Rats Sample Group

n

Control

5

Week 1

Week 2

Week 3

MDA Level (nmol/ml) Average MDA Level +SD 0.707+0.203

6

Note: * Kruskal-Wallis non-parametrical test

0.432+0.179

3

0.746+0.225

polyunsaturated fatty acid by itself therefore, starting a chain reaction which will damage the membrane thus, causing more extensive damage to the adjacent cells. Along the process a plenty of ROS were formed. In normal circumstances, the ROS need to be quenched by antioxidant in order to prevent extensive damage. To date, the durian is majorly linked with its antioxidant properties including flavonoid, flavonol, ascorbic acid and tannin.1–6 The durian consumption on rats was significantly correlated with the plasma MDA level. In the rat experiment the plasma MDA levels of rats decreased in the week 1 and week 2 treatment groups compared to the control group. The decrease of the plasma MDA level on the week 1 and week 2 treatment groups is probably related to the antioxidant compounds in durians as stated by many studies including the comparative study held by Haruenkit R et al. The study asserted that durian nevertheless is a fruit that shows in vitro antioxidant activities and is the highest compared with the Mangosteen and Snake fruit.5 The antioxidant in durian might be able to decrease the level of damage from ROS to the lipid, thus decreasing plasma MDA level. On the contrary, after 3 weeks of durian consumption on the experimental rats, the

Table 4 Comparison Sample Group

plasma MDA level was dramatically increased compared to the group of week 1 and week 2, and slightly exceeded the control group. Although the data obtained was insignificant to control but clearly significant to week 2, the increase of plasma MDA level on the week 3 treatment group was important. Basically, the antioxidant is a compound that gives electron (electron donors). Biologically, the antioxidant is widely known as the scavenger of oxidants and free radicals. The action of antioxidant does not only depend on the dose and the duration of administration but also on the type of the antioxidant itself as well as on the environment. For instance, vitamin E can only act as an antioxidant when the pO2 is low. Furthermore, the antioxidant also has a capacity of becoming pro-oxidant or radicals as occurred in vitamin E, vitamin C, and flavonoids.9 Flavonoids which can be found in the durian including flavones, isoflavones, and flavanones acted as antioxidants against peroxyl and hydroxyl radicals and served as pro-oxidants in the presence of Cu2+. Both the antioxidant and the copper-initiated pro-oxidant activities of a flavonoid depend upon the number of hydroxyl substitutions in its backbone structure. The single hydroxyl substitution at position 5 provides no activity, whereas the

MDA Level (nmol/ml) Concentration 1 +SB – Concentration 2 +SB

Control – Week 1

0.028

0.432+0.179 − 0.312+0.101

0.197

0.707+0.203 − 0.312+0.101

Week 1 – Week 3

0.432+0.179 − 0.746+0.225

Control – Week 3 Week 1 – Week 2

Note: * Mann-Whitney 2 independent samples

P Value*

0.707+0.203 − 0,432+0.79

Control – Week 2

Week 2 – Week 3

0.02

0.312+0.101

3

P Value*

0.707+0.203 − 0.746+0.225

0.312+0,101 − 0.746+0.225

0.025

0.655

0.071

0.050

Althea Medical Journal. 2016;3(1)

Anugrah Aulia Ulil Amri, Ani Melani Maskoen, Syarief Hidayat: Durian Consumption Effect on Plasma Malondialdehyde Level as Biomarker of Stress Oxidative in Rats

di-OH substitution at 3′ and 4′ is particularly important to the peroxyl radical absorbing activity of a flavonoid. The conjugation between rings A and B is an important pro-oxidant action of a flavonoid. The O-methylation of the hydroxyl substitutions inactivates the antioxidant and the pro-oxidant activities of the flavonoids.11,12 Moreover, the antioxidant is also produced endogenously in rats’ body, such as the glutathione (GSH). In the same rats, the plasma GSH increased in the first and second week and fell dramatically in the third week compared to the control. The plasma GSH level increased in response to the durian consumption considering the amino acid compound of durian (including glycine, cysteine and glutamic acid) is essential to GSH synthesis. The decrease of the plasma GSH level was strongly related the use of GSH to reduce damage caused by the ROS, meaning that pro-oxidant has been produced in the rats’ body. This experiment successfully decapitated 17 rats as samples. At the beginning of the study, the Sprague-Dawley rats bought were 7 weeks old (before adaptation). Experimental rats usually have a lifespan as long as 2−3.5 years (average 3 years).13 In the experiment, rats died mostly during the period when the second dose has been administered to the first dose on the next day. Other factors that should be considered in this error included the effects of durian supplementation to the rats such as the mechanical trauma, the age of the experimental rats and the operator’s skill. Before the interventions began the rats were 8-week old, which was classified as young adult rats, and the average weight was 162.3 gram. According to the weight measurement, it could be predicted that the rats were young adults. Considering this period, the SpragueDawley rats have an average weight of 100−200 gram.13 Therefore, doubts regarding the age of the rats could be at least cleared away. The operator’s skill is certainly affecting the experimental rats. The durian consumption was given with a conventional gastric tube in which the tube was directly inserted from the mouth of the rat through to the stomach. A mechanical trauma could arise following a repetitive injury of the stomach, including of the throat, liver and other related organs. Besides, the durian aspiration could also cause a fatal damage. However, in this experiment the definite cause of the death was not observed. In conclusion, generally there are differences on the MDA serum level of rats Althea Medical Journal. 2016;3(1)

27

with durian consumption. The MDA level on durian consumption for 1 week and 2 weeks have shown a significant decrease. However, after 3 weeks of durian consumption, the MDA level has increased insignificantly. The data can be used as a prediction for the effect of durian consumption on health. The durian consumption is safe because it does not induce oxidative stress. However, continuous eating in excessive amount for a long period is still not recommended. This study has some limitations including the effect of durian consumption on different doses which remains unclear and the number of rats that died during the intervention period were too many and with unknown cause of death. In the future, to investigate the effect of durian consumption on experimental animals, some factors should be considered including observing the effect of durian consumption according to the dose, the initial training for the feeding operator before the intervention begin, and the use of a permanent feeding tube.

References

1. Avila AP, Toledo F, Park YS, Jung ST, Kang SG, Heo BG, et al. Antioxidant properties of durian fruit as influenced by ripening. LWT-Food Sci Tech. 2006;41(10):2118– 125. 2. Leontowicz H, Leontowicz M, Haruenkit R, Poovarodom S, Jastrzebski Z, Drzewiecki J, et al. Durian (Durio zibethinus Murr.) cultivars as nutritional supplementation to rat’s diets. Food Chem Toxicol. 2008;46(2):581–89. 3. Toledo F, Avila AP, Park YS, Jung ST, Kang SG, Heo BG, et al. Screening of the antioxidant and nutritional properties, phenolic contents and proteins of five durian cultivars. Int J Food Sci Nut. 2008;59(5):415–27. 4. Haruenkit R, Poovardom S, Vearasilp S, Namiesnik J, Sliwka-Kaszynska M, Park Y, et al. Comparison of bioactive compounds, antioxidant and antiproliferative activities of Mon Thong durian ripening. Food Chem. 2010;118(3):540–7. 5. Haruenkit R, Poovarodom S, Leontowicz H, Leontowicz M, Sajewicz M, Kowalska T, et al. Comparative study of health properties and nutritional value of durian, mangosteen, and snake fruit: Experiments in vitro and in vivo. J Agric Food Chem. 2007;55(14):5842−9. 6. Phutdhawong W, Kaewkong S,

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Buddhasukh D. GC–MS analysis of fatty acids in Thai durian aril. Chiang Mai J Sci. 2005;32(2):169–72. 7. Kumar V, Abbas AK, Fausto N, editors. Robbins and Cotran Pathologic Basis of Disease, 8thed. Philadelphia: Elsevier Inc; 2005. 8. Repetto M, Semprine J, Boveris A. Lipid peroxidation: Chemical mechanism, biological implications and analytical determination. In: Catala A, editor. Lipid peroxidation. Rijeka: InTech; 2012. p. 1−21. 9. Purnomo Suryohudoyo. Oksidan, antioksidan dan radikal bebas. In: Ilmu kedokteran molekuler. Kapita Selekta. Jakarta: Sagung Seto; 2000. p.31−46. 10. Linsley MD, Ekinci FJ, Ortiz D, Rogers E,

Shea TB. Monitoring thiobarbituric acidreactive substances (TBARs) as an assay for oxidative damage in neuronal cultures and central nervous system. J Neurosci Methods 2005;141(2):219−22 11. Cao G, Sofic S, Prior RL. Antioxidant and prooxidant behavior of flavonoids: Structure-Activity relationships. J Free Rad Biol Med 2014;22(5):749−60. 12. Amid BT, Mirhosseini H, Kostadinović S. Chemical composition and molecular structure of polysaccharide-protein biopolymer from Durio zibethinus seed: Extraction and purification process. Chem Cent J. 2012;6(1):117. 13. Sengupta P. The laboratory rat: Relating its age with human’s. Int J Prev Med. 2013;4(6):624–6.

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Relation between Preinfarction Angina and Coronary Collateral Circulation in Patients with Acute Myocardial Infarction Achmad Shidiq,1 Syarief Hidayat,2 Januarsih Iwan A. Rachman3 Faculty of Medicine Universitas Padjadjaran, 2Department of Cardiology and Vascular Medicine Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung, 3 Department of Anatomy and Cell Biology, Faculty of Medicine, Universitas Padjadjaran

1

Abstract Background: Coronary collateral circulation conduits an alternative blood flow to the ischemic myocardium in the setting of coronary artery occlusion which can prevent the infarction area to extend more widely. Well-developed coronary collaterals are closely related with the presence of preinfarction angina. However, the duration of preinfarction angina which can induce well-developed coronary collateralization is in controversy. The aim of this study was to evaluate the relation between duration of preinfarction angina and coronary collaterals circulation in patients with acute myocardial infarction. Methods: This cross-sectional study was conducted from May to November 2013 in Dr. Hasan Sadikin General Hospital, Bandung, Indonesia. Seventy three acute myocardial infarction (AMI) patients were included in the study. The patients were divided into Group 1 (<7 days) and Group 2 (≥7 days) based on their preinfarction angina history. The coronary collaterals were assesed and graded as good (Rentrop score 2−3) and poor (Rentrop score 0−1).Statistical analysis was performed using the chi-square test. Result: The presence of a well-developed coronary collateral was not significantly different in <7days than ≥7 days duration of preinfarction angina [50.8% v 75.0%, p=0.124]. Conclusions: There is no relation between the duration of preinfarction angina and coronary collaterals circulation in patients with acute myocardial infarction. [AMJ.2016;3(1):28–33] Keywords: Acute myocardial infarction, coronary collaterals, preinfaction angina

Introduction Acute Myocardial Infarction (AMI) is the leading cause of mortality in the world. The AMI occurs by the occlusion of coronary artery consequently blood perfusion fails to meet the myocardial oxygen demand, leading to the death of the myocardial area supplied by the culprit coronary artery.1 The existence of spontaneous coronary collaterals may be able to limit the expansion of the infarction area, since they provide alternative blood flow to the threatened myocardium. Without significant coronary collaterals, the size of myocardial infarction will continually expand as long as the culprit coronary artery remains occluded.2,3 The presence of functional coronary collaterals also potentially lowers the development of heart failure4 and mortality rate5 after AMI, thus accountable for better prognosis.6 Several previous studies stated the

coronary collaterals is stimulated by ischemia, increasing shear stress in the occluded vessels, and the presence of angiogenic growth factor.7,8 On the other hand coronary collateralization is impaired in patients with hypertension and diabetes mellitus. In the case of ischemia, the episode angina pectoris as a sign of myocardial ischemia becomes the important predictor of well-developed coronary collaterals vessels.9,10 However the duration of preinfarction angina which can induce well-developed coronary collateralization is in controversy. The current study was undertaken to evaluate whether the duration of preinfarction angina was related to the development of coronary collaterals circulation.

Methods

This cross-sectional study was done at Dr. Hasan Sadikin General Hospital, Bandung, Indonesia from May to November 2013. A

Correspondence: Achmad Shidiq, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km.21, Jatinangor, Sumedang, Indonesia, Phone: +62 85794808279 Email: [email protected] Althea Medical Journal. 2016;3(1)

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AMJ March 2016

consecutive series of 148 angiograms from patients with acute myocardial infarction in the period January to December 2012 were included for coronary collateral analysis. Then, 75 patients were excluded due to theirhistory of old myocardial infarction, history of previous elective Percutaneous Coronary Intervention (PCI), history of previous Coronary Artery Bypass Graft (CABG), and missing medical record data. Therefore, 73 patients were enrolled to the final study population. This investigation was reviewed and approved by the ethics committee and all data regarding patients were concealed. Furthermore, the patients were divided into two groups according to the time interval between preinfarction angina and hospitalization as follows: Group 1 represent time interval <7 days and Group 2 represent ≥7 days. Preinfarction angina (a history of angina pectoris prior to AMI) was defined as a typical anginal chest pain occurring at rest or during exercise before the onset of AMI. The diagnosis of AMI was based on the typical chest pain lasting more than 30min, ST-segment elevation of at least 1 mm in 2 contiguous precordial leads, and a subsequent increase in the serum creatine kinase concentration to more than twice the upper limit of normal.11 The patients were considered to have a history of hypertension if their systolic pressure was ≥140 mmHg, and the diastolic pressure was ≥90 mmHg, or if they were currently undergoing a treatment for hypertension. A diagnosis of diabetes mellitus was established on the basis of one of the following three factors: a history of taking insulin or an oral hypoglycemic

agent, abnormal preinfarction fasting glucose levels (126 mg/dl), and positive results on a 75 g oral glucose tolerance test. The Coronary angiograms of the patients were evaluated and collaterals were then scored based on Rentrop classification as Grade 0 (non-developed, no collaterals were visible), Grade 1(less-developed, only side branches, but no major trunk, were visualized through collaterals), Grade 2 (well-developed, partial filling of the epicardial segment of the stenosed artery through collaterals) or Grade 3 (complete filling of the epicardial segment). Then, further classified as good (Rentrop score 2−3) and poor (Rentrop score 0−1) coronary collaterals.12 Moreover, the continuous variables are presented as themean and standard deviation (SD), and thecategorical data are summarized as frequencies or percentages. TheChi-square test was used to examine the proportional differences between categorical variables. The result was considered statistically significant at p value <0.05 for 2-sided test. All data were analyzed by using the computer based Statistical Packages for Social Sciences version 20 for Windows (SPSS, Inc., Chicago, IL, USA).

Results

Among the 73 study patients, there was more male (n=61, 84%) than female. The overall mean age was 57 ± 10.5 with the youngest age at attack was 30 years. While hypertension, diabetes mellitus and critical occlusion were more than 90%, and were more prevalent in group 2 (Table 1).

Table 1 Baseline Characteristics of Study Patients Clinical features Age-yr

Sex

Male

Female

Hypertension

Diabetes Mellitus

Duration of preinfarction angina-days Degree of occluded vessels ≤ 90% occlusion >90% occlusion

All patients (n=73)

Group 1 (<7 days) (n=61)

Group 2 (≥7 days) (n=12)

n

%

n

%

n

%

57

(±10.5)

56.1

(± 9.8)

61.2

(± 13.0)

12

26%

8

13%

4

33%

61

38 16

84%

51% 24%

53

28 10

87%

46% 16%

8

10 6

67%

83% 50%

3.4

(±3.2)

2.5

(±2.3)

8.8

(±2.0)

42

57%

32

52 %

10

83%

31

43%

29

48%

2

17%

Althea Medical Journal. 2016;3(1)

Achmad Shidiq, Syarief Hidayat, Januarsih Iwan A. Rachman: Relation between Preinfarction Angina and Coronary Collateral Circulation in Patients with Acute Myocardial Infarction

31

Table 2 Distribution of the Presence of Coronary Collaterals among StudyPatients All patients Group 1 (<7 days)

Group 2 (≥7 days)

*Chi-square test

Poor collateralization n= 33 (46%) n

%

n

%

30

49%

31

51%

3

25%

Good coronary collateral vessels were found in 40 patients (54%). We found that there were more patients with well-developed collaterals among group 2 patients (n=9, 75.0%) and were likewise among group 1 patients (n=31, 50.8%). However, it found that there was no significant difference between duration of first preinfarction angina to hospitalization and the presence of well-developed coronary collaterals (p=0.124).

Discussion

The current study revealed that there was more male than female study patients. This result is similar with many other studies which shows a higher prevalence of male among patients with acute myocardial infarction. The study also showed the proportion of welldeveloped collaterals was 54%. This result is in accordance with other recent data from patients with acute myocardial infarction. The documented prevalence of well-developed coronary collateral circulation in acute myocardial infarction intervention has varied from 15 to 55 %.13 On the other hand, it found longer duration of preinfarction angina particularly ≥7 days, which was not related to the presence of welldeveloped collateral as other studies. Herlitz et al.6 showed that the patients with chronic angina pectoris before an acute myocardial infarction had smaller infarct compared with short duration angina pectoris before the episode of MI due to the presence of welldeveloped coronary collaterals.14 In addition, Antoniucci et al.15 showed coronary collateral circulation were clearly visible 6 hours after myocardial ischemia. However, our finding can be explained by other experimental and clinical studies which revealed coronary collateral circulation developed perfectly 8 weeks after myocardial infarction or a period of 3 months of ischemic condition marked by preinfarction angina episode.13 These varied findings might be due to the different classification of duration preinfarction angina and the methods used to Althea Medical Journal. 2016;3(1)

Good collateralization n= 40 (54%)

9

75%

p value*

RR (95% CI)

0.124

0.334 (0.085−1.396)

assess coronary collaterals. Preinfarction angina is caused by myocardial ischemia, whereas Myocardial ischemia can be a sufficient stimulus to induce coronary collateral development, possibly through biochemical preconditioning by releasing theangiogenic growth factor. Additionally, the exposure to hypoxia stimulates theaccumulation of vascular endothelial growth factor (VEGF) mRNA. Many other genes involved in angiogenesis are also upregulated in response to hypoxia including cardiac macrophage.16 However the development of collateral arteries through arteriogenesis is not dependent on ischemia. Collateral arteries develop in non hypoxic tissue, and is induced by an increase of shear stress in the setting of coronary occlusion.17 Preinfarction angina, is not only a specific marker of myocardial ishemia but is simultaneously a sign in the presence of severe coronary occlusion. The formation of coronary collateral vessels has initiated the development of an critically acute occluded coronary artery (>90%).17,18,19 An acutely reduction of the arterial diameter creates larger interarterial pressure gradient between the arterial segment before and after the stenoses, inducing shear stress to surrounding arteriolar endothelial cells.This will stimulate the arteriolar endothelial cells, smooth muscle cells and fibroblast leading to their proliferation, migration and remodeling to create larger functional muscular arteries that can provide an alternative blood flow to the jeopardized myocardial area.19,20 This explained that the pathophysiological process of preinfarction angina may lead to the development of good coronary collateral vessels through biochemical and mechanical pathways. There were several limitations in this study. First, the use of coronary angiography, by which some collateral vessels with a diameter of <100 µm were not visualized for the evaluation of collateral circulation. Coronary collaterals may be more accurately

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assessed by thecollateral flow index with the simultaneous measurement of aortic pressure and the distal pressure within the occluded segment of the culprit coronary artery. However, the angiographic approach to the classification of collateral flow still remain the standard of reference in the clinical setting. The second limitation was the difficulty to determine the exact origin of the symptoms of each patient since preinfarction angina is a subjective marker of myocardial ischemia. Finally, myocardial ischemia, not angina, plays an important role in the development of collateral circulation as mentioned above. Therefore, myocardial ischemia including silent ischemia that occurs before the onset of themyocardial infarction should have been evaluated. As more than half of the patients were admitted with a first symptom, it was difficult to document the presence or absence of myocardial ischemia. In conclusion, this study shows that there is no relation between duration of preinfarction angina (<7 days or ≥7 days) and coronary collateral circulation. The development and pathophysiological process of collateralization may explain the results.

References

1. Schoen FJ, Mitchell RN. The heart. In: Kumar V, Abbas AK, Fausto N, Aster JC, editors. Robbins and Cotran: pathologic basis of disease. 8th ed. Philadelphia: WB Saunders; 2010. p. 660−71. 2. Plein S, John F Younger, Sparrow P, Ridgway JP, Ball SG, Greenwood JP. Cardiovascular magnetic resonance of scar and ischemia burden early after acute ST elevation and non-ST elevation myocardial infarction. J Cardiovasc Magn Reson. 2008;10:47−56. 3. Shen Y, Wu F, Pan C, Zhu T, Zhang Q, Zhang R, et al. Clinical relevance of angiographic coronary collaterals during primary coronary intervention sor acute STelevation myocaldial infarction. Chin Med J. 2014;127(1):66−71. 4. Steg PG, Kerner A, Mancini GBJ, Reynolds HR, Carvalho AC, Fridrich V, et al. Impact of collateral flow to the occluded infarctrelated artery on clinical outcomes in patients with recent myocardial infarction. A Report from the randomized occluded artery trial. Circulation. 2010;121(25):2724−30. 5. Meier P, Hemingway H, Lansky AJ, Knapp G, Pitt B, Seiler C. The impact of the coronary collateral circulation on mortality: a meta-

analysis. Eur Heart J. 2011;33(5):614−21. 6. Herlitz J, Karlson B, Richter A. Occurrence of angina pectoris prior to acute myocardial infarction and its relation to prognosis. Eur Heart J. 1993;14:484−91. 7. Steen H, Giannitsis E, Futterer S, Merten C, Juenger C, Katus HA. Cardiac troponin T at 96 hours after acute myocardial infarction correlates with infarct size and cardiac function. J Am Coll Cardiol. 2006;48(11):2192−4. 8. Giannitsis E, Steen H, Kurz K, Ivandic B, Simon AC, Futterer S, et al. Cardiac magnetic resonance imaging study for quantification of infarct size comparing directly serial versus single time-point measurements of cardiac troponin T. J Am Coll Cardiol. 2008;51(3):307−14. 9. Traupe T, Gloekler S, Marchi SFd, Werner GS, Seiler C. Assesment of the human coronary collateral circulation. Circulation. 2010;122:1210−20. 10. Ng S, Soerianata S, Andriantoro H, Ottervanger JP, Grobbee DE. Timing of coronary collateral appearance during ST-elevation myocardial infarction. Interv Cardiol. 2012;4(1):137−43. 11. Thygesen K, Alpert JS, White HD, Jaffe AS, Katus HA, Apple FS, et al. Expert consensus document: third universal definition of myocardial infarction. J Am Coll Cardiol. 2012;60(X):2528−38. 12. Tanboga IH, Topcu S, Nacar T, Aksakal E, Kalkan K, Kiki I, et al. Relation of coronary collateral circulation with red cell distribution width in patients with non-ST elevation myocardial infarction. Clin Appl Thromb Hemost. 2012;0(0):1─5. 13. Schwartz H, Leiboff RH, Bren GB, Wasserman AG, Katz RJ. Temporal evolution of the human coronary collateral circulation after myocardial infarction. J Am Coll Cardiol. 1984;4(6):1088−93. 14. Lonborg J, Kelbaek H, Vejlstrup N, Botker HE. Influence of preinfarction angina, collateral flow, and pre-procedural TIMI flow on myocardial salvage index by cardiac magnetic resonance in patients with ST-segment elevation myocardial infarction. Eur Heart J. 2012;13:433−43. 15. Antoniucci D, Valenti R, Moschi G. Relation between preintervention angiographic evidence of coronary collateral circulation and clinical and angiographic outcomes after primary angioplasty or stenting for acute myocardial infarction. J Am Coll Cardiol. 2002;89:121−5. 16. Koerselma J, Graaf Yvd, Jaegere PPTd, Althea Medical Journal. 2016;3(1)

Achmad Shidiq, Syarief Hidayat, Januarsih Iwan A. Rachman: Relation between Preinfarction Angina and Coronary Collateral Circulation in Patients with Acute Myocardial Infarction

Grobbee DE. Coronary collaterals: An important and underexposed aspect of coronary artery disease. Circulation. 2003;107:2507−11. 17. Lavine KJ, Kovacs A, Weinheimer C, Mann DL. Repetitive myocardial ischemia promotes coronary growth in the adult mamalian heart. J Am Heart Assoc. 2013;2(5):1−30. 18. Schaper W. Collateral circulation: past and present. Basic Res Cardiol. 2009;104(1):5– 21.

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19. Pagonas N, Gross CM, Li Meijing, Bondke A, Klauss V, Buschmann E. Influence of epocardial stenosis severity and central venous pressure on the index of microcirculatory resistance in a follow-up study. Euro Intervention. 2014;9(9):1063−8. 20. Heil M, Schaper W. Influence of mechanical, cellular, and molecular factors on collateral artery growth (Arteriogenesis). Circ Res. 2004;95:449−58.

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Relationship between Short Term Memory and Cardiopulmonary Fitness of Administrative Officers at Universitas Padjadjaran Iswaran Ampalakan,1 Ambrosius Purba,2 Sunaryo B. Sastradimaja3 Faculty of Medicine Universitas Padjadjaran, 2Department of Physiology Faculty of Medicine Universitas Padjadjaran, 3Department of Physical Medicine and Rehabilition, Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung 1

Abstract Background: The work of administrative officers depends a lot on their capability in memorizing. Increased fitness is strongly associated with a better memory. This study was conducted to determine the relationship between cardiopulmonary fitness and short term memory. Methods: This analytical cross sectional study was carried out from August to September 2014. Subjects from administrative offices within Universitas Padjadjaran were chosen by simple random sampling. 101 individuals were selected, comprising of 68 males and 33 females. Data were obtained through Digit Span Test for short term memory and the cardiopulmonary fitness was measured using Harvard Step Test. The VO2 Max obtained was correlated with the Digit Span Test score. Results: The mean for cardiopulmonary fitness of males was found to be 36.1, with standard deviation 8.63, whereas mean cardiopulmonary fitness for females was found to be 32.94, with standard deviation 7.5. For correlation analysis, the result of Spearman’s rank analysis from the study showed that the p-value is 0.00. Comparing to the significance level α=5%, the p value is worth less, thus the null hypothesis, Ho is rejected. Therefore, it could be concluded that there was a relationship between cardiopulmonary fitness and short term memory of male and female administrative officers at Universitas Padjadjaran. Conclusions: There is a relationship between cardiopulmonary fitness and short term memory of male and female administrative officers at Universitas Padjadjaran. [AMJ.2016;3(1):34–7] Keywords: Administrative officers, cardiopulmonary fitness, short term memory

Introduction In today’s modern society, our daily routine is very much determined by administrative officers. Every day, it can be seen that not every administrative officer has the same efficacy when it comes to getting the job done. Some are much more diligent, yet some are just much sloppier. There are two possibilities that might be able to explain the reason behind this difference in behavior. One such reason is the individual’s attitude, while the other is being a physiologic explanation. This study is conducted to determine the existence of a physiologic explanation. Physical fitness plays an important role in maintaining an optimum function of the human body. The cardiopulmonary system

and nervous system, along with the network of blood capillaries function more effective with an increased level of physical fitness.1 Increased physical fitness is associated with an increased short term memory, increased reaction time, decreased anxiety and also decreased stress levels.2 The human brain, capability of cognitive function is what makes all daily tasks possible. It keeps us alert and enables us to process information and make decisions.3 Attention and short term memory are a core part of the brains cognitive function. Two parts of attention helping the formation and storage of short term memory are protection and prioritization. Protection, as its name implies, protects the memory from being degraded. This enables the information said to be recalled again. Prioritization on the other hand, gives “importance” to the certain

Correspondence: Iswaran Ampalakan, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km.21, Jatinangor, Sumedang, Indonesia, Phone: +6287822004607 Email: [email protected] Althea Medical Journal. 2016;3(1)

Iswaran Ampalakan, Ambrosius Purba, Sunaryo B. Sastradimaja: Relationship between Short Term Memory and Cardiopulmonary Fitness of Administrative Officers at Universitas Padjadjaran

information, which then makes this particular information to be stored with higher priority when it is compared to other information.4 There are three theories which support the fact that exercise affects cognitive function. These theories are increased blood flow and angiogenesis which leads to increased oxygen saturation, increase in brain neurotransmitters which facilitate information processing, and regulation of neurotrophins such as brain derived neurotrophic factor (BDNF).5,6 Many previous studies have compared the positive effects of fitness on cognitive function, which showing promising results.7,8 It also proved that older adults were less likely to develop dementia, if they exercised at least three times a week, thus, proving and association between exercise and cognitive were decline.9,10 By doing this research, the results may create the awareness about the importance of exercise. Hopefully, the stigma that exercise is only good for physical health can be corrected by providing valid proof that exercise is beneficial to both physical and mental health. This may help to create a more holistic and healthy individuals within the society. Besides, the results of this research may also provide the information for the decision makers that physical activity can influence the level of short term memory.

Committee, Faculty of Medicine, Universitas Padjadjaran. Participants were selected based on simple random sampling method. A total 130 individuals were interviewed during this study. There were 20 individuals who refused to take part into this study, while 2 individuals dropped out from the study because they could not complete the inclusion criteria and 1 individual was excluded due to exclusion criteria. Administrative officers with a high school background within the age group 30–60years old were in the inclusion criteria. However, respondents currently or previously diagnosed with heart condition, psychological condition and/or neurodegenerative disorder were excluded as per exclusion criteria. Later, 6 individuals were excluded from this study due to unsuccessful completion of the Harvard Step Test. Respondents’ name, age, gender, address, VO2 Max and digit span test score were recorded down throughout the study. Harvard Step Test was used to determine the cardiopulmonary fitness of participants. The Astrand Ryhming Nomogram was then used to estimate VO2 max from the result of Harvard Step Test. For male subjects within the age group 30–39 years old, cardiopulmonary fitness was considered to be ‘fair’ if the score was 23–30, ‘average’ if the score was 31–38, ‘good’ if the score was 39–48 and high if the score was more than 49. For male subjects within the age group 40–49 years old, cardiopulmonary fitness was considered as fair if the score was 20–26, average if the score was 27–35, good if the score was 36–44, and high if the score was above 45. For male

Methods

This cross-sectional study was conducted from August to September 2014, after obtaining clearance from the Health Research Ethics Table 1 Characteristic of Respondents Characteristic

Frequency, N

Percentage, %

Male

68

67

30–39 years old

53

52

Gender Female

Age Interval

40–49 years old

50–59 years old VO2 max score

33

43 5

33

43 5

Fair

23

23

High

13

12

Average Good

Althea Medical Journal. 2016;3(1)

35

33

32

33

32

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Table 2 Cardiopulmonary Fitness of Administrative Officers Gender

Cardiopulmonary Fitness

Mean

n

Std. Deviation

Fair

25.8

15

1.5

50.4

10

3.2

Average

Male

33.3

Good

41.6

Fair

23.8

High

Total

36.1

Average

Female

29

Good

36.5

High

46.3

Total

32.9

subjects within the age group 50–59 years old, cardiopulmonary fitness was considered as fair if the score was 18–24, average if the score was 25–33, ‘good’ if the score was 34– 42 and ‘high’ if the score was above 43. As for the female subjects within the age group of 30–39 years old, cardiopulmonary fitness was considered as fair if the score was 20–27, average if the score was 28–33, good if the score was 34–44 and high if the score was more than 45. Female subjects within the age group 40–49 years old were considered to have a fair cardiopulmonary fitness if the score was 17–23, average if the score was 24–30, good if the score was 31–41, and high if the score was above 42. In addition to that, Digit Span test was used to determine the short term memory of participants. Subjects were told a series of eight numbers randomly, and were asked to repeat the numbers in the same exact sequence. Each participant was given two attempts. 1 point was given to each number repeated in the correct sequence. The raw score obtained was recorded. To determine the relationship between cardiopulmonary fitness and short term memory, the VO2 max was then correlated with the raw score from Digit Span Test using SPSS

27 16 68 8

6

16 3

33

3.5 3.8 8.6

2.6 3.3

3.6 0.6 7.5

Window Version 15.0. Data were statistically analyzed using Spearman’s Rank analysis. The result was considered statistically significant when p≤0.05.

Results

Majority of the administrative officers, 27 out of all 68, had an average cardiopulmonary fitness. Only a small amount of them had a high cardiopulmonary fitness. Most of the female administrative officers, 16 out of 33 fall were under the good category. Similarly, only a small amount of female administrative officers had a high cardiopulmonary fitness (Table 2). The average short term memory score of female administrative officers were higher than male administrative officers. Female administrative officers had an average memory score of 8.6, whereas the average memory score was only 7.9 for male administrative officers. It can also be seen that female administrative officers had a higher maximum score when it was compared to male administrative officers (Table 3). To determine the relationship between short term memory and cardiopulmonary fitness of administrative officers, Spearman’s

Table 3 Short Term Memory Score of Administrative Officers

Male

Female

Mean

n

7.9

68

8.6

33

Memory Score Std. Deviation

Minimum

Maximum

2.9

3.0

14.0

2.6

5.0

16.0

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Iswaran Ampalakan, Ambrosius Purba, Sunaryo B. Sastradimaja: Relationship between Short Term Memory 37 and Cardiopulmonary Fitness of Administrative Officers at Universitas Padjadjaran

rank correlation analysis was used in this study. Results of the calculation showed that the p-value obtained was 0.000. The test would reject Ho if the p-value < α (0.05). When it is compared to the significant value (α) 5%, the p-value was much smaller that Ho was rejected. According to that fact there is a relationship between short term memory and cardiopulmonary fitness of administrative officers at Universitas Padjadjaran. The value of Spearman’s rank correlation coefficient (rs) was found to be 0.471 (Table 4).

Discussion

The result of this study is slightly stronger than the previous study conducted by Walter Swardfager et al.11 The correlation coefficient from the previous study was 0.281, while in this study, the correlation coefficient was 0.471. This can be due to several factors. Firstly, in the previous study, respondents were patients with Coronary Artery Disease, whereas in this study there were no respondents suffering with any coronary disease at the time. Thus, the healthier individuals could provide better results. Besides, one of the limitations in the previous study was a smaller sample size, using only 81 patients. However, this study does not have a similar limitation. This is due to the fact that the number of respondents in this study is 101, which is a larger quantity than the minimum sample size required. This gives a more precise correlation between short term memory and cardiopulmonary fitness. However, this study has its own limitations. The number of male respondents in this study outweighs the number of female respondents vastly. A balanced number of respondents between male and female administrative officers was failed to be achieved. This was due to the time constraint in completing this study. If there had been more time, a more precise selection could have been done to achieve a balanced number of respondents between both genders. As a conclusion, this study proves that there is a relationship between cardiopulmonary fitness and short term memory in male and female administrative officers at Universitas Padjadjaran. It shows that short term memory is better in individuals with higher cardiopulmonary fitness. Therefore, based on the results obtained from this study, it is recommended that all administrative officers Althea Medical Journal. 2016;3(1)

maintain a healthy lifestyle with proper physical activity. This way, they will be able to maintain, or even improve their short term memory.

References

1. Wisloff U, Ellingsen O, Kemi OJ. Highintensity interval training to maximize cardiac benefits of exercise training. Exerc Sport Sci Rev. 2009;37(3):139–46. 2. Erickson KI, Weinstein AM, Lopez OL. Physical activity, brain plasticity, and Alzheimer’s Disease. Arch Med Sci. 2012;43(8):615–21. 3. Barrett KE, Barman SM, Boitano S, Brooks H. Ganong’s Review of Medical Physiology, 24th Edition, New York: Mcgraw-hill; 2012. 4. Matsukura M, Luck SJ, Vecera SP. Attention effects during visual short-term memory maintenance. Percept. Psychophys. 2007;69(8):1422–34. 5. Erickson KI, Voss MW, Prakash RS, Basak C, Szabo A, Chaddock L, et al. Exercise training increases size of hippocampus and improves memory. Proc Natl Acad Sci U.S.A. 2011;108(7):3017–22. 6. Ploughman M. Exercise is brain food: the effects of physical activity on cognitive function. Dev Neurorehabil. 2008;11(3):236–40. 7. Anderson-Hanley C, Arciero PJ, Brickman AM, Nimon JP, Okuma N, Westen SC, et al. Exergaming and older adult cognition: a cluster randomized clinical trial. Am J Prev Med. 2012;42(2):109–19. 8. Chang Y, Labban J, Gapin J, Etnier J. The effects of acute exercise on cognitive performance: A meta-analysis. Brain Res. 2012;1453:87–101. 9. Larson EB, Wang L, Bowen JD, McCormick WC, Teri L, Crane P, et al. Exercise is associated with reduced risk for incident dementia among persons 65 years of age and older. Ann Intern Med. 2006;144(2):73–81. 10. Bherer L, Erickson KI, Liu-Ambrose T. A Review of the Effects of Physical Activity and Exercise on Cognitive and Brain Functions in Older Adults. J Aging Res. 2013;2013:657508. 11. Swardfager W, Herrmann N, Marzolini S, Saleem M, Kiss A, Shammi P, et al. Cardiopulmonary fitness is associated with cognitive performance in patients with coronary artery disease. J Am Geriatr Soc. 2010 Aug;58(8):1519–25.

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Impact of Near Work Activity on Visual Acuity among Junior High School Students Raisha Pratiwi Indrawati,1 Reni Farenia,2 Mayasari Wahyu K.3 Faculty of Medicine Universitas Padjadjaran, 2Department of Physiology Faculty of Medicine, Universitas Padjadjaran, 3Department of Ophthalmology Faculty of Medicine Universitas Padjadjaran/National Eye Center Cicendo Eye Hospital Bandung

1

Abstract

Background: Uncorrected refractive error is experienced by at least 45 million productive-aged adults (aged 16–45 years old) and 13 million children (aged 5–15 years old), and being the main cause of visual impairment in children worldwide and third cause of blindness in any age in Indonesia. Near work activity is estimated as one of environmental risk factor causing this refractive error, leading into decreased visual acuity. This study was conducted to analyse the impact of near work activity on visual acuity among junior high school students in Jatinangor Methods: This study was conducted in junior high school in Jatinangor, using cross sectional method. Total of 147 subjects were screened for visual impairment using Rapid Assessment of Avoidable Blindness (RAAB) tumbling E chart and assesed for near work activity using questionnaire-guided interview method after informed consent had been obtained. Data were analysed using unpaired-T test and Mann-Whitney test. Results: Total diopter hours of near work activity among the group with visual acuity ≥6/18 and group with visual acuity <6/18 showed no significant difference (p=0.329), with latter group had less time-spent in near work activity. Similarly, each activity such as reading, watching TV, and using computer also showed no significant difference , except for playing games where the group with better visual acuity had shown significantly longer time spent than another group (p=0.018). Conclusions: Near work activity does not have impact on visual acuity among junior high school students, except for playing games. [AMJ.2016;3(1):38–42] Keywords: Junior high school students, near work activity, visual acuity

Introduction World Health Organization (WHO) estimates that 314 million people around the world are having vision imparment. One hundred and fifty three million of them are caused by uncorrected refractive error that happened in various ethnic, with at least 45 million productive-aged adults (aged 16–45 years old) and 13 million children (aged 5–15 years old) are affected. Uncorrected refractive error is the main cause of visual impairment in children aged 5–15 worldwide, with significant increased on its prevalence, mostly among South-East Asia children. In Indonesia , this condition becomes the third cause of blindness. 1-3 In order to decrease the rate of visual impairment such as refractive error, possible risk factor should be known. Thus the

effective intervention could be implemented. According to Environment Health Model proposed by Blumm, the risk factor could be either genetic, environment, behavior, or health service. Although a proportion of myopia (nearsightedness) is clearly genetic, there is currently no conclusive evidence of genetic contributions to mild or moderate myopia.4 Thus, beside many factors that interfere vision such as genetic, environment should be considered as the factor that could be intervened to prevent the occurence of visual impairment. Near work activity is assumed asone of the environtmental factors that causes the refractive error. Near work activity, which is the combination between such activities performed in near distance, is assumed to increase accomodation of lens as an adaptation to the near distance.5 A continuous contraction of cilliary muscle

Correspondence: Raisha Pratiwi Indrawati, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya BandungSumedang Km.21, Jatinangor, Sumedang, Indonesia, Phone: +62 813 128 78247 Email: [email protected] Althea Medical Journal. 2016;3(1)

Raisha Pratiwi Indrawati, Reni Farenia, Mayasari Wahyu K.: Impact of Near Work Activity on Visual Acuity among Junior High School Students

during accomodative process leads to an accomodation spasm, causing the lens diverge hardly into its initial curve, then its ability to see distant object decreased. Therefore, near work activity is often associated with myopia resulting in decreased visual acuity, since visual acuity would be impaired if there was any disturbance of visual such as refractive error.4-9 Since there was lack of data about refractive error in Jatinangor, also in order to discover one of the probable risk factors of this refractive error which should be prevented as early as possible, this study was conducted to know the impact of near work activity on visual acuity in junior high school students in Jatinangor.

Methods

This study was an analytical study conducted in cross-sectional approach, carried out in Jatinangor district, from September–October 2013. All examination performed in this study was approved by Health Research Ethics Committee. Samples of this study were chosen by multistage random sampling. From 11 junior high schools available, 3 junior high schools were chosen to represent the population. Samples were taken from each available class. One hundred and forty three males and females of junior high school students varying in aged 11–15 from 7th, 8th, and 9th grade who fit inclusion and exclusion criteria were used as subjects. Inclusion criteria was subjects who agreed to be involved in the study and aged below 15, and exclusion criteria was those who had organic visual disturbance or information Table 1 Characteristic of Subjects Characteristic

of theirs could not be obtained completely. Subjects were examined for visual acuity by a trained examiner at a distance of 6m using RAAB tumbling E chart, each eye separately started from right eye. Subjects who passed the test were classified into ≥6/18 visual acuity group, while subjects who did not pass were classified into<6/18 visual acuity group. Latter group then underwent a further examination using Snellen tumbling E chart and pinhole to differentiate refractive error from any other cause of visual impairment. Both groups were interviewed to fulfill near work activity questionnaire, that was adopted from Sydney Myopia Study questionnaire. Subjects were asked about average amount of time spent (hours/day) in near work activity such as reading and doing homework, reading for pleasure, watching television, using computer, and playing electronic games both in weekday and weekend separately. For each activity, time spent in near work per day were calculated into total time spent each week (hours/week). Total diopter hours were counted as measurement of near work exposure based on accomodative weight required during each activity and its duration.10 This diopter hours was defined as 3 x (hours spent studying + hours spent reading for pleasure) + 2 x (hours spent playing electronic games + using computer) + 1 x (hours spentwatching television).11-14 All data obtained from both examination of visual acuity and questionnaire interview were processed using Microsoft Excel programme and were statistically analyzed using unpaired T-test and Mann-Whitney non-parametric test. Statistically significant was considered when p≤0.05. Analysis was performed by comparing

Frequency (%)

Visual Acuity≥6/18

Visual Acuity<6/18

P value

56 (39.2%)

36 (64.3%)

20 (35.7%)

0.561

1 (0.7%)

1

0

Gender Male

Female Age

11 years

87 (60.8%)

60 (69.0%)

12 years

22 (15.4%)

18

15 years

31 (21.7%)

18

13 years

14 years Total

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44 (30.8%)

45 (31.5%)

143 (100%)

39

27 (31.0%) 4

32

12

96 (67.1%)

47 (32.9%)

27

18

13

1.072

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Table 2 Hours Spent on Near Work Activity by Gender Variables

Time spent (hours/week)

Reading

Watching TV

Using computer

Playing electronic games Near work (diopter hours)

activity

P value

Total

Male

Female

16.0 (2.5–47.5)

15.83 (2.5–47.5)

19.0 (2.5–37.5)

0.007

7.0 (0–25.0)

9.0 (0–25.0)

7.0 (0–25.0)

0.195

16.0 (0–39.0) 7.0 (0–25.0)

101.91±37.37

14.0 (0–39.0)

16.0 (0–36.0)

7.0 (0–25.0)

7.0 (0–23.0)

95.69 ± 38.84

≥6/18 visual acuity group and <6/18 visual acuity group.

Results

Total of 147 subjects involved in this study joined thevisual acuity screening and questionnaire interviewing. Ninety six subjects had the visual acuity more than 6/18, and 51 subjects had the visual acuity less than 6/18. After latter group underwent further examination, 4 subjects were excluded because of organic causes, thus there were 47 subjects left in visual acuity less than 6/18 group. From 143 subjects, there were more female subjects than males, mostly in age of 14 years old, and no significant difference in the visual acuity between male and female (p=0.561) (Table 1). Mean of diopter hours in near work activity was 101.91±37.37 hours/week, with reading as an activity as the most time spent, both reading for study and reading for pleasure (16.0 hours/week), and playing electronic games as an activity with the least time spent (7.0 hours/week). In general, females spent a longer time in most near work activities, except playing electronic games. However, there was no significant difference between

105.92 ± 36.05

0.088 0.967 0.110

time spent in near work activity in males and females, except reading (including studying, doing homework, and reading for pleasure), where females significantly spent more time than males (p=0.007) (Table 2). The group with visual acuity ≥6/18 showed longer time spent in near work activity than group with visual acuity <6/18. Nevertheless, there was no significant difference in diopter hours of near work activity between both group (p=0.329). The same result was shown for time spent in each near work activity, where the group with better visual acuity spent longer time in reading (16.45chours/ week), watching TV (16.00 hours/week), using computer (7.25 hours/week), and playing electronic games (9.00 hours/week). Similar to the diopter hours result, each activity did not have significant differences in time spent between both groups, except time spent in playing electronic games that showed significant difference (p=0.018) (Table 3).

Discussions

This study aimed to determine the impact of near work activity on visual acuity. Based on the statistical result, time spent in near work activity did not have significant impact

Table 3 Hours Spent on Near Work Activity by Visual Acuity Variables Reading

Watching TV

Using computer

Playing electronic games

Near work activity (diopter hours)

*Mann Whitney Test **Unpaired–T Test

Time spent (hours/week)

P value

Visual acuity ≥6/18

Visual acuity <6/18

16.45 (2.5–37.0)

15.50 (3.5–47.5)

0.689*

9.00 (0–25.0)

6.50 (0–24.0)

0.018*

16.00 (0–39.0) 7.25 (0–25.0)

104.05 ±35.88

15.00 (0–30.0) 7.00 (0–24.0)

92.00 (36.0–203.5)

0.120* 0.326*

0.329**

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Raisha Pratiwi Indrawati, Reni Farenia, Mayasari Wahyu K.: Impact of Near Work Activity on Visual Acuity among Junior High School Students

on refractive error, which in this study was measured by visual acuity, where group with visual acuity ≥6/18 and group with visual acuity <6/18 had similar mean in diopter hours of near work activity. This result was consistent with the study conducted by Lu et al.15 and Ip et al.4 in rural China and in Sydney respectively, where time and diopter hours on near work activities did not differ thechildren with and without myopia. Moreover, another cohort study conducted in Singapore13 which is aprevious cross-sectional study concluded that children who read more were in a higher risk of developing myopia. This study alsohad proved that reading book did not associate with incident of myopia. However, there were some similar studies that were contrary with this result, such as other study in Singapore8 and India9 that showed children who spent more time on near work activity such as reading, using computer and watching television were more likely to be affected by refractive error. This difference could be resulted from any other behavior and environtment factor that were not assesed in this study, such as continuity in doing such activities, lighting, type of object seen, and any other factors, and also genetic factor. Also, there were different range of age between the subjects in this study (11–15 years old) and in the previous study in Singapore8 (7–9 years old). Meanwhile, association between reading and myopia was predicted to be stronger in younger subjects, who were still in visual development period, than in the older one. This might explain why there were no significant difference in the time-spent on near work activity between both groups. It is because the subjects in this study were in a narrow age group and already at the age where eye was no longer developing. Thus this study did not show any significant impact. Hence, further study involving younger subjects might be needed in order to find the true impact of near work activity on refractive error development. This study also showed that time spent in playing electronic games gave a significant effect on visual acuity, where group with better visual acuity turned out having longer time spent than another group. This result was quite opposite with any other previous study that had shown no impact of time spent in playing games on refractive error16, but had similarity with Lu et al.15 study where time spent on video games was significantly less in myopic children. Moreover, study conducted by Ip et al.4 showed that playing hand-held console games was associated with Althea Medical Journal. 2016;3(1)

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more hyperopic (farsightedness) refraction, although it was unlikely to have a protective influence on the development of myopia. In this study, some subjects were playing games on their gadget, such as handphone, frequently but only in short period of time. It may explain why group with better visual acuity had longer time spent on playing games without having visual impairment. This condition can happen because they did not do the activities mentioned above continuously, while continuity on near work activity suggested to be a significant factor for myopia.6 Hence, further study considering continuity of near work activity might be needed. There were some limitations in this study that may had influenced those results. Cross sectional study design was chosen rather than cohort due to limited time in conducting this study, so it could not really measure the impact of exposure, in this case is near work activity, on expected outcome in particular period of time. Also, there could be inaccuracy in measurment of near work activity, since it assesed by interview, not direct observation, that could arise recall bias, and imprecision in subjects grouping due to limitation of tool used in measuring visual acuity. In conclusion, this study showed that longer time spent in near work activity does not result in lower visual acuity. Therefore, it could not prove any impact of near work activity on visual acuity among junior high school students, even though there is no exact mechanism already known indeed.

References

1. World Health Organization. VISION2020: The Right to Sight. Global Initiative for the Elimination of Avoidable Blindness: Action Plan 2006–2011. Geneva. WHO; 2007. p. 2–17. 2. Resnikoff S, Pascolini D, Mariotti SP, Pokharel GP. Global magnitude of visual impairment caused by uncorrected refractive errors in 2004. Bull World Health Organ. Public Health. 2008;86(1):63–70. 3. Kementrian Kesehatan Republik Indonesia. Gangguan Penglihatan Masih Menjadi Masalah Kesehatan. Pusat Komunikasi Publik Sekretariat Jenderal Kementerian Kesehatan RI; 2010 [cited 2013 February 9]; Available from: http://www. depkes.go.id/index.php/berita/pressrelease/845-gangguan-penglihatanmasih-menjadi-masalah-kesehatan.pdf. 4. Ip JM, Huynb SC, Robaei D, Rose KA, Morgan

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IG, Smith W, et al. Ethnic differences in the impact of parental myopia: findings from a population-based study of 12-year-old Australian children. Invest Ophtalmol Vis Sci. 2007;48(6):2520–8. 5. Guyton AC, Hall JE. The Nervous System: B. The Special Senses. Textbook of Medical Physiology. 11th ed. Philadelphia. Elsevier Saunders; 2005. p. 613–50. 6. Ip JM, Saw SM, Rose KA, Morgan IG, Kifley A, Wang JJ, et al. Role of near work in myopia: findings in a sample of Australian school children. Invest Ophtalmol Vis Sci. 2008;49(7):2903–10. 7. Pan CW, Ramamurthy D, Saw SM. Worldwide prevalence and risk factors for myopia. Ophthalmol Physiol Opt. 2012;32(1):3–16. 8. Saw SM, Tong L, Chua WH, Chia KS, Koh D, Tan DT, et al. Incidence and progression of myopia in Singaporean school children. Invest Ophtalmol Vis Sci. 2005;46(1):51–7. 9. Prema N. Causing factors of refractive error in children: heredity or environment? Indian J Sci Technol. 2011;4:1773–4. 10. Lorenz B, Moore AT, editors. Pediatric Ophthalmology, Neuro-Ophthalmology,

Genetics. Berlin: Springer; 2006. p. 9-10 11. Saw SM, Chua WH, Gazzard G. Eye growth changes in myopic children in Singapore. Br J Ophtalmol. 2005;89(11):1489–94. 12. Saw SM, Cheng A, Fong A. School grades and myopia. Ophthalmol Physiol Opt. 2007;27(2):126–9. 13. Saw SM, Shankar A, Tan SB, Taylor H, Tan DT, Stone RA, et al. A cohort study of incident myopia in Singaporean children. Invest Ophtalmol Vis Sci. 2006;47(5):1839–44. 14. Jones LA, Sinnott LT, Mutti DO, Mitchell GL, Moeschberger ML, Zadnik K. Parental history of myopia, sports and outdoor activities, and future myopia. Invest Ophtalmol Vis Sci. 2007;48(8):3524–32. 15. Lu B, Congdon N, Liu X, Choi K, Lam DS, Zhang M, et al. Associations between near work, outdoor activity, and myopia among adolescent students in rural China: the Xichang Pediatric Refractive Error Study report no. 2. Arch Ophthalmol. 2009;127(6):769. 16. Liang CL, Yen E, Su JY, Liu C, Chang TY, Park N, et al. Impact of family history of high myopia on level and onset of myopia. Invest Ophtalmol Vis Sci. 2004;45(10):3446–52.

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Frequency and Clinical Characteristics of Tympanic Membrane Perforation Outpatients at Dr. Hasan Sadikin General Hospital in 2011–2013 Veronika Ratih M,1 Sally Mahdiani,2 Fenny Dwiyatnaningrum3 Faculty of Medicine Universitas Padjadjaran, 2Department of Otorhinolaryngology–Head and Neck Surgery Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung, 3Department of Anatomy and Biology Cell Faculty of Medicine, Universitas Padjadjaran 1

Abstract Background: Tympanic membrane perforation is a hearing problem that has become a health problem in the society. In Indonesia, there are only a few studies regarding tympanic membrane perforation. This study was aimed to observe the frequency and clinical characteristics of tympanic membrane perforation patients. Methods: This was a descriptive study performed from August to September 2014. The data was taken retrospectively from medical records of tympanic membrane perforation patients at Dr. Hasan Sadikin General Hospital from January 2011 to December 2013. Results: Of 579 tympanic perforation patients, there were only 214 medical records met the inclusion criteria. The frequency of tympanic membrane perforation patients increased in 2011 it was 28%, in 2013 it was 37.6%. The number of male patients (53.3%) was higher than female patients’. Most patients were in productive age (83.2%). Most patients came with the chief complaint of discharge from ear (36.4%) and the most common etiology was infection (84.1%). Otological examination showed that most patients had unilateral perforation (73.8%). Based on the size of perforation, central perforation (52.3%) was the most common otological finding. From audiogram, most patients had conductive hearing loss (41.5%) with moderate degree of hearing loss (30.4%). Most patients were treated by medications (64.5%). Conclusions: The frequency of tympanic membrane steadily increases with clinical characteristic mostly in male patients in productive age admitted with chieft complain of discharge of ear. The most common etiology is infection. Majority of patients have unilateral central perforation that cause conductive hearing lost. [AMJ.2016;3(1):43–8] Keywords: Clinical characteristic, hearing lost, tympanic membrane perforation

Introduction

Hearing abnormality and deafness are still prevalent and have become a major problem in Indonesia. Globally, World Health Organization (WHO) estimated that 250 million (4.2%) of world populations suffered from hearing abnormality in 2000, 75–140 million (30– 56%) of them were in South–East Asia.1 One of the etiologies of hearing disturbance is tympanic membrane (TM) perforation.2 Incidence of TM perforation in the world is still unknown. However, according to the study conducted by Kaftan et al.3 in Germany, the prevalence of chronic TM perforation was 0.45%. In England, United Kingdom4, Study of Hearing found that the prevalence of TM perforation in adult was 4.1%.

Hearing disturbance has already become a health problem in society.1 However, there is no available data yet regarding the prevalence or incidence of TM perforation in Indonesia, especially in West Java.Thus, the researcher is interested to do a study about the frequency of TM perforation. Moreover, the clinical characteristics of patients are also important to be studied. This study was conducted to observe the frequency and clinical characteristics of TM perforation, including the risk factors of perforation, clinical manifestations, audiogram results, and also the management.

Methods

This was a quantitative-descriptive study

Correspondence: Veronika Ratih M, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km.21, Jatinangor, Sumedang, Indonesia, Phone: +6285624248322 Email: [email protected] Althea Medical Journal. 2016;3(1)

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performed at Otorhinolaryngology–Head and Neck Surgery (ORL-HNS) Polyclinic of Dr. Hasan Sadikin General Hospital. Data was taken retrospectively from patients’ medical records. The method used was total sampling . This study was approved by ethical committee of Dr. Hasan Sadikin General Hospital. Frequency was determined by the number of TM perforation patients at ORLHNSPolyclinic of Dr. Hasan Sadikin General Hospital from January 2011 to December 2013. The distributions and clinical characteristics of patients were observed from the medical records of TM perforation patients at ORLHNS Polyclinic of Dr. Hasan Sadikin General Hospital from January 2011 to December 2013 which fulfilled the inclusion criteria. The inclusion criteria were medical records which contained patient’s identity, etiology, clinical manifestations, result of examination, and management. The missing and incomplete medical records were excluded from this study. Among 579 TM perforation patients, 214 patients’ data (36.96%) were included in this study. Patient’s sex, age at presentation, chief complains, etiology, side of perforation, size of perforation, audiogram, comorbid diagnosis, and management were documented. According to Badan Kependudukan dan Keluarga Berencana Nasional (BKKBN), the age groups were classified into young age (0–14 years old), adult/productive age (15–64 years old), and old age (≥ 65 years old). Chief complaints consisted of hearing loss, tinnitus, discharge from ear, clogged ear, and ear pain. Etiologies were classified into infection, trauma, failure of operation, and malignancy. Side of perforation was divided into unilateral (one side) or bilateral (both sides). According to Bluestone (2007), size of perforation was classified into central perforation (< 25%), subtotal perforation (25–50%), and total perforation (>50%).5 The type of hearing loss was determined by using audiogram that

was classified into conductive hearing loss (CHL), sensorineural hearing loss (SNHL), and mixed hearing loss (MHL). The degree of hearing loss was divided into normal, mild, moderate, severe, and profound. Management was divided into pharmacotherapy, operative, mixed (pharmacotherapy and operative), and education. After being collected, the data was analyzed by computer.

Results

In 2011–2013, the amount of outpatients at ORL-HNS of Dr. Hasan Sadikin General Hospital was 15,253 patients, 579 of them (3.8%) were diagnosed of having TM perforation. The frequency of TM perforation patients increased from 2011 to 2013. Based on sex, the amount of male patients was higher than female patients. Most patients were in adult age (83.2%). The youngest patient was 9 months old while the oldest patient was 92 years old. Mostly, the patients’ chief complain was discharge from ear (36.4%).There were 4.7% of patients who reported other complains, such as itchy ear, nasal congestion, ear bleeding, sore throat, and lump in the ear . Most perforations were caused by infection (88.3%). During 2011–2013, there was no perforation caused by malignancy. Based on the side of perforation, 158 patients (73.8%) had TM perforation on one side of ear (unilateral). Among them, 78 patients had perforation on the right ear (49%) and 80 patients (51%) had perforation on the left ear. Based on the size of perforation, most patients had central perforation (52.3%). The result of this study showed that there were 42.5% of TM perforation patients with comorbid diagnosis, most of them were CSOM and AOM. Most TM perforation patients were treated by pharmacotherapy (64.5%).

Table 1 Distribution of TM Perforation Patients Based on Sex and Age Group Characteristics Sex

Male

Female

Age Group

Young age (0–14 years old)

Adult age (15–64 years old) Old age (≥ 65 years old)

Number of Patients (n=214) 114 (53.3%) 100 (46.7%) 18 (8.4%)

178 (83.2%) 18 (8.4%)

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Veronika Ratih M, Sally Mahdiani, Fenny Dwiyatnaningrum: Frequency and Clinical Characteristics of Tympanic Membrane Perforation Outpatients at Dr. Hasan Sadikin General Hospital in 2011–2013

Table 2 Clinical Characteristics of TM Perforation Patients Characteristics Chief Complaint Hearing loss

Number of Patients (n=214) 45 (21%)

Tinnitus

37 (17.3%)

Ear pain

19 (8.9%)

Discharge from ear Clogged ear Others

Etiology Trauma

78 (36.4%) 25 (11.7%) 10 (4.7%)

25 (11.7%)

Infection

180 (84.1%)

Unilateral

158 (73.8%)

Central

112 (52.3%)

Failure of operation Side of perforation Bilateral

Perforation’s size Subtotal Total

Comorbid

Pharyngitis

Lymphadenopathy Mastoiditis OE

AOM

CSOM

Otomycosis

Otosclerosis

Post mastoidectomy Post tympanoplasty Rhinitis

Tonsilitis Tumor

9 (4.2%)

56 (26.2%) 77 (36%)

25 (11.7%) 1 (0.5%) 1 (0.5%) 2 (0.9%) 2 (0.9%)

16 (7.5%)

41 (19.1%) 1 (0.5%) 1 (0.5%) 5 (2.3%) 4 (1.9%) 9 (4.2%) 2 (0.9%) 3 (1.4%)

There was no comorbid diagnosis

126 (58.9%)

Operative

23 (10.7%)

Management

Pharmacotherapy Education Mixed

138 (64.5%) 24 (11.2%) 29 (13.6%)

Note: *OE: Otitis Externa, AOM: Acute Otitis Media, CSOM: Chronic Suppurative Otitis Media Althea Medical Journal. 2016;3(1)

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Figure 1 Frequency of TM Perforation Patients in 2011–2013 Among 214 TM perforation patients, 164 of them (76.6%) performed audiometry examination. Based on the type of hearing loss, 114 patients (69.5%) suffered from hearing loss. Most patients had conductive hearing loss (41.6%). and moderate hearing loss (30.4%).

Discussions

The frequency of TM perforation patients increased from 2011 to 2013. This result indicated that the increase of ear infection in

Table 3 Audiogram of TM Perforation Patients Characteristics Type of hearing loss

society due to most perforations were caused by ear infection.2 Based on sex, male to female ratio was 1.14:1 This characteristic was considered relatively same as the previous study performed by Pannu et al.2 in India that showed that 52% of the patients were male and 48% were female. The percentage of male patients slightly outnumbered the female patients.2 The study performed by Sarojamma et al.6 in India also stated that the amount of female TM perforation patients (58%) was higher than the males. Number of Patients (n=164)

Normal

50 (23.4%)

MHL

20 (9.3%)

CHL

SNHL

89 (41.6%) 5 (2.3%)

Audiometry was not performed

50 (23.4%)

Mild

18 (8.4%)

Degree of hearing loss Normal

Moderate Severe

Profound

Audiometry was not performed

50 (23.4%) 65 (30.4%) 23 (10.7%) 8 (3.7%)

50 (23.4%)

Note: * CHL: Conductive Hearing Loss, SNHL: Sensorineural Hearing Loss, MHL: Mixed Hearing Loss

Althea Medical Journal. 2016;3(1)

Veronika Ratih M, Sally Mahdiani, Fenny Dwiyatnaningrum: Frequency and Clinical Characteristics of Tympanic Membrane Perforation Outpatients at Dr. Hasan Sadikin General Hospital in 2011–2013

Most TM perforation patients were in productive age group (83.2%). The TM perforation could affect patient’s quality of life, caused hearing loss and reduced their productivity.7 The result was different from the study performed by Olowookere et al.8 in Nigeria which stated that 50% of the TM perforation patients were children. Most patients often complained of discharge from ear (36.4%). Discharge from ear was caused by CSOM.9 Clogged ear was caused by fluid accumulation in middle ear. Moreover, the patients also complained of hearing loss. Hearing loss was caused by the disturbance of sound wave conduction. Other chief complaints, such as nasal congestion and sore throat, were caused by other diseases such as rhinitis, tonsillitis, or pharyngitis. Pannu et al.2 also reported that the most common chief complaints were hearing loss and discharge from ear. Allergic rhinitis, bacterial tonsilitis and pharingistis were risks of factor for developing complicated tympanic membrane. The TM perforation was mostly caused by infection. The infection could be caused by CSOM, AOM, or OE. Besides infection, another common etiology was trauma. TM trauma could be caused by high pressure when diving or flying and could also be caused by temporal bone trauma. This study was similar with the study conducted by Pannu et al.2 that stated 84% of TM perforation was caused by infection and 16% was caused by trauma. After surgery, some patients still had TM perforation. This was caused by failure of TM grafting. Based on the side of perforation, most patients had unilateral perforation. Pannu et al.2 also reported that 80% of patients had unilateral perforation. Olowookere et al.8 also stated that most patients had unilateral perforation. Intact TM in another ear helped the patients to hear. Patients with bilateral perforation would have more severe hearing loss. Based on the size of perforation, the most common was central perforation. This study was similar to the study performed by Pannu et al.2 which stated that 47% of patients had small size perforation, 34% had medium size perforation and 19% had large size perforation. Olowookere et al.8 also stated that 60.6% of patients had central perforation. The size of perforation also has role in hearing loss. The larger the size of perforation, the degree of hearing loss would be more severe.10 There were 42.5% of TM perforation patients who had comorbid. The most common comorbid were CSOM and AOM. Middle Althea Medical Journal. 2016;3(1)

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ear infection and pressure caused by pus production could cause perforation.11 Upper respiratory tract infection, such as rhinitis or pharyngitis could cause middle ear infection and, eventually, caused TM perforation. Most patients were treated by pharmacotherapy. The patients were given antibiotic to stop fluid production in the ear and keep the ear dry.4 Surgical treatments consisted of tympanoplasty and mastoidectomy. Tympanoplasty was performed in 48 patients and mastoidectomy was performed in 4 patients. Some patients were only given education because there was no indication for antibiotic usage or surgical intervention. Central perforation and traumatic perforation would usually heal spontaneously, so surgical intervention was not needed.12 Some patients were indicated to be given surgical intervention, but the patients rejected because of economic aspect. Based on audiogram, there were 69.5% patients with hearing loss, Most patients had conductive hearing loss. It happened because the perforated TM caused the disturbance of sound wave conduction. Cross–sectional study conducted by Ibekwe et al.13 concluded that 59% of TM perforation patients had conductive hearing loss. However, some patients suffered from sensorineural hearing loss. The occurrence of sensorineural hearing loss could be affected by age. Neuron degeneration of cochlear nerve in old people caused sensorineural hearing loss.14 There were 30.5% patients without hearing loss. This happened because most patients had central perforation. Moreover, 23.4% of patients did not perform audiometry examination. Actually, this examination was very important to detect patient’s hearing loss but some patients did not perform this examination because of their limited budget. Based on the degree of hearing loss, most patients had moderate hearing loss. This result was similar with the study performed by Maharjan et al.15 in Kathmandu. The study concluded that 52.9% of the patients had moderate hearing loss. In the other hand, Pannu et al.2 and Sarojamma et al.6 stated that most patients suffered from mild hearing loss. Frequently, the patients with severe and profound hearing loss were accompanied by chronic infection such as CSOM. As the conclusion, there were 579 tympanic membrane perforation outpatients during 2011–2013 and chief complaint of most of patients in productive age group was discharge from ear. The perforation was mostly caused by

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infection. The proportion between unilateral and bilateral perforation was 7:3. More than a half of patients had central perforation. The most common comorbidity at diagnosis was CSOM. Most patients were treated by pharmacotherapy. Most TM perforation was caused by infection. Thus, infection prevention by giving education to society should be performed to increase their personal hygiene. For supporting examination, 23.4% of the patients did not perform audiometry examination because of economic aspect. Simple and more affordable examinations such as turning fork test (Rinne and Weber test) were suggested. Moreover, some patients rejected surgical interventionbecause of the expensive cost. Thus, this study suggests the society to join universal health coverage, so all people are able to get a standardized health service. From this study, only 36.86% of data could be used as the subjects of study because of missing or incompletemedical record. Medical record should be written completely and should be kept systematically.

References

1. Kementerian Kesehatan Republik Indonesia. Rencana strategis nasional penanggulangan gangguanpendengaran dan ketulian untuk mencapai soundhearing 2030. Jakarta: Biro Hukum dan Organisasi Kementerian Kesehatan Republik Indonesia; 2006. p. 4. 2. Pannu KK, Chadha S, Kumar D, Preeti. Evaluation of hearing loss in tympanic membrane perforation. Indian J of Otolaryngol HeadNeck Surg. 2011;63(3):208–13. 3. Kaftan H, Noack M, Friedrich N, Völzke H, Hosemann W. Prevalence of chronic tympanic membrane perforation in the adult population. HNO. 2008;56(2):145– 50. 4. Hamilton J. Chronic otitismedia in childhood. In: Gleeson M, editor. Scott– Brown’s otorhinolaryngology, head and

necksurgery. 7th ed. London: Hodder Arnold; 2008. p. 912–26. 5. Bluestone CD, Klein JO. Otitis media in infants and children. 4th ed. Shelton: W B Saunders; 2007. 6. Sarojamma, Raj S, Satish HS. A clinical study of traumatic perforation tympanic membrane. IOSR J Dent Med Sci. 2014;13(4):24–8. 7. Speets A, Wolleswinkel J, Cardoso C. Societal costs and burden of otitis media in Portugal. J Multidiscip Health. 2011;4:53– 62. 8. Olowookere S, Ibekwe T, Adeosun A. Patterns of tympanic membrane perforation in Ibadan: a retrospective study. Ann Ib Postgrad Med. 2008;6(2):31– 3. 9. Kolo E, Salisu A, Yaro A, Nwaorgu O. Sensorineural hearing loss in patients with chronic suppurative otitis media. Indian J Otolaryngol Head Neck Surg. 2012;64(1):59–62. 10. Mehta RP, Rosowski JJ, Voss SE, O’Neil E, Merchant SN. Determinants of hearing loss in perforations of the tympanic membrane. Otol Neurotol. 2006;27(2):136–43. 11. Shaikh N, Hoberman A, Kearney DH, Yellon R. Tympanocentesis in children with acute otitis media. N Engl J Med. 2011;364(2):1– 3. 12. Al-Juboori AN. Evaluation of spontaneous healing of traumatic tympanic membrane perforation. Gen Med. 2014;2(1):1–3. 13. Ibekwe TS, Nwaorgu OG, Ijaduola TG. Correlating the site of tympanic membrane perforation with hearing loss. BMC Ear Nose Throat Disord. 2009;9(1):1–4. 14. Engle JR, Tinling S, Recanzone GH. Age– related hearing loss in rhesus monkeys is correlated with cochlear histopathologies. PLoS one. 2013;8(2):9–12. 15. Maharjan M, Kafle P, Bista M, Shrestha S, Toran K. Observation of hearing loss in patients with chronic suppurative otitis media tubotympanic type. Kathmandu Univ Med J. 2009;7(4):397–401.

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Characteristics of Thyroiditis Patients in Dr. Hasan Sadikin General Hospital in 2009–2013 Sri Maryanti,1 Hasrayati Agustina,2 Miftahurachman3 Faculty of Medicine Universitas Padjadjaran, 2Department of Pathology Anatomy Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, 3Department of Internal Medicine, Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung 1

Abstract

Background: It is reported that thyroid diseases affect around 200 milion people in the world. One of them is thyroiditis that may cause the risk of cancer. Moreover, thyroiditis can also cause hormonal disorders, such as hypothyroid and hyperthyroid. It is assumed that thyroiditis has distinctive clinical characteristics. The aim of this study was to evaluate the characteristics of thyroiditis based on age, gender, location, and clinical features of the patient. Methods: The study was conducted using descriptive-retrospective method. The data were collected from patients’ medical records through total sampling from January 2009 to Desember 2013 in Dr. Hasan Sadikin General Hospital, Bandung. Results: It was found 35 cases of thyroiditis. Based on the histopathological type, the most frequently found thyroiditis was Hashimoto’s thyroiditis. Based on age, thyroiditis mostly affected people at age 41–60 years old. Based on the gender, thyroiditis mostly affected female and the location of lesions were bilateral. The majority clinical features of patients were hypothyroid in Hashimoto’s thyroiditis, hyperthyroid in acute thyroiditis, and normothyroid in sub-acute granulomatous thyroiditis. Conclusions: Based on age, gender, and the location, the majority type of thyroiditis did not show specific characteristics. However, thyroiditis showed specific characteristics based on the clinical features of patient. [AMJ.2016;3(1):49–53] Keywords: Hashimoto’s thyroiditis, hyperthyroid, thyroiditis

Introduction It is predicted that about 200 million people in the world experienced thyroid diseases.1 In Africa2 the phenomena of thyroid diseases are common phenomena. One of the thyroid diseases is called thyroiditis which can cause the imbalances of thyroid’ functions; both hypothyroid and hyperthyroid.3,4 Moreover, thyroid gland disorders may also cause threatening cancer, thyroid cancer.5-7 The study about thyroid gland disorder in Sri Lanka showed that there were 6.51% cases of Hashimoto’s thyroiditis. Hashimoto’s thyroiditis is the fourth case of the most thyroid disorder cases occurred in India.8 In addition, the study conducted in Utah, Nevada and Arizona showed that the prevalence of thyroiditis case are 5.13%.9 Some types of thyroiditis diseases are

assumed having certain characteristics based on age, location, clinical features and gender of the patient.4,10–12 Hashimoto’s thyroiditis is one type of thyroiditis that mostly cause the decrease of thyroid hormone (hypothyroid).3,13 This disease has risk three times greater than other thyroiditis in threatening the thyroid gland.11,14,15 In addition, sub-acute thyroiditis also may increase the risk of myeloproliferative disorders, lymphoproliferative neoplasms and thyroid lymphoma.6 In Indonesia, the study of thyroiditis disease is still rare. Therefore, this study was conducted to evaluate and describe the characteristics of thyroiditis in Bandung, Indonesia.

Methods

This was a descriptive quantitative retrospective study. The data were taken from

Correspondence: Sri Maryanti, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km.21, Jatinangor, Sumedang, Indonesia, Phone: +62 852 238 89774 Email: [email protected] Althea Medical Journal. 2016;3(1)

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the medical records of Pathology Anatomy Department and the Medical Records Center of Dr. Hasan Sadikin General Hospital, Bandung during five periods (1th January 2009-31th December 2013). The samples of the study were all the patients which were diagnosed thyroiditis based on histopathology such as Hashimoto’s thyroiditis, subacute granulomatous thyroiditis, subacute lymphocytic thyroiditis, acute thyroiditis, Riedel’s thyroiditis, and palpation thyroiditis (multifocal granulomatous folliculitis). The sampling technique used in the study was non-probability sampling, particularly total sampling. There was no exclusion in this study; the samples were the inclusion of all thyroiditis patients varied based on the age, gender, location, clinical features. Thirty five samples taken from medical records had been permitted as the samples of this study by Health Research Ethics Committee. The data found were classified into several variable such as age, gender, clinical features (thyroid functions), and location of the occurrence of the lesion (lobes dextra, sinistra, or bilateral). Thus, the data related to the clinical features about the condition of thyroid function of the patients such as hyperthyroid, normothyroid (euthyroid), and hypothyroid could be obtained. After that, the data was presented in form of frequency in a table.

Results

Based on the histopathology type, the most common type of thyroiditis was Hashimoto’s thyroiditis, followed by acute thyroiditis, sub-acute granulomatous thyroiditis, subacute lymphocytic thyroiditis, and Riedel’s thyroiditis. The case that was not found in this study was multi focal granulomatous folliculitis or thyroiditis palpation. According to the gender, from the 35 cases of thyroiditis, it was found that the thyroiditis cases were mostly occurred in women than men (Table 2). The ratio between women and men were 4.8:1. However, subacute granulomatous thyroiditis, Riedel’ thyroiditis, and subacute lymphocytic thyroiditis only occurred in women. Based on the location, thyroiditis cases were mostly found at bilateral. Meanwhile, subacute and acute thyroiditis was only found at dextra lobe (right lobe). Thyroiditis frequency based on age, majority were found at age 41–60 years old. In this study, sub-acute lymphocytic thyroiditis and Riedel’ thyroiditis was only found at

Table 1 Frequency of thyroiditis based on histopathology Thyroiditis

N

Hashimoto

25

Acute

5

Subacute granulomatous Subacute lymphocytic Riedel

Palpation Total

3 1 1 0

35

age 41–60 years old. According to clinical features, thyroiditis cases were mostly found in hypothyroid condition. Thyroid function of acute thyroiditis was only found at hyperthyroid and in Hashimoto’ thyroiditis was only found at hypothyroid.

Discussions

Hashimoto’ Thyroiditis was the most frequently hyroiditis type in this study. It might be happened since Hashimoto’ Thyroiditis is an autoimmune disease so that the possibilities to be occurred is higher than other types of Thyroiditis.3 The TSH receptor is antigenic site which has important role in the process of autoimmune disease. Autoantibodies may act as an antagonists to the receptor TSH mimicking the actions of TSH in the case of Hashimoto’s thyroiditis.13 According to the frequency of thyroiditis based on the gender, the ratio of Hashimoto’ thyroiditis between women and men was 4:1. Those data were in line with the study conducted by Siriweera and Ratnatunga5 at Sri Lanka, Rosai and Ackermen10 and Ott et al.16 They stated that Hashimoto’ Thyroiditis case more frequently occurred in women than men. However, the ratio (4:1) was different from the result of the research conducted by Siriweera and Ratnatunga5 found that the ratio between women and men was 10.3:1. Furthermore, acute thyroiditis mostly occurred on women than men with the comparison 4:1. It was contrast with Wiyono’s12 statement that the ratio of acute thyroiditis of women and men was 1:1. Based on the data, subacute granulomatous thyroiditis more often occurred on women than men. This result was related to Rosai and Ackermen10 who stated that sub-acute Althea Medical Journal. 2016;3(1)

Sri Maryanti, Hasrayati Agustina, Miftahurachman: Characteristics of Thyroiditis Patients in Dr.Hasan Sadikin 51 General Hospital in 2009–2013

Table 2 Characteristics of thyroiditis based on gender, age, location and clinical features Thyroiditis Characteristics

HSM

SGR

SLF

ACT

RDL

MGF

N=25

N=3

N=1

N=5

N=1

N=0

Female

5

20

0

0

1

0

0

Dextra

4

1

1

2

0

0

Gender Male

Not recorded

Location

Sinistra

Bilateral

0 2 8

Not recorded

11

21–40

7

Age (year) 0–20

41–60 >60

Not recorded

Clinical features Hyperthyroid

Normothyroid Hipothyroid

Not recorded

0

16 2 0 0 0 5

20

3 0 0 2 0 0 2 1 0 0 0 2 0 1

1 0 0 0 0 0 0 1 0 0 0 0 0 1

4 0 0 0 3 0 2 3 0 0 2 1 0 2

1 0 0 1 0 0 0 1 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 0 0 0 0

Note: *HSM: Hashimoto, SGR: Subacutegranulomatous,SLF: Subacute lymphocytic, ACT: acute,RDL: Riedel, MGF: Multifocal granulomatous foliculitis/palpation

granulomatous thyroiditis mostly occurred on women than men with the ratio 4:1. The cases of subacute lymphocytic thyroiditis and Riedel’ thyroiditis showed that both were mostly found on women. It was the same as Wiyono’s12 statement that subacute lymphocytic thyroiditis and Riedel’ thyroiditis more often occurred on women than men. The literature mentioned that the ratio of women and men in subacute lymphocytic thyroiditis is 2:1 while in Riedel’ thyroiditis case is 3-4:1. The possible explanation for the fact that thyroiditis occurred much more often on women because of the relation between X chromosome and immune-related genes which can cause preservation of immune tolerance.11 It is mentioned that hormone affects the binding-hormone capacity, for instance, when estrogen increases then it will affect the escalation of binding protein synthesis for thyroid hormone.13 The difference between Althea Medical Journal. 2016;3(1)

ratio in this research and ratio in the literature is probably caused by the different number of samples. According to the location of the inflammation, it was found 8 bilateral cases of Hashimoto’ thyroiditis, 4 dextra cases of Hashimoto’ thyroiditis, and 2 sinistra cases of Hashimoto’ thyroiditis. It can be inferred that Hashimoto’ thyrioditis frequently occurred in bilateral. However, the literature about such phenomenon has not discovered yet. Furthermore, bilateral also became the most frequent location of subacute granulomatous thyroiditis. This result was accordance with Rosai and Ackermen10, which argued that sub-acute granulomatous thyroiditis mostly occurred in both of lobes or bilateral. In addition, subacute lymphocytic thyroiditis mostly occurred in dextra lobe (right lobe). Cases of acute thyroiditis found occurred in dextra lobe (right lobe). It was in line

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with Longo et al.3 who mentioned that acute thyroiditis occurred more often in a lobe (unilateral); It can be happened since the right part of ultimo branchial body atrophy and does not develop in the period of human thyroid gland formation. In addition, it was found one case of Riedel’ thyroiditis occurred in bilateral. It was not in accordance with the study conducted by Longo et al.3 and Papi and LiValsi17 who revealed that Riedel’s thyroiditis mostly occurred in a lobe or unilateral, either dextra or sinistra. In sub-acute thyroiditis, the inflammation sometimes could attack a lobe which is then immigrated to the another lobe, called “creeping” thyroiditis.13 Table 2 shows the frequency of thyroiditis based on age. It can be seen that Hashimoto’s thyroiditis frequently occurred in the aged group of 41-60 years old. This result was in line with a result of the research conducted by Siriweera and Ratnantunga5 in Sri Lanka which revealed that Hashimoto’ thyroiditis mostly happened in aged group of 41–60 years old. Meanwhile, sub-acute granulomatous thyroiditis case mostly occurred in age 21– 40 years old and followed by the age 41–60 years old. This result was nearly similar with literature from Longo et al.3 who argued that the cases frequently occurred in age 30–50 years old and age 20–60 years old and the study investigating 162 cases as samples conducted by Woolner et al. in Rosai and Ackerman10 In contrast with Wiyono12 who showed that sub-acute lymphocytic thyroiditis, mostly attack people aged 30–40 years old, this study showed that sub-acute lymphocytic thyroiditis was more often on people age 41–60 years old. As well as sub-acute lymphocytic thyroiditis, acute thyroiditis frequently occurred on people aged 41–60 years old. It was different from Rosai and Ackerman10 statement that acute thyroiditis mostly occurred in people aged 2140 years old. In addition, Riedel’ thyroiditis mostly happened in people aged 41-60 years old. It was quite similar to Longo et al.3 and Rosai and Ackerman10 who argued that Riedel’ thyroiditis more frequently occurred on people aged 30–50 years old. Some thyroiditis cases were mostly found in people aged 41–60 years old and were not found in group of people aged 0–20 years old. It could be happened since there were the descents of immune system in people aged above 40 years old so that they were more susceptible to the disease while thyroiditis in children was usually caused by physical and cognitive interference.18 Frequency of thyroiditis based on clinical description was seen according to the function

of thyroid; hyperthyroid, normothyroid, and hypothyroid. Based on clinical features, the majority of Hashimoto’ thyroiditis cases are in hypothyroid. It comports with the study conducted by Staii et al.19 Hypothyroid in adult patient can be caused by the decrease of cell in thyroid gland. Furthermore, it can be caused by autoimmune disease that damages the parenchyme of thyroid gland and as the effect of surgery or radioactive iodine therapy. Moreover, hypothyroid is also caused by the enlargement of the thyroid gland as the consequence of lymphocytic infiltration in Hashimoto’ thyroidis case.13 In addition, in sub-acute granulomatous thyroiditis case, most patients experienced normothyroid. It is similar tothe study conducted by Li et al.20 in China. The study mentioned that thyroid function in sub-acute granulomatous thyroiditis’ case is usually discovered in normothyroid condition. It might be happened since the major of thyroid gland was not damaged.20 However, sub-acute granulomatous thyroiditis was frequently found in hyphothyroid.13 Thyroid function (clinical feature) showed that acute thyroiditis mostly occurred in hyperthyroid and acute thyroiditis was frequently revealed in hyperthyroid.13 Based on the result of the study, it can be inferred that almost all types of thyroiditis have similar characteristics according to age, gender, and location. However, according to the clinical features (thyroid functions), thyroiditis has particular characteristics for each type. Hashimoto thyroiditis was mostly found in hypothyroid; granulomatous thyroiditis was mostly found in normothyroid; and acute thyroiditis was mostly found in hyperthyroid. By founding those characteristics, it is expected that it can help the process of diagnosis and therapy of the patients. The limitation of this study is the samples that were 35 samples. Meanwhile, in order to be able to represent the cases generally, the sample should be 74 samples. Therefore, the results of this study do not represent the thyroiditis case. In addition, some variables in the medical record were not complete enough. The similar studies are still rarely conducted. Therefore, they become another limitation of the study. Thus, those studies led to the difficulties in finding related literature especially journal. The difference of the study’s results with the previous study might be arousen because of different samples. Based on the results of the study it is recommended to conduct the study by Althea Medical Journal. 2016;3(1)

Sri Maryanti, Hasrayati Agustina, Miftahurachman: Characteristics of Thyroiditis Patients in Dr.Hasan Sadikin 53 General Hospital in 2009–2013

involving minimum numbers of samples to be able to describe the case generally. It can be done by adding the samples from the period of the medical records, more hospitals and investigates thyroiditis beside on age, gender, location and clinical features (thyroid functions).

References

1. Lancet. Thyroid diseases more research needed. The Lancet. 2012;379(9821):1076. 2. Ogbera AO, Kuku SF. Epidemiology of thyroid diseases in Africa. Indian J Endocrinol Metab. 2011;15(Suppl 2):S82– 8. 3. Longo D, Fauci A, Kasper D, Hauser S, Jameson J, Loscalzo J. Harrison’s principles of internal medicine. 18th Ed. New York: Mcgraw-Hill; 2011. p. 2237–9. 4. Vanderpump MP. The epidemiology of thyroid disease. Br Med Bull. 2011;99(1):39–51. 5. Siriweera EH, Ratnatunga N. Profile of Hashimoto’s thyroiditis in Sri Langkans: is there an increased risk of ancillary pathologies in Hashimoto’s thyroiditis? J Thyroid Res. 2010;2010:124264. 6. Yoon YH, Kim HJ, Lee JW, Kim JM, Koo BS. The clinicopathologic differences in papillary thyroid carcinoma with or without co-existing chronic lymphocytic thyroiditis. Eur Arch Otorhinolaryngol. 2012;269(3):1013–7. 7. Roh MH, Jo VY, Stelow EB, Faquin WC, Zou KH, Alexander EK, et al. The predictive value of the fine-needle aspiration diagnosis “suspicious for a follicular neoplasm, hürthle cell type” in patients with hashimoto thyroiditis. Am J Clin Pathol.2011;135(1):139–45. 8. Unnikrishnan AG, Menon UV. Thyroid disorders in India: an epidemiological perspective. Indian J Endocrinol Metab. 2011;15(Suppl2):S78–81. 9. Golden SH, Robinson KA, Saldanha I, Anton B, Ladenson PW. Clinical review: prevalence and incidence of endocrine and metabolic disorders in the United States: a comprehensive review. J Clin Endocrinol Metab. 2009;94(6):1853–78.

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10. Rosai J, Ackerman LV. Rosai and Ackerman’s surgical pathology. 10th Ed. New York: Mosby Elsevier; 2011. p. 491–6. 11. Zaletel K, Gaberscek S. Hashimoto’s thyroiditis: from genes to the disease. Curr Genomics. 2011;12(8):576–88. 12. Wiyono P. Tiroiditis. In: Sudoyo AW, Setiyohadi B, Alwi I, Simadribrata M, Setiati S, editors. Buku ajar ilmu penyakit dalam. 5th ed. Jakarta: Interna Publishing; 2009. p. 2016–21. 13. Gardner D, Shoback D. Greenspan’s basic and clinical endocrinology. 9th ed. Ney York: McGraw-Hill Education; 2011. p. 264–7. 14. Konturek A, Barczynski M, Wierzchowski, Stopa M, Nowak W. Coexistence of papillary thyroid cancer with Hashimoto thyroiditis. Langenbecks Arch Surg. 2013;398(3):389–94. 15. Larson SD, Jackson LN, Riall TS, Uchida T, Thomas RP, Qiu S, et al. Increased incidence of well-differentiated thyroid cancer associated with Hashimoto’s thyroiditis and the role of PI3K/AKT pathway. J Am Coll Surg. 2007;204(5):764–75. 16. Ott J, Meusel M, Schultheis A, Promberger R, Pallikunnel SJ, Neuhold N, et al. The incidence of lymphocytic thyroid infiltration and Hashimoto’s thyroiditis increased in patients operated for benign goiter over a 31-year period. Virchows Arch. 2011;459(3):277–81 17. Papi G, LiVolsi VA. Current concepts on Riedel thyroiditis. Am J Clin Pathol. 2009;121 Suppl:S50–63. 18. Kapelari K, Kirchlechner C, Högler W, Schweitzer K, Virgolini I, Moncayo R. Pediatric reference intervals for thyroid hormone levels from birth to adulthood: a retrospective study. BMC Endocrine Disorders. 2008;8:15. 19. Staii A, Mirocha A, Todorova-Koteva K, Glinberg S, Jaume JC. Hashimoto thyroiditis is more frequent then expected when diagnosed by citology which uncovers a pre-clinical state. Thyroid Res. 2010;3:11. 20. Li LX, Wu X, Hu B, Zhang HZ, Lu HK. Localized subacute thyroiditis presenting as a painful hot nodule. BMC Endocrine Disorders. 2014;14:4.

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Clinical and Histopathological Characteristic of Salivary Gland Carcinoma in Dr. Hasan Sadikin General Hospital in 2009–2012 Fatimah Lidya Andriani,1 Ismet Muchtar Nur,2 Sally Mahdiani3 Faculty of Medicine Universitas Padjadjaran, 2Department of Anatomical Pathology Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung, 3Department of Otolaryngology-Head & Neck Surgery Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung 1

Abstract

Background: Salivary gland neoplasm is one of the rare neoplasm. The frequency of this neoplasm is lower than 2% of all type of tumors in human. Malignant salivary gland tumor comprises 6% of all head and neck tumors. Data about salivary gland carcinoma are still limited. The aim of this study was to determine the frequency of malignant salivary gland based on the patients’ age, gender, site of lesion and histopathology type. Methods: This study was conducted descriptively. There were 97 subjects found from histopathological form that had been examined in Department of Anatomical Pathology, Dr. Hasan Sadikin General Hospital in 2009–2012. Total sampling technique was used and all data about patients’ age, gender, site of lesion and histopathology type were collected and analyzed. Results: Of 97 cases, age group 50–59 years old had the highest frequency (29%). The prevalence in male was more frequent than female with male:female ratio was 1.4:1. The most common site of carcinoma was found in parotid gland (45%). Mucoepidermoid carcinoma was the most common histopathology type found in this study (28%). Conclusions: Salivary gland carcinoma is still a rare malignant case in Dr. Hasan Sadikin General Hospital. Carcinoma in parotid gland was the most common site and mucoepidermoid carcinoma was the most common histopathology type. [AMJ.2016;3(1):54–8] Keywords: Carcinoma, histopathology, salivary gland

Introduction Salivary gland neoplasm is one of the rare neoplasms. Department of Ear Nose Throat (ENT) Wroclaw, Polska reported that 304 salivary glands tumor patient were with 83.9% benign tumor and 16.1% malignant tumor in 2001–2010.1 Its peak incidence was varied according to the previous studies. Most of them reported that salivary gland tumor reached the incident peak in sixth-seven decade of life.2 Five years life expectancy ranged between 5–95% depend on various factors including site of lesion, histopathology type, stage of tumor and the involvement of facial nerve or surrounding structure. Original site of salivary glands cancer is one of significant factors. Cancer that can be excised fully from parotid gland has the better result, followed by submandibular gland, sublingual gland and minor salivary glands.3 Based on the background above and

limited data about salivary gland carcinoma, the study was conducted concerning salivary glands carcinoma based on patients’ age, gender, site of lesion and histopathological type in Department of Anatomical Pathology Dr. Hasan Sadikin General Hospital.

Methods

This study was carried out from September– The subject of the study was taken from the histopathological form of the patients in Department of Anatomical Pathology, Dr. Hasan Sadikin General Hospital from January 2009 to December 2012 that were selected using total sampling method. This method was carried out from September–October 2013 in Department of Anatomical Pathology. This study was approved by Health Research Ethics Committe. The inclusion criteria was all the medical records of patients diagnosed

Correspondence: Fatimah Lidya Andriani, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km.21, Jatinangor, Sumedang, Indonesia, Phone: +62 8127577725 Email: [email protected] Althea Medical Journal. 2016;3(1)

Fatimah Lidya Andriani, Ismet Muchtar Nur, Sally Mahdiani: Clinical and Histopathological Characteristic of Salivary Gland Carcinoma in Dr. Hasan Sadikin General Hospital in 2009–2012

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the increasing of age. The peak of salivary gland carcinoma was in the fifth decade of life. The lowest case were found in first and eighth decade of life. Mucoepidermoid carcinoma was the most common of all carcinoma in salivary gland, followed by squamous cell carcinoma, adenoid cystic carcinoma and acinic cell carcinoma. Mucoepidermoid carcinoma and squamous cell carcinoma were distributed widely in the age group and had the peak in fifth decade of life. The peak of acinic cell carcinoma was in third decade of life (Table 1). Salivary gland carcinoma was more frequent in male than female with male:female ratio was 1.4:1 and the most common histopathological type of tumor was mucoepidermoid carcinoma in both male and female (Table 2). Almost half of the cases were found in parotid gland, followed by minor salivary glands, submandibular gland and sublingual gland. Mucopeidermoid carcinoma was mostly found in parotid gland. Adenoid cystic carcinoma and squamous cell carcinoma

as salivary gland carcinoma. The incomplete data of histopathological form was excluded from this study. This descriptive study used retrospective methods. Variables of this study were patients’ age and gender, site of lesion and histopathology type. All cases were classified according to the criteria suggested by 2005 World Health Organization (WHO) histological classification. Data were collected and analyzed using Microsoft Excel 2007. The frequency and percentage of the mentioned variable were calculated. Collected data from medical records were kept confidentially and vanished after the research was done.

Results

During 2009–2012, 97 cases of salivary gland carcinoma were found in Department of Anatomical Pathology, Dr. Hasan Sadikin General Hospital. Patients’ age for cases was ranged from 6–86 years old. The cases increased along with

Table 1 Histopathological Type of Salivary Gland Carcinoma based on Age Group Histophatology

Age (years) 0–9

10–19

Acinic cell carcinoma

1

Adenoid cystic carcinoma

2

Mucoepidermoid carcinoma

Polymorphous lowgrade adenocarcinoma

Clear cell carcinoma

20–29

2

1

1

1

1

30–39

40–49

50–59

5

1

1

5

2

Adenocarcinoma

Myoepithelial carcinoma

Carcinoma ex pleomorphic adenoma

Squamous cell carcinoma

1

1 1

Small cell carcinoma

1

Large cell carcinoma

Lymphoepithelial carcinoma Total (%)

2 (2)

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2

1

Basal cell adenocarcinoma

Oncocytic carcinoma

6

7 (7)

1

2

6 (6)

1

1

2

5

1

1

10 5

60–69 2 3

1 1

1 1

8

70–79 1

1

16 (17) 18 (19) 28 (29) 10 (10)

27 13 4

1

3

Total 9

1

1

1

80–89

2

2

2 1

1

2 1

2 2

7

23 1 2

8 (8)

2 (2)

2

97 (100)

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Table 2 Histopathological Type of Salivary Gland Carcinoma based on Gender Histophatology Acinic cell carcinoma

Mucoepidermoid carcinoma

Adenoid cystic carcinoma

Polymorphous low-grade adenocarcinoma

Clear cell carcinoma

Basal cell adenocarcinoma Oncocytic carcinoma Adenocarcinoma

Myoepithelial carcinoma

Carcinoma ex pleomorphic adenoma

Gender Male

Female

6

7

2

17 2

2 2 1 1 5

Squamous cell carcinoma

15

Lymphoepithelial carcinoma

2

Small cell carcinoma

Large cell carcinoma

Total (%)

widely distributed at each site of lesion. Squamous cell carcinoma had the highest case in minor salivary glands. Oncocytic carcinoma and adenocarcinoma only affected parotid gland. Large cell carcinoma was only discovered in submandibular gland (Table 3).

Discussion

In the present review of 97 salivary gland carcinoma, group aged 50–59 years old was the highest case (29%). In 30–39, 40–49 and 60–69 years old group also showed significant number. This result is similar to the reference which reported that frequency of salivary gland carcinoma increase in fourth to seventh decade of life.3,4 The increase in case occured about 6.9% compared to the previous study by Achmad Thohir in Department of Anatomical Pathology Dr. Hasan Sadikin General Hospital in 2003–2006. Salivary gland carcinoma more often affected male, with male:female ratio was 1.4:1. This result is similar to the study in Iran that reported predominance for men with male:female ratio was 1.4:1.5 In contrast, some references and prior studies reported that women were more often affected than men.4,6,7 According to site of lesion, carcinoma is

1 1

57 (59)

7

10 2

2

1

2

8

1

40 (41)

more frequent in parotid gland, followed by minor salivary glands, submandibular gland and sublingual gland. This result was similar to the reference that reported that 65–80% salivary gland carcinoma occured in parotid gland, 9–23% in minor salivary glands, 10% in submandibular gland and less than 1% in sublingual gland.3,5 Only 3 cases were identified in the sublingual gland. This confirmed the rarity of salivary tumors at this site, as mentioned in other studies.5,7–9 Histopathological type that is mostly found was mucoepidermoid carcinoma. In the second place, there was squamous cell carcinoma, followed by adenoid cystic carcinoma. Yu-Long Wang et al.10 reported that mucoepidermoid carcimona was the most common histophatology type (24.6%), followed by adenoid cyctic carcinoma (18%) in Chinesse population. Some reference also reported that mucoepidermoid carcinoma was the most common carcinoma.11 According to WHO, incidence of squamous cell carcinoma was less than 1% of all carcinoma in salivary gland.5 Prior study by Achmad Thohir in Dr. Hasan Sadikin General Hospital reported that adenoid cystic carcinoma was the most common histopathology. In this study, acinic cell carcinoma occured in almost all age group and increased in 30– Althea Medical Journal. 2016;3(1)

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Table 3 Histopathological Type of Salivary Gland Carcinoma based on Site of Lesion Histophatology Acinic cell carcinoma

Mucoepidermoid carcinoma Adenoid cystic carcinoma Polymorphous low-grade adenocarcinoma Clear cell carcinoma

Site of Lesion (Salivary Gland) Parotid 6

16 5 1

Basal cell adenocarcinoma

1

Myoepithelial carcinoma

1

Oncocytic carcinoma Adenocarcinoma

Carcinoma ex pleomorphic adenoma

Submandibular 8

5

1 2 5

1

4

Lymphoepithelial carcinoma

1

1

Total (%)

44 (45)

39 years old. This result was similar to the reference that reported that this carcinoma was distributed widely in any group of age.4,12 Mucoepidermoid carcinoma is also distributed widely in age group. Enhancement developed in third to fifth decade of life. This malignant tumor occured in child as well. Some author reported that mucoepidermoid carcinoma is common in child and adult, distributed widely in age group, and had the peak in third to fifth decade of life.12 Adenoid cystic carcinoma also spread in any age group and had the peak in 50–59 years old. This result was similar to the reference that reported that this carcinoma is distributed in all age group and increased in fourth to sixth decade of life.3,4,12 Squamous cell carcinoma was found in almost all age group and increased in 40–79 years old. Previous study reported that squamous cell carcinoma was found from 7–95 years old with peak in seventh decade of life.12 Carcinoma ex pleomorphic and squamous cell carcinoma were most often affected men with male:female ratio was 2:1, as reported previously. Acinic cell carcinoma had higher frequency in women with female:male ratio was 2.8:1. This result was similar to previous study by Ilayaraja2 Mucoepidermoid carcinoma were mostly found in men, while another Althea Medical Journal. 2016;3(1)

3 3 2 3 1

5

Large cell carcinoma

1

Minor

2

Squamous cell carcinoma

Small cell carcinoma

Sublingual

2

21 (22)

1

1

1

13

3 (3)

29 (30)

1

study reported that it was more often found in women than men. Polymorphous low-grade adenocarcinoma showed equal case between men and women. However, some authors reported that two to three times is common in women than men.4,12 According to site of lesion, acinic cell carcinoma more often occured in parotid gland and was followed by minor salivary glands, as had been documented that 80% in parotid gland and 17% in minor salivary glands. Mucoepidermoid carcinoma was mostly found in parotid gland, similar to the reference that reported that it was common in major salivary glands, espescially parotid gland.4 The frequency in parotid gland is about 60%.12 Adenoid cystic carcinoma was mostly found in parotid gland and submandibular gland, followed by minor salivary gland and sublingual gland, as mentioned in reference.4 However, other references reported that it was more often affected by minor than mayor salivary gland. Carcinoma ex pleomorphic was also more often found in parotid gland, similar to the reference about 81.7%.12 Polymorphous low-grade adenocarcinoma was more often affected minor salivary gland. This result was similar to the reference that reported 60% occured in minor salivary gland, especially

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palatum.Squamous cell carcinoma is mostly found in minor salivary gland as well, but in contrast with the previous study that reported was more often found in parotid gland and submandibular gland.4,12 Limitations of the study were limited time for data collection and patients’ identity is not completely written in histopathological form. The conclusion of this study is the frequency of salivary gland carcinoma increased in age group 50–59 years old. Male and parotid gland were the most affected and mucoepidermoid carcinoma was the most frequent lesion, followed by squamous cell carcinoma and adenoid cystic carcinoma.

References

1. Kubacka M, Orendorz-Fraczkowska K, Pazdro-Zastawny K, Morawska-Kochman M, Kręcicki T. Epidemiological evaluation of salivary gland tumors in the Wroclaw ENT Department patients in the years 2001– 2010. Polish Otolaryngol. 2013;67(1):30– 3. 2. Ilayaraja V, Prasad H, Anuthama K, Sruthi R. Acinic cell carcinoma of minor salivary gland showing features of high grade transformation. J Oral Maxillofac Pathol. 2014;18(1):97–101. 3. Faquin WC, Powers CN. Salivary Gland Cytopathology. New York: Springer; 2008. 4. Barnes L, Eveson JW, Reichart P, Sidransky D, editors. World Health Organization classification of tumours pathology & genetics head and neck tumours. Lyon: IARC Press; 2005.

5. Ansari MH. Salivary gland tumord in an Iranian population : a retrospective study of 130 cases. J Oral Maxillofac Surg. 2007;65(11):2187–94. 6. Kumar V, Abbas AK, Fausto N, Aster JC. Robbin and Cotran pathologic basis of disease. 8th ed.Philadelphia: Elsevier Saunders; 2010. p.756–9. 7. De Oliveira FA, Duarte EC, Taveira CT, Máximo AA, de Aquino EC, Alencar Rde C, et al. Salivary gland tumor: a review of 599 cases in a Brazilian population. Head Neck Pathol. 2009;3(4):271–5. 8. Ito FA, Ito K, Vargas PA, de Almeida OP, Lopes MA. Salivary gland tumors in a Brazilian population: a retrospective study of 496 cases. Int J Oral Maxillofac Surg. 2005;34:533–6. 9. Al-Kahteeb TH, Ababneh KT. Salivary tumors in north Jordanians: a descriptive study. Oral Surg Med Oral Pathol Oral Radiol Endod. 2007;103(5):e53–9. 10. Wang YL, Zhu YX, Chen TZ, Wang Y, Sun GH, Zhang L, et al. Clinicopathologic study of 1176 salivary gland tumors in a Chinese population: experience of one cancer center 1997–2007. Acta otolaryngol. 2012;132(8):879–86. 11. Ovchinsky A, Har-El G. Salivary Gland Enlargement. In: Lucente FE, Har-El G, editors. Essentials of Otolaryngology. 5thed. Philadephia: Lippincot Williams & Wilkins; 2004. 12. Barnes L. Surgical pathology of the head and neck. 3rd ed. New York: Informa Healthcare; 2009.

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Effect of Midnight Prayer on Sympathetic Tone Hadiyatussalamah Pusfa Kencanasari,1 Achmad Fauzi Yahya,2 Setiawan3 Faculty of Medicine, Universitas Padjadjaran, 2Department of Cardiology and Vascular Medicine Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung 3 Department of Physiology Faculty of Medicine Universitas Padjadjaran

1

Abstract

Background: Hypertension is one of the most dangerous ailments which most common risk factor is stress that can activate sympathetic system leading to increased blood pressure. Midnight prayer is believed to calm mind. This study was conducted to discover the effect of midnight prayer on sympathetic tone. Methods: This cross sectional study was conducted in Bina Siswa Senior High SchoolSMA Plus Cisarua Boarding School, Lembang from October to November 2013. Sixty eight participants were divided into 3 groups based on frequency; high, low, and non midnight prayer. Blood pressure and pulse rate of participants were examined before, during, and after the cold pressor test is taken. Blood pressure and pulse rate duration of recovery were also measured. Results: This study showed no significant difference between 3 groups in term of systolic blood pressure, diastolic blood pressure, and pulse rate. However, the lowest mean of pulse rate (64.38±8.921 vs 66.69±11.482 vs 65.44±9.584 respectively), systolic blood pressure [107.19±6.945 vs 117.13±13.426 vs 104.25 (75–120) respectively], and diastolic blood pressure [70.38±7.719 vs 77.38±10.935 vs 70.63±7.491 respectively] were obtained in the high midnight prayer group. Recovery duration of blood pressure [6.38 (6–8) vs 6.72 (6–11) vs 6.75 (6–11) respectively] and pulse rate (6.69±0.946 vs 7.03±1.341 vs 7.00±1.506 respectively) among the groups showed no significant difference respectively, however the shortest duration was obtained in the high midnight prayer group. Conclusions: Midnight prayer has no significant effect on sympathetic tone. [AMJ.2016;3(1):59–63] Keywords: Blood pressure, cold pressor test, midnight prayer, pulse rate, sympathetic tone.

Introduction Hypertension is one of the most dangerous conditions especially when it is not controlled. This illness has caused 7.5 million deaths in the world, equal to 12.8% from total cause of death.1 Based on Riset Kesehatan Dasar Badan Penelitian dan Pengembangan Kesehatan 2007, the prevalence of hypertension in Indonesia reaches 31.7%.2 One of the most common risk factors of hypertension is stress. Stress response is the way of human body reacting to stress. Sign of this response is the activation of sympathetic system that will lead to a rise in arterial pressure, bloodstream, cellular metabolism, blood glucose consentration, mental activity, glicolysis, muscle strength, and blood coagulation rate.3 When human’s body is experiencing stress, physically or mentally, one of body’s natural

responses which is most measurable is the increased of blood pressure. Midnight prayer, also known as shalat tahajud or qiyamul lail, is one of the Sunnah prayers (optional prayer) that is believed to be able to affect mental condition. The process of praying (shalat) itself is quite close to a meditation, in addition, there are particular movements and reciting of Al Quran. Regular midnight prayer will calm mind and also leads to lower the risk of stress condition. This calm condition will affect the body when it is stressed, due to the inavoidable nature of stress.4 Therefore, theoretically, the risk of hypertension caused by stress can be prevented. Cold sensation is one of the known physical stressor. This condition can be used to observe the body response by giving the stressor. There is a procedure called cold pressor test that is not only used to know the regulation

Correspondence: Hadiyatussalamah Pusfa Kencanasari, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km.21, Jatinangor, Sumedang, Indonesia, Phone: +6285793110035 Email: [email protected] Althea Medical Journal. 2016;3(1)

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of sympathetic nerve to periphery and coronary circulation5 but also can be used as hypertension predictor.6 Before conducting the test, blood pressure is measured and this measurement is considered as a base line. The rise in blood pressure of 15/10 mmHg or more from base line is considered as hyperreactor.5 On the other hand, normoreactor is considered if the rise in blood pressure is less than 15/10 mmHg from base line. According to this fact, the author see the possibility to discover stress response in someone who have been done midnight prayer regularly compared to those who have not done it. The present study aims to study the effect of midnight prayer to cold pressor test result in Bina Siswa Senior High School (Sekolah Menengah Atas, SMA) Plus Cisarua Boarding School Student, Lembang.

Methods

This analytical study conducted in cross sectional approach was performed in Bina Siswa SMA Plus Cisarua Boarding School, Lembang, from October to November 2013. This study was approved by the institutional ethics committee and all data regarding patients were concealed. Fifteen to eighteen years old male participants, had normal BMI, normotensive, healthy, understand about this study, and signed the informed consent were included in this study. Participants who had a history of cardiovascular disease, smoking, drinking alcohol, and open wound on the hand were excluded. Sampling was conducted by total sampling. From those criteria, about 68 out of

144 male students participated in this study. Participant filled-up the questionnaire about identity, medical history, life style, general condition, and midnight prayer performed within 1 last month. Participants were categorized based on midnight prayer frequency’s standard deviation. Participants who had done more than 14 times midnight prayer within 1 last month were considered as high midnight prayer group.Participant who had done midnight prayer 1-14 times within 1 last month were considered as low midnight prayer group, and participants who had never done midnight prayer within 1 last month were considered as non midnight prayer group. Blood pressure of each participant was measured by mercury sphygmomanometer. After taking rest for five minutes, the blood pressure and pulse rate was measured at the left hand of participants. The right hand of the participant was immersed in ice water (4–10 0C) for 1 minute. Blood pressure and pulse rate were measured at the completion of 1 minute. After that, the participants were asked to remove his hand from the cold water. The particpant’s hand was dried up with dry towel and they are allowed to to take a rest. Five minutes after the cold pressor test, blood pressure and pulse rate were noted once more. With 1 minute interval, blood pressure and pulse rate of participants were measured continuously until they reach the baseline. Data were processed using Microsoft Excel and SPSS 15.0 programme. Proportion of normoreactor data was statistically analyzed using chi square parametric test. The average height of increased blood pressure and pulse rate also the average blood pressure and pulse rate duration of recovery data were analyzed

Table 1 Pulse Rate and Blood Pressure Characteristic of Participant

High Midnight Prayer

Conditions

PR* (time/minute)

SBP** (mmHg)

DBP# (mmHg)

Baseline

64.38±8.921

107.19±6.945

70.38±7.719

(n=16)

Ice water exposure

66.69±11. 482

(n=36)

Ice water exposure

73.12±12.139

(n=16)

Ice water exposure

74.44±10.801

Low Midnight prayer Non-Midnight Prayer

Recovery Baseline

Recovery Baseline

Recovery

117.13±13.426

65.44±9.584

104.25 (75–120)

68.61±9.066

109.33±11. 432

67.25±8.497

68.94±10.976

71.50±10.640

77.38±10.935 70.63±7.491

110.64 (89–130)

70.31 (49–100)

109.44±10.046

74.00 (49–100)

121.00±10.918

122.19±13.477 111.88±11.200

Note: *PR = Pulse rate, **SBP = Systolic Blood Pressure, #DBP = Diastolic Blood Pressure

78.11±9.748

70.33 (40–100) 81.75±9.842 73.00±7.127

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Table 2 Proportion of Normoreactor between High Midnight Prayer Group, Low Midnight Prayer Group, and Non-Midnight Prayer Group SBP* DBP**

Normoreactor

Hyperreactor

p

High Midnight prayer

10 (63%)

6 (37%)

0.782

High Midnight prayer

8 (50%)

8 (50%)

0.591

Low Midnight prayer

Non- Midnight prayer

24 (72%)

10 (28%)

17 (65%)

19 (73%)

11 (69%)

Low Midnight prayer

Non- Midnight prayer

5 (31%)

10 (63%)

6 (37%)

Note: *SBP = Systolic Blood Pressure, **DBP = Diastolic Blood Pressure

using one way anova if the data distribution were normal. As an alternative, KruskalWallis non parametric test was also used if the distribution was not normal. Statistically significant was considered when p≤0,05. Analysis was performed by comparing those 3 groups.

Results

From 144 male students, 68 participants fitted to criteria and agreed to be involved in this study. Nineteen participants were considered as high midnight prayer group because they had done more than 10 times midnight prayer within 1 last month, 33 participants were considered as low midnight prayer group because they had done 1–10 times midnight prayer within 1 last month, and 16 participants were considered as non midnight prayer group because they never done midnight prayer

within 1 last month. Mean or median of pulse rate, systolic blood pressure, and diastolic blood pressure before, during, and after cold pressor test are shown in Table 1. Systolic blood pressure (SBP p=0.782) and diastolic blood pressure (DBP p=0.591) between 3 groups have shown no significant difference (Table 2). Height of increased SBP and blood pressure duration of recovery data distribution were not normal, therefore the data were analyzed using Kruskal-Wallis Test. The height of increased DBP and pulse rate also the pulse rate duration of recovery were analyzed using One Way Analysis of Variance (ANOVA) because the data distribution were normal. There was no significant difference between the height of increased SBP among those 3 groups (p=0.626; 95% Confidence interval, 8.84–12.80). Height of increased DBP (p=0.939; 95% Confidence interval, 5.75–9.46) and pulse rate (p=0.215;

Table 3 Proportion of Normoreactor between High Midnight Prayer Group, Low Midnight Prayer Group, and Non-Midnight Prayer Group Median of SBP* (mmHg)

p

Mean of DBP** (mmHg)

p

Mean of PR# (time/minute)

p

9.94 (-10–24)

0.626

7.00±7.950

0.939

2.31±6.887

0.215

High Midnight Prayer

Low Midnight Prayer

10.36 (-7–30)

Non- Midnight Prayer

12.75 (4–32)

7.81±7.804 7.75±7.532

Note: *SBP = Systolic Blood Pressure, **DBP = Diastolic Blood Pressure, #PR = Pulse Rate

6.11±7.383 5.50±7.118

Table 4 Blood Pressure and Pulse Rate Duration of Recovery Median Time of Blood Pressure (minute)

p

Mean Time of Pulse Rate (minute)

p

6.38 (6–8)

0.548

6.69±0.946

0.673

High Midnight Prayer Low Midnight Prayer

Non-midnight Prayer

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6.72 (6–11)

6.75 (6–11)

7.03±1.341 7.00±1.506

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95% Confidence interval, 3.31–6.83) also showed no significant difference (Table 3). Recovery duration of blood pressure (p=0.548; 95% Confidence interval, 6.40–6.90) and pulse rate (p=0.673; 95% Confidence interval, 6.63– 7.25) also showed no significant difference between those 3 groups (Table 4).

Discussions

One of the most common risk factors of hypertension is stress that can activate sympathetic system leading to increased blood pressure. Stress reduction with trancedental meditation program has given an advantage to condition like hypertension and psychological stress7, which is caused bylower blood pressure and pulse rate. The improvement of blood pressure and pulse rate is associated with regularity of trancedental meditation practice.8 Eventhough the underlying physiologic pathway of trancedental meditation advantageous on blood pressure was still unclear, the practice showed a a decreasing on sympathetic tones and reducing neurohormonal activity that decreased shear stress on the circulation and reduced heart load. Therefore, blood pressure reactivity decreases, even when obtaining acute behavioral stress. 9 Contact to cold will lead to increased blood pressure and pulse rate because it activates sympathetic nerve. According to the previous study, trancedental meditation gives effect to improve blood pressure and pulse rate.8 Improvement on blood pressure in this study referred to cold pressor test result that interprets as normoreactor or hyperreactor. In theory, midnight prayer has a similar effect with trancedental meditation, although the study still has to be developed. In this study, the comparation between high midnight prayer group, low midnight prayer group, and non midnight prayer group showed a slight difference even though it did not reach a statistical significance. On the contrary, the other previous study had shown the effect of meditation on developed control over sympathetic function.10 Pulse rate in this study also showed unsignificant difference. The result of pulse rate showed a similliarity to the study conducted by Mendhurwar and Gadakari.11 This unsignificant difference could be caused bythe limitation of this study. History of midnight prayer on the last one month taken by quessionaire, was not recorded every after the participant had performed midnight

prayer. Therefore, it could arise recall bias. This study does not prove the effect of midnight prayer on sympathetic tone. Blood pressure and pulse rate result of this study among those three groups shows no significant difference. Therefore, additional study with more frequent and longer period of midnight prayer should be conducted, because the other previous study which reported the reduction on blood pressure and pulse rate was done in a person practicing transcendental meditation for a long time.11 Midnight prayer probably has no short term effect, but has long term effect similar to transcendental meditation.

References

1. World Health Organization. Raised blood pressure. 2013 [cited 2013 April 22]; Available from: http://www.who.int/ gho/ncd/risk_factors/blood_pressure_ prevalence_text/en/. 2. Badan Penelitian dan Pengembangan Kesehatan Departemen Kesehatan Republik Indonesia. Laporan nasional riset kesehatan dasar 2007. Jakarta: Badan Penelitian dan Pengembangan Kesehatan Departemen Kesehatan Republik Indonesia; 2008. 3. Guyton AC, Hall JE. Textbook of medical physiology. 11th ed. Philadelphia: Elsevier Saunders; 2006. p. 758. 4. Ibrahim BS. Spiritual medicine in the history of islamic medicine. J Int Soc History Islamic Med. 2003;2:45 ̶ 9. 5. Ritesh M, Karia. Blood pressure response to cold pressure test in normal young healthy subjects: a prediction of future possibilities of hypertension. J Phys Pharm Adv. 2012;2(6):223–6. 6. Pramanik T, Regmi P, Adhikari P, Roychowdhury P. Cold pressor test as a predictor of hypertension. J Teh Univ Heart Ctr. 2009;3:177–80. 7. Schneider RH, Grim CE, Rainforth MV, Kotchen T, Nidich SI, GaylordKing C, et al. Stress reduction in the secondary prevention of cardiovascular disease: randomized, controlled trial of transcendental meditation and health education in blacks. Circ Cardiovasc Qual Outcomes. 2012;5:750–8. 8. Anderson JW, Liu C, Kryscio RJ. Blood pressure response to transcendental meditation a meta-analysis. Am J Hypertens. 2008;21:310–6. 9. Barnes VA, Treiber FA, Johnson MH. Impact of transcendental meditation on Althea Medical Journal. 2016;3(1)

Hadiyatussalamah Pusfa Kencanasari, Achmad Fauzi Yahya, Setiawan: Effect of Midnight Prayer on Sympathetic Tone

ambulatory blood pressure in africanamerican adolescents. Am J Hypertens. 2004;17(4):366–9. 10. Deepak D, Sinha AN, Gusain VS, Goel A. A Study on effects of meditation on sympathetic nervous system functional

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status in meditators. J Clin Diagn Res. 2012;6(6):938–42. 11. Mendhurwar SS, Gadakari JG. Effect of transcendental meditation on pulse rate and blood pressure. Int J of Medi and Clin Res. 2012;3(1):107–9.

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Streptococcus pneumoniae Drugs Resistance in Acute Rhinosinusitis Chong Jie Hao,1 Chrysanti Murad,2 Trias Nugrahadi3 Faculty of Medicine Universitas Padjadjaran, 2Department of Microbiology and Parasitology Faculty of Medicine Universitas Padjadjaran, 3Department of Nuclear Medicine Faculty of Medicine Universitas Padjadjaran/ Dr. Hasan Sadikin General Hospital, Bandung

1

Abstract Background: Acute rhinosinusitis that usually caused by Streptococcus pneumoniae becomes the reason why patients seek for medical care. Drugs resistance in Streptococcus pneumoniae is increasing worldwide. This study was conducted to determine drugs resistance of Streptococcus pneumonia from acute rhinosinusitis in Dr. Hasan Sadikin General Hospital. Methods: A descriptive laboratory study was conducted in June–October 2014 at the Laboratory of Microbiology Faculty of Medicine Universitas Padjadjaran. The sample was taken using nasopharyngeal swabbing from 100 acute rhinosinusitis patients in Dr. Hasan Sadikin General Hospital and planted on tryptic soy agar containing 5% sheep blood and 5 μg/ml of gentamicin sulphate and then incubated in 5% CO2 incubator at 37°C for 24 hours. The identification of Streptococcus pneumonia was performed by optochin test. The susceptibility test against Streptococcus pneumoniae was done using disk diffusion method.The antibiotic disks were trimethoprim-sulfamethoxazole, oxacillin, levofloxacin, azithromycin, and doxycycline. Results: Out of 100 samples, 8 of them were tested positive for Streptococcus pneumoniae. Three of Streptococcus pneumoniae isolates died with unknown reason after it were stored at -80 .The drugs resistance test showed the resistance of Streptococcus pneumonia to oxacillin, azithromycin and trimethoprim were 6, whereas levofloxacin and doxycycline are 4. Conclusions: Streptococcus pneumonia drugs resistance in acute rhinosinusitis shows the resistance of Streptococcus pneumoniae to oxacillin, azithromycin and trimethoprim are 6, whereas the resistance to levofloxacin and doxycycline are 4. [AMJ.2016;3(1):64–8] Keywords: Acute rhinosinusitis, drugs resistance, Streptococcus pneumoniae

Introduction Streptococcus pneumonia (S. pneumoniae) of acute bacterial rhinosinusitis occurs in adults is 20 to 45% whereas in children is 30 to 43%.1 According to European position paper on rhinosinusitis and nasal polyps 2012 (EPOS 12), rhinosinusitis is an inflammation on the nose and paranasal sinuses mucosa, characterized by two or more symptoms, with one symptoms should include nasal congestion, their nasal discharge, facial pain in the sinus area or reduction of smell. Acute rhinosinusitis is when the symptoms last less than 12 weeks and experiencing complete resolution.2 Data on the Department Otorhinolaryngology-Head and Neck Surgery

Dr. Hasan Sadikin General Hospital in 2008 found comorbid allergic rhinitis patients in the form of rhinosinusitis as much as 75%. Whereas in 2010, the incidence of rhinosinusitis is about 44%.3 The first line therapy for acute bacterial rhinosinusitis in Department of Otorhinolaryngology-Head and Neck Surgery, Dr. Hasan Sadikin General Hospital is penicillin beta lactam combine with beta lactamase inhibitor; second line is floroquinolone and macrolide. According to Infectious Disease Society of America clinical practice guideline, the first line therapy for acute bacterial rhinosinusitis in adults is amoxicillinclavulanate.4 However, amoxicillin as the first-line therapy are recorded in American Family Physician.5 For patients who allergic to

Correspondence: Chong Jie Hao, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km.21, Jatinangor, Sumedang, Indonesia, Phone: +6287822004661 Email: [email protected] Althea Medical Journal. 2016;3(1)

Chong Jie Hao, Chrysanti Murad, Trias Nugrahadi: Streptococcus pneumoniae Drugs Resistance in Acute Rhinosinusitis

penicillin, trimethoprim-sulfamethoxazole, a macrolide such as azithromycin, doxycycline and levofloxacin may be used as an alternative to amoxicillin.5,6 High medical costs and high mortality rates are associated with high S. pneumoniae antimicrobial resistance rates.7,8 This study was aimed to describe the pattern of drugs resistance, S. pneumonia from acute rhinosinusitis in Dr. Hasan Sadikin General Hospital. It is beneficial to carry out a study on drugs resistance about S. pneumoniae from acute rhinosinusitis to provide information of drug sresistance S. pneumoniae, and the approach to the management of drugs resistance S. pneumoniae infections may change greatly in the next few years.

Methods

This study was conducted using secondary data descriptive laboratory method. The susceptibility test was conducted from June to October 2014 at the Laboratory of Microbiology Faculty of Medicine Universitas Padjadjaran Bandung. The study was already approved by Health Research Ethics Committee. The samples of this study were 8 S. pneumonia that was isolated from specimens of 100 adult patients with acute rhinosinusitis in Dr. Hasan Sadikin General Hospital that was done in a previous research from Department of Otorhinolaryngology-Head and Neck Surgery. Dr. Hasan Sadikin General Hospital Bandung. The specimens of 100 acute rhinosinusitis patients were taken by nasopharyngeal swabbing and were transported using amines medium. After that, swab specimens were inoculated on tryptic soy agar plates containing 5% sheep blood and 5 μg/ml of gentamicin sulfate. Then, tryptic soy agar plates were incubated in 5% CO2 incubator at 37°C for 24 to 48 hours. Colonies of S. pneumoniae appears as a small, grey, moist (sometimes mucoidal), colonies and characteristically produce a zone of alpha-hemolysis (green) on tryptic soy agar plates.9 For confirmation of S. pneumoniae colonies, identification test of S. pneumoniae such as gram staining, catalase test,optochin test and bile solubility test should be done. After S. Pneumoniae isolates were identified, antimicrobial susceptibility testing of S. pneumoniae isolates were started by disk diffusion method. Mueller-Hinton agar medium supplemented with 5% sheep blood is recommended. The agar plates should have a uniform depth of 3 to 4 mm. The inoculum Althea Medical Journal. 2016;3(1)

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for antimicrobial susceptibility testing of S. pneumoniae from fresh pure cultures of S. pneumoniae was grown overnight on blood or chocolateagar was prepared. Cell suspensions of the bacteria were prepared to be tested in the sterile physiologicalsaline or MuellerHinton broth. A cell suspension equal to a density of a 0.5 McFarland turbidity standard was used for the inoculum. Viable colonies from an overnight sheep blood agar plate were suspended in a tube of broth to achieve a bacterial suspension equivalent to a 0.5 McFarland turbidity standard. This suspension should be used within 15 minutes. The density of the suspension was compared to the 0.5 McFarland turbidity standard.9 After the plate was dry, the antimicrobial disks such as levofloxacin, doxycycline, trimethoprim-sulfamethoxazole, azithromycin and oxacillin were placed on the plates. Sterile forceps was used to place the disks on the Mueller Hinton agar and tap them gently to ensure they adhere to the agar. The plates were incubated in an inverted position in 5% CO2 atmosphere for 20 to 24 hours at 35°C. After an overnight incubation, the diameter of each zone of inhibition was measured by a ruler or callipers. The antimicrobial susceptibility of the test strain was interpreted by comparing the results to the Clinical and Laboratory Standards (CLS ) Institute standard zone sizes and European Committee on Antimicrobial Susceptibility Testing (EUCAST) standard zone sizes.9

Results

Out of 100 samples, 8 of them were tested positive for S. pneumoniae. Three of S. pneumoniae isolates died with unknown reason after it was stored at -80 . The drugs resistance test showed the resistance of S. pneumonia to oxacillin, azithromycin and trimethoprim were 6, whereas levofloxacin and doxycycline are 4. (Figure 1)

Discussions

S. pneumonia was chosen in this study because S. pneumonia is one of the main etiology in acute rhinosinusitis. From previous study, it was described that there were 54% bacterial isolates from 100 patients with acute rhinosinusitis such as 17% Staphylococcus epidermidis, 8% S. pneumoniae, 6% Staphylococcus aureus, 5% Enterobacterdoacae,

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Figure 1 Antimicrobial Susceptibility Test of five S. pneumonia isolates 2 % Streptococcus viridans, 2% Staphylococcus saprophytious, 2% Moraxella sp, 1% Klebsiellapneumoniae, 1% Haemophillus influenzae, 2% Pseudomonas aeruginosa,1% other Haemophillus, 1% Pseudomonas luteola , and 1% Serratialiquefaciens.3 The sample sizes that are needed for this study are 65 S. pneumoniae isolates. S. pneumonia occurs in acute bacterial rhinosinusitis in adults is 20 to 45%.1 In this study, 8% samples were positive for presence of S. pneumonia. This is because specimens of 100 acute patients with acute rhinosinusitis were taken using nasopharyngeal swabbing with Dacron swabs and the swabs were transported and stored in amies medium based on the previous research from Department of Otorhinolaryngology-Head and Neck Surgery Dr. Hasan Sadikin General Hospital Bandung. There are some evidences that rayon swabs perform better than Dacron swabs for the culture of pneumococci from nasopharyngeal swabs.10 Besides, there is recommendation that rayon swabs are transported and stored in skim milk-tryptone-glucose-glycerin (STGG) prior to bacterial culture.11 All specimens should be processed within 6 hours after collection.12 S. pneumoniae isolates survived for at least 3 years in STGG (skim milk, tryptone, glucose, glycerol) medium at -80°C.13 However, out of 8 samples of S. pneumoniae isolates, there were 3 samples isolates died after it is stored at -80°C with STGG medium. Furthermore, some

evidences showed the toxins produced by bacteria that kill or inducesuicide (apoptosis and autolysis) in genetically identical members of their own species such as the murein hydrolases and the choline-binding proteins responsible for autolysis and allolysis in S. pneumoniae.14 In this study resistance of S. pneumoniae to oxacillin is 6. Oxacillin that is an alternative to beta lactams group such as amoxicillinclavulanate which is the first line therapy for acute bacterial rhinosinusitis in adults.4 This condition is happen because beta lactams group do not provide reproducible results used in this study. If the zone of inhibition around the oxacillin disk is less than 20 mm which means resistant, additional minimum inhibitory concentration (MIC) testing must be performed to assess whether the isolate is resistant or susceptible to penicillin.9 Global surveillance studies have shown that -lactamnonsusceptibility rates of S. pneumoniae increased in the worldwide during 1990s and 2000s because structural changes in the penicillin targets, the penicillin-binding proteins 1a, 1b, 2x , 2a, 2b and 3.15 In addition, increased resistance among penicillinnon-susceptibility S. pneumoniae is due to a mutation in penicillin binding protein 3 that cannot be overcome by the addition of a lactamase inhibitor.4 On the other hand, similar results showed 56 % of the S. pneumoniae isolates were penicillin-resistant.16 The study in US showed that the highest penicillin-nonAlthea Medical Journal. 2016;3(1)

Chong Jie Hao, Chrysanti Murad, Trias Nugrahadi: Streptococcus pneumoniae Drugs Resistance in Acute Rhinosinusitis

susceptibility S. pneumoniae were found in South Africa(74%),the Far East( 63%) and the Middle East (54%).15 Resistance of S. pneumoniae to azithromycin is 6. According Chow et al.4 and Liñares et al.15 showed the emergence of S. pneumoniae that carry both ermB and mefE macrolide resistance genes is a cause for concern, especially in Asia countries, Russia, South Africa, and the USA. On the other hand, the increasing in the prevalence of macrolide resistance is strongly correlated to prior antibiotic use, particularly macrolides such as azithromycin, lactams, and trimethoprim.4,15 Some similar studies showed the rates of resistance to azithromycin range from 22% to 67% for S. pneumoniae.16 Besides, macrolide resistance in Europe was high in isolates collected such as France(55.6%) were also reported.15 In this study, the resistance rate of S.pneumoniae to trimethoprim is as the same as the result during oxacillin susceptibility test of S. pneumoniae. Indeed, reports from similar studies showed the rates of resistance to trimethoprim range from 50% to 75% for S. pneumoniae. The study by Chow et al.4 showed that the resistance to trimethoprim among S. pneumoiae isolates occurs because of the mutations in the dihydrofolate reductase gene and prior exposure to trimethoprim, macrolides or penicillin. In this study resistance of S. pneumonia to levofloxacin is 4, because the mutation point producing amino acid changes in the quinolone resistance-determining regions of the subunits of DNA topoisomerase IV and DNA gyrase.15 However, some studies showed that resistance rate of S. pneumoniae to levofloxacin was 1.4% to 1.6% in more than 500 S. pneumoniae isolates.17,18 Doxycycline is active against S. pneumoniae. Data from national surveys in Canada showed that Doxycycline is highly active against S. pneumoniae (93.2%).18 Similar reports from England, Wales, and Northern Ireland, reveal that invasive isolates of S. pneumoniae have remained highly susceptible to doxycycline(91%).3 However, susceptible rate of S. pneumoniae to doxycycline is 6 because of the tetracycline resistance determinant (tetM) related to ermB macrolide resistance gene.19 There are several limitations in this study. First, limited S. pneumoniae isolates because of the lack of time in collecting the data and lack of acute rhinosinusitis patients in Dr. Hasan Sadikin General Hospital. Several steps that need to be considered for further improve the research include the use of larger sample size Althea Medical Journal. 2016;3(1)

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taken more different area which is the different hospital in Bandung to yield a better result. There are also a few steps that need to be concerned in order to prevent the spread of drugs resistance S. Pneumoniae in both community setting and health-care setting, so that the further complication can be prevented. For example, reduce antibiotic use in communities and increased understanding of other factors that contribute to the development and transmission of resistance. The most important way to reduce S. pneumoniae infections is to increase the use of existing polysaccharide vaccines and to begin to use of new polysaccharide-protein conjugate vaccines in young children. After that, educate the community and staff in health-care facilities about covering mouth and nose while sneezing and coughing and personal hygiene such as hand washing. As a conclusion, drugs resistance S. Pneumoniae from acute rhinosinusitis patient in Dr. Hasan Sadikin General Hospital showed the resistance of S. pneumoniae to oxacillin, azithromycin and trimethoprim are 6 whereas resistance to levofloxacin and doxycycline are 4.

References

1. Benninger M, Woodard T. Microbiology of acute, subacute, and chronic rhinosinusitis in adults. In: Chang CC, Incaudo GA, Gershwin ME, editors. Diseases of the Sinuses: Springer New York; 2014. p. 99 –107. 2. Mullol, Baroody, Douglas, Goossens, Hopkins, Kalogjera, et al. EPOS 2012: european position paper on rhinosinusitis and nasal polyps 2012. A summary for otorhinolaryngologists. Rhinology. 2012;50(1):1–12. 3. Pradana Y, Madiadipoera T, Sudiro M, Dermawan A. Efektivitas imunoterapi terhadap gejala, temuan nasoendoskopik dan kualitas hidup pasien rinosinusitis alergi. Oto Rhino Laryngologica Indonesiana. 2012;42(2): 88–95. 4. Chow AW, Benninger MS, Brook I, Brozek JL, Goldstein EJ, Hicks LA, et al. IDSA Clinical Practice Guideline: acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54(8):e72–e112. 5. LU I, EIM H. Acute rhinosinusitis in adults. Am Fam Physician.2011;83:1057–63. 6. Siow J, Alshaikh N, Balakrishnan A, Chan K, Chao S, Goh L, et al. Ministry of Health Clinical Practice Guidelines: management

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of rhinosinusitis and allergic rhinitis. Singap Med J. 2010;51(3):190–7. 7. Lynch III JP, Zhanel GG. Streptococcus pneumoniae: epidemiology and risk factors, evolution of antimicrobial resistance, and impact of vaccines.Curr Opin Pulm Med. 2010;16(3):217–25. 8. Jean, Hsueh. High burden of antimicrobial resistance in Asia. Int J Antimicrob Ag. 2011;37(4):291–5. 9. WHO. Manual for the laboratory identification and antimicrobial susceptibility testing of bacterial pathogens of public health importance in the developing world. 2003. p. 45–62. 10. Rubin LG, Rizvi A, Baer A. Effect of swab composition and use of swabs versus swabcontaining skim milk-tryptone-glucoseglycerol (STGG) on culture-or PCR-based detection of Streptococcus pneumoniae in simulated and clinical respiratory specimens in STGG transport medium. J Clin Microbiol. 2008;46(8):2635–40. 11. Hammitt LL, Murdoch DR, Scott JAG, Driscoll A, Karron RA, Levine OS, et al. Specimen collection for the diagnosis of pediatric pneumonia. Clin Infect Dis. 2012;54(suppl 2):S132–S9. 12. Neves FP, Pinto TC, Corrêa MA, dos Barreto R, de Moreira L, Rodrigues HG, et al. Nasopharyngeal carriage, serotype distribution and antimicrobial resistance of Streptococcus pneumoniae among children from Brazil before the introduction of the 10-valent conjugate vaccine. BMC Infect Dis. 2013;13(1):318. 13. Kaijalainen T, Ruokokoski E, Ukkonen P, Herva E. Survival of Streptococcus

pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis frozen in skim milktryptone-glucose-glycerol medium. J Clin Microbiol. 2004;42(1):412–4. 14. Cornejo OE, Rozen DE, May RM, Levin BR. Oscillations in continuous culture populations of Streptococcus pneumoniae: population dynamics and the evolution of clonal suicide. P Roy Soc B-Biol Sci. 2009;276(1659):999–1008. 15. Liñares J, Ardanuy C, Pallares R, Fenoll A. Changes in antimicrobial resistance, serotypes and genotypes in Streptococcus pneumoniae over a 30‐year period.Clin Microbiol Infec. 2010;16(5):402–10. 16. Puglisi S, Privitera S, Maiolino L, Serra A, Garotta M, Blandino G, et al. Bacteriological findings and antimicrobial resistance in odontogenic and non-odontogenic chronic maxillary sinusitis. J Med Microbiol. 2011;60(9):1353–9. 17. Orr D, Wilkinson P, Moyce L, Martin S, George R, Pichon B. Incidence and epidemiology of levofloxacin resistance in Streptococcus pneumoniae: experience from a tertiary referral hospital in England. J Antimicrob Chemoth. 2010;65(3):449– 52. 18. Patel SN, McGeer A, Melano R, Tyrrell GJ, Green K, Pillai DR, et al. Susceptibility of Streptococcus pneumoniae to fluoroquinolones in Canada. Antimicrob Agents Ch. 2011;55(8):3703–8. 19. Varaldo PE, Montanari MP, Giovanetti E. Genetic elements responsible for erythromycin resistance in streptococci. Antimicrob Agents Ch. 2009;53(2):343– 53.

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Detection of Streptococcus pyogenes from Throat Swab in Acute Pharyngitis Patients Ibnu Tsabit Maulana,1 Imam Megantara,2 Ike Rostikawati Husen3 Faculty of Medicine Universitas Padjadjaran, 2Department of Microbiology and Parasitology Faculty of Medicine, Universitas Padjadjaran, 3Department of Pharmacology and Therapy Faculty of Medicine Universitas Padjadjaran 1

Abstract Background: Pharyngitis is an inflammation of throat that may be caused by viral and bacteria. Although Streptococcus pyogenes is only responsible for 5−15% of cases of pharyngitis in adults. Antibiotics are highly prescribed for this infection, thus it could lead to antibiotic resistance. The main reason for antibiotic overprescription is the difficulty to obtain a rapid and correct etiological diagnosis. This study aimed to determine the frequency of Streptococcus pyogenes from throat swab in patient with acute pharyngitis in Padjadjaran Clinic. Methods: This study was a descriptive study. Specimen was taken from the patients in Padjadjaran Clinic on September until October 2014. Thirty-five patients with acute pharyngitis that met the selection criteria were recruited for throat swab. Then, specimens obtained were performed an identification testing to determine whether there was a colonization of Streptococcus pyogenes. Results: Thirty five patients were found with acute pharyngitis consist of 14 male and 21 female, with age ranged between 16−34 years old. From the identification testing result, Streptococcus pyogenes was not found from throat swabs of patient with acute pharyngitis in Padjadjaran Clinic. Conclusions: This study found no colonization of Steptococcus pyogenes in throat swabs of acute pharyngitis patients in Padjadjaran Clinic, however Streptococcus pyogenes was not the causative fact of acute pharyngitis. [AMJ.2016;3(1):69–72] Keywords: Acute Pharyngitis, streptococcus pyogenes, throat swab

Introduction Acute pharyngitis is an inflammation of the throat which is very common in primary health care facilities. An accurate diagnosis needs to be established so that the management given is appropriate. Virus infection is a major cause of acute pharyngitis, whereas several are caused by bacteria. However, in 15−30% of acute pharyngitis in children, and 5−15% in adults, Streptococcus pyogenes are found as the causative organism, which possibly cause a variety of serious complications, such as acute rheumatic fever and glomerulonephritis, if not dealt with accordingly.1 Antibiotics are only needed in the management of acute pharyngitis caused by Streptococcus pyogenes. Although Streptococcus pyogenes were found in only a few cases in adults, but the prescribing of

antibiotics had reached 78−98%.2 In a research by Shehadeh et al.3 it shows that the use of antibiotics among adults, especially students, are often caused by sore throat complaints, regardless the prescribing of antibiotics given. Thus, in addition to microbial resistance to antibiotics, exposure to high antibiotic will also increase the duration of treatment, cost of treatment and the number of deaths; caused by the complication of infection that has not been dealt properly.4 Centor criteria, consists of fever with temperature above 38.5oC, enlarged lymph nodes, tonsils exudation, with the absence of coughing, can be used to predict the likelihood of streptococcal pharyngitis. However, laboratory tests still need to be performed to determine the causative diagnosis. Throat swab culture is the gold standard in diagnosing streptococcal pharyngitis with 90−95%

Correspondence: Ibnu Tsabit Maulana, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km.21, Jatinangor, Sumedang, Indonesia, Phone: +6285722332332 Email: [email protected] Althea Medical Journal. 2016;3(1)

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sensitivity compared to Rapid Antigen Detection Test (RADT) which is only ranging about 70% sensitivity. High level of antibiotics prescription can be caused by various factors, such as difficulty in determining the causative diagnosis promptly, clinician assumptions about the patient’s desire to be prescribed antibiotics, as well as the tendency of clinicians to prescribe antibiotics even though the etiology is not clear.2 The frequency of Streptococcus pyogenes found on acute pharyngitis might be considered by clinicians in prescribing antibiotics. Padjadjaran Clinic is a university clinic that provides a health care access for the students and the community in Jatinangor. However, there were no studies on the frequency of streptococcal pharyngitis in this clinic. This study aimed to determine the frequency of Streptococcus pyogenes from throat swabs of adult patients with acute pharyngitis in Padjadjaran Clinic.

Methods

The study was a descriptive which conducted at the Laboratory of Microbiology, Faculty of Medicine, Universitas Padjadjaran in September to October 2014 after receiving approval from the Health Research Ethics Committee Faculty of Medicine, Universitas Padjadjaran. From the population who met the selection criteria, 35 people were selected as subjects by using consecutive sampling method. The selection criteria set out in this study were: acute pharyngitis patients with Centor criteria in Padjadjaran Clinic, aged over 15 years old, and were not on antibiotics treatment in the last 2 weeks. The subjects

Table 1 Laboratory Test Results Identification Test Types of Hemolysis Α β

were given an explanation of the purpose and the procedures to obtain the throat swabs and were asked to state their willingness by filling out and signing the informed consent. Throat swab specimen collection was conducted on the research subjects who were willing. The throat swabs obtained were taken to the laboratory to be planted on blood agar medium, observed with Gram staining, and confirmed by bacitracin test. Throat swab culture is the method used in this study, because it is the gold standard in the diagnosis of streptococcal pharyngitis which had the highest sensitivity (90−95%) compared to other methods (RADT).5 The minimum number of samples was determined using the minimum sample formula for descriptive categorical variables which resulted in 35 minimum samples.

Results

From the 35 subjects, there were 14 male and 21 female with age ranging from 16 to 34 years old. The laboratory tests showed that, from the culture on blood agar media, the percentage of beta-hemolytic colonies were 23%. Gram staining was done on those samples to identify the streptococcal colonies. From the gram staining test, 5% (2 out of 34) were positive streptococci, which both were confirmed by bacitracin test later. The bacitracin test showed negative results on both of the sample, which means the bacteria Streptococcus pyogenes were not found in this study. Based on the isolation and identification of bacteria, the results showed no bacterial colonization of Streptococcus pyogenes in Total

Percentage (%)

9

25.7

2

5.72

8

22.9

non-hemolytic (-)

18

Positive, cocci, chain (-)

6

17.14

0

0

GramStaining on β Hemolytic Positive, cocci, chain (+)

BacitracinTest on β Hemolytic and Gram-Positive Cocci Resistent (R) Sensitive (S)

2

51.4

5.72

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Table 2 Amount and Percentage of Streptococcus pyogenes Colonization S. Pyogenes Colonization Positive (+)

Negative (-)

throat swabs of all subjects.

Discussions

This study showed that, from 35 patients with acute pharyngitis, there was no colonization of Streptococcus pyogenes found in their throat swabs. This result is different when it is compared to similar studies conducted in other countries. In a study in Pakistan6, from 137 throat swabs of acute pharyngitis patients, 4.4% of Streptococcus pyogenes colonies were found. Likewise, a study in Taiwan7, 1% of Streptococcus pyogenes were found from 294 patients with pharyngitis. This condition can be caused by the number of subjects and different sampling sites, in which patients who visited the hospital tend to have more severe symptoms compared with patients who came to the clinic. In addition, more number of samples in the other two study could lead to a higher probability of finding Streptococcus pyogenes. In this study, the majority of subjects were students, whereas the rest are secondary school students and employees. This could be caused by the ownership of Padjadjaran Clinic, which is a clinic belonging to a university, so students are more likely to seek treatment at this clinic. In addition, dense population and interaction between individuals who have good health status on campus or residency area may be a risk factor of pharyngitis, allowing the subjects in this study to be mostly students.8 Hence, this may be a factor that caused Streptococcus pyogenes colonies were not found in this study. In this study, Centor criteria was used in subjects selection. It consists of fever above 38.5oC, enlarged cervical lymph nodes, tonsillar exudates, without the presence of coughing.9 Although the Centor criteria are believed to predict the streptococcal pharyngitis, but a study conducted by Roggen et al.10 indicated that the Centor criteria are not effective in predicting the presence or absence of Streptococcus pyogenes from throat swabs in children. Therefore the study still includes all acute pharyngitis patients to become research subjects although they did not meet all the Althea Medical Journal. 2016;3(1)

Frequency

Percentage (%)

0

0

35

100

Centor criteria.10 In laboratory testing, the specimens were planted on blood agar medium, and incubated for 24 hours to observe the growth of colony and the type of hemolysis formed. Although β-hemolytic colonies were found in blood agar media, but in most of the gram staining, the bacteria found were gram-negative. This can be due to gram-negative such as Haemophilus influenzae and E. coli, including the normal flora in the oropharynx, have characteristics of β-hemolysis.11 From the streptococci found in gram staining, no colonies were sensitive to bacitracin. This might because the streptococci found may not be Streptococcus pyogenes, but were Streptococcus agalactiae or Streptococcus anginosus which also have the characteristics of β-hemolysis and residential flora in the throat, resulted in the colonies found were not sensitive to bacitracin.11 Based on the survey in Jordan, 60% of people have poor knowledge on antibiotic resistance, as well as the behavior of antibiotics without prescription to treat specific symptoms, especially sore throat.3 Hence, it was suggested to conduct public education about the use of antibiotics, especially to students, in order to reduce the rate of antibiotic treatment without prescription in the community. The entire sampling and laboratory testing in this study was conducted in accordance with the standard procedures and carried out by trained staff, but do not exempt the possibility of error that Streptococcus pyogenes did not grow in blood agar medium. Further research can also be done with a larger scale, in order to obtain a more accurate percentage that can be compared to previous studies. In conclusion, this study found no colonization of Steptococcus pyogenes in throat swabs of acute pharyngitis patients in Padjadjaran Clinic

References

1. Carapetis JR. The current evidence for the burden of group a streptococcal diseases. Geneva: World Health Organization. 2004:1−57. 2. Madurell J, Balagué M, Gómez M, Cots JM,

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4. 5. 6.

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Llor C. Impact of rapid antigen detection testing on antibiotic prescription in acute pharyngitis in adults. Faringocat study: a multicentric randomized controlled trial. BMC Fam Pract. 2010;11(1):1−5. Shehadeh M, Suaifan G, Darwish RM, Wazaify M, Zaru L, Alja’fari S. Knowledge, attitudes and behavior regarding antibiotics use and misuse among adults in the community of Jordan a pilot study. Saudi Pharm J. 2012;20(2):125−33. Anis K, Ariyani K, Ikaningsih I, Retno K. Emerging resistance pathogen: recent situation in Asia, Europe, USA, Middle East, and Indonesia. Maj Kedok Indones. 2011;57(03):75−9. Choby BA. Diagnosis and treatment of streptococcal pharyngitis. Am Fam Physician. 2009;79(5):383−90. Palla AH, Khan RA, Gilani AH, Marra F. Over prescription of antibiotics for adult pharyngitis is prevalent in developing

countries but can be reduced using McIsaac modification of Centor scores: a cross-sectional study. BMC Pulm Med. 2012;12(1):1−7. 7. Hsieh TH, Chen PY, Huang FL, Wang JD, Wang LC, Lin HK, et al. Are empiric antibiotics for acute exudative tonsillitis needed in children? J Microbiol Immunol Infect. 2011;44(5):328−32. 8. Bope E. Conn’s current therapy. Philadelphia: Saunders Elsevier; 2013. p. 40−3. 9. Wessels MR. Streptococcal pharyngitis. N Engl J Med. 2011;364(7):648−55. 10. Roggen I, van Berlaer G, Gordts F, Pierard D, Hubloue I. Centor criteria in children in a paediatric emergency department: for what it is worth. BMJ Open. 2013;3(4):1−4. 11. Brooks GF, Butel JS, Morse SA. Jawetz, Melnick & Adelberg’s medical microbiology. 24th ed. New York: The McGraw-Hill Companies, Inc.; 2007.

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Knowledge and Attitude of Senior High School Students toward Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome Arnova Reswari,1 Kuswandewi Mutyara,2 Lynna Lidyana3 Faculty of Medicine Universitas Padjadjaran, 2Department of Public Health Faculty of Medicine, Universitas Padjadjaran, 3Department of Psychiatry Faculty of Medicine Universitas Padjadjaran/ Dr. Hasan Sadikin General Hospital Bandung 1

Abstract Background: Indonesia has experienced more than 25% rise of Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) incidence. One of the provinces mostly affected is West Java. Proper knowledge of HIV/AIDS can develop attitude and practice to prevent the spread of HIV/AIDS, and in effect, its incidence. This study was conducted to describe the knowledge and attitude of Senior High School (Sekolah Menengah Atas, SMA) students toward HIV/AIDS. Methods: This descriptive study was conducted using a cross-sectional method and used secondary data with total sampling technique, from Jatinangor Cohort Research Team of the Faculty of Medicine, Universitas Padjadjaran. The samples were obtained by stratified cluster random sampling. Two hundred and seventy seven students’ knowledge and attitude were assessed in Senior High School in Jatinangor, on May 2013 Results: Senior High School students in Jatinangor mostly (50.2%) had a poor level of knowledge, yet 51.3% positive attitude toward HIV/AIDS. There were still misconception regarding transmission media of HIV/AIDS and mode of transmission HIV/AIDS. Information source on HIV/AIDS were teachers (96.4%), followed by television (93.5%), internet (86.6%), friends (84.8%), health workers (69.7%), newspapers (62.1%), parents (61%), magazines (55.2%), and radio (33.2%). Conclusions: Although most of the Senior High School students in Jatinangor have a poor level of knowledge, they have a positive attitude toward HIV/AIDS. The main information source on HIV/AIDS is teacher. [AMJ.2016;3(1):73–8] Keywords: Attitude, HIV/AIDS, Jatinangor, knowledge

Introduction Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) is a disease related to the decrease of immunological functions, and it has been a major problem in many countries.1,2 According to the Joint United Nations Program on HIV/ AIDS (UNAIDS) report in 2012, Indonesia was included into the group of nations that have experienced HIV incidence more than 25% on adults (15−49 years of age) from 2001 to 2011.1 West Java is the province with the highest prevalence of AIDS in Indonesia after Papua, Jakarta Region, and East Java.3 One of the methods to prevent HIV/AIDS is by improving knowledge and attitude which can help to decrease the incidence of HIV/AIDS.4 The spread of HIV/AIDS in society can be

determined by individual knowledge and attitude towards HIV/AIDS. As such, before implementing a public health policy to prevent HIV/AIDS, much information is needed on the knowledge and attitude towards HIV/ AIDS.4 A study conducted in 2005 regarding the knowledge and attitude of society and students towards HIV/AIDS in Turkey, found a good level of knowledge to contribute a positive attitude towards HIV/AIDS.5,6 In accordance to that fact, this study aimed to describe the knowledge and attitude of Senior High School (Sekolah Menengah Atas, SMA) students towards HIV/AIDS in Jatinangor, in 2013.

Methods

This descriptive study was conducted using

Correspondence: Arnova Reswari, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km.21, Jatinangor, Sumedang, Indonesia, Phone: +62 89698281661 Email: [email protected] Althea Medical Journal. 2016;3(1)

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a cross-sectional method conducted in two Senior High School in Jatinangor, on May 2013. Total sampling was taken from Jatinangor Cohort Research Team of the Faculty of Medicine, Universitas Padjadjaran. Total respondents were the same as the total data appropriated by Jatinangor Cohort Research Team of the Faculty of Medicine, Universitas Padjadjaran, which were 277 respondents. Samples were obtained by stratified cluster random sampling conducted at Jatinangor Cohort Research Team of the Faculty of Medicine, Universitas Padjadjaran. The first stage was to choose two schools from 10 Senior High Schools (Sekolah Menengah Atas, SMA) in Jatinangor subdistrict. The SMA Negeri Jatinangor and SMA PGRI Jatinangor were chosen. In each school, a randomized method was employed to pick the classes that were the samples for the study. The study instrument was a questionnaire on knowledge and attitude prepared by the researcher. From the validation of the questionnaire, an alpha-cronbach value of 0.891 was retrieved. After signing an informed consent form, respondents would answer forty four questions in questionnaire, consisted of twenty seven questions on knowledge of HIV/AIDS, nine questions on information source on HIV/AIDS, and eight statements on attitude towards HIV/AIDS. For each question on knowledge, a correct answer was graded with value ten, while an incorrect answer or ‘do not know’ was graded zero; maximal grade in the knowledge questionnaire was 270, while the minimal was zero. The choices of information source on HIV/AIDS asked on the questionnaire were teachers, parents, health workers, friends, newspapers, magazines, television, radio, and internet. There were four positive attitude statements that were graded at thirty on strongly agree, twenty on agree, ten on disagree, and zero on strongly disagree. On the other hand, there were four negative attitude statements that were graded at zero on strongly agree, ten on agree, twenty on disagree, and thirty on strongly disagree. The maximal grade for the attitude questionnaire was 240, while the minimal was zero. After a scoring process, the data distribution of knowledge and attitude using the Kolmogorov-Smirnov method was reviewed. The level of knowledge was divided into two groups, which were good knowledge and poor knowledge. The grouping of the respondent’s knowledge level was based on the mean because the data distribution was normal (p-value was 0.116). The attitudes

of the respondents were also grouped into positive attitude and negative attitude. The basis for this grouping was the median because the data distribution was not normal (p-value was 0.001). Before conducting this study, ethical clearance was fulfilled to Health Research Ethics Committee by researcher and by Jatinangor Cohort Research Team of the Faculty of Medicine, Universitas Padjadjaran.

Results

Most students had a good knowledge on definition and causes of HIV/AIDS. As many as 219 respondents (79.1%) knew that HIV/ AIDS attacked the immunological functions of a human body. As many as 253 respondents (91.3%) knew that HIV/AIDS was categorized as a sexually transmitted infection. More than 70% of respondents knew that HIV/AIDS was caused by a virus (Table 1). Most respondents did not know the transmission media of HIV/AIDS. More than 65% of respondents knew that sperm, vaginal discharge, and blood were a transmission media of HIV/AIDS, but only 119 respondents answered that breast-milk was also a transmission media of HIV/AIDS. There were a few misconceptions on the transmission media of HIV/AIDS; some answered that tears, sweat, urine, saliva, and feces were transmission media of HIV/AIDS (Table 2). The knowledge of respondents on mode transmission of HIV/AIDS was good, more than 80% of respondents knew that sexual Table 1 Characteristics of Respondents Variable

n (%)

Gender Male

115 (41.5)

SMA Negeri Jatinangor

199 (71.8)

Female

Senior High School

SMA PGRI Jatinangor Age

15 years old 16 years old 17 years old 18 years old 19 years old

162 (58.5) 78 (28.2) 1 (0.4)

41 (14.8)

172 (62.1) 61 (22.0) 2 (0.7)

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Table 2 Knowledge of Respondents on the Transmission Media of HIV/AIDS The Transmission Media of HIV/ AIDS Tears

True

False

Do Not Know

%

%

%

44

Sperm

0.7

81.2

Vaginal Discharge

0.7

68.6

Blood

35.4

Saliva

25.3

Urine

Breast-milk

30.3

5.4

28.2

13

50.9

16.6

38.6

44.8

32.5

5.4

62.1

43

Feces

18.1

1.1

66.4

Sweat

55.2

intercourse with HIV afflicted individuals, usage of intravenous needle shared with HIV afflicted individuals, and blood transfusion contaminated with HIV were modes transmission of HIV/AIDS. There were 162 respondents recognized that tattooing needle and piercing are were a mode transmission of HIV/AIDS. However, some had misconceptions on the mode transmission of HIV/AIDS, such as mosquito bite, hand shaking, hugging, mouthto-mouth kissing, swimming in the same pool, and coughing/sneezing (Table 3). The respondents’ knowledge level on prevention of HIV/AIDS was also good. More than 80% of respondents knew that avoiding multi-partnered sexual relationship, be faithful

12.6

44.4

35

39.7

with one partner, and avoiding intravenous drug abuse were methods to prevent HIV/ AIDS (Table 4). More than 80% respondents answered disagree and strongly disagree with negative statement that HIV/AIDS was a deprecation disease. Most respondents (74.3%) had a positive attitude on statement that using condom when sexual intercourse could prevent transmission of HIV/AIDS. More than 80% respondents also had positive attitude on statement that having sexual partner more than one and using injecting drug abuse could improve risk of transmission of HIV/AIDS. However, more than 50% respondents stated negative attitude toward statement that the

Table 3 Knowledge of Respondents on Mode Transmission of HIV/AIDS Mode Transmission of HIV/AIDS Sexual intercourse individuals

with

Mother infected HIV to baby

HIV

afflicted

Usage of intravenous needle shared with HIV afflicted individuals Tattooing needle and piercing Mosquito bite

Blood transfusion contaminated with HIV

Hand shaking with HIV afflicted individuals Hugging with HIV afflicted individuals

Mouth-to-mouth Kissing

Swimming in the same pool Coughing/Sneezing

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True

False

Do Not Know

%

%

%

86.6

5.1

8.3

67.9

4.7

27.4

58.5

9.4

32.1

86.3 53.4 80.9 59.6 55.6

16.6

41.2 30.0

1.8 9.0 3.2 8.7

10.1

55.2 9.0

30.0

11.9 37.5 15.9 31.8

34.3

27.8 49.8

40.1

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Table 4 Knowledge of Respondents on Prevention of HIV/AIDS Prevention of HIV/AIDS Avoiding multi-partnered sexual relationship

False

Do Not Know

%

%

%

93.5

Be faithful with one partner

1.4

92.4

Use condom when doing high risk sexual intercourse

4.7

2.9

37.9

Avoiding intravenous drug abuse

only one of route transmission of HIV/AIDS was sexual intercourse. Most students (more than 75%) had positive attitude and stated that students afflicted with HIV/AIDS could continue schooling and were not to be isolated. However, most respondents presented a negative attitude (71.1%) to the statement that men and women with HIV/AIDS had done an immoral deed (Table 5). According to analysis using KolmogorovSmirnov method, total score of knowledge from respondents in this study had a normal distribution (p-value = 0.116). Therefore, a grouping of knowledge of respondents on

True

4.0

15.5

81.2

46.6

3.2

15.5

HIV/AIDS was based on the mean. However, total score of attitude from respondents in this study did not have normal distribution (p-value = 0.001). As such, the grouping of respondents’ attitude towards HIV/AIDS was determined using the median. The respondents’ knowledge and attitude toward HIV/AIDS were in the following (Table 6). Teachers (96.4%) were the most cited information source on HIV/AIDS, followed by television (93.5%), internet (86.6%), friends (84.8%), health workers (69.7%), newspapers (62.1%), parents (61.0%), magazines (55.2%), and radio (33.2%).

Table 5 Attitude of Respondents on Definition of HIV/AIDS, Prevention of HIV/AIDS, Transmission of HIV/AIDS, and HIV/AIDS afflicted individuals Strongly Agree

Agree

Disagree

Strongly Disagree

%

%

%

%

9.0

65.3

22.7

2.2

In my opinion, having sexual partner more than one person can improve risk of transmission of HIV/AIDS

51.3

47.7

0

1.1

In my opinion, using injecting drug abuse can do transmission of HIV/AIDS

In my opinion, HIV/AIDS is deprecation disease

41.9

7.9

0.7

In my opinion, the only one way of transmission of HIV/AIDS is sexual intercourse

3.2

49.5

25.3

32.1

In my opinion, HIV/AIDS afflicted friend shall be isolated

5.1

9.0

Attitude of Respondents Positive Attitude

In my opinion, using condom when sexual intercourse can prevent transmission of HIV/ AIDS

Negative Attitude

In my opinion, HIV/AIDS afflicted student cannot continue schooling

In my opinion, HIV/AIDS afflicted women/men have done an immoral deed

6.5

20.9

13

52.7

30.3

18.4

57.4

17.7

21.7

6.1

50.2

36.5

57.4

6.1

28.5

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Table 6 Knowledge and Attitude of Respondents toward HIV/AIDS Knowledge Mean <160.43

≥160.43

Attitude

Category

Frequency (%)

Median

Category

Frequency (%)

Poor

139 (50.2)

<150

Negative

135 (48.7)

Good

138 (49.8)

Discussions This study found that respondents mostly had poor knowledge (below the mean) on HIV/ AIDS (50.2%). There were still misconceptions on the media of transmission for HIV/AIDS. Some of these misconceptions were found in previous studies in North West Ethiophia, Turkey, Lao Democratic Republic, Isfahan City, Iran, Sudan, Sana’a City, and Merkelle City.4,6-14 In this study, a poor knowledge on respondents was not necessarily accompanied by a negative attitude, because more than 50% of respondents had positive attitude towards HIV/AIDS. Previous study on knowledge, attitude and risk behavior toward HIV/AIDS and other sexual transmitted infection among preparatory students in Gondar Town, North West Ethiopia4 showed different results that poor knowledge are accompanied by negative attitude. Poor knowledge are followed by negative attitude because in determine the whole of attitude, knowledge, mind, belief, and emotion hold the important role.15 On the other hand, previous studies in Lao Democratic Republic7, Isfahan City8, Iran10, Province of Mazandaran, Iran11, and Ethiopia16 showed that a negative attitude can follow even an individual had a good knowledge. Although the most of respondents had a positive attitude toward HIV/AIDS, a stigma remains that the HIV afflicted individual has conducted immoral deeds. This stigma was also presented in a previous study (North West Ethiophia, 2011) which stated that students’ attitude towards HIV/AIDS was combined with their concept of sexual morality, which caused them to see HIV/AIDS as a consequence to moral deviation.4 A study in Merakou10 on knowledge, attitude, and behavior after 15 years of prevention of HIV/AIDS in school showed different result, that only few students (5%) refuse to socialize with those afflicted with HIV/AIDS. Teacher was the most frequently information main source on HIV/AIDS, which differed from the previous studies that found television or radio is the most information main Althea Medical Journal. 2016;3(1)

≥150

Positive

142 (51.3)

source on HIV/AIDS.4-6,8,10-14,17 Teachers were the best source of information on HIV/AIDS since television and radio were not the most trustable source due to their manipulation with cultural values and presumption on the situation of living with people with HIV/AIDS, and the information given were frequently shallow and misleading.10 This study concluded that the level of HIV/ AIDS related to knowledge is relatively poor, yet, most respondents show positive attitude. Misconception regarding transmission media of HIV/AIDS and mode of transmission HIV/ AIDS still exist. Although the most respondents received their information from teachers in school, the introduction to HIV/AIDS through a curriculum in school can give a better and a comprehensive knowledge. Previous study have shown that educational intervention by schools have resulted higher knowledge and a more positive attitude towards HIV/AIDS.4 This study has confronted several limitations. First, because this study used secondary data from Jatinangor Cohort Research Team of the Faculty of Medicine, Universitas Padjadjaran, the researcher was not directly involved when data collected. Second, the researcher was not directly involved in questionnaire validation. Third, limitation in this study as the result of this study may only generalize to similar population of student. This study may not be applicable to students in another area because of demography factor, and also may not be applicable to adolescent who are not attending school. Fourth, the other limitation is because this study used a self-report of questionnaire, the honesty of students’ responses may be questioned. The future study hopefully can answer relationship between knowledge and attitude toward HIV/AIDS that cannot be answered in this study.

References

1. UNAIDS. Global Report: UNAIDS report on the global AIDS epidemic. Geneva, Switzerland: The Joint United Nation Programme on HIV/AIDS; 2012. [cited

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5. 6. 7.

8.

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2012 December 22]. Available from: http://www.unaids.org/en/media/ u n a i d s / c o n te n t a s s e t s / d o c u m e n t s / epidemiology/2012/gr/2012/20121120_ unaids_global_report_2012_with_ annexes_en.pdf. Pusat Data dan Informasi Departemen Kesehatan Republik Indonesia. Situasi HIV/AIDS di Indonesia Tahun 1987−2006. Pusat Data dan Informasi Departemen Kesehatan Republik Indonesia; 2006. [cited 2012 December 22]. Available from : www.depkes.go.id/downloads/publikasi/ Situasi%20HIV-AIDS%202006.pdf. Direktorat Jendral Pengendalian Penyakit dan Penyehatan Lingkungan. Laporan Kementrian Kesehatan Triwulan Ketiga 2012. Kementrian Kesehatan Republik Indonesia; 2012. [cited 2012December 22]. Available from: www.aidsindonesia.or.id/ ck_uploads/files/Fixed_LAPORAN%20 HIV-AIDS,TRIWULAN%203,%202012(1). pdf. Shiferaw Y, Alemu A, Girma A, Getahun A, Kassa A, Gashaw A, et al. Assessment of knowledge, attitude and risk behaviours towards HIV/AIDS and other sexual transmitted infection among preparatory students of Gondar Town, north west Ethiopia. BMC Res Notes. 2011;4:505. Ayranci U. AIDS knowledge and attitude in Turkish population : an epidemiological study. BMC Public Health. 2005;5:95. Koksal S, Namal N, Vehid S, Yurtsever E. Knowledge and Attitude Toward HIV/ AIDS among Turkish Students. Infect Dis J Pakistan. 2005;14:118−23. Thanavanh B, Harun-Or-Rashid M, Kasuya H, Sakamoto J. Knowledge, attitude and practices regarding HIV/AIDS among male high school students in Lao People’s Democratic Republic. J Int AIDS Soc. 2013;16:17387 Ghojavand G, Einali B, Ghaeliniya M. HIV/AIDS Knowledge and Attitude of Adolescent to Prevent AIDS in Isfahan City. IJEEFUS. 2013;3(1):63−70.

9. Nur N. Turkish school teacher’s knowledge and attitude toward HIV/AIDS. Croat Med J. 2012;7:271−7. 10. Tavoosi A, Zaferani A, Enzevaei A, Tajik P, Ahmadinezhad Z. Knowledge and attitude toward HIV/AIDS among Iranian student. BMC Public Health. 2004;4:17. 11. Majdi MR, Khani H, Azadmarzabadi E, Montazeri A, Babamahmodi F, Kariminasab MH, et al. Knowledge, attitude and practice toward HIV/AIDS among Iranian prisoner in Mazandaran province in the south-coast area of the Caspian Sea. East Mediterr Health J. 2011;17(12):904–10. 12. Khamis AH. HIV and AIDS related knowledge, beliefs and attitudes among rural communities hard to reach in Sudan. Health. 2013;5(9):1494−1501. [cited 2013 October 30]. Available from: http:// dx.doi.org/10.4236/health.2013.59203. 13. Al-Rabeei NA, Dallak AM, Al-Awadi FG. Knowledge, attitude and belief toward HIV/AIDS among students of health institutes in Sana’a city. East Mediterr Health J. 2012;18(3):221−6. 14. Swati A, Sushma B. Knowledge, attitude, and sources of information for increasing awareness about HIV/AIDS among college student. Healthline. 2013;4(1):50−7. [cited 24 October 2013]. Available from: http://www.iapsmgc.org/index_pdf/114. pdf. 15. Notoatmodjo S. Ilmu perilaku kesehatan. 1st Ed. Jakarta: Rineka Cipta; 2010. p. 29−30. 16. Tadese A, Menasbo B. Knowledge, attitude, and practice regarding HIV/ AIDS among secondary school students in Mekelle City, Ethiopia. Afr J AIDS HIV Res. 2013;1(1):001−7. 17. Nasir EF, Astrom AN, David J, Ali RW. HIV and AIDS related knowledge, sources of information, and reported need for futher education among dental students in Sudan-a cross sectional study. BMC Public Health. 2008;8:286.

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Association between Exclusive Breastfeeding and Child Development Ghaniyyatul Khudri,1 Eddy Fadlyana,2 Nova Sylviana3 Faculty of Medicine, Universitas Padjadjaran, 2Departement of Child Health Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, 3Departement of Physiology, Faculty of Medicine, Universitas Padjadjaran

1

Abstract Background: Child development highly correlates with child’s quality. The fastest child development period is during the first three years, also called golden period. This research was aimed to discover correlation between exclussive breastfeeding and child development in Cipacing Village Jatinangor, district of Sumedang. Methods: This research was conducted using cross-sectional method in thirteen Pos Pelayanan Terpadu (Posyandu) Cipacing Village in Jatinangor. One hundred and two children aged 12−24 months with their caregiver were recruited as respondents by using cluster sampling method. Hist ory of exclusive breastfeeding was assessed with questionnaire while child development status was assesed with Kuesioner Pra Skrining Perkembangan (KPSP) in September 2013 after informed consent was obtained. Chi-square test analysis was performed to determine correlation between exclusive breastfeeding and child development status. Results: Overall, children in Cipacing Village had non-exclusive breastfeeding history (83.3%), and only 16.7% respondents had exclusive breastfeeding history. Meanwhile, 89.2% of children had normal development status, and 10.8% had delayed development status. Statistic analysis using chi-square test in the level of 95% confidence between exclusive breastfeeding and child development showed p=0.686 and odds ratio 2.133. Conclusions: There is no significant relationship between history of exclusive breastfeeding and child development status. [AMJ.2016;3(1):79–84] Keywords: Child development, exclusive breastfeeding, one year old children

Introduction Development is a result from interaction between matured central nervous system and effected organs, biological changes to control gross and fine muscles, psychological changes in sosial relationship, language, and personality.1 Delayed in this aspect indicates developmental delay on children, that is still a problem in developing country, especially Indonesia. World Health Organization (WHO) in 2007 recorded that more than two hundreds million children in developing country did not reach complete development,2 while in Indonesia about 12.8−28.5% children had delayed development.3 The only food source with complete nutrients that needed by children until six months is mother’s breastmilk. Nutrient deficieny on children under two years old may reduce brain cells about 15−20%,4 disruption in

brain cell maturation processes, interupted nerve interaction for development process, such as physcomotoric, cognitive and sosial behavior. In Indonesia only 15.3% infants get exclusive breasfeeding.5 A survey on exclusive breastfeeding by World Breastfeeding Trends Initiative (WTBi) on March 2012, Indonesia ranked 3 of 81 countries.2 Locally, prevalence exclusive breastfeeding in 2012 based on data in Pusat Kesehatan Masyarakat (Puskesmas) Jatinangor is only 1.3%. A case control research conducted in Lowokharu, Malang6 in 2007, stated that there was no difference in developmental status among children aged 1−2 years old with or without exclusive breatfeeding. Contrast to a prospective cohort study in Krakow, Poland7 in 2011, that showed exclusive breastfeeding in early infancy improve cognitive children development. In accordance to explanation above, this research was aimed to discover correlation between exclusive breastfeeding

Correspondence: Ghaniyyatul Khudri, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km.21, Jatinangor, Sumedang, Indonesia, Phone: +62 852 7492 5956 Email: [email protected] Althea Medical Journal. 2016;3(1)

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and 12−24 months children development in Cipacing, Jatinangor.

Methods

This was a cross-sectional research conducted in Pos Pelayanan Terpadu (Posyandu) Cipacing Village, Jatinangor, in September 2013. After ethical clearance was approved by Health Research Ethics Committee, thirteen Posyandu were choosen from eighteen Posyandu in Cipacing Village. Samples were obtained by cluster sampling. Total respondents in this study were 102 children included their mother or caregiver. Inclusion criteria was children aged one years old that registered in Posyandu, Cipacing Village, with complete gestational age or birth weight >2500 grams, without congenital abnormality and chronic disease. Meanwhile, children without caregiver’s permission or ill children when data collection were excluded. After caregivers were explained and understood about informed consent, they should sign the form. The instruments were validated questionnaires for exclusive breastfeeding history and Kuesioner Pra Skrining Perkembangan (KPSP) questionnare for children development. Caregivers would answer five questions for children history of breastfeeding and Makanan Pendamping ASI (MP-ASI) then children development status was observed using KPSP questionnaire. Four

aspects assessed were gross motors, fine motors, language, and sosial behavior. After scoring KPSP scores, developmental status was divided into two groups, normal development (KPSP score nine to ten) and delayed development. Delayed development itself was divided into suspect developmental delay for KPSP score seven to eightand delayed development for KPSP score equal or less than six. The collected data were analyzed by using chi-square test to discover correlation between exclusive breastfeeding and children developmental status

Results

Most mother’s age were ranged in 24−34 years old (52%), more than half of them did not complete senior high school (59.8%), and there were 74.5% respondents come from upper middle sosioeconomic status based on the regional minimum wage (Upah Minimum Regional/UMR) of Sumedang. Most of the mothers work as housewives (87.3%) (Table 1). According to gender of children, it was found that boys are more than girls about 57.8%. Children with age group 12−17 months have highest percentage (60.2%) than other age ranges. There were 55.9% respondents who had siblings (Table 2). Children in Cipacing Village had nonexclusive breastfeeding history (83.3%),

Table 1 Maternal Characteristics Variable

Frequency

Percentage (%)

25−34

28

53

27.5


61

59.8

Maternal Age (years old) 15−24

≥35

Mother’s Education Level ≥senior high school Occupation Housewife Work

Sosioeconomic status Below UMR

Upper middle UMR

21 41 89 13 26 76

52

20.6 40.2 87.3 12.7 25.5 74.5

Note: UMR= Upah Minimum Regional/ Regional Minimun Wage. UMR of Sumedang District Rp 1.300.000,−/month

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Table 2 Characteristics of Children Variable

Frequency

Percentage (%)

Boy

59

57.8

12−17

62

60.2

Sex

Girl

43

Children ages (month) 18−24

42.2

40

Number of Sibling none

39.2

45

≥2

44.1

57

IMD Yes

55.9

82

No

80.4

20

MP-ASI

Appropriate by age

19.6

89

Not appropriate by age

87.3

13

Head Circumference Appropriate by age

12.7

87

Not apprpriate by age

85.3

15

14.7

Note: IMD= Inisiasi Menyusu Dini/Early Initiation of Breastfeeding,MP-ASI= Makanan Pendamping ASI/Weaning Food

and only 16.7% respondents had exclusive breastfeeding history. Meanwhile, 89.2% of children had normal development status, and 10.8% had delayed development status. Statistic analysis using chi-square test in the level of 95% confidence between exclusive breastfeeding and child development showed p=0.686 and odds ratio 2.133 (Table 3). There are misconceptions on information about breastfeeding for children under six months old. Thus, misconceptions arise from local belief when their child cries, it means that breaskmilk is not enough. Some mothers complained that there was no breastmilk is produced, that may be caused by wrong

breastfeeding technique, and others got recommendation from medical staffs nearby that combining breastmilk and formula milk even before six months were good for children nutritional status. Based on maternal age groups, the highest developmental delay are mothers in aged range 15−24 years old (45.5%). Statistically, there was no correlation between a mother’s age and the child’s development. (Table 4,5) The occupational status of mothers showed no significant relationship (p=0.35) because all children with developmental disorders came from housewives who do not work. Number of sibling’s respondents

Table 3 Correlation between Exclusive Breastfeeding and Developmental Status Exclusive Breastfeeding No

Exclusive Total

Note: OR= odds ratio

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Child Development Good n(%)

Delayed n(%)

75(88.2 %)

10 (11.8%)

16 (94.1%) 91 (89.2%)

1 (5.9%)

11(10.8%)

Total n(%)

p

OR

85(83.3%)

0.686

2.133

17(16.7%)

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Table 4 Correlation between Developmental Status and Maternal Characteristics Variable Maternal Age (year) 15−24

25−34

≥35

Mother’s Education Level

Child Development Good

Delayed

23

5

50

3

18

3


54

7

Housewife

78

11

Below UMR

22

4

≥senior high school

Occupation Work

Sosioeconomic status Upper middle UMR

37

4

13

0

69

7

p

OR

0.201 1

1.199

0.351

1.167

0.465

1.331

Note: OR= odds ratio, UMR= Upah Minimum Regional/ Regional Minimun Wage. UMR of Sumedang District Rp 1.300.000,−/month

showed no correlation with the child’s developmental status (p=1). Weaning food feeding also showed no relationship with

child’s development. Therefore, none of the characteristics have a significant relationship with child development.

Table 5 Correlation between Developmental Status and Characteristics of Children Variable

Child Development Good

Delayed

Boy

52

7

12−17

53

9

Sex

Girl

Children ages (month)

18−24

Number of Sibling

39

38

4

2

none

40

5

Yes

73

9

Appropriate by age

81

8

Appropriate by age

77

10

≥2

EarIMD No

MP-ASI

Not appropriate by age

Head Circumference

Not appropriate by age

51

18

10

14

6

2

3 1

p

OR

0.757

1.313

0.194

3.22

1

1.063

1

0.901

0.146

0.329

1

0.55

Note: OR= odds ratio, IMD= Inisiasi Menyusu Dini/ Early Initiation of Breastfeeding, MP-ASI= Makanan Pendamping ASI/Weaning Food Althea Medical Journal. 2016;3(1)

Ghaniyyatul Khudri, Eddy Fadlyana, Nova Sylviana: Association between Exclusive Breastfeeding and Child Development

Discussion Golden period is the most important phase for child development. Developmental distrubance in this phase affects worse than other period of time. Basic needs for child development includes care, affection, and stimulation. While, development itself depends on many factors such as nutrition, health, genetic, race, and sex. There are internal factor and external factor. The internal factor consists of nutrition, endocrine, immunological, maternal pshycology, radiation and infection, while the external factor is chemical.1 In the development, brain cell grows continously until three years old,4 therefore besides exclusive breastfeeding, early initiation of breastfeeding and weaning food were assessed in this research to exlude the possibility of confounding factor that might arise.8 Maternal breastmilk is the main nutrient for equal or less than six month old infant, and it was suggested to be continued until two years old. It is rich source of fatty acids and other bioactive components essential for the infant brain development. The breastmilk also contains docosahexaeoic acid and arachidonic acid that is not contained in cow’s milk.7 Related to other studies that revealed infant who were breastfeed exclusively had better score in cognitive development test than nonexclusively breastfeed infants.9 In this study, children with good development at the first year in exclusive breastfeeding group were 94.1% and in nonexclusive breastfeeding group were 88.2%. Children with delayed development were higher in non-exclusive breastfeeding group (11.8%), Therefore, no correlation found between exclusive breastfeeding and child’s developmental status (p=0.686). It was similiar to the previous research that showed no significant correlation between exclusive breastfeeding and child’s developmental status, but there were higher risk possibilities of developmental disorders for non-exclusive breastfeeding infant than exclusive breastfeed infant.4,6,7 The correlation strengh parameter used to determine risk estimate in this research is odds ratio,10 which generates value about 2.133. The value was meant that the children with non-exclusive breastfeed had 2.133 times more risk for developmental delay than exclusive breastfeeding child. The percentage of developmental delays on children in Cipacing was slightly lower (16.7%) than the average of Indonesia developmental Althea Medical Journal. 2016;3(1)

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delays on children.3 Based on maternal age groups, the highest developmental delay are mothers in aged range 15−24 years old (45.5%). Nevertheless, most mother’s age were ranged in 24−34 years old (52%), this result was in accordance with the age of pregnancy and childbirth in Indonesia.11 However, there was no correlation between a mother’s age and the child’s development, but mothers who have children less than 20 years old have a higher risk for having children with disorder and psychological health.7 Maternal education is a significant predictor of child care. The education gives mothers more knowledge about what is needed for their children such as prenatal care, nutrition prenatal and postnatal, development stimulus, authoritative parenting, positive mother-child, and parental management that is important for child development.12 In this study, more than half of the mothers did not complete the nine years study program (59.8%), this data shows poor rate of maternal education in Cipacing. Most of the mothers work as housewives (87.3%). A profession as a housewive spends more time at home that gives more opportunity for interacting and caring their children, so her expectation provide a good stimulus for child development.13 According to sosioeconomic status, there were 74.5% respondents come from upper middle sosioeconomic status based on the regional minimum wage (Upah Minimum Regional/UMR) of Sumedang, the recent study showed that sosioeconomic families were the external factors that could affect a child’s development.14 However there was no characteristic of respondent had significant correlation with children developmental status. Even though, continual poverty is more harmful on cognitive ability, intelligence quotient, and other enviromental factors that affect child development.15 In conclusion, there is no correlation between exclusive breastfeeding and child development status. Limitation for this study was insufficient number of respondents because it was restricted in one village area. Also, there were recalled bias because it depended on caregiver’s memory to retrive history foods eaten by child during last one year. Therefore, next research can be done using larger size sample and prospective cohort as research design.

References

1. Departemen

Kesehatan

Republik

84

2. 3.

4. 5. 6.

7.

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Indonesia. Pedoman pelaksanaan stimulasi, deteksi dan intervensi dini tumbuh kembang anak ditingkat pelayanan kesehatan dasar. Jakarta: Direktorat jenderal pembinaan kesehatan masyarakat; 2006. WHO. Early child development: a powerful equalizer. Final Report.Vancouver: Commission on The Social Determinants of Health; 2007. p.5−12. Purwanti R, Chair I, Soedjamiko. Penilaian perkembangan bayi risiko tinggi dan rendah pada usia 3 dan 6 bulan dengan instrumen bayley scales of infant and toddler development edisi III. Sari Pediatri. 2012;14(1):24−9. Gunawan G, Fadlyana E, Rusmil K. Hubungan status gizi dan perkembangan anak usia 1−2 tahun. Sari Pediatri. 2011;13(2):142−6. Kementrian Kesehatan Republik Indonesia. Riset Kesehatan Dasar (RISKESDAS) 2010. Jakarta: Badan Penelitian dan Pengembangan Kesehatan; 2010. Fitri LE, Putra KR. Perbedaan tingkat perkembangan anak usia 1−2 tahun menurut DDST (Denver Development Screening Test) antara yang diberikan ASI eksklusif dan yang diberikan non ASI eksklusif di Kelurahan Sumber Sari Kecamatan Lowokwaru Malang [thesis]. Malang: Brawijaya University; 2008. Jedrychowski W, Perera F, Jankowski J, Butscher M, Mroz E, Flak E, et al. Effect of exclusive breastfeeding on the development of children’s cognitive function in the Krakow prospective birth cohort study. Eur J Pediatr. 2012;171(1):151−8.

8. Rajeshwari K, Bang A, Chaturvedi P, Kumar V, Yadav B, Bharadva K, et al. Infant and young child feeding guidelines: 2010. Indian Pediatr. 2010;47(12):995−1004. 9. Syahrir L, Fadlyana E, Effendi SH. Comparison of language and visual-motor developments between exclusively and non-exclusively breastfed infants through cognitive adaptive test/ clinical linguistic and auditory milestone scale. Paediatr Indones. 2009;49(6):337−41. 10. Sopiyudin DM. Statistik untuk kedokteran dan kesehatan. 5th ed. Jakarta: Salemba Medika; 2011. 11. Kementrian Kesehatan Republik Indonesia. Pendewasaan usia perkawinan dan hak-hak reproduksi bagi remaja Indonesia. Jakarta: Badan penelitian dan pengembangan kesehatan; 2008. 12. Augustine JM, Cavanagh SE, Crosnoe R. Maternal education, early child care and the reproduction of advantage. Soc Forces. 2009;88(1):1−29. 13. Sinaga R. Hubungan pola asuh ibu bekerja dengan perkembangan sosial anak usia prasekolah di Kelurahan Karang Anyar Gunung Kecamatan Candi Sari Semarang [thesis]. Semarang: Diponegoro University; 2008. 14. Tanuwidjaya S. Kebutuhan dasar tumbuh kembang anak. In: Narendra MB, Sularyo TS, Soetjiningsih, editors. Tumbuh kembang anak dan remaja. 1st ed. Jakarta: Sagung Seto; 2002. p. 13−21. 15. Schoon I, Jones E, Cheng H, Maughan B. Family hardship, family instability, and cognitive development. J Epidemiol Community Health. 2012;66(8):716−22.

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Knowledge, Attitude, and Practice Survey among Nurses in Dr. Hasan Sadikin General Hospital toward Tuberculosis-Human Immunodeficiency Virus Collaboration Program Helen Oktavia Sutiono,1 Arto Yuwono Soeroto,2 Bony Wiem Lestari3 Faculty of Medicine Universitas Padjadjaran, 2Department of Internal Medicine Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung, 3Department of Epidemiology and Biostatistics Faculty of Medicine Universitas Padjadjaran 1

Abstract

Background: One of the barriers on implementation of Tuberculosis-Human Immunodeficiency Virus (TBHIV) collaboration is lack of health care workers’ knowledge to this program. This study aimed to measure level of knowledge, attitude, and practice among inpatient nurses in Dr. Hasan Sadikin General Hospital toward TB-HIV collaboration program and to measure their correlation. Methods: This was a cross-sectional study with total sampling method which started on May–October 2013 at Internal Medicine Department ward in Dr. Hasan Sadikin General Hospital. Knowledge, attitude, and practice of research subjects were measured using modified questionnaire about TB-HIV collaboration program, based on guidelines from WHO and National Ministry of Health. Results:Of 88 respondents, there were no respondent had high level, 33 respondents (38%) had moderate level, and 55 respondents (63%) had low level of knowledge toward collaboration. For attitude, 53 respondents (60%) had positive attitude and 35 respondents (40%) had negative attitude. The study also showed 48 respondents (55%) had positive practice and 40 respondents (46%) had negative practice. The correlation between knowledge and attitude, knowledge and practice, and attitude and practice were not statistically significant (p>0.05). Conclusions: The level of knowledge among inpatient nurses in Dr. Hasan Sadikin General Hospital toward TB-HIV collaboration program was low but they showed positive attitude toward the collaboration itself. There was no correlation between knowledge, attitude, and practice among inpatient nurses toward collaboration. Further efforts were needed to improve nurses’ knowledge, attitude, and practice on TB-HIV collaboration. [AMJ.2016;3(1):85–92] Keywords: Attitude, knowledge, nurses, practice, TB-HIV

Introduction Tuberculosis (TB) is the most common opportunistic infection among Human Immunodeficiency Virus (HIV) infections.1 In 2012, 320,000 people died of TB-HIV and there were an estimated 1.1 million new TBHIV cases.2 Indonesia was included as one of the high TB-HIV burden countries and ranked fourth as a country with the most TB-HIV cases in Southeast Asia Region.3 The prevalence of HIV infection among new TB cases was 3% while according to second quarterly report in 2011 the prevalence of TB among AIDS cases was 50%.4 Indonesia was increasingly important in the global TB-HIV control.5 The World Health Organization (WHO) and

Stop TB Partnership devised an international policy guideline toward TB-HIV collaboration which important to monitor TB-HIV collaboration and to decrease the mortality of TB-HIV patients.6-8 Nevertheless, there were still some barriers in implementation of collaboration. Lack of knowledge and skill of health care workers are one of some barriers in collaboration beside the limitedness of health care workers, infrastructure of the hospital, drug supply, referral system, and internal factors of patients.5,9-11 This lack of knowledge among health care workers could lead to denied access among patients to health services, suboptimal health care services and lead to an increasing non communicable disease burden and death.12 The studies

Correspondence: Helen Oktavia Sutiono, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km.21, Jatinangor, Sumedang, Indonesia, Phone: +62 817 9622 266 Email: [email protected] Althea Medical Journal. 2016;3(1)

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AMJ March 2016

regarding level of knowledge, attitude, and practice among health care workers toward TBHIV collaboration at Dr. Hasan Sadikin General Hospital have yet never been done. This study aimed to measure level of knowledge, attitude, and practice among inpatient nurses in Dr. Hasan Sadikin General Hospital toward TBHIV collaboration program and to measure their correlation.

Methods

This cross-sectional study was conducted in May–December 2013. Inpatient nurses in Dr. Hasan Sadikin General Hospital who actively involved in TB-HIV collaboration had been given informed consent. The nurses willing to complete a questionnaire were selected as research subjects. Total sampling or survey method was used in this study because of a few researches discussing specifically about knowledge, attitude, and practice survey among health care workers toward this program. The study used primary data, a modified questionnaire based on guidelines from WHO and National Ministry of Health, which was proved by Health Research Ethics Committee and applied in October 2013 at Internal Medicine Department ward of Dr. Hasan Sadikin General Hospital. The questionnaire consisted of questions about characteristics of respondent and questions about knowledge, attitude, and practice among inpatient nurses toward TB-HIV collaboration program. Knowledge questions were 21 items in multiple choice questions. Attitude questions were 21 items and practice questions were 9 items, in likert scale. Validation of questionnaire had been conducted on July–September 2013. Validity testing conducted were face validity, a validity test by consultation with the experts about the contents, either by TB or HIV doctors’ team, and content validity resulting a strong and very strong correlation. Reliability testing was also measured using α-cronbach value (α=0.749) which means strong or high correlation. Afterward, the valid questionnaire was applied with an agreed mechanism by the room leaders in each department. The collected data was then analyzed. In the beginning, an investigation whether the data is distributed normally (parametric test) or not (nonparametric test) using KolmogorovSmirnov was done. Level of knowledge was categorized into high, moderate, and low

level based on classification of knowledge by Arikunto. It can be called as high if percentage ≥75%, moderate if 56% ≤ percentage <75%, and low if percentage <56%. Attitude of respondents was categorized into positive attitude (percentage ≥median) and negative attitude (percentage
Results

From 111 research subjects, 88 questionnaires had been obtained from nurses who agreed to become respondents and signed informed consent sheet. Other 23 nurses could not fill the questionnaire because of study and pilgrimage issues. From 88 respondents, only 12 nurses (14%) had attended TB-HIV training, including DOTS (Directly Observed Treatment, Shortcourse) training, collaborative TB-HIV, PMDT (Programmatic Management of Drug-resistant TB), HDL (Hospital DOTS Linkage), PITC (Provider-Initiated Counseling and Testing) & VCT (Voluntary HIV Counseling and Testing), MDR-TB (Multi-drug-resistant tuberculosis), IMAI (Integrated Management of Adolescent and Adult Illness), palliative care for PLWA (People Living with HIV/AIDS), and treatment compliance. Survey presented there were no respondent had high level, 33 respondents (38%) had moderate level, and 55 respondents (63%) had low level of knowledge toward collaboration. Median of attitude percentage in this study was 80% with minimum 67% and maximum 95%. This survey results stated that 53 respondents (60%) had positive attitude and 35 respondents (40%) had negative attitude. Median of practice percentage in this study was 40% with minimum 20% and maximum 80%. In 88 inpatient respondents, 48 respondents (55%) had positive practice and 40 respondents (46%) had negative practice. In Kolmogorov-Smirnov test, knowledge, attitude, and practice score have p=0.000. Because of p<0.05, these three variables had not normal distribution. In Spearman test, the correlation between knowledge and attitude of the respondents was negative and very weak (r=-0.069), not statistically significant Althea Medical Journal. 2016;3(1)

Helen Oktavia Sutiono, Arto Yuwono Soeroto, Bony Wiem Lestari: Knowledge, Attitude, and Practice Survey among Nurses in Dr. Hasan Sadikin General Hospital toward Tuberculosis-Human Immunodeficiency Virus Collaboration Program

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Table 1 Characteristic of Respondents Variable

Frequency

Percentage (%)

20–29 years

33

38

50–59 years

2

2

Age

30–39 years 40–49 years

Sex

41 12

47 14

Male

22

25

Civilian employee

62

71

Female

Employment status Contract staff Others

Length of civilian employee <2 years

66 22 4

2

75 25 5

2

2–10 years

37

42

1st floor Fresia

14

16

>10 years

Department

2nd floor Fresia 3rd floor Fresia Flamboyan

1st floor Kemuning

23 24 23 11

26

27 26 8

7

10

17

19

≤10 years

71

81

Ever

12

14

5th floor Kemuning

Profession

S1 Keperawatan

D3 Keperawatan SPK/SPR

Length of work >10 years

TB-HIV training which had been accepted Never

(p>0.05). The correlation between knowledge and practice of the respondents was positive and very weak (r=0.153), not statistically significant (p>0.05). The correlation between attitude and practice of the respondents was also positive and very weak (r=0.155), not Althea Medical Journal. 2016;3(1)

9

70 1

17 76

13

80 1

19 86

statistically significant (p>0.05). In Kolmogorov-Smirnov test, knowledge, attitude, and practice score have p=0.000. Because of p<0.05, these three variables had not normal distribution. In Spearman test, the correlation between knowledge and attitude

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Table 2 Description of Level of Knowledge among Respondents toward TB-HIV Collaboration Program Know

Do not know

N

%

N

%

collaboration

61

69

27

31

3.

Example of TB-HIV collaboration activities to decrease TB burden for PLWAs

38

43

50

57

5.

Control of TB infection in health care services and specific places.

75

85

7.

Role and function of nurses in TB unit

1. Objectives of TB-HIV implementation in Indonesia

2. Model of TB-HIV collaboration program service in Dr. Hasan Sadikin General Hospital

4. Example of TB-HIV collaboration activities to decrease HIV burden for TB patients

6. Role of health care workers in TB-HIV collaboration 8. 9.

Screening of TB in PLWA

Thorax x-ray examination for TB suspects AFB negative in diagnosis of TB for PLWH

10. Strategy of HIV testing and counseling in TB patients to decrease HIV burden in TB patients

5

48

66

86

66

43 4

6

55

75

98

96

14. Referral system in TB-HIV collaboration services

6

68 7

15. Indication of cotrimoxazole therapy

20

23

18. Reporting of collaborative TB-HIV program from HIV unit

19

22

19. The success indicator of TB-HIV collaboration program

20. The success indicator of TB-HIV collaboration activities in HIV unit

21. The success indicator of TB-HIV collaboration activities in TB unit

of the respondents was negative and very weak (r=-0.069), not statistically significant (p>0.05). The correlation between knowledge and practice of the respondents was positive and very weak (r=0.153), not statistically significant (p>0.05). The correlation between attitude and practice of the respondents was also positive and very weak (r=0.155), not statistically significant (p>0.05).

28

33

75

42

45

2

84

78

17. Reporting of collaborative TB-HIV program

2

25

5

69

16. Recording of HIV cases in TB program

22

15

25

42

13. Action of PITC implementation in DOTS unit

13

46

22

49

37

60

40

94

75

11. Definition of PITC (Provider Initiated Testing and Counseling) 12. Principal of PITC implementation

83

32

38

85

48

51

45

51

28

19

82

68

60

55

69

13

46

43

51

58

32

22

93

77

68

63

78

15

52

49

Discussion Survey presented that there were no respondent had high level, 33 respondents (38%) had moderate level, and 55 respondents (63%) had low level of knowledge toward collaboration. The study showed that the level of knowledge of respondents was mostly low and lower if compared to the research conducted by Tikuye13 about knowledge, Althea Medical Journal. 2016;3(1)

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Table 3 Description of Attitude of Respondents toward TB-HIV Collaboration Program Statement

VA n (%)

A n (%)

D n (%)

1. Implementation of TB-HIV collaboration in Indonesia is important to decrease TB and HIV burden in society.

72 (82)

15 (17)

1 (1)

0 (0)

0 (0)

3. In my opinion, TB-HIV collaboration program increases my work burden as health care worker.

19 (22)

48 (55)

16 (18)

2 (2)

3 (3)

17 (19)

12 (14)

38 (43)

13 (15)

59 (67)

6 (7)

3 (3)

1 (1)

2. Model of TB-HIV collaboration service should be appropriate with health care facility condition. 4. 5.

In my opinion, TB-HIV collaboration activities purposed to decrease HIV burden in TB patients are important to do, beside to decrease TB burden in PLWA.

In my opinion, effort to control both of TB infection and HIV infection will make stigmatization and discrimination to TB and HIV patients.

36 (41)

51 (58) 8 (9)

6. In my opinion, just counselor and doctor had a right to do TB screening, whereas nurses had not.

19 (22)

8.

13 (15)

7. In my opinion, assessment of HIV risk factor in TB patients and patient reference to HIV unit can be done by both doctors and nurses in TB services. 9.

In my opinion, TB screening only needs to do to PLWH who complain TB sign and symptom. AFB examination is important to diagnose TB for PLWH.

10. One of HIV testing and counseling strategy for TB patients in Indonesia is toward screening of risk factor.

11. PITC which had been done to TB patients is an effort to decrease HIV burden in TB patients. 12. Communication, information, and education about TB-HIV is important to give to patients before doing PITC.

13. In my opinion, HIV risk factor screening in TB patients is very important for early TB-HIV cases finding. 14 In my opinion, it is important to know whether the TB patients are HIV positive or not to determine the appropriate treatment.

15. Cotrimoxazole therapy for PLWH is purposed to decrease the number of morbidity and mortality because of co-infected or not with TB.

16. Recording and reporting of TB-HIV collaboration program is important to do in TB and HIV unit.

17. In my opinion, monitoring and evaluating of TB-HIV collaboration program is important to determine the accomplishment of program by indicator of program success.

18. In my opinion, important components in monitoring and evaluating of TB-HIV collaboration program are recording and reporting process.

19. In my opinion, data in TB-HIV collaboration report should be integrated between TB and HIV unit, so it makes easier data tabulation and analysis.

20. In my opinion, total of PLWH receiving TB service is one of important indicator for TB-HIV collaboration program success in HIV care unit.

21. In my opinion, total of HIV positive patients receiving cotrimoxazole preventive therapy is important indicator for TB-HIV collaboration program success in TB care unit.

Althea Medical Journal. 2016;3(1)

19 (22)

51 (58)

37 (42) 48 (55) 40 (46)

1 (1)

0 (0)

11 (13)

0 (0)

50 (57)

12 (14)

63 (72)

1 (1)

24 (27)

32 (36)

16 (18)

36 (41)

24 (27)

20 (23)

37 (42)

28 (32)

20 (23)

54 (61)

62 (71)

52 (59)

63 (72)

65 (74)

47 (53)

57 (65)

45 (51)

5 (6)

1 (1)

25 (28)

54 (61)

5 (6)

0 (0)

10 (11)

0(0)

29 (33)

0 (0)

0 (0)

22 (25)

38(43) 58 (66)

0 (0)

3 (3)

43(49) 22 (25)

NA VNA n (%) n (%)

5 (6)

1 (1)

1 (1)

8 (9)

0 (0)

0 (0)

3 (3)

2 (2)

2 (2)

19 (21)

7(8) 3 (3)

3 (3)

0 (0)

1 (1)

2 (2)

0 (0)

0 (0)

0 (0)

1 (1)

0 (0) 2 (2)

0(0) 0 (0)

1 (1)

0 (0)

0 (0)

0 (0)

0 (0)

1 (1)

0 (0)

1 (1)

1 (1) 2 (2)

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AMJ March 2016

Table 4 Description of Practice of Respondents toward TB-HIV Collaboration Program Statement 1.

2.

3.

4. 5.

6.

Attending the TB-HIV collaboration meeting in Dr. Hasan Sadikin General Hospital. Doing TB screening to PLWHs.

Doing HIV risk factor screening to hospitalized TB patients. Asking TB patients to be done HIV examination.

Giving information about the result of HIV testing in TB patients. Giving information about TB screening to PLWHs.

7. Giving communication, information, and hospitalized TB patients about HIV/AIDS. 8.

9.

Attending the collaborative TB-HIV training.

education

Filling the TB05 form for sputum examination demand.

Note: * A=always; O=often; S=sometimes; SE=seldom; N=never

attitude, and practice of health care providers towards Isoniazid Preventive Therapy (IPT) provision in Addis Ababa, Ethiopia. That research concluded that from 104 health care providers, 74 respondents (71%) had high knowledge towards IPT, 29 respondents (28%) had moderate knowledge, and only one respondent (1%) had low knowledge. This could be caused by many respondents who had been trained in collaborative TB-HIV, including IPT. 13 In Dr. Hasan Sadikin General Hospital, TBHIV training had always been conducted but only a few nurses had attended TB-HIV training. From 88 respondents, only 12 respondents (14%) who had attended TB-HIV training and 76 respondents (86%) had not. A research in Uganda by Okot-Chono14 and Uwimana et al.15 explained that collaborative TB-HIV activities might had not been well implemented due to lack of training of TB-HIV collaboration for all health care workers related to this collaboration, besides minimal follow-up supervising after training, lack of structural collaborative TB-HIV mechanism in facilities, low and unstandardized collaborative TBHIV stipend for health care workers leading demotivation, and lack of manual for TB-HIV collaboration. In addition, a study from PakenhamWalsh et al.12 stated that lack of knowledge of health care workers was due to little access to information among health care workers and failure of international information policies. A clear, authoritative, referenced manual was also important for avoiding discrepancies between recommended services and practice. A study also revealed that active participation

to

A n (%)

O n (%)

S n (%)

SE n (%)

N n (%)

1(1)

4(5)

6(7)

14(16)

63(72)

24(27)

22(25)

17(19)

7(8)

19(22)

16(18)

0(0)

3(3)

16(18)

12(14) 2(2)

3(3)

2(2)

0(0)

9(10)

13(15)

13(15)

14(16)

12(14) 1(1)

11(13)

11(13)

21(24)

26(30) 8(9)

26(30)

27(31)

31(35)

18(21)

23(26)

22(25)

11(13)

14(16)

19(22)

31(35)

51(58)

27(31)

26(30)

68(77)

28(32)

like training of health care workers was fundamental.12 This study illustrated that over 50% of respondents seemed did not know about model of TB-HIV collaboration service in Dr. Hasan Sadikin General Hospital that was a parallel model because of the independent between unit TB and unit HIV.4 This study also found that over 50% of respondents appeared did not know about the strategy of HIV testing and the definition of PITC. A study of Okot-Chono14 said that it is important to know PITC in TBHIV collaboration since the implementation of PITC will increase the number of TB-HIV patients who were screened for HIV resulting in lower rates of morbidity and mortality of TB-HIV patients. Over 50% respondents also appeared did not know about referral system, therapy, recording, and reporting in TB-HIV collaboration. An analysis of interaction between TB-HIV programs in Sub-Saharan Africa16 established by WHO showed that the lack of knowledge of health care workers was caused by low national awareness to TB-HIV interaction, lack of priority to collaborative TB-HIV activity, lack of resources, lack of ability from an organization in implementation of TB-HIV collaboration program, and lack of communication between two units. This survey revealed that there were 53 respondents (60%) had positive attitude and 35 respondents (40%) had negative attitude. The study has the same result with a study conducted in Ethiopia by Tikuye13 which attitude of health care workers toward IPT practice in average was positive attitude (69%). This is due to the high level of knowledge of Althea Medical Journal. 2016;3(1)

Helen Oktavia Sutiono, Arto Yuwono Soeroto, Bony Wiem Lestari: Knowledge, Attitude, and Practice Survey among Nurses in Dr. Hasan Sadikin General Hospital toward Tuberculosis-Human Immunodeficiency Virus Collaboration Program

the IPT.13 Awareness of duty and authority of respondents in TB-HIV collaboration program were might had been good. It was evidenced by more than 50% respondents’ statement that they were willing to give service for TBHIV patients and nurses have rights doing TB and HIV screening. The study revealed that there were 48 respondents (55%) had positive practice and 40 respondents (46%) had negative practice. Practice of respondents of the study in TBHIV collaboration generally was relatively less when compared to practice of health care providers towards IPT practice in the study by Tikuye13 that good practice in average (81.7%) and the rest had fair practice. Over 50% of respondents stated that they have never attended TB-HIV collaboration meeting and training as well as have been given information about result of HIV testing to TB patients. Most of respondents also stated that they hardly or have never done TB screening to PLWHs and HIV risk factor screening to hospitalized TB patients. They also have never asked TB patients for doing HIV examination have never given information about TB screening and HIV/AIDS, and have never filled the TB05 form for sputum examination. This was similar to a research conducted by Okot-Chono14 which explained that the implementation of TB-HIV collaboration in the recording and reporting of TB-HIV cases was somewhat poor. Then, from sample of 28 patients with HIV in the Forum Group Discussion (FGD), 21% had never been screened for TB.14 One of the causes was due to the lack of knowledge among health care providers about the program and policy of the collaboration and the role of each health care providers in collaboration itself.14 Negative practice of these respondents might be caused by different program and policy structure between Dr. Hasan Sadikin General Hospital and National Ministry of Health, as well as lack of an internationally agreed package of care for TB-HIV patients.16 This study found that there was no correlation between knowledge, attitude, and practice among respondents toward collaboration itself. It might indicate that their knowledge, attitude, and practice were built independently each other.17 A research of IPT practice by Tikuye13 explained that there was a significant relationship between knowledge and attitude (p=0.000), which meant a high level of knowledge would form a positive attitude. However, there was no significant relationship between knowledge and practice Althea Medical Journal. 2016;3(1)

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(p=0.368) as well as between attitude and practice (p=0.257) IPT. Limitations of this study were restricted time for data collection. Therefore, questionnaires were applied to each room leader and took one week later. Because of the self-report questionnaires, the honesty of respondents’ answers should be questioned. In conclusion, knowledge among inpatient nurses in Dr. Hasan Sadikin General Hospital toward TB-HIV collaboration program was mostly low, attitude among most inpatient nurses toward this program was positive, but practice among inpatient nurses toward this program was still lacking. Nevertheless, there was no statistically significant correlation between knowledge, attitude, and practice among inpatient nurses toward TB-HIV collaboration program. Suggestion from this study was there is a need to increase TB-HIV collaboration training and enclose more health care workers who active in this program for joining the training, provisioning of follow up after TBHIV collaboration training, constructing specific modules for the program, increasing communication and integration of TB-HIV collaboration, involving TB & HIV community in every TB-HIV workshops, and integrating political commitment in TB-HIV collaboration. For the next research, it was suggested to prolong time of data collection for more reliable data collection method, by an example to gather the respondents in a room for answering the questionnaires collectively.

References

1. Corbett E, Watt C, Walker N, Maher D, Williams B, Raviglione M, et al. The growing burden of tuberculosis: global trends and interactions with the HIV epidemic. Arch Intern Med. 2003;163:1009–21. 2. WHO. Tuberculosis. Saudi Med J. 2013;34(11):1205–7. 3. Aung M, Moolphate S, Paudel D, Jayathunge M, Duangrithi D, Wangdi K, et al. Global evidence directing regional preventive strategies in Southeast Asia for fighting TB/HIV. J Infect Dev Ctries. 2013; 7(3):191–202. 4. Mustikawati D, Wandra T, Surya A, Rizkiyati N, Nugrahini N, Sampoerno H, et al. Manual pelaksanaan kolaborasi TBHIV di Indonesia. Jakarta; Kementerian Kesehatan RI; 2012. 5. Mahendradhata Y, Ahmad R, Lefevre P, Boelaert M, Stuyft P. Barriers for introducing

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HIV testing among tuberculosis Patients in Jogjakarta, Indonesia: a qualitative study. BMC Public Health. 2008; 8:385. 6. Harries A, Zachariah R, Corbett E, Lawn S, Santos-Filho E, Chimzizi R, et al. The HIVassociated tuberculosis epidemic. Lancet. 2010; 375:1906–19. 7. Getahun H, Gunneberg C, Granich R, Nunn P. HIV infection-associated tuberculosis: the epidemiology and the response. Clinical Infectious Diseases. 2010; 50(S3): S201–7. 8. Eang M T, Vun M C, Eam K K, Sovannarith S, Sopheap S, Bora N, et al. The multi-step process of building TB/HIV collaboration in Cambodia. Health Research Policy and Systems. 2012; 10: 34 9. Nansera D, Bajunirwe F, Kabakyenga J, Asiimwe PK J, Mayanja-Kizza H. Opportunities and barriers for implementation of integrated TB and HIV care in lower level health units: experiences from a rural western Ugandan district. African Health Sciences. 2010; 10(4): 312–9. 10. Njozing B, Edin K, Sebastián M, Hurtig A. Voices from the frontline: counsellors’ perspectives on TB-HIV collaborative activities in the Northwest Region, Cameroon. BioMed Central. 2011;11:328. 11. Wandwalo E, Kapalata N, Tarimo E, Corrigan C, Morkve O. Collaboration between the national tuberculosis programme and a non-governmental organization in TB-HIV care at a district level: experience from

Tanzania. African Health Sciences. 2004; 4(2):109–14. 12. Pakenham-Walsh N, Bukachi F. Information needs of health care workers in developing countries: a literature review with a focus on Africa. Human Resources for Health. 2009; 7: 30. 13. Tikuye A. Knowledge, attitude, and practices of health care providers towards isoniazide preventive therapy (IPT) provision in Addis Ababa, Ethiopia [dissertation]. South Africa: University of South Africa; 2013. 14. Okot-Chono R, Mugisha F, Adatu F, Madraa E, Dlodlo R, Fujiwara P. Health system barriers affecting the implementation of collaborative TB-HIV services in Uganda. Int J Tuberc Lung Dis. 2009; 13(8):955–61. 15. Uwimana J, Zarowsky C, Hausler H, Jackson D. Engagement of nongovernment organisations and community care workers in collaborative TB/HIV activities including prevention of mother to child transmission in South Africa: Opportunities and challenges. BMC Health Services Research. 2012; 12: 233. 16. Stop TB Department Communicable Diseases Programme. An analysis of interaction between TB and HIV/AIDS programmes in Sub-Saharan Africa. Geneva: WHO; 2001. 17. Chendake M, Mohite V. Assess the knowledge and attitude of nursing students towards HIV/AIDS. Indian J Sci Res. 2013; 4(1): 69–74.

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Association of Ascariasis with Nutritional and Anemic Status in Early School-Age Students Chin Annrie Eidwina,1 Lia Faridah,2 Yudith Setiati Ermaya,3 Dida Akhmad Gurnida3 1 Faculty of Medicine, Universitas Padjadjaran, 2Departmen of Microbiology & ParasitologyFaculty of Medicine Universitas Padjadjaran, 3Department of Child Health Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung Abstract Background: Ascariasis is one of the most frequent helminthias is that occurred in school-age children. Commonly, severe intensity of infection will seriously affect the nutritional and anemic status of the students. The aim of this study was to determine the association of ascariasis with nutritional and anemic status in early school-age students. Methods: An analytical cross-sectional study was conducted based on the secondary data from Jatinangor Cohort. The secondary data of 74 students who met the criteria were included in this study. Data collection was conducted in the Department of Epidemiology and Biostatistics from August to September 2014. The data obtained was analyzed based on the characteristics of the students regarding gender, age, class, parents’ education, ascariasis, nutritional and anemic status. Then, the data were further analyzed to determine the association of ascariasis with nutritional and anemic status of the students using the chi square test or Fisher test if the requirement was not fulfilled. Results: Sixteen (22%) students were having Ascaris lumbricoides infection, six (8.1%) students were thin and seventeen (23%) students were anemic. There was no statistically significant association found of Ascaris lumbricoides infection with nutritional and anemic status in early school-age students (P value <0.05) in this study. Conclusions: There is no statistically significant association of Ascaris lumbricoides infection with nutritional and anemic status of the early school-age students. [AMJ.2016;3(1):93–8] Keywords: Anemia, ascariasis, nutritional status, early school-age students

Introduction Helminthiasis is a disease that is usually neglected by the community whereby it will not affect people when light intensity infection occurs. However, when the infection becomes more severe, it will give out a range of health symptoms.1 Children are the most unprotected people from helminthiasis which usually comes from a poor sanitation area that lacks hygiene, clean water supplement and access to health care. It can become worse with a low family status with low educational level.2 Among the types of helminthiasis, infection of Ascaris lumbricoides is recorded the highest with 819.0 million people worldwide when compared to Trichuris trichiura and hookworms in 2010.3 Fulfilling all the risk factors of ascariasis such as high air humidity, poor sanitation and

hygiene plus located in a tropical area with the community’s bad habits, has caused Indonesia becomes one of the endemic countries with ascariasis. Ascaris lumbricoides grows, feeds and breeds inside the human body. As theworm population increase exceeds 500, it covers most of the intestine of the child and may disturb the nutrient’s digestion and absorption. Then, this will lead to protein-energy malnutrition, vitamin A deficiency and anemia.4 Seemingly, the condition of the surroundings fulfilled the requirement for the ascariasis life cycle thus, this study was conducted to know the association of ascariasis with nutritional and anemic status in early school-age students.

Methods

An analytical cross-sectional study was

Correspondence: Chin Annrie Eidwina, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km.21, Jatinangor, Sumedang, Indonesia, Phone: +62 81912765289 Email: [email protected] Althea Medical Journal. 2016;3(1)

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conducted based on the secondary data from Jatinangor Cohort that was carried out from July to August 2013. The secondary data collection was from a larger study conducted at the Department of Epidemiology and Biostatistics Faculty of Medicine Universitas Padjadjaran from August to September 2014. The population of this study was students aged 5 to 9 years who were in Class I to Class III from 2 elementary schools in Jatinangor. The selected subjects were all early school-age students particularly from Class 1 to Class 3 (aged 5-9 years) by using the total sampling technique. The subjects who had performed the fecal examination to identify presence of Ascaris lumbricoides eggs with complete data about the nutritional (body mass index) and anemic (hemoglobin level) status were included in this study. However, in accordance with the part of knowledge, attitude and practices in the questionnaire of the study, the students who got other infections and incomplete data were excluded from this study. The minimal sample in this study was 105 students. Besides, the secondary data of 74 students who met the criteria were also included in this study. The secondary data were analyzed based on the student’s characteristics of gender, age, class, parents’ education, ascariasis,

nutritional and anemic status. Further analysis was performed to determine the association of ascariasis with nutritional and anemic status of the student. The analysis of association was carried out by using the SPSS 15.0 software. The independent variable was ascariasis and the dependent variables were nutritional and anemic status of the students whereby both independent and dependent variables were classified based on the nominal classification. Consequently, the data obtained were analyzed by using the Chi-square test with p value<0.05. However, Fisher’s exact test was the alternative way if the requirement of the Chi-square test was not fulfilled.

Results

More than half of the students in this study were female when compared to male students. The number of students involved according to age varied between 7-9 years old. It seemed that the higher class, the number of students also increased. The educational level of parents was mostly from senior high school followed by the second highest was from junior high school. This could indicate the educational level of the parents in this study was moderate (Table 1).

Table 1 Characteristic of Students Characteristic

Frequency (n)

%

Male

34

46

7 years

21

28

Gender Female Age

8 years 9 years Class

Class I

Class II

Class III

Parents’ Education Elementary School Junior High School

Senior High School College

40 25 28 19 25 30 19 20 32 3

54 34 38 26 34 40 26 27 43 4

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Table 2 Prevalence of Ascariasis in Each Class Ascariasis Class

Positive

Negative

Frequency,n

Percentage,%

Frequency,n

Percentage,%

9

12

10

13

16

22

I

II

5

III

7

2

Total

20

3

27

28

38

58

78

Table 3 Prevalence of Nutritional and Anemic Status among Students Characteristic

Frequency (n)

Nutritional status Thin

%

6

8

Normal

68

92

Normal

57

77

Anemic status Anemia

17

It showed that the most number of students infected by ascariasis was in Class I, whereby the number of students in Class I was the lowest among the 3 classes. However, the least infected with ascarisis were students from Class III, whereby the number of students in Class III was the highest (Table 2). Most of the students in this study had normal nutritional and anemic status. However, the number of students who were thin was less than the student who was anemic (Table 3). There were no significant association of infection with Ascaris lumbricoides and nutritional status based on the Fisher’s exact test statistics with P-value was above α value=0.05 (Table 4). There were no significant association of infection with Ascaris lumbricoides and anemic status based on the Fisher’s exact test statistics with P-value was above α value=0.05

23

(Table 5).

Discussion It was found that the number of students infected with ascariasis showed a decrease as the class increased. This was supported by a study conducted in Edo state, Nigeria5 which stated that as the age of children increased, the prevalence of the child to get infected wih Ascaris lumbricoides would decrease. However, there was one study conducted in Osun State, Southwest of Nigeria by Adefioye OA et al.6 who stated that the prevalence of ascariasis that occurred in students at Osun5 was as much as 36.2%. The percentage was considered higher than the prevalence of Ascaris lumbricoides infection in school-age students of this study. This could be influenced

Table 4 Distribution of Students Based on Ascariasis and Nutritional Status Nutritional Status Infection Positive

Negative

Thin

Normal

Frequency

Percentage

Frequency

Percentage

1

2

15

20

5

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7

53

71

Total (%)

P-value

16(22)

0.614

58(78)

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Table 5 Distribution of Students Based on Ascariasis and Anemic Status Anemic Status Infection Positive

Negative

Anemia

Non-anemia

Frequency

Percentage

Frequency

Percentage

3

4

13

18

14

19

by several factors such as the timing of the fecal collection, surrounding conditions and other geographical factors that lead to the difference in the prevalence of Ascariasis.6 In addition, it showed that the majority of students had a normal nutritional status. This number was nearly lower when compared to the statistics in ‘Indonesia Basic Health Research 2013’ by the Ministry of Health Indonesia which showed that there was 11.2% of children aged 5 to 12 years who were having thin nutritional status.7 This could indicate that the nutritional status of the students in this study was good because of the balance between the nutrients intake and requirements of the body. This could be influenced by several factors such as the parent’s education level and the volume of food intakes. Most of the parents in this study had a moderate educational level since most of them were from senior high school (Sekolah Menengah Atas, SMA) or junior high school (Sekolah Menengah Pertama, SMP). This was be supported by a previous study conducted by Srivastava et al.8 in India who stated that mothers who had an educational level ≤6th standard were significant risk factor of malnutrition in their children. There was also another study conducted in Banda Aceh, Indonesia9 which showed that the students who have healthy weight with mother who have middle and high educational level have higher prevalence than those who have mother with lower educational level. However, the percentage of the thin students in this study had not reached the standard of prevalence of the World Health Organization (WHO).10 The WHO has stated that the standard of prevalence of the underweight child in a population must be ≤5%.10 Anemia is a pathological condition where the hemoglobin level is low. It was found that more than half of the students had normal hemoglobin level which means the students have no anemia. This condition might be considered good since most of the students had enough nutrition according to the

44

59

Total (%)

P-value

16(22)

0.467

58(78)

statistical analysis above about nutritional status in this study that led to the avoidance of occurrence of anemia. However, the number of students who had anemia was lower than that in the ‘Indonesia Basic Health Research’ where it showed 29% of children aged 5 to 12 years have anemia.7 This may indicate the numbers of early school-age students who are anemic have decreased. This was supported by the study conducted in Mexico by Torres et al.11 who stated that the children with low body mass index have the highest prevalence of anemia. As in this study, the number of students who were thin was lower than students who were anemic. This can be influenced by the increased risk for the co-occurrence of anemia and obesity that is associated with gender and age of the children.11 Based on the research conducted in Mexico, the children who are aged 5 to 9 years are easier to have the condition of anemia and obesity that occurred at the same time.11 It showed that there was no significant association of ascariasis with nutritional status in this study. This can be supported by the study carried out in Ethiopia12 which reported that ascariasis and malnutrition have no association significantly. In contrast, Shang et al.13 have conducted a study in China reported that one of the risk factor to cause stunting is the moderate-to-heavy intensity infection of soil-transmitted helminth. When compared with this study, the method to identify the infection is different with which they had used to find the intensity of infection by using the Kato-Katz technique.13 However, in this study, the bigger research just used the saline wet mount technique to identify whether the eggs of Ascaris lumbricoides was present or not. The Kato-Katz technique could not be performed in this study due to the stool sample given by the students was in little portion. To be more specific, a study conducted in Nigeria14 proved that Ascaris lumbricoides infection had associated with anthropometric measurement among 418 children who lived in both rural and urban area that meant the infection could Althea Medical Journal. 2016;3(1)

Chin Annrie Eidwina, Lia Faridah, Yudith Setiati Ermaya, Dida Akhmad Gurnida: Association of Ascariasis with Nutritional and Anemic Status in Early School-Age Students

cause worse effect of nutritional status. In addition, there was also no significant association between ascariasis and anemic status in this study. Based on the study conducted in Malaysia by Ngui et al.15, it reported that there was no significant correlation between Ascaris lumbricoides eggs and hemoglobin level of the children. Besides, they also used the serum ferritin level in order to identify the anemia that is caused by Ascaris lumbricoides infection which is the iron deficiency anemia.15 This was due to the sensitivity of the test which was higher when compared with the hemoglobin level in order to detect anemia in children.5 However, the study conducted in Edo state, Nigeria5 showed a significant association between Ascariasis and anemia that used hemoglobin levels as the parameter. This was caused by the technique used to identify the Ascaris lumbricoides infection. The study which was conducted in Nigeria5 used the same technique as in this study. The difference between these two studies was that in the study conducted in Nigeria5, a recheck was performed for the negative infection by using a formal ether concentration method. Besides, the number of students in the study conducted in Nigeria was higher than in this study.5 This was due to most of the data from the larger study was incompletely based on each variable in this study which led to more samples were excluded. As conclusion, this study finds that there is no significant association of ascariasis with nutritional and anemic status in early schoolage students. This is due to several limitations in the study such as the number of sample did not reach the minimal sample because of the incomplete data and the method used by the larger study to identify the Ascaris lumbricoides eggs was not specific. There are several recommendations from this study. Firstly, more samples are needed in order to find a very significant association of ascariasis with nutritional and anemic status. In addition, the technique used to identify the Ascaris lumbricoides infection needs to be more specific either use the Kato-Katz technique to find the intensity of the infection or use a more concentrated method as suggested in the WHO. Lastly, increase awareness of parents about the importance of the examination should be performed to the students in order to identify the types and the impact of the infection to nutritional and anemic status of the students and the filling out of data from the larger study should be completed according to actions or Althea Medical Journal. 2016;3(1)

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examinations performed to the students.

References

1. Ogbaini-Emovon E, Eigbedion A, Ojide C, Kalu E. Prevalence and impact of socioeconomic/enviromental factors on soiltransmitted helminth infection in children attending clinic in a Tertiary Hospital in Benin City, Nigeria. IJBAIR. 2014;3(2):65– 70. 2. Abossie A, Seid M. Assessment of the prevalence of intestinal parasitosis and associated risk factors among primary school children in Chencha town, Southern Ethiopia. BMC Public Health. 2014;14(1):166. 3. Pullan RL, Smith JL, Jasrasaria R, Brooker SJ. Global numbers of infection and disease burden of soil transmitted helminth infections in 2010. Parasit Vectors. 2014;7(1):37. 4. Paniker CJ. Textbook of medical parasitology. 6th ed. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd; 2007. 5. Osazuwa F, Ayo OM, Imade P. A significant association between intestinal helminth infection and anaemia burden in children in rural communities of Edo state, Nigeria. N Am J Med Sci. 2011;3(1):30–4. 6. Adefioye OA, Efunshile AM, Ojurongbe O, Akindele AA, Adewuyi I, Bolaji O, et al. Intestinal helminthiasis among school children in Ilie, Osun State, Southwest, Nigeria. Sierra Leone J Biomed Res. 2011;3(1):36–42. 7. Kementerian Kesehatan Republik Indonesia. Riset Kesehatan Dasar. Jakarta: Kementerian Kesehatan Republik Indonesia; 2013. 8. Srivastava A, Mahmood SE, Srivastava PM, Shrotriya VP, Kumar B. Nutritional status of school-age children-A scenario of urban slums in India. Arch Public Health. 2012;70(1):8. 9. Badrialaily, Jutatip Sillabutra, Pantyp Ramasoota. Nutritional status and related factors among elementary school students in Banda Aceh Municipality, Nanggroe Aceh Darussalam province, Indonesia. Journal of Public Health and Development. 2008;6(1):102–12. 10. Kementerian Kesehatan Republik Indonesia. Profil Kesehatan Indonesia Tahun 2012. Jakarta: Kementerian Kesehatan Republik Indonesia; 2012. 11. Torres OP, Evangelista-Salazar JJ, Martínez-

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Salgado H. Coexistence of obesity and anemia in children between 2 and 18 years of age in Mexico. Bol Med Hosp Infant Mex. 2011;68(6):431–7. 12. Amare B, Ali J, Moges B, Yismaw G, Belyhun Y, Gebretsadik S, et al. Nutritional status, intestinal parasite infection and allergy among school children in northwest Ethiopia. BMC Pediatr. 2013;13(1):7. 13. Shang Y, Tang LH, Zhou SS, Chen YD, Yang YC, Lin SX. Stunting and soil-transmittedhelminth infections among school-age pupils in rural areas of southern China.

Parasit Vectors. 2010;3(1):97. 14. Opara KN, Udoidung NI, Opara DC, Okon OE, Edosomwan UE, Udoh AJ. The impact of intestinal parasitic infections on the nutritional status of rural and urban school-aged children in Nigeria. IJMA. 2012;1(1):73–82. 15. Ngui R, Lim YAL, Kin LC, Chuen CS, Jaffar S. Association between anaemia, iron deficiency anaemia, neglected parasitic infections and socioeconomic factors in rural children of West Malaysia. PLoS Negl Trop Dis. 2012;6(3):e1550.

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Visual Acuity of Patients after Neodymium:Yttrium-Aluminium-Garnet Laser at Cicendo Eye Hospital in 2013-2014 Lee Pei Yie,1 Budiman,2 Ihrul Prianza Prajitno3 Faculty of Medicine Universitas Padjadjaran, 2Department of Ophthalmology Faculty of Medicine, Universitas Padjadjaran/National Eye Center Cicendo Eye Hospital, Bandung, 3 Department of Anatomy and Cell Biology Faculty of Medicine Universitas Padjadjaran

1

Abstract Background: Indonesia ranks the second highest in blindness worldwide. One of the factors that may cause blindness is posterior capsule opacification (PCO), a secondary cataract that developed after cataract surgery. PCO eventually leads to visual impairment. The common management for PCO is neodymium:yttriumaluminium-garnet (Nd:YAG) laser posterior capsulotomy. It is an effective, non-invasive, and painless procedure. The aim of this study was to describe the visual acuity of PCO patients after Nd: YAG laser posterior capsulotomy. Methods: A descriptive study was conducted based on simple randomized secondary data from Cicendo Eye Hospital, Bandung from January 2013 to August 2014. Results: Out of 102 patients, 53 patients (51.96%) were male and 49 (48.04%) were females. The male to female ratio was 1:1. The maximum number of patients was at age group of 60−69 years (33.33%). Sixty− nine patients (67.65%) presented mild or no visual impairment uncorrected visual acuity (UCVA) postlaser. Eighty-nine patients (87.25%) presented mild or no visual impairment best-corrected visual acuity (BCVA) post-laser. Generally, 94 patients (92.16%) showed improvement of visual acuity after Nd:YAG laser posterior capsulotomy. Three patients (2.49%) were suffering from blindness UCVA post-laser and 1 patient (0.98%) falls at blindness BCVA post-laser respectively. Conclusions: Improvement of visual acuity is achieved after Nd:YAG laser posterior capsulotomy in PCO patients. [AMJ.2016;3(1):99–102] Keywords: Nd:YAG laser, posterior capsule opacification, visual acuity

Introduction According to the World Health Organization (WHO), approximately 285 million people in the world are visually impaired. This includes 39 million people are blind and 246 million people are having low vision. Globally, cataract is the second major cause of visual impairment, which occupied 33%.1,2 Indonesia is the second country with the highest rate of blindness in the world, which is around 1.5 percent of the population, or 3.5 million people , who are listed as legally blind. Cataract is an opacity of the crystalline lens of the eye or its capsule.3 To remove the opacification a cataract surgery is needed. However, there is a common complication for this surgery, the posterior capsule opacification (PCO).4 The PCO is a development of opacity or

clouding at the posterior part of the capsule. It obstructs the light passage, and causes visual impairment. The incidence of PCO around the world is 20% within a year after cataract surgery and 50% five years after surgery. The risk factors of PCO are the type of lens and young age. Some studies show the growth of the epithelial cells of young people is more than elderly.4 There is a simple and effective procedure, neodymium:yttrium-aluminiumgarnet (Nd:YAG) laser posterior capsulatomy, which is indicated to treat posterior capsule opacification. This Nd:YAG laser is focus at the center of the opacified posterior capsule, and an opening is formed, therefore the light can pass though the capsule, and lead to a clear vision.5 Therefore, a study was conducted to describe the visual outcome of Nd:YAG laser posterior capsulatomy in posterior capsule opacification patients at Cicendo Eye Hospital

Correspondence: Lee Pei Yie, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km.21, Jatinangor, Sumedang, Indonesia, Phone: +6282115211528 Email: [email protected] Althea Medical Journal. 2016;3(1)

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from January 2013 to August 2014.

Methods

A descriptive study was conducted and data collected from January 2013 to August 2014 by using the retrospective method at Cicendo Eye Hospital Bandung. The study population was the patients who were admitted to Cicendo National Eye Hospital Bandung with posterior capsule opacification and were treated with Nd:YAG laser posterior capsulatomy from January 2013 to August 2014. The samples were selected using the simple random sampling method. The samples were taken from the medical records with certain inclusion and exclusion criteria. Inclusion Criteria were such as the medical records of posterior capsule opacification patients with completed visual acuity data and completed with 1 week postoperative follow up. The medical records of posterior capsule opacification patients with eye diseases other than posterior capsule opacification or treated with operations other than Nd:YAG laser posterior capsulatomy were excluded from the study. The variables included gender, age, and visual acuity. Thus, the patients were categorized into male and female. For the age group, the patients were categorized into age 0−9, 10−19, 20−29, 30−39, 40−49, 50−59, 60−69, 70−79, and 80−89 years old. Meanwhile, the visual acuity of the patients was categorized according to the WHO visual acuity classification, no light perception, 0−˂0.02, 0.02−˂0.05, 0.05−˂0.1, 0.1−˂.03, 0.3−1. The study instrument was the medical records of posterior capsule opacification patients who were treated with Nd:YAG laser posterior capsulatomy at Cicendo Eye Hospital from January 2013 to August 2014. Furthermore, the medical records that met the inclusion and exclusion criteria were categorized into variables and calculated to

obtain the percentage. Data collected from the medical records included the gender, age, preoperative UCVA, preoperative BCVA, postoperative UCVA, and postoperative BCVA. Then, the percentage of each variable in the total of patients was calculated. Additionally, the information of patients taken from medical records was confidential to protect the patients’ privacy.

Results

Out of 102 patients, 53 patients (51.96%) were male and 49 (48.04%) were females. The male to female ratio was 1:1. The maximum number of patients was at the age group of 60-69 years, which occupied by 34 patients (33.33%). Sixty-nine patients (67.65%) presented mild or no visual impairment uncorrected visual acuity (UCVA) post-laser. Eighty-nine patients (87.25%) presented mild or no visual impairment best-corrected visual acuity (BCVA) post-laser. Three patients (2.49%) were suffering from blindness UCVA postlaser and 1 patient (0.98%) falls at blindness BCVA post-laser respectively. Generally, 94 patients (92.16%) showed improvement of visual acuity after Nd:YAG laser posterior capsulotomy.

Discussion

The emergence of Nd:YAG laser in the management of PCO, has improved the visual outcome of cataract surgeries. Fifty three patients (51.96%) were males and 49 patients (48.04%) were females (Table 1). The male to female ratio was 1:1. Based on a previous study, there were 47 male patients (52.2%) and 43 females patients (47.8%), the male to female ratio was equal to 1:1, these results were the same as in this study. Another study also showed almost similar sex ratio.6 This is due to the leading cause of blindness worldwide, that cataract occurs equally among male and

Table 1Gender of Patients who had Undergone Nd: YAG Laser Posterior Capsulotomy from January 2013 to August 2014. Gender Male

Female Total

Frequency

%

53

51.96

49

102

48.04

100.00

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Lee Pei Yie, Budiman, Ihrul Prianza Prajitno: Visual Acuity of Patients after Neodymium:Yttrium-Aluminium- 101 Garnet Laser at Cicendo Eye Hospital in 2013-2014

Table 2 Age of Patients who had Undergone Nd: YAG Laser Posterior Capsulotomy from January 2013 to August 2014. Age (in years)

Frequency

%

0−9

3

2.94

10−19

6

20−29

5.88

3

30−39

2.94

1

40−49

0.98

10

50−59

21.57

6

5.88

60−69

34

Total

102

70−79

9.80

22

33.33

17

80−89

female, thus when routine cataract surgeries are performed, complications such as PCO can also occur in equal proportions.7 The maximum number of patients was in the age group of 60−69 years (33.33%), the second was in the age group of 50−59 years (21.57%) with 22 patients, then in the age group of 70−79 years (16.17%) with 17 patients. A total 71.07% of patients were at the range of 50-79 years, this may due to these patients had consulted the Ophthalmologist with age related cataract (Table 2). Based on a previous study, most patients (77.8%) were in the 41−80 years age range. It showed a wider age range, this was due to wider setting of age range (20 years) in the previous study, whereas this study applied a smaller age range (10 years) to show more accurate and precise results.7 At the same time, another previous study showed that the average age of patients

16.17

100.00

was 76.49 years.8 After the treatment of Nd: YAG laser posterior capsulotomy, both number of patients in mild and no visual impairment of BCVA and UCVA were the highest numbers, which were 69 patients (67.65%) and 89 patients (87.25%) respectively. In general, 94 patients (92.16%) had significant improvement of vision outcome after Nd: YAG laser capsulotomy (Table 3). Based a on previous study, 97% patients were having improved visual acuity, which was higher than in this study, this was probably due to the threemonth follow-up after the Nd: YAG laser capsulotomy. Meanwhile, the data available for this study was limited, which was one week follow-up after the Nd: YAG laser capsulotomy.9 Based on another previous study, most of the patients (86%) showed improved visual acuity, which was lower than in this study (92.16%), but this may be due to

Table 3 UCVA dan BCVA 1 Week Pre-laser and Post-laser

Frequency (%) UCVA NLP

0−˂0.02

0.02−˂0.05

0.05−˂0.1

0.1−˂0.3 0.3−1.0 Total

UCVA

BCVA

Pre-laser

Post laser

Pre-laser

Post-laser

0

0

0

0

0

12 (11.76)

14 (13.73)

38 (37.52) 38 (37.52)

102 (100.00)

0

3 (2.49)

4 (3.92)

26 (25.49) 69 (67.65)

102 (100.00)

Note: *UCVA=uncorrected visual acuity, *BCVA=best-corrected visual acuity Althea Medical Journal. 2016;3(1)

0

7 (6.86)

7 (6.86)

25 (24.51) 63 (61.76)

102 (100.00)

0

1 (0.98)

2 (1.96)

10 (9.80)

89 (87.25)

102 (100.00)

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the larger sample size, the 86% means 160 patients out of 200 patients.10 However, 3 patients (2.49%) were having BCVA blindness and 1 patient (0.98%) was having UCVA blindness respectively, even though they were treated with the laser. These non-improvements in vision outcome may be attributable to the presence of media opacities or other ocular pathology which were not detected earlier before the procedure. Based on a previous study, 5 patients (5.6%) presented with visual acuity of blindness post laser procedure, which was higher than in this study, which probably means currently, Indonesia can provide doctors with better skills, environments for better healing, or increase awareness of public the importance of eyes caring.7 Due to lack of time and the great number of uncompleted medical records data may cause the limitations of this study. A few recommendations are suggested after conducting this study. The time assigned for data collection can be prolonged for the sake of adequate sample size. Follow up by the patients after treatment should be demanding to assess the condition of recovery phase, since a lot of patients did not return to the hospital for a follow up in this study. A computerized storage of medical records will provide a lot benefit, such as saving space, easy to look for, neat and tidy. In conclusion, the improvement of visual acuity is achieved after the Nd:YAG laser posterior capsulotomy in PCO patients at Cicendo Eye Hospital from January 2013 to August 2014.

References

1. WHO. Visual impairment and blindness.

2013 [cited 2014 October 28]. Available from: http://www.who.int/mediacentre/ factsheets/fs282/en/index.html. 2. Vision 2020 Australia. Towards 2020. 2010 [cited 2014 October 28]. Available from: http://www.vision2020australia. org.au/. 3. Wormstone IM, Wride MA. The ocular lens: a classic model for development, physiology and disease. Philos Trans R Soc Lond B Biol Sci. 2011;366(1568):1190−2. 4. Hashemi H, Mohammadi SF, Majdi M, Fotouhi A, Khabazkhoob M. Posterior capsule opacification after cataract surgery and its determinants. Iranian Journal of Ophthalmology. 2012;24(2):3−8. 5. Khanzada MA, Jatoi SM, Narsani AK, Dabir SA, Gul S. Is the Nd:YAG laser a safe procedure for posterior capsulotomy. Pak J Ophthalmol. 2008;24(2):73−8. 6. Bari KN. Nd:YAG laser posterior capsulotomy and visual outcome. Delta Med Col J. 2013;1(1):16−9. 7. Ajite KO, Ajayi IA, Omotoye OJ, Fadamiro CO. Visual outcome of patients with posterior capsular opacificationn treated with Nd:YAG laser. JMMR. 2013;1(4):23−7. 8. Hawlina G, Olup BD. Nd: YAG laser capsulotomy for treating posterior capsule opacification. Journal of the Laser and Health Academy. 2013;2013(1):S34−S5. 9. Gupta ML. Visual benefits of nd yag laser capsulotomy study in South Eastern Rajasthan. Int J Biol Med Res. 2012;3(4):2507−14. 10. Gregor VS. The sudy of complications of Nd:YAG laser capsulotomy. Int J Bioinformatics Res. 2012;4(2):265−8.

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Characteristics of Older Adult with Balance Disorder in Rehabilitation Clinic of Dr. Hasan Sadikin General Hospital 2014 Ku Shi Yun,1 Irma Ruslina Defi,2 Lazuardhi Dwipa3 Faculty of Medicine Universitas Padjadjaran, 2Department of Physical Medicine and Rehabilitation Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung,, 3Department of Internal Medicine Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung 1

Abstract Background: Older adult population is increasing worldwide. Balance has an important role in conducting daily activity and mobility. Impaired balance can lead to negative impacts, for example falling. This study was conducted to obtain common factors and characteristics of older adult with balance disorder to provide better rehabilitation services. Methods: A descriptive study was conducted at Physical Medicine and Rehabilitation Clinic of Dr. Hasan Sadikin General Hospital Bandung, from August to October 2014 using total sampling method and a 5 times sit-to-stand (5STS) test was conducted. The total samples obtained were 34. Results: The characteristics of older adult with balance disorder in this study were mostly from young old (n=17), male gender (n=19), and mean 5STS test which was 18.48 seconds. Most of the patients had high blood pressure (n=29), normal body mass index (BMI) (n=22), independent activity of daily living (ADL) (n=21), and use of greater than 3 drugs (n=21).The most common disease found was musculoskeletal disease and majority of patients had one medical disease. Conclusions: Older adult categorized as young old have the greatest frequency of having balance disorder. Increase in age, increases the duration of 5STS test conducted. The most common problem among older adult is high blood pressure, musculoskeletal disease, and hypertension, and majority of the patients consume greater than 3 drugs. Lastly, most of the BMI and the ADL of the older adults are normal. [AMJ.2016;3(1):103–9] Keywords: Balance disorder, five time-sit-to-stand, older adult

Introduction The older adult population is increasing, based on World Health Organization (WHO), it is approximated that in 2050, the population of older adults will be 16% of the total population in the world.1 In Indonesia, the aging population increases with the country development and it is predicted to rise four times of the origin of year 2010 around 18.04 million (7.59%).2 Older adult is defined as people who are 60 years old and above, or in some countries, are 65 years and above.1 Older adult categorization is divided into young old (60–69 years), middle-aged old (70–79 years), old old (80–89 years), very old old (greater than 90 years).3 Aging is a normal physiological process; increase in age causes physiological

changes and may affect the ability to conduct the activity of daily living (ADL). Balance disorder is commonly faced by older adults, and they often encounter instability leading to negative impacts, for example falling.4 This problem is often neglected among older adults and much effort is required to visit the physician’s office.5 Balance involves a complex multisensory system which includes vision, auditory, and proprioception. Balance control is required in everyday life, which includes the ability to carry out daily activities.4 Balance disorder is a “condition that makes you feel unsteady or dizzy, as if you are moving, spinning, or floating, even though you are standing still or lying down” as stated by National Institute on Deafness and Other Communication Disorders

Correspondence: Ku Shi Yun, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km.21, Jatinangor, Sumedang, Indonesia, Phone: +62 1221682051 Email: [email protected] Althea Medical Journal. 2016;3(1)

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using a standardized chair with height 43cm. Patients were asked to sit and stand as fast as possible for 5 times, and the time required to complete the task was recorded. The cut-off point used for this 5STS test was 12 second or more; patients with 12 seconds and above during test were regarded as having balance disorder. The 5STS test does not require specialized equipment and has the ability to measure balance, muscle strength, and also risk of fall.8 The ADL questionnaire was measured using the barthel index to assess the independence of the older adult. Blood pressure, height, and weight were measured and converted into body mass index (BMI).The numbers of drug consumed and current medical illness were asked through interviewing the patients and some were read of the charts. The data collected were recorded in a research formula, and were transferred into Microsoft Excel. The variables of the study are age, gender, BMI, blood pressure, ADL, numbers of drug used, and current medical disease. The results are presented in table form with frequency.

(NIDCD).6 There are many factors that may affect balance, these include age, gender, underlying diseases, body weight, multiple use of drugs and many others.4 Based on previous study, balance is much common among female gender and increasing age. Moreover, hypertension, diabetes, and arthritis are common among common underlying diseases.7 The main objective of this study was to obtain the common characteristics that present among older adults with balance disorder and to provide better rehabilitation services to patients. Early identification of older adults with balance disorder can prevent negative impacts and precautionary steps should be taken.

Methods

The study conducted was a descriptive study using total sampling methods of patients who visited the Physical Medicine and Rehabilitation Outpatient Clinic of Dr. Hasan Sadikin General Hospital Bandung from August to October 2014. Subjects were selected based on inclusion criteria where patients were 60 years old and above, signed inform consent, were willing to cooperate, and able to follow the instructions, had the ability to ambulate their household, and lastly, based on the 5 times sitto-stand test (5STS) of 12 seconds or greater. The exclusion criteria were those who were using walking aid, numerating pain scale of 5 or above, and cognitive problems. Therefore, there were 34 older adults who met inclusion critera. The ethical clearance was obtained from the Dr. Hasan Sadikin General Hospital Bandung before the study was conducted. Patients were approached and inform consent was done before conducting the study. Simple instructions were explained to patients in conducting the 5STS test. The patients were asked to be seated with backs leaning on the chair with arms folded throughout the test,

Result

The numbers of sample obtained were 34 older adults aged 60 years and above. The mean 5STS test was 18.48 seconds among older adults with balance disorder with a minimum of 12.03 seconds and a maximum of 44.54 seconds. The characteristics studied were gender, age, 5STS test, blood pressure, body mass index (BMI), activity of daily living (ADL), numbers of drug used and medical disease. The table below showed the general characteristic of the data. Table 2 shows that male older adults with balance disorder were greater compared to female older adults, whereas the mean 5STS among both genders was above 12 seconds,

Table 1 General Characteristics of Older Adult with Balance Disorder General Characteristics Gender (n=34) Age (n=34)

Male

Female

Young old

(60–69 years)

Middle-aged old ( 70–79 years) Old old

Very old old

(80–89 years) (>90 years)

Frequency(n) 19 15 17 11 6 0

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Table 2 Characteristic based on Gender of Older Adult with Balance Disorder Gender

Age (year)

5 STS (seconds)

BMI (Kg⁄((m)2 ))

(mean ± SD)

(mean ± SD)

(mean ± SD)

(70 ± 8)

(16 ± 4)

(24 ± 3)

Male (n=19)

Female (n=15)

Note: *SD: standard deviation

(70 ± 8)

(22 ± 9)

and in female older adults the mean time required to complete the 5STS was greater than males. In this study, the BMI was of a normal range in both genders. Table 3 shows that with increasing age, the mean time required to complete the 5STS was greater, the range of the test was differed by 5 seconds from the minimum time required to the maximum time required. Table 4 shows the majority of the older adults with balance disorder who had abnormal blood pressure which was high, whereas, BMIolder adults with balance disorder which was greater than half had normal BMI. In the

(22 ± 4)

abnormal category, BMI of older adults who are overweight was 8 and underweight 4. The results of ADL were typically independent for older adults with balance disorder and none of the older adult was presented with moderate, severely, and very severe disability. Whereas, the numbers of drug consumed among 34 older adults with balance disorder were 4 kinds or more drugs. The table 5 shows most of the older adult present in the clinic had musculoskeletal, cardiovascular, and neurological disease. Osteoarthritis, hypertension, and past history of stroke were common among older adults.

Table 3 Characteristics of Mean 5STS Test based on Age Age Young old (60–69)

Middle-aged old (70–79) Old old (80–89)

Very old old (>90)

Frequency(n)

5STS( second)

17

17

0

0

11

19

6

22

Table 4 Characteristics of Older Adult with Balance Disorder Characteristic Blood pressure Normal*

Frequency (n) 5

Abnormal**

29

Abnormal ( <18.5 and 25 >)

12

BMI

Normal (18.5–24.9) ADL

Mild disability (15–19) Independent ADL (20) Numbers of drug used 4 or more (>3)

Less than 4 (<4)

22 13 21 21 13

Note: *normal: systolic < 120) and diastolic <80) **abnormal: (systolic >120 or diastolic >80) or (systolic <90 and diastolic<60) Althea Medical Journal. 2016;3(1)

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Table 5 Current Medical Disease of Older Adults with Balance Disorder Current Medical Disease Type of disease

Musculoskeletal disease Cardiovascular disease Neurological disease Metabolic disease

Gastrointestinal disease

Infectious and other disease

Number of current medical disease/person 1 disease 2 disease

3 disease

4 or more disease

Besides, from the results, it was shown that majority of older adults had one current medical disease compared to 3 medical diseases.

Discussion

This study aimed to observe the characteristics of older adults with balance disorders. Table 2 showed balance disorder among gender. In this study, it was found that 19 out of 34 were male (55.88%), which was more than females. In previous studies, it was stated that female possess a greater risk compared to males with an approximation of 56.9% (± 0.9%). This result differed from the previous study where the number of females is lesser than males. This is because the difference of sample size used and the numbers of patient that are limited due to the change in health referral system.4 Table 2 showed that young older adults had an average reading of 17 seconds. Older adults categorized as old old had an average of 22 seconds. In this study, with the increase in age, the mean 5 STS test results was longer. The result is similar to previous studies where prevalence rate increases with age for balance disorder.4,9 In mean 5STS, older adults with 12.5 seconds are categorized as non-multiple fallers and those with 14.8 second are multiple fallers based on previous study. This test not only has the ability in measuring balance, but also the fall risk, because older adults with longer test result have higher risk of having multiple falls. The test has a relative risk of 2.0 in predicting subjects of multiple falls and a

Frequency (n) 26 14 11 6 3 3

17 9 5 3

reliability of 0.89.8 Table 3 showed that, 28 out of 34 older adults were aged from 60 to 79. The mean age from previous studies of older adults with balance disorder is 74.46 ± 0.1 years. Table 3 showed that those among young old adults had a greater frequency by 6 individual from middle-age. The total mean age of this study was 69.79 years which differed from the previous study around 4.67 years. The previous study were based on a larger population where the age used is older adults who are 65 and above. The study may vary due to sample size and variation of human samples where samples used are Asians.4 From a study conducted by Whitney et al.10, the mean age of the patients with balance disorder is 75 years old (SD ± 7) with an age range of 61–90 years old. The result supports this study because it is within the age range.10 Another study found that balance disorder increases with age, with an odd ratio of 6.99 for older adults aged 80 and above, whereas dizziness do not associate with increase in age. The reason is unclear but is likely allied to physiological changes in aging. Similarly, the reason relates to the study; increase in age, increases the time required to complete the 5STS. Therefore, this condition increases the risk of balance disorder.7 In this study, 29 older adults had high blood pressure and balance disorder. Increase in age, increases blood pressure where the physiologic regulation of blood pressure decreases. A study conducted on orthostatic hypotension and ability to maintain balance in standing, showed that older adults have Althea Medical Journal. 2016;3(1)

Ku Shi Yun, Irma Ruslina Defi, Lazuardhi Dwipa: Characteristics of Older Adult with Balance Disorder in Rehabilitation Clinic of Dr. Hasan Sadikin General Hospital 2014

decreased ability to maintain balance if the systolic pressure drops at least 20mmHg or 10mmHg of diastolic change from supine position to standing position. Moreover, it was found that the ability of balance from eyes open to closed, and narrower base have increased difficulty in maintaining balance for patients with orthostatic hypotension. The inability to regulate the blood pressure fluctuations causes transient hypoperfusion to the brain, where blood flow and oxygen supply to the brain is reduced, thus, ability to maintain standing balance is affected. Therefore, decrease of blood pressure from supine to standing position plays a role in maintaining balance and this can be taken into account for future study.11,12 In this study, the results of BMI showed that most of older adults had normal BMI which was a total of 22 older adults. Other studies showed that with weight increase during older age increases the risk of physical impairment which impairs the quality of life. it means the greater the BMI, the greater the physical mobility burden.13,14 Individuals who are obese have lower muscle strength and more fat mass, but in this study, most patients were in range of normal BMI. Even with normal BMI, the patient’s definite muscle mass is not known, with increase in age muscle mass may have been loss. Results of majority of the older adults are categorized as normal BMI.13 In older adults, many physiological changes occur, where body weight was found to decrease after the age of 60 years and the fat free mass decreases due to loss of skeletal muscle. From the study, it was found that older adult loses 0.5% of body weight per year, and this can be due to multiple causes, for example sedentary lifestyle, decreased metabolic rate, hormones and physiologic changes of increase catabolism in older adults.15 Obesity causes adaptation in rising and sitting where older adults tend to have greater trunk flexion when shifting position. Individual obesity also causes shift in the center of mass anteriorly, and a greater effort is required to transfer from different positions. Thus, it increases the balance impairment.16 Table 4 showed that 21 out of 34 older adults with balance disorder had independent ADL which was a full score of 20, and mild disability with a total of 13 older adults. The patients were still able to do their daily activities without assistance, even with balance disorder, precaution remained be taken to prevent and support them to avoid injuries and falls. There were not many studies Althea Medical Journal. 2016;3(1)

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about the impact of balance disorder on ADL. Lower scores of ADL affects the functional impact, that the daily activities will be limited and it causes increase dependency and care required.4 In previous studies, the samples used for the balance study were based on older adults who did independent ADL as the inclusion criteria. In this study, the samples obtained were based on total sampling to avoid bias, and this study also had similar result where most of the samples had independent ADL, even without limiting patients in doing independent ADL.7 Older adults with balance disorder who consume 4 or more drugs are 21 out of 34 older adults. Polypharmacy, where an individual consumes 4 or more medication, causes balance problems and increases the risk of falling. Increase use of drugs may cause interactions among medication prescribed and may causesdizziness, postural instability and fall. It is important for the medications to be checked, to prevent any drug interactions. Removal or increased medication used should be assessed frequently to prevent adverse outcome.4,17 In another study it is noted that 87% of patients consumed 1 or 2 drugs and 13% take greater than 2 medications.7 A study conducted in Taiwan18; increase in medication use from 0 until greater than 4 or more medication, the odd ratio admission for fall-related fractures varies from 1 until 2.4 with the increase in numbers of drug used. The study also categorize medication used into different categories which include alimentary tract and metabolism, blood and blood forming organs, cardiovascular system, musculoskeletal system and nervous system.18 In this study, only the numbers of drug consumed were noted. Thus, in future study, researcher can divide the types of drug into categories for comparison. Table 5 showed that the presence of medical disease also contributed to balance disorder. The most common disease was musculoskeletal disease, cardiovascular, and neurological disease. Majority of the patients had 1 disease with a total 17 older adults from 34 older adults, and decrease in frequency with increase in numbers of disease present. In musculoskeletal disease, the most common problem was osteoarthritis. In a previous study, in gait and balance disorder, it had been found that the most common cause among older adults with balance disorder who had difficulty in walking had arthritis and postural hypotension. The presence of joint pain and stroke affects the older adult’s gait. In arthritis,

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there is limited range of motion and the shift of weight bearing position due to the presence of pain thus, affecting the ability in maintaining balance, showing antalgic gait in older adult. The change in gait and displacement of the posture affects the ability of balance.16,19 In this study, cardiovascular disease is common among older adults, it is found that most patients suffers from hypertension and some interventions were done for example coronary bypass, cardiac rehabilitation and others. Patients who came to the clinic are referral patient and also patients that required physiotherapy. It is thought that increase in number of disease increases with balance disorder but in this study most of the patients had one medical disease. However this may not be accurate as some patients were unsure of their current medical problems and some patients stated they were healthy. A study conducted by Stevens et al.7, it is found that patients with poor balance had diabetes, hypertension, hyperlipidemia, heart disease and renal disease. In the previous study, it is found that there is association between balance disorder with increasing age, diabetes (OR=1.53), arthritis (OR=1.33), eyesight (OR=1.94) this is similar to the disease present in our study.7 The limitations in this study were total number of sample size obtained. A small sample size was used, due to the limited time range of the study. Moreover the change in health system has decreased the number of patients present as the hospital is currently a tertiary hospital. Bias is present in the study, questionnaire were used to obtain patients information which includes the activity of daily living (ADL), numbers of drug used and current medical disease. There were difficulties in recalling the numbers of drug and current medical diseases, and some diseases were read off the medical charts. There may be human error in measuring blood pressure, height, and weight; for the 5STS test, some patient’s feet were not able to reach the ground, therefore, they were seated more forward to allow the feet to be at ground level. Standardized height chairs were used in this study, the common height chairs may vary in various studies from 40 to 46 cm. Inappropriate height chairs which is too low will affect the result of the study because it requires greater trunk flexion. This does not greatly affect the test result as it showed 2% of variance in the test performance.20 From this study, it can be concluded that increase in age among older adults have

balance disorder. The mean age of older adults with balance disorder is 70 years. The mean score of the 5 times sittostandtest is 18 seconds which exceeds the cut-off point of the test which is set at a minimum of 12 seconds or more. The most common problems among older adults are high blood pressure and majority of the patients consuming 4 or more types of drug. The most common medical diseases encountered by the older adults were musculoskeletal disease and hypertension, and patients who visited the clinic were subjected to physiotherapy. Thus, the quality of life of the older adults is important in maintaining selfindependence than the quantity. The suggestion for this study is to consider screening for older adults for their balance to allow early prevention and care to avoid falls, fractures, or even any disability. Besides, patients should be accessed constantly to attain the types of drug used as they can cause drug to drug interactions. Home saving and also support should be given to patients to build older adults’ confidence. Some interventions can be done, for example, the use of walking canes or walking aids to increase balance support, and in home support, bars can be placed in bathrooms to prevent slips as well squat toilets can be replaced with seated toilets. Families, physicians, and nurses play an important role in keeping the patients motivated for more regular follow up and in increasing physical exercise, and also awareness of the current diseases and problems encountered by the older adults. In future, the study cut-off point of the sit-to-stand-test for each age range should be determined and used as a reference for balance disorder. Patients who have fallen or have had multiple falls can be used as samples for furtherstudy as well as a reference. A larger sample size can be used for future study and use of other methods to assess balance disorder. Moreover, more study and test should be conducted to assess patients’ balance problems.

References

1. World Health Organization. Global health and ageing. Geneva: WHO;2011. 2. Badan Pusat Statistik Republik Indonesia. Statistik penduduk lanjut usia Indonesia tahun 2010. 2010 [cited 2013 April 13]; Available from: http://www.bps.go.id/ hasil_publikasi/stat_lansia_2010/index3. php?pub=Statistik%20Penduduk%20 Lansia%20Indonesia%202010%20 Althea Medical Journal. 2016;3(1)

Ku Shi Yun, Irma Ruslina Defi, Lazuardhi Dwipa: Characteristics of Older Adult with Balance Disorder in Rehabilitation Clinic of Dr. Hasan Sadikin General Hospital 2014

%28Hasil%20SP%202010%29. 3. Stuart-Hamilton I. The psychology of ageing: an introduction. 5th ed. Philsdelphia: Jessica Kingsley. 2012. 4. Lin HW, Bhattacharyya N. Balance disorders in the elderly: epidemiology and functional impact. Laryngoscope. 2012;122(8):1858–61. 5. Roberts DS, Lin HW, Bhattacharyya N. Health care practice patterns for balance disorders in the elderly. Laryngoscope. 2013;123(10):2539–43. 6. National Institute on Deafness and other Communication Disorders. Balance disorders. 2009 [cited 2013 February 20]; Available from: http://www.nidcd. nih.gov/health/balance/pages/balance_ disorders.aspx. 7. Steven KN, Lang IA, Guralnik JM, Melzer D. Epidemiology of balance and dizziness in a national population: findings from the english longitudinal study of aging. Age Ageing. 2008;37(3):300–5. 8. Tiedemann A, Shimada H, Sherrington C, Murray S, Lord S. The comparative ability of eight functional mobility tests for predicting falls in community-dwelling older people. Age Ageing. 2008;37(4):430– 5. 9. Jönsson R, Sixt E, Landahl S, Rosenhall U. Prevalence of dizziness and vertigo in an urban elderly population. J Vestib Res. 2004;14(1):47–52. 10. Whitney SL, Wrisley DM, Marchetti GF, Gee MA, Redfern MS, Furman JM. Clinical measurement of sit-to-stand performance in people with balance disorders: validity of data for the Five-Times-Sit-to-Stand Test. PhysTher. 2005;85(10):1034–45. 11. Pasma JH, Bijsma AY, Klip JM, Stijntjes M, Blauw GJ, Muller M, et al. Blood pressure associates with standing balance in eldery

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outpatients. PLoS ONE. 2014;9(9):1–9. 12. Hart EC, Joyner MJ, Wallin BG, Charkoudian N. Sex, ageing and resting blood pressure: gaining insights from the integrated balance of neural and haemodynamic factors. J Physiol (Lond). 2012;590(9):2069–79. 13. Lang IA, Llewellyn DJ, Alexander K, Melzer D. Obesity, physical function, and mortality in older adults. J Am Geriatr Soc. 2008;56(8):1474–8. 14. Villareal DT, Chode S, Parimi N, Sinacore DR, Hilton T, Armamento-Villareal R, et al. Weight loss, exercise, or both and physical function in obese older adults. N Engl J Med. 2011;364(13):1218–29. 15. Ahmed T, Haboubi N. Assessment and management of nutrition in older people and its importance to health. Clin Interv Aging. 2010;5:207–16. 16. Porto HCD, Pechak CM, Smith DR, ReedJones JR. Biomechanical Effects of Obesity on Balance. Int J Exerc Sci. 2012;(4):301–9. 17. Ziere G, Dieleman JP, Hofman A, Pols HAP, van der Cammen TJ, Stricker BHCH. Polypharmacy and falls in the middle age and elderly population. Br J Clin Pharmacol. 2006;61(2):218–23. 18. Pan HH, Li CY, Chen TJ, Su TP, Wang KY. Association of polypharmacy with fallrelated in older Taiwanese people: age and gender -specific analyses. BMJ Open. 2013;4(3):1–7. 19. Salzman B. Gait and Balance Disorders in Older Adults. Am Fam Physician. 2010;82(1):61–8. 20. Thaweewannakij T, Wilaichit S, Chuchot R, Yuenyong Y, Saengsuwan J, Siriatiwat W, et al. Reference values of physical performance in elderly thai people who are functioning well and dwelling in the community. Phys Ther. 2013;93(10):1312– 20.

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Success Rate of Trabeculectomy in Primary Glaucoma at Cicendo Eye Hospital on January–December 2013 Erva Monica Saputro,1 Maula Rifada,2 RB. Soeherman3 Faculty of Medicine Universitas Padjadjaran, 2Department of Ophtalmology Faculty of Medicine Universitas Padjadjaran/National Eye Center Cicendo Eye Hospital, 3Department of Anatomy and Cell Biology Faculty of Medicine Universitas Padjadjaran 1

Abstract Background: Trabeculectomy is a surgical therapy for glaucoma to preserve visual function by lowering intraocular pressure (IOP). In some studies, the success of trabeculectomy in lowering IOP is greater than medication. Success is defined by IOP <21 mmHg, with or without glaucoma medication. Primary glaucoma based on the mechanism of aquous humor outflow is divided into primary open-angle glaucoma (POAG) and primary angle-closure glaucoma (PACG). This study aimed to know the success rate of trabeculectomy in POAG and PACG. Methods: This study was a descriptive study conducted at Cicendo Eye Hospital using medical record of POAG and PACG patients who underwent trabeculectomy surgery on January–December 2013 with minimal one month follow-up. Data collection was conducted during September 2014. Data processed in this study were 100 eyes from 76 patients with diagnosis POAG and PACG. Results: The success rate for trabeculectomy in POAG was 79% and PACG was 86%, failure (IOP ≥ 21 mmHg) 21% in POAG, and 14% in PACG for period 2013 at Cicendo Eye Hospital. Conclusions: The success rate of trabeculectomy at Cicendo Eye Hospital is good in one month, with or without glaucoma medication after surgery. [AMJ.2016;3(1):110–4] Keywords: Primary angle-closure glaucoma, primary open-angle glaucoma, trabeculectomy

Introduction Glaucoma is the second most leading cause of blindness in the world after cataract.1 Glaucoma still become the global concern because early diagnosis is difficult to make and can cause permanent visual impairment. Most common type of glaucoma is primary open-angle glaucoma (POAG) and primary angle-closure glaucoma (PACG).2 In 2013, 64.3 millions cases of glaucoma were estimated and 60% were in Asia, with POAG cases 54.3% and PACG 74.7%.3 The goal of glaucoma treatment is to preserve visual function by lowering intraocular pressure below a level that is likely to produce further damage to the optic nerve.4 The most common surgical therapy for glaucoma is trabeculectomy. As increasing prevalence of glaucoma, trabeculectomy is needed to help reduce the number of blindness in the world. In some studies, the success of

trabeculectomy in lowering IOP is greater than medication.5 Success is defined by IOP <21 mmHg with/or decrease of >30% IOP with or without glaucoma medication.6 Success rate of trabeculectomy in POAG in England is 80% without medication.7 In Indonesia, success rate of trabeculectomy in PACG at Cipto Mangunkusumo Hospital is 18.8% for success without medication and 68.8% for success with medication.8 At Cicendo Eye Hospital, as a referral hospital, there has not been a recent study about the success of trabeculectomy, therefore, this research aimed to evaluate the success rate of trabeculectomy in POAG and PACG at Cicendo Eye Hospital in 2013.

Methods

This was a descriptive retrospective study, using medical record from patients with POAG and PACG, who underwent trabeculectomy

Correspondence: Erva Monica Saputro, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km.21, Jatinangor, Sumedang, Indonesia, Phone: +62 81313516911 Email: [email protected] Althea Medical Journal. 2016;3(1)

Erva Monica Saputro, Maula Rifada, RB. Soeherman: Success Rate of Trabeculectomy in Primary Glaucoma at Cicendo Eye Hospital on January–December 2013

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Table 1 Characteristic of Respondents Characteristics Sex

Male

Female

Age (years) Mean±SD

POAG

PACG

Total

16 (67%)

15 (29%)

31 (41%)

8 (33%)

37 (71%)

43-85

40-82

61±10

Range

Median

60

Address

Bandung

10 (42%)

Other Cities

14(58%)

Total

24 (100%)

60±10 58

16 (31%) 36 (69%)

52 (100%)

45 (59%)

26 (34%) 50 (66%)

76 (100%)

Note: * POAG: Primary Open-Angle Glaucoma; PACG: Primary Angle-Closure Glaucoma; SD: Standard Deviation

surgery from January to December 2013 at Cicendo Eye Hospital, Bandung, West Java, Indonesia. Data collection was conducted during September 2014 after permitted by Health Research Ethics Committee Faculty of Medicine Universitas Padjadjaran. Of 89 medical records, 76 patients (24 POAG and 52 PACG) were met in inclusion criteria which had minimal follow up for one month. The rests were excluded because incomplete follow up and the medical record cannot be accessed when collecting data. Of 76 patients, 100 eyes underwent trabeculectomy surgery (34 POAG and 66 PACG). Data collected from medical record were sex; age; address; diagnosis; pre-operative Table 2 Subjects’ Clinical Characteristics Characteristics

visual acuity; pre-operative IOP; one week, one month, three months post-operative IOP; and also the numbers of medication given after trabeculectomy surgery. The success rate was defined by IOP that is lower than 21mmHg with or without medication in one month after surgery. Failure was defined by IOP that is higher than 21 mmHg one month after surgery. Data were processed using Microsoft Excel and analyzed using statistical analysis program.

Results

The characteristics in this research were sex, age, and address. Patients’ characteristics POAG

PACG

Total

Normal ( 6/6–6/18)

10 (29%)

21 (32%)

31 (31%)

Blind (<3/60)

18 (53%)

34 (52%)

16 (47%)

36 (55%)

Pre-operative Visual Acuity

Visual impairment(<6/18–6/60)

Severe visual impairment (<6/603/60) Pre-operative IOP(mmHg) Mean ±SD Laterality OD OS

Total

6 (18%) 0 (0%) 38±18

18 (53%)

34 (100%)

7 (11%) 4 (6%) 41±12

30 (46%)

66 (100%)

Note: * IOP: Intraocular Pressure; OD: Oculus Dextra(Right Eye); OS: Oculus Sinistra (Left Eye) Althea Medical Journal. 2016;3(1)

13 (13%) 4 (4%)

52 (52%)

52 (52%) 48 (48%)

100 (100%)

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Figure1 Graphic of TIO from pre-surgery, 1 week after surgery, 1 month after surgery, 3 months after surgery showed that males were more common in POAG and females were more common in PACG. Minimum age for patient was 40 years old with the mean age of 61 years old in POAG and 60 years old in PACG. The origin of patients were commonly from other cities than Bandung (Table 1). Patients’ characteristics of pre-operative visual acuity were mostly categorized as blind. Pre-operative IOP was higher in PACG with mean IOP 41 mmHg than POAG with mean IOP 38 mmHg (Table 2). Figure 1 showed the decrease of IOP after trabeculectomy. The mean of IOP after surgey in PACG was slightly lower than POAG in one week, one month, and three months after surgery. This study showed the success rate of trabeulectomy in POAG and PACG at Cicendo Eye Hospital in 2013 that was 79% and 86% (Table 3), yet, the success still needed glaucoma medication to control the IOP

after surgery (Table 4), mostly one item of medication (Table 5).

Discussion

Primary glaucoma based on onaquous humor drainage mechanism was divided into primary open-angle glaucoma and primary angleclosure glaucoma; the ratio in Asia was higher in PACG than POAG, as mentioned in the study by Tham et al.3 In this study, males were common in POAG and females were common in PACG.4,6,9 The distribution of sex in some studies showed that there is no significant difference, but according to American Academy of Ophtalmology (AAO), females were more common in PACG, probably because of the shallow anterior chamber in female compared to male. Some studies also mentioned that males are common in POAG.6,10,11 The distribution of POAG and PACG based on theory

Table 3 Success Rate of Trabeculectomy (One month post-trabeculectomy) IOP (mmHg) <21 ≥21

Total

POAG

PACG

Total

27 (79%)

57 (86%)

84 (84%)

7 (21%)

34 (100%)

9 (14%)

66 (100%)

16 (16%)

100 (100%)

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Table 4 Success Rate of Trabeculectomy With or Without Glaucoma Medication Success Rate Success without medication

Success with medication Failure

Total

will increase with age, meanwhile, the mean of age in this study was 60 years old, same as the results in some studies in Asia that showed the mean age of glaucoma patients which above 50 years old.12 Patients mostly came from other cities than Bandung to Cicendo Eye Hospital as National Eye Center. It can be one of the reasons to undergo trabeculectomy surgery for patients who live far from health facility to ease the accomodation and to get the best IOP result, to control the visual function. The same consideration was also mentioned in a study at Cipto Mangunkusumo Hospital.8 POAG and PACG patients who came to Cicendo Eye Hospital were categorized as blind (<3/60), based on WHO classification for blindness. In a study in Nigeria conducted by Adegbehingbe et al.13 pre-operative visual acuity below 6/18 is 93%, and did not show any significant changes in follow up after surgery. The high blindness prevalence caused by glaucoma definitely will increase number of blindness in the world so that glaucoma becomes the second most leading cause of blindness in the world.1 The mean of IOP in this tudy before surgery in POAG and PACG was 38 mmHg and 41 mmHg, high enough compared to other studies. A study in Singapore showed that the mean IOP is higher in PACG than in POAG (26 mmHg and 24 mmHg).14 At Cipto Mangunkusumo Hospital, the mean of preoperative IOP is 29 mmHg.8 The higher IOP in PACG may be caused by shallow anterior chamber.4 Based on Kanski, usually the preoperative IOP in PACG patients will be higher

POAG

PACG

Total

4 (12%)

10 (15%)

14 (14%)

34 (100%)

66 (100%)

23 (67%) 7 (21%)

47 (71%) 9 (14%)

70 (70%)

16 (16%)

100 (100%)

than POAG between 50–100 mmHg.15 Post surgery mean IOP in this study was slightly lower in PACG, as mentioned by Mahar that mean IOP in PACG is 12.17±7.23 and in POAG is 12.83±5.71.16 In a study by Tabassum et al., the decrease of mean IOP after surgeryis 15.78 mmHg and effective to control IOP in one year.17 In this study, the success rate of trabeculectomy in POAG and PACG was 79% and 86%, but it still needed glaucoma medication to control IOP. The success rate in POAG with medication was 67%, without medication was 12%,, and success rate in PACG with medication was 71%, without medication was 15%. In Indonesia, a study conducted at Cipto Mangunkusumo Hospital showed that success rate of trabeculectomy in PACG with medication is 68.8% and without medication is 18.8%.8 In Malaysia, success rate for trabeculectomy (6 months post trabeculectomy) in POAG with medication is 12.2%, without medication is 85.1%, and in PACG, success rate with medication is 22.2%, without medication is 72.2%.18 Success rate of trabeculectomy in England without medication is 80%.7 Failure of trabeculectomy can be caused by the length of use of glaucoma medication before surgery and also by extensive scar in conjunctiva and thin sclera, because it might increase fibroblast and inflammatory cells which cause scar after surgery.19,20 In conclusion, the success rate of trabeculectomy in POAG and PACG at Cicendo

Table 5 Medication Given to POAG and PACG Patients after Surgery Number of Medication Without medication

1 item

2 items

3 items Total

Althea Medical Journal. 2016;3(1)

POAG 5 (15%)

17 (50%)

12 (35%) 0 (0%)

34 (100%)

PACG 10 (15%)

29 (44%)

25 (38%) 2 (3%)

66 (100%)

Total 15 (15%)

46 (46%)

37 (37%) 2 (2%)

100 (100%)

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Eye Hospital from January to December 2013 is good in one month follow up. Limitation in this study is the limited time to collect data. Suggestions for further studies, it will be better if the length of follow up is longer to evaluate the long term success rate of trabeculectomy and to increase the numbers of data collection by increasing the duration of study.

References

1. Pascolini D, Mariotti SP. Global estimates of visual impairment: 2010. Br J Ophthalmol. 2011;96(5):614–8. 2. WHO. VISION 2020: The right to sight: a global initiative to eliminate avoidable blindness: action plan 2006–2011. Geneva: WHO Library Cataloguing-in-Publication Data; 2007. 3. Tham Y-C, Li X, Wong TY, Quigley HA, Aung T, Cheng C-Y. Global prevalence of glaucoma and projections of glaucoma burden through 2040: a systematic review and meta-analysis. Ophthalmology. 2014;121(11):2081–90. 4. Cioffi GA. 2011–2012 basic and clinical science course, section 10: Glaucoma. 1st ed. San Fransisco: American Academy of Ophtalmology; 2011.. 5. Burr J, Azuara-Blanco A, Avenell A, Tuulonen A. Medical versus surgical interventions for open angle glaucoma. Cochrane Database Syst Rev. 2012(9):Cd004399. 6. Yanoff M, Duker JS. Ophthalmology.. 3rd ed. Philadelphia Mosby/Elsevier; 2009. 7. Kirwan JF, Lockwood AJ, Shah P, Macleod A, Broadway DC, King AJ, et al. Trabeculectomy in the 21st century: a multicenter analysis. Ophthalmology. 2013;120(12):2532–9. 8. Artini W. Outcome of primary angle closure glaucoma management in indonesian population. J IndonMed Assoc. 2011;61(7):280–4 9. Thapa SS, Paudyal I, Khanal S, Twyana SN, Paudyal G, Gurung R, et al. A populationbased survey of the prevalence and types of glaucoma in Nepal: the Bhaktapur Glaucoma Study. Ophthalmology. 2012; 119(4):759–64.

10. Kim C-S, Seong GJ, Lee N-H, Song K-c. Prevalence of primary open-angle glaucoma in Central South Korea. Ophthalmology. 2011;118(6):1024–30. 11. Yamamoto S, Sawaguchi S, Iwase A, Yamamoto T, Abe H, Tomita G. Primary open-angle glaucoma in a population associated with high prevalence of primary angle-closure glaucoma. Ophthalmology. 2014;121(8):1558–65. 12. Cho H, Kee C. Population-based glaucoma prevalence studies in Asians. Surv Ophthalmol. 2014;59(4):434¬47. 13. Adegbehingbe B, Majemgbasan T. A review of trabeculectomies at a Nigerian teaching hospital. Ghana med J. 2007;41(4):176-80. 14. Ngo CS. A prospective comparison of chronic primary angle-closure glaucoma versus primary open-angle glaucoma in Singapore. Singapore Med J. 2013;54(3):140–5. 15. Kanski JJ, Bowling B. Clinical ophthalmology: a systematic approach 7th ed. Philadephia: Elsevier Health Sciences UK; 2011. 16. Mahar P, Laghari A. Intraocular pressure control and post operative complications with mitomycin-c augmented trabeculectomy in primary open angle and primary angle-closure glaucoma. Pak J Ophthalmol. 2011;27(1):35–9. 17. Tabassum G, Ghayoor I, Ahmed R. The Effectiveness of conventional trabeculectomy in controlling intraocular pressure in our population. Pak J Ophthalmol. 2013;29(1):26. 18. Hah MH, Omar RNR, Jalaluddin J, Jalil NFA, Selvaturai A. Outcome of trabeculectomy in Hospital Melaka, Malaysia. Int J Ophtalmol. 2012;5(3):384–8. 19. Bhatia J. Outcome of trabeculectomy surgery in primary open angle glaucoma. Oman Med J. 2008;23(2):86–9. 20. Landers J, Martin K, Sarkies N, Bourne R, Watson P. A twenty-year follow-up study of trabeculectomy: risk factors and outcomes. Ophthalmology. 2012;119(4):694–702.

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Knowledge of Housewives Regarding Non Steroid Anti Inflammatory Drug Use on Joint Pain in Hegarmanah Village Jatinangor Adi Mulyono Gondopurwanto,1 Kuswinarti,2 Yusuf Wibisono3 Faculty of Medicine Universitas Padjadjaran, 2Department of Pharmacology and Therapy Faculty of Medicine Universitas Padjadjaran, 3Department of Neurology Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung

1

Abstract Background: Joint pain is frequently found in daily life activities. The prevalence of joint pain increases within the age. One of the medicine used for joint pain is non-steroidal anti-inflammatory drug (NSAID). In connection with inappropriate usage and their side effects, this study aimed to seek the extent ofhousewives’ knowledge on the use of NSAID for joint pain in Hegarmanah village, Jatinangor subdistrict. Methods: This cross-sectional descriptive study was conducted in October 2013 to the housewives resided in Hegarmanah village, Jatinangor subdistrict, West Java. Questionaire sheet was distributed to each of 110 housewives that had been stratifiedly with randomized sample. The questionaire contained identity, age, education level, and knowledge of NSAID in related to joint pain. Results: Based on the data collected, 73 subjects had adequate level of the knowledge and 37 subjects were in a poor level of the knowledge. The proportion of respondents who knew that joint pain was the pain occurs in the joint was 99.1%, the proportion of respondents who knew that the pain relieving drugs are called NSAID group was 40.9%, the proportion of respondents who knew that NSAID had a side-effect was 73.6%, and the proportion of respondents who knew that the side-effect of NSAID is abdominal pain was 61.8%. Conclusions: Most of the housewives in Hegarmanah Subdistrict have adequate knowledge in the use ofNSAID for joint pain relief. [AMJ.2016;3(1):115–9] Keywords: Housewife, joint pain, knowledge, NSAID

Introduction Pain is a sensation of inconvenience and emotional experience with substantial or potential tissue damage or reflected by the damage.1 Based on the localization, pain can be divided into head pain, joint pain, back pain, and neck pain.1 Joint pain is a a type of pain with the highest prevalence as much as 28% and most frequently occurs in women.2 One of medicines that frequently used for treating joint pain is non-steroidal antiinflammatory drug (NSAID).3 Ibuprofen is one of over-the-counter (OTC) drug that is often use in worldwide.3 The NSAID are mostly used by women, both for one week and longterm use (more than 6 months).4 In Indonesia, many NSAIDs have been distributed to the market with a variety of trademarks. In Indonesia, NSAID which mostly used are

ibuprofen, aspirin, diclofenac, mephenamic acid, naproxen, piroxicam, meloxicam, and celecoxib.1 Long-term utilization of NSAID is very hazardous due to thevarious sideeffects of NSAID, especially to gastrointestinal system.5,6 Therefore, people need to pay attention to the use of NSAID, including to not too often administering of NSAID in order to avoid the possibility of hazardous sideeffects. This study was conducted to seek the extent housewives’ knowledge on the use of NSAID for joint pain in Hegarmanah village, Jatinangor subdistrict.

Methods

This cross-sectional descriptive study was conducted in October 2013 to the housewives resided in Hegarmanah village, Jatinangor subdistrict, West Java. This study was approved

Correspondence: Adi Mulyono Gondopurwanto, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya BandungSumedang Km.21, Jatinangor, Sumedang, Indonesia, Phone: +6285221517788 Email: [email protected] Althea Medical Journal. 2016;3(1)

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Table 1 Characteristic of the Respondents Respondents

Frequency (N=110)

Percentage

20–29

17

15.5

50–59

19

17.3

The housewive’ age (years old) 30–39

35

40–49

29

≥60

10

Education level

Elementary school

Junior high school

by Health Research Ethics Committee Faculty of Medicine Uniuversitas Padjadjaran. The sampling was taken by stratified random method on 110 subjects of the population meanwhile, the calculation sample size used was a descriptive categorical formula.7 One hundred and ten housewives were asked to fill in the validated questionaire sheet. There were 12 questionaires. The questionaire contained identity, age, education level, and knowledge of NSAID in related to joint pain.

9.1

27.3

7

4.2

42

Bachelor/Master

26.4

30 31

Senior High School

31.8

28.3 38.3

The knowledge levels are divided into adequate and poor based on the median of total score of knowledge by 10. The level is poor if the median of total scored true is less than 10. The level is adequate if the median of total scored true is more than 10.

Results

From 110 respondents, most of respondents

Table 2 The Total Score of Housewives’ Knowledge on NSAID Usage for Joint Pain. Question Joint pain is the pain on motion joint

Joint pain can affect the knee

True n(%)

False n(%)

109(99.1)

1(0.9)

106(96.4)

4(3.6)

Respondents knows the part of the body that frequently affected

100(90.9)

The joint pain medicine used torelief the pain in joint

109(99.1)

The joint pain drugs must not be applied for long-term period (> 6 months)

59(53.6)

51(46.4)

81(73.6)

29(26.3)

When suffering the joint pain, the respondents seeks for help from the health center.

The respondents knows the examples of NSAID medicines

Joint pain relief can be purchased in OTC (without prescription)

The joint pain drugs have side-effect

One of the join pain drug side-effects is abdominal pain

The people who suffers joint pain only gets one drug type

Joint pain relief can be bought at a dispensary (apotik)

10(9.1)

97(88.2)

13(11.8)

45(40.9)

65(59.1)

83(75.5)

68(61.8)

97(88.2)

108(98.2%)

1(0.9)

27(24.5)

42(38.2)

13(11.8) 2(1.8%)

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Table 3 The List of Joint Pain Medicines Used by Housewives Medicine

(n=110)

(%)

Ibuprofen and paracetamol

35

31.8

Ibuprofen

2

1.8

NSAID

Acetylsalicylic acid Piroxicam

Diclofenac

Non-NSAID drugs Ignorance

were 30–39 years old (31.8%), and the education level was Senior High School (38.3%). Almost all housewives in Hegarmanah village knows the joint pain based on the definition (99.1%), part of body suffers joint pain (90.9%), visiting doctor when suffers joint pain (88.2%) and the indication of joint pain medicine (99.1%). The proportion of respondents who knew that the pain relieving drugs are called NSAID group was 40.9%, the proportion of respondents who knew that NSAID had a side-effect was 73.6%, and the proportion of respondents who knew that the side-effect of NSAID is abdominal pain was 61.8%. The NSAID which mostly used for joint pain was combination of ibuprofen and paracetamol (31.8%), while 34.5% used Non-NSAID drugs. Based on the data collected, 73 subjects had adequate level of the knowledge and 37 subjects were in a poor level of the knowledge.

Discussion

Almost all housewives in Hegarmanah village knows the joint pain based on the definition (99.1%), part of body suffers joint pain (90.9%), visiting doctor when suffers joint pain (88.2%) and the indication of joint pain medicine (99.1%). The housewives still found difficulties in

2

5

1

38 27

1.8

4.5

0.9

34.5 24.5

mentioning the name of joint pain medicines of NSAID group; only 45 (40.9%) subjects were able to mention NSAID joint pain names properly. The combination of ibuprofen and paracetamol were mostly mentioned by 31.5% of the housewives. The present study results are similar to that by Wilcox et al.3 and Lanas et al.6 it is suggested that ibuprofen is NSAID which frequently used. However, there are still greater number (69.1%) of subjects who did not recognize the names of NSAID joint pain relief. Greater number of subjects who did not recognize the names of NSAID joint pain relief indicates a necessary education on NSAID medicine types for joint pain. The prevalence of joint pain increases within the age.1 Age related to the disease affecting joint for example osteoarthritis which cause joint pain. This may cause an increasing in the use of NSAID on older housewives.1 About 59 housewives considered that NSAID medicines are not allowed to administer in long-term, for instance more than 6 months. Using NSAID in long-term may rise harmful side-effects, such as gastric ulceration and hemorrage.3,8 The risk for a serious gastrointestinal complication isworse with the increasing of age on the subject.4,6 Therefore, it is recommended to not useNSAID for a long-term period. Eighty-three housewives considered that joint pain medicines can be purchased without prescription. The joint pain medicines,

Table 4 Housewives’ Knowledge on NSAID Usage for Joint Pain Level of knowledge Adequate Poor

Total

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Frequency (N)

Percentage (%)

73

66.4

37

110

33.6 100

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such as ibuprofen that is frequently used by housewives in Hegarmanah village, is classified into OTC drugs that are permitted to buy without a doctor prescription.3 Almost all (73.6%) housewives know that NSAID joint pain medicines have sideeffects. One of the side-effects is gastric pain (61.8%). Non steroid anti inflammation inhibits cyclooxygenase (COX)-1 and COX-2 in reducing prostaglandin level.9 Inhibition in prostaglandin synthesis and direct cytotoxicity of NSAID provokes gastric acid secretion causing gastric irritation.10 Chronic bleeding may result in anemia.11 This gastric irritation may cause bleeding, perforation, and pain of stomach,3,12,13 whereas the new, selective COX-2 has the lower probability to irritate the stomach.3 The risk of gastric irritation depending on the presence of three main risk factors. The three main risk factors are prior history of peptic ulcer, age and concomitant NSAID usage.14 This result is higher compared to the study by Braund et al.15 describing that 70% of the subject were able to mention the NSAID side-effects. Most housewives (88.2%) also know that the administering joint pain is one of the best type for relieving a joint pain. The combination of two types or more NSAID can enhance the occurrence of their side-effects in gastrointestinal tract. One hundred and eight housewives also prefer to choose buying the NSAID medicine at a dispensary. By purchasing the drugs in dispensary, the housewives expect the explanatory information about taking the medicine and to avoid the expiry date of the medicines. The whole results of this questionaire study indicates that most (66.4%) of the housewives have adequate knowledge. It is caused by high level of housewive education, such as, senior high school, an easy access to primary health care, and they also frequently got an education about health. In this study, there was a difficulty in communicative language. The language applied in the questionaire is Indonesian, whereas the daily language of the related respondents is Sundanese; therefore some respondents could not understand some of the sentences in the questionaire. As the consequence, it took a lot of time to explain the intention of the related questions for the respondents. In conclusion, the knowledge on NSAID use for joint pain of housewives in Hegarmanah village, Jatinangor subdistrict, mostly have adequate knowledge. Though, most of the respondents have adequate knowledge, the

knowledge of the NSAID names is still poor. For that reason, it is recommended to educate people about the use and the side effect of NSAID. This study is conducted descriptively, consequently there is no analysis of association is done between the knowledge and the education level. It is recommended to Public Health Center of Hegarmanah to apply a health education on drug utilization with a greater caution to the community. The related physicians, expectedly can carry out the education programme of NSAID, especially the types and their sideeffects as expectedby related communities. The researcher do not only explore the science but also behavior and attitude.

References

1. Purba JS. Patofisiologi dan penatalaksanaan nyeri. Jakarta: Balai penerbit FKUI Jakarta; 2011. 2. Pfizer. The burden pain among adult in the united state. New York: Pfizer Medical Division; 2008. 3. Wilcox CM, Cryer B, Triadafilopoulos G. Pattern of use and public perception of OTC pain reliever: focus on NSAID.J Rheumatol. 2005;32(11):2218–24. 4. Motola D, Vaccheri A, Silvani MC, Poluzzi E, Bottoni A, De Ponti F, et al. Pattern of NSAID use in the italian general population : a questionnaire-based survey. Eur J Clin Pharmacol . 2004; 60(10):731–8. 5. Fosbol EL, Gislason GH, Jacobsen S, Abildstrom SZ, Hansen LM, Schramm Ken SS, et al. The pattern of use of nonsteroid anti drugs from 1997-2005: a nationwide study on 4.6 million people. Pharmacoepidemiol Drug Saf. 2008; 17(8):822–33. 6. Lanas A, Ferrandez A. Inappropiate prevention of NSAID-induced gastrointestinal event among long-term users in the elderly. Drug Aging. 2007; 24(2):121–31. 7. Sopiyudin DM. Besar sampel dan cara pengambilan sampel dalam penelitian kedokteran dan kesehatan. Jakarta: Penerbit Salemba Medika; 2009. 8. Cullen G, Kelly E, Murray FE. Patients’ knowledge of adverse reactions to current medication. Br J Clin Pharmacol. 2006; 62(2):232–6. 9. Suleyman H, Demircan B, Karagoz Y. Anti inflammatory and side effect of cyclooxygenase inhibitors. Pharmacol Rep.2007;59:257–68 Althea Medical Journal. 2016;3(1)

Adi Mulyono Gondopurwanto, Kuswinarti, Yusuf Wibisono: Knowledge of Housewives Regarding Non Steroid Anti Inflammatory Drug Use on Joint Pain in Hegarmanah Village Jatinangor

10. Tomisato W, Tsutsumi S, Hoshino T, Hwang HJ, Mio M, Tsuchiya T, et al. Role of direct cytotoxic effect of NSAID in the induction of gastric lesion. Biochem Pharmacol. 2004;67(3):575–85. 11. Yilmaz H, Gurel S, Ozdemir O. Turkish patients with osteoarthritis: their awareness of the side effects on NSAIDs. Turk J Gastroenterol. 2005;16(2):89–92. 12. Graham DY, Opekun AR, Willingham FF, Qureshi WA. Visible small-intestinal mucosa injury in chronic NSAID users. Clin Gastroenterol Hepatol. 2005; 3(1):55–9. 13. Sostres C, Gargallo CJ, Arroyo MT, Lanas

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A. Adverse effect of non-steroid antiinflammatory drugs (NSAIDs, aspirin and coxibs) on upper gastrointestinal tract. Best Prac Res Cl Ga. 2010;24(2):121–32. 14. Thiefin G, Beaugerie L. Toxic effect of nonsteroidal anti inflammatory drugs on the small bowel, colon and rectum. Joint Bone Spine. 2005;72(4):286–94. 15. Braund R, Abbot JH. Recommending NSAIDs and paracetamol: a survey of new zealand physiotherapists’ knowledge and behaviours. Physiother Res Int. 2011; 16(1):43–9.

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Knowledge and Intention to Use Personal Protective Equipment among Health Care Workers to Prevent Tuberculosis

Hasanah,1 Elsa Pudji Setiawati,2 Lika Apriani3 Faculty of Medicine, Universitas Padjadjaran, 2Department of Public Health Faculty of Medicine Universitas Padjadjaran, 3Department of Epidemiology and Biostatistic Faculty of Medicine Universitas Padjadjaran

1

Abstract Background: Tuberculosis (TB) is one of the main world health problems. Indonesia has the fourth highest incidence in the world. Tuberculosis is very infectious, but it can be prevented in high risk group such as health care worker by using personal protective equipment (PPE). This study aimed to reveal knowledge and intention to use PPE among health care worker to prevent TB transmission in Public Health Center (Pusat Kesehatan Masyarakat, Puskesmas) in Bandung. Methods: Descriptive study was conducted from September to October 2014 in 15 Puskesmas in Bandung. Those 15 Puskesmas had been reported as having the highest incidence in TB cases. Ninety seven health care workers were assessed using questionnaire. Samples were obtained using purposive sampling method. Data were collected and analyzed for frequency and proportion. Results: Among 97 health care workers, 76 (78.4%) had good knowledge, 16 (16.5%) had sufficient knowledge, and 5 (5.2%) had poor knowledge. Based on intention of PPE usage among health care workers, it was found that 41.2% had positive intention and 58.8% had negative intention. Conclusions: Most of health care workers have good knowledge about TB transmission, however, intentions to use PPE are low. [AMJ.2016;3(1):120–5] Keywords: Intention, knowledge, personal protective equipment, tuberculosis

Introduction Tuberculosis (TB) is one of the diseases with high mortality rate. Indonesia is ranked as the fourth country with highest cases of TB worldwide. There are 0.4–0.5 million new cases of TB in Indonesia. In 2013, the prevalence of TB was 0.4%.1 TB is an infectious disease caused by Mycobacterium tuberculosis. Risk of TB transmission infection in Indonesia every year is calculated using Annual Risk of Tuberculosis Infection (ARTI) and the result is 1–3%. TB infects various groups of people and health care workers are included as a high risk group. Annual incidence of TB infection in health care workers is 69–5,780 in 100,000.2 TB is an occupational hazard among health care workers. Several efforts have been initiated to reduce TB transmission in health care facilities, such as administration control, environmental control,

and use of personal protection equiment (PPE). Use of PPE is influenced by predisposing factors, such as knowledge, enabling factors, reinforcing factors, and intention is the best predictor of a behavior.3 Considering PPE usage is important for health care workers, this study aimed to reveal knowledge and intention to use PPE among health care workers to prevent TB transmission in public health center (Pusat Kesehatan Masyarakat, Puskesmas) in Bandung.

Methods

This was a descriptive study. Purposive sampling was conducted to select research subjects. Based on sample size calculation, minimum sample of 97 subjects were required. Among 73 Puskesmas in Bandung City, 15 centers with highest incidence of TB cases were selected as research population.

Correspondence: Hasanah, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km.21, Jatinangor, Sumedang, Indonesia, Phone: +6285720846550 Email: [email protected] Althea Medical Journal. 2016;3(1)

Hasanah, Elsa Pudji Setiawati, Lika Apriani: Knowledge and Intention to Use Personal Protective Equipment 121 among Health Care Workers to Prevent Tuberculosis

Table 1 Subjects’ characteristics Subject

Sex

Numbers of participating health care workers (%)

Male

21 (21.6)

<31

27 (27.8)

Female

Age, year 31–40 41–50 >50

Public health center Babatan

Caringin Cetarip

Cibuntu

Cijagra Lama Cijerah

Garuda Kopo

Kujangsari

Moch. Ramdan Padasuka Puter

Sukajadi

Talagabodas Tamblong

Highest level of education

76 (78.4) 31 (32.0) 26 (26.8) 13 (13.4) 5 (5.2) 6 (6.2) 6 (6.2) 5 (5.2) 6 (6.2) 5 (5.2)

11 (11.3) 6 (6.2) 3 (3.1) 5 (3.1) 7 (7.2)

16 (16.5) 5 (5.2) 6 (6.2) 5 (5.2)

Senior high school

13 (13.4)

Medical Doctor

27 (27.8)

Diploma

Bachelor’s degree Master’s

Length of employment, years <1

1–5

6–10

11–15 16–20 21–25 >25

Occupation

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39 (40.2) 17 (17.5) 1 (1.0) 9 (9.3)

26 (26.8) 13 (13.4) 11 (11.3) 5 (5.2)

17 (17.5) 16 (16.5)

Physician Nurse

Laboratory assistant TB history Yes

29 (29.9) 57 (58.8) 11 (11.3) 7 (7.2)

No

90 (92.8)

Yes

7 (7.2)

TB history on contacted or lived with family members No

90 (92.8)

Puskesmas workers such as doctors, nurses, and laboratory workers were involved in this study. This study was approved by Health Research Ethics Committee Faculty of Medicine Universitas Padjadjaran. The permission to conduct research was also given by local government and Bandung District Health Office. Data collection using validated questionnaire was conducted from September to October 2014. Questionnaire was given to health care workers who had agreed to participate in this study. Besides, verbal and written informed consents were given. The questionnaires assessed knowledge and intention. Knowledge questionnaire consisted of 10 questions regarding TB transmission, including transmission media, modes, control, and high risk groups in Puskesmas. Intention questionnaire consisted of 17 questions about the intention to use PPE, such as mask and gloves, and the responds were recorded using likert scale (5, strongly agree; 4, agree; 3, neutral; 2, disagree; 1, strongly disagree).4-7 Data were collected and analyzed for frequency and proportion. Knowledge was grouped into 3 categories based on accumulated score percentage (good, 76– 100%; sufficient, 56–75%; poor, ≤55%), while intention was classified as positive and negative.

Results

Total respondents from appointed Puskesmas were 154. Only 97 subjects qualified according inclusion criteria who participated in this study. These numbers were appropriate to minimum sample size required. Most of health care workers were female. Age range of health care workers were 22–55 years old. Most of health care workers were 31–40 years old and the least subjects were

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Figure 2 Proportion of Participants based on Intention over than 50 years old (Table 1). Most of health care workers were from Puskesmas Puter followed by Puskesmas Garuda, and the least subjects were from Puskesmas Kujangsari. Numbers of subjects from each Puskesmas were affected by the presence of doctors or nurses who were doing internship program and the event of Bulan Imunisasi Anak Sekolah (BIAS) program in Puskesmas during data collection. Highest level of education among health

care workers varied from senior high school until master’s degree. Most of them were diploma 1 and diploma 3. Based on length of employment, there were health care workers that had been working for 7 months. On the contrary, there were health care workers that had been working for 33 years. In this study, most of them had been working for 1–5 years and the least subjects had been working for 16–20 years. The doctors, nurses, and laboratory

Figure 1 Proportion of Participants based on Knowledge Althea Medical Journal. 2016;3(1)

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Table 2 Cross tabulation participant characteristic, knowledge and intention Number of participating health care workers (%) Knowledge Good Highest level of education Senior high school

9 (69.2)

Sufficient 4 (30.8)

Diploma

32 (82.1)

5 (12.8)

Master’s

1 (100.0)

0 (0)

Bachelor’s degree Medical Doctor

Length of employment, yr <1

11 (64.7)

23 (85.2) 7 (77.8)

1-5

22 (84.6)

16-20

3 (60.0)

6-10

11-15

9 (69.2)

9 (81.8)

2 (40.0)

25 (86.2)

4 (13.8)

6 (85.7)

Laboratory assistant

TB history Yes

No

TB history on contacted or lived with family members Yes

No

46 (80.7) 5 (45.5)

70 (77.8) 6 (85.7)

70 (77.8)

workers were included in this study because they worked in clinic in which their interactions with TB patients might increase the risk of acquiring infection. Most of subjects (58.8%) were nurses, followed by doctors (29.9%), and laboratory workers (11.3%) (Table 1). According to TB history among health care workers, 7.2% had TB infection previously. Similar to TB history among health care workers, 7.2% contacted or lived with family members who had been infected with TB previously. This number was similar but it happened to different subject. There were 76 subjects (78.4%) had good knowledge, 16 subjects (16.5%) had sufficient knowlege, and 5 subjects (5.2%) had poor knowledge (Figure 1). Based on intention, 57 Althea Medical Journal. 2016;3(1)

0 (0)

1 (100.0)

0 (0)

Physician Nurse

0 (0)

2 (18.2)

4 (30.8)

0 (0)

6 (66.7)

0 (0)

1 (20.0)

4 (80.0)

0 (0)

6 (46.2)

5 (45.5)

7 (53.8)

6 (54.5)

1 (5.9)

7 (41.2)

10 (58.8)

0 (0)

12 (41.4)

17 (58.6)

4 (57.1)

3 (42.9)

5 (8.8)

1 (14.3)

0 (0)

1 (14.3)

3 (33.3)

16 (59.3)

15 (57.7)

6 (10.5)

15 (16.7)

11 (40.7)

12 (70.6)

11 (42.3)

2 (12.5)

15 (16.7)

5 (29.4)

1 (3.8)

1 (6.3)

6 (54.5)

8 (61.5)

20 (51.3)

1 (11.1)

3 (11.5)

5 (38.5)

Negative

19 (48.7)

1 (11.1)

4 (14.8)

3 (17.6)

13 (81.3)

0 (0)

Positive

2 (5.1)

3 (17.6)

13 (76.5)

>25

Poor

3 (17.6)

21-25

Occupation

Intention

0 (0)

5 (5.6) 0 (0)

5 (5.6)

7 (43.8)

22 (38.6) 6 (54.5)

36 (40.0 ) 5 (71.4)

35 (38.9)

9 (56.3)

35 (61.4) 5 (45.5)

54 (60.0) 2 (28.6)

55 (61.1)

subjects (58.8%) were classified as having negative intention and 40 subjects (41.2%) were classified as having positive intention to use PPE (Figure 2). After stratification based on highest level of education, 32 subjects with good knowledge had diploma degree but proportionally most of subjects who had good knowledge were medical doctors and had master’s degree. These findings indicated that good knowledge was related to education level. In each education level, more than half subjects had negative intention (Table 2). Based on employment, most subjects (46 nurses) had good knowledge, followed by doctors and laboratory workers. Proportion of doctors with good knowledge washigher

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Table 3 Cross tabulation knowledge and intention Number of participating health care workers (%) Good

Sufficient Poor

Positive

Negative

29 (38.2)

47 (61.8)

8 (50.0) 3 (60.0)

compared with nurses and laboratory workers. According to length of employment, most of subjects with positive intention to use PPE had been working for 1–5 years, followed by subjects who had been working for 21–25 years and more than 25 years. Based on occupation, most of subjects with positive intention to use PPE were nurses. In proportion, laboratory assistants, whose proportion of positive intention to use PPE was more than fifty percents, had highest proportion compared to nurses and doctors. Table 3 showed among subjects with positive intention to use PPE, 29, 9, and 8 subjects had good, sufficient, and poor knowledge, respectively. Among subjects with negative intention to use PPE, 47, 8, and 2 subjects had good, sufficient, and poor knowledge, respectively. Many subjects who had good knowledge regarding TB transmission, in contrast did not have positive intention to use PPE.

Discussion

TB is transmitted via inhalation of respiratory droplet in which high amounts of bacteria are contained. The droplet is spread when active TB patients are coughing, sneezing, talking, or spitting. Use of PPE in high risk group is one of TB prevention methods. In this study, females were the most subjects participating. Similar result to 88% female subjects was found in study about perception of health care worker regarding the use of PPE conducted by Gralton et al.8 Based on employment, doctors have a higher proportion of good knowledge compared to nurses and laboratory workers. Significant differences in level of knowledge based on employment were also found in study conducted by Woith et al.9 Most of subjects had good knowledge regarding transmission of TB, including transmission media, modes, control, and high risk groups in Puskesmas. Similar results were found in study conducted by Hashim et al.10 which stated that 98.4% health care workers

8 (50.0) 2 (40.0)

Total 76 16 5

have good knowledge. Level of knowledge is influenced by education level, age, and length of employment. National TB training or health promotion program may also modify level of knowledge.10 Knowledge may be reached by a person through experience of an object using special senses. Knowledge or cognition influences a person’s behavior. Good knowledge about TB transmission will determine someone’s behavior in attempt to prevent the disease. A person with a good knowledge about TB transmission should have better prevention action compared to a person with poor knowledge. The results from intention questionnaire stated that 41.2% subjects have positive intention, while 58.8% have negative intention. These suggested that majority of health care workers do not have self awareness to use PPE, like masks or hand gloves, to prevent TB transmission in Puskesmas in where they work. Previous study with similar findings showed that health care workers’ intention to wear mask during contact with patients are low.8 This may be related to application of prophylaxis or vaccination before contacts with patients. There is also ethical consideration regarding the use of mask. Some doctors believe that wearing a mask may disrupt doctor-patient relationship and communication. Other study stated that intention to vaccination as an attempt to prevent infection is also low.11 Specific study about the use of PPE by health care workers to prevent TB have not been conducted previously. According to planned behavior theory and reasoned action theory, negative intention is associated with negative behavior because intention is a best predictor of behavior. An action of wearing PPE was the behavior considered in this study. By using this approach, it was assumed that in this study, the action of wearing PPE was low in health care workers. In conclusion, majority of subjects have good knowledge regarding TB transmission. However, this knowledge was not followed with positive intention. Limitation of Althea Medical Journal. 2016;3(1)

Hasanah, Elsa Pudji Setiawati, Lika Apriani: Knowledge and Intention to Use Personal Protective Equipment among Health Care Workers to Prevent Tuberculosis

this study is that this study cannot explain the relation between the variables. Health care workers should protect themselves when they have contacts with TB patients. One of the protection methods is by using PPE. Although the knowledge about TB transmission is good, in contrast the intention to wear PPE is poor. It is recommended to conduct health promotion program about TB transmission for all workers, not limited only for health care workers in Puskesmas facilities. District Health Office needs to provide adequate and satisfactory PPEs to prevent TB. Provision of PPEs might improve the willingness to wear them. Further study to determine the reasons health care workers, despite having a good knowledge, do not have a positive intention to use PPE needs to be done. A qualitative study is recommended to explore the causes.

References

1. WHO. Global tuberculosis report. Geneva: WHO. 2013. 2. Joshi R, Reingold AL, Menzies D, Pai M. Tuberculosis among health-care workers in low-and middle-income countries: a systematic review. PLoS Medicine. 2006;3(12):2376–91. 3. Glanz K, Rimer BK, Viswanath K, editors Health behavior and health education: theory, research, and practice. In:, editors.. 4th ed. San Fransisco:Jossey Bass; 2008. 4. Bryce EA, Scharf S, Walker M, Walsh A. The infection control audit: the standardized audit as a tool for change. Am J Infect

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Control. 2007;35(4):271–83. 5. Mphahlele MT, Tudor C, Van der Walt M, Farley J. An infection control audit in 10 primary health-care facilities in the Western Cape Province of South Africa. Int J Infect Control. 2012;8(3):1–5. 6. Baig AS, Knapp C, Eagan AE, Junior LJR, Gainesville, Florida. Health care workers’ views about respirator use and features that should be included in the next generation of respirators. Am J Infect Control. 2010;38:18–25. 7. Pratt RJ, Pellowe C, Wilson J, Loveday H, Harper P, Jones S, et al. epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect. 2007;65:S1–S59. 8. Gralton J, Rawlinson WD, McLaws M-L. Health care workers’ perceptions predicts uptake of personal protective equipment. Am J Infect Control. 2013;41(1):2–7. 9. Woith WM, Volchenkov G, Larson JL. Russian healthcare workers’ knowledge of tuberculosis and infection control. Int J Tuberc Lung Dis. 2010;14(11):1489-92. 10. Hashim DS, Al Kubaisy W, Al Dulayme A. Knowledge, attitude and practises survey among health care workers and tuberculosis patients in Iraq. East Mediterr Health J. 2003;9:718–30. 11. Maltezou HC, Dedoukou X, Patrinos S, Maragos A, Poufta S. Determinants of intention to get vaccinated against novel (pandemic) influenza A H1N1 among health-care workers in a nationwide survey. J Infect. 2010;61:252–8.

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Functional Status of Stroke Patients at Neurologic Outpatient Clinic Dr. Hasan Sadikin General Hospital Lee Shok Chen,1 Marina A. Moeliono,2 Lisda Amalia3 Faculty of Medicine Universitas Padjadjaran, 2Department of Physical Medicine and Rehabilitation Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung, 3Department of Neurology Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung, 1

Abstract

Background: Functional status refers to the ability of an individual to perform normal daily activity required to meet basic needs, fulfill usual roles, and maintain health and well-being. The objective of this study was to evaluate the level of disability and independency of stroke patients who had undergone rehabilitation therapy as the routine activity using Instrumental Activity of Daily Living (IADLs) and basic Activity of Daily Living (BADLs). Methods: This descriptive study carried out from September to October 2014 at Neurologic outpatient clinic Dr. Hasan Sadikin General Hospital Bandung with a total 33 subjects. Barthel index and IADLs questionnaire was used as an instrumental tool. Barthel index was used to measure the level of disability and IADLs was used to measure the level of independency of an individual. Results: From the 33 patients, 20 patients completed their rehabilitation therapy; 5 patients showed a moderate disability and 15 patients showed a mild disability at the Barthel Index of ADLs. The result of IADLs showed that 7 patients who completed the therapy had moderate level of independency, and 3 patients were at the category of high level of independency. Conclusions: Most of the stroke patients have moderate disability in Barthel Index and had low level of independency in IADLs. [AMJ.2016;3(1):126–31] Keywords: Barthel Index, disability, functional status, independent instrumental activity of daily living

Introduction Stroke is defined as rapidly developing signs of focal disturbances of cerebral functions, leading to death or disability, lasting longer than 24 hours, with no apparent cause other than vascular. Globally, it is the second most common cause of death with total 5.7 million deaths around the world.1 Stroke is no longer a disease in developed country. About 85% of all stroke deaths are caused by low and middle income worldwide. Stroke in terms of disability-adjusted life years, calculated worldwide in 72 million per year, accounts for 87% of total lost.2 The basic Activity of Daily Living (ADLs) of post stroke patients is measured by Barthel Index and Instrumental Activity of Daily Living (IADLs) to assess the functional abilities as in complex task. Barthel Index is an instrument to measure basic self-care of the individual.

The IADLs are defined as activities which are necessary to accomplish to continue independent residence in a community. Those activities are household activities include answering telephone call, having responsibility to own medication, preparing meal, going shopping, washing clothes, and handling household finances. Stroke recovery depends on many factors: the specific site of brain injury, the patients’ condition. Stroke rehabilitation begins during the acute hospitalization, when the diagnosis is established and life-threatening events are under control. To prevent complications, early intervention is encouraged. Rehabilitation is to promote proper management of functional outcome, encourage resumption of self-care activities, and provide mental support to the patients and their family.3 Functional status refers to the ability of an individual to perform normal ADLs required

Correspondence: Lee Shok Chen, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km.21, Jatinangor, Sumedang, Indonesia, Phone: +6287822004580 Email: [email protected] Althea Medical Journal. 2016;3(1)

Lee Shok Chen, Marina A. Moeliono, Lisda Amalia: Functional Status of Stroke Patients at Neurologic Outpatient 127 Clinic Dr. Hasan Sadikin General Hospital

to meet basic needs, fulfill usual roles, and maintain health and well-being.4 Disability is a complex phenomenon, reflecting the interaction between features of a person’s body and features of the society where he or she lives.5 Functional is classified as IADLs and basic ADLs.6 They use to evaluate the functional status and their disability after stroke in routine activity, and to measure the level of independency. Basic ADLs are self-maintenance abilities such as dressing, grooming, or bathing. Instrumental IADLs are more complex on everyday tasks, which are skills beyond basic self-care skills needed to function independently at home and in the community.7 Effective rehabilitation interventions initiated early after stroke can enhance the recovery process and minimize functional disability. The reviews above address have found some of the inconsistent findings in assessing the functional abilities of stroke patients. There is a lack from previous researches convincing

evidence on the compliance of rehabilitation therapy improvement of the functional status of stroke patients. The purpose of this study was to evaluate the level of disability and independency of stroke patients who had undergone rehabilitation therapy as the routine activity. This study was conducted in Dr. Hasan Sadikin General Hospital, one of national hospitals referred in Indonesia whose the rehabilitation department has useful equipment and physiotherapist to guide patients in rehabilitation therapy.

Methods

This was a descriptive study about the functional status of stroke outpatients carried out from September to October 2014 at Neurologic Outpatient Clinic Dr. Hasan Sadikin General Hospital Bandung. This study conducted under the ethical clearance issued by the Health Research Ethics Committee

Table 1 Demographic Characteristic Demographic Characteristic

Total (N)

Percentage %

< 30

3

9.09

50–59

8

Age range (years old) 30–39 40–49

1 9

27.27

8

24.24

> 60

12

Junior high school

12

Education level

Elementary school Senior high school

Diploma/Bachelor Sex

7 7

Male

14

Married

30

Female

Marital status Single

Address

City town Outskirts Total

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3.03

19 3

22

11

33

24.24

36.36 36.36 21.21 21.21

42.42

57.57

90.90 9.09

66.66

33.33 100

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Table 2 Barthel Index of the Stroke Patients Level of Disability

Total (N)

Very severe disability (0–4)

2

Mild disability (15–20 )

23

Severe disability (5–9)

0

Moderate disability (10–14 ) Total

Faculty of Medicine Universitas Padjadjaran. The participants in this study were stroke patients who came to the Neurologic Outpatient Clinic. Sampling method of this study was minimal total sampling which was minimal 30 patients. The inclusion criteria were the participants who signed the informed consent. However, the subjects with aphasia, severe heart disease, hemodialysis, severe pulmonary disease, and visual field defect were excluded. The study used Barthel Index of ADL and IADL questionnaire. The demographic characteristic, age, sex, educational level, marital status, and house address were recorded. The participants took part in interview after they agreed to sign the informed consent. There were ten domains of function assess with Barthel Index. Besides, there were eight domains that corresponded to the patient’s current functional ability for each task on IADLs. The writer interviewed patients witnessed by family members and medical staffs. The Barthel Index of ADL is classified according to level of disability: very severe disability (0–4), severe disability(5–9), moderate disability (10–14), mild disability (15–20).8 The IADL is classified according to level of independency: low (0–3), moderate (4–6), and high (7–8). 7 The results were analyzed by categorized Barthel Index into very severe disability, severe disability, moderate disability, and mild disability. IADLs were categorized into high,

8

33

moderate, and low level of independency.

Results

The total of 33 subjects, 12 stroke patients were above 60 years old which had the highest number of patients. Mostly patients completed their junior high school. Seven of the patients had a diploma or bachelor’s degree. From the interview, male and female had the slight equal number of patients and the marital status mostly was married (Table 1). The results of the interview using Barthel Index of ADL, 23 patients had moderate disability on basic self-care activities. Only 2 patients had very severe disability (Table 2). The result from the IADL questionnaire, 13 patients had low level of independency in performing more complex daily tasks. However, 8 patients had low level of independency. Most of the educated patients had mild disability on basic ADLs with a total 12 patients. The patients, who had highest number of mild disability, were 40–49 years old. Among the patients who completed the rehabilitation therapy, 15 patients had mild disability on basic self-care activity (Table 4). The IADL presented by the patients who completed elementary school had low level of independency with a number of six patients. The patients at the age range 40–49 and 50–59 showed equal number of low level of independency.

Table 3 Instrumental Activities of Daily Living (IADL) Level of Independency

Total (N)

Low (0–3)

13

Total

33

Moderate (4–6) High (7–8)

12 8

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Table 4 Characteristic of Barthel Index Level of Disability Education level

Elementary school

Junior high school

Senior high school

Very severe

Severe

Moderate

Mild

2

0

0

6

0

0

Diploma/Bachelor

0

30–39

0

Age (years old) < 30

40–49

50–59

> 60

Complete therapy Yes

No

Not yet

Total

Discussion

0

0

0

0

0

0

0

0

1

0

1

0

2

0

0

0

0 2

Educational level is associated with a better functional outcome, measured by the ability to perform self-maintenance and mobility.9 All

0

0

5

2

1

1

0

3

3

1

6

5

6

2

1

6

4

10

5

15

8

23

3

0

6

2

the educated patients and thirty-one patients showed a moderate and mild disability on basic ADLs at this study. The remaining two patients only completed elementary school and showed a very severe disability in Barthel

Table 5 Instrumental Activity of Daily Living (IADL) Level of Independency

Low

Moderate

High

Elementary school

6

1

1

Diploma/Bachelor

1

4

2

Education level

Junior high school

Senior high school Age (years old) < 30

30–39

40–49

50–59 > 60

Complete therapy Yes No

Not yet

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4

2

1

0

5

5

2

10 3

0

4

3

1

0

2

0

9 7

4

1

3

2

1

1

2

3

1 3

4

1

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Index. However, the patients who had a diploma or bachelor’s degree were presented with a better outcome compared to the others slight lower educational level patients. The stroke patients who had a higher education showed that they had a higher functional status compared to the poor educated patients.2 From the IADLs, the patients who had completed elementary school had low level of independency. A study of examination of IADLs, a lower education is associated with a low level of functional status.6 Age is a non-modifiable risk factor for stroke; aging will slow down the motor function and strength of the elderly.10 Thus, from table 1, twenty out of thirty-three patients who were at the age above sixty encountered stroke events in this study. Two elderly had severe disability at Barthel Index and two elderly had low level of independency. Based on study by Holloway et al.3 there are more elderlies who have disability on IADLs to ADL. It does not correspond with this study. Rehabilitation is a strategy to enhance functional independence in patients with stroke.11 Based on study by Holloway et al.3 rehabilitation that is started earlier and completed will reduce the complication and have a good compliance with a better outcome. In this study, the fifteen stroke patients who completed rehabilitation had mild disability on basic ADLs. Mild disability indicates an individual has mild dysfunctional on performing basic self-care daily activity.6 Eight out of 33 patients with moderate disability in this study are comparable to 40% of stroke patients with moderate disability in a similar study at Barthel Index.6 This study established that the stage of recovery of various impairments provides significant prognostic indicators for outcomes. The outcomes considered were ADLs, recovery of the arm, leg, and postural control and gross motor function and gait.1 According to this study, full recovery of motor function after stroke was incomplete. However, stimulation can facilitate on the motor function of a human and thus facilitate the motor performance.12 The functional status of the stroke patients depends on the frequency of rehabilitation and compliance of rehabilitation. The IADLs are skills beyond basic selfcare skills needed to function independently at home and in the community. Patients who were staying alone, are required to evaluate IADLs.13 From table 5, patients completed the rehabilitation; three patients had high level of independency. This indicated the ability of

the patients to perform complex tasks such as prepare a meal, use safety precaution, take medicines, and get emergency aid when it is necessary. There are some limitations of this study; the questionnaire for Barthel Index and IADLs were written in English, whereas, interviewer had to interview in Bahasa Indonesia. The study will observe along the patients on the ADLs to obtain the accuracy of data. The recomendation for future study is starting a study using Bahasa version of instrumental activity. In conclusion, rehabilitation therapy shows improvement from the functional status of stroke patients and a transition from dependent to independent on their daily living. The patients should be educated about the benefits of therapy and being encouraged to obtain good compliance of therapy. Therefore, increasing the awareness and understanding of stroke patients and family members on rehabilitation therapy improves the functional status of stroke patients. Prevention of stroke are made by detection of early disease, identification of risk factors, a combination of pharmacological and psychosocial interventions, and a long term follow up with regular monitoring and promotion of adherence to treatment.14

References

1. Canning CG, Ada L, Adams R, O’Dwyer NJ. Loss of strength contributes more to physical disability after stroke than loss of dexterity. Clin Rehabil. 2004;18(3):300–8. 2. Di Carlo A. Human and economic burden of stroke. Age Ageing. 2009;38(1):4–5. 3. Holloway R, Arnold R, Creutzfeldt C, Lewis E, Lutz B, Macann R, et al. Pallitative and end of life care in stroke. Am Heart J. 2014;45(6):1887-916. 4. Davenport R, Manson J, De’Ath H, Platton S, Coates A, Allard S, et al. Functional definition and characterisation of acute traumatic coagulopathy. Crit care med. 2011;39(12):2652–8. 5. Kwon S, Hartzema AG, Duncan PW, Min-Lai S. Disability measures in stroke relationship among the Barthel Index, the functional independence measure, and the modified Rankin Scale. Stroke.2004;35(4):918–23. 6. Gold AD. An examination of instrumental activities of daily living assessment in older adults and mild cognitive impairment. J Clin Exp Neuropsychol. 2012;34(1):11–34. 7. Graf C. The Lawton instrumental activities of daily living scale. AJN. 2008;108(4):52– Althea Medical Journal. 2016;3(1)

Lee Shok Chen, Marina A. Moeliono, Lisda Amalia: Functional Status of Stroke Patients at Neurologic Outpatient 131 Clinic Dr. Hasan Sadikin General Hospital

62. 8. Sangha H, Lipson D, Foley N, Salter K, Bhogal S, Pohani G, et al. A comparison of the Barthel Index and the functional independence measure as outcome measures in stroke rehabilitation: patterns of disability scale usage in clinical trials. Int J Rehabil Res. 2005;28(2):135–9. 9. Kusuma Y, Venketasubramanian N, Kiemas L, Misbach J. Burden of stroke in Indonesia. Int J Stroke. 2009;4(5):379–80. 10. Ferri CP, Acosta D, Guerra M, Huang Y, Llibre-Rodriguez JJ, Salas A, et al. Socioeconomic factors and all cause and cause-specific mortality among older people in Latin America, India, and China: a population-based cohort study. PLoS Med. 2012;9(2):e1001179. 11. Dobkin BH. Rehabilitation after stroke. N

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Eng J Med. 2005;352(16):1677–84. 12. Hummel F,Celnik P,Giraux P, Floel A,Wan Hsun W, Gerloff C, et al. Effects of noninvasive cortical stimulation on skilled motor function in chronic stroke. Brain J Neurol. 2005;128(3):490–9. 13. Duncan PW, Zorowitz R, Bates B, Choi JY, Glasberg JJ, Graham GD, et al. Management of adult stroke rehabilitation care a clinical practice guideline. Am Heart J. 2005;36(9):100–43. 14. Beaglehole R, Epping Jordan J, Patel V, Chopra M, Ebrahim S, Kidd M, et al. Improving the prevention and management of chronic disease in lowincome and middle-income countries: a priority for primary health care. Lancet. 2008;372(9642):940–9.

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Clinical and Cerebrospinal Fluid Abnormalities as Diagnostic Tools of Tuberculous Meningitis Fiona Lestari,1 Sofiati Dian,2 Ida Parwati3 Faculty of Medicine Universitas Padjadjaran, 2Department of Neurology Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital,Bandung, 3Department of Clinical Pathology Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital,Bandung

1

Abstract Background: Tuberculous meningitis (TBM) is the most severe form of extrapulmonary tuberculous (TB) disease and remains difficult to diagnose. The aim of the study was to determine the diagnostic value of clinical and laboratory findings of cerebrospinal fluid (CSF) examinations for diagnosing TBM using bacterial culture result as the gold standard. Methods: A prospective cross sectional study was carried out to 121 medical records of hospitalized TBM patients in neurological ward at Dr. Hasan Sadikin General Hospital Bandung, from 1 January 2009–31 May 2013. The inclusion criteria were medical records consisted of clinical manisfestations and laboratory findings. The clinical manisfestations were headache and nuchal rigidity, whereas the laboratory findings were CSF chemical analysis (protein, glucose, and cells) and CSF microbiological culture. Validity such as sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) for clinical and laboratory findings were calculated, using bacterial culture result as the gold standard. Results: The most clinical findings of TBM was nuchal rigidity and it had the highest sensitivity value, but the lowest spesificity value. Decreased of CSF glucose had the highest sensitivity value compared to other laboratory findings, but the value was low. Conclusions: The clinical manisfestations and the laboratory findings are not sensitive and specific enough for diagnosing TBM. [AMJ.2016;3(1):132–6] Keywords: Cerebrospinal fluid, clinical manisfestations, diagnostic tools, laboratory findings, tuberculous meningitis

Introduction Tuberculous (TB) is one of the major health problems in the world, especially in developing countries.1,2 Manifestations of TB can be pulmonary and or extrapulmonary, which 20.4% cases are extra-pulmonary TB.3,4 Based on data from Centers for Disease Control and Prevention (CDC) in 2011, it was indicated that 5.7% extrapulmonary TB involved the Central Nervous System (CNS).4,5 The most severe manifestation of CNS TB is Tuberculous Meningitis (TBM) which causes high mortality in children and adult.5-8 The mortality rate of TBM in Bandung, the capital city of West Java, Indonesia, is 50% in the first week of admission to the hospital and increases to 67% after one month treatment in the hospital.9 Early

diagnosis and accurate treatment are promptly needed in order to improve the outcomes.8,10,11 Standardized diagnostic criteria for TBM have not been established, because the clinical manifestations of TBM are not specific, especially in the early stages of disease.12 Patients usually come to the hospital after having headache, fever, nuchal rigidity, irritability, vomiting or even after having many neurologic symptoms and signs within a few days.9,12 Many patients come with history of typical systemic symptoms of TB infection, such as cough, lethargy, weight loss, and night sweating that might be suggestive of TB, but also non-specific.12 Lumbar puncture is the first procedure to be conducted for patients who are suspected with CNS infections. Routine analysis of cerebrospinal fluid (CSF)

Correspondence: Fiona Lestari, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km.21, Jatinangor, Sumedang, Indonesia, Phone: +62 81931207624 Email: [email protected] Althea Medical Journal. 2016;3(1)

Fiona Lestari, Sofiati Dian, Ida Parwati: Clinical and Cerebrospinal Fluid Abnormalities as Diagnostic Tools of Tuberculous Meningitis

in most patients with TBM shows clear appearance, increased protein, decreased glucose concentration (a CSF glucose to plasma ratio or absolute value) and pleocytosis with lymphocyte predominance.12 The aim of the study was to analyze the sensitivity and specificity of TBM clinical manifestations and cerebrospinal fluid abnormalities compared to bacterial culture result.

Methods

A restrospective cross sectional study was carried out to medical records of TBM patients in neurological ward at Dr. Hasan Sadikin General Hospital Bandung, top referral hospital for West Java Province, Indonesia from 1 January 2009 to 31 May 2013. The inclusion criteria in this study were medical records of hospitalized TBM patients, consisted of clinical manisfestations and laboratory findings. The clinical manisfestations were headache and nuchal rigidity, whereas the laboratory findings were CSF chemical analysis (protein, glucose, and

cells), CSF microbiological culture. From 509 available medical records, only 121 medical records which met the inclusion criteria (Figure 1). The operational variables in this study were defined as nuchal rigidity defined by a resistance to flexion of the neck due to muscle spasm of the extensor muscles; increased CSF protein defined by positive in concentration >100 mg/dL; decreased CSF glucose defined by positive in CSF to plasma glucose ratio of <50%; CSF pleocytosis with lymphocytic predominance defined by positive in CSF cells count 10 ̶ 500 /µL and lymphocyte >50%; CSF abnormalities defined by positive for all three CSF findings in increased CSF protein, decreased CSF glucose and CSF pleocytosis with lymphocytic predominance. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for each variable using bacterial culture result as the gold standard. All of the clinical data were entered and calculated using computer. Prior to this study, ethical approval was obtained from the Health Research Ethics Committee of Dr. Hasan Sadikin General Hospital/Faculty of Medicine,

Figure 1 The Inclusion Criteria among 509 TBM Patients Althea Medical Journal. 2016;3(1)

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Universitas Padjadjaran, Bandung, Indonesia (No.LB.02.01/C02/9324/VIII/2013).

Results

This study discovered that from 121 TBM cases, most of the patients had nuchal rigidity and headache. From the laboratory findings, the highest percentage of laboratory abnormalitiy was the decrease of the glucose level in CSF (Table 1). Moreover, only 28.93% had positive bacterial culture. Among 6 variables identified and measured, the symptom of nuchal rigidity had the highest positive culture result, compared to other variables. This study discovered that nuchal rigidity was the highest sensitivity among 6 variables, but the lowest specificity value. This study revealed that CSF abnormalities was the best variable which incorrectly identified the negative cultural result. All variables in this study showed low percentages for PPV, on the other hand the NPV showed higher percentages (Table 3).

Discussion In this study, nuchal rigidity had the highest sensitivity and CSF abnormalities had the highest specificity among 6 analyzed variables. Among 121 patients, 93.39% patients had positive sign of nuchal rigidity and 88.43% patients complained of headache. In previous TBM study, it was reported on 77.2% patients with nuchal rigidity and 67% patients with headache.8 There was an increase number of nuchal rigidity sign and headache in TBM patients. According to Rock et al.7, adult TBM patients normally come with classic signs of meningitis such as fever, headache, and meningismus/nuchal rigidity.7 This study revealed that sensitivity for all of the variables was quite high but less specificity. Diagnosing TBM persistence is still difficult.13 Sensitivity of nuchal rigidity in this study was 97% positive when cultural result was positive either. Nevertheless, specificity for nuchal rigidity was very low as 8%. It described that nuchal rigidity was not specific to identify the positive culture of TBM. Ideally, the greater sensitivity and specificity

Table 1 Clinical Manisfestations and Laboratory Findings

Total n (%) Clinical Manifestation Nuchal rigidity

113 (93.39)

Decreased of CSF* glucose

100 (82.64)

Headache

107 (88.43)

Laboratory Findings

Increased of CSF protein

79 (65.29)

CSF pleocytosis lymphocytic predominance

60 (49.59)

CSF abnormalities

37 (30.58)

Positive bacteria in CSF culture

35 (28.93)

Note: *CSF= cerebrospinal fluid

Table 2 Clinical Manifestations and Laboratory Findings according to Bacterial Culture Nuchal rigidity

Headache

Decreased CSF glucose

Increased CSF protein

CSF pleocytosis lymphocytic predominance

CSF abnormalities

Positive Culture

Negative Culture

Total

34

79

113

30

30

22

16 9

77

107

70

100

28

37

57

44

79

60

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Table 3 Sensitivity, Specificity, PPV and NPV of Clinical Manifestations and Laboratory Findings. Sensitivity (%) Specificity (%) Nuchal rigidity

97

Increased CSF protein

63

Headache

Decreased CSF glucose

CSF pleocytosis lymphocytic predominance CSF abnormalities

PPV* (%)

NPV** (%)

8

30

88

34

28

69

86

10

46

49

86

26

19

67

Note: *PPV= positive predictive value; **NPV= negative predictive value

of test will make a better diagnostic tool from identifying a disease. A prospective cross sectional study which comparing signs of meningeal inflammation (nuchal rigidity, head jolt accentuation of headache, Kernig’s sign and Brudzinski’s sign) to the reference CSF white cell count >5 cells as the gold standard concluded that physical signs of meningeal inflammation do not accurately discriminate between patients with meningitis from those without it accurately regarding the poor accuracy.11 Moreover, headache and nuchal rigidity in meningitis caused by M. tuberculosis and in meningitis caused by other etiological factors cannot be differentiated. Laboratory findings of CSF examinations revealed that CSF glucose have the highest sensitivity value but the lowest specificity value. A prospective cross-sectional study in the Philipines5, using culture or acid fast staining or basal meningeal enhancement on computerized axial tomography (CT) head contrast as gold standard for analyzing the laboratory findings showed similar results.5 This study revealed that 35 patients have positive result for M. tuberculosis. The culture results explained that 28.93% patients have definite diagnosis of TBM, and the remaining patients are categorized as probable or possible diagnosis TBM based on the scoring systems. However, the absence of mycobacterial findings in culture result does not exclude the patients from diagnosis of TBM.12 One study in Philipine5 reported that among 68 patients who were diagnosed with TBM, 5.9% culture positive or acid fast staining were found. Another study by Chaidir et al.8 discovered that 36% TBM patients have positive culture. Study in Shanghai13 reported that 12% of 25 patients TBM have positive culture. The CDC informed that culture was used as the gold standard for laboratory Althea Medical Journal. 2016;3(1)

28

30

27

24

64

76

69

69

confirmation of TB disease.14 Culture result positive established that patients have positive TBM infections. Ideally, sensitivity of a good culture media is 100% which it will grow the etiologic factor in whole TBM infections cases. Nonetheless, culture is an imperfect gold standard. Literature studies informed that M. tuberculosis culture has low sensitivity. It is limited because of the low concentration of bacilli in CSF, characteristic of mycobacterial itself with the need of high enrichment media, or because the patients have already taken the anti tuberculosis drugs before the lumbar puncture done.5,13,15,16 The chances of positive diagnosis can be increased by doing more lumbar punctures.12 There are some limitations of this study. First, acid fast staining and Polymerase Chain Reaction (PCR) method were not used to identify bacteria in CSF. Polymerase Chain Reaction was not routinely done because it is expensive. Second, some medical records were not written completely enough and available to be analyzed in this study. Third, there is no separation calculation for the Human Immunodeficiency Virus (HIV)-co infection patient, which it possibly affects the clinical presentation and laboratory findings in TBM patients. The ideal diagnostic tests which are validated, rapid, sensitive, and specific are absolutely needed so that appropriate and accurate therapy can be started early, toxicities of unnecessary treatment can be avoided, morbidity and mortality prevalences can be lowered. In conclusion, from clinical findings and laboratory examinations, we found that the sensitivity was quite high but lack for specificity. Combination of all CSF examinations abnormalities showed higher specificity, but less sensitivity. Culture result has low sensitivity.

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References 1. WHO. Global tuberculosis report 2012. Geneva: World Health Organization, 2012. 2. Tai MLS. Tuberculous meningitis: diagnostic and radiological features, pathogenesis and biomarkers. Neuroscience & Medicine. 2013;4(2):101–7. 3. Pedoman Nasional Pengendalian Tuberkulosis. In: Indonesia KKR, editor. 2nd ed. Jakarta: Kementrian Kesehatan Republik Indonesia Direktorat Jenderal Pengendalian Penyakit dan Penyehatan Lingkungan; 2011. p. 1–99. 4. CDC. Reported tuberculosis in United States 2011. Atlanta: Central for Disease Control and Prevention; 2012. p. 1–154. 5. Pasco PM. Diagnostic features of tuberculous meningitis: a cross-sectional study. BMC Res Notes. 2012;5:49. 6. Galimi R. Extrapulmonary tuberculosis: tuberculosis meningitis new developments. Eur Rev Med Pharmacol Sci. 2011;15(4):365–86. 7. Rock RB, Olin M, Baker CA, Molitor TW, Peterson PK. Central nervous system tuberculosis: pathogenesis and clinical aspects. Clin Microbiol Rev. 2008;21(2):243–61. 8. Chaidir L, Ganiem AR, Van der Zanden A, Muhsinin S, Kusumaningrum T, Kusumadewi I, et al. Comparison of real time IS6110-PCR, microscopy, and culture for diagnosis of tuberculous meningitis in a cohort of adult patients in Indonesia. PloS One. 2012;7(12):e52001. 9. Basuki A, Dian S, editors. Neurology in daily

practise. 2nd ed. Bandung: Bagian/UPF Ilmu Penyakit Saraf Fakultas Kedokteran UNPAD/ RS. Hasan Sadikin; 2011. 10. Christie LJ, Loeffler AM, Honarmand S, Flood JM, Baxter R, Jacobson S, et al. Diagnostic challenges of central nervous system tuberculosis. Emerg Infect Dis. 2008;14(9):1473–5. 11. Waghdhare S, Kalantri A, Joshi R, Kalantri S. Accuracy of physical signs for detecting meningitis: a hospital-based diagnostic accuracy study. Clin Neurol Neurosurg. 2010;112(9):752–7. 12. Marais S, Thwaites G, Schoeman JF, Torok ME, Misra UK, Prasad K, et al. Tuberculous meningitis: a uniform case definition for use in clinical research. Lancet Infect Dis. 2010;10(11):803–12. 13. Quan C, Lu C-Z, Qiao J, Xiao B-G, Li X. Comparative evaluation of early diagnosis of tuberculous meningitis by different assays. J Clin Microbiol. 2006;44(9):3160– 6. 14. CDC. Diagnosis of tuberculosis. Atlanta: Central for Disease Control and Prevention; 2005. p. 75–107. 15. Velenzuela PB, Mendoza MT, Ang C, Guzman JD. Validation of the Thwaites’ diagnostic rule in the diagnosis of tuberculous meningitis in adults at the Philippine General Hospital. Philippine J Microbiol Infect Dis. 2008;37(1):11–9. 16. Thwaites GE, Tran TH. Tuberculous meningitis: many questions, too few answers. Lancet Neurol. 2005;4(3):160– 70.

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Profile of Anemia on Lung Tuberculosis at Dr. Hasan Sadikin General Hospital and Community Lung Health Center Bandung Marizka Adzani,1 Nadjwa Zamalek Dalimoenthe,2 Indra Wijaya3 Faculty of Medicine Universitas Padjadjaran, 2Department of Clinical Pathology Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung, 3Department of Internal Medicine Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung 1

Abstract Background: Tuberculosis (TB) is a chronic infectious disease caused by Mycobacterium tuberculosis that can cause anemia. Anemia is a lack of erythrocyte mass needed to carry adequate oxygen to the whole bodies. The aim of this study was to describe the anemia in adult lung TB patients at Dr. Hasan Sadikin General Hospital and Community Lung Health Center (Balai Kesehatan Paru Masyarakat, BKPM) Bandung. Methods: This descriptive study was conducted from August to October 2014. Study subjects were adult TB patients who came for their first control to TB Clinic Dr. Hasan Sadikin General Hospital and BKPM Bandung after receiving oral antituberculosis drugs, and willing to comply in study. The exclusion criteria were patients with other chronic diseases, pregnant, menorrhagia, and hemoptoe. Three mL of vein blood was taken and put into EDTA tube for routine hematologic measurement using automatic hematologic analyzer, sysmex KX-21®. Results: There was 31 (63.26%) from 49 adult lung TB patients suffered anemia. In male subjects, mild and moderate anemia were found 57.14% and 42.86% respectively, and in female subjects were 58.82% and 41.18% respectively. In males, there were 42.86% normochromic normocytic, 42.86% hypochromic microcytic, 7.14% normochromic microcytic, and 7.14% hypochromic normocytic, while in females, there were 5.88% normochromic normocytic, 47.06% hypochromic microcytic, 17.65% normochromic microcytic, 29.41% hypochromic normocytic. Conclusions: Anemia is found in 63.26% adult lung TB patients, most of which are mild anemia and hypochromic microcytic, especially in female subjects. [AMJ.2016;3(1):137–40] Keywords: Anemia, hemoglobin, lung tuberculosis

Introduction Tuberculosis (TB) is one of the major health problems and causes second-most deaths due to infectious diseases worldwide. Indonesia ranks fourth in countries with most TB patients after India, China, and South Africa.1 Tuberculosis is a chronic infectious disease caused by Mycobacterium tuberculosis which commonly attacks the lungs.2 TB can cause various and complex hematologic abnormalities, one of which is anemia.3 Isanaka et al.4 in 2011 reported that iron deficiency anemia as well as anemia without iron deficiency in TB patients are related to 2–3 fold increased risk of death. In TB patients,

anemia could manifest as chronic-diseaserelated anemia, anemia due to coughing blood (hemoptysis), anemia due to malnutrition and sideroblastic anemia as side effect of isoniazid.2,5,6 Anemia is functionally defined as insufficiency of eryhtrocyte mass to deliver oxygen in sufficient amount to peripheral tissues.6 Al Omar et al.7 in 2009 reported that anemia in adult TB patients happened as much as 60% in male and 45% in female, and 80% was normochromic normocytic anemia. The aim of this study was to describe the anemia in adult lung TB patients at Dr. Hasan Sadikin General Hospital and Community Lung Health Center (Balai Kesehatan Paru Masyarakat, BKPM) Bandung.

Correspondence: Marizka Adzani, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km.21, Jatinangor, Sumedang, Indonesia, Phone: +6287821584924 Email: [email protected] Althea Medical Journal. 2016;3(1)

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Methods This was a quantitative descriptive study, conducted from August to October 2014. The subjects were adult lung TB patients who came to TB Clinic Dr. Hasan Sadikin General Hospital and BKPM Bandung. Subjects were chosen by consecutive sampling. Study data was a primary data based on routine hematologic test results in adult lung TB patients. The inclusion criteria were patients diagnosed with TB, who received oral antituberculosis drugs and came for first time control to TB Clinic at Dr. Hasan Sadikin General Hospital and BKPM Bandung, who were willing to comply for study, adult aged >18 years old. The exclusion criteria were patients with other chronic diseases, hemoptysis, pregnancy, and menorrhagia. Diagnosis of anemia in adult TB patients was confirmed when hemoglobin levels below 13 g/dl for male and below 12 g/dl for female; hematocrit levels below 42% for male and below 37% for female; eryhtrocyte count less than 4.95 million /mm3 for male and less than 4.25 million/mm3 for female. Anemia is classified as hypochromic microcytic when MCV<80 fL and MCHC <32%, as normochromic normocytic when MCV 80–100 fL and MCHC 32–36%, as macrocytic when MCV>100 fL. Severity of anemia in male patients is graded as mild:11–12.9 g/dl; moderate :8–10.9 g/

dl; and severe:≤8 g/dl. Severity of anemia in female patients is graded as mild:11–11.9 g/ dl; moderate: 8–10.9 g/dl, and severe: ≤8 g/ dl.6 Study procedures conducted were getting study permit from Dr. Hasan Sadikin General Hospital and BKPM; ethical clearance from study Ethical Commitee of Dr. Hasan Sadikin General Hospital; TB patients screening who fulfilled the inclusion and exclusion criteria in TB Clinic Dr. Hasan Sadikin General Hospital and BKPM; performing informed consent by examiner; preparing study equipments and materials; taking 3ml blood samples from vein and putting into EDTA tubes; homogenizing samples and hematologic measurement using hematology analyzer device, sysmex KX-21®; processing and analyzing study results; and announcing the results to patients through clinic

Results

The number of adult pulmonary tuberculosis patients who suffered from anemia was larger. The result showed that 31 of 49 subjects (63.26%) suffered anemia. Seventeen was female (Table 1). Results of anemia distribution and frequency showed that there was no severe anemia found in male and female subjects

Table 1 Characteristics of Adult Lung TB Patients Characteristics

Anemia (n= 31)

No anemia (n= 18)

14

12

32.4

32.9

Gender Male

Female

17

Age (year) Mean

Body Mass Index (m/kg2) Mean

18.2

6

Table 2 Frequency Distribution of Anemia in Adult Lung TB Patients Gender Male

Female Total

Anemia Mild N (%)

Moderate N(%)

8 (57.14%)

6 (42.86)

10 (58.82%) 18

7 (41.18) 13

18.8 Total 14 (100%)

17 (100%) 31

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Table 3 Anemia Description in Adult Lung TB Patients Male n=14

Female n=17

Normochromic normocytic

6

1

Hipochromic normocytic

1

5

Anemia Type Hypochromic microcytic

6

Normochromic microcytic

8

1

(Table 2). The most classification of anemia in women was hypochromic mikrositer, whereas, the most in men was normokrom normositer and hypochromic mikrositer (Table 3). Moderate anemia dominated with hypochromic microcytic anemia (Table 4).

3

suffered from anemia had less nutrition, it is consistent with study by Oliveira et al.10 in 2014 that mentioned 68.7% of pulmonary TB patients with anemia have a BMI of 18.21 kg/ m2, so that concludes anemia is associated with malnutrition. The distribution frequency results of this study showed that in male, 57.14% adult lung TB patients suffered mild anemia and 42.86% suffered moderate anemia. In female subjects, 58.82% had mild anemia and 41.18% had moderate anemia. There was no subject presented with severe anemia in this study. These results are comparable to the study conducted in 2012 by Hungund et al.11, who reported that out of 100 TB patients, 50% have mild anemia, 37% have moderate anemia, but in Hungund study, 9% have severe anemia. Study Kumar et al.12 in 2013 reported that 63 people have mild anemia. Anemia in TB patients is related to chronic inflammation process, where erythropoiesis is inhibited by cytokines and iron metabolism is altered, which results mild to moderate degree of anemia.13,14 Hematological changes that occur are often associated with the body’s immune response to TB infection. This study reported that in male adult, patients with lung TB, 42.86% had normochromic normocytic anemia, 42.86% had hypochromic microcytic anemia, 7.14% had normochromic microcytic anemia, 7.14% had hypochromic normocytic anemia, and

Discussion

This study found that 31 out of 49 subjects (63.26%) had anemia. Result of other studies was various outcomes. Yaranal et al.3 in 2013 showed that anemia in TB patients occurred in as high as 74% of cases. Lee et al.8 in 2006 reported that 31.9% TB patients suffer anemia. Characteristic and frequency distribution of adult lung TB patients who had anemia in this study were 28.57% in males and 34.69% in females. Al Omar et al.7 in 2009 reported that anemia in adult lung TB patients occurs as much as 60% in male and 45% in female. This diversity in results maybe due to another coexisting disease.6 The median age for male and female lung TB patients in this study was 31 years old with range 15–57 years old. Karoum et al.9 study reported that mostly, TB patients with anemia are over 16 years old. This study also showed that the average BMI of TB patients with anemia were 18.2 kg/cm2 (underweight) and in TB patients without anemia 18.8 kg/cm2 (normal) respectively. The data showed that TB patients who

Table 4 Anemia Classification in Adult Lung TB Patients based on Severity Anemia Type

Mild

Moderate

Total

Normochromic normocytic

6

1

7

Normochromic microcytic

3

Hypochromic microcytic Macrocytic

Hypochromic normocytic Total

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4

10

14

5

1

6

0

18

0 1

13

0 4

31

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none of them had macrocytic anemia. In female adult, patients with lung TB, 5.88% had normochromic normocytic anemia, 47.06% had hypochromic microcytic anemia, 17.65% had normochromic microcytic anemia, 29.41% had hypochromic normocytic anemia, and also none of them had macrocytic anemia. Overall, this study reported that most of the cases were hypochromic microcytic anemia. This result is different compared to the study conducted by Al Omar et al.7 in 2009, which reported that 80% anemia in TB patients are normochromic normocytic type and only 20% anemia are hypochromic microcytic type; and study by Lee et al.8 in 2006 which reported that 71.9% cases have normochromic normocytic anemia. Study by Atomsa et al.15 in 2014 reported that 37.5% cases have normokrom normositer and 30.4% hypochromic normositer. These differences in results might be caused by the existence of underlying anemia, most probably iron deficiency anemia. Theoretically, iron deficiency anemia presents itself in 3 stages: iron depletion, iron deficient erythropoiesis, and finally iron deficiency anemia. In the first two stages, anemia does not occur yet. In the third stage, anemia is detected initially with normochromic normocytic type, which slowly progresses to be normochromic microcytic anemia and finally, hypochromic microcytic anemia occurs.6 Conclusion of this study is 63.26% adult lung TB patients suffer anemia, most of which are mild anemia and the most category are hypochromic microcytic anemia. The limitation of this study is the absence of database for previous health examination results before laboratory checkup and previous medical history. Recommendations for clinicians is to consider the importance of the examination of anemia in patients with TB and provide treatment of anemia.

References

1. WHO. Global Tuberculosis Report 2012. Geneva: WHO; 2012 2. Loscalzo J, editor. Harrison’s pulmonary and critical care medicine. New York: McGraw-Hill Education; 2010. 3. Yaranal PJ, Umashankar T, Harish SG. Hematological profile in pulmonary

tuberculosis. Int J Health Rehabil Sci. 2013;2(1):50–5. 4. Isanaka S, Mugusi F, Urassa W, Willett WC, Bosch RJ, Villamor E, et al. Iron deficiency and anemia predict mortality in patients with tuberculosis. J Nutr. 2011;142(2):350–7. 5. Piso RJ, Kriz K, Desax M-C. Severe isoniazid related sideroblastic anemia. Hematol Rep. 2011;3(1):e2. 6. Harmening D,editor. Clinical hematology and fundamentals of hemostasis. Philadelpia: F.A Davis Co; 2009. 7. Al-Omar I, Al-Ashban R, Shah A. Hematological Abnormalities in Saudia suffering from pulmonary tuberculosis and their response to the treatment. Res J Pharma. 2009;3(4):78–85. 8. Lee SW, Kang YA, Yoon YS, Um SW, Lee SM, Yoo CG, et al. The prevalence and evolution of anemia associated with tuberculosis. J Korean Med Sci. 2006;21:1028–32. 9. Karoum A, Mohamed B, Siddig M, Bari E. Anemia in Kassala area Eastern Sudan. Sudan Journal of Medical Sciences. 2009;4(1):31–5. 10. Oliveira M, Delogo K, Oliveira Hd, Ruffino N, Kritski A, Oliveira M. Anemia in hospitalized patients with pulmonary tuberculosis. J Bras Pneumol. 2014;40(4):403–10. 11. Hungund B, Sangolli S, Bannur H, Malur P, Pilli G, Chavan R, et al. Blood and bone marrow findings in tuberculosis in adults. Al Ameen J Med Sci. 2012;5(4):362–366. 12. Kumar S, Singh U, Saxena MK, Saxena R. Hematological and biochemical abnormalities in case of pulmonary tuberculosis patients in malwa region. IJBPS. 2013;3(3):237–41. 13. Muhammad A, Sianipar O. Determination of iron deficiency in chronic disease anemia by the role of sTfR-F index. Indonesian Journal of Clinical Pathology and Medical Laboratory. 2005;12(1):9–15. 14. Weiss G, Goodnough LT. Anemia of chronic disease. N Engl J Med. 2005; 352(10):1011– 23. 15. Atomsa D, Abebe G, Sewunet T. Immunological markers and hematological parameters among newly diagnosed tuberculosis patients at Jimma University Specialized Hospital. Ethiop J Health Sci. 2014;24(4):311–8.

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Anesthesia Technique Selection Pattern in Patients Undergoing Lower Extremities Surgery at Dr. Hasan Sadikin General Hospital from January–June 2013 Keshia Amalia Mivina Mudia,1 Ezra Oktaliansah,2 Ihrul Prianza Prajitno3 Faculty of Medicine Universitas Padjadjaran, 2Department of Anesthesiology and Intensive Care Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung, 3 Department of Anatomy and Cell Biology Faculty of Medicine Universitas Padjadjaran 1

Abstract Background: Musculoskeletal problems of the lower extremities are becoming more frequent lately. This problem usually requires surgery to be dealt quickly . The role of the anesthesiologist is needed to determine which anesthesia technique that has to be performed. Selection of proper anesthesia technique can reduce the incidence of complications . Objective of this study was to determine anesthesia technique selection pattern in patients undergoing orthopedic surgery at Dr. Hasan Sadikin General Hospital from January–June 2013. Methods: A quantitative study with retrospective descriptive method was conducted. This study was carried out from September–October 2013 at Dr. Hasan Sadikin General Hospital Bandung. Medical records were used as a research instrument. Data collection was conducted using total sampling method. There were 228 data of all cases, but only 151 patients who met the inclusion and exclusion criteria. Results: One hundred fifty one patients were identified. Sixty five subjects (43%) were performed under general anesthesia, 83 subjects (55%) under regional anesthesia and 3 subjects (2%) under combination of general-regional anesthesia. Regional anesthesia techniques consisted of spinal anesthesia (29%), epidural anesthesia (64%), combination of spinal-epidural anesthesia (5%), and peripheral nerve block (2%). Conclusions: Regional anesthesia is the most frequently technique used in lower extremities orthopedic surgery, with epidural anesthesia as the most common regional technique used because of all the benefits. [AMJ.2016;3(1):141–6] Keywords: Anesthesia techniques, epidural anesthesia, lower extremities, orthopedic surgery

Introduction Musculoskeletal problems which are the responsibility of orthopedic surgery, later are becoming more frequent. Data obtained from a study in the United Kingdom (2006) showed that the most common musculoskeletal problems occurring at any age are a problem on the back, with the second most common is on the knee. Unlike in children, the most common complaint is on foot.1 Complaint in the lower extremities is one of the most common musculoskeletal problems. Lower extremities musculoskeletal problems in both adults and children usually require surgery. This action should be dealt quickly. The roles of anesthesiologists are needed to determine which anesthesia technique that has to be

performed either in emergency surgery, or elective surgery. There are various anesthesia techniques that can be used in lower extremities surgery, thus general anesthesia, regional anesthesia, and combination of general-regional anesthesia techniques. Many researchers have conducted studies to compare the most effective anesthesia technique, between general anesthesia, regional anesthesia, and combination of these two techniques.2,3 All types of anesthesia techniques have advantages and disadvantages of each. In general, all types of anesthetic techniques have risks. However, this can be reduced if the selection of anesthetic technique is conducted with careful consideration of all factors. The aims of this study were to know

Correspondence: Keshia Amalia Mivina Mudia, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya BandungSumedang Km.21, Jatinangor, Sumedang, Indonesia, Phone: +62 82182182192 Email: [email protected] Althea Medical Journal. 2016;3(1)

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Table 1 Frequency of Anesthesia Technique Usage Anesthesia Techniques

f

%

General

65

43

Total

151

100

Regional

83

Combination

the frequency of using various anesthesia techniques, and to determine the selection pattern of all anesthesia techniques based on variables. This study was conducted at Dr. Hasan Sadikin General Hospital Bandung because it is considered as a top referral hospital in West Java Province. Plenty of orthopedic surgeries in particular lower extremities surgery have been performed.

Methods

This study was carried out from September– October 2013 at Dr. Hasan Sadikin General Hospital Bandung. All data were taken from Dr. Hasan Sadikin General Hospital’s Medical Record Department after approved by Health Research Ethics Committee. This retrospective study was conducted by collecting secondary data from medical records of all patients who underwent orthopedic surgery of the lower extremities under anesthesia techniques from January– June 2013. Data collection was conducted using total sampling method. Emergency and elective surgery cases were included. Outpatients, patients who underwent one day surgery (ODS), patients who received local anesthesia, and patients whose data were incomplete or unclear in medical record were excluded in this study. There were 228 data of all cases, but only 151 patients who underwent orthopedic surgery of the lower extremities under anesthesia techniques from January–June 2013 who were subjects who met the inclusion

3

55 2

and exclusion criteria. Data processing was conducted after data collection had been completed. First, it was calculated how many patients undergoing orthopedic surgery on the lower extremities under general anesthesia, regional anesthesia, or combination of general-regional anesthesia at Dr. Hasan Sadikin General Hospital from January–June 2013. Then, anesthesia technique used, patient’s age, sex, part of body being operated, The American Society of Anesthesiologists (ASA) score category, scope of orthopedic surgery, length of surgery, and hospital length of stay after surgery were recorded. Calculation of each type anesthesia technique used was presented by using a single table. At the same time, the calculation for the characteristics of age, sex, part of the body being operated, ASA score category, scope of orthopedic surgery, length of surgery and hospital length of stay were presented by using cross-tabulation table. Then, the results would be described through discussion.

Results

There were 151 patients who underwent orthopedic surgery of the lower extremities under anesthesia techniques from January– June 2013 who were identified. Of a final 151 subjects identified, patients who underwent lower extremities orthopedic surgery under anesthesia techniques were divided into three groups. Anesthesia technique used at most was regional anesthesia. Of a total 83 subjects who were performed

Table 2 Frequency of Regional Anesthesia Technique Usage Regional Anesthesia techniques

f

%

Spinal

24

29

Peripheral nerve block

2

2

Epidural

Spinal epidural Total

53 4

83

64 5

100

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Table 3 Selection of Anesthesia Techniques based on Characteristics Anesthesia Techniques Regional General f

%

<18

36

23.8

Male

42

27.8

Age (years old) ≥18

Sex

Female

Region

Gluteal

29 23 6

ASA Score 1

1E 2

2E 3

3E 4

II

RAM DBJ ND

Tumor

f

%

f

%

1.3

0

0.0

0

0.0

0

0.0

25.2

2

1.3

0

0.0

2

1.3

2

9

6.0

15

9.9

4.0 2.0

16.6 6.6

15 2 9 2 8 1 2

9.9 1.3

38 5

6.0

14

0.7

3

1.3 5.3 1.3

4

3.3 9.3 2.7

24

15.9

3

2.0 2.0

45

29.8

16

10.6

25

16.6

2

1.3

0

0.0

2

1.3

5

11

3.3 7.3

1

0.7

0

0.0

1

0.7

Scope of Orthopedic Surgery CDA

%

15.2

2.0

10

f

33.8

3

Foot

%

51

Ankle

3

1.3

f

14.6

11.9

25

2

%

22

18

Leg

f

Epidural

19.2

Femoral Knee

Spinal

8

5.3

3

2.0

2

1.3

0 1 6

0.0 0.7 4.0

0 6 2 0 0 0 1 1

0.0 4.0 1.3 0.0 0.0 0.0 0.7 0.7

1

0.66

3 1

2.0 0.7

2

14 9 1 0 0 3 1 4 5 2

1.3 9.3 6.0 0.7 0.0 0.0 2.0 0.7 2.7 3.3 1.3

Trauma

45

29.8

17

11.3

38

25.2

60–120

32

21.2

14

9.3

25

16.6

<1

52

34.4

22

14.6

46

30.5

Length of Surgery (min) <60

>120

4

29

2.7

19.2

Hospital Length of Stay (week) 1–2 >2

13 0

8.6

0.0

5 5 1

1

3.3 3.3 0.7

0.7

1

27 6

1

0.7

17.9 4.0

0.7

4 2 1 0 1 1 1 0 2 0 1 0 1 0 0 0 0 0 0 1 0 3 1 2 1 3

1

0

2.7 1.3 0.7 0.0 0.7 0.7 0.7 0.0 1.3 0.0 0.7 0.0 0.7 0.0 0.0 0.0 0.0 0.0 0.0 0.7 0.0 2.0 0.7 1.3 0.7 2.0

0.7

0.0

Peripheral Nerve Block

Combination

SpinalEpidural

2 2 0 0 0 0 0 2 0 0 0 1 1 0 0 0 0 0 0 2 0 0 1 1 0 2

0 0

1.3 1.3 0.0 0.0 0.0 0.0 0.0 1.3 0.0 0.0 0.0 0.7 0.7 0.0 0.0 0.0 0.0 0.0 0.0 1.3 0.0 0.0 0.7 0.7 0.0 1.3

0.0 0.0

3 1 1 1 0 0 0 1 2 0 1 0 0 0 0 0 0 0 0 0 0 3 0 0 3 2

1 0

2.0 0.7 0.7 0.7 0.0 0.0 0.0 0.7 1.3 0.0 0.7 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 2.0 0.0 0.0 2.0 1.3

0.7 0.0

Note: ASA=The American Society of Anesthesiologists; CDA=congenital and developmental abnormalities; II=infection and inflammation; RAM=rheumatic disease, arthropathy, and metabolic arthritis; DBJ=degenerative disorder of bones and joints; ND=neuromuscular disorder

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under regional anesthesia, epidural anesthesia was the most common regional anesthesia technique used (64%). More than half of a total subjects were performed under epidural anesthesia (Table 2). While the most common anesthesia technique used in adult group (≥18 years old) was regional anesthesia, particularly epidural anesthesia (33.8%), in children group (<18 years old) it was general anesthesia (23.8%). Identified from patients’ sex, the most common anesthesia technique used in male subjects was regional anesthesia, particularly epidural anesthesia (25.2%). The same result was obtained in female group. Epidural anesthesia (9.9%) was also the most common regional anesthesia technique used in female group. Lower extremities were divided into six regions. Surgery on the leg region (38.4%) was the most common with the most widely anesthesia technique used was regional anesthesia, particularly epidural anesthesia (15.9%). To assess the physical status of patients before surgery, ASA physical status classification system was used. The most common ASA score was ASA 1, with the most widely anesthesia technique used was general anesthesia (29.8%). Identified from scope of orthopedic surgery found in this study, trauma cases (70.2%) were the most common case, with the most widely anesthesia technique used was regional anesthesia, particularly epidural anesthesia (25.2%). Most of the surgeries finished between 60–120 minutes (49.0%), which was nearly half of a total subjects, with the most frequent anesthesia technique used was regional anesthesia, particularly epidural anesthesia (16.6%) More than half of total subjects were hospitalized in less than one week after surgery (84.1%), with the most widely anesthesia technique used was regional anesthesia, particularly epidural anesthesia (30.5%).

Discussion

The regional anesthesia (55%) was the major option of all subjects rather than general (43%) and combination anesthesia (2%). More than half of a total subjects were performed under regional anesthesia (Table 1). The results of this study are consistent with literature suggesting that lower extremities

orthopedic surgery is usually performed under regional anesthesia.4 Regional anesthesia was shown to have lower complication and mortality incidences.5 Furthermore, the systemic effects from drugs, respiratory depression, aspiration risks, and complications after major surgery, particularly orthopedic surgery, can be reduced. Equipment and cost involved are also much less than other anesthesia techniques.6 Surgery performed under regional anesthesia is the one option, with lowest risk surgery with the goal of patient safety. These benefits might be the reason why regional anesthesia tends to be performed in this study. The regional anesthesia used most frequently in this study was epidural anesthesia (63.86%). Epidural anesthesia proved that it could reduce the incidence and severity of perioperative physiologic disturbance and postoperative morbidity.7 Subjects in the study had a diverse age range. The youngest subject was one year old patient, and the oldest was 87 years old patient. Of a total 151 subjects, there were 111 subjects (73.51%) in adult group (≥18 years old) and 40 subjects (26.49%) in children group (<18 years old). One study in Netherlands8 also showed that lower extremities problems complain more in adults. There is a propensity to use epidural anesthesia rather than other techniques in adult group. This may be caused by all the benefits. In children, general anesthesia is the main option in performing lower extremities surgery. Children who are usually extremely anxious or afraid and cognitively immature, will be best handled by using general anesthesia technique during surgery.9 There were 99 (65.56%) male and 52 (34.44%) female subjects. Number of male subjects who exceeded half of a total subjects did not show any particular trend in selection of anesthesia technique, but only showed that there were more male subjects in number than female subjects who underwent lower extremities orthopedic surgery. It might be caused by the number of fractures because traffic accidents victims were mostly males. Of a total 151 subjects who underwent lower extremities orthopedic surgery, there were 58 cases (38.41%) performed on leg region. Leg region lies between knee and distal leg. It includes tibia and fibula bones. The narrowest part of shaft tibia, the junction of its middle and inferior thirds, is the most frequent site of fracture. Moreover, because its anterior surface is subcutaneous, tibial shaft is the most common site for compound Althea Medical Journal. 2016;3(1)

Keshia Amalia Mivina Mudia, Ezra Oktaliansah, Ihrul Prianza Prajitno: Anesthesia Technique Selection Pattern in Patients Undergoing Lower Extremities Surgery at Dr. Hasan Sadikin General Hospital from January–June 2013

fracture.10 Fibula fracture cases are usually caused by combination between tibia and ankle fractures.10 Because of all the benefits, patients undergoing leg region surgery also tended to use epidural anesthesia. Ninety subjects (59.6%) were ASA 1 category patients who mostly performed under general anesthesia during the surgery. Risks of complication due to general anesthesia were increasing in higher ASA score category. General anesthesia performed in patients do not have lung disease, heart disease, certain organ failure, and elderly patients.11 It means general anesthesia is better given in healthy and cooperative patients, that is patients with ASA 1 category. Patients with ASA 1 category are healthy patients with no psychological nor organic disease, as well as pathological process which becomes the reason for undergoing localized surgery and do not cause systemic disruption.6 Selection of techniques and drugs of anesthesia is performed by anesthetists based on multifactorial assessment and also both patient and surgeon preferences. Physical condition and patient’s general health is the most important consideration. The most common scoring system to classify the patient’s physical status according to ASA is used. Patients who classified in a higher score category have a higher risk of perioperative mortality.6 Therefore, to know the physical status of the patients before selecting an appropriate anesthesia technique is very important to avoid complications. Trauma, which is one of orthopedic surgery scope, was the most cases in this study. There were 106 trauma cases (70.20%) of a total 151 cases. Most of trauma cases were performed under regional anesthesia. Trauma is often caused by traffic accident12 and traffic accidents become the major cause of death in the world. Passengers, drivers, or even pedestrians can be the victims. The causes of all are due to the increasing number of vehicles, the lack of public awareness in obeying traffic rules, the poor safety procedure, and the low safety driving training.13 Traffic injury cases occupy more than 50% beds in many hospitals. An orthopedic surgeon commits in handling orthopedic cases and trauma musculoskeletal. Scope of orthopedic surgery is not only limited to bones and joints, other structures such as muscles, tendons, ligaments, bursa, synovial, nerves and blood vessels are also handled by orthopedic surgeons.12 There were 74 subjects (49.01%) undergoing surgery in 60 to 120 minutes. This group was the largest group with nearly half of Althea Medical Journal. 2016;3(1)

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a total subjects. They were performed under regional anesthesia at most, particularly epidural anesthesia (16.56%). Length of surgery under epidural anesthesia can be extended by adding dose through inserted epidural cathether.14 Patients who have undergone any surgery usually need hospitalization for recovery. Most of subjects (84.11%) in this study stayed for less than a week after surgery. Anesthesia technique used in subjects with hospital length of stay less than a week was mostly regional anesthesia, particularly epidural anesthesia (30.46%). Memtsoudis15 suggested that there is association between anesthesia used and hospital length of stay. More patients receiving general anesthesia have a prolong length of hospital stay. Study in Washington7 also suggested that surgeries performed under regional anesthesia are decreased in hospital length of stay rather than under general anesthesia. In conclusion, regional anesthesia is the most frequently technique used in patients undergoing lower extremities orthopedic surgery at Dr. Hasan Sadikin General Hospital from January–June 2013, with epidural anesthesia as the most common regional technique used due to all the benefits.

References

1. Jordan KP, Kadam UT, Hayward R, Porcheret M, Young C, Croft P. Annual consultation prevalence of regional musculoskeletal problems in primary care: an observational study. BMC Musculoskelet Disord. 2010;11:144. 2. Neuman MD, Silber JH, Elkassabany NM, Ludwig JM, Fleisher LA. Comparative effectiveness of regional versus general anesthesia for hip fracture surgery in adults. Anesthesiology. 2012;117(1):72– 92. 3. Larson MD. Combined regional-general anesthesia. Revista Mexicana de Anestesiologia. 2010;33:(Suppl 1):265–9. 4. Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC. Handbook of clinal anesthesia. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2009. p. 843–61. 5. Imbelloni LE, Beato L. Comparison between spinal, combined spinal-epidural, and continuous spinal anesthesias for hip surgeries in elderly patients: a retrospective study. Rev Bras Anestesiol. 2002;52(3):316–25. 6. Gwinnutt CL. Anestesi klinis: catatan

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kuliah. 3rd ed. Jakarta: Penerbit Buku Kedokteran EGC; 2009. 7. Moraca RJ, Sheldon DG, Thirlby RC. The role of epidural anesthesia and anelgesia in surgical practice. Ann Surg. 2003;238(5): 663–73 8. van der Waal JM, Bot SD, Terwee CB, van der Windt DA, Schellevis FG, Bouter LM, et al. The incidences of and consultation rate for lower extremity complaints in general practice. Ann Rheum Dis. 2006; 65(6):809–15. 9. Silverman J, Reggiardo P, Litch CS. An essential health benefit: general anesthesia for treatment of early childhood caries. Chicago: American Academy of Pediatric Dentistry, Pediatric Oral Health Research and Policy Center. 2012 [cited 2013 November 14]. Available from: http:// www.aapd.org 10. Moore KL, Dalley AF, Agur AMR. Lower limb. Clinically oriented anatomy. 6th ed. Philadelphia: Lippincott Williams & Wilkins, a Wolters Kluwer business; 2010. p. 508–669. 11. Siribaddana P. Contraindications for

general anesthesia. Andover: Living Healthy360; 2010 [cited 2013 October 30]. Available from: http://www. livinghealthy360.com/ 12. Rasjad C. Pengantar ilmu bedah ortopedi. 7th ed. Jakarta: PT. Yarsif Watampone; 2012. 13. Dewi RY, Widjasena B, Kurniawan B. Perbandingan faktor risiko kecelakaan kerja antara BRT (bus rapid transit) dan non BRT jurusan Mangkang-Penggaron. Semarang: Jurnal Kesehatan Masyarakat FKM UNDIP; 2013 [cited 2013 November 12]. Available from: http://ejournals1. undip.ac.id/index.php/jkm 14. Hawkins JL. Epidural analgesia and anesthesia. In: Duke J, editor. Anesthesia secret. 3rd ed. Philadelphia: Elsevier; 2006. p. 440–7. 15. Mamtsoudis. Comparative effectiveness research identifies anesthesia technique that has lower rates of complications. New York: Hospital for Special Surgery; 2013 [cited 2013 October 31]. Available from: http://www.hss.edu/

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Upper Lower Segment Ratio Comparison between Obese and Normal Children Aged 7 to 10 Years Old Muhammad Zulfikar Azhar,1 RM. Ryadi Fadil,2 Edhyana K. Sahiratmadja3 Faculty of Medicine, Universitas Padjadjaran, 2Department of Child Health Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung, 3Departement of Biochemistry and Molecular Biology Faculty of Medicine, Universitas Padjadjaran

1

Abstract Background: Upper lower segment ratio is an anthropometric measurement that often used to detect the presence of abnormal growth. Growth is affected by many factor, one of them is nutrional status. Obesity prevalence in Indonesian children increases annually. These children show an accelerated growth in prepuberty compared to normal children in their age. This study aimed to analyze the difference in upper lower segment ratio between obese and normal children aged 7 to 10 years old. Methods: A cross sectional study was carried out in children aged 7 to 10 years old in three Elemantary School in Bandung during September–October 2013. Height and weight were measured to calculate body mass index (BMI) score and were grouped into obese (BMI >95th percentile) and normal (BMI 10th–85th percentile). The upper lower segment ratio was compared between obese and normal children and the level of the significant difference were analyzed by unpaired T-test. Results: From a total of 200 children recruited, 90 were obese and 110 were normal. There was no significant difference between upper lower segment ratio in obese and normal children (p=0.603) with mean ratio 1.137 and 1.142 respectively. The mean of upper lower segment ratio in obese boys was higher than normal boys (mean ratio 1.15 and 1.14 respectively), but obese girls had a lower ratio compared to normal girls (mean ratio 1.12 and 1.14 respectively). Conclusions: There is no difference between upper lower segment ratio in obese and normal children aged 7 to 10 years old. [AMJ.2016;3(1):147–51] Keywords: Children, obesity, upper lower segment ratio

Introduction Upper lower segment ratio is a component of growth anthropometric measurement in children. This measurement is often used to detect the presence of abnormal growth especially in school-aged children.1 Change of upper lower segment ratio can cause abnormal body proportions. This can affect psychosocial aspect in school-age children.2 The measurement of upper lower segment ratio is affected by several factors, such as age, gender, and race.1 Obesity is one of nutritional status disorders that can affect growth in children. . Obese children as those who have body mass index (BMI) more than 95th percentile in CDC BMI-for-age growth chart.3 World Health Organization (WHO) stated that obesity was

ranked as the fifth leading cause of death globally. WHO estimates that there are more than 1.4 billion adults and 40 million children in the world considered overweight and obese.4 According to the study of de Onis et al.5 the prevalence of overweight and obese children in Southeast Asia showed an increasing for every 5 years. According to Riset Kesehatan Dasar (Riskesdas) conducted by Indonesia Department of Health in 2010, the number of obese children aged 6 to 12 years reached 12%.6 In pre-pubertal age, most of obese children experience growth velocity earlier than other children at their age.7 Hormonal changes is one of the factor that caused obese. Hormonal changes that occurs such as presence of abnormalities in the Growth hormoneInsulin-like growth factor-1 axis (GH-IGF-1

Correspondence: Muhammad Zulfikar Azhar, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya BandungSumedang Km.21, Jatinangor, Sumedang, Indonesia, Phone: +6283829243963 Email: [email protected] Althea Medical Journal. 2016;3(1)

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axis), increased aromatization of androgen into estrogen, and increased level of leptin.8 This study aimed to observe the difference in upper lower segment ratio between obese and normal children aged 7 to 10 years old.

excluded if their parents did not give consent, had chronic disease or other disease e.g. body dysplasia, Klinefelter syndrome, Marfan syndrome, or was undergoing specific therapy i.e. radiation therapy that could interfere upper lower segment ratio measurement. All measurements were performed by team of 3 medical students who had been trained and standardized. Each measurement performed twice by the same observer, and the final value were the mean valueof these measurements. Weight was measured by weight scales. The subjects were measured without shoes, and subjects were asked to remove any object from their pocket that could affect the measurement results. Height was measured with microtoise. The subjects were asked to remove their shoes and socks. The observer made sure that the heels, buttock and occiput were contact to the wall or vertical measure. The subjects were instructed to look straight ahead, relax their shoulder, and place part of their lower margin of the eye parallel to external auditory meatus (Frankfurt plane). Sitting height was measured after height measurements were complete. A 40 centimeters chair was placed just below the location of microtoise and parallel to the wall. The subjects were asked to sit on the chair with their buttock and occiput were contact to the wall. They were asked to look straight

Methods

A cross sectional study was carried out from October to November 2013 in 7 to 10 years old children from three elementary schools in Bandung which were selected by multistage random sampling. The first stage randomization was done at subdistrict level, the 3 selected subdistricts were Mandalajati, Bandung Kulon, and Sumur Bandung. Each subdistrict represented east, west, and central Bandung region, respectively. The second stage randomization was performed at the school level in each district, the 3 selected schools were Elementary School (Sekolah Dasar/SD) Negeri Jatihandap 2, SD Negeri Tunas Harapan, and SD Kartika Siliwangi IX-1. The primary data were collected with minimal sample of 84 children for each group, whether their BMI status were obese or normal. An informed consent regarding the procedure of this study was informed to the children’s parents a week prior to the measurement. This study included healthy boys and girls aged 7-10 years old who hadBMI designated as obese and normal in Bandung. Subject were Table 1 Characteristic of Subjects Characteristic Age (years old) 7–< 8

8–< 9

9–< 10

10–< 11

Sex

Male

Female

Height, mean (SD) in cm Weight, mean(SD) inkg BMI, mean (SD) Total

Obese n (%)

Normal n (%)

Total

16 (17.8)

20 (18.2)

36 (18)

21 (23.3)

31 (34.4)

25 (22.7)

35 (31.8)

22 (24.4)

30 (27.3)

45 (50)

55 (50)

45 (50)

46 (23)

66 (33)

52 (26)

55 (50)

100 (50) 100 (50)

133.8 (8.6)

125.03 (8.7)

128.98 (9.7)

90

110

200

44.3 (9.9)

24.46 (3.0)

25.28 (5.2)

15.99 (1.48)

Note: SD= Standard Deviation; Obese= >95th percentile; Normal= 10th–85th percentile

33.84 (12.2)

19.80 (4.81)

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Muhammad Zulfikar Azhar, RM. Ryadi Fadil, Edhyana K. Sahiratmadja: Upper Lower Segment Ratio Comparison between Obese and Normal Children Aged 7 to 10 Years Old

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Table 2 Comparison of Upper Lower Segment Ratio between Obese and Normal Children US/LS ratio Mean SD

Obese

Normal

p-value

1.13

1.14

0.60

0.08

Note: US/LS ratio= Upper lower Segment ratio; SD= Standard Deviation

0.04

Table 3 Means of Upper Lower Segment Ratio in Obese and Normal Boys Based on Age Age 7 8

Obese n

US/LS ratio

SD

n

US/LS ratio

SD

9

1.19

0.03

10

1.20

0.02

7

9

18

10

11

Total

Normal

45

1.13

1.13

1.15

1.15

0.07

0.11

0.04

0.08

10

20

15

55

Note: US/LS ratio= Upper lower Segment ratio; SD= Standard Deviation

ahead, with their part of the lower margin of the eye parallel to external auditory meatus (Frankfurt plane). The subjects were asked to relax the shoulder when the measurement was performed. Upper segment was calculated by subtracting the sitting height with height of chair (40 cm). Lower segment was calculated by subtracting height with upper segment. The upper lower segment ratio was calculated by dividing the upper segment with lower segment. The BMI was obtained after all measurements were completely performed. The BMI was calculated by dividing body weight with square of height in meters, then BMI was plotted to BMI for age based on Centers for Disease Control and Prevention (CDC) BMI-for-age growth chart to classify BMI category of all subject. Obese category wasdetermined if BMI of the children was

1.18

1.14

1.09

1.14

0.03

0.03

p-value 0.61

0.02

0.05

above 95th percentile, while normal category wasdetermined if BMI of children was in range of 10th to 85th percentile. The data that was obtained were analyzed to normality distribution test using Kolmogorov-Smirnov test. If the p value >0.05, it could be concluded that the data had normal distribution. Moreover, the data were analyzed by unpaired T-test to assess the level of significantdifference upper lower segment ratio in obesity and normal children aged 7 to 10 years old. This study was approved by Health Research Ethics Committee, Universitas Padjadjaran (No.327/UN6/C2.1.2/ KEPK/2013) and Bandung Department of Education (No.070/5511-Disdik/2013).

Results

From the three elementary schools, there were

Table 4 Means of Upper Lower Segment Ratio in Obese and Normal Girls Based on Age Age 7 8

9

10

Total

Obese

Normal

n

US/LS ratio

SD

n

US/LS ratio

SD

7

1.15

0.06

10

1.18

0.02

14

13

11

45

1.12

1.13

1.10

1.12

0.07

0.11

0.09

0.08

15

15

15

55

Note: US/LS ratio= Upper lower Segment ratio; SD= Standard Deviation Althea Medical Journal. 2016;3(1)

1.16

1.14

1.10

1.14

0.04

0.02

0.02

0.04

p-value 0.21

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200 children recruited in this study and ninety subjects defined as obese children. Most of the children were above 9 years old. There was no significant difference between upper lower segment ratio in obese children and normal children aged 7 to 10 years (p>0.05, unpaired T-test). The upper lower segment ratio has no significant different (p=0.61) among obese and normal boys. Interestingly, there was a tendency that the value decreased from aged 7 to 9. However, the ratio was increased again in the age of 10 (Table 3). There was no significant different between both group obese and normal girls (p=0.21) (Table 4). Overall, the means of upper lower segment ratio in obese girls was lower than normal girls, and tendency, similar to the boys, that there were decreasing ratios from aged 7 to 10

Discussion

The upper lower segment ratio has been used for growth anthropometric measurement in children. This study reveals that the upper lower segment ratio decrease gradually from age 7 to 10 in both obese and normal children. These results are similar to a study conducted in healthy Turkish children.9 These differences might be due to the age that influence the measurement upper lower segment ratio. The upper lower segment ratio at birth is about 1.7 and decrease to 1.3 at 3 years old. At the age 7 to 10, the ratio is decrease to 1.0, and in adult it gradually decreases to 0.9.10 The age influences on upper lower segment ratio were also be seen in the body proportion in sickle cell anemia11 and in Dutch children origin at age 0 to 21 years old.12 The ratio in boys aged 7–10 years old in Turkey shows higher upper lower segment compared to girls.9 These results were similar to this study. However, when comparing between Turkish children with Indonesian children, the result showed that the means of upper lower segment ratio in Indonesian children is higher than Turkish children. Most likely, this is due to racial difference between Turkey and Indonesia, where race is one of the components that influence the measurement result of upper lower segment ratio. There is a significance racial difference in upper lower segment ratio, where Caucasian and African American have a longer leg than Asian.1, 13 Therefore, when Asian was compared to Caucasian and African American, Asian was more likely has higher upper lower segment

ratio in the same age. Furthermore, study performed in Yucatecans and Poles also has shown racial factor that influence upper lower segment ratio measurements.14 Other factors contributing to difference measurement upper lower segment can be explained by secular trends, socioeconomic and environmental factor. In Japanese children, it showed 10% secular increase in height and 40% secular increase in body weight in the period 1985 to 2000. Secular increase in height was due to increased sub-ischial leg length that can affect the lower segment as well as the upper lower segment ratio.15 A study conducted in China16 also showed a significant secular increase in growth from 1985 to 2010. The study also revealed that there were different characteristic trends in socioeconomic levels. Mean stature in small and moderate cities were lower than in big cities. Study comparing Maya children living in United States and Guatemala showed different height, weight, and sitting height ratio for each group. This study revealed that Maya children in United States were significantly taller at all ages than Maya children in Guatemala.17 In pre-pubertal age, most of obese children experience growth velocity earlier than normal children at their age.7 This study also revealed that same phenomenon. Height difference did not significantly affect the upper lower segment ratio possibly because the upper segment grows as rapid as the lower segment. So, there was no significant difference between the upper lower segment ratio in obese and normal children. Some other factors such as arm-span measurement, race, and socioeconomic status contributing to difference measurement of upper lower segment ratio in children were not analyzed, and it contributed to the limitations of this study. To conclude, this study shows no difference between upper lower segment ratio in obese and normal children aged 7 to 10 years. This ratio might impact other races and is served as anthropometric measurements. Further study about exploring arm-span measurement, race, and socioeconomic status might reveal the significant difference.

References

1. Hall JG, Allanson J. Handbook of physical measurements. New York: Oxford University Press; 2006. 2. Behrman RE, Kliegeman RM, Jenson HB. Nelson textbook of pediatrics. 18th ed. Althea Medical Journal. 2016;3(1)

Muhammad Zulfikar Azhar, RM. Ryadi Fadil, Edhyana K. Sahiratmadja: Upper Lower Segment Ratio Comparison between Obese and Normal Children Aged 7 to 10 Years Old

Philadelphia: Elsevier Science Health Science Division; 2007. 3. Hellerstein MK, Park EJ. Obesity & overweight. Greenspan’s Basic & Clinical Endocrinology. 8th ed. San Francisco: McGraw-Hill Medical; 2007. p. 796–7. 4. World Health Organization. Obesity and overweight. 2013. [cited 2013 March 15]. Available from: http://www.who.int/ mediacentre/factsheets/fs311/en/. 5. Onis Md, Blossner M, Borghi E. Global prevalence and trends of overweight and obesity among preschool children. Am J Clin Nutr. 2010;92:1257–64. 6. Badan Penelitian dan Pengembangan Kesehatan Departemen Kesehatan Republik Indonesia. Laporan nasional riset kesehatan dasar 2010. Jakarta: Badan Penelitian dan Pengembangan Kesehatan Departemen Kesehatan Republik Indonesia; 2010. 7. Lailani D, Hakimi. Pertumbuhan fisik anak obesitas. Sari Pediatri. 2003;5(3):99–102. 8. De Leonibus C, Marcovecchio ML, Chiarelli F. Update on statural growth and pubertal development in obese children. Pediatri Rep 2012. 2012;6(4):e35. 9. Turan S, Bereket A, Omar A. Upper segment/ lower segment ratio and armspan–height difference in healthy Turkish children. Acta Pediatrica. 2005;94:407–13. 10. Nwosu BU, Lee MM. Evaluation of short and tall stature in children. Am Fam Physician.

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2008;78(5):597–604. 11. Diaku-Akinwuni IN, Akodu SO, Njokanma OF. Upper body segment to lower body segment and arm span to height ratios among children with sickle cell anaemia in Lagos. Niger J Paed. 2013;40(3):222–6. 12. Fredriks AM, Buuren Sv. Nationwide age references for sitting height, leg length, and sitting height/height ratio, and their diagnostic value for disproportionate growth disorders. Arch Dis Child. 2005;90:807–12. 13. Batubara JR. Practices of growth assessment in children: Is anthropometric measurement important? Pediatrica Indonesiana. 2005;45:145–153.. 14. Siniarska A, Wolanski N. Ethnic differences in body proportions genes or environment?. J Hum Ecol. 2002;13(5):337–43. 15. Kagawa M, Hills AP. Secular changes in BMI obesity risk in Japanese children: consideration from a morphologic perspective. The Open Obesity Journal. 2011;3:9–16. 16. Jiao CT, Ye JC. Secular changes in stature of urban Chinese children and adolescent 1985–2010. Biomed Environ Sci. 2013;26(1):13–22. 17. Bogin B, Smith P, Orden AB. Rapid change in height and body proportions of Maya American children. Am J Hum Biol. 2002;14:753–61.

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Correlation between Oxygen Saturation and Hemoglobin and Hematokrit Levels in Tetralogy of Fallot Patients Farhatul Inayah Adiputri,1 Armijn Firman,2 Arifin Soenggono3 Faculty of Medicine Universitas Padjadjaran, 2Department of Child Health Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung, 3Department of Anatomy and Cell Biology Faculty of Medicine Universitas Padjadjaran 1

Abstract Background: Hemoglobin and hematocrit levels increase in Tetralogy of Fallot (TOF) but the oxygen saturation declines. Reduced hemoglobin in circulating blood as a parameter of cyanosis does not indicate rising hemoglobin due to the ‘not-working’ hemoglobins that affect the oxygen saturation. Increasing hematocrit is the result of secondary erythrocytosis caused by declining oxygen level in blood, which is related to the oxygen saturation. This study was conducted to find the correlation between oxygen saturation and hemoglobin and hematocrite levels in TOF patients. Methods: This study was undertaken at Dr. Hasan Sadikin General Hospital in the period of January 2011 to December 2012 using the cross-sectional analytic method with total sampling technique. Inclusion criteria were medical records of TOF patients diagnosed based on echocardiography that included data on oxygen saturation, hemoglobin, and hematocrite. Exclusion criteria was the history of red blood transfusion. Results: Thirty medical records of TOF patiens from Dr. Hasan Sadikin General Hospital Bandung were included in this study. Due to skewed data distribution, Spearman correlation test was used to analyze the data. There was a significant negative correlation between oxygen saturation and hematocrit level (r= -0.412; p=0.024) and insignificant correlation between oxygen saturation and hemoglobin (r=-0.329; p= 0.076). Conclusions: There is a weak negative correlation between oxygen saturation and hematocrite levels. [AMJ.2016;3(1):152–5] Keywords: Hematocrit, hemoglobin, oxygen saturation, tetralogy of fallot

Introduction Tetralogy of Fallot (TOF) is the most frequent disease found in patients with cyanotic congenital heart disease. Nevertheless, not all TOF patients experience cyanosis because it depends on the severity of the disease.1 Cyanosis occurs due to several factors, including decreased pulmonary blood flow resulting in the obstruction of the pulmonary valve, known as pulmonary stenosis, making oxygen distribution to the tissue inadequate and increasing right to left shunt.2 In addition, another factor that may cause cyanosis is drastically reduced hemoglobin level in circulating blood that affects oxygen saturation.3 Oxygen saturation indicates the amount of oxygen bound by hemoglobins in a percentage of maximum

binding at the time of measurement. One of the variables that affect oxygen saturation is hemoglobin concentration. However, it is not sure whether there is a correlation between oxygen saturation and hemoglobin in TOF. Hematocrit increases in TOF patients as a response to hypoxia. The oxygen delivery to tissues depends on many factors, particularly the total number of circulating erythrocytes, systemic arterial oxygen tension (PaO2), oxygen saturation, oxygen-hemoglobin dissociation curve position, cardiac output, and regional blood flow.4,5 Theoretically, rising hematocrit with declined oxygen saturation indicate increase in erythrocyte production to supply increased demand of oxygen in the tissue.5 It is postulated that there might be a correlation between oxygen saturation and hematocrit. This study aimed to find the

Correspondence: Farhatul Inayah Adiputri, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya BandungSumedang Km.21, Jatinangor, Sumedang, Indonesia, Phone: +6285720471165 Email: [email protected] Althea Medical Journal. 2016;3(1)

Farhatul Inayah Adiputri, Armijn Firman, Arifin Soenggono: Correlation between Oxygen Saturation and Hemoglobin and Hematokrit Levels in Tetralogy of Fallot Patients

Table 1 Baseline Characteristics of the Subjects

correlation between oxygen saturation with hemoglobin and hematocrit levels in patients with TOF.

Characteristics

n (%)

Age

Methods

0-28 days

This study was performed in October 2013 through the use of secondary data, i.e. medical records. This study has been approved by the Health Reasearch Ethics Committee, Faculty of Medicine, Universitas Padjadjaran and Dr. Hasan Sadikin General Hospital Bandung. The inclusion criterion in this study was medical records from patients with tetralogy of Fallot diagnosed by echocardiography that includes information on hemoglobin, hematocrit, and saturation oxygen levels. The exclusion criteria were incomplete medical record and TOF patients who received packed red cell transfusion. In this study, data were not classified by age or sex. From the medical records, we obtained data on oxygen saturation and hematologic examination (hemoglobin level and hematocrit level) in which the results of hematologic data were taken from the Clinical Pathology Department of Dr. Hasan Sadikin General Hospital, Bandung. Oxygen saturation was measured using pulse oximeter by the examiner. Oxygen saturation value collected was the first value noted in the medical record by the examiner. Data were analyzed using Statistical Product and Service Solutions (SPSS) with a normality test by Shapiro-Wilk. Since two of the variables did not have normal distribustion, Spearman correlation test was then used.

1

1-12 months

10

6-12 years

12

Girl

16

1-2 years

4

2-6 years

3

Sex

Boy

14

Results There were thirty medical records of TOF in Dr. Hasan Sadikin General Hospital Bandung during the period of January 2011–December 2012 that were included in this study. One patient was excluded because he received packed red cell transfusion. The age range of the subjects when they first visited the hospital was very large. The youngest was 15 days old and the oldest was 12 years old. The average age of the samples was 4.44 years. The sample consisted of 14 boys and 16 girls. Before the correlation was analyzed, data were tested for the the normality of their distribution using Shapiro-Wilk test. It was revealed that the data distribution of hematocrit was normal, but the data on oxygen saturation and

Table 2 Mean and Standard Deviation of the Variables Variable

Mean

Standard Deviation

Oxygen Saturation (%)

82.45

9.88

Hemoglobin (g/dL)

15.55

Hematocrit (%)

11.34

48

10.63

Table 3 Spearman Correlation Test between Oxygen Saturation and Hemoglobin and Hematocrit Levels

Oxygen Saturation

Hemoglobin (g/dL)

Hematocrit (%)

-0.329

-0.412

r

p

n

Note: r = correlation coefficient; p = p-value; n = sample size Althea Medical Journal. 2016;3(1)

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0.076 30

0.024 30

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hemoglobin level were not normal. Data were then analyzed using bivariate analysis. Most of the subjects were in 6–12 years old category. The mean for the oxygen saturation was low with the normal range of healthy children’s oxygen saturation of 96–100%.7 Table 2 shows that the oxygen saturation correlated negatively with hemoglobin (r=0.329); however, the the correlation was not statistically significant (p>0,05). There was a significant correlation between the oxygen saturation and hematocrit (p<0.05). Both correlative values revealed negative and moderate correlations.

Discussion

The statistic results showed that oxygen saturation and hematocrit correlated inversely. This is in line with a study that reveals that the best correlation was obtained between oxygen saturation and hematocrit, r=-0.74.5 The increased hematocrit level due to secondary erythrocytosis usually occurs in cyanotic congenital heart disease (CCHD) because of the physiological response when the tissue experiences hypoxia. Patients experience hypoxemia due to reduced oxygenated blood which is represented as the oxygen saturation. Consequently, this stimulates bone marrow to produce erythrocytes by first excreting erythropoietin from kidney. Increased erythrocyte level, known as erythrocytosis, will increase red blood cell mass, hematocrit, and viscosity. This condition causes hyperviscosity in cyanotic congenital heart diseases, marked by increased hematocrit.4 Iron deficiency anemia also becomes a preciptitating factor for hyperviscosity.9 Finally, hiperviscosity can decrease blood flow to the tissue; thus, the amount of oxygen delivered to the tissue declines. Furthermore, in TOF patients, the pulmonary blood flow (PBF) decreases because of the anatomy malformation in the development of heart during pregnancy, i.e. pulmonary stenosis. It causes reduced perfussion to the tissue. The manifestation includes cyanosis, in addition to the rising of hematocrit.10 Therefore, the inverse correlation between the oxygen saturation and hematocrit level in Tetralogy of Fallot was moderate in this study. Clinically, the increased hemoglobin can decrease the degree of right to left shunt and systemic vascular resistance as well as increasing the pulmonary blood flow, oxygen transport to the tissue, and aortic oxygen

saturation as the physiologic responses to cyanosis.11 Thus, oxygen saturation often relates to hemoglobin as the compensation because decreased oxygen saturation will led to higher erythrocyte production to comply to the oxygen need. However, the statistical test results showed no correlation between oxygen saturation and hemoglobin level despite the fact that studies on cyanotic congenital heart diseases reveals that correlation between oxygen saturation and hemoglobin has the same pattern as the correlation between oxygen saturation and hematocrit.5 This means that there was a correlation between oxygen saturation and hemoglobin level albeit insignificant. In another study, cyanosis affects the rise in hemoglobin level but no significant change in oxygen saturation. The increased hemoglobin level will increase the oxygen capacity binding without any change in oxygen saturation and provide greater oxygen supply for the tissue. However, clinical manifestations, such as cyanosis, still exists in an even more severe state despite the clinical improvement in this phase. This is known as relative anemia phenomenon.3 This occurrs due to many factors. Not all TOF patients experience cyanosis or relative anemia. If cyanosis presents, the degree of cyanosis is different among patients depending on the severity of the obstruction pulmonary valve, the degree of right ventricular outflow tract obstruction (RVOTO), and the status of the systemic vascular resistance relative to the degree of right ventricular obstruction.2 The ratio of pulmonary to systemic blood flow leads to patient’s condition, which can be fully saturated, cyanotic, or severely cyanotic.3 The irregular changes in oxygen saturation and hemoglobin level result in different degree of cyanosis. In conclusion, this study shows that TOF oxygen saturation correlates negatively with hemoglobin and hematocrit levels. Patient’s condition can be monitored and the cause of cyanosis, whether it is due to heart disease or not, can be determined using this correlation. Further research on oxygen saturation, hemoglobin, and hematocrit levels as the parameters for selecting the best management for TOF patients, either by surgery or blood transfusion, is needed.

References

1. Bailliard F, Anderson RH. Tetralogy of fallot. Orphanet J Rare Dis. 2009, 4:2 Althea Medical Journal. 2016;3(1)

Farhatul Inayah Adiputri, Armijn Firman, Arifin Soenggono: Correlation between Oxygen Saturation and Hemoglobin and Hematokrit Levels in Tetralogy of Fallot Patients

2. Qu JZ. Congenital heart diseases with right-to-left shunts. Int Anesthesiol Clin 2004;42(4):59–72. 3. Rudolph AM, Nadas AS, Borge WH. Hematologic adjustment to cyanotic congenital heart disease. Pediatricts. 1953;11: 454–464. 4. Puspitasari F, Harimurti GM. Hyperviscoucity in cyanotic congenital heart disease. Jurnal Kardiologi Indonesia. 2010;31:41–7. 5. Haga P, Cotes P, Till J, Minty B, Shinebourne E. Serum immunoreactive erythropoietin in children with cyanotic and acyanotic congenital heart disease. Blood.1987;70(3):822–6. 6. Soetjiningsih S. Tumbuh kembang anak. Jakarta: EGC; 2007. 7. Balfour-Lynn DJF, Gringras P, Hicks B, Jardine E, Jones RC, Magee AG,, et al. BTS guidelines for home oxygen in children.

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Thorax. 2009;64(Suppl 2):ii1–26. 8. Adamson JW, Longo DL. Anemia and polycythemia. In: Longo DL, Fauci AS, Kasper DL, Hauser AL, Jameson JL, Loscalzo J. Harrison’s principles of internal medicine. 18th ed. New York: Mc Graw Hill; 2012. p. 450. 9. Rose SS, Shah AA, Hoover DR, Saidi P. Cyanotic congenital heart disease (CCHD) with symptomatic erythrocytosis. J Gen Intern Med. 2007;22(12):1775–7 10. Murphy PJ. The fetal circulation. Contin Educ Anaesth Crit Care Pain. 2005;5(4):107–12. 11. Beekman RH, Tuuri DT. Acute of hemodynamic effects of increasing hemoglobin concentration in children with right to left ventricular and relative anemia. J Am Coll Cardiol. 1985;5(2 Pt1):357–62.

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Age at Menarche and Eating Pattern among High School Students in Jatinangor in 2013 Fani Fitrya Nafisah,1 Insi Farisa Desy Arya,2 Eppy Darmadi Achmad3 Faculty of Medicine Universitas Padjadjaran, 2Department of Public Health Faculty of Medicine Universitas Padjadjaran, 3Department of Obstetrics and Gynecology Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung

1

Abstract Background: Age at menarche has notably declined over the past several decades; the fact is in line with the improvement of nutritional intake. Age at menarche can affect health outcomes in adulthood. This study aimed to describe the age at menarche and eating pattern among students in Jatinangor. Methods: Data were obtained from Survey of Adolescent Reproductive Health in Jatinangor in 2013 with total sampling technique. The sample criteria were data from students who had started their periodwhen the study was conducted. Dietary information was collected by eating pattern recall questionnaire and was taken by trained enumerators. Nutrient intakes and proportion of energy intake were divided into groups according to Recommended Dietary Allowance 2012. Results: In total, 59 data were analyzed. The age at menarche were ranged from 9 (n=1) to 15 (n=1). Most of students had their menarche at 12 (37.3%). Intake of energy (49.2%), protein (64.4%), fat (61%), and carbohydrate (54.2%) were mostly deficient, but the proportion of energy intake from fat (49.2%) and carbohydrate (66.1%) were mostly adequate. The student with youngest age at menarche had adequate energy intake, excess protein intake and excess proportion of energy intake from fat. Student with the oldest age had deficient energy, fat, and protein intake and excess proportion of energy intake from carbohydrate. Conclusions: This study shows that student with youngest age at menarche has different eating pattern compared to the oldest, while the others seem similar. [AMJ.2016;3(1):156–63] Keywords: Eating pattern, Jatinangor, menarche

Introduction Puberty is the period of sexual function maturation to reach the capability of sexual reproduction. the first menstruation (menarche) occurred at the end of puberty.1 Over the past several decades, age at menarche has notably declined, particularly in western.2 Early age at menarche has been associated with adverse health outcomes in adulthood, including greater body mass index, insulin resistance, metabolic syndrome, breast cancer, cardiovascular disease, and depression, while the later age at menarche has been associated with osteoporosis and increased risk of bone fracture.3-8 National Report on Basis Health Research 20109 reported that 37.5% Indonesian girls had started their period at 13 to 14, 0.1% at age 6 to 8 years, 19.8% at

15 to 16 years, and 4.5% at older age than 17 years. Another study showed that 0.4% girls in Bandung10 had started their period at 9 and 6.2% at age older than 15 years. Age at menarche changed in line with the improvement of nutritional intake.2 Consumption of fruits and vegetables were declined, while consumption of foodstuffs from animals were increased. This alteration of eating pattern was allegedly caused by the increasing of vegetable oil availability and due to the advertisement which influence people to consume many products containing sugar.11 Previous studies reported that high intake of energy, protein, and fat were associated with the early age at menarche, while high intake of carbohydrate was associated with the late age at menarche.12,13 Energy and protein intake in Indonesia were still deficient, as reported

Correspondence: Fani Fitrya Nafisah, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km.21, Jatinangor, Sumedang, Indonesia, Phone: +62 85294164130 Email: [email protected] Althea Medical Journal. 2016;3(1)

Fani Fitrya Nafisah, Insi Farisa Desy Arya, Eppy Darmadi Achmad: Age at Menarche and Eating Pattern among High School Students in Jatinangor in 2013

by National Report on Basis Health Research, 9 on the contrary the proportion of energy intake from fat and carbohydrate are higher than recommendation of Dietary Guidelines for Indonesian. Over the past several decades, the economy has improved in Jatinangor. This happens because Jatinangor which was once the plantation area is now the site of several universities. Agricultural land has turned into rental houses for students and shops along the road. Even now there are apartments and shopping malls.14 The changes may affect the alteration of eating pattern as well as the age at menarche. There were only a few studies were conducted in Jatinangor about age at menarche

Note: RDA = Recommended Dietary Allowance

Figure 1 Dietary Information’s Schem Althea Medical Journal. 2016;3(1)

157

and eating pattern. Regarding those issues, this study used data from Survey of Adolescent Reproductive Health in Jatinangor to assess the age at menarche and eating pattern among high school students in Jatinangor.

Methods

Data for this descriptive study was obtained from Survey of Adolescent Reproductive Health in Jatinangor at 2013 which was done by Research Team of Faculty of Medicine, Universitas Padjadjaran. This study was approved by Health Research Ethics Committee. Samples were obtained by stratified cluster random sampling. The first

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stage was to choose two schools from Junior High School and two schools from Senior High School in the subdistrict of Jatinangor. The second stage was a randomized method to pick the classes. Data for this study were obtained with total sampling techniques. The inclusion criteria were the data from students who were residents of Jatinangor or at least 2 years in school and had started menstruation when the study was conducted. The exclusion criteria were incomplete data and energy intake was less than 50% from Recommended Dietary Allowance (RDA). The dietary information used in this study was collected by eating pattern recall questionnaire, comprised of energy, protein, fat, and carbohydrate intake. Data were taken by trained enumerators. The questionnaires included questions about the quantity and type of food which is frequently consumed every week, included meal time, brand name, the process of preparation, composition, weekly frequency, and portions of food and beverage.

Food model was used as the standard portion sizes. Data from the questionnaires were converted to nutrient intake using Nutrisurvey 2007, augmented with manufacturers’ and Food Nutritive Value information. To predict daily mean of nutrient intake, each type of food was multiplied by weekly frequency of consumption and then was summed to all food consumed. Nutrient intakes and proportion of energy intake from fat and carbohydrate were divided into groups according to RDA 2012. The groups for nutrient intakes were deficient intakes (less than 80% of RDA), adequate intakes (between 80−100% of RDA), and excess intakes (greater than 100% RDA). The groups for proportion of energy intake from fat were deficient proportion (less than 25% of total energy), adequate proportion (25−35% of total energy), and excess proportion (higher than 35% of total energy intake). The groups for proportion of energy intake from carbohydrate were deficient proportion (less than 40% of total energy), adequate

Table 1 Characteristic of Subject Based on School, Age and Age at Menarche Variable

n (N=59)

(%)

Junior high school

26

44

12

1

1.7

School

Senior high school

Age (years old) 13

33 9

15.3

8

13.6

1.7

14

14

17

20

9

1

15

16 18

Age at menarche 10

11

2

5

2

3.4

33.9 8.5

3.4

15.3

7

11.9

22

15

1

14

23.7

9

12 13

66

17

37.3 28.8 1.7

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Fani Fitrya Nafisah, Insi Farisa Desy Arya, Eppy Darmadi Achmad: Age at Menarche and Eating Pattern among High School Students in Jatinangor in 2013

159

Table 2 Characteristic of Subject Based on Eating Pattern Variable

n (N=59)

(%)

29

49.2

38

64.4

Energy intake Deficient

Adequate Excess

Protein intake Deficient

Adequate Excess

Fat intake

Deficient

Adequate Excess

Carbohydrate intake Deficient

Adequate Excess

Proportion of energy from fat Deficient

Adequate Excess

Proportion of energy from carbohydrate Deficient

Adequate Excess

proportion (40−60% of total energy), and excess proportion (higher than 60% of total energy intake).15

Results

Not all the sample of Survey of Adolescent Reproductive Health in Jatinangor were taken to this study due to some missing data. In total, 83 eating pattern recall questionnaire were reviewed, 18 questionnaires were excluded due to energy intake less than 50% of RDA and 6 questionnaires were excluded due to incomplete data. Subjects ranged in age from 12 to 18 Althea Medical Journal. 2016;3(1)

18 12 11 10 36

30.5 20.3 18.6 16.9 61

10

16.9

32

54.2

18

30.5

13 12 15 29 12 1

39 19

22

20.3 25.4 49.2 20.3 1.7

66.1 32.2

years, mostly 17 years (33.9%) with median 16 years. The youngest age at menarche was 9 (n=1) and the oldest was 15 (n=1), mostly were 12 (37.3%). Intake of energy, protein, fat, and carbohydrate was mostly deficient, respectively 49.2%, 64.4%, 61%, and 54.2%, but the proportion of energy from fat and carbohydrate was mostly adequate, respectively 49.2% and 66.1%. Energy intake of girls who had menarche at 9, was different to the girls who had menarche at 15 (Table 3). The student who had menarche at 9 had adequate energy intake and proportion of energy intake from carbohydrate but proportion of energy intake from fat was excess. The student who had menarche at 15

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Table 3 Distribution of Energy Intake and Proportion of Energy from Fat and Carbohydrate Based on Age at Menarche Age at menarche Energy intake Deficient Count

% within age at menarche

9

10

11

12

13

14

15

0

1

5

12

5

5

1

Total

29

0

50

55.6

54.5

29.4

71.4

100

49.2

% within age at menarche

100

50

33.3

22.7

41.2

14.3

0

30.5

% within age at menarche

0

0

11.1

22.7

29.4

14.3

0

20.3

100

100

100

100

100

100

100

100

0

1

2

6

4

4

1

18

Adequate Count

1

Excess Count

0

Total

Count

1

% within age at menarche

Proportion of energy from fat Deficient Count

% within age at menarche

Adequate Count

Excess Count

Total

Count

% within age at menarche

Proportion of carbohydrate Deficient

energy

Count

% within age at menarche

Adequate Count

from

2

1

9

5

5

22

7

5

17

1

1

7

0

0

1

18

12

59

50

22.2

27.3

23.5

57.1

100

30.5

0

0

66.7

58.8

58.8

42.9

0

49.2

100

50

11.1

17.6

17.6

0

0

20.3

100

100

100

100

100

100

100

100

0

0

0

1

0

0

0

1

1

% within age at menarche

0

3

0

0

% within age at menarche

1

1

0

1

0

1

2

0

2

6

1

9

10 6

22

0

4.5

6

13

10 3

17

0

11

3

0

0

0

7

1

0

6

29

12

59

0

1.7

0

66.1

0

39

% within age at menarche

100

100

66.7

59.1

64.7

85.7

% within age at menarche

0

0

33.3

36.4

35.3

14.3

100

32.2

100

100

100

100

100

100

100

Excess Count

Total

Count

% within age at menarche

0

1

100

0

2

3

9

8

22

6

17

1

7

1

1

19

59

Althea Medical Journal. 2016;3(1)

Fani Fitrya Nafisah, Insi Farisa Desy Arya, Eppy Darmadi Achmad: Age at Menarche and Eating Pattern among High School Students in Jatinangor in 2013

161

Table 4 Distribution of Nutrient Intake Based on Age at Menarche Age at menarche 9 Protein intake Deficient Count

% within age at menarche

0

10

1

11

7

12

15

13

9

14

5

15

1

Total

38

0

50

77.8

68.2

52.9

71.4

100

64.4

0

50

11.1

9.1

35.3

14.3

0

18.6

% within age at menarche

100

0

11.1

22.7

11.8

14.3

0

16.9

% within age at menarche

100

100

100

100

100

100

100

100

0

1

6

13

10

5

1

36

Adequate Count

% within age at menarche

Excess Count

Total

Count

Fat intake Deficient Count

% within age at menarche

Adequate Count

% within age at menarche

Excess Count

0

1

1

1

0

2

1

1

9

2

5

22

6

2

17

1

1

7

0

0

1

11

10

59

0

50

66.7

59.1

58.8

71.4

100

0

0

33.3

27.3

5.9

0

0

16.9

0

13.6

35.3

28.6

0

22

0

1

0

1

3

0

6

3

1

6

0

2

0

0

61

10

13

% within age at menarche

100

50

% within age at menarche

100

100

100

100

100

100

100

100

0

2

5

13

8

4

0

32

Total

Count

Carbohydrate intake Deficient Count

% within age at menarche

1

2

9

22

17

7

0

100

55.6

59.1

47.1

57.1

% within age at menarche

100

0

11.1

13.6

23.5

% within age at menarche

0

0

33.3

27.3

100

100

100

Adequate Count

Excess Count

Total

Count

% within age at menarche Althea Medical Journal. 2016;3(1)

1

0

1

100

0

0

2

1

3

9

3

6

22

1

59

0

54.2

28.6

100

20.3

29.4

14.3

0

25.4

100

100

100

100

4

5

17

2

1

7

1

0

1

12

15

59

162

AMJ March 2016

had deficient energy intake and proportion of energy intake from fat but the proportion of energy intake from carbohydrate was excess. Students who had menarche at 11 and 12 shows identical pattern, i.e. deficient energy intake (55.6%, 54.5%) with adequate proportion of fat (66.7%, 58,8%) and carbohydrate (66.7%, 59.1%). Intake of protein and fat in thegirls who had menarche at 9,was excess, conversely girls who had menarche at 15 had deficient intake (Table 4). Carbohydrate intake was adequate for both of them. Girls who had menarche at 11 to 14 mostly had deficient intake of protein, fat, and carbohydrate.

Discussion

Most of the subjects in this study had startedtheir menstruation at 12 (37.3%), the age is earlier compared to age at menarche of Bandung girls (2010) which mostly had started their menstruation at 13 (37%). This difference indicated the possibility role of nutrition and socioeconomic status in age at menarche.10 This study showed that girls in Jatinangor mostly had a deficient nutritional intake. Adequate intake of energy and other nutrients are required for teenagers, such as time of rapid growth and developmental changes at multiple levels, including shifts in fat distribution, increases in height and weight, and emergence of secondary sex characteristics.16 Adolescents who had deficient intake of energy and other nutrients may not achieve optimal growth and development; moreover sub clinical deficits of nutrient may cause impaired immune response.17 Girl with youngest age at menarche had an adequate energy intake with protein intake and proportion of energy intake from fat was excess. These findings are in accordance to the previous study, which suggested that higher fat intake and lower carbohydrate intake associated with accelerated menarche.12 The mechanism of fat in affecting age at menarche is mediated by leptin. Excessive fat intake will be stored in adipose tissue which secrete the leptin. Leptin can affect the reproduction system by triggering the release of Gonadotropin Releasing Hormone (GnRH) from hypothalamus. In response to GnRH secretion, anterior pituitary cells secreting follicle-stimulating hormone (FSH) and luteinizing hormone (LH). The FSH and

LH were circulated through the blood vessels and stimulate the secretion of ovarian steroid hormones.18 In addition the availability of circulating estrogen may be enhanced by high consumption of fat, thereby influencing pubertal development.12 In the puberty stage, hypothalamic gonadotropin-releasing hormone secretion systems are re-activated and cause an enhancement in amplitude and frequency of GnRH pulses. It increased the gonadotropin circadian rhythms and gonadal steroid secretion. At the final stage of hypothalamicpituitary development, apositive feedback occurs from the rise of estradiol that cause a midcycle LH surge and then menarche occurs.1,2 Excessive protein intake will increase the frequency of peak LH and elongation of the follicular phase, so as to accelerate a person to enter the puberty stage; the fact is consistent to the previous studies which suggested that higher protein intake person at 5 to 6 was related to an early age at menarche.13,19 Furthermore high consumption of protein, especially animal protein, stimulates the secretion of insulin and insulin-like growth factor 1 (IGF-1). Then, Insulin and IGF-1 will affect the production of somatopedin, which is an activator of sexual maturity, so as to accelerate a person to enter the puberty stage too.13 Another finding in this study is girls with oldest age at menarche had an excess proportion of energy intake from carbohydrate. The result is consistent to the previous studies which suggested that higher intakes of carbohydrate in girls were associated with the later timing of menarche.12 Eating pattern of adolescence may associate with nutritional knowledge, but there were misconceptions about personal dietary intake levels; in addition, the eating patterns can be affected by innate food preferences, familiarity, and social and environmental influence.17 This study showed that most girls eat food sold in schools which most of them are fried food and snack containing salt or sugar. Limitations of the study are the sample size which were small because of the high frequency of missing data, eating pattern recall on the subject to both under- and overreporting and it may not represent the habitual dietary intake, weight of the subject was not considered to calculate the nutritional needs instead of using RDA which is not specific, and current dietary data may not be an accurate marker of long term intake in childhood. Althea Medical Journal. 2016;3(1)

Fani Fitrya Nafisah, Insi Farisa Desy Arya, Eppy Darmadi Achmad: Age at Menarche and Eating Pattern among High School Students in Jatinangor in 2013

The conclusions of this study are the age at menarche in Jatinangor girls ranged from 9 to 15 and the student with youngest age at menarche had a different eating pattern compared to the oldest, while the others seem similar. Further studies is recommended to determine the relationship between age at menarche and eating pattern by considering other factors such as genetic, body mass index, and physical activity and the impact of early and late menarche need to be observed so further morbidity can be prevented.

References

1. Rebar RW. Puberty. In: Berek JS, editor. Berek & Novak’s gynecology. 14th ed. Philadelphia: Lippincott Williams & Wilkins; 2007. p. 992. 2. Styne D. Puberty. In: Gardner DG, Shoback D, editors. Greenspan’s Basic & Clinical Endocrinology. 8th ed. San Francisco: The McGraw-Hill Companies; 2007. p. 611. 3. Feng Y, Hong X, Wilker E, Li Z, Zhang W, Jin D, et al. Effects of age at menarche, reproductive years, and menopause on metabolic risk factors for cardiovascular disease. Atherosclerosis. 2008;196(2):590−7. 4. Remsberg KE, Demerath EW, Schubert CM, Cameron WC, Sun SS, Siervogel RM. Early menarche and the development of cardiovascular disease risk factors in adolescent girls: the fels longitudinal study. J Clin Endocrine Metab. 2005;90(5):2178−724. 5. Kaltiala-Heino R, Kosunen E, Rimpela M. Pubertal timing, sexual behaviour and selfreported depression in middle adolescent J Adolescence. 2003;26(5):531−45. 6. Chevalley T, Bonjour JP, Ferrari S, Rizzoli R. Influence of age at menarche on forearm bone microstructure in healthy young women. J Clin Endocrinol Metab. 2008;93(7):2594−601. 7. Chevalley T, Bonjour JP, Ferrari S, Rizzoli R. The influence of pubertal timing on bone mass acquisition: A predtermined trajectory detectable five years before menarche. J Clin Endocrinol Metab. 2009;94(9):3424−31. 8. Yang XR, Sherman ME, Rimm DL, Lissowska J, Brinton LA, Peplonska B, et al. Differences in risk factors for breast cancer molecular subtypes in a population-based study. Cancer Epidemiol Biomararkers Althea Medical Journal. 2016;3(1)

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Prev. 2007;16(3):439−43. 9. Badan Penelitian dan Pengembangan Kesehatan Departemen Kesehatan Republik Indonesia. Laporan Nasional Riset Kesehatan Dasar 2010. In: Indonesia DKR, editor. Jakarta: Badan Penelitian dan Pengembangan Kesehatan Departemen Kesehatan Republik Indonesia; 2010. 10. Batubara JRL, Soesanti F, van de Waal HD. Age at menarche in Indonesian girls: a national survey. Indonesia J Intern Med. 2010;42(2):78−81. 11. Caballero B. The nutrition transition: global trends in diet and disease. In: Shils ME, Shike M, Ross AC, Caballero B, Cousins RJ, editors. Modern Nutrition in Health and Disease. 10th ed. Philadelphia: Lippincott Williams & Wilkins; 2006. p. 1718. 12. Cheng G, Gerlach S, Libuda L, Kranz S, Gunther ALB, Karaolis-Danckert N, et al. Diet quality in childhood is prospectively associated with the timing of puberty but not with body composition at puberty onset. J Nutr. 2010;140:95−102. 13. Gunther ALB, Karaolis-Danckert N, Kroke A, Remer T, Buyken AE. Dietary protein intake throughout childhood is associated with the timing of puberty. J Nutr. 2010;140:565−71. 14. Badan Perencanaan Pembangunan Daerah. Laporan Akhir Studi Kelayakan Kawasan Jatinangor Sebagai Kawasan Perkotaan. Sumedang: Badan Perencanaan Pembangunan Daerah; 2009. 15. Hardinsyah, Riyadi H, Napitupulu V. Kecukupan energi, protein, lemak dan karbohidrat. Widya Karya Nasional Pangan dan Gizi. Jakarta;2012. 16. Treuth MS, Griffin IJ. Adolescence. In: Shils ME, Shike M, Ross AC, Caballero B, Cousins RJ, editors. Modern Nutrition in Health and Disease. 10th ed. Philadelphia: Lippincott Williams & Wilkins; 2006. p. 819. 17. Moreno L, Gonzales-Gross M, Kersting M, Molnar D, de Henauw S, Beghin L, et al. Assessing, understanding and modifying nutritional status, eating habits and physical activity in European adolescents: The HELENA (Healthy Lifestyle in Europe by Nutrition in Adolescence) Study. Public Health Nutr. 2008;11(3):288−99. 18. Quennell JH, Mulligan AC, Tups A, Liu X, Phipps SJ, Kemp CJ, et al. Leptin indirectly regulates gonadotropinreleasing hormone neuronal function. Endocrinology. 2009;150(6):2805−12.

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19. Susanti AV, Sunarto. Faktor risiko kejadian menarche dini pada remaja di SMP N 30

Semarang. Journal of Nutrition College. 2012;1(1):115−26.

Althea Medical Journal. 2016;3(1)

165

Index Althea Medical Journal Author Index A Achmad Fauzi Yahya, 59 Achmad Sidiq, 28 Adi Mulyono Gondopurwanto, 115 Ambrosius Purba, 34 Anggraini Widjajakusuma, 6 Ani Melani Maskoen, 22 Anugrah Aulia Amri, 22 Arifin Soenggono, 152 Armijn Firman, 152 Arnova Reswari, 73 Arto Yuwono Soeroto, 85 B Basuki Hidayat, 1 Bony Wiem Lestari, 85 Budiman, 99

C Chin Annrie Eidwina, 93 Chong Jie Hao, 64 Christian Prinjana, 1 Chrysanti, 64

D Dida Akhmad Gurnida, 93

E Eddy Fadlyana, 79 Edhyana K. Sahiratmadja, 147 Enny Rohmawaty, 17 Elsa Pudji Setiawati, 120 Eppy Darmadi Achmad, 156 Erva Monica Saputro, 110 Ezra Oktaliansah, 141 F Fani Fitrya Nafisah, 156 Farhatul Inayah Adiputri, 152 Fatimah Lidya Andriani, 54 Fenny Dwiyatnaningrum, 43 Fiona Lestari, 132 G Ghaniyyatul Khudri, 79

H Hadiyatussalamah Pusfa Kencanasari, 59 Hasanah, 120 Hasrayati Agustina, 49 Helen Oktavia Sutiono, 85 Althea Medical Journal. 2016;3(1)

I Ibnu Tsabit Maulana, 69 Ida Parwati, 132 Ihrul Prianza Prajitno, 99, 141 Ike Rostikawati Husen, 69 Imam Megantara, 69 Indra Wijaya, 137 Insi Farisa Arya, 156 Irma Ruslina Defi, 103 Ismet Muchtar Nur, 54 Iswaran Ampalakan, 34

J Januarsih Iwan Rachman, 28 Jeevithaambigai Subramaniam, 12 Juliati, 6 K Karthik Yogaswaran, 6 Keshia Amalia Mivina Mudia, 141 Ku Shi Yun, 103 Kusmandewi Mutyara, 73 Kuswinarti, 115 L Lazuardhi Dwipa, 17, 103 Lee Shok Chen, 126 Lee Pei Yie, 99 Lia Faridah, 93 Lika Apriani, 120 Lisda Amalia, 126 Lynna Lidyana, 73

M Marina A. Moeliono, 126 Marizka Adzani, 137 Maula Rifada, 110 Mayasari Wahyu Kuntoyo, 38 Miftahurachman, 49 Muhammad Zulfikar Azhar, 147

N Nadjwa Zamalek Dalimoenthe, 137 Nova Sylviana, 79 R Rahmi Fauziah, 17 Raisha Pratiwi Indrawati, 38 Reni Farenia, 38 R.B. Soeherman Herdiningrat, 110 R.M. Ryadi Fadil, 12, 147

166

AMJ March 2016

S Sally Mahdiani, 43 Sally Mahdiani 54 Setiawan, 59 Sofiati Dian, 132 Sri Maryanti, 49 Sunaryo Barki Sastradimaja, 34 Syarief Hidayat, 22, 28 T Trias Nugrahadi, 64

V Veronika Ratih M, 43

Y Yanti Mulyana, 1 Yudith Setiati Ermaya, 93 Yulia Sofiatin, 12 Yusuf Wibisono, 115

Althea Medical Journal. 2016;3(1)

167 Subject Index A Acute myocardial infarction, 28–33 Acute Pharyngitis, 69–72 Acute rhinosinusitis, 64–8 Administrative officers, 34–7 Anemia, 93–8, 137–40 Anesthesia techniques, 141–6 Antihypertensive agent, 17–21 Ascariasis, 93–8 Attitude, 73–8, 85–95 B Balance disorder, 103–9 Barthel Index, 126–31 Blood pressure, 59–63 Body mass index, 12–6

C Carcinoma, 54–8 Cardiopulmonary fitness, 34–7 Cerebrospinal fluid, 132–6 Child development, 79–84 Children, 147–51 Clinical characteristic, 43–8 Clinical manisfestations, 132–6 Cold pressor test, 59–63 Coronary collaterals, 28–33 D Diagnostic tools, 132–6 Disability, 126–31 Drugs resistance, 64–8 Durian, 22–8

E Early school-age students, 93–8 Eating pattern, 156–63 Epidural anesthesia, 141–6 Exclusive breastfeeding, 79–84 F Five time-sit-to-stand, 103–9 Functional status, 126–31 G Growth media, 1–5

H Hashimoto’s thyroiditis, 49–53 Hearing lost, 43–8 Hematocrit, 152–5 Hemoglobin, 137–40, 152–5 Histopathology, 54–8 HIV/AIDS, 73–8 Housewife, 115–9 Hypertension, 17–21 Althea Medical Journal. 2016;3(1)

Hyperthyroid, 49–53

I Independent instrumental activity of daily living, 126–31 Intention, 120–5 J Jatinangor, 6–11, 73–8, 156–63 Joint pain, 115–9 Junior high school students, 38–42

K Knowledge, 73–8, 85–92, 115–9, 120–5 L Laboratory findings, 132–6 Lower extremities, 141–6 Lung tuberculosis, 137–40 M Male students, 12–6 Male school students, 6–11 Malondialdehyde, 22–8 Menarche, 156–63 Microbiology, 1–5 Microwave, 1–5 Midnight prayer, 59–63

N Near work activity, 38–42 Nurses, 85–92 Nutritional status, 12–6, 93–8 Nd:YAG laser, 99–102 NSAID, 115–9 O Obesity, 147–51 Older adult, 17–21, 103–9 One year old children, 79–84 Onset of puberty, 12–6 Orthopedic surgery, 141–6 Oxidative stress, 22–8 oxygen saturation, 152–5

P Personal protective equipment, 120–5 Posterior capsule opacification, 99–102 Practice, 85–92 Preinfaction angina, 28–33 Primary angle-closure glaucoma, 110–4 Primary open-angle glaucoma, 110–4 Pubertal age, 6–11 Puberty, 6–11 Pulse rate, 59–63

168

AMJ March 2016

S Salivary gland, 54–8 Short term memory, 34–7 Sterilization, 1–5 Streptococcus pneumoniae, 64–8 Streptococcus pyogenes, 69–72 Sympathetic tone, 59–63 T TB-HIV, 85–92 Tetralogy of fallot, 152–5 Throat swab, 69–72 Thyroiditis, 49–53

Trabeculectomy, 110–4 Tuberculosis, 120–5 tuberculous meningitis, 132–6 Tympanic membrane perforation, 43–8 U Upper lower segment ratio, 147–51 V Visual acuity, 38–42, 99–102

Althea Medical Journal. 2016;3(1)

169

2016 Guest Peer Reviewer Acknowledgment AMJ editorial board extends its deepest gratitude to the following reviewers of the Althea Medical Journal Volume 3, Number 1, March, 2016 for their contribution: Dr. Achadiyani, dr., M.Kes (Department of Anatomy and Cell Biology, Faculty of Medicine, Universitas Padjadjaran, Indonesia) Dr. Achmad Hussein S. Kartamihardja, dr., Sp.KN, M.H.Kes (Department of Nuclear Medicine, Faculty of Medicine, Universitas Padjadjaran, Indonesia)

Dr. Agnes Rengga Indrati, dr., Sp.PK., M.Kes (Department of Clinical Pathology, Faculty of Medicine, Universitas Padjadjaran, Indonesia) Dr. Anam, dr.,SpS(K) (Department of Neurology, Faculty of Medicine, Universitas Padjadjaran, Indonesia)

Andri Reza Rahmadi, dr., Sp.PD-KR.,M.Kes. (Department of Internal Medicine, Faculty of Medicine, Universitas Padjadjaran, Indonesia) Dr. Ardini S. Raksanagara, dr., MPH (Department of Public Health, Faculty of Medicine, Universitas Padjadjaran, Indonesia)

Dian Marta Sari,dr.,M.Kes.,Sp.KFR (Department of Physical Medicine and Rehabilition, Faculty of Medicine, Universitas Padjadjaran, Indonesia) Dini Saraswati Handayani, S.ST.,M.KM (Department of Public Health, Faculty of Medicine, Universitas Padjadjaran, Indonesia) Dr. Eddy Fadlyana, dr.,SpA(K), M.Kes (Department of Child Health, Faculty of Medicine, Universitas Padjadjaran, Indonesia)

Edhyana K. Sahiratmadja, dr., Ph.D (Department of Biochemistry and Molecular Biology, Faculty of Medicine, Universitas Padjadjaran, Indonesia) Faisal, dr.,Sp.A, M.Kes (Department of Child Health, Faculty of Medicine, Universitas Padjadjaran, Indonesia)

Gita Indah Triyanti Rukmana, dr., M.Kes (Department of Microbiology and Parasitology, Faculty of Medicine, Universitas Padjadjaran, Indonesia) Dr. H. Hikmat Permana, dr., SpPD-KEMD (Department of Internal Medicine, Faculty of Medicine, Universitas Padjadjaran, Indonesia)

Dr. Hermawan Nagar Rasyid, dr., SpOT(K)., MT(BME), Ph.D., FICS (Department of Orthopaedic & Traumatology, Faculty of Medicine, Universitas Padjadjaran, Indonesia) Dr. Leonardo Lubis, dr., AIFO.,M.Kes (Department of Anatomy and Cell Biology, Faculty of Medicine, Universitas Padjadjaran, Indonesia) Marlianti Hidayat, drg., M.H.Kes (Department of Oral Health, Faculty of Medicine, Universitas Padjadjaran, Indonesia)

Dr. Meita Dhamayanti, dr., Sp.AK., M.Kes (Department of Child Health, Faculty of Medicine, Universitas Padjadjaran, Indonesia) Althea Medical Journal. 2016;3(1)

170

AMJ March 2016 Dr. Merry Wijaya, Dra.,M.Kes (Department of Public Health, Faculty of Medicine, Universitas Padjadjaran, Indonesia)

Mohammad Rizki Akbar, dr., M.Kes., SpJP (Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Padjadjaran, Indonesia) Nanny Natalia Mulyani Soetedjo, dr., SpPD., KEMD.,DCN.,M.Kes. (Department of Internal Medicine, Faculty of Medicine, Universitas Padjadjaran, Indonesia)

Nita Arisanti, dr., M.Sc.FM (Department of Public Health, Faculty of Medicine, Universitas Padjadjaran, Indonesia)

Putri Teesa Radhiyanti Santoso, dr., M.Kes (Department of Physiology, Faculty of Medicine, Universitas Padjadjaran, Indonesia)

R. Andri Primadhi, dr.,Sp.OT (Department of Orthopaedic & Traumatology, Faculty of Medicine, Universitas Padjadjaran, Indonesia) Dr. R. Reni Farenia Soedjana Ningrat, dr., M.Kes., AIF. (Department of Physiology, Faculty of Medicine, Universitas Padjadjaran, Indonesia)

Raden Angga Kartiwa, dr., Sp.M., M.Kes (Department of Ophthalmology, Faculty of Medicine, Universitas Padjadjaran, Indonesia)

Dr. Ratna Anggraeni S.Poerwana,dr.,Sp.THT-KL(K).,M.Kes (Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, Universitas Padjadjaran, Indonesia) Ronny, dr.,M.Kes.,AIFO.,Ph.D (Department of Physiology, Faculty of Medicine, Universitas Padjadjaran, Indonesia)

Rudi Wisaksana, dr., SpPD-KPTI.,Ph.D (Department of Internal Medicine, Faculty of Medicine, Universitas Padjadjaran, Indonesia) Dr. Shanti Fitrianti Boesoirie, dr., Sp.M., M.Kes (Department of Ophthalmology, Faculty of Medicine, Universitas Padjadjaran, Indonesia)

Dr. Shinta Fitri Boesoirie, dr., Sp.THT-KL., M.Kes. (Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, Universitas Padjadjaran, Indonesia) Siti Aminah, dr.,SpS(K).,M.Si Med (Department of Neurology, Faculty of Medicine, Universitas Padjadjaran, Indonesia)

Siti Nur Fatimah,dr.,MS.,SpGK (Department of Medical Nutrition, Faculty of Medicine, Universitas Padjadjaran, Indonesia) Dr. Susi Susanah, dr.,SpA(K), M.Kes (Department of Child Health, Faculty of Medicine, Universitas Padjadjaran, Indonesia)

Dr. Sylvia Rachmayati, dr., Sp.PK(K)., M.Kes (Department of Clinical Pathology, Faculty of Medicine, Universitas Padjadjaran, Indonesia) Dr. Vita Murniati Tarawan, dr., Sp.OG., M.Kes.,AIFO.,SH. (Department of Physiology, Faculty of Medicine, Universitas Padjadjaran, Indonesia)

Dr. Wijana, dr., SpTHT-KL (Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, Universitas Padjadjaran, Althea Medical Journal. 2016;3(1)

171 Indonesia)

Yanti Mulyana, Dra.Apt., MS., DMM (Department of Microbiology and Parasitology, Faculty of Medicine, Universitas Padjadjaran, Indonesia) Yenni Zuhairini, dr.,M.Gizi.,Sp.GK (Department of Medical Nutrition, Faculty of Medicine, Universitas Padjadjaran, Indonesia) Yuni Susanti Pratiwi, dr.,AIFO.,M.Kes. (Department of Physiology, Faculty of Medicine, Universitas Padjadjaran, Indonesia)

Yussy Afriani Dewi, dr., Sp.THT-KL(K)., M.Kes (Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, Universitas Padjadjaran, Indonesia)

Althea Medical Journal. 2016;3(1)

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